局部解剖学（上肢）

局部解剖学regional anatomy,河北医科大学 基础课教学部 解剖组胚教研室 张边江,背部,一、上肢概述,上肢的境界与分区,与颈部的界线1. 锁骨上缘外1/32. 肩峰至第7颈椎棘突连线的外1/3与胸、背区的界线1. 三角肌前、后缘上份2. 腋前、后襞下缘中点的连线,表面解剖：喙突、肩峰、肱骨大结节、肱骨外上髁、三角肌粗隆、肱骨内上髁、桡骨头、桡骨茎突、尺骨头、尺骨茎突、剑突、颈静脉切迹、胸骨角、肋弓,表面解剖,表面解剖,肘后三角,B尺骨鹰嘴,C,A,B,C,A,B,A肱骨内上髁,C肱骨内上髁,肘外侧三角,肱骨外上髁,桡骨头,尺骨鹰嘴,肘外侧三角,肘 畸 形,上肢动脉与神经干的投影,肘前横纹中点远侧2cm,二、上肢浅层结构Superficial structures of upper limb,浅静脉 Superficial vein手背静脉网（弓） Dorsal venous network(arch)头静脉 Cephalic vein贵要静脉 Basilic vein肘正中静脉 Median cubital vein皮神经 Cutaneous nerve前臂外侧皮神经 Lateral antebrachial nerve前臂内侧皮神经 Medial antebrachial nerve,前臂后区和肘后区浅静脉和皮神经,前臂前区和肘前区浅静脉和皮神经,臂前区和肘前区浅静脉和皮神经,肘窝内浅静脉的类型,上肢淋巴管和淋巴结,浅淋巴管肘淋巴结锁骨下淋巴结腋淋巴结,三、腋 区Axillary Region,腋区的位置腋窝的概念,腋窝的一顶、一底、四壁,Axillary fossa 腋窝,The axillary fossa is a pyramid-shaped space through which major neurovascular structures pass between the thorax and upper extremity,腋窝的底：由皮肤、浅筋膜和腋筋膜构成。 Base of the axilla is formed by the skin, subcutaneous tissue and axillary fascia.腋窝的前璧：由胸大肌、胸小肌锁骨下肌和锁胸筋膜构成。 Anterior wall of the axilla is formed by the pectoralis major, subclavius, clavipectoral fascia, pectoralis minor and suspensory ligament of axilla.腋窝的后璧：由大圆肌、背阔肌、肩胛下肌和肩胛骨构成。 Posterior wall of the axilla is formed by the scapula , the subscapularis, the teres major and latissimus dorsi.,腋窝的后璧： 由大圆肌、背阔肌、肩胛下肌和肩胛骨构成。 Posterior wall of the axilla is formed by the scapula , the subscapularis, the teres major and latissimus dorsi.,腋窝的外侧璧： 由肱骨结节间沟、肱二头肌长头、短头和喙肱肌构成。 Lateral wall of the axilla is the narrow bony wall formed by the intertubercular groove of the humerus，the two heads of biceps and the coracobrachialis.,腋窝的内侧壁：由前锯肌、上4为肋骨及肋间肌构成。 Medial wall of the axilla is formed by the thoracic wall(1st to 4th ribs and intercostal muscles)and the overlying serratus anterior.,腋窝的四壁Four Walls of the Axilla,腋窝的顶：是腋窝的上口，向上内通颈根部，由锁骨中1/3、第1肋外缘和肩胛骨上缘围成。 Apex of the axilla, the entrance from neck to axilla, lies between the 1st rib, the middle one-third of clavicle, and superior border of the scapula.,腋动脉 Axillary artery腋静脉 Axllary vein臂丛锁骨下部及其分支 Infraclavicular part of brachial plexus and its branches腋淋巴结 Axillary nodes脂肪和疏松结缔组织 Fat and loose areolar tissue,腋窝的内容Contents of axillary fossa,腋动脉的分段及其分支(1),Arteries of upper limb,Axillary artery Continuation of subclavian artery at lateral border of first ribBecomes brachial artery at lower border of teres majorDivided into three parts by overlying pectoralis minorFirst portion, above musclegives rise to thoracoacromial a. 胸肩峰动脉Second portion, behind musclegives rise to lateral thoracic a. 胸外侧动脉Third portion, below musclegives rise to subscapular a. 肩胛下动脉, anterior and posterior humeral circumflex a. 旋肱前、后动脉; the former then divides into throcodorsal a. 胸背动脉 and circumflex scapular a. 旋肩胛动脉,腋动脉的分段及其分支(2),肩胛动脉网,位于肩胛骨周围，由肩胛上动脉、肩胛背动脉、旋肩胛动脉等的分支彼此吻合成的动脉网，是肩部的重要侧支循环途径。腋动脉血流受阻或结扎时，可借此网维持上肢的血供。,臂丛锁骨下部及其毗邻,臂丛及其分支,臂丛及其分支,臂丛后束的分支与分布三边孔、四边孔的构成及其穿行的结构,The posterior wallteres major, latissimus dorsi, subscapularis and scapula Trilateral and quadrilateral foramina 三边孔和四边孔Between the subscapularis and teres major, there is a long triangular space whose lateral side is surgical neck of humerus. The long head of triceps brachii subdivides this space into a medial trilateral foramen and a lateral quadrilateral foramen.The posterior humeral circumflex a. and axillary n. pass through the quadrilateral foramen. The circumflex scapular a. passes through the triangular space to reach the dorsum of the scapula.,旋肱前动脉、旋肱后动脉、腋神经,肋间臂神经Intercostobrachial nerve腋静脉 Axillary vein胸外侧动脉和静脉 Lateral thoracic artery and vein胸腹璧静脉 Thoracoepigastric vein,腋淋巴结 axillary lymph node: 位于腋窝疏松结缔组织内，沿血管排列，分5群。,1.胸肌淋巴结pectoral lymph node2.外侧淋巴结 lateral lymph node,3.肩胛下淋巴结 subscapular lymph node4.中央淋巴结 central lymph node,5.尖淋巴结 apical lymph node:收集上述4群淋巴结和锁骨下淋巴结的输出淋巴管，其输出淋巴管合成锁骨下干，分别注入胸导管和右淋巴导管。,腋 鞘Axillary Sheath,腋鞘为包裹包绕腋动脉、腋静脉和臂丛周围的结缔组织膜，向上与颈部椎前筋膜相延续，亦称颈腋管。,又称肩袖，为冈上肌、冈下肌、小圆肌和肩胛下肌的肌腱，在肩关节囊周围连成腱板，围绕肩关节的上、后、前方，对肩关节起稳定作用。当肩关节脱位或扭伤时，可伴有肌腱袖的撕裂。,肌腱袖Myotendinous Cuff,皮肤切口,四、臂前区Anterior Region of Arm,浅层结构 Superficial structures深层结构 Deep structures,（一）浅层结构：皮肤,皮肤：较薄。浅筋膜：薄而松弛，内有浅静脉和皮神经。,（一）浅层结构,臂筋膜brachial fascia, 骨筋膜鞘及其内容 osseofibrous sheath and its contents,臂肌,喙肱肌肱二头肌肱肌,血管神经束Neurovascular Bundle,肱动脉及其分支。 Brachial artery and its branches. 肱静脉及其属支，贵要静脉。Brachial vein and its tributaries, basilic vein.正中神经 Median nerve尺神经和尺侧上副动脉。Ulnar nerve and superior ulnar collateral artery.桡神经和肱深动脉。 Radial nerve and deep brachial artery.肌皮神经Musculocutaneous nerve前臂外侧皮神经 Lateral antebrachial cutaneous nerve,神经分布： *臂外侧上皮神经腋神经分支 *臂外侧下皮神经 *臂后皮神经 桡神经分支 *前臂后皮神经,臂后区浅层结构,臂后区深层结构,肱骨肌管 组成：肱三头肌的内、外头和 长头与肱骨的桡神经沟 形成的管道。 内容：桡神经和肱深血管。,肘窝,肘窝,腱膜的游离上缘 与肱二头肌腱的交角,测量血压的听诊部位,前臂筋膜 Antebrachial Fascia 骨筋膜鞘及其内容 Osseofibrous Sheath and its Contents,前臂前群肌 Muscles of the front of the forearm,前臂前区的血管神经束,前臂血管和神经,桡血管神经束尺血管神经束正中血管神经束骨间前血管神经束,前臂后区,位置：尺骨、桡骨和前臂骨间膜的后方 内容：前臂伸肌群、血管、神经,前臂层次,浅层结构,浅筋膜 血 管 头静脉 贵要静脉 神 经 前臂后皮神经 前臂内、外侧皮神经,深筋膜,近侧肱三头肌腱膜增厚 远侧伸肌支持带,浅层（ 5块 ）桡侧腕长伸肌桡侧腕短伸肌指伸肌小指伸肌尺侧腕伸肌,肌,深层（ 5块）旋后肌拇长展肌拇短伸肌拇长伸肌示指伸肌,骨间后血管神经束,桡神经深支骨间后神经 骨间后动脉（静脉）,血管神经束,旋前圆肌 与血管神经的关系,旋前圆肌的浅面，有桡神经和桡动、静脉跨过。旋前圆肌的深面，有尺动、静脉通过。旋前圆肌的中间，有正中神经穿过。,指浅屈肌与血管神经的关系,指浅屈肌的外缘有桡血管神经束，该血管神经束的上、下处血管与神经分开，中合并，即呈形伴行关系。指浅屈肌的内缘有尺血管神经束，该血管神经束的上处血管与神经分开；而下处血管与神经合并伴行，即呈形伴行关系。指浅屈肌的深面为正中血管神经束和骨间前血管神经束，二者间隔拇长屈肌和指深屈肌。,局部解剖学,手部的局部解剖与操作,一、手部的表面解剖,局部解剖学,手 休 息 时的正常姿势,皮肤和浅筋膜,手掌深筋膜,屈指肌腱和蚓状肌,手掌筋膜间隙,手掌侧腱滑液鞘,指端结构特点,下肢局解,上肢 手休息时的正常姿势,手休息时正常姿势即手的“休息位”，手指、桡腕关节的屈、伸和拇指的外展、内收等肌力均处于平衡和稳定状态。表现为腕关节背伸30，25指呈半握拳状态，拇指外展，其指尖接近示指的远侧指间关节。,三条腕横纹：腕近侧纹、腕中纹、腕远侧纹三条肌腱隆起：桡侧腕屈肌腱、掌长肌腱、尺侧腕屈肌腱,桡动脉Radial artery(1), 正中神经median nerve(2), 尺动脉ulnar artery(4), 尺神经ulnar nerve(3),解剖学“鼻烟壶” anatomical snuff box,位置：位于手背外侧部的浅凹。境界：桡侧界为拇长展肌腱(1)和拇短伸肌腱(2)；尺侧界