Upper limb: topographic anatomy. Projection of the upper limb. Topographic anatomy of the upper limbs Topographic anatomy of the upper limb
6.Topography of the shoulder girdle. The collarbone can be felt along its entire length. The inner end is determined in the jugular notch, and to determine the outer one, you must first palpate the apex of the acromial process of the scapula: inward of it is the outer end of the clavicle. The pectoralis major muscle begins from the medial half of the lower edge of the clavicle, and the deltoid muscle muscle begins from the lateral third. The space between these parts, constituting 1/6 of the lower edge of the clavicle, remains free of muscle, this is the base of the triangle called the tregonum deltoid pectorale. The boundaries of the triangle are: above - the clavicle, outside - the m. deltoideus, inside - the m. pectoralis major. On the skin, this triangle corresponds to the subclavian fossa, in the depths of which you can always feel the coracoid process of the scapula. At the back of the scapula, the scapular spine with the acromion process is clearly palpable. Below, the greater tubercle of the humerus can be felt, and with the arm lowered and in a supinated position, the groove can be identified medially from the greater tubercle. it runs down the midline of the shoulder and corresponds to the intertubercular groove of the key bone, in which the tendon of the long head of the biceps muscle lies. Inward from the groove, the lesser tubercle of the humerus can be identified. Both tubercles can be felt under the deltoid muscle during rotational movements of the shoulder. When the arm is abducted, the axillary fossa is revealed; in front it is limited by the clearly visible and palpable edge of the pectoralis major muscle. Immediately under it you can feel the tendon of the short head of the biceps muscle, which lies along it on the inside of the clavicular brachialis muscle. at the inner edge of the latter lies a. axillaris, the pulsation of which is well defined.
22 FACIAL SECTION OF THE HEAD GENERAL DATA The facial part of the head includes the cavities of the eye sockets, nose, and mouth. These cavities with the adjacent parts of the face are given as separate areas (regio orbitalis, regio nasalis, regio oris); Adjacent to the mouth area is the chin area - regio mentalis. The rest of the face is considered as lateral about sweetness of face(regio facialis lateralis), consisting of three smaller areas of the buccal (regio buccalis), parotid-masticatory (regio parotideomasseterica) and the deep region of the face (regio facialis pro-funda). Most of the facial muscles are located in the buccal region, as a result of which it can be called the region of facial muscles. In the parotid-masticatory region and the deep region of the face there are organs related to the masticatory apparatus, as a result of which they can be combined into the maxillary-masticatory region. The skin of the face is thin and mobile. In subcutaneous fat, the amount of which can change sharply in the same person (a. maxillaris externa - BNA) and maxillaris (a. maxillaris interna - BNA). In addition, it takes part in the blood supply to the face Anda. ophthalmica(froma. carotis interna). The vessels of the face form an abundant network with well-developed anastomoses, which ensures good blood supply to the soft tissues. Thanks to this, wounds of the soft tissues of the face, as a rule, heal quickly, and plastic surgery on the face ends favorably. The veins of the face form two networks: superficial and deep. The first consists of veins: facial and retromaxillary. Persons vienna, v. facialis (v. facialis anterior -BNA), accompanies the facial artery, and the initial section of the vein (at the inner corner of the eye) is called the angular vein (v. angularis), which anastomoses with the superior orbital vein. Postmaxillary vein v. retromandibularis (v. facialis posterior -BNA), formed by the fusion of v. temporal superficialis and w. maxillares and collects blood from areas supplied by the terminal branches of the external carotid artery. V. facialis is connected to the pterygoid plexus through v. faciei profunda, passing at the anterior edge of the masticatory muscle, approximately at the level of the corner of the mouth. V. facialis, having taken in v. retromandibularis, flows into v. jugularis i nterna 1 The deep venous network is represented mainly by the pterygoid plexus - pterygoid plexus - lying between the branch of the mandible and the pterygoid muscles. The outflow of venous blood from this plexus occurs along vv. maxilares. In addition, and this is especially important from a practical point of view, the pterygoid plexus is connected to the cavernous sinus of the dura mater through emissaries and veins of the orbit (see Fig. 288), and the superior superior orbit aya venaanastomozir It is, as already said, with the angular vein. Due to the abundance of anastomoses between the veins of the face and the venous sinuses of the dura mater, purulent processes on the face (boils, carbuncles) are often complicated by inflammation of the meninges, phlebitis of the sinuses, etc. Lymphatic vessels of the tissues of the medial parts of the face are directed to the submandibular and submental nodes. Some of these vessels are interrupted in the buccal nodes (nodi lymphatici buccates; faciales profundi - BNA), lying on the outer surface of the buccal muscle, some in the jaw nodes (nodi lymphatici mandibulares), lying at the anterior edge of the masticatory muscle, slightly above the edge of the lower jaw Lymphatic vessels tissues of the medial parts of the face, auricle and temporal region are directed "to the nodes" of the lymphatics of the parotid gland, and part of the lymphatic "vessels of the auricle ends in the protective lymphatici retroauriculares). In the area gl. parotis there are two groups of interconnected parotid lymph nodes, one of which lies superficially, the other deep; nodi lymphatici parotidei superficiales and profundi. The superficial parotid nodes are located just outside the capsule of the gland, or immediately under the capsule; some of them lie in front of the tragus of the auricle (nodi lymphatici auriculares anteriores - BNA), others - below the auricle, near the posterior edge of the lower pole of the parotid gland. The deep parotid nodes lie deep in the gland, mainly along the external carotid artery. From about ear lymph nodes and flows to g deep cervical lymph nodes The lymphatic vessels of the orbit pass through the delicate orbital fissure and end partly in the buccal nodes, partly in the nodes located on the lateral wall of the pharynx. Lymphatic sections from the anterior sections of the nasal and oral cavities end in the submandibular and mental nodes. Lymphatic vessels from the posterior sections of the oral and nasal cavities, as well as from the nasopharynx, are collected partly into the retropharyngeal nodes, located in the tissue of the peripharyngeal space, and partly into the deep cervical nodes. The motor nerves in the face belong to two systems: the facial nerve and the third branch of the trigeminal nerve. The first supplies the facial muscles, the second - the chewing muscles. L and c e w o n e r at the exit from the bone canal (canalis facialis) through the foramen styldmastoideum enters thick parotid salivary gland. Here it crumbles into numerous branches forming a plexus. There are groups of radially diverging branches of the facial nerve - temporal, zygomatic, buccal, marginal branch of the mandible and cervical branch. The third branch of the trigeminal nerve supplies, in addition to the masticatory muscles, mm. masseter, temporaJis, pterygoideus lateralis (extemus - BNA) and medialis (internus - BNA), anterior abdomen m. digastricus and m. mylohy-oideus. Innervation of the skin of the face is carried out mainly by the terminal branches of all three trunks of the trigeminal nerve, and to a lesser extent by the branches of the appendicular plexus (in particular, the greater auricular nerve). The branches of the trigeminal nerve for the skin of the face emerge from bone canals, the openings of which are located on the same vertical line: foramen of the trigeminal nerve, foramen infraorbitale for n. infraorbitalis from the second branch of the trigeminal nerve and jbramen warm for n. mentalis from the third branch of the trigeminal nerve (Fig. 289) . Connections are formed between the branches of the trigeminal and facial nerves on the face. The projections of the bone holes through which the nerves pass are as follows. The foramen inforaorbitale is projected 0.5 cm inferiorly from the middle of the lower orbital margin. Foramen mentale is most often projected in the middle of the height of the body of the lower jaw, between the first and second small molars. The foramen mandibulare, leading into the canal of the mandible and located on the inner surface of its branch, is projected from the side of the oral cavity onto the buccal mucosa in the middle of the distance between the anterior and posterior edges of the mandibular branch, 2.5-3 cm upward from the lower edge. The significance of these projections lies in the fact that they are used in the clinic for anesthesia or nerve blockade for neuritis.
17 SHIN AREA (REGIOCRURIS GENERAL CHARACTERISTICS The lower leg area is limited by two horizontal planes: the upper one, passing through the tuberosity of the tibia, and the lower one, passing over the bases of both ankles. The area is divided into two - regio cruris anterior and regio cruris posterior. The border between these areas runs along the inner edge of the tibia (medially) and the groove separating the peroneal muscles from the gastrocnemius muscle (laterally). The fascia of the leg over most of its length has a significant density. Strong plates extending from its inner surface in the direction k s of the fibula, which play the role of septum: septum intermusculare anterius and posterius, of which the first is attached to the anterior edge of the fibula, the second - to the posterior. Together with both bones of the leg and the interosseous membrane, these septa delimit three bone-fibrous sheaths, or muscle beds: anterior, external and. rear
EXTERNAL LINKS The anterior inner surface of the tibia is not covered with muscles and is therefore palpable along its entire length. The medial malleolus, crista tibiae (margo anterior - PNA), tuberositas tibiae and the medial edge of the bone are easily accessible for examination on the tibia. The fibula is surrounded by muscles for most of its length, so that only its head (above) and the lateral malleolus with the adjacent part of the bone (below) can be felt. In the anterior outer part of the leg, palpation identifies a groove separating the group of external (peroneal) muscles from the group of anterior (extensor) muscles. The Achilles tendon is easily palpable in the posterior leg. FRONT SHIN AREA(REGIOCRURISANTERIOR) The skin of the anterior area of the leg is relatively little mobile. The veins passing through the subcutaneous tissue and under the superficial fascia flow from the medial side into the v. saphena magna, from the lateral - in v. saphena parva. Superficial nerves located medially are branches of the n. saphenus, laterally the n. cutaneus surae lateralis and peroneus superficialis (see Fig. 87).
The fascia proper (fascia cruris) at the top firmly fuses with the muscles that partially begin from it, and is attached here to the caput fibulae and tuberositas tibiae. In the lower part of the leg, the own fascia forms the retinaculum mm. extensorum superius (lig. transversum cruris - BNA), running in front from one ankle to the other. The muscles of the anterior region of the leg lie in the anterior and external osteo-fibrous sheaths. The osteofibrous sheath is formed by: the fascia of the leg - in the front, the interosseous membrane - in the back, the tibia - medially and the anterior muscular septum with the fibula - laterally. It contains the extensible we shtsy, passing- located on the dorsum of the foot, anterior tibial vessels and the deep peroneal nerve (Fig. 111). In the upper half of the anterior receptacle there are two muscles - r m. tihialis qptftrinT (medially) and. m. extensor digitorum longus (lateral), and in the lower there are three muscles, the third being m. extensor hallucis longus - located between the two previous ones. All these muscles originate, in addition to the fascia of the leg and the interosseous membrane, also from the bones of the leg. Between the muscles there is a neurovascular bundle consisting of a. tibialis anterior with two veins and n. peroneus profundus. External osteofibrous vagina It is formed by: the fibula, the fascia of the leg and two intermuscular septa extending from it. It contains a group of peroneus muscles (mm. peroneus longus and brevis), which abduct and pronate 1 foot, and p. peroneus superficialis. The tendons of these muscles, starting from the fibula, pass to the foot behind the lateral malleolus.
Between the long peroneal muscle and the fibula in the upper third of the leg there is a canal - canalis musculoperoneus superior. The canal contains the terminal section of the common peroneal nerve, as well as the superficial peroneal nerve that arises as a result of its division.
BACK AREA OF THE SHIN (REGIO CRURIS POSTERIOR) The skin of the posterior area of the lower leg is more mobile than the skin of the anterior area. The superficial veins of the posterior region are represented by two large trunks located between the superficial and proper fascia. From bottom v. saphena magna accompanied by.p. saphenus runs along the inner surface of the tibia, immediately posterior to the medial edge of the tibia, and v. saphena parva - along its back surface. V. saphena parva usually lies between the superficial and proper fascia only on the foot and in the lower half (or lower third) of the leg. Heading upward, the vein pierces its own fascia and passes further in the Pirogov canal between its leaves, corresponding to the groove formed by the gastrocnemius muscle, to the popliteal fossa, where it flows into the v. poplitea. Cutaneous nerves are branches of the rm. saphenus 2 (inside), cutaneus surae mediaiis (inside and back), cutaneus surae lateralis (back and outside). The posterior branch of the latter - ramus communicans peroneus - approximately in the middle of the lower leg pierces the fascia and further below connects with the cutaneus surae mediaiis, forming together with it the sujralis point (see Fig. 87). The latter, accompanied by v.saphena parva, passes behind the lateral malleolus. Before connecting with the mentioned branch, the cutaneus surae medialis passes through the thickness of the fascia next to the v. saphena parva, penetrating the fascia at the beginning of the Achilles tendon. Under the superficial layer of the proper fascia of the leg there is a layer of superficial flexors, of which the gastrocnemius muscle lies closer to the skin , l behind it is a long thin tendon of the plantar muscle. Deeper is the soleus muscle, separated from the gastrocnemius by a layer of fascia and starting from both bones of the leg, it is supported by special tendon bundles that form an arch (arcus tendineus m. solei). , spreading in the form of a bridge over the interosseous space of the leg. All three muscles of the superficial layer in the lower third of the leg form a common powerful tendon - tento calcaneus, s. Achillis, attached to the tuber of the calcaneus (tuber calcanei), according to N. G. Pirogov. has a double vagina, with the outer one formed by the fascia of the leg, and the inner one, directly adjacent to the tendon, reminiscent of the synovial membrane in its structure and is better expressed on the posterior surface of the tendon.
Under the layer of superficial flexors lies a deep layer of fascia of the leg, which gives two plates: one of them covers the deep surface of m. soleus, and the other is the posterior surface of the deep flexors.
Due to both plates, the sheath of the posterior neurovascular bundle of the leg is formed, consisting of yasa tibialia posteriora, n. tibialis and vasa peronea (Fig. 112). In the upper third of the leg, above the arcus m. solei, the posterior neurovascular bundle is located on the fascia covering the popliteus muscle. Passing under the tendinous arch of the soleus muscle, the neurovascular bundle is located on the fascia covering the tibialis posterior muscle and the flexor digitorum longus muscle, being covered at the back by loose tissue adjacent to the anterior surface of the soleus muscle. With the appearance of a well-defined deep fascia, i.e. at the level of the beginning of the long flexor pollicis, the neurovascular bundle is covered with it from behind, going into what? side bed. The deepest layer of the posterior region of the leg is the deep flexor group. It is enclosed in a deep bed of the lower leg, which is formed by: in front of the membrana interossea cruris, on the sides - the tibia and fibula, and behind - a deep layer of fascia of the lower leg. Under this leaf lie three muscles located in one row: medially - m. flexor digitorum longus (starts from the tibia), laterally - m. flexor hallucis longus, the most powerful muscle of the deep layer (starts from the fibula) and in the middle between them - m. tibialis posterior (starts from the interosseous membrane and the adjacent edges of the tibia, attaches to the tuberosity of the scaphoid bone, to the intermediate and lateral sphenoid bones). Before reaching the medial malleolus, the tibialis posterior tendon intersects with the flexor digitorum longus tendon and, as a result, is located immediately behind the ankle.
DEEP FIBER OF THE CHIB The most important for the development of deep phlegmons of the leg is the cell localized in the deep fascial bed of the leg, where the deep flexors are located and pass through the posterior tibial vessels, peroneal vessels and tibial nerve, surrounded by their fascial sheath. They are accompanied by quite numerous lymphatic vessels, along which small intercalary lymph nodes are often located. Upwards, the fiber of the deep bed of the leg communicates with the fiber of the popliteal fossa, anteriorly - with the fiber of the anterior intermuscular space along the anterior tibial artery, downwards - along the tendons of the deep flexors of the leg and the fiber accompanying the posterior tibial vessels and tibial nerve, through the canalis malleolaris with the fiber space of the sole .
18 FOOT AREA (REGIOPEDIS) EXTERNAL LINKS
On the foot, in addition to the ankles, you can feel under them, on both sides, the calcaneus, a tubercle which - sustentaculum tali - is recognized under the medial malleolus (at a distance of 2.5 cm downward from it) in the form of a transverse narrow protrusion. Along the inner edge of the foot, at a distance of 4 cm below and anterior to the ankle, the navicular bone with its tuberosity is determined. Posterior to the scaphoid, between it and the ankle, you can identify the head of the talus, separated from the scaphoid by a transverse fissure.
Anterior to the scaphoid bone, at a distance of about 3 cm from it, the base of the first metatarsal bone is less clearly felt, then the head of this bone, followed by the first phalanx of the big toe. Along the outer edge of the foot, you can palpate the heel bone, on which, at a distance of 2.5 cm downward and slightly anterior to the lateral malleolus, you can identify a narrow bony protrusion (trochlea peronealis): in front of it lies the tendon m. peroneus brevis, posteriorly - the tendon of the t. peroneus longus. Anterior to the trochlea, on the outer edge of the foot, a sharply protruding tuberosity is identified - tuberositas ossis metatarsalis V. Immediately outward from the tendon of the long extensor pollicis, you can feel the pulse on a. dorsalis pedis DORSUM PEDIS In the superficial layers there is a venous plexus - rete venosum dorsale pedis, from the medial part of which v arises. saphena magna, from lateral - v. saphena parva. Distal from the venous network is the arcus venosum dorsalis pedis, which connects to it, into which the dorsal metatarsal veins flow.
The skin of the area is supplied by branches nn. saphenus, suralis, peroneus superficialis and profundus. N. peroneus superficialis gives nn on the dorsum of the foot. cutaneus dorsalis medialis and intermedius, a n. suralis, running along the lateral edge of the foot, is called n. cutaneus dorsalis laterelis. Under the skin, between the heads of the metatarsal bones, there are synovial bursae: the three medial ones are always present, the fourth is not constant. The region's own fascia - fascia dorsalis pedis - is a continuation of the fascia of the leg. Together with the deep fascia, which is located on the metatarsal bones and dorsal interosseous muscles, it forms a sac containing the long extensor tendons, muscle parts and short extensor tendons, p. peroneus profundus and a. dorsalis pedis (with veins). The long extensor tendons pass each in its sheath under the reticunaculum mm. extensorum inferius. Of these, the tendon m. tibialis anterior is attached to the medial sphenoid and first metatarsal bones; the remaining tendons go to the phalanges of the fingers. The second layer contains m. extensor digitorum brevis, etc. extensor hallucis brevis. The neurovascular bundle of the dorsum of the foot is composed of A. dorsalis pedis with two accompanying veins i.p. peroneus profundus. The artery passes outward from the tendon of m. extensor hallucis longus (between it and extensor digitorum longus), being covered in the distal section by the tendon of the short extensor pollicis (Fig. 121). Before reaching the first intermetatarsal space, a. dorsalis pedis gives off passing under the extensor digitorum brevis a. arcuata (from the latter aa. metatarseae dorsales arise, giving aa. digitales dorsales), and then in the intermetatarsal space they break up into two branches: 1) a. metatarsea dorsalis I, serving as a continuation of the trunk, and 2) ramus plantaris profundus, passing to the sole through the first intermetatarsal space and participating in the formation of arcus plantaris (connects with A. plantaris lateralis). N. peroneus profundus lies inward from the artery, but often outward from it. The nerve gives off a branch to the extensor digitorum brevis and sensory branches to the skin of the first interdigital space and the sides of the first and second fingers facing each other.
SOLE (PLANTA PEDIS) The skin of the sole is dense and thick, the subcutaneous tissue is highly developed and penetrated by powerful fibrous bundles emanating from the plantar aponeurosis. Between the tissue and the aponeurosis there are several synovial bursae in the area of the calcaneal tubercle and at the level of the first and fifth metatarsophalangeal joints). Plantar aloneurosis (aponeurosis plantaris), containing strongly pronounced tendon bundles, extends from the calcaneal tubercle to the heads of the metatarsal bones. At the level of these heads, the transverse and longitudinal fibers of the plantar aponeurosis form commissural openings, similar to those found on the palm. Fascial beds and channels of the sole. The subgaleal space of the sole is divided into four receptacles, or beds, for the muscles of the sole by septa and deep (interosseous) fascia extending deep from the aponeurosis. The septa extend into the area of the sulcus plantaris medialis (between the m. flexor digitorum brevis and m. abductor hallucis) and sulcus plantaris lateralis (I wait for the m. flexor digitorum brevis and m. abductor digiti minimi) and connect the plantar aponeurosis with the long ligament of the sole; they are best expressed in the anterior tarsus. The deep bed contains the interosseous muscles, the other three belong to the plantar muscles; of these, the medial bed contains the muscles of the thumb, the late bed contains the muscles of the small finger, and the middle bed contains the remaining muscles (Fig. 123). Thus, the middle bed contains m. flexor djgitorum brevis
(the most superficial layer), deep fascia of the sole, m. quadratus plantae, tendons of the m. flexor digitorum longus (and so on. lumbricales), etc. adductor hallucis. The medial bed is filled with mm. flexor hallucis brevis, abductor hallucis and tendon m. flexor hallucis longus. The lateral bed is occupied by the muscles of the small finger: mm. abductor and flexor digiti minimi brevis. The lateral and medial beds of the sole are usually isolated, while the middle bed communicates with the deep bed of the tibia through three channels passing into one another. Directly connected to the middle bed is the plantar canal, which proximally passes into the calcaneal canal; the latter passes into the ankle canal, communicating with the deep bed of the posterior region of the leg. The plantar canal is located in the deep layers of the tarsus, under the arch of the foot. The walls of the plantar canal are formed: from the sides - by fascial septa, from above - by the long ligament of the sole, from below - by the deep fascia of the plantar, located between the short flexor of the digitorum and the quadratus plantar muscle. The contents of the plantar canal are the quadratus plantar muscle, the long flexor tendons and both neurovascular bundles of the sole. Distally, the plantar canal leads into the cellular fissure of the middle fascial bed. Phlegmons of the foot, as a rule, are localized in the cellular space of the middle bed of the sole. Further ways of spread of pus with this phlegmon are mainly as follows: 1) perforation by pus of the anterior part of the aponeurosis with the formation of a subcutaneous abscess: 2) along the lumbrical muscles and the oblique head of the adductor pollicis muscle, pus can pass into the interdigital spaces, on the lateral and dorsal sides of the fingers; 3) spread of pus to the dorsum of the foot along the deep plantar branch of the dorsal artery of the foot; 4) the most severe complication is the spread of pus along the canalis malleolaris (along the finger flexor tendons and the lateral plantar neurovascular bundle) to the deep fascial bed of the leg. Vessels And nerves of the sole(Fig. 124 and 125). Of the two plantar arteries a. plantaris medialis is less developed and runs along the medial septum (in sulcus plantaris medialis). A. plantaris. lateralis - large terminal branch of a. tibialis posterior. It passes between m. flexor digitorum brevis, etc. quadratus plantae, then along the lateral septum (in the sulcus plantaris lateralis) to the base of the fifth metatarsal bone, at the level of which they are directed inwards, forming an arc - arcus plantaris. The latter is located under the oblique head of the adductor pollicis muscle and connects to the deep plantar branch of the dorsal artery of the foot. Aa depart from the arc. metatarseae plantares, from which aa arise. digitales plantares. Nerves (nn. plantares medialis and lateralis) accompany the arteries of the same name. The nerves give off branches to the muscles of the sole and metatarsal bones, as well as the plantar digital nerves. FINGERS (DIGITI) On the back surface of the fingers the skin is thin, on the plantar surface it is dense and developed in the form of pillows. The dorsal aponeurosis, into which the extensor tendons pass, is attached by the lateral parts to the bases of the terminal phalanges, and by the middle parts to the bases of the middle phalanges. The tendons of the long flexor are attached to the bases of the terminal phalanges, the tendons of the short flexor are pierced by the tendons of the long and attached to the bases of the middle phalanges. On each finger, the tendons of both flexors are enclosed in a common synovial sheath. Unlike the hand, the synovial sheaths of the first and fifth toes do not form such long synovial sacs that run along the entire hand and end on the forearm. On all toes, the synovial sheaths of the flexor tendons end blindly, approximately at the level of the heads of the metatarsal bones. Vessels and nerves pass on the dorsal and plantar surfaces of the fingers, closer to their lateral side. The plantar vessels are much more developed than the dorsal ones. The dorsal arteries are branches of the dorsal metatarsal, with the exception of two arteries that supply the surfaces of the first and second i fingers facing each other and arise from the dorsal artery of the foot. Dorsal nerves arise: the first 7 (for 3 1 / 2 medial fingers) - from itemp erprjeus super ficialisAnd last 3 (for 1 1 / 2 lateral legs) - from p. suralis. The sides of the first two fingers facing each other receive branches from the n. peroneus profundus. The plantar digital arteries arise from the plantar metatarsal at fingertips form networks. Plantar nerves (10) are: the first 7 (for 3"/2 medial fingers) from n. plantaris medialis (homo-■ distal section of n. medialis), the last 3 (for 1"/2 lateral fingers) from n. plantaris lateralis (homolog of p. ulnaris).
53. Surgery- a mechanical effect on the patient’s tissues and organs, performed by a doctor for the purpose of treatment, diagnosis or restoration of body function and performed mainly through incisions and various methods of connecting tissues.
Stages of the operation: preparing the patient for surgery, pain relief and performing the surgical intervention itself.
Hir. The intervention includes: tissue incision to expose the damaged organ; carrying out the operation on the field itself; connection of tissues damaged during surgery.
2 groups: palliative and radical.
Single-stage, two-stage or multi-stage.
Emergency (immediate), urgent (can be postponed), planned, deferred.
Therapeutic and diagnostic operations.
Apodactyl method. Ablastic method.
52. Surgical instruments: 4 groups: 1) instruments for tissue separation; 2) hemostatic instruments; 3) auxiliary; 4) for connecting fabrics.
59. Surgical treatment of wounds: 1. removal of the edges and bottom of the wound; 2 dissection with excision a) wide dissection of the wound; b) excision of wounds deprived of nutrition and contaminated soft tissues; c) stopping bleeding; d) removal of loose foreign bodies; e) wide drainage of the wound; f) immobilization of the injured limb.
TOPOGRAPHY OF THE UPPER LIMB
Topography of the axillary region(regio axillaris), or pits (fossa axillaris). When the arm is abducted, the axillary, or axillary, pit is clearly revealed under the armpit. Its borders (with the arm abducted) in front are the lower edge of m. pectoralis major, behind - the lower edge of m. latissimus dorsi and m. teres major, medially - a conditional line connecting the edges of the indicated muscles on the chest, outside - a line connecting the same edges on the inner surface of the shoulder. After removing the fascia, which together with the skin forms the bottom of the axillary pit, we find ourselves in the axillary cavity, cavum axillare. Walls of the axillary cavity: anterior - mm. pectorales major et minor, posterior - mm. latissimus dorsi, teres major et subscapulars, medial - m. serratus anterior, lateral - humerus with m covering it. coracobrachial and short head m. biceps brachii.
Downwards, the axillary cavity opens with a hole, and upwards it narrows and communicates with the neck area. The cavity is filled with fatty tissue, which contains nerves, blood vessels and lymph nodes. For. For a more accurate description of the topography of vessels and nerves, the anterior wall of the axillary cavity is divided into 3 triangles, located sequentially one below the other. The uppermost one is formed by the clavicle and the upper edge of m. pectoralis minor - trigonum clavipectorale. The middle one corresponds to m. pectoralis minor - trigonum pectorale. The lower one is limited by the lower edge of m. pectoralis minor, lower edge of m. pectoralis major and m. deltoideus - trigonum subpectoral.
On the posterior wall of the cavum axillare there is a triangular space formed by the surgical neck of the humerus (laterally), m. teres major (bottom) and m. subscapulars (above), which is divided vertically by a long head m. triceps into two holes.
1. Lateral, quadrilateral, foramen quadrilaterum, formed by the named muscles and bone (a. circumflexa humeri posterior and n. axillaris pass through it).
2. Medial, trilateral, foramen trilaterum (the a. circumflexa scapulae passes through it), limited only by the named muscles.
Between the muscles, fascia and bones of the upper limb there are spaces, channels and grooves in which blood vessels and nerves lie. Knowing them is important for surgery.
Sulcus n. The radialis of the humerus, being covered by the triceps brachii muscle, turns into a canal, canalis humeromuscularis, s. canalis n. radialis, s. canalis spiralis (the named nerve passes through it, accompanied by a. and v. profiindae brachii).
On the front surface of the shoulder, between m. brachialis and the edges of m. biceps hracii there are two grooves: sulcus bicipitalis medialis et lateralis. Of these, the deeper medial one, sulcus bicipitalis medialis, serves as a bed for the neurovascular bundle of the shoulder.
In front of the elbow joint, in the area of the elbow bend, lies cubital fossa, fossa cubit i, limited by t. brachioradialis (laterally) and m. pronator teres (medially). The bottom of the fossa and its upper border are formed by m. brachialis.
There are three grooves between the muscles of the forearm:
1. Medial, ulnar, sulcus uinaris: between m. flexor carpi ulnaris (medially) and m. flexor digitorium superficialis (lateral). It contains the ulnar nerve, artery and veins.
2. Lateral, radial, sulcus radialis: between m. brachioradialis (lateral) and m. flexor carpi radialis (medially). The nerve, artery and veins pass through it.
3. Median, sulcus medianus: between m. flexor carpi radialis (lateral) and m. flexor digitorum superficialis (medially). It contains n. medianus.
In the area of the wrist joint there are three canals, resulting from the presence of the retinaculum flexorum. Spreading in the form of a bridge from eminentia carpi ulnaris to eminentia carpi radialis, it turns the groove between the named elevations, sulcus carpi, into a canal, canalis carpalis, and bifurcating into the radial and ulnar sides, it forms canalis carpi radialis and canalis carpi ulnaris, respectively. In the cubital canal there are the ulnar nerve and vessels, which continue here from the sulcus ulnaris of the forearm. In the canalis carpi radialis lies the tendon of m. flexor carpi radialis, surrounded by a synovial sheath. Finally, in the canalis carpalis there are 2 separate synovial sheaths: 1) for the tendons mm. flexores digitorum superficialis et profiindus and 2) for the tendon of m. flexoris pollicis longus (Fig. 95).
First vag. synovialis communis mm. flexorum is a medially located voluminous sac covering the 8 tendons of the deep and superficial flexor digitorum. At the top it protrudes 1-2 cm proximal to the retinaculum flexorum, and at the bottom it reaches the middle of the palm. Only on the side of the little finger does it continue along the tendons of the long muscles that flex it, surrounding them and reaching with them the base of the distal phalanx of the fifth finger.
Second vagina, vag. tendinis m. The flexoris pollicis longi, located laterally, is a long and narrow canal that contains the flexor pollicis longus tendon. At the top, the vagina also protrudes 1-2 cm proximal to the retinaculum flexorum, and at the bottom it continues along the tendon to the base of the distal phalanx of the first finger. The remaining 3 fingers have separate vaginas, vag. synoviales tendinum digitorum (manus), covering the flexor tendons of the corresponding finger. These sheaths extend from the line of the metacarpophalangeal joints to the base of the nail phalanges. Consequently, the II-IV fingers on the palmar side have isolated sheaths for the tendons of their common flexors, and on the segment corresponding to the distal halves of the metacarpal bones they are completely devoid of them.
Recently, an opinion has been expressed that vagina synovialis communis mm. flexorum, covering the tendons of the fifth finger, at the same time does not surround the tendons of the II-IV fingers on all sides; it is believed that it forms three protrusions, one of which is located in front of the superficial flexor tendons, the other between them and the deep flexor tendons, and the third behind these tendons. Thus, the ulnar synovial sheath is a true synovial sheath only for the tendon of the fifth finger.
The tendon sheaths on the palmar side of the fingers are covered with a dense fibrous plate, which, growing to the ridges along the edges of the phalanges, forms a bone-fibrous canal on each finger, surrounding the tendons along with their sheath. The fibrous walls of the canal are very dense in the area of the bodies of the phalangeal bones, where they form transverse thickenings, pars anularis vaginae fibrosae. In the area of the joints they are much weaker and are reinforced by obliquely intersecting connective tissue bundles, pars cruciformis vaginae fibrosae. The tendons located inside the vagina are connected to their walls through thin mesenteries, mesotendineum, carrying blood vessels and nerves.
Shoulder areasSubclavian region
Axillary area
Scapular region
Deltoid region
Anterior and posterior shoulder area Upper limb
(membrum superius)
Comprises:
fixed to the chest
shoulder girdle (suprabrachium)
or shoulder girdle
(cingulum membri superioris)
and free part
upper limb
(membrum superius liberum), to
to which the shoulder is attributed
(brachium), forearm
(antebrachium) and brush
(manus). The shoulder girdle (suprabrachium) has 4 areas:
1. Scapular (regio scapularis)
2. Deltoid (regio deltoidea)
3. Subclavian (regio infraclavicularis)
4. Axillary (regio axillaris) 1 – finger areas
2 – palm area
16 – area of the back of the hand
3 – anterior area
wrists
15 – back of the wrist
4 – anterior area
forearms
14 – posterior region
forearms
5 – anterior ulnar
region
13 – posterior ulnar area
6 – anterior shoulder area
12 – posterior shoulder area
7 and 11 – deltoid region
8 – subclavian region
9 – axillary region
10 – scapular region
Shoulder areas
1. Subclavian region(regio infraclavicularis)
limited:
above the collarbone,
from below – third rib,
medially - the edge of the sternum,
lateral – anterior edge
deltoid muscle Layer-by-layer topography of the subclavian
areas:
1.Skin (cutis)
2. Fat deposits – in the lower
departments are more pronounced, in the area
collarbone layer of fatty deposits
thin, allowing it to be palpated
throughout
3. Superficial fascia
superficialis) from above is fixed to
clavicle, in the upper sections contains
platyzma fibers, below, divided into
2 leaves, covers the mammary gland.
The area between the collarbone and breast
the gland is called the suspensory gland
ligament of the mammary gland (lig.
suspensorium mammae) or ligaments
Cooper. 4. Pectoral fascia (own) (fascia
pectoralis) is fixed to the collarbone.
Superficial and deep plates with
covers both sides of the pectoralis major
muscle, laterally passes passes
into the axillary fascia (fascia axillaris).
Between superficial and deep
the leaves of the fascia are located
fascial bridges, as a result
why the spread of purulent processes
occurs from the surface to depth.
Along the jumpers there are
lymphatic vessels -
spread of cancer metastases
mammary gland to deep
surface of the pectoralis major muscle.
5. Pectoralis major muscle (m.
pectoralis major) occupies
inferomedial part of the subclavian
areas.
Clavicular, sternocostal and abdominal
parts of the pectoralis major muscle
converge to form the anterior wall
axillary fossa and attached to
crest of the greater tubercle of the humerus. Pectoralis major muscle
(m.pectoralis major)
Pars clavicularis, begins on
medial half
collarbone
Pars sternocostalis, on the front
surface of the sternum and
cartilages of the upper 6 ribs
Pars abdominalis, on the front
straight vaginal wall
abdominal muscles
Attached to crista
tuberculi majoris humeri
Muscle fibers form
front wall
axillary fossa. In the superolateral part
subclavian region
located trigonum
clavipectorale.
Thin people have this
corresponds to a triangle
depression in the skin
subclavian fossa (fossa
Morenheim). bottom corner
this triangle
passes into the deltoid pectoral groove. 6. Fiber of the subpectoral space
behind the pectoralis major muscle between the deep
plate of the pectoral fascia and clavipectoral
fascia. 7. Clavipectoral fascia (fascia clavipectoralis)
starts from the clavicle and coracoid process of the scapula,
forms sheaths for the subclavian and pectoralis minor muscles. IN
This fascia has an opening for the branches of a. thoracoacromialis,
v.cephalica. Thickened bundles of fascia clavipectoralis are attached
to the fascia axillaris and are called lig. suspensorium axillae. 8. Pectoralis minor muscle (m. pectoralis minor)
It begins on the II (III) -V ribs, near their anterior ends.
Attached to the processus coracoideus scapulae.
Forms the anterior wall of the axilla.
Subclavian muscle (m. subclavius)
Between the first rib and the collarbone.
It begins on the cartilage of the 1st rib.
Attached to the lower surface of extremitas acromialis claviculae. Vessels and nerves of the subclavian region
1. There are branches in the fat deposits under the collarbone
supraclavicular nerves, which innervate the skin and are
branches of the cervical plexus.
In the lower parts of the subclavian region, the innervation of the skin
carried out by branches of the intercostal nerves. Cutaneous branches
cervical plexus:
1) n.occipitalis minor (from C2
and C3) to the skin
lateral part
occipital region
2) n. auricularis magnus (from
C3) innervates the ear
sink and outdoor
ear canal
3) n.transversus colli (C2-3)
innervates the skin of the neck
4) nn.supraclavicularis
(C3-4) innervates
supraclavicular skin
area, over the big
thoracic and deltoid
muscles. 2. In fat deposits
subclavian region
along the deltoid-thoracic
furrow – v.cephalica
(lateral
saphenous vein of the arm),
pierces the clavipectoral fascia and
drains into the axilla
vein (v.axillaris). 3. a. et v. subclavia accompanied by the infraclavicular part of the humerus
plexuses emerge from under the collarbone, then at the outer edge of the first rib
they are called a. et v. axillaris and pass behind the pectoralis minor
muscles into the axillary cavity.
In the clavipectoral triangle, the vessels and nerves are located in
following order:
more superficial and lower than everything – v. axillaris,
Memorization trick - VAPlex
above it and deeper – a.axillaris,
even higher and deeper - plexus brachialis. 4. Branches of a.axillaris in the clavicular-thoracic triangle:
a. thoracica superior
b. a. thoracoacromialis begins at the level of the upper edge
pectoralis minor muscle, gives off the following branches: r.
acromialis – supplies blood to the shoulder joint, rr.pectorales
– supplies blood to the pectoralis major and minor muscles,
r.deltoideus goes down the deltoid-thoracic
furrow, supplies blood to the deltoid and large
pectoral muscles.
5. The above arteries are accompanied
veins of the same name, draining into the axillary
vein. 6. Thoraacromial
vessels accompany
medial and
lateral pectoral
nerves (nn. pectoralis
medialis et lateralis),
innervating the large
and pectoralis minor muscles.
7. Lymphatic drainage from
subclavian region
carried out along the way
venous vessels in
subclavian
lymph nodes, from
lower parts of the region in
axillary
The lymph nodes. Axillary region (regio axillaris)
Bounded anteriorly by the lower edge of the pectoralis major muscle, posteriorly by the
the lower edge of the latissimus dorsi and subscapularis muscles.
A line connecting the lower edges of these muscles and drawn along the pectoral
wall at the level of the third rib - medial border, the same line,
drawn along the medial surface of the shoulder - lateral border
areas. In the center of the axillary region there is a depression - fossa axillaris.
Layer-by-layer topography of the axillary region
1. The skin (cutis) is thin, mobile, has a largenumber of sweat and sebaceous glands in individuals
have reached puberty, there is good
pronounced hair. For inflammation
Boils and hidradenitis may develop.
2. Fat deposits – thin, uniform
layer, are located superficial
The lymph nodes.
3. Superficial fascia (fascia superficialis)
– loose connective tissue plate 4. Axillary fascia (proprietary) (fascia axillaris) – dense
fibrous plate at the edges of the area, thinned in the center and has
openings that allow cutaneous nerves and blood vessels to pass through.
At the edge of the pectoralis major muscle, the fascia is attached to the fascia axillaris
clavipectoralis, forming here lig. suspensorium axillae, which
pulls it upward, due to which the axillary area has the shape
pits. 5. The axillary cavity (cavitas axillaris) has
the shape of a truncated pyramid, the base is directed downwards
and closed by the axillary fascia, the apex is directed
up and medially, between the first rib and the clavicle. Through
a. pass this gap into the cavity. et v. axillaris, tufts
brachial plexus, located cellular
space. 4 sides of the pyramid (walls of the axillary fossa):
1 – m. pectoralis major et minor (front wall)
2 – m.subscapularis and wide flat tendon m. latissimus dorsi (posterior wall)
3 – m. serratus anterior (medial wall)
4 – humerus (lateral wall) On the posterior wall of the axillary cavity
three- and four-sided
holes.
Via foramen quadrilaterum axillary
the cavity communicates with the subdeltoid
space, through foramen trilaterum – with
fiber of the scapular region.
The axillary cavity is filled with fat
fiber in which the lymph nodes are located,
subclavian part of the brachial plexus, a. et v.
axillaris. Under fascia axillaris –
fiber
space
axillary fossa.
Axillary fiber
cavity communicates with
neighboring fiber
areas:
Superior and medial
go a. axillaris and a.
subclavia and plexus brachialis
axillary fiber
region communicates with
fiber of the lateral
neck triangle and
interscalene
space. Below along the brachial artery there is fiber
The axillary cavity communicates with the deep
fiber of the anterior region of the shoulder, along the
deep brachial artery - with deep tissue
posterior region of the shoulder. Rear fiber
axillary region
reported from:
Fiber
scapular region
through through foramen
trilaterum
With subdeltoid
fiber
space through
foramen quadrilaterum by
move n.axillaris and
a.circumflexa humeri
posterior. Anterior tissue of the axillary cavity
demarcated from the tissue located
between the fascial sheaths large and small
pectoral muscles, the connection of the pectoral and clavipectoral fascia along the outer edge of the greater
pectoral muscle.
With purulent inflammation of the tissue, the spurs of the fascia,
separating the axillary tissue from
interthoracic cellular space, can
melt, causing it to spread
infections in the interthoracic tissue
space.
Vessels and nerves of the axillary region
1. a.axillaris – continuation of a. subclavia.Projection along the anterior edge of the scalp
parts of the axillary fossa. Syntopy in trigonum pectorale:
Anterior and medial – v. axillaris, above and
more laterally – a. axillaris, medial, lateral
and behind the artery - medial,
lateral and posterior bundles of the brachial
plexus. A. thoracica lateralis (from a.axillaris) goes down
anterior edge of the serratus anterior muscle, supplies blood
This muscle is involved in the blood supply to the mammary gland.
Accompanied by n.thoracicus longus (from
supraclavicular part of the brachial plexus). Syntopy in trigonum subpectorale:
Anterior and medial – v.axillaris, lateral –
a.axillaris. The axillary artery is surrounded by branches
plexus brachialis:
In front – n.medianus,
laterally – n. musculocutaneus,
behind – nn.radialis et axillaris,
medially – n.ulnaris. V. axillaris – formed neither
level of the bottom edge
pectoralis major muscle
at the confluence of two
vv.brachiales and v. basilica
V. axillaris medially and
in front of a. axillaris,
passes with it in the clavipectoral, thoracic and
inframammary triangles.
At the outer edge of the first rib
goes into v. subclavia.
Tributaries v. axillaris - veins,
accompanying branches
axillary artery and v.
cephalica. Subclavian part
brachial plexus consists
from three bundles -
medial, lateral and
rear
Lateral bundle
gives:
n.pectoralis lateralis to
pectoralis major muscle
n. musculocutaneus –
pierces the coracobrachialis muscle and lies down
between the biceps and the humerus
muscles, innervates
anterior muscle group
shoulder and gives n. cutaneus
antebrachii lateralis. The medial bundle gives off the following branches:
Uniting with the lateral root it forms
n.medianus accompanied by a. brachialis. His
easy to find at the junction of its two roots
– medial and lateral, in the shape of the letter Y.
N. pectoralis medialis enters the large
pectoral muscle
N.ulnaris
N. cutaneus brachii medialis
N. cutaneus antebrachii medialis The posterior bundle gives off the following branches:
N.subscapularis innervates the subscapularis and
pectoralis major muscle
N.thoracodorsalis is parallel to N.subscapularis,
innervates the latissimus dorsi muscle.
N. radialis
N. axillaris passes through the quadrilateral
hole, gives branches to the deltoid muscle and
n.cutaneus brachii lateralis superior. From the supraclavicular part of the brachial plexus to
the axillary cavity passes through the n.thoracicus
longus, innervates the serratus anterior muscle. The axillary lymph nodes are located in the axillary region.
Lateral (brachial) axillary lymph nodes are collected
lymph from the free upper limb
Medial (thoracic) are located on the anterior
serratus muscle, take lymph from the breast
glands, from the anterolateral surface of the chest and abdomen
(above the navel)
At the level of the 3rd rib there is a lymph node
Zorgius – sentry LU (on the 3rd tooth of the serratus
muscles).
In breast cancer, it is affected earlier than
central axillary lymph nodes.
The posterior (subscapular) lymph nodes receive lymph from
upper back and back of the neck.
Central lymph nodes along the axillary vein
Apical lymph nodes receive lymph from underlying lymph nodes and
from the upper pole of the breast With felons, phlegmons within the hand and
forearms axillary lymph nodes increase,
may purulently melt.
Scapular region
Bounded at the top by a linecarried out from the acromioclavicular joint to
spinous process of VII cervical
vertebra,
Below - a line drawn
through the lower angle of the scapula,
Medial-medial edge
shoulder blades,
Lateral - posterior edge
deltoid muscle and posterior
axillary line. Layer-by-layer topography
scapular region:
1 – leather
2 – body fat
3 – superficial fascia
4 – own fascia
forms a vagina for
m.trapezius et m. latissimus
dorsi Superficial back muscles.
m. trapezius
Begins with protuberantia occipitales externa, linea nuchae superior,
lig. nuchae, lig.supraspinale of all thoracic vertebrae.
Attached to the spina
scapulae, acromion, extremitas
acromialis claviculae
Function: when contracting
all beams - scapula
approaching
spine.
When reducing the upper
bunches - rises,
lower ones - goes down.
When fixing the scapula and
bilateral contraction –
pull the head back when
one-sided - tilts
head to your side. m. latissimus dorsi
Starts from processus
spinosus 5-6 lower
thoracic vertebrae, all
lumbar and sacral
vertebrae, from crista iliaca, from
4 lower ribs.
Attached to crista
tuberculi minoris
humeri.
Function: brings the shoulder to
torso, pronates
shoulder. Takes part in
displacement of the lower ribs
up when breathing
movement. 5. Supraspinatus and infraspinatus fascia (fascia supra-et
fascia infraspinata) form containers for
muscles of the same name. m.supraspinatus
In the supraspinatus fossa. Begins
above the scapular spine, on
supraspinatus fascia.
Attached to the top
tuberculum majus site
into the capsule of the shoulder joint.
Function: abducts the shoulder, pulls
joint capsule.
m.infraspinatus
Begins under the scapular
spine, on the infraspinatus fascia.
Attaches to the middle
tuberculum majus site
humeri, some of the tufts are woven
into the capsule of the shoulder joint.
Function: rotates the shoulder
outward (supination), pulls
joint capsule upward. m.teres minor
Starts with margo lateralis
Attaches to the bottom
tuberculum majus site
humeri.
Function: rotates the shoulder outward
(supination)
m.teres major
Starts at the bottom of margo
lateralis scapulae, on angulus inferior
scapulae, on the infraspinatus fascia.
Attaches to crista tuberculi
minoris (together with m.latissimus
dorsi).
Function: extends the shoulder,
turning it at the same time
inwards (pronation), raised hand
leads to the body, pulls
the lower angle of the scapula outwards and
forward. Between big and small
round muscles
a gap is formed through
which passes
long head
triceps muscle,
sharing it
space for 2
holes - three- and
four-sided.
Quadrilateral
the hole is located
outside the scapular
areas being considered
in the armpit area. 7. Spatula
8. m. subscapularis
9. The subscapularis fascia forms a container for m. subscapularis
10. A layer of loose fiber communicating with the axillary region
11. m.serratus anterior, covered with its own fascia.
12. Layer of loose fiber
13. Ribs and external intercostal muscles Serratus anterior muscle
(m. serratus anterior).
Adjacent to the chest
on the side. Begins
large teeth on
upper 8-9 ribs and
attached to
medial edge and
bottom corner
shoulder blades.
Function:
Pulling the scapula, especially
bottom corner, forward and
laterally.
With a strengthened shoulder blade
raises the ribs
promoting expansion
chest.
Vessels and nerves of the scapular region
1.A pass over the upper edge of the scapula. et v. suprascapularis(artery – branch of truncus thyrocervicalis) and n. suprascapularis,
arising from the supraclavicular part of the brachial plexus.
They supply blood and innervate m.supra et m.infraspinatus
Branches of the suprascapular artery
anastomose with branches
a.circumflexa scapulae and a.
thoracodorsalis, as well as with deep
branch of a.transversa colli (a.dorsalis
scapulae)
This anastomosis is the main
collateral pathway
blood supply to the upper limb
with thrombosis or ligation
axillary artery above
origin of the subscapular artery. n. subscapularis - branch of the brachial plexus, innervates
subscapularis and teres major muscles. A. transversa colli from the 3rd segment of the subclavian
arteries. Her deep branch is accompanied
vein of the same name and n.dorsalis scapulae from
brachial plexus, runs along the medial
the edges of the scapula under the rhomboid muscles, gives
branches to the supraspinatus and infraspinatus muscles.
Deltoid region
Bounded in front by the front, in back by the backthe edge of the deltoid muscle, from above - the external
third of the clavicle, acromion, outer third
spine of the scapula, below – line from the lower edge
pectoralis major to latissimus muscle
backs.
Layer-by-layer topography of the deltoid region
1.Leather2. Fat deposits above the acromion -
subcutaneous acromial bursa.
Branches nn.supraclaviculares (from the cervical plexus) and
n.cutaneus brachii lateralis superior (from n.axillaris).
3. The superficial fascia is fixed to the top
clavicle and acromion 4. Deltoid fascia
(own) from above
goes into its own
fascia of the neck, in front
fascia of the chest, from below into the fascia
shoulder
Deltoid fascia from two
sides cover
deltoid muscle, forming
her case. Deltoid
fascia extends into the thickness
deltoid muscle
partitions separating it
on the clavicular, acromial,
spinous parts. m.deltoideus
Located superficially, under
skin.
Sulcus deltoideopectoralis
Starts on the lateral third
clavicle, acromion, spine of the scapula.
3 parts – clavicular, acromial,
scapular
Attaches to tuberositas
deltoidea
Function:
The clavicular part flexes the shoulder,
turning it inwards, raised
lowers his hand down.
The scapular part extends the shoulder,
turning it outwards, raised
lowers his hand down.
The acromion abducts the arm.
When the entire muscle contracts -
abducts the arm up to 70.̊ 5. Subdeltoid cellular tissue
the space contains loose fiber, in
where the serous bursae are located -
subdeltoid - surrounds the greater tubercle
The humerus usually communicates with
subacromial bursa.
subacromial, facilitating movements
deltoid muscle relative to the humerus.
The subacromial bursa is not always present,
usually communicates with the cavity of the shoulder joint. 7. Under the anterior edge of the deltoid muscle -
short head of the biceps muscle, coracobrachialis muscle, long head of the biceps muscle
muscles.
Under the posterior edge of the deltoid muscle -
lateral and long heads of the triceps muscle,
infraspinatus and teres minor muscles.
Under the acromial part of the deltoid muscle -
articular capsule of the shoulder joint.
Collateral circulation in the areas of the shoulder girdle
1) scapulararterial
collateral circle
Branches of the artery surrounding
shoulder blades (from a.axillaris),
anastomose with
a.suprascapularis (from
truncus thyrocervicalis from
a.subclavia 1 department) and
a. dorsalis scapulae (deep
branch a. transversa colli from
a.subclavia 3 departments). Scapular arterial collateral circle.
If there is difficulty or cessation of blood flow along the main line
the axillary artery above the place where the subscapularis arises from it
arteries – thrombosis, ligation (due to anastomoses of the scapular circle it can
blood circulation throughout the upper limb is maintained.
The branches of the listed arteries anastomose with each other in the infraspinatus
fiber and in the thickness of the infraspinatus muscle 2) Acromiodeltoid network:
Acromial and deltoid
branches a. Thoracoacromialis,
aa.circumflaxa humeri anterior et
posterior, ramus deltoideus
a.profunda brachii.
These branches anastomose
interconnect the system
axillary artery and
deep brachial artery.
Small diameter listed
vessels explains that this network
can compensate
disturbance of blood flow
main artery only in
case of slow and
gradual development of the process,
leading to this violation
(growth of atherosclerotic
plaques)
Shoulder
Located betweenshoulder girdle and elbow.
The upper limit is the line
carried out along the lower
edge of the pectoralis major
muscles and latissimus
back muscles, rounding
deltoid edge
muscles.
The lower limit is 2
cross fingers
above the epicondyles
shoulder When viewed on the anteromedial surface of the shoulder,
on the sides of which the sulci bicipitalis medialis et lateralis are visible,
reaching the ulnar fossa.
In muscular subjects, behind the sulci bicipitalis lateralis
you can see the elevation of m.brachialis, on the back
surface of the shoulder - the eminence of the heads of the triceps
muscles. In women and children
because of more
quantities
fat
sediments
listed
furrows and
elevation less
noticeable.
Layered topography of the shoulder
1.Leather2. Fat deposits, which contain:
v.cephalica first in sulcus bicipitalis lateralis, then in
sulcus deltoideopectoralis
v.basilica in sulcus bicipitalis medialis, it is accompanied by
n.cutaneus antebrachii medialis
n.cutaneus brachii medialis
n. cutaneus brachii lateralis superior (from n.axillaris) and
n. cutaneus brachii lateralis inferior (from n.radialis) 3. Superficial fascia
4. The fascia of the shoulder covers the muscles of the shoulder, from below
passes into the fascia of the forearm.
In the lower half, they extend from the fascia to the humerus
intermuscular septa (septa intermusculare laterale)
et mediale), separating the fascial beds of the anterior and
posterior shoulder groups. Walls of the anterior fascial bed:
Proper fascia, humerus with attachments to it
intermuscular septa. Contents: biceps brachii muscle,
coracobrachialis (upper third of the shoulder) and brachialis muscles (2
lower thirds of the shoulder)
Topography of deep vessels and nerves of the shoulder
A. axillaris lies in the anterior muscle bed, surrounded byfascial sheath, which is formed by spurs
medial intermuscular septum of the shoulder.
Projection a. brachialis - sulcus bicipitalis medialis or
line connecting the anterior edge of the scalp
axillary fossa with the middle of the ulnar fossa.
In the upper third of the shoulder between the coracobrachialis
muscle and medial head of the triceps, below the sulcus
bicipitalis medialis descends into the cubital fossa.
Accompanied by two vv. brachiales and n. medianus. Hney
territory is located on the front, and in the lower third - on
medial surface of the brachial artery. The largest branch departs in the upper third -
a.profunda brachii, which together with n.radialis
passes into canalis humeromuscularis.
a.profunda brachii is divided into 2 branches – a. collateralis
media, a. collateralis radialis, which
supply blood to the triceps muscle.
n.radialis and a. collateralis radialis reach to
humerus, spiral around it, then
extend into the anterior muscle bed between
m.brachialis et m.brachioradialis. Muscles arise from the radial nerve in the shoulder
branches to the triceps muscle, cutaneous nerves of the shoulder -
nn.cutanei brachii posterior et lateralis.
For fractures of the middle third of the shoulder due to
adjacency of the radial nerve directly to
the bone may be damaged by fragments. Ulnar nerve (n.ulnaris) in the upper third of the shoulder
located in the anterior muscle bed
medial from a.brachialis.
Medial to n.ulnaris are located v. basilica with
n. cutaneus antebrachii medialis.
At the border of the upper and posterior third of the shoulder n.ulnaris
pierces the medial intermuscular
septum and is located in the posterior muscular
bed.
In the lower third of the shoulder is located in the back
muscle bed. In the middle third, a.collateralis departs from a.brachialis
ulnaris superior, which matches n.ulnaris and
goes with it to the medial epicondyle,
where it anastomoses with a.recurrens ulnaris. N.musculocutaneus, passing through the coracobrachialis muscle, gives off branches for its innervation
and heads down. Between the biceps and the humerus
muscles gives off branches innervating these
muscles.
At the border with the elbow area it comes out from under
the outer edge of the biceps muscle in the form of n.
cutaneus antebrachii lateralis.
PROJECTIONS OF MAIN VESSELS AND NERVES
Projection anatomy of vessels and nerves of the facial part of the head
1). Facial artery (a. facialis) is projected from the intersection of the anterior edge of the masticatory muscle with the lower edge of the lower jaw in an upward direction to the inner corner of the eye.
2). Mandibular foramen (foramen mandibulare) - is projected from the side of the oral cavity onto the buccal mucosa in the middle of the distance between the anterior and posterior edges of the lower jaw branch, 2.5-3 cm upward from its lower edge.
3). Infraorbital foramen (foramen infraorbitalis) - the projection is carried out 0.5-0.8 cm downward from the middle of the lower orbital margin.
4). Chin hole (foramen mentalis) - projected in the middle of the height of the body of the lower jaw between the first and second small molars.
5). Facial nerve trunk (truncus n.facialls) - corresponds to a horizontal line drawn through the base of the earlobe.
Projection anatomy of vessels and nerves of the neck area
1). Common carotid artery (a. carotis communis) - position of the patient: the head is turned in the opposite direction and pulled up;
- left common carotid artery– the projection line is drawn from the middle of the distance between the apex of the mastoid process and the angle of the lower jaw to the middle of the distance between the legs of the sternocleidomastoid muscle;
-right common carotid artery- the projection is carried out from the middle of the distance between the apex of the mastoid process and the angle of the lower jaw to the sternoclavicular joint.
2. Venous angle N.I. Pirogov - projected between the legs of the sternocleidomastoid muscle. 3 Venous angle N.I. Pirogov - projected in the angle formed by the posterior edge of the sternocleidomastoid muscle and the upper edge of the clavicle.
4). Brachial plexus projection (plexus brachialis) - the position of the patient - the head is turned in the opposite direction and pulled up; the projection corresponds to the line connecting the border between the middle and lower third of the posterior edge of the sternocleidomastoid muscle with the middle of the upper edge of the clavicle.
5). Subclavian artery (a. subclavia) - the projection corresponds to a line drawn 1.5-2 cm above the middle of the clavicle and parallel to the latter.
6). The origin of the branches of the cervical plexus (plexus cervicalis) is projected on the middle of the posterior edge of the sternocleidomastoid muscle.
7). External jugular vein (i. jugularis externa) - lower jaw to the angle between the clavicle and the posterior edge of the sternocleidomastoid muscle.
8). Accessory nerve (n.accessorius) - the projection corresponds to a line drawn from the border between the upper and middle third of the posterior edge of the sternocleidomastoid muscle to the outer third of the anterior edge of the trapezius muscle.
Projection anatomy of the heart and great vessels onto the chest wall
Adjacent to the anterior chest wall the following parts of the heart:
To the left and above is the left atrial appendage;
To the left and below is a narrow strip of the left ventricle;
To the right and above is the right atrium;
To the right and below is the right ventricle.
Boundaries of the heart:
Upper border - projected at the level of the upper edges of the third pair of costal cartilages;
The lower border corresponds to the line that is drawn from the lower edge of the cartilage of the 5th right rib through the base of the xiphoid process to the 5th left intercostal space, not reaching the midclavicular line by 1-1.5 cm (projection of the apex of the heart);
Left border - projected as a convex outward line at the top 3-3.5 cm outward from the edge of the sternum, and at the bottom 1.5 cm inward from the midclavicular line;
Right border - (drawing from top to bottom) - starts from the upper edge of the 3rd rib 1.5-2 cm outward from the edge of the sternum, then continues with a convex line to the place of attachment of the cartilage of the right 5th rib to the sternum.
Right atrium (atrium dexter) - projected onto the anterior chest wall behind and to the right of the sternum, from the upper edge of the cartilage of the 3rd rib to the lower edge of the cartilage of the 5th rib.
Right ventricle (ventnculus sinister) - projected onto the anterior surface of the sternum and left costal cartilages from the 3rd to the 6th inclusive, medial from the parasternal line. A small part of the right ventricle is projected to the right of the sternum, corresponding to the anterior ends of the 6th and 7th costal cartilages.
Left atrium (atrium sinister) - is projected mostly onto the posterior chest wall at the level of the 7-9th thoracic vertebrae. A small part of the left atrium is projected onto the anterior chest wall, corresponding to the left half of the sternum, the anterior ends of the 2nd costal cartilage and the 2nd m/r on the left.
Left ventricle (ventriculus sinister) - projected onto the anterior chest wall at the level of the 2-5th left intercostal spaces from the parasternal line, not reaching the midclavicular line 1.5-2 cm.
Note: the projection of the atria and ventricles onto the chest wall largely depends on the condition of the heart and lungs. In pathology, significant changes are more often found on the left side of the heart.
Projection of the openings of the heart;
- left arterial foramen(ostium arteriosum sinistrum) - projected onto the anterior chest wall behind the sternum on the left at the level of the cartilage of the 3rd rib and 3rd intercostal space; aortic sounds are heard in the 2nd intercostal space on the right at the edge of the sternum;
- right arterial foramen(pulmonary trunk) - is projected onto the anterior chest wall, corresponding to the anterior end of the 3rd costal cartilage and the left part of the body of the sternum at the same level. The sounds of the semilunar valves of the pulmonary trunk are heard in the 2nd intercostal space on the left at the edge of the sternum;
- left venous opening(ostium venosus sinistrum) - located on the left in the 3rd intercostal space near the sternum. The function of the bicuspid valve is heard at the apex of the heart;
- right venous opening of the heart(ostium venosum dextrum) is projected in an oblique direction behind the lower third of the body of the sternum. The sounds of the tricuspid valve are heard in the 4th intercostal space on the right at the edge of the sternum.
Aorta projection:
1). Ascending aorta(pars ascendens aortae).- projected onto the anterior chest wall, starting from the 3rd intercostal space on the left to the level of the connection of the 2nd rib with the sternum on the right.
2). Aortic arch(arcus aortae) is projected onto the anterior chest wall in the sternum at the level of the cartilage of the 1st rib and 1st intercostal space; the highest point of the aortic arch corresponds to the center of the manubrium of the sternum.
Projection of large vessels:
Brachiocephalic trunk(truncus brachiocephalicus) - is the first branch of the aortic arch, extends from its upper semicircle and projects onto the sternoclavicular joint on the right.
Pulmonary trunk(truncus pulmonalis) - the beginning of the pulmonary trunk is projected at the level of attachment of the 3rd costal cartilage to the sternum on the left; its division into the left and right arteries corresponds to the upper edge of the left 3rd costal cartilage or the middle of the body of the 4th thoracic vertebra.
Arterial (Botallov) duct(ductus arteriosus) - projected onto the anterior chest wall: in children six months of age - in the area of the left edge of the sternum, corresponding to the attachment of the 2nd costal cartilage, over six months - on the left at the sternum at the level of the 2nd intercostal space.
Superior vena cava(vena сava superior) - is projected onto the anterior chest wall in the area of the right edge of the sternum and the right costal cartilages from the 1st to the 3rd.
Projection of the most important main vessels and nerve formations of the abdominal cavity
1). Abdominal aorta (aorta abdominalis):
The projection is carried out from the top of the xiphoid process to the navel; - in relation to the spine -
The abdominal aorta is projected from the xiphoid process to a point located 1.5-2.0 cm below and to the left of the navel (according to D.I. Lubotsky).
2). Celiac trunk (truncus coeliacus):
Projected in the middle of the horizontal line connecting the anterior ends of the 10th costal cartilages; the projection of the celiac trunk is determined at a point located 4 cm above the middle of the distance between the xiphoid process and the navel;
In relation to the spine, the celiac trunk is located - T12 or the intervertebral disc - T12-L1.
3). Celiac (solar) plexus area (plexus coeliacus):
According to S.I. Ilizarov and P.A. Kupriyanov is projected onto the vertices of the right angle of the right epigastric triangle, formed by the midline of the right costal arch and the right half of the line connecting the anterior ends of the cartilages of the 9th ribs;
According to V.V. Kovanov and 10.M. Bomash zone of location of the celiac plexus is projected on both sides of the truncus coeliacus projection point,
In relation to the spine – T12 or intervertebral disc – T12 – L1.
4). Superior mesenteric artery (a.mesenterica superior):
The mouth of this artery is projected on the anterior abdominal wall at a point located 1-1.5 cm below the projection of the celiac arterial trunk;
The projection of the mouth of the superior mesenteric artery is determined at a point located 2-3 cm above the middle of the distance between the xiphoid process and the navel;
To auscultate the trunk of the superior mesenteric artery (within the Choffard triangle), a projection is used, which is drawn from a point located 1-1.5 cm below the projection of the celiac trunk to a point located on the border between the internal and middle third of the inguinal ligament (on the right);
In relation to the spine - intervertebral disc T12 - LI.
5). Renal artery (a. renalis):
It is projected in the middle of the distance between the apex of the xiphoid process and the navel;
The projection of the renal artery corresponds to a point that is located 1 cm below the origin of a. mesenterica superior,
The origin of the right renal artery is located 0.5 cm below the left artery;
In relation to the spine – L1 or intervertebral disc – L2.
6). Lower mesenteric artery (a.mesenterica inferior):
Projected at a point located 2.5 cm below the navel along the midline;
In relation to the spine – L3.
7). Bifurcation of the abdominal aorta (bifurcatio aortae abdominalis):
Located in the middle of the line connecting the most distant points between both crests of the ilium;
In relation to the spine - the middle of the body L4 or intervertebral disc - L4 - L5.
8). Right external iliac artery (a. iliaca extema dextra):
The projection line is drawn from the bifurcation of the abdominal aorta to a point located between the inner and middle third of the Pupart ligament.
9). Left external iliac artery (a. iliaca extema sinistra):
Corresponds to the line connecting the projection point of the bifurcation of the abdominal aorta with the middle of the left Pupart ligament. Note: in p.p. 8, 9 - the upper third of these lines corresponds to the direction of the common iliac artery, and the lower 2/3 coincide with the external iliac artery.
10). Superior epigastric artery (a.epigastrica superior).
The projection corresponds to a vertical line running down from the attachment of the 6th costal cartilage to the sternum.
eleven). Inferior epigastric artery (a.epigastrica inferior):
The projection line is drawn from the navel to the middle of the inguinal ligament.
Projection anatomy of arteries and nerves of the upper limb
1). Subclavian artery (a. subclavia):
The projection corresponds to a line drawn parallel and 1.5-2 cm below the middle of the clavicle.
2). Axillary artery (a. axillans):
Lisfranc line - is drawn on the border between the anterior and middle third of the width of the armpit;
The projection line is drawn along the honey. (anterior) edge of the coracobrachialis muscle;
Line N.I. Pirogov - corresponds to the anterior edge of hair growth in the armpit.
3). Axillary nerve (n. axillaris):
A line is drawn on the shoulder from the middle of the scapular spine to the insertion of the deltoid muscle;
According to Voina-Yasenetsky, the projection is determined by the point of intersection of a vertical line drawn from the acromion with the posterior edge of the deltoid muscle, i.e. 6 cm below the angle of the acromion process (corresponds to the level of the surgical neck of the humerus).
4). Brachial artery (a. brachialis):
The projection is carried out from the top of the armpit to the middle of the elbow fold.
5). Radial nerve (n. radialis):
The projection line is drawn from the middle of the posterior edge of the deltoid muscle to the lower third of the external groove of the biceps brachii muscle (sulcus bicipitalis lateralis).
According to N.I. Pirogov’s projection line for the middle and lower third of the forearm is drawn from the medial epicondyle of the shoulder to the pisiform bone;
For the upper third of the forearm - from the middle of the elbow to the border between the upper and middle third of the Pirogov line.
7). Radial artery (a. radialis):
The projection line is drawn from the inner edge of the biceps brachii tendon or from the middle of the elbow crease to a point that is located 0.5 cm inward from the styloid process of the radius (pulse point).
8). Median nerve (n. medianus):
The projection is carried out from the middle of the distance between the medial epicondyle and the biceps brachii tendon to the middle of the distance between the styloid processes of the ulna and radius;
From the middle of the ulnar fossa to the middle of the distance between the styloid processes of the radius and ulna.
The projection is carried out from the medial epicondyle of the humerus to the inner edge of the pisiform bone (Pirogov line).
10). Radial artery in an anatomical snuffbox (a. radialis):
Line L.M. Nagibina - from the styloid process of the radius to the lateral side of the head of the second metacarpal bone.
eleven). Superficial palmar arterial arch (arcus palmaris super ficialis):
Shevkunenko's line is drawn from the pisiform bone to the lateral edge of the palmar-digital fold of the index finger;
Line N.I. Pirogov - carried out from the pisiform bone to the 2nd digital space.
12). Median nerve in the hand (n. medianus):
Projection line is a vertical line drawn between the tener and hypotener.
The projection is carried out from the inner edge of the pisiform bone to the 4th interdigital space.
Projection anatomy of arteries and nerves of the lower limb
1). Suprapiriform opening of the gluteal region (foramen suprapiriforme):
corresponds to a point that is located on the border between the upper and middle third of a line drawn from the posterior superior iliac spine to the apex of the greater trochanter of the femur.
2). Infrapiriform foramen (foramen infrapiriforme):
The projection corresponds to a point that is located on the border between the middle and lower third of a line drawn from the posterior superior iliac spine to the outer edge of the ischial tuberosity.
3). Femoral artery (a. femoralis):
The projection line (Kan line) is drawn “from the middle of the distance between the anterior superior iliac spine and the symphysis to the internal epicondyle of the femur (tuberculum adductorium): provided that the limb is bent at the hip and knee joints and rotated outward.
4). Sciatic nerve (p. ischiadicus):
a) from the middle of the distance between the greater trochanter and the ischial tuberosity to the middle of the popliteal fossa;
b) from the middle of the gluteal fold to the middle of the distance between the epicondyles of the thigh behind.
5). Popliteal artery (a. poplitea):
the projection is carried out 1 cm inward from the midline of the popliteal fossa.
6). Peroneal nerve (n. communis):
The projection line is drawn from the upper corner of the popliteal fossa to the outer surface of the neck of the fibula; on the lower leg - the projection corresponds to a horizontal plane drawn through the base of the head of the fibula.
7). Anterior tibial artery (a. tibialis anterior):
The projection is carried out from the middle of the distance between the head of the fibula and the tibial tuberosity to the middle of the distance between the ankles in front.
8). Posterior tibial artery (a. tibialis posterior):
The projection line is drawn:
a) one transverse finger posterior from the medial crest of the tibia to the middle of the distance between the posterior edge of the inner malleolus and the medial edge of the Achilles tendon;
b). from the middle of the patellar fossa to the middle of the distance between the posterior edge of the inner malleolus and the medial edge of the Achilles tendon.
9). Dorsal artery of the foot (a. dorsalis pedis):
The projection is carried out from the middle of the distance between the medial and lateral ankles to the first interdigital space.
10). Medial plantar artery (a. plantans medialis):
It is projected along a line drawn from the middle of the inner half of the width of the sole to the first interdigital space.
eleven). Lateral plantar artery (a. plantans lateralis):
A line is drawn from the middle of the width of the sole (or from the middle of the line connecting the tops of the medial and lateral ankles) to the 4th interdigital space.
The upper shoulder area borders the collarbone with the neck area; the front border is a vertical line from the middle of the collarbone down; behind - the inner edge of the scapula; below, the border runs along the tendon of the latissimus and teres dorsi muscles, separating the shoulder area below.
The shoulder girdle consists of four subsections: anterior - regio infraclavicularis, lateral - regio deltoidea, posterior - regio scapularis posterior, axillary or axillary cavity - regio sive fossa axillaris.
In the subcutaneous tissue of the shoulder girdle, below the clavicle, in the regio infraclavicularis, are located the anterior and middle branches of the supraclavicular nerves - nn. supraclaviculares anteriores et medii, in the lower part of this area the innervation is carried out by the cutaneous anterior and lateral branches of the intercostal nerves, and in the uppermost part of the shoulder and in the axillary fossa the terminal branches of the interosseous brachial nerve - n. intercosto-brachialis and internal cutaneous nerve of the shoulder - n. cutanei brachii medialis.
In the deltoid region of the shoulder girdle, which is separated from the previous one by the trunk v. cephalica, lying in the sulcus deltoideo-pectoralis, the posterior supraclavicular nerves extend above the clavicle and at the spine of the scapula - nn. supraclaviculares posteriores; below - in the outer part of the region, innervation is carried out by the branches of the lateral cutaneous nerve of the shoulder - n. cutanei brachii posterioris (n. axillaris).
In the scapular region of the shoulder girdle, the posterior branches of the lateral cutaneous branches of the intercostal nerves and the dorsal cutaneous branches from the ramorum posteriorum nn extend. thoracalium. Deeper than the listed nerve formations, the ends of which extend into the thickness of the superficial fascia, lie the aponeurotic sheaths of the muscles that make up the main cover of individual parts of the shoulder girdle area. In front is the fascia of the pectoralis major muscle - fascia pectoralis - starting from the collarbone; the fascia comes in the form of a case, including the entire thickness of the u. pectoralis majoris, and passes at the edge of the latter into the axillary fascia. Deeper than the proper fascia of the pectoralis major muscle there is the fascia clavicoraco-pectoralis, which includes the entire thickness of the m. pectoralis minor. The fascia begins from the coracoid process, connecting with the fascia of the subclavian muscle, passes to the chest, like the fascia of the pectoralis major muscle, and is woven into the aponeurosis of the axillary fossa.
The same area of the shoulder girdle is approached by aponeuroses covering the inner, outer and posterior walls of the axillary fossa. The aponeurosis covering the deltoid muscle is attached to the place of fixation of the latter to the tuberositas deltoidea, connecting in front with the aponeurosis of the pectoralis major muscle, and behind with the thickened aponeurosis of the regio scapularis. The aponeurosis of the posterior part of the scapula tightly covers the suprascapular and subscapular fossae and partly serves as an attachment site for the suprascapular, subscapular, and teres minor muscles.
The article was prepared and edited by: surgeonVideo:
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