Volume 1

Eighth
BD Chaurasia’s Edition

Human
Anatomy
Regional and Applied Dissection and Clinical
As per Medical Council of India: Competency based Undergraduate Curriculum for the Indian Medical Graduate, 2018

Upper Limb
Thorax
 Dr BD Chaurasia (1937–1985)
was Reader in Anatomy at GR Medical College, Gwalior.
He received his MBBS in 1960, MS in 1965 and PhD in 1975.
He was elected fellow of National Academy of Medical Sciences (India) in 1982.
He was a member of the Advisory Board of the Acta Anatomica since 1981,
member of the editorial board of Bionature, and in addition
member of a number of scientific societies.
He had a large number of research papers to his credit.
 Volume 1
Eighth
BD Chaurasia’s Edition

Human
Anatomy
Regional and Applied Dissection and Clinical
As per Medical Council of India: Competency based Undergraduate Curriculum for the Indian Medical Graduate, 2018

Upper Limb
Thorax
Chief Editor
Krishna Garg
MBBS MS PhD FIMSA FIAMS FAMS FASI
Member and Fellow, Academy of Medical Sciences
Fellow, Indian Academy of Medical Specialists
Fellow, International Medical Science Academy
Fellow, Anatomical Society of India
Lifetime Achievement Awardee
DMA Distinguished Service Awardee

Ex-Professor and Head, Department of Anatomy

Lady Hardinge Medical College
New Delhi

Editors

Pragati Sheel Mittal MBBS MS Mrudula Chandrupatla MBBS MD

Associate Professor, Department of Anatomy Professor and Head, Department of Anatomy
Government Institute of Medical Sciences Apollo Institute of Medical Sciences
Greater Noida, UP Hyderabad, Telangana

CBS Publishers & Distributors Pvt Ltd

New Delhi • Bengaluru • Chennai • Kochi • Kolkata • Mumbai
Bhopal • Bhubaneswar • Hyderabad • Jharkhand • Nagpur • Patna • Pune • Uttarakhand • Dhaka (Bangladesh) • Kathmandu (Nepal)
 Disclaimer
Science and technology are constantly
changing fields. New research and experi-
ence broaden the scope of information and
knowledge. The editors have tried their best
in giving information available to them while
preparing the material for this book. Although,
all efforts have been made to ensure optimum
accuracy of the material, yet it is quite possible
some errors might have been left uncorrected.
The publisher, the printer and the editors will
not be held responsible for any inadvertent
errors, omissions or inaccuracies.

ISBN: 978-93-88902-73-1
Copyright © Publisher and author

Eighth Edition: 2020 1

First Edition: 1979
Reprint: 1980, 1981, 1982, 1983, 1984, 1985, 1986, 1987, 1988
Second Edition: 1989
Reprint: 1990, 1991, 1992, 1993, 1994
Third Edition: 1995
Reprint: 1996, 1997, 1998, 1999, 2000, 2001, 2002, 2003, 2004
Fourth Edition: 2004
Reprint: 2005, 2006, 2007, 2008, 2009
Fifth Edition: 2010
Reprint: 2011, 2012
Sixth Edition: 2013
Reprint: 2014, 2015
Seventh Edition: 2016
Reprint: 2017, 2018, 2019

All rights are reserved. No part of this book may be reproduced or transmitted in any form or by any
means, electronic or mechanical, including photocopying, recording, or any information storage and
retrieval system without permission, in writing, from the author, Chief Editor and the publisher.

Published by Satish Kumar Jain and produced by Varun Jain for

CBS Publishers & Distributors Pvt Ltd
4819/XI Prahlad Street, 24 Ansari Road, Daryaganj, New Delhi 110 002
Ph: 011-23289259, 23266861, 23266867 Fax: 011-23243014 Website: www.cbspd.com
e-mail: [email protected]; [email protected]

Corporate Office: 204 FIE, Industrial Area, Patparganj, Delhi 110 092
Ph: 011-4934 4934 Fax: 011-4934 4935 e-mail: [email protected]; [email protected]

Branches
• Bengaluru: Seema House 2975, 17th Cross, K.R. Road, Banasankari 2nd Stage, Bengaluru 560 070, Karnataka
Ph: +91-80-26771678/79 Fax: +91-80-26771680 e-mail : [email protected]
• Chennai: 7, Subbaraya Street, Shenoy Nagar, Chennai 600 030, Tamil Nadu
Ph: +91-44-26260666, 26208620 Fax: +91-44-42032115 e-mail: [email protected]
• Kochi: 42/1325, 1326, Power House Road, Opp KSEB Power House, Eranakulam 682 018, Kochi, Kerala
Ph: +91-484-4059061-65 Fax: +91-484-4059065 e-mail: [email protected]

• Kolkata: No. 6/B, Ground Floor, Rameswar Shaw Road, Kolkata-700014 (West Bengal), India
Ph: +91-33-2289-1126, 2289-1127, 2289-1128 e-mail: [email protected]

• Mumbai: 83-C, Dr E Moses Road, Worli, Mumbai-400018, Maharashtra

Ph: +91-22-24902340/41 Fax: +91-22-24902342 e-mail: [email protected]

Representatives
• Bhopal 0-8319310552 • Bhubaneswar 0-9911037372 • Hyderabad 0-9885175004
• Jharkhand 0-9811541605 • Nagpur 0-9421945513 • Patna 0-9334159340
• Pune 0-9623451994 • Uttarakhand 0-9716462459 • Dhaka (Bangladesh) 01912-003485
• Kathmandu (Nepal) 977-9818742655

Printed at Thomson Press (India) Ltd.

 to
my teacher
Shri Uma Shankar Nagayach
— BD Chaurasia
This human anatomy is not systemic but regional
Oh yes, it is theoretical as well as practical
Besides the gross features, it is chiefly clinical
Clinical too is very much diagrammatical.

Lots of tables for the muscles are provided

Even methods for testing are incorporated
Improved colour illustrations are added
So that right half of brain gets stimulated

Tables for muscles acting on joints are given

Tables for branches of nerves and arteries are given
Hope these volumes turn highly useful
Editors’ hardwork under Almighty’s guidance prove fruitful
 Preface to the Eighth Edition

T he Seventh edition was published in 2016. The newly added fourth volume on brain–neuroanatomy
received an excellent response from the students and the teachers alike.
The Eighth edition also brings new changes, surprises, modifications and highlights. It has been designed
as per MCI BoG Syllabus 2018 featuring the text and headings following the “Competency based
Undergraduate Curriculum for the Indian Medical Graduate 2018”, prescribed by Medical Council of
India.
Many readers and teachers gave a feedback of retaining the cranial nerves in Volume 3, therefore,
a brief description of all the cranial nerves has been given in the appropriate chapters.
Text, along with the illustrations, has been thoroughly updated. Many new diagrams have been
added and the earlier ones modified for easy comprehension. Some selected diagrams from the very
first edition have been adapted, recreated and incorporated in these volumes.
Quite a few radiographs and MRIs have been added to keep up with the new developments. Extensive
editing, especially developmental editing, has been done.
Extensive research has decoded the molecular control of development of organ tissues of the body.
An attempt has been made to introduce molecular regulation of development of some organs in the
book. Hope the teachers would explain them further for better understanding of the interesting aspect
of embryology. It is known that many of the adult diseases have a foetal origin.
The text provides essential and relevant information to all the students. For still better and detailed
learning, some selected bibliographic references have been given for inquisitive students.
The cadaveric dissection is the ‘real/actual anatomy’. Since some of these were introduced in the
seventh edition, more diagrams of dissection have been added for the undergraduate students, so
they will not miss carrying out the dissections (due to lack of cadavers).
For testing the knowledge acquired after understanding the topic, Viva Voce questions have been
added. These would prove useful in theory, practical, viva voce and grand viva voce examinations.
Since so much has been added to these holistic volumes, the size would surely increase, though making
the text as compatible with the modern literature as is possible. Most of it is visual and anatomy as a
basic component of medicine remains a subject of practical exploration.
We have satisfactorily modified text to suit requirements of horizontal and vertical integrations of
anatomy with other preclinical, paraclinical and clinical subjects as per BoG NMC (erstwhile MCI)
guidelines.
Happy Reading.
Krishna Garg
Chief Editor
email: [email protected]
Preface to the First Edition (Excerpts)

T he necessity of having a simple, systematized and complete book on anatomy has long been felt.
The urgency for such a book has become all the more acute due to the shorter time now available
for teaching anatomy, and also to the falling standards of English language in the majority of our
students in India. The national symposium on ‘Anatomy in Medical Education’ held at Delhi in 1978
was a call to change the existing system of teaching the unnecessary minute details to the
undergraduate students.
This attempt has been made with an object to meet the requirements of a common medical
student. The text has been arranged in small classified parts to make it easier for the students to
remember and recall it at will. It is adequately illustrated with simple line diagrams which can be
reproduced without any difficulty, and which also help in understanding and memorizing the
anatomical facts that appear to defy memory of a common student. The monotony of describing
the individual muscles separately, one after the other, has been minimised by writing them out in
tabular form, which makes the subject interesting for a lasting memory. The relevant radiological and
surface anatomy have been treated in separate chapters. A sincere attempt has been made to
deal, wherever required, the clinical applications of the subject. The entire approach is such as to
attract and inspire the students for a deeper dive in the subject of anatomy.
The book has been intentionally split in three parts for convenience of handling. This also makes a
provision for those who cannot afford to have the whole book at a time.
It is quite possible that there are errors of omission and commission in this mostly single-handed
attempt. I would be grateful to the readers for their suggestions to improve the book from all angles.
I am very grateful to my teachers and the authors of numerous publications, whose knowledge has
been freely utilised in the preparation of this book. I am equally grateful to my professor and colleagues
for their encouragement and valuable help. My special thanks are due to my students who made
me feel their difficulties, which was a great incentive for writing this book. I have derived maximum
inspiration from Prof. Inderbir Singh (Rohtak), and learned the decency of work from Shri SC Gupta
(Jiwaji University, Gwalior).
I am deeply indebted to Shri KM Singhal (National Book House, Gwalior) and Mr SK Jain (CBS
Publishers & Distributors, Delhi), who have taken unusual pains to get the book printed in its present
form. For giving it the desired get-up, Mr VK Jain and Raj Kamal Electric Press are gratefully
acknowledged. The cover page was designed by Mr Vasant Paranjpe, the artist and photographer
of our college; my sincere thanks are due to him. I acknowledge with affection the domestic assistance
of Munne Miyan and the untiring company of my Rani, particularly during the odd hours of this work.

BD Chaurasia
 Acknowledgements

F oremost acknowledgement is the extreme gratefulness to almighty for ‘All Time Guidance’ during the
preparation of the Eighth edition. All the editors are sincerely obliged to Dr VG Sawant, Dr NA
Faruqi, Dr Gayatri Rath, Dr Ritesh Shah, Dr SN Kazi, Dr N Vasudeva, Dr Sabita Mishra, Dr Mangla Kohli,
Dr Satyam Khare, Dr Nisha Kaul, Dr Azmi Mohsin, Dr Medha Joshi and Dr Surbhi Garg for making this
edition noteworthy.
The suggestions provided by Dr DC Naik, Dr Ved Prakash, Dr Mohini Kaul, Dr Indira Bahl, Dr SH Singh,
Dr Rewa Choudhary, Dr Shipra Paul, Dr Anita Tuli, Dr Shashi Raheja, Dr Sneh Aggarwal, Dr RK Suri,
Dr Vadana Mehta, Dr Veena Bharihoke, Dr Mahindra Nagar, Dr Renu Chauhan, Dr Sunita Kalra, Dr RK
Ashoka, Dr Vivek Parashar, Mr Buddhadev Ghosh, Mr Kaushik Saha, Dr Dinesh Kumar, Dr AK Garg,
Dr Archana Sharma, Dr Shipli Jain, Dr Poonam Kharab, Dr Mahindra K Anand, Dr Daisy Sahni, Dr Kiran
Vasudeva, Dr Rashmi Bhardwaj, Dr Arqam Miraj, Dr Joseph, Dr Harsh Piumal, Dr Yogesh Sontakke, HA
Buch, Umang Sharma, Dr Nikha Bhardwaj and many friends and colleagues are gratefully
acknowledged. They have been providing help and guidance to sustain the responsibility of upkeeping
the standard of these volumes.
Videos of bones and soft parts of human body prepared at Kathmandu University School of Medical
Sciences were added in the CDs along with the Frequently Asked Questions. I am grateful to Dr R Koju,
CEO of KUSMS and Dhulikhel Hospital, for his generosity. This material is now available at our mobile
App CBSiCentral.
The moral support of the family members is appreciated. The members are Dr DP Garg, Mr Satya
Prakash Gupta, Mr Ramesh Gupta, Dr Suvira Gupta, Dr JP Gupta, Mr Manoj, Ms Rekha, Master Shikhar,
Mr Sanjay, Mrs Meenakshi, Kriti, Kanika, Dr Manish, Dr Shilpa, Meera and Raghav. Dr Shilpa Mittal and
Dr Sushant Rit, Mr Rishabh Malhotra have been encouraging and inspiring us in the preparation of the
volumes.
The magnanimity shown by Mr SK Jain (Chairman) and Mr Varun Jain (Director), CBS Publishers &
Distributors Pvt Ltd, has been ideal and always forthcoming.
The unquestionable support of Mr YN Arjuna (Senior Vice President—Publishing, Editorial and Publicity) and his entire
team comprising Ms Ritu Chawla (GM—Production), Mr Sanjay Chauhan (graphic artist) with his untiring
efforts on drawings, Ms Jyoti Kaur (DTP operator), for excellent formatting, Mr Surendra Jha (copyeditor),
Mr Neeraj Sharma (copyeditor), Ms Meena Bhaskar (typing) and Mr Neeraj Prasad (graphic artist) for layout
and cover designing have done excellent work to bring out the eighth edition. I am really obliged to
all of them.
Krishna Garg
Chief Editor
Thus spoke the cadaver

Handle me with little love and care

As I had missed it in my life affair
Was too poor for cremation or burial
That is why am lying in dissection hall

You dissect me, cut me, section me

But your learning anatomy should be precise
Worry not, you would not be taken to court
As I am happy to be with the bright lot

Couldn't dream of a fridge for cold water

Now my body parts are kept in refrigerator
Young students sit around me with friends
A few dissect, rest talk, about food, family and movies
How I enjoy the dissection periods
Don't you? Unless you are interrogated by a teacher

When my parts are buried post-dissection

Bones are taken out for the skeleton
Skeleton is the crown glory of the museum
Now I am being looked up by great enthusiasm

If not as skeletons as loose bones

I am in their bags and in their hostel rooms
At times, I am on their beds as well
Oh, what a promotion to heaven from hell

I won't leave you, even if you pass anatomy

Would follow you in forensic medicine and pathology
Would be with you even in clinical teaching
Medicine line is one where dead teach the living

One humble request I'd make

Be sympathetic to persons with disease
Don't panic, you'll have enough money
And I bet, you'd be singularly happy
 Contents

Preface to the Eighth Edition vii

Preface to the First Edition (excerpts) viii
Index of Competencies xix

Section 1 UPPER LIMB

1. Introduction 3 Clinical Anatomy 33

Sesamoid Bones 33
Parts of the Upper Limb 3 Mnemonics 33
Evolution of Upper Limbs 4 Facts to Remember 33
Study of Anatomy 5 Clinicoanatomical Problem 33
Frequently Asked Questions 5 Further Reading 34
2. Bones 6 Frequently Asked Questions 34
Multiple Choice Questions 34
Introduction 6 Viva Voce 34, 35
Clavicle 6
Ossification 8 3. Pectoral Region 36
Clinical Anatomy 8
Scapula 8 Introduction 36
Ossification 12 Surface Landmarks 36
Clinical Anatomy 13 Dissection 37
Humerus 13 Superficial Fascia 37
Ossification 16 Breast 38
Clinical Anatomy 17 Lymphatic Drainage 41
Radius 18 Clinical Anatomy 43
Ossification 21 Deep Fascia 45
Clinical Anatomy 21 Muscles of the Pectoral Region 45
Ulna 22 Serratus Anterior 48
Ossification 23 Dissection 49
Clinical Anatomy 23 Mnemonics 49
Ossification of Humerus, Radius and Ulna 24 Facts to Remember 49
Importance of Capsular Attachments and Clinicoanatomical Problem 49
Epiphyseal Lines 24 Further Reading 49
Clinical Anatomy 25 Frequently Asked Questions 50
Carpal Bones 25 Multiple Choice Questions 50
Ossification 27 Viva Voce 50
Clinical Anatomy 27
4. Axilla 51
Metacarpal Bones 27
Ossification 31 Introduction 51
Clinical Anatomy 31 Dissection 51
Phalanges 32 Boundaries 51
Ossification 32 Contents of Axilla 53
xii HUMAN ANATOMY—UPPER LIMB AND THORAX

Clinical Anatomy 54 Further Reading 81

Axillary Artery 54 Frequently Asked Questions 82
Relations of Axillary Artery 54 Multiple Choice Questions 82
Clinical Anatomy 58 Viva Voce 82
Axillary Vein 58
Axillary Lymph Nodes 58 7. Cutaneous Nerves, Superficial Veins and
Clinical Anatomy 59 Lymphatic Drainage 83
Spinal Nerve 59 Introduction 83
Brachial Plexus 59
Cutaneous Nerves 83
Dissection 62
Dissection 85
Clinical Anatomy 62
Dermatomes 86
Mnemonics 63
Clinical Anatomy 87
Facts to Remember 64
Superficial Veins 88
Clinicoanatomical Problem 64
Individual Veins 88
Further Reading 64
Clinical Anatomy 89
Frequently Asked Questions 65
Lymph Nodes and Lymphatic Drainage 90
Multiple Choice Questions 65
Clinical Anatomy 91
Viva Voce 65
Facts to Remember 92
5. Back 66 Clinicoanatomical Problems 92
Further Reading 92
Introduction 66 Frequently Asked Questions 93
Surface Landmarks 66 Multiple Choice Questions 93
Skin and Fasciae of the Back 67 Viva Voce 93
Dissection 67
Muscles Connecting the Upper Limb with the 8. Arm 94
Vertebral Column 68
Introduction 94
Dissection 68
Surface Landmarks 94
Additional Features of Muscles of the Back 70
Compartments of the Arm 95
Trapezius 70
Anterior Compartment 95
Latissimus Dorsi 70
Muscles 95
Dissection 71
Nerves 95
Facts to Remember 71 Musculocutaneous Nerve 95
Clinicoanatomical Problem 71 Median Nerve 99
Further Reading 72 Ulnar Nerve 99
Frequently Asked Questions 72 Radial Nerve 99
Multiple Choice Questions 72 Dissection 99
Viva Voce 72 Clinical Anatomy 99
Brachial Artery 100
6. Scapular Region 73
Dissection 101
Introduction 73 Clinical Anatomy 102
Surface Landmarks 73 Changes at the Level of Insertion of
Muscles of the Scapular Region 73 Coracobrachialis 102
Deltoid 73 Cubital Fossa 103
Dissection 76 Dissection 105
Clinical Anatomy 77 Clinical Anatomy 105
Rotator Cuff 78 Posterior Compartment 105
Intermuscular Spaces 78 Triceps Brachii Muscle 106
Dissection 79 Dissection 107
Axillary or Circumflex Nerve 79 Clinical Anatomy 107
Anastomoses Around Scapula 80 Radial Nerve or Musculospiral Nerve 107
Clinical Anatomy 81 Clinical Anatomy 109
Mnemonics 81 Profunda Brachii Artery 110
Facts to Remember 81 Mnemonics 110
Clinicoanatomical Problem 81 Facts to Remember 110
 CONTENTS xiii

Clinicoanatomical Problem 110 Mnemonics 151

Further Reading 110 Facts to Remember 152
Frequently Asked Questions 111 Clinicoanatomical Problems 152
Multiple Choice Questions 111 Further Reading 153
Viva Voce 111, 112 Frequently Asked Questions 153
Multiple Choice Questions 153
9. Forearm and Hand 113 Viva Voce 154
Introduction 113
Surface Landmarks of Front of Forearm 113 10. Joints of Upper Limb 155
Muscles of Front of Forearm 114 Introduction 155
Superficial Muscles 116 Shoulder Girdle 155
Deep Muscles 116 Sternoclavicular Joint 155
Dissection 119 Dissection 156
Arteries of Front of Forearm 119 Acromioclavicular Joint 156
Radial Artery 119 Movements of Shoulder Girdle 156
Ulnar Artery 120 Dissection 158
Dissection 121 Shoulder Joint 158
Nerves of Front of Forearm 121 Movements of Shoulder Joint 160
Median Nerve 122 Dissection 161
Ulnar Nerve 122 Clinical Anatomy 162
Radial Nerve 123 Elbow Joint 164
Dissection 123 Dancing Shoulder 164
Palmar Aspect of Wrist and Hand 124 Carrying Angle 166
Dissection 124 Dissection 166
Flexor Retinaculum 124
Clinical Anatomy 166
Clinical Anatomy 126
Radioulnar Joints 168
Intrinsic Muscles of the Hand 127
Interosseous Membrane 168
Testing of Some Intrinsic Muscles 127
Middle Radioulnar Joint 169
Dissection 133
Supination and Pronation 169
Arteries of Hand 133
Dissection 170
Ulnar Artery 133
Clinical Anatomy 170
Clinical Anatomy 134
Wrist (Radiocarpal) Joint 170
Radial Artery 134
Dissection 173
Dissection 135
Clinical Anatomy 173
Nerves of Hand 136
Joints of Hand 174
Ulnar Nerve 136
Intercarpal, Carpometacarpal and
Clinical Anatomy 137
Intermetacarpal Joints 174
Median Nerve 138
First Carpometacarpal Joint 174
Clinical Anatomy 138
Dissection 175
Fascial Spaces of Hand 141
Clinical Anatomy 175
Clinical Anatomy 143
Metacarpophalangeal Joint 175
Back of Forearm and Hand 143
Interphalangeal Joints 175
Surface Landmarks 143
Mnemonics 177
Dorsum of Hand 143
Facts to Remember 177
Anatomical Snuffbox 144
Clinicoanatomical Problem 177
Extensor Retinaculum 145
Further Reading 177
Dissection 146
Frequently Asked Questions 178
Muscles of Back of Forearm 146
Multiple Choice Questions 178
Superficial Muscles 146
Viva Voce 179
Deep Muscles 147
Dorsal Digital Expansion/Extensor Expansion 147 11. Surface Marking, Radiological Anatomy
Dissection 149
and Comparison of Upper and Lower
Posterior Interosseous Nerve 149
Dissection 150 Limbs 180
Posterior Interosseous Artery 150 Introduction 180
Arches of Hand 151 Surface Marking 180
xiv HUMAN ANATOMY—UPPER LIMB AND THORAX

Arteries 180 Axillary or Circumflex Nerve 191

Nerves 182 Radial Nerve 192
Joints 184 Median Nerve 194
Retinacula 184 Ulnar Nerve 194
Synovial Sheaths of the Flexor Tendons 185 Clinical Anatomy 196
Radiological Anatomy of Upper Limb 185 Arteries of Upper Limb 198
Comparison of Upper and Lower Limbs 188 Sympathetic Innervation 200
Further Reading 190 Embryology of the Upper Limb 200
Frequently Asked Questions 190 Molecular Regulation of Limb Development 200
Clinical Terms 200
Appendix 1: Nerves, Arteries and Further Reading 202
Clinical Terms 191 Frequently Asked Questions 202
Multiple Choice Questions 202
Introduction 191 Spots on Upper Limb 205
Musculocutaneous Nerve 191 Answers 206

Section 2 THORAX

Joints of Thorax 232

12. Introduction 209
Respiratory Movements 234
Surface Landmarks of Thorax 209 Clinical Anatomy 236
Skeleton of Thorax 210 Mnemonics 237
Formation 210 Facts to Remember 237
Clinical Anatomy 212 Clinicoanatomical Problem 238
Shape 212 Further Reading 238
Clinical Anatomy 212 Frequently Asked Questions 238
Superior Aperture/Inlet of Thorax 213 Multiple Choice Questions 238
Clinical Anatomy 215 Viva Voce 239
Inferior Aperture/Outlet of Thorax 215
14. Walls of Thorax 240
Facts to Remember 217
Clinicoanatomical Problem 217 Introduction 240
Further Reading 217 Thoracic Wall Proper 240
Frequently Asked Questions 217 Intercostal Muscles 240
Multiple Choice Questions 217 Intercostal Nerves 242
Viva Voce 218 Dissection 242
Clinical Anatomy 244
13. Bones and Joints of Thorax 219 Typical Intercostal Spaces 245
Intercostal Arteries 245
Introduction 219 Intercostal Veins 247
Bones of Thorax 219 Lymphatics of an Intercostal Sapce 248
Ribs or Costae 219 Internal Thoracic Artery 248
Ossification of a Typical Rib 221 Azygos Vein 249
Ossification 222 Hemiazygos Vein 250
Ossification 223 Accessory Hemiazygos Vein 250
Costal Cartilages 223 Thoracic Sympathetic Trunk 250
Clinical Anatomy 224 Clinical Anatomy 251
Sternum 224 Facts to Remember 253
Development and Ossification 226 Clinicoanatomical Problem 253
Clinical Anatomy 226 Further Reading 253
Vertebral Column 227 Frequently Asked Questions 253
Ossification 231 Multiple Choice Questions 254
Clinical Anatomy 231 Viva Voce 254
 CONTENTS xv

15. Thoracic Cavity and Pleurae 255 Fibrous Pericardium 284

Serous Pericardium 284
Thoracic Cavity 255 Dissection 285
Dissection 255 Clinical Anatomy 285
Pleura 257 Heart 286
Nerve Supply of the Pleura 260 External Features 286
Clinical Anatomy 261 Clinical Anatomy 286
Mnemonics 262 Right Atrium 288
Facts to Remember 262 Dissection 288
Clinicoanatomical Problem 262 Right Ventricle 290
Further Reading 262 Dissection 292
Frequently Asked Questions 263 Left Atrium 292
Multiple Choice Questions 263 Dissection 293
Viva Voce 263 Left Ventricle 293
Dissection 294
16. Lungs 264 Clinical Anatomy 294
Introduction 264 Structure of Heart 294
Dissection 264 Valves 294
Fissures and Lobes of the Lungs 265 Clinical Anatomy 295
Root of the Lung 267 Fibrous Skeleton 296
Bronchial Tree 269 Musculature of the Heart 296
Dissection 269 Conducting System 297
Development of Respiratory System 272 Clinical Anatomy 298
Molecular Regulation 272 Right Coronary Artery 298
Histology 273 Dissection 299
Clinical Anatomy 274 Left Coronary Artery 299
Mnemonics 275 Dissection 300
Facts to Remember 275 Cardiac Dominance 300
Clinicoanatomical Problems 276 Clinical Anatomy 301
Further Reading 276 Veins of the Heart 301
Frequently Asked Questions 276 Nerve Supply of Heart 302
Multiple Choice Questions 277 Clinical Anatomy 303
Viva Voce 277 Developmental Components 303
Molecular Regulation of Cardiac
17. Mediastinum 278 Development 304
Foetal Circulation 304
Introduction 278
Mnemonics 307
Superior and Inferior Mediastina 278
Facts to Remember 307
Dissection 278
Clinicoanatomical Problems 307
Superior Mediastinum 278 Further Reading 308
Inferior Mediastinum 279 Frequently Asked Questions 308
Anterior Mediastinum 279 Multiple Choice Questions 308
Middle Mediastinum 279 Viva Voce 309
Posterior Mediastinum 280
Clinical Anatomy 280 19. Superior Vena Cava, Aorta and Pulmonary
Mnemomics 281 Trunk 310
Facts to Remember 281
Introduction 310
Clinicoanatomical Problem 281 Dissection 310
Frequently Asked Questions 282 Superior Vena Cava 310
Multiple Choice Questions 282 Clinical Anatomy 311
Viva Voce 282 Aorta 311
Ascending Aorta 312
18. Pericardium and Heart 283
Arch of Aorta 312
Introduction 283 Descending Thoracic Aorta 314
Pericardium 283 Clinical Anatomy 316
xvi HUMAN ANATOMY—UPPER LIMB AND THORAX

Pulmonary Trunk 317 Parietal Pleura 330

Development of Arteries 317 Surface Marking of Lungs 331
Development of Superior Vena Cava 318 Borders of the Heart 332
Mnemonics 318 Arteries 333
Facts to Remember 319 Veins 334
Clinicoanatomical Problem 319 Trachea 335
Frequently Asked Questions 320 Right Bronchus 335
Multiple Choice Questions 320 Left Bronchus 335
Viva Voce 320 Oesophagus 335
Thoracic Duct 335
20. Trachea, Oesophagus and 321
Radiological Anatomy 335
Thoracic Duct
Numericals 337
Introduction 321 Further Reading 337
Trachea 321
Histology of Trachea 322 Appendix 2: Autonomic Nervous System,
Clinical Anatomy 323 Arteries, Nerves and Clinical Terms 338
Oesophagus 323 Introduction 338
Dissection 323 Autonomic Nervous System 338
Histology of Oesophagus 325 Sympathetic Nervous System 338
Clinical Anatomy 326 Thoracic Part of Sympathetic Trunk 339
Thoracic Duct 327 Nerve Supply of Heart 340
Facts to Remember 328
Nerve Supply of Lungs 340
Clinicoanatomical Problem 328
Typical Intercostal Nerve 341
Further Reading 328
Atypical Intercostal Nerves 341
Frequently Asked Questions 329
Arteries of Thorax 341
Multiple Choice Questions 329
Clinical Terms 341
Viva Voce 329
Frequently Asked Questions 344
21. Surface Marking and Radiological Multiple Choice Questions 345
Anatomy of Thorax 330 Spots on Thorax 347
Answers 348
Introduction 330
Surface Marking 330 Index 349
 CURRICULUM xvii

Ethical Aspects of Cadaveric Dissection

T he cadaver, the dead body, that we dissect, plays an important role in the teaching of anatomy to medical
students. The cadaver and the bones become an important part of our life as medical students as some
academics have even referred to the cadaver as the ‘first teacher’ in the medical school.
We must pay due respect to the cadavers and bones kept in the dissection hall or museum. In some
medical schools it is mandatory to take an ‘oath’ before beginning the cadaveric dissection which aims to
uphold the dignity of the mortal remains of the departed soul while other medical schools help the student to
undertake dissection in a proper manner and empathise with the families of the donor. During the course of
dissection the student is constantly reminded of the sanctity of the body he/she is studying so that the noble
donation of someone's body is used only as a means of gaining scientific knowledge/progress. Each and every
dissected part afterwards is disposed or cremated with full dignity.
Honour of the donor and his/her family is the prime responsibility of the health professional. ‘The dead teach
the living’, and the living pledge to use this knowledge for the upliftment of humankind.
Three-dimensional models and computer simulations cannot replace the tactile appreciation achieved
by cadaveric dissection and we should always be grateful to those who have donated their bodies and strive
to respect them. We have the privilege to study the human being through a body of a fellow human and have
to be humble and carry forward the legacy of nobility and selflessness in our careers.
(Contributed by Dr Puneet Kaur)
Index of Competencies
Competency based Undergraduate Curriculum for the Indian Medical Graduate

Code Competency Chapter Page no

AN 8.1 Identify the given bone, its side, important features and keep it in anatomical position 2 6
AN 8.2 Identify and describe joints formed by the given bone 2 6
AN 8.3 Enumerate peculiarities of clavicle 2 6
AN 8.4 Demonstrate important muscle attachment on the given bone 2 7, 8
AN 8.5 Identify and name various bones in articulated hand, specify the parts of metacarpals 2 25
and phalanges and enumerate the peculiarities of pisiform
AN 8.6 Describe scaphoid fracture and explain the anatomical basis of avascular necrosis 2 27
AN 9.1 Describe attachment, nerve supply and action of pectoralis major and pectoralis minor 3 45
AN 9.2 Breast: Describe the location, extent, deep relations, structure, age changes, blood supply, 3 38
lymphatic drainage, microanatomy and applied anatomy of breast.
AN 9.3 Describe development of breast 3 42
AN 10.1 Identify and describe boundaries and contents of axilla 4 51
AN 10.2 Identify, describe and demonstrate the origin, extent, course, parts, relations and 4 54
branches of axillary artery and tributaries of vein
AN 10.3 Describe, identify and demonstrate formation, branches, relations, area of supply of 4 59
branches, course and relations of terminal branches of brachial plexus
AN 10.4 Describe the anatomical groups of axillary lymph nodes and specify their areas of drainage 3, 4 41, 58
AN 10.5 Explain variations in formation of brachial plexus 4 59
AN 10.6 Explain the anatomical basis of clinical features of Erb's palsy and Klumpke’s paralysis 4 62
AN 10.7 Explain anatomical basis of enlarged axillary lymph nodes 3, 4 41, 58
AN 10.8 Describe, identify and demonstrate the position, attachment, nerve supply and actions 5 68
of trapezius and latissimus dorsi
AN 10.9 Describe the arterial anastomosis around the scapula and mention the boundaries of 5, 6 71, 80
triangle of auscultation
AN 10.10 Describe and identify the deltoid and rotator cuff muscles 6 73, 78
AN 10.11 Describe and demonstrate attachment of serratus anterior with its action 3 48
AN 10.12 Describe and demonstrate shoulder joint for-type, articular surfaces, capsule, synovial 10 158
membrane, ligaments, relations, movements, muscles involved, blood supply, nerve
supply and applied anatomy
AN 10.13 Explain anatomical basis of Injury to axillary nerve during intramuscular injections 6 76, 79, 81
AN 11.1 Describe and demonstrate muscle groups of upper arm with emphasis on biceps and 8 95, 105
triceps brachii
AN 11.2 Identify and describe origin, course, relations, branches (or tributaries), termination of 8 95, 100
important nerves and vessels in arm
AN 11.3 Describe the anatomical basis of Venepuncture of cubital veins 7 89
AN 11.4 Describe the anatomical basis of Saturday night paralysis 8 109
AN 11.5 Identify and describe boundaries and contents of cubital fossa 8 103
AN 11.6 Describe the anastomosis around the elbow joint 8 101
AN 12.1 Describe and demonstrate important muscle groups of ventral forearm with attachments, 9 114
nerve supply and actions
AN 12.2 Identify and describe origin, course, relations, branches (or tributaries), termination of 9 119
important nerves and vessels of forearm
xx HUMAN ANATOMY—UPPER LIMB AND THORAX

Code Competency Chapter Page no

AN 12.3 Identify and describe flexor retinaculum with its attachments 9 124
AN 12.4 Explain anatomical basis of carpal tunnel syndrome 9 138
AN 12.5 Identify and describe small muscles of hand. Also describe movements of thumb and 9 130
muscles involved
AN 12.6 Describe and demonstrate movements of thumb and muscles involved 10 174
AN 12.7 Identify and describe course and branches of important blood vessels and nerves in hand 9 133
AN 12.8 Describe anatomical basis of Claw hand 9 138
AN 12.9 Identify and describe fibrous flexor sheaths, ulnar bursa, radial bursa and digital 9 117
synovial sheaths
AN 12.10 Explain infection of fascial spaces of palm 9 141
AN 12.11 Identify, describe and demonstrate important muscle groups of dorsal forearm with 9 146
attachments, nerve supply and actions
AN 12.12 Identify and describe origin, course, relations, branches (or tributaries), termination of 9 149
important nerves and vessels of back of forearm
AN 12.13 Describe the anatomical basis of Wrist drop 8 109
AN 12.14 Identify and describe compartments deep to extensor retinaculum 9 145
AN 12.15 Identify and describe extensor expansion formation 9 147
AN 13.1 Describe and explain fascia of upper limb and compartments, veins of upper limb 7 87
and its lymphatic drainage
AN 13.2 Describe dermatomes of upper limb 7 86
AN 13.3 Identify and describe the type, articular surfaces, capsule, synovial membrane, ligaments, 10 164
relations, movements, blood and nerve supply of elbow joint, proximal and distal
radio-ulnar joints, wrist joint and first carpometacarpal joint
AN 13.4 Describe sternoclavicular joint, acromioclavicular joint, carpometacarpal joints and 10 155, 174
metacarpophalangeal joint
AN 13.5 Identify the bones and joints of upper limb seen in anteroposterior and lateral view 11 185
radiographs of shoulder region, arm, elbow, forearm and hand
AN 13.6 Identify and demonstrate important bony landmarks of upper limb: Jugular notch, 3 36
sternal angle, acromial angle, spine of the scapula, vertebral level of the medial end,
inferior angle of the scapula
AN 13.7 Identify and demonstrate surface projection of: Cephalic and basilic vein, palpation of 11 180
brachial artery, radial artery, testing of muscles: trapezius, pectoralis major, serratus anterior,
latissimus dorsi, deltoid, biceps brachii, brachioradialis
AN 13.8 Describe development of upper limb including its molecular regulation Appendix 1 200
AN 21.1 Identify and describe the salient features of sternum, typical rib, Ist rib and typical 13 219, 221
thoracic vertebra 224, 229
AN 21.2 Identify and describe the features of 2nd , 12th ribs, 1st, 11th and 12th thoracic vertebrae 13 221, 222,
223, 231
AN 21.3 Describe and demonstrate the boundaries of thoracic inlet, and outlet 12 213, 215
AN 21.4 Describe and demonstrate extent, attachments, direction of fibres, nerve supply and 14 240
actions of intercostal muscles
AN 21.5 Describe and demonstrate origin, course, relations and branches of a typical intercostal nerve 14 242
AN 21.6 Mention origin, course and branches/ tributaries of: 14 245
1) anterior and posterior intercostal vessels
2) internal thoracic vessels
AN 21.7 Mention the origin, course, relations and branches of: 14 242, 245
1) atypical intercostal nerve
2) superior intercostal artery, subcostal artery
AN 21.8 Describe and demonstrate type, articular surfaces and movements of manubriosternal, 13 232
costovertebral, costotransverse and xiphisternal joints
AN 21.9 Describe and demonstrate mechanics and types of respiration 13 234
 INDEX OF COMPETENCIES xxi

Code Competency Chapter Page no

AN 21.10 Describe costochondral and interchondral joints 13 232
AN 21.11 Mention boundaries and contents of the superior, anterior, middle and posterior 17 278
mediastinum
AN 22.1 Describe and demonstrate subdivisions, sinuses in pericardium, blood supply and nerve 18 283
supply of pericardium
AN 22.2 Describe and demonstrate external and internal features of each chamber of heart 18 288
AN 22.3 Describe and demonstrate origin, course and branches of coronary arteries 18 298
AN 22.4 Describe anatomical basis of ischaemic heart disease 18 301
AN 22.5 Describe and demonstrate the formation, course, tributaries and termination of 18 302
coronary sinus
AN 22.6 Describe the fibrous skeleton of heart 18 296
AN 22.7 Mention the parts, position and arterial supply of the conducting system of heart 18 297
AN 23.1 Describe and demonstrate the external appearance, relations, blood supply, nerve supply, 20 323
lymphatic drainage and applied anatomy of oesophagus
AN 23.2 Describe and demonstrate the extent, relations tributaries of thoracic duct and enumerate 20 326
its applied anatomy
AN 23.3 Describe and demonstrate origin, course, relations, tributaries and termination of 14, 19 249, 310
superior venacava, azygos, hemiazygos and accessory hemiazygos veins
AN 23.4 Mention the extent, branches and relations of arch of aorta and descending thoracic aorta 19 312
AN 23.5 Identify and Mention the location and extent of thoracic sympathetic chain 14 250
AN 23.6 Describe the splanchnic nerves 14 250
AN 23.7 Mention the extent, relations and applied anatomy of thoracic duct 20 327
AN 24.1 Mention the blood supply, lymphatic drainage and nerve supply of pleura, extent of 15 257
pleura and describe the pleural recesses and their applied anatomy
AN 24.2 Identify side, external features and relations of structures which form root of lung and 15 267
bronchial tree and their clinical correlate
AN 24.3 Describe a bronchopulmonary segment 15 269
AN 24.4 Identify phrenic nerve and describe its formation and distribution 19 316
AN 24.5 Mention the blood supply, lymphatic drainage and nerve supply of lungs 15 267
AN 24.6 Describe the extent, length, relations, blood supply, lymphatic drainage and nerve supply 20 321
of trachea
AN 25.1 Identify, draw and label a slide of trachea and lung and molecular regulation 20 322
AN 25.2 (a) Describe development of respiratory system 16 272
(b) Describe development of heart and molecular regulation 18 303
AN 25.3 Describe fetal circulation and changes occurring at birth 18 304
AN 25.4 Describe embryological basis of: 18, 20 306, 336
1) atrial septal defect
2) ventricular septal defect
3) Fallot’s tetralogy
4) tracheo-oesophageal fistula
AN 25.5 Describe developmental basis of congenital anomalies, transposition of great vessels, 19 312
dextrocardia, patent ductus arteriosus and coarctation of aorta
AN 25.6 Mention development of aortic arch arteries, SVC, IVC and coronary sinus 19 317
AN 25.7 Identify structures seen on a plain x-ray chest (PA view) 21 335
AN 25.8 Identify and describe in brief a barium swallow 21 337
AN 25.9 Demonstrate surface marking of lines of pleural reflection, lung borders and fissures, 21 330
trachea, heart borders, apex beat and surface projection of valves of heart
Upper Limb
1
1. Introduction 3
2. Bones 6
3. Pectoral Region 36
4. Axilla 51
5. Back 66
6. Scapular Region 73
7. Cutaneous Nerves, Superficial Veins and Lymphatic Drainage 83
8. Arm 94
9. Forearm and Hand 113
10. Joints of Upper Limb 155
11. Surface Marking, Radiological Anatomy and 180
Comparison of Upper and Lower Limbs
Appendix 1: Nerves, Arteries and Clinical Terms 191
Spots on Upper Limb 205
 Ichchak dana, bichchak dana, dane upar dana
Hands naache, feet naache, brain hai khushnama
Ichchak dana
Ulna upar radius ghoome—Ulna upar radius ghoome,
haath hai anjana
Ichchak dana
Pronators prone kare, supinators reverse kare,
midprone mai haath jud jayen aakhon ka lajana
Ichchak dana
Bolo kya—pronation, supination
Bolo kya—pronation, supination
 1
Introduction
!One pronates while giving, and supinates while getting !
—Anonymous

The fore- and hindlimbs were evolved basically for PARTS OF THE UPPER LIMB
bearing the weight of the body and for locomotion as It has been seen that the upper limb is made up of
is seen in quadrupeds, e.g. cows or dogs. The two pairs four parts: (1) Shoulder region; (2) arm or brachium;
of limbs are, therefore, built on the same basic principle. (3) forearm or antebrachium; and (4) hand or manus.
Each limb is made up of a basal segment or girdle, Further subdivisions of these parts are given in Table
and a free part divided into proximal, middle and distal 1.2 and Fig. 1.1.
segments. The girdle attaches the limb to the axial
skeleton. The distal segment carries five digits.
Table 1.1 shows homologous parts of upper and lower
limbs.
However, with the evolution of the erect posture in
man, the function of weight-bearing was taken over by
the lower limbs. Thus the upper limbs, especially the
hands, became free and gradually evolved into organs
having great manipulative skills.
This has become possible because of a wide range of
mobility at the shoulder. The whole upper limb works
as a jointed lever. The human hand is a grasping tool.
It is exquisitely adaptable to perform various complex
functions under the control of a large area of the brain.
The unique position of man as a master mechanic of
the animal world is because of the skilled movements
of his hands.

Table 1.1: Homologous parts of the limbs

Upper limb Lower limb
1. Shoulder girdle Hip girdle
2. Shoulder joint Hip joint
3. Arm with humerus Thigh with femur
4. Elbow joint Knee joint
5. Forearm with radius and ulna Leg with tibia and fibula
6. Wrist joint Ankle joint
7. Hand with Foot with
a. Carpus a. Tarsus
b. Metacarpus b. Metatarsus
c. 5 digits c. 5 digits
Fig. 1.1: Parts and 32 bones of the upper limb

3
 UPPER LIMB
4

Table 1.2: Parts of the upper limb

Parts Subdivisions Bones Joints
1. Shoulder region a. Pectoral region on the Bones of the shoulder girdle • Sternoclavicular joint
front of the chest a. Clavicle • Acromioclavicular joint
b. Axilla or armpit b. Scapula
c. Scapular region on the
back
2. Upper arm (arm or brachium) — Humerus Shoulder joint
from shoulder to the elbow (scapulohumeral joint)
3. Forearm (antebrachium) — a. Radius • Elbow joint
from elbow to the wrist b. Ulna • Radioulnar joints
4. Hand a. Wrist • Carpus, made up of • Wrist joint
8 carpal bones (radiocarpal joint)
• Intercarpal joints
b. Hand proper • Metacarpus, made up of • Carpometacarpal joints
5 metacarpal bones
c. Five digits, numbered • 14 phalanges—two for • Intermetacarpal joints
from lateral to medial side the thumb, and three for
First = Thumb or pollex each of the four fingers • Metacarpophalangeal
Second = Index or forefinger joints
Third = Middle finger • Proximal and distal
Fourth = Ring finger interphalangeal joints
Fifth = Little finger

1 The shoulder region includes: 4 The hand (manus) includes:

a. The pectoral or breast region on the front of the chest; a. The wrist or carpus, supported by 8 carpal bones
b. The axilla or armpit; and arranged in two rows.
c. The scapular region on the back comprising parts b. The hand proper or metacarpus, supported by 5
around the scapula. metacarpal bones.
The bones of the shoulder girdle are the clavicle and c. Five digits (thumb and four fingers). Each finger
the scapula. is supported by three phalanges, but the thumb
Of these, only the clavicle articulates with the axial has only 2 phalanges (there being 14 phalanges
skeleton at the sternoclavicular joint. The scapula is in all).
mobile and is held in position by muscles. The The carpal bones form the wrist joint with the radius,
clavicle and scapula articulate with each other at the intercarpal joints with one another, and carpometa-
acromioclavicular joint. carpal joints with the metacarpals.
2 The arm (upper arm or brachium) extends from the The phalanges form metacarpophalangeal joints with
shoulder to the elbow (cubitus). The bone of the arm the metacarpals and interphalangeal joints with one
is the humerus. Its upper end meets the scapula and another.
forms the shoulder joint. The shoulder joint permits Movements of the hand are permitted chiefly at the
wrist joint. The thumb moves at the first carpometa-
Upper Limb

movements of the arm.

3 The forearm (antebrachium) extends from the elbow carpal joint; where an exclusive movement of
to the wrist. The bones of the forearm are the radius opposition besides the other usual movements is
and the ulna. At their upper ends, they meet the permitted. Each of the second to fifth digits moves at
lower end of the humerus to form the elbow joint. metacarpophalangeal, proximal and distal inter-
Their lower ends meet the carpal bones to form the phalangeal joints. Figure 1.2 and Flowchart 1.1 show
wrist joint. The radius and ulna meet each other at the lines of force transmission.
the radioulnar joints.
The elbow joint permits movements of the forearm, EVOLUTION OF UPPER LIMBS
1

namely flexion and extension. The radioulnar joints The forelimbs have evolved from the pectoral fins of
Section

permit rotatory movements of the forearm called fishes. In tetrapods (terrestrial/land vertebrates), all the
pronation and supination. In a mid-flexed elbow, the four limbs are used for supporting body weight, and for
palm faces upwards in supination and downwards locomotion. In arboreal (tree-dwelling) human ances-
in pronation. During the movement of pronation, the tors, the forelimbs have been set free from their weight-
radius rotates around the ulna (see Fig. 10.23). bearing function. The forelimbs, thus ‘emancipated’,
 INTRODUCTION
5

Flowchart 1.1: Lines of force transmission

disproportionate lengthening of the forearms, and also

in elongation of the palm and fingers.

STUDY OF ANATOMY
Before studying the anatomy of any region, it is usual
to begin by learning general features of the skin, the
superficial fascia and its contents, the deep fascia, the
bones, the muscles, joints, blood vessels and nerves.
All these are provided in BD Chaurasia’s Handbook of
General Anatomy, 6th edition. This is followed by the
Fig. 1.2: Scheme of skeleton of upper limb showing lines of study of the muscles of the region, and finally, the blood
force transmission
vessels and nerves. These descriptions should be read
only after the part has been dissected with the help of
the steps of dissection provided in the book.
acquired a wide range of mobility and were used for Before undertaking the study of any part of the body,
prehension or grasping, feeling, picking, holding, it is essential for the students to acquire some
sorting, breaking, fighting, etc. These functions became knowledge of the bones of the region. It is for this reason
possible only after necessary structural modifications: that a chapter on bones (osteology) is given at the
a. Appearance of joints permitting rotatory movements beginning of each section. While reading the chapter,
of the forearm (described as supination and the students should palpate the various parts of bones
pronation), as a result of which food could be picked on themselves. The next chapter must be studied with
up and taken to the mouth. the help of loose human bones. Upper Limb
b. Addition of the clavicle, which has evolved with the
function of prehension.
c. Rotation of the thumb through 90°, so that it can be
opposed to other digits for grasping.
d. Appropriate changes for free mobility of the fingers 1. Make a flowchart to show lines of force transmission
and hand. in upper limb.
The primitive pentadactyl limb of amphibians, 2. Tabulate the homologous parts of upper and lower
1

terminating in five digits, has persisted through limbs.

Section

evolution and is seen in man. In some other species, 3. Enumerate:

however, the limbs were altogether lost, as in snakes; a. Subdivisions of shoulder region
while in others the digits were reduced in number as b. Joints related to the forearm
in ungulates. The habit of brachiation, i.e. suspending c. Name of carpal bones in order
the body by the arms, in anthropoid apes resulted in d. Joints of the hand
 UPPER LIMB
6

2
Bones
!Palpation of ulnar nerve behind medial epicondyle of humerus makes some persons smile, that is why the bone is called humerus !
—Anonymous

Competency achievement: The student should be able to: 1 The lateral end is flat, and the medial end is large
AN 8.1 Identify the given bone, its side, important features and and quadrilateral.
keep it in anatomical position.1 2 The shaft is slightly curved, so that it is convex
AN 8.2 Identify and describe joints formed by the given bone.2 forwards in its medial two-thirds, and concave
forwards in its lateral one-third.
3 The inferior surface is grooved longitudinally in its
INTRODUCTION
middle one-third.
Out of 206 total bones in man, the upper limbs contain as
many as 64 bones. Each side consists of 32 bones, the Peculiarities of the Clavicle
distribution of which is shown in Table 1.2 and 1 It is the only long bone that lies horizontally.
Fig. 1.1 (see Chapter 1). Since bones of the two upper limbs 2 It is subcutaneous throughout.
are similar, one needs to learn only 32 bones out of a total 3 It is the first bone to start ossifying.
64 bones. This applies to soft parts as well. One learns only 4 It is the only long bone which ossifies in membrane.
one upper limb, the other upper limb gets learnt on its 5 It is the only long bone which has two primary centres
own. This is true for the whole body except parts of of ossification.
abdomen. Actually, one needs to master only 50% of the 6 There is no medullary cavity.
body and other 50% gets mastered itself. The individual 7 It is occasionally pierced by the middle supraclavicular
bones of the upper limb will be described one by one. nerve.
Their features and attachments should be read with the It receives weight of upper limb via lateral one-third
bones before undertaking the dissection of the part through coracoclavicular ligament and transmits
concerned. The paragraphs on attachments should be weight of upper limb to the axial skeleton via medial
revised when the dissection of a particular region has been two-thirds part (see Flowchart 1.1).
completed.
Features
Upper Limb

Competency achievement: The student should be able to: Shaft

AN 8.3 Enumerate peculiarities of clavicle.3 The shaft (Figs 2.1a and b) is divisible into the lateral
one-third and the medial two-thirds.
The lateral one-third of the shaft is flattened from above
CLAVICLE downwards. It has two borders—anterior and
posterior. The anterior border is concave forwards. The
The clavicle (Latin a small key) is a long bone. It supports posterior border is convex backwards. This part of the
the shoulder so that the arm can swing clearly away bone has two surfaces—superior and inferior. The
from the trunk. The clavicle transmits the weight of the superior surface is subcutaneous and the inferior surface
1

limb to the sternum. The bone has a curved part called presents an elevation called the conoid (Greek cone)
Section

the shaft, and two ends, lateral and medial. tubercle and a ridge called the trapezoid ridge.
The medial two-thirds of the shaft is rounded and
Side Determination is said to have four surfaces. The anterior surface is
The side to which a clavicle belongs can be determined convex forwards. The posterior surface is smooth. The
from the following characters. superior surface is rough in its medial part. The inferior
6
 BONES
7

Figs 2.1a and b: General features of right clavicle: (a) Superior aspect, and (b) inferior aspect

surface has a rough oval impression at the medial end. Competency achievement: The student should be able to:
The lateral half of this surface has a longitudinal AN 8.4 Demonstrate important muscle attachments on the given
subclavian groove. The nutrient foramen lies at the lateral bone.4
end of the groove.
Attachments
Lateral and Medial Ends 1 At the lateral end, the margin of the articular surface
1 The lateral or acromial (Greek peak of shoulder) end for its acromioclavicular joint gives attachment to the
is flattened from above downwards. It bears a facet joint capsule.
that articulates with the acromion process of the 2 At the medial end, the margin of the articular surface
scapula to form the acromioclavicular joint. for the sternum gives attachment to:
2 The medial or sternal end is quadrangular and
a. Fibrous capsule of sternoclavicular joint all around
articulates with the clavicular notch of the
(Figs 2.2a and b).
manubrium sterni to form the sternoclavicular joint.
The articular surface extends to the inferior aspect, b. Articular disc posterosuperiorly.
for articulation with the first costal cartilage. c. Interclavicular ligament superiorly.

Upper Limb
1Section

Figs 2.2a and b: Attachments of right clavicle: (a) Superior aspect, and (b) inferior aspect
 UPPER LIMB
8

3 Lateral one-third of shaft CLINICAL ANATOMY

a. The anterior border gives origin to the deltoid
muscle (Fig. 2.2a). • The clavicle is commonly fractured by falling on
b. The posterior border provides insertion to the the outstretched hand (indirect violence). The
trapezius muscle. most common site of fracture is the junction
c. The conoid tubercle and trapezoid ridge give between the two curvatures of the bone, which is
attachment to the conoid and trapezoid parts of the the weakest point. The lateral fragment is
coracoclavicular ligament (Fig. 2.2b). displaced downwards by the weight of the limb
4 Medial two-thirds of the shaft as trapezius muscle alone is unable to support the
a. Most of the anterior surface gives origin to the weight of upper limb (Fig. 2.4).
pectoralis major (Figs 2.2a and b). • The clavicles may be congenitally absent, or
b. Half of the rough superior surface gives origin to imperfectly developed in a disease called
the clavicular head of the sternocleidomastoid cleidocranial dysostosis. In this condition, the
(Fig. 2.2a). shoulders droop, and can be approximated
c. The oval impression on the inferior surface at the anteriorly in front of the chest (Figs 2.5a and b).
medial end gives attachment to the costoclavicular
ligament (Fig. 2.2b).
d. The subclavian groove gives insertion to the
subclavius muscle. The margins of the groove give
attachment to the clavipectoral fascia.
e. The posterior surface close to medial end gives
origin to sternohyoid muscle.
f. The subclavian vessels and divisions of trunks of
brachial plexus pass towards the axilla lying
between the inferior surface of the clavicle and
upper surface of first rib. Subclavius muscle acts
as a cushion.
The nutrient foramen transmits a branch of the
suprascapular artery.

OSSIFICATION
Fig. 2.4: Fracture of clavicle
• The clavicle is the first bone in the body to ossify
(Fig. 2.3). Except for its medial end, it ossifies in Competency achievement: The student should be able to:
membrane. It ossifies from two primary centres AN 8.4 Demonstrate important muscle attachment on the given
and one secondary centre. bone.5
• The two primary centres appear in the shaft
between the fifth and sixth weeks of intrauterine SCAPULA
life, and fuse about the 45th day.
Upper Limb

• The secondary centre for the medial end appears The scapula (Latin shoulder blade) is a thin bone placed
during 15–17 years, and fuses with the shaft on the posterolateral aspect of the thoracic cage. The
during 21–22 years. Occasionally, there may be a scapula has two surfaces, three borders, three angles,
secondary centre for the acromial end. and three processes (Fig. 2.6).

Side Determination
1 The lateral or glenoid (Greek socket) angle is large
and bears the glenoid cavity.
2 The dorsal surface is convex and is divided by the
1

triangular spine into the supraspinous and

Section

infraspinous fossae. The costal surface is occupied

by the concave subscapular fossa to fit on the convex
chest wall (Figs 2.6 and 2.7).
3 The thickest lateral border runs from the glenoid
Fig. 2.3: Ossification of clavicle cavity above to the inferior angle below.
 BONES
9

2 The lateral border is thick. At the upper end, it presents

the infraglenoid tubercle.
3 The medial border is thin. It extends from the superior
angle to the inferior angle.
Angles
1 The superior angle is covered by the trapezius.
2 The inferior angle is covered by the latissimus dorsi. It
moves forwards round the chest when the arm is
abducted.
3 The lateral or glenoid angle is broad and bears the
glenoid cavity or fossa, which is directed forwards,
laterally and slightly upwards (Fig. 2.7). A supra-
glenoid tubercle is present above the glenoid cavity.
Processes
1 The spine or spinous process is a triangular plate of
bone with three borders and two surfaces. It divides
the dorsal surface of the scapula into the
supraspinous and infraspinous fossae. Its posterior
border is called the crest of the spine. The crest has
upper and lower lips.
2 The acromion process has two borders, medial and
lateral; two surfaces, superior and inferior; and a
facet for the clavicle (Fig. 2.7).
3 The coracoid (Greek like a crow’s beak) process is
directed forwards and slightly laterally. It is bent and
finger-like. It is an atavistic type of epiphysis.
Attachments
1 The multipennate subscapularis muscle arises from
the medial two-thirds of the subscapular fossa
(Figs 2.8 and 6.4).
2 The supraspinatus arises from the medial two-thirds
Figs 2.5a and b: Cleidocranial dysostosis: (a) Clavicles of the supraspinous fossa including the upper
absent on both sides, and (b) shoulders approximated surface of the spine (Fig. 2.9).
3 The infraspinatus arises from the medial two-thirds
of the infraspinous fossa, including the lower
Features surface of the spine (Fig. 2.9).
Surfaces 4 The deltoid arises from the lower border of the crest
of the spine and from the lateral border of the acromion
Upper Limb
1 The costal surface or subscapular fossa is concave and
is directed medially and forwards. It is marked by (Fig. 2.10). The acromial fibres are multipennate.
three longitudinal ridges. Another thick ridge adjoins 5 The trapezius is inserted into the upper border of
the lateral border. This part of the bone is almost the crest of the spine and into the medial border of
rod-like. It acts as a lever for the action of the serratus the acromion process (Fig. 2.10).
anterior in overhead abduction of the arm. 6 The serratus anterior is inserted along the medial
2 The dorsal surface gives attachment to the spine of border of the costal surface: One digitation from the
the scapula which divides the surface into a smaller superior angle to the root of spine, two digitations
supraspinous fossa and a larger infraspinous fossa. The to the medial border, and five digitations to the
1

two fossae are connected by the spinoglenoid notch, inferior angle (Fig. 2.8).
Section

situated lateral to the root of the spine. 7 The long head of the biceps brachii arises from the
supraglenoid tubercle; and the short head from the
Borders lateral part of the tip of the coracoid process.
1 The superior border is shortest. Near the root of the 8 The coracobrachialis arises from the medial part of
coracoid process, it presents the suprascapular notch. the tip of the coracoid process.
 UPPER LIMB
10

Fig. 2.6: General features of right scapula: Costal surface

Upper Limb
1
Section

Fig. 2.7: General features of right scapula: Dorsal surface

 BONES
11

Fig. 2.8: Attachments of right scapula: Costal aspect

Upper Limb
1Section

Fig. 2.9: Attachments of right scapula: Dorsal aspect

 UPPER LIMB
12

Fig. 2.10: Right scapula: Superior aspect

9 The pectoralis minor is inserted into the medial 21 The coracoclavicular ligament is attached to the
border and superior surface of the coracoid process coracoid process: The trapezoid part on the superior
(Fig. 2.8). aspect, and the conoid part near the root (Fig. 2.10).
10 The long head of the triceps brachii arises from the 22 The transverse ligament bridges across the supra-
infraglenoid tubercle. scapular notch and converts it into a foramen which
11 The teres minor arises by two slips from the upper transmits the suprascapular nerve. The suprascapular
two-thirds of the rough strip on the dorsal surface vessels lie above the ligament (Fig. 2.10).
along the lateral border (Fig. 2.9). Circumflex 23 The spinoglenoid ligament may bridge the spino-
scapular artery lies between the two slips. glenoid notch. The suprascapular vessels and nerve
12 The teres major arises from the lower one-third of pass deep to it (Fig. 10.3).
the rough strip on the dorsal aspect of the lateral
border (Fig. 2.9). Latissimus dorsi arises from
inferior angle. OSSIFICATION
13 The levator scapulae is inserted along the dorsal • The scapula ossifies from one primary centre
aspect of the medial border, from the superior angle and seven secondary centres.
up to the root of the spine (Fig. 2.9). • The primary centre appears near the glenoid
14 The rhomboid minor is inserted into the medial cavity during the eighth week of development.
border (dorsal aspect) opposite the root of the spine • The first secondary centre appears in the middle
(Fig. 2.9). of the coracoid process during the first year and
15 The rhomboid major is inserted into the medial fuses by the 15th year. The subcoracoid centre
border (dorsal aspect) between the root of the spine appears in the root of the coracoid process
Upper Limb

and the inferior angle. during the 10th year and fuses by the 16th to
16 The inferior belly of the omohyoid arises from the 18th years (Fig. 2.11).
upper border near the suprascapular notch (Fig. 2.8). • The other centres, including two for the
17 The margin of the glenoid cavity gives attachment acromion process, one for the lower two-thirds
to the capsule of the shoulder joint and to the of the margin of the glenoid cavity, one for the
glenoidal labrum (Latin lip) (Fig. 2.8). medial border and one for the inferior angle,
18 The margin of the facet on the medial aspect of the appear at puberty and fuse by the 25th year.
acromion process gives attachment to the capsule of
• The fact of practical importance is concerned with
the acromioclavicular joint (Fig. 2.10).
1

the acromion process. If the two centres appearing

19 The coracoacromial ligament is attached: (a) to the
for acromion process fail to unite, it may be
Section

lateral border of the coracoid process, and (b) to the

interpreted as a fracture on radiological examina-
medial side of the tip of the acromion process
tion. In such cases, a radiograph of the opposite
(Figs 2.10 and 6.7).
acromion process will mostly reveal similar failure
20 The coracohumeral ligament is attached to the root
of union.
of the coracoid process (Fig. 2.10).
 BONES
13

Fig. 2.11: Ossification of scapula

CLINICAL ANATOMY Side Determination

1 The upper end is rounded to form the head. The
• Paralysis of the serratus anterior causes ‘winging’ lower end is expanded from side-to-side and
of the scapula. The medial border of the bone flattened from before backwards.
becomes unduly prominent, and the arm cannot 2 The head is directed medially, upwards and
be abducted beyond 90° (Fig. 2.12). backwards.
• The scaphoid scapula is a developmental anomaly, 3 The lesser tubercle projects from the front of the
in which the medial border is concave. upper end and is limited laterally by the
intertubercular sulcus or bicipital groove.
Features
Upper End
1 The head is directed medially, backwards and
upwards. It articulates with the glenoid cavity of the
scapula to form the shoulder joint. The head forms
about one-third of a sphere and is much larger than
the glenoid cavity.
2 The line separating the head from the rest of the
upper end is called the anatomical neck.
3 The lesser tubercle (Latin lump) is an elevation on the

Upper Limb
anterior aspect of the upper end (Fig. 2.13a).
4 The greater tubercle is an elevation that forms the
lateral part of the upper end. Its upper and posterior
aspect is marked by three impressions—upper,
middle and lower.
5 The intertubercular sulcus or bicipital groove separates
the lesser tubercle medially from the anterior part of
Fig. 2.12: Winging of right scapula
the greater tubercle. The sulcus has medial and lateral
lips that represent downward prolongations of the
1

lesser and greater tubercles.

HUMERUS
Section

6 The narrow line separating the upper end of the

humerus from the shaft is called the surgical neck
The humerus is the bone of the arm. It is the longest (Fig. 2.13b).
bone of the upper limb. It has an upper rounded end, a 7 Morphological neck lies 0.5 cm below surgical neck.
lower flattened end and a shaft (Figs 2.13 and 2.14). It shows the position of epiphyseal line (Fig. 2.13b).
 UPPER LIMB
14
Upper Limb

Figs 2.13a and b: General features of right humerus: (a) Seen from front, and (b) seen from back

Shaft upper part, it is barely traceable up to the posterior

The shaft is rounded in the upper half and triangular in surface of the greater tubercle. In the middle part, it
the lower half. It has three borders and three surfaces. is interrupted by the radial or spiral groove (Fig. 2.13b).
3 The upper part of the medial border forms the medial
Borders lip of the intertubercular sulcus. About its middle, it
1 The upper one-third of the anterior border forms the presents a rough strip. It is continuous below with
1

lateral lip of the intertubercular sulcus. In its middle the medial supracondylar ridge.
Section

part, it forms the anterior margin of the deltoid

tuberosity. The lower half of the anterior border is Surfaces
smooth and rounded. 1 The anterolateral surface lies between the anterior and
2 The lateral border is prominent only at the lower end lateral borders. The upper half of this surface is covered
where it forms the lateral supracondylar ridge. In the by the deltoid. A little above the middle, it is marked
 BONES
15

Upper Limb
Figs 2.14a and b: Attachments of right humerus: (a) Anterior view, and (b) posterior view

by a V-shaped deltoid (Greek triangular-shaped) oblique ridge. The middle one-third is crossed by
tuberosity. Behind the deltoid tuberosity, the radial groove the radial groove (Fig. 2.13b).
runs downwards and forwards across the surface.
Lower End
2 The anteromedial surface lies between the anterior and
The lower end of the humerus forms the condyle which
1

medial borders. Its upper one-third is narrow and

is expanded from side-to-side, and has articular and
forms the floor of the intertubercular sulcus. A
Section

non-articular parts. The articular part includes the

nutrient foramen is seen near the medial border following.
below its middle part (Fig. 2.13a). 1 The capitulum (Latin little head) is a rounded
3 The posterior surface lies between the medial and projection which articulates with the head of the
lateral borders. Its upper part is marked by an radius (Fig. 2.13a).
 UPPER LIMB
16

2 The trochlea (Greek pulley) is a pulley-shaped 11 The brachialis arises from the lower halves of the
surface. It articulates with the trochlear notch of anteromedial and anterolateral surfaces of the shaft.
the ulna. The medial edge of the trochlea projects Part of the area extends onto the posterior aspect
down 6 mm more than the lateral edge—this (Figs 2.14a and b).
results in the formation of the carrying angle 12 The brachioradialis arises from the upper two-thirds
(see Fig. 10.14). of the lateral supracondylar ridge (Figs 2.14a and b).
The non-articular part includes the following. 13 The extensor carpi radialis longus arises from the
1 The medial epicondyle is a prominent bony projection lower one-third of the lateral supracondylar ridge.
on the medial side of the lower end. It is sub- 14 The pronator teres (humeral head) arises from the
cutaneous and is easily felt on the medial side of the lower one-third of the medial supracondylar ridge.
elbow (Fig. 2.13a). 15 The superficial flexor muscles of the forearm arise by
2 The lateral epicondyle is smaller than the medial a common origin from the anterior aspect of the medial
epicondyle. Its anterolateral part has a muscular epicondyle. This is called the common flexor origin.
impression. 16 The superficial extensor muscles of the forearm and
3 The sharp lateral margin just above the lower end is supinator have a common origin from the lateral
called the lateral supracondylar ridge. epicondyle. This is called the common extensor origin.
4 The medial supracondylar ridge is a similar ridge on 17 The anconeus (Greek elbow) arises from the posterior
the medial side. surface of the lateral epicondyle (Fig. 2.14b).
5 The coronoid fossa is a depression just above the 18 Lateral head of triceps brachii arises from oblique
anterior aspect of the trochlea. It accommodates the ridge on the upper part of posterior surface above
coronoid process of the ulna when the elbow is flexed the radial groove, while its medial head arises from
(Fig. 2.13a).
posterior surface below the radial groove.
6 The radial fossa is a depression present just above the
19 The capsular ligament of the shoulder joint is
anterior aspect of the capitulum. It accommodates
attached to the anatomical neck except on the medial
the head of the radius when the elbow is flexed.
7 The olecranon (Greek ulna head) fossa lies just above side where the line of attachment dips down by
the posterior aspect of the trochlea. It accommodates about 2 centimetres to include a small area of the
the olecranon process of the ulna when the elbow is shaft within the joint cavity. The line is interrupted
extended (Fig. 2.13b). at the intertubercular sulcus to provide an aperture
through which the tendon of the long head of the
Attachments biceps brachii leaves the joint cavity (Fig. 2.14a).
1 The multipennate subscapularis is inserted into the 20 The capsular ligament of the elbow joint is attached
lesser tubercle (Fig. 2.14a). to the lower end along a line that reaches the upper
2 The supraspinatus is inserted into the uppermost limits of the radial and coronoid fossae anteriorly;
impression on the greater tubercle. and of the olecranon fossa posteriorly; so that these
3 The infraspinatus is inserted into the middle fossae lie within the joint cavity. Medially, the line
impression on the greater tubercle (Fig. 2.14b). of attachment passes between the medial epicondyle
4 The teres minor is inserted into the lower impression and the trochlea. On the lateral side, it passes
on the greater tubercle (Fig. 2.14b). between the lateral epicondyle and the capitulum
5 The pectoralis major is inserted into the lateral lip (Figs 2.14a and b).
Upper Limb

of the intertubercular sulcus. The insertion is 21 Three nerves are directly related to the humerus and
bilaminar (Figs 2.14a and b). are, therefore, liable to injury—the axillary nerve at the
6 The latissimus dorsi is inserted into the floor of the surgical neck, the radial nerve at the radial groove, and the
intertubercular sulcus. ulnar nerve behind the medial epicondyle (Fig. 2.15).
7 The teres major is inserted into the medial lip of the
intertubercular sulcus.
8 The contents of the intertubercular sulcus are: OSSIFICATION
a. The tendon of the long head of the biceps brachii, and • The humerus ossifies from one primary centre and
its synovial sheath.
1

seven secondary centres.

b. The ascending branch of the anterior circumflex
• The primary centre appears in the middle of the
Section

humeral artery.
9 The deltoid is inserted into the deltoid tuberosity diaphysis during the 8th week of development.
(Figs 2.14a and b). • The upper end ossifies from three secondary
10 The coracobrachialis is inserted into the rough area centres—one for the head (first year), one for the
on the middle of the medial border.
 BONES
17

CLINICAL ANATOMY

• The common sites of fracture of humerus are the

surgical neck, shaft and supracondylar region.
• Supracondylar fracture is common in young age. It
is produced by a fall on the outstretched hand.
The lower fragment is mostly displaced back-
wards, so that the elbow is unduly prominent, as
in dislocation of the elbow joint. This fracture may
cause injury to the median nerve. It may also lead
to Volkmann’s ischaemic contracture caused by
occlusion of the brachial artery (Figs 2.16a and b).
• The three bony points of the normal elbow form
the equilateral triangle in a flexed elbow and are
in one line in an extended elbow (Figs 2.17a and b).

Fig. 2.15: Relation of axillary, radial and ulnar nerves to the back
of humerus

Figs 2.16a and b: (a) Supracondylar fracture of humerus, and

greater tubercle (second year), and one for the (b) Volkmann’s ischaemic contracture
lesser tubercle (fifth year). The three centres fuse
together during the sixth year to form one
compound epiphysis, which fuses with the shaft
during the 20th year. The epiphyseal line encircles
the bone at the level of the lowest margin of the
head. This is the growing end of the bone.
(Remember that the nutrient foramen is always Upper Limb
directed away from the growing end.)
• The lower end ossifies from four centres which
form two epiphyses. The centres include one for
the capitulum and the lateral flange of the trochlea
(first year), one for the medial flange of the
trochlea (9th year), and one for the lateral
epicondyle (12th year). All three fuse during the
1

14th year to form another compound epiphysis,

which fuses with the shaft at about 16 years.
Section

• The centre for the medial epicondyle appears

Figs 2.17a and b: Relationship of lateral epicondyle,
during 4–6 years, forms a separate epiphysis, and olecranon process and medial epicondyle in: (a) Flexed elbow,
fuses with the shaft during the 20th year. and (b) extended elbow
 UPPER LIMB
18

2 The neck is enclosed by the narrow lower margin of

the annular ligament. The head and neck are free
from capsular attachment and can rotate freely
within the socket.
3 The radial tuberosity lies just below the medial part
of the neck. It has a rough posterior part and a
smooth anterior part.

Shaft
It has three borders and three surfaces (Fig. 2.20).

Borders
1 The anterior border extends from the anterior margin
of the radial tuberosity down close to the styloid
process. It is oblique in the upper half of the shaft,
and vertical in the lower half. The lowest part is sharp
and crest-like. The oblique part is called the anterior
oblique line (Fig. 2.19).
Fig. 2.18: Inferior dislocation of humerus
2 The posterior border is the mirror image of the anterior
border, but is clearly defined only in its middle one-
• The humerus has a poor blood supply at the third. The upper oblique part is known as the posterior
junction of its upper one-third and lower two- oblique line (Fig. 2.20).
thirds. Fractures at this site show delayed union 3 The medial or interosseous border is the sharpest of the
or non-union. three borders. It extends from the radial tuberosity
• The head of the humerus commonly dislocates above to the posterior margin of the ulnar notch
inferiorly (subglenoid) (Fig. 2.18). below. The interosseous membrane is attached to its
lower three-fourths (Fig. 2.21a). In its lower part, it
RADIUS forms the posterior margin of an elongated triangular
area (Fig. 2.22).
The radius is the lateral bone of the forearm, and is Surfaces
homologous with the tibia of the lower limb. It has an 1 The anterior surface lies between the anterior and
upper rounded end, a lower broad end with a styloid interosseous borders. A nutrient foramen opens in
process and a shaft. its upper part, and is directed upwards. The nutrient
artery is a branch of the anterior interosseous artery
Side Determination (Fig. 2.19).
1 Upper end is having disc-shaped head, a narrow 2 The posterior surface lies between the posterior and
neck while lower end is expanded with a styloid interosseous borders.
process. Close to neck, it presents a radial tuberosity. 3 The lateral surface lies between the anterior and
2 At the lower end, the anterior surface is in the form posterior borders. It shows a roughened area in its
of thick prominent ridge. While the posterior surface middle part.
Upper Limb

presents four grooves for the extensor tendons.

3 Lower end presents a tubercle on the posterior Lower End
surface called as dorsal tubercle of Lister. The lower end is the widest part of the bone. It has
4 The sharpest border of the shaft is the medial border. five surfaces.
1 The anterior surface is in the form of a thick
Features prominent ridge. The radial artery is palpated against
Upper End this surface.
1 The head is disc-shaped and is covered with hyaline 2 The posterior surface presents four grooves for the
1

cartilage (Fig. 2.19). It has a superior concave surface extensor tendons. The dorsal tubercle of Lister lies
Section

which articulates with the capitulum of the humerus lateral to an oblique groove (Fig. 2.20).
at the elbow joint. The circumference of the head is 3 The medial surface is occupied by the ulnar notch for
also articular. It fits into a socket formed by the radial the head of the ulna (Fig. 2.20).
notch of the ulna and the annular ligament, thus 4 The lateral surface is prolonged downwards to form
forming the superior radioulnar joint. the styloid (Greek pillar) process (Fig. 2.20).
 BONES
19

Fig. 2.19: Features of anterior surfaces of radius and ulna

Upper Limb
Fig. 2.20: Features of right radius and ulna, posterior aspect
1Section

Figs 2.21a and b: (a) Radius (R) and ulna (U) in transverse section, and (b) tendons in six compartments/grooves (1–6) under the
extensor retinaculum
 UPPER LIMB
20

Fig. 2.22: Attachments of right radius and ulna: Anterior aspect Fig. 2.23: Attachments of right radius and ulna: Posterior aspect
Upper Limb

5 The inferior surface bears a triangular area for the 4 The brachioradialis is inserted into the lowest part
scaphoid bone, and a medial quadrangular area for of the lateral surface just above the styloid process
the lunate bone. This surface takes part in forming (Fig. 2.22).
the wrist joint (see Fig. 10.24). 5 The radial head of the flexor digitorum superficialis
Attachments takes origin from the anterior oblique line and the
1 The biceps (Latin two heads) brachii is inserted into upper part of anterior border (Fig. 2.22).
the rough posterior part of the radial tuberosity. The 6 The flexor pollicis (Latin thumb) longus takes origin
1

anterior part of the radial tuberosity is covered by a from the upper two-thirds of the anterior surface
(Fig. 2.22).
Section

bursa (Figs 2.22 and 8.4).

2 The supinator (Latin to bend back) is inserted into 7 The pronator quadratus is inserted into the lower
the upper part of the lateral surface (Fig. 2.23). part of the anterior surface and into the triangular
3 The pronator teres is inserted into the middle of the area on the medial side of the lower end. The radial
lateral surface (Fig. 2.22). artery is palpated for ‘radial pulse’, as it lies on the
 BONES
21

pronator quadratus medial to the sharp anterior CLINICAL ANATOMY

border of radius, lateral to the tendon of flexor carpi
radialis. • The radius commonly gets fractured about 2 cm
8 The abductor pollicis longus and the extensor pollicis above its lower end (Colles’ fracture). This fracture
brevis arise from the posterior surface (Fig. 2.23). is caused by a fall on the outstretched hand
9 The quadrate ligament is attached to the medial part (Fig. 2.24a). The distal fragment is displaced
of the neck. upwards and backwards, and the radial styloid
10 The oblique cord is attached on the medial side just process comes to lie proximal to the ulnar styloid
below the radial tuberosity (Fig. 2.22). process. (It normally lies distal to the ulnar styloid
11 The articular capsule of the wrist joint is attached process.) If the distal fragment gets displaced
to the anterior and posterior margins of the inferior anteriorly, it is called Smith’s fracture (Fig. 2.24b).
articular surface. • A sudden powerful jerk on the hand of a child may
12 The articular disc of the inferior radioulnar joint is dislodge the head of the radius from the grip of the
attached to the lower border of the ulnar notch annular ligament. This is known as subluxation of
(see Fig. 10.24). the head of the radius (pulled elbow) (Figs 2.25a and
13 The extensor retinaculum is attached to the lower b). The head can normally be felt in a hollow behind
part of the sharp anterior border (see Fig. 9.52b). the lateral epicondyle of the humerus.
14 The interosseous membrane is attached to the lower
three-fourths of the interosseous border.
15 The first groove between sharp crest-like lowest
part of anterior border and styloid process gives
passage to abductor pollicis longus and extensor
pollicis brevis (Fig. 2.21b).
16 The second groove between styloid process and
dorsal tubercle gives way to extensor carpi radialis
longus and extensor carpi radialis brevis tendons.
17 The third oblique groove medial to dorsal tubercle
gives passage to extensor pollicis longus tendon.
18 The fourth groove on the medial aspect gives
passage to tendons of extensor digitorum, extensor
indicis, posterior interosseous nerve and anterior
interosseous artery.
19 In addition, at the junction of lower ends of radius Figs 2.24a and b: (a) Colles’ fracture with dinner fork
and ulna, the fifth groove gives passage to the deformity, and (b) Smith’s fracture
tendon of extensor digiti minimi.
20 Lastly in relation to ulna, between its head and
styloid process is the sixth groove, traversed by the
tendon of extensor carpi ulnaris (Fig. 2.21b).
These are six compartments/grooves under extensor

Upper Limb
retinaculum of wrist, four are in relation to radius, 5th
at the junction of radius and ulna and 6th on the ulna
itself between its head and styloid process (Fig. 2.21b).

OSSIFICATION

• The shaft of radius ossifies from a primary centre

which appears during the 8th week of development.
• The lower end ossifies from a secondary centre
1

which appears during the first year and fuses with

Section

shaft at 20th year; it is the growing end of the bone.

• The upper end (head) ossifies from a secondary
centre which appears during the 4th year and fuses (a) (b)
with shaft at 18th year (Table 2.1). Figs 2.25a and b: (a) Position of bones, and (b) pulled elbow
 UPPER LIMB
22

ULNA
The ulna is the medial bone of the forearm, and is
homologous with the fibula of the lower limb. It has an
upper end with two processes, a shaft and a narrow
rounded lower end.
Side Determination
1 The upper end is hook-like, with its concavity
directed forwards.
2 The lateral border of the shaft is sharp and crest-like.
3 Pointed styloid process lies posteromedial to the
rounded head of ulna at its lower end.
Features
Upper End Fig. 2.26: Features of upper end of ulna
The upper end presents the olecranon and coronoid
processes, and the trochlear and radial notches (Fig. 2.19). Shaft
1 The olecranon process projects upwards from the shaft.
The shaft has three borders and three surfaces
It has superior, anterior, posterior, medial and lateral
(Fig. 2.21).
surfaces.
• The anterior surface is articular, it forms the upper
part of the trochlear notch (Fig. 2.19). Borders
• The posterior surface forms a triangular sub- 1 The interosseous or lateral border is the sharpest in its
cutaneous area which is separated from the skin middle two-fourths. Inferiorly, it can be traced to the
by a bursa. Inferiorly, it is continuous with the lateral side of the head. Superiorly, it is continuous
posterior border of the shaft of the ulna (Fig. 2.20). with the supinator crest.
Its upper part forms the point of the elbow. 2 The anterior border is thick and rounded. It begins
• The medial surface is continuous inferiorly with the above on the medial side of the ulnar tuberosity,
medial surface of the shaft. passes backwards in its lower one-third, and
• The lateral surface is smooth, continues as posterior terminates at the medial side of the styloid process.
surface of shaft. 3 The posterior border is subcutaneous. It begins, above,
• The superior surface in its posterior part shows a at the apex of the triangular subcutaneous area at
roughened area. the back of the olecranon process, and terminates at
2 The coronoid (Greek like crow’s beak) process projects the base of the styloid process (Fig. 2.20).
forwards from the shaft just below the olecranon
process and has four surfaces, namely superior, Surfaces
anterior, medial and lateral. 1 The anterior surface lies between the anterior and
• The superior surface forms the lower part of the interosseous borders. A nutrient foramen is seen on
trochlear notch. the upper part of this surface. It is directed upwards.
• The anterior surface is triangular and rough. Its The nutrient artery is derived from the anterior
Upper Limb

lower corner forms the ulnar tuberosity. interosseous artery (Fig. 2.19).
• The upper part of its lateral surface is marked by
2 The medial surface lies between the anterior and
the radial notch for the head of the radius. The
annular ligament is attached to the anterior and posterior borders (Fig. 2.19).
posterior margins of the notch. The lower part of 3 The posterior surface lies between the posterior and
the lateral surface forms a depressed area to interosseous borders. It is subdivided into three areas
accommodate the radial tuberosity. It is limited by two lines. An oblique line divides it into upper
behind by a ridge called the supinator crest (Fig. 2.26). and lower parts. The lower part is further divided
• Medial surface is continuous with medial surface by a vertical line into a medial and a lateral area.
1

of the shaft.
Lower End
Section

3 The trochlear notch forms an articular surface that

articulates with the trochlea of the humerus to form The lower end is made up of the head and the styloid
the elbow joint. process. The head articulates with the ulnar notch of
4 The radial notch articulates with the head of the radius the radius to form the inferior radioulnar joint. It is
to form the superior radioulnar joint (Fig. 2.26). separated from the wrist joint by the articular disc
 BONES
23

(see Fig. 10.24). Ulnar artery and nerve lie on the anterior 15 The annular ligament of the superior radioulnar
aspect of head of ulna. joint is attached to the two margins of radial notch
The styloid process projects downwards from of ulna (Fig. 2.26).
posteromedial side of lower end of the ulna. Posteriorly, 16 The ulnar collateral ligament of the wrist is attached
between the head and the styloid process, there to the styloid process.
is a groove for the tendon of the extensor carpi ulnaris 17 The articular disc of the inferior radioulnar joint is
(Fig. 2.21b). attached by its apex to a small rough area just lateral
to the styloid process (see Fig. 10.24).
Attachments
1 The triceps brachii is inserted into the rough posterior
OSSIFICATION
part of the superior surface of the olecranon process
(Fig. 2.23). The anterior part of the surface is covered • The shaft and most of the upper end of ulna ossify
by a bursa. from a primary centre which appears during the
2 The brachialis is inserted into the anterior surface 8th week of development.
of the coronoid process including the ulnar • The superior part of the olecranon process ossifies
tuberosity (Fig. 2.22). from a secondary centre which appears during the
3 The supinator arises from the supinator crest and 10th year. It forms a scale-like epiphysis which
from the triangular area in front of the crest (Fig. 2.22). joins the rest of the bone by 16th year.
4 The ulnar head of the flexor digitorum superficialis • The lower end ossifies from a secondary centre
arises from a tubercle at the upper end of the medial which appears during the 5th year, and joins with
margin of the coronoid process. the shaft by 18th year. This is the growing end of
5 The ulnar head of the pronator teres arises from the the bone (Table 2.1).
medial margin of the coronoid process.
6 The flexor digitorum profundus (Latin deep) arises from:
a. The upper three-fourths of the anterior and CLINICAL ANATOMY
medial surfaces of the shaft.
b. The medial surfaces of the coronoid and • The ulna is the stabilising bone of the forearm,
olecranon processes. with its trochlear notch gripping the lower end of
c. The posterior border of the shaft through the humerus. On this foundation, the radius can
an aponeurosis which also gives origin to the pronate and supinate for efficient working of the
flexor carpi ulnaris and the extensor carpi ulnaris upper limb.
(Fig. 2.23). • The shaft of the ulna may fracture either alone or
7 The pronator quadratus takes origin from the along with that of the radius. Cross-union between
oblique ridge on the lower part of the anterior the radius and ulna must be prevented to preserve
surface (Fig. 2.22). pronation and supination of the hand.
8 The flexor carpi ulnaris (ulnar head) arises from the • Dislocation of the elbow is produced by a fall on the
medial side of the olecranon process and from the outstretched hand with the elbow slightly flexed.
posterior border. The olecranon process shifts posteriorly and the
9 The extensor carpi ulnaris arises from the posterior elbow is fixed in slight flexion.

Upper Limb
border (Fig. 2.23). Normally, in an extended elbow, the tip of the
10 The anconeus is inserted into the lateral aspect of olecranon process lies in a horizontal line with the
the olecranon process and the upper one-fourth of two epicondyles of the humerus; and in the flexed
the posterior surface (Fig. 2.23) of the shaft. elbow, the three bony points form an equilateral
triangle (Figs 2.17a and b). These relations are
11 The lateral part of the posterior surface gives origin
disturbed in dislocation of the elbow.
from above downwards to the abductor pollicis
longus, the extensor pollicis longus and the extensor • Fracture of the olecranon process is common and is
indicis. caused by a fall on the point of the elbow. Fracture
of the coronoid process is uncommon, and usually
1

12 The interosseous membrane is attached to the

accompanies dislocation of the elbow.
interosseous border.
Section

• Madelung’s deformity is dorsal subluxation

13 The oblique cord is attached to the ulnar tuberosity. (displacement) of the lower end of the ulna, due
14 The capsular ligament of the elbow joint is attached to retarded growth of the lower end of the radius
to the margins of the trochlear notch, i.e. to the (Fig. 2.27).
coronoid and olecranon processes (Fig. 2.22).
 UPPER LIMB
24

its shaft at a later period than its corresponding other

ends.
The direction of the nutrient foramen in these bones,
as a rule, is opposite to the growing end.
The time of appearance and time of fusion (either of
various parts at one end, or with the shaft) are given in
Table 2.1.

Importance of Capsular
Fig. 2.27: Madelung’s deformity Attachments and Epiphyseal Lines
Metaphysis is the epiphyseal end of the diaphysis. It is
OSSIFICATION OF HUMERUS, RADIUS AND ULNA an actively growing part of the bone with rich blood
supply. Infections in this part of the bone are most
Law of Ossification common in the young age. The epiphyseal line is the
In long bones possessing epiphyses at both their ends, line of union of metaphysis with the epiphysis. At the
the epiphysis of that end which appears first is last to end of the bone, besides the epiphyseal line, is the
join with the shaft. As a corollary, epiphysis which attachment of the capsule of the respective joints.
appears last is first to join. So, infection in the joint may affect the metaphysis
These ends of long bones which unite last with the of the bone, if it is partly or completely inside the joint
shaft are designated as growing end of the bone. In case capsule. As a corollary, the disease of the metaphysis,
of long bones of the upper limb, growing ends are at if inside a joint, may affect the joint. So, it is worthwhile
shoulder and wrist joints. This implies that the upper to know the intimate relation of the capsular attachment
end of humerus and lower ends of both radius and ulna and the epiphyseal line at the ends of humeral, radial
are growing ends; and each will, therefore, unite with and ulnar bones as shown in Table 2.2.

Table 2.1: Ossification of humerus, radius and ulna

Name of bone and parts Primary centre Secondary centres Time of fusion together Time of fusion
with shaft
Humerus
• Shaft 8 wk IUL — — —
• Upper end: (intrauterine life)
Head 1st yr
Greater tubercle 2nd yr 6th yr 20th yr
Lesser tubercle 5th yr compound epiphysis
• Lower end:
Capitulum + lateral
part of trochlea 1st yr
Medial part of trochlea 9th yr 14th yr 16th yr
Lateral epicondyle 12th yr compound
Upper Limb

• Medial epicondyle 5th yr epiphysis 20th yr

Radius
• Shaft 8 wk IUL — — —
• Lower end — 1st yr — 20th yr
• Upper end — 4th year 18th yr
1

Ulna
• Shaft 8 wk IUL — — —
Section

• Lower end — 5th yr — 18th yr

• Upper end — 10th yr 16th yr
 BONES
25

Table 2.2: Relation of capsular attachments and epiphyseal lines

Name of bone and part Capsular attachment (CA) Epiphyseal line (EL) Metaphysis
Humerus, upper end Laterally to the anatomical neck, At the lowest part of articular Metaphysis is partly
medially 2 cm below the shaft surface of the head intracapsular
and deficient at bicipital groove
Humerus, lower end Follows the margins of radial A horizontal line at the level of Metaphysis is partly
and coronoid fossae and the lateral epicondyle. Medial intracapsular
olecranon fossa epicondyle owns a separate
Both epicondyles are extracapsular epiphyseal line
Radius, upper end Attached to the neck of the radius The head forms the epiphysis Metaphysis is
intracapsular
Radius, lower end Close to the articular margin all Horizontal line at the level of Metaphysis is completely
around the upper part of ulnar notch extracapsular
Ulna, upper end Near the articular surface of ulna Scale-like epiphysis on the Metaphysis and part of
upper surface of olecranon diaphysis are related to
process capsular line. The epi-
physis is extracapsular
Ulna, lower end Around the head of ulna Horizontal line at the level of Metaphysis is partly
articulating surface of radius intracapsular

CLINICAL ANATOMY iii. The capitate (Latin head), and

iv. The hamate (Latin hook).
Relation of capsular attachments and epiphyseal
lines: If epiphyseal line, i.e. site of union of epiphysis Identification
and metaphyseal end of diaphysis is intracapsular, 1 The scaphoid is boat-shaped and has a tubercle on its
the infections of the joints are likely to affect the lateral side.
metaphysis, the actively growing part of the bone
2 The lunate is half-moon-shaped or crescentic.
especially in young age.
3 The triquetral is pyramidal in shape and has an
isolated oval facet on the distal part of the palmar
surface.
Competency achievement: The student should be able to:
AN 8.5 Identify and name various bones in articulated hand, specify
4 The pisiform is pea-shaped and has only one oval facet

Upper Limb
the parts of metacarpals and phalanges and enumerate the
peculiarities of pisiform.6 on the proximal part of its dorsal surface.
5 The trapezium is quadrangular in shape, and has a
crest and a groove anteriorly. It has a sellar (conca-
CARPAL BONES voconvex) articular surface distally.
6 The trapezoid resembles the shoe of a baby.
The carpus is (Greek Karpos, wrist) made up of 8 carpal
bones, which are arranged in two rows (Fig. 2.28). 7 The capitate is the largest carpal bone, with a rounded
head.
1 The proximal row contains (from lateral to medial side):
8 The hamate is wedge-shaped with a hook near its base.
i. The scaphoid (Greek boat, wrist),
1

ii. The lunate (Latin moon-shaped), Side Determination

Section

iii. The triquetral (Latin three-cornered), and

iv. The pisiform (Greek pea) General Points
2 The distal row contains in the same order: 1 The proximal row is convex proximally, and concave
i. The trapezium (Greek four-sided geometric figure), distally.
ii. The trapezoid (Greek baby’s shoe), 2 The distal row is convex proximally and flat distally.
 UPPER LIMB
26

Fig. 2.28: Skeleton of the right hand: Palmar aspect

3 Each bone has 6 surfaces. 2 The lunate:

i. The palmar and dorsal surfaces are non-articular, i. A small semilunar articular surface for the
except for the triquetral and pisiform. scaphoid is on the lateral side.
ii. A quadrilateral articular surface for the triquetral
ii. The lateral surfaces of the two lateral bones
is on the medial side.
(scaphoid and trapezium) are non-articular.
3 The triquetral:
iii. The medial surfaces of the three medial bones i. The oval facet for the pisiform lies on the distal
Upper Limb

(triquetral, pisiform and hamate) are non- part of the palmar surface.
articular. ii. The medial and dorsal surfaces are continuous
4 The dorsal non-articular surface is always larger and non-articular.
than the palmar non-articular surface, except for the 4 The pisiform:
lunate, in which the palmar surface is larger than i. The oval facet for the triquetral lies on the
the dorsal. proximal part of the dorsal surface.
ii. The lateral surface is grooved by the ulnar nerve.
The general points help in identifying the proximal,
5 The trapezium:
distal, palmar and dorsal surfaces in most of the bones. i. The palmar surface has a vertical groove for the
1

The side can be finally determined with the help of the tendon of the flexor carpi radialis.
specific points.
Section

ii. The groove is limited laterally by the crest of the

trapezium.
Specific Points iii. The distal surface bears a sellar concavoconvex
1 The scaphoid: The tubercle is directed laterally, articular surface for the base of the first metacarpal
forward and downwards. bone.
 BONES
27

6 The trapezoid: 6 The trapezoid: Scaphoid, trapezium, 2nd metacarpal

i. The distal articular surface is bigger than the and capitate.
proximal. 7 The capitate: Scaphoid, lunate, hamate, 2nd, 3rd and
ii. The palmar non-articular surface is prolonged 4th metacarpals and trapezoid.
laterally. 8 The hamate: Lunate, triquetral, capitate, and 4th and
7 The capitate: The dorsomedial angle is the distal-most 5th metacarpals.
projection from the body of the capitate. It bears a
small facet for the 4th metacarpal bone. Competency achievement: The student should be able to:

8 The hamate: The hook projects from the distal part of

AN 8.6 Describe scaphoid fracture and explain the anatomical basis
of avascular necrosis.7
the palmar surface, and is directed laterally.

Attachments OSSIFICATION
There are four bony pillars at the four corners of the The year of appearance of centre of ossification in
carpus. All attachments are to these four pillars (Fig. 2.28). the carpal bones is shown in Fig. 2.29.
1 The tubercle of the scaphoid:
i. The flexor retinaculum,
CLINICAL ANATOMY
ii. A few fibres of the abductor pollicis brevis.
2 The pisiform gives: • Fracture of the scaphoid is quite common. The
i. Insertion to be Flexor carpi ulnaris (FCU). bone fractures through the waist at right angles
Pisiform is a sesamoid bone in tendon of FCU. to its long axis. The fracture is caused by a fall
ii. Flexor retinaculum and its superficial slip (see on the outstretched hand, or on the tips of the
Fig. 9.15), fingers. This causes tenderness and swelling
in the anatomical snuffbox, and pain on
iii. Abductor digiti minimi (Fig. 2.32b),
longitudinal percussion of the thumb and index
iv. Extensor retinaculum (see Fig. 9.52). finger. The residual disability is more marked
3 The trapezium: in the midcarpal joint than in the wrist joint. The
i. The crest gives origin to the abductor pollicis importance of the fracture lies in its liability to
brevis, flexor pollicis brevis, and opponens non-union, and avascular necrosis of the body
pollicis. These constitute muscles of thenar of the bone with pain in anatomical snuffbox.
eminence (Fig. 2.32b). Normally, the scaphoid has two nutrient
ii. The edges of the groove give attachment to the arteries, one entering the palmar surface of the
two layers of the flexor retinaculum. tubercle and the other the dorsal surface of the
iii. The lateral surface gives attachment to the lateral body. Occasionally (13% of cases), both vessels
ligament of the wrist joint. enter through the tubercle or through the distal
iv. The groove lodges the tendon of the flexor carpi half of the bone. In such cases, fracture may
radialis. deprive the proximal half of the bone of its blood
supply leading to avascular necrosis (Fig. 2.30).
4 The hamate: • It may be treated on the lines of osteoarthritis.
i. The tip of the hook gives attachment to the flexor • Dislocation of the lunate may be produced by a

Upper Limb
retinaculum (see Fig. 9.15). fall on the acutely dorsiflexed hand with the elbow
ii. The medial side of the hook gives attachment to the joint flexed. This displaces the lunate anteriorly,
flexor digiti minimi and the opponens digiti minimi. also leading to carpal tunnel syndrome like features
(Figs 2.31a to c).
Articulations
1 The scaphoid: Radius, lunate, trapezium, trapezoid
capitate (Figs 2.32b and c). METACARPAL BONES
2 The lunate: Radius, scaphoid, capitate, hamate and
1 The metacarpal bones are 5 miniature long bones,
1

triquetral.
which are numbered from lateral to the medial side
3 The triquetral: Pisiform, lunate, hamate and articular
Section

(Fig. 2.28).
disc of the inferior radioulnar joint. 2 Each bone has a head placed distally, a shaft and a
4 The pisiform articulates only with the triquetral. base at the proximal end.
5 The trapezium: Scaphoid, 1st and 2nd metacarpals i. The head is round. It has an articular surface which
and trapezoid. extends more anteroposteriorly than laterally. It
 UPPER LIMB
28

Fig. 2.29: Ossification of lower ends of radius, ulna, carpal bones, metacarpals and phalanges
Upper Limb
1
Section

Figs 2.31a to c: (a) Normal position of nerves, (b) Dislocation

of lunate leading to carpal tunnel syndrome, and (c) Ape-like
Fig. 2.30: Fracture of the scaphoid deformity of the hand (flattened thenar eminence)
 BONES
29

Fig. 2.32a: Bases of I–V metacarpal bones

extends more on the palmar surface than on the this rotation, the movements of the thumb take
dorsal surface. The heads of the metacarpal bones place at right angles to those of other digits.
form the knuckles during flexion. f. It does not articulate with any other metacarpal
ii. The shaft is concave on the palmar surface. Its bone.
dorsal surface bears a flat triangular area in its 2nd The base is grooved from before backwards. The
distal part. medial edge of the groove is larger (Fig. 2.32a).
iii. The base is irregularly expanded (Fig. 2.32a). 3rd The base has a styloid process projecting up from
3 A metacarpal bone can be distinguished from a the dorsolateral corner (Fig. 2.32a).
metatarsal bone because of the differences given in 4th The base has two small oval facets on its lateral side
Table 2.3. for the third metacarpal, and on its medial side it
has a single elongated facet for the 5th metacarpal
Characteristics of Individual Metacarpal Bones (Fig. 2.32a).
1st a. It is the shortest and stoutest of all metacarpal 5th The base has an elongated articular strip on its
bones (Fig. 2.32b). lateral side for the 4th metacarpal. The medial side
b. The base is occupied by a concavoconvex of the base is non-articular and bears a tubercle.
articular surface for the trapezium.
Side Determination of Metacarpals
c. The dorsal surface of the shaft is uniformly
convex (Fig. 2.32c). The proximal, distal, palmar and dorsal aspects of each
metacarpal bone can be made out from what has been
d. The head is less convex and broader from side- stated above. The lateral and medial sides can be
to-side than the heads of other metacarpals. The confirmed by the following criteria.
ulnar and radial corners of the palmar surface
1st The anterolateral surface is larger than the
show impressions for sesamoid bones. anteromedial (Fig. 2.32b).
e. The first metacarpal bone (lying on a more 2nd i. The medial edge of the groove on the base is
anterior plane) is rotated medially through 90° deeper than the lateral edge.
relative to the other metacarpals. As a result of ii. The medial side of the base bears an articular
strip which is constricted in the middle. Upper Limb
Table 2.3: Differences between metacarpals and meta- 3rd i. The styloid process is dorsolateral.
tarsals ii. The lateral side of the base bears an articular
Metacarpal Metatarsal strip which is constricted in the middle.
1. The head and shaft are 1. The head and shaft are iii. The medial side of the base has two small oval
prismoid flattened from side-to-side facets for the 4th metacarpal.
2. The shaft is of uniform 2. The shaft tapers distally 4th i. The lateral side of the base has two small oval
thickness facets for the 3rd metacarpal.
1

3. The dorsal surface of 3. The dorsal surface of

ii. The medial side of the base has an elongated
Section

the shaft has an elongated, the shaft is uniformly

articular strip for the 5th metacarpal.
flat triangular area convex 5th i. The lateral side of the base has an elongated
articular strip for the 4th metacarpal.
4. The base is irregular 4. The base appears to be
ii. The medial side of the base is non-articular and
cut sharply and obliquely
has a tubercle.
 UPPER LIMB
30
Upper Limb
1
Section

Figs 2.32b and c: Attachments on the skeleton of hand: (b) Anterior aspect, and (c) posterior aspect
 BONES
31

Main Attachments of Metacarpals CLINICAL ANATOMY

The main attachments from shaft of metacarpals are of
palmar and dorsal interossei muscles. Palmar interossei • Fracture of the base of the first metacarpal is called
arise from one bone each except the 3rd metacarpal Bennett’s fracture. It involves the anterior part of
(Fig. 2.32b). Dorsal interossei arise from adjacent sides the base, and is caused by a force along its long
of two metacarpals (Fig. 2.32c). The other attachments axis. The thumb is forced into a semiflexed
are listed below. position and cannot be opposed. The fist cannot
1st a. The opponens pollicis is inserted on the radial be clenched (Fig. 2.33).
border and the anterolateral surface of the shaft • The other metacarpals may also be fractured by
(Fig. 2.32b). direct or indirect violence. Direct violence usually
b. The abductor pollicis longus is inserted on the displaces the fractured segment forwards. Indirect
lateral side of the base. violence displaces them backwards (Fig. 2.34).
c. The first palmar interosseous muscle arises
from the ulnar side of the base.
2nd a. The flexor carpi radialis is inserted on a tubercle
on the palmar surface of the base (Fig. 2.32b).
b. The extensor carpi radialis longus is inserted
on the dorsal surface of the base (Fig. 2.32c).
c. The oblique head of the adductor pollicis arises
from the palmar surface of the base.
3rd a. A slip from the flexor carpi radialis is inserted
on the palmar surface of the base.
b. The extensor carpi radialis brevis is inserted on
the dorsal surface of the base, immediately
beyond the styloid process.
c. The oblique head of the adductor pollicis arises
from the palmar surface of the base (Fig. 2.32b).
d. The transverse head of the adductor pollicis
arises from the distal two-thirds of the palmar
surface of the shaft (Fig. 2.32b)
4th Only the interossei arise from it (Figs 2.32b and c).
5th a. The extensor carpi ulnaris is inserted on the
tubercle at the base.
b. The opponens digiti minimi is inserted on the
medial surface of the shaft (Fig. 2.32b).
Fig. 2.33: Bennett’s fracture
Articulations at the Bases
1st : With the trapezium forms saddle-shaped joint.
2nd : With the trapezium, the trapezoid, the capitate
and the 3rd metacarpal (Fig. 2.32b and c).

Upper Limb
3rd : With the capitate and the 2nd and 4th
metacarpals.
4th : With the capitate, the hamate and the 3rd and
5th metacarpals.
5th : With the hamate and the 4th metacarpal.

OSSIFICATION

• The shafts ossify from one primary centre each,

1

which appears during the 9th week of development.

• A secondary centre for the head appears in the
Section

2nd–5th metacarpals, and for the base in the

1st metacarpal. It appears during the 2nd–3rd year Fig. 2.34: Fracture through the neck of metacarpal (usually
and fuses with the shaft at about 16–18 years angulated)
(Fig. 2.29).
 UPPER LIMB
32

• Tubercular or syphilitic disease of the metacarpals Head

or phalanges in a child is located in the middle of In the proximal and middle phalanges, the head has a
the diaphysis rather than in the metaphysis because pulley-shaped articular surface. In the distal phalanges,
the nutrient artery breaks up into a plexus the head is non-articular, and is marked anteriorly by
immediately upon reaching the medullary cavity. a rough horseshoe-shaped tuberosity which supports
In adults, however, the chances of infection the sensitive pulp of the finger/tip.
are minimised because the nutrient artery is replaced
(as the major source of supply) by periosteal vessels. Attachments
• When the thumb possesses three phalanges, the 1 Base of the distal phalanx
first metacarpal has two epiphyses one at each a. The flexor digitorum profundus is inserted on the
end. Occasionally, the first metacarpal bifurcates palmar surface (Fig. 2.32b).
distally. Then the medial branch has no distal b. Two-side slips of digital expansion fuse to be inserted
epiphysis, and has only two phalanges. The lateral on the dorsal surface. These also extend the
branch has a distal epiphysis and three phalanges insertion of lumbrical and interossei muscles
(Fig. 2.35). Total digits are six in such case (Fig. 2.32c).
(polydactyly).
2 The middle phalanx
a. The two slips of flexor digitorum superficialis are
inserted on each side of the shaft (Fig. 2.32b).
b. The fibrous flexor sheath is also attached to the
side of the shaft.
c. A major part of the extensor digitorum is inserted
on the dorsal surface of the base through dorsal
digital expansion (Fig. 2.32c).
3 The proximal phalanx
a. The fibrous flexor sheath is attached to the sides
of the shaft.
b. On each side of the base, parts of the lumbricals
and interossei are inserted.
4 In the thumb, the base of the proximal phalanx
provides attachments to the following structures
(Fig. 2.32b).
a. The abductor pollicis brevis and flexor pollicis
brevis are inserted on the lateral side.
Fig. 2.35: Six digits (polydactyly)
b. The adductor pollicis and the first palmar
interosseous are inserted on the medial side.
PHALANGES c. The extensor pollicis brevis is inserted on the
dorsal surface (Fig. 2.32c).
There are 14 phalanges in each hand, three for each
Upper Limb

5 In the little finger, the medial side of the base of the

finger and two for the thumb. Each phalanx has a base, proximal phalanx provides insertion to the abductor
a shaft and a head. digiti minimi and the flexor digiti minimi (Fig. 2.32b).
Base
OSSIFICATION
In the proximal phalanx, the base is marked by a
concave oval facet for articulation with the head of the • The shaft of each phalanx ossifies from a primary
metacarpal bone. In the middle phalanx, or a distal centre which appears during the 8th week of
phalanx, it is marked by two small concave facets development in the distal phalanx, 10th week in the
1

separated by a smooth ridge. proximal phalanx and 12th week in the middle
phalanx.
Section

Shaft • The secondary centre appears for the base during

The shaft tapers towards the head. The dorsal surface is 2–4 years and fuses with the shaft during 15–18
convex from side-to-side. The palmar surface is flattened years (Fig. 2.29).
from side-to-side, but is gently concave in its long axis.
 BONES
33

CLINICAL ANATOMY – Scaphoid

– Lunate
Fracture of distal phalanx of middle finger is – Triquetral
commonest. It is treated by splinting the injured – Pisiform
phalanx to the adjacent normal finger. This is called Distal row
‘buddy splint’. Figure 2.36 shows buddy splint of – Trapezium
the fingers. – Trapezoid
– Capitate
– Hamate
Elbow
Which side has common flexor origin
FM (as in FM Radio)
Flexor medial, so common flexor origin is on the medial side.
Bicipital groove of humerus “Lady between 2 majors”
Lateral lip—pectoralis major
Medial lip—teres major
Floor—latissimus dorsi
Arm Fracture: nerves affected by humerus fracture
ARM fracture:
From superior to inferior:
Axillary—neck of humerus
Radial—mid-shaft
Ulnar—behind medial epicondyle

Fig. 2.36: Buddy splint of the fingers FACTS TO REMEMBER

• Axillary, radial and ulnar nerves are intimately
related to humerus and are liable to be injured.
SESAMOID BONES • Radial pulse is felt close to the lower end of shaft
of radius.
Sesamoid bones (Latin sesum, seed-like) are small • Pisiform bone is a sesamoid bone in the tendon of
rounded masses of bones located in some tendons at flexor carpi ulnaris muscle.
points where they are subjected to great pressure. They • First metacarpal is the shortest, and strongest of
are variable in their occurrence. These are as follows. metacarpals. It is situated at an angle to the other
1 The pisiform is often regarded as a sesamoid bone bones, thus permitting opposition of the thumb.
lying within the tendon of the flexor carpi ulnaris. • Third metacarpal is the longest and the axis of
2 Two sesamoid bones are always found on the palmar abduction and adduction passes through its centre.
surface of the head of the first metacarpal bone.
3 One sesamoid bone is found in the capsule of the
interphalangeal joint of the thumb, in 75% of subjects. CLINICOANATOMICAL PROBLEM

Upper Limb
4 One sesamoid bone is found on the ulnar side of the A 50-year-old man fell off his bicycle. He heard a
capsule of the metacarpophalangeal joint of the little cracking noise and felt severe pain in his right
finger, in about 75% of subjects. shoulder region. He noted that the lateral part of the
5 Less frequently, there is a sesamoid bone on the shoulder drooped and medial end of clavicle was
lateral side of the metacarpophalangeal joint of the elevated.
index finger. • Which is the common site of fracture of clavicle
6 Sometimes sesamoid bone may be found at other and why?
metacarpophalangeal joints. • Why did his shoulder droop down?
1

Ans: The clavicle gets fractured at the junction of

Mnemonics medial two-thirds and lateral one-third. This is the
Section

weak point as it lies at the junction of two opposing

Carpal bones curvatures.
“She Looks Too Pretty, Try To Catch Her” The shoulder drooped down, because of the
Lateral to medial, proximal row weight of the unsupported shoulder.
 UPPER LIMB
34

FURTHER READING
• Boileau P, Walch G. The three-dimensional geometry of the • Oehmke MJ, Podranski T, Klaus R, et al. The blood supply
proximal humerus. Implication for surgical technique and of the scaphoid bone. J Hand Surg 2009;34E:351–57.
prosthetic design. J Bone Joint Surg br 1997;79:857–65. An anatomical study of 12 cadaver hands which demonstrates a
The seminal European publication that introduced the science of variety of vascular anastomoses around the scaphoid. It notes that
measurement to the understanding of the morphology of the proximal a dorsal approach to the scaphoid bone is possible as there is an
humerus, and from which all subsequent work takes its lead. available blood supply from the palmar circulation.

1–7
From Medical Council of India, Competency based Undergraduate Curriculum for the Indian Medical Graduate, 2018;1:44–80.

1. Name the muscles attached to greater and lesser 4. Name the muscles arising from the aponeurosis
tubercles of humerus. attached to the posterior border of ulna.
2. Name the muscles attached to medial border of 5. Name the attachment of deltoid and trapezius on
scapula on the dorsal and costal surfaces. the clavicle.
3. Name the tendons present on the posterior surface 6. Name the attachment of flexor digitorum
of lower end of radius. superficialis and flexor digitorum profundus
muscles on the phalanges.

1. Which of the following bones is the first one to start c. Shaft of humerus
ossification? d. Radial tuberosity
a. Ulna b. Scapula 4. All the following muscles are flexors of the wrist, except:
c. Clavicle d. Humerus a. Flexor carpi b. Flexor digitorum
2. Fracture of humerus at midshaft is likely to cause radialis superficialis
injury to which of the following nerves? c. Pronator teres d. Flexor carpi ulnaris
a. Median b. Radial 5. The axis of abduction/adduction of digits passes
through centre of which digit?
c. Ulnar d. Musculocutaneous
a. 2nd b. 3rd
3. Attachments of biceps brachii are to all of the c. 4th d. 5th
following, except:
a. Tip of coracoid process 6. All are heads of triceps brachii, except:
b. Supraglenoid tubercle a. Long head b. Short head
c. Lateral head d. Medial head
Upper Limb

1. c 2. b 3. c 4. c 5. b 6. b
1

CLAVICLE • Which is the common site of fracture of clavicle and

why?
Section

• Enumerate the peculiarities of the clavicle.

• What is cleidocranial dysostosis?
• What type of joint is sternoclavicular joint?
• What fascia is attached to the margins of subclavian SCAPULA
groove? • What type of muscle is subscapularis?
 BONES
35

• Name the muscle attached to medial border of costal • Mark the attachment of anconeus muscle. What is
surface of scapula. its action?
• Name the muscles attached to coracoid process of • What tendon passes through the gap between head
scapula. and styloid process of ulna?
• Enumerate the arteries related to all three borders of • How does Madelung’s deformity occur?
scapula.
CARPUS
• What nerve lies deep to transverse ligament/
suprascapular ligament? Name the muscles supplied • Name the carpal bones in order.
by this nerve. • What type of bone is pisiform? Name other bones of
• What is ‘winging’ of the scapula? the same type.
• Name the tendon traversing through the groove on
HUMERUS trapezium. Where is its insertion?
• Name the muscles attached to greater tubercle of • Name the attachments of the flexor retinaculum.
humerus. Which nerves innervate these muscles? • Name the structures passing deep to the flexor
• What muscle is attached to lateral lip of bicipital retinaculum.
groove of humerus? Show its actions. • What is carpal tunnel syndrome?
• Mark the attachments of two heads of biceps brachii • Where is the pain of scaphoid fracture felt?
muscle. Show its actions. • What leads to avascular necrosis of the scaphoid?
• Show the position of important nerves related to the
humerus. METACARPUS
• Name the muscles attached to lateral supracondylar • Name the peculiarities of 1st metacarpal bone.
ridge of humerus. • Where are the sesamoid bones placed in relation to
• What muscle arises from the front of lower part of the metacarpal bone?
humerus? Name the nerves supplying this muscle. • Which metacarpal does not give attachment to
• What leads to Volkmann’s ischaemic contracture? palmar interosseous? Which is smallest palmar
interosseous?
RADIUS • Where is the attachment of opponens pollcis muscle?
• Where is the insertion of biceps brachii muscle. Show What is its action?
its actions? • Which muscle is attached to the palmar surface of
• What muscle arises from anterior surface of radius? shaft of 3rd metacarpal?
What type of muscle is it according to arrangement • How does one distinguish the metacarpals from the
of its muscle fibres? metatarsals?
• Where is radial pulse felt in relation to radius? • What is ‘Bennett’s fracture’?
• Name the tendons on the dorsal surface of radius. • What is polydactyly?
• Which border of radius gives attachment to • What is the importance of 3rd metacarpal?
interosseous membrane? Name the functions of this
Upper Limb
membrane. PHALANGES
• Name the carpal bones which articulate with distal • Which muscle is inserted into the palmar surface of
end of radius. base of distal phalanx?
• What is Colles’ fracture? • Slips of which expansion are attached into the dorsal
• What causes the ‘pulled elbow’? surface of base of distal phalanx?
• Slips of which muscle are attached on each side of
ULNA the shaft of middle phalanx?
• Slip of which muscle is attached do the dorsal surface
1

• How many joints are formed between radius and

ulna? What are the types of these joints? of base of middle phalanx?
Section

• Which muscle is attached to maximum area of ulna? • Name the muscles attached on each side of the base
What type of muscle is it according to its nerve of proximal phalanx.
supply? • What is buddy splint?
 UPPER LIMB
36

3
Pectoral Region
!Who ever thought of the word “Mammogram?”. Every time I hear it, I think‘
I’m supposed to put my breast in an envelope and send it to someone’ !
—Jan Kingz

INTRODUCTION
The pectoral region lies on the front of the chest. It
essentially consists of structures which connect the
upper limb to the anterolateral chest wall. Breast lies
in this region.

Competency achievement: The student should be able to:

AN 13.6 Identify and demonstrate important bony landmarks of
upper limb: Jugular notch, sternal angle, acromial angle, spine of
the scapula, vertebral level of the medial end, inferior angle of the
scapula.1

SURFACE LANDMARKS

The following features of the pectoral region can be seen

or felt on the surface of body.
1 The clavicle lies horizontally at the root of the neck,
separating it from the front of the chest. The bone is
subcutaneous, and therefore, palpable throughout its
length. Medially, it articulates with the sternum at the
sternoclavicular joint, and laterally with the acromion Fig. 3.1: Surface landmarks: Shoulder, axilla, arm and elbow
Upper Limb

process at the acromioclavicular joint. Both the joints regions (anterior aspect)
are palpable because of the upward projecting ends
of the clavicle (Fig. 3.1). The sternoclavicular joint may 4 The epigastric fossa (pit of the stomach) is the
be masked by the sternocleidomastoid muscle. depression in the infrasternal angle. The fossa
2 The jugular notch (interclavicular or suprasternal overlies the xiphoid process, and is bounded on each
notch) lies between the medial ends of the clavicles, side by the seventh costal cartilage.
at the superior border of the manubrium sterni. 5 The nipple is markedly variable in position in
3 The sternal angle (angle of Louis) is felt as a females. In males, and in immature females, it
transverse ridge about 5 cm below the jugular notch usually lies in the fourth intercostal space just
1

(Fig. 3.1). It marks the manubriosternal joint. medial to the midclavicular line; or 10 cm from the
Section

Laterally, on either side, the second costal cartilage midsternal line. In fact, the position of the nipple is
joins the sternum at this level. The sternal angle thus variable even in males.
serves as a landmark for identification of the second 6 The midclavicular line passes vertically through the
rib. Other ribs can be identified by counting middle of clavicle, the tip of the ninth costal cartilage
downwards from the second rib. and the midinguinal point.
36
 PECTORAL REGION
37

7 The infraclavicular fossa (deltopectoral triangle) is a

triangular depression below the junction of the
lateral and middle thirds of the clavicle. It is
bounded medially by the pectoralis major, laterally
by the anterior fibres of the deltoid, and superiorly
by the clavicle.
8 The tip of the coracoid process of the scapula lies
2–3 cm below the clavicle, overlapped by the
anterior fibres of the deltoid. It can be felt on deep
palpation just lateral to the infraclavicular fossa.
9 The acromion process of the scapula (acron = summit;
omos = shoulder) is a flattened piece of bone that
lies subcutaneously forming the top of the shoulder.
The posterior end of its lateral border is called the
acromial angle, where it is continuous with the lower
lip of the crest of the spine of the scapula. The
anterior end of its medial border articulates with
the clavicle at the acromioclavicular joint.
10 The deltoid is triangular muscle with its apex directed
downwards. It forms the rounded contour of the
shoulder, extending vertically from the acromion
process to the deltoid tuberosity of the humerus.
Fig. 3.2: Points and lines of incision
11 The axilla (Latin armpit) is a pyramidal space
between the arm and chest. When the arm is raised
(abducted), the floor of the axilla rises, the anterior upward and laterally till you reach to the third point on
and posterior folds stand out, and the space becomes the areolar margin.
more prominent. The anterior axillary fold contains Encircle the areola and carry the incision upwards
the lower border of the pectoralis major, and posterior and laterally till the anterior axillary fold is reached.
axillary fold contains the tendon of the latissimus dorsi Continue the line of incision downwards along the
winding round the fleshy teres major. medial border of the upper arm till its junction of upper
The medial wall of the axilla is formed by the upper one-third and lower two-thirds. Extend this incision
4 ribs covered by the serratus anterior. The narrow transversely across the arm (refer to BDC App).
lateral wall presents the upper part of the humerus Make another incision horizontally from the xiphoid
covered by the short head of the biceps, and the process across the chest wall till the posterior axillary fold.
coracobrachialis. Axillary arterial pulsations can be Lastly, give horizontal incision from the centre of supra-
felt by pressing the artery against the humerus. The sternal notch to the lateral (acromial) end of the clavicle.
cords of the brachial plexus can also be rolled against Reflect the two flaps of skin towards the upper limb.
the humerus. The head of the humerus can be felt
by pressing the fingers upwards into the axilla.
12 The midaxillary line is a vertical line drawn midway SUPERFICIAL FASCIA

Upper Limb
between the anterior and posterior axillary folds.
The superficial fascia (Latin a band) of the pectoral
DISSECTION region is visualised after the skin has been incised. It
Mark the following points. contains moderate amount of fat, and is continuous
i. Centre of the suprasternal notch with that of surrounding regions. The breast, which is
ii. Xiphoid process
well developed in females, is the most important of all
contents of this fascia. The fibrous septa given off by
iii. 7 o’clock position at the margin of areola (left
the fascia support the lobes of the gland, and the skin
side), and 5 o’clock position at the margin of
covering the gland.
1

areola (right side)

iv. Lateral end of clavicle (Fig. 3.2). Contents
Section

Give an incision vertically down from the first point In addition to fat, the superficial fascia of the pectoral
to the second which joins the centre of the suprasternal region contains the following.
notch to the xiphoid process in the midsagittal plane. i. Cutaneous nerves derived from the cervical plexus
From the lower end of this line, extend the incision and from the intercostal nerves.
 UPPER LIMB
38

ii. Cutaneous branches from the internal thoracic and 1 The medial, intermediate and lateral supraclavicular
posterior intercostal arteries. nerves are branches of the cervical plexus (C3, C4).
iii. The platysma (Greek broad). They supply the skin over the upper half of the
iv. The breast. deltoid and from the clavicle down to the second rib.
2 The anterior and lateral cutaneous branches of the
Cutaneous Nerves of the Pectoral Region second to sixth intercostal nerves supply the skin
The cutaneous nerves of the pectoral (Latin pectus, below the level of the second rib. The inter-
chest) region are as follows (Figs 3.3 and 3.4). costobrachial nerve of T2 supplies the skin of the
floor of the axilla and the upper half of the medial
side of the arm (Fig. 3.3).
It is of interest to note that the area supplied by spinal
nerves C3 and C4 directly meets the area supplied by
spinal nerves T2 and T3. This is because of the fact that
the intervening nerves (C5–C8 and T1) have been
‘pulled away’ to supply the upper limb. It may also be
noted that normally the areas supplied by adjoining
spinal nerves overlap, but because of what has been said
above there is hardly any overlap between the areas
supplied by C3 and C4 above and T2 and T3 below
(Fig. 3.4).

Cutaneous Vessels
The cutaneous vessels are very small. The anterior
cutaneous nerves are accompanied by the perforating
branches of the internal thoracic artery. The second, third
and fourth of these branches are large in females for
supplying the breast. The lateral cutaneous nerves are
accompanied by the lateral cutaneous branches of the
posterior intercostal arteries (Fig. 3.8).
Fig. 3.3: Cutaneous nerves of the pectoral region
Platysma
The platysma (Greek broad) is a thin, broad sheet of
subcutaneous muscle. The fibres of the muscle arise
from the deep fascia covering the pectoralis major; run
upwards and medially, crossing the clavicle and the
side of the neck; and are inserted into the base of the
mandible, and into skin over the posterior and lower
part of the face. The platysma is supplied by a branch
of the facial nerve. When the angle of the mouth is pulled
Upper Limb

down, the muscle contracts and wrinkles the skin of

the neck. The platysma may protect the external jugular
vein (which underlies the muscle) from external
pressure.

Competency achievement: The student should be able to:

AN 9.2 Describe the location, extent, deep relations, structure, age
changes, blood supply, lymphatic drainage, microanatomy and
applied anatomy of breast.2
1
Section

BREAST

Fig. 3.4: Areas supplied by cutaneous nerves of the pectoral The breast is the most important structure present in
region the pectoral region.
 PECTORAL REGION
39

The breast is found in both sexes, but is rudimentary

in the male. It is well developed in the female after
puberty. It forms an important accessory organ of the
female reproductive system, and provides nutrition to
the newborn in the form of milk. Its shape may be
hemispherical, conical, pyriform, pendulous or flat.

Situation
The breast lies in the superficial fascia of the pectoral
region. It is divided into four quadrants, i.e. upper
medial, upper lateral, lower medial and lower lateral.
A small extension of the upper lateral quadrant, called
the axillary tail of Spence, passes through an opening in
the deep fascia and lies in the axilla (Fig. 3.5). The
opening is called foramen of Langer. Its base is circular.

Extent of the Base

i. Vertically, it extends from the second to the sixth Fig. 3.5: Extent of the breast
ribs.
ii. Horizontally, it extends from the lateral border of 3 The breast is separated from the pectoral fascia by
the sternum to the midaxillary line. loose areolar tissue, called the retromammary space.
Because of the presence of this loose tissue, the
Deep Relations normal breast can be moved freely over the pectoralis
The deep surface of the breast is related to the following major.
structures in that order (Fig. 3.6).
1 The breast lies on the deep fascia (pectoral fascia) Structure of the Breast
covering the pectoralis major. The structure of the breast may be conveniently studied
2 Still deeper there are the parts of three muscles, by dividing it into the skin, the parenchyma, and the
namely the pectoralis major, the serratus anterior, and stroma. The parenchyma is known as the mammary
the external oblique muscle of the abdomen. gland.

Upper Limb
1Section

Figs 3.6a and b: (a) Axillary tail and the four quadrants of breast, and (b) the muscles situated deep to the breast
 UPPER LIMB
40

Skin Stroma
It covers the gland and presents the following features. It forms the supporting framework of the gland. It is
1 A conical projection, called the nipple, is present just partly fibrous and partly fatty.
below the centre of the breast at the level of the The fibrous stroma forms septa, known as the
fourth intercostal space 10 cm from the midline. The suspensory ligaments of Cooper, which anchor the skin
nipple is pierced by 15 to 20 lactiferous ducts. It and gland to the pectoral fascia (Fig. 3.7a).
contains circular and longitudinal smooth muscle The fatty stroma forms the main bulk of the gland. It
fibres which can make the nipple stiff or flatten it, is distributed all over the breast, except beneath the
respectively. It has a few modified sweat and areola and nipple.
sebaceous glands. It is rich in nerve supply and has Blood Supply
many sensory end organs at the termination of
nerve fibres. The mammary gland is extremely vascular. It is
supplied by branches of the following arteries (Fig. 3.8).
2 The skin surrounding the base of the nipple is
1 Internal thoracic artery, a branch of the subclavian
pigmented and forms a circular area called the areola.
artery, through its perforating branches.
This region is rich in modified sebaceous glands,
2 The lateral thoracic, superior thoracic and acromio-
particularly at its outer margin. These become
thoracic (thoracoacromial) branches of the axillary
enlarged during pregnancy and lactation to form
artery.
raised tubercles of Montgomery. Oily secretions of these 3 Lateral branches of the posterior intercostal arteries.
glands lubricate the nipple and areola, and prevent The arteries converge on the breast and are distri-
them from cracking during lactation. Apart from buted from the anterior surface. The posterior surface
sebaceous glands, the areola also contains some is relatively avascular.
sweat glands, and accessory mammary glands. The The veins follow the arteries. They first converge
skin of the areola and nipple is devoid of hair, and towards the base of the nipple where they form an
there is no fat subjacent to it. Below the areola lie anastomotic venous circle, from where veins run in
lactiferous sinus where stored milk is seen. superficial and deep sets.
1 The superficial veins drain into the internal thoracic
Parenchyma (Mammary Gland) vein and into the superficial veins of the lower part
Mammary gland is a compound tubuloalveolar gland of the neck.
which secretes milk. As it lies in superficial fascia, there 2 The deep veins drain into the axillary and posterior
is no capsule. Mammary gland is a modified sweat intercostal veins.
gland. The gland consists of 15 to 20 lobes. Each lobe is
a cluster of alveoli, and is drained by a lactiferous duct. Nerve Supply
The lactiferous ducts converge towards the nipple and The breast is supplied by the anterior and lateral
open on it. Near its termination, each duct has a cutaneous branches of the 4th to 6th intercostal nerves.
dilatation called a lactiferous sinus (Figs 3.7a and b). The nerves convey sensory fibres to the skin, and
Upper Limb
1
Section

Figs 3.7a and b: (a) Suspensory ligaments of the breast and its lobes, and (b) structure of one lobe of the mammary gland
 PECTORAL REGION
41

Fig. 3.8: Arterial supply of the breast Fig. 3.9: Lymph nodes draining the breast. Radial incision is
shown to drain breast abscess
autonomic fibres to smooth muscle and to blood vessels.
The nerves do not control the secretion of milk. Lymphatic Vessels
Secretion is controlled by the hormone prolactin, 1 The superficial lymphatics drain the skin over the
secreted by the pars anterior of the hypophysis cerebri. breast except for the nipple and areola. The
The diagnosis and management of breast disease lymphatics pass radially to the surrounding lymph
should be done carefully. nodes (axillary, anterior thoracic, supraclavicular
and cephalic).
Competency achievement: The student should be able to:
2 The deep lymphatics drain the parenchyma of the breast.
AN 10.4 Describe the anatomical groups of axillary lymph nodes They also drain the nipple and areola (Fig. 3.11).
and specify their areas of drainage.3
Some further points of interest about the lymphatic
AN 10.7 Explain anatomical basis of enlarged axillary lymph nodes.4
drainage are as follows.
Lymphatic Drainage
1 About 75% of the lymph from the breast drains into
the axillary nodes; 20% into the anterior thoracic
Lymphatic drainage of the breast assumes great
importance to the surgeon because carcinoma of the
breast spreads mostly along lymphatics to the regional
lymph nodes. The subject can be described under two
heads—the lymph nodes, and the lymphatic vessels.
Lymph Nodes

Upper Limb
Groups of lymph nodes are shown in Fig. 3.9.
Lymph from the breast drains into the following
lymph nodes (Fig. 3.9).
1 The axillary lymph nodes, chiefly the anterior (or
pectoral) group. The posterior, lateral, central and
apical groups of nodes also receive lymph from
the breast either directly or indirectly.
2 The anterior thoracic (parasternal) nodes which
lie along the internal mammary (thoracic) vessels
1

(Fig. 3.10).
Section

3 Some lymph from the breast also reaches the

supraclavicular nodes, the cephalic (deltopectoral)
node, the posterior intercostal nodes (lying in front
of the heads of the ribs), the subdiaphragmatic and Fig. 3.10: The routes of lymph from the breast. The arrows show
subperitoneal lymph plexuses. the direction of lymph flow
 UPPER LIMB
42

clavipectoral fascia to reach the apical nodes, and also

to the anterior thoracic nodes (Fig. 3.12).
5 Lymphatics from the lower and inner quadrants of
the breast may communicate with the subdiaphrag-
matic and subperitoneal lymph plexuses after
crossing the costal margin and then piercing the
anterior abdominal wall through the upper part of
the linea alba.
6 Anterior and central groups of nodes are commonly
involved in carcinoma breast.
Fig. 3.11: Subareolar lymph plexus of Sappey
Competency achievement: The student should be able to:
AN 9.3 Describe development of the breast.5
nodes; and 5% into the posterior intercostal nodes.
Among the axillary nodes, the lymphatics end mostly
Development of the Breast
in the anterior group (closely related to the axillary
tail), and partly in the posterior and apical groups. 1 The breast develops from an ectodermal thickening,
Lymph from the anterior and posterior groups passes called the mammary ridge, milk line, or line of Schultz
to the central and lateral groups, and through them (Fig. 3.13). This ridge extends from the axilla to the
to the apical group. Finally, it reaches the supra- groin. It appears during the fourth week of
clavicular nodes. intrauterine life, but in human beings, it disappears
2 The anterior thoracic nodes drain the lymph not only over most of its extent persisting only in the pectoral
from the inner half of the breast, but from the outer region. The gland is ectodermal, and the stroma
half as well. mesodermal in origin.
3 A plexus of lymph vessels is present deep to the 2 The persisting part of the mammary ridge is
areola. This is the subareolar plexus of Sappey converted into a mammary pit. Secondary buds
(Fig. 3.11). Subareolar plexus and most of lymph (15–20) grow down from the floor of the pit. These
from the gland drain into the anterior or pectoral buds divide and subdivide to form the lobes of the
group of lymph nodes. gland. The entire system is first solid, but is later
4 The lymphatics from the deep surface of the gland canalised. At birth or later, the nipple is everted at
pass through the pectoralis major muscle and the the site of the original pit.
Upper Limb
1
Section

Figs 3.12a and b: (a) Deep lymphatics of the breast passing to the apical lymph nodes and the structures piercing the clavipectoral
fascia, and (b) structures piercing the clavipectoral fascia. Branches of thoracoacromial artery: a—acromial, p—pectoral, c—clavicular,
d—deltoid
 PECTORAL REGION
43

Fig. 3.14: Mammary gland—resting phase

Fig. 3.13: Milk line with possible positions of accessory nipples

Lactating Phase
3 Growth of the mammary glands, at puberty, is The gland is full of acini with minimum amount of
caused by oestrogens. Apart from oestrogens, connective tissue. Some acini are lined by tall columnar
development of secretory alveoli is stimulated by cells, others by normal columnar cells. The nucleus may
progesterone and by the prolactin hormone of the be round or oval and is seen in the middle of the cell
hypophysis cerebri. (Fig. 3.15). Droplets of fat accumulate near the free
4 Developmental anomalies of the breast are: surface of the cell. Myoepithelial cells may be seen
a. Amastia (absence of the breast), between the basement membrane and secretory cells.
b. Athelia (absence of nipple), Ducts are also seen, but they are fewer in number as
compared to the acini. The bigger ducts are lined by
c. Polymastia (supernumerary breasts),
stratified columnar or columnar epithelium.
d. Polythelia (supernumerary nipples),
e. Gynaecomastia (development of breasts in a male)
which occurs in Klinefelter’s syndrome.

Histology of Breast
The mammary glands are specialised accessory glands
of the skin, which have evolved in mammals to provide
nourishment to the young ones. Mammary gland
consists of 15–20 lobes with the same number of ducts.
Each lobe is made up of many lobules containing acini.

Upper Limb
Histologically, only lobules are discernible in the gland.
Resting Phase in Non-Pregnant Adult Female
The mammary gland in this phase consists mainly of
ducts and their branches (Fig. 3.14). The stroma has
connective tissue and fat cells.
The intralobular ducts are usually lined by low
columnar epithelium resting on a basement membrane. Fig. 3.15: Mammary gland—lactating phase
The intralobular connective tissue which is derived
1

from the papillary layer of the dermis is more cellular,

CLINICAL ANATOMY
Section

containing fibroblasts.
The interlobular connective tissue, which lies
The upper and outer quadrant of breast is a frequent
between the ducts of adjacent lobules, is derived from
site of carcinoma (cancer). The first lymph node
the reticular layer of the dermis, and is more
draining the tumour-bearing area is called ‘sentinal
fibroreticular in nature. It contains fat lobules.
 UPPER LIMB
44

node.’ Abscesses may also form in the breast and c. Retraction of nipple is a sign of cancer.
may require drainage. The following facts are worthy d. Discharge from nipple on squeezing it.
of note. e. Palpate all four quadrants with palm of hand.
• Incisions of breast are usually made radially to Note any palpable lump.
avoid cutting the lactiferous ducts (Fig. 3.9). f. Raise the arm to feel lymph nodes in axilla.
• Cancer cells may infiltrate the suspensory • Mammogram may reveal cancerous mass
ligaments. The breast then becomes fixed. (Fig. 3.19).
Contraction of the ligaments can cause retraction • Fine needle aspiration cytology is safe and quick
or puckering (folding) of the skin. method of diagnosis of lesion of breast.
• Infiltration of lactiferous ducts and their consequent
fibrosis can cause retraction of the nipple.
• Obstruction of superficial lymph vessels by cancer
cells may produce oedema of the skin giving rise
to an appearance like that of the skin of an orange
(peau d’orange appearance) (Fig. 3.16).
• Because of communications of the superficial
lymphatics of the breast across the midline, cancer
may spread from one breast to the other (Fig. 3.17).
• Because of communications of the lymph vessels
with those in the abdomen, cancer of the breast
may spread to the liver, and cancer cells may
‘drop’ into the pelvis producing secondaries there
(Fig. 3.17).
• Apart from the lymphatics, cancer may spread
through the segmental veins. In this connection,
it is important to know that the veins draining the
breast communicate with the vertebral venous
plexus of veins. Through these communications,
cancer can spread to the vertebrae and to the brain
(Fig. 3.18).
• Carcinoma usually arises from epithelium of large
ducts.
• Self-examination of breasts:
a. Inspect: Symmetry of breasts and nipples.
b. Change in colour of skin. Fig. 3.17: Lymphatic spread of breast cancer
Upper Limb
1
Section

Fig. 3.16: Peau d’orange appearance Fig. 3.18: Vertebral system of veins
 PECTORAL REGION
45

DEEP FASCIA

The deep fascia covering the pectoralis major muscle is

called the pectoral fascia. It is thin and closely attached
to the muscle by numerous septa passing between the
fasciculi of the muscle. It is attached superiorly to the
clavicle, and anteriorly to the sternum. Superolaterally, it
passes over the infraclavicular fossa and deltopectoral
groove to become continuous with the fascia covering
the deltoid. Inferolaterally, the fascia curves round the
inferolateral border of the pectoralis major to become
continuous with the axillary fascia. Inferiorly, it is
continuous with the fascia over the thorax and the rectus
sheath.

Fig. 3.19: Mammogram showing cancerous lesion Competency achievement: The student should be able to:
AN 9.1 Describe attachment, nerve supply and action of pectoralis
major and pectoralis minor.6
• Retracted nipple is a sign of tumour in the breast.
• Size of mammary gland can be increased by
putting an implant inside the gland. The size can MUSCLES OF THE PECTORAL REGION
be reduced by breast reduction surgery.
• Cancer of the mammary glands is the most Introduction
common cancer in females of all ages. It is more Muscles of the pectoral region are described in
frequently seen in postmenopausal females due Tables 3.1 and 3.2, study them on the articulated
to lack of oestrogen hormones. skeleton. Some additional features are given below.
• Self-examination of the mammary gland is the only
way for early diagnosis and appropriate treatment. Pectoralis Major
• Mastectomy is the medical term for the surgical
removal of one or both breasts, partially or Structures under Cover of Pectoralis Major
completely. A mastectomy is usually carried out a. Bones and cartilages: Sternum, costal cartilages and ribs.
to treat breast cancer. Lumpectomy is the removal b. Fascia: Clavipectoral.
of only the tumour. c. Muscles: Subclavius, pectoralis minor, serratus
• Radical mastectomy is a surgical procedure anterior, intercostals and upper parts of the biceps
involving the removal of breast, underlying brachii and coracobrachialis.
pectoral muscles and lymph nodes of the axilla as d. Vessels: Axillary.
a treatment for advanced breast cancer. e. Nerves: Cords of brachial plexus with their branches.

Table 3.1: Muscles of the pectoral region

Upper Limb
Muscle Origin Insertion
Pectoralis major • Anterior surface of medial two-thirds of clavicle It is inserted by a bilaminar tendon on the
(Fig. 3.20) • Half the breadth of anterior surface of manubrium and lateral lip of the bicipital groove in form of
sternum up to 6th costal cartilages ‘U’
• Second to sixth costal cartilages, sternal end of 6th rib The two laminae are continuous with each
• Aponeurosis of the external oblique muscle of abdomen other inferiorly
The anterior lamina is thicker and shorter
than the thinner and longer posterior lamina.
Anterior lamina receives superficial clavicular
1

and deep manubrial fibres; posterior lamina

gets costal, sternal and aponeurotic fibres
Section

Pectoralis minor • 3, 4, 5 ribs, near the costochondral junction Medial border and upper surface of the
(Fig. 3.21) • Intervening fascia covering external intercostal muscles coracoid process
Subclavius First rib at the costochondral junction Subclavian groove in the middle one-third
(Fig. 3.21) of the clavicle
 UPPER LIMB
46

Figs 3.20a and b: (a) The origin and insertion of the pectoralis major muscle, and (b) the bilaminar insertion of the pectoralis
major. The anterior lamina is formed by the clavicular and manubrial fibres; the rest of the sternocostal and aponeurotic fibres form
the base and posterior lamina. Part of the posterior lamina is twisted upside down

Table 3.2: Nerve supply and actions of muscles

Muscle Nerve supply Actions
Pectoralis major Medial and lateral pectoral nerves • Acting as a whole the muscle causes: Adduction and
(Fig. 3.20) Medial pectoral reaches it after piercing medial rotation of the shoulder joint (arm)
pectoralis minor. The lateral pectoral reaches • Clavicular part produces: Flexion of the arm
the muscle by piercing clavipectoral fascia • Sternocostal part is used in
– Extension of flexed arm against resistance
Pectoralis minor Medial and lateral pectoral nerves • Draws the scapula forward (with serratus anterior)
(Fig. 3.21) (Fig. 3.22a) • Depresses the point of the shoulder
Subclavius Nerve to subclavius from upper trunk of Steadies the clavicle during movements of the shoulder
(Fig. 3.21) brachial plexus joint. Forms a cushion for axillary vessels and divisions
of trunks of brachial plexus

Bilaminar Tendon of Pectoralis Major to get inserted the highest and form a crescentic fold
The muscle is inserted by a bilaminar tendon into the which fuses with the capsule of the shoulder joint.
lateral lip of the intertubercular sulcus of the humerus.
The anterior lamina is thicker and shorter than the
Upper Limb

posterior. It receives two strata of muscle fibres:

Superficial fibres arising from the clavicle and deep
fibres arising from the manubrium (Fig. 3.20).
The posterior lamina is thinner and longer than the
anterior lamina. It is formed by fibres from the front of
the sternum, 2nd–6th costal cartilages, sternal end of
6th rib and from the aponeurosis of the external oblique
muscle of the abdomen. Out of these, only the fibres
1

from the sternum and aponeurosis are twisted around

Section

the lower border of the rest of the muscle. The twisted

fibres form the anterior axillary fold.
These fibres pass upwards and laterally to get
inserted successively higher into the posterior lamina
of the tendon. Fibres arising lowest, find an opportunity Fig. 3.21: The pectoralis minor and subclavius muscles
 PECTORAL REGION
47

Clinical Testing
i. The clavicular head is made prominent by flexing
the arm to a right angle. The sternocostal head can
be tested by extending the flexed arm against
resistance.
ii. Sternocostal head is made prominent by abducting
arm to 60° and then touching the opposite hip.
iii. Pressing the fists against each other makes the whole
muscle prominent (Fig. 3.22b).
iv. Lifting a heavy rod makes clavicular part prominent
(right arm). Depressing a heavy rod shows
sternocostal part as prominent (left arm) (Fig. 3.22c).

Clavipectoral Fascia
Clavipectoral fascia is a fibrous sheet situated deep to
the clavicular portion of the pectoralis major muscle. It
extends from the clavicle above to the axillary fascia
below (Fig. 3.23). Its upper part splits to enclose the
subclavius muscle. The posterior lamina is fused to the
investing layer of the deep cervical fascia and to the
axillary sheath. Inferiorly, the clavipectoral fascia splits
to enclose the pectoralis minor muscle (see Fig. 4.3).
Medially, it is attached to external intercostal muscle
of upper intercostal spaces and laterally to coracoid
process. Below this muscle, it continues as the
suspensory ligament which is attached to the dome of
the axillary fascia, and helps to maintain it.
The clavipectoral fascia is pierced by the following
structures.
i. Lateral pectoral nerve (Figs 3.12a and b).
ii. Cephalic vein.

Figs 3.22b and c: Pectoralis major being tested

Upper Limb
1Section

Fig. 3.22a: Nerve supply of pectorals, subclavius and serratus

anterior Fig. 3.23: Clavipectoral fascia
 UPPER LIMB
48

Figs 3.24a and b: (a) The serratus anterior; (b) schematic representation

iii. Thoracoacromial artery.

iv. Lymphatics passing from the breast and pectoral
region to the apical group of axillary lymph nodes
(Fig. 3.12a).

Competency achievement: The student should be able to:

AN 10.11 Describe and demonstrate attachment of serratus
anterior with its action.7

Serratus Anterior
Serratus anterior muscle is not strictly muscle of the
pectoral region, but it is convenient to consider it here.
It is also called boxer’s muscle/swimmer’s muscle.

Origin
Serratus anterior muscle arises by eight digitations from
the upper 8 ribs in the midaxillary plane and from the
fascia covering the intervening intercostal muscles. The
Upper Limb

first digitation appears in the posterior triangle of neck. Fig. 3.25: Horizontal section through the axilla showing the
It arises from the outer border of 1st rib and from a rough position of the serratus anterior
impression on the 2nd rib. Also 5th–8th digitations
interdigitate with the costal origin of external oblique The lower five digitations are inserted into a large
muscle of abdomen. triangular area over the inferior angle (Fig. 3.25).
Insertion Nerve Supply
All 8 digitations pass backwards around the chest wall. The nerve to the serratus anterior is a branch of the
1

The muscle is inserted into the costal surface of the brachial plexus. It arises from roots C5, C6 and C7 and
scapula along its medial border.
Section

is also called long thoracic nerve. The nerve enters

The first digitation is inserted from the superior angle through the apex of axilla behind 1st part of axillary
to the root of the spine. artery to reach the medial wall of axilla. It lies on the
The next two digitations are inserted lower down surface of the muscle (Figs 3.22a and 3.24a).
on the medial border. • C5 root supplies 1st and 2nd digitations.
 PECTORAL REGION
49

• C6 root supplies 3rd and 4th digitations.

• C7 root supplies 5th to 8th digitations. Mnemonics
Branches of any artery/nerve M-CAT
Actions
M—Muscular
1 Along with the pectoralis minor, the muscle pulls the
C—Cutaneous
scapula forwards around the chest wall to protract the
upper limb (in pushing and punching movements). A—Articular
2 The fibres inserted into the inferior angle of the T—Terminal
scapula pull it forwards and rotate the scapula so
that the glenoid cavity is turned upwards. In this
action, the serratus anterior is helped by the trapezius FACTS TO REMEMBER
which pulls the acromion process upwards and
backwards (see Fig. 10.6c). • Pectoralis major forms part of the bed for the
3 The muscle steadies the scapula during weight mammary gland. 75% of lymph from mammary
carrying. gland drains into axillary; 20% into anterior
4 It helps in forced inspiration. thoracic and 5% into posterior intercostal lymph
nodes.
Additional Features • The sternocostal head of pectoralis major causes
1 Paralysis of the serratus anterior produces ‘winging extension of the flexed arm against resistance.
of scapula’ in which the inferior angle and the medial • Pectoralis minor divides the axillary artery into
border of the scapula are unduly prominent. The three parts.
patient is unable to do any pushing action, nor can
he raise his arm above the head. Any attempt to do
these movements makes the inferior angle of the CLINICOANATOMICAL PROBLEM
scapula still more prominent.
2 Clinical testing: Forward pressure with the hands A 45-year-old woman complained of a firm painless
against a wall, or against resistance offered by the mass in the upper lateral quadrant of her left breast.
examiner, makes the medial border and the inferior The nipple was also raised. Axillary lymph nodes were
angle of the scapula prominent (winging of scapula), palpable and firm. It was diagnosed as cancer breast.
if the serratus anterior is paralysed (see Fig. 2.12). • Where does the lymph from upper lateral
quadrant drain?
DISSECTION • What causes the retraction of the nipple?
Identify the extensive pectoralis major muscle in the Ans: The lymph from the upper lateral quadrant
pectoral region and the prominent deltoid muscle on drains mainly into the pectoral group of axillary
the lateral aspect of the shoulder joint and upper arm. lymph nodes. The lymphatics also drain into
Demarcate the deltopectoral groove by removing the supraclavicular and infraclavicular lymph nodes.
deep fascia. Now identify the cephalic vein, a small Blockage of some lymph vessels by the cancer cells
artery and a few lymph nodes in the groove. causes oedema of skin with dimpled appearance.
Clean the fascia over the pectoralis major muscle This is called peau d’orange. When cancer cells
and look for its attachments. Divide the clavicular head
invade the suspensory ligaments, glandular tissue
of the muscle and reflect it laterally. Medial and lateral
Upper Limb
pectoral nerves will be seen supplying the muscle. or the ducts, there is retraction of the nipple.
Make a vertical incision 5 to 6 cm from the lateral border
of sternum and reflect its sternocostal head laterally.
Identify the pectoralis minor muscle under the central FURTHER READING
part of the pectoralis major. Note clavipectoral fascia • Ellis H, Colborn GL, Skandalakis JE. Surgical embryology
extending between pectoralis minor muscle and the and anatomy of the breast and its related anatomic structures.
clavicle bone (refer to BDC App). Surg Clin North Am 1993;73:611–32.
Identify the structures piercing the clavipectoral
• Streit JJ, Lenarz CJ, Shishani Y, et al. Pectoralis major tendon
fascia: These are cephalic vein, thoracoacromial artery
1

transfer for the treatment of scapular winging due to long

and lateral pectoral nerve. If some fine vessels are also
thoracic nerve palsy. J shoulder Elbow Surg 2012;21:685–90.
seen, these are the lymphatic channels.
Section

Also, identify the serratus anterior muscle showing The largest series of the direct or indirect transfer of the sternal
serrated digitations on the side of the chest wall. head of pectoralis major for insufficiency of serratus anterior in
symptomatic scapular dyskinesia.
1–7
From Medical Council of India, Competency based Undergraduate Curriculum for the Indian Medical Graduate, 2018;1:44–80.
 UPPER LIMB
50

1. Describe mammary gland under following 3. Write short notes/enumerate:

headings: Extent, relations, blood supply, lymphatic a. Structures piercing clavipectoral fascia
drainage and clinical anatomy.
b. Winging of scapula
2. Describe pectoralis major muscle under following
c. Origin and insertion of pectoralis minor muscle
headings: Origin, insertion, nerve supply, structures
deep to it, actions and clinical anatomy. d. Root value of long thoracic nerve

1. Which of the following muscles does not form deep a. Superior thoracic
relation of the mammary gland? b. Thoracodorsal branch of subscapular artery
a. Pectoralis major c. Lateral thoracic artery
b. Pectoralis minor d. Thoracoacromial artery
c. Serratus anterior 4. Axillary sheath is derived from which fascia?
d. External oblique muscle of abdomen a. Pretracheal
2. One of the following structures does not pierce b. Prevertebral
clavipectoral fascia: c. Investing layer of cervical
a. Cephalic vein d. Pharyngobasilar
b. Thoracoacromial artery 5. Winging of scapula occurs in paralysis of:
c. Medial pectoral nerve a. Pectoralis major
d. Lateral pectoral nerve b. Pectoralis minor
3. Which of the following arteries does not supply the c. Latissimus dorsi
mammary gland? d. Serratus anterior

1. b 2. c 3. b 4. b 5. d
Upper Limb

• Name the cutaneous nerves innervating the skin of • What is peau d'orange appearance of the skin
pectoral region. overlying the breast?
• What muscles form the deep relations of the • How can cancer of one breast spread to other breast;
mammary gland? to abdomen or pelvis or spread to cranial cavity?
• What is axillary tail and what is its importance? • How does one examine the clavicular and
sternocostal heads of pectoralis major muscle?
• Where does the lymph from breast drain?
• How is the integrity of serratus anterior muscle tested?
• Name the arteries supplying the breast. • Which muscle divides the axillary artery in three
• What structures pierce the clavipectoral fascia? parts?
1
Section
 4
Axilla
!Tailors know about the asymmetry of the arm and stitch the right sleeve a little looser than left !
—Anonymous

Competency achievement: The student should be able to:

AN 10.1 Identify and describe boundaries and contents of axilla.1

INTRODUCTION
The axilla (Latin armpit) is a pyramidal space situated
between the upper part of the arm and the chest wall.
It resembles a four-sided pyramid, and has the
following.
i. An apex
ii. A base
iii. Four walls: Anterior, posterior, medial and lateral.
The axilla is disposed obliquely in such a way that
the apex is directed upwards and medially towards the
root of the neck, and the base is directed downwards
(Figs 4.1a and b).

DISSECTION

Place a rectangular wooden block under the neck and

shoulder region of cadaver (Fig. 4.1). Ensure that the
block supports the body firmly. Abduct the limb at right
angles to the trunk; and strap the wrist firmly on block
projecting towards your side. In continuation with earlier
dissection, reflect the lower skin flap till the posterior
axillary fold, made up by the subscapularis, teres major,
and latissimus dorsi muscles, is seen. Clean the fat,
and remove the lymph nodes and superficial veins to
reach depth of the armpit. Identify two muscles arising Figs 4.1a and b: (a) Dissection of axilla, and (b) position of
from the tip of the coracoid process of scapula; out of axilla
these, the short head of biceps brachii muscle lies on
the lateral side and the coracobrachialis on the medial Reflect the upper skin flap on the arm till the incision
side (refer to BDC App). already given at its junction of upper one-third and lower
The pectoral muscles with the clavipectoral fascia two-thirds.
form anterior boundary of the region.
Look for upper three intercostal muscles and serratus BOUNDARIES
anterior muscle which make the medial wall of axilla. Apex/Cervicoaxillary Canal
Clean and identify the axillary vessels. Trace the It is directed upwards and medially towards the root
course of the branches of the axillary artery. of the neck.
51
 UPPER LIMB
52

Figs 4.2a to c: (a) Boundaries of the apex of the axilla, (b) walls of the axilla, and (c) opened up axilla

It is truncated (not pointed), and corresponds to a

triangular interval bounded:
i. Anteriorly, by the posterior surface of clavicle.
ii. Posteriorly, by the superior border of the scapula
and medial aspect of coracoid process.
iii. Medially, it is bounded by the outer border of
the first rib.
This oblique passage is called the cervicoaxillary
Upper Limb

canal (Figs 4.2a to c). The axillary artery, axillary vein

and the brachial plexus enter the axilla through this
canal.

Base or Floor
It is directed downwards, and is formed by skin, Fig. 4.3: Anterior and posterior walls of the axilla with the axillary
superficial and axillary fasciae. It is convex upwards in artery
congruence with concavity of axilla.
1

Anterior Wall Posterior Wall

Section

It is formed by the following. It is formed by the following.

i. The pectoralis major in front (Fig. 4.3). i. Subscapularis above (Fig. 4.4),
ii. The clavipectoral fascia ii. Teres major, and
iii. Pectoralis minor. iii. Latissimus dorsi below.
 AXILLA
53

3 Infraclavicular part of the brachial plexus.

4 Five groups of axillary lymph nodes and the
associated lymphatics.
5 The long thoracic and intercostobrachial nerves.
6 Axillary fat and areolar tissue in which the other
contents are embedded.

Layout
1 Axillary artery and the brachial plexus of nerves run
from the apex to the base along the lateral wall of
the axilla, nearer the anterior wall than the posterior
wall.
2 The thoracic branches of the axillary artery lie in
contact with the pectoral muscles, the lateral thoracic
vessels running along the lower border of the
pectoralis minor (Fig. 4.10a).
Fig. 4.4: Muscles forming the posterior wall of axilla with their
3 a. The subscapular vessels run along the lower
nerve supply border of the subscapularis.
b. The subscapular nerves and the thoracodorsal
Medial Wall
nerve (nerve to latissimus dorsi) cross the anterior
It is convex laterally and formed by the following. surface of the subscapularis (Fig. 4.4).
i. Upper four ribs with their intercostal muscles. c. The circumflex scapular vessels wind round the
ii. Upper part of the serratus anterior muscle (Fig. 4.5). lateral border of the scapula (see Fig. 6.12).
d. The axillary nerve and the posterior circumflex
Lateral Wall
humeral vessels pass backwards close to the
It is very narrow because the anterior and posterior surgical neck of the humerus.
walls converge on it. It is formed by the following. 4 a. The medial wall of the axilla is avascular, except
i. Upper part of the shaft of the humerus in the region for a few small branches from the superior thoracic
of the bicipital groove, and artery.
ii. Coracobrachialis and short head of the biceps b. The long thoracic nerve (nerve to the serratus
brachii (Fig. 4.5). anterior) descends on the surface of the muscle
(Fig. 4.5).
CONTENTS OF AXILLA c. The intercostobrachial nerve pierces the antero-
1 Axillary artery and its branches (Figs 4.6 and 4.7). superior part of the medial wall and crosses the spa-
2 Axillary vein and its tributaries. ces to reach the medial side of the arm (see Fig. 3.3).

Upper Limb
1Section

Fig. 4.5: Walls and contents of axilla

 UPPER LIMB
54

Competency achievement: The student should be able to:

AN 10.2 Identify, describe and demonstrate the origin, extent,
course, parts, relations and branches of axillary artery and tributaries
of vein.2

AXILLARY ARTERY

Axillary artery is the continuation of the subclavian

artery. It extends from the outer border of the first rib
to the lower border of the teres major muscle where it
continues as the brachial artery. Its direction varies with
the position of the arm.
The pectoralis minor muscle crosses the artery and
divides it into three parts (Fig. 4.6).
• First part, superior (proximal) to the muscle.
• Second part, posterior (deep) to the muscle.
• Third part, inferior (distal) to the muscle.
Fig. 4.6: The extent and parts of the axillary artery
RELATIONS OF AXILLARY ARTERY
5 The axillary lymph nodes are 20 to 30 in number,
Relations of First Part
and are arranged in five sets.
a. The anterior group lies along the lower border of Anterior
the pectoralis minor, on the lateral thoracic vessels. 1 Skin
b. The posterior group lies along the lower margin 2 Superficial fascia, platysma and supraclavicular nerves
of the posterior wall along the subscapular vessels. 3 Deep fascia
4 Clavicular part of the pectoralis major (Fig. 4.7a)
c. The lateral group lies posteromedial to the axillary
5 Clavipectoral fascia with cephalic vein, lateral
vein (Fig. 4.11).
pectoral nerve, and thoracoacromial artery.
d. The central group lies in the fat of the axilla. 6 Loop of communication between the lateral and
e. The apical group lies behind and above the medial pectoral nerves.
pectoralis minor, medial to the axillary vein.
Posterior
CLINICAL ANATOMY 1 First intercostal space with the external intercostal
muscle.
• The axilla has abundant axillary hair. Infection of 2 First and second digitations of the serratus anterior
the hair follicles and sebaceous glands gives rise with the nerve to serratus anterior.
to boils which are common in this area. 3 Medial cord of brachial plexus with its medial
pectoral branch.
Upper Limb
1
Section

Fig. 4.7a: Diagrammatic relations of first part of axillary artery

 AXILLA
55

Lateral Relations of Second Part

Lateral and posterior cords of the brachial plexus. Anterior

Medial
1 Skin
2 Superficial fascia
Axillary vein: The first part of the axillary artery is
enclosed (together with the brachial plexus) in the 3 Deep fascia
axillary sheath, derived from the prevertebral layer of 4 Pectoralis major
deep cervical fascia. 5 Pectoralis minor (Fig. 4.7b)

Fig. 4.7b: Diagrammatic relations of second part of axillary artery

Fig. 4.7c: Diagrammatic relations of third part of axillary artery (upper part)

Upper Limb
1Section

Fig. 4.7d: Diagrammatic relations of third part of axillary artery (lower part)
 UPPER LIMB
56

Posterior
1 Posterior cord of brachial plexus
2 Subscapularis

Lateral
1 Lateral cord of brachial plexus
2 Coracobrachialis (Fig. 4.8)

Medial
1 Medial cord of brachial plexus
2 Medial pectoral nerve
3 Axillary vein

Relations of Third Part

Anterior
1 Skin
2 Superficial fascia
3 Deep fascia
4 In the upper part, there are the pectoralis major and
the medial root of the median nerve (Fig. 4.7c).
Posterior
1 Radial nerve (Fig. 4.9) Fig. 4.8: Relation of the brachial plexus to the axillary artery. C5–
2 Axillary nerve in the upper part C8 and T1 are ventral primary rami of respective spinal segments.
3 Subscapularis in the upper part LC—lateral cord; MC—medial cord; MR—medial root; LR—
4 Tendons of the latissimus dorsi and the teres major lateral root; M—median nerve; U—ulnar nerve; Mc—
in the lower part (Fig. 4.7d). musculocutaneous nerve
Upper Limb
1
Section

Fig. 4.9: Relations of branches of brachial plexus to the axillary vessels

 AXILLA
57

Lateral Thoracoacromial (Acromiothoracic) Artery

1 Coracobrachialis Thoracoacromial artery is a branch from the second part
2 Musculocutaneous nerve in the upper part (Fig. 4.8) of the axillary artery. It emerges at the upper border of
3 Lateral root of median nerve in the upper part the pectoralis minor, pierces the clavipectoral fascia, and
4 Trunk of median nerve in the lower part. soon divides into the following four terminal branches.
a. The pectoral branch passes between the pectoral
Medial muscles, and supplies these muscles as well as the
1 Axillary vein breast.
2 Medial cutaneous nerve of the forearm and ulnar b. The deltoid branch runs in the deltopectoral groove,
nerve, between the axillary artery and the axillary vein along with the cephalic vein.
3 Medial cutaneous nerve of arm, medial to the axillary
c. The acromial branch crosses the coracoid process and
vein (Fig. 4.9).
ends by joining the anastomoses over the acromion
Branches process.
The axillary artery gives six branches. One branch arises d. The clavicular branch runs superomedially deep to the
from the first part, two branches from the second part, pectoralis major, and supplies the acromioclavicular
and three branches from the third part. These are as joint and subclavius.
follows (Fig. 4.10).
Lateral Thoracic Artery
Superior Thoracic Artery Lateral thoracic artery is a branch of the second part of
Superior thoracic artery is a very small branch which the axillary artery. It emerges at, and runs along, the
arises from the first part of the axillary artery (near the lower border of the pectoralis minor in close relation
subclavius). It runs downwards, forwards and medially, with the anterior group of axillary lymph nodes.
passes between the two pectoral muscles, and ends by In females, the artery is large and gives off the lateral
supplying these muscles and the thoracic wall (Fig. 4.10). mammary branches to the breast.

Upper Limb
1Section

Figs 4.10a and b: The branches of the axillary artery

 UPPER LIMB
58

Subscapular Artery CLINICAL ANATOMY

Subscapular artery is the largest branch of the axillary
artery, arising from its third part. It runs along the lower • Axillary arterial pulsations can be felt against the
border of the subscapularis to terminate near the lower part of the lateral wall of the axilla.
inferior angle of the scapula. It supplies the latissimus In order to check bleeding from the distal part of
dorsi and the serratus anterior. the limb (in injuries, operations and amputations),
It gives off a large branch, the circumflex scapular the artery can be effectively compressed against
artery, which is larger than the continuation of the the humerus in the lower part of the lateral wall
main artery. This branch passes through the upper of the axilla.
triangular intermuscular space, winds around the
AXILLARY VEIN
lateral border of the scapula between two slips of the
teres minor, and gives a branch to the subscapular The axillary vein is the continuation of the basilic vein.
fossa, and another branch to the infraspinous fossa, The axillary vein is joined by the venae comitantes of
both of which take part in the anastomoses around the the brachial artery, a little above the lower border of
scapula (see Fig. 6.12). the teres major. It lies on the medial side of the axillary
artery (Fig. 4.9). At the outer border of the first rib, it
Anterior Circumflex Humeral Artery becomes the subclavian vein. It receives 5 out of 6
tributaries corresponding to the branches of axillary
Anterior circumflex humeral artery is a small branch artery and the cephalic vein. Veins accompanying
arising from the third part of the axillary artery, at the branches of thoracoacromial artery drain directly into
lower border of the subscapularis. the cephalic vein.
It passes laterally in front of the intertubercular Lateral thoracic vein of upper limb is joined to
sulcus of the humerus, and anastomoses with the superficial epigastric vein of lower limb by thoraco-
posterior circumflex humeral artery, to form an arterial epigastric vein enabling blood to return to heart in
circle round the surgical neck of the humerus. blockage of inferior vena cava (see Flowcharts 14.1 and
It gives off an ascending branch which runs in the 14.2).
intertubercular sulcus, and supplies the head of the
humerus and shoulder joint (Fig. 4.10b). Competency achievement: The student should be able to:
AN 10.4 Describe the anatomical groups of axillary lymph nodes
and specify their areas of drainage.3
Posterior Circumflex Humeral Artery
AN 10.7 Explain anatomical basis of enlarged axillary lymph nodes.4
Posterior circumflex humeral artery is much larger than
the anterior artery. It arises from the third part of the AXILLARY LYMPH NODES
axillary artery at the lower border of the subscapularis.
It runs backwards, accompanied by the axillary nerve, The axillary lymph nodes are scattered in the fibrofatty
passes through the quadrangular intermuscular space, tissue of the axilla. They are divided into five groups.
and ends by anastomosing with the anterior circumflex 1 The nodes of the anterior (pectoral) group lie along the
humeral artery around the surgical neck of the humerus lateral thoracic vessels, i.e. along the lower border
(see Figs 6.6 and 6.12). of the pectoralis minor. They receive lymph from the
upper half of the anterior wall of the trunk, and from
It supplies the shoulder joint, the deltoid, and the
the major part of the breast (Fig. 4.11).
muscles bounding the quadrangular space.
Upper Limb

2 The nodes of the posterior (scapular) group lie along

It gives off a descending branch which anastomoses the subscapular vessels on the posterior fold of the
with the ascending branch of the profunda brachii artery. axilla. They receive lymph from the posterior wall
of the upper half of the trunk, and from the axillary
Anastomoses and Collateral Circulation tail of the breast.
The branches of the axillary artery anastomose with one 3 The nodes of the lateral group lie along the upper part
another and with branches derived from neighbouring of the humerus, medial to the axillary vein. They
arteries (internal thoracic, intercostal, suprascapular, receive lymph from the upper limb.
deep branch of transverse cervical, profunda brachii). 4 The nodes of the central group lie in the fat of the
1

When the axillary artery is blocked, a collateral upper axilla. They receive lymph from the preceding
Section

circulation is established through the anastomoses groups and drain into the apical group. They receive
around the scapula which links the first part of the some direct vessels from the floor of the axilla. The
subclavian artery with the third part of the axillary intercostobrachial nerve is closely related to them.
artery (apart from communications with the posterior 5 The nodes of the apical or infraclavicular group lie deep
intercostal arteries) (see Fig. 6.12). to the clavipectoral fascia, along the axillary vessels.
 AXILLA
59

these lymph nodes is, therefore, important in

clinical practice. Left axillary nodes to be palpated
by right hand. Right axillary nodes have to be
palpated by left hand.
• An axillary abscess should be incised through the
floor of the axilla, midway between the anterior
and posterior axillary folds, and nearer to the
medial wall in order to avoid injury to the main
vessels running along the anterior, posterior and
lateral walls.

SPINAL NERVE
Each spinal nerve is formed by union of dorsal root
and ventral root. Dorsal root is sensory and is
characterised by the presence of spinal or dorsal root
ganglion and enters the dorsal horn and posterior
Fig. 4.11: The axillary lymph nodes
funiculus of spinal cord. Ventral root is motor, arises
from anterior horn cells of spinal cord (Fig. 4.13).
They receive lymph from the central group, from the The motor and sensory fibres get united in the
upper part of the breast, and from the thumb and its spinal nerve which divides into short dorsal ramus and
web. The lymphatics from the thumb accompany the long ventral ramus. Both the rami thus contain motor
cephalic vein. and sensory fibres. In addition, these also manage to
Anterior and central groups of nodes are often obtain sympathetic fibres via grey ramus communicans.
involved in carcinoma breast. Only the ventral primary rami form plexuses.
Brachial plexus is formed by ventral primary rami
of C5–C8 and T1 segments of spinal cord.
CLINICAL ANATOMY

• The axillary lymph nodes drain lymph not only Competency achievement: The student should be able to:
from the upper limb but also from the breast and AN 10.3 Describe, identify and demonstrate formation, branches,
the anterior and posterior body walls above the
relations, area of supply of branches, course and relations of
terminal branches of brachial plexus.5
level of the umbilicus. Therefore, infections or
AN 10.5 Explain variations in formation of brachial plexus.6
malignant growths in any part of their territory
of drainage give rise to involvement of the axillary
lymph nodes (Fig. 4.12). Bimanual examination of
BRACHIAL PLEXUS

The plexus consists of roots, trunks, divisions, cords

and branches (Fig. 4.14).

Upper Limb
Roots
These are constituted by the anterior primary rami
of spinal nerves C5–C8 and T1, with occasional
contributions from the anterior primary rami of C4 and
T2 (Fig. 4.8).
The origin of the plexus may shift by one segment
either upward or downward, resulting in a prefixed or
postfixed plexus, respectively.
1

In a prefixed plexus, the contribution by C4 is large

Section

and C5 is present , T1 is small, from T2 is often absent.

In a postfixed plexus, the contribution by T1 is
Fig. 4.12: Lymph above umbilicus drains into axillary lymph large, T2 is always present, C4 is absent, and C5 is
nodes while below umbilicus drains into inguinal group reduced in size. The roots join to form trunks as
follows.
 UPPER LIMB
60

Fig. 4.13: Mixed fibres of a spinal nerve

Upper Limb
1
Section

Fig. 4.14: The right brachial plexus

 AXILLA
61

Roots and Trunks—Supraclavicular Part Branches

Roots C5 and C6 join to form the upper trunk. Root C7 The roots value of each branch is given in brackets.
forms the middle trunk. Roots C8 and T1 join to form
the lower trunk. These lie in the neck between scalenus Branches of the Roots
anterior and scalenus medius muscles, carrying axillary The roots value of each branch is given in brackets.
sheath from prevertebral fascia (see Fig. 12.10). 1 Nerve to serratus anterior (long thoracic nerve) (C5–
C7). It only supplies serratus anterior muscle, one of
Divisions of the trunks—Retroclavicular Part
the key muscles, for overhead abduction.
Each trunk (three in number) divides into ventral and
2 Nerve to rhomboids (dorsal scapular nerve) (C5).
dorsal divisions (which ultimately supply the anterior
This nerve supplies rhomboid minor and rhomboid
and posterior aspects of the limb). These divisions join
major muscles, responsible for retraction of the
to form cords.
shoulder girdle gives a branch to levator scapulae.
Cords and Branches—Infraclavicular Part 3 Branches to longus colli and scaleni muscles (C5–C8)
i. The lateral cord is formed by the union of ventral and branch to phrenic nerve (C4). The root of phrenic
divisions of the upper and middle trunks (two nerve from C5 is small one, the main root is from C4.
divisions). Phrenic nerve is the sole motor nerve supply of
thoracoabdominal diaphragm. In addition, it carries
ii. The medial cord is formed by the ventral division
afferent fibres from mediastinal pleura, fibrous
of the lower trunk (one division).
pericardium and part of the parietal peritoneum.
iii. The posterior cord is formed by union of the dorsal
divisions of all the three trunks (three divisions). Branches of the Trunks
These are named according to relation of cords to
the 2nd part of axillary artery. These arise only from the upper trunk which gives two
branches:
Sympathetic Innervation 1 Suprascapular (C5, C6). This nerve supplies
1 Sympathetic nerves for the upper limb are derived supraspinatus and infraspinatus muscles.
from spinal segments T2 to T6. Most of the vaso- 2 Nerve to subclavius (C5, C6). It supplies the small
constrictor fibres supplying the arteries emerge from subclavius muscles. It may give a root for phrenic
segments T2 and T3. nerve.
2 The preganglionic fibres arise from lateral horn cells
and emerge from the spinal cord through ventral Branches of the Cords
nerve roots. Branches of lateral cord
3 Passing through white rami communicantes, they 1 Lateral pectoral (C5–C7). This nerve supplies both
reach the sympathetic chain. pectoralis major and pectoralis minor muscles.
4 They ascend within the chain and end in the middle 2 Musculocutaneous (C5–C7). This is the nerve of
cervical, inferior cervical and first thoracic ganglia. muscles of front of arm, i.e. coracobrachialis both the
5 Postganglionic fibres from middle cervical ganglion long and short heads of biceps brachii and the
pass through grey rami communicantes to reach C5, brachialis muscles.
and C6 nerve roots. 3 Lateral root of median (C5–C7). It joins the medial

Upper Limb
6 Postganglionic fibres from inferior cervical ganglion root of median nerve. Median nerve is the chief nerve
pass through grey rami communicantes to reach C7, of the muscles of front of forearm and of muscles of
and C8 nerve roots. thenar eminence.
7 Postganglionic fibres from first thoracic sympathetic Branches of medial cord
ganglion pass through grey rami communicantes to 1 Medial pectoral (C8, T1). It also supplies both the
reach T1 nerve roots. pectoralis minor and pectoralis major muscles.
8 The arteries of skeletal muscles are dilated by 2 Medial cutaneous nerve of arm (C8, T1) carries
sympathetic activity. For the skin, however, these sensory impulses from a small area of medial side of
1

nerves are vasomotor, sudomotor and pilomotor. arm.

3 Medial cutaneous nerve of forearm (C8, T1) carries
Section

Vasomotor: Constricts the arterioles of skin.

sensory impulses from large area of medial side of
Sudomotor: Increases the sweat secretion. the forearm.
Pilomotor: Contracts the arrector pilorum muscle to 4 Ulnar (C7, C8, T1). C7 fibres reach by a communi-
cause erection of the hair. cating branch from lateral root of median nerve.
 UPPER LIMB
62

This is the nerve of one and a half muscles of front (C5–C8) and the first thoracic (T1) nerves. The first
of forearm and 15 intrinsic muscles of the palm. and second parts of the axillary artery are related to
5 Medial root of median (C8, T1). It joins the lateral the cords; and third part is related to the branches of
root and gets distributed with branches of median the plexus. Study the description of the brachial plexus
nerve. before proceeding further (refer to BDC App).

Branches of posterior cord

1 Upper subscapular (C5, C6). This nerve supplies Competency achievement: The student should be able to:
large multipennate subscapularis muscles. AN 10.6 Explain the anatomical basis of clinical features of Erb’s
palsy and Klumpke’s paralysis.7
2 Nerve to latissimus dorsi (C6–C8). Only supplies
muscles of its name. It is also called thoracodorsal
nerve. CLINICAL ANATOMY
3 Lower subscapular (C5, C6). It helps upper Global total brachial plexus birth baby is the most
subscapular nerve in supplying of the subscapularis severe type of paralysis.
muscles. In addition, it supplies the teres major
muscle. Erb’s Paralysis
4 Axillary (circumflex) (C5, C6). It is responsible for Site of injury: One region of the upper trunk of the
supplying one of the important muscles of the brachial plexus is called Erb’s point (Fig. 4.15). Six
shoulder, the deltoid. It also supplies small teres nerves meet here. Injury to the upper trunk causes
minor muscle. Erb’s paralysis.
Causes of injury: Undue separation of the head from
5 Radial (C5–C8, T1). This is the thickest branch of
the shoulder, which is commonly encountered in the
brachial plexus. It supplies all the three heads of
following.
triceps brachii muscle. Then it supplies 12 muscles
i. Birth injury/difficult childbirth
on the back of forearm.
ii. Fall on the shoulder
In addition to the branches of the brachial plexus, iii. During anaesthesia.
the upper limb is also supplied, near the trunk, by the Nerve roots involved: Mainly C5 and partly C6.
supraclavicular branches of the cervical plexus, and by Muscles paralysed: Mainly biceps brachii, deltoid,
the intercostobrachial branch of the second intercostal brachialis and brachioradialis. Partly supraspinatus,
nerve. Sympathetic nerves are distributed through the infraspinatus and supinator.
brachial plexus. The arrangement of the various nerves Deformity and position of the limb:
in the axilla, was studied with the relations of the • Arm: Hangs by the side; it is adducted and
axillary artery. medially rotated.
• Forearm: Extended and pronated.
Special Features The deformity is known as ‘policeman’s tip hand’
The lateral cord, medial cord and their branches form or waiter’s tip hand or ‘porter’s tip hand’ (Fig. 4.16).
the letter ‘M’ with the three corners extended Disability: The following movements are lost.
(Fig. 4.8 inset). Lateral cord gives musculocutaneous
and lateral root of median.
Medial cord gives ulnar and medial root of median.
Upper Limb

The lateral and medial roots of median nerve join to

form the median nerve.

Blood Supply of Brachial Plexus

Vertebral artery and thyrocervical trunk with its
branches, the suprascapular and transverse cervical
arteries, supply blood to the brachial plexus. These are
the life line of this important plexus.
1
Section

DISSECTION
After cleaning the branches of the axillary artery,
proceed to clean the brachial plexus. It is formed by
the ventral primary rami of the lower four cervicals Fig. 4.15: Erb’s point
 AXILLA
63

• Abduction and lateral rotation of the arm at • Horner’s syndrome: If T1 is injured proximal to white
shoulder joint. ramus communicans to first thoracic sympathetic
• Flexion and supination of the forearm. ganglion, there is ptosis, miosis, anhydrosis,
• Biceps and supinator jerks are lost. enophthalmos, and loss of ciliospinal reflex—may
• Sensations are lost over a small area over the be associated. This is because of injury to
lower part of the deltoid. sympathetic fibres to the head and neck that leave
the spinal cord through nerve T1 (Fig. 4.18).
Klumpke’s Paralysis
• Vasomotor changes: The skin area with sensory loss
Site of injury: Lower trunk of the brachial plexus. is warmer due to arteriolar dilation. It is also drier
Cause of injury: Undue abduction of the arm, as in due to the absence of sweating as there is loss of
clutching something with the hands after a fall from a sympathetic activity.
height, or sometimes in birth injury. • Trophic changes: Long-standing case of paralysis
Nerve roots involved: Mainly T1 and partly C8. leads to dry and scaly skin. The nails crack easily
Muscles paralysed with atrophy of the pulp of fingers.
• Intrinsic muscles of the hand (T1). Injury to the Nerve to Serratus Anterior (Nerve of Bell)
• Ulnar flexors of the wrist and fingers (C8).
Causes:
Deformity and position of the hand: Claw hand due to
1 Sudden pressure on the shoulder from above.
the unopposed action of the long flexors and extensors
of the fingers. In a claw hand, there is hyperextension 2 Carrying heavy loads on the shoulder.
at the metacarpophalangeal joints and flexion at the Deformity: Winging of the scapula, i.e. excessive
interphalangeal joints. prominence of the medial border of the scapula.
Disability: Normally, the pull of the muscle keeps the medial
border against the thoracic wall.
• Complete claw hand (Fig. 4.17).
• Cutaneous anaesthesia and analgesia in a narrow Disability:
zone along the ulnar border of the forearm and hand. • Loss of pushing and punching actions. During
attempts at pushing, there occurs winging of the
scapula (see Fig. 2.12).
• Overhead abduction of shoulder girdle is partly
affected due to intact trapezius muslce.

Upper Limb
Fig. 4.18: Ptosis due to Horner’s syndrome

Mnemonics
Fig. 4.16: Erb’s paralysis of right arm
Brachial plexus: Branches of posterior cord
STAR:
Subscapular (upper and lower)
Thoracodorsal
1

Axillary
Radial
Section

Axillary artery branches “Slap The Lawyer

Save A Patient”:
1st part gives 1 branch; 2nd part 2 branches; and
Fig. 4.17: Complete claw hand 3rd part 3 branches.
 UPPER LIMB
64

Superior thoracic branch of 1st part smooth anterior and posterior walls of the axilla
Thoracoacromial branch of 2nd part are formed.
Lateral thoracic branch of 2nd part • Infraclavicular part of brachial plexus lies in the
Subscapular branch of 3rd part axilla.
Anterior circumflex humeral branch of 3rd part • Apex of the axilla is known as cervicoaxillary canal
Posterior circumflex humeral branch of 3rd part and gives passage to axillary vessels and lower part
of brachial plexus.
Thoracoacromial artery branches “ABCD”: • Axillary sheath is derived from prevertebral fascia.
Acromial
Breast (pectoral)
Clavicular CLINICOANATOMICAL PROBLEM
Deltoid A patient came with inability to: (i) abduct right
Brachial plexus branches: “My Aunt Ragged My Uncle”: shoulder, (ii) flex elbow joint, and (iii) supinate the
forearm
From lateral to medial:
• Musculocutaneous • What is the site of injury of the nerves?
• Axillary • What is the point called?
• Radial • What are the nerves affected?
• Median
• Ulnar Ans: The site of injury is called Erb’s point.
Six nerves are involved:
Brachial plexus “Ramu Tailor Drinks Cold Beer”:
i. Ventral ramus of cervical five segment of
Roots (ventral rami) C5–T1
spinal cord
Trunks (upper, middle, lower)
ii. Ventral ramus of cervical six segment of spinal
Divisions (3 anterior and 3 posterior)
cord
Cords (lateral, posterior, medial) These two rami join to form the upper trunk.
Branches
iii. Suprascapular nerve from upper trunk
Median nerve: Recognizing it in an opened axilla iv. Nerve to subclavius from upper trunk
The Median nerve is the Middle of a giant capital v. Anterior division of upper trunk
"M" formed by the musculocutaneous and ulnar vi. Posterior division of upper trunk
nerves.
These divisions give fibres to deltoid, brachialis,
Pectoral nerves: Path of lateral versus medial biceps brachii, supinator, so the arm cannot be
"Lateral Less, Medial More". abducted. The elbow is extended and forearm is
Lateral pectoral nerve only goes through Pectoralis pronated. This paralysis is called Erb’s paralysis.
major, but Medial pectoral nerve goes through both
Pectoralis major and minor. FURTHER READING
• Birch R. Surgical Disorders of the Peripheral Nerves, 2nd ed.
Upper Limb

Serratus anterior: Innervation and action

London: Springer-Verlag, 2011.
"C5–C7 raise your arms up to heaven". An account of the current state-of-the-art practice of diagnosis and
Long thoracic nerve roots (C5–C7) innervate management of surgical lesions of the peripheral nerves, including
Serratus anterior. the brachial plexus.
Test C5–C7 roots clinically by ability to raise arm • Kuntz A. Distribution of the sympathetic rami to the brachial
past 90°. plexus: its relation to sympathectomy affecting the upper
extremity. Arch Surg 1927;15:871–77.
A description of the significant number of individuals in whom
the intrathoracic somatic branches from the second thoracic
FACTS TO REMEMBER spinal nerve join the first thoracic spinal nerve. These 'Kuntz's
1

• Sternoaponeurotic part of pectoralis major twists nerves' join the lower part of the brachial plexus without passing
Section

around the upper fibres of same muscle. Latissimus through the stellate ganglion, explaining the incomplete
dorsi twists around the teres major. Thus the sympathetic blockade of the upper extremities in stellate
ganglion blockade.

1–7
From Medical Council of India, Competency based Undergraduate Curriculum for the Indian Medical Graduate, 2018;1:44–80.
 AXILLA
65

1. Describe the axillary artery under following 3. Write short notes/enumerate:

headings: Beginning, course and branches. Add a a. Boundaries of axilla
note on anastomoses around scapula. b. Areas draining into axillary lymph nodes
c. Branches of posterior cord of brachial plexus
2. Enumerate the roots, trunks, cords, divisions and
d. Erb’s paralysis
branches of brachial plexus.
e. Klumpke’s paralysis

1. Which of the following is not a branch of posterior a. Musculocutaneous

cord of brachial plexus? b. Lateral root of median
a. Upper subscapular c. Medial root of median
b. Lower subscapular d. Lateral pectoral
c. Suprascapular 4. Erb’s paralysis causes weakness of all muscles,
d. Axillary except:
2. Porter’s tip or policeman’s tip deformity occurs due a. Supraspinatus b. Deltoid
to: c. Biceps brachii d. Triceps brachii
a. Klumpke’s paralysis 5. Posterior wall of axilla is formed by all muscles,
b. Paralysis of median nerve except:
c. Paralysis of radial nerve a. Teres major
d. Erb’s paralysis b. Teres minor
3. Which is not a branch of lateral cord of brachial c. Latissimus dorsi
plexus? d. Subscapularis

1. c 2. d 3. c 4. d 5. b

• Name the muscles forming posterior wall of axilla.

Upper Limb
• Name the branches from roots of BP (brachial
Which nerves supply these muscles. plexus).
• What are the boundaries of cervicoaxillary canal? • Name the branches of lateral cord of BP.
• Which muscle divides the axillary artery into 3 parts? • Name the branches of medial cord of BP.
• What is the relation of the cords of brachial plexus • Name the branches of posterior cord of BP.
to the 1st and 2nd parts of axillary artery?
• Which is the thickest branch of brachial plexus?
• Name the branches of axillary artery.
• Which is the largest branch of axillary artery? • What is Erb’s point?
1

• Name the lymph nodes in the axilla. • What is the disability in Erb’s paralysis?
Section

• Which nerves form the brachial plexus? • What is the disability in Klumpke’s paralysis?
• Which sympathetic ganglia give sympathetic fibers • What is Bell’s paralysis? How does one test this
to the roots of brachial plexus? paralysis?
 5
Back
!A little learning is a dangerous thing !
—Alexander Pope

INTRODUCTION
This chapter deals mainly with structures which
connect the upper limb with the back of the trunk.

SURFACE LANDMARKS

1 The scapula (shoulder blade) is placed on the

posterolateral aspect of the upper part of the thorax.
It extends from the second to seventh ribs. Although
it is thickly covered by muscles, most of its outline
can be felt in the living subject. The acromion process
lies at the top of the shoulder. The crest of the spine of
the scapula runs from the acromion process medially
and slightly downwards to the medial border of the
scapula. The medial border and the inferior angle of the
scapula can also be palpated (Fig. 5.1).
2 The eighth rib is just below the inferior angle of the
scapula. The lower ribs can be identified on the back
by counting down from the eighth rib.
3 The iliac crest is a curved bony ridge lying below the
waist. The anterior end of the crest is the anterior
superior iliac spine. The posterior superior iliac spine is
felt in a shallow dimple above the buttock, about
5 cm from the median plane.
Fig. 5.1: Surface landmarks and lines of dissection
4 The sacrum lies between the right and left dimples
mentioned above. Usually three sacral spines are
palpable in the median plane. 7 The junction of the back of the head with that of the
5 The coccyx lies between the two buttocks in the neck is indicated by the external occipital
median plane. protuberance and the superior nuchal lines. The
6 The spine of the seventh cervical vertebra or vertebra external occipital protuberance is a bony projection felt
prominens is readily felt at the root of the neck. Higher in the median plane on the back of the head at the
up on the back of the neck, the second cervical spine upper end of the nuchal furrow (running vertically
can be felt about 5 cm below the external occipital on the back of the neck). The superior nuchal lines are
protuberance. Other spines that can be recognised are indistinct curved ridges which extend on either side
T3 at the level of root of the spine of the scapula, L4 from the protuberance to the mastoid process. The
at the level of the highest point of the iliac crest, and nuchal furrow extends to the external occipital
S2 at the level of the posterior superior iliac spine. protuberance above and to the spine of C7 below.
66
 BACK
67

SKIN AND FASCIAE OF THE BACK posterior primary rami provide the cutaneous
branches. Each cutaneous nerve divides into a
Position smaller medial and a larger lateral branch before
supplying the skin (Fig. 5.2).
Human being mostly lies on his back. Therefore, the
skin and fasciae of the back are adapted to sustain 3 The posterior primary rami supply the intrinsic
pressure of the body weight. Accordingly, the skin is muscles of the back and the skin covering them. The
thick and fixed to the underlying fasciae; the superficial cutaneous distribution extends further laterally than
fascia containing variable amount of fat, is thick and the extensor muscles.
strong and is connected to overlying skin by connective 4 No posterior primary ramus ever supplies skin or
tissue; and the deep fascia is dense in texture. muscles of a limb. The cutaneous branches of the
posterior primary rami of nerves L1, 2, 3 and
Cutaneous Nerves S1–3 are exceptions in this respect: They turn
The cutaneous nerves of the back are derived from the downwards unlike any other nerve and supply the
posterior primary rami of the spinal nerves. Their skin of the gluteal region.
distribution extends up to the posterior axillary lines.
The following points may be noted. DISSECTION
1 The posterior primary rami of the spinal nerves C1, Identify the external occipital protuberance (i) of the skull.
C7, C8, and L4, 5 do not give off any cutaneous Draw a line in the midline from the protuberance to the
branches. All twelve thoracic, L1–3 and five spine of the last thoracic (T12) vertebra (ii). Make incision
sacral nerves, however, give cutaneous branches. along this line (Fig. 5.1). Extend the incision from its lower
2 Each posterior/dorsal primary ramus divides into end to the deltoid tuberosity (iii) on the humerus which is
medial and lateral branches, both of which supply present on lateral surface about the middle of the arm.
Note that the arm is placed by the side of the trunk.
the erector spinae muscles, but only one of them,
Make another incision along a horizontal line from
either medial or lateral, continues to become the
seventh cervical spine—vertebra prominens (iv) to the
cutaneous nerves. In the upper half of the body (up acromion process of scapula (v). Reflect the skin flap
to T6), the medial branches, and in the lower half of laterally.
the body (below T6) the lateral branches, of the

Upper Limb
1Section

Fig. 5.2: Typical thoracic spinal nerve. The ventral primary ramus is the intercostal nerve
 UPPER LIMB
68

Competency achievement: The student should be able to:

AN 10.8 Describe, identify and demonstrate the position,
attachment, nerve supply and actions of trapezius and latissimus
dorsi.1

MUSCLES CONNECTING THE UPPER LIMB

WITH THE VERTEBRAL COLUMN
Features
Muscles connecting the upper limb with the vertebral
column are the trapezius (Figs 5.3a and b), the
latissimus dorsi, the levator scapulae, and the rhomboid
minor and rhomboid major. The attachments of these
muscles are given in Table 5.1, and their nerve supply
and actions are shown in Table 5.2.

DISSECTION
Identify the attachments of trapezius muscle in the upper
part of back; and that of latissimus dorsi in the lower
part. Cut vertically through trapezius 5 cm lateral to the
vertebral spines. Divide the muscle horizontally between
the clavicle and spine of scapula; and reflect it laterally
to identify the accessory nerve and its accompanying
blood vessels, the superficial branch of transverse
cervical artery and vein (refer to BDC App).
Look for the suprascapular vessels and nerve, deep
Fig. 5.3a: The trapezius muscle and latissimus dorsi
to trapezius muscle, towards the scapular notch.
Cut through levator scapulae muscle midway
between its two attachments and clean the dorsal Pull the medial or inner scapular border away from
scapular nerve (supplying the rhomboids) and the chest wall for looking at the serratus anterior
accompanying blood vessels. Identify rhomboid minor muscle.
from rhomboid major muscle. Define attachments of latissimus dorsi muscle.
Upper Limb
1
Section

Fig. 5.3b: Dissection of the back showing superficial muscles

 BACK
69

Table 5.1: Attachments of muscles connecting the upper limb to the vertebral column (Figs 5.4 and 5.6)
Muscle Origin Insertion
Trapezius • Medial one-third of superior nuchal line • Upper fibres into the posterior border of
The right and left muscles • External occipital protuberance lateral one-third of clavicle
together form a trapezium that • Ligamentum nuchae • Middle fibres into the medial margin of
covers the upper half of the back • C7 spine the acromion process and upper lip of the
(Figs 5.3a and b) • T1–T12 spines crest of spine of the scapula
• Corresponding supraspinous ligaments • Lower fibres on the apex of triangular
area at the medial end of the spine, with
a bursa intervening
Latissimus dorsi • Posterior one-third of the outer lip of The muscle winds round the lower
It covers a large area of iliac crest border of the teres major, and forms the
the lower back, and is • Posterior layer of lumbar fascia; thus posterior fold of the axilla
overlapped by the trapezius attaching the muscle to the lumbar and The tendon is twisted upside down and is
(Figs 5.3a and 5.4) sacral spines inserted into floor of the intertubercular
• Spines of T7–T12, lower four ribs sulcus
• Inferior angle of the scapula
Levator scapulae • Transverse processes of C1, C2 Superior angle and upper part of medial
(Fig. 5.4) • Posterior tubercles of the transverse border (up to triangular area) of the scapula
processes of C3, C4
Rhomboid minor (Fig. 5.4) • Lower part of ligamentum nuchae Base of the triangular area at the root of the
• Spines C7 and T1 spine of the scapula
Rhomboid major (Fig. 5.4) • Spines of T2–T5 Medial border of scapula below the root of
• Supraspinous ligaments the spine

Table 5.2: Nerve supply and actions of muscles connecting the upper limb to the vertebral column
Muscle Nerve supply Actions
Trapezius • Spinal part of accessory nerve (XI) • Upper fibres act with levator scapulae, and elevate
• Branches from C3, C4 (proprioceptive) the scapula, as in shrugging. Upper fibres of both sides
extend the neck
• Middle fibres act with rhomboids, and retract the
scapula
• Upper and lower fibres act with serratus anterior, and
rotate the scapula forwards around the chest wall thus
playing an important role in abduction of the arm
beyond 90o (Fig. 5.7)
• Steadies the scapula

Upper Limb
Latissimus dorsi Thoracodorsal nerve (C6–C8) • Adduction, extension, and medial rotation of the
(nerve to latissimus dorsi) shoulder as in swimming, rowing, climbing, pulling,
folding the arm behind the back, and scratching the
opposite scapula
• Helps in violent expiratory effort like coughing, sneezing,
etc.
• Essentially a climbing muscle
• Hold inferior angle of the scapula in place
1

Levator scapulae • A branch from dorsal scapular nerve (C5) • Helps in elevation of scapula
Section

• Branches from C3, C4 • Steadies the scapula during movements of the arm
Rhomboid minor Dorsal scapular nerve (C5) • Retraction of scapula
Rhomboid major Dorsal scapular nerve (C5) • Retraction of scapula
 UPPER LIMB
70

ADDITIONAL FEATURES OF MUSCLES OF THE BACK 8 Infraspinatus

Trapezius 9 Latissimus dorsi
10 Serratus posterior superior
1 Developmentally, the trapezius is related to the
sternocleidomastoid. Both of them develop from B. Vessels
branchial arch mesoderm and are supplied by the 1 Suprascapular artery and vein
spinal accessory nerve. 2 Superficial branch of the transverse cervical
2 The principal action of the trapezius is to rotate the artery (superficial cervical) (Fig. 5.5) and
scapula during abduction of the arm beyond 90°. accompanying veins
Clinically, the muscle is tested by asking the patient 3 Deep branch of transverse cervical artery (Fig. 5.6)
to shrug his shoulder against resistance. (dorsal scapular) and accompanying veins
C. Nerves
Structures under Cover of the Trapezius 1 Spinal root of accessory nerve (Fig. 5.5)
A large number of structures lies immediately under 2 Suprascapular nerve
cover of the trapezius. Some of them are shown in 3 C3, C4 nerves
Figs 5.5 and 5.6 and are listed below. 4 Posterior primary rami of C2–C6 and T1–T12
A. Muscles pierce the muscle to become cutaneous nerves.
1 Semispinalis capitis D. Bursa: A bursa lies over the smooth triangular area
2 Splenius capitis at the root of the spine of the scapula.
3 Levator scapulae (Fig. 5.4)
4 Inferior belly of omohyoid Latissimus Dorsi
5 Rhomboid minor 1 This is the only muscle which connects the pelvic
6 Rhomboid major girdle and vertebral column to upper limb. It
7 Supraspinatus possesses extensive origin and narrow insertion.
Upper Limb
1
Section

Fig. 5.4: The latissimus dorsi, the levator scapulae, the Fig. 5.5: Some of the structures under cover of the right
rhomboid minor and the rhomboid major muscles trapezius muscle
 BACK
71

Fig. 5.7: Rotation of the scapula during abduction of the arm

beyond 90°, brought about by the trapezius and the serratus
anterior muscles

Fig. 5.6: Transverse section showing the arrangement of

structures on the back lateral border of the latissimus dorsi, laterally by the
posterior border of the external oblique muscle of the
abdomen, and inferiorly by the iliac crest (which forms
2 The latissimus dorsi develops in the extensor the base). The occasional hernia at this site is called
compartment of the limb. Thereafter, it migrates to lumbar hernia (Fig. 5.4).
its wide attachment on the trunk, taking its nerve After completing the dissection of the back, the limb
supply (thoracodorsal nerve) along with it (latus = with clavicle and scapula is detached from the trunk.
wide). It is also called a swimmer’s muscle.
3 The latissimus dorsi is tested clinically by feeling the DISSECTION
contracting muscle in the posterior fold of the axilla For detachment of the limb, muscles which need to be
after asking the patient to cough. incised are trapezius, levator scapulae, rhomboid minor
Competency achievement: The student should be able to: and major, serratus anterior, latissimus dorsi and
AN 10.9 Describe the arterial anastomosis around the scapula and sternocleidomastoid.
mention the boundaries of triangle of auscultation.2 The sternoclavicular joint is opened to free clavicle
from the sternum. Upper limb with clavicle and scapula
Triangle of Auscultation is removed en bloc.
Triangle of auscultation is a small triangular interval
bounded medially by the lateral border of the trapezius, FACTS TO REMEMBER
laterally by the medial border of the scapula, and • Trapezius is a shrugging muscle supplied by spinal

Upper Limb
inferiorly by the upper border of the latissimus dorsi. root of XI nerve.
The floor of the triangle is formed by the 6th and 7th • Trapezius and serratus anterior cause 90°–180° of
rib, and 6th intercostal space (ICS), and the rhomboid abduction at shoulder joints.
major. This is the only part of the back which is not
covered by big muscles. Respiratory sounds of apex of
lower lobe heard through a stethoscope are better heard CLINICOANATOMICAL PROBLEM
over this triangle on each side. On the left side, the
cardiac orifice of the stomach lies deep to the triangle, A poor young adult felt multiple nodules in the
and in days before X-rays were discovered, the sounds region of his neck above the clavicle. A lymph node
1

of swallowed liquids were auscultated over this triangle biopsy was advised from right side of his neck. A
few days after the biopsy he was unable to shrug his
Section

to confirm the oesophageal tumour (Fig. 5.3a).

right shoulder
Lumbar Triangle of Petit • Why was the biopsy advised?
Lumbar triangle of Petit is another small triangle • Why is he not able to shrug his shoulder?
surrounded by muscles. It is bounded medially by the
 UPPER LIMB
72

FURTHER READING
Ans: For proper diagnosis and treatment, a lymph
node biopsy was advised from the posterior triangle • Mehra L, Tuli A, Raheja S. Dorsoscapularis triangularis:
of neck. The spinal root of accessory nerve got injured Embryological and phylogenetic characterization of a rare
variation of Trapezius. Anatomy and Cell Biology 2016;
during the biopsy procedure. This nerve supplies
49(1):68–72.
trapezius muscle, responsible for shrugging of the
shoulder. Due to the injury to spinal root of XI nerve,
he is unable to shrug his shoulder.

1–2
From Medical Council of India, Competency based Undergraduate Curriculum for the Indian Medical Graduate, 2018;1:44–80.

1. Describe trapezius muscle under following 2. Enumerate structures under cover of trapezius.
headings: 3. Describe latissimus dorsi under following headings:
a. Origin a. Origin
b. Insertion b. Insertion
c. Nerve supply c. Nerve supply
d. Actions d. Actions

1. Boundaries of triangle of auscultation are not 3. Trapezius is not attached to:

formed by one of the following structures: a. Clavicle b. First rib
a. Lateral border of trapezius c. Occiput d. Scapula
b. Medial border of scapula 4. Posterior primary rami of one of the following
c. Upper border of latissimus dorsi nerves give cutaneous branch:
d. Upper border of teres major
a. C1 b. C7, C8
2. Boundaries of lumbar triangle of Petit are formed
c. L4, 5 d. S1
by all, except:
5. Which structure does not lie just deep to trapezius?
a. Lateral border of latissimus dorsi
b. Posterior border of external oblique muscle of a. Spinal accessory nerve
abdomen b. Superficial branch of transverse cervical artery
c. Iliac crest c. Deep branch of transverse cervical artery
d. Quadratus lumborum d. C3 and C4 nerves
Upper Limb

1. d 2. d 3. b 4. d 5. c
1
Section

• Mark the insertion of trapezius on the scapula. • What is the action of rhomboid major and minor
• Name structures under cover of trapezius. muscles?
• Give the attachments of latissimus dorsi muscle. • Give the boundaries of triangle of auscultation.
• What are the nerves supplying trapezius? • Give the boundaries of lumbar triangle of Petit.
 6
Scapular Region
! Action speaks louder than words !
—English Proverb

INTRODUCTION b. The greater tubercle of the humerus forms the

The shoulder or scapular region comprises structures most lateral bony point of the shoulder.
which are closely related to and surround the shoulder 2 The skin covering the shoulder region is supplied by:
joint. For a proper understanding of the region, revise a. The lateral supraclavicular nerve, over the upper
some features of the scapula and the upper end of the half of the deltoid
humerus. b. The upper lateral cutaneous nerve of the arm, over
the lower half of the deltoid
SURFACE LANDMARKS c. The dorsal rami of the upper thoracic nerves, over
the back, i.e. over the scapula.
1 a. The upper half of the humerus is covered on its 3 The superficial fascia contains (in addition to some fat
anterior, lateral and posterior aspects by the deltoid and cutaneous nerves) the inferolateral part of the
muscle. This muscle is triangular in shape and platysma arising from the deltoid fascia.
forms the rounded contour of the shoulder (Fig. 6.1). 4 The deep fascia covering the deltoid sends numerous
septa between its fasciculi. The subscapularis,
supraspinatus and infraspinatus fasciae provide
origin to a part of the respective muscle.

MUSCLES OF THE SCAPULAR REGION

Features
Muscles of scapular region are the deltoid (Fig. 6.2), the
supraspinatus, the infraspinatus, the teres minor, the sub-
scapularis, and the teres major. The other muscles are
described in Tables 6.1 and 6.2. The deltoid is described
below.

Competency achievement: The student should be able to:

AN 10.10 Describe and identify the deltoid and rotator cuff muscles.1

DELTOID (DELTA LIKE OR TRIANGULAR)

Origin with Features
1 The anterior border and adjoining surface of the
lateral one-third of the clavicle (Fig. 6.2).
2 The lateral border of the acromion process where
four septa of origin are attached (Fig. 6.2).
Fig. 6.1: Surface landmarks: Shoulder, arm and elbow regions 3 Lower lip of the crest of the spine of the scapula.
73
 UPPER LIMB
74

Table 6.1: Attachments of muscles of scapular region (except deltoid)

Muscle Origin Insertion
1. Supraspinatus Medial two-thirds of the supraspinous fossa Upper impression on the greater tubercle
(Fig. 6.3) of the scapula. The muscle passes as a tendon of the humerus
laterally beneath coracoacromial arch to blend
with the capsule of shoulder joint.
The tendon is separated from the arch by the
subacromial bursa (Fig. 6.7).
2. Infraspinatus Medial two-thirds of the infraspinous fossa Middle impression on the greater
of the scapula tubercle of the humerus
3. Teres minor Upper two-thirds of the dorsal surface of the Lowest impression on the greater
lateral border of the scapula as 2 slips tubercle of the humerus
4. Subscapularis (multipennate) Medial two-thirds of the subscapular fossa Lesser tubercle of the humerus
(Fig. 6.4)
5. Teres major Lower one-third of the dorsal surface of lateral Medial lip of the bicipital groove of the
border and inferior angle of the scapula humerus (see Fig. 4.4)

Table 6.2: Nerve supply and actions of muscles of scapular region (except deltoid)
Muscle Nerve supply Actions
1. Supraspinatus Suprascapular nerve (C5, C6) • Along with other short scapular muscles, it steadies the
(Fig. 6.3) head of the humerus during movements of the arm. Its action
as abductor of shoulder joint from 0°–15° is controversial.
Both supraspinatus and deltoid are involved in initiation of
abduction and continuation of abduction.
2. Infraspinatus Suprascapular nerve (C5, C6) • Lateral rotator of arm (at shoulder joint)
3. Teres minor Axillary nerve (C5, C6) Same as infraspinatus
4. Subscapularis Upper and lower subscapular nerves Medial rotator and adductor of arm
(Fig. 6.4) (C5, C6)
5. Teres major Lower subscapular nerve (C5, C6) Medial rotator, adductor and extensor of arm
Upper Limb
1
Section

Figs 6.2a and b: The origin and insertion of the deltoid muscle
 SCAPULAR REGION
75

The acromial part of deltoid is an example of a

multipennate muscle. Many fibres arise from four septa
of origin that are attached above to the acromion process.
The fibres converge onto three septa of insertion which
are attached to the deltoid tuberosity (Fig. 6.2).

Insertion
The deltoid tuberosity of the humerus where three septa
of insertion are attached.
Nerve Supply
Axillary nerve (C5, C6).

Actions
1 The multipennate acromial fibres are powerful
abductors of the arm at the shoulder joint from Fig. 6.3: The origins and insertions of the supraspinatus,
beginning to 90°. infraspinatus and teres minor muscles of right side
A multipennate arrangement allows a large
number of muscle fibres to be packed into a relatively
small volume. As the strength of contraction of a
muscle is proportional to the number of muscle fibres
present in it (and not on their length), a multipennate
muscle is much stronger than other muscles having
the same volume.
2 The anterior fibres are flexors and medial rotators of
the arm.
3 The posterior fibres are extensors and lateral rotators
of the arm.

Structures under Cover of the Deltoid

Bones
i. The upper end of the humerus
ii. The coracoid process

Muscles
Insertions of
i. Pectoralis minor on coracoid process. Fig. 6.4: The subscapularis muscle
ii. Supraspinatus, infraspinatus, and teres minor (on Vessels
the greater tubercle of the humerus) (Fig. 6.3).
Upper Limb
i. Anterior circumflex humeral
iii. Subscapularis on lesser tubercle of humerus (Fig. 6.4). ii. Posterior circumflex humeral (Fig. 6.6)
iv. Pectoralis major, teres major and latissimus dorsi
on the intertubercular sulcus of the humerus Nerve
(Fig. 6.5). Axillary (Fig. 6.6).
Origin of Joints and Ligaments
i. Coracobrachialis and short head of biceps brachii
i. Shoulder joint
from the coracoid process (Fig. 6.5).
ii. Musculotendinous cuff of the shoulder (Fig. 6.7).
1

ii. Long head of the biceps brachii from the supra- iii. Coracoacromial ligament.
glenoid tubercle.
Section

iii. Long head of the triceps brachii from the infra- Bursae
glenoid tubercle. Subscapular, infraspinatus bursae around the shoulder
iv. The lateral head of the triceps brachii from the upper joint, including the subacromial or subdeltoid bursa
part of posterior surface of the humerus. (Fig. 6.8).
 UPPER LIMB
76

Fig. 6.5: Horizontal section of the deltoid region showing arrangement of the muscles in and around the bicipital groove

Fig. 6.6: Horizontal section of the deltoid region showing the axillary nerve and vessels around the surgical neck of humerus
Upper Limb

DISSECTION
Define the margins of the deltoid muscle covering the
shoulder joint region. Reflect the part of the muscle
arising from spine of scapula downwards. Separate the
infraspinatus muscle from teres major and minor
muscles which run from the lateral scapular border
towards humerus. Axillary nerve accompanied with
posterior circumflex humeral vessels lies on the deep
1

aspect of the deltoid muscle (refer to BDC App).

Section

Competency achievement: The student should be able to:

AN 10.13 Explain anatomical basis of injury to axillary nerve during
intramuscular injections.2 Fig. 6.7: Subacromial bursa in sagittal section, with the
musculotendinous cuff of the shoulder
 SCAPULAR REGION
77

CLINICAL ANATOMY

• Intramuscular injections are often given into

the deltoid. They should be given in the middle
of the muscle to avoid injury to the axillary nerve
(Fig. 6.9a). If injection is given in upper part of
deltoid, axillary nerve may be damaged.
• The deltoid muscle is tested by asking the patient
to abduct the arm against resistance applied with
one hand, and feeling for the contracting muscle
with the other hand (Fig. 6.9b).
• The axillary nerve may be damaged by disloca-
tion of the shoulder or by the fracture of the surgical
neck of the humerus. The effects produced are:
a. Rounded contour of shoulder is lost; greater
tubercle of humerus becomes prominent
(Fig. 6.10a).
b. Deltoid is paralysed, with loss of the power of
abduction up to 90° at the shoulder.
Fig. 6.8: The subacromial bursa as seen in coronal section

Figs 6.9a and b: (a) Intramuscular injection being given in deltoid muscle, and (b) deltoid muscle being tested

Upper Limb
1Section

Figs 6.10a and b: (a) Normal rounded contour is lost on the right side. Inset shows normal contour, and (b) the sensory loss (regimental badge)
 UPPER LIMB
78

c. There is sensory loss over the lower half of the INTERMUSCULAR SPACES
deltoid in a badge-like area called regimental
badge (Fig. 6.10b). INTRODUCTION
• The tendon of the supraspinatus may undergo The long head of triceps brachii spans the length of the
degeneration. This can give rise to calcification and arm arising from infraglenoid tubercle of scapula to the
even spontaneous rupture of the tendon. olecranon process of ulna. It lies medial to humerus.
• In subacromial bursitis, pressure over the deltoid Teres minor crosses posterior aspect of the shoulder
below the acromion process with the arm by the joint and origin of the long head as it passes from its
side causes pain. However, when the arm is origin from scapula to the humerus. The muscle is
abducted, pressure over the same point causes no replaced by subscapularis on the anterior aspect of
pain, because the bursa disappears under the shoulder joint. Teres major also crosses the long head
acromion process (Dawbarn’s sign). Subacromial as it runs to bicipital groove for its insertion.
or subdeltoid bursitis is usually secondary to Thus potential spaces are formed between lateral
inflammation of the supraspinatus tendon. border of scapula, medial aspect of humerus, long head
of triceps brachii, teres minor or subscapularis and teres
major muscles.
Competency achievement: The student should be able to: In the upper part, there is a quadrangular space
AN 10.10 Describe and identify the deltoid and rotator cuff muscles.3 laterally and upper triangular space medially. In the
lower part is the lower triangular space. Their
boundaries are as follows.
Musculotendinous Cuff of the Shoulder or Rotator Cuff
Musculotendinous cuff of the shoulder is a fibrous Quadrangular Space
sheath formed by the four flattened tendons which blend
with the capsule of the shoulder joint and strengthen it. Boundaries
The muscles which form the cuff arise from the scapula Superior:
and are inserted into the lesser and greater tubercles of i. Subscapularis in front.
the humerus. They are the subscapularis, the ii. Capsule of the shoulder joint. This is the loose
supraspinatus, the infraspinatus and the teres minor inferior part of the capsule of the shoulder joint. In
(Fig. 6.7). Their tendons, while crossing the shoulder anatomical position, the capsule lies in this space.
joint, become flattened and blend with each other on one The capsule gets taut as it is used up during
hand, and with the capsule of the joint on the other hand, abduction of the shoulder joint.
before reaching their points of insertion. iii. Inferior border of teres minor behind.
The cuff gives strength to the capsule of the shoulder Inferior: Superior border of teres major.
joint all around except inferiorly. This explains why
dislocations of the humerus occur commonly in a Medial: Lateral border of long head of the triceps brachii.
anteroinferior direction. Thus rotator cuff rests on Lateral: Surgical neck of the humerus.
tuberosities, fused to the capsule, strengthens the
Contents
capsule and steadies head of humerus.
i. Axillary nerve (Fig. 6.11)
Upper Limb

Subacromial Bursa
ii. Posterior circumflex humeral vessels
Subacromial bursa is the largest bursa of the body, Upper Triangular Space
situated below the coracoacromial arch and the deltoid
muscle. Below the bursa, there are the tendon of the Boundaries
supraspinatus and the greater tubercle of the humerus Superior: Inferior border of teres minor.
(Fig. 6.8). Lateral: Medial border of long head of the triceps brachii.
The subacromial bursa is of great value in the Inferior: Superior border of teres major.
1

abduction of the arm at the shoulder joint.

i. It protects the supraspinatus tendon against Contents
Section

friction with the acromion process. Circumflex scapular artery. It interrupts the origin of
ii. During overhead abduction, the greater tubercle the teres minor and reaches the infraspinous fossa for
of the humerus passes under the acromion process; anastomoses with the suprascapular artery and deep
this is facilitated by the presence of this bursa. branch of transverse cervical artery.
 SCAPULAR REGION
79

Fig. 6.11: The intermuscular spaces in the scapular region, including the quadrangular, upper triangular and lower triangular spaces

Lower Triangular Space

Look for the structures covered with deltoid muscle.
It is diagonally opposite the upper triangular space.
Identify a lower triangular space which is bounded
Boundaries above by the lower border of teres major muscle,
Medial: Lateral border of long head of the triceps brachii. medially by the long head of triceps brachii and laterally
Lateral: Medial border of humerus. by the medial border of humerus. The radial nerve and
profunda brachii vessels pass through the space.
Superior: Lower border of teres major (Fig. 6.11).
Dissect and identify the arteries taking part in the
Contents anastomoses around scapula. These are suprascapular
i. Radial nerve along upper border, deep branch of transverse cervical
ii. Profunda brachii vessels (dorsal scapular) along medial border and circumflex
scapular along lateral border of scapula (Fig. 6.12).
DISSECTION
The quadrangular intermuscular space is a space in
between the scapular muscles. The quadrangular space Competency achievement: The student should be able to:
is bounded by teres minor above and teres major below; AN 10.13 Explain anatomical basis of injury to axillary nerve during
by the long head of triceps muscle medially and the
Upper Limb
intramuscular injections.4
surgical neck of humerus laterally. The axillary nerve
accompanied with posterior circumflex humeral vessels
lie in this space. Identify the nerve to the teres minor
muscle (Fig. 6.11) (refer to BDC App). Identify part of AXILLARY OR CIRCUMFLEX NERVE
the capsule of the shoulder joint. Axillary or circumflex nerve is an important nerve
Another intermuscular space, the upper triangular because it supplies the deltoid muscle which is the
space should be dissected. It is bounded by the teres main abductor of the arm. Surgically, it is important,
minor muscle medially, long head of triceps laterally, because it is commonly involved in dislocations of the
1

and teres major muscle below. shoulder and in fractures of the surgical neck of the
Now the remaining two-thirds of deltoid muscle can humerus.
Section

be reflected towards its insertion. Identify subscapularis The axillary nerve is a smaller terminal branch of
muscle anteriorly. the posterior cord of the brachial plexus (C5, C6).
Define the attachments of infraspinatus and cut
Root value: Its root value is ventral rami of cervical
muscle at the neck of scapula and reflect it on both sides.
5, 6 segments of spinal cord (see Fig. 4.14).
 UPPER LIMB
80

Fig. 6.12: Anastomoses around the scapula (dorsal aspect)

Course c. The anterior branch is accompanied by the posterior

Axillary nerve courses through lower part of axilla into circumflex humeral vessels. It winds around the
the quadrangular space where it terminates by dividing surgical neck of the humerus, deep to the deltoid
into two branches (Fig. 6.6). muscle supplying the deltoid and the skin over its
anteroinferior part.
Relations and Branches d. The posterior branch supplies the teres minor and the
posterior part of the deltoid. The nerve to the teres
a. In the lower part of the axilla, the nerve runs
minor bears a pseudoganglion, i.e. fibrous tissue and
downwards behind the third part of the axillary
fat without any neurons (Fig. 6.6). The posterior
artery. Here it lies on the subscapularis muscle. It is
branch then pierces the deep fascia at the lower part
related medially to the radial nerve, and laterally to
of the posterior border of the deltoid and continues
the coracobrachialis (see Fig. 4.9).
as the upper lateral cutaneous nerve of the arm.
The nerve leaves the axilla by winding round the
Its clinical anatomy has been given on p-77.
lower border of the subscapularis in close relation
to the lowest part of the capsule of the shoulder joint Competency achievement: The student should be able to:
where it gives a branch to the capsule of the joint AN 10.9 Describe the arterial anastomosis around the scapula and
and enters the quadrangular space (Fig. 6.8).
Upper Limb

mention the boundaries of triangle of auscultation.5

b. The nerve then passes backwards through the
quadrangular space. Here it is accompanied by the
posterior circumflex humeral vessels and has the ANASTOMOSES AROUND SCAPULA
following relations (Fig. 6.11).
Anastomosis Around the Body of the Scapula
• Superiorly:
i. Subscapularis anteriorly or teres minor The anastomosis occurs in the three fossae—subscap-
posteriorly. ular, supraspinous and infraspinous. It is formed by:
ii. Lowest part of the capsule of the shoulder a. The suprascapular artery, a branch of the thyro-
1

joint. cervical trunk (Fig. 6.12).

• Laterally: Surgical neck of humerus.
Section

b. The deep branch of the transverse cervical artery,

• Inferiorly: Teres major. another branch of the thyrocervical trunk.
• Medially: Long head of the triceps brachii. c. The circumflex scapular artery, a branch of the
In the quadrangular space, the nerve divides into subscapular artery which arises from the third part
anterior and posterior branches (Fig. 6.6). of the axillary artery.
 SCAPULAR REGION
81

Note that it is the anastomosis between branches of

the first part of the subclavian artery and the branches FACTS TO REMEMBER
of the third part of the axillary artery. These arteries
• Branches of axillary nerve with accompanying
also anastomose with intercostal arteries.
blood vessels pass through the quadrangular inter-
Anastomosis Over the Acromion Process
muscular space.
• Loose fold of capsule of shoulder joint forms upper
It is formed by: boundary of the quadrangular intermuscular space.
a. The acromial branch of the thoracoacromial artery • Radial nerve and profunda brachii vessels course
(2nd part of axillary). through the lower triangular intermuscular space.
b. The acromial branch of the suprascapular artery (1st • Only circumflex scapular vessels pass through the
part of subclavian). upper triangular space.
c. The acromial branch of the posterior circumflex • Long head of triceps brachii is placed between
humeral artery (3rd part of axillary). quadrangular and upper triangular spaces. Lower
Note that this is the anastomosis between the first down it forms a boundary of lower triangular
part of the subclavian artery and the branches of the space.
second and third parts of the axillary artery (Fig. 6.12).

Competency achievement: The student should be able to: CLINICOANATOMICAL PROBLEM

AN 10.13 Explain anatomical basis of injury to axillary nerve during
intramuscular injections.6 A patient came with injury on left shoulder region
after an accident. He was not able to abduct his
shoulder joint.
CLINICAL ANATOMY • Which nerve is injured?
The arterial anastomoses provide a collateral • Where is the sensory loss?
circulation through which blood can flow to the limb Ans: Due to the injury to the surgical neck of
when the distal part of the subclavian artery, or the humerus, the axillary nerve got damaged. Patient
proximal part of the axillary artery is blocked
feels inability to abduct the shoulder joint.
(Fig. 6.12).
Fracture of middle one-third of humerus causes The sensory loss is over the lower half of deltoid
injury to radial nerve as it lies in lower triangular muscle and is called regimental-badge area due to
space. This results in ‘wrist drop’. injury to upper lateral cutaneous nerve of the arm, a
branch of the axillary nerve.

Mnemonics FURTHER READING

Suprascapular nerve and artery • Hertel R, lambert SM, Ballmer FT. The deltoid extension lag
sign for diagnosis and grading of axillary nerve palsy. I
Army (artery) goes over the bridge Shoulder Elbow Surg 1998;7:97–99.
Navy (nerve) goes under the bridge A description of an example of the value of testing muscle capacity
Artery—suprascapular by eccentric activity, a more sensitive clinical method of

Upper Limb
Nerve—suprascapular determining weakness (i.e. decrement from normal without testing
Bridge—superior transverse scapular ligament. against the power of the observer) than using resistance against a
load (concentric activity).
Rotator cuff muscles • Leijnse JNAL, Han S-H, Kwon YH. Morphology of deltoid
The SITS muscles origin and end tendons—a generic model. J Anat 2008; 213:
Clockwise from top 733–42.
A description of the internal architecture of deltoid in relation to
Supraspinatus
the discrete functions of the parts of that muscle.
Infraspinatus • Shabana S, Mrudula C. Anatomy of suprascapular notch,
1

Teres minor suprascapular nerve entrapment and its clinical significance.

Advance research of multidisciplinary discovery 2018;25:12–
Section

Subscapularis
15.
1–6
From Medical Council of India, Competency based Undergraduate Curriculum for the Indian Medical Graduate, 2018;1:44–80.
 UPPER LIMB
82

1. Describe deltoid muscle under following headings: 3. Write short notes/enumerate:

a. Origin, insertion, action and nerve supply a. Course and branches of axillary nerve
b. Structures under cover of deltoid b. Anastomoses around the body of scapula
c. Effect of paralysis of the muscle c. Anastomses over the acromion process
2. Describe the boundaries and contents of d. Musculotendinous cuff of shoulder/rotator cuff
quadrangular, upper and lower triangular spaces.

1. Skin of lateral side of arm is supplied by all, except: 5. Boundaries of quadrangular space are not formed by:
a. Lateral supraclavicular nerve a. Teres minor
b. Intermediate supraclavicular nerve b. Long head of biceps brachii
c. Upper lateral cutaneous nerve of arm c. Surgical neck of humerus
d. Lower lateral cutaneous nerve of arm d. Teres major
2. Which part of deltoid is multipennate? 6. Which is not a content of lower triangular space?
a. Clavicular fibres a. Profunda brachii artery
b. Acromial fibres b. Radial nerve
c. Fibres from spine of scapula c. Superior ulnar collateral artery
d. Whole of the muscle d. Profunda brachii vein
3. Rotator cuff is formed by all, except:
7. Anastomosis around body of scapula is between:
a. Supraspinatus b. Infraspinatus
a. 1st part of subclavian artery and 3rd part of
c. Teres major d. Subscapularis axillary artery
4. Which of the following nerves has a pseudo- b. 2nd part of subclavian artery and 2nd part of
ganglion? axillary artery
a. Suprascapular nerve c. 3rd part of subclavian artery and 3rd part of
b. Axillary nerve axillary artery
c. Nerve to teres minor d. 1st part of subclavian artery and 2nd part of
d. Nerve to serratus anterior axillary artery

1. b 2. b 3. c 4. c 5. b 6. c 7. a
Upper Limb

• What type of fibres are the middle fibres of deltoid • What structures lie in the lower triangular space?
muscle? • What does the word ‘profunda’ mean?
• Show the main action of deltoid muscle.
• Why is axillary nerve called circumflex nerve?
1

• Name the structures under cover of deltoid.

• Where is intramuscular injection given in deltoid and • Name muscles supplied by the axillary nerve.
Section

why? • Name the arteries taking part in the anastomoses

• Name the muscles forming rotator cuff of shoulder. around scapula.
• Name the boundaries of quadrangular space and • What is the clinical importance of the anastomoses
give its contents. around scapula?
Cutaneous Nerves, Superficial 7
Veins and Lymphatic Drainage
! Eye, ear, nose and palpating fingers are the gems of a physician. An intact brain is the necklace !
—Hippocrates

INTRODUCTION dermatomes). This is so because each cutaneous

The superficial fascia seen after the reflection of skin nerve contains fibres from more than one ventral
contains cutaneous nerves, cutaneous or superficial ramus (of a spinal nerve); and each ramus gives
veins and lymphatics. The cutaneous nerves are the fibres to more than one cutaneous nerve.
continuation of the spinal nerves and carry sympathetic b. Adjacent areas of skin supplied by different cuta-
fibres for supplying the sweat glands, arterioles in the neous nerves overlap each other to a considerable
dermis and arrector pilorum muscles in relation to the extent. Therefore, the area of sensory loss after
hair follicle. Thus, the effects of sympathetic on the skin damage to a nerve is much less than the area of
are sudomotor (increase sweat secretion); vasomotor distribution of the nerve. The anaesthetic area is
(narrow the arterioles of skin) and pilomotor (contract surrounded by an area in which the sensations are
arrector pilorum muscle to make the hair erect or somewhat altered.
straight), respectively. The nerves also carry sensation c. In both the upper and lower limbs, the nerves of
of pain, touch, temperature and pressure. Superficial the anterior or flexor surface have a wider area of
veins are seen along with the cutaneous nerves. These distribution than those supplying the posterior or
are utilised for giving intravenous transfusions, cardiac extensor surface.
catheterisation and taking blood samples. Lymphatic The individual cutaneous nerves, from above
vessels though important are not easily seen in ordinary downwards, are described below with their root values.
dissection. Figures 7.1a and b show the cutaneous nerves of the
upper limb.
CUTANEOUS NERVES 1 The supraclavicular nerves (C3, C4) are branches
of the cervical plexus. They pierce the deep fascia
in the neck, descend superficial to the clavicle,
Position
and supply:
The skin of the upper limb is supplied by 15 sets of a. The skin of the pectoral region up to the level
cutaneous nerves (Table 7.1). Out of these, only one set of the second rib.
(supraclavicular) is derived from the cervical plexus, b. Skin covering the upper half of the deltoid.
and another nerve (intercostobrachial) is derived from 2 The upper lateral cutaneous nerve of the arm (C5, C6)
the second intercostal nerve. The remaining 13 sets are is the continuation of the posterior branch of the
derived from the brachial plexus through the axillary nerve. It supplies the skin covering the
musculocutaneous, median, ulnar, axillary and radial lower half of the deltoid.
nerves. Some branches arise directly from the medial 3 The lower lateral cutaneous nerve of the arm (C5, C6)
cord of the plexus. is a branch of the radial nerve given off in the
It should be noted as follows: radial groove. It supplies the skin of the lower
a. The areas of distribution of peripheral cutaneous half of the lateral side of the arm.
nerves do not necessarily correspond with those 4 The intercostobrachial nerve (T2) is the lateral
of individual spinal segments (areas of the skin cutaneous branch of the second intercostal nerve.
supplied by individual spinal segments are called It crosses the axilla, and supplies the skin of the
83
 UPPER LIMB
84

Table 7.1: The cutaneous nerves (Figs 7.1a and b)

Region supplied Nerve(s) Root value Derived from
Upper part of pectoral region, and skin Supraclavicular C3, C4 Cervical plexus
over upper part of deltoid
ARM
1. Upper medial part Intercostobrachial (Figs 7.1a and b) T2 2nd intercostal
2. Lower medial part Medial cutaneous nerve of arm T1, T2 Medial cord
3. Upper lateral part (including skin over Upper lateral cutaneous nerve of arm C5, C6 Axillary nerve
lower part of deltoid)
4. Lower lateral part Lower lateral cutaneous nerve of arm C5, C6 Radial nerve
5. Posterior aspect Posterior cutaneous nerve of arm C5 Radial nerve
FOREARM
1. Medial side Medial cutaneous nerve of forearm C8, T1 Medial cord
2. Lateral side Lateral cutaneous nerve of forearm C5, C6 Musculocutaneous
3. Posterior side Posterior cutaneous nerve of forearm C6–C8 Radial nerve
PALM
1. Lateral two-thirds Palmar cutaneous branch of median C6, C7 Median
2. Medial one-third Palmar cutaneous branch of ulnar C8 Ulnar
DORSUM OF HAND
1. Medial half including proximal and Dorsal branch of ulnar C8 Ulnar
middle phalanges of medial 2½ digits
2. Lateral half including proximal and Superficial terminal branch of radial C6, C7 Radial
middle phalanges of lateral 2½ digits
DIGITS
Palmar aspect, and dorsal aspect of
distal phalanges
1. Lateral 3½ digits Palmar digital branch of median C7 Median
2. Medial 1½ digits Palmar digital branch of ulnar C7, C8 Ulnar

upper half of the medial and posterior parts of 9 The posterior cutaneous nerve of the forearm
the arm. It lies amongst the central group of (C6–C8) arises from the radial nerve, in the radial
axillary lymph nodes. groove. It descends posterior to the lateral
5 The medial cutaneous nerve of the arm (T1, T2) is epicondyle and supplies the skin of the back of
the smallest branch of the medial cord of the the forearm.
brachial plexus. 10 The median nerve gives off two sets of cutaneous
6 The posterior cutaneous nerve of the arm (C5) is a branches in the hand.
Upper Limb

branch of the radial nerve given off in the axilla. a. The palmar cutaneous branch (C6–C8) arises a
It supplies the skin of the back of the arm from short distance above the wrist, lies superficial to
the insertion of the deltoid to the olecranon process. flexor retinaculum and supplies skin over the
7 The lateral cutaneous nerve of the forearm (C5, C6) lateral two-thirds of the palm including that
is the continuation of the musculocutaneous over the thenar eminence (Fig. 7.1a).
nerve. It pierces the deep fascia just lateral to the b. Palmar digital branches (C6–C8) are five in
tendon of the biceps 2–3 cm above the bend of number and arise in the palm. The medial two
the elbow, and supplies the skin of the lateral branches are common palmar digital nerves;
side of the forearm, extending anteriorly to a each divides near a digital cleft to form two
1

small part of the ball of the thumb. proper palmar digital nerves. The lateral three
Section

8 The medial cutaneous nerve of the forearm branches are proper palmar digital nerves for
(C8, T1) is a branch of the medial cord of the the medial and lateral sides of the thumb and
brachial plexus. It runs along the medial side of for the lateral side of the index finger. The
the axillary and brachial arteries, and supplies various digital branches of the median nerve
the skin of the medial side of the forearm. supply palmar skin of the lateral 3½ digits,
 CUTANEOUS NERVES, SUPERFICIAL VEINS AND LYMPHATIC DRAINAGE
85

Figs 7.1a and b: The cutaneous nerves

the nail beds, and skin on the dorsal aspect of times two) dorsal digital nerves. Typically, the
the distal phalanges of the same digits (Fig. region of skin supplied by the dorsal branch
7.1b). covers the medial half of the back of the hand,
11 The ulnar nerve gives off three sets of cutaneous and the skin on the dorsal aspect of the medial
nerves in hand. 2½ digits (see Fig. 11.6).
a. The palmar cutaneous branch (C7, C8) arises in 12 The superficial terminal branch of the radial nerve
the middle of the forearm and descends, (C6–C8) arises in front of the lateral epicondyle
crossing superficial to flexor retinaculum and of the humerus. It descends through the upper
supplies skin of the medial one-third of the two-thirds of the forearm lateral to the radial
palm. artery, and then passes posteriorly about 7 cm
b. The palmar digital branches of the ulnar nerve (C7, above the wrist. While winding round the radius
C8) are two in number. They arise from the it pierces the deep fascia and divides into four
superficial terminal branch of the ulnar nerve or five small dorsal digital nerves. In all, the
superficial terminal branch supplies the skin of
Upper Limb
just distal to the pisiform bone. The medial of
the two branches is a proper palmar digital the lateral half of the dorsum of the hand, and
nerve for the medial side of the little finger. The the dorsal surfaces of the lateral 2½ digits
lateral branch is a common palmar digital including the thumb, except for the terminal
nerve which divides into two proper digital portions supplied by the median nerve.
nerves for supply of adjacent sides of the ring
and little fingers. Thus it supplies skin of DISSECTION
medial 1½ digits, their nail beds and skin on Make one horizontal incision in the arm at its junction
the dorsal aspects of distal phalanges of medial of upper one-third and lower two-thirds segments
1

1½ digits (Figs 7.1a and b). (see Fig. 3.2) and a vertical incision through the centre
of arm and forearm till the wrist where another
Section

c. The dorsal branch of the ulnar nerve

(C7, C8) arises about 5 cm above the wrist. It transverse incision is given.
descends with the main trunk of the ulnar Reflect the skin on either side on the front as well as
nerve almost to the pisiform bone. Here, it on the back of the limb. Use this huge skin flap to cover
passes backwards to divide into three (some- the limb after the dissection.
 UPPER LIMB
86

Competency achievement: The student should be able to:

AN 13.2 Describe dermatomes of upper limb.1

DERMATOMES
Definition
The area of skin supplied by one spinal segment is
called a dermatome. A typical dermatome extends
from the posterior median line to the anterior median
line around the trunk (see Fig. 5.2). However, in the
limbs, the dermatomes have migrated rather irregularly,
so that the original uniform pattern is disturbed.
Embryological Basis
The early human embryo shows regular segmentation
of the body. Each segment is supplied by the corres- Fig. 7.3: Distribution of various segments in upper limb
ponding segmental nerve. In an adult, all structures
including the skin, developed from one segment, are
supplied by their original segmental nerve. The limb b. Partly from the overlapping segments from above
may be regarded as an extension of the body wall, and (C3, C4) as well from below (T2, T3). The addi-
the segments from which they are derived can be tional segments are found only at the proximal
deduced from the spinal nerves supplying them. The end of the limb (Fig. 7.3).
limb buds arise in the area of the body wall supplied 2 Since the limb bud appears on the ventrolateral
by the lateral branches of anterior primary rami. The aspect of the body wall, it is invariably supplied by
nerves to the limbs represent these branches (Fig. 7.2). the anterior primary rami of the spinal nerves.
Posterior primary rami do not supply the limb.
Important Features It is possible that the ventral and dorsal divisions
1 The cutaneous innervation of the upper limb is of the trunks of the brachial plexus represent the
derived: anterior and posterior branches of the lateral
a. Mainly from segments C5–C8 and T1 of the spinal cutaneous nerves (see Figs 4.14, 5.2 and 7.4).
cord, and 3 There is varying degree of overlapping of adjoining
dermatomes, so that the area of sensory loss
following damage to the cord or nerve roots is always
less than the area of distribution of the dermatomes
(Fig. 7.5).
4 Each limb bud has a cephalic and a caudal border,
known as preaxial and postaxial borders, respectively.
In the upper limb, the thumb and radius lie along the
Upper Limb
1
Section

Fig. 7.2: The body wall is supplied by (A) the posterior primary
rami, (B) the lateral branches of the anterior primary rami, and
(C) the anterior branches of the anterior primary rami of the Fig. 7.4: The upper limb bud grows out from the part of the
spinal nerves. The limb buds develop from the area supplied by body wall supplied by the lateral cutaneous branches of the
the lateral branches of the anterior primary rami anterior primary rami of spinal nerves
 CUTANEOUS NERVES, SUPERFICIAL VEINS AND LYMPHATIC DRAINAGE
87

b. The middle three digits (index, middle and ring

fingers) and the adjoining area of the palm are
supplied by segment C7.
c. The postaxial border is supplied (from below
upwards) by segments C8, T1, T2. There is
overlapping of the dermatomes.
6 As the limb elongates, it rotates laterally and gets
adducted and the central dermatome C7 gets pulled
in such a way that these are represented only in the
distal part of the limb, and are buried proximally.
On the front of the limb, areas supplied by C5 and
C6 segments adjoin the areas supplied by C8, T1 and
T2 segments. There is a dividing line between them,
known as the ventral axial line along which C7 is
buried proximally. It reaches the skin just proximal
Fig. 7.5: Overlapping of the dermatomes to the wrist (Fig. 7.6a).
On the back of the limb, C7 reaches the skin just
preaxial border, and the little finger and ulna along proximal to the elbow. So the dorsal axial line ends
the postaxial border. more proximal to the ventral axial line. There is no
5 The dermatomes of the upper limb are distributed overlapping across the ventral and dorsal axial lines
in an orderly numerical sequence (Figs 7.6a and b). (Fig. 7.6b).
a. Along the preaxial border, by segments C3–C6
with overlapping of the dermatomes.
CLINICAL ANATOMY

• The area of sensory loss of the skin, following injuries

of the spinal cord or of the nerve roots, conforms to
the dermatomes. Therefore, the segmental level of
the damage to the spinal cord can be determined by
examining the dermatomes for touch, pain and
temperature. Note that injury to a peripheral nerve
produces sensory loss corresponding to the area of
distribution of that nerve.
• The spinal segments do not lie opposite the
corresponding vertebrae. In estimating the
position of a spinal segment in relation to the
surface of the body, it is important to remember
that a vertebral spine is always lower than the
corresponding spinal segment. As a rough guide,
it may be stated that in the cervical region, there
Upper Limb
is a difference of one segment, e.g. the 5th cervical
spine lies lower than the 5th cervical spinal
segment. It overlies the 6th cervical spinal segment.
Spinal segments Spine of vertebra
C1–C8 C1–C7
T1–T6 T1–T4
T7–T12 T5–T9
1

L1–L5 T10–T11
S1–S5 and Co1 T12–L1
Section

Competency achievement: The student should be able to:

Figs 7.6a and b: Dermatomes: (a) Anterior aspect, and AN 13.1 Describe veins of upper limb and its lymphatic drainage.2
(b) posterior aspect
 UPPER LIMB
88

SUPERFICIAL VEINS 5 The superficial veins are accompanied by cutaneous

nerves and superficial lymphatics, and not by
arteries. The superficial lymph nodes lie along the
Superficial veins of the upper limb assume importance
veins, and the deep lymph nodes along the arteries.
in medical practice because these are most commonly
used for intravenous injections and for withdrawing 6 The superficial veins are best utilised for intravenous
blood for testing. injections.

General Remarks INDIVIDUAL VEINS

1 Most of the superficial veins of the limb join together Dorsal Venous Arch
to form two large veins, cephalic (preaxial) and Dorsal venous arch lies on the dorsum of the hand
basilic (postaxial). (Figs 7.7a and c). Its afferents (tributaries) include:
2 The superficial veins run away from pressure points. i. Three dorsal metacarpal veins.
Therefore, they are absent in the palm (fist area),
ii. A dorsal digital vein from the medial side of the
along the ulnar border of the forearm (supporting
little finger.
border) and in the back of the arm and trapezius
region. This makes the course of the veins spiral, from iii. A dorsal digital vein from the radial side of the index
the dorsal to the ventral surface of the limb. finger.
3 The preaxial vein is longer than the postaxial. In other iv. Two dorsal digital veins from the thumb.
words, the preaxial vein drains into the deep v. Most of the blood from the palm courses through
(axillary) vein more proximally (at the root of the veins passing around the margins of the hand and
limb) than the postaxial vein which becomes deep also by perforating veins passing through the
in the middle of the arm. interosseous spaces. Pressure on the palm during
4 The earlier a vein becomes deep the better, because gripping fails to impede the venous return due to
the venous return is then assisted by muscular the mode of drainage of the palm into the dorsal
compression. The load of the preaxial (cephalic) vein venous arch. The efferents of dorsal venous arch are
is greatly relieved by the more efficient postaxial the cephalic and basilic veins.
(basilic) vein through a short circuiting channel (the
median cubital vein situated in front of the elbow) Cephalic Vein
and partly also by the deep veins through a perforator Cephalic vein is the preaxial vein of the upper limb
vein connecting the median cubital to the deep vein. (cf. great saphenous vein of the lower limb).
Upper Limb
1
Section

Figs 7.7a and b: The superficial veins of the upper limb: (a) On the back, (b) on the front of the limb, and (c) schematic
 CUTANEOUS NERVES, SUPERFICIAL VEINS AND LYMPHATIC DRAINAGE
89

It begins from the lateral end of the dorsal venous medial epicondyle. It is separated from the brachial
arch. artery by the bicipital aponeurosis.
It runs upwards: It may receive tributaries from the front of the
i. Through the roof of the anatomical snuffbox. forearm (median vein of the forearm) and is connected
ii. Winds around the lateral border of the distal part to the deep veins through a perforator vein which
of the forearm (Figs 7.7b and c). pierces the bicipital aponeurosis. The perforator vein
iii. Continues upwards in front of the elbow and fixes the median cubital vein and thus makes it ideal
along the lateral border of the biceps brachii. for intravenous injections.
iv. Pierces the deep fascia at the lower border of the
Median Vein of the Forearm
pectoralis major.
v. Runs in the deltopectoral groove up to the Median vein of the forearm begins from the palmar
infraclavicular fossa. venous network, and ends in any one of the veins in
vi. It pierces the clavipectoral fascia and joins the front of the elbow mostly in median cubital vein.
axillary vein (see Fig. 3.12). Deep Veins
At the elbow, the greater part of its blood is drained
Deep veins start as small venae comitantes running on
into the basilic vein through the median cubital vein, and
each side of digital veins. These continue proximally
partly also into the deep veins through the perforator
as superficial and deep palmar arches.
vein.
Then, these course proximally to continue as venae
It is accompanied by the lateral cutaneous nerve comitantes of radial and ulnar arteries; which further
of the forearm, and the terminal part of the radial join to form the brachial veins.
nerve. Brachial veins lie on each side of brachial artery.
An accessory cephalic vein is sometimes present. It These join the axillary vein at the lower border of teres
ends by joining the cephalic vein near the elbow. major. Axillary vein is described in axilla (see chapter 4).
Basilic Vein Competency achievement: The student should be able to:
Basilic vein is the postaxial vein of the upper limb AN 11.3 Describe the anatomical basis of venepuncture of cubital
(cf. short saphenous vein of the lower limb). veins.3
It begins from the medial end of the dorsal venous
arch (Figs 7.7a and c).
CLINICAL ANATOMY
It runs upwards:
i. Along the back of the medial border of the forearm, • The median cubital vein is the vein of choice for
ii. Winds around this border near the elbow, intravenous injections, for withdrawing blood
from donors, and for cardiac catheterisation,
iii. Continues upwards in front of the elbow (medial because it is fixed by the perforator and does not
epicondyle) and along the medial margin of the slip away during piercing. When the median
biceps brachii up to the middle of the arm, where cubital vein is absent, the basilic vein is preferred
• It pierces the deep fascia, and over the cephalic vein because the former is a more
• Runs along the medial side of the brachial efficient channel (Fig. 7.8). Basilic vein runs along
artery up to the lower border of teres major straight path, whereas cephalic vein bends acutely
Upper Limb
where it becomes the axillary vein. to drain into the axillary vein.
About 2.5 cm above the medial epicondyle of the • The cephalic vein frequently communicates with
humerus, it is joined by the median cubital vein. the external jugular vein by means of a small vein
It is accompanied by the posterior branch of which crosses in front of the clavicle. In operations
the medial cutaneous nerve of the forearm and the for removal of the breast (in carcinoma), the axillary
terminal part of the dorsal branch of the ulnar nerve. lymph nodes are also removed, and it sometimes
becomes necessary to remove a segment of the
Median Cubital Vein
axillary vein also. In these cases, the communication
between the cephalic vein and the external jugular
1

Medial cubital vein is a large communicating vein vein enlarges considerably and helps in draining
Section

which shunts blood from the cephalic to the basilic vein blood from the upper limb (Fig. 7.9).
(Fig. 7.7a). In case of fracture of the clavicle, the rupture of
It begins from the cephalic vein 2.5 cm below the the communicating channel may lead to formation
bend of the elbow, runs obliquely upward and of a large haematoma, i.e. collection of blood.
medially, and ends in the basilic vein 2.5 cm above the
 UPPER LIMB
90

Along the course of these lymph vessels, there are

groups of lymph nodes.
Lymph vessels are difficult to see and special
techniques are required for their visualisation.
Lymph nodes are small bean-like structures that are
usually present in groups. These are not normally
palpable in the living subject.
However, they often become enlarged in disease,
particularly by infection or by malignancy in the area
from which they receive lymph. They then become
palpable and examination of these nodes provides
valuable information regarding the presence and
spread of disease.
It is, therefore, of importance for the medical student
to know the lymphatic drainage of the different parts
of the body.

Lymph Nodes
The main lymph nodes of the upper limb are the axillary
Fig. 7.8: Intravenous injection being given in the median cubital lymph nodes. These comprise anterior, posterior,
vein lateral, central and apical groups. These have been
described in Chapter 4 (see Fig. 4.11). Other nodes are
as follows:
1 The infraclavicular nodes lie in or on the clavipectoral
fascia along the cephalic vein. They drain the upper
part of the breast, and the thumb with its web.
2 The deltopectoral node lies in the deltopectoral groove
along the cephalic vein. It is a displaced node of the
infraclavicular set, and drains similar structures.
3 The superficial cubital or supratrochlear nodes lie just
above the medial epicondyle along the basilic vein.
They drain the ulnar side of the hand and forearm.
4 A few other deep lymph nodes lie in the following
regions:
i. Along the medial side of the brachial artery.
ii. At the bifurcation of the brachial artery (deep
cubital lymph node).
iii. Occasionally along the arteries of the forearm.

Lymphatics
Upper Limb

Superficial Lymphatics
Fig. 7.9: A communicating vein helps in venous drainage from
upper limb Superficial lymphatics are much more numerous than
the deep lymphatics. They collect lymph from the skin
and subcutaneous tissues. Most of them ultimately
drain into the axillary nodes, except for:
LYMPH NODES AND LYMPHATIC DRAINAGE i. A few vessels from the medial side of the forearm
which drain into the superficial cubital nodes.
When circulating blood reaches the capillaries, part of ii. A few vessels from the lateral side of the forearm
1

its fluid content passes through them into the which drain into the deltopectoral or infraclavicular
Section

surrounding tissue as tissue fluid. Most of this tissue nodes.

fluid re-enters the capillaries at their venous ends. Some The dense palmar plexus drains mostly into the lymph
of it is, however, returned to the circulation through a vessels onto the dorsum of the hand, where these
separate set of lymphatic vessels. These vessels begin as continue with the vessels of the forearm. Lymph vessels
lymphatic capillaries which drain into larger vessels. of the back of forearm and arm curve round their medial
 CUTANEOUS NERVES, SUPERFICIAL VEINS AND LYMPHATIC DRAINAGE
91

Figs 7.10a and b: The superficial lymphatics of the upper limb

and lateral surfaces and ascend up to reach the floor of

the axilla. Thus, there is a vertical area of lymph shed in
the middle of back of forearm and arm (Figs 7.10a and b).
Deep Lymphatics
Deep lymphatics are much less numerous than the
superficial lymphatics. They drain structures lying deep
to the deep fascia. They run along the main blood vessels
of the limb, and end in the axillary nodes. Some of the
lymph may pass through the deep lymph nodes present
along the axillary vein as mentioned above. Fig. 7.11: Lymphangitis

CLINICAL ANATOMY
• Inflammation of lymph vessels is known as
Upper Limb
lymphangitis. In acute lymphangitis, the vessels
may be seen through the skin as red, tender
(painful to touch) streaks (Fig. 7.11).
• Inflammation of lymph nodes is called lymphadenitis.
It may be acute or chronic. The nodes enlarge and
become palpable and painful (Fig. 7.12).
• Obstruction to lymph vessels can result in accumu-
lation of tissue fluid in areas of drainage. This is
1

called lymphoedema. This may be caused by

carcinoma because of surgical removal of lymph
Section

nodes (Fig. 7.13b).

• Pain along the medial side of upper arm is due to
pressure on the intercostobrachial nerve by
enlarged central group of axillary lymph nodes. Fig. 7.12: Enlarged axillary lymph nodes
 UPPER LIMB
92

Ans: Median cubital vein is most conveniently placed

anterior to the elbow joint.
Deep to the vein is bicipital aponeurosis which
mostly prevents the needle from entering into the
underlying brachial artery.
The vein is made prominent by tying a tourniquet
on the arm or by keeping one’s hand tightly around
the arm, and asking the patient to do flexion and
extension of elbow in a fast mode.
Due to this exercise, the venous return gets
increased, but is prevented from drainage into deeper
veins due to compression applied to the arm. This
Figs 7.13a and b: (a) Normal upper limb, and (b) lympho-
makes the superficial veins prominent.
edema due to removal of axillary lymph nodes in case of
carcinoma of the breast Case 2
A female patient of 60 years felt two nodular
swellings in her right axilla.
FACTS TO REMEMBER
• What parts of the body have to be examined?
• Ventral axial line ends close to wrist joint, while
• What is the probable diagnosis of these swellings?
dorsal axial line ends close to elbow joint.
• Dermatome is an area of skin supplied by single Ans: The parts to be examined are both the mammary
spinal segment through a pair of right and left spinal glands for any tumour, axilla of both sides for more
nerves with both of its dorsal and ventral rami. palpable lymph nodes, supraclavicular and infra-
• There is no overlapping of the nerve supply across clavicular lymph nodes, examination of abdomen and
the axial lines. pelvis for any spread in the liver or ovary.
• Cephalic vein at its beginning in the ‘anatomical
On examination of her right breast, there was a firm
snuffbox’ and median cubital vein near the elbow
mass which she did not feel.
are the veins of choice for intravenous infusions.
• Median cubital vein is protected from the brachial Since there was a firm painless mass in the upper
artery by the bicipital aponeurosis. lateral quadrant of her right breast, the diagnosis would
be secondary (metastasis) in the axillary lymph node
from primary breast tumour. It would be confirmed
CLINICOANATOMICAL PROBLEMS by fine needle aspiration cytology and other tests.
Case 1
A patient came dehydrated with history of diarrhoea
and vomiting. He needed intravenous fluids. FURTHER READING
• Which vein is most convenient for intravenous • Tanis PJ, Nieweg OE, Valdes Olmos RA, et al. Anatomy and
infusion of glucose and why? physiology of lymphatic drainage of the breast from the
Upper Limb

perspective of sentinel node biopsy. J Am Coll Surg 2001;

• How does one make the vein prominent?
192:399–409.

1–3
From Medical Council of India, Competency based Undergraduate Curriculum for the Indian Medical Graduate, 2018;1:44–80.
1
Section
 CUTANEOUS NERVES, SUPERFICIAL VEINS AND LYMPHATIC DRAINAGE
93

1. Write short notes/enumerate: 2. Describe the beginning, course and termination of

a. Nerve supply of dorsum of hand basilic vein.
b. Nerve supply nail beds of all 5 digits 3. Describe the lymphatic drainage of upper limb.
Enumerate the groups of lymph nodes of the
c. Median cubital vein
axilla.
d. Ventral axial line

1. Skin of nail bed of ring finger is supplied by: 4. Cephalic vein drains into axillary vein:
a. Lateral half by median, medial half by ulnar a. In lower part of arm
b. Medial half by median, lateral half by radial b. In upper part of arm
c. Whole by median nerve c. In the forearm
d. Whole by ulnar nerve d. In infraclavicular fossa
2. Skin of anterior, medial and lateral sides of arm is 5. Lymph shed lies on the:
supplied by all, except: a. Lateral side of arm
a. Medial cutaneous nerve of arm b. Medial side of arm
b. Lateral supraclavicular nerve c. Anterior aspect of arm
c. Posterior cutaneous nerve of arm d. Posterior aspect of arm
d. Intercostobrachial nerve 6. Spinal segments T1–T6 lie opposite to:
3. Ventral axial line extends till: a. Spines of 1–4 thoracic vertebrae
a. Wrist joint b. Spines of 1–6 thoracic vertebrae
b. Elbow joint c. Spines of 2–7 thoracic spines
c. Middle of forearm d. Spines of 2–8 thoracic spines
d. Middle of arm

1. a 2. c 3. a 4. d 5. d 6. a

Upper Limb
• Name the cutaneous nerves supplying various areas • What fascia is pierced by cephalic vein before it
of the arm. drains into a big vein?
• Name the cutaneous nerves innervating the palm. • At what level, basilic vein becomes the axillary vein?
• Name the nerve supply all nail beds. • Name the axillary lymph nodes and other lymph
• Where does cephalic vein start? nodes in upper limb.
• In which box cephalic vein lies on the lateral side of • What is lymphoedema? What is its common cause?
1

the wrist? • Where does ventral axial line end in UL (upper limb)?
Section

• Where does median cubital vein start and end? • Where does dorsal axial line end in UL?
• What is the importance of median cubital vein? • Which are the commonly used veins for veni-
• Where does cephalic vein drain? puncture?
 8
Arm
! The man who gets angry, at the right things, with the right people, in the right
way, at the right time and for the right length of time is commended!
—Aristotle

INTRODUCTION
The arm extends from the shoulder joint till the elbow
joint. The skeleton of the arm is a ‘solo’ bone, the
humerus. Medial and lateral intermuscular septa divide
the arm into an anterior or flexor compartment and a
posterior or extensor compartment, to give each
compartment its individuality and freedom of action.
Since the structures in the front of arm continue across
the elbow joint into the cubital fossa, the cubital fossa
is also included in this chapter. The arm is called
brachium, so most of the structures in this chapter are
named accordingly, like brachialis, coracobrachialis and
brachial artery.

SURFACE LANDMARKS

The following landmarks can be felt in the living subject.

1 The greater tubercle of the humerus is the most lateral
bony point in the shoulder region. It can be felt just Fig. 8.1: Surface landmarks—front of upper arm
below the acromion process, deep to the deltoid
when the arm is by the side of the trunk (Fig. 8.1). the lower one-fourth of the arm as upward
2 The shaft of the humerus is felt only indistinctly continuations of the epicondyles.
because it is surrounded by muscles in its upper 6 The deltoid forms the rounded contour of the
half. In the lower half, the humerus is covered shoulder. The apex of the muscle is attached to the
anteriorly by the biceps brachii and brachialis, and deltoid tuberosity located at the middle of the
posteriorly by the triceps brachii. anterolateral surface of the humerus.
3 The medial epicondyle of the humerus is a prominent 7 The coracobrachialis forms an inconspicuous rounded
bony projection on the medial side of the elbow. It ridge in the upper part of the medial side of the arm.
is best seen and felt in a mid-flexed elbow. Pulsations of the brachial artery can be felt in the
4 The lateral epicondyle of the humerus is less prominent depression behind it.
than the medial. It can be felt in the upper part of 8 The biceps brachii muscle is overlapped above by the
the depression on the posterolateral aspect of the pectoralis major and by the deltoid. Below these
elbow in the extended position of the forearm. muscles, the biceps forms a conspicuous elevation
5 The medial and lateral supracondylar ridges are better on the front of the arm. Upon flexing the elbow, the
defined in the lower portions of the medial and contracting muscle becomes still more prominent.
lateral borders of the humerus. They can be felt in The tendon of the biceps can be felt in front of the
94
 ARM
95

elbow. The tendon is a guide to the brachial artery Two additional septa are present in the anterior
which lies on its medial side. compartment of the arm. The transverse septum
9 The brachial artery can be felt in front of the elbow separates the biceps from the brachialis and encloses
joint just medial to the tendon of the biceps brachii. the musculocutaneous nerve. The anteroposterior septum
Brachial pulsations are used for recording the blood separates the brachialis from the muscles attached to
pressure. the lateral supracondylar ridge; it encloses the radial
10 The ulnar nerve can be rolled by the palpating finger nerve and the anterior descending branch of the
behind the medial epicondyle of the humerus. During profunda brachii artery.
leprosy, this nerve becomes thick and enlarged.
11 The superficial cubital veins can be made more Competency achievement: The student should be able to:
prominent by applying tight pressure round the arm AN 11.1 Describe and demonstrate muscle groups of upper arm
and then contracting the forearm muscles by with emphasis on biceps and triceps brachii.1
clenching and releasing the fist a few times. The
cephalic vein runs upwards along the lateral border
of the biceps. The basilic vein can be seen along the ANTERIOR COMPARTMENT
lower half of the medial border of the biceps. The
cephalic and basilic veins are connected together in MUSCLES
front of the elbow by the median cubital vein which Muscles of the anterior compartment of the arm are
runs obliquely upwards and medially. the coracobrachialis, the biceps brachii and the
brachialis. They are described in Tables 8.1 and 8.2.
COMPARTMENTS OF THE ARM Morphological Importance of Coracobrachialis
The arm is divided into anterior and posterior Morphologically, the muscle is very important for
compartments by extension of deep fascia which are following reasons.
called the medial and lateral intermuscular septa The coracobrachialis represents the medial compart-
(Fig. 8.2). These septa provide additional surface for the ment, which is so well developed in the thigh.
attachment of muscles. They also form planes along In some animals, it is a tricipital muscle. In human,
which nerves and blood vessels travel. The septa are well the upper two heads have fused and musculocutaneous
nerve passes between the two, and the lowest third head
defined only in the lower half of the arm and are attached
has disappeared. Persistence of the lower head in
to the medial and lateral borders and supracondylar
human is associated with the presence of ‘ligament of
ridges of the humerus. The medial septum is pierced by
Struthers’, which is a fibrous band extending from the
the ulnar nerve and the superior ulnar collateral artery;
trochlear spine to the medial epicondyle of the humerus,
the lateral septum is pierced by the radial nerve and
to which the third head of the coracobrachialis is
radial collateral artery or the anterior descending branch
inserted, and from the lower part of which the pronator
of the profunda brachii artery (Fig. 8.7).
teres muscle takes origin. Beneath the ligament pass the
median nerve or brachial artery or both.
The front or anterior compartment of the arm is
homologous with flexor and medial compartments of
the thigh. The flexor compartment of thigh lies

Upper Limb
posteriorly because the lower limb bud rotates medially.

Competency achievement: The student should be able to:

AN 11.2 Identify and describe origin, course, relations, branches
(or tributaries), termination of important nerves and vessels in arm.2

NERVES
Musculocutaneous Nerve
1

The musculocutaneous nerve is the main nerve of the

Section

front of the arm, and continues below the elbow as the

lateral cutaneous nerve of the forearm (see Fig. 7.1a).
It is a branch of the lateral cord of the brachial plexus,
Fig. 8.2: Transverse section through the distal one-third of the arising at the lower border of the pectoralis minor (see
arm, showing the intermuscular septa and the compartments Fig. 4.14) in the axilla.
 UPPER LIMB
96

Table 8.1: Attachments of muscles

Muscle Origin Insertion
1. Coracobrachialis • The medial aspect of tip of the coracoid process with • The middle 5 cm of the medial border of
(see Fig. 2.8) the short head of the biceps brachii (Fig. 8.3a) the humerus
2. Biceps brachii It has two heads of origin: • Posterior rough part of the radial tuberosity.
(Fig. 8.3b) • The short head arises with coracobrachialis from the The tendon is twisted; the anterior fibres
lateral aspect of tip of the coracoid process become lateral and posterior fibres become
• The long head arises from the supraglenoid tubercle medial. The tendon is separated from the
of the scapula and from the glenoidal labrum. The anterior part of the tuberosity by a bursa
tendon is intracapsular (Fig. 8.4)
• The tendon gives off an extension called
the bicipital aponeurosis which extends to
ulna and it separates median cubital vein
from brachial artery
3. Brachialis • Lower half of the front of the humerus, including both • Coronoid process and ulnar tuberosity
(Fig. 8.5) the anteromedial and anterolateral surfaces and the • Rough anterior surface of the coronoid
anterior border process of the ulna
Superiorly the origin embraces the insertion of the
deltoid
• Medial and lateral intermuscular septa

Table 8.2: Nerve supply and actions of muscles

Muscle Nerve supply Actions
1. Coracobrachialis Musculocutaneous nerve (C5–C7) Flexes the arm at the shoulder joint
(Fig. 8.3a)
2. Biceps brachii Musculocutaneous nerve (C5–C6) • It is strong supinator when the forearm is flexed
(Figs 8.3b and c, All screwing movements are done with it
8.6, 8.7) • It is a flexor of the elbow
• The short head is a flexor of the arm
• The long head prevents upwards displacement of the
head of the humerus
• It can be tested against resistance as shown in Fig. 8.8
3. Brachialis • Musculocutaneous nerve is motor Flexes forearm at the elbow joint
• Radial nerve is proprioceptive

Root Value Relations

Upper Limb

The root value of musculocutaneous nerve is ventral In the lower part of the axilla: It accompanies the third
rami of C5–C7 segments of spinal cord. part of the axillary artery and has the following relations.
Anteriorly: Pectoralis major.
Origin, Course and Termination
Posteriorly: Subscapularis.
Musculocutaneous nerve arises from the lateral cord
of brachial plexus in the lower part of the axilla. It Medially: Axillary artery and lateral root of the median
nerve (see Fig. 4.9).
accompanies the third part of the axillary artery. It then
enters the front of arm, where it pierces coracobrachialis Laterally: Coracobrachialis (see Fig. 4.9).
muscle. Musculocutaneous nerve leaves the axilla, and enters
1

Musculocutaneous nerve runs downwards and the front of the arm by piercing the coracobrachialis
Section

laterally between biceps brachii and brachialis muscles (Fig. 8.6).

to reach the lateral side of the tendon of biceps brachii. In the arm: It runs downward and laterally between
It terminates by continuing as the lateral cutaneous the biceps brachii and brachialis to reach the lateral side
nerve of forearm 2 cm above the bend of the elbow of the tendon of the biceps. It ends by piercing the fascia
(Fig. 8.6). 2 cm above the bend of the forearm.
 ARM
97

Fig. 8.3a: Short head of biceps brachii and coacobrachialis

muscles

Fig. 8.3b: The biceps brachii muscle in extended elbow

Upper Limb
1Section

Fig. 8.3c: Intracapsular course of long head of biceps brachii muscle

 UPPER LIMB
98

Branches and Distribution

Muscular branches: It supplies the following muscles of
the front of the arm.
i. Coracobrachialis
ii. Biceps brachii, long and short heads
iii. Brachialis (Figs 8.6 and 8.7).
Cutaneous branches: Through the lateral cutaneous nerve
of the forearm, it supplies the skin of the lateral side of
the forearm from the elbow to the wrist including the
ball of the thumb (see Fig. 7.1a).
Articular branches:
i. The elbow joint through its branch to the brachialis.
Fig. 8.4: The precise mode of insertion of the biceps brachii ii. The shoulder joint through a separate branch which
muscle enters the humerus along with its nutrient artery.
Communicating branches: The musculocutaneous nerve
through lateral cutaneous nerve of forearm
communicates with the neighbouring nerves, namely
the superficial branch of the radial nerve, the posterior
cutaneous nerve of the forearm, and the palmar
cutaneous branch of the median nerve.
Upper Limb
1
Section

Fig. 8.5: The origin and insertion of the brachialis muscle Fig. 8.6: The course of the musculocutaneous nerve
 ARM
99

Fig. 8.7: Transverse section passing through the lower one-third of the arm

Median Nerve DISSECTION

Median nerve is closely related to the brachial artery Make an incision in the middle of deep fascia of the
throughout its course in the arm (Fig. 8.9). upper arm right down up to the elbow joint. Reflect the
In the upper part, it is lateral to the artery; in the flaps sideways.
middle of the arm, it crosses the artery from lateral to The most prominent muscle seen is the biceps
the medial side; and remains on the medial side of the brachii. Deep to this, another muscle called brachialis
artery right up to the elbow. is seen easily. In the fascial septum between the two
In the arm, the median nerve gives off a branch to muscles lies the musculocutaneous nerve (a branch of
the pronator teres just above the elbow and vascular the lateral cord of brachial plexus). Trace the tendinous
branches to the brachial artery. long head of biceps arising from the supraglenoid
An articular branch to the elbow joint arises at the tubercle and the short head arising from the tip of the
elbow. coracoid process of scapula. Identify coracobrachialis
muscle on the medial side of biceps brachii. This muscle
Ulnar Nerve is easily identified as it is pierced by musculocutaneous
nerve. Clean the branches of the nerve supplying all
Ulnar nerve runs on the medial side of the brachial
the three muscles dissected (refer to BDC App).
artery up to the level of insertion of the coraco-
brachialis, where it pierces the medial intermuscular
septum and enters the posterior compartment of the CLINICAL ANATOMY
arm. It is accompanied by the superior ulnar collateral Physician holds the patient’s wrist firmly, not letting it
vessels. move. Patient is requested to flex the elbow against
At the elbow, it passes behind the medial epicondyle
Upper Limb
the resistance offered by physician’s hand. One can see
where it can be palpated with a finger (Fig. 8.13a). and palpate hardening biceps brachii muscle (Fig. 8.8).

Radial Nerve
At the beginning of the brachial artery, the radial nerve
lies posterior to the artery (see Fig. 4.9). Soon the nerve
leaves the artery by entering the radial (spiral) groove
on the back of the arm where it is accompanied by the
profunda brachii artery (Fig. 8.13a).
1

In the lower part of the arm, the nerve appears

Section

again on the front of the arm where it lies between

the brachialis (medially); and the brachioradialis
and extensor carpi radialis longus (laterally)
(Fig. 8.17). Its branches will be discussed with the Fig. 8.8: Testing biceps brachii against resistance
back of the arm.
 UPPER LIMB
100

Biceps reflex: Musculocutaneous nerve is tested by downwards and laterally in the front of arm and crosses
biceps reflex. Tap the tendon of biceps with forearm the elbow joint. It ends at the level of the neck of radius
pronated and partially extended at the elbow. in the cubital fossa by dividing into its two terminal
Normal reflex is jerk-like flexion of elbow joint. branches, the radial and ulnar arteries.
Relations
Competency achievement: The student should be able to: 1 It runs downwards and laterally, from the medial
AN 11.2 Identify and describe origin, course, relations, branches (or side of the arm to the front of the elbow.
tributaries), and termination of important nerves and vessels in arm.3
2 It is superficial throughout its extent and is
accompanied by two venae comitantes.
BRACHIAL ARTERY
3 Anteriorly, in the middle of the arm, it is crossed by
Features the median nerve from the lateral to the medial side;
Brachial artery is the continuation of the axillary artery. and in front of the elbow, it is covered by the bicipital
It extends from the lower border of the teres major aponeurosis and the median cubital vein (Fig. 8.9).
muscle to a point in front of the elbow, at the level of 4 Posteriorly, it is related to:
the neck of the radius, just medial to the tendon of the
i. The triceps brachii
biceps brachii.
ii. The radial nerve and the profunda brachii artery.
Beginning, Course and Termination 5 Medially, in the upper part, it is related to the ulnar
Brachial artery begins at the lower border of teres major nerve and the basilic vein, and in the lower part to
muscle as continuation of axillary artery. It runs the median nerve (Figs 8.9a and b).
Upper Limb
1
Section

Figs 8.9a and b: The course and relations of the brachial artery
 ARM
101

Figs 8.10a and b: Anastomoses around the elbow joint

6 Laterally, it is related to the coracobrachialis, Anastomoses around the Elbow Joint

the biceps brachii and the median nerve in its upper Anastomoses around the elbow joint link the brachial
part; and to the tendon of the biceps brachii at the artery with the upper ends of the radial and ulnar arteries.
elbow (Figs 8.9a and b). They supply the ligaments and bones of the joint. The
7 At the elbow, the structures from the medial to the anastomoses can be subdivided into the following parts.
lateral side are: In front of the lateral epicondyle of the humerus, the
i. Median nerve anterior descending (radial collateral) branch of the
ii. Brachial artery profunda brachii anastomoses with the radial recurrent
iii. Biceps brachii tendon branch of the radial artery (Figs 8.10a and b).
iv. Radial nerve on a deeper plane (MBBR). Behind the lateral epicondyle of the humerus, the
posterior descending branch of the profunda brachii
Branches artery (middle collateral) anastomoses with the
1 Unnamed muscular branches. interosseous recurrent branch of the posterior

Upper Limb
2 The profunda brachii artery arises just below the teres interosseous artery.
major and accompanies the radial nerve. In front of the medial epicondyle of the humerus, the
3 The superior ulnar collateral branch arises in the upper inferior ulnar collateral branch of the brachial artery
part of the arm and accompanies the ulnar nerve anastomoses with the anterior ulnar recurrent branch
(Figs 8.10a and b). of the ulnar artery.
4 A nutrient artery is given off to the humerus. Behind the medial epicondyle of the humerus, the
5 The inferior ulnar collateral (or supratrochlear) branch superior ulnar collateral branch of the brachial artery
arises in the lower part and takes part in the anastomoses with the posterior ulnar recurrent branch
of the ulnar artery.
1

anastomoses around the elbow joint.

6 The artery ends by dividing into two terminal
Section

branches, the radial and ulnar arteries. DISSECTION

Dissect the brachial artery as it lies on the medial side
Competency achievement: The student should be able to: of the upper part of the arm medial to median nerve
AN 11.6 Describe the anastomoses around the elbow joint.4 and lateral to ulnar nerve (Figs 8.9a and b).
 UPPER LIMB
102

In the lower half of the upper arm, the brachial artery

is seen lateral to the median nerve as the nerve crosses
the brachial artery from lateral to medial side. Note that
the median nerve and brachial artery are forming
together a neurovascular bundle (refer to BDC App).
Ulnar nerve accompanied by the superior ulnar
collateral branch of the brachial artery will be dissected
later as it reaches the posterior (extensor) compartment
of the upper arm after piercing the medial intermuscular
septum (refer to BDC App).
Look for the radial nerve on the posterior aspect of
artery before it enters the radial groove.
Clean the branches of brachial artery and identify
other arteries which take part in the arterial
anastomoses around the elbow joint.
Fig. 8.11: Blood pressure being taken

CLINICAL ANATOMY
• Brachial pulsations are felt or auscultated in front
of the elbow just medial to the tendon of biceps
for recording the blood pressure (Fig. 8.11).
Figure 8.12 shows other palpable arteries.
• Although the brachial artery can be compressed
anywhere along its course, it can be compressed
most favourably in the middle of the arm, where
it lies on the tendon of the coracobrachialis.
• Blood for blood gas analysis is collected from
brachial artery.

Changes at the Level of Insertion of Coracobrachialis

1 Bone: The circular shaft becomes triangular below
this level.
2 Fascial septa: The medial and lateral intermuscular
septa become better defined from this level down
(Fig. 8.5).
3 Muscles:
i. Deltoid and coracobrachialis are inserted at this level
(Fig. 8.3a).
ii. Upper end of origin of brachialis.
Upper Limb

iii. Upper end of origin of the medial head of triceps

brachii.
4 Arteries:
i. The brachial artery passes from the medial side
of the arm to its anterior aspect.
ii. The profunda brachii artery runs in the spiral
groove and divides into its anterior descending/
radial collateral artery and posterior descending/
middle collateral branches (Fig. 8.9). Fig. 8.12: Palpable arteries in the body
1

iii. The superior ulnar collateral artery originates

Section

from the brachial artery, and pierces the medial ii. Two venae comitantes of the brachial artery may
intermuscular septum along with the ulnar nerve. unite to form one brachial vein.
iv. The nutrient artery of the humerus enters the bone. 6 Nerves:
5 Veins: i. The median nerve crosses the brachial artery from
i. The basilic vein pierces the deep fascia (Fig. 8.13b). the lateral to the medial side (Fig. 8.9).
 ARM
103

Figs 8.13a and b: Changes in positions of nerve, veins and arteries

ii. The ulnar nerve pierces the medial intermuscular

septum with the superior ulnar collateral artery
and goes to the posterior compartment (Fig. 8.9).
iii. The radial nerve pierces the lateral intermuscular
septum with the anterior descending (radial
collateral) branch of the profunda brachii artery
and passes from the posterior to the anterior
compartment (Fig. 8.13a).
iv. The medial cutaneous nerve of the arm pierces
the deep fascia (Fig. 8.13b).
v. The medial cutaneous nerve of the forearm
pierces the deep fascia (Fig. 8.13b).
Competency achievement: The student should be able to:

Upper Limb
AN 11.5 Identify and describe boundaries and contents of cubital
fossa.5

CUBITAL FOSSA

Features
Cubital (Latin cubitus, elbow) fossa is a triangular hollow
situated on the front of the elbow. (It is homologous Fig. 8.14: Boundaries of the right cubital fossa
1

with the popliteal fossa of the lower limb situated on

the back of the knee.)
Section

Medially – Lateral border of the pronator teres.

Boundaries Base – It is directed upwards, and is represented
Laterally – Medial border of the brachioradialis by an imaginary line joining the front of
(Fig. 8.14). two epicondyles of the humerus.
 UPPER LIMB
104

Apex – It is directed downwards, and is formed

by the area where brachioradialis crosses
the pronator teres muscle.

Roof
The roof of the cubital fossa (Fig. 8.15) is formed by:
a. Skin
b. Superficial fascia containing the median cubital vein
joining the cephalic and basilic veins. The lateral
cutaneous nerve of the forearm lies along with
cephalic vein and the medial cutaneous nerve of the
forearm along with basilic vein.
c. Deep fascia
d. Bicipital aponeurosis

Floor
It is formed by:
i. Brachialis (Figs 8.16a and b)
ii. Supinator surrounding the upper part of radius

Contents
The fossa is actually very narrow. The contents
described are seen after retracting the boundaries. From
medial to the lateral side, the contents are as follows:
1 The median nerve: It gives branches to flexor carpi
radialis, palmaris longus, flexor digitorum
superficialis and leaves the fossa by passing between Figs 8.16a and b: The floor of the cubital fossa is formed by
the two heads of pronator teres (Fig. 8.18). the brachialis and supinator muscles: (a) Surface view, and
(b) cross-sectional view
Upper Limb
1

Fig. 8.17: Contents of the right cubital fossa; mnemonic—MBBR

Section

2 The termination of the brachial artery, and the beginning

of the radial and ulnar arteries lie in the fossa.
The radial artery is smaller and more superficial than
Fig. 8.15: Structures in the roof of the right cubital fossa the ulnar artery. It gives off the radial recurrent branch.
 ARM
105

4 The radial nerve: It descends medial to lateral

epicondyle to enter cubital fossa. In the fossa, it gives
off the posterior interosseous nerve or deep branch
of the radial nerve which gives branches to extensor
capri radialis brevis and supinator. Then it leaves
the fossa by piercing the supinator muscle (Fig. 8.18).
The remaining superficial branch runs in the front
of forearm for some distance.

DISSECTION
Identify the structures (see text) present in the roof of a
shallow cubital fossa located on the front of the elbow.
Separate the lateral and medial boundaries formed
respectively by the brachioradialis and pronator teres
muscles (Figs 8.14 and 8.19). Clean the contents:
i. Median nerve on the medial side of brachial artery.
ii. Terminal part of brachial artery bifurcating into radial
Fig. 8.18: Contents of right cubital fossa (schematic) and ulnar arteries (refer to BDC App).
iii. The tendon of biceps brachii muscle between the
brachial artery and radial nerve.
The ulnar artery goes deep to both heads of pronator iv. The radial nerve on a deeper plane on the lateral
teres and runs downwards and medially, being side of biceps tendon.
separated from the median nerve by the deep head Identify brachialis and supinator muscles, forming
of the pronator teres (Fig. 8.19). the floor of cubital fossa.
Ulnar artery gives off the anterior ulnar recurrent,
the posterior ulnar recurrent, and the common
CLINICAL ANATOMY
interosseous branches (Fig. 8.10).
The common interosseous branch divides into the • The cubital region is important for the following
anterior and posterior interosseous arteries, and reasons:
latter gives off the interosseous recurrent branch. a. The median cubital vein is often the vein of
3 The tendon of the biceps brachii (Fig. 8.17). choice for intravenous injections (see Fig. 7.8).
It is used for introducing cardiac catheters to
get sample of blood from various chambers of
heart.
b. The blood pressure is universally recorded by
auscultating the brachial artery in front of the
elbow (Fig. 8.11).
• The anatomy of the cubital fossa is useful while
dealing with the fracture around the elbow, like

Upper Limb
the supracondylar fracture of the humerus.

POSTERIOR COMPARTMENT

Features
The region contains the triceps muscle, the radial nerve
and the profunda brachii artery. The nerve and artery
run through the muscle. The ulnar nerve runs through
1

the lower part of this compartment.

Section

Competency achievement: The student should be able to:

AN 11.1 Describe and demonstrate muscle groups of upper arm
with emphasis on biceps and triceps brachii.
Fig. 8.19: Contents of the cubital fossa seen in cross-section Biceps has been discribed in Tables 8.1 and 8.2.6
 UPPER LIMB
106

TRICEPS BRACHII MUSCLE medial head is inserted partly into the superficial
Origin tendon, and partly into the olecranon process. Although
the medial head is separated from the capsule of the
Triceps brachii muscle arises by the following three elbow joint by a small bursa, a few of its fibres are
heads (Figs 8.20a and b). inserted into this part of the capsule: This prevents
1 The long head arises from the infraglenoid tubercle nipping of the capsule during extension of the arm.
of the scapula; it is the longest of the three heads These fibres are referred to as the articularis cubiti, or as
(Fig. 8.21). the subanconeus.
2 The lateral head arises from an oblique ridge on the
upper part of the posterior surface of the humerus, Nerve Supply
corresponding to the lateral lip of the radial (spiral) Each head receives a separate branch from the radial
groove (Fig. 8.20a and b). nerve (C7, C8). The branches arise in the axilla and in
3 The medial head arises from a large triangular area on the radial groove.
the posterior surface of the humerus below the
radial groove, as well as from the medial and lateral Actions
intermuscular septa. At the level of the radial The triceps is a powerful active extensor of the elbow.
groove, the medial head is medial to the lateral head The long head causes extension and adduction of arm
(see Figs 2.14a and b). at shoulder joint. It supports the head of the humerus
in the abducted position of the arm. Gravity extends
Insertion the elbow passively.
The long and lateral heads converge and fuse to form a Electromyography has shown that the medial head
superficial flattened tendon which covers the medial of the triceps is active in all forms of extension, and the
head and are inserted into the posterior part of the actions of the long and lateral heads are minimal, except
superior surface of the olecranon process (Fig. 8.20). The when acting against resistance.
Upper Limb
1
Section

Figs 8.20a and b: The triceps brachii muscle

 ARM
107

Fig. 8.21: Transverse section through the arm a little below the insertion of the coracobrachialis and deltoid showing arrangement
of three heads of the triceps, and the radial nerve in the radial groove

DISSECTION
Reflect the skin of back of arm to view the triceps brachii
muscle. Define its attachments and separate the long
head of the muscle from its lateral head.
Radial nerve will be seen passing between the long
head of triceps and medial border of the humerus. Note
the continuity of radial nerve up to axilla. Carefully cut
through the lateral head of triceps to expose radial nerve
along with profunda brachii vessels. Note that the radial
nerve lies in the radial groove, on the back of humerus,
passing between the lateral head of triceps above and
its medial head below. In the lower part of arm, the radial
nerve lies on the front of elbow just lateral to the
brachialis, dividing into two terminal branches in the Fig. 8.22: Testing triceps brachii against resistance
cubital fossa (refer to BDC App).
The ulnar nerve (which was seen in the anterior
compartment of arm till its middle) pierces the medial Origin, Course and Termination
intermuscular septum with its accompanying vessels, Radial nerve is given off from the posterior cord in the
reaches the back of elbow and may easily be palpated lower part of axilla.
on the back of medial epicondyle of humerus. 1 It runs behind third part of axillary artery (see

Upper Limb
Figs 4.7c and d).
CLINICAL ANATOMY 2 In the arm, it lies behind the brachial artery (Fig. 8.9a).
3 Leaves the brachial artery to enter the lower
• In radial nerve injuries in the arm, the triceps triangular space to reach the oblique radial sulcus
brachii usually escapes complete paralysis because on the back of humerus (Fig. 8.13a).
the two nerves supplying it, arise in the axilla. 4 The nerve reaches the lateral side of arm 5 cm below
• Physician holds the flexed forearm firmly. Patient deltoid tuberosity, pierces lateral intermuscular
is requested to extend his elbow against the septum to enter the anterior compartment of arm on
resistance of the physician’s hand. The contracting its lateral aspect (Fig. 8.13a).
1

triceps brachii is felt (Fig. 8.22). 5 It descends down medial to the lateral epicondyle
Section

into cubital fossa.

RADIAL NERVE OR MUSCULOSPIRAL NERVE Radial nerve terminates by dividing into a superficial
Radial nerve is the largest branch of the posterior cord and a deep branch (posterior interosseous nerve) just
of the brachial plexus with a root value of C5–C8 and below the level of lateral epicondyle. These are seen in
T1 (see Fig. 4.14). the cubital fossa (Fig. 8.18).
 UPPER LIMB
108

Relations It then enters the radial groove with the profunda

a. In the lower part of the axilla, radial nerve passes vessels (see Fig. 6.11).
downwards and has the following relations. c. In the radial groove, the nerve runs downwards and
Anteriorly: Third part of the axillary artery (see Fig. 4.8). laterally between the lateral and medial heads of the
triceps brachii, in contact with the humerus (Fig. 8.13a).
Posteriorly: Subscapularis, latissimus dorsi and teres
At the lower end of the groove, 5 cm below the deltoid
major.
tuberosity, the nerve pierces the lateral intermuscular
Laterally: Axillary nerve and coracobrachialis. septum and passes into the anterior compartment of
Medially: Axillary vein (see Fig. 4.9). the arm (Fig. 8.17) to reach the cubital fossa where it
b. In the upper part of the arm, it continues behind the ends by dividing into superficial and deep branches.
brachial artery, and passes posterolaterally (with the
profunda brachii vessels) through the lower Branches and Distribution
triangular space, below the teres major, and between Various branches of radial nerve are shown in
the long head of the triceps brachii and the humerus. Figs 8.23a–c.
Upper Limb
1
Section

Figs 8.23a and b: Distribution of right radial nerve

 ARM
109

or even the pressure of the crutch (crutch

paralysis) (Figs 8.24a and b).
b. Fractures of the shaft of the humerus. This
results in the weakness and loss of power of
extension at the wrist (wrist drop) (Fig. 8.25)
and sensory loss over a narrow strip on the back
of forearm, and on the lateral side of the dorsum
of the hand (Fig. 8.26).
• Wrist drop is quite disabling, because the patient
cannot grip any object firmly in the hand without
the synergistic action of the extensors.

Fig. 8.23c: Distribution of radial nerve (schematic)

Muscular
1 Before entering the spiral groove, radial nerve supplies
the long and medial heads of the triceps brachii.
2 In the spiral groove, it supplies the lateral and medial
heads of the triceps brachii and the anconeus.
3 Below the radial groove, on the front of the arm, it
supplies the brachialis with proprioceptive fibres.
The brachioradialis and extensor carpi radialis Figs 8.24a and b: Injury to radial nerve: (a) Saturday night
longus are supplied with motor fibres (Fig. 8.23a). palsy, and (b) crutch paralysis

Cutaneous Branches
1 In the axilla, radial nerve gives off the posterior
cutaneous nerve of the arm which supplies the skin
on the back of the arm (see Fig. 7.1b).
2 In the radial groove, the radial nerve gives off the
lower lateral cutaneous nerves of the arm and the
posterior cutaneous nerve of the forearm.
Upper Limb
Articular branches: The articular branches near the
elbow supply the elbow joint.

Competency achievement: The student should be able to:

AN 11.4 Describe the anatomical basis of Saturday night paralysis.7
AN 12.13 Describe the anatomical basis of wrist drop.8

CLINICAL ANATOMY
1

• The radial nerve is very commonly damaged in

Section

the region of the radial (spiral) groove. The

common causes of injury are as follows.
a. Sleeping in an armchair with the limb hanging
by the side of the chair (Saturday night palsy), Fig. 8.25: Wrist drop
 UPPER LIMB
110

Mnemonics
Cubital fossa contents MBBR
From medial to lateral:
• Median nerve
• Brachial artery
• Tendon of Biceps
• Radial nerve
Biceps brachii muscle: Origins
“You walk shorter to a street corner. You ride longer
on a superhighway”
Short head originates from coracoid process.
Long head originates from the supraglenoid tubercle.

FACTS TO REMEMBER
Fig. 8.26: Sensory loss over back of forearm and dorsum of • Medial root of median nerve crosses the axillary
hand artery in front to join lateral root to form the
median nerve.
PROFUNDA BRACHII ARTERY • The order of structures from medial to lateral side
in the cubital fossa is median nerve, brachial artery,
Profunda brachii artery is a large branch, arising just
tendon of biceps brachii and radial nerve.
below the teres major. It accompanies the radial nerve
through the radial groove, and before piercing the • Triceps brachii is the only active extensor of elbow
lateral intermuscular septum, it divides into the anterior joint. Gravity extends the joint passively.
and posterior descending branches which take part in • Biceps brachii is a strong supinator of the flexed
the anastomoses around the elbow joint (Fig. 8.10). elbow, besides being its flexor.

Branches
CLINICOANATOMICAL PROBLEM
1 The radial collateral (anterior descending) artery is one
of the terminal branches, and represents the In a motorcycle accident, there was injury to the
continuation of the profunda artery. It accompanies middle of back of arm.
the radial nerve, and ends by anastomosing with the • What nerve is likely to be injured?
radial recurrent artery in front of the lateral • What muscles are affected? Name five of them.
epicondyle of the humerus (Fig. 8.10). • What is the effect of injury?
2 The middle collateral (posterior descending) artery is the
largest terminal branch, which descends in the Ans: Due to injury to the middle of back of arm, the
substance of the medial head of the triceps. It ends radial nerve gets injured. The muscles of arm affected
by anastomosing with the interosseous recurrent partially are lateral and medial heads of triceps
artery, behind the lateral epicondyle of the humerus brachii. A part of muscle escapes paralysis as it gets
Upper Limb

(Fig. 8.10). It usually gives a branch which supplied in the axilla.

accompanies the nerve to the anconeus. The other muscles affected are the extensors of
3 The deltoid (ascending) branch ascends between the forearm. These are brachioradialis, extensor carpi
long and lateral heads of the triceps, and radialis longus and brevis, extensor digitorum and
anastomoses with the descending branch of the extensor pollicis longus.
posterior circumflex humeral artery. The effect of injury is ‘wrist drop’.
4 The nutrient artery to the humerus is often present. It
enters the bone in the radial groove just behind the FURTHER READING
1

deltoid tuberosity. However, it may be remembered • Jayakumari S, Rath G, Arora J. Unilateral double axillary and
that the main artery to the humerus is a branch of
Section

double brachial arteries. Embryological basis and clinical

the brachial artery. implications. Int J Morph 2006;24(3):463–68.
1–8
From Medical Council of India, Competency based Undergraduate Curriculum for the Indian Medical Graduate, 2018;1:44–80.
 ARM
111

1. Describe musculocutaneous nerve under following 3. Write short notes on:

headings: a. Changes at the level of insertion of coraco-
a. Root value b. Course brachialis
c. Branches d. Relations b. Anastomoses around the elbow joint
e. Clinical anatomy
c. Origin and insertion of triceps brachii muscle
2. Enumerate all the boundaries and contents of
cubital fossa. Give the clinical importance of the d. Branches of deep branch of radial nerve. What
fossa. is the effect of its injury?

1. Which event does not occur at the insertion of 5. Lateral boundary of cubital fossa is formed by
coracobrachialis? which muscle?
a. Median nerve crosses brachial artery from the a. Biceps brachii b. Brachioradialis
lateral to the medial side c. Brachialis d. Extensor carpi radialis
b. Ulnar nerve pierces medial intermuscular septum longus
c. Lateral cutaneous nerve of forearm pierces the 6. Fracture of humerus at mid-shaft is likely to cause
deep fascia injury to which of the following nerves?
d. Radial nerve pierces lateral intermuscular septum
a. Median b. Radial
2. Interosseous recurrent artery is a branch of which c. Ulnar d. Musculocutaneous
artery?
7. Correct order of structures from medial side to
a. Ulnar
lateral side in cubital fossa is:
b. Common interosseous
a. Median nerve, brachial artery, biceps tendon and
c. Anterior interosseous
radial nerve
d. Posterior interosseous
b. Median nerve, biceps tendon, radial nerve,
3. Which nerve is felt behind medial epicondyle of branchial artery
humerus? c. Median nerve, brachial artery, radial nerve and
a. Radial biceps tendon
b. Median d. Brachial artery, median nerve, biceps tendon,
c. Musculocutaneous radial nerve
d. Ulnar 8. Which are the heads of triceps brachii muscle?
4. Which of the following nerve injury leads to wrist a. Long, medial and posterior
drop? b. Long, lateral and medial
a. Ulnar b. Radial c. Long, lateral and posterior
Upper Limb
c. Median d. Axillary d. Lateral, medial and posterior

1. c 2. d 3. d 4. b 5. b 6. b 7. a 8. b
1Section

• How many compartments are there in the upper • Name the events occurring at the level of insertion
arm? of coracobrachialis.
• Name the root value of musculocutaneous nerve. • What is name of its cutaneous branch?
 UPPER LIMB
112

• Name the muscles supplied by musculocutaneous • Enumerate the structures forming its roof.
nerve. • Name the muscles forming floor of the fossa.
• Which muscle does coracobrachialis correspond to • What are the main contents of the fossa?
in lower limb?
• Name the branches of median nerve in the fossa.
• Name the branches of brachial artery.
• What is the clinical importance of brachial artery? • Name the branches of brachial artery in the fossa.
• Name the nerves present on the medial side of • Name the branches of radial nerve in the fossa.
brachial artery in its course in upper part and in • What is the clinical importance of bicipital
lower part of arm. aponeurosis?
• How is median nerve formed? Why is it called • What is clinical importance of cubital fossa?
median nerve? • Name the heads of triceps brachii muscle and show
• Name the branches of median nerve in the arm. their origins and insertion.
• Name the branches of radial nerve in the axilla. • Name the regions through which radial nerve passes.
• Which movement will be affected in paralysis of the • Name the branches of radial nerve in all these regions.
musculocutaneous nerve?
• What is wrist drop?
CUBITAL FOSSA • What is the course of profunda brachii artery? Name
• What muscle forms lateral boundary of cubital fossa? its branches.
• What muscle forms its medial boundary? • What does word ‘profunda’ mean?
Upper Limb
1
Section
 9
Forearm and Hand
! God gave you ears, eyes and hands. Use them on the patients in that order !
—William Kelsey

INTRODUCTION
Forearm extends between the elbow and the wrist
joints. Radius and ulna form its skeleton. These two
bones articulate at both their ends to form superior
and inferior radioulnar joints. Their shafts are kept at
optimal distance by the interosseous membrane.
Muscles accompanied by nerves and blood vessels are
present both on the front and the back of the forearm.
Hand is the most distal part of the upper limb, meant
for carrying out diverse activities. Numerous muscles,
tendons, bursae, blood vessels and nerves are
artistically placed and protected in this region.

SURFACE LANDMARKS OF FRONT OF FOREARM

1 The epicondyles of the humerus have been examined
(chapter 8). Note that medial epicondyle is more
prominent than the lateral (Fig. 9.1). The posterior
surface of the medial epicondyle is crossed by the
ulnar nerve which can be rolled under the palpating Fig. 9.1: Surface landmarks—front of forearm and hand
finger. Pressure on the nerve produces tingling sensa-
tions on the medial side of the hand (see Fig. 8.13a). 5 The head of the ulna forms a surface elevation on the
2 The tendon of the biceps brachii can be felt in front of medial part of the posterior surface of the wrist
the elbow. It can be made prominent by flexing the when the hand is pronated.
elbow joint against resistance. Pulsations of the 6 The styloid process of the ulna projects downwards
brachial artery can be felt just medial to the tendon from the posteromedial aspect of the lower end of
(see Fig. 8.17). the ulna. Its tip can be felt on the posteromedial
3 The head of the radius can be palpated in a depression aspect of the wrist, where it lies about 1 cm above
on the posterolateral aspect of the extended elbow, the tip of the styloid process of the radius (Fig. 9.1).
distal to the lateral epicondyle. Its rotation can be 7 The pisiform bone can be felt at the base of the
felt during pronation and supination of the forearm. hypothenar eminence (medially) where the tendon
4 The styloid process of the radius projects 1 cm lower of the flexor carpi ulnaris terminates. It becomes
than the styloid process of the ulna (Fig. 9.51). It can visible and easily palpable at the medial end of the
be felt in the upper part of the anatomical snuffbox. distal transverse crease (junction of forearm and
Its tip is concealed by the tendons of the abductor hand) when the wrist is fully extended.
pollicis longus and the extensor pollicis brevis, which 8 The hook of the hamate lies one finger breadth below
must be relaxed during palpation. the pisiform bone, in line with the ulnar border of
113
 UPPER LIMB
114

Fig. 9.2: Surface landmarks: Wrist and palm

the ring finger. It can be felt only on deep palpation

through the hypothenar muscles.
9 The tubercle of the scaphoid lies beneath the lateral
part of the distal transverse crease in an extended
wrist. It can be felt at the base of the thenar eminence
in a depression just lateral to the tendon of the flexor
carpi radialis (Fig. 9.2).
10 The tubercle (crest) of the trapezium may be felt on deep
palpation inferolateral to the tubercle of the scaphoid.
11 The brachioradialis becomes prominent along the
lateral border of the forearm when the elbow is
flexed against resistance in the midprone position
of the hand.
Fig. 9.3a: The superficial muscles of the front of the right forearm
12 The tendons of the flexor carpi radialis, palmaris longus,
and flexor carpi ulnaris can be identified on the front
of the wrist when the hand is flexed against Competency achievement: The student should be able to:
resistance. The tendons lie in the order stated, from AN 12.1 Describe and demonstrate important muscle groups of
lateral to medial side (Figs 9.3a–c). ventral forearm with attachments, nerve supply and actions.1
13 The pulsation of the radial artery can be felt in front
of the lower end of the radius just lateral to the
Upper Limb

tendon of the flexor carpi radialis.

MUSCLES OF FRONT OF FOREARM
14 The pulsations of the ulnar artery can be felt by The muscles of the front of the forearm may be divided
careful palpation just lateral to the tendon of the into superficial and deep groups.
flexor carpi ulnaris. Here the ulnar nerve lies medial
to the artery. Components
15 The transverse creases in front of the wrist are
The front of the forearm presents the following
important landmarks. The proximal transverse
components for study.
crease lies at the level of the wrist joint, and distal
1

crease corresponds to the proximal border of the 1 Eight muscles, five superficial and three deep.
2 Two arteries, radial and ulnar.
Section

flexor retinaculum.
16 The median nerve is very superficial in position at 3 Three nerves, median, ulnar and radial.
and above the wrist. It lies along the lateral edge of These structures can be better understood by
the tendon of the palmaris longus at the middle of reviewing the long bones of the upper limb and having
the wrist. an articulated hand by the side.
 FOREARM AND HAND
115

Fig. 9.3b: Dissection of cubital fossa, front of forearm and palm

Upper Limb
1Section

Figs 9.3c and d: Superficial muscles of front of forearm

 UPPER LIMB
116

SUPERFICIAL MUSCLES It is easily seen and is a guide to radial pulse which

There are five muscles in the superficial group. These lies lateral to the tendon (Fig. 9.5b).
are the pronator teres, the flexor carpi radialis, the 3 Palmaris longus: Palmaris longus (vestigeal muscle)
palmaris longus, the flexor carpi ulnaris and the flexor continues as palmar aponeurosis into the palm to
digitorum superficialis (Tables 9.1 and 9.2). protect the nerves and vessels there. Its tendon lies
superficial to flexor retinaculum.
Common Flexor Origin 4 Flexor carpi ulnaris: It is inserted into pisiform bone.
All the superficial flexors of the forearm have a common Pisiform is a sesamoid bone in this tendon.
origin from the front of the medial epicondyle of the 5 Flexor digitorum superficialis: Flexor digitorum
humerus. This is called the common flexor origin. superficialis comprises the humeroulnar and radial
heads. The two heads of the muscle are joined by a
Additional Features of Superficial Muscles fibrous arch. Median nerve and ulnar artery pass
1 Pronator teres: Pronator teres comprises a big humeral downwards deep to the fibrous arch (Fig. 9.4).
and a smaller ulnar head. Between the two heads,
median nerve leaves the cubital fossa. Deep to the DEEP MUSCLES
two heads exits ulnar artery from cubital fossa into Deep muscles of the front of the forearm are the
the front of forearm. It forms medial boundary of flexor digitorum profundus, the flexor pollicis longus
the cubital fossa. It is the pronator of forearm and the pronator quadratus and are described in
(Figs 9.5a and 9.11). Tables 9.3 and 9.4. Following are some other points of
2 Flexor carpi radialis: It passes through a separate deep importance about these muscles.
compartment of the flexor retinaculum.
Flexor carpi radialis gets inserted into anterior Additional Points about the Flexor Digitorum Profundus
aspects of bases of second and third metacarpal 1 It is the most powerful, and most bulky muscle of
bones. the forearm. It forms the muscular elevation seen and

Table 9.1: Attachments of the superficial muscles

Muscle Origin Insertion
1. Pronator teres (Figs 9.3a–c) Medial epicondyle of humerus and medial Middle of lateral aspect of shaft of radius
margin of coronoid process
2. Flexor carpi radialis Medial epicondyle of humerus Bases of second and third metacarpal bones
3. Palmaris longus Medial epicondyle of humerus Flexor retinaculum and palmar aponeurosis
4. Flexor digitorum
superficialis
(Fig. 9.8)
• Humeroulnar head Medial epicondyle of humerus; medial Muscle divides into 4 tendons. Each tendon
border of coronoid process of ulna divides into 2 slips which are inserted on
Radial head Anterior oblique line of shaft of radius sides of middle phalanx of 2nd to 5th digits
5. Flexor carpi ulnaris (Figs 9.3b and d)
• Humeral head Medial epicondyle of humerus Pisiform bone; insertion prolonged to hook of
Upper Limb

• Ulnar head Medial aspect of olecranon process and the hamate and base of fifth metacarpal bone
posterior border of ulna (see Fig. 2.32b)

Table 9.2: Nerve supply and actions of the superficial muscles

Muscle Nerve supply Actions
1. Pronator teres Median nerve Pronation of forearm
1

2. Flexor carpi radialis Median nerve Flexes and abducts hand at wrist joint
Section

3. Palmaris longus Median nerve Flexes wrist joint

4. Flexor digitorum superficialis Median nerve Flexes middle phalanx of fingers and assists
(Figs 9.4 and 9.5) in flexing proximal phalanx and wrist joint
5. Flexor carpi ulnaris Ulnar nerve Flexes and adducts the hand at the wrist joint
 FOREARM AND HAND
117

2 The main gripping power of the hand is provided

by the flexor digitorum profundus.
3 The muscle is supplied by two different nerves. So it
is a hybrid muscle.

Additional Points about the Flexor Pollicis Longus

1 The anterior interosseous nerve and vessels descend
on the anterior surface of the interosseous membrane
between the flexor digitorum profundus and the
flexor pollicis longus (Fig. 9.5).
2 The tendon passes deep to the flexor retinaculum
between the opponens pollicis and the oblique head
of the adductor pollicis, to enter the fibrous flexor
sheath of the thumb. It lies in radial bursa (Fig. 9.7).

Competency achievement: The student should be able to:

AN 12.9 Identify and describe fibrous flexor sheaths, ulnar bursa,
radial bursa and digital synovial sheaths.2

Synovial Sheaths of Flexor Tendons

1 Common flexor synovial sheath (ulnar bursa): The long
flexor tendons of the fingers (flexor digitorum
superficialis and profundus) are enclosed in a
common synovial sheath while passing deep to the
flexor retinaculum (carpal tunnel). The sheath has a
parietal layer lining the walls of the carpal tunnel,
and a visceral layer closely applied to the tendons
(Fig. 9.7). From the arrangement of the sheath, it
appears that the synovial sac has been invaginated by
the tendons from its lateral side. The synovial sheath
Fig. 9.4: Muscles, nerves and arteries seen in the forearm extends upwards for 5.0 or 7.5 cm into the forearm
and downwards into the palm up to the middle of
felt on the posterior surface of the forearm medial to the shafts of the metacarpal bones. It is important to
the subcutaneous posterior border of the ulna note that the lower medial end is continuous with
(Fig. 9.6). the digital synovial sheath of the little finger.

Upper Limb
1Section

Fig. 9.5a: Transverse section through the middle of forearm showing the compartments, nerves and arteries
 UPPER LIMB
118

Fig. 9.5b: Transverse section passing just above wrist showing

arrangement of the structures in flexor (anterior) compartment

2 Synovial sheath of the tendon of flexor pollicis longus

(radial bursa): This sheath is separate. Superiorly,
it is coextensive with the common sheath and
inferiorly it extends up to the distal phalanx of the
thumb (Fig. 9.7).
3 Digital synovial sheaths: The sheaths enclose the flexor
tendons in the fingers and line the fibrous flexor Fig. 9.6: Deep muscles of front of forearm
sheaths. The digital sheath of the little finger is
continuous with the ulnar bursa, and that of the vessels to the tendons (Fig. 9.8). These are the remnants
thumb with the radial bursa. However, the digital of mesotendon.
sheaths of the index, middle and ring fingers are
separate and independent (Fig. 9.7). DISSECTION

Vincula Longa and Brevia The skin of the forearm has already been reflected on
each side. Cut through the superficial and deep fasciae
The vincula longa and brevia are synovial folds, which
to expose the superficial muscles of the forearm.
connect the tendons to the phalanges. They transmit

Table 9.3: Attachments of the deep muscles

Muscle Origin Insertion
Upper Limb

1. Flexor digitorum • Upper three-fourths of the anterior and • The muscle forms 4 tendons for the medial 4 digits
profundus medial surface of the shaft of ulna which enter the palm by passing deep to the flexor
(composite or • Upper three-fourths of the posterior retinaculum in ulnar bursa and digital synovial sheaths
hybrid muscle) border of ulna • Opposite the proximal phalanx of the corresponding
(Fig. 9.6) • Medial surface of the olecranon and digit, the tendon perforates the tendon of the flexor
coronoid processes of ulna digitorum superficialis (Fig. 9.8)
• Adjoining part of the anterior surface of • Each tendon is inserted on the palmar surface of the
the interosseous membrane base of the distal phalanx (Fig. 9.8)
2. Flexor pollicis • Upper three-fourths of the anterior surface • The tendon enters the palm by passing deep to the
1

longus of the shaft of radius (Fig. 9.6) flexor retinaculum

• Adjoining part of the anterior surface of • It is inserted into the palmar surface of the distal phalanx
Section

the interosseous membrane of the thumb

3. Pronator Oblique ridge on the lower one-fourth of • Superficial fibres into the lower one-fourth of the anterior
quadratus anterior surface of the shaft of ulna, and surface and the anterior border of the radius
the area medial to it (Fig. 9.6) • Deep fibres into the triangular area above the ulnar notch
 FOREARM AND HAND
119

Table 9.4: Nerve supply and actions of the deep muscles

Muscle Nerve supply Actions
1. Flexor digitorum • Medial half by ulnar nerve • Flexor of distal phalanges after the flexor digitorum superficialis
profundus • Lateral half by anterior has flexed the middle phalanges
(Fig. 9.6) interosseous nerve (C8, T1) • Secondarily, it flexes the other joints of the fingers, and the
(branch of median nerve) wrist
• It is the chief gripping muscle. It acts best when the wrist
is extended
2. Flexor pollicis Anterior interosseous nerve • Flexes the distal phalanx of the thumb. Continued action
longus may also flex the proximal joints crossed by the tendon
3. Pronator quadratus Anterior interosseous nerve • Superficial fibres pronate the forearm
• Deep fibres bind the lower ends of radius and ulna

flexor digitorum superficialis passing through the palm

and most medially the flexor carpi ulnaris getting inserted
into the pisiform bone (Figs 9.3a and b) (refer to BDC App).

Deep Muscles
Cut through the origin of superficial muscles of forearm
at the level of medial epicondyle of humerus and reflect
them distally. This will expose the three deep muscles,
e.g. flexor pollicis longus, flexor digitorum profundus
and pronator quadratus (refer to BDC App).

Competency achievement: The student should be able to:

AN 12.2 Identify and describe origin, course, relations, branches
(or tributaries), termination of important nerves and vessels of
forearm.3

Fig. 9.7: The synovial sheaths of the flexor tendons, i.e. ulnar
bursa, radial bursa and digital synovial sheaths ARTERIES OF FRONT OF FOREARM

Features
The most conspicuous arteries of the forearm are the
radial and ulnar arteries. However, they mainly supply
the hand through the deep and superficial palmar
arches. The arterial supply of the forearm is chiefly
derived from the common interosseous branch of the
ulnar artery, which divides into anterior and posterior
Upper Limb
interosseous arteries. The posterior interosseous artery
is reinforced in the upper part and replaced in the lower
part by the anterior interosseous artery.

RADIAL ARTERY
Fig. 9.8: The flexor tendons of a finger showing the vincula longa Beginning, Course and Termination
and brevia Radial artery (Fig. 9.9) is the smaller terminal branch
of the brachial artery in the cubital fossa. It runs
1

Superficial Muscles downwards to the wrist with a lateral convexity. It

Section

Identify these five superficial muscles. These are from leaves the forearm by turning posteriorly and
lateral to medial side, pronator teres getting inserted into entering the anatomical snuffbox. As compared to
middle of radius, flexor carpi radialis reaching till the wrist, the ulnar artery, it is quite superficial throughout its
palmaris longus continuing with palmar aponeurosis, whole course. Its distribution in the hand is described
later.
 UPPER LIMB
120

Fig. 9.9: Muscles lying deep to the radial artery

Fig. 9.10: The radial, median and ulnar nerves and vessels in
the forearm
Relations
1 Anteriorly: It is overlapped by the brachioradialis in 3 The palmar carpal branch arises near the lower border
its upper part, but in the lower half, it is covered of the pronator quadratus, runs medially deep to the
only by skin, superficial and deep fasciae. flexor tendons, and ends by anastomosing with the
2 Posteriorly: It is related to the muscles attached to palmar carpal branch of the ulnar artery, in front of
anterior surface of radius, i.e. biceps brachii, flexor the middle of the recurrent branch of the deep palmar
pollicis longus, flexor digitorum superficialis and arch, to form a cruciform anastomosis. The palmar
pronator quadratus. carpal arch supplies bones and joints at the wrist.
3 Medially: It is related to the pronator teres in the 4 Dorsal carpal branch. It forms dorsal carpal arch with
upper one-third and the tendon of the flexor carpi branch of ulnar artery.
Upper Limb

radialis in the lower two-thirds of its course 5 The superficial palmar branch arises just before the
(Figs 9.9 and 9.10). radial artery leaves the forearm by winding
4 Laterally: Brachioradialis in the whole extent and the backwards. The branch passes through the thenar
radial nerve in the middle one-third. muscles, and ends by joining the terminal part of the
5 The artery is accompanied by venae comitantes. ulnar artery to complete the superficial palmar arch
(Fig. 9.20).
Branches in the Forearm
ULNAR ARTERY
1 The radial recurrent artery arises just below the elbow,
1

runs upwards deep to the brachioradialis, and ends Beginning, Course and Termination
Section

by anastomosing with the radial collateral artery Ulnar artery is the larger terminal branch of the brachial
(anterior branch of profunda brachii artery) in front artery, and begins in the cubital fossa (Fig. 9.10). The
of the lateral epicondyle of the humerus (see Fig. 8.10). artery runs obliquely downwards and medially in the
2 Muscular branches are given to the lateral muscles of upper one-third of the forearm; but in the lower two-
the forearm. thirds of the forearm its course is vertical (Fig. 9.4). It
 FOREARM AND HAND
121

enters the palm by passing superficial to the flexor The anterior interosseous artery is the deepest artery
retinaculum. Its distribution in the hand is described later. on the front of the forearm. It accompanies the
anterior interosseous nerve.
Relations It descends on the surface of the interosseous
1 Anteriorly: In its upper half, the artery is deep and is membrane between the flexor digitorum profundus
covered by muscles arising from common flexor and the flexor pollicis longus (Fig. 9.5a).
origin and median nerve. The lower half of the artery It pierces the interosseous membrane at the
is superficial and is covered only by skin and fascia upper border of the pronator quadratus to enter
(Fig. 9.4). the extensor compartment.
2 Posteriorly: It lies on brachialis and on the flexor The artery gives muscular branches to the deep
digitorum profundus. muscles of the front of the forearm, nutrient
3 Medially: It is related to the ulnar nerve, and to the branches to the radius and ulna and a median artery
flexor carpi ulnaris (Fig. 9.11). which accompanies the median nerve.
4 Laterally: It is related to the flexor digitorum Near its origin, the posterior interosseous artery
superficialis (Fig. 9.4) and median nerve. gives off the interosseous recurrent artery which
5 The artery is accompanied by venae comitantes. runs upwards, and ends by anastomosing with
middle collateral artery (posterior branch of
Branches profunda brachii artery) behind the lateral
1 The anterior and posterior ulnar recurrent arteries epicondyle. The posterior interosseous artery
anastomose around the elbow. The smaller passes through a gap above the interosseous
anterior ulnar recurrent artery runs up and ends membrane to the back of forearm (Fig. 8.10).
by anastomosing with the inferior ulnar collateral 3 Muscular branches supply the medial muscles of
artery in front of the medial epicondyle. The larger the forearm.
posterior ulnar recurrent artery arises lower than 4, 5 Palmar and dorsal carpal branches take part in the
the anterior and ends by anastomosing with the anastomoses around the wrist joint. The palmar
superior ulnar collateral artery behind the medial carpal branch helps to form the palmar carpal arch.
epicondyle (see Fig. 8.10). The dorsal carpal branch arises just above the
2 The common interosseous artery (about 1 cm long) pisiform bone, winds backwards deep to the
arises just below the radial tuberosity. It passes tendons, and ends in the dorsal carpal arch.
backwards to reach the upper border of the This arch is formed medially by the dorsal
interosseous membrane, and end by dividing into carpal branch of the ulnar artery, and laterally by
the anterior and posterior interosseous arteries. the dorsal carpal branch of the radial artery.

DISSECTION
Having dissected the superficial and deep group of
muscles of the forearm, identify the terminal branches
of the brachial artery, e.g. ulnar and radial arteries and
their branches (refer to BDC App).
Radial artery follows the direction of the brachial

Upper Limb
artery (Fig. 9.9) (refer to BDC App).
Ulnar artery passes obliquely deep to heads of
pronator teres and then runs vertically till the wrist.
Carefully look for common interosseous branch of
ulnar artery and its anterior and posterior branches.

NERVES OF FRONT OF FOREARM

1

Nerves of the front of the forearm are the median, ulnar

Section

and radial nerves. The radial and ulnar nerves run along
the margins of the forearm, and are never crossed by the
corresponding vessels which gradually approach them.
Fig. 9.11: Relations of the median nerve in right cubital fossa, The ulnar artery, while approaching the ulnar nerve, gets
and its entry into the forearm crossed by the median nerve (Fig. 9.10).
 UPPER LIMB
122

MEDIAN NERVE Relations

Median nerve is the main nerve of the front of the 1 In the cubital fossa, median nerve lies medial to the
forearm. It also supplies the muscles of thenar eminence brachial artery, behind the bicipital aponeurosis, and
(Fig. 9.10). in front of the brachialis (see Fig. 8.17).
The median nerve controls coarse movements of the 2 The median nerve enters the forearm by passing
hand, as it supplies most of the long muscles of the front between the two heads of the pronator teres. Here it
of the forearm. It is, therefore, called the ‘labourer’s crosses the ulnar artery from which it is separated
nerve’. by the deep head of the pronator teres (Fig. 9.11).
3 Along with the ulnar artery, the median nerve passes
Course beneath the fibrous arch of the flexor digitorum
Median nerve lies medial to brachial artery and enters superficialis, and runs deep to this muscle on the
the cubital fossa. It is the most medial content of cubital surface of the flexor digitorum profundus. It is
fossa (Fig. 9.11). Then it enters the forearm to lie accompanied by the median artery, a branch of the
between flexor digitorum superficialis and flexor anterior interosseous artery. About 5 cm above the
digitorum profundus. It lies adherent to the back of flexor retinaculum (wrist), it becomes superficial and
superficialis muscle (Fig. 9.5). Then it reaches down the lies between the tendons of the flexor carpi radialis
region of wrist where it lies deep and lateral to palmaris (laterally) and the flexor digitorum superficialis
longus tendon (Fig. 9.10). Lastly, it passes deep to flexor (medially). It is overlapped by the tendon of the
retinaculum through carpal tunnel to enter the palm palmaris longus.
(Fig. 9.12). 4 The median nerve enters the palm by passing
deep to the flexor retinaculum through the carpal
tunnel.

Branches
1 Muscular branches are given off in the cubital fossa to
flexor carpi radialis, palmaris longus and flexor
digitorum superficialis (Fig. 9.12).
2 The anterior interosseous branch is given off in the
upper part of the forearm. It supplies the flexor
pollicis longus, the lateral half of the flexor digitorum
profundus (giving rise to tendons for the index and
middle fingers) and the pronator quadratus. The
nerve also supplies the distal radioulnar and wrist
joints (Fig. 9.12).
3 The palmar cutaneous branch arises a short distance
above the flexor retinaculum, lies superficial to it and
supplies the skin over the thenar eminence and the
central part of the palm (see Fig. 7.1a).
4 Articular branches are given to the elbow joint and to
Upper Limb

the proximal radioulnar joint.

5 Vascular branches supply the radial and ulnar arteries.
6 A communicating branch is given to the ulnar nerve.

ULNAR NERVE
The ulnar nerve is also known as the ‘musician’s nerve’
because it controls fine movements of the fingers. Its
course in the palm will be considered in the later part
1

of this chapter.
Section

Course
Ulnar nerve is palpable as it lies behind medial
epicondyle of humerus and is not a content of cubital
Fig. 9.12: Distribution of median nerve fossa (Fig. 9.13). It enters the forearm by passing
 FOREARM AND HAND
123

2 Palmar cutaneous branch arises in the middle of the

forearm and supplies the skin over the hypothenar
eminence (see Fig. 7.1a).
3 Dorsal cutaneous branch arises 7.5 cm above the
wrist, winds backwards and supplies the proximal
parts of the medial 2½ digits and the adjoining area
of the dorsum of the hand (see Fig. 7.1b).
4 Articular branches are given off to the elbow joint.
5 Its branches in the palm are shown in Figs 9.13 and
9.34.

RADIAL NERVE
Course
The radial nerve divides into its two terminal branches
in the cubital fossa just below the level of the lateral
epicondyle of the humerus (Fig. 9.10).

Branches
The deep terminal branch (posterior interosseous) soon
enters the back of the forearm by passing through the
supinator muscle. It will be studied further in back of
forearm as posterior interosseous nerve.
The superficial terminal branch (the main continuation
of the nerve) runs down in front of the forearm.
The superficial terminal branch of the radial nerve
is closely related to the radial artery only in the middle
one-third of the forearm (Fig. 9.10). It is purely cutaneous.
In the upper one-third, it is widely separated from
Fig. 9.13: Course and branches of ulnar nerve the artery, and in the lower one-third it passes
backwards under the tendon of the brachioradialis to
reach the anatomical snuffbox from where it is
between two heads of flexor carpi ulnaris, i.e. cubital
distributed to the lateral half of the dorsum of the hand,
tunnel, to lie along the lateral border of flexor carpi
and to the proximal parts of the dorsal surfaces of the
ulnaris in the forearm. In the last phase, it courses thumb, the index finger, and lateral half of the middle
superficial to the flexor retinaculum, covered by its finger (see Fig. 7.1b).
superficial slip or volar carpal ligament to enter the Injury to this branch results in small area of sensory
region of palm. loss over the root of the thumb.
Relations
DISSECTION
1 At the elbow, the ulnar nerve lies behind the medial

Upper Limb
Median nerve is the chief nerve of the forearm. It enters
epicondyle of the humerus (Fig. 9.10). It enters the
the forearm by passing between two heads of pronator
forearm by passing between the two heads of the
teres muscle. Its anterior interosseous branch is given
flexor carpi ulnaris. off as it is leaving the cubital fossa. Identify median
2 In the forearm, the ulnar nerve runs on the medial nerve stuck to the fascia on the deep surface of flexor
part of the flexor digitorum profundus muscle. digitorum superficialis muscle. Thus, the nerve lies deep
3 At the wrist, the ulnar neurovascular bundle lies to the flexor digitorum superficialis (Fig. 9.4).
between the flexor carpi ulnaris and the flexor Dissect the anterior interosseous nerve as it lies on
digitorum profundus. The bundle enters the palm the interosseous membrane between flexor pollicis longus
1

by passing superficial to the flexor retinaculum, and flexor digitorum profundus muscles (Fig. 9.5a).
Section

lateral to the pisiform bone (Fig. 9.13).

Identify the ulnar nerve situated behind the medial
Branches epicondyle. Trace it vertically down till the flexor
retinaculum (Figs 9.10 and 9.11) (refer to BDC App).
1 Muscular, to the flexor carpi ulnaris and the medial
half of the flexor digitorum profundus.
 UPPER LIMB
124

Trace the radial nerve and its two branches in the

lateral part of the cubital fossa. Its deep branch is mus-
cular and superficial branch is cutaneous (Fig. 9.11).

PALMAR ASPECT OF WRIST AND HAND

Features
The human hand is designed:
i. For grasping,
ii. For precise movements, and
iii. For serving as a tactile organ.
There is a big area in the motor cortex of brain for muscles
of hand.
The skin of the palm is:
i. Thick for protection of underlying tissues.
ii. Immobile because of its firm attachment to the
underlying palmar aponeurosis.
iii. Creased. All of these characters increase the Fig. 9.14: Incisions of palm and digits (1–4)
efficiency of the grip.
The skin is supplied by spinal nerves C6–C8 on their respective sides. The skin of the intermediate
(see Fig. 7.1a) through the median and ulnar nerves. flap is reflected distally towards the distal palmar crease.
The superficial fascia of the palm is made up of Further the skin of middle finger is to be reflected on
dense fibrous bands which bind the skin to the deep either side.
fascia (palmar aponeurosis) and divide the sub- Superficial fascia and deep fascia
cutaneous fat into small tight compartments which Remove the superficial fascia to clean the underlying
serve as water-cushions during firm gripping. The deep fascia.
fascia contains a subcutaneous muscle, the palmaris
Deep fascia is modified to form the flexor retinaculum
brevis, which helps in improving the grip by steadying
at wrist, palmar aponeurosis in the palm, and fibrous
the skin on the ulnar side of the hand. The superficial
flexor sheaths in the digits. Identify the structures on its
metacarpal ligament which stretches across the roots
superficial surface. Divide the flexor retinaculum
of the fingers over the digital vessels and nerves, is a
between the thenar and hypothenar eminences,
part of this fascia.
carefully preserving the underlying median nerve and
The deep fascia is specialised to form: long flexor tendons (refer to BDC App).
i. The flexor retinaculum at the wrist. Identify long flexor tendons enveloped in their
ii. The palmar aponeurosis in the palm. synovial sheaths including the digital synovial sheaths.
iii. The fibrous flexor sheaths in the fingers.
All three form a continuous structure which holds
the tendons in position and thus increase the efficiency Competency achievement: The student should be able to:
of the grip.
Upper Limb

AN 12.3 Identify and describe flexor retinaculum with its

attachments.4
DISSECTION
1. A horizontal incision at the distal crease of front of Flexor Retinaculum
the wrist has already been made. Flexor retinaculum (Latin to hold back) is a strong fibrous
2. Make a vertical incision from the centre of the above band which bridges the anterior concavity of the carpus
incision through the palm to the centre of the middle and converts it into a tunnel, the carpal tunnel (Fig. 9.15).
finger (Fig. 9.14).
3. Make one horizontal incision along the distal palmar Attachments
1

crease. Medially, to:

4. Make an oblique incision starting 3 cm distal to incision 1 The pisiform bone, and
Section

no. 2 and extend it till the tip of the distal phalanx of 2 The hook of the hamate.
the thumb. Laterally, to:
Thus the skin of the palm gets divided into 1 The tubercle of the scaphoid, and
three areas. Reflect the skin of lateral and medial flaps 2 The crest of the trapezium.
 FOREARM AND HAND
125

Fig. 9.15: Flexor retinaculum with its relations (schematic). Sca: scaphoid; Lun: lunate; Tri: triquetral; Pi: pisiform; Tra: trapezium;
Trz: trapezoid; Cap: Capitate; Ham: hamate

On either side, the retinaculum has a slip: Palmar Aponeurosis

1 The lateral deep slip is attached to the medial lip of the This term is often used for the entire deep fascia of the
groove on the trapezium which is thus converted into palm. However, it is better to restrict this term
a tunnel for the tendon of the flexor carpi radialis. to the central part of the deep fascia of the palm which
2 The medial superficial slip (volar carpal ligament) is also covers the superficial palmar arch, the long flexor
attached to the pisiform bone. The ulnar vessels and tendons, the terminal part of the median nerve, and
nerves pass deep to this slip (Fig. 9.15). the superficial branch of the ulnar nerve (Fig. 9.16).

Relations Features
The structures passing superficial to the flexor retina- Palmar aponeurosis is triangular in shape. The apex
culum are: which is proximal, blends with the flexor retinaculum
i. The palmar cutaneous branch of the median nerve
(Fig. 9.16).
ii. The tendon of the palmaris longus.
iii. The palmar cutaneous branch of the ulnar nerve.
iv. The ulnar vessels.
v. The ulnar nerve.

Upper Limb
The thenar and hypothenar muscles arise from the
retinaculum (Fig. 9.15).
The structures passing deep to the flexor retinaculum
are:
i. The median nerve (Fig. 9.15).
ii. Four tendons of the flexor digitorum superficialis.
iii. Four tendons of the flexor digitorum profundus.
1

iv. The tendon of the flexor pollicis longus.

v. The ulnar bursa.
Section

vi. The radial bursa.

vii. The tendon of the flexor carpi radialis lies between
the retinaculum and its deep slip, in the groove Fig. 9.16: The deep fascia of the hand forming the flexor
on the trapezium (Fig. 9.15). retinaculum, palmar aponeurosis and fibrous flexor sheaths
 UPPER LIMB
126

Figs 9.17a to c: The fibrous flexor sheath and its contents: (a) Bony attachments of the sheath and of the flexor tendons, (b) the
fibrous sheath showing transverse fibres in front of the bones and cruciate fibres in front of joints, and (c) the flexor tendons after
removal of the sheath

and is continuous with the tendon of the palmaris The sheath holds the tendons in position during
longus. The base is directed distally. It divides into flexion of the digits.
superficial and deep strata, superficial is attached to
dermis. Deep strata divides into four slips opposite the CLINICAL ANATOMY
heads of the metacarpals of the medial four digits. Each
slip divides into two parts which are continuous with Dupuytren’s contracture: This condition is due to
the fibrous flexor sheaths. Extensions pass to the deep inflammation involving the ulnar side of the palmar
transverse metacarpal ligament, the capsule of the aponeurosis. There is thickening and contraction of
metacarpophalangeal joints and the sides of the base the aponeurosis. As a result, the proximal phalanx
of the proximal phalanx. The digital vessels and nerves, and later the middle phalanx become flexed and
and the tendons of the lumbricals emerge through the cannot be straightened. The terminal phalanx
intervals between the slips. From the lateral and medial remains unaffected. The ring finger is most commonly
margins of the palmar aponeurosis, the lateral and involved (Fig. 9.18).
medial palmar septa pass backwards and divide the palm
into compartments.
Functions
Upper Limb

Palmar aponeurosis fixes the skin of the palm and thus

improves the grip. It also protects the underlying
tendons, vessels and nerves.

Fibrous Flexor Sheaths of the Fingers

The fibrous flexor sheaths are made up of the deep
fascia of the fingers. The fascia is thick and arched. It is
attached to the sides of the phalanges and across the
base of the distal phalanx. Proximally, it is continuous
1

with a slip of the palmar aponeurosis.

Section

In this way, a blind osseofascial tunnel is formed

which contains the long flexor tendons enclosed in the
digital synovial sheath (Figs 9.17a–c). The fibrous
sheath is thick opposite the phalanges and thin opposite Fig. 9.18: Dupuytren’s contracture
the joints to permit flexion.
 FOREARM AND HAND
127

INTRINSIC MUSCLES OF HAND place in planes at right angles to those of the other digits
because the thumb (first metacarpal) is rotated medially
through 90°. Flexion and extension of the thumb take
Features
place in the plane of the palm; while abduction and
The intrinsic muscles of the hand serve the function of adduction at right angles to the plane of palm.
adjusting the hand during gripping and also for carrying Movement of the thumb across the palm to touch the
out fine skilled movements. Their attachments, nerve other digits is known as ‘opposition’. This movement
supply and actions are given in Tables 9.5 and 9.6. is a combination of flexion and medial rotation.
There are 20 muscles in the hand. These are:
1 a. Three muscles of thenar eminence Actions of Dorsal Interossei
i. Abductor pollicis brevis (Fig. 9.19) All dorsal interossei cause abduction of the digits away
ii. Flexor pollicis brevis from the line of the middle finger. This movement
iii. Opponens pollicis occurs in the plane of palm (Fig. 9.25) in contrast to the
b. One adductor of thumb: Adductor pollicis. movement of thumb where abduction occurs at right
2 Four hypothenar muscles angles to the plane of palm (Fig. 9.26). Note that
i. Palmaris brevis movement of the middle finger to either medial or
ii. Abductor digiti minimi lateral side constitutes abduction. Also note that the
iii. Flexor digiti minimi (Fig. 9.20) first and fifth digits do not require dorsal interossei as
iv. Opponens digiti minimi (Fig. 9.22) they have their own abductors.
Muscles (ii) to (iv) are muscles of hypothenar eminence.
3 Four lumbricals (Fig. 9.21) Testing of Some Intrinsic Muscles
4 Four palmar interossei (Figs 9.23, 9.24b and c) a. Pen/pencil test for abductor pollicis brevis: Lay the hand
5 Four dorsal interossei (Figs 9.23, 9.24a and c) flat on a table with the palm directed upwards. The
These muscles are described in Tables 9.5 and 9.6. patient is unable to touch with his thumb a pen/
pencil held in front of the palm (Fig. 9.27).
Actions of Thenar Muscles b. Test for opponens pollicis: Request the patient to touch
In studying the actions of the thenar muscles, it must the proximal phalanx of 2nd to 5th digits with the
be remembered that the movements of the thumb take tip of thumb.

Upper Limb
1Section

Fig. 9.19: The origin and insertion of the thenar and hypothenar muscles
 UPPER LIMB
128

Fig. 9.20: Anterior view of right palm. Palmar aponeurosis and greater part of flexor retinaculum have been removed to display
superficial palmar arch, ulnar nerve and median nerve, two muscles each of thenar and hypothenar eminences
Upper Limb
1
Section

Fig. 9.21: The origin of the lumbrical muscles from tendons of flexor digitorum profundus
 FOREARM AND HAND
129

Fig. 9.22: Deep palmar arch, deep branch of ulnar nerve, adductor pollicis and opponens muscles

Upper Limb
1Section

Fig. 9.23: Palmar and dorsal interossei muscles

 UPPER LIMB
130

Competency achievement: The student should be able to:

AN 12.5 Identify and describe small muscles of hand. Also describe movements of thumb and muscles involved.5

Figs 9.24a–c: (a) The dorsal interossei muscles, (b) palmar interossei muscles, and (c) dorsal and palmar interossei

Table 9.5: Attachments of small muscles of the hand

Name Origin Insertion
Muscles of thenar eminence
Abductor pollicis brevis Tubercle of scaphoid, crest of trapezium, Base of proximal phalanx of thumb
(Fig. 9.20) flexor retinaculum
Flexor pollicis brevis Flexor retinaculum, crest of trapezium and Base of proximal phalanx of thumb
capitate bones
Opponens pollicis (Fig. 9.22) Flexor retinaculum crest of trapezium Lateral half of palmar surface of the
shaft of metacarpal bone of thumb
Adductor of thumb
Adductor pollicis Oblique head: Bases of 2nd–3rd metacarpals; Base of proximal phalanx of thumb
transverse head: Shaft of 3rd metacarpal on its medial aspect
Muscle of medial side of palm
Upper Limb

Palmaris brevis Flexor retinaculum Skin of palm on medial side

Muscles of hypothenar eminence
Abductor digiti minimi Pisiform bone Base of proximal phalanx of little finger
Flexor digiti minimi Flexor retinaculum Base of proximal phalanx of little finger
Opponens digiti minimi Flexor retinaculum Medial border of fifth metacarpal bone
Lumbricals (Fig. 9.21)
Lumbricals (4) 1st Lateral side of tendon of flexor Via extensor expansion into dorsum
Arise from 4 tendons of flexor digitorum profundus of 2nd digit of bases of distal phalanges
1

digitorum profundus 2nd Lateral side of same tendon of 3rd digit

Section

3rd Adjacent sides of same tendons of 3rd and

4th digits
4th Adjacent sides of same tendons of 4th and
5th digits
(Contd...)
 FOREARM AND HAND
131

Table 9.5: Attachments of small muscles of the hand (Contd...)

Name Origin Insertion
Palmar interossei
Palmar (4) 1st Medial side of base of 1st metacarpal Medial side of base of proximal
(Figs 9.24b and c) phalanx of thumb or 1st digit
2nd Medial side of shaft of 2nd metacarpal Via extensor expansion into dorsum
3rd Lateral side of shaft of 4th metacarpal of bases of distal phalanges of 2nd,
4th Lateral side of shaft of 5th metacarpal 4th and 5th digits (Fig. 9.53)
Dorsal interossei
Dorsal (4) 1st Adjacent sides of shafts of 1st and 2nd MC Via extensor expansion into dorsum
(Figs 9.24a and c) 2nd Adjacent sides of shafts of 2nd and 3rd MC of bases of distal phalanges of 2nd,
3rd Adjacent sides of shafts of 3rd and 4th MC 3rd, 3rd and 4th digits
4th Adjacent sides of shafts of 4th and 5th MC
MC: Metacarpal

Table 9.6: Nerve supply and actions of small muscles of the hand
Muscle Nerve supply Actions
Muscles of thenar eminence
Abductor pollicis brevis (Fig. 9.20) Median nerve Abduction of thumb
Flexor pollicis brevis Median nerve Flexes metacarpophalangeal joint of thumb
Opponens pollicis (Fig. 9.22) Median nerve Pulls thumb medially and forward across palm
(opposes thumb towards the fingers)
Adductor of thumb
Adductor pollicis Deep branch of ulnar nerve which Adduction of thumb
ends in this muscle
Muscle of medial side of palm
Palmaris brevis Superficial branch of ulnar nerve Wrinkles skin to improve grip of palm
Muscles of hypothenar eminence
Abductor digiti minimi Deep branch of ulnar nerve Abducts little finger
Flexor digiti minimi Deep branch of ulnar nerve Flexes little finger
Opponens digiti minimi Deep branch of ulnar nerve Pulls fifth metacarpal forward as in cupping the
palm
Lumbricals (Fig. 9.21)
Lumbricals (4) First and second, i.e. lateral two by Flex metacarpophalangeal joints, extend
median nerve; third and fourth by interphalangeal joints of 2nd–5th digits
deep branch of ulnar nerve
Palmar interossei
Palmar (4) (Fig. 9.24b) Deep branch of ulnar nerve Palmar interossei adduct fingers towards centre
of third digit or middle finger

Upper Limb
Dorsal interossei
Dorsal (4) (Figs 9.23 and Deep branch of ulnar nerve Dorsal interossei abduct fingers from centre of third
9.24a and c) digit. Both palmar and dorsal interossei flex the
metacarpophalangeal joints and extend the
interphalangeal joints

c. The dorsal interossei are tested by asking the subject e. Froment’s sign, or the book test which tests the
to spread out the fingers against resistance. As index adductor pollicis muscle. When the patient is asked
1

finger is abducted one feels 1st dorsal interosseous to grasp a book firmly between the thumbs and
Section

(Fig. 9.28). other fingers of both the hands, the terminal

d. The palmar interossei and adductor pollicis are tested phalanx of the thumb on the paralysed side becomes
by placing a piece of paper between the fingers flexed at the interphalangeal joint (by the flexor
(Fig. 9.29), between thumb and index finger and pollicis longus which is supplied by the median
seeing how firmly it can be held (Fig. 9.30). nerve) (Fig. 9.31).
 UPPER LIMB
132

Fig. 9.28: Testing first dorsal interosseous muscle of hand

Fig. 9.29: Test for palmar interossei

Fig. 9.25: The planes of movements of the fingers

Fig. 9.26: The planes of movements of the thumb

Fig. 9.30: Testing adductor pollicis

Upper Limb
1

Fig. 9.27: Pen test for abductor pollicis brevis

Section

f. The lumbricals and interossei are tested by asking

the subject to flex the fingers at the metacarpo-
phalangeal joints against resistance. Fig. 9.31: Froment’s test
 FOREARM AND HAND
133

DISSECTION Competency achievement: The student should be able to:

Clean the thenar and hypothenar muscles. Carefully AN 12.7 Identify and describe course and branches of important
preserve the median nerve and superficial and deep blood vessels and nerves in hand.6
branches of ulnar nerve which supply these muscles.
Abductor pollicis brevis is the lateral muscle; flexor ARTERIES OF HAND
pollicis brevis is the medial one. Both these form the
superficial lamina. The deeper lamina is constituted by Features
opponens pollicis (Figs 9.19 to 9.22). Arteries of the hand are the terminal parts of the ulnar
Cut through the abductor pollicis brevis and flexor and radial arteries. Branches of these arteries unite and
pollicis brevis to expose the opponens pollicis. These form anastomotic channels called the superficial and
three muscles constitute the muscles of thenar deep palmar arches.
eminence.
Incise flexor pollicis brevis in its centre and reflect ULNAR ARTERY
its two parts. This will reveal the tendon of flexor pollicis
The course of this artery in the forearm has been described
longus and adductor pollicis on a deeper plane. The
earlier. It enters the palm by passing superficial to the
three muscles of thenar eminence are supplied by thick
flexor retinaculum but deep to volar carpal ligament
recurrent branch of median nerve (Figs 9.20 and 9.22).
(Fig. 9.15). It ends by dividing into the superficial palmar
On the medial side of hand, identify thin palmaris branch, which is the main continuation of the artery, and
brevis muscle in the superficial fascia. It receives a twig the deep palmar branch. These branches take part in the
from the superficial branch of ulnar nerve. formation of the superficial palmar arch and deep palmar
Hypothenar eminence is comprised by abductor digiti arch, respectively.
minimi medially, flexor digiti minimi just lateral to it. Deep
to both these lies opponens digiti minimi. Identify these Superficial Palmar Arch
three muscles and trace their nerve supply from deep The arch represents an important anastomosis between
branch of ulnar nerve (refer to BDC App). the ulnar and radial arteries.
Between the two eminences of the palm, deep to The convexity of the arch is directed towards the
palmar aponeurosis, identify the superficial palmar arch fingers, and its most distal point is situated at the level
formed mainly by superficial branch of ulnar and of the distal border of the fully extended thumb.
superficial palmar branch of radial artery. Identify its
common and proper digital branches. Formation
Clean, dissect and preserve the branches of the The superficial palmar arch is formed as the direct
median nerve and superficial division of ulnar nerve in continuation of the ulnar artery beyond the flexor
the palm lying between the superficial palmar arch and retinaculum, i.e. by the superficial palmar branch. On
long flexor tendons (Fig. 9.20). the lateral side, the arch is completed by superficial
palmar branch of radial artery (Fig. 9.32).
Lying on a deeper plane are the tendons of flexor
digitorum superficialis muscle. Dissect the peculiar
Relations
mode of its insertion in relation to that of tendon of flexor
digitorum profundus (Fig. 9.21). The superficial palmar arch lies deep to the palmaris brevis
and the palmar aponeurosis. It crosses the palm over the
Upper Limb
Cut through the tendons of flexor digitorum super-
ficialis 5 cm above the wrist. Divide both ends of flexor digiti minimi, the flexor tendons of the fingers, the
superficial palmar arch. Reflect them distally towards lumbricals, and the digital branches of the median nerve.
the metacarpophalangeal joints.
Branches
Identify four tendons of flexor digitorum profundus
diverging in the palm with four delicate muscles, the Superficial palmar arch gives off three common digital
lumbricals, arising from them. Dissect the nerve supply and one proper digital branches which supply the
to these lumbricals. The first and second are supplied medial 3½ digits. The lateral three common digital
from median and third and fourth from the deep branch branches are joined by the corresponding palmar
1

of ulnar nerve (Fig. 9.21). metacarpal arteries from the deep palmar arch.
Section

Divide the flexor digitorum profundus 5 cm above The deep branch of the ulnar artery arises in front of
the wrist and reflect it towards the metacarpophalangeal the flexor retinaculum immediately beyond the
joints. Trace one of its tendons to its insertion into the pisiform bone. Soon it passes between the flexor and
base of distal phalanx of one finger (refer to BDC App). abductor digiti minimi to join and complete the deep
palmar arch.
 UPPER LIMB
134

Fig. 9.32: The superficial and deep palmar arches

CLINICAL ANATOMY Relations

1 It leaves the forearm by winding backwards round
The radial artery is used for feeling the (arterial) pulse the wrist.
at the wrist. The pulsations can be felt well in this 2 It passes through the anatomical snuffbox where it
situation because of the presence of the flat radius lies deep to the tendons of the abductor pollicis
with pronator quadratus muscle behind the artery longus, the extensor pollicis brevis and the extensor
(Fig. 9.10). pollicis longus.
It is also crossed by the digital branches of the radial
nerve.
RADIAL ARTERY
The artery is superficial to the lateral ligament of the
In this part of its course, the radial artery runs obliquely wrist joint, the scaphoid and the trapezium.
downwards, and backwards deep to the tendons of the 3 It reaches the proximal end of the first interosseous
abductor pollicis longus, the extensor pollicis brevis,
Upper Limb

space and passes between the two heads of the first

and the extensor pollicis longus, and superficial to the dorsal interosseous muscle to reach the palm.
lateral ligament of the wrist joint (Fig. 9.52a). Thus it 4 In the palm, the radial artery runs medially. At first
passes through the anatomical snuffbox to reach the it lies deep to the oblique head of the adductor
proximal end of the first interosseous space. Further, it pollicis, and then passes between the two heads of
passes between the two heads of the first dorsal this muscle to form deep palmar arch. Therefore, it
interosseous muscle and between the two heads of is known as the deep palmar arch (Fig. 9.33).
adductor pollicis to form the deep palmar arch in the
palm (Fig. 9.33). Branches
1

Dorsum of hand: On the dorsum of the hand, the radial

Course
Section

artery gives off:

Radial artery runs obliquely from the site of ‘radial 1 A branch to the lateral side of the dorsum of the thumb.
pulse’ to reach the anatomical snuffbox. From there, it 2 The first dorsal metacarpal artery. This artery arises just
passes forwards to reach first interosseous space and before the radial artery passes into the interval
then into the palm. between the two heads of the first dorsal interosseous
 FOREARM AND HAND
135

Fig. 9.33: Course of radial artery (schematic)

muscle. It at once divides into two branches for the The deep branch of the ulnar nerve lies within the
adjacent sides of the thumb and the index finger. concavity of the arch.
Palm: In the palm (deep to the oblique head of the Branches
adductor pollicis), the radial artery gives off:
1 The princeps pollicis artery which divides at the base 1 From its convexity, i.e. from its distal side, the arch
of the proximal phalanx into two branches for the gives off three palmar metacarpal arteries, which run
palmar surface of the thumb (Fig. 9.33). distally in the 2nd, 3rd and 4th spaces, supply the
2 The radialis indicis artery descends between the first medial four metacarpals, and terminate at the finger
dorsal interosseous muscle and the transverse head clefts by joining the common digital branches of the
of the adductor pollicis to supply the lateral side of superficial palmar arch (Fig. 9.32).
the index finger. 2 Dorsally, the arch gives off three (proximal)
perforating digital arteries which pass through the
Deep Palmar Arch medial three interosseous spaces to anastomose with
Deep palmar arch provides a second channel connecting the dorsal metacarpal arteries.

Upper Limb
the radial and ulnar arteries in the palm (the first one The digital perforating arteries connect the palmar
being the superficial palmar arch already considered). It digital branches of the superficial palmar arch with
is situated deep to the long flexor tendons. the dorsal metacarpal arteries.
3 Recurrent branch arises from the concavity of the arch
Formation and passes proximally to supply the carpal bones
The deep palmar arch is formed mainly by the terminal and joints, and ends in the palmar carpal arch.
part of the radial artery, and is completed medially at
the base of the fifth metacarpal bone by the deep palmar DISSECTION
branch of the ulnar artery (Fig. 9.32).
1

Deep to the lateral two tendons of flexor digitorum

Relations profundus muscle, note an obliquely placed muscle
Section

extending from two origins, i.e. from the shaft of the

The arch lies on the proximal parts of the shafts of the third metacarpal bone and the bases of 2nd and 3rd
metacarpals, and on the interossei; under the cover of metacarpal bones and adjacent carpal bones to the
the oblique head of the adductor pollicis, the flexor base of proximal phalanx of the thumb. This is adductor
tendons of the fingers, and the lumbricals.
 UPPER LIMB
136

pollicis (Fig. 9.22). Reflect the adductor pollicis muscle Relations

from its origin towards its insertion. 1 The ulnar nerve enters the palm by passing
Identify the deeply placed interossei muscles. Identify superficial to the flexor retinaculum where it lies
the radial artery entering the palm between two heads between the pisiform bone and the ulnar vessels.
of first dorsal interosseous muscle and then between Here the nerve divides into its superficial and deep
two heads of adductor pollicis muscle turning medially terminal branches (Figs 9.13).
to join the deep branch of ulnar artery to complete the 2 The superficial terminal branch supplies the palmaris
deep palmar arch (Fig. 9.32). Identify the deep branch brevis and divides into two digital branches for the
of ulnar nerve lying in its concavity. Carefully preserve medial 1½ fingers (Fig. 9.34a).
it, including its multiple branches. Deep branch of ulnar 3 The deep terminal branch accompanies the deep
nerve ends by supplying the adductor pollicis muscle. branch of the ulnar artery. It passes backwards
It may supply deep head of flexor pollicis brevis also. between the abductor and flexor digiti minimi, and
Lastly, define four small palmar interossei and then between the opponens digiti minimi and the
four relatively bigger dorsal interossei muscles (Figs 9.23 fifth metacarpal bone, lying on the hook of the
and 9.24a–c) (refer to BDC App). hamate.
Finally, it turns laterally within the concavity of the
deep palmar arch. It ends by supplying the adductor
NERVES OF HAND pollicis muscle (Fig. 9.22).

ULNAR NERVE Branches

Ulnar nerve is the main nerve of the hand (like the From Superficial Terminal Branch
lateral plantar nerve in the foot). 1 Muscular branch: To palmaris brevis.
2 Cutaneous branches: Two palmar digital nerves
Course supply the medial 1½ fingers with their nail beds
Ulnar nerve lies superficial to flexor retinaculum, (Fig. 9.34a).
covered only by the superficial slip of the retinaculum The medial branch supplies the medial side of the
(volar carpal ligament—Fig. 9.15). It terminates by little finger.
dividing into a superficial and a deep branch. The lateral branch is a common palmar digital nerve.
Superficial branch is cutaneous. The deep branch It divides into two proper palmar digital nerves for the
passes through the muscles of the hypothenar eminence adjoining sides of the ring and little fingers.
to lie in the concavity of the deep palmar arch to end in The common palmar digital nerve communicates
the adductor pollicis (Fig. 9.22). with the median nerve.
Upper Limb
1
Section

Figs 9.34a and b: Distribution of the branches of the ulnar nerve

 FOREARM AND HAND
137

From Deep Terminal Branch

1 Muscular branches: also drier due to absence of sweating because
of loss of sympathetic supply.
a. At its origin, the deep branch supplies three muscles
d. Trophic changes: Long-standing cases of
of hypothenar eminence (Fig. 9.34b).
paralysis lead to dry and scaly skin. The nails
b. As the nerve crosses the palm, it supplies the
crack easily with atrophy of the pulp of fingers.
medial two lumbricals and eight interossei.
e. The patient is unable to spread out the fingers
c. The deep branch terminates by supplying the due to paralysis of the dorsal interossei. The
adductor pollicis, and occasionally the deep head power of adduction of the thumb, and flexion
of the flexor pollicis brevis. of the ring and little fingers are lost. It should
2 An articular branch supplies the wrist joint. be noted that median nerve lesions are more
disabling. In contrast, ulnar nerve lesions leave
a relatively efficient hand.
CLINICAL ANATOMY
• The ulnar nerve is also known as the ‘musician’s
nerve’ because it controls fine movements of the
fingers (Fig. 9.34a).
• The ulnar nerve is commonly injured at the elbow,
behind the medial epicondyle or distal to elbow
as it passes between two heads of flexor carpi
ulnaris (cubital tunnel) or at the wrist in front of
the flexor retinaculum.
Ulnar nerve injury at the elbow: Flexor carpi ulnaris
and the medial half of the flexor digitorum
profundus are paralysed.
• Due to this paralysis, the medial border of the
forearm becomes flattened. An attempt to produce
flexion at the wrist results in abduction of the
hand. The tendon of the flexor carpi ulnaris does
not tighten on making a fist. Flexion of the
terminal phalanges of the ring and little fingers is
lost.
• The ulnar nerve controls fine movements of the
fingers through its extensive motor distribution Fig. 9.35: Clawing of ring and little fingers
to the short muscles of the hand. There is ulnar
claw hand as well.
Ulnar nerve lesion at the wrist: Produces ‘ulnar claw-
hand’.
• Ulnar claw hand is characterised by the following
signs.
a. Hyperextension at the metacarpophalangeal
joints and flexion at the interphalangeal joints,
involving the ring and little fingers—more than Upper Limb
the index and middle fingers (Fig. 9.35). The
intermetacarpal spaces are hollowed out due
to wasting of the interosseous muscles. Claw
hand deformity is more obvious in wrist lesions
as the profundus muscle is spared: This causes
marked flexion of the terminal phalanges (action
of paradox) (see p 197).
1

b. Sensory loss is confined to the medial one-third

of the palm and the medial 1½ fingers including
Section

their nail beds (Figs 9.36a and b). Medial half of

dorsum of hand also shows sensory loss.
Figs 9.36a and b: Sensory loss on: (a) Palmar aspect, and
c. Vasomotor changes: The skin areas with sensory
(b) dorsal aspect of hand in ulnar nerve injury
loss is warmer due to arteriolar dilatation; it is
 UPPER LIMB
138

MEDIAN NERVE Branches

The median nerve is important because of its role in In the hand, the median nerve supplies:
controlling the movements of the thumb which are a. Five muscles, namely the abductor pollicis brevis,
crucial in the mechanism of gripping by the hand. the flexor pollicis brevis, the opponens pollicis and
the first and second lumbrical muscles.
Course b. Palmar skin over the lateral 3½ digits with their nail
Median nerve lies deep to flexor retinaculum in the beds.
carpal tunnel and enters the palm (Fig. 9.20). Soon it
terminates by dividing into muscular and cutaneous Competency achievement: The student should be able to:
branches. AN 12.4 Explain anatomical basis of carpal tunnel syndrome.7
AN 12.8 Describe anatomical basis of claw hand.8
Relations
1 The median nerve enters the palm by passing deep
to the flexor retinaculum where it lies in the narrow CLINICAL ANATOMY
space of the carpal tunnel in front of the ulnar bursa
enclosing the flexor tendons. • The median nerve controls coarse movements of
Immediately, below the retinaculum, the nerve the hand, as it supplies most of the long muscles
divides into lateral and medial divisions (Fig. 9.20). of the front of the forearm. It is, therefore, called
2 The lateral division gives off a muscular branch to the labourer’s nerve. It is also called ‘eye of the hand’
the thenar muscles, and three digital branches for as it is sensory to most of the hand.
the lateral 1½ digits including the thumb. • When the median nerve is injured above the level
The muscular branch curls upwards around the of the elbow, as might happen in supracondylar
distal border of the retinaculum and supplies the fracture of the humerus, the following features are
thenar muscles. seen.
Out of the three digital branches, two supply the a. The flexor pollicis longus and lateral half of
thumb and one the lateral side of the index finger. flexor digitorum profundus are paralysed. The
The digital branch to the index finger also supplies patient is unable to bend the terminal phalanx
the first lumbrical (Fig. 9.37). of the thumb and index finger when the
3 The medial division divides into two common digital proximal phalanx is held firmly by the clinician
branches for the second and third interdigital clefts, (to eliminate the action of the short flexors)
supplying the adjoining sides of the index, middle (Fig. 9.38). Similarly, the terminal phalanx of the
and ring fingers. middle finger can be tested.
The lateral common digital branch also supplies the b. The forearm is kept in a supine position due to
second lumbrical. paralysis of the pronators.
Upper Limb
1
Section

Fig. 9.37: Distribution of the median nerve in the hand. The main divisions of the ulnar nerve are also shown
 FOREARM AND HAND
139

c. The hand is adducted due to paralysis of the

flexor carpi radialis, and flexion at the wrist is
weak.
d. Flexion at the interphalangeal joints of the index
and middle fingers is lost so that the index and
the middle (to a lesser extent) fingers tend to
remain straight while making a fist. This is
called pointing index finger, occurs due to
paralysis of long flexors of the digit (Fig. 9.39).
e. Ape or monkey-like thumb deformity is present
due to paralysis of the thenar muscles (Fig. 9.40).
f. The area of sensory loss corresponds to its
distribution (Fig. 9.41) in the hand.
g. Vasomotor and trophic changes: The skin on
lateral 3½ digits is warm, dry and scaly. The
nails get cracked easily (Fig. 9.42).
• Carpal tunnel syndrome (CTS): Involvement of the
median nerve in carpal tunnel at wrist has become Fig. 9.40: Ape-/monkey-like thumb deformity
a very common entity (Fig. 9.15).

Fig. 9.38: Testing for anterior interosseous nerve

Fig. 9.41: Sensory loss in median, ulnar and radial nerves

paralysis

Upper Limb
1Section

Fig. 9.42: Vasomotor and trophic changes in right hand

Fig. 9.39: Pointing index finger
 UPPER LIMB
140

a. This syndrome consists of motor, sensory, h. It occurs both in males and females between
vasomotor and trophic symptoms in the hand the age of 25 and 70. They complain of
caused by compression of the median nerve in intermittent attacks of pain in the distribution
the carpal tunnel. Examination reveals wasting of the median nerve on one or both sides. The
of thenar eminence (ape-like hand), hypo- attacks frequently occur at night. Pain may be
aesthesia to light touch on the palmar aspect of referred proximally to the forearm and arm. It
lateral 3½ digits. However, the skin over the is more common because of excessive working
thenar eminence is not affected as the branch of on the computer. Phalen’s test (Fig. 9.44) is
median nerve supplying it arises in the forearm. attempted for CTS.
b. Froment’s sign/book holding test: The patient • Complete claw hand: If both median and ulnar
is unable to hold the book with thumbs and nerves are paralysed, the result is complete claw
other fingers. hand (Fig. 9.45).
c. Paper holding test: The patient is unable to hold
paper between thumb and fingers.
Both these tests are positive because of paralysis
of thenar muscles.
d. Motor changes: Ape-/monkey-like thumb
deformity (Fig. 9.40), loss of opposition of
thumb. Index and middle fingers lag behind
while making the fist due to paralysis of 1st and
2nd lumbrical muscles (Fig. 9.43).
e. Sensory changes: Loss of sensations on lateral 3½
digits including the nail beds and distal
phalanges on dorsum of hand (Fig. 9.41).
f. Vasomotor changes: The skin areas with sensory
loss is warmer due to arteriolar dilatation; it is
also drier due to absence of sweating due to
loss of sympathetic supply.
g. Trophic changes: Long-standing cases of
paralysis lead to dry and scaly skin. The nails
crack easily with atrophy of the pulp of fingers
(Fig. 9.42). Fig. 9.44: Phalen’s test: Acutely flexed wrist causes pain in
carpal tunnel syndrome
Upper Limb

Fig. 9.45: Complete claw hand

1
Section

RADIAL NERVE
Fig. 9.43: Lagging behind of index and middle fingers in
making the fist due to paralysis of first and second lumbrical The part of the radial nerve seen in the hand is a
muscles in median nerve paralysis continuation of the superficial terminal branch. It
reaches the dorsum of the hand (after winding round
 FOREARM AND HAND
141

the lateral anatomical snuffbox on side of the radius) Palmar Spaces

and divides into 4 dorsal digital branches which supply Pulp Space of the Fingers
the skin of the digits as follows (see Fig. 7.1).
The tips of the fingers and thumb contain subcutaneous
1st : Lateral side of thumb fat arranged in tight compartments formed by fibrous
2nd : Medial side of thumb septa which pass from the skin to the periosteum of
3rd : Lateral side of index finger the terminal phalanx. Infection of this space is known
4th : Contiguous sides of index and middle fingers as whitlow. The rising tension in the space gives rise to
Note that skin over the dorsum of the distal severe throbbing pain.
phalanges is supplied by the median nerve (not radial) Infections in the pulp space (whitlow) can be drained
(Fig. 9.46). Sensory loss is less because of overlapping by a lateral incision which opens all compartments and
of nerves. avoids damage to the tactile tissue in front of the finger.
If neglected, a whitlow may lead to necrosis of the
distal four-fifths of the terminal phalanx due to
occlusion of the vessels by the tension. The proximal
one-fifth (epiphysis) escapes because its artery does not
traverse the fibrous septa (Fig. 9.47).
Midpalmar and Thenar Spaces
Midpalmar and thenar spaces are shown in Table 9.7
and Fig. 9.48.

Dorsal Spaces
The dorsal subcutaneous space lies immediately deep to
the loose skin of the dorsum of the hand. The dorsal
subaponeurotic space lies between the metacarpal bones
and the extensor tendons which are united to one
another by a thin aponeurosis.
Fig. 9.46: Sensory loss in injury to superficial branch of radial Forearm Space of Parona
nerve
Forearm space of Parona is a rectangular space situated
deep in the lower part of the forearm just above the
Competency achievement: The student should be able to: wrist. It lies in front of the pronator quadratus, and deep
AN 12.10 Explain infection of fascial spaces of palm.9 to the long flexor tendons. Superiorly, the space extends
up to the oblique origin of the flexor digitorum
superficialis. Inferiorly, it extends up to the flexor
FASCIAL SPACES OF HAND retinaculum, and communicates with the midpalmar
space. The proximal part of the flexor synovial sheaths
Having learnt the anatomy of the whole hand, the protrudes into the forearm space.
clinically significant spaces of the hand need to be
understood and their boundaries to be identified from
the following text. Upper Limb
The arrangement of fasciae and the fascial septa in
the hand is such that many spaces are formed. These
spaces are of surgical importance because they may
become infected and distended with pus. The important
spaces are as follows.
A. Palmar spaces
1. Pulp space of the fingers
1

2. Midpalmar space
Section

3. Thenar space
B. Dorsal spaces
1. Dorsal subcutaneous space
2. Dorsal subaponeurotic space
C. The forearm space of Parona. Fig. 9.47: The digital pulp space
 UPPER LIMB
142

Table 9.7: Midpalmar and thenar spaces (Figs 9.48 and 9.49)
Features Midpalmar space Thenar space
1. Shape Triangular Triangular
2. Situation Under the inner half of the hollow of the palm Under the outer half of the hollow of the palm
3. Extent:
Proximal Distal margin of the flexor retinaculum Distal margin of the flexor retinaculum
Distal Distal palmar crease Proximal transverse palmar crease
4. Communications:
Proximal Forearm space of Parona Forearm space of Parona
Distal Fascial sheaths of the 3rd and 4th lumbricals Fascial sheath of the first lumbrical
5. Boundaries:
Anterior • Flexor tendons of 3rd, 4th and 5th digits • Short muscles of thumb
• 2nd, 3rd and 4th lumbricals • Flexor tendons of the index finger
• Palmar aponeurosis • First lumbrical
• Palmar aponeurosis
Posterior Fascia covering interossei and metacarpals Transverse head of adductor pollicis (Fig. 9.49)
Lateral Intermediate palmar septum • Tendon of flexor pollicis longus with radial bursa
• Lateral palmar septum
Medial Medial palmar septum Intermediate palmar septum
6. Drainage Incision in either the 3rd or 4th web space Incision in the first web, posteriorly
Upper Limb

Fig. 9.48: Thenar, midpalmar, dorsal subcutaneous and dorsal subaponeurotic spaces. I, II, III, IV — dorsal interossei and 1, 2, 3,
4 — palmar interossei

The forearm space may be infected through Digital Synovial Sheaths

infections in the related synovial sheaths, especially of The synovial sheaths of the 2nd, 3rd and 4th digits
the ulnar bursa. Pus points at the margins of the distal are independent and terminate proximally at the
part of the forearm where it may be drained by giving levels of the heads of the metacarpals. The synovial
1

incision along the lateral margin of forearm. sheath of the little finger is continuous proximally
Section

with the ulnar bursa, and that of the thumb with the
SYNOVIAL SHEATHS radial bursa. Therefore, infections of the little finger
Many of the tendons entering the hand are surrounded and thumb are more dangerous because they can
by synovial sheaths. The extent of these sheaths is of spread into the palm and even up to 2.5 cm above
surgical importance as they can be infected (Fig. 9.7). the wrist (Fig. 9.7).
 FOREARM AND HAND
143

BACK OF FOREARM AND HAND

This section deals mainly with the extensor retinaculum
of the wrist, muscles of the back of the forearm, the
deep terminal branch of the radial nerve, and the
posterior interosseous artery.

SURFACE LANDMARKS
1 The olecranon process of the ulna is the most
prominent bony point on the back of a flexed elbow
(Fig. 9.51). Normally, it forms a straight horizontal
line with the two epicondyles of the humerus when
the elbow is extended, and an equilateral triangle
Fig. 9.49: Muscles forming floor of the thenar and midpalmar when the elbow is flexed to a right angle (see Fig. 2.17).
spaces The relative position of the three bony points is
disturbed when the elbow is dislocated.
Ulnar Bursa 2 The head of the radius can be palpated in a depression
Infection of this bursa is usually secondary to the on the posterolateral aspect of an extended elbow
infection of the little finger, and this in turn may spread just below the lateral epicondyle of the humerus. Its
to the forearm space of the Parona. It results in an hour- rotation can be felt during pronation and supination
glass swelling (so called because there is one swelling in of the forearm.
the palm and another in the distal part of the forearm, 3 The posterior border of the ulna is subcutaneous in its
the two being joined by a constriction in the region of entire length. It can be felt in a longitudinal groove
the flexor retinaculum). It is also called compound on the back of the forearm when the elbow is flexed
palmar ganglion. and the hand is supinated. The border ends distally
in the styloid process of the ulna. It separates the
Radial Bursa flexors from the extensors of the forearm. Being
Infection of the thumb may spread to the radial bursa. superficial, it allows the entire length of the ulna to
be examined for fractures.
CLINICAL ANATOMY 4 The head of the ulna forms a surface elevation on the
posteromedial aspect of the wrist in a pronated
Surgical Incisions forearm.
The surgical incisions of the hand are shown in 5 The styloid processes of the radius and ulna are
Fig. 9.50. important landmarks of the wrist. The styloid
process of the radius can be felt in the upper part of
the anatomical snuffbox. It projects down 1 cm lower
than the styloid process of the ulna. The latter
descends from the posteromedial aspect of the ulnar
head. The relative position of the two styloid
processes is disturbed in fractures at the wrist, and
Upper Limb
is a clue to the proper realignment of fractured bones.
6 The dorsal tubercle of the radius (Lister’s tubercle) can
be palpated on the dorsal surface of the lower end of
the radius in line with the cleft between the index
and middle fingers. It is grooved on its medial side
by the tendon of the extensor pollicis longus.
7 The heads of the metacarpals form the knuckles.
1

DORSUM OF HAND
Section

1 Skin: It is loose on the dorsum of hand. It can be

pinched off from the underlying structures.
Fig. 9.50: The surgical incisions of the hand 2 Superficial fascia: The fascia contains dorsal venous
plexus, cutaneous nerves, and dorsal carpal arch.
 UPPER LIMB
144

a. Dorsal venous plexus: The digital veins from adja- c. Dorsal carpal arch: It is formed by dorsal carpal
cent sides of index, middle, ring and little fingers branches of radial and ulnar arteries and lies close
form 3 dorsal metacarpal veins (see Fig. 7.7). These to the wrist joint. The arch gives three dorsal
join with each other on dorsum of hand. The metacarpal arteries which supply adjacent sides
lateral end of this arch is joined by one digital vein of index, middle; ring and little fingers. One digital
from index finger and two digital veins from artery goes to medial side of little finger. The arch
thumb to form cephalic vein. It runs proximally also gives branches to the dorsum of hand.
in the anatomical snuffbox, curves, round the lateral 3 Spaces on dorsum of hand: There are two spaces on
border of wrist to come to front of forearm. In a the dorsum of hand:
similar manner, the medial end of the arch joins a. Dorsal subcutaneous space, lying just subjacent to
with one digital vein only from medial side of little skin. Skin of dorsum of hand is loose can be
finger to form basilic vein. It also curves around pinched and lifted off.
the medial side of wrist to reach front of forearm. b. Dorsal subtendinous space lies deep to the extensor
These metacarpal veins may unite in different tendons, between the tendons and the metacarpal
ways to form a dorsal venous plexus. bones (Fig. 9.48).
b. Cutaneous nerves: These are superficial branch of 4 Deep fascia: The deep fascia is modified at the back
radial nerve and dorsal branch of ulnar nerve. The of hand to form extensor retinaculum.
nail beds and skin of distal phalanges of 3½ lateral
nails is supplied by median nerve and 1½ medial Anatomical Snuffbox
nails by ulnar nerve. The superficial branch of The anatomical snuffbox (Fig. 9.52a) is a triangular
radial nerve supplies lateral half of dorsum of depression on the posterolateral side of the wrist. It is
hand with two digital branches to thumb and one seen best when the thumb is extended.
to lateral side of index and another common
digital branch to adjacent sides of index and Boundaries
middle fingers (see Fig. 7.1b). It is bounded anteriorly by tendons of the abductor
Dorsal branch of ulnar supplies medial half of pollicis longus and extensor pollicis brevis, and
dorsum of hand with proper digital branches to posteriorly by the tendon of the extensor pollicis longus.
medial side of little finger; two common digital It is limited above by the styloid process of the radius.
branches for adjacent sides of little and ring fingers The floor of the snuffbox is formed by the scaphoid,
and adjacent sides of ring and middle fingers. the trapezium and base of 1st metacarpal.
Upper Limb
1
Section

Fig. 9.51: Surface landmarks Fig. 9.52a: Anatomical snuffbox

 FOREARM AND HAND
145

Contents
The radial artery is deep while the superficial branch
of radial nerve and cephalic vein are superficial.

Competency achievement: The student should be able to:

AN 12.14 Identify and describe compartments deep to extensor
retinaculum.10

Extensor Retinaculum
The deep fascia on the back of the wrist is thickened to
form the extensor retinaculum which holds the extensor
tendons in place. It is an oblique band, directed
downwards and medially. It is about 2 cm broad
vertically (Fig. 9.52b).

Attachments
Laterally: Lower part of the sharp anterior border of
the radius.
Medially:
i. Styloid process of the ulna
ii. Triquetral
iii. Pisiform

Compartments
The retinaculum sends down septa which are attached
to the longitudinal ridges on the posterior surface of
the lower end of radius. In this way, 6 osseofascial
compartments are formed on the back of the wrist
(see Fig. 2.21b). The structures passing through each
compartment, from lateral to the medial side, are listed
in Table 9.8 and Fig. 9.53.
Each compartment is lined by a synovial sheath,
which is reflected onto the contained tendons. Fig. 9.52b: Muscles of the back of forearm

Upper Limb
1Section

Fig. 9.52c: Dissection of back of forearm

 UPPER LIMB
146

Table 9.8: Structures in various compartments under attachments. Identify the structures traversing its six
extensor retinaculum compartments.
Compartment Structure Clear the deep fascia over the back of forearm.
I • Abductor pollicis longus (Fig. 9.52c) Define the attachment of triceps brachii muscle on the
• Extensor pollicis brevis olecranon process of ulna. Define the attachments of
II • Extensor carpi radialis longus the seven superficial muscles of the back of the forearm.
• Extensor carpi radialis brevis Separate the anterolateral muscles, i.e. brachioradialis,
III • Extensor pollicis longus extensor carpi radialis longus and brevis from the extensor
IV • Extensor digitorum (Fig. 9.52c) digitorum lying in the centre and extensor digiti minimi
• Extensor indicis and extensor carpi ulnaris situated on the medial aspect
• Posterior interosseous nerve of the wrist (Fig. 9.52b). Anconeus is situated on the
posterolateral aspect of the elbow joint. Dissect all these
• Anterior interosseous artery
muscles and trace their nerve supply (refer to BDC App).
V • Extensor digiti minimi
VI • Extensor carpi ulnaris
Competency achievement: The student should be able to:
AN 12.11 Identify, describe and demonstrate important muscle
DISSECTION groups of dorsal forearm with attachments, nerve supply and
actions.11
Make the incision in the centre of dorsum of hand.
Reflect the skin of dorsum of hand till the respective
borders. Reflect the skin of dorsum of middle finger on
MUSCLES OF BACK OF FOREARM
each side. Look for nerves on the back of forearm and
hand. These are superficial branch of radial nerve and
SUPERFICIAL MUSCLES
dorsal branch of ulnar nerve.
The dorsal venous network is the most prominent There are seven superficial muscles on the back of the
component of the superficial fascia of dorsum of hand. forearm:
(Identify the beginning of cephalic and basilic veins by 1 Anconeus
tying a tourniquet on the forearm and exercising the 2 Brachioradialis (Fig. 9.52b)
closed fist on oneself.) 3 Extensor carpi radialis longus
The deep fascia at the back of wrist is thickened to 4 Extensor carpi radialis brevis
form extensor retinaculum. Define its margins and
5 Extensor digitorum (Fig. 9.52c).
Upper Limb
1
Section

Figs 9.53a and b: (a) Attachments of extensor retinaculum; (b) transverse section passing just above the wrist showing structures
passing through I–VI compartments deep to the extensor retinaculum
 FOREARM AND HAND
147

6 Extensor digiti minimi (Fig. 9.52b) DEEP MUSCLES

7 Extensor carpi ulnaris. Features
All the seven muscles cross the elbow joint. Most of These are as follows:
them take origin (entirely or in part) from the tip of the 1 Supinator
lateral epicondyle of the humerus.
2 Abductor pollicis longus
These muscles with their nerve supply and actions
3 Extensor pollicis brevis
are described in Tables 9.9 and 9.10.
4 Extensor pollicis longus (see Fig. 2.23)
Additional Points 5 Extensor indicis
1 The extensor digitorum and extensor indicis pass In contrast to the superficial muscles, none of the
through the same compartment of the extensor deep muscles crosses the elbow joint. These have been
retinaculum, and have a common synovial sheath. tabulated in Tables 9.11 and 9.12.
2 The four tendons of the extensor digitorum emerge Competency achievement: The student should be able to:
from undercover of the extensor retinaculum and fan
AN 12.15 Identify and describe extensor expansion formation.12
out over the dorsum of the hand. The tendon to the
index finger is joined on its medial side by the tendon
of the extensor indicis, and the tendon to the little Dorsal Digital Expansion/Extensor Expansion
finger is joined on its medial side by the two tendons The dorsal digital expansion (extensor expansion) is a
of the extensor digiti minimi. small triangular aponeurosis (related to each tendon
3 On the dorsum of the hand, adjacent tendons are of the extensor digitorum) covering the dorsum of the
variably connected together by three intertendinous proximal phalanx. Its base, which is proximal, covers
connections directed obliquely downwards and the metacarpophalangeal (MP) joint. The main tendon
laterally. The medial connection is strong; the lateral of the extensor digitorum occupies the central part of
connection is weakest and may be absent. the extension, and is separated from the MP joint by a
The four tendons and three intertendinous bursa.
connections are embedded in deep fascia, and The posterolateral corners of the extensor expansion
together form the roof of the subtendinous are joined by tendons of the interossei and of lumbrical
(subaponeurotic) space on the dorsum of the hand. muscles. The corners are attached to the deep transverse

Table 9.9: Attachments of superficial muscles of back of forearm

Muscle Origin Insertion
1. Anconeus (see Fig. 2.14b) Lateral epicondyle of humerus Lateral surface of olecranon process of ulna
2. Brachioradialis (see Upper two-thirds of lateral supracondylar Base of styloid process of radius (see Fig. 2.22)
Fig. 2.14a) ridge of humerus
3. Extensor carpi radialis Lower one-third of lateral supracondylar Posterior surface of base of second metacarpal
longus (see Fig. 2.14a) ridge of humerus bone
4. Extensor carpi radialis brevis Lateral epicondyle of humerus Posterior surface of base of third metacarpal
5. Extensor digitorum Lateral epicondyle of humerus Bases of middle phalanges of the 2nd–5th digits

Upper Limb
6. Extensor digiti minimi Lateral epicondyle of humerus Extensor expansion of little finger
7. Extensor carpi ulnaris Lateral epicondyle of humerus Base of fifth metacarpal bone (Fig. 9.52b)

Table 9.10: Nerve supply and actions of superficial muscles of back of forearm
Muscle Nerve supply Actions
1. Anconeus Radial nerve Extends elbow joint
2. Brachioradialis Radial nerve Flexes forearm at elbow joint; rotates forearm to the
midprone position from supine or prone positions
1

3. Extensor carpi radialis longus Radial nerve Extends and abducts hand at wrist joint
Section

4. Extensor carpi radialis brevis Deep branch of radial nerve Extends and abducts hand at wrist joint
5. Extensor digitorum Deep branch of radial nerve Extends fingers of hand
6. Extensor digiti minimi Deep branch of radial nerve Extends metacarpophalangeal joint of little finger
7. Extensor carpi ulnaris Deep branch of radial nerve Extends and adducts hand at wrist joint
 UPPER LIMB
148

Table 9.11: Attachments of deep muscles of back of forearm

Muscle Origin Insertion
1. Supinator (see Fig. 2.22) Lateral epicondyle of humerus, annular Neck and whole shaft of upper one-
ligament of superior radioulnar joint, third of radius (see Fig. 2.23)
supinator crest of ulna and depression
anterior to it
2. Abductor pollicis longus (see Fig. 2.23) Posterior surface of shafts of radius and ulna Base of first metacarpal bone
3. Extensor pollicis brevis Posterior surface of shaft of radius Base of proximal phalanx of thumb
4. Extensor pollicis longus Posterior surface of shaft of ulna Base of distal phalanx of thumb
5. Extensor indicis Posterior surface of shaft of ulna Extensor expansion of index finger

Table 9.12: Nerve supply and actions of deep muscles of back of forearm
Muscle Nerve supply Actions
1. Supinator (Fig. 9.9) Deep branch of radial nerve Supination of forearm when elbow is extended
2. Abductor pollicis longus Deep branch of radial nerve Abducts and extends thumb
3. Extensor pollicis brevis Deep branch of radial nerve Extends metacarpophalangeal joint of thumb
4. Extensor pollicis longus Deep branch of radial nerve Extends distal phalanx of thumb
5. Extensor indicis Deep branch of radial nerve Extends metacarpophalangeal joint of index finger

metacarpal ligament. The points of attachment of the margin of the extensor expansion. They then join each
interossei (proximal) and lumbrical (distal) are often other and are inserted on the dorsum of the base of
called ‘wing tendons’ (Fig. 9.54). the distal phalanx.
Near the proximal interphalangeal joint, the At the metacarpophalangeal and interphalangeal
extensor tendon divides into a central slip and two joints, the extensor expansion forms the dorsal part of
collateral slips. The central slip is joined by some fibres the fibrous capsule of the joints.
from the margins of the expansion, crosses the The retinacular ligaments (link ligaments) extend from
proximal interphalangeal joint, and is inserted on the the side of the proximal phalanx, and form its fibrous
dorsum of the base of the middle phalanx. The two flexor sheath, to the margins of the extensor expansion
collateral slips are joined by the remaining thick to reach the base of the distal phalanx (Fig. 9.54).
Upper Limb
1
Section

Fig. 9.54: The dorsal digital expansion of right index, middle, ring and little fingers. Note the insertions of the lumbricals and
interossei into it
 FOREARM AND HAND
149

POSTERIOR INTEROSSEOUS NERVE

Features
It is the chief nerve of the back of the forearm. It is a branch
of the radial nerve given off in the cubital fossa, just
below the level of the lateral epicondyle of the humerus.

Course
It begins in cubital fossa. Passes through supinator
muscle to reach back of forearm, where it descends
downwards. It ends in a pseudoganglion in the 4th
compartment of extensor retinaculum.

Relations
1 Posterior interosseous nerve leaves the cubital fossa
and enters the back of the forearm by passing
between the two planes of fibres of the supinator.
Within the muscle it winds backwards around the
lateral side of the radius (Fig. 9.55).
2 It emerges from the supinator on the back of the
forearm. Here it lies between the superficial and deep
Fig. 9.55: Course and relations of the posterior interosseous muscles. At the lower border of the extensor pollicis
nerve and the interosseous arteries
brevis, it passes deep to the extensor pollicis longus.
It then runs on the posterior surface of the
interosseous membrane up to the wrist where it
The muscles inserted into the dorsal digital expansions of: enlarges into a pseudoganglion and ends by supplying
• Index finger: First dorsal interosseous, second palmar the wrist and intercarpal joints.
interosseous, first lumbrical, extensor digitorum slip,
and extensor indicis (Fig. 9.54). Branches
• Middle finger: Second and third dorsal interossei, Posterior interosseous nerve gives muscular, articular
second lumbrical, extensor digitorum slip. and sensory branches (Figs 9.56a and b).
• Ring finger: Fourth dorsal interosseous, third palmar A. Muscular branches
interosseous, third lumbrical and extensor digitorum a. Before piercing the supinator, branches are given
slip. to the extensor carpi radialis brevis and to the
• Little finger: Fourth palmar interosseous, fourth supinator.
lumbrical, extensor digitorum slip and extensor digiti b. While passing through the supinator, another
minimi. branch is given to the supinator.
c. After emerging from the supinator, the nerve
DISSECTION gives three short branches to:

Upper Limb
Separate extensor carpi radials brevis from extensor i. The extensor digitorum (Fig. 9.56b).
digitorum and identify deeply placed supinator ii. The extensor digiti minimi.
muscle. iii. The extensor carpi ulnaris.
Just distal to supinator is abductor pollicis longus. It also gives two long branches:
Other three muscles: Extensor pollicis longus, extensor i. A lateral branch supplies the abductor pollicis
pollicis brevis and extensor indicis are present distal to longus and the extensor pollicis brevis.
abductor pollicis longus. Identify them all (refer to BDC ii. A medial branch supplies the extensor pollicis
App). longus and the extensor indicis.
1

B. Articular branches: Articular branches are given to:

Section

i. The wrist joint.

Competency achievement: The student should be able to: ii. The distal radioulnar joint.
AN 12.12 Identify and describe origin, course, relations, branches iii. Intercarpal and intermetacarpal joints.
(or tributaries), termination of important nerves and vessels of back
of forearm.13 C. Sensory branches: Sensory branches are given to the
interosseous membrane, the radius and the ulna.
 UPPER LIMB
150

Figs 9.56a and b: Branches of the posterior interosseous nerve

DISSECTION POSTERIOR INTEROSSEOUS ARTERY

Deep terminal branch of radial nerve/posterior
interosseous nerve and posterior interosseous artery: Course
Identify the posterior interosseous nerve at the distal Posterior interosseous artery is the smaller terminal
border of exposed supinator muscle. Trace its branches branch of the common interosseous, given off in the
to the various muscles. cubital fossa. It enters the back of the forearm and lies
Look for the radial nerve in the lower lateral part of in between the muscles there.
front of arm between the brachioradialis, extensor carpi It terminates by anastomosing with the anterior
radialis longus laterally and brachialis muscle medially. interosseous artery.
Trace the two divisions of this nerve in the lateral part
Relations
Upper Limb

of the cubital fossa. The deep branch (posterior intero-

sseous nerve) traverses between the two planes of 1 It is the smaller terminal branch of the common
supinator muscle and reaches the back of the forearm interosseous artery in the cubital fossa.
where it is already identified. 2 It enters the back of the forearm by passing between
The nerve runs amongst the muscles of the back of the oblique cord and the upper margin of the
the forearm, and ends at the level of the wrist in a interosseous membrane (Fig. 9.55).
pseudoganglion (Fig. 9.55). 3 It appears on the back of the forearm in the interval
This nerve is accompanied by posterior interosseous between the supinator and the abductor pollicis
artery distal to the supinator muscle. This artery is longus and thereafter accompanies the posterior
1

supplemented by anterior interosseous artery in lower interosseous nerve. At the lower border of the
Section

one-fourth of the forearm. extensor indicis, the artery becomes markedly

reduced and ends by anastomosing with the anterior
interosseous artery which reaches the posterior
compartment by piercing the interosseous membrane
at the upper border of the pronator quadratus. Thus
 FOREARM AND HAND
151

in its lower one-fourth, the back of the forearm is base for better prehensile activities. Arches are
supplied by the anterior interosseous artery. maintained by palmar aponeurosis, palmar
4 The posterior interosseous artery gives off an metacarpal ligaments, muscles of thenar and
interosseous recurrent branch which runs upwards hypothenar eminences, long flexor tendons and
and takes part in the anastomosis on the back of the dorsal interossei.
lateral epicondyle of the humerus (see Fig. 8.10). Palmar arches permit palm and digits to hold the
objects firmly. Opponens digit minimi can flex and
rotate 5th metacarpal along its long axis. Stability
ARCHES OF HAND of 2nd and 3rd carpometacarpal joints is a functional
adaptation to improve actions of flexor carpi
Hand like foot also has arches. The daily tasks are radialis, extensor carpi radialis longus and extensor
helped by these arches. The arches are: carpi radialis brevis.
i. Proximal transverse arch formed by the two rows
of carpal bones.
Mnemonics
ii. Distal transverse arch formed by distal ends of
metacarpal bones (Fig. 9.57). Anterior forearm muscles: Superficial group
2nd and 3rd carpometacarpal joints are immobile “Pretti Found Pamela for Fight”
and have zero degree of freedom. 4th has some Pronator teres
movement, 5th carpometacarpal joint is a saddle Flexor carpi radialis
joint with good amount of movement, i.e. flexion/ Palmaris longus
extension; abduction/adduction and opposition. Flexor carpi ulnaris
iii. Longitudinal arch runs along the length of the hand. Flexor digitorum superficialis
2nd and 3rd metacarpal bones form the keystone of
the arches. As these are the fixed bones. 1st, 4th and Interossei muscles: Actions of dorsal vs. palmar
5th metacarpal bones fold on the sides of 2nd and in hand “PAd and DAb”
3rd metacarpal bones. These arches form concave

Upper Limb
1Section

Fig. 9.57: Arches of the hand

 UPPER LIMB
152

The Palmar Adduct and the Dorsal Abduct. • Flexor retinaculum has a superficial slip medially and
– Use your hand to dab with a pad. a deep slip laterally. Deep to superficial slip course
ulnar nerve and vessels and superficial to the deep
Median nerve: Hand muscles innervated “The slip passes the tendon of flexor carpi radialis.
LOAF muscles” • Thenar eminence does not include the adductor
Lumbricals 1 and 2 pollicis muscle. It comprises abductor pollicis
Opponens pollicis brevis, flexor pollicis brevis and opponens pollicis.
• Median nerve supplies 5 muscles in the palm, three
muscles of thenar eminence and 1st and 2nd
Abductor pollicis brevis
Flexor pollicis brevis lumbricals. It is called ‘labourer’s nerve’. Median
Radial nerve: Muscles supplied (simplified) nerve is also the ‘Eye of the hand’.
• Ulnar nerve is called ‘Musician’s nerve’. It supplies
“BEST muscles” 15 intrinsic muscles of the hand.
Brachioradialis • There are 12 muscles on the back of forearm, two
Extensors of wrist metacarpophalangeal and are smaller (supinator and anconeus) lying in upper
‘interphalangeal joints’ one-fourth of the forearm, five are inserted close to
Supinator, anconeus the wrist (BR, APL, ECRL, ECRB and ECU); five get
Triceps brachii inserted into the phalanges (EPB, EPL, EI, ED and
EDM). All are supplied by radial or posterior
Lumbricals action interosseous nerve. Injury to the nerve causes
Lumbricals action is to hold a pea, that is to flex the ‘wrist drop’.
metacarpophalangeal joints and extend the • Lateral 3½ nail beds are supplied by median nerve
interphalangeal joints. When one looks at hand in and medial 1½ nail beds by ulnar nerve.
this position, can see this makes an “L” shape, since
L is for Lumbrical.
Brachioradialis: Function, innervation, one CLINICOANATOMICAL PROBLEMS
relation, on attachment Case 1
BrachioRadials: A young man practising tennis complained of severe
Function: It’s the Beer Raising muscle, flexes elbow, pain over lateral part of his right elbow. The pain
strongest when wrist is oriented like holding a beer was pin-pointed over his lateral epicondyle.
mug. • Why does pain occur over lateral epicondyle
Innvervation: Breaks Rule: It’s a flexor muscle. But during tennis games?
Radial (Radial nerve usually is for extensors) supplies • Which other games can cause similar pain?
it BEST rule: B was for brachioradials). Ans: The pain is due to lateral epicondylitis, also called
Important relation: Behind it is the Radial nerve in tennis elbow. This is due to repeated microtrauma to
the cubital fossa. the common extensor origin of extensor muscles of
Attachment: Attaches to Bottom of Radius. the forearm. It can also occur in swimming, gymnastics,
basketball, table tennis, i.e. any sport which involves
strenuous use of the extensors of the forearm. It may
Upper Limb

Elbow: Which side has common flexor origin

FM (as in FM Radio) be a degenerative condition.
Flexor Medial, so Common Flexor Origin is on the Case 2
medial side. A 55-year-old woman complained of abnormal
sensations in her right thumb, index, middle and part
of ring fingers. Her pain increased during night.
FACTS TO REMEMBER There was weakness of her thumb movements.
• Median nerve exits the cubital fossa by passing • Which nerve was affected and where? Name the
syndrome.
1

between two heads of pronator teres while ulnar

artery passes deep to both the heads of pronator teres. Ans: Median nerve is affected while it travels deep to
Section

• Anterior interosseous branch of median nerve the flexor retinaculum. The syndrome is ‘carpal tunnel
supplies 2½ muscles of front of the forearm, i.e. syndrome’. There are abnormal sensation in lateral 3½
flexor pollicis longus, pronator quadratus and digits, but there is no loss of sensation over lateral two-
lateral half of flexor digitorum profundus. thirds of palm. The nerve supply of this area is from
 FOREARM AND HAND
153

palmar cutaneous branch of median nerve given in the Presents the Oberg, Manske and Tonkin (OMT) classification
forearm and then it passes superficial to the flexor of upper limb anomalies and the challenges of incorporating
retinaculum. the molecular mechanisms of limb anomalies into current
systems.
FURTHER READING • Singh S, Mahajan R, Raheja S, Rani N, Tuli A. Anatomical
• Gupta A, Kay SPJ, Scheker LR. The Growing Hand. London: diversity in flexor pollicis longus muscle. International
Harcourt, 2000. Medical Journal 2016;23(1):84–85.
A source that includes articles on embryology growth and • Tonkin MA, Tolerton SK, Quick TJ, et al. Classification of
congenital anomalies of the hand. congenital anomalies of the hand in upper limb: develop-
• Kakar S, Raheja S, Dinesh K. Bilateral accessory extensor ment and assessment of a new system. J Hand Surg Am 2013;
digitorum muscle in hand. A case report. JIMSA 2004;17(4): 38:1845–53.
235–36.
1–13
From Medical Council of India, Competency based Undergraduate Curriculum for the Indian Medical Graduate, 2018;1:44–80.

1. Describe flexor digitorum profundus muscle under c. Midpalmar and thenar spaces
following headings: Origin, insertion, nerve supply, d. Extensor retinaculum of wrist and structures
actions and special features. passing in various compartments under the
2. Discuss the formation, course and branches of retinaculum
superficial and deep palmar arches. e. Carpal tunnel syndrome
3. Write short notes on: f. Wrist drop
a. Flexor retinaculum of wrist g. Complete claw hand
b. Layers of palm with their components

1. Which of the following nerves leads to wrist drop? c. Opponens pollicis

a. Ulnar b. Radial d. Adductor pollicis
c. Median d. Musculocutaneous 5. Which of the following nerves is involved in carpal
2. Which nerve supplies adductor pollicis? tunnel syndrome?
a. Median a. Ulnar b. Median
b. Radial c. Radial d. Musculocutaneous
c. Superficial branch of ulnar 6. Which of the following structures does not pass Upper Limb
d. Deep branch of ulnar through the carpal tunnel?
3. Which of the following is the action of dorsal a. Palmar cutaneous branch of median nerve
interosseous? b. Median nerve
a. Abduction of fingers c. Tendons of flexor digitorum profundus
b. Flexion of thumb d. Tendon of flexor pollicis longus
c. Adduction of fingers 7. Superficial cut only on the flexor retinaculum of
1

d. Extension of metacarpophalangeal joints wrist would damage all structures, except:

Section

4. Which of the following muscles is not supplied by a. Median nerve

median nerve? b. Palmar cutaneous branch of median nerve
a. Abductor pollicis brevis c. Palmar cutaneous branch of ulnar nerve
b. Flexor pollicis brevis d. Ulnar nerve
 UPPER LIMB
154

8. All the following structures are present in the carpal c. Adduct the thumb
tunnel, except: d. Abduct the thumb
a. Tendon of palmaris longus 10. de Quervain’s disease affects:
b. Tendon of flexor pollicis longus a. Tendons of abductor pollicis longus and
c. Tendons of flexor digitorum profundus abductor pollicis brevis
d. Median nerve b. Tendons of abductor pollicis longus and extensor
pollicis brevis
9. Compression of median nerve within carpal tunnel c. Tendons of extensor carpi radialis longus and
causes inability to: extensor carpi radialis brevis
a. Flex the interphalangeal joint of thumb d. Tendons of flexor pollicis longus and flexor
b. Extend the interphalangeal joint of thumb pollicis brevis

1. b 2. d 3. a 4. d 5. b 6. a 7. a 8. a 9. d 10. b

• Name the superficial muscles of front of forearm. • Why does ‘carpal tunnel syndrome’ occur and what
Name their nerve supply. are its symptoms?
• How many deep muscles are there in front of • What are the attachments of flexor retinaculum?
forearm? Which nerve innervates them? Name structures passing superficial to the
• Where is the origin of lumbrical muscles? How many retinaculum.
are unipennate and how many are bipennate • Show the actions of palmar interossei and dorsal
muscles? How are the lumbricals innervated? interossei muscles.
• Name the branches of radial artery in forearm, wrist • Name the boundaries and contents of ‘anatomical
and palm. snuffbox’.
• Name the branches of ulnar artery in forearm and • Which is the common site of injury to ulnar nerve?
palm. • What is ape-/monkey- like deformity of thumb?
• What are the branches of common interosseous • Name the attachments of extensor retinaculum of
artery? wrist.
• Which is the most important nerve of the front of • How many compartments are there under extensor
forearm? retinaculum of wrist? Enumerate their contents?
• Which nerve supplies maximum muscles in the • Name the muscles supplied by posterior
palm? Name these muscles. interosseous/deep branch of radial nerve.
Upper Limb
1
Section
 10
Joints of Upper Limb
! Pronation is giving and supination is getting. There is no less joy in giving than in getting
If I have seen farther, it is by standing on the shoulder of giants !
—Sir Issac Newton

INTRODUCTION
STERNOCLAVICULAR JOINT
Joints are sites where two or more bones or cartilages
articulate. Free movements occur at the synovial joints. Features
Shoulder joint is the most freely mobile joint. Shoulder The sternoclavicular joint is a synovial joint. It is a
joint gets excessive mobility at the cost of its own compound joint as there are three elements taking part
stability, since both are not feasible to the same degree. in it; namely the medial end of the clavicle, the
The carrying angle in relation to elbow joint is to clavicular notch of the manubrium sterni, and the upper
facilitate carrying objects like buckets without hitting surface of the first costal cartilage. It is a complex joint
the pelvis. as its cavity is subdivided into two compartments—
Supination and pronation are basic movements for superomedial and inferolateral by an intra-articular disc
the survival of human being. During pronation, the (Fig. 10.1).
food is picked and by supination it is put at the right The articular surface of the clavicle is covered with
place—the mouth. While ‘giving’, one pronates, while fibrocartilage (as the clavicle is a membrane bone). The
‘getting’ one supinates. surface is convex from above downwards and slightly
The first carpometacarpal joint allows movements concave from front to back. The sternal surface is
of opposition of thumb with the fingers for picking up smaller than the clavicular surface. It has a reciprocal
or holding things. Thumb is the most important digit. convexity and concavity. Because of the concavoconvex
Remember Guru Dronacharya asked Eklavya to give shape of the articular surfaces, the joint can be classified
his right thumb as Guru-Dakshina, so that he is not able as a saddle joint.
to outsmart Arjuna in archery. The capsular ligament is attached laterally to the
margins of the clavicular articular surface; and medially
SHOULDER GIRDLE to the margins of the articular areas on the sternum
and on the first costal cartilage. It is strong anteriorly
The shoulder girdle connects the upper limb to the axial
and posteriorly where it constitutes the anterior and
skeleton. It consists of the clavicle and the scapula.
posterior sternoclavicular ligaments.
Anteriorly, the clavicle reaches the sternum and
articulates with it at the sternoclavicular joint. The However, the main bond of union at this joint is the
articular disc. The disc is placed laterally to the clavicle
clavicle and the scapula are united to each other at the
on a rough area above and posterior to the articular
acromioclavicular joint. The scapula is not connected
area for the sternum. Inferiorly, the disc is placed to
to the axial skeleton directly, but is attached to it
the sternum and to the first costal cartilage at their
through muscles. The clavicle and the scapula have
junction. Anteriorly and posteriorly, the disc fuses with
been studied in Chapter 2. The joints of the shoulder
the capsule.
girdle are described below.
There are two other ligaments associated with this
joint. The interclavicular ligament passes between the
Competency achievement: The student should be able to: sternal ends of the right and left clavicles, some of its
AN 13.4 Describe sternoclavicular joint, acromioclavicular joint.1 fibres being attached to the upper border of the
manubrium sterni (Fig. 10.1).
155
 UPPER LIMB
156

Fig. 10.1: The sternoclavicular and acromioclavicular joints

The costoclavicular ligament is attached above to the The facets are covered with fibrocartilage. The cavity
rough area on the inferior aspect of the medial end of of the joint is subdivided by an articular disc which
the clavicle. Inferiorly, it is attached to the first costal may have perforation in it (Fig. 10.1).
cartilage and to the first rib. It consists of anterior and The bones are held together by a fibrous capsule and
posterior laminae. by the articular disc. However, the main bond of union
Blood supply: Internal thoracic and suprascapular between the scapula and the clavicle is the
arteries. coracoclavicular ligament described below (Fig. 10.1).
Blood supply: Suprascapular and thoracoacromial
Nerve supply: Medial supraclavicular nerve. arteries.
Movements: Movements of the sternoclavicular joint Nerve supply: Lateral supraclavicular nerve.
can be best understood by visualizing the movement
Movements: See movements of shoulder girdle.
at the lateral end of clavicle. These movements are
elevation/depression, protraction/retraction and Coracoclavicular Ligament
anterior and posterior rotation of the clavicle. The
The ligament consists of two parts—conoid and
anterior and posterior rotation of clavicle is utilized in
trapezoid. The trapezoid part is attached, below to the
overhead movements of the shoulder girdle.
upper surface of the coracoid process; and above to the
trapezoid line on the inferior surface of the lateral part
DISSECTION of the clavicle. The conoid part is attached, below to
Remove the subclavius muscle from first rib at its the root of the coracoid process just lateral to the
attachment with its costal cartilage. Identify the costo- scapular notch. It is attached above to the inferior
clavicular ligament. surface of the clavicle on the conoid tubercle.
Define the sternoclavicular joint and clean the anterior Movements of the Shoulder Girdle
Upper Limb

and superior surfaces of the capsule of this joint. Cut

carefully through the joint to expose the intra-articular Movements at the two joints of the girdle are always
disc positioned between the clavicle and the sternum. associated with the movements of the scapula
The fibrocartilaginous disc divides the joint cavity into a (Figs 10.2a to f). The movements of the scapula may or
superomedial and an inferolateral compartments. may not be associated with the movements of the
shoulder joint. The various movements of shoulder
girdle are described below.
ACROMIOCLAVICULAR JOINT a. Elevation of the scapula (as in shrugging the
shoulders). The movement is brought about by the
1

Features upper fibres of the trapezius and by the levator

Section

The acromioclavicular joint is a plane synovial joint. It scapulae.

is formed by articulation of small facets present: It is associated with the elevation of the lateral end,
i. At the lateral end of the clavicle. and depression of the medial end of the clavicle. The
ii. On the medial margin of the acromion process of clavicle moves around an anteroposterior axis
the scapula. formed by the costoclavicular ligament (Fig. 10.2a).
 JOINTS OF UPPER LIMB
157

Figs 10.2a to f: Movements of the right shoulder girdle: (a) Elevation, (b) depression, (c) protraction, (d) retraction, (e) lateral
rotation of inferior angle, and (f) medial rotation of inferior angle

b. Depression of the scapula (drooping of the shoulder). the arm. The scapula rotates around the coraco-
It is brought about by gravity, and actively by the clavicular ligaments. The movement is brought about
lower fibres of the serratus anterior and by the by the upper and lower fibres of the trapezius and
pectoralis minor. the lower fibres of the serratus anterior. This
It is associated with the depression of the lateral movement is associated with rotation of the clavicle
end, and elevation of the medial end of the clavicle around its long axis (Fig. 10.2e).
(Fig. 10.2b). Movements (a) and (b) occur in f. Medial or backward rotation of the scapula occurs
inferolateral compartment. under the influence of gravity, although it can be
c. Protraction of the scapula (as in pushing and punching brought about actively by the levator scapulae and

Upper Limb
movements). It is brought about by the serratus the rhomboids (Fig. 10.2f).
anterior and by the pectoralis minor (Fig. 10.2c).
Movements (e) and (f) occur in inferolateral
It is associated with forward movements of the
compartment.
lateral end and backward movement of the medial
end of the clavicle (Fig. 10.2c).
Ligaments of the Scapula
d. Retraction of the scapula (squaring the shoulders) is
brought about by the rhomboids and by the middle The coracoacromial ligament (see Fig. 6.7): It is a triangular
fibres of the trapezius. ligament, the apex of which is attached to the tip of the
It is associated with backward movement of the acromion process, and the base to the lateral border of
1

lateral end and forward movement of the medial end the coracoid process.
Section

of the clavicle (Fig. 10.2d). The acromion process, the coracoacromial ligament
Movements (c) and (d) occur in superomedial and the coracoid process, together form the coraco-
compartment. acromial arch, which is known as the secondary socket
e. Lateral or forward rotation of the scapula around the for the head of the humerus. It adds to the stability of
chest wall takes place during overhead abduction of the joint and protects the head of the humerus.
 UPPER LIMB
158

Structurally, it is a weak joint because the glenoid

cavity is too small and shallow to hold the head of the
humerus in place (the head is four times the size of the
glenoid cavity). However, this arrangement permits
great mobility. Stability of the joint is maintained by
the following factors.
1 The coracoacromial arch or secondary socket for
the head of the humerus (see Fig. 6.8).
2 The musculotendinous cuff of the shoulder
(see Fig. 6.7).
3 The glenoidal labrum (Latin lip) helps in
deepening the glenoid fossa. Stability is also
provided by the muscles attaching the humerus
to the pectoral girdle, the long head of the biceps
brachii, and the long head of the triceps brachii.
Atmospheric pressure also stabilises the joint.

Fig. 10.3: The suprascapular and spinoglenoid ligaments Ligaments

1 The capsular ligament: It is very loose and permits free
The suprascapular ligament: It converts the scapular movements. It is least supported inferiorly where
notch into a foramen. The suprascapular nerve passes dislocations are common. Such a dislocation may
below the ligament, and the suprascapular artery and damage the closely related axillary nerve (see Fig. 6.8).
vein above the ligament (Fig. 10.3). • Medially, the capsule is attached to the scapula
The spinoglenoid ligament: It is a weak band which beyond the supraglenoid tubercle and the margins
bridges the spinoglenoid notch. The suprascapular of the labrum.
nerve and vessels pass beneath the arch to enter the • Laterally, it is attached to the anatomical neck of
infraspinous fossa (Fig. 10.3). the humerus with the following exceptions.
– Inferiorly, the attachment extends down to the
DISSECTION surgical neck (see Figs 2.14a and b).
Remove the muscles attached to the lateral end of – Superiorly, it is deficient for passage of the
clavicle and acromial process of scapula. Define the tendon of the long head of the biceps brachii
articular capsule surrounding the joint. Cut through the (Fig. 10.4a).
capsule to identify the intra-articular disc. Look for the • Anteriorly, the capsule is reinforced by supple-
strong coracoclavicular ligament. mental bands called the superior, middle and
inferior glenohumeral ligaments (Fig. 10.4b).
Competency achievement: The student should be able to: The area between the superior and middle gleno-
AN 10.12 Describe and demonstrate shoulder joint for—type,
humeral ligament is a point of weakness in the
articular surfaces, capsule, synovial membrane, ligaments, relations, capsule (foramen of Weitbrecht) which is a common
movements, muscles involved, blood supply, nerve supply and site of anterior dislocation of humeral head.
Upper Limb

applied anatomy.2 The capsule is lined with synovial membrane.

An extension of this membrane forms a tubular
SHOULDER JOINT sheath for the tendon of the long head of the biceps
brachii.
Type 2 The coracohumeral ligament: It extends from the root
of the coracoid process to the neck of the humerus
The shoulder joint is a synovial joint of ball and socket opposite the greater tubercle. It gives strength to the
variety. capsule.
The articular surface, ligaments, and bursae related 3 Transverse humeral ligament: It bridges the upper part
1

to this important joint are explained below. of the bicipital groove of the humerus (between the
Section

greater and lesser tubercles). The tendon of the long

Articular Surface head of the biceps brachii passes deep to the ligament.
The joint is formed by articulation of the glenoid cavity 4 The glenoidal labrum: It is a fibrocartilaginous rim
of scapula and the head of the humerus. Therefore, it is which covers the margins of the glenoid cavity, thus
also known as the glenohumeral articulation. increasing the depth of the cavity.
 JOINTS OF UPPER LIMB
159

Figs 10.4a and b: The shoulder joint

Bursae Related to the Joint mechanism can lead to inflammatory conditions of the
1 The subacromial (subdeltoid) bursa (see Figs 6.7 and 6.8). supraspinatus tendon.
2 The subscapularis bursa—communicates with the Relations
joint cavity.
• Superiorly: Coracoacromial arch, subacromial bursa,
3 The infraspinatus bursa—may communicate with the supraspinatus and deltoid (Fig. 10.4c).
joint cavity. • Inferiorly: Long head of the triceps brachii, axillary
The subacromial and the subdeltoid bursae are nerves and posterior circumflex humeral artery.
commonly continuous with each other but may be • Anteriorly: Subscapularis, coracobrachialis, short
separate. Collectively they are called the subacromial head of biceps brachii and deltoid.
bursa, which separates the acromion process and the • Posteriorly: Infraspinatus, teres minor and deltoid.
coracoacromial ligaments from the supraspinatus • Within the joint: Tendon of the long head of the biceps
tendon and permits smooth motion. Any failure of this brachii.

Upper Limb
1Section

Fig. 10.4c: Schematic sagittal section showing relations of the shoulder joint
 UPPER LIMB
160

Blood Supply and coronal planes (Fig. 10.5). When the arm is by the side
1 Anterior circumflex humeral vessels (in the resting position) the glenoid cavity faces almost
2 Posterior circumflex humeral vessels equally forwards and laterally; and the head of the
humerus faces medially and backwards. Keeping these
3 Suprascapular vessels
directions in mind, the movements are analysed as
4 Subscapular vessels
follows.
Nerve Supply 1 Flexion and extension: During flexion, the arm moves
1 Axillary nerve forwards and medially, and during extension, the
2 Musculocutaneous nerve arm moves backwards and laterally. Thus flexion
3 Suprascapular nerve and extension take place in a plane parallel to the
surface of the glenoid cavity (Figs 10.6a and b).
Movements of Shoulder Joint 2 Abduction and adduction take place at right angles
The shoulder joint enjoys great freedom of mobility to the plane of flexion and extension, i.e.
at the cost of stability. There is no other joint in the approximately midway between the sagittal and
body which is more mobile than the shoulder joint. This coronal planes. In abduction, the arm moves
wide range of mobility is due to laxity of its fibrous anterolaterally away from the trunk. This
capsule, and the four times large size of the head of the movement is in the same plane as that of the body
humerus as compared with the shallow glenoid cavity. of the scapula (Figs 10.6c and d).
The range of movements is further increased by 3 Medial and lateral rotations are best demonstrated
concurrent movements of the shoulder girdle (Figs 10.5 with a midflexed elbow. In this position, the hand
and 10.6). is moved medially across the chest either in front
However, this large range of motion makes or behind the chest in medial rotation, and
glenohumeral joint more susceptible to dislocations, laterally in lateral rotation of the shoulder joint
instability, degenerative changes and other painful (Figs 10.6e and f).
conditions specially in individuals who perform 4 Circumduction is a combination of different move-
repetitive overhead motions (cricketers). ments as a result of which the hand moves along
a circle. The range of any movement depends on
Movements of the shoulder joint are considered in
the availability of an area of free articular surface
relation to the scapula rather than in relation to the sagittal
on the head of the humerus.
Muscles bringing about movements at shoulder joint
are shown in Table 10.1. Abduction has been analysed.

Analysis of the Overhead Movement of the Shoulder

The overhead movements of flexion and abduction of
the shoulder are brought about by smooth and
coordinate motion at all joints of the shoulder complex:
Glenohumeral, sternoclavicular, acromioclavicular, and
scapulothoracic. Only glenohumeral joint motion
cannot bring about the 180° of movement that takes
Upper Limb

place in overhead shoulder movements. The scapula

contributes to overhead flexion and abduction by
rotating upwardly by 50°–60°. The glenohumeral joint
contributes 100°–120° of flexion and 90°–120° of abduc-
tion to the total 170°–180° of overhead movements. This
makes the overall ratio of 2° of motion of shoulder to
1° of scapulothoracic motion and is often referred to as
‘scapulohumeral rhythm’. Thus for every 15° of
elevation, 10° occur at shoulder joint and 5° are due to
1

movement of the scapula.

Section

The humeral head undergoes lateral rotation at

around 90° of abduction to help clear the greater
Figs 10.5a and b: Planes of movements of the shoulder joint: tubercle under the acromion process. Although deltoid
(a) Flexion, extension, abduction, adduction, and (b) medial and is the main abductor of the shoulder, the rotator
lateral rotations muscles, namely the supraspinatus, infraspinatus, teres
 JOINTS OF UPPER LIMB
161

Figs 10.6a to f: Movements of the shoulder joint: (a) Flexion, (b) extension, (c) abduction, (d) adduction, (e) medial rotation, (f) lateral
rotation

Upper Limb
minor and the subscapularis play a very important role DISSECTION
in providing static and dynamic stability to the head of
the humerus. Thus the deltoid and these four muscles Having studied all the muscles at the upper end of the
scapula, it is wise to open and peep into the most mobile
constitute a ‘couple’ which permits true abduction in
the plane of the body of the scapula. shoulder joint.
In addition, the scapular muscles such as trapezius, Identify the muscles attached to the greater and
lesser tubercles of humerus. Deep to the acromion
serratus anterior, levator scapulae and rhomboids
provide stability and mobility to the scapula in the process look for the subacromial bursa.
coordinated overhead motion. Identify coracoid process, acromion process and
1

triangular coracoacromial arch binding these two bones

Serratus anterior is chiefly inserted into the inferior
together (see Fig. 6.7).
Section

angle of scapula. It rotates this angle laterally. At the

same time, trapezius rotates the medial border at root Trace the supraspinatus muscle from supraspinous
fossa of scapula to the greater tubercle of humerus. On
of spine of scapula downwards. The synergic action of
these two muscles turns the glenoid cavity upwards its way, it is intimately fused to the capsule of the shoulder
increasing the range of abduction at the shoulder joint.
 UPPER LIMB
162

Table 10.1: Muscles bringing about movements at the shoulder joint

Movements Main muscles Accessory muscles
1. Flexion • Clavicular head of the pectoralis major • Coracobrachialis
• Anterior fibres of deltoid • Short head of biceps brachii
2. Extension • Posterior fibres of deltoid • Teres major
• Latissimus dorsi • Long head of triceps brachii
• Sternocostal head of the pectoralis major
3. Adduction • Pectoralis major • Teres major
• Latissimus dorsi • Coracobrachialis
• Short head of biceps brachii
• Long head of triceps brachii
4. Abduction • Both supraspinatus and deltoid muscles initiate —
abduction and are involved throughout the range of
abduction from 0°–90°.
• Serratus anterior 90°–180°
• Upper and lower fibres of trapezius 90°–180°
5. Medial rotation • Pectoralis major • Subscapularis
• Anterior fibres of deltoid
• Latissimus dorsi
• Teres major
6. Lateral rotation • Posterior fibres of deltoid —
• Infraspinatus
• Teres minor

joint. In the same way, tendons of infraspinatus and teres its attachment to the joint capsule, the disc is also
minor also fuse with the posterior part of the capsule. attached above to the medial end of the clavicle,
Inferiorly, trace the tendon of long head of triceps and below to the manubrium. This prevents the
brachii from the infraglenoid tubercle of scapula. sternal end of the clavicle from tilting upwards
Cut through the subscapularis muscle at the neck of when the weight of the arm depresses the acromial
scapula. It also gets fused with the anterior part of end (Fig. 10.1).
capsule of the shoulder joint as it passes to the lesser • The clavicle dislocates upwards at the acromio-
tubercle of humerus. clavicular joint, because the clavicle overrides the
Having studied the structures related to shoulder acromion process.
joint, the capsule of the joint is to be opened. • The weight of the limb is transmitted from the
A vertical incision is given in the posterior part of the scapula to the clavicle through the coraco-
capsule of the shoulder joint. The arm is rotated medially clavicular ligament, and from the clavicle to the
and laterally. This helps in head of humerus getting sternum through the sternoclavicular joint. Some
separated from the shallow glenoid cavity. of the weight also passes to the first rib by the
Inside the capsule, the shining tendon of long head of costoclavicular ligament. The clavicle usually
Upper Limb

biceps brachii is visible as it traverses the intertubercular fractures between these two ligaments (Fig. 10.1).
sulcus to reach the supraglenoid tubercle of scapula. • Dislocation: The shoulder joint is more prone to
This tendon also gets continuous with the labrum dislocation than any other joint. This is due to
glenoidale attached to the rim of glenoid cavity. laxity of the capsule and the disproportionate area
of the articular surfaces. Dislocation usually occurs
when the arm is abducted. In this position, the
CLINICAL ANATOMY head of the humerus presses against the lower
unsupported part of the capsular ligament. Thus
• The clavicle may be dislocated at either of its ends. almost always the dislocation is primarily
1

At the medial end, it is usually dislocated subglenoid. Dislocation endangers the axillary
Section

forwards. Backward dislocation is rare as it is nerve which is closely related to the lower part of
prevented by the costoclavicular ligament. the joint capsule (see Fig. 2.15).
• The main bond of union between the clavicle and • Optimum attitude: In order to avoid ankylosis,
the manubrium is the articular disc. Apart from many diseases of the shoulder joint are treated in
 JOINTS OF UPPER LIMB
163

Figs 10.7a and b: (a) Shoulder tip pain. Other sites of referred pain also shown, and (b) anatomical basis of referred pain

an optimum position of the joint. In this position,

the arm is abducted by 45°–90°.
• Shoulder tip pain: Irritation of the peritoneum
underlying diaphragm from any surrounding
pathology causes referred pain in the shoulder.
This is so because the phrenic nerve carrying
impulses from peritoneum and the supraclavicular
nerves (supplying the skin over the shoulder) both
arise from spinal segments C3, C4 (Figs 10.7a
and b).
• The shoulder joint is most commonly approached
(surgically) from the front. However, for
aspiration, the needle may be introduced either
anteriorly through the deltopectoral triangle Upper Limb
(closer to the deltoid), or laterally just below the
Fig. 10.8: Site of aspiration of shoulder joint
acromion process (Fig. 10.8).
• Frozen shoulder: This is a common occurrence.
Pathologically, the two layers of the synovial to excessive use of scapular motion while
membrane become adherent to each other. performing overhead flexion and abduction.
Clinically, the patient (usually 40–60 years of age) The surrounding muscles show disuse atrophy.
complains of progressively increasing pain in the The disease is self-limiting and the patient may
recover spontaneously in about two years and
1

shoulder, stiffness in the joint and restriction of

all movements particularly external rotation, much earlier by physiotherapy.
Section

abduction and medial rotation. As the contri- • Shoulder joint disease can be excluded, if the
bution of the glenohumeral joint is reduced, the patient can raise both his arms above the head and
patient shows altered scapulohumeral rhythm due bring the two palms together (Fig. 10.9). Deltoid
muscle and axillary nerve are likely to be intact.
 UPPER LIMB
164

DANCING SHOULDER
When one flexes the arm at shoulder joint,
there is one small point
which you must remember;
whether it is July or November
there is a gamble of two muscles
Pectoralis major and Anterior deltoid in the tussles.

To Teres major, Latissimus dorsi was happily married

but while extending, these got joined with Posterior deltoid.

In adduction of course,
the joint decided a better course.
It went off with two majors (Pectoralis major and Teres
major),
On the way they stopped for some gazers,
The two majors danced with Subscapularis
during medial rotation,
Even Anterior deltoid and Latissimus dorsi,
soon joined the happy flirtation

If one wants the joint to laterally rotate,

Fig. 10.9: Exclusion of shoulder joint disease then there is difference in the mate.
Posterior deltoid dances with Infraspinatus,
Even Teres minor comes and triangulates.
Competency achievement: The student should be able to:
AN 13.3 Identify and describe the type, articular surfaces, capsule, When just abduction is desired,
synovial membrane, ligaments, relations, movements, blood and Supraspinatus and Mid-deltoid are required.
nerve supply of elbow joint, proximal and distal radioulnar joints, But if Kapil Dev has to do the bowling
wrist joint and first carpometacarpal joint.3 come Trapezius and Serratus anterior following.

Small muscles provide stability

ELBOW JOINT Large ones give it mobility
And shoulder joint dances,
Features dances and dances.
The elbow joint is a hinge variety of synovial joint
between the lower end of humerus and the upper ends ii. Trochlear notch of the ulna articulates with the
of radius and ulna bones. trochlea of the humerus (Fig. 10.10).
Elbow joint is the term used for humeroradial and The elbow joint is continuous with the superior
humeroulnar joints. The term elbow complex also radioulnar joint. The humeroradial, the humeroulnar
includes the superior radioulnar joint also. and the superior radioulnar joints are together known
Upper Limb

as cubital articulations.
Articular Surfaces
Upper Ligaments
The capitulum and trochlea of the humerus. 1 Capsular ligament: Superiorly, it is attached to the lower
end of the humerus in such a way that the capitulum,
The coronoid fossa lies just above the trochlea and is
the trochlea, the radial fossa, the coronoid fossa and
designed in a manner that the coronoid process of ulna
the olecranon fossa are intracapsular. Inferomedially,
fits into it in extreme flexion. Similarly, the radial fossa
it is attached to the margin of the trochlear notch of
1

just above the capitulum allows for radial head fitting

the ulna except laterally; inferolaterally, it is attached
in the radial fossa in extreme flexion.
Section

to the annular ligament of the superior radioulnar

joint. The synovial membrane lines the capsule and
Lower the fossae, named above.
i. Upper surface of the head of the radius articulates The anterior ligament, and the posterior ligament are
with the capitulum. thickenings of the capsule.
 JOINTS OF UPPER LIMB
165

superficialis. It is closely related to the flexor carpi

ulnaris and the triceps brachii.
3 The radial collateral or lateral ligament: It is a fan-shaped
band extending from the lateral epicondyle to the
annular ligament. It gives origin to the supinator and
to the extensor carpi radialis brevis (Fig. 10.12).

Relations
• Anteriorly: Brachialis, median nerve, brachial artery
and tendon of biceps brachii.
• Posteriorly: Triceps brachii and anconeus.
• Medially: Ulnar nerve, flexor carpi ulnaris and
common flexors.
• Laterally: Supinator, extensor carpi radialis brevis and
other common extensors.

Blood Supply
From anastomoses around the elbow joint (see Fig. 8.10).

Fig. 10.10: The cubital articulations, including the elbow and Nerve Supply
superior radioulnar joints
The joint receives branches from the following nerves.
i. Ulnar nerve
2 The ulnar collateral ligament is triangular in shape ii. Median nerve
(Fig. 10.11). Its apex is attached to the medial iii. Radial nerve
epicondyle of the humerus, and its base to the ulna. iv. Musculocutaneous nerve through its branch to the
The ligament has thick anterior and posterior bands: brachialis
These are attached below to the coronoid process and
the olecranon process, respectively. Their lower ends Movements
are joined to each other by an oblique band which 1 Flexion is brought about by:
gives attachment to the thinner intermediate fibres i. Brachialis (see Fig. 8.6)
of the ligament. The ligament is crossed by the ulnar ii. Biceps brachii
nerve and it gives origin to the flexor digitorum iii. Brachioradialis

Upper Limb
1Section

Fig. 10.11: The ulnar collateral ligament of the elbow joint

showing anterior, posterior and oblique bands Fig. 10.12: The radial collateral ligament of the elbow joint
 UPPER LIMB
166

2 Extension is produced by: mostly used. This arrangement of gradually increasing

i. Triceps brachii (Fig. 10.13) carrying angle during extension of the elbow increases
ii. Anconeus the precision with which the hand (and objects held in
it) can be controlled. The angle is 10°–15° in males
Carrying Angle (Fig. 10.14a) and more than 15° in females (Fig. 10.14b).
The transverse axis of the elbow joint is directed
medially and downwards. Because of this, the extended DISSECTION
forearm is not in straight line with the arm, but makes Cut through the muscles arising from the lateral and
an angle of about 13° with it. This is known as the medial epicondyles of humerus and reflect them distally,
carrying angle. The factors responsible for formation if not already done. Also cut through biceps brachii,
of the carrying angle are as follows. brachialis and triceps brachii 3 cm proximal to the elbow
a. The medial flange of the trochlea is 6 mm deeper joint and reflect them distally.
than the lateral flange. Remove all the muscles fused with the fibrous
b. The superior articular surface of the coronoid process capsule of the elbow joint and define its attachments
of the ulna is placed oblique to the long axis of the (refer to BDC App).
bone.
The carrying angle disappears in full flexion of the CLINICAL ANATOMY
elbow, and also during pronation of the forearm. The
forearm comes into line with the arm in the midprone • Distension of the elbow joint by an effusion
position, and this is the position in which the hand is occurs posteriorly because here the capsule is
weak and the covering deep fascia is thin.
Aspiration is done posteriorly on any side of the
olecranon process (Fig. 10.15).
• Dislocation of the elbow is usually posterior, and
is often associated with fracture of the coronoid
process. The triangular relationship between the
olecranon process and the two humeral
epicondyles is lost (see Fig. 2.17).
• Subluxation of the head of the radius (pulled elbow)
occurs in children when the forearm is suddenly
pulled in pronation. The head of the radius slips
out from the annular ligament (see Fig. 2.25).
• Tennis elbow occurs in tennis players. Abrupt
pronation with fully extended elbow may lead to
pain and tenderness over the lateral epicondyle
which gives attachment to common extensor
origin (Fig. 10.16a). This is possibly due to:
a. Sprain of radial collateral ligament.
b. Tearing of fibres of the extensor carpi radialis
brevis.
Upper Limb

c. Recent researches have pointed out that it is

more of a degenerative condition rather than
inflammatory condition.
• Student’s (miner’s) elbow is characterised by
effusion into the bursa over the subcutaneous
posterior surface of the olecranon process.
Students during lectures support their head (for
sleeping) with their hands with flexed elbows. The
bursa on the olecranon process gets inflamed
1

(Fig. 10.16b).
Section

• Golfer’s elbow is the microtrauma of medial

epicondyle of humerus, occurs commonly in golf
players. The common flexor origin undergoes

Fig. 10.13: Triceps brachii

 JOINTS OF UPPER LIMB
167

Figs 10.14a and b: Carrying angle: (a) 10°–15° in males, and (b) more than 15° in females

Fig. 10.16b: Student’s elbow

Fig. 10.15: Aspiration of elbow joint

repetitive strain and results in a painful condition

on the medial side of the elbow (Fig. 10.17).
• If carrying angle (normal is 13°) is more, the Upper Limb
condition is cubitus valgus, ulnar nerve may get
stretched leading to weakness of intrinsic muscles
of hand. If the angle is less, it is called cubitus
varus (Fig. 10.18).
• Under optimal position of the elbow: Generally
elbow flexion between 30° and 40° is sufficient
to perform common activities of daily living such
1

as eating, combing, dressing, etc. Because of this

reason even people who have lost terminal
Section

flexion or extension after a fracture/trauma are

able to accomplish these personal tasks without
Fig. 10.16a: Tennis elbow much problems.
 UPPER LIMB
168

Fig. 10.17: Golfer’s elbow Fig. 10.18: Normal, cubitus valgus, and cubitus varus

RADIOULNAR JOINTS downwards and medially from the radius to ulna

(Fig. 10.19). The two bones are also connected by the
Features oblique cord which extends from the tuberosity of the
radius to the tuberosity of the ulna. The direction of its
The radius and the ulna are joined to each other at the
fibres is opposite to that in the interosseous membrane.
superior and inferior radioulnar joints. These are
described in Table 10.2. The radius and ulna are also 1 Superiorly, the interosseous membrane begins 2–3 cm
connected by the interosseous membrane which below the radial tuberosity. Between the oblique cord
constitutes middle radioulnar joint (Fig. 10.19). and the interosseous membrane, there is a gap for
passage of the posterior interosseous vessels to the
INTEROSSEOUS MEMBRANE back of the forearm.
The interosseous membrane connects the shafts of the 2 Inferiorly, a little above its lower margin, there is an
radius and ulna. It is attached to the interosseous aperture for the passage of the anterior interosseous
borders of these bones. The fibres of the membrane run vessels to the back of the forearm.

Table 10.2: Radioulnar joints (Fig. 10.19)

Features Superior radioulnar joint Inferior radioulnar joint
Type Pivot type of synovial joint Pivot type of synovial joint
Articular surfaces • Circumference of head of radius • Head of ulna
Upper Limb

• Osseofibrous ring, formed by the radial notch of • Ulnar notch of radius

the ulna and the annular ligament
Ligaments • The annular ligament forms four-fifths of the ring • The capsule surrounds the joint. The weak upper
within which the head of the radius rotates. It is part is evaginated by the synovial membrane
attached to the margins of the radial notch of the to form a recess (recessus sacciformis) in front
ulna, and is continuous with the capsule of the of the interosseous membrane
elbow joint above
• The quadrate ligament extends from the neck of • The apex of triangular fibrocartilaginous articular
the radius to the lower margin of the radial notch of disc is attached to the base of the styloid
the ulna process of the ulna, and the base to the lower
1

margin of the ulnar notch of the radius (Fig. 10.20)

Section

Blood supply Anastomoses around the lateral side of the elbow Anterior and posterior interosseous arteries
joint
Nerve supply Musculocutaneous, median, and radial nerves Anterior and posterior interosseous nerves
Movements Supination and pronation Supination and pronation
 JOINTS OF UPPER LIMB
169

is attached to posterior border of medial surface at

lower end of radius.
The interosseous membrane performs the following
functions.
a. It binds the radius and ulna to each other.
b. It provides attachments to many muscles.
c. It transmits forces (including weight) applied to
the radius (through the hand) to the ulna. This
transmission is necessary as radius is the main
bone taking part in the wrist joint, while the ulna
is the main bone taking part in the elbow joint
(see Fig. 1.2 and Flowchart 1.1).
d. Separates the forearm into flexor and extensor
compartments.

SUPINATION AND PRONATION

Supination and pronation are rotatory movements of the
forearm/hand around a vertical axis. In a semiflexed
elbow, the palm is turned upwards in supination, and
downwards in pronation (kings pronate, beggars
supinate). The movements are permitted at the superior
and inferior radioulnar joints.
Fig. 10.19: Radioulnar joints During pronation, head of radius spins within
annular ligament. As radius with the hand comes
medially across the lower part of ulna, the interosseous
membrane is spiralised. During supination, the
membrane is despiralised.
The vertical axis of movement of the radius passes
through the centre of the head of the radius above,
and through the ulnar attachment of the articular disc
below (Fig. 10.19). However, this axis is not
stationary because the lower end of the ulna is not
fixed: It moves backwards and laterally during
pronation, and forwards and medially during
supination. As a result of this movement, the axis
(defined above) is displaced laterally in pronation,
and medially in supination.
Supination is more powerful than pronation because
Fig. 10.20: Triangular fibrocartilaginous disc of inferior radio-
ulnar joint it is an antigravity movement. Supination movements

Upper Limb
are responsible for all screwing movements of the hand,
3 The anterior surface is related to the flexor pollicis e.g. as in tightening nuts and bolts. Morphologically,
longus, the flexor digitorum profundus, the pronator pronation and supination were evolved for picking up
quadratus, and to the anterior interosseous vessels food and taking it to the mouth.
and nerve (see Fig. 2.22). Around 50° of supination and 50° of pronation are
generally required to perform many of the routine
4 The posterior surface (see Fig. 9.55) is related to the activities.
supinator, the abductor pollicis longus, the extensor Pronation is brought about chiefly by the pronator
pollicis brevis, the extensor pollicis longus, the quadratus. It is aided by the pronator teres when the
1

extensor indicis, the anterior interosseous artery and movement is rapid and against resistance. Gravity also
the posterior interosseous nerve.
Section

helps (Fig. 10.21).

Supination is brought about by the supinator muscle
MIDDLE RADIOULNAR JOINT and the biceps brachii. Slow supination, with elbow
Type: Syndesmosis, joined by interosseous membrane extended, is done by the supinator. Rapid supination
attached to interosseous borders of radius and ulna. It with the elbow flexed, and when performed against
 UPPER LIMB
170

resistance, is done mainly by the biceps brachii DISSECTION

(Fig. 10.22). Remove all the muscles covering the adjacent sides of
radius, ulna and the intervening interosseous membrane.
This will expose the superior and inferior radioulnar joints
including the interosseous membrane.
Cut through the annular ligament to see the superior
radioulnar joint.
Clean and define the interosseous membrane. Lastly
cut through the capsule of inferior radioulnar joint to locate
the intra-articular fibrocartilaginous disc of the joint.
Learn the movements of supination and pronation
on dry bones and on yourself (refer to BDC App).

CLINICAL ANATOMY

Supination and pronation: During supination, the

radius and ulna are parallel to each other. During
pronation, radius crosses over the ulna (Figs 10.23a
and b). In synostosis (fusion) of upper end of radius
and ulna, pronation is not possible.

Fig. 10.21: Pronators of the forearm

Upper Limb

Figs 10.23a and b: (a) Supination, and (b) pronation

WRIST (RADIOCARPAL) JOINT

1

Type
Section

Wrist joint is a synovial joint of the ellipsoid variety

between lower end of radius and articular disc of
inferior radioulnar joint proximally and three lateral
bones of proximal row of carpus, i.e. scaphoid, lunate
Fig. 10.22: Supinators of the forearm and triquetral distally.
 JOINTS OF UPPER LIMB
171

The pisiform does not play a role in the radiocarpal The palmar ulnocarpal ligament is a rounded
articulation. It is a sesamoid bone acting as a pulley for fasciculus. It begins above from the base of the styloid
flexor carpi ulnaris. process of the ulna and the anterior margin of the
articular disc, runs downwards and laterally, and is
Articular Surfaces attached to the lunate and triquetral bones.
Upper Both the palmar carpal ligaments are considered
1 Inferior surface of the lower end of the radius to be intracapsular.
(Fig. 10.24). 3 On the dorsal aspect of the joint, there is one dorsal
2 Articular disc of the inferior radioulnar joint radiocarpal ligament. It is weaker than the palmar
(Fig. 10.24). ligaments. It begins above from the posterior margin
Lower of the lower end of the radius, runs downwards and
medially, and is attached below to the dorsal surfaces of
1 Scaphoid the scaphoid, lunate and triquetral bones (Fig. 10.25).
2 Lunate
3 Triquetral bones 4 The radial collateral ligament extends from the tip of
the styloid process of the radius to the lateral side of
Ligaments the scaphoid bone. It is related to the radial artery.
1 The articular capsule surrounds the joint. It is attached 5 The ulnar collateral ligament extends from the tip of
above to the lower ends of the radius and ulna, and the styloid process of the ulna to the triquetral and
below to the proximal row of carpal bones. A protru- pisiform bones.
sion of synovial membrane, called the recessus Both the collateral ligaments are poorly developed.
sacciformis, lies in front of the styloid process of the
ulna and in front of the articular disc. It is bounded Relations
inferiorly by a small meniscus projecting inwards
from the ulnar collateral ligament between the • Anterior: Long flexor tendons with their synovial
styloid process and the triquetral bone. The fibrous sheaths, and median nerve (see Fig. 9.7).
capsule is strengthened by the following ligaments. • Posterior: Extensor tendons of the wrist and fingers
with their synovial sheaths (see Figs 9.52b and c).
2 On the palmar aspect, there are two palmar carpal
ligaments. • Lateral: Radial artery (see Fig. 9.33).
The palmar radiocarpal ligament is a broad band. It
begins above from the anterior margin of the lower Blood Supply
end of the radius and its styloid process, runs Anterior and posterior carpal arches.
downwards and medially, and is attached below to
the anterior surfaces of the scaphoid, the lunate and Nerve Supply
triquetral bones. Anterior and posterior interosseous nerves.

Upper Limb
1Section

Fig. 10.24: Cavity of wrist, inferior radioulnar, intercarpal and 1st carpometacarpal joints
 UPPER LIMB
172

Fig. 10.25: Some ligaments of the wrist

Movements
Movements at the radiocarpal joints are accompanied
by movements at the midcarpal joint. The midcarpal
joint is anatomically separate from radiocarpal joint. Figs 10.26a and b: Flexors of the wrist
The joint between the two rows of carpal bones does
not have smooth joint line because of multiple small
joints. However, it still behaves as a functional unit in
all movements of the wrist joint.
In addition to the congruency and the shape of the
articular surfaces of radius and carpal bones, the length
of the ulna can also affect the amount of motion
available at the wrist joint. In the ulnar negative
variance, the distal end of ulna is shorter than the radius
and vice versa in ulnar positive variance. The wrist joint
has the following movements.
1 Flexion: It takes place more at the midcarpal than
at the wrist joint. The main flexors are:
Upper Limb

i. Flexor carpi radialis (Figs 10.26a and b)

ii. Flexor carpi ulnaris
iii. Palmaris longus.
The movement is assisted by long flexors of the
fingers and thumb (Figs 10.34a and b), and abductor
pollicis longus.
2 Extension: It takes place mainly at the wrist joint.
The main extensors are:
1

i. Extensor carpi radialis longus

Section

ii. Extensor carpi radialis brevis

iii. Extensor carpi ulnaris.
It is assisted by the extensors of the fingers and Figs 10.27a and b: (a) Extensor digitorum, and (b) extensor
thumb (Figs 10.27a and b). digiti minimi
 JOINTS OF UPPER LIMB
173

3 Abduction (radial deviation): It occurs mainly at the

midcarpal joint. The main abductors are: • The back of the wrist is the common site for a
ganglion. It is a cystic swelling resulting from
i. Flexor carpi radialis
mucoid degeneration of synovial sheaths around
ii. Extensor carpi radialis longus and extensor the tendons (Fig. 10.29).
carpi radialis brevis • The wrist joint can be aspirated from the posterior
iii. Abductor pollicis longus and extensor pollicis surface between the tendons of the extensor pollicis
brevis longus and the extensor digitorum (Fig. 10.30).
4 Adduction (ulnar deviation): It occurs mainly at the • The joint is immobilised in optimum position of
wrist joint. The main adductors are: 30° dorsiflexion (extension).
i. Flexor carpi ulnaris • Because of the complex nature of the joint and the
ii. Extensor carpi ulnaris multiple articulations, any injury to the ligaments
attached to the proximal or the distal row of carpal
5 Circumduction: The range of flexion is more than
bones may cause subluxation of the carpals
that of extension. Similarly, the range of adduction
ventrally or dorsally leading to painful condition
is greater than abduction (due to the shorter
of the wrist.
styloid process of ulna).

DISSECTION
Cut through the thenar and hypothenar muscles from
their origins and reflect them distally.
Separate the flexor and extensor retinacula of the
wrist from the bones.
Cut through flexor and extensor tendons (if not already
done) and reflect them distally (refer to BDC App).
Define the capsular attachments and ligaments and
relations of the wrist joint.

CLINICAL ANATOMY

• The wrist joint and interphalangeal joints are

Fig. 10.29: Ganglion cyst at the back of wrist
commonly involved in rheumatoid arthritis
(Figs 10.28a and b).

Upper Limb
1Section

Fig. 10.30: Aspiration of the wrist joint

Figs 10.28a and b: Rheumatoid arthritis leading to deformities
 UPPER LIMB
174

Competency achievement: The student should be able to: 3 The anterior ligament
AN 13.4 Describe sternoclavicular joint, acromioclavicular joint, 4 The posterior ligaments are oblique bands running
carpometacarpal joints and metacarpophalangeal joint.4 downwards and medially.

Relations
JOINTS OF HAND • Anteriorly: The joint is covered by the muscles of the
thenar eminence (see Fig. 9.22).
INTERCARPAL, CARPOMETACARPAL AND
• Posteriorly: Long and short extensors of the thumb
INTERMETACARPAL JOINTS
(Figs 10.32a and b).
There are three joint cavities among the intercarpal, • Medially: First dorsal interosseous muscle, and the
carpometacarpal and intermetacarpal joints, which are: radial artery (passing from the dorsal to the palmar
1 Pisotriquetral, aspect of the hand through the interosseous space).
2 First carpometacarpal, and
3 A common cavity for the rest of the joints. The • Laterally: Tendon of the abductor pollicis longus.
common cavity may be described as the midcarpal
(transverse intercarpal) joint between the proximal Blood Supply
and distal rows of the carpus, which communicates Radial vessels supply blood to the synovial membrane
with intercarpal joints superiorly, and with and capsule of the joint.
intercarpal, carpometacarpal and intermetacarpal
joints inferiorly (Figs 10.24a and b). Nerve Supply
The midcarpal joint permits movements between the First digital branch of median nerve supplies the
two rows of the carpus as already described with the capsule of the joint.
wrist joint.

Competency achievement: The student should be able to:

Movements
AN 12.6 Describe and demonstrate movements of thumb and Flexion and extension of the thumb take place in the
muscles involved.5 plane of the palm, and abduction and adduction at right
angles to the plane of the palm. In opposition, the thumb
FIRST CARPOMETACARPAL JOINT (JOINT OF THUMB) crosses the palm and touches other fingers. Flexion is
associated with medial rotation, and extension with
First carpometacarpal joint is only carpometacarpal lateral rotation at the joint.
joint which has a separate joint cavity. Movements at
this joint are, therefore, much more free than at any Circumduction is a combination of different move-
other corresponding joint. ments mentioned. The following muscles bring about
the movements (Figs 10.31a to e).
Type 1 Flexion • Flexor pollicis brevis (see Fig. 9.20)
Saddle variety of synovial joint (because the articular • Opponens pollicis
surfaces are concavoconvex).
2 Extension • Extensor pollicis brevis (Fig. 10.32a)
Articular Surfaces • Extensor pollicis longus (Fig. 10.32b)
Upper Limb

i. The distal surface of the trapezium 3 Abduction • Abductor pollicis brevis (see Fig. 9.20)
ii. The proximal surface of the base of the first • Abductor pollicis longus
metacarpal bone. 4 Adduction Adductor pollicis (see Fig. 9.22)
The articulating surface of trapezium is concave in
5 Opposition • Opponens pollicis (see Fig. 9.22)
the sagittal plane and convex in the frontal plane.
The concavoconvex nature of the articular surfaces • Flexor pollicis brevis
permits a wide range of movements (Fig. 10.24). The opposition is a sequential movement of
abduction, flexion, adduction of the 1st metacarpal with
1

Ligaments simultaneous rotation. Opposition is unique to human

beings and is one of the most important movements of
Section

1 Capsular ligament surrounds the joint. In general, it

is thick but loose, and is thickest dorsally and the hand considering that this motion is used in almost
laterally. all types of gripping actions.
2 Lateral ligament is broad band which strengthens The adductor pollicis and the flexor pollicis longus
the capsule laterally. exert pressure on the opposed fingers.
 JOINTS OF UPPER LIMB
175

• The synovial lining of the tendons of extensor

pollicis brevis and abductor pollicis longus can
get inflamed due to repetitive strain and can lead
to a painful condition called De Quervain’s
tenosynovitis. Movement of the thumb can
aggravate pain in this condition.

METACARPOPHALANGEAL JOINTS
Type
Metacarpophalangeal joints are synovial joints of the
ellipsoid variety.
Ligaments
Each joint has the following ligaments.
1 Capsular ligament: This is thick in front and thin
behind.
2 Palmar ligament: This is a strong fibrocartilaginous
plate (volar plate) which replaces the anterior part
of the capsule. It is more firmly attached to the
phalanx than to the metacarpal. The various palmar
ligaments of the metacarpophalangeal joints are
joined to one another by the deep transverse
metacarpal ligament.
3 Medial and lateral collateral ligaments: These are
oblique bands placed at the sides of the joint. Each
runs downwards and forwards from the head of the
metacarpal bone to the base of the phalanx. These
are taut in flexion and relaxed in extension.

Movements at First Joint and Muscles Producing Them

Figs 10.31a to e: Movements of the thumb
1 Flexion: Flexor pollicis longus and flexor pollicis brevis.
2 Extension: Extensor pollicis longus and extensor
DISSECTION pollicis brevis (Figs 10.32a and b).
Out of these, the most important joint with a separate 3 Abduction: Abductor pollicis brevis (see Fig. 9.20).
joint cavity is the first carpometacarpal joint. This is the 4 Adduction: Adductor pollicis (see Fig. 9.22).
joint of the thumb and a wide variety of functionally
useful movements take place here. Identify the distal Movements at Second to Fifth
surface of trapezium and base of first metacarpal bone. Joints and Muscles Producing Them
1 Flexion: Interossei and lumbricals (see Figs 9.21 and 9.23).
Upper Limb
Define the metacarpophalangeal and interphalangeal
joints. 2 Extension: Extensors of the fingers (Fig. 10.27).
For their dissection, remove all the muscles and 3 Abduction: Dorsal interossei (see Fig. 9.23).
tendons from the anterior and posterior aspects of any 4 Adduction: Palmar interossei (see Fig. 9.23).
two metacarpophalangeal joints. Define the articular 5 Circumduction: Above muscles in sequence.
capsule and ligaments. Do the same for proximal and
distal interphalangeal joints of one of the fingers and
INTERPHALANGEAL JOINTS (PROXIMAL AND DISTAL)
define the ligaments (refer to BDC App).
Type
1

CLINICAL ANATOMY Hinge variety of synovial joints (Fig. 10.33).

Section

• The 1st carpometacarpal joint can undergo Ligaments

degenerative changes with age which is a painful Similar to the metacarpophalangeal joints, that is one
condition of the base of the thumb. palmar fibrocartilaginous ligament and two collateral
bands running downwards and forwards.
 UPPER LIMB
176

Movements at Second to Fifth Digits

1 Flexion: Flexor digitorum superficialis at the proximal
interphalangeal joint, and the flexor digitorum
profundus at the distal joint (Fig. 10.34).
2 Extension: Interossei and lumbricals (see Figs 9.21
and 9.23).

Segmental Innervation of Movements of Upper Limb

Figures 10.35a to f show the segments of the spinal cord
responsible for movements of the various joints of the
upper limb.
The proximal muscles of upper limb are supplied
by proximal nerve roots forming brachial plexus and
distal muscles by the distal or lower nerve roots. In
shoulder, abduction is done by muscles supplied by
C5 spinal segment and adduction by muscles
innervated by C6, C7 spinal segments.
Elbow joint is flexed by C5, C6 and extended by C7,
C8 innervated muscles. Supination is caused by muscle
innervated by C6 spinal segment even pronation is done
through C6 spinal segment.
Extension and flexion of wrist is done through C6,
C7 spinal segments. Both the palmar and dorsal
interossei are innervated by T1 spinal segment.
Figs 10.32a and b: Extensors of the joints of thumb
The interphalangeal joints also are flexed and
extended by same spinal segments, i.e. C7, C8.
Upper Limb
1

Fig. 10.33: Joints of the fingers

Section

Movements at Interphalangeal Joint of Thumb

Flexion: Flexor pollicis longus. Figs 10.34a and b: (a) Flexor digitorum superficialis, and
Extension: Extensor pollicis longus. (b) flexor digitorum profundus
 JOINTS OF UPPER LIMB
177

• Ulnar nerve lies behind medial epicondyle. It is

not a content of the cubital fossa.
• Carrying angle separates the wrist from the hip
joint while carrying buckets, etc.
• Biceps brachii is an important supinator of forearm
when the elbow is flexed.
• Kings pronate, while beggars supinate.
• Movements of pronation and supination are not
occurring at the elbow or wrist joints.
• First carpometacarpal joint is the most important
joint as it permits the thumb to oppose the palm/
fingers for holding things.
• Shoulder joint commonly dislocates inferiorly.
• Ulnar nerve lies behind medial epicondyle,
pressing the nerve cause tingling sensation. That
is why the bone is named ‘humerus’.
• Giving is pronation, receiving is supination.
Picking up food with digits is pronation, putting
it in the mouth is supination.
• Axis of movements of abduction and adduction
of fingers is through the centre of the middle finger.

CLINICOANATOMICAL PROBLEM

A 70-year-old lady fell on her left forearm. She heard

a crack in the wrist. There was swelling and a bend
just proximal to wrist with lateral deviation of the
Figs 10.35a to f: Segmental innervation of movements of the hand.
upper limb • Which forearm bone is fractured?
• Reason of bend just proximal to wrist.
• What joints can be subluxated?

Mnemonics Ans: There is fracture of the distal end of radius. The

backward bend just proximal to the wrist is due to
Elbow: Muscles that flex it the pull of extensor muscles on the distal segment of
Three Bs Bend the elBow: radius. The inferior radioulnar joint is usually
Brachialis subluxated.
Biceps—2 heads
FURTHER READING
Brachioradialis

Upper Limb
• Abrams RA, Peterson M, Botte MJ. Arthroscopic portals of
the wrist: An anatomic study. J Hand Surg 1994;19A:940–44.
A review of the surface and intra-articular anatomy of the wrist,
FACTS TO REMEMBER the technique of establishing a safe portal and the specific uses of
• Sternoclavicular joint is a saddle variety of synovial the radiocarpal, metacarpal and special-use portals.
joint. Its cavity is divided into two parts by an • Burkart AC, Debski RE. Anatomy and function of
articular disc. glenohumeral ligaments in anterior shoulder instability. Clin
Orthopaed Related Res 2002;400:32.
• Movements of shoulder girdle help the movements
• An KN, Berger RA, Coonery WB (eds). Biomechanics of Wrist
of shoulder joint during 90°–180° abduction.
Joint. New York Springer-Verlag, 1991.
1

• Shoulder joint is freely mobile and is vulnerable

• Garg K, Batra V. Dancing shoulder. J Anat Soc India 1991;
to dislocation.
Section

40(2):119–20.

1–5
From Medical Council of India, Competency based Undergraduate Curriculum for the Indian Medical Graduate, 2018;1:44–80.
 UPPER LIMB
178

1. Describe the shoulder joint under the following 3. Write short notes on:
headings: a. Carrying angle
a. Type b. Movements of the thumb with muscles
b. Articular surface responsible for these movements.
c. Ligaments c. Movements of wrist. Enumerate the muscles
causing these movements.
d. Movements with their muscles
d. Movements occurring at the shoulder girdle.
e. Clinical anatomy e. Movements at metacarpophalangeal joint of
2. Tabulate the features of superior and inferior radio- middle finger with the muscles responsible for
ulnar joints. them.

1. One of the following muscles is not a medial rotator c. Shoulder

of the shoulder joint: d. Elbow
a. Pectoralis major 6. Which of the following muscles causes protraction
b. Teres major of scapula?
c. Teres minor a. Serratus anterior
d. Latissimus dorsi b. Levator scapulae
2. What type of joint is superior radioulnar joint? c. Trapezius
a. Pivot d. Latissimus dorsi
b. Saddle 7. Which of the following muscles is supplied by two
c. Plane nerves with different root values?
d. Hinge a. Flexor pollicis longus
3. First carpometacarpal joint is: b. Pronator teres
a. Saddle c. Flexor digitorum superficialis
b. Ellipsoid d. Flexor digitorum profundus
c. Hinge 8. Trapezius retracts the scapula along with which of
d. Pivot the following muscles?
4. Articular surface of sternal end of clavicle is covered a. Rhomboids
Upper Limb

by: b. Latissimus dorsi

a. Fibrocartilage c. Serratus anterior
b. Hyaline cartilage d. Levator scapulae
c. Elastic cartilage 9. Which of the following muscles is flexor, adductor
d. None of the above and medial rotator of shoulder joint?
5. Which of the following joints contains an articular a. Pectoralis minor
disc? b. Pectoralis major
1

a. Sternoclavicular c. Teres minor

Section

b. Superior radioulnar d. Infraspinatus

1. c 2. a 3. a 4. a 5. a 6. a 7. d 8. a 9. b
 JOINTS OF UPPER LIMB
179

• What type of joint is sternoclavicular joint? • What type of joints are superior and inferior radio-
• Name the ligaments of sternoclavicular joint. ulnar joints?
• Where are the attachments of coracoclavicular • Name the functions of interosseous membrane.
ligament? • Name the supinators and pronators of the forearm
• Name the movements of shoulder girdle. with their nerve supply.
• Name the movements occurring at the wrist joint.
• Which muscles cause lateral rotation of the shoulder
girdle? • Name bones participating in the 1st carpometacarpal
joint. Show the movements of this joint.
• Mark the attachment of capsule of shoulder joint.
• How many joint cavities are there amongst the
• Which tendon is intracapsular in the shoulder joint? intercarpal, carpometacarpal and intermetacarpal
• Which muscles cause abduction and lateral rotation joints?
of shoulder joint? Show these movements. • Which is the only muscle causing flexion of distal
• What type of joint is elbow joint? interphalangeal joints of the fingers?

Upper Limb
1Section
 UPPER LIMB
180

11 Surface Marking, Radiological

Anatomy and Comparison of
Upper and Lower Limbs
! Happiness doesn’t result from what we get,
but from what we give. Do your best and let God do the rest !
—Ben Carson

INTRODUCTION
Surface marking is the projection of the deeper
structures on the surface. Its importance lies in various
medical and surgical procedures.

SURFACE MARKING

The bony landmarks seen in different regions of the

upper limb have been described in appropriate
sections.
The surface marking of important structures is given
in this chapter.
Fig. 11.1: Axillary and brachial arteries with musculocutaneous
Competency achievement: The student should be able to: nerve
AN 13.7 Identify and demonstrate surface projection of—cephalic
and basilic vein, palpation of brachial artery, radial artery; testing
of muscles—trapezius, pectoralis major, serratus anterior, latissimus
dorsi, deltoid, biceps brachii, brachioradialis.1

ARTERIES
Axillary Artery
Upper Limb

Hold the arm at right angles to the trunk with the palm
directed upwards. The artery is then marked as a
straight line by joining the following two points.
• Point 1: Midpoint of the clavicle.
• Point 2: At the lower limit of the lateral wall of axilla
where the arterial pulsations can be felt in living
person (Fig. 11.1).
At its termination, the axillary artery, along with the
accompanying nerves, forms a prominence which lies
1

behind another projection caused by the biceps and Fig. 11.2: Median nerve in front of arm related to axillary and
brachial arteries
Section

coracobrachialis.

Brachial Artery • Point 1: At the lower limit of the lateral wall of the
Brachial artery is marked by joining the following two axilla. Here the axillary artery ends and the brachial
points. artery begins (Fig. 11.2).
180
 SURFACE MARKING, RADIOLOGICAL ANATOMY AND COMPARISON OF UPPER AND LOWER LIMBS
181

• Point 2: At the level of the neck of the radius medial

to the tendon of the biceps brachii (Fig. 11.2).
Thus the artery begins on the medial side of the
upper part of the arm, and runs downwards and
slightly laterally to end in front of the elbow. At its
termination, it bifurcates into the radial and ulnar
arteries.
Radial Artery
In the Forearm
Radial artery is marked by joining the following points.
• Point 1: In front of the elbow at the level of the neck
of the radius medial to the tendon of the biceps
brachii (Fig. 11.3).
• Point 2: At the wrist between the anterior border of
the radius laterally and the tendon of the flexor carpi
radialis medially, where the radial pulse is
commonly felt (Fig. 11.3).
Its course is curved with a gentle convexity to the
lateral side.

In the Hand
Radial artery is marked by joining the following points.
• Point 1: Just below the tip of the styloid process of Fig. 11.4: Surface projection of axillary, radial, posterior
the radius (Fig. 11.4). interosseous nerves and radial artery in anatomical snuffbox
• Point 2: At the proximal end of the first inter- (posterior view of left limb)
metacarpal space (Fig. 11.4).
In this part of its course, the artery runs obliquely
downwards and backwards deep to the tendons of the
abductor pollicis longus, the extensor pollicis brevis,
and superficial to the lateral ligament of the wrist joint.
Thus it passes through the anatomical snuffbox to reach
the proximal end of the first intermetacarpal space.

Deep Palmar Arch

Deep palmar arch is formed as the direct continuation
of the radial artery. It has a slight convexity towards the
fingers.
• Point 3: At proximal part of 1st dorsal intermeta-
carpal space (Fig. 11.3).
• Point 4: Just distal to hook of hamate (Fig. 11.3). Upper Limb
It is marked by a slightly convex line, 4 cm long, just
distal to the hook of the hamate bone (Fig. 11.3).
The deep palmar arch lies 1.2 cm proximal to the
superficial palmar arch across the metacarpals,
immediately distal to their bases. The deep branch of
ulnar nerve lies in its concavity (see Fig. 9.22).
1

Ulnar Artery
Section

Ulnar artery is marked by joining the following three

points.
• Point 1: In front of the elbow at the level of the neck
Fig. 11.3: Arteries and nerves of front of forearm and the deep of the radius medial to the tendon of the biceps
palmar arch brachii (Fig. 11.3).
 UPPER LIMB
182

• Point 5: At the junction of the upper one-third and In the Forearm

lower two-thirds of the medial border of the forearm Median nerve is marked by joining the following two
(lateral to the ulnar nerve) (Fig. 11.3). points.
• Point 6: Lateral to the pisiform bone (Fig. 11.3). • Point 1: Medial to the brachial artery at the bend of
Thus the course of the ulnar artery is oblique in its the elbow (Fig. 11.3).
upper one-third, and vertical in its lower two-thirds. • Point 2: In front of the wrist, over the tendon of the
The ulnar nerve lies just medial to the ulnar artery in palmaris longus or 1 cm medial to the tendon of the
the lower two-thirds of its course. The ulnar artery flexor carpi radialis (Fig. 11.3).
continues in the palm as the superficial palmar arch.
In the Hand
Superficial Palmar Arch Median nerve enters the palm by passing deep to flexor
Superficial palmar arch is formed by the direct retinaculum, immediately below which it divides
continuation of the ulnar artery, and is marked as a into lateral and medial branches. Lateral branch
curved line by joining the following points: supplies the three muscles of thenar eminence and gives
two branches to the thumb, and one to lateral side of
• Point 1: Just lateral and distal to the pisiform bone index finger. Medial branch gives branches for the
(Fig. 11.5). adjacent sides of index, middle and ring fingers. The
• Point 2: Medial to the hook of the hamate bone (Fig. 11.5). lateral 3½ nail beds are also supplied (Figs 11.5 and
• Point 3: On the distal border of the thenar eminence 11.6).
in line with the cleft between the index and middle
fingers (see Figs 9.32 and 11.5). Radial Nerve
The convexity of the arch is directed towards the In the Arm
fingers, and its most distal point is situated at the level Radial nerve is marked by joining the following points.
of the distal border of the fully extended thumb.
• Point 1: At the lateral wall of the axilla at its lower
limit (Figs 11.1 and 11.4).
NERVES • Point 2: At the junction of the upper one-third and
Axillary Nerve with its Divisions lower two-thirds of a line joining the lateral epicondyle
Axillary nerve is marked as a horizontal line on the with the insertion of the deltoid (Fig. 11.4).
deltoid muscle, 2 cm above the midpoint between the • Point 3: On the front of the elbow just below the level
tip of the acromion process and the insertion of the of the lateral epicondyle 1 cm lateral to the tendon
deltoid (Fig. 11.4). of the biceps brachii (Fig. 11.4).
Intramuscular injections in the deltoid are given The first and second points are joined across the back
below the middle part of the muscle to avoid injury to of the arm to mark the oblique course of the radial nerve
the axillary nerve and its accompanying vessels. in the radial (spiral) groove (posterior compartment).
The second and third points are joined on the front of
Musculocutaneous Nerve the arm to mark the vertical course of the nerve in the
anterior compartment.
Musculocutaneous nerve is marked by joining the
following two points.
In the Forearm
Upper Limb

• Point 1: Just lateral to the axillary artery 3 cm

proximal to its termination (Fig. 11.1). Superficial branch of radial nerve is marked by joining
the following three points.
• Point 2: Lateral to the tendon of the biceps brachii
• Point 1: 1 cm lateral to the biceps tendon just below
muscle 2 cm above the bend of the elbow. Here it
the level of the lateral epicondyle (Fig. 11.3).
pierces the deep fascia and continues as the lateral
• Point 2: At the junction of the upper two-thirds and
cutaneous nerve of the forearm (see Fig. A1.1).
lower one-third of the lateral border of the forearm
just lateral to the radial artery (Fig. 11.3).
Median Nerve • Point 4: At the anatomical snuffbox (Fig. 11.4).
1

In the Arm The nerve is vertical in its course between points one
Section

Mark the brachial artery. The nerve is then marked and two. At the second point, it inclines backwards to
lateral to the artery in the upper half, and medial to reach the snuffbox.
the artery in the lower half of the arm. The nerve The nerve is closely related to the lateral side of the
crosses the artery anteriorly in the middle of the arm radial artery only in the middle one-third of the
(Fig. 11.2). forearm.
 SURFACE MARKING, RADIOLOGICAL ANATOMY AND COMPARISON OF UPPER AND LOWER LIMBS
183

Fig. 11.5: Branches of median nerve and ulnar nerve in the palm. Superficial palmar arch is also shown

Posterior Interosseous Nerve/

Deep Branch of Radial Nerve
It is marked by joining the following three points.
• Point 3: 1 cm lateral to the biceps brachii tendon just

Upper Limb
below the level of the lateral epicondyle (Fig. 11.4).
• Point 5: At the junction of the upper one-third and
lower two-thirds of a line joining the middle of the
posterior aspect of the head of the radius to the dorsal
tubercle at the lower end of the radius or Lister’s
tubercle (Fig. 11.4).
• Point 6: On the back of the wrist 1 cm medial to the
dorsal tubercle (Fig. 11.4).
1

Posterior interosseous nerve supplies the muscles of

posterior aspect of the forearm.
Section

Ulnar Nerve
Fig. 11.6: Cutaneous nerve supply of palm and dorsum of In the Arm
hand Ulnar nerve is marked by joining the following points.
 UPPER LIMB
184

superficial branch supplies medial 1½ digits

including their nail beds (Fig. 11.7). The deep branch
passes backwards between pisiform and hook of
hamate to lie in the concavity of the deep palmar arch
(Fig. 11.3).

JOINTS
Shoulder Joint
The anterior margin of the glenoid cavity corresponds
to the lower half of the shoulder joint. It is marked by a
line 3 cm long drawn downwards from a point just
lateral to the tip of the coracoid process. The line is
slightly concave laterally.

Elbow Joint
The joint line is situated 2 cm below the line joining the
two epicondyles, and slopes downwards and medially.
This slope is responsible for the carrying angle.

Wrist Joint
The joint line is concave downwards, and is marked
by joining the styloid processes of the radius and
ulna.

RETINACULA
Flexor Retinaculum
Flexor retinaculum is marked by joining the following
four points.
Fig. 11.7: Course of ulnar nerve
i. Pisiform bone
• Point 1: On the lateral wall of the axilla at its lower ii. Tubercle of the scaphoid bone
limit (lower border of the teres major muscle) iii. Hook of the hamate bone (Fig. 11.8)
(Fig. 11.7). iv. Crest of the trapezium.
• Point 2: At the middle of the medial border of the
arm.
• Point 3: Behind the base of the medial epicondyle of
the humerus.
Upper Limb

In the Forearm
Ulnar nerve is marked by joining the following two
points.
• Point 3: On the back of the base of the medial
epicondyle of the humerus (Fig. 11.7).
• Point 4: Lateral to the pisiform bone.
In the lower two-thirds of the forearm, the ulnar
nerve lies medial to the ulnar artery (Fig. 11.3).
1
Section

In the Hand
Ulnar nerve lies superficial to the medial part of
flexor retinaculum and medial to ulnar vessels where
it divides into superficial and deep branches. The Fig. 11.8: Flexor retinaculum
 SURFACE MARKING, RADIOLOGICAL ANATOMY AND COMPARISON OF UPPER AND LOWER LIMBS
185

The upper border is obtained by joining the first and limb should be available for comparison. The skeleton,
second points, and the lower border by joining the third owing to its high radiopacity, forms the most striking
and fourth points. The upper border is concave feature in plain skiagrams. In general, the following
upwards, and the lower border is concave downwards information can be obtained from plain skiagrams of the
(see Figs 9.15 and 9.16). limbs.
1 Fractures are seen as breaks in the surface continuity
Extensor Retinaculum of the bone. A fracture line is usually irregular and
Extensor retinaculum is an oblique band directed down- asymmetrical. An epiphyseal line of an incompletely
wards and medially, and is about 2 cm broad (vertically). ossified bone, seen as a gap, should not be mistaken
Laterally, it is attached to the lower salient part of the for a fracture: It has regular margins, and is bilaterally
anterior border of the radius, and medially to the medial symmetrical. Supernumerary or accessory bones are
side of the carpus (pisiform and triquetral bones) and to also symmetrical.
the styloid process of the ulna (see Fig. 9.52). 2 Dislocations are seen as deranged or distorted
relations between the articular bony surfaces forming
SYNOVIAL SHEATHS OF THE FLEXOR TENDONS a joint.
Common Flexor Synovial Sheath (Ulnar Bursa) 3 Below the age of 25 years, the age of a person can be
Above the flexor retinaculum (or lower transverse determined from the knowledge of ossification of the
crease of the wrist), it extends into the forearm for bones.
about 2.5 cm. Here its medial border corresponds to 4 Certain deficiency diseases like rickets and scurvy can
the lateral edge of the tendon of the flexor carpi be diagnosed.
ulnaris, and its lateral border corresponds roughly to 5 Infections (osteomyelitis) and growths (osteoma,
the tendon of the palmaris longus. osteoclastoma, osteosarcoma, etc.) can be diagnosed.
A localised rarefaction of a bone may indicate an
Ulnar bursa becomes narrower behind the flexor
infection.
retinaculum, and broadens out below it.
6 Congenital absence or fusion of bones can be seen.
Most of it terminates at the level of the upper trans-
verse creases of the palm, but the medial part is continued Reading Plain Skiagrams of Limbs
up to the distal transverse crease of the little finger. 1 Identify the view of the picture, anteroposterior or
Synovial Sheaths for the Tendon lateral. Each view shows a specific shape and
of Flexor Pollicis Longus (Radial Bursa) arrangement of the bones.
2 Identify all the bones and their different parts visible
Radial bursa is a narrow tube which is coextensive with
in the given radiogram. Normal overlapping and
the ulnar bursa in the forearm and wrist. Below the
‘end-on’ appearances of bones in different views
flexor retinaculum, it is continued into the thumb up
should be carefully studied.
to its distal crease (see Fig. 9.7).
3 Study the normal relations of the bones forming
Digital Synovial Sheaths joints. The articular cartilage is radiolucent
The synovial sheaths of the flexor tendons of the index, and does not cast any shadow. The radiological ‘joint
middle and ring fingers extend from the necks of the space’ indicates the size of the articular cartilages.
Normally, the joint space is about 2–5 mm in adults.
metacarpal bones (corresponding roughly to the lower
4 Study the various epiphyses visible in young bones
transverse crease of the palm) to the bases of the
and try to determine the age of the person concerned.
Upper Limb
terminal phalanges (see Fig. 9.7).
Shoulder
Competency achievement: The student should be able to: A. The following are seen in an AP view of the shoulder
AN 13.5 Identify the bones and joints of upper limb seen in (Figs 11.9a and b).
anteroposterior and lateral view radiographs of shoulder region,
1 The upper end of the humerus, including the head,
arm, elbow, forearm and hand.2
greater and lesser tubercles and intertubercular
sulcus.
2 The scapula, including the glenoid cavity, coracoid
RADIOLOGICAL ANATOMY OF UPPER LIMB (seen end-on), acromion process, its lateral, medial
1

and superior borders, and the superior and

General Remarks
Section

inferior angles. The suprascapular notch may be

In the case of the limbs, plain radiography is mainly seen.
required. For complete information, it is always 3 The clavicle, except for its medial end.
advisable to have anteroposterior (AP) as well as lateral 4 Upper part of the thoracic cage, including the
views; and as far as possible radiographs of the opposite upper ribs.
 UPPER LIMB
186

Figs 11.9a and b: (a) Anteroposterior view of the shoulder joint, and (b) diagrammatic depiction of (a)

B. Study the normal appearance of the following joints. Elbow

1 Shoulder joint: The glenoid cavity articulates only A. Identify the following bones in an AP and lateral
with the lower half of the head of the humerus views of the elbow (Figs 11.10a and b).
(when the arm is in the anatomical position). The 1 The lower end of humerus, including the medial
upper part of the head lies beneath the acromion and lateral epicondyles, the medial and lateral
process. The greater tuberosity forms the lateral supracondylar ridges, trochlea, the capitulum and
most bony point in the shoulder region. the olecranon fossa.
2 Acromioclavicular joint. 2 The upper end of the ulna, including the olecranon
C. Note the epiphyses, if any, and determine the age and coronoid processes.
with the help of ossifications described with 3 The upper end of the radius including its head,
individual bones. neck and tuberosity.
Upper Limb
1
Section

Figs 11.10a and b: (a) Anteroposterior view of the elbow joint, and (b) diagrammatic depiction of (a)
 SURFACE MARKING, RADIOLOGICAL ANATOMY AND COMPARISON OF UPPER AND LOWER LIMBS
187

Figs 11.11a and b: (a) Lateral view of the elbow joint, and (b) diagrammatic depiction of (a)

B. Study the normal appearance of the following joints Hand

in AP view. A. Identify the following bones in an AP skiagram
1 Elbow joint (Figs 11.12a and b).
2 Superior radioulnar joint 1 The lower end of the radius with its styloid process.
C. Note the olecranon and coronoid processes in a 2 The lower end of the ulna with its styloid process.
lateral view of the elbow (Figs 11.11a and b). 3 The eight carpal bones. Note the overlapping of the
D. Note the epiphyses (if any) and determine the age triquetral and pisiform bones; and of the trapezium
with the help of ossifications described with with the trapezoid. Also identify the tubercle of the
individual bones. scaphoid and the hook of the hamate.

Upper Limb
1Section

Figs 11.12a and b: (a) Anteroposterior view of the hand, and (b) diagrammatic depiction of (a)
 UPPER LIMB
188

COMPARISON OF UPPER AND LOWER LIMBS

Upper limb Lower limb
General The upper limb is for range and variety of Lower limb with long and heavy bones supports and stabilises
movements. the body.
Thumb assisted by palm and fingers has the Lower limb bud rotates medially, so that big toe points medially.
power of holding articles. Nerve supply: Ventral rami of lumbar 2–5 and sacral 1–3
Upper limb bud rotates laterally, so that the thumb segments of spinal cord. The two gluteal nerves supply glutei.
points laterally. Sciatic and one of its terminal branches, the tibial nerve supplies
Nerve supply: Ventral rami of cervical 5–8 and the flexor aspect of the limb. The other terminal branch of sciatic
thoracic 1 segments of spinal cord. Musculo- nerve, i.e. common peroneal, supplies the extensors of ankle
cutaneous, median and ulnar nerves supply the joint (dorsiflexors) through its deep peroneal branch. Its
flexor aspects of the limb, while the axillary nerve superficial branch supplies the peroneal muscles of the leg.
supplies deltoid and radial nerve supplies the Femoral supplies the quadriceps femoris (extensor of knee)
triceps brachii (extensor of elbow) and its branch, while obturator nerve supplies the adductors.
the posterior interosseous, supplies the extensors
of wrist.
Arm Thigh

Bones Humerus is the longest bone of upper limb Femur is the longest bone of lower limb and of the body
Joints Shoulder joint is a multiaxial joint Hip joint is a multiaxial joint
Muscles Anteriorly: Biceps, brachialis and coraco- Posteriorly: Hamstrings supplied by sciatic nerve
brachialis supplied by musculocutaneous nerve Anteriorly: Quadriceps by femoral nerve
Posteriorly: Triceps brachii supplied by radial Medially: Adductors by obturator nerve
nerve
Nerves Musculocutaneous for anterior compartment of Sciatic nerve for posterior compartment of thigh, femoral nerve
arm. Radial for posterior compartment. Coraco- for anterior compartment of thigh, obturator nerve for adductor
brachialis equivalent to medial compartment of muscles of medial compartment of thigh
arm also supplied by musculocutaneous nerve
(Fig. A1.1)
Branches Muscular, cutaneous, articular/genicular, vascular Muscular, cutaneous, articular/genicular, vascular and terminal
and terminal branches branches
Arteries Axillary, brachial, profunda (deep) brachii Femoral, popliteal and profunda femoris (deep)

Forearm Leg
Bones Radius: Preaxial bone Tibia: Preaxial bone
Ulna: Postaxial bone Fibula: Postaxial bone
Joints Elbow joint formed by humerus, radius and ulna, Knee joint formed by femur, tibia and patella. Fibula does not
communicates with superior radioulnar joint. participate in knee joint. An additional bone (sesamoid) patella
Forearm is characterised by superior and inferior makes its appearance. This is an important weight-bearing
radioulnar joints. These are both pivot variety of joint
synovial joints permitting rotatory movements of
Upper Limb

pronation and supination, e.g. meant for picking

up food and putting it in the mouth (Fig. 10.19)
Muscles Palmaris longus (see Fig. 9.3a) Plantaris
Flexor digitorum profundus Flexor digitorum longus
Flexor pollicis longus Flexor hallucis longus
Flexor digitorum superficialis Soleus and flexor digitorum brevis
Flexor carpi ulnaris Gastrocnemius (medial head)
Flexor carpi radialis Gastrocnemius (lateral head)
1

Abductor pollicis longus Tibialis anterior

Extensor digitorum Extensor digitorum longus
Section

Extensor pollicis longus Extensor hallucis longus

General Anterior aspect: Flexors of wrist and pronators Anterior aspect: Dorsiflexors of ankle joint
of forearm Posterior aspect: Plantar flexors (flexors) of ankle joint
Posterior aspect: Extensors of wrist, and supinator Lateral aspect: Evertors of subtalar joint
(Contd.)
 SURFACE MARKING, RADIOLOGICAL ANATOMY AND COMPARISON OF UPPER AND LOWER LIMBS
189

Upper limb Lower limb

Forearm Leg

Nerves Median nerve for 6½ muscles and ulnar nerve Tibial nerve for all the plantar flexors of the ankle joint. Common
for 1½ muscles of anterior aspect of forearm. peroneal winds around neck of fibula (postaxial bone) and
These are flexors of wrist and pronators of divides into superficial and deep branches. The deep peroneal
forearm. Posterior interosseous nerve or deep supplies dorsiflexors (extensors) of the ankle joint. The
branch of radial supplies the extensors of the wrist superficial peroneal nerve supplies a separate lateral
and the supinator muscle of forearm. It winds compartment of leg
around radius (preaxial bone) and corresponds
to deep peroneal nerve. The superficial branch
of radial nerve corresponds to the superficial
peroneal nerve
Arteries Brachial divides into radial and ulnar branches Popliteal divides into anterior tibial and posterior tibial in the
in the cubital fossa. Radial corresponds to popliteal fossa. Posterior tibial corresponds to ulnar artery
anterior tibial artery

Hand Foot

Bones There are eight small carpal bones occupying very Seven big tarsal bones occupying almost half of the foot. There
and small area of the hand. First carpometacarpal are special joints between talus, calcaneus and navicular, i.e.
joints joint, i.e. joint between trapezium and base of 1st subtalar and talocalcaneonavicular joints. They permit the
metacarpal is a unique joint. It is of saddle variety movements of inversion and eversion (raising the medial
and permits a versatile movement of opposition border/lateral border of the foot) for walking on the uneven
in addition to other movements. This permits the surfaces. This movement of inversion is similar to supination
hand to hold things, e.g. doll, pencil, food, bat, and of eversion to pronation of forearm. Flexor digitorum
etc. Opponens pollicis is specially for opposition accessorius is a distinct muscle to straighten the action of flexor
digitorum longus tendons in line with the toes on which these
act. Tibialis anterior, tibialis posterior and peroneus longus
reach the foot and sole for the movements of inversion (first
two) and eversion (last one), respectively
Nerves Median nerve supplies 5 muscles of hand Medial plantar supplies four muscles of the sole including 1st
including 1st and 2nd lumbricals (abductor pollicis lumbrical (abductor hallucis, flexor hallucis brevis, flexor
brevis, flexor pollicis brevis, opponens pollicis, digitorum brevis, 1st lumbrical)
1st and 2nd lumbricals) (see Fig. 9.37)
Ulnar nerve corresponds to lateral plantar nerve Lateral plantar corresponds to ulnar nerve and supplies 14
and supplies 15 intrinsic muscles of the hand intrinsic muscles of the sole
(see Fig. 9.34)
Muscles Muscles which enter the palm from forearm, e.g. Muscles which enter the sole from the leg, e.g. flexor digitorum
flexor digitorum superficialis, flexor digitorum longus, flexor hallucis longus, tibialis posterior, peroneus
profundus, flexor pollicis longus are supplied by longus, are supplied by the nerves of the leg. 1st lumbrical is
the nerves of the forearm. 1st and 2nd lumbricals unipennate and is supplied by medial plantar, 2nd–4th are

Upper Limb
are unipennate and are supplied by median bipennate being supplied by deep branch of lateral plantar
nerve. 3rd and 4th are bipennate being supplied nerve. Extensor digitorum brevis present on dorsum of foot
by deep branch of ulnar nerve. No muscle on
dorsum of hand
Blood Radial artery corresponds to anterior tibial while Posterior tibial artery divides into medial plantar and lateral
vessels ulnar artery corresponds to posterior tibial artery. plantar branches. There is only one arch, the plantar arch
Ulnar artery divides into superficial and deep formed by lateral plantar and dorsalis pedis (continuation of
branches. There are two palmar arches— anterior tibial) arteries
superficial and deep. The superficial arch mainly The great saphenous vein with perforators lies along the
1

is formed by ulnar artery and deep arch is formed preaxial border. The short saphenous vein lies along the
mainly by the radial artery. Cephalic vein is along postaxial border but it terminates in the popliteal fossa
Section

the preaxial border. Basilic vein runs along the

postaxial border of the limb and terminates in the
middle of the arm
 UPPER LIMB
190

Upper limb Lower limb

Hand Foot

Axis The axis of movement of adduction and abduction The axis of movement of adduction and abduction passes
is through the third digit or middle finger. So the through the 2nd digit. So 2nd toe possesses two dorsal
middle finger has two dorsal interossei muscles interossei muscles

Palm Sole
Abductor pollicis brevis (see Fig. 9.20) Abductor hallucis brevis
Flexor pollicis brevis Flexor digitorum brevis
Flexor digiti minimi Abductor digiti minimi
Abductor digiti minimi

Superficial palmar arch No such arch

Branches of median nerve Branches of medial plantar nerve and artery
Branches of superficial branch of ulnar nerve Branches of superficial branch of lateral plantar nerve
Tendons of flexor digitorum superficialis
Tendons of flexor digitorum profundus and Tendon of flexor digitorum longus, lumbricals and flexor
lumbricals (see Fig. 9.21) digitorum accessorius
Tendon of flexor pollicis longus Tendon of flexor hallucis longus
Opponens pollicis (see Fig. 9.22) Flexor hallucis brevis
Adductor pollicis Adductor hallucis
Opponens digiti minimi Flexor digiti minimi brevis
Deep palmar arch and deep branch of ulnar nerve Plantar arch with deep branch of lateral plantar nerve
1–4 palmar interossei (see Fig. 9.23) 1–3 plantar interossei
1–4 dorsal interossei 1–4 dorsal interossei
Tendons of tibialis posterior and peroneus longus

4 The five metacarpal bones FURTHER READING

5 The fourteen phalanges • Hale SJ, Mirjalili SA, Stringer MD. Inconsistencies in surface
6 The sesamoid bones present in relation to the anatomy: the need for an evidence-based reappraisal. Clin
thumb, and occasionally in relation to the other Anat 2010;23:922–30.
fingers An argument that an evidence-based framework is essential, if
surface anatomy is to be accurate and clinically relevant.
B. Study the normal appearance of these joints.
1 The wrist joint
Upper Limb

2 The inferior radioulnar joint

3 The intercarpal, carpometacarpal, metacarpo-
phalangeal and interphalangeal joints 1. Trace the beginning and course of radial and ulnar
arteries in the forearm.
C. Note the following bones in a lateral skiagram.
2. Trace the beginning, course of radial, median and
1 Lunate
ulnar nerves in the forearm.
2 Scaphoid 3. Write short notes on:
3 Capitate a. Anatomical snuffbox
1

4 Trapezium b. Synovial sheaths of the flexor tendons

Section

D. Note the epiphyses and other incomplete c. Surface marking of flexor retinaculum of wrist
ossifications, and determine the age with the help of d. Surface marking and attachments of extensor
ossifications described with individual bones. retinaculum
1–2
From Medical Council of India, Competency based Undergraduate Curriculum for the Indian Medical Graduate, 2018;1:44–80.
 Nerves, Arteries and 1
Clinical Terms
! The only equipment lacking in the modern hospital; somebody to meet you at the entrance with a handshake!
—Martin H Fischer

INTRODUCTION Branches
The nerves are very important and precious component Muscular Coracobrachialis, long head of
of our body. This appendix deals with the main nerves biceps brachii, short head of biceps
of the upper limb. Most of the nerves course through brachii, and brachialis (Fig. A1.1).
different regions of the upper limb and have been Cutaneous Lateral side of forearm (both on
described in parts in the respective regions. In this the front and the back).
appendix, the course of the entire nerve from origin to Articular Elbow joint.
its termination including the branches and clinical This nerve rarely gets injured.
aspects has been described briefly (Fig. A1.1a). Arteries
of upper limb have been tabulated in Table A1.5.
Important clinical terms related to upper limb have AXILLARY OR CIRCUMFLEX NERVE
been defined and multiple choice questions are given.
Axillary nerve is called axillary as it runs through the
upper part of axilla though it does not supply any
MUSCULOCUTANEOUS NERVE structure there. It is called circumflex as it courses around
the surgical neck of humerus (see Fig. 6.6) to supply the
Musculocutaneous nerve is so named as it supplies prominent deltoid muscle.
muscles of front of arm and skin of lateral side of
forearm. Root Value
Root Value Ventral rami of C5, C6 segments of spinal cord.
Ventral rami of C5–C7 segments of spinal cord. Course
Course Axilla
Axilla and Arm Axillary or circumflex nerve is the smaller terminal
Musculocutaneous nerve is a branch of the lateral cord branch of posterior cord seen in the axilla (see Fig. 4.14).
of brachial plexus, lies lateral to axillary and upper part
Quadrangular Space
of brachial artery. It supplies coracobrachialis, pierces
the muscle to lie in the intermuscular septum between The nerve passes backwards through the quadrangular
biceps brachii and brachialis muscles, both of which space (bounded by subscapularis above, teres major
are supplied by this nerve (see Fig. 8.6 and A1.1). below, long head of triceps brachii medially and
surgical neck of humerus laterally) (see Fig. 6.11). Here
Forearm it lies below the capsule of the shoulder joint.
About 2.5 cm above the crease of elbow, it becomes
cutaneous by piercing the deep fascia. The nerve is Surgical Neck of Humerus
called the lateral cutaneous nerve of forearm which Then it passes behind the surgical neck of humerus
supplies skin of lateral side of forearm both on the front where it divides into anterior and posterior divisions
and back. (Fig. A1.1).
191
 UPPER LIMB
192

Fig. A1.1: Brachial plexus and muscular branches of the main nerves

Table A1.1: Branches of axillary nerve

Trunk Anterior division Posterior division
Upper Limb

Muscular — Deltoid (most part) Deltoid (posterior part) and teres minor. The nerve to teres
minor is characterised by the presence of a pseudoganglion
Cutaneous — — Upper lateral cutaneous nerve of arm
Articular and vascular Shoulder joint — To posterior circumflex humeral artery

Branches Root Value

The branches of axillary nerve are presented in Ventral rami of C5–C8, T1 segments of spinal cord
1

Table A1.1. (see Fig. 4.14).

Section

Course
RADIAL NERVE
Axilla
Radial nerve is the thickest branch of brachial plexus. Radial nerve lies against the muscles forming the
posterior wall of axilla, i.e. subscapularis, teres major and
 NERVES, ARTERIES AND CLINICAL TERMS
193

latissimus dorsi. It then lies for a short distance in arm Front of Forearm
behind brachial artery. Then it enters in the lower The superficial branch leaves the cubital fossa to enter
triangular space between teres major, long head of triceps lateral side of front of forearm, accompanied by the
brachii and shaft of humerus. It gives two muscular and radial vessels in its upper two-thirds (see Fig. 9.10). At
one cutaneous branches in the axilla (Fig. A1.1). the junction of upper two-thirds and lower one-third,
the superficial branch turns laterally to reach the
Radial Sulcus posterolateral aspect of forearm.
Radial nerve enters through the lower triangular space
into the radial sulcus, where it lies between the lateral Wrist and Dorsum of Hand
and medial heads of triceps brachii along with profunda The superficial branch descends till the anatomical
brachii vessels (see Fig. 6.11). Long and lateral heads form snuffbox to reach dorsum of hand, where it supplies
the roof of the radial sulcus. It leaves the sulcus by skin of lateral half of dorsum of hand and lateral
piercing the lateral intermuscular septum. In the sulcus, 2½ digits till distal interphalangeal joints (see Figs 7.1b
it gives three muscular and two cutaneous branches. and 9.52a).

Front of Arm Back of Forearm and Wrist

The radial nerve descends on the lower and lateral side The deep branch of radial nerve enters the back of
of front of arm deep in the interval between brachialis forearm, where it supplies the muscles mentioned in
on medial side and brachioradialis with extensor carpi Table A1.2b. Lower down it passes through the 4th
radialis longus on the lateral side to reach capitulum compartment under the extensor retinaculum to reach
of humerus (see Fig. 8.17). the back of wrist where it ends in a pseudoganglion,
branches of which supply the neighbouring joints
Cubital Fossa (see Fig. 9.56).
The nerve enters the lateral side of cubital fossa. There
the radial nerve terminates by dividing into superficial Branches of Radial Nerve
and deep branches. The branches of radial nerve are presented in
The deep branch supplies extensor carpi radialis Table A1.2a.
brevis and supinator. Then it courses between two heads Branches of deep division of radial nerve are shown
of supinator to reach back of forearm. in Table A1.2b.

Table A1.2a: Branches of radial nerve

Axilla Radial sulcus Lateral side of arm
Muscular Long head of triceps brachii Lateral head of triceps brachii Brachioradialis
Medial head of triceps brachii Medial head of triceps brachii Extensor carpi radialis longus
Anconeus Lateral part of brachialis (proprioceptive)
Cutaneous Posterior cutaneous nerve Posterior cutaneous nerve of forearm –
of arm Lower lateral cutaneous nerve of arm
Vascular To profunda brachii artery –

Upper Limb
Terminal – – Superficial and deep or posterior
interosseous branches

Table A1.2b: Branches of deep division of radial nerve

Cubital fossa Back of forearm Wrist
Muscular Extensor carpi radialis brevis Abductor pollicis longus, —
and supinator extensor pollicis brevis,
extensor pollicis longus,
1

extensor digitorum, extensor

indicis, extensor digiti minimi
Section

and extensor carpi ulnaris

Articular — — To inferior radioulnar,
wrist and intercarpal
joints
 UPPER LIMB
194

Table A1.2c: Branches of superficial division of radial nerve

Forearm Anatomical snuffbox and dorsum of hand
Cutaneous and vascular Lateral side of forearm Skin over anatomical snuffbox, lateral half of
and radial vessels dorsum of hand and lateral 2½ digits till their distal
interphalangeal joints
Articular — To wrist joint, 1st carpometacarpal joint,
metacarpophalangeal and interphalangeal joints of
the thumb, index and middle fingers

Branches of superficial division of radial nerve are branches to lateral 3½ digits and their nail beds
shown in Table A1.2c. including skin of distal phalanges on their dorsal aspect
(see Figs 7.1, 9.12 and 9.41).
MEDIAN NERVE Branches of Median Nerve
The branches of median nerve are presented in
Median nerve is called median as it runs in the median Table A1.3.
plane of the forearm.
Root Value ULNAR NERVE
Ventral rami of C5–C8, T1 segments of spinal cord.
Ulnar nerve is named so as it runs along the medial or
Course ulnar side of the upper limb.
Axilla Root Value
Median nerve is formed by two roots, lateral root from Ventral rami of C8 and T1. It also gets fibres of C7 from
lateral cord (C5, 6, 7) and medial root from medial cord the lateral root of median nerve (see Fig. 4.14).
(C8, T1) of brachial plexus. Medial root crosses the
axillary artery to join the lateral root. The median nerve Course
runs on the lateral side of axillary artery (see Fig. 8.9). Axilla
Arm Ulnar nerve lies in the axilla between the axillary vein
Median nerve continues to run on the lateral side of and axillary artery on a deeper plane.
brachial artery till the middle of arm, where it crosses Arm
in front of the artery, passes anterior to elbow joint into
Ulnar nerve lies medial to brachial artery. Runs
the cubital fossa (see Figs 8.9 and 8.17 and A1.1).
downwards with the brachial artery in its proximal part
Cubital Fossa (see Fig. 8.9). At the middle of arm, it pierces the medial
Median nerve lies most medial in the cubital fossa. It intermuscular septum to lie on its back and descends on
gives three branches to flexor muscles of the forearm. the back of medial epicondyle of humerus where it can
It leaves the fossa by passing between two heads of be palpated. Palpation causes tingling sensations (see
pronator teres (see Figs 8.18 and 8.19). Fig. 8.13a). That is why humerus is called ‘funny bone’.
Forearm
Upper Limb

Forearm
Median nerve enters the forearm and lies in the centre Ulnar nerve enters the forearm by passing between two
of forearm. It lies deep to fibrous arch of flexor digitorum heads of flexor carpi ulnaris. There it lies on medial
superficialis on the flexor digitorum profundus. Adheres part of flexor digitorum profundus.
to deep surface of flexor digitorum superficialis, leaves Ulnar nerve is not a content of cubital fossa.
the muscle, along its lateral border. Lastly, it is placed It is accompanied by the ulnar artery in lower two-
deep and lateral to palmaris longus. thirds of forearm (see Fig. 9.10).
It gives two muscular and two cutaneous branches
Flexor Retinaculum (Table A1.4 and Fig. A1.1).
1

Median nerve lies deep to flexor retinaculum to enter

Section

palm (see Fig. 9.10). Flexor Retinaculum

Finally, it lies on the medial part of flexor retinaculum
Palm to enter palm. At the distal border of retinaculum, the
Median nerve lies medial to the muscles of thenar nerve divides into its superficial and deep branches
eminence, which it supplies. It also gives cutaneous (see Figs 9.13 and 9.15).
 NERVES, ARTERIES AND CLINICAL TERMS
195

Table A1.3: Branches of median nerve

Axilla and arm Cubital fossa Forearm Palm
Muscular Pronator teres in Flexor carpi radialis, Anterior interosseous which Recurrent branch for abductor
lower part of arm flexor digitorum supplies: Lateral half of flexor pollicis brevis, flexor pollicis
superficialis, palmaris digitorum profundus, pronator brevis, opponens pollicis. 1st
longus quadratus, and flexor and 2nd lumbricals (see Fig. 9.12)
pollicis longus from the digital nerves
Cutaneous — — Palmar cutaneous branch • Two digital branches to lateral
for lateral two-thirds of palm and medial sides of thumb
• One to lateral side of index finger
• Two to adjacent sides of index
and middle fingers
• Two to adjacent sides of middle
and ring fingers. These branches
also supply dorsal aspects of
distal phalanges of lateral 3½
digits including nail beds
Articular and Gives sympathetic Elbow joint Gives sympathetic fibres to Gives articular branches to joints
vascular fibres to axillary radial and ulnar arteries of hand
and brachial
arteries

Palm
Superficial branch supplies palmaris brevis and gives
digital branches to medial 1½ digits including medial
1½ nail beds till the distal interphalangeal joints
(Fig. A1.2).
Deep branch supplies most of the intrinsic muscles of
the hand. At first, it supplies three muscles of hypothenar
eminence. Running in the concavity of deep palmar arch,
it gives branches to 4th and 3rd lumbricals from deep
aspect; 4,3,2,1 dorsal interossei and 4,3,2,1 palmar
interossei to end in adductor pollicis (Table A1.5).
Since it supplies intrinsic muscles of hand responsible
for finer movements, this nerve is called ‘musician’s
nerve’ (see Figs 9.34a and b).
Branches
The branches of ulnar nerve are presented in Table A1.4 Fig. A1.2: Sensory loss in median, ulnar and radial nerves
and Fig. A1.1. paralyses

Upper Limb
Table A1.4: Branches of ulnar nerve
Forearm Hand (see Fig. 9.13)
Muscular Medial half of flexor digitorum profundus, Superficial branch—palmaris brevis.
flexor carpi ulnaris Deep branch—muscles of hypothenar
eminence, medial two lumbricals, 4–1 dorsal
interossei and 4–1 palmar interossei and
adductor pollicis. May supply deep head of
1

flexor pollicis brevis

Cutaneous/digital Dorsal cutaneous branch for medial half of dorsum of
Section

hand. Palmar cutaneous branch for medial one-third of

palm. Digital branches to medial 1½ fingers,
nail beds and dorsal aspects of distal phalanges
Vascular/articular Also supplies digital vessels and joints of medial side of hand
 UPPER LIMB
196

Table A1.5: Comparison of injury of median and ulnar nerves at wrist

Injury to median nerve at wrist Injury to ulnar nerve at wrist
Loss of thenar eminence Loss of hypothenar eminence
Normal fist making by 4th, 5th digits Clawing of 4th and 5th digits
Lagging behing of 2nd and 3rd digits in fist making Slight clawing of 2nd and 3rd digits
Gutters seen in palm
Sensory loss over lateral 3½ digits Sensory loss over medial 1½ digits
Loss of pronation of forearm Loss of adduction of 2nd, 4th and 5th digits
Loss of opposition of thumb Loss of abduction of 2nd–4th digits

CLINICAL ANATOMY
Musculocutaneous nerve injury
1 and 2: Paralysis of biceps and brachialis
3. Sensory loss on lateral side of forearm

Axillary nerve injury

Loss of abduction from beginning to 90°
Sensory loss over lower half of deltoid—regimental/badge sign.

Radial nerve injury

1. No extension of elbow
2. Wrist drop
3. Sensory loss (Fig. A1.2)
Upper Limb
1
Section
 NERVES, ARTERIES AND CLINICAL TERMS
197

Median nerve injury 1. Weak flexion of wrist

2. Loss of pronation of forearm
3. Loss of flexion of proximal interphalangeal and distal
interphalangeal joints of index and middle fingers
4. Loss of flexion at interphalangeal joint of thumb
5. Loss of thenar eminence
6. Sensory, trophic and vasomotor changes (see Figs 9.40 to 9.44 and A1.2)

Ulnar nerve injury

1. Flattening of medial border of forearm

2. Loss of flexion at distal interphalangeal joints of 4th and 5th
digits
3. Loss of hypothenar eminence
4. Loss of adduction of thumb
5. Loss of abduction of all fingers except little finger
6. Loss of adduction of 2nd, 4th and 5th digits
7. Slight clawing of 2nd and 3rd digits
8. Marked clawing of 4th and 5th digits
9. Sensory, trophic and vasomotor changes (Fig. A1.2)

• If ulnar nerve is injured at the elbow, the clawing of the fingers is less, because medial half of flexor digitorum Upper Limb
profundus (flexor of proximal and distal interphalangeal joints) also gets paralysed. If ulnar nerve is injured
at wrist, the clawing of the fingers is more as intact flexor digitorum profundus flexes the digits more. Thus
if lesion is proximal (near elbow), clawing is less. On the contrary, if lesion is distal (near wrist), clawing is
more. This is called ‘action of paradox’/ulnar paradox.
• If both ulnar and median nerves get paralysed, there is complete claw hand (see Fig. 9.45).
Table A1.5 shows the comparison between injuries of median and ulnar nerves at the wrist. Table A1.6
gives the arteries of upper limb with their branches and area of distribution.
1Section
 UPPER LIMB
198

Table A1.6: Arteries of upper limb

Artery Origin, course and termination Area of distribution
AXILLARY ARTERY Starts at the outer border of first rib as continuation Supplies all walls of axilla, pectoral
(see Fig. 4.6 and of subclavian artery, runs through axilla and region including mammary gland
Fig. A1.3) continues as brachial artery at the lower border of
teres major muscle
Superior thoracic artery From 1st part of axillary artery Supplies upper part of thoracic wall and
(see Fig. 4.10) the pectoral muscles
Thoracoacromial artery From 2nd part of axillary artery, pierces clavipectoral Supplies pectoral and deltoid muscles
fascia and divides into deltoid, acromial and clavi-
cular and pectoral branches
Lateral thoracic artery From 2nd part of axillary artery runs along Supplies the muscles of thoracic wall
inferolateral border of pectoralis minor including the mammary gland
Anterior circumflex From third part of axillary artery runs on the anterior Supplies the neighbouring shoulder joint
humeral artery aspect of intertubercular sulcus and anastomoses and the muscles
with large posterior circumflex humeral artery
Posterior circumflex From third part of axillary artery lies along the Supplies huge deltoid muscle, skin
humeral artery surgical neck of humerus with axillary nerve overlying it and the shoulder joint
Subscapular artery Largest branch of axillary artery runs along the Supplies muscles of posterior wall of axilla,
(see Figs 4.10 and 6.12) muscles of posterior wall of axilla i.e. teres major, latissimus dorsi, sub-
scapularis. Takes part in anastomoses
around scapula
BRACHIAL ARTERY Starts at the lower border of teres major as continu- Supplies muscles of the arm, humerus
(see Fig. 8.9) ation of axillary artery. Runs on anterior aspect of bone and skin of whole of arm. Takes
arm and ends by dividing into radial and ulnar part in anastomoses around elbow joint
arteries at neck of radius in the cubital fossa
Profunda brachii artery Largest branch of brachial artery. Runs with radial Supplies muscles of back of arm and its
(see Fig. 8.10) nerve in the radial sulcus of humerus. Reaching the branches anastomose with branches of
lateral side of arm, ends by dividing into anterior and radial artery and ulnar artery on lateral
posterior branches epicondyle of humerus
Superior ulnar collateral Branch of brachial artery. Accompanies ulnar nerve. Supplies muscles of arm and elbow joint
artery (see Fig. 8.10) Takes part in anastomoses around elbow joint on its medial aspect
Muscular branches Branches arise from brachial artery Supplies biceps and triceps brachii muscles
Nutrient artery Branch of brachial and enters the nutrient foramen Supplies blood to red bone narrow
of humerus
Inferior ulnar collateral Branch of brachial Takes part in the anastomoses around
artery elbow joint from medial side
RADIAL ARTERY Starts as smaller branch of brachial artery, lies on the Muscles of lateral side of forearm,
(see Fig. 9.20) lateral side of forearm, then in the anatomical snuff- including the overlying skin. Gives a
box to reach the palm, where it continues as deep branch for completion of superficial
palmar arch palmar arch.
Upper Limb

Digital branches to thumb and lateral side

of index finger
Radial recurrent artery Branch of radial artery Supplies elbow joint. Takes part in anasto-
(see Fig. 8.10) moses around elbow joint
Muscular branches Branches of radial artery Muscles attached to radius, e.g. biceps
brachii, pronator teres, pronator quadratus,
flexor pollicis longus, flexor digitorum
superficialis
Superficial palmar Branch of radial artery in lower part of forearm, Crosses front of thenar muscles and joins
branch (see Fig. 9.20) before radial artery winds posteriorly the superficial branch of ulnar artery to
1

complete superficial palmar arch

Section

Dorsal carpal branch Branch of radial artery as it lies in the anatomical Supplies wrist joint
snuffbox
Princeps pollicis artery Branch of radial artery in palm, runs along thumb Supplies muscles, tendons, skin and
(see Fig. 9.20) joints in relation to thumb
 NERVES, ARTERIES AND CLINICAL TERMS
199

Table A1.6: Arteries of upper limb (Contd...)

Artery Origin, course and termination Area of distribution
Radialis indicis artery Branch of radial artery in palm, runs along radial Supplies tendons, joints and skin of
(see Fig. 9.20) side of index finger index finger
ULNAR ARTERY Originates as the larger terminal branch of brachial Gives branches to take part in the
(see Fig. 9.10) artery at neck of radius. Courses first obliquely in anastomoses around elbow joint.
upper one-third and then vertically in lower two-thirds Branches supply muscles of front of
of forearm. Lies superficial to flexor retinaculum and forearm, back of forearm and nutrient
ends by dividing into superficial and deep branches arteries to forearm bones
Anterior and posterior ulnar Branches of ulnar artery curve upwards and reach Take part in anastomoses around
recurrent arteries elbow joint elbow joint
(see Fig. 8.10)
Common interosseous Large branch of ulnar artery Supplies all the muscles of forearm
branches
a. Anterior interosseous Branch of common interosseous artery runs on Supplies both the bones of forearm and
artery interosseous membrane muscles attached to these bones
b. Posterior interosseous Branch of common interosseous artery reaches Supplies muscles of back of forearm.
artery back of forearm Also take part in anastomoses around
elbow joint
Superficial branch Larger terminal branch of ulnar artery joins Gives branches to tendon in the palm,
(see Fig. 9.20) superficial palmar branch of radial artery to form digital branches along fingers. Also
superficial palmar arch supply joints and overlying skin
Deep branch (see Fig. 9.22) Smaller terminal branch of ulnar artery that joins Branches of deep palmar arch join the
with the terminal part of radial artery to form the digital branches of superficial palmar
deep palmar arch which lies deep to the long arch, supplementing the blood supply
flexor tendons of the palm. It is also proximal to to the digits or fingers
the superficial palmar arch

Upper Limb
1Section

Fig. A1.3: Arteries of the upper limb

 UPPER LIMB
200

SYMPATHETIC INNERVATION 4 Patterning of anteroposterior axis of limb is

1 The sympathetic innervation of the upper limb is controlled by zone of polarizing activity (ZPA) by
derived from the upper six thoracic segments of the secreting retinoic acid (RA) and sonic hedgehog
spinal cord. The fibres arise from the lateral horn (SHH).
cells and come out with the ventral roots as 5 Distal growth of the limb is affected by progressive
preganglionic (white rami) fibres. These fibres zone, which in turn is maintained by FGF4 and
ascend in the sympathetic chain to their appropriate FGF8.
ganglia for relay. Molecular Regulation of Muscle Development
2 The postganglionic (grey rami) fibres emerge from
the middle and inferior cervical and the first Lateral plate mesoderm expresses BMP4 and FGFs
thoracic (stellate) sympathetic ganglia, and join the which with the help of wingless/integrated (WNT)
five roots (C5–C8, T1) of the brachial plexus. proteins from adjacent ectoderm signal upper lateral
3 The blood vessels to the skeletal muscles are dilated cells of dermomyotome to express muscle specific gene
by the sympathetic activity. To the skin, however, muscle differentiation (MyoD).
these nerves are vasomotor, sudomotor and pilomotor. MyoD and myogenic factor 5 (Myf5) are members
of family of transcription factor called myogenic
Competency achievement: The student should be able to: regulatory factors (MRFs). These activate pathways for
AN 13.8 Describe development of upper limb.1 muscle development.

Molecular basis for Laterality Sequencing

EMBRYOLOGY OF THE UPPER LIMB
The molecular basis for laterality sequencing is the
1 The upper limb bud appears on the ventrolateral accumulation of the signaling molecules, the serotonin
aspect of the body wall opposite the lower cervical [5-hydroxytryptamine (5-HT)], mnodal and fibroblast
segments, at the end of the fourth week of growth factor 8 (FGF8) on left side and monoamine
development. The development of the upper limb oxidase (MAO) on right side. The paried like homeo-
precedes that of the lower limb by a few days. domain 2 (PITX2) is the master gene for left sidedness.
2 Most investigators believe that the muscles of the
upper limb develop in situ from the local mesoderm,
and do not receive by contribution from the somites. CLINICAL TERMS
3 The axis artery of the upper limb develops from
the seventh cervical intersegmental artery. In Shoulder joint may be dislocated inferiorly: The
adults, it persists as axillary, brachial and anterior shoulder joint is surrounded by short muscles on all
interosseous arteries, and as the deep palmar arch. aspects except inferiorly. Since the joint is quite
The other arteries are secondary outgrowth from mobile, it dislocates at the unprotected site, i.e.
the axial artery. inferiorly (see Fig. 2.18).
4 Limb muscles: Mesenchyme from dorsolateral cells Student’s elbow: Inflammation of the bursa over
the insertion of triceps brachii is called student’s
of somites thickens to form muscles. Muscles are
elbow. It is common in students as they use the
derived from several segments. Spinal nerves
flexed elbow to support the head while attempting
supply muscles and also provide sensory nerves
hard to listen to the lectures in between their ‘naps’
for dermatomes. Radial nerve is formed by
(see Fig. 10.16b).
combination of dorsal segmental branches. Ulnar
Upper Limb

Tennis elbow: Lateral epicondylitis occurs in

and median nerves are formed by combination of
players of lawn tennis or table tennis. The extensor
ventral branches.
muscles of forearm are used to hit the ball sharply,
causing repeated microtrauma to the lateral
Molecular Regulation of Limb Development
epicondyle and its subsequent inflammation (see
1 Limb outgrowth in the forelimb is initiated by Fig. 10.16a). It may be a degenerative condition.
T-box family 5 (for transcription); brachyury gene Pulled elbow: While pulling the children by their
for tail growth (TBX 5) and fibroblast growth factor hands (getting them off the bus), the head of radius
10 (FGF 10). may slip out of the annular ligament. Annular
1

2 Positioning of limb along craniocaudal axis is ligament is not tight in children as in adults, so the
Section

regulated by homeobox genes (HOX genes). head of radius slips out (see Fig. 2.25).
3 Apical ectodermal ridge formation is induced by Boxer’s palsy or swimmer’s palsy: Serratus anterior
bone morphogenetic proteins (BMPs) by signaling causes the movement of protraction. If the long
through homeobox gene muscle segment homeobox thoracic nerve is injured, the muscle gets paralysed,
(MSX 2).
 NERVES, ARTERIES AND CLINICAL TERMS
201

seen as ‘winging of scapula’ (see Fig. 2.12). Such a finger is affected the most. It remains extended and
person cannot hit his opponent by that hand. Neither keeps pointing forwards (despite the fact that
can he make strokes while swimming. remaining three fingers are pointing towards self)
Golfer’s elbow/medial epicondylitis: Occurs in (see Fig. 9.39).
golf players. Repeated microtrauma to medial Complete claw hand: Complete claw hand is due
epicondyles causes inflammation of common flexor to injury of lower trunk of brachial plexus especially
origin and pain in flexing the wrist (see Fig. 10.17). the root, which supplies intrinsic muscles of hand.
Waiter’s tip or policeman’s tip: ‘Taking the tip The injury is called ‘Klumpke’s paralysis’. The
quietly’ Erb–Duchenne paralysis occurs due to metacarpophalangeal joints are extended while both
involvement of Erb’s point. At Erb’s point, C5, C6 the interphalangeal joints of all fingers are actually
roots join to form upper trunk, two divisions of the flexed (see Fig. 9.45).
trunk arise and two branches, the suprascapular and Breast: The breast is a frequent site of carcinoma
nerve to subclavius also arise (see Fig. 4.16). (cancer). Several anatomical facts are of importance
Wrist drop: Paralysis of radial nerve in axilla or in diagnosis and treatment of this condition.
radial sulcus or anterolateral side of lower part of Abscesses may also form in the breast and may
arm or paralysis of its deep branch in cubital fossa require drainage. The following facts are worthy to
leads to wrist drop (see Fig. 8.25). note.
Carpal tunnel syndrome: Median nerve gets Incisions into the breast are usually made radially
compressed under the flexor retinaculum, leading to avoid cutting the lactiferous ducts (see Fig. 3.9).
to paralysis of muscles of thenar eminence. It is called Cancer cells may infiltrate the suspensory
‘ape-like or monkey-like hand’. There is loss of ligaments. The breast then becomes fixed. Con-
sensation in lateral 3½ digits including nail beds. traction of the ligaments can cause retraction or
Median nerve is the ‘eye of the hand’. There is little puckering (folding) of the skin.
clawing of index and middle fingers also (see Infiltration of lactiferous ducts and their
Figs 9.40 to 9.44). consequent fibrosis can cause retraction of the skin.
Cubital tunnel syndrome: Ulnar nerve gets Obstruction of superficial lymph vessels by cancer
entrapped between two heads of flexor carpi ulnaris cells may produce oedema of the skin giving rise to
muscle, leading to paralysis of medial half of flexor an appearance like that of the skin of an orange
digitorum profundus and muscles of hypothenar (peau d’orange appearance) (see Fig. 3.16).
eminence, all interossei and adductor pollicis and 3rd Because of bilateral communications of the
and 4th lumbricals. There is clawing of medial two lymphatics of the breast across the midline, cancer
digits, gutters in the hand and loss of hypothenar may spread from one breast to the other (see
eminence (see Figs 9.35 and 9.36). Fig. 3.17).
Volkmann’s ischaemic contracture: This condition Because of communications of the lymph vessels
occurs due to fibrosis of the muscles of the forearm, with those in the abdomen, cancer of the breast may
chiefly the flexors. It usually occurs with injury to spread to the liver. Cancer cells may ‘drop’ into the
the brachial artery in supracondylar fractures of pelvis especially ovary (Krukenberg’s tumour)
humerus (see Fig. 2.16b). producing secondaries there (see Fig. 3.17).
Dupuytren’s contracture: This clinical condition is Apart from the lymphatics, cancer may spread
due to fibrosis of medial part of palmar aponeurosis through the veins. In this connection, it is important
Upper Limb
especially the part reaching the ring and little fingers. to know that the veins draining the breast
The fibrous bands are attached to proximal and communicate with the vertebral venous plexus of
middle phalanges and not to distal phalanges. So veins. Through these communications, cancer can
proximal and middle phalanges are flexed, while spread to the vertebrae and to the brain (see Fig. 3.17).
distal phalanges remain extended (see Fig. 9.18). Ligaments of Cooper: Fibrous strands extending
Funny bone: Ulnar nerve is palpable in flexed elbow between skin overlying the breast to the underlying
behind the medial epicondyle. Palpating the nerve pectoral muscles. These support the gland.
gives rise to funny sensations in the medial side of Montgomery’s glands: Glands beneath the areola
of mammary gland.
1

forearm. Since medial epicondyle is part of humerus,

it is called humerus or funny bone (see Fig. 2.15). Subareolar plexus of Sappey: Lymphatic plexus
Section

Pointing finger: Branch of anterior interosseous beneath the areola of the breast.
nerve to lateral half of flexor digitorum profundus Blood pressure: The blood pressure is universally
is injured in the middle of the forearm. The index recorded by auscultating the brachial artery on the
anteromedial aspect of the elbow joint (see Fig. 8.11).
 UPPER LIMB
202

Intravenous injection: The median cubital vein is de Quervain’s disease is a thickening of sheath
the vein of choice for intravenous injections, for around tendons of abductor pollicis longus and
withdrawing blood from donors, and for cardiac extensor pollicis brevis giving rise to pain on lateral
catheterisation, because it is fixed by the perforator side of wrist.
and does not slip away during piercing (see Fig. 7.8).
Intramuscular injection: Intramuscular injections FURTHER READING
are often given into the deltoid. They should be given • Birch R. Latrogenous injuries. In: Surgical Disorders of the
in the middle of the muscle to avoid injury to the Peripheral Nerves, 2nd ed. London: Springer-Verlag: 2011;
axillary nerve (see Fig. 6.9). 483–526.
Radial pulse: The radial artery is used for feeling • O'Rahilly R, Gdner E. The timing and sequence of events in
the (arterial) pulse at the wrist. The pulsation can be the development of the limbs in the human embryo. Anat
felt well in this situation because of the presence of Embryol 1975;148:1–23.
the flat radius behind the artery (see Fig. 9.10). A description of the stages in human limb development.
Lister’s tubercle: Dorsal tubercle on lower end of
posterior surface of radius. This acts as a pulley for
the tendon of extensor pollicis longus (see Fig. 2.20).

1
From Medical Council of India, Competency based Undergraduate Curriculum for the Indian Medical Graduate, 2018;1:44–80.

1. Enumerate: • Branches of musculocutaneous nerve

• Branches of radial nerve in axilla and in radial • Branches of brachial artery
sulcus • Branches of ulnar artery in forearm
• Branches of median nerve in forearm • Branches of radial artery in forearm
• Branches of median nerve in palm • The palpable arteries in upper limb
• Branches of ulnar nerve in palm • Branches of superficial palmar arch

A. Match the following on the left side with their c. Latissimus dorsi iii. Abduction
appropriate answers on the right side: d. Teres minor iv. Extension
Upper Limb

1. The nerve injury and the clinical signs: 4. Muscles and their nerve supply:
a. Radial nerve i. Partial claw hand a. Deltoid i. Ulnar
b. Median nerve ii. Wrist drop b. Supinator ii. Median
c. Long thoracic nerve iii. Ape thumb c. 1st lumbrical iii. Axillary
d. Ulnar nerve iv. Winging of scapula d. Adductor pollicis iv. Radial
2. Tendon reflexes and segmental innervation: 5. Sensory innervation of skin:
a. Triceps i. C5, C6, C7 a. Palmar surface of ring i. C3, C4
1

b. Biceps brachii ii. C5, C6 and little fingers

Section

c. Brachioradialis iii. C6, C7, C8 b. Palmar surface of ii. C8

3. Muscles and the movements at shoulder joints: thumb and index finger
a. Deltoid i. Medial rotation c. Medial aspect of arm iii. T1, T2
b. Subscapularis ii. Lateral rotation d. Tip of the shoulder iv. C6
 NERVES, ARTERIES AND CLINICAL TERMS
203

B. For each of the incomplete statements or 8. Clavicle:

questions below, one or more completions or a. Is a long bone
answers given is/are correct. Select.
b. Develops by intramembranous ossification
A. If only a, b and c are correct
B. If only a and c are correct c. Is the first bone to ossify
C. If only b and d are correct d. Has a well-developed medullary cavity
D. If only d is correct 9. In Erb’s paralysis:
E. If all are correct a. Abduction and lateral rotation of the arm are lost
6. Injury to the median nerve in the arm would affect:
b. Flexion and pronation of the forearm are lost
a. Pronation of the forearm
b. Flexion of the wrist c. Biceps and supinator jerks are lost
c. Flexion of the thumb d. Sensations are lost over the medial side of the
d. Supination of the forearm arm
7. Which of the following is/are true regarding 10. Which of the following statements is/are true
humerus? regarding ‘mammary gland’?
a. The head of the humerus commonly dislocates a. It is modified sweat gland
posteriorly.
b. Lies in superficial fascia
b. Common sites of fracture are surgical neck, shaft
and supracondylar region c. 75% of the lymph from mammary gland drains
c. Lower end is the growing end. into axillary lymph nodes
d. Axillary, radial and ulnar nerves are directly d. Some lymphatic vessels communicate with the
related to the bone lymph vessels of opposite side

1. a.–ii, b.–iii, c.–iv, d.–i, 2. a.–iii, b.–ii, c.–i,

3. a.–iii, b.–i, c.–iv, d.–ii, 4. a.–iii, b.–iv, c.–ii, d.–i
5. a.–ii, b.–iv, c.–iii, d.–i, 6. A
7. C 8. A 9. B 10. E.

Upper Limb
1Section
 SPOTS ON UPPER LIMB

1. a. Identify the muscle.

6. a. Identify the joint.
b. Name its nerve
b. Name its movements.
supply.

2. a. Identify the cord of 7. a. Identify the structure

brachial plexus. on right middle
b. Enumerate its finger
branches. b. Name the muscles
inserted.

3. a. Identify the muscle. 8. a. Identify the structure.

b. Name its heads. b. Name the structures
lying on its superficial
aspect.

4. a. Identify the area. 9. a. Identify the structure.

b. Name its contents in b. Name the contents of
order. its 4th compartment.

5. a. Identify the nerve. 10. a. Identify the muscle.

b. Name its muscular b. Name the nerves
branches in the palm. supplying it.

205
 UPPER LIMB
206

ANSWERS: SPOTS ON UPPER LIMB

1. a. Pectoralis major
b. Medial pectoral and lateral pectoral nerves

2. a. Medial cord of brachial plexus

b. • Medial pectoral
• Medial cutaneous nerve of arm
• Medial cutaneous nerve of forearm
• Ulnar nerve
• Medial root of median

3. a. Biceps brachii
b. Long head and short head

4. a. Cubital fossa
b. • Median nerve
• Brachial artery
• Tendon of biceps brachii
• Radial nerve

5. a. Median nerve
b. • Flexor pollicis brevis
• Abductor pollicis brevis
• Opponens pollicis
• 1st and 2nd lumbricals

6. a. 1st carpometacarpal joint

b. • Flexion with medial rotation
• Extension with lateral rotation
• Abduction
• Adduction
• Opposition
7. a. Extensor expansion of right middle finger
b. • Tendon of extensor digitorum
• 2nd lumbrical
• 2nd and 3rd dorsal interossei

8. a. Flexor retinaculum
b. • Palmar cutaneous branch of median nerve
• Tendon of palmaris longus
• Palmar cutaneous branch of ulnar nerve
Upper Limb

• Ulnar artery
• Ulnar nerve

9. a. Extensor retinaculum
b. • Tendon of extensor digitorum
• Tendon of extensor indicis
• Anterior interosseous artery
• Posterior interosseous nerve
1

10. a. Flexor digitorum profundus

b. Medial half by ulnar nerve and lateral half by anterior interosseous branch of median nerve
Section
 2
Thorax
12. Introduction 209
13. Bones and Joints of Thorax 219
14. Walls of Thorax 240
15. Thoracic Cavity and Pleurae 255
16. Lungs 264
17. Mediastinum 278
18. Pericardium and Heart 283
19. Superior Vena Cava, Aorta and Pulmonary Trunk 310
20. Trachea, Oesophagus and Thoracic Duct 321
21. Surface Marking and Radiological Anatomy of Thorax 330
Appendix 2: Autonomic Nervous System, Arteries, Nerves and Clinical Terms 338
Spots on Thorax 347
 Ichchak dana, beechak dana, dane upar dana
Hands naache, feet naache, brain hai khushnama
Ichchak dana.
Closed cage mai baitha ek naajuk bechara
lub dub, lub dub hi karta hai ye aawara
Lekin iska bahut sensitive hai mijajana
agar tute to mushkil hai samjhana
is liye kisi ka “ye” na dukhana
Ichchak dana
Bolo kya—heart, bolo kya—heart
 12
Introduction
!Pray as if everything depended on God and work as if everything depended upon man !
—Anonymous

Thorax (Latin chest) forms the upper part of the trunk b. It marks the plane which separates the superior
of the body. It not only permits boarding and lodging mediastinum from the inferior mediastinum.
of the thoracic viscera, but also provides necessary c. The ascending aorta ends at this level.
shelter to some of the abdominal viscera. d. The arch of the aorta begins and also ends at this
The trunk of the body is divided by the diaphragm level.
into an upper part, called the thorax, and a lower part, e. The descending aorta begins at this level.
called the abdomen. The thorax is supported by a f. The trachea divides into two principal bronchi.
skeletal framework, thoracic cage. The thoracic cavity g. The azygos vein arches over the root of the right
contains the principal organs of respiration—the lungs lung and opens into the superior vena cava.
and of circulation—the heart, both of which are vital h. The pulmonary trunk divides into two pulmonary
for life. arteries just below this level.
i. The thoracic duct crosses from the right to the left
side at the level of the fifth thoracic vertebra and
SURFACE LANDMARKS OF THORAX reaches the left side at the level of the sternal angle.
Bony Landmarks j. It marks the upper limit of the base of the heart.
k. The cardiac plexuses are situated at the same level.
1 Suprasternal or jugular notch (Fig. 12.1): It is felt just 3 Xiphisternal joint: The costal margin on each side is
above the superior border of the manubrium formed by the seventh to tenth costal cartilages.
between the sternal ends of the clavicles. It lies at Between the two costal margins, there lies the
the level of the lower border of the body of the
second thoracic vertebra. The trachea can be
palpated in this notch.
2 Sternal angle/angle of Louis: It is felt as a transverse
ridge about 5 cm below the suprasternal notch. It
marks the manubriosternal joint, and lies at the level
of the second costal cartilage anteriorly, and the disc
between the fourth and fifth thoracic vertebrae
posteriorly. This is an important landmark for the
following reasons.
a. The ribs are counted from this level downwards.
There is no other reliable point (anteriorly) from
which the ribs may be counted. The second costal
cartilage and second rib lie at the level of the
sternal angle or angle of Louis (French physician
1787–1872). The ribs are counted from here by
tracing the finger downwards and laterally
(because the lower costal cartilages are crowded
and the anterior parts of the intercostal spaces Fig. 12.1: Shape and construction of the thoracic cage as seen
are very narrow). from the front

209
 THORAX
210

infrasternal or subcostal angle. The depression in the

angle is also known as the epigastric fossa.
The xiphoid (Greek sword) process lies in the floor
of the epigastric fossa. At the apex of the angle, the
xiphisternal joint may be felt as a short transverse
ridge. It lies at the level of the upper border of the
ninth thoracic vertebra (Fig. 12.1).
4 Costal cartilages: The second costal (Latin rib) cartilage
is attached to the sternal angle. The seventh cartilage
bounds the upper part of the infrasternal angle. The
lateral border of the rectus abdominis or the linea
semilunaris joins the costal margin at the tip of the
ninth costal cartilage. The tenth costal cartilage forms
the lower part of the costal margin (Figs 12.1 and
12.2a).
5 Ribs: The scapula overlies the second to seventh ribs
on the posterolateral aspect of the chest wall. The
tenth rib is the lowest point, lies at the level of the
third lumbar vertebra. Though the eleventh rib is
longer than the twelfth, both of them are confined to
the back and are not seen from the front (Fig. 12.2b
and c).
6 Thoracic vertebral spines: The first prominent spine felt
at the lower part of the back of the neck is that of the
seventh cervical vertebra or vertebra prominens. Below this
spine, all the thoracic spines can be palpated along the
posterior median line (Fig. 12.3). The third thoracic
spine lies at the level of the roots of the spines of the
scapulae. The seventh thoracic spine lies at the level
of the inferior angles of the scapulae.

Soft Tissue Landmarks

1 The nipple: The position of the nipple varies
considerably in females, but in males it usually lies
in the fourth intercostal space about 10 cm from the
midsternal line (Fig. 12.4).
2 Apex beat: It is a visible and palpable cardiac impulse
in the left fifth intercostal space, 9 cm from the
midsternal line, or medial to the midclavicular line.
3 Trachea: It is palpable in the suprasternal notch
midway between the two clavicles.
Thorax

4 Midclavicular: It is a vertical plane passing through

the midinguinal point, the tip of the ninth costal
cartilage and middle of clavicle (Fig. 12.5).
5 Midaxillary line: It passes vertically between the two Fig. 12.2: Shape and construction of the thoracic cage as seen
folds of the axilla (Fig. 12.5). from the (a) front, (b) lateral side and; (c) back
6 Scapular line: It passes vertically along the inferior
angle of the scapula. intrathoracic pressure, so that air is sucked into the
2

lungs during inspiration and expelled during

SKELETON OF THORAX expiration.
Section

The skeleton of thorax is also known as the thoracic FORMATION

cage. It is an osseocartilaginous elastic cage which is Anteriorly, by the sternum (Greek chest) (Figs 12.1 and
primarily designed for increasing and decreasing the 12.2).
 INTRODUCTION
211

Fig. 12.3: Shape and construction of the thoracic cage as seen

from behind

Posteriorly, by the 12 thoracic vertebrae and the

intervening intervertebral discs (Fig. 12.3). Fig. 12.4: Soft tissue landmarks
On each side, by 12 ribs with their cartilages.
Each rib articulates posteriorly with the vertebral
column. Anteriorly, only the upper seven ribs articulate
with the sternum through their cartilages and these The anterior ends of the eleventh and twelfth ribs are
are called true or vertebrosternal ribs. free: These are called floating or vertebral ribs. The
The costal cartilages of the next three ribs, i.e. the vertebrochondral and vertebral ribs, i.e. the last five ribs,
eighth, ninth and tenth end by joining the next higher are also called false ribs because they do not articulate
costal cartilage. These ribs are, therefore, known as with the sternum.
vertebrochondral ribs. The costal cartilages of the The costovertebral, costotransverse, manubrio-sternal
seventh, eighth, ninth and tenth ribs form the sloping and chondrosternal joints permit movements of the
costal margin. thoracic cage during breathing.

Thorax
2Section

Fig. 12.5: Surface marking of midclavicular and midaxillary lines

 THORAX
212

CLINICAL ANATOMY

The chest wall of the child is highly elastic, and

fractures of the ribs are, therefore, rare. In adults,
the ribs may be fractured by direct or indirect
violence (Fig. 12.6). In indirect violence, like crush
injury, the rib fractures at its weakest point located
at the angle. The upper two ribs which are protected
by the clavicle, and the lower two ribs which are free
to swing are least commonly injured.

Fig. 12.7: Scheme to show how the size of the thoracic cavity
is reduced by the upward projection of the diaphragm, and by
the inward projection of the shoulders

Fig. 12.6: Vulnerable site of fracture of the rib

SHAPE
The thorax resembles a truncated cone which is narrow
above and broad below (Fig. 12.7). The narrow upper
end is continuous with the root of the neck from which
it is partly separated by the suprapleural membrane or
Sibson’s fascia. The broad or lower end is almost
completely separated from the abdomen by the
diaphragm which is deeply concave downwards. The
thoracic cavity is actually much smaller than what it
appears to be because the narrow upper part appears
broad due to the shoulders, and the lower part is greatly
encroached upon by the abdominal cavity due to the
upward convexity of the diaphragm.
In transverse section, the thorax is reniform (bean-
shaped, or kidney-shaped). The transverse diameter is
Thorax

greater than the anteroposterior diameter. However, Fig. 12.8: The shape of the thorax as seen in transverse section
in infants below the age of two years, it is circular. In in: Human adult, infants, and quadrupeds
quadrupeds, the anteroposterior diameter is greater
than the transverse, as shown in Fig. 12.8.
In infants, the ribs are horizontal and as a result the CLINICAL ANATOMY
respiration is purely abdominal by the action of the
diaphragm. • Diaphragm descends during inspiration to
In adults, the thorax is oval. The ribs are oblique and increase the vertical diameter of thoracic cage.
2

their movements alternately increase and decrease the • Hiccups: These occur due to spasmodic involun-
Section

diameters of the thorax. This results in the drawing in tary contractions of the diaphragm accompanied
of air into the thorax called inspiration and its expulsion by closed glottis. These usually occur due to
is called expiration. This is called thoracic respiration. In gastric irritation. Hiccups may also be due to
the adult, we, therefore, have both abdominal and phrenic nerve irritation, uraemia or hysteria.
thoracic respirations.
 INTRODUCTION
213

Competency achievement: The student should be able to:

AN 21.3 Describe and demonstrate the boundaries of thoracic
inlet, cavity and outlet.1

SUPERIOR APERTURE/INLET OF THORAX

The narrow upper end of the thorax, which is

continuous with the neck, is called the inlet of the
thorax (Fig. 12.9). It is kidney-shaped. Its transverse
diameter is 10–12.5 cm. The anteroposterior diameter
is about 5 cm.

Boundaries
Fig. 12.9: The plane of the inlet of the thorax
Anteriorly: Upper border of the manubrium sterni.
Posteriorly: Superior surface of the body of the first
the thorax from the neck. The membrane is triangular in
thoracic vertebra.
shape. Its apex is attached to the tip of the transverse
On each side: First rib with its cartilage. process of the seventh cervical vertebra and the base to the
The plane of the inlet is directed downwards and inner border of the first rib and its cartilage.
forwards with an obliquity of about 45°. The anterior Morphologically, Sibson’s fascia is regarded as the
part of the inlet lies 3.7 cm below the posterior part, so flattened tendon of the scalenus minimus (pleuralis)
that the upper border of the manubrium sterni lies at muscle. It is thus formed by scalenus minimus and
the level of the upper border of the third thoracic endothoracic fascia. Functionally, it provides rigidity to
vertebra. the thoracic inlet, so that the root of the neck is not puffed
up and down during respiration. The inferior surface
Partition at the Inlet of Thorax of the membrane is fused to the cervical pleura, beneath
The partition is in two halves—right and left, with a cleft which lies the apex of the lung. Its superior surface is
in between. Each half is covered by a fascia, known as related to the subclavian vessels and other structures at
Sibson’s fascia or suprapleural membrane. It partly separates the root of the neck (Figs 12.10 and 12.11a and b).

Thorax
2Section

Fig. 12.10: Thoracic inlet showing cervical dome of the pleura on left side of body and its relationship to inner border of first rib
 THORAX
214

Figs 12.11a and b: The suprapleural membrane: (a) Surface view, and (b) sectional view

Fig. 12.12: Structures passing through the inlet of the thorax

Structures Passing through the Inlet of Thorax 2 Right and left superior intercostal arteries
Thorax

Viscera 3 Right and left first posterior intercostal veins

Trachea, oesophagus, apices of the lungs with pleura, 4 Inferior thyroid veins
remains of the thymus. Figure 12.12 depicts the
structures passing through the inlet of the thorax. Nerves
1 Right and left phrenic nerves
Large Vessels
2 Right and left vagus nerves
Brachiocephalic artery on right side.
2

Left common carotid artery and the left subclavian 3 Right and left sympathetic trunks
Section

artery on the left side. Right and left brachiocephalic 4 Right and left first thoracic nerves as they ascend
veins. across the first rib to join the brachial plexus.

Smaller Vessels Muscles

1 Right and left internal thoracic arteries Sternohyoid, sternothyroid and longus colli
 INTRODUCTION
215

CLINICAL ANATOMY

• A cervical rib is a rib attached to vertebra C7. It

occurs in about 0.5% of subjects (Fig. 12.13). Such
a rib may exert traction on the lower trunk of the
brachial plexus which arches over a cervical rib.
Such a person complains of paraesthesia or
abnormal sensations along the ulnar border of the
forearm, and wasting of the small muscles of the
hand supplied by segment T1 (Fig. 12.14).
Vascular changes may also occur.
• In coarctation or narrowing of the aorta, the
posterior intercostal arteries get enlarged greatly
to provide a collateral circulation. Pressure of the
enlarged arteries produces characteristic notching

Fig. 12.15: Tortuous intercostal artery receives blood from

anterior intercostal artery, transfers it to descending aorta
beyond coarctation. Tortuous intercostal artery produces
notches in the rib

on the ribs (Fig. 12.15) especially in their posterior

parts.
• Thoracic inlet syndrome: Two structures arch over
the first rib—the subclavian artery and first
thoracic nerve. These structures may be pulled or
pressed by a cervical rib or by variations in the
insertion of the scalenus anterior. The symptoms
may, therefore, be vascular, neural, or both.

Fig. 12.13: Cervical rib on both sides

INFERIOR APERTURE/OUTLET OF THORAX

The inferior aperture is the broad end of the thorax

which surrounds the upper part of the abdominal cavity,
but is separated from it by the diaphragm (Greek across
fence).

Boundaries Thorax
Anteriorly: Infrasternal angle between the two costal
margins.
Posteriorly: Inferior surface of the body of the twelfth
thoracic vertebra.
On each side: Costal margin formed by the cartilages of
seventh to twelfth ribs.
2

Diaphragm at the Outlet of Thorax

Section

The outlet is closed by a large musculotendinous

partition, called the diaphragm—the thoracoabdominal
Fig. 12.14: Wasting of small muscles of hand
diaphragm—which separates the thorax from the
abdomen.
 THORAX
216

Fig. 12.16: Structures passing through the diaphragm

Structures Passing through the Diaphragm and 7th costal cartilaginous slip of the diaphragm.
There are three large and several small openings in the When foramen is enlarged it is known as foramen of
diaphragm which allow passage to structures from Morgagni.
thorax to abdomen or vice versa (Fig. 12.16). Musculophrenic artery perforates diaphragm at the
Large openings: These are vena caval opening in the level of 9th costal cartilage.
central tendon, oesophageal opening in the right crus Lower 5 intercostal vessels and nerves pass between
of diaphragm and aortic opening behind the median costal origins of diaphragm and transversus abdominis.
arcuate ligament. Subcostal vessels and nerves pass behind lateral
The structures passing through large openings are arcuate ligament. Sympathetic trunk passes behind
put in Table 12.1. medial arcuate ligament. Greater and lesser splanchnic
Small openings: Superior epigastric artery passes in nerves pierce each crus. Left phrenic nerve pierces left
space of Larrey present between slip of xiphoid process cupola.

Table 12.1: Large openings in thoracoabdominal diaphragm

Thorax

Opening Situation Shape Structures passing Effect on contraction

Vena cava T8, right part of Quadrilateral IVC Dilation

central tendon Right phrenic nerve
Lymphatic of liver

Oesophageal T10, splitting of Elliptical Oesophagus Constriction

right crus Both vagal trunks
2

Left gastric vessels

Section

Aortic T12, behind Rounded Aorta No change

median arcuate Thoracic duct
ligament Azygos vein
 INTRODUCTION
217

CLINICOANATOMICAL PROBLEM
FACTS TO REMEMBER
A young adult suffering from chronic anaemia was
• Thoracic cavity houses a single heart with asked to get sternal puncture done to find out the
pericardium, two lungs with pleurae, blood reason for anaemia.
vessels, nerves and lymphatics. • What is sternal puncture/bone marrow biopsy?
• Rib may be present in relation to cervical seven • Classify bones according to shape.
and lumbar one vertebrae. The cervical rib may Ans: The sternum is single median line bone in the
give symptoms. anterior part of the thoracic cage. It is a flat bone. Its
• Ribs are weak at their angles and are vulnerable upper part, manubrium is wider and comprises two
to injury at that area. plates of compact bone with intervening cancellous
• Apex beat lies below and medial to the normally bone. During sternal puncture, a thick needle is
placed left nipple. pierced through the skin, fascia and anterior plate of
compact bone till it reaches the bone marrow in the
• 2nd costal cartilage at the manubriosternal angle cancellous bone. About 0.3 cc of bone marrow is
is extremely important landmark. The 2nd aspirated and slides are prepared immediately to be
intercostal space lies below this cartilage and is stained and studied to find out, if the defect is in
used for counting the intercostal spaces for the maturation of RBC or WBC.
position of heart, lungs and liver. Bones are classified as long bone, e.g. humerus;
• 1–7 ribs with costal cartilages reach the sternum, short bone, e.g. tarsal bones; flat bone, e.g. sternum;
costal cartilages of 8–10 ribs form the costal irregular bone, e.g. vertebra; sesamoid bone, e.g.
margin, while 11th and 12th ribs do not reach the patella; pneumatic bone, e.g. maxilla.
front at all.
FURTHER READING
• Celli B. The diaphragm and respiratory muscles. Chest Surg
Clin N Am 1998;8:207–24.
1
From Medical Council of India, Competency based Undergraduate Curriculum for the Indian Medical Graduate, 2018;1:44–80.

1. Enumerate the landmarks at the level of sternal c. Main openings in the thoracoabdominal
angle. diaphragm, including their levels and contents
2. Enumerate various structures passing through the d. Sternal puncture/bone marrow biopsy
inlet of thorax.
e. Coarctation of aorta
3. Write short notes on:
4. Enumerate the parts of rib and the joints formed by
a. Boundaries of thorax
a typical rib.
b. Cervical rib
Thorax

1. Three large openings in the diaphragm are at levels b. Oesophagus

of which of the following thoracic vertebrae? c. Thymus
a. T8, T9, T10 d. Left recurrent laryngeal nerve
b. T7, T8, T9
2

3. Suprapleural membrane is attached to:

c. T8, T10, T12
Section

d. T9, T10 T12 a. Anterior aspect of clavicle

2. All the following structures course through the b. Upper border of scapula
inlet of thorax in the median plane, except: c. Inner margin of 1st rib and its cartilage
a. Trachea d. Transverse process of 6th cervical vertebra
 THORAX
218

4. The outlet of thorax is highest in which of the 5. Which spinal nerve is affected in thoracic inlet
following lines? syndrome?
a. Posterior median a. Seventh cervical
b. Anterior median b. Eighth cervical
c. Midaxillary c. First thoracic
d. Scapular line d. Second thoracic

1. c 2. d 3. c 4. b 5. c

• What is the importance of sternal angle? • What symptoms can occur due to fracture of cervical rib?
• Name the types of ribs. • Where is the apex beat normally palpable?
• Name the structures passing through the inlet of • Name the main openings in the diaphragm.
thorax. • What structures pass through the aortic opening?
Thorax
2
Section
 13
Bones and Joints of Thorax
!Vegetarianism, nonviolence and compassion for all beings are fundamental to health, healing and social order !
—Rig Veda

INTRODUCTION
The thorax is an osseocartilaginous cavity or cage for
various viscera, providing them due support and pro-
tection. This cage is not static, but dynamic, as it moves
at its various joints, increasing or decreasing the various
diameters of the cavity for an extremely important
process of respiration, which is life for all of us.

Competency achievement: The student should be able to:

AN 21.1 Identify and describe the salient features of sternum,
typical rib, Ist rib and typical thoracic vertebra.1

BONES OF THORAX

RIBS OR COSTAE
Fig. 13.1: A typical rib of the left side
1 There are 12 ribs on each side forming the greater
part of the thoracic skeleton.
The number may be increased by development of a Classification
cervical or a lumbar rib; or the number may be a. According to articulations with sternum the ribs are true
reduced to 11 by the absence of the twelfth rib. and false: The first 7 ribs which are connected through
2 The ribs are bony arches arranged one below the their cartilages to the sternum are called true ribs, or
other (Fig. 13.1). The gaps between the ribs are called vertebrosternal ribs. The remaining five are false ribs.
intercostal spaces (see Fig. 12.1). Out of these, the cartilages of the eighth, ninth and
The spaces are deeper in front than behind, and tenth ribs are joined to the next higher cartilage and
deeper between the upper than between the lower are known as vertebrochondral ribs. The anterior ends
ribs. of the eleventh and twelfth ribs are free and are called
3 The ribs are placed obliquely, the upper ribs being floating ribs or vertebral ribs.
less oblique than the lower. The obliquity reaches b. According to morphological features the ribs are atypical
its maximum at the ninth rib, and thereafter it and typical: The first two and last three ribs have
gradually decreases to the twelfth rib. special features, and are atypical ribs. The third to
4 The length of the ribs increases from the first to the ninth ribs are typical ribs.
seventh ribs, and then gradually decreases from the
eighth to twelfth ribs. Typical Ribs
5 The breadth of the ribs decreases from above Side Determination
downwards. In the upper 10 ribs, the anterior ends 1 The anterior end bears a concave depression. The
are broader than the posterior ends. posterior end bears a head, a neck and a tubercle.
219
 THORAX
220

2 The shaft is convex outwards and there is a costal

groove situated along the lower part of its inner
surface, so that the lower border is thin and the upper
border is rounded.
Features
Each rib has two ends—anterior and posterior. Its shaft
comprises upper and lower borders and outer and inner
surfaces.
The anterior sternal end is oval and concave for
articulation with its costal cartilage.
The posterior or vertebral end is made up of the
following parts.
1 The head has two facets that are separated Fig. 13.3: A costal arch (side view)
by a crest. The lower larger facet articulates with the
body of the numerically corresponding vertebra
2 The inner surface is smooth and covered by the pleura.
while the upper smaller facet articulates with the next
This surface is marked by a ridge which is continuous
higher vertebra (Figs 13.2 and 13.24).
behind with the lower border of the neck. The costal
2 The neck lies in front of the transverse process of its groove lies between this ridge and the inferior
own vertebra, and has two surfaces—anterior and border. The costal groove contains the posterior
posterior; and two borders—superior and inferior. intercostal vessels and intercostal nerve (Fig. 13.4).
The anterior surface of the neck is smooth. The
3 The upper border is thick and has outer and inner lips.
posterior surface is rough. The superior border or
crest of the neck is thin. The inferior border is rounded. Attachments and Relations of a Typical Rib
3 The tubercle is placed on the outer surface of the rib 1 Anteriorly, the head provides attachment to the
at the junction of the neck and shaft. Its medial part radiate ligament (Fig. 13.5) and is related to the
is articular and forms the costotransverse joint with sympathetic chain and to the costal pleura.
the transverse process of the corresponding vertebra. 2 The crest of the head provides attachment to the
The lateral part is non-articular (Fig. 13.1). intra-articular ligament of the costovertebral joint.
The shaft is flattened so it has two surfaces—outer 3 Attachments to the neck:
and inner; and two borders—upper and lower. The a. The anterior surface is covered by costal pleura.
shaft is curved with its convexity outwards (Fig. 13.3). b. The inferior costotransverse ligament is attached
It is bent at the angle which is situated about 5 cm lateral to the rough posterior surface (Fig. 13.5).
to the tubercle. It is also twisted at the angle. c. The two laminae of the superior costotransverse
1 The outer surface: The angle is marked by an oblique ligament are attached to the crest of the neck
line on the outer surface, directed downwards and (Fig. 13.6).
laterally. 4 The lateral non-articular part of the tubercle gives
attachment to the lateral costotransverse ligament
(Fig. 13.5).
Thorax
2
Section

Fig. 13.2: Articulations of the 5th rib Fig. 13.4: Contents of costal groove and intercostal muscles
 BONES AND JOINTS OF THORAX
221

OSSIFICATION OF A TYPICAL RIB

A typical rib ossifies in cartilage from:

a One primary centre (for the shaft) which appears,
near the angle, at about the eighth week of
intrauterine life.
b Three secondary centres, one for the head and two
for the tubercle, which appear at puberty and unite
with the rest of the bone after 20 years.

Competency achievement: The student should be able to:

AN 21.2 Identify and describe the features of 2nd, 11th and 12th
ribs, 1st, 11th and 12th thoracic vertebrae.2

First Rib
Fig. 13.5: Attachments and articulations of the posterior end of
a typical rib Identification
1 It is the shortest, broadest and most curved rib.
2 The shaft is not twisted. There is no costal groove.
3 It is flattened from above downwards so that it has
superior and inferior surfaces; and outer and inner
borders.

Side Determination
1 The anterior end is larger, thicker and pitted. The
posterior end is small and rounded.
2 The outer border is convex with no costal groove.
3 The upper surface of the shaft is crossed obliquely
by two shallow grooves separated by a ridge. The
ridge is enlarged at the inner border of the rib to form
Fig. 13.6: The superior costotransverse, radiate and intra- the scalene tubercle (Fig. 13.7a).
articular ligaments When the rib is placed on a horizontal plane, i.e. with
the superior surface facing upwards, both the ends of
5 Attachments on the shaft: the rib touch the surface.
a. The thoracolumbar fascia and the lateral fibres of
the sacrospinalis muscle are attached to the angle.
Medial to the angle, the levator costae and the
sacrospinalis (longissimus) are attached (Fig. 13.8).
About 5 cm from the anterior end, there is an
indistinct oblique line, known as the anterior angle,
which separates the origins of the external oblique
from serratus anterior in case of fifth to eighth ribs. Thorax
The anterior angle also separates the origin of
external oblique from that of latissimus dorsi in
case of ninth and tenth ribs (Fig. 13.8b).
b. The internal intercostal muscle arises from the
floor of the costal groove. The intercostalis intimus
arises from the middle two-fourths of the ridge
above the groove (Fig. 13.4). The subcostalis is
2

attached to the inner surfaces of the lower ribs.

Section

c. The external intercostal muscle is attached on the

outer lip of the upper border, while the internal
intercostal and intercostalis intimi are attached on
the inner lip of the upper border (Fig. 13.4).
Fig. 13.7a: Superior view of the first rib (left side)
 THORAX
222

Features of First Rib first intercostal nerve which is very small.

1 The anterior end is larger and thicker than that in the 6 The outer border gives origin to:
other ribs. It is continuous with the first costal a. The external intercostal muscle, and
cartilage. b. The upper part of the first digitation of the serratus
2 The posterior end comprises the following. anterior, just behind the groove for the subclavian
a. The head is small and rounded. It articulates with artery. The thick portion of the outer border is
the body of first thoracic vertebra. covered by the scalenus posterior.
b. The neck is rounded directed laterally, upwards
7 The inner border gives attachment to the supra-
and backwards.
pleural membrane.
c. The tubercle is large. It coincides with the angle of
the rib. It articulates with the transverse process 8 The tubercle gives attachment to the lateral
of first thoracic vertebra to form the costo- costotransverse ligament.
transverse joint.
3 The shaft (body) has two surfaces—upper and lower;
OSSIFICATION
and two borders—outer and inner.
a. The upper surface is marked by two shallow The first rib ossifies from one primary centre for the
grooves, separated near the inner border by the shaft at 8th week of intrauterine life. For the shaft
scalene tubercle. there are only two secondary centres, one for the
b. The lower surface is smooth and has no costal head and the other for the tubercle. These secondary
groove. centres appear at puberty and unite with rest of bone
c. The outer border is convex, thick behind and thin after 20 years.
in front.
d. The inner border is concave.
Second Rib
Features
Attachments and Relations
1 Anteriorly, the neck is related from medial to lateral The features of the second rib are:
side to: 1 The length is twice that of the first rib.
a. Sympathetic chain 2 The shaft is sharply curved, like that of the first rib.
b. Posterior intercostal vein 3 The non-articular part of the tubercle is small.
c. Superior intercostal artery 4 The angle is slight and is situated close to the
d. Ventral ramus of first thoracic nerve (Fig. 13.7a). tubercle.
(Mnemonic—chain pulling a VAN) 5 The shaft has no twist. The outer surface is convex
2 Superiorly, the neck is related to: and faces more upwards than outwards. Near its
middle, it is marked by a large rough tubercle
a. The deep cervical vessels (Fig. 13.7b). This tubercle is a unique feature of the
b. The eighth cervical nerve second rib. The inner surface of the shaft is smooth
3 The anterior groove on the superior surface of the and concave. It faces more downwards than inwards.
shaft lodges the subclavian vein, and the posterior There is a short costal groove on the posterior part
groove lodges the subclavian artery and the lower of this surface.
trunk of the brachial plexus.
Thorax

4 The structures attached to the upper surface of the

shaft are:
a. The origin of the subclavius muscle at the anterior
end.
b. The attachment of the costoclavicular ligament at
the anterior end behind the subclavius.
c. The insertion of the scalenus anterior on the
2

scalene tubercle.
Section

d. The insertion of the scalenus medius on the

elongated rough area behind the groove for the
subclavian artery.
5 The lower surface of the shaft is covered by costal
pleura and is related near its outer border to the small Fig. 13.7b: Superior surface of 2nd rib
 BONES AND JOINTS OF THORAX
223

The posterior part of the upper border has distinct 3 The following are attached to the outer surface.
outer and inner lips. The part of the outer lip just in a. Attachments on the medial half
front of the angle is rough. i. Costotransverse ligament (Fig. 13.8b).
ii. Lumbocostal ligament
Attachments iii. Lowest levator costae
1 The rough tubercle on the outer surface gives origin iv. Iliocostalis and longissimus parts of
to 1½ digitations of the serratus anterior muscle. sacrospinalis.
2 The rough part of the upper border receives the b. Attachments on the lateral half
insertion of the scalenus posterior. i. Insertion of serratus posterior inferior
ii. Origin of latissimus dorsi
Tenth Rib iii. Origin of external oblique muscle of abdomen.
The tenth rib closely resembles a typical rib, but is: 4 The intercostal muscles are attached to the upper
1 Shorter. border.
2 Has only a single facet on the head, for the body of 5 The structures attached to the lower border are:
the tenth thoracic vertebra. a. Middle layer of thoracolumbar fascia.
b. Lateral arcuate ligament, at the lateral border of
Eleventh and Twelfth Ribs the quadratus lumborum.
Eleventh and twelfth ribs are short. They have pointed c. Lumbocostal ligament near the head, extending
ends. The necks and tubercles are absent. The angle and to the transverse process of first lumbar vertebra.
costal groove are poorly marked in the eleventh rib and
are absent in the twelfth rib. OSSIFICATION

Attachments and Relations of the Twelfth Rib The eleventh and twelfth ribs ossify from one
primary centre for the shaft and one secondary centre
1 The capsular and radiate ligaments are attached to for the head.
the head of the rib (Fig. 13.6).
2 The following are attached on the inner surface.
COSTAL CARTILAGES
a. The quadratus lumborum is inserted on the lower
part of the medial half to two-thirds of this surface The costal cartilages represent the unossified anterior
(Fig. 13.8a). parts of the ribs. They are made up of hyaline cartilage.
b. The fascia covering the quadratus lumborum is They contribute materially to the elasticity of the
also attached to this part of the rib. thoracic wall.
c. The internal intercostal muscle is inserted near the The medial ends of the costal cartilages of the first
upper border. seven ribs are attached directly to the sternum. The
d. The costodiaphragmatic recess of the pleura is eighth, ninth and tenth cartilages articulate with one
related to the medial three-fourths of the costal another and form the costal margin. The cartilages of
surface. the eleventh and twelfth ribs are small. Their ends are
e. The diaphragm takes origin from the anterior end free and lie in the muscles of the abdominal wall.
of this surface.

Thorax
2Section

Figs 13.8a and b: The right twelfth rib: (a) Inner surface, and (b) outer surface
 THORAX
224

The direction of the costal cartilages is variable. As the Posterior Surface

first costal cartilage approaches the sternum, it descends 1 The first cartilage gives origin to the sternothyroid
a little. The second cartilage is horizontal. The third muscle.
ascends slightly. The remaining costal cartilages are 2 The second to sixth cartilages receive the insertion
angular. They continue the downward course of the rib of the sternocostalis (Fig. 13.12).
for some distance, and then turn upwards to reach either 3 The seventh to twelfth cartilages give attachment to
the sternum or the next higher costal cartilage the transversus abdominis and to the diaphragm.
(see Fig. 12.1).
Each cartilage has two surfaces—anterior and Superior and Inferior Borders
posterior; two borders—superior and inferior; and two 1 The borders give attachment to the internal
ends—lateral and medial. intercostal muscles and the external intercostal
membranes of the spaces concerned (see Fig. 14.1).
Attachments 2 The seventh to tenth cartilages articulate with one
another at the points of their maximum convexity,
Anterior Surface
to form synovial joints.
1 Anterior surface of the first costal cartilage articulates
with the clavicle and takes part in forming the Lateral End
sternoclavicular joint. It gives attachment to: The lateral end of each cartilage forms a primary
a. The sternoclavicular articular disc (see Chapter 10). cartilaginous joint with the rib concerned.
b. The joint capsule of sternoclavicular joint Medial End
c. The costoclavicular ligament
1 The first cartilage forms a primary cartilaginous joint
d. The subclavius muscle (Fig. 13.7) with the manubrium.
2 The second to sixth costal cartilages give origin to 2 The second to seventh cartilages form synovial joints
the pectoralis major (Fig. 13.9). with the sternum.
3 The remaining cartilages are covered by and give 3 The eighth and ninth cartilages are connected to the
partial attachment to some of the flat muscles of the next higher cartilage by synovial joints.
anterior abdominal wall. The internal oblique muscle 4 The tenth cartilage is united to ninth cartilage by
is attached to the, eighth, ninth and tenth cartilages; fibrous tissue.
and the rectus abdominis to the fifth, sixth and 5 The ends of the eleventh and twelfth cartilages are
seventh cartilages. pointed and free.

CLINICAL ANATOMY

• Weakest area of rib is the region of its angle. This

is the commonest site of fracture.
• Cervical rib occurs in 0.5% of persons. It may
articulate with first rib or may have a free end. It
may cause pressure on lower trunk of brachial
plexus, resulting in paraesthesia along the medial
border of forearm and wasting of intrinsic muscles
Thorax

of hand (see Fig. 12.14). It may also cause pressure

on the subclavian artery.
• In rickets, there is inadequate mineralisation of
bone matrix at the growth plates due to increased
bone resorption. Due to deposition of unminera-
lised matrix, there is widening of the wrist and
rachitic rosary, i.e. prominent costochondral
2

junctions in thoracic cage.

Section

STERNUM
The sternum is a flat bone, forming the anterior median
part of the thoracic skeleton. In shape, it resembles a
Fig. 13.9: The sternum: Anterior aspect, with muscle attachment short sword. The upper part, corresponding to the
 BONES AND JOINTS OF THORAX
225

handle, is called the manubrium. The middle part, Manubrium

resembling the blade is called the body. The lowest The manubrium is quadrilateral in shape. It is the
tapering part forming the point of the sword is the thickest and strongest part of the sternum. It has two
xiphoid process or xiphisternum. surfaces—anterior and posterior; and four borders—
The sternum is about 17 cm long. It is longer in males superior, inferior, and two lateral.
than in females (Figs 13.9 to 13.11). The anterior surface is convex from side-to-side and
concave from above downwards (Fig. 13.10).
The posterior surface is concave and forms the anterior
boundary of the superior mediastinum.
The superior border is thick, rounded and concave. It
is marked by the suprasternal notch or jugular notch
or interclavicular notch in the median part, and by the
clavicular notch on each side. The clavicular notch
articulates with the medial end of the clavicle to form
the sternoclavicular joint (Fig. 13.11).
The inferior border forms a secondary cartilaginous
joint with the body of the sternum. The manubrium
makes a slight angle with the body, convex forwards,
called the sternal angle of Louis. Events at the sternal
angle:
i. Formation of cardiac plexus
ii. Upper limit of base of heart
iii. Arch of aorta starts here as continuation of
ascending aorta.
iv. Arch of aorta ends here to continue as descending
thoracic aorta.
v. Trachea divides into 2 branches.
Each lateral border forms a primary cartilaginous joint
Fig. 13.10: The sternum: Anterior aspect
with the first costal cartilage, and present a demifacet
for synovial articulation with the upper part of the
second costal cartilage.

Attachments
1 The anterior surface gives origin on either side to:
a. The pectoralis major.
b. The sternal head of the sternocleidomastoid
(Fig. 13.9).
2 The posterior surface gives origin to:
a. The sternohyoid in upper part (Fig. 13.12). Thorax
b. The sternothyroid in lower part.
c. The lower half of this surface is related to the arch
of the aorta. The upper half is related to the left
brachiocephalic vein, the brachiocephalic artery,
the left common carotid artery and the left sub-
clavian artery. The lateral portions of the surface
are related to the corresponding lung and pleura.
2

3 The suprasternal notch gives attachment to the lower

Section

fibres of the interclavicular ligament, and to the two

subdivisions of the investing layer of cervical fascia.
4 The margins of each clavicular notch give attachment
to the capsule of the corresponding sternoclavicular
Fig. 13.11: The sternum: Lateral aspect joint (see Chapter 10).
 THORAX
226

Xiphoid Process
The xiphoid process is the smallest part of the sternum.
It is at first cartilaginous, but in the adult it becomes
ossified near its upper end. It varies greatly in shape
and may be bifid or perforated. It lies in the floor of the
epigastric fossa (Fig. 13.10).

Attachments
1 The anterior surface provides insertion to the medial
fibres of the rectus abdominis, and to the
aponeuroses of the external and internal oblique
muscles of the abdomen.
2 The posterior surface gives origin to the diaphragm.
It is related to the anterior surface of the liver.
3 The lateral borders of the xiphoid process give
attachment to the aponeuroses of the internal oblique
Fig. 13.12: Attachments on the posterior surface of the sternum and transversus abdominis muscles.
4 The upper end forms a primary cartilaginous joint
with the body of the sternum.
Body of the Sternum 5 The lower end affords attachment to the linea alba.
The body is longer, narrower and thinner than the
manubrium. It is widest close to its lower end opposite
the articulation with the fifth costal cartilage. It has two DEVELOPMENT AND OSSIFICATION
surfaces—anterior and posterior; two lateral borders; The sternum develops by fusion of two sternal plates
and two ends—upper and lower. formed on either side of the midline. The fusion of
1 The anterior surface is nearly flat and directed the two plates takes place in a craniocaudal direction.
forwards and slightly upwards. It is marked by three Manubrium is ossified from 2 centers appearing
ill-defined transverse ridges, indicating the lines of in 5th month.
fusion of the four small segments called sternebrae. First and second sternebrae ossify from one centre
2 The posterior surface is slightly concave and is marked appearing in 5th month. Third and fourth sternebrae
by less distinct transverse lines. ossify from paired centres which appear in 5th and
3 The lateral borders form synovial joints with the 6th months. These fuse with each other from below
lower part of the second costal cartilage, the third to upwards during puberty. Fusion is completed by 25
sixth costal cartilages, and the upper half of the years of age.
seventh costal cartilage (Fig. 13.11). The manubriosternal joint is a secondary
4 The upper end forms a secondary cartilaginous joint cartilaginous joint and usually persists throughout
with the manubrium at the sternal angle. life.
5 The lower end is narrow and forms a primary The centre for the xiphoid process appears during
cartilaginous joint with the xiphisternum. the third year or later. It fuses with the body at about
40 years (Figs 13.13a and b).
Attachments
Thorax

1 The anterior surface gives origin on either side to

the pectoralis major muscle (Fig. 13.9). CLINICAL ANATOMY
2 The lower part of the posterior surface gives origin
on either side to the sternocostalis muscle. • Bone marrow for examination is usually obtained
by manubriosternal puncture (Fig. 13.14). It is done
3 On the right side of the median plane, the posterior
in its upper half to prevent injury to arch of aorta
surface is related to the anterior border of the right lung
which lies behind its lower half.
and pleura. On the left side, the upper two pieces of
2

the body are related to the left lung and pleura, and • The slight movements that take place at the
manubriosternal joint are essential for movements
Section

the lower two pieces to the pericardium (Fig. 13.12).

4 Between the facets for articulation with the costal of the ribs.
cartilages, the lateral borders provide attachment to • In the anomaly called ‘funnel chest’, the sternum
the external intercostal membranes and to the is depressed (Fig. 13.15a).
internal intercostal muscles (see Fig. 14.1).
 BONES AND JOINTS OF THORAX
227

of elastic costal cartilages. Indirect violence may

lead to fracture of sternum.
• Non-fusion of the sternal plates causes ectopia
cordis, where the heart lies uncovered on the
surface. Partial fusion of the plates may lead to
the formation of sternal foramina, bifid xiphoid
process, etc. (Fig. 13.9).

VERTEBRAL COLUMN
Vertebral Column as a Whole
The vertebral column is also called the spine, the spinal
column, or back bone. It is the central axis of the body.
It supports the body weight and transmits it to the
Figs 13.13a and b: Ossification of sternum ground through the lower limbs.
The vertebral column is made up of 33 vertebrae:
Seven cervical, twelve thoracic, five lumbar, five sacral
and four coccygeal. In the thoracic, lumbar and sacral
regions, the number of vertebrae corresponds to the
number of spinal nerves, each nerve lying below the
corresponding vertebra. In the cervical region, there are
eight nerves, the upper seven lying above the
corresponding vertebrae and the eighth below the
seventh vertebra. In the coccygeal region, there is only
one coccygeal nerve.
Sometimes the vertebrae are also grouped according
to their mobility. The movable or true vertebrae include
the seven cervical, twelve thoracic and five lumbar
vertebrae, making a total of 24. Twelve thoracic verte-
brae have ribs attached to them. The fixed vertebrae
include those of the sacrum and coccyx.
The length of the spine is about 70 cm in males and
Fig. 13.14: Sternal puncture for bone marrow biopsy about 60 cm in females. The intervertebral discs
contribute one-fifth of the length of the vertebral
column.
As a result of variations in the width of the vertebrae,
the vertebral column can be said to be made up of four
pyramids (Fig. 13.16a). This arrangement has a
functional bearing. The narrowing of the vertebral
column at the level of the disc between fourth thoracic
and fifth thoracic vertebrae is partly compensated by Thorax
the transmission of weight to the lower thoracic region
through the sternum and ribs.
Figs 13.15a and b: (a) Funnel chest, and (b) pigeon chest

Curvatures
• In another anomaly called ‘pigeon chest’, there is
forward projection of the sternum like the keel of In Sagittal Plane
a boat, and flattening of the chest wall on either 1 Primary curves are present at birth due to the shape
2

side (Fig. 13.15b). of the vertebral bodies. The primary curves are
Section

• For cardiac surgery, the manubrium and/or body thoracic and sacral, both of which are concave
of sternum need to be splitted in midline and the forwards.
incision is closed with stainless steel wires. 2 Secondary curves are postural and are mainly due to
• Sternum is protected from injury by attachment the shape of the intervertebral disc. The secondary
or compensatory curves are cervical and lumbar,
 THORAX
228

Figs 13.16a to c: (a) Scheme to show that the vertebral column is divisible into a number of pyramidal segments, (b) primary
curves, and (c) secondary curves

both of which are convex forwards. The cervical

curve appears during 4 to 5 months after birth when
the infant starts supporting its head: The lumbar
curve appears during 12 to 18 months when the child
assumes the upright posture (Figs 13.16b and c).

In Coronal Plane (Lateral Curve)

There is slight lateral curve in the thoracic region with
its concavity towards the left. It is possible due to the
greater use of the right upper limb and the pressure of
the aorta.
The curvatures add to the elasticity of the spine, and
the number of curves gives it a higher resistance to
weight than would be afforded by a single curve.

Parts of a Typical Vertebra Fig. 13.17: Typical thoracic vertebra—superior aspect

A typical vertebra is made up of the following parts:
1 The body lies anteriorly. It is shaped like a short 5 Passing backwards and usually downwards from the
cylinder, being rounded from side-to-side and junction of the two laminae, there is the spine or
having flat upper and lower surfaces that are spinous process (Fig. 13.18).
attached to those of adjoining vertebrae by 6 Passing laterally and usually somewhat downwards
intervertebral discs (Fig. 13.17). from the junction of each pedicle and the corres-
2 The pedicles, right and left, are short rounded bars ponding lamina, there is a transverse process. The
that project backwards, and somewhat laterally, from spinous and transverse processes serve as levers for
Thorax

the posterior aspect of the body. muscles acting on the vertebral column.
3 Each pedicle is continuous, posteromedially, with From a morphological point of view, the transverse
a vertical plate of bone called the lamina. The processes are made up of two elements—the
laminae of the two sides pass backwards and transverse element and the costal element. In the
medially to meet in the midline. The pedicles and thoracic region, the two elements remain separate,
laminae together constitute the vertebral or neural and the costal elements form the ribs. In the rest of the
arch. vertebral column, the derivatives of costal element are
2

4 Bounded anteriorly by the posterior aspect of the different from those derived from transverse element.
Section

body, on the sides by the pedicles, and behind by This is shown in Table 13.1.
the lamina, there is a large vertebral foramen. 7 Projecting upwards from the junction of the pedicle
Each vertebral foramen forms a short segment of the and the lamina, there is on either side, a superior
vertebral canal that runs through the whole length articular process; and projecting downwards there is
of the vertebral column and lodges the spinal cord. an inferior articular process (Fig. 13.19). Each process
 BONES AND JOINTS OF THORAX
229

Table 13.1: The transverse and costal elements of the vertebrae

Region Transverse element Costal element (Fig. 13.20)
1. Thoracic Forms the descriptive transverse process Forms the rib
2. Cervical Fuses with the costal element and forms 1. Anterior wall of foramen transversarium,
the medial part of the posterior wall of the 2. Anterior tubercle,
foramen transversarium 3. Costotransverse bar,
4. Posterior tubercle, and
5. Lateral part of the posterior wall of the foramen
3. Lumbar Forms the accessory process Forms the real (descriptive) transverse process
4. Sacral Fuses with the costal element to form Forms the anterior part of the lateral mass
the posterior part of the lateral mass

Fig. 13.18: Typical thoracic vertebra (5th)—lateral view

Fig. 13.20: Costal elements in various vertebrae

the intervertebral foramina which give passage to the

dorsal and ventral rami of the spinal nerves emerging Thorax
from the spinal cord.
Fig. 13.19: Typical thoracic vertebra—posterior aspect
Thoracic Vertebrae
bears a smooth articular facet: The superior facet of Identification
one vertebra articulates with the inferior facet of the The thoracic vertebrae are identified by the presence
vertebra above it. of costal facets on the sides of the vertebral bodies.
2

8 The pedicle is much narrower in vertical diameter The costal facets may be two or only one on each side
Section

than the body and is attached nearer its upper border. (Fig. 13.18).
As a result, there is a large inferior vertebral notch There are 12 thoracic vertebrae, out of which the
below the pedicle. Above the pedicle, there is a much second to eighth are typical, and the remaining five
shallower superior vertebral notch. The superior and (first, ninth, tenth, eleventh and twelfth) are
inferior notches of adjoining vertebrae join to form atypical.
 THORAX
230

Typical Thoracic Vertebrae c. The inferior costotransverse ligament along the

1 The body is heart-shaped with roughly the same anterior surface.
measurements from side-to-side and antero- d. The intertransverse ligaments and muscles to
posteriorly. On each side, it bears two costal demi- upper and lower borders.
facets. The superior costal demifacet is larger and placed e. The levator costae on the posterior surface.
on the upper border of the body near the pedicle. It 4 The spines give attachment to the supraspinous and
articulates with the head of the numerically interspinous ligaments. They also give attachment to
corresponding rib. The inferior costal demifacet is several muscles including the trapezius, the rhom-
smaller and placed on the lower border in front of boids, the latissimus dorsi, the serratus posterior
the inferior vertebral notch. It articulates with the superior and the serratus posterior inferior, and
next lower rib (Fig. 13.18). many deep muscles of the back.
2 The vertebral foramen is comparatively small and
First Thoracic Vertebra
circular.
1 The body of this vertebra resembles that of a cervical
3 The vertebral arch shows:
vertebra. It is broad and not heart-shaped. Its upper
a. The pedicles are directed straight backwards. The surface is lipped laterally and bevelled anteriorly.
superior vertebral notch is shallow, while the The superior costal facet on the body is complete
inferior vertebral notch is deep and conspicuous. (Fig. 13.21). It articulates with the head of the first
b. The laminae overlap each other from above. rib. The inferior costal facet is a ‘demifacet’ for the
c. The superior articular processes project upwards second rib.
from the junction of the pedicles and laminae. The 2 The spine is thick, long and nearly horizontal.
articular facets are flat and are directed backwards.
This direction permits rotatory movements of the
spine.
d. The inferior articular processes are fused to the laminae.
Their articular facets are directed forwards.
e. The transverse processes are large, and are directed
laterally and backwards from the junction of the
pedicles and laminae. The anterior surface of each
process bears a facet near its tip, for articulation
with the tubercle of the corresponding rib. In the
upper six vertebrae, the costal facets on the
transverse processes are concave, and face
forwards and laterally. In lower four, the facets
are flat and face upwards, laterally and slightly
forwards (Fig. 13.24). In the last two vertebrae, the
articular facets are absent (see costotransverse
joints below).
f. The spine is long, and is directed downwards and
backwards. The fifth to ninth spines are the longest,
more vertical and overlap each other. The upper
Thorax

and lower spines are less oblique in direction.

Attachments
1 The upper and lower borders of the body give
attachment, in front and behind respectively to the
anterior and posterior longitudinal ligaments (Fig. 13.5).
2 The upper borders and lower parts of the anterior
2

surfaces of the laminae provide attachment to the

ligamenta flava.
Section

3 The transverse process gives attachment to:

a. The lateral costotransverse ligament at the tip.
b. The superior costotransverse ligament along the
lower border. Fig. 13.21: Features of atypical thoracic vertebrae
 BONES AND JOINTS OF THORAX
231

3 The superior vertebral notches are well marked, as

in cervical vertebrae.
4 Facet on transverse process is concave on T1–T6
vertebrae.
Ninth Thoracic Vertebra
The ninth thoracic vertebra resembles a typical thoracic
vertebra except that the body has only the superior
costal demifacets. The inferior costal facets are absent
(Fig. 13.21). Facet on transverse process is flat on T7–
T10 vertebrae.
Tenth Thoracic Vertebra
The tenth thoracic vertebra resembles a typical thoracic
vertebra except that the body has a single complete Fig. 13.22: Ossification of a thoracic vertebra
superior costal facet on each side, extending onto the
root of the pedicle (Fig. 13.21). Five secondary centres—one for the upper surface
Eleventh Thoracic Vertebra and one for the lower surface of the body, one for
each transverse process, and one for the spine appear
1 The body has a single large costal facet on each side, at about the 15th year and fuse with the rest of the
extending onto the upper part of the pedicle vertebra at about the 25th year (Fig. 13.22).
(Fig. 13.21).
2 The transverse process is small, and has no articular
facet. CLINICAL ANATOMY
Sometimes it is difficult to differentiate between
tenth and eleventh thoracic vertebrae. • Failure of fusion of the two halves of the neural
arch results in ‘spina bifida’. Sometimes the body
Twelfth Thoracic Vertebra ossifies from two primary centres, and if one
1 The shapes of the body, pedicles, transverse processes centre fails to develop, one half, right or left of
and spine are similar to those of a lumbar vertebra. the body is missing. This results in a hemivertebra
However, the body bears a single costal facet on each and lateral bend in the vertebral column or
side, which lies more on the lower part of the pedicle scoliosis.
than on the body. • In young adults, the discs are very strong.
2 The transverse process is small and has no facet, but However, after the second decade of life,
has superior, inferior and lateral tubercles (Fig. 13.21). degenerative changes set in resulting in weakness
3 The inferior articular facets are lumbar in type. These of the annulus fibrosus. When such a disc is
are everted and are directed laterally, but the superior subjected to strain, the annulus fibrosus may
articular facets are thoracic in type. rupture leading to prolapse of the nucleus
pulposus. This is commonly referred to as disc
prolapse. It may occur even after a minor strain. In
OSSIFICATION
addition to prolapse of the nucleus pulposus,
The ossifications of typical vertebra and a thoracic internal derangements of the disc may also take Thorax
vertebra are similar. It ossifies in cartilage from three place.
primary and five secondary centres. • Disc prolapse is usually posterolateral. The
The three primary centres—one for the centrum prolapsed nucleus pulposus presses upon adjacent
and one for each half of the neural arch, appear nerve roots and gives rise to pain that radiates
during eighth to ninth weeks of fetal life. along the distribution of the nerve. Such pain
At birth, the vertebra consists of three parts, the along the course of the sciatic nerve is called
centrum and two halves of the neural arch. The two sciatica. Motor effects, with loss of power and
2

halves of the neural arch fuse posteriorly during the reflexes, may follow. Disc prolapse occurs most
Section

first year of life. The neural arch is joined with the frequently in the lower lumbar region (Fig. 13.23).
centrum by the neurocentral synchondrosis. Bony It is also common in the lower cervical region from
fusion occurs here during the third to sixth years of fifth to seventh cervical vertebrae.
life.
 THORAX
232

The capsular ligament is strengthened by three

costotransverse ligaments. The superior costotransverse
ligament has two laminae which extend from the crest
on the neck of the rib to the transverse process of the
vertebra above. The inferior costotransverse ligament
passes from the posterior surface of the neck to the
transverse process of its own vertebra. The lateral costo-
transverse ligament connects the lateral non-articular
part of the tubercle to the tip of the transverse process
of its own vertebra.
The articular facets on the tubercles of the upper six
ribs are convex, and permit rotation of the neck of the
rib for pump-handle movements (Fig. 13.24). Rotation of
rib-neck backwards causes elevation of second to sixth
ribs with moving forwards and upwards of the sternum.
This increases the anteroposterior diameter of the thorax
(Fig. 13.25).
Fig. 13.23: Disc prolapse causing pressure on the spinal The articular surfaces of the seventh to tenth ribs
nerve are flat, permitting up and down gliding movements
or bucket-handle movements of the lower ribs. When
Competency achievement: The student should be able to: the neck of seventh to tenth ribs moves upwards,
AN 21.8 Describe and demonstrate type, articular surfaces and backwards and medially, the result is increase in
movements of manubriosternal, costovertebral, costotransverse and infrasternal angle. This causes increase in transverse
xiphisternal joints.3 diameter of thorax (Fig. 13.26).
For explanation of the terms ‘pump-handle’ and
‘bucket-handle’ movements, see ‘Respiratory Move-
JOINTS OF THORAX ments’.

Manubriosternal Joint
Manubriosternal joint is a secondary cartilaginous joint.
It permits slight movements of the body of the sternum
on the manubrium during respiration.

Costovertebral Joints
The head of a typical rib articulates with its own
vertebra, and also with the body of the next higher
vertebra, to form two plane synovial cavities separated
by an intra-articular ligament (Fig. 13.6). This ligament
is attached to the ridge on the head of the rib and to the
intervertebral disc.
Other ligaments of the joint include a capsular
Thorax

ligament and a triradiate ligament. The upper ligament

is attached to vertebra above. The lower ligament is
attached to vertebra below. The middle band of the
triradiate ligament forms the hypochordal bow
(Fig. 13.5), uniting the joints of the two sides.

Competency achievement: The student should be able to:

2

AN 21.10 Describe costochondral and interchondral joints.4

Section

Costotransverse Joints
The tubercle of a typical rib articulates with the facet Fig. 13.24: A section through the costotransverse joints from the
on anterior surface of transverse process of the third to the ninth inclusive. Contrast the concave facets on the
corresponding vertebra to form a synovial joint. upper with the flattened facets on the lower transverse processes
 BONES AND JOINTS OF THORAX
233

The second to seventh costal cartilages articulate with

the sternum by synovial joints. Each joint has a single
cavity except in the second joint where the cavity is
divided in two parts. The joints are held together by
the capsular and radiate ligaments.

Interchondral Joints
The fifth to ninth costal cartilages articulate with one
another by synovial joints. The tenth cartilage is united
to the ninth by fibrous tissue.
The movements taking place at the various joints
described above are considered under ‘Respiratory
Movements’.
Intervertebral Joints
Adjoining vertebrae (Th 5 and Th 6) are connected to
each other at three joints. There is a median joint
between the vertebral bodies, and two joints—one on
Fig. 13.25: The axes of movement (AB and CD) of a
the right side and one on the left side—between the
vertebrosternal rib. The interrupted lines indicate the position of articular processes.
the rib in inspiration The joints between the articular processes are plane
synovial joints.
The joint between the vertebral bodies is a symphysis
(secondary cartilaginous joint). The surfaces of the
vertebral bodies are lined by thin layers of hyaline
cartilage. Between these layers of hyaline cartilage,
there is a thick plate of fibrocartilage which is called
the intervertebral disc.
Intervertebral Discs
These are fibrocartilaginous discs which intervene
between the bodies of adjacent vertebrae, and bind them
together. Their shape corresponds to that of the vertebral
bodies between which they are placed. The thickness of
the disc varies in different regions of the vertebral
column, and in different parts of the same disc. In the
cervical and lumbar regions, the discs are thicker in front
than behind, while in the thoracic region they are of
uniform thickness. The discs are thinnest in the upper
thoracic region, and thickest in the lumbar region.
The discs contribute about one-fifth of the length of
Fig. 13.26: The axis of movement (AB) of a vertebrochondral the vertebral column. The contribution is greater in the Thorax
rib. The interrupted lines indicate the position of the rib in cervical and lumbar regions than in the thoracic region.
inspiration
Each disc is made up of the following two parts.
1 The nucleus pulposus is the central part of the disc. It
Costochondral Joints is soft and gelatinous at birth. It is kept under tension
Each rib is continuous anteriorly with its cartilage, to and acts as a hydraulic shock absorber. With
form a primary cartilaginous joint. No movements are advancing age, the elasticity of the disc is much
permitted at these joints. reduced (Figs 13.27a and c).
2

2 The annulus fibrosus forms the peripheral part of the

Chondrosternal Joints
Section

disc. It is made up of a narrower outer zone of colla-

The first chondrosternal joint is a primary cartilaginous genous fibres and a wider inner zone of fibrocartilage.
joint, it does not permit any movement. This helps in The fibres form laminae that are arranged in the form
the stability of the shoulder girdle and of the upper of incomplete rings. The rings are connected by strong
limb. fibrous bands. The outer collagenous fibres blend
 THORAX
234

4 The interspinous ligaments connect adjacent spines.

5 The supraspinous ligaments connect the tips of the
spines of vertebrae from the seventh cervical to the
sacrum. In the cervical region, they are replaced by
the ligamentum nuchae.
6 The ligamenta flava (singular = ligamentum flavum)
connect the laminae of adjacent vertebrae. They are
made up mainly of elastic tissue.

Movements of the Vertebral Column

Movements between adjacent vertebrae occur
simultaneously at all the joints connecting them.
Movement between any two vertebrae is slight.
However, when the movements between several
vertebrae are added together the total range of
movement becomes considerable. The movements are
those of flexion, extension, lateral flexion and a certain
amount of rotation. The range of movement differs in
different parts of the vertebral column. This is
influenced by the thickness and flexibility of the
intervertebral discs and by the orientation of the
Figs 13.27a to c: Structure of an intervertebral disc. (a) Superior articular facets.
view, (b) arrangement of laminae, and (c) vertical section Flexion and extension occur freely in the cervical and
lumbar regions, but not in the thoracic region. Rotation
is free in the thoracic region, and restricted in the lumbar
with the anterior and posterior longitudinal liga- and cervical regions.
ments (Figs 13.27a to c).

Functions
Competency achievement: The student should be able to:
AN 21.9 Describe and demonstrate mechanics and types of
1 The intervertebral discs give shape to the vertebral respiration.5
column.
2 They act as a remarkable series of shock absorbers
or buffers. RESPIRATORY MOVEMENTS
3 Because of their elasticity, they allow slight
movement of vertebral bodies on each other, more Introduction
so in the cervical and lumbar regions. When the slight The lungs expand during inspiration and retract during
movements at individual discs are added together, expiration. These movements are governed by the
they become considerable. following two factors.
1 Alterations in the capacity of the thorax are brought
Ligaments Connecting Adjacent Vertebrae
about by movements of the thoracic wall. Increase
Apart from the intervertebral discs and the capsules in volume of the thoracic cavity creates a negative
around the joints between the articular processes,
Thorax

intrathoracic pressure which sucks air into the lungs.

adjacent vertebrae are connected by several ligaments Movements of the thoracic wall occur chiefly at the
which are as follows. costovertebral and manubriosternal joints.
1 The anterior longitudinal ligament passes from the 2 Elastic recoil of the pulmonary alveoli and of the
anterior surface of the body of one vertebra to thoracic wall expels air from the lungs during expira-
another. Its upper end reaches the basilar part of the tion.
occipital bone (Fig. 13.5).
2 The posterior longitudinal ligament is present on the Principles of Movements
2

posterior surface of the vertebral bodies within the 1 Each rib may be regarded as a lever, the fulcrum of
Section

vertebral canal. Its upper end reaches the body of which lies just lateral to the tubercle. Because of the
the axis vertebra (C2) beyond which it is continuous disproportion in the length of the two arms of the
with the membrana tectoria (Fig. 13.5). lever, the slight movements at the vertebral end of
3 The intertransverse ligaments connect adjacent the rib are greatly magnified at the anterior end
transverse processes. (Fig. 13.28).
 BONES AND JOINTS OF THORAX
235

the position of the smaller upper rib which pushes

sternum forwards. This also increases the transverse
diameter of the thorax (Fig. 13.30).
5 Vertical diameter is increased by the ‘piston
movements’ of the thoracoabdominal diaphragm
(Fig. 13.31).

Fig. 13.28: Diagram comparing a rib to a lever

2 The anterior end of the rib is lower than the posterior

end. Therefore, during elevation of the rib, the
anterior end also moves forwards. This occurs mostly
in the vertebrosternal ribs. Along with the up and
down movements of the second to sixth ribs, the
body of the sternum also moves up and down called
pump-handle movements (Fig. 13.29). In this way, the
anteroposterior diameter of the thorax is increased.
3 The middle of the shaft of the rib lies at a lower level
than the plane passing through the two ends.
Therefore, during elevation of the rib, the shaft also
moves outwards. This causes increase in the
transverse diameter of the thorax.
Such movements occur in the vertebrochondral ribs,
and are called bucket-handle movements.
4 The thorax resembles a cone, tapering upwards. As
a result, each rib is longer than the next higher rib.
On elevation, the larger lower rib comes to occupy Fig. 13.30: Scheme showing how ‘bucket-handle’ movements
of the vertebrochondral ribs bring about an increase in the
transverse diameter of the thorax

Thorax
2Section

Fig. 13.29: Diagram showing how ‘pump-handle’ movements Fig. 13.31: Scheme showing how piston movements of
of the sternum bring about an increase in the anteroposterior thoracoabdominal diaphragm bring about an increase in the ver-
diameter of the thorax tical diameter of the thorax
 THORAX
236

Summary of the Factors Producing b. The scapulae are elevated and fixed by the
Increase in Diameters of the Thorax trapezius, the levator scapulae and the rhomboids,
The anteroposterior diameter is increased: so that the serratus anterior and the pectoralis
1 Mainly by the pump-handle movements of the minor muscles may act on the ribs.
sternum brought about by elevation of the vertebro- c. The action of the erector spinae is appreciably
sternal second to sixth ribs. increased.
2 Partly by elevation of the seventh to tenth vertebro-
Expiration
chondral ribs.
1 Quiet expiration: The air is expelled mainly by the
The transverse diameter is increased: elastic recoil of the chest wall and pulmonary alveoli,
1 Mainly by the bucket-handle movements of the and partly by the tone of the abdominal muscles.
seventh to tenth vertebrochondral ribs. 2 Deep and forced expiration: Deep and forced expiration
2 Partly by elevation of the second to sixth verte- is brought about by strong contraction of the
brosternal ribs. abdominal muscles and of the latissimus dorsi.
The vertical diameter is increased by descent of the
diaphragm as it contracts. This is called piston mecha-
nism. During inspiration, the diaphragm contracts and CLINICAL ANATOMY
it comes down by 2 cm. It is aided by relaxation of • In dyspnoea or difficulty in breathing, the patients
muscles of anterior abdominal wall. During expiration, are most comfortable on sitting up, leaning
abdominal muscles contract and diaphragm is pushed forwards and fixing the arms. In the sitting posture,
upwards. It facilitates in inspiration of at least 400 ml the position of diaphragm is the lowest allowing
of air during each contraction. maximum ventilation. Fixation of the arms fixes the
In females, respiration is thoracoabdominal and in scapulae, so that the serratus anterior and pectoralis
males it is abdominothoracic type. minor may act on the ribs to good advantage.
Respiratory Muscles • The height of the diaphragm in the thorax is
variable according to the position of the body and
For inspiration—diaphragm, external intercostal
tone of the abdominal muscles. It is highest on
muscle and interchondral part of internal intercostal
lying supine, so the patient is extremely
of contralateral side.
uncomfortable, as he/she needs to exert
Deep inspiration—erector spinae, scalene muscles,
immensely for inspiration. The diaphragm is
pectoral muscles.
lowest while sitting. The patient is quite
For expiration—passive process.
comfortable as the effort required for inspiration
Forced expiration—muscles of anterior abdominal
is the least.
wall.
The diaphragm is midway in position while
Respiratory Movements during standing, but the patient is too ill or exhausted to
Different Types of Breathing stand. So dyspnoeic patients feel comfortable
Inspiration while sitting (Figs 13.32a to c).
• Most prominent role in respiration is played by
1 Quiet inspiration
diaphragm.
a. The anteroposterior diameter of the thorax is
increased by elevation of the second to sixth ribs. • Respiration occurs in two phases:
Thorax

The first rib remains fixed. Inspiration—active phase of 1 second

b. The transverse diameter is increased by elevation Expiration—passive phase of 3 second.
of the seventh to tenth ribs. • In young children (up to 2 years of age), the
c. The vertical diameter is increased by descent of thoracic cavity is almost circular in cross-section
the diaphragm. so the scope for anteroposterior or side-to-side
2 Deep inspiration expansion is limited. The type of respiration in
a. Movements during quiet inspiration are increased. children is abdominal.
2

b. The first rib is elevated directly by the scaleni, and • In women of advanced stage of pregnancy,
indirectly by the sternocleidomastoid.
Section

descent of diaphragm is limited, so the type of

c. The concavity of the thoracic spine is reduced by respiration in them is mainly thoracic.
the erector spinae.
3 Forced inspiration
a. All the movements described are exaggerated.
 BONES AND JOINTS OF THORAX
237

– Three joints between sternebrae—primary

cartilaginous.
– One joint between sternum and xiphoid
process—primary cartilaginous.
– Sternum forms two joints with clavicles of the
two sides—saddle type of synovial joint.
– It articulates with 1st–7th costal cartilages on
each side forming a total of 14 joints—all plane
synovial joints except 1st chondrosternal which
is synchondrosis.
• A typical thoracic vertebra forms following joints:
– Body of one vertebrae with body of vertebra
above and body of vertebra below—secondary
cartilaginous joint (2 joints).
– Lower larger part of head of corresponding rib
for the demifacet along the upper border of the
body on each side (2 cavities, 1 joint).
– Upper smaller part of head of a lower rib for
the demifacet along the lower border of the body
on each side (2 cavities, 1 joint).
– Superior articular processes on each side with
Figs 13.32a to c: Position of diaphragm: (a) Sitting, (b) stand- the inferior articular processes of the vertebra
ing, and (c) lying down above (2 joints).
– Inferior articular processes on each side with the
superior articular processes of the vertebra
below (2 joints).
Mnemonics – Transverse process of the vertebra with the
articular part of the tubercle of the rib on each
Structures in costal groove: VAN from above side (2 joints).
downwards – Body of the vertebra with the pedicle of the
Posterior intercostal vein vertebra on each side—primary cartilaginous
Posterior intercostal artery joints (2 joints).
Intercostal nerve Thus there are 12 joints which a typical thoracic
Structures on neck of 1st rib: sympathetic trunk and vertebra makes.
VAN from medial to lateral side 2 secondary cartilaginous joints
Posterior intercostal vein 2 primary cartilaginous joints
Superior intercostal artery 8 plane joints of synovial variety
1st thoracic nerve • The ribs are arched bones. Joints formed by a typical
Vertebrae: Recognising a Thoracic from Lumbar rib are:
• Presence of costal facets on the sides of the body – Posterior end or head of a typical rib articulates
with two adjacent vertebrae, corresponding one
Thorax
and transverse process
• Shape of the vertebral body and one above it and the intervening
– Thoracic is heart-shaped body (since your heart intervertebral disc.
is in your thorax). – The articular part of the tubercle articulates with
– Lumbar is kidney-/bean-shaped body (since transverse process of corresponding vertebra.
kidneys are in lumbar area) – The anterior part of the shaft of rib continues as
• Spine is long and oblique the costal cartilage. It is primary cartilaginous joint.
– A costal cartilage forms plane synovial joint with
the side of sternum.
2

FACTS TO REMEMBER • Respiratory movements produced by movements

Section

of thoracoabdominal diaphragm are called

• Sternum forms joints with its own parts:
‘abdominal respiration’.
– One manubriosternal joint—secondary carti-
• Respiratory movements produced by movements
laginous.
of intercostal muscles are called ‘thoracic respiration’.
 THORAX
238

CLINICOANATOMICAL PROBLEM During inspiration, the vertical diameter increases

by 3–5 cm and during expiration, the vertical
During ‘Pranayama’, deep regulated and smooth diameter decreases.
breathing occurs.
• Which diameters increase during deep breathing?
FURTHER READING
Ans: The anteroposterior diameter increases by • Berdajs D, Zünd G, turina MI, Genoni M. Blood supply of
‘pump-handle movement’ of the sternum. the sternum and its importance in internal thoracic artery
The transverse diameter increases by the ‘bucket- harvesting. Ann Thorac Surg 2006;81(6):2155–59.
handle movement’ of the 7–10 ribs. • Kurihara Y, Yakushiji, Matsremoto J, Ishikawa T, Mirata K.
The vertical diameter increases by ‘piston The ribs; anatomic 1999;19:105–19.
movement’ of the thoracoabdominal diaphragm. • Mirra JM. Unique tumors of the ribs. In: Mirra JM (ed) Bone
Tumours. Lea and Febiger, Philadelphia, 1989;1519–48.

1–5
From Medical Council of India, Competency based Undergraduate Curriculum for the Indian Medical Graduate, 2018;1:44–80.

1. Enumerate the parts of a rib and the joints formed 5. When do the secondary curvatures appear in the
by a typical rib. vertebral column?
2. Name the structures related to the neck of first rib. 6. Name the joints formed by typical thoracic vertebra.
3. Enumerate the joints formed by the manubrium, 7. Give an account of the various respiratory
and by sternum with the costal cartilages. movements. Name the muscles responsible for
4. Which area of sternum is related to the pericardium? inspiratory and expiratary movements.

1. Transverse diameter of thoracic cage increases by: c. Third

a. Pump-handle movement of ribs d. Fourth
b. Bucket-handle movement of ribs 5. The tubercle of a typical rib articulates with the facet
c. Caliper movement of ribs on the transverse process of:
d. Contraction of diaphragm a. Vertebra above
2. Anteroposterior diameter of thorax increases by: b. Vertebra below
a. Pump-handle movement of ribs c. Its own vertebra
Thorax

b. Bucket-handle movement of ribs d. All of the above

c. Contraction of diaphragm 6. Which of the following ribs articulates with
d. Relaxation of diaphragm transverse process of a thoracic vertebra?
3. Which one of the following joints is a primary a. Eleventh
cartilaginous joint? b. Twelfth
a. Costovertebral c. First
b. Costotransverse d. None of the above
2

c. First costochondral 7. The most characteristic feature of the thoracic

d. Manubriosternal vertebrae is:
Section

4. Which of the following ribs articulates with one a. The body is heart-shaped
vertebra only? b. The spine is oblique
a. First c. The body has costal facets
b. Second d. Vertebral foramen is small and circular
 BONES AND JOINTS OF THORAX
239

8. The lower larger facet on the head of a typical rib c. Inferior part of vertebra above the corresponding
articulates with the demifacet on: vertebrae
a. Inferior part of corresponding vertebrae d. Superior part of vertebra below the corres-
b. Superior part of corresponding vertebrae ponding vertebrae

1. b 2. a 3. c 4. a 5. c 6. c 7. c 8. b

• Name the vertebrae with which head of 4th rib • Name the blood vessels related to manubrium sterni.
articulates. • What is sternal puncture? Where is it done and why?
• What structures lie at the neck of 1st rib? • Which are the primary and secondary curvatures of
• Costodiaphragmatic recesses lie in relation to which the vertebral column?
rib. What is its clinical importance? • What are pump-handle and bucket-handle move-
• What type of joint is manubriosternal joint? ments?

Thorax
2Section
 THORAX
240

14
Walls of Thorax
!Internal thoracic arteries are being used for cardiac bypass.!
—Anonymous

INTRODUCTION Muscles of the Back

The thorax is covered by muscles of pectoral region of Erector spinae (sacrospinalis).
upper limb. In addition, the intercostal muscles and In addition to the muscles listed above, a number of
membranes fill up the gaps between adjacent ribs and other muscles of the abdomen and of the head and neck
cartilages. These muscles provide integrity to the are attached to the margins of the two apertures of the
thoracic wall. A right and left pair of thoracic nerves thorax.
fulfil the exact definition of the dermatome.
The posterior intercostal vein, posterior intercostal THORACIC WALL PROPER
artery and intercostal nerve (VAN) lie from above
downwards in the costal groove of the ribs.
Features
Sympathetic part of autonomic nervous system starts
from the lateral horns of thoracic 1 to thoracic 12 The thoracic cage forms the skeletal framework of the
segments of the spinal cord. It continues up to lumbar wall of the thorax. The gaps between the ribs are called
2 segment. intercostal spaces. They are filled by the intercostal
muscles and contain the intercostal nerves, vessels and
Coverings of the Thoracic Wall lymphatics. There are nine intercostal spaces anteriorly
and eleven intercostal spaces posteriorly.
The thoracic wall is covered from outside to inside by
the following structures—skin, superficial fascia, deep Competency achievement: The student should be able to:
fascia, and extrinsic muscles. The extrinsic muscles AN 21.4 Describe and demonstrate extent, attachments, direction
covering the thorax are as follows. of fibres, nerve supply and actions of intercostal muscles.1

Muscles of the Upper Limb

INTERCOSTAL MUSCLES
1 Pectoralis major
These are:
2 Trapezius
1 The external intercostal muscle
Thorax

3 Serratus anterior 2 The internal intercostal muscle

4 Pectoralis minor Each comprises intercartilaginous in front and inter-
5 Latissimus dorsi osseous in posterolateral part.
6 Levator scapulae 3 The transversus thoracis muscle which is divisible
7 Rhomboid major into three parts, namely the subcostalis, the inter-
8 Rhomboid minor costalis intimi (innermost intercostal) and the sterno-
costalis. The attachments of these muscles are given
2

9 Serratus posterior superior

in Table 14.1.
10 Serratus posterior inferior
Section

Extent
Muscles of the Abdomen The external intercostal muscle extends from the tubercle
1 Rectus abdominis of the rib posteriorly to the costochondral junction
2 External oblique anteriorly. Between the costochondral junction and the
240
 WALLS OF THORAX
241

sternum, it is replaced by the external or anterior 2 The fibres of the internal intercostal run downwards,
intercostal membrane. The posterior end of the muscle is backwards and laterally, i.e. at right angle to those
continuous with the posterior fibres of the superior of the external intercostal.
costotransverse ligament (Figs 14.1a and b). 3 The fibres of the transversus thoracis run in the same
The internal intercostal muscle extends from the lateral direction as those of the internal intercostal.
border of the sternum to the angle of the rib. Beyond
the angle, it becomes continuous with the internal or Nerve Supply
posterior intercostal membrane, which is continuous with All intercostal muscles are supplied by the intercostal
the anterior fibres of the superior costotransverse ligament. nerves of the spaces in which they lie.
The subcostalis is confined to the posterior part of
the lower intercostal spaces only. Actions of the Intercostal Muscles
The intercostalis intimi is confined to the middle two- 1 The main action of the intercostal muscles is to
fourths of all the intercostal spaces (Fig. 14.4). prevent intercostal spaces being drawn in during
The sternocostalis is present in relation to the anterior inspiration and bulging outwards during expiration.
parts of the upper intercostal spaces (Fig. 14.4). 2 The external intercostals, interchondral portions of
the internal intercostals, and the levator costae may
Direction of Fibres elevate the ribs during inspiration.
In the anterior part of the intercostal space: 3 The internal intercostals except for the interchondral
1 The fibres of the external intercostal muscle run portions and the transversus thoracis may depress the
downwards, forwards and medially in front. ribs or cartilages during expiration.

Figs 14.1a and b: External and internal intercostal muscles with external and internal intercostal membranes

Table 14.1: The attachments of the intercostal muscles (Figs 14.1 and 14.2)
Muscle Origin Insertion Thorax
1. External intercostal Lower border of the rib above the space Outer lip of the upper border of the rib below
2. Internal intercostal Floor of the costal groove of the rib above Inner lip of the upper border of the rib below
3. Transversus thoracis
a. Subcostalis Inner surface of the rib near the angle Inner surface of two or three ribs below
b. Intercostalis intimi/ Middle two-fourths of the ridge above the Inner lip of the upper border of the rib below
innermost intercostal costal groove
2

c. Sternocostalis • Lower one-third of the posterior surface of Costal cartilages of the 2nd to 6th ribs
Section

the body of the sternum

• Posterior surface of the xiphoid
• Posterior surface of the costal cartilages of
the lower 3 or 4 true ribs near the sternum
 THORAX
242

In the posterior part of the costal groove, the nerve

lies between the pleura, with the endothoracic fascia
and the internal intercostal membrane.
In the greater part of the space, the nerve lies
between the intercostalis intimi and the internal
intercostal muscle (Fig. 14.4).
3 Near the sternum, the nerve crosses in front of the
internal thoracic vessels and the sternocostalis
muscle. It then pierces the internal intercostal muscle,
the external intercostal membrane and the pectoralis
major muscle to terminate as the anterior cutaneous
nerve of the thorax.

Branches
Muscular Branches
1 Numerous muscular branches supply the intercostal
muscles, the transversus thoracis and the serratus
Fig. 14.2: Section through intercostal space showing neuro- posterior superior.
vascular bundle and its collateral branches
2 A collateral branch arises near the angle of the
Competency achievement: The student should be able to: rib and runs in the lower part of the space in the same
AN 21.5 Describe and demonstrate origin, course, relations and neurovascular plane. It supplies muscles of the space.
branches of a typical intercostal nerve.2
Sensory Branches
AN 21.7 Mention the origin, course, relations and branches of:3
1. Atypical intercostal nerve. 1 The main branch and the collateral branch also
2. Superior intercostal artery, subcostal artery. supply parietal pleura, periosteum of the ribs. The
lower nerves in addition supply the parietal
INTERCOSTAL NERVES peritoneum.
The intercostal nerves are the ventral primary rami of 2 The lateral cutaneous branch arises near the angle
thoracic one to thoracic eleven (Fig. 14.3) spinal nerves of the rib and accompanies the main trunk up to the
after the dorsal primary ramus has been given off. The lateral thoracic wall where it pierces the intercostal
anterior primary ramus of the twelfth thoracic nerve muscles and other muscles of the body wall along
forms the subcostal nerve. In addition to supplying the the midaxillary line. It is distributed to the skin after
intercostal spaces, the upper two intercostal nerves also dividing into anterior and posterior branches.
supply the upper limb. The lower five intercostal nerves, 3 The anterior cutaneous branch emerges on the side
seventh to eleventh thoracic nerves, also supply of the sternum to supply the overlying skin after
abdominal wall. These are, therefore, said to be thoraco- dividing into medial and lateral branches.
abdominal nerves. The remaining nerves, third to sixth,
supply only the thoracic wall; they are called typical Communicating Branches
intercostal nerves. 1 Each nerve is connected to a thoracic sympathetic
The subcostal nerve is distributed to the abdominal wall ganglion by a distally placed white and a proximally
and to the skin of the buttock. placed grey ramus communicans (Fig. 14.3).
Thorax

2 The lateral cutaneous branch of the second intercostal

Course nerve is known as the intercostobrachial nerve. It
Intercostal nerve runs in the costal groove and ends supplies the skin of the floor of the axilla and of the
near the sternum. upper part of the medial side of the arm (see Fig. 7.1).

Relations DISSECTION
1 Each nerve passes below the neck of the rib of the Detach the serratus anterior and the pectoralis major
2

same number and enters the costal groove. muscles from the upper ribs. Note the external
Section

2 In the costal groove, the nerve lies below the poste- intercostal muscle in the second and third intercostal
rior intercostal vessels. The relationship of structures spaces. Its fibres run anteroinferiorly. Follow it forwards
in the costal groove from above downwards is to the external intercostal membrane which replaces it
posterior intercostal vein, posterior intercostal artery between the costal cartilages (Figs 14.1a and b and 14.2).
and intercostal nerve (VAN) (Fig. 14.2).
 WALLS OF THORAX
243

Fig. 14.3: Typical thoracic spinal nerve

Thorax

Fig. 14.4: The course and branches of a typical intercostal nerve

Cut the external intercostal membrane and muscle

Trace the nerve and accompanying vessels round the
along the lower border of two spaces. Reflect them
2

thoracic wall. Note their collateral branches lying along

upwards to expose the internal intercostal muscle. The the upper margin of the rib below. Trace the muscular
Section

direction of its fibres is posteroinferior, at right angle to

branches of the trunk of intercostal nerve and its
that of external oblique. collateral branch. Trace the anterior cutaneous nerve
Follow the lateral cutaneous branch of one intercostal as well (Fig. 14.3).
nerve to its trunk deep to internal intercostal muscle.
 THORAX
244

Identify the deepest muscle in the intercostal space, Flowchart 14.1: Superior vena cava blockage before entry
the innermost intercostal muscle (Table 14.1). This of vena azygos
muscle is deficient in the anterior and posterior ends of
the intercostal spaces, where the neurovascular bundle
rests directly on the parietal pleura.
Expose the internal thoracic artery 1 cm from the
lateral margin of sternum by carefully removing the
intercostal muscles and membranes from the upper
three intercostal spaces (Fig. 14.11a).
Trace the artery through the upper six intercostal
spaces and identify its two terminal branches (see
Fig. 21.7). Trace its venae comitantes upwards till third
costal cartilage where these join to form internal thoracic
vein, which drains into the brachiocephalic vein.
Follow the course and branches of both anterior and
posterior intercostal arteries including the course and
tributaries of azygos vein (refer to BDC App).

CLINICAL ANATOMY

• Irritation of the intercostal nerves causes severe

pain which is referred to the front of the chest or
abdomen, i.e. at the peripheral termination of the
nerve. This is known as root pain or girdle pain.
• Herpes virus may cause infection of intercostal
nerves. If herpes infection is in 2nd thoracic nerve, vascular bundle, and may point at any of the three
there is referred pain via intercostobrachial nerve sites of exit of the branches of a thoracic nerve;
to the upper medial side of arm. one dorsal primary ramus and two cutaneous
• Internal thoracic artery is mobilised and its distal branches (Fig. 14.5).
cut end is joined to the coronary artery distal to • In superior vena caval obstruction before the
its narrowed segment. entry of vena azygos, the vena azygos is the
• Pus from the vertebral column tends to track main channel which transmits the blood from the
around the thorax along the course of the neuro- upper half of the body to distal part of superior
Thorax
2
Section

Fig. 14.5: Possible paths of cold abscess (due to TB of vertebra) along the branches of spinal nerve
 WALLS OF THORAX
245

Flowchart 14.2: Superior vena cava blockage after entry of Competency achievement: The student should be able to:
vena azygos AN 21.6 Mention origin, course and branches/tributaries of:4
1. Anterior and posterior intercostal vessels.
2. Internal thoracic vessels.
AN 21.7 Mention the origin, course, relations and branches of:5
1. Atypical intercostal nerve.
2. Superior intercostal artery, subcostal artery.

TYPICAL INTERCOSTAL SPACES

Typical intercostal spaces are the spaces whose
intercostal nerves and vessels are confined to thoracic
wall only.
Boundaries
Superior: Upper border of the costal groove of the rib
above.
Inferior: Blunt upper border of the rib below.
Anterior: Lateral border of sternum.
Posterior: Body of thoracic vertebra.
Contents
1 All intercostal muscles
2 Two anterior intercostal arteries and veins
3 Posterior interocostal artery and vein with its
collateral branch and tributary
4 Intercostal nerve and its collateral branch (Fig. 14.2)
vena cava (see Fig. 19.4 and Flowchart 14.1). In its INTERCOSTAL ARTERIES
blockage after entry of vena azygos, flow of blood Each intercostal space contains one posterior intercostal
is shown in Flowchart 14.2 and Fig. 14.6. artery with its collateral branch and two anterior
intercostal arteries. The greater part of the space is
supplied by the posterior intercostal artery (Fig. 14.7).

Posterior Intercostal Arteries

These are 11 in number on each side, one in each space.
1 The first and second posterior intercostal arteries
arise from the superior intercostal artery which is a
branch of costocervical trunk of the subclavian artery.
2 The third to eleventh arteries arise from the
descending thoracic aorta (Fig. 14.8). The right-sided Thorax
arteries are longer than those of the left side as aorta
is to the left of median plane.

Course and Relations

In front of the vertebrae: The right posterior intercostal
arteries are longer than the left, and pass behind the
oesophagus, the thoracic duct, the azygos vein and the
2

sympathetic chain (Fig. 14.9).

The left posterior intercostal arteries pass behind the
Section

hemiazygos vein and the sympathetic chain.

In the intercostal space: The artery is accompanied by
Fig. 14.6: Obstruction to superior vena cava after entry of vena
the intercostal vein and nerve, the relationship from
azygos
above downwards being vein–artery–nerve (VAN).
 THORAX
246

Fig. 14.7: Scheme showing the intercostal arteries. Each intercostal space contains one posterior intercostal, its collateral branch
and two anterior intercostal arteries

Fig. 14.8: Branches of descending thoracic aorta

The neurovascular bundle runs forwards in the costal

groove, first between the pleura and the internal
Thorax

intercostal membrane and then between the internal

intercostal and intercostalis intimi muscles (Fig. 14.4).
Termination
Each posterior intercostal artery ends at the level of the
costochondral junction by anastomosing with the upper
anterior intercostal artery of the space (Fig. 14.7).
2

Branches
Section

1 A dorsal branch supplies the muscles and skin of

the back, and gives off a spinal branch to the spinal
Fig. 14.9: The origin of the right and left posterior intercostal cord and vertebrae (Fig. 14.7).
arteries from the aorta. Note that the arteries are longer on the 2 A collateral branch arises near the angle of the rib,
right side descends to the upper border of the lower rib, and
 WALLS OF THORAX
247

ends by anastomosing with the lower anterior artery. In the succeeding spaces, they end in the venae
intercostal artery of the space. comitantes accompanying musculophrenic artery.
3 Muscular arteries are given off to the intercostal There is one posterior intercostal vein and one collateral
muscles, the pectoral muscles and the serratus vein in each intercostal space. Each vein accompanies
anterior. the corresponding artery and lies superior to the artery.
4 A lateral cutaneous branch accompanies the nerve The tributaries of these veins correspond to the branches
of the same name. of the arteries. They include veins from the vertebral
5 Mammary branches arise from the second, third and canal, the vertebral venous plexus, and the muscles and
fourth arteries and supply the mammary gland. skin of the back. Vein accompanying the collateral
6 The right bronchial artery arises from the right third branch of the artery drains into the posterior intercostal
posterior intercostal artery. vein.
The mode of termination of the posterior intercostal
Anterior Intercostal Arteries veins is different on the right and left sides as given in
There are nine intercostal spaces anteriorly as only ten Table 14.2, and shown in Fig. 14.10.
ribs reach front of body. There are two anterior
Table 14.2: Termination of posterior intercostal veins
intercostal arteries in each space. In the upper six spaces,
they arise from the internal thoracic artery (see Fig. 21.7). Veins On right side On left side
they drain into they drain into
In seventh to ninth spaces, the arteries are branches of
musculophrenic artery. The two anterior intercostal 1st Right brachiocephalic Left brachiocephalic
arteries end at the costochondral junction by vein vein
anastomosing with the respective posterior intercostal 2nd, 3rd, Join to form right Join to form left superior
arteries and with the collateral branches of the posterior 4th superior intercostal intercostal vein which
intercostal arteries. vein which drains into drains into the left
the azygos vein brachiocephalic vein
INTERCOSTAL VEINS
5th to 8th Azygos vein Accessory hemiazygos
There are two anterior intercostal veins in each of the upper vein
nine spaces. They accompany the corresponding
arteries. In the upper three spaces, the veins end in the 9th to 11th Azygos vein Hemiazygos vein
internal thoracic vein. In 4–6 spaces, the veins end in and
subcostal
venae comitantes accompanying internal thoracic

Thorax
2Section

Fig. 14.10: The veins on the posterior thoracic wall. Note the drainage of the posterior intercostal veins
 THORAX
248

The azygos and hemiazygos veins are described The artery terminates in the sixth intercostal space
later. by dividing into the superior epigastric and musculo-
phrenic arteries.
LYMPHATICS OF AN INTERCOSTAL SPACE
The artery is accompanied by two venae comitantes
Lymphatics from the anterior part of the spaces pass to which unite at the level of the fourth costal cartilage to
the anterior intercostal or internal mammary nodes which form the internal thoracic or internal mammary vein.
lie along the internal thoracic artery. Their efferents unite The vein runs upwards along the medial side of the
with those of the tracheobronchial and brachiocephalic artery to end in the brachiocephalic vein at the inlet of
nodes to form the bronchomediastinal trunk, which joins the thorax.
the right lymphatic trunk on the right side and the thoracic A chain of lymph nodes lies along the artery.
duct on the left side.
Lymphatics from the posterior part of the space pass
Relations
to the posterior intercostal nodes which lie on the heads
and necks of the ribs. Their efferents in the lower four Above the first costal cartilage, it runs downwards,
spaces unite to form a trunk which descends and opens forwards and medially, behind:
into the cisterna chyli. The efferents from the upper spaces 1 The sternal end of the clavicle
drain into left bronchomediastinal lymph trunk on the left 2 The internal jugular vein
side and into right bronchomediastinal lymph trunk on the 3 The brachiocephalic vein
right side (see Fig. 20.13). 4 The first costal cartilage
INTERNAL THORACIC ARTERY 5 The phrenic nerve. It descends in front of the cervical
pleura.
Origin
Internal thoracic artery arises from the inferior aspect Below the first costal cartilage, the artery runs vertically
of the first part of the subclavian artery opposite the downwards up to its termination in the 6th intercostal
thyrocervical trunk. The origin lies 2 cm above the space. Its relations are as follows.
sternal end of the clavicle (Figs 14.11a and b).
Anteriorly
Beginning, Course and Termination
1 Pectoralis major
Internal thoracic artery arises from lower border of 1st
2 Upper six costal cartilages
part of subclavian artery. It descends medially and
downwards behind sternal end of clavicle, and 1st 3 External intercostal membranes
costal cartilage. Runs vertically downwards 2 cm from 4 Internal intercostal muscles
lateral border of sternum till 6th intercostal space. 5 The first six intercostal nerves (Fig. 14.4).
Thorax
2
Section

Figs 14.11a and b: (a) The origin of the internal thoracic artery from the first part of the subclavian artery, (b) course of internal
thoracic artery
 WALLS OF THORAX
249

Fig. 14.12: Transverse section through the anterior thoracic wall to show the relations of the internal thoracic vessels. In the lower
part of their course, the vessels are separated from the pleura by the sternocostalis muscle

Posteriorly AZYGOS VEIN

The endothoracic fascia and pleura up to the second or The azygos vein drains the thoracic wall and the upper
third costal cartilage. Below this level, the sternocostalis lumbar region (Figs 14.10 and see 20.6b and c). It forms
muscle separates the artery from the pleura (Fig. 14.12). an important channel connecting the superior and
inferior venae cavae. The term ‘azygos’ means unpaired.
Branches The vein occupies the upper part of the posterior
1 The pericardiacophrenic artery arises in the root of the abdominal wall and the posterior mediastinum. It also
neck and accompanies the phrenic nerve to reach the connects portal venous system, caval venous system
diaphragm. It supplies the pericardium and the and vertebral venous system.
pleura (see Fig. 15.1).
2 The mediastinal arteries are small irregular branches Formation
that supply the thymus, in front of the pericardium, The azygos vein is formed by union of the lumbar
and the fat in the mediastinum. azygos, right subcostal and right ascending lumbar
3 Two anterior intercostal arteries are given to each of veins.
the upper six intercostal spaces. 1 The lumbar azygos vein may be regarded as the
4 The perforating branches accompany the anterior abdominal part of the azygos vein. It lies to the right
cutaneous nerves. In the female, the perforating of the lumbar vertebrae. Its lower end communicates
branches in the second, third and fourth spaces are with the inferior vena cava.
large and supply the breast. 2 The right subcostal vein accompanies the corres-
5 The superior epigastric artery runs downwards behind ponding artery.
the seventh costal cartilage and enters the rectus 3 The ascending lumbar vein is formed by vertical
sheath by passing between the sternal and costal slips anastomoses that connect the lumbar veins. The
of the diaphragm (Fig. 14.11b). azygos vein may be formed by union of the right
6 The musculophrenic artery runs downwards and subcostal and ascending lumbar veins (Fig. 14.10).
laterally behind the seventh, eighth, and ninth costal
cartilages. It gives two anterior intercostal branches Course
to each of these three spaces. It perforates the 1 The azygos vein enters the thorax by passing through
Thorax
diaphragm near the 9th costal cartilage and termi- the aortic opening of the diaphragm (see Fig. 12.16).
nates by anastomosing with other arteries on the 2 The azygos vein then ascends up to fourth thoracic
undersurface of the diaphragm (Fig. 14.11b). vertebra where it arches forwards over the root of
Note that through its various branches, the internal the right lung and ends by joining the posterior
thoracic artery supplies the anterior thoracic and aspect of the superior vena cava before it pierces the
abdominal walls from the clavicle to the umbilicus. pericardium (see Fig. 15.2).
2

Relations
Section

Competency achievement: The student should be able to:

AN 23.3 Describe and demonstrate origin, course, relations, Anteriorly: Oesophagus.
Posteriorly:
tributaries and termination of superior vena cava, azygos,
hemiazygos and accessory hemiazygos veins.6
1 Lower eight thoracic vertebrae
2 Right posterior intercostal arteries
For superior vena cava see chapter 19.
 THORAX
250

To the right: Tributaries

1 Right lung and pleura 1 Fifth to eighth left posterior intercostal veins
2 Greater splanchnic nerve 2 Sometimes the left bronchial veins.
To the left:
1 Thoracic duct and aorta in lower part
Competency achievement: The student should be able to:
AN 23.5 Identify and mention the location and extent of thoracic
2 Oesophagus, trachea and vagus in the upper part sympathetic chain.7
AN 23.6 Describe the splanchnic nerves.8
Tributaries
1 Right superior intercostal vein formed by union of
the second, third and fourth posterior intercostal THORACIC SYMPATHETIC TRUNK
veins.
2 Fifth to eleventh right posterior intercostal veins Features
(Fig. 14.10). The thoracic sympathetic trunk is a ganglionated chain
3 Hemiazygos vein at the level of lower border of situated one on each side of the thoracic vertebral
eighth thoracic vertebra. column. Superiorly, it is continuous with the cervical
4 Accessory hemiazygos vein at the level of upper part of the chain and inferiorly with the lumbar part
border of eighth thoracic vertebra. (Figs 14.13 and 14.14).
5 Right bronchial vein, near the terminal end of the
Theoretically, the chain bears 12 ganglia corres-
azygos vein.
ponding to the 12 thoracic nerves. The first thoracic
6 Several oesophageal, mediastinal, pericardial veins.
ganglion is commonly fused with the inferior cervical
HEMIAZYGOS VEIN ganglion to form the cervicothoracic, or stellate ganglion.
The remaining thoracic ganglia generally lie at the levels
Hemiazygos vein is also called the inferior hemiazygos of the corresponding intervertebral discs and the
vein. It is the mirror image of the lower part of the intercostal nerves.
azygos vein. The hemiazygos is formed by the union of
the left lumbar azygos, left ascending lumbar, and left Course and Relations
subcostal veins (Fig. 14.10). The chain crosses the neck of the first rib, the heads of
the second to tenth ribs, and bodies of the eleventh and
Course twelfth thoracic vertebrae. The whole chain descends
Hemiazygos vein pierces the left crus of the in front of the posterior intercostal vessels and the
diaphragm, ascends on the left side of the vertebra intercostal nerves, and passes deep to the medial
overlapped by the aorta. At the level of eighth thoracic arcuate ligament to become continuous with the lumbar
vertebra, it turns to the right, passes behind the part of the sympathetic chain.
oesophagus and the thoracic duct, and joins the azygos
vein (Fig. 14.10). Branches
Lateral Branches for the Limbs and Body Wall
Tributaries
Each ganglion is connected with its corresponding
Ninth to eleventh left posterior intercostal veins and spinal nerve by two rami, the white (preganglionic) and
oesophageal veins. grey (postganglionic) rami communicantes. The white
Thorax

ramus is distal to the grey ramus (see Appendix;

ACCESSORY HEMIAZYGOS VEIN Fig. A2.3). The grey rami communicantes along with
Accessory hemiazygos vein is also called the superior spinal nerves supply structures in the skin and blood
hemiazygos vein. It is the mirror image of the upper part vessels of skeletal muscles of the whole body (Fig.
of the azygos vein. 14.14).

Course Medial Branches for the Viscera

2

Accessory hemiazygos vein begins at the medial end 1 Medial branches from the upper 5 ganglia
Section

of the fourth or fifth intercostal space, and descends are postganglionic and get distributed to the heart,
on the left side of the vertebral column. At the level of the great vessels, the lungs and the oesophagus,
eighth thoracic vertebra, it turns to the right, passes through the following.
behind the aorta and the thoracic duct, and joins the a. Pulmonary branches to the pulmonary plexuses
azygos vein. b. Cardiac branches to the deep cardiac plexus
 WALLS OF THORAX
251

Fig. 14.13: The thoracic part of the sympathetic trunk and its splanchnic branches

c. Aortic branches to thoracic aortic plexus pierces the corresponding crus of the diaphragm.
d. Oesophageal branches which join the oesophageal The sympathetic nervous system may be revised
plexus (Fig. 14.13). from Chapter 7 of BD Chaurasia’s Handbook of
2 Medial branches from the lower 7 ganglia are General Anatomy, 6th edition.
preganglionic and form three splanchnic nerves. Thorax
a. The greater splanchnic nerve is formed by 5 roots
CLINICAL ANATOMY
from ganglia 5 to 9. It descends obliquely on the
vertebral bodies, pierces the crus of the • Cardiac pain is an ischaemic pain caused by
diaphragm, and ends (in the abdomen) mainly incomplete obstruction of a coronary artery.
in the coeliac ganglion, and partly in the aortico- Axons of pain fibres conveyed by the sensory
renal ganglion and the suprarenal gland. sympathetic cardiac nerves reach thoracic one to
b. The lesser splanchnic nerve is formed by two roots thoracic five segments of spinal cord mostly through
2

from ganglia 10 and 11. Its course is similar to the dorsal root ganglia of the left side. Since these
Section

that of the greater splanchnic nerve. It pierces the dorsal root ganglia also receive sensory impulses
crus of the diaphragm, and ends in the coeliac from the medial side of arm, forearm and upper part
ganglion (Fig. 14.14). of front of chest, the pain gets referred to these areas
c. The least (lowest) splanchnic nerve (renal nerve) is as depicted in Fig. 18.26.
tiny. It arises by one root from ganglion 12. It
 THORAX
252
Thorax
2
Section

Fig. 14.14: Autonomic nervous system and its divisions: Sympathetic and parasympathetic nervous systems
 WALLS OF THORAX
253

Though the pain is usually referred to the left side, CLINICOANATOMICAL PROBLEM
it may even be referred to right arm, jaw, epigastrium
or back. One student is climbing the stairs at a fast pace as he
is late for his examination and the lift got out of order.
His heart is beating fast against his chest wall. He
has dryness of mouth and sweating of the palm.
FACTS TO REMEMBER • What is the reason for rapid heart beat (tachy-
• Intercostal spaces are 11 on the back and only 9 in cardia)?
front of chest. • What is the effect of sympathetic on the skin?
• Intercostal muscles are in 3 layers—external, Ans: As he is late for the examination, the sym-
internal and transversus. These correspond to the pathetic system gets overactive, increasing the heart
muscle layers of anterior abdominal wall. rate, and blood pressure.
• Neurovascular bundle lies in the upper part of the Sympathetic has three fold effect on the skin, i.e.
intercostal space in between internal and inner- vasomotor, pilomotor and sudomotor. The sweat
most intercostal muscles. secretion is markedly increased, including the pale
• Posterior intercostal artery and its collateral skin with hair standing erect.
branch supplies two-thirds of the intercostal space. Sympathetic activity decreases the secretion of the
• Right posterior intercostal arteries are longer than glands. Dryness of mouth results from decreased
the left ones. salivary secretion.
• Accessory hemiazygos vein drains 5–8 left
intercostal spaces and hemiazygos vein drains 9– FURTHER READING
11 left intercostal spaces. Corresponding veins on • Marchetti-Filho MA, Leão LE, Costa-Junior Ada S. The role
right side drain into vena azygos. of intercostal nerve preservation in acute pain control after
thoracotomy. J Bras Pneumol 2014;40(2):164–70.
• Miller JI. Muscles of the chest wall. Thorac Surg Clin
2007;17(4):463–72.

1–8
From Medical Council of India, Competency based Undergraduate Curriculum for the Indian Medical Graduate, 2018;1:44–80.

Thorax

1. Describe the course, branches of a typical thoracic

spinal nerve. What is its applied anatomy? c. Splanchnic nerves
d. Cardiac pain referred to medial side of left arm
2

2. Describe the internal thoracic artery under

following headings: Origin, course, termination and e. Structures in the costal groove in order
Section

branches. f. Name the parts of parietal pleura with their nerve

3. Write short notes on: supply.
a. Posterior intercostal arteries g. Name the recesses of the pleura. What is their
b. Vena azygos clinical importance?
 THORAX
254

1. The order of structures in the upper part of 4. Which posterior intercostal veins of left side drain
intercostal space from above downwards is: into accessory hemiazygos vein?
a. Vein, artery and nerve a. 1st to 5th b. 2nd to 4th
b. Artery, vein and nerve c. 9th to 11th d. 5th to 8th
c. Vein, nerve and artery 5. Which one is not a branch of internal thoracic artery?
d. Vein, nerve, artery and vein a. Superior epigastric b. Musculophrenic
2. Parts of transversus thoracis are all, except: c. Anterior intercostal d. Posterior intercostal
a. Subcostalis b. Intercostalis intimi 6. Thoracolumbar outflow starts from lateral horn of
which segments of spinal cord?
c. Sternocostalis d. Serratus posterior superior
a. T1–L1 segments b. T1–T12 segments
3. Which of the following arteries are enlarged in
coarctation of aorta? c. T1–L2 segments d. T1–L5 segments
a. Subclavian 7. Following are the effects of sympathetic on skin,
b. Internal mammary except:
c. Posterior intercostals a. Sudomotor b. Vasomotor
d. Anterior intercostals c. Pilomotor d. Decreased pigmentation

1. a 2. d 3. c 4. d 5. d 6. c 7. d

• Name the structures ‘in order’ present in a costal • How many spinal nerves have both white and grey
groove. rami communicantes?
• Which are the typical intercostal nerves? • How many intercostal spaces are present on anterior
and posterior aspects of thoracic cage?
• What is the importance of thoracoepigastric vein? • What is the common site for paracentesis thoracis
• What does the word ‘azygos’ mean? and why is this procedure carried out?
Thorax
2
Section
 15
Thoracic Cavity and Pleurae
! Laughter is the best medicine but being seldom used !
—Anonymous

THORACIC CAVITY Note the origin of diaphragm from the xiphoid process
and divide it. Identify the course and branches of
The spongy lungs occupying a major portion of intercostal nerve again. Trace the nerve medially
thoracic cavity are enveloped in a serous cavity—the superficial to the internal thoracic vessels.
pleural cavity. There is always slight negative pressure Pull the lung laterally from the mediastinum and find
in this cavity. During inspiration, the pressure becomes its root with the pulmonary ligament extending down-
more negative, and air is drawn into the lungs covered wards from it. Cut through the structures, i.e. bronchus/
with its visceral and parietal layers of pleura. Visceral bronchi, pulmonary vessels, nerves, comprising its root
layer is inseparable from the lung and is supplied and from above downwards close to the lung. Remove the
drained by the same arteries, veins and nerves as lungs. lung on each side. Be careful not to injure the lung or
In a similar manner, the parietal pleura follows the walls your hand from the cut ends of the ribs.
of the thoracic cavity with cervical, costal, dia- Identify the phrenic nerve with accompanying blood
phragmatic and mediastinal parts. Pleural cavity limits vessels anterior to the root of the lung. Make a
the expansion of the lungs (Figs 15.1a–c). longitudinal incision through the pleura only parallel to
and on each side of the phrenic nerve. Strip the pleura
posterior to the nerve backwards to the intercostal
DISSECTION spaces. Pull the anterior flap forwards to reveal part of
the pericardium with the heart. Identify the following
Divide the manubrium sterni transversely immediately
structures seen through the pleura.
inferior to its junction with the first costal cartilage. Cut
through the parietal pleura in the first intercostal space
Right side
on both sides as far back as possible. Cut sternum at
the level of xiphisternal joint. Use a bone cutter to cut 1. Bulge of the heart and pericardium anteroinferior to
2nd to 7th ribs in midaxillary line on each side of thorax. the root of the lung (Fig. 15.2).
Separate intercostal muscles in 1–6 spaces from 2. A longitudinal ridge formed by right brachiocephalic
underlying pleura. vein down to first costal cartilage and by superior
Lift the inferior part of manubrium and body of vena cava up to the bulge of the heart.
sternum with ribs and costal cartilages and reflect it 3. A smaller longitudinal ridge formed by inferior vena
towards abdomen. Identify the pleura extending from cava formed between the heart and the diaphragm.
the back of sternum onto the mediastinum to the level 4. Phrenic nerve with accompanying vessels forming
of lower border of heart. Note the smooth surface of a vertical ridge on these two venae cavae passing
pleura where it lines the thoracic wall and covers the anterior to root of the lung.
lateral aspects of mediastinum. Trace the surface 5. Vena azygos arching over root of the lung to enter
marking of parietal pleura on the skeleton. the superior vena cava.
Remove the pleura and the endothoracic fascia from 6. Trachea and oesophagus posterior to the phrenic
the back of sternum and costal cartilages which is nerve and superior vena cava.
reflected towards abdomen. Identify the transversus 7. Right vagus nerve descending posteroinferiorly
thoracis muscle and internal thoracic vessels. across the trachea, behind the root of the lung.

255
 THORAX
256

Fig. 15.1: (a) Schematic transverse section of the thorax showing parts of the thoracic cavity, (b) vertical reflections of the pleura,
(c) transverse reflections of the pleura
Thorax
2
Section

Fig. 15.2: Mediastinum as seen from the right side

 THORACIC CAVITY AND PLEURAE
257

8. Bodies of the thoracic vertebrae behind oesophagus On the right side, identify and follow one of the divisions
with posterior intercostal vessels and azygos vein of trachea to the lung root and the superior and inferior
lying over them. venae cavae till the pericardium.
9. Sympathetic trunk on the heads of the upper ribs On the left side of thoracic cavity, dissect the arch of
and on the sides of the vertebral bodies below this, aorta. Identify the superior cervical cardiac branch of
anterior to the posterior intercostal vessels and the left sympathetic trunk and the inferior cervical
intercostal nerves. cardiac branch of the left vagus on the arch of the aorta
Left side between the vagus nerve posteriorly and phrenic nerve
1. Bulge of the heart (Fig. 15.3). anteriorly (cardiac nerves) (see Fig. 19.9).
2. Root of lung posterosuperior to it. The cavity of the thorax contains the right and left
3. Descending aorta between (1) and (2) in front and pleural cavities which are completely invaginated and
vertebral column behind. occupied by the lungs. The right and left pleural cavities
4. Arch of aorta over the root of the lung. are separated by a thick median partition called the
5. Left common carotid and left subclavian arteries mediastinum. The heart lies in the mediastinum.
passing superiorly from the arch of aorta.
6. Phrenic and vagus nerves descending between
these vessels and the lateral surface of the aortic
Competency achievement: The student should be able to:
arch. AN 24.1 Mention the blood supply, lymphatic drainage and nerve
7. Sympathetic trunk same as on right side.
supply of pleura, extent of pleura and describe the pleural recesses
and their applied anatomy.1
Identify longitudinally running sympathetic trunk on
the posterior part of thoracic cavity. Find delicate greater
and lesser splanchnic nerves arising from the trunk on PLEURAE
the medial side. Look carefully for grey and white rami
communicantes between the intercostal nerve and the Features
ganglia on the sympathetic trunk (see Fig. 14.3).
Like the peritoneum, the pleura is a serous membrane
Trace the intercostal vessels above the intercostal
which is lined by mesothelium (flattened epithelium).
nerve. The order being vein, artery and nerve (VAN).
There are two pleural sacs, one on either side of the

Thorax
2Section

Fig. 15.3: Mediastinum as seen from the left side

 THORAX
258

Table 15.1: Comparison of visceral and parietal pleurae

Visceral Parietal
Development Splanchnopleuric mesoderm Somatopleuric mesoderm
Position Lines surface of lung including Lines thoracic wall, mediastinum
the fissures and diaphragm
Nerve supply Sympathetic nerves from T2–T5 ganglia Thoracic nerves and
Parasympathetic from vagus nerve phrenic nerves
Sensitivity Insensitive to pain Sensitive to pain which may be
referred.
Blood supply Bronchial vessels Intercostal and
pericardiacophrenic vessels
Lymph drainage Tracheobronchial lymph nodes Intercostal lymph nodes

mediastinum. Each pleural sac is invaginated from its Surface Marking of the Lung/Visceral Pleura
medial side by the lung, so that it has an outer layer, The apex of the visceral pleura coincides with the
the parietal pleura, and an inner layer, the visceral or cervical pleura, and is represented by a line convex
pulmonary pleura. The two layers are continuous with upwards with a point 1 rising 2.5 cm above the medial
each other around the hilum of the lung, and enclose one-third of the clavicle (Fig. 15.4).
between them a potential space, the pleural cavity. The anterior border of the right visceral pleura
Table 15.1 shows comparison between visceral corresponds very closely to the anterior margin or
pleura and parietal pleura. costomediastinal line of the pleura and is obtained by
joining:
Pulmonary/Visceral Pleura • A point 2 at the sternoclavicular joint,
The serous layer of pulmonary pleura covers the • A point 3 in the median plane at the sternal angle,
surfaces and fissures of the lung, except at the hilum • A point 4 in the median plane just above the
and along the attachment of the pulmonary ligament xiphisternal joint.
where it is continuous with the parietal pleura. It is The anterior border of the left visceral pleura corresponds
firmly adherent to the lung and cannot be separated to the anterior margin of the pleura up to the level of
from it. the fourth costal cartilage points I–IV left side.
Thorax
2
Section

Fig. 15.4: Surface projection of the parietal pleura (black); visceral pleura and lung (pink) on the front of thorax
 THORACIC CAVITY AND PLEURAE
259

In the lower part, it presents a cardiac notch of subclavian artery and the scalenus anterior; posteriorly
variable size. From the level of the fourth costal to the neck of the first rib and structures lying over it;
cartilage, it passes laterally for 3.5 cm from the sternal laterally to the scalenus medius; and medially to the
margin (V), and then curves downwards and medially large vessels of the neck (see Fig. 12.10).
to reach the sixth costal cartilage 4 cm from the median Diaphragmatic pleura lines the superior aspect of
plane (VI). In the region of the cardiac notch, the peri- diaphragm. It covers the base of the lung and gets
cardium is covered only by a double layer of pleura. continuous with mediastinal pleura medially and costal
The area of the cardiac notch is dull on percussion pleura laterally.
and is called the area of superficial cardiac dullness
(Fig. 15.4). Features of Parietal Pleura
The lower border of each visceral pleura lies two ribs The cervical pleura is represented by a curved line
higher than the parietal pleural reflection. It crosses the forming a dome over the medial one-third of the clavicle
sixth rib in the midclavicular line (5), the eighth rib in with a height of about 2.5 cm above the clavicle
the midaxillary line (6 and VII), the tenth rib at the (Fig. 15.4). Pleura lies in the root of neck on both sides.
lateral border of the erector spinae, and ends 2 cm
The anterior margin, or the costomediastinal line of
lateral to the tenth thoracic spine.
pleural reflection is as follows: On the right side, it
Parietal Pleura extends from the sternoclavicular joint downwards and
medially to the midpoint of the sternal angle. From here,
The parietal pleura is thicker than the pulmonary
it continues vertically downwards to the midpoint of
pleura, and is subdivided into the following four
the xiphisternal joint crosses to right of xiphicostal
parts.
angle. On the left side, the line follows the same course
1 Costal
up to the level of the fourth costal cartilage. It then
2 Diaphragmatic
arches outwards and descends along the sternal margin
3 Mediastinal
up to the sixth costal cartilage.
4 Cervical (Figs 15.5a and b)
The costal pleura lines the thoracic wall which The inferior margin, or the costodiaphragmatic line of
comprises ribs and intercostal spaces to which it is pleural reflection passes laterally from the lower limit of
loosely attached by a layer of areolar tissue called the its anterior margin, so that it crosses the eighth rib in the
endothoracic fascia. midclavicular line, the tenth rib in the midaxillary line,
The mediastinal pleura lines the corresponding surface and the twelfth rib at the lateral border of the
of the mediastinum. It is reflected over the root of the sacrospinalis muscle. Further it passes horizontally a
lung and becomes continuous with the pulmonary little below the 12th rib to the lower border of the twelfth
pleura around the hilum. thoracic vertebra, 2 cm lateral to the upper border of the
The cervical pleura extends into the neck, nearly 5 cm twelfth thoracic spine (Fig. 15.7).
above the first costal cartilage and 2.5 cm above the Thus the parietal pleurae descend below the costal
medial one-third of the clavicle, and covers the apex of margin at three places, at the right xiphicostal angle,
the lung (see Fig. 12.10). It is covered by the suprapleural and at the right and left costovertebral angles, below
membrane. Cervical pleura is related anteriorly to the the twelfth rib behind the upper poles of the kidneys.

Thorax
2Section

Figs 15.5a and b: (a) The parietal pleura. The lung represented on the right is the early stage; (b) the parietal pleura as a half cone
 THORAX
260

The latter fact is of surgical importance in exposure of

the kidney. The pleura may be damaged at this site
(Fig. 15.7).
The posterior margins of the pleura pass from a point
2 cm lateral to the twelfth thoracic spine to a point 2 cm
lateral to the seventh cervical spine. The costal pleura
becomes the mediastinal pleura along this line.

Pulmonary Ligament
The parietal pleura surrounding the root of the lung
extends downwards beyond the root as a fold called the
pulmonary ligament. The fold contains a thin layer of loose
areolar tissue with a few lymphatics. Actually, it
provides a dead space into which the pulmonary veins
can expand during increased venous return as in
exercise. The lung roots can also descend into it with the
descent of the diaphragm (Fig. 15.6). Fig. 15.8: Reflections of the pleura to show costodiaphragmatic
and costomediastinal recesses
Recesses of Pleura
There are two recesses of parietal pleura, which act as The costomediastinal recess (Fig. 15.4) lies anteriorly,
‘reserve spaces’ for the lung to expand during deep behind the sternum and costal cartilages, between the
inspiration (Figs 15.7 and 15.8). costal and mediastinal pleurae, particularly in relation
to the cardiac notch of the left lung. This recess is filled
up by the anterior margin of the lungs even during quiet
breathing. It is only obvious in the region of the cardiac
notch of the lung.
The costodiaphragmatic/costovertebral recess lies
inferiorly between the costal and diaphragmatic pleurae.
Vertically, it measures about 5 cm, and extends from the
eighth to tenth ribs along the midaxillary line (Fig. 15.7).
During inspiration, the lungs expand into these
recesses. So these recesses are obvious only in expiration
and not in deep inspiration.

Nerve Supply of the Pleura

The parietal pleura develops from the somatopleuric
layer of the lateral plate mesoderm, and is supplied by
Fig. 15.6: Pleura at root of lung the somatic nerves. These are the intercostal and phrenic
nerves. The parietal pleura is pain sensitive. The costal
and peripheral parts of the diaphragmatic pleurae are
supplied by the intercostal nerves, and the mediastinal
Thorax

pleura and central part of the diaphragmatic pleurae are

supplied by the phrenic nerves (C4).
The pulmonary pleura develops from the splan-
chnopleuric layer of the lateral plate mesoderm, and
is supplied by autonomic nerves. The sympathetic
nerves are derived from second to fifth sympathetic
ganglia while parasympathetic nerves are drawn
2

from the vagus nerve. The nerves accompany the

Section

bronchial vessels. This part of the pleura is not sensitive

to pain.
Sympathetic system dilates the bronchi. The para-
sympathetic system narrows the bronchial tree and is
Fig. 15.7: The pleural reflections—from behind also secretory to the glands.
 THORACIC CAVITY AND PLEURAE
261

Blood Supply and Lymphatic Drainage of Pleura

The parietal pleura is a part and parcel of the thoracic
wall. Its blood supply and lymphatic drainage are,
therefore, the same as that of the body wall. It is thus
supplied by intercostal, internal thoracic and musculo-
phrenic arteries.
The veins drain mostly into the azygos and internal
thoracic veins. The lymphatics drain into the intercostal,
internal mammary, posterior mediastinal and dia-
phragmatic nodes.
The pulmonary pleura, like the lung, is supplied by
the bronchial arteries while the veins drain into
bronchial veins. It is drained by the bronchopulmonary
lymph nodes.

CLINICAL ANATOMY Fig. 15.9: Paracentesis thoracis

• Aspiration of any fluid from the pleural cavity is
called paracentesis thoracis. It is usually done in the
eighth intercostal space in the midaxillary line
(Fig. 15.9). The needle is passed through the lower
part of the space to avoid injury to the principal
neurovascular bundle, i.e. vein, artery and nerve
(VAN).
• Some clinical conditions associated with the pleura
are as follows.
a. Pleurisy: This is inflammation of the pleura. It
may be dry, but often it is accompanied by
collection of fluid in the pleural cavity. The con-
dition is called the pleural effusion (Fig. 15.10).
Dry pleurisy is more painful because during
inspiration both layers come in contact and
there is friction. Fig. 15.10: Pleural effusion
b. Pneumothorax: Presence of air in the pleural
cavity.
c. Haemothorax: Presence of blood in the pleural
cavity.
d. Hydropneumothorax: Presence of both fluid and
air in the pleural cavity.
e. Empyema: Presence of pus in pleural cavity.
• Costal and peripheral parts of diaphragmatic
pleurae are innervated by intercostal nerves (Fig. Thorax
15.11). Hence irritation of these regions cause
referred pain along intercostal nerves to throacic
or abdominal wall. Mediastinal and central parts
of diaphragmatic pleurae are innervated by
phrenic nerve (C4). Hence irritation here causes
referred pain on tip of shoulders.
• Pain on right shoulder occurs due to inflam-
2

mation of gallbladder, while on left shoulder is

Section

due to splenic rupture. Fig. 15.11: Nerve supply of parietal pleura. Costal pleura and
• Pleural effusion causes obliteration of costodia- cervical pleura innervated by intercostal nerves, and
phragmatic recess. mediastinal pleura and central part of diaphragmatic pleura
innervated by phrenic nerve
 THORAX
262

• Pleura extends beyond the thoracic cage at • Paracentesis thoracis is done in the lower part of
following areas: the intercostal space to avoid injury to the main
– Right xiphicostal angle (Fig. 15.4) intercostal vessels and nerve.
– Right and left costovertebral angles (Fig. 15.7) • Pleural effusion is one of the sign of tuberculosis
– Right and left sides of root of neck as cervical of the lung.
dome of pleura (Fig. 15.4).
The pleura may be injured at these sites during
surgical procedures. These sites have to be
remembered. CLINICOANATOMICAL PROBLEM
• During inspiration, pure air is withdrawn in the A child about 10 years of age had been having sore
lungs. At the same time, deoxygenated blood is throat, cough and fever. On the third day, he
received through the pulmonary arteries. Thus an developed severe cough, difficulty in breathing and
exchange of gases occurs at the level of alveoli. high temperature, with pain in his right side of chest,
The deoxygenated blood gets oxygenated and sent right shoulder and around umbilicus.
via pulmonary veins to the left atrium of heart. • What is the probable diagnosis?
The impure air containing carbon dioxide gets • Why does pain radiate to right shoulder and
expelled during expiration. periumbilical region?
Ans: The most probable diagnosis is pneumonia of
Mnemonics the right lung. The infection from pharynx spreads
down to the lungs. Pleura consists of two layers—
Pleura surface markings visceral and parietal; the former is insensitive to pain
“All the even ribs, in order: 2,4,6,8,10,12 show its and the latter is sensitive to pain. The costal part of
route”. parietal pleura is supplied by intercostal nerves and
Rib 2: Both sides parietal pleura come close the mediastinal and central parts of diaphragmatic
Rib 4: The left pleura does a lateral shift to accommodate pleurae are supplied by phrenic nerve (C4).
heart In pneumonia, there is always an element of
Rib 6: Both diverge laterally pleural infection. The pain of pleuritis radiates to
Rib 8: Midclavicular line other areas. Due to infection in mediastinal and
Rib 10: Midaxillary line central part of diaphragmatic pleura, the pain is
Rib12: The back referred to tip of the right shoulder as this area is
supplied by supraclavicular nerves with the same
root value as phrenic nerve (C4).
FACTS TO REMEMBER The costal pleura is supplied by intercostal nerves.
• Parietal pleura limits the expansion of the lungs. These nerves also supply the skin of anterior
abdominal wall. So the pain of lower part of costal
• Visceral pleura behaves in same way as the lung. pleura gets referred to skin of abdomen, in the
• Parietal pleura has same nerve supply and blood periumbilical area.
supply as the thoracic wall.
• Pleural cavity normally contains a minimal serous
fluid for lubrication during movements of thoracic FURTHER READING
Thorax

cage. • Rajanna MJ. Anatomical and surgical considerations of the

• Pleura lies beyond the thoracic cage at 5 places. phrenic and accessory phrenic nerves. J Inter Coll Surg 1947;
These are right and left cervical pleurae above the 60:42–52.
1st rib and the clavicle; right and left costovertebral • Tuli A, Mansda M, Raheja S, Gandhi A, Prakash A. Vascular
angles and only right xiphicostal angle. Pleura is endothelial growth factor as a consequentional marker in
likely to be injured at these places. chronic obstructive pulmonary disease. Annals of anatomy
2014;196:101.
2

1
From Medical Council of India, Competency based Undergraduate Curriculum for the Indian Medical Graduate, 2018;1:44–80.
Section
 THORACIC CAVITY AND PLEURAE
263

1. Write short notes on: c. Name four clinical conditions associated with the
a. Comparison of visceral and parietal pleura pleura
b. Paracentesis thoracis d. Sites where pleura (parietal) lies beyond the
thoracic cage

1. Which of the following nerves innervates the costal 4. One of the following arteries supplies the visceral
pleura? pleura:
a. Vagus b. Intercostal a. Bronchial
c. Splanchnic d. Phrenic b. Musculophrenic
2. Which of the following nerves innervates the c. Internal thoracic
mediastinal pleura?
d. Superior epigastric
a. Vagus b. Phrenic
5. All are main big recesses of pleura, except:
c. Intercostal d. Splanchnic
a. Right costodiaphragmatic recess
3. All the following arteries supply parietal pleura,
except: b. Left costodiaphragmatic recess
a. Musculophrenic b. Internal thoracic c. Right costomediastinal recess
c. Intercostal d. Bronchial d. Left costomediastinal recess

1. b 2. b 3. d 4. a 5. c

• What are the parts of parietal pleura? Name their • Name the sites where pleura extends beyond the
nerve supply. thoracic cage.
• Which nerves innervate the visceral pleura and why? • What are the differences between parietal and
• Name the root value of phrenic nerve. What are the visceral pleurae?
parts of parietal pleura innervated by this nerve?

Thorax
2Section
 THORAX
264

16
Lungs
!One thousand Americans and same number of Indians stop smoking everyday – by dying !
—Anonymous

INTRODUCTION plexus. The pulmonary artery lies above the bronchus.

The lungs occupying major portions of the thoracic Anterior to the bronchus is the upper pulmonary vein, while
cavity, leave little space for the heart, which excavates the lower vein lies below the bronchus.
more of the left lung. The two lungs hold the heart tight The mediastinal surface of left lung has the
between them, providing it the protection, it rightly impression of left ventricle, ascending aorta. Behind the
deserves. There are ten bronchopulmonary segments root of the left lung are the impressions of descending
in each lung. thoracic aorta while oesophagus leaves an impression
The lungs are a pair of respiratory organs situated in the lower part only (Refer to BDC App).
in the thoracic cavity. Each lung invaginates the
corresponding pleural cavity. The right and left lungs LUNGS
are separated by the mediastinum. Features
The lungs are spongy in texture. In the young, the Each lung is conical in shape (Fig. 16.1). It has:
lungs are brown or grey in colour. Gradually, they 1 An apex at the upper end.
become mottled black because of the deposition of 2 A base resting on the diaphragm.
inhaled carbon particles. The right lung weighs about 3 Three borders, i.e. anterior, posterior and inferior.
700 g; it is about 50 to 100 g heavier than the left lung. 4 Two surfaces, i.e. costal and medial. The medial
surface is divided into vertebral and mediastinal parts.
DISSECTION
The apex is blunt and lies above the level of the
Identify the lungs by the thin anterior border, thick anterior end of the first rib. It reaches nearly 2.5 cm
posterior border, conical apex, wider base, medial surface above the medial one-third of the clavicle, just medial
with hilum and costal surface with impressions of the to the supraclavicular fossa. It is covered by the cervical
ribs and intercostal spaces. In addition, the right lung is pleura, the suprapleural membrane, and is grooved by
distinguished by the presence of three lobes, whereas the subclavian artery on the medial side and anteriorly
left lung comprises two lobes only (refer to BDC App).
Thorax

(see Fig. 12.10).

On the mediastinal part of the medial surface of right The base is semilunar and concave. It rests on the
lung identify two bronchi—the eparterial and hyparterial diaphragm which separates the right lung from the
bronchi, with bronchial vessels and posterior pulmonary right lobe of the liver, and the left lung from the left
plexus, the pulmonary artery between the two bronchi lobe of the liver, the fundus of the stomach, and the
on an anterior plane. The upper pulmonary vein is spleen (see Fig. 15.8).
situated still on an anterior plane while the lower The anterior border is very thin (Figs 16.2 and 16.3). It
pulmonary vein is identified below the bronchi. is shorter than the posterior border. On the right side,
2

The impressions on the right lung in front of root of it is vertical and corresponds to the anterior or
Section

lung are of superior vena cava, inferior vena cava, and costomediastinal line of pleural reflection. The anterior
right ventricle. The impressions behind the root of lung border of the left lung shows a wide cardiac notch below
are those of vena azygos and oesophagus (Table 16.1). the level of the fourth costal cartilage. The heart and
Hilum of the left lung shows the single bronchus situated pericardium are not covered by the lung in the region
posteriorly, with bronchial vessels and posterior pulmonary of this notch.
264
 LUNGS
265

Fissures and Lobes of the Lungs

The right lung is divided into three lobes (upper, middle
and lower) by two fissures (oblique and horizontal).
The left lung is divided into two lobes by the oblique
fissure (Fig. 16.1a).
The oblique fissure cuts into the whole thickness of
the lung, except at the hilum. It passes obliquely
downwards and forwards, crossing the posterior
border about 6 cm below the apex and the inferior
border about 5 cm from the median plane. Due to the
oblique plane of the fissure, the lower lobe is more
posterior and the upper and middle lobes more anterior.
In the right lung, the horizontal fissure passes from
the anterior border up to the oblique fissure and
separates a wedge-shaped middle lobe from the upper
Fig. 16.1a: The trachea and lungs as seen from the front lobe. The fissure runs horizontally at the level of the
fourth costal cartilage and meets the oblique fissure in
The posterior border is thick and ill defined. It the midaxillary line.
corresponds to the medial margins of the heads of the The tongue-shaped projection of the left lung below
ribs. It extends from the level of the seventh cervical the cardiac notch is called the lingula. It corresponds to
spine to the tenth thoracic spine. the middle lobe of the right lung.
The inferior border separates the base from the costal The lungs expand maximally in the inferior direction
and medial surfaces. because movements of the thoracic wall and diaphragm
The costal surface is large and convex. It is in contact are maximal towards the base of the lung. The presence
with the costal pleura and the overlying thoracic wall. of the oblique fissure of each lung allows a more
The medial surface is divided into a posterior or uniform expansion of the whole lung.
vertebral part, and an anterior or mediastinal part. The
vertebral part is related to the vertebral bodies, Surface Marking of the Lung
intervertebral discs, the posterior intercostal vessels and Surface marking of lung is same as that of visceral pleura
the splanchnic nerves (see Figs 15.2 and 15.3). The described in Chapter 15. The surface marking of oblique
mediastinal part is related to the mediastinal septum, and horizontal fissures is mentioned here.
and shows a cardiac impression, the hilum and a The oblique fissure can be drawn by joining:
number of other impressions which differ on the two a. A point 2 cm lateral to the third thoracic spine.
sides. Various relations of the mediastinal surfaces of b. Another point on the fifth rib in the midaxillary
the two lungs are listed in Table 16.1. line (see Fig. 15.4).

Thorax
2Section

Fig. 16.1b: Trachea, lungs and heart as seen from the front
 THORAX
266

Fig. 16.2: Impressions on the mediastinal surface of the right lung

Thorax
2
Section

Fig. 16.3: Impressions on the mediastinal surface of the left lung

 LUNGS
267

Table 16.1: Structures related to the mediastinal Arrangement of Structures in the Root
surfaces of the right and left lungs Right side: From posterior to anterior side:
Right side (Fig.16.2) Left side (Fig.16.3) 1. Eparterial bronchus, hyparterial bronchus with
1. Right atrium and auricle 1. Left ventricle, left auricle, bronchial vessels and posterior pulmonary plexus
infundibulum and adjoining along their posterior walls (Figs 16.4a and b).
part of the right ventricle 2. Pulmonary artery in midplane between the two bronchi.
2. A small part of the right 2. Pulmonary trunk 3. Superior and inferior pulmonary veins in anterior part.
ventricle 4. Anterior pulmonary plexus, lymph nodes and lymph
3. Superior vena cava 3. Arch of aorta vessels in the anterior and inferior parts.
4. Lower part of the right 4. Descending thoracic aorta Left side: From posterior to anterior side:
brachiocephalic vein
1. Single bronchus with bronchial vessels and posterior
5. Azygos vein 5. Left subclavian artery pulmonary plexus along its posterior wall.
6. Oesophagus 6. Thoracic duct
2. Pulmonary artery in middle area placed above the
7. Inferior vena cava 7. Oesophagus bronchus (Figs 16.4a and b).
8. Trachea 8. Left brachiocephalic vein
3. Superior and inferior pulmonary veins in anterior part.
9. Right vagus nerve 9. Left vagus nerve
4. Anterior pulmonary plexus, lymph nodes and lymph
10.Right phrenic nerve 10. Left phrenic nerve
vessels in the anterior and inferior parts.
11. Left recurrent laryngeal nerve
Relations of the Root
c. A third point on the sixth costal cartilage 7.5 cm
from the median plane. Anterior
1 Common on the two sides:
The horizontal fissure is represented by a line joining: a. Phrenic nerve
a. A point on the anterior border of the right lung at
b. Pericardiacophrenic vessels
the level of the fourth costal cartilage.
c. Anterior pulmonary plexus
b. A second point on the fifth rib in the midaxillary line.
2 On the right side:
Competency achievement: The student should be able to: a. Superior vena cava (Fig. 16.2)
AN 24.2 Identify side, external features and relations of structures b. A part of the right atrium.
which form root of lung and bronchial tree and their clinical
Posterior
correlate.1
1 Common on the two sides:
Root of the Lung
a. Vagus nerve
b. Posterior pulmonary plexus
Root of the lung is a short, broad pedicle which connects 2 On left side: Descending thoracic aorta
the medial surface of the lung to the mediastinum. It is
formed by structures which either enter or come out of Superior
the lung at the hilum (Latin depression). The roots of 1 On right side: Terminal part of azygos vein
the lungs lie opposite the bodies of the fifth, sixth and 2 On left side: Arch of the aorta.
seventh thoracic vertebrae. Inferior
Contents Pulmonary ligament.
The root is made up of the following structures. Thorax
Differences between the Right and Left Lungs
1 Principal bronchus on the left side, and eparterial and
hyparterial bronchi on the right side in posterior part. Differences between right and left lungs are given in
Table 16.2.
2 One pulmonary artery in middle part.
3 Two pulmonary veins, superior and inferior, in Competency achievement: The student should be able to:
anterior part (Figs 16.4a and b). AN 24.5 Mention the blood supply, lymphatic drainage and nerve
4 Bronchial arteries—one on the right side and two on supply of lungs.2
2

the left side.

Arterial Supply
Section

5 Bronchial veins
6 Anterior and posterior pulmonary plexuses of nerves The bronchial arteries supply nutrition to the bronchial
7 Lymphatics of the lung tree and to the pulmonary tissue. These are small
8 Bronchopulmonary lymph nodes arteries that vary in number, size and origin, but usually
9 Areolar tissue they are as follows:
 THORAX
268

Table 16.2: Differences between the right and left lungs 1 On the right side, there is one bronchial artery
Right lung (Fig. 16.4a) Left lung
which arises from the third right posterior inter-
costal artery.
1. Shorter and broader 1. Longer and narrower 2 On the left side, there are two bronchial arteries, both
2. Larger and heavier, 2. Smaller and lighter, weighs of which arise from the descending thoracic aorta,
weighs about 700 g about 600 g the upper opposite fifth thoracic vertebra and the
lower just below the left bronchus.
3. Anterior border is 3. Anterior border is interrupted
straight by the cardiac notch
Deoxygenated blood is brought to the lungs by the
two pulmonary arteries and oxygenated blood is
4. Cardiac impression 4. Cardiac impression deep
returned to the heart by the four pulmonary veins.
shallow/absent
There are precapillary anastomoses between
5. Absence of lingula 5. Lingula present
bronchial and pulmonary arteries. These connections
6. It has 2 fissures and 6. It has only one fissure and enlarge when any one of them is obstructed in
3 lobes 2 lobes disease.

Fig. 16.4a: Roots of the right and left lungs

Thorax
2
Section

Fig. 16.4b: Gross anatomy of lungs including their roots

 LUNGS
269

Venous Drainage of the Lungs

BRONCHIAL TREE
The venous blood from the first and second divisions
of the bronchi is carried by bronchial veins. Usually Features
there are two bronchial veins on each side. The right
The trachea divides at the level of the lower border of
bronchial veins drain into the azygos vein. The left
the fourth thoracic vertebra into two primary principal
bronchial veins drain into the hemiazygos vein.
bronchi, one for each lung. The right principal bronchus
The greater part of the venous blood from the lungs is 2.5 cm long. It is shorter, wider and more in line with
is drained by the pulmonary veins. the trachea than the left principal bronchus (Fig. 16.5a).
Inhaled particles or foreign bodies, therefore, tend to
Lymphatic Drainage pass more frequently to the right lung, with the result
There are two sets of lymphatics, both of which drain that infections are more common on the right side than
into the bronchopulmonary nodes. on the left.
1 Superficial vessels drain the peripheral lung tissue The left principal bronchus is 5 cm. It is longer,
lying beneath the pulmonary pleura. The vessels pass narrower and more oblique than the right bronchus.
round the borders of the lung and margins of the Right bronchus makes an angle of 25° with tracheal
fissures to reach the hilum. bifurcation, while left bronchus makes an angle of 45°
with the trachea.
2 Deep lymphatics drain the bronchial tree, the Each principal bronchus enters the lung through the
pulmonary vessels and the connective tissue septa. hilum, and divides into secondary lobar bronchi, one for
They run towards the hilum where they drain into each lobe of the lungs. Thus there are three lobar
the bronchopulmonary nodes (Fig. 16.4a). bronchi on the right side, and only two on the left
The superficial vessels have numerous valves and side. Each lobar bronchus divides into tertiary or
the deep vessels have only a few valves or no valves at segmental bronchi, one for each bronchopulmonary
all. Though there is no free anastomosis between the segment; which are 10 on the right side and 10 on the
superficial and deep vessels, some connections exist left side. The segmental bronchi divide repeatedly to
which can open up, so that lymph can flow from the form very small branches called terminal bronchioles.
deep to the superficial lymphatics when the deep Still smaller branches are called respiratory bronchioles
vessels are obstructed in disease of the lungs or of the (Fig. 16.6).
lymph nodes. Each respiratory bronchiole aerates a small part of
the lung known as a pulmonary unit. The respiratory
Nerve Supply bronchiole ends in microscopic passages which are
termed:
1 Parasympathetic nerves are derived from the vagus. 1 Alveolar ducts (Fig. 16.7)
These fibres are:
2 Atria
a. Motor to the bronchial muscles, and on stimul- 3 Air saccules
ation cause bronchospasm. 4 Pulmonary alveoli (Latin small cavity). Gaseous
b. Secretomotor to the mucous glands of the exchanges take place in the alveoli.
bronchial tree.
c. Sensory fibres are responsible for the stretch reflex DISSECTION
of the lungs, and for the cough reflex. Dissect the principal bronchus into the left lung. Remove Thorax
2 Sympathetic nerves are derived from second to fifth the pulmonary tissue and follow the main bronchus till
sympathetic ganglia. These are inhibitory to the it is seen to divide into two lobar bronchi. Try to dissect
smooth muscle and glands of the bronchial tree. That till these divide into the segmental bronchi (Fig. 16.5a).
is how sympathomimetic drugs, like adrenaline, cause Dissect the principal bronchus into the right lung.
bronchodilatation and relieve symptoms of bronchial Remove the pulmonary tissue and follow the main
asthma. bronchus till it is seen to divide into three lobar bronchi.
Both parasympathetic and sympathetic nerves first Try to dissect till these divide into segmental bronchi.
2

form anterior and posterior pulmonary plexuses

Section

situated in front of and behind the lung roots: From Competency achievement: The student should be able to:
the plexuses, nerves are distributed to the lungs along AN 24.3 Describe a bronchopulmonary segment.3
the blood vessels and bronchi (Fig. 16.4).
 THORAX
270

Figs 16.5a–c: Bronchopulmonary segments of the lungs (both sides 1 to 10, see Table 16.3). Medial basal segments are not seen
in (b) and (c).
Table 16.3: The bronchopulmonary segments
Right lung
Bronchopulmonary Segments Lobes Segments
The most widely accepted classification of segments is A. Upper 1. Apical
given in Table 16.3. There are 10 segments on the right 2. Posterior
side and 10 on the left side (Figs 16.5a–c and 16.8 a and b). 3. Anterior
B. Middle 4. Lateral
Definition 5. Medial
C. Lower 6. Superior
Bronchopulmonary segments are well-defined
7. Medial basal
anatomical segments aerated by tertiary/segmental
Thorax

8. Anterior basal
bronchus. These are pyramidal in shape with apex 9. Lateral basal
directed towards hilum and base directed towards 10. Posterior basal
periphery having their own arterial supply; but venous Left lung
drainage is shared by adjacent bronchopulmonary
A. Upper 1. Apical
segment. • Upper division 2. Posterior
3. Anterior
Features
• Lower division 4. Superior lingular
2

1 These are well-defined anatomic, functional and 5. Inferior lingular

surgical sectors of the lung.
Section

B. Lower 6. Superior
2 Each one is aerated by a tertiary or segmental 7. Medial basal
bronchus. 8. Anterior basal
9. Lateral basal
3 Each segment is pyramidal in shape with its apex 10. Posterior basal
directed towards the root of the lung (Fig. 16.8).
 LUNGS
271

Fig. 16.7: Parts of a pulmonary unit

Fig. 16.6: Bronchial tree

Thorax
2Section

Figs 16.8a and b: The bronchopulmonary segments as seen on: (a) The costal aspects of the right and left lungs. Medial basal
segments (no. 7) are not seen, and (b) segments seen on the medial surface of left and right lungs. Lateral segment of middle lobe
(no. 4) is not seen on right side
 THORAX
272

4 Each segment has a segmental bronchus, segmental epithelial lining of the respiratory system is
artery, autonomic nerves and lymph vessels. endodermal in origin. It forms the lining of the larynx,
5 The segmental venules lies in the connective tissue the trachea, the bronchi and the pulmonary alveoli.
between adjacent pulmonary units of bronchopul- The connective tissue, cartilage and smooth muscles
monary segments. of these structures develop from splanchnic
6 During segmental resection, the surgeon works mesenchyme surrounding the foregut. As develop-
along the segmental veins to isolate a particular ment progresses, the diverticulum separates from the
segment. foregut by the tracheo-oesophageal septum (except at
the entrance to the larynx).
Relation to Pulmonary Artery The respiratory diverticulum below the larynx grows
The branches of the pulmonary artery accompany the caudally and forms the trachea in the midline. This
bronchi. The artery lies dorsolateral to the bronchus. bifurcates into two lateral outpocketings; the lung buds.
Thus each segment has its own separate artery In the fifth week of intrauterine life, the proximal parts
(Fig. 16.9). of each lung bud forms the principal bronchi. Each of
these grows laterally and invaginates the pericardio-
Relation to Pulmonary Vein peritoneal canals (primitive pleural cavities). Following
The pulmonary veins do not accompany the bronchi this, the primary bronchi divide into secondary bronchi
or pulmonary arteries. They run in the intersegmental (3 on the right side and 2 on the left side). These divide
planes. Thus each segment has more than one vein and dichotomously into tertiary bronchi. Each tertiary
each vein drains more than one segment. Near the bronchus with its surrounding mesenchyme forms a
hilum, the veins are ventromedial to the bronchus. bronchopulmonary segment. By 24th week, about 17
It should be noted that the bronchopulmonary orders of branches are formed and the lung parenchyma
segment is not a bronchovascular segment because it develops in four stages.
does not have its own vein. 1 Pseudoglandular stage (between 5 and 17 weeks).
In this stage, developing lung resembles a gland.
Competency achievement: The student should be able to: 2 Canalicular stage (between 16 and 25 weeks), the
AN 25.2 Describe development of pleura, lung and heart.4 lumina of bronchi and bronchioles become larger and
tissue becomes more vascular.
DEVELOPMENT OF RESPIRATORY SYSTEM 3 Terminal sac stage (between 24 weeks to birth). Many
saccules appear at the ends of terminal bronchioles
The lower respiratory tract primordium appears in the
(terminal sacs). Capillaries bulge into these sacs.
third week of intrauterine life in the form of an
4 Alveolar stage (late fetal period to 8 years after birth).
outgrowth (respiratory diverticulum) from the ventral
The epithelial lining of the sacs becomes an extremely
wall of the primitive pharynx, i.e. the part of the
thin squamous layer and the alveolocapillary
foregut caudal to the hypobranchial eminence. Hence
membrane allows exchange of gases.
The four stages overlap each other because the
cranial segments of the lungs mature faster than the
caudal ones.
By 28–32 weeks, some of the alveolar epithelial cells
secrete a substance which is capable of lowering the
surface tension at the air–alveolar interface and thus
Thorax

helps maintaining the patency of the alveoli; this is

known as pulmonary surfactant.
Table 16.4 and Flowchart 16.1 show the development
of respiratory system.

Molecular Regulation
1. Transcription factor (TBX4) expressed in the
2

endoderm of gut tube at the site of respiratory

Section

diverticulum induces formation of lung bud and is

responsible for growth and differentiation of lungs.
2. Fibroblast growth factor 10 (FGF10) and other signals
Fig. 16.9: Distal portions of adjacent bronchopulmonary from splanchnic mesenchyme probably induces the
segments outgrowth of tracheal bud.
 LUNGS
273

Table 16.4: Development of components of respiratory system

S. no. Component Developed from
1 Epithelium of larynx, trachea, bronchi and alveoli Endoderm of foregut
2 Muscles of larynx Branchial mesoderm of IVth and VIth arches
3 Cartilages of larynx IV arch cartilage
• Thyroid VI arch cartilage
• Cricoid
• Arytenoid
4 Epiglottis Dorsal part of hypobranchial eminence (fused
ventral part of III and IV arches)
5 Glands of respiratory tract Endoderm
6 Muscles, cartilages and connective tissue of trachea and bronchi Splanchnic mesoderm

Flowchart 16.1: Quick review of sequence of development of Congenital Anomalies

respiratory system
1 Tracheo-oesophageal fistula: This abnormal
communication between the trachea and the
oesophagus is due to a deviation of the oesophago-
tracheal septum or from mechanical factor pushing
the dorsal wall of the foregut anteriorly.
2 Tracheal stenosis
3 Azygos lobe of lung around vena azygos: This may be
due to an additional respiratory bud which develops
independently of the main respiratory system.
4 Hyaline membrane disease or distress syndrome:
This is due to a deficiency of pulmonary surfactant.
5 Agenesis of lung.

HISTOLOGY
In a section of the lung, the mesothelial covering of
visceral pleura may be visible. The structure of the lung
is a lacework of alveoli separated by thin-walled septa.
This is traversed by system of intrapulmonary bronchi,
bronchioles and alveolar ducts, into which atria,
alveolar sacs and alveoli open.

Intrapulmonary Bronchus
Intrapulmonary bronchus is lined by pseudostratified
ciliated columnar epithelium with goblet cells resting on
a thin basement membrane. Cilia prevent the Thorax
accumulation of mucus in the bronchial tree. The
lamina propria consists of reticular and elastic fibres.
The submucous coat contains both mucous and serous
acini. A complete layer of smooth muscle fibres is
present which is responsible for infoldings of the
mucous membrane. Outermost is the hyaline cartilage
which is visible as small cartilaginous plates of varying
2

sizes and shapes (Fig. 16.10) with tunica adventitia.

Section

Terminal bronchiole is part of the conducting system

3. Sonic hedgehog (SHH-GLi) and other signaling of respiratory pathway which is less than 1 mm in
molecules are involved in the epithelial mesenchyme diameter. It is lined by simple columnar epithelium. The
interaction which governs the branching of tracheal lamina propria contains elastic and smooth muscle fibres.
bud and its proliferation. Both the glands and cartilage plates are absent (Fig. 16.11).
 THORAX
274

membrane. The main support of the alveoli is provided

by elastic fibres. Majority of cells lining the alveoli are
the squamous cells or type I pneumocytes. A few cells are
larger cells or type II pneumocytes. Type II cells secrete
the surfactant which lowers surface tension and prevents
alveoli from collapsing.
The interalveolar septum containing numerous
capillaries lined by continuous non-fenestrated
endothelial cells is present between the adjacent alveoli.

CLINICAL ANATOMY

• Usually, the infection of a bronchopulmonary

segment remains restricted to it, although
tuberculosis and bronchogenic carcinoma may
spread from one segment to another.
• Knowledge of the detailed anatomy of the
bronchial tree helps considerably in:
Fig. 16.10: Intrapulmonary bronchus
a. Segmental resection (Fig. 16.12).
b. Visualising the interior of the bronchi through
a bronchoscope passed through the mouth and
trachea. The procedure is called bronchoscopy.
• Carina is a hook-shaped process projecting
backwards from the lower margin of lowest
tracheal ring. It helps to divide trachea into
two primary bronchi. Right bronchus makes an
angle of 25°, while left one makes an angle of 45°.
Foreign bodies mostly descend into right bronchus
(Fig. 16.13) as it is wider and more vertical than
the left bronchus. Enlarged lymph nodes present
in this area may distort the carina.
• Carina (Latin keel) of the trachea is a sensitive area.
When patient is made to lie on her/his left side,
secretions from right bronchial tree flow towards
the carina due to effect of gravity. This stimulates
the cough reflex, and sputum is brought out. This
is called postural drainage (Fig. 16.14).

Fig. 16.11: Structure of terminal bronchiole

Thorax

Respiratory Bronchiole
Respiratory bronchiole is lined by cuboidal epithelium.
The walls consist of collagenous connective tissue
containing bundles of interlacing smooth muscle fibres
and elastic fibres. At number of places, the alveolar sacs
and alveoli arise from the respiratory bronchiole and
2

its cuboidal epithelium is continuous with the

Section

squamous epithelium of alveolar sacs and alveoli.

Alveoli
Alveoli are thin-walled polyhedral sacs. The alveoli are
Fig. 16.12: Segmental resection
lined by two types of cells, which rest on a basement
 LUNGS
275

• Bronchial asthma is a common disease of res-

piratory system. It occurs due to bronchospasm
of smooth muscles in the wall of bronchioles.
Patient has difficulty especially during expiration.
It is accompanied by wheezing. Epinephrine, a
sympathomimetic drug, relieves the symptoms.
• Auscultation of lung: Upper lobe is auscultated
above 4th rib on both sides; lower lobes are best
heard on the back. Middle lobe is auscultated
between 4th and 6th ribs on right side.
• Superior segment of lower lobe is the most depen-
dent bronchopulmonary segment in supine
position. Foreign bodies are likely to be lodged here.

Mnemonics

Bronchopulmonary segments of right lung

Fig. 16.13: Angles of right and left bronchi with carina “A PALM Seed Makes Another Little Palm”.
In order from superior to inferior:
Apical
Posterior
Anterior
Lateral
Medial
Superior
Medial basal
Anterior basal
Lateral basal
Fig. 16.14: Postural drainage from right lung Posterior basal
Lung lobes: One having lingula, lobe numbers
• Paradoxical respiration: During inspiration,
Lingula is on Left
the flail (abnormally mobile) segments of ribs are
pulled inside the chest wall while during expira- The lingula is like an atrophied lobe, so the left lung
tion the ribs are pushed out (Fig. 16.15). must have two "other" lobes, and, therefore, right lung
has three lobes.
• Tuberculosis of lung is one of the commonest
diseases. A complete course of treatment must be
taken under the guidance of a physician.
FACTS TO REMEMBER
• Large spongy lungs occupy almost whole of Thorax
thoracic cage leaving little space for the heart and
accompanying blood vessels, etc.
• Bronchopulmonary segments are independent
functional units of lung.
• Lungs are subjected to lot of insult by the smoke
of cigarette/bidis/pollution.
• Tuberculosis of lung is one of the commonest killer
2

in an underdeveloped or a developing country.

Section

Complete treatment of TB is a must, otherwise the

bacteria become resistant to antitubercular treatment.
People harbouring resistant bacteria spread the
Fig. 16.15: Paradoxical respiration
disease to people around through their sputum.
 THORAX
276

CLINICOANATOMICAL PROBLEMS Ans: The bronchogenic carcinoma spreads to the

bronchomediastinal lymph nodes. The left supra-
Case 1
clavicular nodes are also enlarged and palpable; so
A young boy with sore throat while playing with
these are called ‘sentinal nodes’. The enlarged
small coins, puts 3 coins in his mouth. When asked
bronchomediastinal lymph nodes may exert pressure
by his mother, he takes out two of them, and is not
on the left recurrent laryngeal nerve in the thorax
able to take out one.
causing alteration of voice. The cancer of lung is
• Where is the third coin likely to pass? mostly due to smoking.
• What can be the dangers to the boy?
Ans: Since the boy was having sore throat, it is likely
the coin has been inhaled into his respiratory FURTHER READING
passages. The coin would pass down the larynx, • Chandrupatla M, Krishnaiah. The study of bronchial tree.
trachea, right principal bronchus, as it is in line with International Journal of Pharma and Biological Sciences
trachea. The coin further descends into lower lobe 2011;2:166–72.
bronchus, and into its posterior basal segment. That • Hush A. Asthma research: The real action is in children.
segment of the lung would get blocked, causing Paediatr Respair Rev 2005;6:101–10.
respiratory symptoms. A review of how early problems with lung growth and development
impact on later lung disease.
If the coin goes into oropharynx and oesophagus,
• Morrisery EE, Hogan BL. Preparing for the first breath:
it will comfortably travel down whole of digestive
Genetic and cellular mechanisms in lung development. Dev
tract and would come out in the faecal matter next Cell 2010;18:8–23.
day. This paper presents an overview of the molecular mechanisms of
Case 2 lung development.
A 45-year-old man complained of severe cough, loss • Ornitz DM, Yoin. Signalling networks regulating
of weight, alteration of his voice. He has been development of the lower respiratory tract. Cold Spring Harb
smoking for last 25 years. Radiograph of the chest ZPerspect Biol 2012;1;4.
followed by biopsy revealed bronchogenic car- This paper presents a review of the signaling factors in lung
cinoma in the left upper lobe of the lung. development.
• Where did the cancer cells metastasise? • Shabana S, Mrudula C. Anatomical variations of pulmonary
• What caused alteration of his voice? veins at the hilum of lung. Int J Applied Research 2017;7:50–
51.
1–4
From Medical Council of India, Competency based Undergraduate Curriculum for the Indian Medical Graduate, 2018;1:44–80.
Thorax
2

1. Describe the gross anatomy of the lungs. Define a

b. Carina of trachea
bronchopulmonary segment. Enumerate the
Section

segments of the lungs. What is the clinical c. Postural drainage

importance of these segments? d. Effects of parasympathetic nerves on the lung
2. Write short notes on: e. Various subdivisions of a segmental bronchus
a. Comparison of the roots of right and left lungs f. Intrapulmonary bronchus
 LUNGS
277

1. Which one of the following structures is not related 6. The effects of parasympathetic system on lungs are
to medial surface of right lung? all, except:
a. Superior vena cava a. Motor to bronchial muscle
b. Thoracic duct b. Secretomotor to mucous glands of bronchial tree
c. Trachea c. Responsible for cough reflex
d. Oesophagus d. Causes bronchodilation
2. Which of the following structures is single at the 7. Which of the following structures run in the
root of each lung? intersegmental planes of the lungs?
a. Pulmonary vein a. Segmental venules
b. Pulmonary artery b. Bronchial vessels
c. Bronchus c. Pulmonary arteries
d. Bronchial artery d. Bronchus
3. Which one of the following is not a common relation 8. Order of origin of segmental bronchi in lower lobe
to the roots of both lungs? of lung is:
a. Anterior pulmonary plexus a. Superior, anterior basal, medial basal, lateral
b. Pericardiacophrenic vessels basal and posterior basal
c. Superior vena cava b. Superior, medial basal, anterior basal and lateral
d. Phrenic nerve basal and posterior basal
4. Part of lung aerated by a respiratory bronchiole is: c. Medial basal, superior, anterior basal, lateral
a. A lobule basal and posterior basal
b. A segment d. Anterior basal, superior, medial basal, lateral
basal and posterior basal
c. Alveolus
9. Permanent overdistension of alveoli is known as:
d. Pulmonary unit
a. Empyema
5. Respiratory bronchiole ends in all microscopic b. Emphysema
passages except:
c. Pneumothorax
a. Alveolar ducts d. Dyspnoea
b. Atria 10. Angles of right and left bronchi at carina are:
c. Pulmonary alveoli a. 20° and 40° b. 25° and 45°
d. Terminal bronchiole c. 40° and 40° d. 45° and 25°

1. b 2. b 3. c 4. d 5. d 6. d 7. a 8. b 9. b 10. b

Thorax

• Name the borders and surfaces of lung. • Why does the foreign body mostly enter through the
• Name the structures present in the hilum of right lung. right bronchus?
• Which lobe of lung is auscultated from the posterior
2

• What is the function of pulmonary ligament?

• What structure arches above the root of left lung? aspect of thoracic cage?
Section

• Define a bronchopulmonary segment. • What is postural drainage?

• Where do the cartilage and smooth muscle fibres end • Which is the most dependent bronchopulmonary
in the bronchial tree? segment in supine position?
 THORAX
278

17
Mediastinum
! Amitabh Bachhan, the great actor suffered from myasthenia gravis, a disorder of thymus, present in the anterior mediastinum !
—Anonymous

INTRODUCTION
Mediastinum (plural—mediastina) (Latin intermediate)
is the middle space left in the thoracic cavity in between
the lungs. Its most important content is the heart,
enclosed in the pericardium in the middle part of the
inferior mediastinum or the middle mediastinum.
Above it lies superior mediastinum. Anterior and post-
erior to the heart are anterior mediastinum and
posterior mediastinum, respectively.
The mediastinum is the median septum of the thorax
between the two lungs. It includes the mediastinal
pleurae.
Competency achievement: The student should be able to:
AN 21.11 Mention boundaries and contents of the superior,
anterior, middle and posterior mediastinum.1
Fig. 17.1: Subdivisions of the mediastinum

SUPERIOR AND INFERIOR MEDIASTINA

body of the fourth thoracic vertebra posteriorly. The
Boundaries inferior mediastinum is subdivided into three parts by
Anteriorly: Sternum the pericardium. The area in front of the pericardium
is the anterior mediastinum. The area behind the
Posteriorly: Vertebral column
pericardium is the posterior mediastinum. The
Superiorly: Thoracic inlet pericardium and its contents form the middle medi-
Thorax

Inferiorly: Diaphragm astinum.

On each side: Mediastinal pleura. DISSECTION

Reflect the upper half of manubrium sterni upwards and
Divisions study the boundaries and contents of superior and three
For descriptive purposes, the mediastinum is divided divisions of the inferior mediastinum.
into the superior mediastinum and the inferior medi-
2

astinum. The inferior mediastinum is further divided SUPERIOR MEDIASTINUM

Section

into the anterior, middle and posterior mediastina Boundaries

(Fig. 17.1).
The superior mediastinum is separated from the Anteriorly: Manubrium sterni (Fig. 17.1)
inferior by an imaginary plane passing through the Posteriorly: Upper four thoracic vertebrae
sternal angle anteriorly and the lower border of the Superiorly: Plane of the thoracic inlet
278
 MEDIASTINUM
279

Inferiorly: An imaginary plane passing through the superior mediastinum with the pretracheal space of the
sternal angle in front, and the lower border of the body neck. It contains areolar tissue and part of thymus gland.
of the fourth thoracic vertebra behind.
Boundaries
On each side: Mediastinal pleura.
Anteriorly: Body of sternum
Contents Posteriorly: Pericardium
1 Trachea and oesophagus Superiorly: Imaginary plane separating the superior
2 Muscles: Origins of (i) sternohyoid, (ii) sterno- mediastinum from the inferior mediastinum.
thyroid, (iii) lower ends of longus colli.
Inferiorly: Superior surface of diaphragm
3 Arteries: (i) Arch of aorta, (ii) brachiocephalic artery,
(iii) left common carotid artery, (iv) left subclavian On each side: Mediastinal pleura
artery (Fig. 17.2).
Contents
4 Veins: (i) Right and left brachiocephalic veins,
(ii) upper half of the superior vena cava, (iii) left 1 Sternopericardial ligaments (Fig. 17.1)
superior intercostal vein. 2 Lymph nodes with lymphatics
5 Nerves: (i) Vagus, (ii) phrenic, (iii) cardiac nerves of 3 Small mediastinal branches of the internal thoracic
both sides, (iv) left recurrent laryngeal nerve. artery
6 Thymus 4 The lowest part of the thymus
7 Thoracic duct 5 Areolar tissue.
8 Lymph nodes: Paratracheal, brachiocephalic, and
Middle Mediastinum
tracheobronchial.
Middle mediastinum is occupied by the pericardium
and its contents, along with the phrenic nerves and the
pericardiacophrenic vessels.

Boundaries
Anteriorly: Sternopericardial ligaments
Posteriorly: Oesophagus, descending thoracic aorta,
azygos vein (see Figs 15.2 and 15.3)
On each side: Mediastinal pleura

Contents
1 Heart enclosed in pericardium (Fig. 17.2)
2 Arteries: (i) Ascending aorta, (ii) pulmonary trunk,
(iii) two pulmonary arteries (Fig. 17.3)

Thorax
Fig. 17.2: Arrangement of the large structures in the superior
mediastinum. Note the relationship of superior vena cava,
ascending aorta and pulmonary trunk to each other in the middle
mediastinum, i.e. within the pericardium. The bronchi are not shown

INFERIOR MEDIASTINUM
The inferior mediastinum is divided into—anterior,
2

middle and posterior mediastina.

Section

Anterior Mediastinum
Anterior mediastinum is a very narrow space in front
of the pericardium, overlapped by the thin anterior Fig. 17.3: Some structures present in superior, middle and
borders of both lungs. It is continuous through the posterior mediastina
 THORAX
280

3 Veins: (i) Lower half of the superior vena cava, 5 Lymph nodes and lymphatics:
(ii) terminal part of the azygos vein, and (iii) right a. Posterior mediastinal lymph nodes lying along-
and left pulmonary veins. side the aorta.
4 Nerves: (i) Phrenic, and (ii) deep cardiac plexus. b. The thoracic duct (Fig. 17.4).
5 Lymph nodes: Tracheobronchial nodes.
CLINICAL ANATOMY
Posterior Mediastinum
Boundaries • The prevertebral layer of the deep cervical fascia
Anteriorly: (i) Pericardium, (ii) bifurcation of trachea, extends to the superior mediastinum, and is
(iii) pulmonary vessels, and (iv) posterior part of the attached to the fourth thoracic vertebra. An
upper surface of the diaphragm. infection present in the neck behind this fascia can
pass down into the superior mediastinum but not
Posteriorly: Lower eight thoracic vertebrae and lower down.
intervening discs.
The pretracheal fascia of the neck also extends to
On each side: Mediastinal pleura. the superior mediastinum, where it blends with
the arch of the aorta. Neck infections between the
Contents pretracheal and prevertebral fasciae can spread
1 Oesophagus (Fig. 17.4). into the superior mediastinum, and through it into
2 Arteries: Descending thoracic aorta and its branches. the posterior mediastinum. Thus mediastinitis can
result from infections in the neck.
3 Veins: (i) Azygos vein, (ii) hemiazygos vein,
and (iii) accessory hemiazygos vein. • There is very little loose connective tissue between
4 Nerves: (i) Vagi, (ii) splanchnic nerves, greater, lesser the mobile organs of the mediastinum. Therefore,
and least, arising from the lower eight thoracic the space can be readily dilated by inflammatory
ganglia of the sympathetic chain (see Fig. 15.1). fluids, neoplasms, etc.
• In the superior mediastinum, all large veins
are on the right side and the arteries on the left
side. During increased blood flow, veins expand
enormously, while the large arteries do not expand
at all. Thus there is much ‘dead space’ on the
right side and it is into this space that tumour
or fluids of the mediastinum tend to project
(Fig. 17.5).
• Compression of mediastinal structures by any
tumour gives rise to a group of symptoms known
as mediastinal syndrome. The common symptoms
are as follows:
a Obstruction of superior vena cava gives rise to
engorgement of veins in the upper half of the
body.
Thorax

b. Pressure over the trachea causes dyspnoea, and

cough.
c. Pressure on oesophagus causes dysphagia.
d. Pressure or the left recurrent laryngeal nerve
gives rise to hoarseness of voice (dysphonia).
e. Pressure on the phrenic nerve causes paralysis
of the diaphragm on that side.
2

Fig. 17.4: Structures in the posterior part of the superior media- f. Pressure on the intercostal nerves gives rise to
Section

stinum, and their continuation into the posterior mediastinum. pain in the area supplied by them. It is called
Note the relationship of the arch of the aorta to the left bronchus, intercostal neuralgia.
and that of the azygos vein to the right bronchus
 MEDIASTINUM
281

"BATS AND TENT"

Brachiocephalic veins
Arch of aorta
Thymus
Superior vena cava
Trachea
Esophagus
Nerves (vagus and phrenic)
Thoracic duct

FACTS TO REMEMBER
• Mediastinum is the middle space between the
lungs.
• It is chiefly occupied by the heart enclosed in
Fig. 17.5: Large vessels in relation to heart pericardium with blood vessels and nerves.
• Unit structures in the superior mediastinum are
trachea, oesophagus, left recurrent laryngeal nerve
g. Pressure on the vertebral column may cause between the two tubes and thoracic duct on the
erosion of the vertebral bodies. left of the oesophagus.
The common causes of mediastinal syndrome are
bronchogenic carcinoma, Hodgkin’s disease causing
enlargement of the mediastinal lymph nodes, CLINICOANATOMICAL PROBLEM
aneurysm or dilatation of the aorta, etc. A patient presents with lots of dilated veins in the
front of chest and anterior thoracic wall.
• What is the reason for so many veins seen on
Mnemonics the anterior body wall?
Superior mediastinum contents: PVT Left • How does venous blood go back in circulation?
BATTLE Ans: This appears to be a case of blockage of superior
Phrenic nerve vena cava after the entry of vena azygos. The blood
Vagus nerve needs to return to heart and it is done through
Thoracic duct inferior vena cava. The backflow occurs:
Left recurrent laryngeal nerve (not the right) Superior vena cava blockage brachiocephalic
Brachiocephalic veins veins subclavian veins axillary veins lateral
Aortic arch (and its 3 branches) thoracic veins thoracoepigastric veins
Thymus superficial epigastric veins great saphenous veins
Trachea femoral veins common iliac veins inferior
vena cava right atrium of heart (see Fig. 14.6).
Lymph nodes Thorax
Esophagus Many veins open up to assist the drainage.

1
From Medical Council of India, Competency based Undergraduate Curriculum for the Indian Medical Graduate, 2018;1:44–80.
2Section
 THORAX
282

1. Enumerate the boundaries and contents of superior 3. Enumerate:

mediastinum. a. Contents of middle mediastinum
2. Enumerate the boundaries of mediastinum and its b. Contents of posterior mediastinum
subdivisions.

1. Boundaries of mediastinum are all, except: 4. Which one is not a content of superior media-
a. Sternum b. Cervical vertebrae stinum?
c. Thoracic inlet d. Diaphragm a. Arch of aorta b. Lower half of superior
2. Inferior mediastinum is divided into: vena cava
a. Anterior b. Middle c. Trachea d. Oesophagus
c. Posterior d. Posteroinferior 5. Which one is not a content of posterior media-
3. Contents of middle mediastinum are all, except: stinum?
a. Heart with pericardium a. Oesophagus b. Descending thoracic aorta
b. Pulmonary arteries
c. Arch of vena d. Vagus nerve
c. Upper half of superior vena cava azygos
d. Bifurcation of trachea

1. b 2. d 3. c 4. b 5. c

• Name the boundaries of superior mediastinum. • What are the contents of posterior mediastinum?
• Name the contents of superior mediastinum. • Which are the ‘unit structures’ in the superior
• What are the contents of middle mediastinum? mediastinum?
Thorax
2
Section
 18
Pericardium and Heart
!When there is room in the heart, there is room in the house !
—Anonymous

INTRODUCTION
PERICARDIUM
Pericardium, comprising fibrous and serous layers,
encloses the heart pulsating from ‘womb to tomb’. Features
Heart is a vital organ, pumping blood to the entire The pericardium (Greek around heart) is a fibroserous
body (Figs 18.1 and 18.2). Its pulsations are governed sac which encloses the heart and the roots of the great
by the brain through various nerves. Since heartbeat is vessels. It is situated in the middle mediastinum. It
felt or seen against the chest wall, it appears to be more consists of the fibrous pericardium and the serous
active than the ‘quiet brain’ controlling it. That is why pericardium (Figs 18.1b and 18.2).
there are so many songs on the heart and few on the Fibrous pericardium encloses the heart and fuses with
brain. Meditation, yoga and exercise help in regulating the vessels which enter/leave the heart. Heart is situated
the heartbeat through the brain. within the fibrous and serous pericardial sacs. As heart
develops, it invaginates itself into the serous sac, without
causing any breach in its continuity. The last part to enter
Competency achievement: The student should be able to:
is the region of atria, from where the visceral pericardium
AN 22.1 Describe and demonstrate subdivisions, sinuses in
pericardium, blood supply and nerve supply of pericardium.1
is reflected as the parietal pericardium. Thus parietal
layer of serous pericardium gets adherent to the inner
surface of fibrous pericardium, while the visceral layer
of serous pericardium gets adherent to the outer layer
of heart and forms its epicardium.

Figs 18.1a and b: (a) Lines of incision, and (b) layers of the pericardium

283
 THORAX
284

5 On each side, it is related to the mediastinal pleura,

the mediastinal surface of the lung, the phrenic nerve,
and the pericardiacophrenic vessels.
6 It protects the heart against sudden overfilling and
prevents overexpansion of the heart.

SEROUS PERICARDIUM
Serous pericardium is thin, double-layered serous
membrane lined by mesothelium. The outer layer or
parietal pericardium is fused with the fibrous peri-
cardium. The inner layer or the visceral pericardium,
or epicardium is fused to the heart, except along the
cardiac grooves, where it is separated from the heart
by blood vessels. The two layers are continuous with
Fig. 18.2: Development of the layers of serous pericardium each other at the roots of the great vessels, i.e. ascending
aorta, pulmonary trunk, two venae cavae, and four pul-
monary veins.
FIBROUS PERICARDIUM The pericardial cavity is a potential space between the
Fibrous pericardium is a conical sac made up of fibrous parietal pericardium and the visceral pericardium. It
tissue. The parietal layer of serous pericardium is contains only a thin film of serous fluid which lubricates
attached to its deep surface. The following features of the apposed surfaces and allows the heart to beat
the fibrous pericardium are noteworthy. smoothly.
1 The apex is blunt and lies at the level of the sternal
angle. It is fused with the roots of the great vessels Sinuses of Pericardium
and with the pretracheal fascia. The epicardium at the roots of the great vessels is
2 The base is broad and inseparably blended with the arranged in form of two tubes. The arterial tube
central tendon of the diaphragm. encloses the ascending aorta and the pulmonary trunk
3 Anteriorly, it is connected to the upper and lower at the arterial end of the heart tube, and the venous
ends of body of the sternum by weak superior and tube encloses the venae cavae and pulmonary veins at
inferior sternopericardial ligaments (Fig. 18.3). the venous end of the heart tube. The passage between
4 Posteriorly, it is related to the principal bronchi, the the two tubes is known as the transverse sinus of
oesophagus with the nerve plexus around it and the pericardium. During development, to begin with, the
descending thoracic aorta.
veins of the heart are crowded together. As the heart
increases in size and these veins separate out, a
pericardial reflection surrounds all of them and forms
the oblique pericardial sinus. This cul-de-sac is posterior
to the left atrium (Fig. 18.4).
The transverse sinus is a horizontal gap between the
arterial and venous ends of the heart tube. It is bounded
anteriorly by the ascending aorta and pulmonary trunk,
Thorax

and posteriorly by the superior vena cava and inferiorly

by the left atrium; on each side, it opens into the general
pericardial cavity (Fig. 18.5). It develops from
degeneration of the central part of dorsal mesocardium.
The oblique sinus is a narrow gap behind the heart. It
is bounded anteriorly by the left atrium, and posteriorly
by the parietal pericardium and oesophagus. On the
2

right and left sides, it is bounded by reflections of

Section

pericardium as shown in Fig. 18.5. Below and to the

left, it opens into the rest of the pericardial cavity. The
oblique sinus permits pulsations of the left atrium to
Fig. 18.3: The relations of the fibrous pericardium to the roots take place freely (Figs 18.4 and 18.5). It develops due
of the great vessels, the diaphragm and the sternum to rearrangement of veins at the venous end.
 PERICARDIUM AND HEART
285

Nerve Supply
The fibrous and parietal pericardia are supplied by the
phrenic nerves. They are sensitive to pain. The
epicardium is supplied by autonomic nerves of the
heart and is not sensitive to pain. Pain of pericarditis
originates in the parietal pericardium alone. On the
other hand, cardiac pain or angina originates in the
cardiac muscle or in the vessels of the heart.

Development
Fibrous pericardium develops from septum transversum.

DISSECTION
Make a vertical cut through each side of the pericardium
Fig. 18.4: The pericardial cavity seen after removal of the heart. immediately anterior to the line of the phrenic nerve.
Note the reflections of pericardium, and the mode of formation Join the lower ends of these two incisions by a trans-
of the transverse and oblique sinuses verse cut approximately 1 cm above the diaphragm.
Turn the flap of pericardium upwards and sideways to
examine the pericardial cavity. See that the turned flap
comprises fibrous and parietal layer of visceral
pericardium. The pericardium enclosing the heart is its
visceral layer (Figs 18.2 and 18.3) (refer to BDC App).
Pass a probe from the right side behind the
ascending aorta and pulmonary trunk till it appears on
the left just to the right of left atrium. This probe is in the
transverse sinus of the pericardium (Fig. 18.4).
Lift the apex of the heart upwards. Put a finger behind
the left atrium into a cul-de-sac, bounded to the right
and below by inferior vena cava and above and to left
by lower left pulmonary vein. This is the oblique sinus
of pericardium.
Define the borders, surfaces, grooves, apex and base
of the heart.

Fig. 18.5: Transverse section through the upper part of the heart.
Note that oblique sinus forms posterior boundary of left atrium CLINICAL ANATOMY

• Collection of fluid in the pericardial cavity is

referred to as pericardial effusion (Fig. 18.6) or
Contents of Pericardium
1 Heart with cardiac vessels and nerves
2 Ascending aorta
3 Pulmonary trunk Thorax
4 Lower half of the superior vena cava
5 Terminal part of the inferior vena cava
6 The terminal parts of the pulmonary veins

Blood Supply
The fibrous and parietal pericardia are supplied by
2

branches from:
Section

1 Internal thoracic arteries

2 Musculophrenic arteries
3 The descending thoracic aorta
Fig. 18.6: Drainage of pericardial effusion
4 Veins drain into corresponding veins
 THORAX
286

cardiac tamponade. The fluid compresses the

heart and restricts venous filling during diastole.
It also reduces cardiac output. Pericardial effusion
can be drained by puncturing the left fifth or sixth
intercostal space just lateral to the sternum, or in
the angle between the xiphoid process and left
costal margin, with the needle directed upwards,
backwards and to the left (Fig. 18.6).
• In mitral stenosis, left atrium enlarges and com-
presses the oesophagus causing dysphagia.
• During heart surgery, the ligature is passed
through the transverse sinus around aorta and the
pulmonary trunk.

Fig. 18.7: Gross features: Sternocostal surface of heart

HEART

The heart is a conical hollow muscular organ situated anterior and posterior parts. Anterior part consists of
in the middle mediastinum. It is enclosed within the right and left halves. Right half is oblique between right
pericardium. It pumps blood to various parts of the auricle and right ventricle, lodging right coronary
body to meet their nutritive requirements. The Greek artery. Left part is small between left auricle and left
name for the heart is cardia from which we have the ventricle, lodges circumflex branch of left coronary
adjective cardiac. The Latin name for the heart is cor artery.
from which we have the adjective coronary. The coronary sulcus is overlapped anteriorly by the
The heart is placed obliquely behind the body of the ascending aorta and the pulmonary trunk. The inter-
sternum and adjoining parts of the costal cartilages, so atrial groove is faintly visible posteriorly, while ante-
that one-third of it lies to the right and two-thirds to riorly, it is hidden by the aorta and pulmonary trunk.
the left of the median plane. The direction of blood flow, The anterior interventricular groove is nearer to the left
from atria to the ventricles is downwards, forwards and margin of the heart. It runs downwards and to the left.
to the left. The heart measures about 12 × 9 cm and The lower end of the groove separates the apex from
weighs about 300 g in males and 250 g in females. the rest of the inferior border of the heart. The posterior
interventricular groove is situated on the diaphragmatic
EXTERNAL FEATURES or inferior surface of the heart. It is nearer to the right
The human heart has four chambers. These are the right margin of this surface (Figs 18.8a and b). The two inter-
and left atria and the right and left ventricles. The atria ventricular grooves meet at the inferior border near the
(Latin chamber) lie above and behind the ventricles. On apex.
the surface of the heart, they are separated from the Apex of the Heart
ventricles by an atrioventricular groove. The atria are
separated from each other by an interatrial groove. The Apex of the heart is formed entirely by the left ventricle.
ventricles are separated from each other by an It is directed downwards, forwards and to the left and
is overlapped by the anterior border of the left lung. It
Thorax

interventricular groove, which is subdivided into

anterior and posterior parts (Fig. 18.7). The heart has: is situated in the left fifth intercostal space 9 cm lateral
• An apex directed downwards, forwards and to to the midsternal line just medial to the midclavicular
the left. line. In the living subject, pulsations may be seen and
• A base (posterior surface) directed backwards felt over this region (Fig. 18.7).
• Three surfaces—anterior/sternocostal, inferior In children below 2 years, apex is situated in the left
and left lateral fourth intercostal space in midclavicular line.
• Borders: The surfaces are demarcated by upper,
2

inferior, right and left borders.

CLINICAL ANATOMY
Section

For surface marking, see Fig. 21.5.

Grooves or Sulci Normally, the cardiac apex or apex beat is on the
left side. In the condition called dextrocardia, the
The atria are separated from the ventricles by a circular apex is on the right side (Fig. 18.9). Dextrocardia may
atrioventricular or coronary sulcus, which is divided into
 PERICARDIUM AND HEART
287

Figs 18.8a and b: The posterior base and inferior surface of the heart

posture, and descends by one vertebra in the erect

posture. It is separated from the vertebral column by
the pericardium, the right pulmonary veins, the
oesophagus and the aorta (see Figs 15.3 and 17.2).
Borders of the Heart
1 The upper border is slightly oblique, and is formed
by the two atria, chiefly the left atrium.
2 The right border is more or less vertical and is formed
by the right atrium. It extends from superior vena
cava to inferior vena cava (IVC).
3 The inferior border is nearly horizontal and is formed
mainly by the right ventricle. A small part of it near
the apex is formed by left ventricle. It extends from
IVC to apex.
4 The left border is oblique and curved. It is formed
mainly by the left ventricle, and partly by the left
auricle. It separates the anterior and left surfaces of
the heart (Fig. 18.7). It extends from apex to left
Fig. 18.9: Dextrocardia
auricle.
Surfaces of the Heart Thorax
be part of a condition called situs inversus in which
The anterior or sternocostal surface is formed mainly by
all thoracic and abdominal viscera are a mirror image
the right atrium and right ventricle, and partly by the
of normal.
left ventricle and left auricle (Fig. 18.7). The left atrium
is not seen on the anterior surface as it is covered by
Base of the Heart the aorta and pulmonary trunk. Most of the sternocostal
The base of the heart is also called its posterior surface. surface is covered by the lungs, but a part of it that lies
It is formed mainly by the left atrium and by a small behind the cardiac notch of the left lung is uncovered.
2

part of the right atrium. The uncovered area is dull on percussion. Clinically, it
Section

In relation to the base, one can see the openings of is referred to as the area of superficial cardiac dullness.
four pulmonary veins which open into the left atrium; The inferior or diaphragmatic surface rests on the
and of the superior and inferior venae cavae (Latin, central tendon of the diaphragm. It is formed in its left
empty vein) which open into the right atrium. It is related two-thirds by the left ventricle, and in its right one-
to thoracic five to thoracic eight vertebrae in the lying third by the right ventricle. It is traversed by the
 THORAX
288

Table 18.1: Comparing the systemic circulation and pulmonary circulation

Systemic circulation Pulmonary circulation
Left ventricle Right ventricle

Aortic valve Pulmonary valve

Aorta Pulmonary trunk and pulmonary arteries

Oxygenated blood to all tissues except lungs Only to lungs

Venous blood collected Deoxygenated blood gets oxygenated

Superior and inferior venae cavae 4 pulmonary veins

Right atrium Left atrium

posterior interventricular groove, and is directed to the left side. Similarly cut along its lower edge by an
downwards and slightly backwards (Fig. 18.8). incision extending from the anterior end of the inferior
The left surface is formed mostly by the left ventricle, vena caval opening to the left side. Incise the anterior
and at the upper end by the left auricle. In its upper wall of the right atrium near its left margin and reflect the
part, the surface is crossed by the coronary sulcus. It is flap to the right (Fig. 18.10) (Refer to BDC App).
related to the left phrenic nerve, the left peri-
On its internal surface, see the vertical crista
cardiacophrenic vessels and the pericardium.
terminalis and horizontal pectinate muscles.
Crux of the Heart The fossa ovalis is on the interatrial septum and the
Crux of the heart is the meeting point of interatrial, opening of the coronary sinus is to the left of the inferior
vena caval opening.
atrioventricular and posterior interventricular grooves.
Define the three cusps of tricuspid valve.
Types of Circulation
There are two main types of circulations—systemic and External Features
pulmonary. Table 18.1 shows their comparison. 1 The chamber is elongated vertically, receiving the
superior vena cava at the upper end and the inferior
Competency achievement: The student should be able to: vena cava at the lower end (Fig. 18.11).
AN 22.2 Describe and demonstrate external and internal features 2 The upper end is prolonged to the left to form the
of each chamber of heart.2 right auricle (Latin little ear). The auricle covers the
root of the ascending aorta and partly overlaps the
infundibulum of the right ventricle. Its margins are
RIGHT ATRIUM
Thorax

notched and the interior is sponge-like, which

prevents free flow of blood.
Position
3 Along the right border of the atrium, there is a
The right atrium is the right upper chamber of the heart. shallow vertical groove which passes from the
It receives venous blood from the whole body, pumps superior vena cava to the inferior vena cava. This
it to the right ventricle through the right atrioventricular groove is called the sulcus terminalis. It is produced
or tricuspid opening. It forms the right border, part of by an internal muscular ridge called the crista
the upper border, the sternocostal surface and the base terminalis (Fig. 18.11a). The upper part of the sulcus
2

of the heart (Fig. 18.7). contains the sinuatrial or SA node which acts as the
Section

pacemaker of the heart.

DISSECTION 4 The right atrioventricular groove separates the right
Cut along the upper edge of the right auricle by an incision atrium from the right ventricle. It is more or less
from the anterior end of the superior vena caval opening vertical and lodges the right coronary artery and the
small cardiac vein.
 PERICARDIUM AND HEART
289

Fig. 18.10: External features of heart: (1) Line of incision for right atrium, (2) for right ventricle, and (3) for left ventricle

Thorax
Fig. 18.11a: Interior of right atrium (cut along sulcus terminalis)

Right Atrioventricular Orifice

Blood passes out of the right atrium through the right
Tributaries or Inlets of the Right Atrium atrioventricular or tricuspid orifice and goes to the right
1 Superior vena cava ventricle. The tricuspid orifice is guarded by the
2

2 Inferior vena cava tricuspid valve which maintains unidirectional flow of

Section

3 Coronary sinus blood (Fig. 18.11b).

4 Anterior cardiac veins Internal Features
5 Venae cordis minimae (thebesian veins) The interior of the right atrium can be broadly divided
6 Sometimes the right marginal vein into the following three parts:
 THORAX
290

Fig. 18.11b: Interior of right atrium (cut along coronary sulcus)

Smooth Posterior Part or Sinus Venarum orifice, giving the appearance of the teeth of a comb. In
1 Developmentally, it is derived from the right horn the auricle, the muscles are interconnected to form a
of the sinus venosus. reticular network.
2 Most of the tributaries except the anterior cardiac
veins open into it. Interatrial Septum
a The superior vena cava opens at the upper end. 1 Developmentally, it is derived from the septum
b The inferior vena cava opens at the lower end primum and septum secundum.
(Fig. 18.11a).
2 It presents the fossa ovalis, a shallow saucer-shaped
The opening of inferior vena cava is guarded depression, in the lower part. The fossa represents
by a rudimentary valve of the inferior vena cava the site of the embryonic septum primum.
or Eustachian valve. During embryonic life, the
3 The annulus ovalis or limbus (Latin a border) fossa ovalis
valve guides the inferior vena caval blood to the
is the prominent margin of the fossa ovalis. It
left atrium through the foramen ovale.
represents the lower free edge of the septum
c. The coronary sinus opens between the opening of
secundum. It is distinct above and at the sides of the
the inferior vena cava and the right atrioven-
fossa ovalis, but is deficient inferiorly. Its anterior
tricular orifice. The opening is guarded by the valve
edge is continuous with the left end of the valve of
of the coronary sinus or thebesian valve.
the inferior vena cava.
d. The venae cordis minimae are numerous small veins
present in the walls of all the four chambers. They 4 The remains of the foramen ovale are occasionally
open into the right atrium through small foramina. present. This is a small slit-like valvular opening
3 The intervenous tubercle of Lower is a very small pro- between the upper part of the fossa and the limbus. It
Thorax

jection, scarcely visible, on the posterior wall of the is normally occluded after birth, but may sometimes
atrium just below the opening of the superior vena persist.
cava. During embryonic life, it directs the superior
caval blood to the right ventricle.
RIGHT VENTRICLE
Rough Anterior Part or Pectinate Part,
including the Auricle Position
2

1 Developmentally, it is derived from the primitive The right ventricle is a triangular chamber which
Section

atrial chamber. receives blood from the right atrium and pumps it to
2 It presents a series of transverse muscular ridges the lungs through the pulmonary trunk and pulmonary
called musculi pectinati (Figs 18.11a and b). arteries. It forms the inferior border and two-thirds part
They arise from the crista terminalis and run for- of the sternocostal surface and one-third part of inferior
wards and downwards towards the atrioventricular surface of the heart (Fig. 18.7).
 PERICARDIUM AND HEART
291

Fig. 18.12a and b: Interior of the right ventricle. Note the moderator band and the supraventricular crest

External Features muscle is small and irregular. The septal muscle is

1. Externally, the right ventricle has two surfaces— divided into a number of little nipples. Each papillary
anterior or sternocostal and inferior or diaphragmatic. muscle is attached by chordae tendineae to the
2. The interior has two parts: contiguous sides of two cusps (Fig. 18.13).
a. The inflowing part is rough due to the presence of 3 The septomarginal trabecula or moderator band is a
muscular ridges called trabeculae carneae. It muscular ridge extending from the ventricular
develops from the proximal part of bulbus cordis septum to the base of the anterior papillary muscle.
of the heart tube. It contains the right branch of the AV bundle
(Figs 18.12 and 18.14).
b. The outflowing part or infundibulum is smooth
4 The cavity of the right ventricle is crescentic in section
and forms the upper conical part of the right
because of the forward bulge of the interventricular
ventricle which gives rise to the pulmonary trunk.
septum (Fig. 18.15).
It develops from the midportion of the bulbus
5 The wall of the right ventricle is thinner than that of
cordis.
the left ventricle in a ratio of 1:3.
The two parts are separated by a muscular ridge called
the supraventricular crest or infundibuloventricular crest Interventricular Septum
situated between the tricuspid and pulmonary orifices. The septum is placed obliquely. Its one surface faces
forwards and to the right and the other faces backwards
Internal Features
1 The interior shows two orifices:
a The right atrioventricular or tricuspid orifice,
guarded by the tricuspid valve. Thorax
b. The pulmonary orifice guarded by the pulmonary
valve (Figs 18.12a and b).
2 The interior of the inflowing part shows trabeculae
carneae or muscular ridges of three types:
a. Ridges or fixed elevations
b. Bridges
c. Pillars or papillary muscles with one end attached
2

to the ventricular wall, and the other end

Section

connected to the cusps of the tricuspid valve by

chordae tendineae (Latin strings to stretch). There
are three papillary muscles in the right ventricle—
anterior, posterior and septal. The anterior muscle
is the largest (Fig. 18.12). The posterior or inferior Fig. 18.13: Structure of an atrioventricular valve
 THORAX
292

along the inferior border till the inferior end of anterior

interventricular groove. Next cut along the infundibulum.
Now the anterior wall of right ventricle is reflected to
the left to study its interior (Fig. 18.10) (Refer to BDC App).

LEFT ATRIUM

Position
The left atrium is a quadrangular chamber situated
posteriorly. Its appendage, the left auricle projects
anteriorly to overlap the infundibulum of the right
ventricle. The left atrium forms the left two-thirds of
the base of the heart, the greater part of the upper
border, parts of the sternocostal and left surfaces and
the left border. It receives oxygenated blood from the
lungs through four pulmonary veins, and pumps it to
Fig. 18.14: The conducting system of the heart the left ventricle through the left atrioventricular or
bicuspid (Latin two tooth point) or mitral orifice (Latin
like bishop’s mitre) which is guarded by the valve of the
and to the left. The upper part of the septum is thin and same name.
membranous and separates not only the two ventricles
but also the right atrium and left ventricle. The lower Features
part is thick muscular and separates the two ventricles 1 The posterior surface of the atrium forms the anterior
(Fig. 18.15). Its position is indicated by the anterior and wall of the oblique sinus of pericardium (Fig. 18.5).
posterior interventricular grooves. 2 The anterior wall of the atrium is formed by the
interatrial septum.
DISSECTION 3 Two pulmonary veins open into the atrium on each
Incise along the ventricular aspect of right AV groove, side of the posterior wall (Fig. 18.8).
till you reach the inferior border. Continue to incise 4 The greater part of the interior of the atrium is smooth
walled. It is derived embryologically from the
Thorax
2
Section

Fig. 18.15: Schematic transverse section through the ventricles of the heart showing the atrioventricular orifices, papillary muscles,
and the pulmonary and aortic orifices
 PERICARDIUM AND HEART
293

Table 18.2: Comparison of right atrium and left atrium

Right atrium Left atrium
Receives venous blood of the body Receives oxygenated blood from lungs
Pushes blood to right ventricle through tricuspid valve Pushes blood to left ventricle through bicuspid valve
Forms right border, part of sternocostal and Forms major part of base of the heart
small part of base of the heart
Enlarged in tricuspid stenosis Enlarged in mitral stenosis

absorbed pulmonary veins which open into it. LEFT VENTRICLE

Musculi pectinati are present only in the auricle where
they form a reticulum. This part develops from the
Position
original primitive atrial chamber of the heart tube.
The septal wall shows the fossa lunata corresponding The left ventricle receives oxygenated blood from the
to the fossa ovalis of the right atrium. In addition to left atrium and pumps it into the aorta. It forms the
the four pulmonary veins, the tributaries of the atrium apex of the heart, a part of the sternocostal surface, most
include a few venae cordis minimae. of the left border and left surface, and the left two-thirds
Table 18.2 compares the right atrium and the left of the diaphragmatic surface (Figs 18.7 and 18.8).
atrium.
Features
DISSECTION 1 Externally, the left ventricle has three surfaces—
anterior or sternocostal, inferior or diaphragmatic,
Cut off the pulmonary trunk and ascending aorta,
and left.
immediately above the three cusps of the pulmonary
and aortic valves. Remove the upper part of the left 2 The interior is divisible into two parts:
atrium to visualise its interior (Fig. 18.8). See the upper a. The lower rough part with trabeculae carneae
surface of the cusps of the mitral valve. Revise the fact develops from the primitive ventricle of the heart
that left atrium forms the anterior wall of the oblique tube (Fig. 18.16).
sinus of the pericardium (Fig. 18.5) (refer to BDC App). b. The upper smooth part or aortic vestibule gives
origin to the ascending aorta: It develops from the

Thorax
2Section

Figs 18.16a and b: Interior of left atrium and left ventricle

 THORAX
294

midportion of the bulbus cordis. The vestibule lies

• Slow pulse or decreased heart rate is called
between the membranous part of the inter-
bradycardia (Greek slow heart).
ventricular septum and the anterior or aortic cusp
• Irregular pulse or irregular heart rate is called
of the mitral valve.
arrhythmia.
3 The interior of the ventricle shows two orifices:
• Consciousness of one’s heartbeat is called
a. The left atrioventricular or bicuspid or mitral
palpitation.
orifice, guarded by the bicuspid or mitral valve.
• Inflammation of the heart can involve more than
b. The aortic orifice, guarded by the aortic valve one layer of the heart. Inflammation of the
(Fig. 18.15). pericardium is called pericarditis; of the myo-
4 There are two well-developed papillary muscles— cardium is myocarditis; and of the endocardium is
anterior and posterior. Chordae tendineae from both endocarditis.
muscles are attached to both the cusps of the mitral • Normally, the diastolic pressure in ventricles is
valve. zero. A positive diastolic pressure in the ventricle
5 The cavity of the left ventricle is circular in cross- is evidence of its failure. Any one of the four
section (Fig. 18.15). chambers of the heart can fail separately, but
6 The walls of the left ventricle are three times thicker ultimately the rising back pressure causes right-
than those of the right ventricle. sided failure (congestive cardiac failure or CCF)
Table 18.3 compares the right ventricle and the left which is associated with increased venous
ventricle. pressure, oedema on feet, and breathlessness on
exertion. Heart failure (right sided) due to lung
DISSECTION disease is known as cor pulmonale.
Open the left ventricle by making a bold incision on the
ventricular aspect of atrioventricular groove below left
auricle and along whole thickness of left ventricle from
above downwards till its apex. Curve the incision
STRUCTURE OF HEART
towards right till the inferior end of anterior inter-
ventricular groove. Reflect the flap to the right and clean VALVES
the atrioventricular and aortic valves (Fig. 18.10). The valves of the heart maintain unidirectional flow
Remove the surface layers of the myocardium. Note of the blood and prevent its regurgitation in the
the general directions of its fibres and the depth of the opposite direction. There are two pairs of valves in
coronary sulcus, the wall of the atrium passing deep to the the heart, a pair of atrioventricular valves and a pair
bulging ventricular muscle. Dissect the musculature and of semilunar valves. The right atrioventricular valve
the conducting system of the heart (refer to BDC App). is known as the tricuspid valve because it has three
cusps. The left atrioventricular valve is known as the
bicuspid valve because it has two cusps. It is also called
CLINICAL ANATOMY the mitral valve. The semilunar valves include the
• The area of the chest wall overlying the heart is aortic and pulmonary valves, each having three
called the precordium. semilunar cusps. The cusps are folds of endocardium,
• Rapid pulse or increased heart rate is called strengthened by an intervening layer of fibrous tissue
tachycardia (Greek rapid heart). (Figs 18.17a and b).
Thorax

Table 18.3: Comparison of right ventricle and left ventricle

Right ventricle Left ventricle
Thinner than left, one-third thickness of Much thicker than right, 3 times thicker than right
left ventricle ventricle
Pushes blood only to the lungs Pushes blood to top of the body and down to the toes
2

Contains three small papillary muscles Contains two strong papillary muscles
Section

Cavity is crescentic Cavity is circular

Contains deoxygenated blood Contains oxygenated blood
Forms two-thirds sternocostal and one-third Forms one-third sternocostal and two-thirds diaphragmatic
diaphragmatic surfaces surfaces
 PERICARDIUM AND HEART
295

Figs 18.17a and b: (a) Interior of heart, and (b) the cusps of atrioventricular valves

Atrioventricular Valves 4 The mitral or bicuspid valve has two cusps—a large
1 Both valves are made up of the following com- anterior or aortic cusp, and a small posterior cusp. It
ponents. admits the tips of two fingers. The anterior cusp lies
a. A fibrous ring to which the cusps are attached between the mitral and aortic orifices. The mitral
(Fig. 18.13). cusps are smaller and thicker than those of the tricuspid
valve.
b. The cusps are flat and project into the ventricular For surface marking of valves, see Fig. 21.6.
cavity. Each cusp has an attached and a free
margin, and an atrial and a ventricular surface. Semilunar Valves
The atrial surface is smooth (Fig. 18.16). The free
1 The aortic and pulmonary valves are called semilunar
margins and ventricular surfaces are rough and
valves because their cusps are semilunar in shape. Both
irregular due to the attachment of chordae
valves are similar to each other (Figs 18.17a and b).
tendineae. The valves are closed during ventricular
2 Each valve has three cusps which are attached directly
systole (Greek contraction) by apposition of the atrial
to the vessel wall, there being no fibrous ring. The
surfaces near the serrated margins (Fig. 18.15).
cusps form small pockets with their mouths directed
c. The chordae tendineae connect the free margins and away from the ventricular cavity. The free margin of
ventricular surfaces of the cusps to the apices of the each cusp contains a central fibrous nodule from each
papillary muscles. They prevent eversion of the side of which a thin smooth margin the lunule extends
free margins and limit the amount of ballooning up to the base of the cusp. These valves are closed
of the cusps towards the cavity of the atrium. during ventricular diastole when each cusp bulges
d. The atrioventricular valves are kept competent by towards the ventricular cavity (Fig. 18.17).
active contraction of the papillary muscles, which 3 Opposite the cusps, the vessel walls are slightly
pull on the chordae tendineae during ventricular dilated to form the aortic and pulmonary sinuses.
systole. Each papillary muscle is connected to the The coronary arteries arise from the anterior and the Thorax
contiguous halves of two cusps (Fig. 18.13). left posterior aortic sinuses (Fig. 18.18).
2 Blood vessels are present only in the fibrous ring and For surface marking, see Fig. 21.6.
in the basal one-third of the cusps. Nutrition to the
central two-thirds of the cusps is derived directly CLINICAL ANATOMY
from the blood in the cavity of the heart. • The first heart sound is produced by closure of
3 The tricuspid valve has three cusps are can admit the the atrioventricular valves. The second heart
2

tips of three fingers. The three cusps—the anterior, sound is produced by closure of the semilunar
Section

posterior or inferior, and septal. These lie against the valves (Figs 18.19a and b).
three walls of the ventricle. Of the three papillary
• Narrowing of the valve orifice due to fusion of
muscles, the anterior is the largest, the inferior is
the cusps is known as ‘stenosis’, viz. mitral
smaller and irregular, and the septal is represented
stenosis, aortic stenosis, etc.
by a number of small muscular elevations.
 THORAX
296

FIBROUS SKELETON
The fibrous rings surrounding the atrioventricular and
arterial orifices, along with some adjoining masses of
fibrous tissue, constitute the fibrous skeleton of the
heart. It provides attachment to the cardiac muscle and
keeps the cardiac valves competent (Fig. 18.20).
The atrioventricular fibrous rings are in the form of
the figure of 8. The atria, the ventricles and the
membranous part of the interventricular septum are
attached to them. There is no muscular continuity
between the atria and ventricles across the rings except
for the atrioventricular bundle or bundle of His.
There is large mass of fibrous tissue between the
atrioventricular rings behind and the aortic ring in front.
Fig. 18.18: Structure of the aortic valve It is known as the trigonum fibrosum dextrum. In some
mammals, like sheep, a small bone the os cordis is
present in this mass of fibrous tissue.
Another smaller mass of fibrous tissue is present
between the aortic and mitral rings. It is known as the
trigonum fibrosum sinistrum. The tendon of the infundi-
bulum (close to pulmonary valve) binds the posterior
surface of the infundibulum to the aortic ring.

MUSCULATURE OF THE HEART

Cardiac muscle fibres form long loops which are
attached to the fibrous skeleton. Upon contraction of the
muscular loops, the blood from the cardiac chambers is
wrung out like water from a wet cloth. The atrial fibres
are arranged in a superficial transverse layer and a deep
anteroposterior (vertical) layer.
The ventricular fibres are arranged in superficial and
deep layers.
The superficial fibres arise from skeleton of the heart
to undergo a spiral course. First these pass across the
inferior surface, wind round the lower border and then
Thorax

Figs 18.19a and b: (a) First heart sound, and (b) second heart
sound

• Dilatation of the valve orifice, or stiffening of the

cusps causes imperfect closure of the valve leading
to back flow of blood. This is known as incom-
2

petence or regurgitation, e.g. aortic incompetence

or aortic regurgitation.
Section

Fig. 18.20: Heart seen from above after removing the atria. The
Competency achievement: The student should be able to: mitral, tricuspid, aortic and pulmonary orifices and their valves
are seen. The fibrous skeleton of the heart is also shown
AN 22.6 Describe the fibrous skeleton of heart.3
(anatomical position)
 PERICARDIUM AND HEART
297

Fig. 18.21a: Superficial transverse fibres of atria and superficial

fibres of ventricles 1, 2
Fig. 18.21b: Vertical fibres of atria and superficial fibres of
ventricle 3
across the sternocostal surface to reach the apex of heart,
where these fibres form a vortex and continue with the
deep layer.
Superficial fibres are:
a. Fibres start from tendon of infundibulum (1) pass
across the diaphragmatic surface, curve around
inferior border to reach the sternocostal surface.
Then these fibres cross the anterior interventri-
cular groove to reach the apex, where these form
a vortex and end in anterior papillary muscle of
left ventricle (Fig. 18.21a).
b. Fibres arise from right AV ring take same course
as (2) but end in posterior papillary muscle
(Fig. 18.21a).
c. Fibres arise from left AV ring, lie along the Fig. 18.21c: Deep fibres of ventricles in three layers
diaphragmatic surface, cross the posterior inter-
ventricular groove to reach the papillary muscles Thorax
of right ventricle (Fig. 18.21b). CONDUCTING SYSTEM
d. Deep fibres are ‘S’ shaped. These arise from The conducting system is made up of myocardium that
papillary muscle of one ventricle, turn in inter- is specialised for initiation and conduction of the cardiac
ventricular groove, to end in papillary muscle of impulse. Its fibres are finer than other myocardial fibres,
other ventricle. Fibres of first layer circle RV, cross and are completely cross-striated. The conducting
through interventricular septum and end in system has the following parts.
papillary muscle of LV. Layers two and three have 1 Sinuatrial node or SA node: It is known as the
2

decreasing course in RV and increasing course in ‘pacemaker’ of the heart. It generates impulses at the
LV (Fig. 18.21c).
Section

rate of about 70–100 beats/min and initiates the

heartbeat. It is horseshoe-shaped and is situated at
the atriocaval junction in the upper part of the sulcus
Competency achievement: The student should be able to:

terminals. The impulse travels through the atrial wall

AN 22.7 Mention the parts, position and arterial supply of the
conducting system of heart.4
to reach the AV node (Fig. 18.14).
 THORAX
298

2 Atrioventricular node or AV node: It is smaller than Features of Coronary Arteries

the SA node and is situated in the lower and dorsal i. The blood flows through these arteries during
part of the atrial septum just above the opening of diastole of heart.
the coronary sinus. It is capable of generating ii. Diameter is 1.5–5.2 mm.
impulses at a rate of about 40 to 60 beats/minute. iii. Left coronary is larger in calibre and supplies
3 Atrioventricular bundle or AV bundle or bundle of His: It more myocardium.
is the only muscular connection between the atrial and iv. These arteries are ‘functional end arteries’.
ventricular musculatures. It begins as the atrio- Though their branches anastomose with each
ventricular (AV) node crosses AV ring and descends other but one cannot compensate for the other
along the posteroinferior border of the membranous artery in case of thrombosis.
part of the ventricular septum. At the upper border v. The origin of posterior interventricular artery
of the muscular part of the septum, it divides into right determines the dominance of the artery.
and left branches. vi. Sympathetic stimulation dilates the intra-
4 The right branch of the AV bundle passes down the muscular arteries and constricts the epicardial
right side of the interventricular septum. A large part arteries.
enters the moderator band to reach the anterior wall
of the right ventricle where it divides into Purkinje RIGHT CORONARY ARTERY
fibres. Position
5 The left branch of the AV bundle descends on the Right coronary artery is smaller than the left coronary
left side of the interventricular septum and is artery. It arises from the anterior aortic sinus
distributed to the left ventricle after dividing into (Figs 18.22a and b) of ascending aorta.
Purkinje fibres.
6. The Purkinje fibres form a subendocardial plexus. Course
They are large pale fibres striated only at their 1 It first passes forwards and to the right to emerge on
margins. They usually possess double nuclei. These the surface of the heart between the root of the
generate impulses at the rate of 20–35 beats/minute. pulmonary trunk and the right auricle.
2 It then runs downwards in the right anterior
Blood supply: Whole of conducting system except left coronary sulcus to the junction of the right and
branch of AV bundle is supplied by right coronary inferior borders of the heart.
artery. In 40% cases, left coronary artery supplies SA
3 It winds round the inferior border to reach the
node.
diaphragmatic surface of the heart. Here it runs
backwards and to the left in the right posterior
CLINICAL ANATOMY coronary sulcus to reach the posterior inter-
ventricular groove.
Defects of or damage to conducting system results 4 It terminates by anastomosing with the circumflex
in cardiac arrhythmias, i.e. defects in the normal branch of left coronary artery at the crux.
rhythm of contraction. Except for a part of the left
branch of the AV bundle supplied by the left Branches
coronary artery, the whole of the conducting system • Atrial branches are anterior, posterior and lateral.
is usually supplied by the right coronary artery. One of the anterior atrial branches is called SA nodal
Thorax

Vascular lesions of the heart can cause a variety of artery. It arises from right coronary artery in 60%
arrhythmias. cases.
• Right conus artery forms an arterial circle around
Competency achievement: The student should be able to: pulmonary trunk with a similar branch from the left
AN 22.3 Describe and demonstrate origin, course and branches of coronary artery. The circle is called, ‘annulus of
coronary arteries.5 Vieussens’.
• Ventricular branches are as anterior and posterior
2

groups. The anterior group lies on the sternocostal

ARTERIES SUPPLYING THE HEART
Section

surface while posterior group traverses the

diaphragmatic surface of the heart.
The heart is supplied by two coronary arteries, arising • Right marginal artery arises as the right coronary
from the ascending aorta. Both arteries run in the artery crosses the right border of heart. It runs along
coronary sulcus. its inferior border till the apex of heart.
 PERICARDIUM AND HEART
299

DISSECTION
Carefully remove the fat from the coronary sulcus.
Identify the right coronary artery in the depth of the right
part of the atrioventricular sulcus (Figs 18.22a and b).
Trace the right coronary artery superiorly to its
origin from the right aortic sinus and inferiorly till it turns
onto the posterior surface of the heart to lie in its
atrioventricular sulcus. It gives off the posterior inter-
ventricular branch which is seen in posterior inter-
ventricular groove.
The right coronary artery ends by anastomosing with
the circumflex branch of left coronary artery or by
dipping itself deep in the myocardium there.

LEFT CORONARY ARTERY

Position
Left coronary artery is larger than the right coronary
artery. It arises from the left posterior aortic sinus of
ascending aorta.

Course
1 The artery first runs forwards and to the left and
emerges between the pulmonary trunk and the left
auricle. Here it gives the anterior interventricular
branch which runs downwards in the groove of the
same name. The further continuation of the left
coronary artery is called the circumflex artery
(Figs 18.22a and 18.23).
2 After giving off the anterior interventricular branch,
the artery runs to the left in the left anterior coronary
sulcus.

Figs 18.22a and b: Arterial supply of heart: (a) Sternocostal

surface, and (b) diaphragmatic surface

• Posterior interventricular branch arises close to the

crux of heart and lies in the posterior interventicular
groove. It gives septal branches to posterior one-third
of interventricular septum. It also supplies AV node.
Thorax
Area of Distribution
1 Right atrium
2 Ventricles:
a. Greater part of the right ventricle, except the area
adjoining the anterior interventricular groove.
b. A small part of the left ventricle adjoining the
2

posterior interventricular groove.

Section

3 Posterior one-third part of the interventricular septum.

4 Whole of the conducting system of the heart except
a part of the left branch of the AV bundle. The SA Fig. 18.23: Origin of the coronary arteries from the aortic sinuses
node is supplied by the left coronary artery in about and their course in the coronary sulcus, as seen after removal
40% of cases. of the atria (anatomical position)
 THORAX
300

3 It winds round the left border of the heart and

continues in the left posterior coronary sulcus. Near
the posterior interventricular groove, it terminates
by anastomosing with the right coronary artery.
Branches
• Anterior interventricular branch is a large branch. It
descends in the anterior interventricular groove. It
gives following branches.
i. Anterior ventricular branches for the ventricles.
The large branch is called ‘left diagonal artery’.
ii. Septal branches which supply anterior two-thirds
of the interventricular septum.
iii. Left conus artery forms an arterial ring around
the pulomonary trunk with a similar branch from
right coronary artery. Fig. 18.24: Transverse section through the ventricles showing
• Circumflex branch is the terminal part of left the areas supplied by the two coronary arteries
coronary artery after it has given off the large anterior
interventricular branch. Circumflex branch runs in CARDIAC DOMINANCE
the left anterior coronary sulcus, then curves around In about 10% of hearts, the right coronary is rather small
the left border of heart to lie in the left posterior and is not able to give the posterior interventricular
coronary sulcus. It ends by anastomosing with the branch. In these cases, the circumflex artery, the
terminal part of right coronary artery, a little to the continuation of left coronary, provides the posterior
left of the crux. Its branches are: interventricular branch as well as to the AV node. Such
i. Left marginal artery which lies along the left cases are called left dominant.
border of heart till the apex of heart.
Mostly, the right coronary gives posterior inter-
ii. Anterior and posterior ventricular branches
ventricular artery. Such hearts are right dominant. Thus
iii. Atrial branches which are in anterior, posterior
the artery giving the posterior interventricular branch
and lateral groups.
is the dominant artery.
Area of Distribution
Collateral Circulation
1 Left atrium
2 Ventricles: Cardiac Anastomoses
a. Greater part of the left ventricle, except the area The two coronary arteries anastomose with each other
adjoining the posterior interventricular groove. in myocardium.
b. A small part of the right ventricle adjoining the
anterior interventricular groove. Extracardiac Anastomoses
3 Anterior part of the interventricular septum (Fig. 18.24).
The coronary arteries anastomose with the following.
4 A part of the left branch of the AV bundle. 1 Vasa vasorum of the aorta
2 Vasa vasorum of the pulmonary arteries
DISSECTION 3 The internal thoracic arteries
Thorax

Strip the visceral pericardium from the sternocostal 4 The bronchial arteries
surface of the heart. Expose the anterior interventricular 5 The pericardiacophrenic arteries
branch of the left coronary artery and the great cardiac The last three anastomose through the pericardium.
vein by carefully removing the fat from the anterior These channels may open up in emergencies when both
interventricular sulcus. Note the branches of the artery coronary arteries are obstructed.
to both ventricles and to the interventricular septum
Retrograde flow of blood in the veins may irrigate the
which lies deep to it. Trace the artery inferiorly to the
myocardium.
2

diaphragmatic surface and superiorly to the left of the

These anastomoses are of little practical value. They
pulmonary trunk (Fig. 18.22b).
Section

are not able to provide an alternative source of blood

Trace the circumflex branch of left coronary artery
in case of blockage of a branch of a coronary artery.
on the left border of heart into the posterior part of
Blockage of arteries or coronary thrombosis usually
the sulcus, where it may end by anastomosing with the
leads to death of myocardium. The condition is called
right coronary artery or by dipping into the myocardium.
myocardial infarction.
 PERICARDIUM AND HEART
301

Competency achievement: The student should be able to: • Incomplete obstruction, usually due to spasm of
AN 22.4 Describe anatomical basis of ischaemic heart disease.6 the coronary artery causes angina pectoris, which
is associated with agonising pain in the precordial
region and down the medial side of the left arm
CLINICAL ANATOMY and forearm (Fig. 18.26). Pain gets relieved by
putting appropriate tablets below the tongue.
• Thrombosis of coronary artery is a common cause
of sudden death in persons past middle age. This • Coronary angiography determines the site(s) of
is due to myocardial ischaemia infarction and narrowing or occlusion of the coronary arteries
ventricular fibrillation (Fig. 18.25). or their branches.
• Angioplasty helps in removal of small blockage.
It is done using small stent or small inflated
balloon (Fig. 18.27) through a catheter passed
upwards through femoral artery, aorta, into the
coronary artery.
• If there are large segments or multiple sites of
blockage, coronary bypass is done using either
great saphenous vein or internal thoracic artery
as graft(s) (Fig. 18.28).

Fig. 18.25: Myocardial infarction due to blockage of anterior

interventricular branch of left coronary artery Fig. 18.27: Stent passed in the blocked coronary artery

Thorax

Fig. 18.28: Grafts put beyond the site of blockage

2

VEINS OF THE HEART

Section

These are the great cardiac vein, the middle cardiac

vein, the right marginal vein, the posterior vein of the
Fig. 18.26: Pain of angina pectoris felt in precordium and
along medial border of left arm
left ventricle, the oblique vein of the left atrium, the
anterior cardiac veins, and the venae cordis minimae
 THORAX
302

Figs 18.29a and b: Veins of the heart: (a) Sternocostal surface, and (b) diaphragmatic surface

(Figs 18.29a and b). All veins except the last two drain 6 The right marginal vein accompanies the marginal
into the coronary sinus which opens into the right branch of the right coronary artery. It may either drain
atrium. The anterior cardiac veins and the venae cordis into the small cardiac vein, or may open directly into
minimae open directly into the right atrium. the right atrium.
Competency achievement: The student should be able to: Anterior Cardiac Veins
AN 22.5 Describe and demonstrate the formation, course, The anterior cardiac veins are three or four small veins
tributaries and termination of coronary sinus.7 which run parallel to one another on the anterior wall of
the right ventricle and usually open directly into the
Coronary Sinus right atrium through its anterior wall.
The coronary sinus is the largest vein of the heart. It is
situated in the left posterior coronary sulcus. It is about Venae Cordis Minimae
3 cm long. It ends by opening into the posterior wall of The venae cordis minimae or thebesian veins or smallest
the right atrium. It receives the following tributaries: cardiac veins are numerous small valveless veins present
1 The great cardiac vein accompanies first the anterior in all four chambers of the heart which open directly into
interventricular artery and then the circumflex artery the cavity. These are more numerous on the right side
to enter the left end of the coronary sinus of the heart than on the left. This may be one reason why
(Fig. 18.29a). It receives the left marginal vein from left-sided infarcts are more common.
the left ventricle.
LYMPHATICS OF HEART
2 The middle cardiac vein accompanies the posterior
interventricular artery, and joins the middle part of Lymphatics of the heart accompany the coronary
the coronary sinus. arteries and form two trunks. The right trunk ends in
Thorax

3 The small cardiac vein accompanies the right coronary the brachiocephalic nodes, and the left trunk ends in the
artery in the right posterior coronary sulcus and joins tracheobronchial lymph nodes at the bifurcation of
the right end of the coronary sinus. The right marginal the trachea.
vein may drain into the small cardiac vein (Fig. 18.29b).
4 The posterior vein of the left ventricle runs on the NERVE SUPPLY OF HEART
diaphragmatic surface of the left ventricle and ends
in the coronary sinus. Parasympathetic nerves reach the heart via the vagus.
2

5 The oblique vein of the left atrium of Marshall is a small These are cardioinhibitory; on stimulation, they slow
Section

vein running on the posterior surface of the left down the heart rate.
atrium. It terminates in the left end of the coronary Sympathetic nerves are derived from the upper four
sinus. It develops from the left common cardinal vein to five thoracic segments of the spinal cord. These are
or duct of Cuvier which may sometimes form a large cardioacceleratory, and on stimulation, they increase
left superior vena cava. the heart rate, and also dilate the coronary arteries.
 PERICARDIUM AND HEART
303

Fig. 18.30: Formation of superficial and deep cardiac plexuses

Both parasympathetic and sympathetic nerves form

the superficial and deep cardiac plexuses, the branches • Axons of pain fibres conveyed by the sensory
of which run along the coronary arteries to reach the sympathetic cardiac nerves reach thoracic one to
myocardium. thoracic five segments of spinal cord mostly
through the dorsal root ganglia of the left side.
The superficial cardiac plexus is situated below the arch Since these dorsal root ganglia also receive
of the aorta in front of the right pulmonary artery. It is sensory impulses from the medial side of arm,
formed by: forearm and upper part of front of chest, the pain
a. The superior cervical cardiac branch of the left gets referred to these areas as depicted in
sympathetic chain. Fig. 18.26.
b. The inferior cervical cardiac branch of the left • Viscera have low amount of sensory output
vagus nerve. whereas skin is an area of high amount of sensory
The plexus is connected to the deep cardiac plexus, output. So pain arising from area of low sensory
the right coronary artery, and to the left anterior output area is projected as coming from high
pulmonary plexus (Fig. 18.30). sensory output area.
The deep cardiac plexus is situated in front of the
bifurcation of the trachea, and behind the arch of the Competency achievement: The student should be able to:
aorta. It is formed by all the cardiac branches derived AN 25.2 Describe development of respiratory system and heart.8 Thorax
from all the cervical and upper thoracic ganglia of the Development of respiratory system has been
sympathetic chain, and the cardiac branches of the vagus described in Chapter 16 and development of heart has
and recurrent laryngeal nerves, except those which form been described in this chapter.
the superficial plexus. The right and left halves of the
plexus distribute branches to the corresponding
coronary and pulmonary plexuses. Separate branches DEVELOPMENTAL COMPONENTS
are given to the atria.
2

1 Right atrium (Fig. 18.11)

a. Rough anterior part—atrial chamber proper.
Section

CLINICAL ANATOMY b. Smooth posterior part:

– Absorption of right horn of sinus venosus
• Cardiac pain is an ischaemic pain caused by
– Interatrial septum
incomplete obstruction of a coronary artery.
Demarcating part—crista terminalis.
 THORAX
304

2 Left atrium (Figs 18.16 and 18.29b) Competency achievement: The student should be able to:
a. Rough part—atrial chamber proper AN 25.3 Describe fetal circulation and changes occurring at birth.9
b. Smooth part:
– Absorption of pulmonary veins.
FOETAL CIRCULATION
– Interatrial septum.
3 Right ventricle The foetus (Greek offspring) is dependent for its entire
a. Rough part—proximal portion of bulbus cordis nutrition on the mother, and this is achieved through
(Fig. 18.12). the placenta attached to the uterus. As the lungs are
b. Smooth part—the conus cordis or middle portion not functioning, the blood needs to bypass the
of bulbus cordis. pulmonary circuit. The oxygenated blood reaches the
4 Left ventricle (Fig. 18.16) foetus through the single ‘umbilical vein’. This vein
a. Rough part—whole of primitive ventricular containing oxygenated blood traverses the umbilical
chamber. cord to reach the liver. The oxygenated blood bypasses
b. The conus cordis or the middle portion of bulbus the liver via ‘the ductus venosus’ to join inferior vena
cordis forms the smooth part. cava. As inferior vena cava drains into the right atrium,
the oxygenated and nutrient-rich blood brought by it
5 Interatrial septum
enters the right atrium. Then it passes into the left
a. Septum primum—fossa ovalis. atrium through ‘foramen ovale’, thus bypassing the
b. Septum secundum—limbus fossa ovalis. pulmonary circuit (Figs 18.31 and 18.32).
6 Interventricular septum From the left atrium, it enters the left ventricle and
a. Thick muscular in lower part by the two ventricles. traverses the systemic circuit via the ascending aorta,
b. Thin membranous in upper part by fusion of arch of aorta and descending thoracic and descending
inferior atrioventricular cushion and right and abdominal aortae. The last mentioned vessel divides
left conus swelling. Membranous part not only into common iliac arteries. Each common iliac artery
separates the two ventricles, but also separates terminates by dividing into external and internal iliac
right atrium from left ventricle. arteries. Arising from two internal iliac arteries are the
7 Truncus arteriosus or distal part of bulbus cordis two umbilical arteries which in turn pass through the
forms the ascending aorta and pulmonary trunk, as umbilical cord to end in the placenta.
separated by spiral septum. The deoxygenated blood from the viscera, lower
Spiral septum is responsible for triple relation of limbs, head and neck and upper limbs also enters the
ascending aorta and pulmonary trunk. At the beginning, right atrium via both the inferior and superior venae
pulmonary trunk is anterior to ascending aorta, then it cavae. This venous blood gains entry into the right
is to the left and finally the right pulmonary artery is ventricle and leaves it via the pulmonary trunk and
posterior to ascending aorta (Fig. 18.10). left pulmonary artery. The left pulmonary artery is
joined to the left end of arch of aorta via the ‘ductus
Heart is fully functional at the end of second month
arteriosus’. Thus the venous blood traversing through
of intrauterine life.
the left pulmonary artery and ductus arteriosus enters
the left end of arch of aorta. So the descending thoracic
MOLECULAR REGULATION OF CARDIAC DEVELOPMENT and abdominal aortae get mixed blood. At the internal
The genes involved in cardiac development are iliac end, it passes via the two umbilical arteries to
Nirenberg and Kim 2 Homeobox 5 (NKX-2). This is the reach the placenta for oxygenation.
Thorax

master gene regulating development of heart. So for bypassing the lungs and for providing oxygen
Heart and neural crest derivative 1 (HAND-1) and and nutrition to the developing embryo and foetus, the
HAND-2 are other genes involved in development of following structures had to be improvised.
the ventricles. a. One umbilical vein
Singnaling molecules involved are bone morpho- b. Ductus venosus
genic proteins (BMPs 2 and 4) secreted by the endoderm c. Foramen ovale
and lateral plate mesoderm which induce the heart d. Ductus arteriosus
2

forming region of splanchnic mesoderm. e. Two umbilical arteries.

Section

Crescent and cerebrus produced by endoderm cells Flowchart 18.1 shows the details of foetal
inhibit WNT proteins 3a and 8 secreted by neural tube circulation.
which inhibit heart development. Thus cardiac At the time of birth, with the start of breathing
development proceeds uninhibited. Cardiac looping is process, these structures (a–e) retrogress and gradually
dependent on lefty 2. TBX 5 is important for septation. the adult form of circulation takes over (Flowchart 18.2).
 PERICARDIUM AND HEART
305

Changes at birth: b. Ductus venosus forms ligamentum venosum.

Lungs start functioning. c. Foramen ovale closes.
a. Umbilical vein forms ligamentum teres. d. Ductus arteriosus forms ligamentum arteriosum.

Thorax
2Section

Fig. 18.31: Foetal circulation in situ (schematic)

 THORAX
306

Flowchart 18.1: Foetal circulation

Fig. 18.32: Details of foetal circulation. Percentage of oxygen

2. Ventricular septal defect: Ventricular septal defect is
in blood vessels is put in numbers due to defect in the formation of membranous part
of interventricular septum. This septum is formed
by right and left bulbar ridges and proliferating
Thorax

e. Umbilical arteries form medial umbilical ligaments. posterior endocardial cushion. Improper fusion of
Placenta is delivered and removed. these three leads to ventricular septal defect. The
Competency achievement: The student should be able to:
membranous part of interventricular septum is of
AN 25.4 Describe embryological basis of:
neural crest origin.
1) Atrial septal defect, 2) Ventricular septal defect, 3) Fallot’s 3. Fallot’s tetralogy: The components of Fallot’s tetralogy
tetralogy.10 are:
a. Patent interventricular foramen
2

1. Atrial septal defect: Normally septum primum fuses

with septum secondum to obliterate interatrial b. Overriding of the aorta
Section

foramen. Incomplete fusion of the two septa leads c. Pulmonary stenosis

to atrial septal defect. d. Right ventricular hypertrophy
 PERICARDIUM AND HEART
307

Flowchart 18.2: Postnatal circulation

• All the components of left ventricle are thicker as
it has to push the blood from top of head to the
toes of foot.
• Left atrium forms most of the base of the heart.
• Coronary arteries are functional end arteries.
• Pain of heart due to myocardial infarction is
referred to left side of chest between 3rd and 6th
intercostal spaces. It also get extended to medial
side of left upper limb in the area of distribution
of C8 and T1 spinal segments.

CLINICOANATOMICAL PROBLEMS
Case 1
An adult man was stabbed on his upper left side of
chest. He was taken to the casualty department of
the hospital. The casualty physician noted that the
stab wound was in left third intercostal space close
to the sternum. Further the patient has engorged
veins on the neck and face.
• What is the site of injury?
• Why are the veins of the neck and face engorged?
• What procedure would be done as an emergency
measure before taking him to operation theatre?
Ans: The injury is in left third intercostal space
injuring the pericardium and right ventricle, causing
haemopericardium. Veins of the neck and face are
engorged as the venae cavae are not able to pour
blood in the right atrium. Pericardial tapping is done
Mnemonics to take out the blood from the pericardial cavity. It
is done as an emergency measure.
Heart valves “Try Pulling My Aorta” Case 2
Tricuspid A 40-year-old lady while playing tennis, suddenly
Pulmonary fell down, holding onto her chest and left arm due
to severe pain.
Mitral
• Why is the pain in her chest?
Aorta • Why is the pain in her left arm?
Atrioventricular valve Ans: Tennis is a very strenuous game. The lady
fainted as there was more need for the oxygen. Since
"LAB RAT"
it could not be supplied, the myocardium got
Left atrium: Bicuspid ischaemic which caused visceral pain. The pain is Thorax
Right atrium: Tricuspid carried by afferents which travel mostly with left side
sympathetic nerves to the thoracic one and thoracic
Lung lobe numbers: Right vs left
2–5 segments of the spinal cord. Since somatic nerves
Tricuspid heart valve and tri-lobed lung both on the (T1–T5) also travel to the same segments, the pain is
right side. referred to the skin area. T1 supplies the medial side
Bicuspid and bi-lobed lung both on the left side. of arm and T2–T5 supply the intercostal spaces.
Case 3
2

A 10-year-old boy had mild cough and fever. The

FACTS TO REMEMBER
physician could feel the increased rate of his pulse,
Section

• Heart is a pump for pushing blood to the lungs but could not hear the heartbeat on the left side of
and for rest of the organs of the body. Due to his chest. After some thought, the physician was able
sympathetic stimulation, it is felt thumping against to feel the heartbeat as well.
the chest wall.
 THORAX
308

• Where is the normal apex beat heard? • Krishnaiah, Mrudula. Morphometedic study of mitral
valve—an echocardiographic study. Int J Pharma and
• Name the congenital anomaly of the heart which
Biological Sciences 2011;2:181–87.
could cause inability of heart beat to be felt on the • Mizeres NJ. The cardiac plexus in man. Am J Anat 1963;
left side. 12:141–51.
Ans: Apex beat is normally heard in the left fifth • Naveena S, Mrudula C. Patent foramen ovale: A cadaveric
intercostal space, 9 cm from midsternal line, within observational study. Int J Health Sciences and Research
the left lateral line. The congenital anomaly in this case 2015;5:387–89.
is dextrocardia, when the heart is placed on the right • Shashi Raheja, Lalit Mehra, Inch Agarwal, Kalwinder Kaur
side of the heart. The apex beat is heard in right fifth Yashoda Rani, Anita Tuli. Morphological and surgical
intercostal space to the right of the inferior end of the anatomy of coronary sinus, its tributaries and relation to the
sternum. In a few cases, not only the heart but the initial valve annulus. Annals of Anatomy 2014;196:85.
viscera of abdomen and thorax are a mirror image of • Sinha P, Saxena S, Jethani SL, Khare S, Jain S, Mehrotra N.
Major primary congenital coronary artory anomalies: An
normal. The condition is called ‘situs inversus’.
angiographic study. Anatomical Society of India 2012;61(2):
172–76.
FURTHER READING • Sinha P, Saxena S, Khare S, Jain S, Ghai R, Tripathi A.
• Kawashima T. Anatomy of the cardiac nervous system with Angiographic study of origin of sinoatrial nodal artery in
clinical and comparative morphological implications. Anat northern Indian population. J Anatomical Society of India
Sci Int 2011;86:30–49. 2016;24 (2):7–10.
An exploration of the future implications of autonomic cardiac • Sylva M, van den Hoff MJ, Moorman AF. Development of
nervous system (ACNS) preservation in cardiovascular surgery. the human heart. Am J Med Genet A 2013;164A:1347–71.
Morphological studies are described from macroscopic, clinical and This paper presents the signaling factors in heart development.
evolutionary anatomical viewpoints, together with their • Van Vonderen JJ, Roset AAW, Siew ML, et al. Measuring
applications in improving surgical technique and for future physiological changes during the transition to life after birth.
evaluation in regenerative medicine. Neonatology 2014;105:230–42.

1–10
From Medical Council of India, Competency based Undergraduate Curriculum for the Indian Medical Graduate, 2018;1:44–80.

1. Describe the gross features of heart like apex, base, 3. Write short notes on:
borders, surfaces and grooves. a. Sinuses of pericardium
2. Describe the right ventricle under following heads: b. Interventricular septum
External features, openings, internal features, c. Valves of the heart
conducting tissue. d. Comparison of right and left coronary arteries
e. Coronary sinus

1. The structures covering the heart are: c. Pericardium

Thorax

a. Fibrous pericardium d. Ascending aorta

b. Parietal layer of serous pericardium 4. Apex of the heart is felt at:
c. Pericardial cavity a. 8 cm lateral to midclavicular line in left 5th
d. All of the above intercostal space
2. Boundaries of oblique sinus are all, except: b. 9 cm lateral to midclavicular line in left 5th
intercostal space
a. Superior and inferior venae cavae on right side
c. 9 cm lateral to midclavicular line in left 6th
b. Anteriorly by left atrium
2

intercostal space
c. Posteriorly by right atrium d. 9 cm lateral to midclavicular line in right 5th
Section

d. Left side by left pulmonary veins intercostal space

3. Boundaries of base of heart are formed by all, except: 5. Entry channels of heart are all, except:
a. Four pulmonary veins a. Superior vena cava b. Inferior vena cava
b. Oesophagus and descending aorta c. 4 pulmonary veins d. Pulmonary trunk
 PERICARDIUM AND HEART
309

6. Trabeculae carneae of right ventricle are in all d. Anterior two-thirds by left coronary artery and
following forms, except: posterior one-third by right coronary artery
a. Ridges b. Bridges 9. Coronary arteries anastomose with all the following
c. Papillary muscles d. Chordae tendineae arteries except:
7. Right coronary artery arises from which sinus? a. Vasa vasorum of the aorta
a. Anterior aortic sinus b. Vasa vasorum of pulmonary arteries
b. Right posterior aortic sinus c. Bronchial arteries
c. Left posterior aortic sinus d. Anterior intercostal arteries
d. From anterior and posterior aortic sinuses 10. Rough part of left ventricle develops from:
8. Blood to the interventricular septum is supplied by: a. Whole of primitive ventricular chamber
a. Only right coronary artery b. Proximal part of bulbus cordis
b. Only left coronary artery c. Middle part of bulbus cordis
c. Anterior half by right coronary artery and d. Distal part of bulbus cordis
posterior half by left coronary artery

1. d 2. c 3. d 4. b 5. d 6. d 7. a 8. d 9. d 10. a

• Name the ligaments connecting the fibrous • Name the cusps of the aortic and pulmonary valve.
pericardium to the sternum. • Trace the course of right coronary artery.
• What are the boundaries of transverse sinus of the • Trace the course of left coronary artery.
pericardium? • What is cardiac dominance?
• Name the boundaries of oblique sinus of the • Which nerves form the superficial cardiac plexus?
pericardium. • Where is apex beat normally felt?
• Name the veins opening in right atrium and in left • Where is pain of myocardial infarction (MI) referred?
atrium. • Define angina pectoris.
• What is moderator band of right ventricle? • What is mitral stenosis and mitral regurgitation?
• Why is left ventricle the thickest chamber of the • Why is mitral stenosis common after throat infection?
heart? Which bacteria are responsible for such an incident?
• What is ‘cor pulmonale’? • How is interatrial septum formed?

Thorax
2Section
 THORAX
310

19 Superior Vena Cava, Aorta

and Pulmonary Trunk
!Blood is meant to circulate, otherwise it forms clots blocking the vessels.!
—Anonymous

INTRODUCTION right and left brachiocephalic or innominate veins behind

Superior vena cava brings deoxygenated blood from the the lower border of the first right costal cartilage close to
head and neck, upper limbs and thorax to the heart. Aorta the sternum. Each brachiocephalic vein is formed behind
and pulmonary trunk are the only two exit channels from the corresponding sternoclavicular joint by the union of
the heart, developing from a single truncus arteriosus. The the internal jugular and subclavian veins (Fig. 19.1).
two are intimately related to each other. Course
The superior vena cava is about 7 cm long. It begins
DISSECTION
behind the lower border of the sternal end of the first
Trace superior vena cava from level of first right costal right costal cartilage, pierces the pericardium opposite
cartilage where it is formed by union of left and right the second right costal cartilage, and terminates by
brachiocephalic veins till the third costal cartilage where opening into the upper part of the right atrium behind
it opens into right atrium (Fig. 19.1). the third right costal cartilage (Fig. 19.2). It has no valves.
Trace the ascending aorta from the vestibule of left
ventricle upwards between superior vena cava and Relations
pulmonary trunk (Fig. 19.2). 1 Anterior
Arch of aorta is seen above the bifurcation of a. Chest wall
pulmonary trunk. b. Internal thoracic vessels
Cut ligamentum arteriosum as it connects the left c. Anterior margin of the right lung and pleura
pulmonary artery to the arch of aorta. d. The vessel is covered by pericardium in its lower
Trace the left recurrent laryngeal nerve to the medial half (Fig. 19.2).
aspect of arch of aorta. 2 Posterior
Lift the side of oesophagus forwards to expose the a. Trachea and right vagus (posteromedial to the
anterior surface of the descending aorta. upper part of the vena cava) (see Fig. 16.2)
Lift the diaphragm forwards and expose the aorta in b. Root of right lung posterior to the lower part
Thorax

the inferior part of the posterior mediastinum. 3 Medial

a. Ascending aorta
b. Brachiocephalic artery
4 Lateral
Competency achievement: The student should be able to:

a. Right phrenic nerve with accompanying vessels

AN 23.3 Describe and demonstrate origin, course, relations,
tributaries and termination of superior vena cava (described below),
azygos, hemiazygos and accessory hemiazygos veins (described in b. Right pleura and lung (Fig. 19.5)
Chapter 14).1
Tributaries
2

1 The azygos vein arches over the root of the right lung
Section

SUPERIOR VENA CAVA and opens into the superior vena cava at the level of
the second costal cartilage, just before the latter enters
Superior vena cava is a large venous channel which the pericardium.
collects blood from the upper half of the body and drains 2 Several small mediastinal and pericardial veins drain
it into the right atrium. It is formed by the union of the into the vena cava.
310
 SUPERIOR VENA CAVA, AORTA AND PULMONARY TRUNK
311

Fig. 19.1: Formation of superior vena cava

Fig. 19.2: The superior vena cava and its relations

CLINICAL ANATOMY both the chest and abdomen up to the saphenous

opening in the thigh. The superficial vein
• When the superior vena cava is obstructed above connecting the lateral thoracic vein with the
the opening of the azygos vein, the venous blood Thorax
superficial epigastric vein is known as the
of the upper half of the body is returned through thoracoepigastric vein (Fig. 19.4) (see Flowchart 14.2).
the azygos vein; and the superficial veins are
• In cases of mediastinal syndrome, the signs of
dilated on the chest up to the costal margin
superior vena caval obstruction are the first to
(Fig. 19.3). Blood from upper limb is returned
appear.
through the communicating veins joining the
veins around the scapula with the intercostal
2

veins. The latter veins of both sides drain into vena

AORTA
azygos (see Flowchart 14.1).
Section

• When the superior vena cava is obstructed below

The aorta is the great arterial trunk which receives
the opening of the azygos veins, the blood is
oxygenated blood from the left ventricle and distributes
returned through the inferior vena cava via the
it to all parts of the body. It is studied in thorax in the
femoral vein; and the superior veins are dilated on
following three parts:
 THORAX
312

Fig. 19.3: Obstruction to superior vena cava above the Fig. 19.4: Obstruction to superior vena cava below the
opening of vena azygos opening of vena azygos

1 Ascending aorta 2 Left atrium

2 Arch of the aorta 3 Right pulmonary artery
3 Descending thoracic aorta. 4 Right bronchus (Fig. 19.5)

ASCENDING AORTA To the Right

1 Superior vena cava
Origin and Course
2 Right atrium
The ascending aorta arises from the upper end of the
left ventricle. It is about 5 cm long and is enclosed in To the Left
the pericardium (Fig. 19.2). It begins behind the left half 1 Pulmonary trunk above
of the sternum at the level of the lower border of the 2 Left atrium below
third costal cartilage. It runs upwards, forwards and to
the right and becomes continuous with the arch of the Branches
aorta at the sternal end of the upper border of the second 1 The right coronary artery arises from anterior aortic
right costal cartilage. sinus (see Fig. 18.18).
At the root of the aorta, there are three dilatations of
Thorax

2 Left coronary artery arises from the left posterior

the vessel wall, called the aortic sinuses. The sinuses are aortic sinus.
anterior, left posterior and right posterior.
Competency achievement: The student should be able to:
Relations AN 25.5 Describe developmental basis of congenital anomalies,
Anterior transposition of great vessels, dextrocardia, patent ductus arteriosus
1 Sternum and coarctation of aorta.2
2 Right lung and pleura AN 23.4 Mention the extent, branches and relations of arch of aorta
2

3 Infundibulum of the right ventricle and descending thoracic aorta.3

Section

4 Root of the pulmonary trunk (Fig. 19.5)

5 Right auricle ARCH OF AORTA
Arch of the aorta is the continuation of the ascending
Posterior aorta. It is situated in the superior mediastinum behind
1 Transverse sinus of pericardium the lower half of the manubrium sterni.
 SUPERIOR VENA CAVA, AORTA AND PULMONARY TRUNK
313

Figs 19.5a and b: (a) CT scan, and (b) Transverse section of the thorax passing through the fifth thoracic vertebra

Course Relations Thorax

1 It begins behind the upper border of the second right Anteriorly and to the Left
sternochondral joint (see Figs 17.2 and 17.4).
1 Four nerves from before backwards:
2 It runs upwards, backwards and to the left across
the left side of the bifurcation of trachea. Then it a. Left phrenic
passes downwards behind the left bronchus and on b. Lower cervical cardiac branch of the left vagus
the left side of the body of the fourth thoracic c. Superior cervical cardiac branch of left sympathetic
vertebra. It thus arches over the root of the left lung. chain.
2

3 It ends at the lower border of the body of the fourth d. Left vagus (Fig. 19.6).
Section

thoracic vertebra by becoming continuous with the

2 Left superior intercostal vein, deep to the phrenic
descending aorta.
nerve and superficial to the vagus nerve
Thus the beginning and the end of arch of aorta are
at the same level, although it begins anteriorly and ends 3 Left pleura and lung
posteriorly. 4 Remains of thymus
 THORAX
314

Posteriorly and to the Right 3 Ligamentum arteriosum with superficial cardiac

1 Trachea, with the deep cardiac plexus and the plexus on it.
tracheobronchial lymph nodes 4 Left recurrent laryngeal nerve.
2 Oesophagus
Branches
3 Left recurrent laryngeal nerve
4 Thoracic duct 1 Brachiocephalic artery which divides into the right
5 Vertebral column common carotid and right subclavian arteries (Fig. 19.2).
2 Left common carotid artery
Superior 3 Left subclavian artery
1 Three branches of the arch of the aorta:
a. Brachiocephalic DESCENDING THORACIC AORTA
b. Left common carotid Descending thoracic aorta is the continuation of the arch
c. Left subclavian arteries (Fig. 19.7) of the aorta. It lies in the posterior mediastinum
2 All three arteries are crossed close to their origin by (see Fig. 17.4). It continues as abdominal aorta which ends
the left brachiocephalic vein. by dividing into right and left common iliac arteries.

Inferior Course
1 Bifurcation of the pulmonary trunk (Fig. 19.2). 1 It begins on the left side of the lower border of the
2 Left bronchus body of the fourth thoracic vertebra.
Thorax
2
Section

Figs 19.6: (a) CT scan, and (b) transverse section of the thorax passing through the fourth thoracic vertebra
 SUPERIOR VENA CAVA, AORTA AND PULMONARY TRUNK
315

2 It descends with an inclination to the right and To the Right Side

terminates at the lower border of the twelfth thoracic 1 Oesophagus in the upper part
vertebra. 2 Azygos vein
3 Thoracic duct (Fig. 19.5)
Relations
4 Right lung and pleura
Anterior
1 Root of left lung To the Left Side
2 Pericardium and heart Left lung and pleura
3 Oesophagus in the lower part Branches
4 Diaphragm 1 Nine posterior intercostal arteries on each side for
the third to eleventh intercostal spaces (Fig. 19.8).
Posterior 2 The subcostal artery on each side (see Fig. 14.8).
1 Vertebral column 3 Two left bronchial arteries. The right bronchial artery
2 Hemiazygos veins arises from the third right posterior intercostal artery.

Thorax
2Section

Figs 19.7a and b: (a) CT scan and (b) transverse section of thorax passing through the third thoracic vertebra
 THORAX
316

pericardium and part of peritoneum. Phrenic nerves

of two sides are compared as follows:
Right phrenic nerve: Right phrenic nerve is shorter,
vertical and deeply placed (see Fig 16.2). It crosses 2nd
part of right subclavian artery. It runs along right side
of venous system (Fig. 19.6) and passes through vena
caval opening of the diaphragm (see Fig. 12.16).
Left phrenic nerve: Left phrenic nerve is longer, oblique
and not deeply placed (see Fig. 16.3). It crosses 1st part
of left subclavian artery. It runs along left side of arterial
system and pierces the left cupola of the diaphragm.

CLINICAL ANATOMY
Fig. 19.8: Transverse section of posterior mediastinum at the
• Aortic knuckle: In posteroanterior view of
level of 8th vertebra
radiographs of the chest, the arch of the aorta is
4 Oesophageal branches, supplying the middle one- seen as a projection beyond the left margin of the
third of the oesophagus. mediastinal shadow. The projection is called the
aortic knuckle. It becomes prominent in old age
5 Pericardial branches, to the posterior surface of the
(see Fig. 21.12).
pericardium.
• Coarctation of the aorta is a localised narrowing of
6 Mediastinal branches, to lymph nodes and areolar the aorta opposite to or just beyond the attachment
tissue of the posterior mediastinum. of the ductus arteriosus. An extensive collateral
7 Superior phrenic arteries to the posterior part of the circulation develops between the branches of the
superior surface of the diaphragm. Branches of these subclavian arteries and those of the descending
arteries anastomose with those of the musculo- aorta. These include the anastomoses between the
phrenic and pericardiacophrenic arteries. anterior and posterior intercostal arteries. These
arteries enlarge greatly and produce a charac-
Competency achievement: The student should be able to: teristic notching on the ribs (Figs 19.9a and b).
AN 24.4 Identify phrenic nerve and describe its formation and • Ductus arteriosus, ligamentum arteriosum and patent
distribution.4 ductus arteriosus: During foetal life, the ductus
arteriosus (Fig. 19.10) is a short wide channel
PHRENIC NERVE connecting the beginning of the left pulmonary
Phrenic nerve arising from (C3–C5) cervical nerves is a artery with the arch of the aorta immediately distal
to the origin of the left subclavian artery. It
mixed nerve carrying motor fibres to the diaphragm
conducts most of the blood from the right ventricle
and sensory fibres from mediastinal pleura,
Thorax
2
Section

Figs 19.9a and b: (a) Coarctation of aorta, and (b) notches on the ribs
 SUPERIOR VENA CAVA, AORTA AND PULMONARY TRUNK
317

surrounding structures and cause the mediastinal

syndrome (Fig. 19.11), i.e. dyspnoea, dysphagia,
dysphonia, etc.

PULMONARY TRUNK

The wide pulmonary trunk starts from the summit of

infundibulum of right ventricle. Both the ascending
aorta and pulmonary trunk are enclosed in a common
sleeve of serous pericardium, in front of transverse
sinus of pericardium. Pulmonary trunk carrying
deoxygenated blood, overlies the beginning of
ascending aorta. It courses to the left and divides
into right and left pulmonary arteries under the
concavity of aortic arch at the level of sternal angle
Fig. 19.10: Patent ductus arteriosus (Figs 19.2 and 19.5).
The right pulmonary artery courses to the right
into the aorta, thus short circuiting the lungs. After behind ascending aorta, and superior vena cava and
birth, it is closed functionally within about a week anterior to oesophagus to become part of the root of the
and anatomically within about eight weeks. The lung. It gives off its first branch to the upper lobe before
remnants of the ductus form a fibrous band called entering the hilum. Within the lung, the artery descends
the ligamentum arteriosum. The left recurrent posterolateral to the main bronchus and divides like the
laryngeal nerve hooks around the ligamentum bronchi into lobar and segmental arteries.
arteriosum. The left pulmonary artery passes to the left anterior
The ductus may remain patent after birth. The to descending thoracic aorta to become part of the root
condition is called patent ductus arteriosus and may of the left lung. At its beginning, it is connected to the
cause serious problems. The condition can be inferior aspect of arch of aorta by ligamentum arteriosus,
surgically treated. a remnant of ductus arteriosus. Rest of the course is same
• Aortic arch aneurysm is a localised dilatation of the as of the right branch.
aorta which may press upon the left recurrent
laryngeal nerve leading to paralysis of left vocal
Competency achievement: The student should be able to:

cord and hoarseness. It may also press upon the

AN 25.6 Mention development of aortic arch arteries, SVC, IVC and
coronary sinus.5

Thorax
2Section

Fig. 19.11: Aortic aneurysm

 THORAX
318

Fig. 19.12: Fetal aortic arches showing development of arch arteries

DEVELOPMENT OF ARTERIES (Fig. 19.12) Lower half of superior vena cava (intrapericardial)
Brachoicephalic artery: Right aortic sac develops from right common cardinal vein.
Right subclavian artery: Proximal part from the right 4th Coronary Sinus
aortic arch artery and remaining part from right 7th Coronary sinus is a remnant of left horn of sinus
cervical intersegmental artery. venosus. Great, middle and anterior cardiac veins drain
Left subclavian artery: Only left 7th cervical inter- into this sinus.
segmental artery.
Common carotid: Third aortic arch, distal to the external Mnemonics
carotid bud and original dorsal aorta cranial to the
attachment of third aortic arch. Thoracic cage: Relations to the important venous
External carotid artery: Develop as sprout from the third structures
aortic arch. Behind sternoclavicular joints: The brachiocephalic
veins begin.
Pulmonary trunk: Part of truncus arteriosus. Behind the 1st costal cartilage on the right: The superior
Arch of aorta: Left aortic sac. Left 4th aortic arch. Left vena cava begins.
dorsal aorta. Behind the 2nd costal cartilage on the right: The azygos
Relation to recurrent laryngeal nerve. Recurrent vein ends.
laryngeal is given off from vagi in relation to distal part Behind the 3rd costal cartilage on the right: The superior
Thorax

of 6th arch artery. Since this distal part forms vena cava ends.
ligamentum arteriosum on left side only, the recurrent Arch of Aorta
laryngeal nerve hooks around this ligamentum in “Know your ABC’S”
thorax to reach tracheo-oesophageal groove. Aortic arch gives rise to:
On the right side, there is no ligamentum arteriosum. Brachiocephalic trunk
The recurrent laryngeal nerve slips upwards in the neck Left Common Carotid
and hooks around the right subclavian artery to reach
2

Left Subclavian
the tracheo-oesophageal groove.
Section

Lung Lobe numbers: Right versus left

DEVELOPMENT OF SUPERIOR VENA CAVA Tricuspid heart valve and tri-lobed lung both on the
right side.
Upper half of superior vena cava (extrapericardial) Bicuspid heart valve and bi-lobed lung both on the
develops from caudal part of right anterior cardinal left side.
vein.
 SUPERIOR VENA CAVA, AORTA AND PULMONARY TRUNK
319

CLINICOANATOMICAL PROBLEM
FACTS TO REMEMBER
A teenage girl was complaining of breathlessness.
• Superior vena cava is the second largest vein of The physician heard a ‘machine-like murmur’ during
the body. auscultation on the second left intercostal space, close
• Vena azygos brings the venous blood from the to the margin of sternum. There was continuous thrill
posterior parts of thoracic and abdominal wall. on the same site. On getting radiographs of chest and
• Aorta is the largest elastic artery of the body. It angiocardiography, a diagnosis of patent ductus
takes oxygenated blood to all parts of the body arteriosus was made.
except the lungs. • What is the ‘machine-like’ murmur?
• There is a gradual transition from its elastic nature • How can the shunting of blood be prevented?
to muscular nature of its branches.
• Describe briefly the function of ductus arteriosus
• Pulmonary trunk arises from the right ventricle.
during prenatal life. When does it close?
It soon divides into right and left pulmonary
arteries which carry deoxygenated blood from Ans: The ductus arteriosus is a patent channel during
right ventricle to the lungs for oxygenation. fetal life for conducting the blood from left
• Pulmonary trunk and ascending aorta develop pulmonary artery to arch of aorta beyond the origin
from a common source, the truncus arteriosus. of left subclavian artery. The ductus carries blood
• There is triple relationship between these two from right ventricle to descending thoracic aorta.
vessels: This is necessary as lungs are not functioning. After
– Close to heart, pulmonary trunk lies anterior to birth, with the functioning of lungs, ductus arteriosus
ascending aorta. obliterates and becomes ligamentum arteriosus. If
– At upper border of heart, pulmonary trunk lies this does not take place (as it occurs in one out of
to the left of ascending aorta (Fig. 19.2). 3000 births), there is back flow of blood from aorta
– A little above this, the right pulmonary artery into pulmonary artery giving rise to ‘machine-like’
lies posterior to the ascending aorta. murmur. The treatment is surgical.

1–5
From Medical Council of India, Competency based Undergraduate Curriculum for the Indian Medical Graduate, 2018;1:44–80.

Thorax
2Section
 THORAX
320

1. Name the parts of aorta. Describe arch of aorta 2. Describe the foetal circulation
under the following heading: 3. Write short notes on:
a. Beginning a. Branches of descending thoracic aorta
b. Course b. Patent ductus arteriosus
c. Relations c. Obstruction of superior vena cava
d. Branches

1. Branches of arch of aorta are all, except: 3. Aortic aneurysm may cause following symptoms:
a. Brachiocephalic trunk a. Dyspnoea b. Dysphagia
b. Left common carotid c. Dysphonia d. All of the above
c. Left subclavian
4. Posterior relations of ascending aorta are all, except:
d. Vertebral
a. Transverse sinus of pericardium
2. How many pairs of posterior intercostal arteries
arise from descending thoracic aorta? b. Right atrium
a. Nine b. Eleven c. Right pulmonary artery
c. Ten d. Twelve d. Right bronchus

1. d 2. a 3. d 4. b

• How is superior vena cava formed? • Name the collateral circulation which develops
• What are the parts of aorta? during coarctation of aorta.
• Name the branches of ascending aorta. • What is the function of ductus arteriosus?
• Name the branches of arch of aorta. • What is the triple relation between pulmonary trunk
• Name the branches of descending thoracic aorta. and ascending aorta?
Thorax
2
Section
 Trachea, Oesophagus and 20
Thoracic Duct
!The best thing about animals is that they don’t talk much !
—T. Wilder

INTRODUCTION
Trachea or windpipe is the patent tube for passage of
air to and from the lungs. In contrast, oesophagus lying
behind the trachea opens only while drinking or eating.
Thoracic duct brings the lymph from major parts of the
body to the root of the neck.

Competency achievement: The student should be able to:

AN 24.6 Describe the extent, length, relations, blood supply,
lymphatic drainage and nerve supply of trachea.1

TRACHEA

The trachea (Latin air vessel) is a wide tube lying more

or less in the midline, in the lower part of the neck and
in the superior mediastinum. Its upper end is con-
tinuous with the lower end of the larynx. The trachea
in the neck is covered by the isthmus of the thyroid
gland and acts as a shield for trachea. At its lower end,
the trachea ends by dividing into the right and left
principal bronchi (Fig. 20.1).
The trachea is 10 to 15 cm in length. Its external
diameter measures about 2 cm in males and about
1.5 cm in females. The lumen is smaller in the living Fig. 20.1: Trachea and its relations
than in the cadaver. It is about 3 mm at one year of age.
During childhood, it corresponds to the age in years, Over most of its length, the trachea lies in the median
with a maximum of about 12 mm in adults, i.e. it plane, but near the lower end, it deviates slightly to the
increases 1 mm per year up to 12 years. right. As it runs downwards, the trachea passes slightly
The upper end of the trachea lies at the lower border backwards following the curvature of the spine.
of the cricoid cartilage, opposite the sixth cervical
Relations of the Thoracic Part
vertebra. In the cadaver, its bifurcated lower end lies
at the lower border of the fourth thoracic vertebra, Anteriorly
corresponding in front to the sternal angle. However, 1 Manubrium sterni
in living subjects, in the erect posture, the bifurcation 2 Sternothyroid muscles
lies at the lower border of the sixth thoracic vertebra 3 Remains of the thymus
and descends still further during inspiration. 4 Left brachiocephalic and inferior thyroid veins
321
 THORAX
322

5 Aortic arch, brachiocephalic and left common carotid

arteries
6 Deep cardiac plexus (see Fig. 19.6)
7 Some lymph nodes
Posteriorly
1 Oesophagus
2 Vertebral column

On the Right Side

1 Right lung and pleura
2 Right vagus
3 Azygos vein (Fig. 20.2)

On the Left Side

1 Arch of aorta, left common carotid and left sub-
clavian arteries
2 Left recurrent laryngeal nerve (Fig. 20.3)

Structure
The trachea has a fibroelastic wall supported by a
cartilaginous skeleton formed by C-shaped rings. The Fig. 20.3: Mediastinum as seen from the left side
rings are about 16 to 20 in number and make the tube
convex anterolaterally. Posteriorly, there is a gap which
is closed by a fibroelastic membrane and contains Arterial Supply: Inferior thyroid arteries.
transversely arranged smooth muscle known as the Venous drainage: Into the left brachiocephalic vein.
trachealis. The lumen is lined by ciliated columnar Lymphatic drainage: To the pretracheal and paratracheal
epithelium and contains many mucous and serous nodes.
glands.
Nerve Supply
1 Parasympathetic: Nerves through vagi and recurrent
laryngeal nerves. It is:
a. Sensory and secretomotor to the mucous membrane.
b. Motor to the trachealis muscle.
2 Sympathetic: Fibres from the middle cervical
ganglion reach it along the inferior thyroid arteries
and are vasomotor.
Development
Development of trachea is described in respiratory
system (see Chapter 16).
Thorax

Competency achievement: The student should be able to:

AN 25.1 Identify, draw and label a slide of trachea and lung.2

HISTOLOGY OF TRACHEA
Trachea is a thin-walled flexible tube. The trachea is lined
by pseudostratified ciliated columnar epithelium with
2

interspersed goblet cells resting on a basement

Section

membrane. The lamina propria consists of elastic fibres,

lymphocytes both segregated and aggregated and short
ducts of the glands (Fig. 20.4). The submucosa which
contains both mucous and serous acini that keep the
Fig. 20.2: Mediastinum as seen from the right side epithelium moist. The most characteristic feature of
 TRACHEA, OESOPHAGUS AND THORACIC DUCT
323

• Mucus secretions help in trapping inhaled foreign

particles, and the soiled mucus is then expelled by
coughing. The cilia of the mucous membrane beat
upwards, pushing the mucus towards the pharynx.
• The trachea may get compressed by pathological
enlargements of the thyroid, the thymus, lymph
nodes and the aortic arch. This causes dyspnoea,
irritative cough, and often a husky voice.

Competency achievement: The student should be able to:

AN 23.1 Describe and demonstrate the external appearance,
relations, blood supply, nerve supply, lymphatic drainage and applied
anatomy of oesophagus.3

OESOPHAGUS
Fig. 20.4: Various layers of wall of trachea Features
The oesophagus is a narrow muscular tube, forming
trachea is its supporting framework of 16–20 C-shaped the food passage between the pharynx and stomach. It
hyaline cartilages that encircle it on its ventral and lateral extends from the lower part of the neck to the upper
aspects. The cartilage is covered by perichondrium on part of the abdomen (Fig. 20.2). The oesophagus is
all sides which separates it from the neighbouring about 25 cm long. The tube is flattened antero-
structures. The outermost layer is the adventitia which posteriorly and the lumen is kept collapsed; it dilates
contains blood vessels and nerves. only during the passage of the food bolus. The
pharyngo-oesophageal junction is the narrowest part
of the alimentary canal except for the vermiform
CLINICAL ANATOMY
appendix.
• In radiographs, the trachea is seen as a vertical The oesophagus begins in the neck at the lower
translucent shadow due to the contained air in border of the cricoid cartilage, where it is continuous
front of the cervicothoracic spine (see Fig. 21.12). with the lower end of the pharynx.
• Clinically, the trachea is palpated in the supra- It descends in front of the vertebral column through
sternal notch. Normally, it is median in position. the superior and posterior parts of the mediastinum,
Shift of the trachea to any side indicates a and pierces the diaphragm at the level of tenth thoracic
mediastinal shift. vertebra. It ends by opening into the stomach at its
cardiac end at the level of eleventh thoracic vertebra.
• During swallowing when the larynx is elevated,
the trachea elongates by stretching because the
DISSECTION
tracheal bifurcation is not permitted to move by
the aortic arch. Any downward pull due to sudden Remove the posterior surface of the parietal pericardium
and forced inspiration, or aortic aneurysm will between the right and left pulmonary veins. This
produce the physical sign known as ‘tracheal tug’. uncovers the anterior surface of the oesophagus in the Thorax
• Tracheostomy: It is a surgical procedure which allows posterior mediastinum.
air to enter directly into trachea. It is done in cases Find the azygos vein and its tributaries on the
of blockage of air pathway in nose or larynx. vertebral column to the right of the oesophagus. Find
• As the tracheal rings are incomplete posteriorly, and follow the thoracic duct on the left of azygos vein.
the oesophagus can dilate during swallowing. This Identify the sternal, sternocostal, interchondral and
also allows the diameter of the trachea to be costochondral joints on the anterior aspect of chest wall
controlled by the trachealis muscle. This muscle which was reflected downwards.
2

narrows the caliber of the tube, compressing the Expose the ligaments which unite the heads of the
Section

contained air, if the vocal cords are closed. This ribs to the vertebral bodies and intervertebral discs.
increases the explosive force of the blast of com- Curvatures
pressed air, as occurs in coughing and sneezing.
In general, the oesophagus is vertical, but shows slight
curvatures in the following directions. There are two
 THORAX
324

side-to-side curvatures, both towards the left (see Posteriorly

Fig. 17.4). One is at the root of the neck and the other 1 Vertebral column
near the lower end. It also has anteroposterior 2 Right posterior intercostal arteries
curvatures that correspond to the curvatures of the 3 Thoracic duct
cervicothoracic spine. 4 Azygos vein with the terminal parts of the hemi-
Constrictions azygos veins
5 Thoracic aorta
Normally, the oesophagus shows four constrictions. 6 Right pleural recess
These are seen as indentations. 7 Diaphragm (Fig. 20.5)
1 At its beginning, 15 cm/6-inch from the incisor teeth,
where it is crossed by cricopharyngeus muscle. To the Right
2 Where it is crossed by the aortic arch, 22.5 cm/9-inch 1 Right lung and pleura
from the incisor teeth. 2 Azygos vein
3 Where it is crossed by the left bronchus, 27.5 cm/11- 3 The right vagus (Figs 20.6a to c)
inch from the incisor teeth (Fig. 20.9).
To the Left
4 Where it pierces the diaphragm 37.5 cm/15-inch from
the incisor teeth. 1 Aortic arch
The distances from the incisor teeth are important 2 Left subclavian artery
in passing instruments like endoscope into the 3 Thoracic duct
oesophagus. 4 Left lung and pleura
For the sake of convenience, the relations of the 5 Left recurrent laryngeal nerve, all in the superior
oesophagus may be studied in three parts—cervical, mediastinum (see Figs 19.5 and 19.6)
thoracic and abdominal. The relations of the cervical
part are described in BD Chaurasia’s Human Anatomy, In the posterior mediastinum, it is related to:
Volume 3, and those of the abdominal part in Volume 2. 1 The descending thoracic aorta
2 The left lung and mediastinal pleura (see Fig. 16.3)
Relations of the Thoracic Part of the Oesophagus
Anteriorly Arterial Supply
1 Trachea 1 The cervical part including the segment up to the arch
of aorta is supplied by the inferior thyroid arteries.
2 Right pulmonary artery
2 The thoracic part is supplied by the oesophageal
3 Left bronchus branches of the aorta.
4 Pericardium with left atrium 3 The abdominal part is supplied by the oesophageal
5 The diaphragm (Figs 20.2 and 20.3). branches of the left gastric artery.
Thorax
2
Section

Fig. 20.5: Structures in the posterior mediastinum seen after removal of the heart and pericardium
 TRACHEA, OESOPHAGUS AND THORACIC DUCT
325

nerves are sensory, motor and secretomotor to the

oesophagus.
2 Sympathetic nerves: For upper half of oesophagus,
the fibres come from middle cervical ganglion and
run with inferior thyroid arteries. For lower half,
the fibres come directly from upper four thoracic
ganglia, to form oesophageal plexus before
supplying the oesophagus. Sympathetic nerves are
vasomotor.
The oesophageal plexus is formed mainly by the
parasympathetic through vagi but sympathetic
fibres are also present. Towards the lower end of
the oesophagus; the vagal fibres form the anterior
and posterior gastric nerves which enter the
abdomen through the oesophageal opening of the
diaphragm.
Development
Described in Chapter 19 of BD Chaurasia’s Human
Anatomy, Volume 2.

HISTOLOGY OF OESOPHAGUS
The oesophagus is a muscular tube that rapidly propels
the food from pharynx into the stomach. It is about
25 cm long. The mucous membrane is thrown into
longitudinal folds when empty. The epithelium is
stratified squamous non-keratinised in character and
protective in function. The lamina propria sends
papillae into the epithelium. The muscularis mucosae
is indistinct at the beginning of oesophagus, but
becomes distinct lower down (Fig. 20.7). The

Figs 20.6a to c: Outline drawings of three sections through the

oesophagus at different levels of thoracic vertebrae

Venous Drainage
Blood from the upper part of the oesophagus drains
into the brachiocephalic veins; from the middle part it
goes to the azygos veins; and from the lower end it
goes to the left gastric vein and vena azygos via Thorax
hemiazygos vein. The lower end of the oesophagus is
one of the sites of portosystemic anastomoses.
Lymphatic Drainage
The cervical part drains to the deep cervical nodes; the
thoracic part to the posterior mediastinal nodes; and the
abdominal part to the left gastric nodes.
2

Nerve Supply
Section

1 Parasympathetic nerves: The upper half of the

oesophagus is supplied by the recurrent laryngeal
nerves, and the lower half by the oesophageal plexus
formed mainly by the two vagi. Parasympathetic Fig. 20.7: Histology of oesophagus
 THORAX
326

submucosa contains oesophageal glands. These are mucus by inability of the oesophagus to dilate is known
secreting glands with acini which are round or oval in as ‘achalasia cardia’. It may be due to congenital
shape. The muscularis externa has striated muscle absence of nerve cells in wall of oesophagus.
fibres in upper third, mixed, i.e. both striated and • Improper separation of the trachea from the
smooth muscle fibres in the middle third and smooth oesophagus during development gives rise to
muscle fibres in the lower third of oesophagus. tracheo-oesophageal fistula (Fig. 20.10).
The outermost layer is the adventitia which is made • Compression of the oesophagus in cases of
up of loose connective tissue with capillaries and nerves. mediastinal syndrome causes dysphagia or
difficulty in swallowing.
CLINICAL ANATOMY

• In portal hypertension, the communications

between the portal and systemic veins draining
the lower end of the oesophagus dilate. These
dilatations are called oesophageal varices. Rupture
of these varices can cause serious haematemesis
or vomiting of blood. The oesophageal varices can
be visualised radiographically by barium swallow;
they produce worm-like shadows (Fig. 20.8).
• Left atrial enlargement as in mitral stenosis can
also be visualised by barium swallow. The
enlarged atrium causes a shallow depression on
the front of the oesophagus. Barium swallow also
helps in the diagnosis of oesophageal strictures,
carcinoma and achalasia cardia.
• The normal indentations on the oesophagus
should be kept in mind during oesophagoscopy Fig. 20.9: Normal indentations constrictions of oesophagus
(Fig. 20.9).
• The lower end of the oesophagus is normally kept
closed. It is opened by the stimulus of a food
bolus. In case of neuromuscular incoordination,
the lower end of the oesophagus fails to dilate
with the arrival of food which, therefore,
accumulates in the oesophagus. This condition
of neuromuscular incoordination characterised
Thorax
2

Fig. 20.10: Tracheo-oesophageal fistula

Section

Competency achievement: The student should be able to:

AN 23.2 Describe and demonstrate the extent, relations, tributaries
Fig. 20.8: Oesophageal varices of thoracic duct and enumerate its applied anatomy.4
 TRACHEA, OESOPHAGUS AND THORACIC DUCT
327

Competency achievement: The student should be able to:

AN 23.7 Mention the extent, relations and applied anatomy of right
lymphatic duct.5

THORACIC DUCT

Features
The thoracic duct is the largest lymphatic vessel in the
body. It extends from the upper part of the abdomen
to the lower part of the neck, crossing the posterior and
superior parts of the mediastinum. It is about 45 cm/
18 inch long. It has a beaded appearance because of the
presence of many valves in its lumen (Fig. 20.11).

Course
The thoracic duct begins as a continuation of the upper
end of the cisterna chyli near the lower border of the
twelfth thoracic vertebra and enters the thorax through
the aortic opening of the diaphragm (see Fig. 12.16). Fig. 20.11: The course of the thoracic duct
It then ascends through the posterior mediastinum
from level of twelfth thoracic vertebra to fifth thoracic artery and ends by opening into the angle of junction
vertebra, where it crosses from the right side to the left between the left subclavian and left internal jugular
side. Then it courses through the superior mediastinum veins (Fig. 20.12).
along the left edge of the oesophagus and reaches the neck.
Relations
In the neck, it arches laterally at the level of the
transverse process of seventh cervical vertebra. Finally At the Aortic Opening of the Diaphragm
it descends in front of the first part of the left subclavian Anteriorly: Diaphragm

Thorax
2Section

Fig. 20.12: The tributaries of the thoracic duct

 THORAX
328

Posteriorly: Vertebral column trunk, and those from nodes in the axilla form the left
To the right: Azygos vein subclavian trunk. These trunks end in the thoracic duct.
To the left: Aorta (see Fig. 12.16) The left bronchomediastinal trunk drains lymph from the
left half of the thorax and ends in the thoracic duct.
In the Posterior Mediastinum On the right side, there is right lymphatic duct into
Anteriorly which right bronchomediastinal, right jugular and right
1 Diaphragm (Fig. 20.6c) subclavian lymph trunks drain. The right lymphatic
2 Oesophagus trunk ends in the right brachiocephalic vein at the junc-
3 Right pleural recess tion of right subclavian and right internal jugular veins.

Posteriorly FACTS TO REMEMBER

1 Vertebral column
2 Right posterior intercostal arteries • Trachea contains C-shaped hyaline cartilaginous
rings which are deficient posteriorly, so that the
3 Terminal parts of the hemiazygos veins
oesophagus situated behind the trachea is not
To the right: Azygos vein compressed by trachea.
To the left: Descending thoracic aorta (Fig. 20.6c) • Trachea begins at sixth cervical vertebra and ends
at thoracic 4 (in expiration) by dividing into two
In the Superior Mediastinum principal bronchi. Trachea is always patent.
• Oesophagus is 25 cm long, like duodenum and
Anteriorly
ureter. Its maximum part about 20 cm/8-inch lie
1 Arch of aorta in thoracic cavity.
2 The origin of the left subclavian artery (Fig. 20.6a) • There is no digestive activity in the oesophagus.
Posteriorly: Vertebral column Lower part of oesophagus is a site of portocaval
To the right: Oesophagus anastomoses.
• Thoracic duct drains lymph from both lower
To the left: Pleura limbs, abdominal cavity, left side of thorax, left
upper limb and left side of head and neck.
In the Neck
The thoracic duct forms an arch rising about 3–4 cm above
CLINICOANATOMICAL PROBLEM
the clavicle. The arch has the following relations.
Anteriorly A young lady during her midpregnancy period
1 Left common carotid artery complained of rapid breathing and difficulty in
2 Left vagus swallowing. She also gave a history of sore throat
3 Left internal jugular vein with pains in her joints during childhood.
• What is the likely diagnosis?
Posteriorly • What is the explanation for her symptoms?
1 Vertebral artery and vein. Ans: The diagnosis most likely is rheumatic heart. It
2 Sympathetic trunk occurs due to streptococcal infection in the throat.
3 Thyrocervical trunk and its branches Its toxins affect the mitral valve of the heart and
4 Left phrenic nerve kidney as well. In this case, her mitral valve got
5 Medial border of the scalenus anterior affected, leading to mitral stenosis which causes left
atrial enlargement due to its incomplete emptying
Thorax

6 Prevertebral fascia covering all the structures

mentioned into the left ventricle.
The enlarged left atrium presses on the oeso-
7 The first part of the left subclavian artery
phagus, as it passes behind the heart and peri-
cardium. So the patient complains of dysphagia. A
Tributaries simple barium swallow can show the enlarged left
The thoracic duct receives lymph from, roughly, both atrium causing pressure on the oesophagus.
halves of the body below the diaphragm and the left As enough blood is not reaching the lungs, there
2

half above the diaphragm (Fig. 20.12). is anoxia in the body, leading to rapid breathing.
In the thorax, the thoracic duct receives lymph
Section

vessels from the posterior mediastinal nodes and from FURTHER READING
small intercostal nodes. At the root of the neck, efferent • Doerr CH, Miller DL, Ryu JH. Chy lo-thorax. Semin respire
vessels of the nodes in the neck form the left jugular Crit Care Med 2001;22:617.
1–5
From Medical Council of India, Competency based Undergraduate Curriculum for the Indian Medical Graduate, 2018;1:44–80.
 TRACHEA, OESOPHAGUS AND THORACIC DUCT
329

1. Describe trachea. Give the relations of thoracic part d. Relations of the thoracic part
of trachea. Add a note on tracheostomy. e. Clinical anatomy
2. Describe oesophagus under following headings: 3. Write short notes on:
a. Beginning a. Thoracic duct and its tributaries
b. Course b. Achalasia cardia
c. Termination c. Normal indentations of oesophagus

1. Indentations in the oesophagus are caused by all, 3. Oesophageal varices are seen in which part of
except: oesophagus?
a. Aortic arch b. Left bronchus a. Upper end
c. Left atrium d. Left ventricle b. Middle region
2. In mitral stenosis, barium swallow is done to see c. Lower end
compression of oesophagus due to enlargement of:
d. Whole of oesophagus
a. Right atrium
b. Left atrium 4. Right side relations of thoracic part of oesophagus
are all, except:
c. Left ventricle
d. Right ventricle a. Right lung and pleura b. Azygos vein
c. Right vagus d. Left vagus

1. d 2. b 3. c 4. d

• What is extent of trachea in supine position? • Where does thoracic duct start?
• What is tracheostomy? Where is it done? • Name the tributaries of thoracic duct.
• What type of cartilage is present in trachea and bronchi? • Name the tributaries of right lymphatic duct.
• Name the sites of anatomical constrictions in the
course of oesophagus.
Thorax
2Section
 THORAX
330

21 Surface Marking and

Radiological Anatomy of Thorax
! Tuberculosis not only affects the poor, but rich as well in same quantum !
—Anonymous

INTRODUCTION Surface Marking of Parietal Pleura

Surface marking is the projection of deeper structures The cervical pleura is represented by a curved line
on the surface of body. forming a dome over the medial one-third of the clavicle
with a height of about 2.5 cm above the clavicle. Pleura
lies in the root of neck on both sides (points 1 and I)
SURFACE MARKING (Fig. 21.1).
The anterior margin, the costomediastinal line of
The bony and soft tissue surface landmarks have been pleural reflection is as follows: On the right side, it
described in Chapter 12. extends from the sternoclavicular joint downwards and
The surface marking of important structures is medially to the midpoint of the sternal angle (point 2).
described here. From here it continues vertically downwards to the
• Parietal pleura (Fig. 21.1) midpoint of the xiphisternal joint crosses to right of
• Lungs (Figs 21.2 to 21.4) xiphicostal angle (point 3). On the left side, the line
• Heart (Fig. 21.5) follows the same course up to the level of the fourth
• Cardiac valves and ascultatory areas (Fig. 21.6) costal cartilage. It then arches outwards and descends
Competency achievement: The student should be able to: along the sternal margin up to the sixth costal cartilage
AN 25.9 Demonstrate surface marking of lines of pleural reflection, (points I–IV).
lung borders and fissures, trachea, heart borders, apex beat and The inferior margin, or the costodiaphragmatic line
surface projection of valves of heart.1 of pleural reflection (same on both sides) passes laterally
Thorax
2
Section

Fig. 21.1: Surface marking of the parietal pleura

330
 SURFACE MARKING AND RADIOLOGICAL ANATOMY OF THORAX
331

the right and left costovertebral angles below the

twelfth rib behind the upper poles of the kidneys. The
latter fact is of surgical importance in exposure of
the kidney. The pleura may be damaged at these sites
(Fig. 21.1).
The posterior margins of the pleura pass from a point
2 cm lateral to the twelfth thoracic spine to a point 2 cm
lateral to the seventh cervical spine. The costal pleura
becomes the mediastinal pleura along this line.
• Points 4 and 5 in Fig. 21.2—right side
• Points 6 and 7 in Fig. 21.3—right side
• Points V and VI in Fig. 21.1—left side
• Points VII and VIII in Fig. 21.3—left side
Surface Making of the Lungs
The apex of the lung coincides with the cervical pleura,
and is represented by a line convex upwards rising
2.5 cm above the medial one-third of the clavicle point
1 on right and I on left side (Fig. 21.4).
Fig. 21.2: Parietal (black) and visceral pleurae and lung (pink) The anterior border of the right lung corresponds very
from the lateral aspect. Costodiaphragmatic recess is seen closely to the anterior margin or costomediastinal line
of the pleura and is obtained by joining:
from the lower limit of its anterior margin, so that it
• Point 2 at the sternoclavicular joint,
crosses the eighth rib in the midclavicular line (Fig. 21.2),
• Point 3 in the median plane at the sternal angle,
the tenth rib in the midaxillary line, and the twelfth rib
• Point 4 in the median plane just above the
at the lateral border of the sacrospinalis muscle
xiphisternal joint.
(Fig. 21.3). Further it passes horizontally a little below
the twelfth rib to the lower border of the twelfth thoracic The anterior border of the left lung corresponds to the
vertebra, 2 cm lateral to the upper border of the twelfth anterior margin of the pleura up to the level of the
thoracic spine (Fig. 21.3). fourth costal cartilage points II–IV.
Thus the pleurae descend below the costal margin In the lower part, it presents a cardiac notch of
at three places, at the right xiphicostal angle, and at variable size. From the level of the fourth costal

Thorax
2Section

Fig. 21.3: Parietal (black) and visceral pleurae (pink) on the back of thorax. Costovertebral angles are seen
 THORAX
332

Fig. 21.4: Surface projection of the parietal pleura (black), visceral pleura and lung (pink) on the front of the thorax

cartilage, it passes laterally for 3.5 cm from the sternal Between the visceral and parietal pleurae, the
margin, and then curves downwards and medially to recesses are present. Costodiaphragmatic recesses are
reach the sixth costal cartilage 4 cm from the median present on both sides and are about 4–5 cm deep.
plane (points V and VI). In the region of the cardiac Costomediastinal recess is prominent on left side, to
notch, the pericardium is covered only by a double layer left of sternum between 4th and 6th costal cartilages.
of pleura. The area of the cardiac notch is dull on
percussion and is called the area of superficial cardiac Surface Marking of the Borders of the Heart
dullness. • Point 1 at the lower border of the second left costal
The lower border of each lung (same on both the sides) cartilage about 1.3 cm from the sternal margin
lies two ribs higher than the parietal pleural reflection. (Fig. 21.5).
It crosses the sixth ribs (points 5 and VI) in the
midclavicular line, the eighth rib (points 6 and VII) in
the midaxillary line (Fig. 21.4), the tenth rib at the lateral
border of the erector spinae, and ends 2 cm lateral to
the tenth thoracic spine (Fig. 21.3).
The posterior border coincides with the posterior
margin of the pleural reflection except that its lower
end lies at the level of the tenth thoracic spine (Fig. 21.3).
Thorax

The oblique fissure can be drawn on both sides by

joining:
• A point 2 cm lateral to the third thoracic spine.
• Another point on the fifth rib in the midaxillary
line (Figs 21.2 and 21.4).
• A third point on the sixth costal cartilage 7.5 cm
from the median plane.
2

The horizontal fissure is represented only on right side

Section

by a line joining:
• A point on the anterior border of the right lung at
the level of the fourth costal cartilage.
• A second point on the fifth rib in the midaxillary
line (Fig. 21.2). Fig. 21.5: Surface projection of the borders of the heart
 SURFACE MARKING AND RADIOLOGICAL ANATOMY OF THORAX
333

• Point 2 at the upper border of the third right costal • First point 1 cm above the sternal end of the clavicle,
cartilage 0.8 cm from the sternal margin. 3.5 cm from the median plane.
• Point 3 in the right 4th intercostal space 3.8 cm from • Next points 2–7 marked over the upper 6 costal
median plane. cartilages at a distance of 1.25 cm from the lateral
• Point 4 at the lower border of the sixth right costal sternal border.
cartilage 2 cm from the sternal margin. • The last point 8 is marked in the sixth intercostal
• Point 5 at the apex of the heart in the left fifth space 1.25 cm from the lateral sternal border.
intercostal space 9 cm from the midsternal line.
• Joining of points 1 and 2 forms upper border. Pulmonary Trunk
• The right border is marked by a line, slightly convex 1 First mark the pulmonary valve by a horizontal line
to the right, joining the points 2, 3 and 4. The 2.5 cm long, mainly along the upper border of the
maximum convexity is about 3.8 cm from the median left 3rd costal cartilage and partly over the adjoining
plane in the fourth space. part of the sternum (Fig. 21.6).
• The inferior border is drawn by joining points 4 and 5. 2 Then mark the pulmonary trunk by two parallel lines
• The left border is marked by a line, fairly convex to 2.5 cm apart from the pulmonary orifice upwards to
the left, joining the points 1 and 5. the left 2nd costal cartilage.
Atrioventricular groove is marked by a line drawn
from the sternal end of left 3rd costal cartilage to the
sternal end of right sixth costal cartilage.
The area of the chest wall overlying the heart is called
the precordium.

Surface Marking of the Cardiac Valves and

the Auscultatory Areas
Sound produced by closure of the valves of the heart
can be heard using a stethoscope. The sound arising in
relation to a particular valve are best heard not directly
over the valve, but at areas situated some distance away
from the valve in the direction of blood flow through
it. These are called auscultatory areas. The position
of the valves in relation to the surface of the body, and
of the auscultatory areas is given in Table 21.1 and
Fig. 21.6.

Arteries
Internal Mammary (Thoracic) Artery Fig. 21.6: Surface projection of the cardiac valves. The position
It is marked by joining the following points (Fig. 21.7). of the auscultatory areas is also shown

Table 21.1: Surface marking of the cardiac valves and the sites of the auscultatory areas (Fig. 21.6)
Valve Diameter of orifice Surface marking Auscultatory area
Thorax
1. Pulmonary 2.5 cm A horizontal line, 2.5 cm long, behind the upper Second left intercostal space
border of the third left costal cartilage and adjoining near the sternum
part of the sternum

2. Aortic 2.5 cm A slightly oblique line, 2.5 cm long, behind the left Second right costal cartilage
half of the sternum at the level of the lower border near the sternum
of the left third costal cartilage
2

3. Mitral 3 cm An oblique line, 3 cm long, behind the left half of Cardiac apex
Section

the sternum opposite the left fourth costal cartilage

4. Tricuspid 4 cm Most oblique of all valves, being nearly vertical, Lower end of the sternum
4 cm long, behind the right half of the sternum
opposite the fourth and fifth spaces
 THORAX
334

Fig. 21.7: The origin, course and terminations of the internal Fig. 21.8: Surface marking of some arteries of thorax
thoracic artery (1st–8th costal cartilages)
Left Common Carotid Artery
Ascending Aorta The thoracic part of this artery is marked by a broad
1 First mark the aortic orifice by a slightly oblique line line extending from a point a little to the left of the centre
2.5 cm long running downwards and to the right of the manubrium to the left sternoclavicular joint.
over the left half of the sternum beginning at the level
of the lower border of the left 3rd costal cartilage Left Subclavian Artery
(Fig. 21.6). The thoracic part of the left subclavian artery is marked
2 Then mark the ascending aorta by two parallel lines by a broad vertical line along the left border of the
2.5 cm apart from the aortic orifice upwards to the manubrium a little to the left of the left common carotid
right half of the sternal angle (Fig. 21.6). artery.

Arch of the Aorta Veins

Arch of the aorta lies behind the lower half of the Superior Vena Cava
manubrium sterni. Its upper convex border is marked Superior vena cava is marked by two parallel lines 2 cm
by a line which begins at the right end of the sternal apart, drawn from the lower border of the right first
angle, arches upwards and to the left through the centre costal cartilage to the upper border of the third right
of the manubrium, and ends at the sternal end of the costal cartilage, overlapping the right margin of the
left second costal cartilage. Note that the beginning and sternum (Fig. 21.9).
the end of the arch lie at the same level. When marked
on the surface as described above, the arch looks much
Thorax

smaller than it actually is because of foreshortening

(Fig. 21.8).
Descending Thoracic Aorta
Descending thoracic aorta is marked by two parallel
lines 2.5 cm apart, which begin at the sternal end of the
left second costal cartilage, pass downwards and
medially, and end in the median plane 2.5 cm above
2

the transpyloric plane (Fig. 21.8).

Section

Brachiocephalic Artery
Brachiocephalic artery is marked by a broad line
extending from the centre of the manubrium to the right
sternoclavicular joint (Fig. 21.8). Fig. 21.9: Surface marking of veins of thorax
 SURFACE MARKING AND RADIOLOGICAL ANATOMY OF THORAX
335

Right Brachiocephalic Vein

It is marked by two parallel lines 1.5 cm apart, drawn
from the medial end of the right clavicle to the lower
border of the right first costal cartilage close to the
sternum (Fig. 21.9).

Left Brachiocephalic Vein

It is marked by two parallel lines 1.5 cm apart, drawn
from the medial end of the left clavicle to the lower
border of the first right costal cartilage. It crosses the
left sternoclavicular joint and the upper half of the
manubrium (Fig. 21.9).

Trachea (Thoracic Part)

Trachea is marked by two parallel lines 2 cm apart,
drawn from the lower border of the cricoid cartilage
(2 cm below the thyroid notch) to the manubriosternal
angle, inclining slightly to the right (Fig. 21.10).
Fig. 21.10: Surface marking of trachea, bronchi and thoracic duct
Right Bronchus
Right bronchus is marked by a broad line running
downwards and to the right for 2.5 cm from the lower
end of the trachea to the sternal end of the right third
costal cartilage.

Left Bronchus
Left bronchus is marked by a broad line running
downwards and to the left for 5 cm from the lower end
of the trachea to the left third costal cartilage 4 cm from
the median plane (Fig. 21.10).

Oesophagus
It is marked by one on each side two parallel lines 2.5 cm
apart by joining the following points:
1 Two points (one on each side) 2.5 cm apart at the
lower border of the cricoid cartilage across the
median plane (Fig. 21.11).
2 Two points (one on each side) 2.5 cm apart at the
root of the neck a little to the left of the median plane Fig. 21.11: Surface marking of the oesophagus
one on each side.
3 Two points (one on each side) 2.5 cm apart at the Thorax
sternal angle across the median plane. 5 A fifth point just above the sternal angle 1.3 cm to
4 Two points (one on each side) 2.5 cm apart at the the left of the median plane.
left 7th costal cartilage 2.5 cm from the median plane.
Competency achievement: The student should be able to:
Thoracic Duct AN 25.7 Identify structures seen on a plain X-ray chest (PA view).2
It is marked by joining the following points.
1 A point 2 cm above the transpyloric plane slightly
2

to the right of the median plane (Fig. 21.10). RADIOLOGICAL ANATOMY

Section

2 A second point 2 cm to right of median plane below

manubriosternal angle. The most commonly taken radiographs are described
3 A third point across to left side at same level. as posteroanterior (PA) views. X-rays travel from
4 A fourth point 2.5 cm above the left clavicle posterior to the anterior side. A study of such radio-
2 cm from the median plane. graphs gives information about the lungs, the dia-
 THORAX
336

Bones
The bones of the vertebrae are partially visible. Costo-
transverse joints are seen on each side. The posterior
parts of the ribs are better seen because of the large
amounts of calcium contained in them. The ribs get
wider and thinner as they pass anteriorly. Costal
cartilages are not seen unless these are calcified. The
medial borders of the scapulae may overlap the
periphery of the lung fields.

Trachea
Trachea is seen as air-filled shadow in the midline of
the neck. It lies opposite the lower cervical and upper
thoracic vertebrae (Fig. 21.12).

Diaphragm
Diaphragm casts dome-shaped shadows on the two
sides. The shadow on the right side is little higher than
on the left side. The angles where diaphragm meets
the thoracic cage are the costophrenic angles—the right
and the left. Under the left costophrenic angle is mostly
the gas in the stomach, while under the right angle is
the smooth shadow of the liver.

Lungs
The dense shadows are cast by the lung roots due to
the presence of the large bronchi, pulmonary vessels,
bronchial vessels and lymph nodes. The lungs readily
permit the passage of the X-rays and are seen as
translucent shadows during full inspiration. Both blood
vessels and bronchi are seen as series of shadows
radiating from the lung roots. The smaller bronchi are
not seen. The lung is divided into three zones—upper
zone is from the apex till the second costal cartilage.
Middle zone extends from the second to the fourth
costal cartilage. It includes the hilar region. Lower zone
extends from the fourth costal cartilage till the bases of
the lungs.

Fig. 21.12: (a) Posteroanterior view of the male thorax; (b) female Mediastinum
thorax
Thorax

Shadow is produced by the superimpositions of

structures in the mediastinum. It is chiefly produced by
phragm, the mediastinum, the trachea, and the skeleton the heart and the vessels entering or leaving the heart.
of the region (Fig. 21.12a). Take radiograph keeping both The transverse diameter of heart is half the transverse
hands on waist to clear lung fields from scapula. diameter of the thoracic cage. During inspiration, heart
Following structures have to be examined in postero- descends down and acquires tubular shape. Right border
anterior view of the thorax. of the mediastinal shadow is formed from above
downwards by right brachiocephalic vein, superior vena
2

Soft Tissues cava, right atrium and inferior vena cava. The left border
Section

Nipples in both the sexes may be seen over the lung of mediastinal shadow is formed from above
fields. The female breasts will also be visualised over downwards by aortic arch (aortic knuckle), left margin
the lower part of the lung fields (Fig. 21.12b). The extent of pulmonary trunk, left auricle and left ventricle. The
of the overlap varies according to the size and inferior border of the mediastinal shadow blends with
pendulance of the breasts. the liver and diaphragm.
 SURFACE MARKING AND RADIOLOGICAL ANATOMY OF THORAX
337

Competency achievement: The student should be able to: NUMERICALS

AN 25.8 Identify and describe in brief a barium swallow.3
• Anteroposterior diameter of inlet of thorax—5 cm.
Barium Swallow • Transverse diameter of inlet of thorax—10 cm.
• Suprasternal notch—T2 vertebra.
50% suspension of barium sulphate is to be swallowed
• Sternal angle—disc between T4 and T5 vertebrae.
2–3 times with patient standing behind fluoroscopic
2nd costal cartilage articulates with the sternum.
screen. Barium swallow shows the normal position
of oesophagus as it lies posterior to aortic arch, • Xiphisternal joint—T9 vertebra.
left bronchus and the left atrium of heart (Fig. 21.13). • Subcostal angle—between sternal attachments of 7th
Enlargement of left atrium would show narrow costal cartilages.
oesophagus. • Vertebra prominence—7th cervical spine.
• Superior angle of scapula—level of T2 spine.
• Root of spine of scapula—level of T3 spine.
• Inferior angle of scapula—level of T7 spine.
• Length of oesophagus—25 cm:
– Cervical part—4 cm
– Thoracic part—20 cm
– Abdominal part—1.25 cm
– Beginning of oesophagus—C6 vertebra
– Termination of oesophagus—T11 vertebra
• Beginning of trachea—C6 vertebra:
– Length of trachea—10–15 cm.
– Bifurcation of trachea—upper border of T5
vertebra.
– Length of right principal bronchus—2.5 cm.
– Length of left principal bronchus—5 cm.

FURTHER READING
Fig. 21.13: Barium swallow • Armstrong P. The normal chest. In: Armstrong P, Wilson AG,
Dec P, Hansell DM (eds). Images of the Diseases of the Chest.
London: Mosby 2000;12:62.
• Halim A. Surface and radiological anatomy. Delhi; CBSPD; 2003.
TOMOGRAPHY • Male SJ, Mirjalili SA, Stringer MD. Inconsistencies in surface
anatomy: the need for an evidence-based reappraisal clin
Tomography is a radiological technique by which Anat 2010;23:922–93.
radiograms of selected layers (depths) of the body can • Mirjalili S, Hale S, Buckenham T, et al. A reappraisal of adult
be made. Tomography is helpful in locating deeply thoracic surface anatomy. Clin Anat 2012;25:827–34.
situated small lesions which are not seen in the usual Examines key thoracic surface anatomical landmarks in vivo using
radiograms. computed tomographic (CT) imaging.

1–3
From Medical Council of India, Competency based Undergraduate Curriculum for the Indian Medical Graduate, 2018;1:44–80. Thorax
2Section
 THORAX
338

2 Autonomic Nervous System,

Arteries, Nerves and Clinical Terms
! The disappointment at losing a patient lasts longer than joy in saving one !
—Murphy’s Law

INTRODUCTION digestion and metabolism of food occurs. Heart beats

Appendix 2 at the end of the section on thorax gives a normally. Person is relaxed and can do creative work
bird’s eye view of the sympathetic component of the (Fig. A2.2).
autonomic nervous system. The course of the typical Autonomic nervous system is controlled by brain-
and atypical intercostal nerves is described briefly. stem and cerebral hemispheres. These include reticular
Arteries of thorax have been tabulated. Clinical terms formation of brainstem, thalamic and hypothalamic
are also given. nuclei, limbic lobe and prefrontal cortex including the
ascending and descending tracts interconnecting these
AUTONOMIC NERVOUS SYSTEM regions.
The autonomic nervous system comprises sympathetic Sympathetic Nervous System
and parasympathetic components. Sympathetic Sympathetic nervous system is the larger of the two
component is active during fright, flight or fight. During components of autonomic nervous system. It consists
any of these activities, the pupils dilate, skin gets pale, of two ganglionated trunks, their branches, prevertebral
blood pressure rises, blood vessels of skeletal muscles, ganglia, plexuses. It supplies all the viscera of thorax,
heart, and brain dilate. The person is tense and gets abdomen and pelvis, including the blood vessels of
tired soon (Fig. A2.1). There is hardly any activity in head and neck, brain, limbs, skin and the sweat glands
the digestive tracts due to which the individual does as well as arrector pilorum muscle of skin of the whole
not feel hungry. body.
Parasympathetic component has the opposite effects The preganglionic fibres are the axons of neurons
of sympathetic component. This component is situated in the lateral horns of T1–L2 segments of spinal
sympathetic to the digestive tract. In its activity, cord. They leave spinal cord through their respective
Thorax
2
Section

Fig. A2.1: Actions of sympathetic system

338
 AUTONOMIC NERVOUS SYSTEM, ARTERIES, NERVES AND CLINICAL TERMS
339

4 These may synapse in the corresponding ganglia and

pass medially to the viscera like heart, lungs,
oesophagus.
5 These white rami communicantes (wrc) pass to cor-
responding ganglia and emerge from these as wrc
(unrelayed) in the form of splanchnic nerves to
supply abdominal and pelvic viscera after synapsing
in the ganglia situated in the abdominal cavity. Some
fibres of splanchnic nerves pass express to adrenal
medulla.
Sympathetic trunk on either side of the body extends
from cervical region to the coccygeal region where both
Fig. A2.2: Actions of parasympathetic system trunks fuse to form a single ganglion impar. Sympathetic
trunk has cervical, thoracic, lumbar, sacral and
ventral roots, to pass in their nerve trunks, and beginn- coccygeal parts.
ing of ventral rami via white ramus communicans (wrc). Thoracic Part of Sympathetic Trunk
There are 14 white rami communicantes on each side.
These fibres can have following alternative routes. There are usually 11 ganglia on the sympathetic trunk
1 They relay in the ganglion of the sympathetic trunks, of thoracic part. The first ganglion lies on neck of Ist
postganglionic fibres pass via the grey rami rib and is usually fused with inferior cervical ganglion
communicantes and get distributed to the blood and forms stellate ganglion. The lower ones lie on the
vessels of muscles, skin, sweat glands and to arrector heads of the ribs. The sympathetic trunk continues with
pili muscles (Fig. A2.3). its abdominal part by passing behind the medial arcuate
2 These may pass through the corresponding ganglion ligament.
and ascend to a ganglion higher before terminating The ganglia are connected with the respective spinal
in the above manner. nerves via the white ramus communicans (from the
3 These may pass through the corresponding ganglion spinal nerve to the ganglion) and the grey ramus
and descend to a ganglion lower and then terminate communicans (from the ganglion to the spinal nerve,
in the above manner. i.e. ganglion gives grey).

Thorax
2Section

Fig. A2.3: Pathways of sympathetic and somatic nerves: Splanchnic afferent fibres and somatic afferent fibres (green); sympathetic
preganglionic efferent fibres (red); sympathetic postganglionic efferent fibres (red dotted); and somatic efferent fibres (black)
 THORAX
340

Branches thetic fibres. It causes vasodilatation of coronary

1 Grey rami communicantes to all the spinal nerves, arteries. Impulses of pain travel along sympathetic
i.e. T1–T12. The postganglionic fibres pass along the fibres. These fibres pass mostly through left
spinal nerves to supply cutaneous blood vessels, sympathetic trunk and reach the spinal cord via T1–T5
sweat glands and arrector pili muscles. spinal nerves. Thus the pain may be referred to the area
2 Some white rami communicantes from T1 to T5 of skin supplied by T1–T5 nerves, i.e. retrosternal,
ganglia travel up to the cervical part of sympathetic medial side of the upper limbs. Since one is more
trunk to relay in the three cervical ganglia. Fibres conscious of impulses coming from skin than the
from the lower thoracic ganglia T10–L2 pass down as viscera, one feels as if the pain is in the skin. This is the
preganglionic fibres to relay in the lumbar or sacral basis of the referred pain.
ganglia. Smaller branches of coronary artery are supplied by
3 The first five thoracic ganglia give postganglionic parasympathetic nerves. These nerves are concerned
fibres to heart, lungs, aorta and oesophagus. with slowing of the cardiac cycle.
4 Lower eight ganglia give fibres which are pregang- The nerves reach the heart by the following two
lionic (unrelayed) for the supply of abdominal plexuses.
viscera. These are called splanchnic (visceral) nerves.
Superficial Cardiac Plexus
Ganglia 5–9 give fibres which constitute greater
splanchnic nerve. Some fibres reach adrenal medulla. Superficial cardiac plexus is formed by the following:
1 Superior cervical cardiac branch of left sympathetic
Ganglia 9–10 give fibres that constitute lesser trunk.
splanchnic nerve. 2 Inferior cervical cardiac branch of left vagus nerve.
Ganglion 11 gives fibres that constitute lowest
splanchnic nerve. Deep Cardiac Plexus
Deep cardiac plexus consists of two halves which are
Nerve Supply of Heart interconnected and lie anterior to bifurcation of trachea
Preganglionic sympathetic neurons are located in lateral (Table A2.1).
horns T1–T5 segments of spinal cord. These fibres pass Branches from the cardiac plexus give extensive
along the respective ventral roots of thoracic nerves, to branches to pulmonary plexuses, right and left coronary
synapse with the respective ganglia of the sympathetic plexuses. Branches from the coronary plexuses supply
trunk. After relay, the postganglionic fibres form thoracic both the atria and the ventricles. Left ventricle gets
branches which intermingle with the vagal fibres, to form richer nerve supply because of its larger size.
cardiac plexus.
Some fibres from T1 to T5 segments of spinal cord Nerve Supply of Lungs
reach their respective ganglia. These fibres then travel The lungs are supplied from the anterior and posterior
up to the cervical part of the sympathetic chain and pulmonary plexuses. Anterior plexus is an extension of
relay in superior, middle and inferior cervical ganglia. deep cardiac plexus. The posterior part is formed from
After relay, the postganglionic fibres form the three branches of vagus and T2–T5 sympathetic ganglia. Small
cervical cardiac nerves. Preganglionic parasympathetic ganglia are found on these nerves for the relay of
neurons for the supply of heart are situated in the dorsal parasympathetic impulses brought via vagus nerve
nucleus of vagus nerve. fibres. Parasympathetic system is bronchoconstrictor or
Thorax

Sympathetic activity increases the heart rate. Larger motor, whereas sympathetic system is inhibitory.
branches of coronary are mainly supplied by sympa- Sympathetic stimulation causes relaxation of smooth

Table A2.1: Components of deep cardiac plexus

Right half Left half

1. Superior, middle, inferior cervical cardiac branches of right Only middle and inferior branches
sympathetic trunk
2

2. Cardiac branches of T2–T4 ganglia of right side Same

Section

3. Superior and inferior cervical cardiac branches of right vagus Only the superior cervical cardiac branch of left vagus
4. Thoracic cardiac branch of right vagus Same
5. Two branches of right recurrent laryngeal nerve arising from Same, but coming from thoracic region
neck region
 AUTONOMIC NERVOUS SYSTEM, ARTERIES, NERVES AND CLINICAL TERMS
341

muscles of bronchial tubes or bronchodilator. The ATYPICAL INTERCOSTAL NERVES

pressure of inspired air also causes bronchodilatation. The thoracic spinal nerves and their branches which
do not follow absolutely thoracic course are designated
TYPICAL INTERCOSTAL NERVE
as atypical intercostal nerves. Thus first and second
Typical intercostal nerve is any of the nerves belonging intercostal nerves are atypical as these two nerves partly
to 3rd to 6th intercostal spaces. supply the upper limb.
Beginning The first thoracic nerve entirely joins the brachial
plexus as its last rami or root. It gives no contribution
Typical thoracic spinal nerve after it has given off dorsal to the first intercostal space. That is why the nerve
primary ramus or dorsal ramus is called the intercostal supply of skin of first intercostal space is from the
nerve. It runs in the intercostal space, i.e. between the supraclavicular nerves (C3, C4) (see Fig. 3.4).
lower border of rib above and upper border of rib below The second thoracic or second intercostal nerve runs
(see Fig. 14.3). in the second intercostal space. But its lateral cutaneous
Course branch as intercostobrachial nerve is rather big and it
supplies skin of the axilla as well. Third to sixth
Typical intercostal nerve enters the posterior part of intercostal nerves are typical (see Fig. 7.1).
intercostal space by passing behind the posterior Also seventh, eight, ninth, tenth, eleventh intercostal
intercostal vessels. So the intercostal nerve lies lowest nerves are atypical, as these course partly through
in the neurovascular bundle. The order from above thoracic wall and partly through anterolateral
downwards is vein, artery and nerve (VAN). At first, abdominal wall. Lastly the twelfth thoracic is known as
the bundle runs between posterior intercostal membrane subcostal nerve. It also passes through the anterolateral
and subcostalis, then between inner intercostal and abdominal muscles. These nerves supply parietal
innermost intercostal and lastly between inner inter- peritoneum, muscles of the anterolateral abdominal wall
costal and sternocostalis muscles (see Fig. 14.2). and overlying skin.
At the anterior end of intercostal space, the
intercostal nerve passes in front of internal thoracic ARTERIES
vessels, pierces internal intercostal muscle and anterior
intercostal membrane to continue as anterior cutaneous The arteries of thorax are internal thoracic artery,
branch which ends by dividing into medial and lateral ascending aorta, arch of aorta, descending thoracic
cutaneous branches (see Fig. 14.4). aorta and coronary arteries. These have been described
with their origin, course, termination and area of
Branches distribution in Tables A2.2 and A2.3.
1 Communicating branches to the sympathetic
ganglion close to the beginning of ventral ramus. The CLINICAL TERMS
anterior or ventral ramus containing sympathetic
fibres from lateral horn of spinal cord gives off a white Site of pericardial tapping: Removal of pericardial
ramus communicans to the sympathetic ganglion. fluid is done in left 4th or 5th intercostal spaces just
These fibres get relayed in the ganglion. Some of to the left of the sternum as pleura deviates exposing
these relayed fibres pass via grey ramus communicans the pericardium against the medial part of left 4th
to ventral ramus. A few pass backwards in the dorsal and 5th intercostal spaces. Care should be taken to
ramus and rest pass through the ventral ramus. avoid injury to internal thoracic artery lying at a
These sympathetic fibres are sudomotor, pilomotor distance of 1 cm from the lateral border of sternum. Thorax
and vasomotor to the skin and vasodilator to the Needle can also be passed upwards and posteriorly
skeletal vessels (see Fig. 14.3). from the left xiphicostal angle to reach the pericardial
2 Before the angle, nerve gives a collateral branch that cavity (see Fig. 18.6).
runs along the upper border of lower rib. This branch Foreign bodies in trachea: Foreign bodies like pins,
supplies intercostal muscles, costal pleura and coins entering the trachea pass into right bronchus;
periosteum of the rib. Right bronchus wider shorter, more vertical and is
3 Lateral cutaneous branch arises along the midaxillary in line with trachea, so the foreign bodies in the
2

line. It divides into anterior and posterior branches. trachea travel down into right bronchus and then
Section

4 The nerve keeps giving muscular, periosteal, and into posterior basal segments of the lower lobe of
branches to the costal pleura during its course. the lung (see Fig. 16.5).
5 Anterior cutaneous branch is the terminal branch of Site of bone marrow puncture: The manubrium
the nerve. It divides into anterior and posterior sterni is the favoured site for bone marrow puncture
branches.
 THORAX
342

Table A2.2: Arteries of thorax

Artery Origin, course and termination Area of distribution
INTERNAL THORACIC Arises from inferior aspect of 1st part of subclavian It supplies pericardium, thymus, upper six
(see Figs 14.11 artery. Its origin lies 2 cm above the sternal end of the intercostal spaces in their anterior parts,
and 21.7) clavicle. It runs downwards, forwards and medially mammary gland, rectus sheath and also
behind the clavicle and behind the 1–6 costal 7–9 intercostal spaces. Thus it supplies
cartilages and 1–5 intercostal spaces to terminate in anterior thoracic and anterior abdominal
the 6th intercostal space by dividing into superior walls from the clavicle to the umbilicus
epigastric and musculophrenic arteries
Pericardiacophrenic Branch of internal thoracic artery Supplies fibrous and parietal layer of serous
artery pericardia and the diaphragm
Mediastinal arteries Small branches of internal thoracic artery Supply thymus and fat in the mediastinum
Two anterior intercostal Two arteries, each arises in 1–6 upper intercostal Supply muscles of the 1–6 intercostal spaces
arteries spaces from internal thoracic artery and parietal pleura
Perforating arteries Arise from internal thoracic artery in 2nd, 3rd and 4th They are large enough to supply the
spaces mammary gland
Superior epigastric Terminal branch of internal thoracic artery. Enters the Supplies the aponeuroses which form the
artery rectus sheath and ends by anastomosing with inferior rectus sheath, including the rectus
epigastric artery, a branch of external iliac artery abdominis.
Musculophrenic This is also the terminal branch of internal thoracic Supplies the muscles of anterior parts of 7–9
artery artery. Ends by giving 2 anterior intercostal arteries in intercostal spaces, and the muscle fibres of
7–9 intercostal spaces and by supplying the thoraco- the thoracoabdominal diaphragm
abdominal diaphragm
ASCENDING AORTA Arises from the upper end of left ventricle. It is about Supplies the heart musculature with the help
(see Fig. 19.2) 5 cm long and is enclosed in the pericardium. It runs of right coronary and left coronary arteries,
upwards, forwards and to the right and continues as the described later.
arch of aorta at the sternal end of upper border of 2nd
right costal cartilage. At the root of aorta, there are three
dilatations of the vessel wall called the aortic sinuses.
These are anterior, left posterior and right posterior
ARCH OF AORTA It begins behind the upper border of 2nd right sterno- Through its three branches, namely brachio-
(see Fig. 19.2) chondral joint. Runs upwards, backwards and to left cephalic, left common carotid and left
across the left side of bifurcation of trachea. Then it subclavian arteries, arch of aorta supplies
passes behind the left bronchus and on the left side part of brain, head, neck and upper limb
of body of T4 vertebra by becoming continuous with
the descending thoracic aorta
Brachiocephalic artery 1st branch of arch of aorta. Runs upwards and soon Through these two branches, part of the right
divides into right common carotid and right subclavian half of brain, head, and neck are supplied.
arteries The distribution of two branches on right side
Thorax

is same as on the left side

Left common carotid It runs upwards on the left side of trachea and at upper The two branches supply brain, structures
artery border of thyroid cartilage. The artery ends by dividing in the head and neck
into internal carotid and external carotid arteries
Left subclavian artery It is the last branch of arch of aorta. Runs to left in the Gives branches which supply part of brain,
root of neck behind scalenus anterior muscle, then on part of thyroid gland, muscles around
the upper surface of 1st rib. At the outer border of 1st scapula, 1st and 2nd posterior intercostal
2

rib, it continues as the axillary artery spaces

Section

DESCENDING Begins on the left side of the lower border of body of 3–11 posterior intercostal spaces, subcostal
THORACIC AORTA T4 vertebra. Descends with inclination to right and area, lung tissue, oesophagus, pericardium,
(see Fig. 14.8) ends at the lower border of T12 vertebra by mediastinum and diaphragm
continuing as abdominal aorta
Contd...
 AUTONOMIC NERVOUS SYSTEM, ARTERIES, NERVES AND CLINICAL TERMS
343

Table A2.2: Arteries of thorax (Contd.)

Artery Origin, course and termination Area of distribution

3–11 posterior 3–11 posterior intercostal arteries of both right and left Supply the muscles of these intercostal
intercostal arteries sides arise from the descending thoracic aorta. Right spaces. Each of these arteries gives a
(see Fig. 14.9) branches are little longer than the left. Each intercostal collateral branch, which runs along the lower
artery and its collateral branch end by anastomosing border of the respective intercostal space
with the two anterior intercostal arteries
Bronchial arteries Two left bronchial arteries arise from descending aorta Bronchial tree
Oesophageal branches 2–3 oesophageal branches arise from descending aorta Supply the oesophagus
Pericardial branches Branches of descending aorta, run on the pericardium Fibrous and parietal layer of serous
pericardia
Mediastinal branches Arise from descending aorta Supply lymph nodes and fat in posterior
mediastinum
Superior phrenic arteries Two branches of descending aorta. End in the superior Supply the thoracoabdominal diaphragm
surface of diaphragm. These arteries anastomose with
branches of musculophrenic and pericardiacophrenic
arteries.

Table A2.3: Comparison of right and left coronary arteries

Right coronary artery (Fig. 18.22) Left coronary artery (Fig. 18.22)
1. Origin: Anterior aortic sinus of ascending aorta 1. Left posterior aortic sinus of ascending aorta
2. Course: Between pulmonary trunk and right auricle 2. Between pulmonary trunk and left auricle
3. Descends in atrioventricular groove on the right side 3. Descends in atrioventricular groove on the left side
4. Turns at the inferior border to run in posterior part of 4. Turns at left border to run in posterior part of atrioventricular
atrioventricular groove groove. It is called circumflex branch
5. Termination: Ends by anastomosing with the circumflex 5. Its circumflex branch ends by anastomosing with right
branch of left coronary artery coronary artery
6. Branches: To right atrium, right ventricle (marginal artery) 6. Left atrium, left ventricle and anterior interventricular branch
and posterior interventricular branch for both ventricles for both ventricles and anterior two-thirds of interventricular
and posterior one-third of interventricular septa septa. Anterior interventricular branch ends by anastomosing
with posterior interventricular branch
7. Supplies sinuatrial node, atrioventricular (AV) node, AV 7. Supplies left branch of atrioventricular bundle including
bundle, right branch of AV bundle including its its Purkinje fibres
Purkinje fibres

in adults. Manubrium is subcutaneous and easily

Patient also fixes the arms by holding the arms of Thorax
a chair, so that serratus anterior and pectoralis major
approachable (see Fig. 13.14). Bone marrow studies
can move the ribs and help in respiration.
are done for various haematological disorders.
Another site is the iliac crest; which is the preferred Paracentesis thoracis or pleural tapping: Aspira-
site in children. tion of any fluid from the pleural cavity is called
paracentesis thoracis. It is usually done in the eighth
Posture of a patient with respiratory difficulty:
intercostal space in midaxillary line. The needle is
Such a patient finds comfort while sitting, as
passed through lower part of space to avoid injury
2

diaphragm is lowest in this position. In lying

to the principal neurovascular bundle (see Fig. 15.9).
position, the diaphragm is highest, and patient is
Section

very uncomfortable (see Fig. 13.32). Some clinical conditions associated with the pleura
are as follows:
In standing position, the diaphragm level is
midway, but the patient is too sick to stand. Pleurisy: This is inflammation of the pleura. It may
be dry, but often it is accompanied by collection of
 THORAX
344

fluid in the pleural cavity. The condition is called of spinal cord mostly through the dorsal root ganglia
the pleural effusion. of the left side. Since these dorsal root ganglia also
Pneumothorax: Presence of air in the pleural cavity. receive sensory impulses from the medial side of
Haemothorax: Presence of blood in the pleural arm, forearm and upper part of front of chest, the
cavity. pain gets referred to these areas as depicted in
Hydropneumothorax: Presence of both fluid and air Fig. 18.26.
in the pleural cavity. Though the pain is usually referred to the left side,
Empyema: Presence of pus in the pleural cavity. it may even be referred to right arm, jaw, epigastrium
or back.
Coronary artery: Thrombosis of a coronary artery Oesophageal varices: In portal hypertension, the
is a common cause of sudden death in persons past communications between the portal and systemic
middle age. This is due to myocardial infarction and veins draining the lower end of the oesophagus
ventricular fibrillation. dilate. These dilatations are called oesophageal varices
Incomplete obstruction, usually due to spasm of (see Fig. 20.8). Rupture of these varices can cause
the coronary artery causes angina pectoris, which is serious haematemesis or vomiting of blood. The
associated with agonising pain in the precordial oesophageal varices can be visualised radiogra-
region and down the medial side of the left arm and phically by barium swallow; they produce worm-
forearm. like shadows.
Coronary angiography determines the site(s) of Barium swallow: Left atrial enlargement as in
narrowing or occlusion of the coronary arteries or mitral stenosis can also be visualised by barium
their branches. swallow. The enlarged atrium causes a shallow
Angioplasty helps in removal of small blockage. depression on the front of the oesophagus. Barium
It is done using small stent or small inflated balloon swallow also helps in the diagnosis of oesophageal
(see Fig. 18.27). strictures, carcinoma and achalasia cardia (Fig. 21.13).
If there are large segments or multiple sites of Coarctation of the aorta: Coarctation of the aorta is
blockage, coronary bypass is done using either great a localised narrowing of the aorta opposite to or just
saphenous vein or internal thoracic artery as graft(s) beyond the attachment of the ductus arteriosus. An
(see Fig. 18.28). extensive collateral circulation develops between the
Cardiac pain is an ischaemic pain caused by branches of the subclavian arteries and those of the
incomplete obstruction of a coronary artery. descending aorta. These include the anastomoses
between the anterior and posterior intercostal
Viscera usually have low amount of sensory output, arteries. These arteries enlarge greatly and produce
whereas skin is an area of high amount of sensory output. a characteristic notching on the ribs (see Fig. 19.9b).
So pain arising from low sensory output area is projected Aortic aneurysm: Aortic aneurysm is a localised
as coming from high sensory output area. dilatation of the aorta which may press upon the
Axons of pain fibres conveyed by the sensory surrounding structures and cause the mediastinal
sympathetic cardiac nerves reach T1 to T5 segments syndrome (see Fig. 19.11).
Thorax
2

1. Describe the thoracic part of sympathetic system. 4. Enumerate the components of superficial cardiac
Section

2. Discuss the nerve supply of lung. What is the plexus.

clinical importance of these nerves. 5. Name the atypical intercostal nerves.
3. Enumerate the components of deep cardiac plexus 6. Give basis of cardiac pain referred to medial side
on the right and left sides. of left arm.
 AUTONOMIC NERVOUS SYSTEM, ARTERIES, NERVES AND CLINICAL TERMS
345

A. Match the following on the left side with their 1. The apex of the heart:
appropriate answers on the right side. a. is formed only by left ventricle
1. Arteries and their branches: b. is situated in the left 5th intercostal space
a. Internal thoracic i. Posterior c. is just medial to midclavicular line
interventricular d. is directed downwards, backwards and to the
b. Descending aorta ii. Posterior intercostal left
c. Right coronary iii. Anterior 2. The aortic opening in the diaphragm:
interventricular a. lies at the lower border of 12th thoracic vertebra
d. Left coronary iv. Anterior intercostal b. transmits aorta, thoracic duct and azygos vein
2. Ribs: c. lies in the central tendinous part of the diaphragm
a. True ribs i. 8th, 9th and 10th d. is quadrangular in shape
b. Atypical ribs ii. 1st, 11th, 12th 3. The trachea:
c. Least fractured ribs iii. 1st–7th a. extends in cadaver from C6 to T4.
d. Vertebrochondral iv. 1st, 2nd, 10th, 12th b. deviates to the right at its termination
ribs c. is lined by ciliated pseudostratified epithelium
3. Vertebral levels: d. is seen as a vertical radio-opaque shadow in
radiograph.
a. Aortic opening i. T8
in diaphragm 4. Thoracic duct:
b. Oesophageal opening ii. T10 a. begins at the lower border of L1
in diaphragm b. is the upward continuation of cisterna chyli
c. Inferior vena cava iii. T11 c. enters the thorax through vena caval opening
in diaphragm in the diaphragm
d. Gastro-oesophageal iv. T12 d. ends by opening at the junction of left
junction subclavian and left internal jugular veins
4. Mediastinum: 5. Bronchopulmonary segment:
a. Anterior mediastinum i. Trachea a. is aerated by a segmental bronchus
b. Middle mediastinum ii. Azygos vein b. is pyramidal in shape with its base directed
c. Posterior mediastinum iii. Heart towards periphery
d. Superior mediastinum iv. Sternopericar- c. is an independent respiratory unit
dial ligaments d. is supplied by its own separate branch of
pulmonary artery and vein
B. For each of the incomplete statements or
questions below, one or more answers given is/ 6. Visceral pleura:
are correct. Select. a. is pain insensitive
A. If only a, b and c are correct b. develops from splanchnopleuric mesoderm Thorax
B. If only a and c are correct c. covers all the surfaces of the lung including
C. If only b and d are correct fissures but not the hilum
D. If only d is correct d. is innervated by autonomic nerves
E. If all are correct
2Section

A. 1. a – iv, b – ii, c – i, d – iii, 2. a – iii, b – iv, c – ii, d–i

3. a – iv, b – ii, c – i, d – iii, 4. a – iv, b – iii, c – ii, d–i
B. 1. A 2. A 3. A 4. C 5. B 6. E.
 SPOTS ON THORAX

1. a. Identify the part of 6. a. Identify the structure.

the bone. b. Name its main
b. Name the structures branches.
related to it.

2. a. Name the joint shown. 7. a. Identify the part.

b. Name its type. b. Name its segments.

3. a. Identify the part 8. a. Name the structure.

shown. b. Name its three
b. Name the structures openings.
present.

4. a. Identify the part 9. a. Identify the part.

shown. b. Name its boundaries.
b. Name its three
branches.

5. a. Identify the sulcus. 10. a. Identify the ganglion.

b. Name the structures b. Name the connec-
present. tions with the ventral
ramus.

347
 THORAX
348

ANSWERS: SPOTS ON THORAX

1. a. Neck of 1st rib

b. • Sympathetic trunk
• Posterior intercostal vein
• Superior intercostal artery
• Ventral ramus of Th1 nerve

2. a. Manubriosternal joint
b. Secondary cartilaginous joint

3. a. Hilum of right lung

b. • Eparterial bronchus
• Pulmonary artery
• Hyparterial bronchus
• Upper and lower pulmonary veins

4. a. Arch of aorta
b. • Brachiocephalic trunk
• Left common carotid artery
• Left subclavian artery

5. a. Anterior interventricular sulcus

b. • Anterior interventricular branch of left coronary artery
• Great cardiac vein

6. a. Right coronary artery

b. • Marginal artery
• Posterior interventricular branch
• Branch to SA node, AV node

7. a. Upper lobar segment

b. 1 Apical
2 Posterior
3 Anterior

8. a. Thoracoabdominal diaphragm
b. • Aortic opening
• Vena caval opening
• Oesophageal opening

9. a. Oblique sinus of pericardium

b. • Inferior vena cava—below and to right
Thorax

• Pulmonary veins—above and to left

• Left atrium—anterior
• Fibrous pericardium and oesophagus—posterior

10. a. Sympathetic ganglion

b. • Grey ramus communicans
• White ramus communicans
2
Section
 Index

cubital fossa 103 ulnar 120

A boundaries 103 anterior and posterior ulnar
Abscesses, breast 44 clinical anatomy 105 recurrent 199
Anatomical snuffbox 27, 114 contents 104 common interosseous 199
Anthropoid 5 posterior compartment 105 anterior interosseous 199
Aorta 311 clinical anatomy 107, 109 posterior interosseous 199
arch of 312 profunda brachii artery 110 superficial branch 199
course 313 branches 110 deep branch 199
relations 313 radial nerve 107 arch of the aorta 312, 334
ascending 312 branches and distribution 108 ascending aorta 334
clinical anatomy 316 origin, course and descending thoracic aorta 314,
descending thoracic 314 termination 107 334
branches 315 relations 108 internal mammary 333
course 314 triceps brachii 106 left common carotid 334
relations 315 shaft of the humerus 94 left subclavian 334
lateral epicondyle 94 pulmonary trunk 333
Aortic aneurysm 344
medial epicondyle 94
Aortic regurgitation 296 Arteries of thorax 341
supracondylar ridges 94
Aortic stenosis 295 Articular disc
surface landmarks of arm 94
Arches of hand 151 in acromioclavicular joint 155
greater tubercle of
distal transverse arch 151 in inferior radioulnar joint 168
the humerus 94
longitudinal arch 151 in sternoclavicular joint 155
Artery/Arteries 333
proximal transverse arch 151 Autonomic nervous system 338
anterior interosseous 121
Arm 94 atypical intercostal nerves 341
axillary 54, 180, 198
anastomoses around the elbow anterior circumflex nerve supply of heart 340
joint 101 humeral artery 58 nerve supply of lungs 340
anterior compartment 95 lateral thoracic 56 sympathetic nervous system 338
median nerve 99 posterior circumflex thoracic part 339
muscles humeral 58 typical intercostal nerve 341
biceps brachii 96 subscapular 58 Axilla 51
brachialis 96 superior thoracic 57 boundaries 51
coracobrachialis 96 thoracoacromial 57 anterior 52
musculocutaneous nerve 95 brachial 100, 180, 198 apex 51
branches and distribution 98 profunda brachii 198 base 52
origin, course and superior ulnar collateral 198 lateral wall 53
termination 96 muscular 198 medial wall 53
relations 96 inferior ulnar collateral 198 posterior wall 52
root value 96 deep palmar arch 135 contents 53
radial nerve 99 development 317 dissection 51
ulnar nerve 99 posterior interosseous 150 layout 53
brachial artery 100 radial 119 Axillary artery 54
beginning, course and radial recurrent 198 branches 57
termination 100 muscular 198 anastomoses 58
branches 101 superficial palmar 198 anterior circumflex humeral
relations 100 dorsal carpal 198 artery 58
changes at the level of insertion princeps pollicis 198 lateral thoracic artery 56
of coracobrachialis 102 radialis indicis 198 posterior circumflex humeral
compartments of 95 superficial palmar arch 133, 182 artery 58
349
350 HUMAN ANATOMY—UPPER LIMB AND THORAX

subscapular artery 58 Bennett’s fracture 31 Capsular ligament of the superior

superior thoracic artery 57 Blood pressure 102, 201 radioulnar joint 16, 188
thoracoacromial artery 57 Bones of thorax 219 Clavicle 4, 6
relations 54 Bones of upper limb 6 lateral and medial ends 7
of first part 54 Bones attachments 7
of second part 55 carpus 4 lateral one-third of shaft 8
of third part 56 clavicle 4 medial two-thirds of the shaft 8
Axillary lymph nodes 58 humerus 4 peculiarities of the clavicle 6
Axillary vein 58 metacarpus 4 shaft 6
phalanges 4 side determination 6
B radius 4 Cleidocranial dysostosis 8
scapula 4 Coarctation of the aorta 344
Back 66 ulna 4 Colles’ fracture 21
surface landmarks of 66 Boxer’s palsy 200 Comparison of upper and
cutaneous nerves of 67 Brachial plexus 59 lower limbs 188
dissection 67 blood supply 62 Complete claw hand 140, 201
muscles connecting the upper branches of the cords 61 Coronary artery blockage 344
limb with the vertebral branches of the roots 61 Costal cartilages 223
column 68 branches of the trunks 61 Cubital tunnel syndrome 137, 201
latissimus dorsi 69 cords and branches 61 Cutaneous nerves of back 67
levator scapulae 69 dissection 62 Cutaneous nerves of
rhomboid major 69 divisions of the trunks 61 upper limb 83, 84
trapezius 69 roots 59
structures under cover of the roots and trunks 61 D
trapezius 70 sympathetic innervation 61
Back of forearm and hand 143 Brachiation 5 de Quervain disease 202
anatomical snuffbox 144 Breast 38, 201 Dermatomes 86
boundaries 144 blood supply 40 clinical anatomy 87
contents 145 deep relations 39 embryological basis 86
dissection 146, 150 development of 42 important features 86
dorsum of hand 143 extent of the base 39 Development of arteries 317
extensor retinaculum 145 histology 43 Development of superior vena
attachments 145 lactating phase 43 cava 318
compartments 145 resting phase 43 Disc prolapse 231
muscles of back of forearm 146 lymphatic drainage 41 Dislocation of lunate 27
deep muscles 147 lymph nodes 41 Dislocation of the elbow 23
abductor pollicis longus 148 lymphatic vessels 41 Dupuytren’s contracture 126, 201
extensor indicis 148 nerve supply 40
extensor pollicis brevis 148 situation 39 E
extensor pollicis longus 148 structure 39
supinator 148 parenchyma 40 Elbow 164, 184, 186
superficial muscles 146 skin 40 Elbow joint 164
anconeus 147 stroma 40 articular surfaces 164
brachioradialis 147 Buddy splint 33 carrying angle 166
dorsal digital expansion 147 dissection 166
extensor carpi radialis ligaments 164
C movements 165
brevis 147
extensor carpi radialis Carpal bones 4, 25 relations 165
longus 147 articulations 27 Embryology/development of upper
extensor carpi ulnaris 147 attachments 27 limb 200
extensor digiti minimi 147 identification 25 Epicondyle
extensor digitorum 147 ossification 27 lateral 16
posterior interosseous artery 150 side determination 25 medial 16
relations 150 general points 25 Erb’s paralysis 62
posterior interosseous nerve 149 specific points 26 Evolution 4
branches 149 Carpal tunnel syndrome 139, 201
course 149 Capsular ligament of the elbow F
relations 149 joint 16, 164 Fascia 45
surface landmarks 143 Capsular ligament of the shoulder deep 45
Barium swallow 344 joint 16, 158 clavipectoral 47
 INDEX 351

superficial 37 G I
contents 37
platysma 38 Golfer’s elbow 201 Importance of capsular
Fine needle aspiration cytology 44 attachments and epiphyseal
Foetal circulation 304 lines 24
H Injury to the nerve to serratus
Forearm 113
arteries of front of 119 Heart 286 anterior 63
deep muscles 118 apex of 286 Interphalangeal joints 175
flexor digitorum profundus 118 base of 287 Intramuscular injection 77, 202
flexor pollicis longus 118 borders 287 Intravenous injection 89, 202
pronator quadratus 118 cardiac dominance 300
median nerve 122 collateral circulation 300 J
branches 122 developmental components 303 Jointed lever 3
course 122 external features 286 Joints of hand 174
relations 122 grooves or sulci 286 articular surfaces 174
muscles of front of 114 left ventricle 293 dissection 175
nerves 121 dissection 294 first carpometacarpal joint 174
radial artery 119 features 293 intercapal, carpometacarpal,
beginning, course and molecular regulation of cardiac intermetacarpal 174
termination 119 development 304 ligaments 174
branches 120 nerve supply of 302 movements 174
relations 120 right atrium 288 relations 174
radial nerve 123 dissection 288 type 174
branches 123 external features 288 Joints of thorax 232
course 123 interatrial septum 290 chondrosternal 233
superficial muscles 116 internal features 289 costochondral 233
flexor carpi radialis 116 tributaries 289 costotransverse 232
flexor carpi ulnaris 116 right ventricle 290 costovertebral 232
flexor digitorum dissection 292 interchondral 233
superficialis 116 external features 291 intervertebral 233
palmaris longus 116 features 292 intervertebral discs 233
pronator teres 116 internal features 291 manubriosternal 232
surface landmarks of 113 interventricular septum 291 Joints of upper limb
synovial sheaths of flexor left atrium 292 acromioclavicular 4, 155
tendons 117 structure of 294 first carpometacarpal 4, 174
ulnar artery 120 arteries supplying the heart 298 intercarpal 4
beginning, course and branches 298, 300 intermetacarpal 4
termination 120 dissection 300 metacarpophalangeal 4, 175
branches 121 left coronary artery 299 proximal and distal
relations 121 right coronary artery 298 interphalangeal 4, 175
ulnar nerve 122 conducting system 297 pronation 4, 169
branches 123 fibrous skeleton 296 supination 4, 169
course 122 musculature of the heart 296 radiocarpal 4, 170, 184
relations 123 valves 294 radioulnar 4, 168
vincula longa and brevia 118 atrioventricular 295 shoulder 158
Foreign bodies in trachea 341 semilunar 295 sternoclavicular 4, 155
Fossa surfaces of 287
coronoid 16 veins of 301
K
cubital 103 coronary sinus 302
infraspinous 9 Homologous parts 3 Klumpke’s paralysis 63
olecranon 16 Horner’s syndrome 63
radial 16 Humerus 4, 13
L
subscapular 9 attachments 16
supraspinous 9 borders 14 Labrum glenoidale 12
Fracture of the olecranon 23 lower end 15 Law of ossification 24
Fracture of the scaphoid 27 ossification 16 Ligaments
Frequent site of carcinoma 43 shaft 14 annular 23
Frozen shoulder 163 side determination 13 of cooper 201
Funny bone/medial surfaces 14 coracoacromial 157
epicondyle 94, 95, 201 upper end 13 coracoclavicular 8, 156
352 HUMAN ANATOMY—UPPER LIMB AND THORAX

coracohumeral 12 pectoralis minor 46 anatomical 13

costoclavicular 8, 156 serratus anterior 48 morphological 13
glenoidale labrum 12, 158 subclavius 46 surgical 13
interclavicular 8, 155 Muscles radius 18
lateral ligament 27, 171 abductor digiti minimi 130 Nerves 191
oblique cord 21 abductor pollicis brevis 130 anterior interosseous 122
radial collateral 165 abductor pollicis longus 148 axillary 79, 182, 191
spinoglenoid 12, 158 adductor pollicis 130 median nerve 99, 122, 138, 182, 194
suprascapular 12, 158 anconeus 147 musculocutaneous 95, 182, 191
transverse 12, 158 biceps brachii 96 posterior interosseous 149
ulnar collateral 23, 165 brachialis 96 radial 99, 107, 123, 182
Lister’s tubercle 202 brachioradialis 147 ulnar 99, 122, 136, 183
Lumbar triangle of Petit 71 coracobrachialis 96 Notch
Lungs 264 deltoid 73 radial 22
bronchial tree 269 dorsal digital expansion 147 spinoglenoid 9
bronchopulmonary segments 270 dorsal interossei 131 suprascapular 9
development of respiratory extensor carpi radialis brevis 147 trochlea 22
system 272 extensor carpi radialis longus 147 Numericals 337
dissection 264, 269 extensor carpi ulnaris 147
features 264 extensor digiti minimi 147 O
histology 273 extensor digitorum 147
molecular regulation 272 extensor indicis 148 Oesophageal varices 344
relations of the root 267 extensor pollicis brevis 148 Oesophagus 323, 335
root of the lung 267 extensor pollicis longus 148 clinical anatomy 326
surface marking 265 flexor carpi radialis 116 curvatures 323
Lymph nodes 90 flexor carpi ulnaris 116 dissection 323
lymphatics 90 flexor digiti minimi 130 histology of 325
deep lymphatics 91 flexor digitorum superficialis 116 relations 324
superficial lymphatics 90 flexor pollicis brevis 130 Opposition 4
Lymphangitis 91 infraspinatus 74 Ossification 8
Lymphoedema 91 latissimus dorsi 69 Palmar aspect of wrist and hand 124
levator scapulae 69 adductor of thumb 130
M lumbricals 130 adductor pollicis 130
opponens digiti minimi 130 arteries of hand 133
Madelung’s deformity 23 opponens pollicis 130 dissection 132, 135
Mammogram 44 palmar interossei 131 dorsal interossei 131
Mastectomy 45 palmaris brevis 130 fascial spaces of hand 141
Medial epicondyle of humerus 94, 95 palmaris longus 116 dorsal spaces 141
Mediastinal syndrome 280 pectoralis major 46 forearm space 141
Mediastinum 278 pectoralis minor 46 palmar spaces 141
inferior 279 pronator teres 116 fibrous flexor sheaths of the
anterior 279 rhomboid major 69 fingers 126
middle 279 rhomboid minor 69 flexor retinaculum 124
posterior 280 serratus anterior 48 attachments 124
superior 278 subclavius 46 relations 125
contents 279 subscapularis 74 intrinsic muscles 127
Membrane interosseous 21 supinator 148 actions of dorsal interossei 127
Metacarpal bones 4, 27 supraspinatus 74 actions of thenar muscles 127
articulations at the bases 31 synovial sheaths of flexor testing of some intrinsic
characteristics 29 tendons 117 muscles 127
main attachments 31 teres major 74 lumbricals 130
side determination 29 teres minor 74 median nerve 138
Metacarpophalangeal joints 175 trapezius 69 branches 138
Molecular regulation of limb triceps brachi 106 course 138
development 200 vincula longa and brevia 118 relations 138
Montgomery’s glands 201 muscle of medial side of palm 130
Muscles of the pectoral region 45 N abductor digiti minimi 130
dissection 49 flexor digiti minimi 130
pectoralis major 46 Neck opponens digiti minimi 130
structures under cover of 46 humerus 13 palmaris brevis 130
 INDEX 353

muscles of thenar eminence 130 R S

abductor pollicis brevis 130
flexor pollicis brevis 130 Radial pulse 202 Saturday night paralysis 109
opponens pollicis 130 Radical mastectomy 45 Scaphoid scapula 13
nerves of hand 136 Radiological anatomy of Scapula 4, 8
upper limb 185 angles 9
palmar aponeurosis 125
elbow 186 attachments 9
palmar interossei 131
hand 187 borders 9
radial artery 134 glenoid cavity 8
branches 134 shoulder 185
ossification 12
Radiological anatomy of thorax 335
course 134 processes 9
barium swallow 337
deep palmar arch 135 side determination 8
bones 336
relations 134 surfaces 9
diaphragm 336
ulnar artery 133 Scapular region 73
lungs 336 anastomoses around scapula
superficial palmar arch 133
mediastinum 336 axillary or circumflex nerve 79
ulnar nerve 136
soft tissues 336 course 80
branches 136
tomography 337 relations and branches 80
course 136 trachea 336 circumflex nerve 80
relations 136 Radioulnar joints 168 deltoid 73
dissection 170 structures under cover of 75
P interosseous membrane 168 infraspinatus 74
supination and pronation 169 intermuscular spaces 78
Paracentesis thoracis 343 lower triangular space 79
Radius 4, 18
Parts of upper limb quadrangular space 78
attachments 20
antebrachium 3 upper triangular space 78
borders 18
axilla 51 muscles of scapular region 73
lower end 18
brachium 3 musculotendinous cuff of the
first groove 21
forearm 4 shoulder or rotator cuff 78
fourth groove 21
manus/hand 3 subacromial bursa 78
second groove 21
shoulder region 4 subscapularis 74
styloid process 18
Peau d'orange appearance 44 supraspinatus 74
surfaces 21
Pentadactyl limb 5 teres major 74
Pericardium 283 third oblique groove 21 teres minor 74
features 283 ossification 21 Segmental innervation of movements
fibrous pericardium 284 shaft 18 of upper limb 176
serous pericardium 284 side determination 18 Segmental resection 274
sinuses of pericardium 284 surfaces 18 Self-examination of breasts 44
dissection 285 upper end 18 Sentinel node 43
Phalanges 4,32 Region pectoral 36 Sesamoid bones 33
attachments 32 dissection 37 at the head of the first metacarpal
ossification 32 surface landmarks 36 bone 33
Pointing finger 201 Respiratory movements 234 in capsule of the interphalangeal
Postural drainage 274 principles of movements 234 joint of the thumb 33
Retinacula in capsules of the metacarpo-
Posture of a patient with
extensor 21, 145, 184 phalangeal joints 33
respiratory difficulty 343
flexor 27, 124, 184 in tendon of the flexor carpi
Process
Retraction of the nipple 44 ulnaris 33
acromion 9
pisiform 33
coracoid 9 Retractionof the skin 44
Site of bone marrow puncture 341
olecranon 22 Rib/s or costae 219
Site of pericardial tapping 341
spinous 9 eleventh and twelfth 223
Shoulder girdle 155
syloid process of radius 18 first 221 acromioclavicular joint 155
syloid process of ulna 23 features 222 coracoclavicular ligament 155
Pulled elbow 21, 200 tenth 223 dissection 155, 158
Pulmonary trunk 317 typical 219 ligaments of the scapula 157
Ridge movements of the shoulder
lateral supracondylar 16 girdle 155
Q
medial supracondylar 16 sternoclavicular joint 155
Quadrupeds 3 trapezoid 6 articular disc 155
354 HUMAN ANATOMY—UPPER LIMB AND THORAX

capsular ligament 155 T right brachiocephalic vein 335

costoclavicular ligament 155 superior vena cava 334
interclavicular ligament 155 Tennis elbow 200 Veins of upper limb
Shoulder joint 158, 184, 185 Thoracic cavity 255 deep 89
analysis of the overhead movement dissection 255 superficial 88
of the shoulder 160 pleura 257 basilic vein 89
articular surface 158 parietal 259 cephalic vein 88
bursae related to the joint 159 pulmonary 258 dorsal venous arch 88
dissection 161 pulmonary ligament 260 median cubital vein 89
ligaments 158 Thoracic duct 327, 335 Vertebral column 227
movements 160 course 327 curvatures 227
relations 159 relations 327 parts of a typical vertebra 228
type 158 thoracic vertebrae 229–231
tributaries 328
Shoulder tip pain 163 Volkmann’s ischaemic
Thorax
Smith’s fracture 21 contracture 201
inlet 213
Spaces
outlet of thorax 215
intermuscular 78
structures passing through the dia- W
Spinal nerve 59
Sternum 224 phragm 216 Waiter’s tip 201
Student’s elbow 200 Trachea 321, 335 Walls of thorax 240
Subareolar plexus of Sappey 201 development 322 accessory hemiazygos vein 250
Superior vena cava 310 histology of 322 course 250
course 310 left bronchus 335 tributaries 250
development 318 relations of the thoracic part 321 azygos vein 249
dissection 310 right bronchus 335 course 249
relations 310 structure 322 formation 249
tributaries 310 Tracheostomy 323 relations 249
Surface landmarks of thorax 209 Triangle of auscultation 71 tributaries 250
Surface marking of thorax 330 Tubercle typical intercostal spaces 245
auscultatory areas 333 conoid 6 intercostal arteries 245
borders of the heart 332 infraglenoid 9 intercostal veins 247
cardiac valves 333 of scaphoid 27 lymphatics 248
parietal pleura 330 supraglenoid 9 dissection 242
the lungs 331 Tubercular disease of the external intercostals 241
Surface marking of upper limb 180 metacarpals 32 hemiazygos vein 250
arteries 180 course 250
axillary 180 tributaries 250
brachial 180 U
intercostal muscles 241
deep palmar arch 181 Ulna 4, 22 intercostal nerves 242
radial 181 attachments 23 internal intercostals 241
superficial palmar arch 182 borders 22 internal thoracic artery 248
ulnar 181 lower end 22 beginning, course and
joints 184 styloid process 23 termination 248
elbow 184 ossification 23 branches 249
shoulder 184 shaft 22
wrist 184 origin 248
side determination 22
nerves 182 relations 248
surfaces 22
axillary 182 thoracic sympathetic trunk 250
upper end 22
median 182 branches 250
Ulnar claw hand 137
musculocutaneous 182 transversus thoracis 241
Ulnar nerve injury at elbow 137
radial 182 Winging of the scapula 13
Ulnar nerve injury at wrist 137
ulnar 183 Wrist drop 201
Ungulates 5
retinacula 184 Wrist (radiocarpal) joint 170
flexor 184 articular surfaces 171
V dissection 173
extensor 185
Supracondylar fracture of Veins of thorax 334 ligaments 171
humerus 138 coronary sinus 318 movements 172
Sympathetic innervation 200 left brachiocephalic vein 335 relations 171