INNOCENT'S ANATOMY

THE HUMERUS.
The humerus is a long bone which consists of a shaft (diaphysis) and two extremities
(epiphysis). It is the longest bone of the upper extremity.

Upper Extremity Features

The head of the humerus is the proximal articular surface of the upper extremity,
which is an irregular hemisphere. It articulates with the glenoid fossa of the scapula.

The anatomical neck is the part between the head and the tuberosities.

The surgical neck is the part between the tuberosities and the shaft.

The greater tuberosity it is located lateral to the head at the proximal end.

The lesser tuberosity is located inferior to the head, on the anterior part of the
humerus, Its very prominent and palpable.

Bicipital (intertubercular) groove is located between the two tuberosities. The long
head of the biceps tendon is placed here.

Body Features
The body of the humerus has three borders and three surfaces.
Borders
Anterior
Lateral
Medial
Surfaces
Antero-lateral
Antero-medial
Posterior
Function
The humerus serves as an attachment to 13 muscles which contribute to the
movements of the hand and elbow, and therefore the function of the upper limb.

Clinical Relevance
Proximal end or Head-Surgical Neck Fracture.

It is caused by a direct blow on the area or fall on an outstretched hand.

It can result in damage to the Axillary nerve and Posterior circumflex artery.
Axillary nerve damage results in paralysis of deltoid and teres minor muscles.
Shaft-Mid-shaft fracture.
This fracture causes damage to radial nerve and Profunda brachii artery.
Sensory loss can be seen over the dorsal surface of the hand, proximal parts of lateral
3 and a half fingers dorsally.
Radial nerve palsy results in wrist drop.

THE FEMUR
The femur is the longest, heaviest, and strongest bone in the human body.
The main function of the femur is weight bearing and stability of gait. An essential
component of the lower kinetic chain.
The upper body’s weight sits on the 2 femoral heads. The capsular ligament is a
strong thick sheath that wraps around the acetabulum periosteum and proximal femur
holding the femoral head within the acetabulum.
Robust shape of the femur provides many sturdy attachment points for the powerful
muscles of the hip and knee that contribute to walking and other propulsive
movements.[1]
The femur acts as the site of origin and attachment of many muscles and ligaments,
and can be divided into three parts; proximal, shaft and distal.

Proximal Femur consists of: femoral head - pointed in a medial, superior, and slightly
anterior direction. Ligamentum teres femoris connects the acetabulum to the fovea
capitis femoris (a pit on the head); neck (Pyramid-shaped) attaches the spherical head
at the apex and the cylindrical shaft at the base; 2 prominent bony protrusions, the
greater trochanter and lesser trochanter, that attach to muscles that move the hip and
knee.
Shaft - has a mild anterior arch.
Distal femur - shaft flares out in a cone-shaped manner onto a cuboidal base made up
of the medial and lateral condyle. Medial and lateral condyle join the femur to the
tibia, forming the knee joint.

Proximal Femur

At the proximal end of the femur, the bulbous femoral head is joined to the shaft of
the femur by the femoral neck. At the base of the neck are the medially oriented lesser
trochanter and laterally placed greater trochanter. A rough line called the
intertrochanteric line connects the greater and lesser trochanter on the anterior aspect
of the femur, while the smoother intertrochanteric crest connects the trochanters
posteriorly.

Blood Supply
The femoral artery is the main blood supply to the lower extremity. The medial
circumflex and anastomoses mainly supply the femoral head with the lateral
circumflex artery and obturator artery (Medial and lateral circumflex are branches of
the femoral artery, obturator artery is a branch of the internal iliac artery).
The foveal artery comes off of the obturator artery that runs through the ligamentum
teres femoris as supportive blood supply to the femoral head, but it is not the main
source during adulthood.
The perforating branches of the deep femoral artery supply the shaft and distal portion
of the femur.

THE AXILLA
The axilla is the space in the interval marking the junction of the upper arm and the
chest wall. It is a key area because many important neurovascular structures pass
through it. It is pyramidal in shape.

The apex of the pyramid is formed by the first rib, the subclavius muscle, and the
collar bone, at the side of the lowest part of the neck. The floor of the axilla is tough
axillary fascia that connects the thoracic wall, the gleno-humeral joint, and the
posterior part of the axilla. The skin of the axilla is supplied by the intercostobrachial
nerve.

Boundaries of the Axilla

The anterior boundary of the axilla comprises the following:

Pectoralis major – the largest muscle in the pectoral region, that lies over the anterior
chest wall and is important in moving the arm forward and up
Clavipectoral fascia – a layer of fascia (tough connective tissue) in the pectoral region
Clavicle - the only bone that directly links the pectoral girdle and the axial skeleton. It
is also the only long bone in the human skeleton that is oriented horizontally.

The posterior boundary consists of:

Subscapularis – one of the 4 muscles that make up the rotator cuff
Teres major - one of the 7 scapulohumeral muscles around the glenohumeral joint that
facilitates movement of the shoulder
Latissimus dorsi - one of the muscles attaching the upper limb and the vertebral
column.
The medial boundary of the axilla is made up of:
Serratus anterior
the upper ribs and their intercostal muscles
The lateral boundary comprises the intertubercular groove on the medial part of the
humerus.

The axillary apex is the interval between the superior border of the scapula, the
posterior border of the clavicle, and the external border of the first rib.

The pectoralis major and the latissimus dorsi form the major anterior and posterior
folds, respectively, of the axilla. If a vertical line were drawn bisecting the distance
between the anterior and posterior folds, it would denote the mid-axillary line.

THE CONTENTS

The main contents of the axilla are the axillary vein and artery, the axillary lymph
nodes, with a portion of the brachial plexus and its branches.

Axillary artery – the major artery which is the continuation of the subclavian artery,
and which continues as the brachial artery, the artery of the arm
Axillary vein – the large blood vessel that drains blood from the lateral thorax, the
upper limb and the axilla into the subclavian vein and thence into the right atrium of
the heart
Brachial plexus - a complex network of nerves formed by the lower cervical and
upper thoracic ventral nerve roots, which begins in the neck and extends into the
axilla. It is responsible for carrying motor and sensory signals with respect to the
pectoral girdle and the upper limb.
Axillary lymph nodes - nodes in the axilla that receive lymph from the arm, the
thoracic wall, the upper abdominal wall, and the breast.
The axilla also contains much adipose tissue, which encloses several other structures,
as follows: The long thoracic nerve - a nerve that arises from the anterior rami of the
5th, 6th, and 7th cervical nerves and supplies the serratus anterior muscle
The tendons of the heads of the biceps muscle- the biceps muscle is attached to the
scapula by 2 tendons – the tendon of the long head, which is attached to the glenoid
rim, and the short head tendon which attaches along the scapula
Pectoralis minor - a muscle in the anterior chest wall that is overlaid by the pectoralis
major.
Coracobrachialis – one of the 3 muscles in the anterior aspect of the arm, that helps to
flex the elbow joint. It is located under the biceps brachii.

FERMORAL TRIANGLE
The femoral triangle is a hollow region located in the supero-medial part of the
anterior thigh. It appears most prominently with hip flexion, abduction and internal
rotation. It is an easily accessible area through which multiple neurovascular
structures pass through. This anatomical landmark is mostly used in dissection and
describing relationships in the groin area.[1] It is also known as "scarpa's triangle" and
"femoral trigone".

CONTENTS
The following structures pass through the femoral triangle:

Femoral nerve - Which innervates the anterior compartment of the thigh

Femoral sheath containing:
Femoral artery and branches - Arterial supply for majority of the lower limb
Femoral vein - The great saphenous vein drains into the femoral vein within the
triangle
Femoral canal - Contains lymph nodes and vessels
Superfical and deep inguinal lymph nodes and vessels.
Borders
The femoral triangle has three borders namely:
Superior (base of triangle): Inguinal ligament
Lateral: Medial border of the sartorius muscle
Medial: Medial border of the adductor longus
Apex: Cross between medial and lateral border

Floor and roof

The floor of the femoral triangle is comprised of the adductor longus, pectineus
(medially), psoas major and illiacus muscles (laterally). The floor is gutter shaped
since all the muscles forming the floor pass to the posterior aspect of the femur.
The roof of the femoral triangle consists of skin, superficial and deep fascia (fascia
lata, cribiform fascia) of the the thigh and subcutaneous tissue.
Clinical Significance
Assessment of pain and swelling in this area can be done by palpation or ultrasound.
It is mostly caused by the following:
Abscesses
Cellulitis
Haematoma
Nodal enlargement
Femoral artery aneurysm
Femoral vein thromobplebitis
Femoral hernias (mostly at proximal opening, a weak areas in the lower abdominal
wall)
Clinically, the area is also commonly used for the following:
Femoral pulse palpation
Drawing blood from the femoral artery
Vascular catheterization for interventional and corrective procedures
Provides access to ipsilateral and contralateral leg, abdominal, thoracic and cerebral
vessels
Femoral artery catherization to access the aortic arch through the abdominal and
descending aorta as well as the left side of the heart.
Used in aortic valve replacements, angiography and angioplasty
Femoral vein: Access right side of heart via inferior vena cava.
Used with patent foramen ovale repair.

CUBITAL FOSSA
The Cubital Fossa is a triangular-shaped depression, located between the forearm and
the arm on the anterior surface of the elbow, with the apex of the triangle pointing
distally. It is also known as the “antecubital” because it lies anteriorly to the elbow. It
is a space filled with different structures that makes up its content. It has three
boundaries/borders, and it also has a floor and a roof.

Boundaries and Borders

Apex - It is an imaginary line directed downwards connecting the medial and lateral
boundaries
Medially- lateral border of the pronator teres
Laterally- medial border of the brachioradialis
The base- directed upwards, and is represented by an imaginary line joining the front
of two epicondyles of the humerus
The floor - formed by the brachialis and supinator muscles
The roof - formed by the skin and fascia of the arm and forearm reinforced by skin,
superficial fascia containing the median cubital vein, the lateral cutaneous nerve of
the forearm and the medial cutaneous of the forearm, deep fascia, bicipital
aponeurosis (which is a sheet of tendon-like material that arises from the tendon of the
biceps brachii). The bicipital aponeurosis forms a partial protective covering to the
median nerve, brachial artery, ulnar artery, and radial artery.

Contents
The cubital fossa contains four structures which from medial to lateral are:

The median nerve- The median nerve leaves the cubital between the two heads of the
pronator teres. It supplies the majority of the flexor muscles in the forearm. It runs
distally in the arm on the lateral side of the brachial artery until it reaches the middle
of the arm, where it crosses to the medial side and contacts the brachialis. The median
nerve descends into the cubital fossa, where it lies deep to the bicipital aponeurosis
and median cubital vein. The median nerve has no branches in the axilla or arm, but it
does supply articular branches to the elbow joint.
The brachial artery – The brachial artery provides the main arterial supply to the
arm and is the continuation of the axillary artery. The brachial artery usually divides at
the apex of the fossa into the radial and ulnar arteries which supplies the forearm, and
it lies between the biceps tendon and the median nerve. The brachial artery may be
felt pulsating deep to the medial border of the biceps. the medial and lateral
epicondyles of the humerus are subcutaneous and can be easily palpated at the medial
and lateral aspects of the elbow.
The tendon of Biceps Brachii- It is a muscle of the anterior compartment of the arm.
The biceps tendon runs through the cubital fossa, attaching to the radial tuberosity,
just distal to the neck of the radius.
The radial nerve- The radial nerves enters the arm posterior to the brachial artery,
medial to the with the profunda brachii artery. Radial nerve It divides into superficial
and deep branches. The radial nerve is in a deep groove also known as the radial
groove between the brachioradialis and brachialis to the level lateral epicondyle of the
humerus dividing into its superficial and deep branches. Anterior to the lateral
epicondyle, the radial nerve divide into deep and superficial branches.
Superficially, in the subcutaneous tissue overlying the cubital fossa are the median
cubital vein, lying anterior to the brachial artery, the medial and lateral cutaneous
nerves of the forearm, related to the basilic and cephalic veins.
Clinical Relevance
Venipuncture – The area superficial to the cubital fossa is a common site used for the
collection of venous blood specimens and blood transfusion. The basilic vein, median
cubital vein, and cephalic vein are superficial veins that are frequently selected for
venipuncture at the cubital fossa. The median cubital vein connects the basilic and
cephalic veins, and it lies directly on the deep fascia, running diagonally from the
cephalic vein of the forearm to the basilic vein of the arm. It crosses the bicipital
aponeurosis, which separates it from the underlying brachial artery and median nerve,
and it provides protection to the later. Because of its characteristics and visibility, it is
easily accessible for the collection of the venous blood specimen. It may also be used
for the insertion of a peripherally inserted central catheter [1] [5].
Brachial pulse and blood pressure- The brachial pulse can be palpated immediately
medial to the biceps tendon in the cubital fossa. Also, when measuring blood pressure
manually, a stethoscope is placed over the cubital fossa to auscultate the brachial
artery for Korotkoff sounds [3].
Supracondylar humeral fracture- Supracondylar fractures are the most common
type of upper arm injury in children. It is an injury to the humerus, or upper arm bone,
at its narrowest point, just above the elbow. They are frequently caused by a fall on an
outstretched elbow or a direct blow to the elbow such as the median and the radial
nerve. The displaced fracture fragments may impinge and damage the contents of the
cubital fossa such as the median and radial nerve. Direct damage or post-fracture
swelling can cause interference to the blood supply of the forearm from the brachial
artery. The resulting ischemia can cause Volkmann’s ischaemic contracture [1].
Cubital Tunnel Syndrome - Cubital tunnel syndrome is a peripheral nerve
compression syndrome. It is an irritation or injury of the ulnar nerve in the cubital
fossa at the elbow.

POPLITEAL FOSSA-
Description The Popliteal Fossa is a diamond-shaped space behind the knee joint[1].
It is formed between the muscles in the posterior compartments of the thigh and leg.
This anatomical landmark is the major route by which structures pass between the
thigh and leg[2].
Boundaries: Its boundaries are: The Biceps Femoris tendon (superolateral) and
Semimembranosus reinforced by Semitendinosus (superomedial). The medial and
lateral heads of Gastrocnemius form the inferomedial and inferolateral boundaries,
respectively.
 Floor: The floor of the fossa is formed by the Popliteal surface of the Femur, the
capsule of the Knee reinforced by the oblique Popliteal ligament and, the Popliteus
muscle covered by its Fascia.
Roof: The roof of the Popliteal fossa is covered by the Fascia Lata which is strongly
reinforced by the transverse fibers. Thus, the roof is pierced by the small Saphenous
vein and the posterior Femoral cutaneous nerve[1].
Content: The major content of the Popliteal fossa are: The Popliteal Artery; This is
the deepest of the neurovascular structures in the Popliteal fossa. It is a continuation
of the Femoral artery and appears on the upper medial side under the margin of the
Semimembranosus muscle. The Popliteal vein: It is superficial to the and travels with
the Popliteal artery. The Tibia nerve and common Fibular nerve: These are the two
major branches of the Sciatic nerve. They are the most superficial of the
neurovascular structures in the Popliteal fossa. They appear under the margin of the
Biceps Femoris muscles.
Clinical Significance: Baker's cyst Popliteal Pulse Popliteal Aneurysm Popliteal nerve
block.

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