The anterior region of the shoulder, regio brachii anterior. External landmarks and projections of the neurovascular bundles of the shoulder girdle Additional examination methods

Layers

Leather thin, moderately mobile.

Subcutaneous fat without features, individually developed. It contains the supraclavicular nerves from the cervical plexus.

Superficial fascia in the upper third of the area forms a case for platysma(subcutaneous muscle of the neck), starting from the own fascia of the chest. At the level of the II-III rib, the fascia thickens, forming the suspensory ligaments of the mammary gland, or Cooper's ligaments. Along all boundaries of the subclavian region, the fascia passes into neighboring areas.

Own fascia areas, fascia pectoralis surrounds pectoralis major muscle in front and behind with superficial and deep leaves. Between them, separating the fibers of the pectoralis major muscle, there are numerous fascial bridges.

As a result of this, the spread of purulent processes in the muscle occurs from the surface to the depth. Lymphatic vessels also pass along the jumpers, which explains the spread of metastases in breast cancer to the deep surface of the pectoralis major muscle.

Superficial and deep leaves fascia pectoralis at the top they are attached to the fascia of the subclavian muscle, as well as to the superficial layer of the own fascia of the neck (second fascia according to Shevkunenko). Below they grow together along the outer edge of the pectoralis major muscle, thus forming a closed case for it. Behind the clavicle, part of the fifth fascia of the neck (prevertebral), covering the anterior scalene muscle, is attached to the first rib.

The next layer (Fig. 2.2) is fiber of the subpectoral space, spatium subpectorale (its walls will be described in detail below).

Rice. 2.2. Layers of the subclavian region:

1 - clavicula; 2 - m. subclavius; 3 - m. pectoralis major; 4 - m. pectoralis minor; 5 - spatium subpectorale; 6 - fascia pectoralis; 7 - fascia clavipectoralis; 8 - fiber of the axillary fossa; 9 - fascia axillaris; 10 - fascia endothoracica; 11 - fascia thoracica; 12 - m. serratus anterior; 13 - pleura parietalis; 14 - a. et v . axillares

Located even deeper clavipectoral fascia,fascia clavipectoralis. Up it starts from the clavicle and the coracoid process of the scapula, with medial sides - at the beginning of the pectoralis minor muscle (III-V ribs), below and outside it is attached to the deep layer of fascia m. pectoralis major at its outer edge. Thickened bundles of the clavipectoral fascia in this place form a ligament attached to the axillary fascia, fascia axillaris(Fig. 2.3).

These bundles are called the suspensory ligament, lig. suspensorium axillae, or a bunch of poles,

The fascia near the collarbone is also thickened. Here the subclavian vein is adjacent to it, which, with a sharp abduction of the arm, can be compressed between the fascia, clavicle and rib with possible acute thrombosis of the vein.

Fascia clavipectoralis forms a case for pectoralis minor and subclavian muscles,m. subclavius.

Thus, subpectoral cellular space located between the pectoralis major and minor muscles with their fascial covers.

Rice. 2.3. Clavipectoral fascia. The pectoralis major muscle has been removed.

1 - m. trapezius; 2 - ramus acromialis a. thoracoacromialis; 3 - ramus deltoideus a. thoracoacromialis; 4 - m. deltoideus; 5 - ramus pectoralis a. thoracoacromialis; 6 - v. cephalica; 7 - m. pectoralis major; 8 - fascia brachii; 9 - m. biceps brachii (caput longum); 10 - fascia thoracica; 11 - fascia axillaris et lig. suspensorium axillae; 12 - m. pectoralis major, fascia pectoralis; 13 - fascia clavipectoralis; 14 - v . axillaris; 15 - lig. costocoracoideum; 16 - clavicula

Front the wall of the space is a deep layer of fascia of the pectoralis major muscle.

Rear- clavipectoral fascia covering the pectoralis minor muscle.

Up it is closed at the collarbone, where both fascia grow together.

Medially- closes at the point where both muscles begin from the ribs.

Lateral and inferior the space is closed by the fusion of the fascia of the pectoralis major muscle and the clavipectoral fascia along the lateral edge of the pectoralis major muscle.

Next layer - fiber of the upper part of the axillary fossa, in which the main neurovascular bundle passes - the axillary vessels and first the bundles, and then the branches of the brachial plexus (sometimes this layer is called deep subpectoral space).

Behind this fiber is the own pectoral fascia, fascia thoracica, covering the serratus anterior muscle and intercostal spaces (see Fig. 2.2).

The upper border of the region is the clavicle. It is located under the skin and subcutaneous tissue and is easily palpated. The fascia propria and the clavipectoral fascia are attached to the lower edge of the clavicle.

The collarbone most often breaks when falling on the shoulder or forearm. The weakest part of the clavicle is at the border between the lateral and middle third. After a fracture of the clavicle, its middle part rises due to traction m. sternocleidomastoideus, and the lateral one descends due to the heaviness of the upper limb (Fig. 2.4).

Rice. 2.4 Divergence of clavicle fragments

It is not uncommon for newborns to have clavicle fractures during passage through the birth canal. Such fractures usually heal quickly on their own. In children of preschool and school age, clavicle fractures occur more often than in adults. Clavicle fractures at this age are often incomplete, where one side of the bone is broken and the other is only bent. The green branches of a tree break in a similar way, which is why the term “greenstick fracture” exists.

Fragments of the clavicle diverging upward and downward can damage the neurovascular bundle located behind the collarbone, therefore the first aid for fractures is to immobilize the shoulder girdle by applying an 8-shaped bandage, sometimes from auxiliary material (clothing).

Topography of the neurovascular bundle

In the subclavian area, the topography of that part of the axillary bundle that runs within clavipectoral triangle(between the collarbone and the upper edge of the pectoralis minor muscle).

In this triangle, immediately below the clavipectoral fascia is located axillary vein, v. axillaris, emerging from under the upper edge of the pectoralis minor muscle and in an oblique direction going from bottom to top to a point located 2.5 cm inward from the middle of the clavicle. In the area between the first rib and the collarbone, the vein is already called subclavian The fascial sheath of the vein is closely connected with the fascia of the subclavian muscle and the periosteum of the first rib, which serves as an obstacle to the collapse of its walls.

In this regard, if a vein is damaged, there is a danger air embolism. At the same time, good fixation of the vein allows puncture in this area.

axillary artery,a. axillaris, lies laterally and deeper than the vein. In the clavipectoral triangle, the superior thoracic artery arises from the axillary artery, a. thoracica superior branching in the first and second intercostal spaces, and the thoracoacromial artery, a. thoracoacromialis, almost immediately splits into three branches: deltoid, thoracic and acromial. All of them pierce the clavipectoral fascia and are directed to the corresponding muscles. In the same place, the lateral saphenous vein of the arm passes through the fascia from the deltoid-pectoral groove into the axillary fossa, v. cephalica, and flows into the axillary vein (see Fig. 2.3).

Brachial plexus bundles are located laterally and deeper arteries.

Thus, both in the direction from front to back, and from the medial side to the lateral side, the elements of the neurovascular bundle are located in the same way: first the vein, then the artery, then the brachial plexus (memorization technique - VAPlex).

If the head is sharply moved to the side (for example, when falling), damage to the upper trunk of the brachial plexus is possible with the development of the so-called Duchenne-Erb palsy [Erb]. Since the nerve fibers that take part in the formation of n. pass through the upper trunk. axillaris, n. musculocutaneus and, partially, n. radialis, the function of the muscles innervated by these nerves will be affected. Therefore, it is impossible to abduct the shoulder (m. deltoideus - inn. n. axillaris), flexion of the forearm is impaired (m. biceps brachii, m. brachialis - inn. n. musculocutaneus), the arm hangs like a whip.

The apical group is located at the medial edge of the axillary vein lymph nodes axillary fossa.

Connection of the fiber of the subclavian region with neighboring areas

1) With the fiber of the axillary fossa through a defect in the posterior wall (f. clavipectoralis) of the subpectoral space, along the branches of a. thoracoacromialis.

2) Along the fiber accompanying the main neurovascular bundle, the purulent process can spread to the lateral triangle of the neck.

3) Along the same bundle, the fiber is connected with the underlying areas of the axillary fossa.

AXILLAR REGION, REGIO AXILLARIS, AND AXILLARY POSTA, FOSSA AXILLARIS

External landmarks. Outlines tm. pectoralis major, latissimus dorsi et coracobrachialis. When the limb is abducted, the area has the shape of a pit, fossa axillaris.

Region boundaries(on the surface of the body! Not to be confused with walls axillary fossa, they will be discussed below).

Front- bottom edge m. pectoralis major, back- bottom edge m. latissimus dorsi, medial- a line connecting the edges of these muscles on the chest wall along the third rib; lateral- a line connecting the edges of the same muscles on the inner surface of the shoulder.

Projection axillary neurovascular bundle (a. et v. axillares, bunches plexus brachialis and the nerves extending from them) - a line drawn from the point between the anterior and middle third of the lateral border of the region (the inner surface of the shoulder) to a point 1 cm inward from the middle of the clavicle (Fig. 2.5).

Rice. 2.5. Projection of the axillary artery.

Layers

Leather thin, has hair, limited to the area, contains many sweat, sebaceous and apocrine glands, when inflamed, boils and hidradenitis can develop. Subcutaneous fatty tissue is poorly expressed and is located in layers between thin plates of the superficial fascia. The subcutaneous tissue contains the cutaneous branches of the nerves of the shoulder and superficial lymph nodes. The outflow from them is carried out into the deep lymph nodes through drainage lymphatic vessels that pierce their own fascia.

Superficial fascia poorly developed.

Own fascia,fascia axillaris, in the center of the area is thin, narrow slits are visible in it, through which small blood and lymphatic vessels and nerves pass to the skin. At the borders of the region, the axillary fascia is denser and freely passes from the front into the pectoral fascia, fascia pectoralis behind - into the lumbar-thoracic fascia, fascia thoracolumbalis, laterally - into the fascia of the shoulder, fascia brachii, and medially - into the own pectoral fascia, fascia thoracica, covering the serratus anterior muscle. To the inner surface of the axillary fascia along the edge m. pectoralis major the ligament that suspends the axillary fascia is attached, lig. suspensorium axillae, ligament Zherdi, - derivative fascia clavipectoralis, discussed in the section on the subclavian region. The ligament pulls its own fascia upward, due to which the axillary region has the shape of a fossa.

Subfascial formations

Cellular space axillary fossa located under fascia axillaris. It contains well-defined fatty tissue, the axillary neurovascular bundle, as well as several groups of lymph nodes.

Like any cellular space, the axillary space is limited by a number of fascia and underlying muscles. In shape it is a tetrahedral pyramid, the base of which is fascia axillaris, and the apex lies at the middle of the clavicle, between it and the 1st rib. Four sides of the pyramid (walls of the axillary fossa, not to be confused with borders!) are formed:

front -f. clavipectoralis with the pectoralis minor muscle enclosed in it;

medial -f. thoracica, covering the chest wall and the serratus anterior muscle;

lateral -f. brachii, covering m. coracobrachialis and a short head m. biceps brachii to the place of their attachment to the coracoid process;

back - f. m. subscapularis and a wide flat tendon m. latissimus dorsi.

Part front The wall as a whole also includes the pectoralis major muscle. As already noted, in the clavipectoral fascia there is an opening that allows branches to pass through a. thoracoacromialis And v. cephalica.

Along medial walls along the teeth of the serratus anterior muscle, m. serratus anterior, or Boxer muscles, go from top to bottom a. thoracica lateralis(from a. axillaris) and somewhat posterior to it - n. thoracicus longus, or Bell's nerve (from the supraclavicular part of the brachial plexus).

In the lower third lateral walls along m. coracobrachialis passes through the axillary neurovascular bundle. Its fascial sheath is connected here with the fascial sheath of the muscle. It is believed that at the inner edge of the coracobrachialis muscle (external landmark) the axillary artery can be pressed against the humerus. However, the muscle can be easily detected only in thin and physically well-developed people, so temporary stopping of bleeding by finger pressure is often carried out using a projection line.

Rear the wall of the axillary fossa is represented by the tendon of the latissimus dorsi muscle and the subscapularis muscle, closely adjacent to it on top. On the front surface m. subscapularis pass in an oblique direction nn. subscapularis et thoracodorsalis.

The latissimus dorsi tendon is always well defined and important internal reference point. With its help, it is easy to find two holes in the posterior wall of the axillary fossa: four-sided and three-sided. These openings connect the axillary fossa with the deltoid and scapular regions (Fig. 2.6).

Quadrilateral edges holes: lower- upper edge of the tendon m. latissimus dorsi, upper- bottom edge m. subscapularis,lateral- surgical neck of the humerus, medial- deeper tendon of the long head m. triceps brachii.

Three-sided edges holes: lower- m. teres major, partially or completely covered by the upper edge of the tendon m. latissimus dorsi, upper- bottom edge m. subscapularis,lateral- tendon of the long head m. triceps brachii.

As can be seen in the figure, the upper and lower edges of both holes are represented by the same formations: m. subscapularis And m. latissimus dorsi with m. teres major . The four-sided foramen lies more lateral, closer to the humerus, and the three-sided foramen lies more medially. To find them, just find the angle between the humerus and the upper edge of the tendon m. latissimus dorsi - this is already part of the four-sided hole. By moving the instrument upward, the subscapularis muscle is immediately identified, and by moving inward and deep into this hole, it is easy to reach the tendon of the long head of the triceps muscle. Continuing over this tendon to the medial side, a trilateral foramen can be easily found in the space between the latissimus dorsi tendon and the subscapularis muscle.

The axillary nerve passes through the quadrilateral foramen from the axillary fossa into the deltoid region. n. axillaris, and the posterior circumflex artery of the humerus, a. circumflexa humeri posterior. The circumflex scapula artery enters the scapular region through the trilateral foramen. a. circumflexa scapulae.

Near the posterior wall there are a number of other important neurovascular formations, the topography of which is discussed below.

Topography of neurovascular formations

A. axillaris , continuation a. subclavia, immediately below the clavicle, it is the main vessel of the upper limb (Fig. 2.7).

1 - clavicula et m. subclavius; 2 - fasciculus lateralis; 3 - v . cephalica; 4 - m. pectoralis major; 5 - n. musculocutaneus; 6 - n. axillaris et a. circumflexa humeri posterior; 7 - radix lateralis n. mediani; 8 - radix medialis n. mediani; 9 - n. medianus; 10 - n. radialis; 11 - n. ulnaris; 12 - n. cutaneus antebrachii medialis; 13 - n. cutaneus brachii medialis; 14 - n. intercostobrachialis; 15 - a. circumflexa scapulae; 16 - a., n. thoracodorsalis; 17 - m. latissimus dorsi; 18 - m. pectoralis major; 19 - m. pectoralis minor; 20 - a. thoracica lateralis; 21 - a. subscapularis; 22 - a. thoracoacromialis; 23 - a., v . axillares; 24 - plexus brachialis

Its topography is usually considered by triangles formed relative to the pectoralis minor muscle: tr. clavipectorale, tr. pectorale And tr. subpectorale(they were discussed in the section on the topography of the subclavian region). In the first of them, the axillary artery gives off branches: a. thoracica superior And a. thoracoacromialis, in the second - a. thoracica lateralis, in the third, inframammary triangle, they extend from it a. subscapularis, aa. circumflexae humeri anterior et posterior.

Topography of the elements of the neurovascular bundle in trigonum clavipectorale discussed in the section on the subclavian region.

IN chest In the triangle, medial (superficial) from the artery are the axillary vein and the lymph nodes running along it. The three bundles of the brachial plexus - medial, lateral and posterior - lie next to a. axillaris according to their names: medial - medial from the artery, lateral - laterally, posterior - behind the artery. A. thoracica lateralis is directed to the medial wall of the axillary fossa, where it gives off branches to the muscles and to the mammary gland.

IN submammary In the triangle, the topography of blood vessels and nerves is the most complex. Here the bundles of the brachial plexus split into several large nerves, each of which occupies a specific position relative to the axillary artery. It is appropriate to remember that medial bundle The brachial plexus gives rise to the medial cutaneous nerve of the shoulder, n. cutaneus brachii medialis, forearms, n. cutaneus antebrachii medialis, ulnar nerve, n. ulnaris, and medial root of the median nerve, n. medianus. From lateral bundle the lateral root of the median nerve and the musculocutaneous nerve arise, n. musculocutaneus, or nerve of Casserio, from rear- radial, n. radialis, and axillary, n. axillaris, nerves.

The most superficial formation is v. axillaris, which in relation to the artery and nerves is located along its entire length anteriorly and medially.

N. medianus located anteriorly from the artery. It is easy to find at the junction of its two roots - medial and lateral (internal landmark), in the shape of the letter Y. In the space between the roots, the trunk of the axillary artery is clearly visible.

Nerves from the medial bundle of the brachial plexus are located medial to the artery. The largest among them is n. ulnaris . In addition to it, medial to the artery are located n. cutaneus antebrachii medialis And n. cutaneus brachii medialis.

Lateral to the artery are the lateral root of the median nerve and the musculocutaneous nerve leading to m. coracobrachialis and piercing it.

Behind the artery the radial and axillary nerves are located (both from the posterior bundle). N. radialis , the largest of the branches of the brachial plexus, lies behind the artery along the entire length of the inframammary triangle and, together with the artery, is adjacent to the tendon of the latissimus dorsi muscle, passing into the anterior region of the shoulder. They also move into the same area n. medianus, nn. cutanei brachii et antebrachii mediales, n. ulnaris.

N. axillaris first located behind and slightly lateral to the artery on the posterior wall of the axillary fossa, then goes obliquely and laterally towards the quadrilateral opening at the upper edge m. latissimus dorsi. The posterior circumflex artery of the humerus is also directed into the same hole. a. circumflexa humeri posterior, and the accompanying veins, which, together with n. axillaris form a neurovascular bundle adjacent to the surgical neck of the shoulder from behind and further directed into the subdeltoid space. Here, deeper than the nerve, under a small layer of loose tissue, the lower portion of the capsule of the shoulder joint is exposed, recessus axillaris.

If you pull the axillary artery to the side, you can see it extending from its posterior wall a. subscapularis. The place of its origin is located at a distance of about 1 cm from the upper edge of the tendon m. latissimus dorsi. A. subscapularis, the largest of the branches of the axillary artery, goes down and almost immediately divides into the circumflex scapular artery, a. circumflexa scapulae, and thoracodorsal artery, a. thoracodorsalis. The first of them goes into the trilateral foramen and further to the lateral edge of the scapula, and the second is a continuation of the subscapular artery, descends down, accompanied by the subscapular nerve, and breaks up into terminal branches at the angle of the scapula.

Ah. circumflexae humeri anterior et posterior start 0.5 - 1 cm distal a. subscapularis. A. circumflexa humeri anterior directed laterally under m. coracobrachialis And caput breve m. bicipitis brachii and is adjacent to the surgical neck of the shoulder anteriorly. Both arteries surrounding the shoulder supply blood to the shoulder joint and deltoid muscle, where they anastomose with the deltoid branch a. thoracoacromialis.

A. axillaris is the main main vessel of the upper limb. Its branches in the area of ​​the shoulder girdle form anastomoses with arteries from the systems of the subclavian and brachial arteries, serving as collateral blood supply routes to the upper limb in case of injury and ligation a. axillaris. A more reliable collateral blood supply develops when the axillary artery is ligated or occluded above (proximally) the origin a. subscapularis and both arteries that circumflex the humerus (for more details, see below, in the section on collateral circulation in the areas of the shoulder girdle).

The lymph nodes The axillary fossa forms 5 groups that are easier to remember in relation to the walls. One of them - the central one - is located at the base of the pyramid, which is formed by the walls. The next three are located along the edges of the pyramid, except for the medial one. Accordingly, these are posterior, lateral and anterior nodes. The fifth group is located at the top of the pyramid (the top is apex) and is therefore called apical.

Nodi lymphoidei centrales are the largest nodes. They are located in the center of the base of the axillary fossa under the own fascia along the axillary vein.

Nodi lymphoidei subscapulares ( posteriores) lie along the subscapular vessels and receive lymph from the upper back and back of the neck.

Nodi lymphoidei humerales ( laterales) are located at the lateral wall of the axillary fossa, medial to the neurovascular bundle, and receive lymph from the upper limb.

Nodi lymphoidei pectorales ( anteriores) located on the serratus anterior muscle along the a. thoracica lateralis. They receive lymph from the anterolateral surface of the chest and abdomen (above the navel), as well as from the mammary gland. One (or several) of the nodes of this group lies at the level of the third rib under the edge m. pectoralis major and stands out especially (Zorgius node). These nodes are often the first to be affected by breast cancer metastases.

Nodi lymphoidei apicales lie in trigonum clavipectorale along v. axillaris and receive lymph from the underlying lymph nodes, as well as from the upper pole of the mammary gland.

Next, the lymphatic vessels pass into the lateral triangle of the neck along the axillary neurovascular bundle and take part in the formation truncus subclavius, subclavian lymphatic trunk.

The main groups of lymph nodes of the axillary fossa are palpated in the position of shoulder adduction; the adduction position is required to relax the axillary fascia under which they are located. Only the Zorgius lymph node is palpated differently. The patient's hand lies on the doctor's shoulder, and he palpates the lymph node at the site of attachment of the lower edge of the pectoralis major muscle to the chest.

Connection of the fiber of the axillary fossa with neighboring areas

1) Along the neurovascular bundle in the proximal direction, the tissue of the axillary fossa is connected with the tissue of the neck, and from there - with the tissue of the anterior mediastinum.

2) In the distal direction along the neurovascular bundle - with the tissue of the shoulder.

3) Through a three-sided hole - with the posterior surface of the scapular region.

4) Through the quadrilateral foramen - with the subdeltoid space.

5) Through the clavipectoral fascia along a. thoracoacromialis - with subpectoral space.

6) Between the deep (anterior) surface of the scapula and the chest wall - with the subscapular space.

SKIN AREA, REGIO SCAPULARIS

External landmarks. The upper edge of the scapula is located at the level of the II rib (the medial angle reaches the level of the I rib), the lower angle is at the level of the VIII rib. The spine of the scapula corresponds approximately to the third rib.

The most accessible for palpation and, therefore, the most reliable external landmarks of the area are the medial edge of the scapula, its lower angle, the spine of the scapula and the acromion. The line connecting the lateral part of the acromion and the inferior angle of the scapula corresponds to the lateral edge of the scapula, which often cannot be palpated due to the muscles covering it.

Boundaries. Upper- a line drawn from the acromioclavicular joint perpendicular to the spine; lower- a horizontal line running through the lower corner of the shoulder blade; medial- along the inner edge of the scapula until it intersects with the upper and lower borders; lateral- from the lateral end of the acromion vertically down to the lower border.

Projections main neurovascular formations of the region. A. et n. suprascapularis are projected along a line running from the middle of the clavicle to the point corresponding to the base of the acromion, that is, the border of the outer and middle third of the spine of the scapula. Projection line r. profundus a. transversae colli (a. scapularis dorsalis, PNA) runs along the inner edge of the scapula 0.5-1 cm medially from it. Entry point a. circumflexa scapulae into the infraspinatus bed it is projected to the middle of the projection of the lateral edge of the scapula.

Layers

Leather thick, inactive, it can hardly be folded. Sometimes men have skin covered with hair.

When the skin is contaminated, in areas of friction with clothing, in elderly and exhausted people, and in patients with diabetes mellitus, boils (furunculosis) may occur in this area. There are many sebaceous glands in the skin; when they are blocked in this area, sebaceous gland cysts often appear - atheromas that require surgical removal.

Subcutaneous fat single-layer, dense, cellular due to connective tissue partitions going from the skin in depth to its own fascia.

Superficial fascia can be represented by several sheets of different densities. There are practically no suprafascial formations; the thin saphenous nerves are branches of the axillary and supraclavicular nerves.

Proprietary fascia of superficial muscles areas ( m. trapezius, m. deltoideus, m. latissimus dorsi) forms cases for them.

Fascia supraspinata et fascia infraspinata- own fascia of the deep muscles of the scapula, starting from its posterior surface. These fasciae are dense and have an aponeurotic structure. As a result of their attachment to the edges of the scapula and spine, two bone-fibrous spaces are formed - supraspinatus and infraspinatus.

The most important anatomical formations of the shoulder are: the brachial artery, radial, ulnar and median nerves. The main branch of the brachial artery is the deep brachial artery, which branches off in the upper third of the shoulder and goes into the spiral canal of the shoulder along with the radial nerve. The median nerve is formed by two roots of the medial and lateral bundles and descends vertically down along the brachial artery, emerging in the middle of the forearm. The ulnar nerve, deviating medially and posteriorly, lies in the ulnar groove on the posterior surface of the medial condyle of the humerus and exits onto the anterior surface of the forearm. The radial nerve is located in the spiral canal of the shoulder along with the deep brachial artery and innervates the posterior group of muscles of the shoulder. In the cubital fossa, the radial nerve exits the anterior surface of the elbow joint capsule and divides into anterior and posterior branches (deep and superficial). With a fracture of the humerus, there may be damage to the radial nerve, since the nerve lies directly on the bone. At the bottom of the cubital fossa, under the aponeurosis of the biceps brachii muscle, there is the brachial artery and median nerve. The brachial artery is divided into the radial and ulnar arteries at the lower edge of the cubital fossa. Each artery has two veins. The radial artery runs along the radial side of the forearm opposite the 1st finger, the ulnar artery runs along the ulnar side opposite the 5th finger. The pulse point is located on the radial artery. Opposite the 3rd finger in the middle of the anterior forearm is the median nerve. There are no vessels along with the median nerve. The ulnar nerve passes along with the ulnar artery. In the subcutaneous tissue of the ulnar region, the lateral and medial saphenous veins of the arm form various anastomoses, which are used for intravenous injections. If the artery is damaged, the blood flow of the limb can almost always be reconstructed microsurgically if there is a peripheral capillary bloodstream and full venous outflow. When suturing nerves, only the nerve sheaths are sutured and only microsurgically. The nerve grows from the central end to the periphery at a rate of 1 mm per day. When the nerve is damaged, the vessels become obliterated and the canal becomes sclerotic.

13.Arteries of the forearm

In the ulnar fossa, the brachial artery gives rise to two independent arteries - the ulnar and radial, located on the palmar side of the forearm. Going down along the bones of the same name, the art supplies blood to the elbow joint, skin and muscles of the forearm. The projection line of the radial artery is from the middle of the distance between the epicondyles of the humerus to the styloid process of the radius (pulse point). Access to the artery is direct, since there is no nerve nearby. The projection line of the ulnar artery is from the medial epicondyle of the humerus to the pisiform bone. In the middle and lower third of the forearm, access to the artery is roundabout, since the ulnar n. lies nearby.

14. Nerves of the forearm.

The ulnar nerve enters the canalis ulnaris, then passes to the forearm into the sulcus ulnaris, where it accompanies the artery and veins of the same name. The ulnar nerve gives off muscular branches to the forearm. Thin branches extend from it to the capsule of the elbow joint. In the lower third of the forearm, the dorsal branch begins from the ulnar nerve, which goes to the posterior surface of the forearm between the flexor carpi ulnaris and the ulna. Perforating the own fascia of the forearm at the level of the head of the ulna, this branch is divided into 5 dorsal digital nerves that innervate the skin of the fifth, fourth and ulnar side of the third fingers. Inn all the muscles of the hypothenar. In addition, the deep branch is involved in the innervation of the joints of the hand. Median nerve. In the ulnar fossa it passes under the aponeurosis m. biceps brachii, where it gives branches to the elbow joint. Then it penetrates m. pronator teres and lies in the sulcus medianus. In the forearm, the median nerve gives off numerous muscle branches that innervate the muscles of the anterior group of the forearm (flexors). In the lower third of the forearm, the palmar branch of the median nerve begins, which innervates the skin in the area of ​​the wrist joint, the middle of the palm and the eminence of the thumb. The radial nerve penetrates the sulcus cubitalis anterior lateralis, in the depths of which it is divided into superficial and deep branches. In canalis humeromuscularis from n. radialis arises from the posterior cutaneous nerve of the forearm, which pierces the fascia of the shoulder above the lateral epicondyle and innervates the skin of the posterior surface of the shoulder, elbow joint and forearm. The superficial branch of the radial nerve, on the forearm, lies in the radial groove outward from the radial artery. In the lower third of the forearm, it passes to the dorsum and is located between the brachioradialis muscle and the radius. 4-5 cm above the styloid process of the radius, this branch pierces the proper fascia of the forearm, gives branches to the base of the thumb and divides into 5 dorsal digital nerves. The deep branch of the radial nerve innervates all the muscles of the posterior surface of the forearm (extensors) and the brachioradialis muscle.

Posterior bundle, fasciculus posterior , is formed by the anterior branches of the fifth, sixth, seventh, eighth cervical and first thoracic nerves (CV - CVIII, ThI).

It gives off the nerves: subscapular, thoracodorsal, axillary and radial.

1. Subscapular nerve, n. subscapularis(CV-CVII), arises from the superior trunk or the initial part of the posterior fasciculus, is located on the anterior surface of the subscapularis muscle and sends thin nerves to this muscle and to the teres major muscle. The subscapular nerve may arise from the axillary nerve.

2. Thoracospinal nerve, n. thoracodorsalis(CVI) СVII - СVIII, descends along the lateral edge of the scapula and, reaching the anterior section of the latissimus dorsi muscle, branches in the thickness of this muscle.

The thoracodorsal nerve can divide into two branches and in rare cases arises from the radial nerve.

3. Axillary nerve, n. axillaris(CV-CVI) - a relatively thick trunk, located in the axillary cavity, behind the axillary artery, on the surface of the subscapularis tendon. Directing slightly downwards, outwards and backwards, the nerve, accompanied by the posterior artery circumflexing the humerus, passes through the quadrilateral foramen and, rounding the back of the surgical neck of the humerus, is located between it and the deltoid muscle, giving off thin articular branches to the capsule of the shoulder joint and to the periosteum of the humerus bones.

The axillary nerve along its course gives off the following branches:

1) muscle branches, rr. musculares, - several branches entering the thickness of the teres minor muscle from its lower outer surface and into the thickness of the deltoid muscle from its inner surface. Among the latter branches, a group of nerves is distinguished, distributed in all bundles of the deltoid muscle.
Some of these nerves, piercing the thickness of the muscle, penetrate the skin. In addition, the axillary nerve can send a muscular branch to the inferolateral part of the subscapularis muscle;

2) superior lateral cutaneous nerve of the shoulder, n. cutaneus brachii lateralis superior, located between the deltoid muscle and the long head of the triceps brachii muscle (less commonly, it can pass through the thickness of the deltoid muscle), is divided into ascending and descending branches, which branch in the skin of the posterior deltoid region, as well as in the skin of the upper half of the lateral surface of the shoulder.

The terminal branches can connect to the posterior cutaneous nerve of the shoulder from the radial nerve and to the posterior cutaneous nerve of the forearm from the radial nerve.

4. Radial nerve, n. radialis(CV - CVIII, ThI), located in the axillary cavity behind the axillary artery. At the level of the lower edge of the latissimus dorsi tendon, the radial nerve is directed posteriorly, outward and downward and, accompanied by the deep brachial artery, enters the superior opening of the brachiomuscular canal.

At the level of the surgical neck of the humerus, a branch extends to the capsule of the shoulder joint. Having passed through this canal, accompanied by the radial collateral artery, the nerve exits between the brachial and brachioradialis muscles. Having reached the level of the lateral epicondyle, the radial nerve divides into superficial and deep branches.

Branches of the radial nerve:

1) posterior cutaneous nerve of the shoulder, n. cutaneus brachii posterior, starts from the main trunk of the radial nerve in the axillary cavity, goes obliquely posteriorly, sometimes penetrating the thickness of the long head of the triceps muscle, pierces the fascia of the shoulder approximately at the level of the deltoid tendon and branches in the skin of the posterolateral surface of the shoulder. Its branches can connect with the branches of the superior lateral cutaneous nerve of the shoulder (from the axillary nerve);

2) lower lateral cutaneous nerve of the shoulder, n. cutaneus brachii lateralis inferior, often arises from the main trunk or from the posterior cutaneous nerve of the forearm at the level of the beginning of the medial head of the triceps muscle. Directing downward and outward along with the posterior cutaneous nerve of the forearm, it ends in the skin of the lateral surface of the lower third of the shoulder and elbow;

3) posterior cutaneous nerve of the forearm, n. cutaneus antebrachii posterior, departs from the main trunk of the radial nerve in the brachiomuscular canal, follows along with it for some distance to the lateral intermuscular septum of the shoulder, pierces it and the fascia of the shoulder at the lateral edge of the brachioradialis muscle.

It branches in the skin of the posterior surface of the distal part of the shoulder and the dorsum of the forearm, reaching the area of ​​the wrist joint. Its branches can connect with the branches of the medial and lateral cutaneous nerves of the forearm, as well as with the dorsal branch of the ulnar nerve and the superficial branch of the radial nerve;

4) muscle branches, rr. musculares, in the shoulder area they are directed to the triceps brachii muscle (to all three of its heads), to the elbow muscle and often to the lateral part of the brachialis muscle;

5) superficial branch, r. superficialis departs from the main trunk of the radial nerve in the ulnar fossa at the level of the lateral epicondyle, located medial to the brachioradialis muscle.

Below it lies outward from the radial artery. In the middle part of the forearm, the superficial branch deviates to the radial side and, passing between the tendons of the brachioradialis muscle and the long extensor carpi radialis to the back of the radial edge of the forearm, pierces the fascia of the forearm slightly above the wrist joint. Next, the superficial branch of the radial nerve branches in the skin of the radial region of the wrist joint, the radial half of the dorsum of the hand and fingers in the form of dorsal digital nerves.

The surface branch sends branches:

a) connecting branches, rr. communicantes, to the lateral and posterior cutaneous nerves of the forearm in the area of ​​the posterior surface of the lower third of the forearm and wrist joint;

b) ulnar connecting branch, r. communications ulnaris, - the largest, which connects the superficial branch of the radial nerve with the dorsal branch of the ulnar nerve on the dorsum of the hand;

c) dorsal digital nerves, nn. digitales dorsales, innervate the following areas of the skin: the skin of the radial and ulnar edges of the dorsum of the thumb to the base of the nail, the skin of the radial and ulnar edges of the dorsum of the index finger to the middle phalanx and the skin of the radial edge of the dorsum of the middle finger also to the middle phalanx;

6) g deep branch, r. profundus, - a thicker than superficial branch, departs from the main trunk in the same way as the superficial one, at the level of the lateral epicondyle of the humerus and, entering the belly of the supinator, bends around the upper section of the radius, heading obliquely down to the dorsum of the forearm.

Having left the muscle, it is located under the extensor digitorum, i.e., between the superficial and deep extensors. Next, the deep branch, accompanied by the posterior interosseous artery, follows distally to the dorsum of the wrist.

The deep branch sends branches:

A) posterior interosseous nerve of the forearm, n. interosseus (antebrachii) posterior. First, it is located between the superficial and deep layers of the extensor muscles, then it lies on the dorsal surface of the interosseous membrane of the forearm, between the tendons of the long and short extensor muscles of the thumb, reaching the wrist.

On its way, the posterior interosseous nerve sends branches to the interosseous membrane, to the periosteum of the dorsal surface of the radius and ulna, to the capsules of the carpal, carpometacarpal, and metacarpophalangeal joints;

b) muscle branches in the forearm are directed to the following muscles: supinator, extensor carpi radialis brevis, extensor digitorum, extensor of the little finger, extensor pollicis brevis, extensor carpi ulnaris, abductor pollicis longus, extensor pollicis longus, extensor index finger .

COMPRESSION SYNDROME OF THE UPPER THORACIC OUTLET (Thoracic Outlet sindrom)

Pain in the upper limb and shoulder girdle can be caused by compression of the neurovascular bundle by various dense structures (bones, ligaments, muscles) in the chest opening. Since the neurovascular bundle passes in the tight space between the collarbone and the first rib, as well as the scalene muscles in the neck, any pathological deviation in them can cause compression of the vessels or nerves. This syndrome has neither etiological nor functional unity and therefore represents a great treatment problem. Some clinicians doubt its existence at all. Those who recognize it are not confident in surgical treatment, since the results of such treatment are very variable.

The cause of compression of the neurovascular bundle may be:

1. True scalene syndrome, which develops as a result of changes in the anterior scalene muscle: more often these are anatomical variants of the muscle and less often its hypertrophy or spasm.

2. Costoclavicular syndrome - too narrow gap between 1 rib and collarbone.

3. Coraco-pectoral syndrome - compression by a ligament passing from the coracoid process to the pectoralis minor muscle. With it, pain appears when the raised arms are abducted.

4. Additional cervical rib.

5. Tumors, trauma (hematoma, false aneurysm).

In the clinical picture, the main symptom is radiating, boring pain in the arm. It intensifies after exercise and in the evening. Later, paresthesia and muscle atrophy appear. In many cases, the pain does not have a specific localization and the patient himself cannot describe its nature or where it comes from (shoulder or elbow joint). This can mislead the doctor about the reality of the complaints presented. Approximately 90% of patients with aperture syndrome have neurological symptoms and only 10% are associated with arterial or venous problems. Sometimes pain in the anterior chest wall simulates angina, which requires differential diagnosis. It is not always clear whether this pain is of organic or mental origin. Many patients with long-term compression syndrome also have mental complaints that overlap with organic ones. When making a diagnosis, you must first answer the following questions:

1. what is the nature of the pain: organic, psychosomatic or combined?

2. what is its origin: neurogenic or vascular?

3. localization of pain (spine, thoracic outlet, elbow, wrist joints)

Physical examination is not very informative. On palpation, pain is sometimes noted along the lateral surface of the neck. It intensifies when the head is tilted to the healthy side and the affected arm is extended. In some patients, during this test, the pulse disappears at arm's length. A more important sign is the appearance of pain when raising and externally rotating the shoulder. Of the neurological symptoms, zones of hypo and hyperesthesia on the hand are more typical; movement disorders are less common. Arterial symptoms, which occur in 5% of all patients, are in the form of chronic ischemia of the arm, absence or weakening of the pulse, acute ischemic syndrome (thrombosis, embolism), Raynaud's syndrome (white fingers, cyanosis, decreased temperature, etc.). Compression of the veins leads to temporary or permanent swelling of the arm, cyanosis, and the development of venous collaterals in the shoulder and anterior chest wall. Differential diagnosis is carried out primarily with cervical osteochondrosis, as shown in Table N1:

Additional examination methods.

1. X-ray of the cervical spine and chest. It can detect an additional cervical rib, which is present in approximately 10% of all people, or an anomaly of 1 rib.

2. Electromyography (nerve conduction study). It is performed to study the speed of nerve impulse conduction. If it is delayed, we can talk about the interest of one or another nerve. However, this study is more reliable for carpal tunnel syndrome than for compression aperture syndrome. Therefore, a positive test result confirms the diagnosis, but a negative test result does not reject it.

3. Angiography. In the usual patient position, it is useful only for dilatation or aneurysm of the subclavian artery, as well as thrombosis or embolism of the peripheral arteries of the upper limb. If the artery is compressed by bone structures or ligaments, it is necessary to perform positional angiography with the arm raised and rotated outward.

4. Phlebography. It is indicated for symptoms of venous insufficiency. In case of intermittent swelling of the arm, it should be performed in a positional position (abduction and rotation of the arm).

Treatment tactics

1. Conservative treatment.

Difficulties in making a diagnosis and a large number of unsatisfactory results of surgical treatment of patients with neurological symptoms force long-term conservative treatment. According to many authors, 8.5-26% of operated patients still have the same complaints.

First of all, a set of special gymnastic exercises is recommended. An approximate set of exercises is given below. Each exercise is done 10 times twice a day. When the shoulder and neck become stronger, the number of exercises can be increased.

1) Stand up straight with your arms spread to the sides, holding a load of up to 2 kg in each hand (sandbag, bottle). a) Movement of the shoulders back and forth; b) relaxation; c) moving the shoulders back and forth; d) relaxation; e) moving the shoulders forward; e) relaxation and repetition of the entire exercise.

2) Stand up straight with your arms out to the sides at shoulder level. Hold a weight of up to 2 kg in each hand. Palms are turned down. A). raise your arms to the sides and up until they meet above your head (elbows extended); b). relax and repeat the exercise. Note: when your arms get stronger and exercise N N 1-2 becomes easier to perform, you need to increase the weight to 5, and then to 10 kg.

3) Stand facing the corner of the room and place your hands on each wall at shoulder level. a) slowly press your upper chest into a corner while inhaling; b) return to the starting position, exhale at the moment of movement.

4) Stand up straight, arms to the sides. a) tilt your head to the left so as to touch your ear to your shoulder without raising your shoulder; b) the same tilt of the head to the right; c) relax and repeat.

5) Lie face down on the floor, clasping your hands behind you. a) raise your head and chest from the floor as high as possible, stretching your neck and forehead forward. Hold this position until the count of 3, inhaling; b). exhale and return to the starting position.

6) Lie on the floor on your back with your arms out to the sides. Place a small pillow under your back between your shoulder blades. a) inhale slowly and raise your arms up and forward above your head; b) exhale and lower your arms to the sides.

In differential diagnosis, as in treatment, cervical traction, therapeutic massage, acupuncture, manual therapy, physiotherapy (galvanic collar, hydromassage, amplipulse, magnetic therapy) can be used.

Indications for surgery:

1. Unbearable pain requiring the use of drugs.

2. Vascular problems:
arterial (aneurysm, embolism)
venous (chronic venous insufficiency)

An absolute indication for surgery is when there is an additional cervical rib that causes symptoms of compression.

If a patient's compression aperture syndrome manifests itself mainly as neurological symptoms, then at the first stage of treatment it is recommended to do minimal decompression by resection of the anterior scalene muscle (scalenotomy). In this case, one cannot limit oneself to only its intersection, since its subsequent fusion with the nerve bundle is possible. At least 2 cm of muscle should be excised.

If there is an additional cervical rib, it is removed using a supraclavicular surgical approach. The entire rib is removed down to the transverse process of the vertebra.

When removing 1 rib, a transaxillary surgical approach is used. The incision is localized along the lower border of hair growth in the armpit. The sensitive intercostobrachial nerve is retracted on a holder. The long thoracic (motor) nerve must be spared, otherwise denervation of the serratus muscle will lead to loss of scapular function. Subperiosteal rib removal is recommended. The rib is resected to the transverse process of the vertebra (which is difficult to do) or to the place where it presses on the nerve.

If the artery is compressed by an additional or 1 rib, they are removed. If the artery is only ectatic in the poststenotic section, then intervention is not required. In case of aneurysm - resection of the aneurysm and artery replacement.

When compression of the subclavian vein leads to thrombosis (Paget-Schroetter syndrome), the best results are achieved by conservative therapy (heparinization, antiplatelet agents). For intermittent swelling of the arm - intersection of the coracothoracic ligament, scalenotomy, removal of 1 rib.

Radial nerve comes to the posterior surface of the shoulder from the anterior fascial bed through the gap between the long and lateral heads of the triceps muscle. Further, it is located in the brachial muscular canal, canalis humeromuscularis, which spirals around the humerus in its middle third. One wall of the canal is formed by bone, the other by the lateral head of the triceps muscle (Fig. 3.18).

In the middle third of the shoulder canalis humeromuscularis radial nerve is adjacent directly to the bone, which explains the occurrence of paresis or paralysis after applying a hemostatic tourniquet to the middle of the shoulder for a long time or in cases of damage to it due to fractures of the diaphysis of the humerus.

Together the deep brachial artery goes with the nerve, a. profunda brachii, which soon after its onset gives off the ramus deltoi-deus, which is important for collateral circulation between the areas of the shoulder girdle and shoulder, anastomosing with the deltoid branch of the thoracoacromial artery and with the arteries around the humerus. In the middle third of the shoulder a. profunda brachii is divided into two terminal branches: a. collateralis radialis and a. collateralis media. Radial nerve together with a. collateralis radialis at the border of the middle and lower third of the region pierces the lateral intermuscular septum and returns to the anterior bed of the shoulder, and then to the anterior ulnar region. There the artery anastomoses with a. recurrent radialis. A. collateralis media anastomoses with a. interossea recurrences.

In the lower third of the shoulder in the posterior fascial bed The ulnar nerve passes from a. collateralis ulnaris superior. Next they are directed to the posterior elbow area.

Connection of the tissue of the posterior region of the shoulder with neighboring areas

1. Along the radial nerve proximally the fiber is connected with the fiber of the anterior fascial bed of the shoulder.

2. Distally- with fiber of the ulnar fossa.

3. Along the long head of the triceps brachii muscle it is associated with the fiber of the axillary fossa.

Educational video of the anatomy of the axillary, brachial arteries and their branches