The axillary cavity of its walls. Topography of the upper limb

Part I. TOPOGRAPHY OF THE UPPER LIMB

1. Axillary cavity

1.1. Axillary location

Axillary fossa is the depression between the lateral surface chest And top shoulder, which opens when it is abducted (Fig. 1). The axillary fossa is limited:

anterior skin fold covering the edge of the large chest muscle;
posterior skin fold covering the latissimus dorsi muscle.

^ Rice. 1. Skin relief of the armpit:

1 - axillary fossa, 2 - edge of the pectoralis major muscle, 3 - edge latissimus dorsi;

axillary cavity, cavum axillare – this is an intermuscular space that opens after removal of the skin, fascia and fatty tissue from the axillary fossa (Fig. 2). The cavity has a pyramidal shape and it contains:

four walls: anterior, posterior, medial and lateral;
two holes: upper aperture and lower aperture

Rice. 2. Axillary cavity (A), its upper (B) and lower (C) apertures (highlighted in black and white dotted line). Front view.

1 - anterior serratus muscle (medial wall of the axillary cavity), 2 - pectoralis major muscle (cut off), 3 - collarbone, 4 - pectoralis minor muscle (cut off), 5 - subscapularis muscle (back wall of the axillary cavity), 6 - beak shoulder muscle, 7 – biceps shoulder (both muscles form the lateral wall of the cavity), 8 - triceps shoulder, 9 - latissimus dorsi

Inferior axillary aperture limited:

in front - the edge of the pectoralis major muscle;
behind - the edge of the latissimus dorsi muscle;
medially - a conditional line connecting the edges of the pectoralis major and latissimus dorsi muscles along the line of the III rib;
laterally - the beak-shoulder muscle and humerus;
below - closed by axillary fascia

Superior aperture of the axillary cavity limited:

below - 1st rib;
above - the collarbone;
behind - the upper edge of the scapula.

Vessels and nerves pass through the upper aperture into the armpit: axillary artery and vein and trunks brachial plexus.

^ 1.2. Axillary wall

The medial wall is formed:

serratus anterior muscle

The lateral wall is formed:

beak-shoulder muscle
biceps brachii;

The back wall is formed:

latissimus dorsi;
large round muscle;
subscapularis muscle;

front wall(See Figure 3 for a sagittal section through the outer third of the clavicle) formed:

pectoralis major muscle
pectoralis minor,
deep sheet of the thoracic fascia.

Rice. 3. Sagittal section of the axillary cavity

A - anterior wall of the cavity, B - posterior wall

1 - clavicle, 2 - clavicular-thoracic fascia, 3 - pectoralis minor muscle, 4 - pectoralis major muscle, 5 - axillary fascia, 6 - latissimus dorsi muscle, 7 - teres major muscle, 8 - teres minor muscle, 9 - infraspinatus muscle , 10 - subscapularis muscle, 11 - supraspinatus muscle, 12 - neurovascular bundle of the armpit, 13 - trapezius muscle

^ 1.3. SEPARATE TOPOGRAPHANATOMICAL FORMATIONS ON THE WALLS OF THE AXILLARY CAVITY

On the anterior wall of the axillary cavity three triangles are distinguished that are related to the topography of blood vessels and nerves: the clavicular-thoracic, thoracic and inframammary triangles (Fig. 4).

These triangles are limited:

A. Clavicular-thoracic triangle:

Top - clavicle
From below - the upper edge of the pectoralis minor muscle;

B. Thoracic triangle:

From above - the upper edge of the pectoralis minor muscle
From below - the lower edge of the pectoralis minor muscle (corresponds to the contours of this muscle);

IN . Breast triangle:

Above - the lower edge of the pectoralis minor muscle
From below - the lower edge of the pectoralis major muscle.

Rice. 4. Triangles of the anterior wall of the armpit. A - clavicular-thoracic triangle, B - thoracic triangle, C - thoracic triangle

1 - pectoralis major (opened), 2 - collarbone, 3 - pectoralis minor

^ On the posterior wall of the armpit two openings are formed through which the vessels and nerves also exit. These are three-sided and four-sided holes (Fig. 6):

^ T
Rice. 5. Holes in the posterior wall of the armpit. A - three-sided hole, B - four-sided hole

1 - infraspinatus muscle, 2 - small round muscle, 3 - head of the humerus, 4 - surgical neck of the humerus, 5 - long head of the triceps muscle of the shoulder, 6 - large round muscle
the three-sided hole (A) is limited:

Above - the edge of the small round muscle
From below - the edge of the large round muscle;
Laterally - the long head of the triceps muscle of the shoulder;

The four-sided hole (B) is limited to:

Medially - the long head of the triceps muscle of the shoulder;
Lateral - surgical neck of the humerus;
Above - the edge of the small round muscle;
From below - the edge of the large round muscle

^ 2. FUROWS AND CHANNELS OF THE SHOULDER AREA

2.1. MEDIAL SHOULDER sulcus

M edial sulcus of the shoulder, sulcus bicipitalis medialis (Fig. 6), is located on the medial surface of the shoulder, starting from the lower border of the axillary cavity and ending in the cubital fossa.

The medial groove of the shoulder is limited:

Front - the biceps of the shoulder;
Behind - the triceps muscle of the shoulder;
On the lateral side - the beak-shoulder and shoulder muscles.

Rice. 6. Medial groove of the shoulder (highlighted in black and white dotted line).

A - medial groove of the shoulder, B - axillary cavity, C - cubital fossa.

1 - biceps muscle of the shoulder, 2 - coracobrachial muscle, 3 - tripartite opening, 4 - lower border of the axillary cavity, 5 - triceps muscle of the shoulder (long head), 6 - medial head of the same muscle, 7 - shoulder muscle

^ 2.2. SHOULDER CANAL

P lechemuscular canal (radial nerve canal), canalis humeromuscularis, located in the back of the shoulder, bypassing the humerus in a spiral. This channel has: an inlet, walls and an outlet (Fig. 7).

^ Channel inlet formed between the inner edges of the medial and lateral heads of the triceps brachii muscle ;

Outlet located in the lateral intermuscular septum of the shoulder, between the shoulder muscle and the initial section of the brachioradialis muscle.

Channel walls are formed:

groove of the radial nerve on the diaphysis of the humerus;
lateral head of the triceps muscle of the shoulder;
medial head of the triceps brachii.

Rice. 7. Shoulder canal with open walls (highlighted by a dotted line)

1 - long head of the triceps muscle of the shoulder, 2 - medial head, 3 - lateral head (cut and turned away), 4 - inlet of the brachial canal, 5 - brachial canal and its neurovascular bundle, 6 - outlet of the canal, 7 - medial intermuscular septum, 8 - brachioradialis muscle

Additionally, the location of the medial sulcus of the shoulder and the brachio-muscular canal can be seen in Figures 8 and 9.

^ Rice. 8. Location of the medial sulcus of the shoulder (the bottom of the sulcus is indicated by a dotted line) and the neurovascular bundle in it. Inside view.

1 - the bottom of the medial groove of the shoulder, 2 - the biceps muscle of the shoulder, 3 - the beak-shoulder muscle, 4 - the heads of the triceps muscle of the shoulder, 5 - vessels and nerves

^ Rice. 9. Horizontal cut through the middle third of the shoulder. The medial sulcus and the brachio-muscular canal are highlighted with dark shading.

1 - medial groove of the shoulder and the vessels and nerves lying in it; 2 - biceps muscle of the shoulder, 3 - shoulder muscle, 4 - triceps muscle of the shoulder, 5 - brachial canal

cubital fossa, fossa cubitalis, located in front of elbow joint and is limited to three muscles (Fig. 10):

from above - the shoulder muscle;
medially - a round pronator.

1 - biceps muscle of the shoulder, 2 - brachioradialis muscle, 3 - brachialis muscle, 4 - round pronator

^ If cut tendon of the biceps muscle of the shoulder and the round pronator, and then push the muscles apart, then two furrows are found along the edges of the cubital fossa: the medial ulnar sulcus and the lateral ulnar sulcus (Fig. 11).

^ Medial ulnar sulcus , which is a continuation of the medial groove of the shoulder, is limited:

medially - round pronator and medial epicondyle of the shoulder;
laterally - the shoulder muscle;

Lateral ulnar groove, which is, as it were, a continuation of the brachio-muscular canal (in this groove lies the radial nerve emerging from the canal), is limited:

Rice. 11. Furrows of the cubital fossa (marked with a white dotted line). A - lateral ulnar sulcus, B - medial ulnar sulcus.

1 - biceps muscle of the shoulder, 2 - shoulder muscle, 3 - brachioradialis muscle, 4 - supinator muscle, 5 - medial groove of the shoulder and its contents, 6 - round pronator (cut off), 7 - medial epicondyle of the shoulder, 8 - superficial flexor of the fingers

^ 4. MUSCLE GROOMS OF THE FOREARM

In the anterior region of the forearm, three intermuscular sulci are distinguished, which are also important for describing the topography of blood vessels and nerves: the radial sulcus, the median sulcus, and the ulnar sulcus (Fig. 12).

Radial sulcus, sulcus radialis, limited to:

laterally - brachioradialis muscle;
medially - radial flexor of the wrist;

Median sulcus, sulcus medianus, limited to:

laterally - radial flexor of the wrist;
medially - superficial flexor of the fingers;

Ulnar furrow, sulcus ulnaris, limited to:

laterally - superficial flexor of the fingers;
medial - ulnar flexor of the wrist

Rice. 12. Furrows of the anterior surface of the forearm. A - radial sulcus, B - median sulcus, C - ulnar sulcus (marked with dark fill).

1 - ulnar fossa, 2 - brachioradialis muscle, 3 - pronator round, 4 - radial flexor of the wrist, 5 - long palmar muscle, 6 - superficial flexor of the fingers, 7 - ulnar flexor of the wrist

^ 5. TOPOGRAPHANATOMICAL ELEMENTS OF THE HAND

5.1. ANATOMICAL SNUFF BOX

T what is the name of the triangular depression located between the styloid process of the radius and the base of the 1st metacarpal bone (see Fig. 13). It got its name from the fact that snuff was poured into this place before pulling it into the nose.

The anatomical snuffbox is limited by the tendons of the short (2) and long (4) extensor thumb and tendon retainer (7).

^ Rice. 13. Anatomical snuffbox (highlighted by a dotted line)

1 - base of the I metacarpal bone, 2 - tendon of the short extensor of the thumb, 3 - radial artery at the bottom of the snuffbox, 4 - tendon of the long extensor of the thumb, 5 - interosseous muscles, 6 - superficial branch of the radial nerve, 7 - extensor retinaculum

^ 5.2. WRIST CHANNEL

carpal tunnel(Fig. 14) serves to pass the flexor tendons of the fingers to the hand. It forms over palmar surface carpal bones and is limited to:

from the inside - the bones of the wrist;
outside - the retainer of the flexor tendons;
laterally - tubercles of the scaphoid and trapezoid bones;
medially - hook of hamate bone

Rice. 14. Carpal tunnel. Horizontal cut at the level of the trapezoid bone

1 - flexor tendon retinaculum, 2 - common synovial sheath of the flexor tendons of the fingers, 3 - tendons of the superficial flexor of the fingers, 4 - tendons of the deep flexor of the fingers, 5 - tendon of the long flexor of the thumb, 6 - tendon radial flexor wrists, 7 - trapezoid bone, 8 - extensor tendons of the fingers, 9 - hooked bone, 10 - tendon of the ulnar flexor of the wrist

^ 5.3. PALMAR APONEUROSIS AND CELLULAR SPACES OF THE PALM

The palmar aponeurosis (Fig. 15) is a thickened own fascia of the hand, which has acquired a tendon structure to strengthen the skin of the palm. It has the shape of a triangle, the apex of which is in the region of the flexor tendon retinaculum (where the long tendon is woven into it). palmar muscle), and the base is facing the fingers. The aponeurosis is formed by longitudinal and transverse fibers.

Longitudinal fibers are combined into 4 bundles, heading to the bases of the II - V fingers. There are transverse bundles in the distal aponeurosis. Between the longitudinal and

^ Rice. 15. Palmar aponeurosis (A).

1 - muscles of the elevation of the little finger, 2 - muscles of the elevation of the thumb, 3 - longitudinal bundles of the palmar aponeurosis, 4 - transverse bundles, 5 - commissural openings

transverse bundles form commissural openings. These holes are filled with adipose tissue, protruding under the skin in the form of pads. Through these openings, the inflammatory process can spread to the deep cellular spaces of the hand.

From the palmar aponeurosis, two fascial septa extend inward - lateral and medial.

^ Lateral intermuscular septum attached to the III metacarpal bone;
Medial intermuscular septum attached to the fifth metacarpal bone.

These partitions divide the inner space of the palm into three fascial beds: lateral, median and medial (Fig. 16).

The medial bed (hypothenar bed) is limited:

own fascia of the palm;
V metacarpal bone;
medial intermuscular septum

The lateral bed (thenar bed) is limited to:

own fascia of the palm;
deep fascia and II metacarpal bone;
lateral intermuscular septum;

The middle bed is limited:

outside - palmar aponeurosis;
from the inside - deep fascia of the palm;
laterally - lateral intermuscular septum;
medially - medial intermuscular septum.

In the middle bed of the palm are the tendons of the flexors of the fingers and the worm-like muscles. These structures divide the bed into two cellular fissures: superficial (subaponeurotic) and deep (subtendonous).

The superficial gap of the median bed of the palm is limited:

Outside - palmar aponeurosis;
From the inside - the tendons of the flexors of the fingers;

Deep gap limited:

Outside - the tendons of the flexors of the fingers and the worm-like muscles;
From the inside - deep palmar fascia covering the metacarpal bones and interosseous muscles

Rice. 16. Cellular spaces of the palm. Horizontal cut.

A - medial fascial bed (space of the hypothenar);

B - median fascial bed:

8 - superficial cellular gap of the median fascial bed (highlighted by round dots),

^ 15 - deep cellular gap of the median fascial bed (highlighted by dotted fill);

B - lateral fascial bed (thenar space).

1 - medial intermuscular septum, 2 - lateral intermuscular septum, 3 - tendons of the superficial and deep flexors of the fingers to the little finger (in the synovial sheath), 4 - worm-like muscles, 5 - flexor tendons to the IV finger, 6 - palmar aponeurosis, 7 - flexor tendons to the III finger; 9 - flexor tendons to the second finger; 10 - tendon of the long flexor of the first finger in the synovial sheath, 11 - muscles of the elevation of the thumb, 12 - metacarpal bones, 13 - interosseous muscles, 14 - extensor tendons of the fingers, 16 - deep palmar fascia.

^ 5.4. SYNOVIAL VAGINA OF FINGER FLEXOR TENDONS

Synovial sheaths are an auxiliary apparatus of muscles and are designed to eliminate friction where the tendons pass through narrow bone-fibrous channels. They are closed bags formed by two synovial layers wrapped around the tendons (Fig. 17).

P
Of practical importance is the knowledge of the topography of the synovial sheaths of the flexors of the fingers, since they can get an infection penetrating through microtraumas of the hand. When an infection enters the vagina, a purulent-inflammatory process develops in its cavity, spreading over its entire length and capable of breaking further into the deep cellular spaces of the palm and forearm.

The following synovial sheaths are isolated on the hand (Fig. 18):

^ Common flexor sheath , located in the carpal tunnel and surrounding the tendons of the superficial and deep flexors of the fingers. The proximal wall of this sheath faces the deep cellular space of the forearm, and the distal wall faces the median fascial bed;
^ Vagina of flexor thumb longus , also continuing to the forearm. In a certain percentage of cases, it communicates with the common flexor sheath;
Tendon sheaths II - IV fingers. These sheaths are isolated, extending only to the length of the fingers. The proximal walls of these sheaths border on the median fascial bed;
Tendon sheath of the fifth finger. This sheath almost always communicates with the common flexor sheath.

T Thus, as follows from a consideration of the anatomy of the vaginas, the most dangerous is the inflammatory lesion of the vaginas of the I and V fingers, because through these vaginas the infection can easily spread to the deep cellular spaces not only of the palm, but also of the forearm.

^ Rice. 18. Synovial sheaths of the flexor tendons of the fingers.

1 - tendon of the deep flexor of the fingers, 2 - tendon of the superficial flexor of the fingers, 3 - flexor retinaculum, 4 - common synovial sheath of the flexors, 5 - sheath of the fifth finger, 6 - sheath of the long flexor of the first finger, 7 - sheaths of the II - IV fingers, 8 - muscles of the elevation of the first finger, 9 - muscles of the elevation of the little finger

Part II. TOPOGRAPHY OF THE LOWER LIMB

^ 1. FEMORAL TRIANGLE

femoral triangle, trigonum femorale, formed in the upper third of the thigh on its anterior surface (Fig. 19). It is limited the following structures:

Above - inguinal ligament;
Laterally - tailor muscle;
Medially - a long adductor muscle.

Rice. 19. Borders of the femoral triangle (highlighted by a dotted line) and subcutaneous cleft (skin and subcutaneous tissue removed up to the fascia lata)

1 - inguinal ligament, 2 - fascia lata, 3 - falciform margin of the fascia lata, 4 - superior horn of the falciform margin, 5 - subcutaneous fissure closed by perforated fascia, 6 - spermatic cord, 7 - adductor longus muscle, 8 - inferior horn of the falciform margin , 9 - tailor muscle

Within the femoral triangle, the own fascia of the thigh (fascia lata) forms an opening closed by a loose connective tissue plate - subcutaneous fissure, hiatus saphenus. This cleft on the lateral side is limited by a thickened edge of the fascia lata - a crescent-shaped edge that has an arched shape. Above, under the inguinal ligament, the sickle-shaped edge forms the upper horn, and below, above the tailor's muscle, the lower horn.

If we consider the region of the femoral triangle after removal of the fascia lata and dissection of the muscles, then the following is found (Fig. 20):

^ Rice. 20. Area of the femoral triangle (highlighted by a dotted line) after muscle preparation.

1 - inguinal ligament, 2 - long adductor muscle, 3 - sartorius muscle, 4 - comb muscle, 5 - iliopectineal groove, 6 - iliopsoas muscle

^ Bottom of the femoral triangle form two muscles:

iliopsoas muscle
comb muscle, covered with a deep sheet of the wide fascia of the thigh - iliac-comb fascia.

Between these muscles is formed iliopectineal groove, continuing downwards into the femoral groove.

In the upper part of the triangle, under the inguinal ligament, two spaces are formed - muscular and vascular lacunae (Fig. 21).

^ Rice. 21. Vascular (A) and muscular (B) lacunae

1 - inguinal ligament, 2 - iliopectineal arch, 3 - femoral artery, 4 - femoral vein, 5 - deep femoral ring, 6 - lacunar ligament, 7 - pectinate fascia, 8 - pectineus muscle, 9 - iliopsoas muscle, 10 - femoral nerve

Vascular lacuna(A) limited:

from above - inguinal ligament;
from below - iliopectineal fascia;
Laterally - iliopectineal arch;
medially - lacunar ligament.

muscle gap(B) limited:

laterally and from below - the ilium;
from above - inguinal ligament;
medially - iliopectineal arch

Through the muscle gap, the iliopsoas muscle and the femoral nerve exit to the thigh, through the vascular gap - the femoral vessels (artery and vein).

In the medial corner of the vascular lacuna, one of the weak points of the abdominal wall is formed - deep femoral ring. This ring (Fig. 21, 22) is limited to:

from above - inguinal ligament;
laterally - femoral vein;
medially - lacunar ligament;
from below - by the pectinate ligament (thickening of the iliopectineal fascia).

Fine this ring is closed by the transverse fascia and lymph nodes, but under certain conditions, femoral hernias can come out through it. In this case, the hernial sac, going to the thigh, forms a new structure that does not exist in the norm - femoral canal(Fig. 23). Its walls are:

From the inside - iliopectineal fascia;
Laterally - femoral vein;
Anteriorly, the inguinal ligament and superior horn of the falciform margin of the fascia lata.

The subcutaneous fissure becomes the external opening of the femoral canal. Therefore, when examining a patient with acute abdominal pain, it is imperative to examine the area of the femoral triangle so as not to miss a strangulated femoral hernia.

^ Rice. 22. Deep femoral ring (dotted line). Inside view

1 - inguinal ligament, 2 - lacunar ligament, 3 - pubic bone, 4 - femoral vein, 5 - vas deferens, 6 - deep femoral ring

Rice. 23. Femoral canal (highlighted by dotted line)

1 - inguinal ligament (dissected), 2 - superior horn of the falciform fascia lata (dissected), 3 - iliopectineal fascia, 4 - inferior horn of the falciform fascia lata, 5 - femoral vein, 6 - spermatic cord, 7 - adductor cleft (external opening of the femoral canal; conventionally indicated by white dotted line)

^ 2. LEADING CHANNEL

P adductor canal, canalis adductorius, is a continuation of the femoral groove (Fig. 24) and connects the anterior region of the thigh with the popliteal fossa.

femoral furrow, which is a continuation of the iliopectineal groove of the femoral triangle (see Fig. 21), limited to:

Medially - long and large adductor muscles;
Laterally - the medial wide muscle of the thigh

Rice. 24. Femoral groove and adductor canal. The course of the adducting channel is marked with a white dotted line.

1 - femoral groove (highlighted by a dotted line), 2 - long adductor muscle, 3 - short adductor muscle, 3 - large adductor muscle, 4 - upper opening of the adductor canal, 5 - medial broad muscle, 6 - lamina vastoadductoria, 7 - anterior opening of the adductor canal, 8 - lower opening of the canal (adductor cleft), 9 - semimembranosus muscle

^ The inlet channel has three walls and three openings: inlet (upper), outlet (lower) and anterior. The walls of the adducting channel are:

Medially - a large adductor muscle;
Laterally - the medial wide muscle of the thigh (part of the quadriceps muscle);
In front - a fibrous plate (lamina vastoadductoria), which is thrown between these two muscles.

^ Top hole the canal continues the femoral groove;

front opening located in the fibrous plate;

bottom hole(see Fig. 25), which opens into the popliteal fossa, is located in adductor cleft- the gap between the bundles of the large adductor muscle, attached to the rough line and the bundle, attached to the medial epicondyle of the thigh

^ Rice. 25. Afferent cleft - the lower opening of the afferent canal (highlighted by a dotted line)

1 - large adductor muscle, 2 - semimembranosus muscle, 3 - semitendinosus muscle, 4 - tendon of the large adductor muscle, attached to the medial epicondyle of the thigh, 5 - medial epicondyle of the thigh, 6 - biceps femoris muscle (long head), 7 - short head of the biceps muscles, 8 - popliteal vessels, 9 - gastrocnemius muscle

^ 3. OBTAINING CHANNEL

obturator canal, canalis obturatorius, is formed in the wall of the small pelvis, at the upper edge of the obturator foramen.

Channel inlet located on the inner wall of the small pelvis (Fig. 26);

Channel walls are formed:

Obturator groove of the pubic bone;
The upper edge of the obturator internus muscle;
The upper edge of the external obturator muscle.

Outlet located in the region of the femoral triangle, between the comb and short adductor muscles (Fig. 27).

^ Rice. 26. Entrance opening of the obturator canal (highlighted by a dotted line).

1 - pubic bone, 2 - internal opening of the canal in the obturator fascia, 3 - pubic symphysis, 4 - obturator fascia covering the internal obturator muscle, 5 - piriformis muscle, 6 - muscle that lifts the anus

The obturator artery and nerve pass through the obturator canal. In rare cases, it can become a place for the formation of obturator hernias.

^ Rice. 27. Outlet of the obturator canal (highlighted with a white line and an arrow)

1 - iliopsoas muscle, 2 - pectineus muscle (opened), 3 - wide medial muscle, 4 - pubic bone, 5 - external obturator muscle, 6 - obturator nerve, 7 - short adductor muscle, 8 - long adductor muscle

^ 4. PEAR-SHAPED AND PEAR-SHAPED HOLES

E These holes are formed along the edges of the large sciatic foramen when the piriformis muscle passes through it (Fig. 28)

^ Rice. 28. Supra-pear-shaped (A) and sub-pear-shaped (B) holes (highlighted by a dotted line)

1 - piriformis muscle, 2 - sacrotuberous ligament, 3 - sacrospinous ligament, 4 - obturator internus muscle, 5 - gluteus medius muscle, 6 - gluteus minimus

Pear hole (A) limited to:

Upper edge of the piriformis muscle
The upper edge of the large sciatic foramen;

Sub-pear hole (B) limited to:

The lower edge of the piriformis muscle
Inferior edge of the greater sciatic foramen

^ 5. BED OF THE SCICIENT NERVE

WITH Strictly speaking, such an object in the nomenclature of topographic and anatomical formations lower limb Excluded. However, this cellular space should be allocated for orientation in the topography of the largest nerve. human body. It is located in the gluteal region and in the back of the thigh (Fig. 29).

In the gluteal region, the bed of the sciatic nerve is limited to:

Behind - the gluteus maximus muscle;
Front - pelvic muscles:

piriformis muscle
obturator internus muscle
quadratus femoris

Rice. 29. Bed of the sciatic nerve. The course of the nerve is indicated by a dotted line.

1 - gluteus maximus (opened), 2 - piriformis, 3 - obturator internus, 4 - quadratus femoris, 5 - ischial tuberosity, 6 - adductor magnus, 7 - vastus lateralis, 8 - short head of biceps femoris , 9 - long head of the biceps femoris muscle (cut off), 10 - semimembranosus muscle, 11 - semitendinosus muscle (cut off), 12 - popliteal fossa

In the posterior region of the thigh, the bed of the sciatic nerve is limited to:

In front - a large adductor muscle;
Medially - semimembranosus muscle;
Laterally - the biceps femoris muscle.

Below the bed of the sciatic nerve communicates with popliteal fossa.

^ 6. Popliteal fossa

Popliteal fossa, fossa poplitea, located posterior to knee joint, has the shape of a rhombus and is limited to the following structures:

Popliteal fossa reported:

Above - with the adductor canal (through the adductor fissure) and with the bed of the sciatic nerve;
Below - with the ankle-popliteal canal.

^ 7. ANCHOLOPELLETIC AND LOWER MUSCULAR-PERONEAL CANALS

Rice. 31. Projection of the course of the ankle-popliteal canal. The holes are marked with a dotted line.

1 - canal inlet, 2 - soleus muscle, 3 - gastrocnemius muscle (cut off), 4 - Achilles tendon, 5 - canal outlet
^ Rice. 32. Ankle-popliteal (A) and inferior musculoperoneal (B) canals (highlighted by dotted lines).

1 - soleus muscle (cut off), 2 - superior opening of the ankle-popliteal canal, 3 - long flexor of the fingers, 4 - posterior tibial muscle, 5 - long flexor of the thumb

^ Ankle-popliteal canal, canalis cruropopliteus (Fig. 31, 32), located in the back of the lower leg. It has front and rear walls, as well as three holes: top (inlet), front and bottom (outlet).

Top hole limited:

Front - popliteal muscle;
Behind - the tendon arch of the soleus muscle;

P front hole(Fig. 33): located in the interosseous membrane at the level of the head of the fibula;

bottom hole:

Located at the level of the beginning of the Achilles tendon;
It is represented by a gap between the tendon and deep muscles.

The channel walls are formed:

WITH
Rice. 33. Anterior opening of the ankle-popliteal canal
1 - anterior opening, 2 - popliteal muscle, 3 - head of the fibula, 4 - soleus muscle (cut off), 5 - posterior tibial muscle
anteriorly - by the tibialis posterior muscle and the long flexor of the thumb;
Behind - the soleus muscle.

Inferior musculoperoneal canal branches off from the ankle-popliteal canal and goes laterally - down. Channel walls are formed:

Front - fibula;
Behind - long flexor of the big toe.

^ 8. UPPER MUSCULAR-PERONEAL CANAL

The superior musculoperoneal canal is located on the lateral surface of the lower leg, bypassing the fibula in a spiral (Fig. 34):

^ Rice. 34. Projection of the course of the superior musculoperoneal canal (indicated by a dotted line).

A. side view:

1 - upper opening of the canal, 2 - head of the fibula, 3 - long peroneus muscle, 4 - lower opening of the canal, 5 - short peroneal muscle, 6 - anterior tibial muscle, 7 - long extensor of the fingers;

^ B. Front view:

1 - upper opening of the canal, 2 - long peroneal muscle, 3 - lower opening of the canal, 4 - short peroneal muscle, 5 - long extensor of the fingers, 6 - anterior tibial muscle.

The canal begins with an upper opening along the line of the beginning of the long peroneal muscle from the fibula (Fig. 35).

WITH channel shadows are formed:

From the inside - the lateral surface of the fibula;
Outside - a long peroneal muscle.

The lower opening of the canal is located between the long peroneal muscle and the long extensor of the fingers.

The superficial peroneal nerve passes through the canal.

Rice. 35. Superior opening of the superior musculoperoneal canal (highlighted with a white dotted line)

1 - head of the fibula, 2 - long peroneal muscle, 3 - opening of the canal, 4 - soleus muscle (cut off)

Four walls: anterior, posterior, medial and lateral;

Two holes: upper aperture and lower aperture

Inferior axillary aperture limited:

In front - the edge of the pectoralis major muscle;

Behind - the edge of the latissimus dorsi;

Medially - a conditional line connecting the edges of the pectoralis major and latissimus dorsi along the line of the III rib;

Laterally - by the beak-shoulder muscle and humerus;

Bottom - closes with axillary fascia

Superior aperture of the axillary cavity limited:

Bottom - 1st rib;

Above - the collarbone;

Behind - the upper edge of the shoulder blade.

Vessels and nerves pass through the upper aperture into the armpit: the axillary artery and vein and trunks of the brachial plexus.

Axillary wall

The medial wall is formed:

Serratus anterior muscle

The lateral wall is formed:

beak-shoulder muscle

biceps brachii;

The back wall is formed:

The latissimus dorsi muscle;

Large round muscle;

Subscapularis muscle;

front wall(See Figure 3 for a sagittal section through the outer third of the clavicle) formed:

pectoralis major muscle,

pectoralis minor muscle,

Deep sheet of the thoracic fascia.

SEPARATE TOPOGRAPHANATOMICAL FORMATIONS ON THE WALLS OF THE AXILLARY CAVITY

These triangles are limited:

A. Clavicular-thoracic triangle:

Top - clavicle

From below - the upper edge of the pectoralis minor muscle;

B. Thoracic triangle:

From above - the upper edge of the pectoralis minor muscle

From below - the lower edge of the pectoralis minor muscle (corresponds to the contours of this muscle);

B. Inframammary triangle:

Above - the lower edge of the pectoralis minor muscle

From below - the lower edge of the pectoralis major muscle.

On the posterior wall of the armpit two openings are formed through which the vessels and nerves also exit. These are three-sided and four-sided holes (Fig. 6).

The axillary region (Regio axillaris) has the following boundaries:

front border - lower edge m. Pectoralis majur;

back - lower edge m. latissimus dorsi, m. teres major;

internal - a line connecting the edges of the above muscles on the chest;

outer - a line connecting the same edges along the inner surface of the shoulder.

Layers. Skin (contains a large number of large sweat glands and sebaceous glands); superficial fascia is practically not expressed; own fascia (faxcia axillaris) - in the center of it, blood vessels and nerves perforate; a plate of the clavicular-sternal fascia, fiber of the armpit is fused with it. Next come the muscles that limit the axillary cavity.

Armpit walls:

anterior - pectoralis major and minor;

back - subclavian muscle;

latissimus dorsi;

large round muscle;

inner wall - the lateral part of the chest (up to 1 and ribs), m. serratus major;

external - medial surface of the humerus, m. coracobrachialis;

short head m. bireps.

Triangles are distinguished on the front wall: trigonum clavpectorale, pectorale, subpectorale.

In the back wall there is a medial and lateral opening. Medial opening (trilateral) - borameu brilaterim, limited from above mm. subscapularis et tcres minor. from below - a large round muscle, laterally - a long head m. triceps. A.v. pass through it. circumfleca scapulae.

Lateral foramen (quadrilateral)- foramen guadrilaterum, limited from above by mm. subscapularis et fores nunor, laterally surgical neck of the humerus. Pass through it - a. v. circumfexa hunuri postcrior, n. axillaris. The contents of the armpit: loose fatty tissue, lymph nodes, a. axillaris and its branches, v. axillaris and its tributaries, plexus brachialis and nerves extending from it, cutaneous branches of the II-III intercostal nerve.

Between m. subscapularis and m. serratus anterior is the prescapular (actescapular) fissure, which is a continuation of the armpit, it communicates with the subfascial space. Under the axillary fascia, there is a subfascial cell space (spatirim axillare subfaxiale). They are sublectural space, it is separated by places of the clavicular-thoracic fascia. A connective tissue plate is separated from the sheath of the neurovascular bundle, which, at the level of the II rib, is connected to the enterosternal fascia, forming a dome, as a result of which the sublectoral space closes.

Through the vessels and nerves passing through the tripartite and quadrilateral opening, a connection is made with the infraspinatus fossa of the scapula, the subdeltoid region is surrounded by fiber and its vagina, which is formed by splitting the posterior wall of the vagina m. coracobrachialis. At the top, this fiber reaches the collarbone, and below it passes into the fiber that accompanies the brachial vessels and their branches (connection with the tissue of the anterior and posterior region of the shoulder).

Borders (with the arm abducted): in front - the lower edge of the pectoralis major muscle; behind - the lower edge of the broad muscle of the back and the large round muscle; medially - a conditional line drawn on the chest between the indicated muscles in the place where they depart from the chest; laterally - a line connecting the same muscles on the medial surface of the shoulder.

The skin is thin, mobile, covered with hair, contains sweat, sebaceous and apocrine glands. In the subcutaneous tissue are small veins, arteries, lymphatic vessels and skin nerves.

The axillary fascia (fascia axillaris) is dense along the periphery and looser in the center due to small vessels and nerves passing through it, has a dome-shaped retraction due to the interweaving of the clavicular-thoracic fascia into it.

After removal of the fascia opens armpit, which, when the arm is abducted, is a tetrahedral pyramid with a base facing outward and downward, and a vertex directed upward and inward and located at the collarbone and I rib.

The walls of the armpit form: the anterior-large and small pectoral muscles and the clavicular-thoracic fascia; back - the subscapularis muscle, the broad muscle of the back and the large round muscle with fascia covering them; medial - serratus anterior muscle and side surface chest to the level of the IV rib; lateral - medial surfaces of the humerus, coracobrachial muscle and short head biceps brachii.

Three triangles are projected onto the anterior wall of the armpit: the superomedial - the clavicular-thoracic triangle (trigonum clavipectorale), located between the clavicle and the superomedial edge of the pectoralis minor muscle; the middle one is the pectoral triangle (trigonum res-torale), located behind the pectoralis minor muscle, and the externally lateral is the pectoral triangle (trigonum subpecto-rale), which lies between the inferolateral edges of the pectoralis major and minor muscles.

On the back wall armpit there are four-sided and three-sided openings that allow vessels and nerves to pass through. The quadrilateral foramen (foramen quadrilaterum) is located laterally and is bounded from above by the subscapularis and small round muscles, from below - by the large round muscle, from the lateral side - by the surgical neck of the humerus, with the medial - by the long head of the triceps muscle of the shoulder. Trilateral hole (foramen trilaterum) is located medially and somewhat lower from the first.

Rice. 13. The neurovascular bundle of the armpit, adjacent to the back of the subclavian region. Right view, front (1/2).
The same as in fig. 12. In addition, the pectoralis minor muscle, the clavicular-thoracic fascia and the fatty tissue of the armpit, which covers the front of the neurovascular bundle, were partially removed. The fasciae covering the serratus anterior, external oblique, and intercostal muscles have been removed. The vagina of the rectus abdominis was opened.

Rice. 14. Fiber and subcutaneous vessels of the axillary region. View from the right, from below (9/10).
The hand is moved to the side. Only the skin has been removed.

It is formed: from above - the subscapularis and small round muscles, from below - a large round muscle, from the lateral side - the long head of the triceps muscle of the shoulder.

The contents of the armpit are the neurovascular bundle, lymph nodes and fatty tissue.

The neurovascular bundle (axillary artery and vein and brachial plexus) penetrates into the armpit from the lateral region of the neck between the clavicle and the 1st rib. In the axillary region, the neurovascular bundle is located at the inner-posterior edge of the coracobrachial muscle and is projected onto the skin at the border of the anterior and middle thirds of the width of the axilla or at the level of the anterior margin of hair growth.
The topography of the neurovascular bundle is different at individual levels of the armpit. In the trigonum clavipectorale, below, medially and in front of the axillary artery, there is v. axillaris. Adjacent directly to the subclavian fascia (part of the clavicular-thoracic fascia), the wall of the vein is fixed to it and does not collapse when damaged, which can lead to a dangerous air embolism. Above and behind the axillary artery is the brachial plexus. Here departs from the axillary artery a. thoracica suprema, branching in the two upper intercostal spaces.

In trigonum pectorale below and more medially located axillary vein, above and lateral to it is the artery. The brachial plexus at this level is divided into three bundles: fasciculus lateralis - lies lateral and above the artery, fasciculus posterior - behind the artery and fasciculus medialis - medially and below the artery and behind the axillary vein. From the axillary artery here depart a. thoracoacromialis and a. thoracica lateralis. The first bends around the pectoralis minor muscle from the medial side and is divided into rr. clavicularis, pectorales, deltoideus, acromialis, which, having passed through the clavicular-thoracic fascia, supply blood to the pectoral, subclavian and deltoid muscles. The second goes down and forward along the anterior serratus muscle and supplies it with blood, the surrounding tissue and the mammary gland. Behind the lateral thoracic artery, n goes down along the surface of the anterior serratus muscle. thoracicus longus.

Rice. 15. Axillary fascia, subcutaneous vessels and nerves perforating the axillary fascia. View from the right, from below (9/10).
The same as in fig. 14. In addition, the subcutaneous fat is removed to the axillary fascia

In trigonum subpectorale below, more medially and most superficially located axillary vein. Above and lateral to it lies the axillary artery, in front of which is located n. medianus, lateral - n. musculocuta-neus, behind - n. radialis and axillaris and medially and below - pp. ulnaris, cutaneus antebrachii medialis and cutaneus brachii medialis. The axillary nerve, together with the posterior artery surrounding the shoulder, leaves the area through the quadrilateral foramen. Under the axillary fascia, approximately on the border of the middle and posterior third of the width of the base of the axilla, are located nn. intercostobrachiales, which are lateral branches of the II and often III intercostal nerves and, together with p. cutaneus brachii medialis, receive
participation in the innervation of the skin of the armpit and the medial surface of the shoulder.

Rice. 16. Vessels and nerves of the armpit and pectoral triangle. View from the right, from below (9/10).
The same as in fig. 15. In addition, the axillary fascia and fiber were removed, the neurovascular bundle was dissected

The axillary artery gives off here a large a. subscapularis, which soon divides into a. thoracodorsalis and a. circumflexa scapulae. The first of them with the nerve of the same name goes down and supplies the subscapularis, anterior serratus and large round muscles and the wide back muscle. The second through a tripartite hole penetrates into the scapular region. A. circumflexa humeri posterior departs from the axillary artery, goes back, located lateral to the axillary nerve, and together with it penetrates into the quadrilateral opening, and then goes around the surgical neck of the shoulder from behind, supplying the shoulder joint and deltoid muscle. A. circumflexa humeri anterior, also a branch of a. axillaris, wraps around the neck of the humerus in front.

Pa anterior surface of the subscapularis muscle located nn. subscapularis n thoracodorsalis, originating from the brachial plexus, and sometimes from n. axillaris. The first of them innervates the subscapularis and a large round muscle, the second - the broad muscle of the back.

Rice. 17. Vessels and nerves of the armpit, pectoral and thoracic triangles. View from the right, from below (9/10).
The same as in fig. 16. In addition, the pectoralis major muscle was dissected and retracted upwards and to the sides, the beak-brachial and pectoralis minor muscles were raised. The armpit veins have been removed.

Rice. 18. Vessels and nerves of the armpit, scapular and subclavian regions. Right, side and top view (3/8).
Kosha, subcutaneous tissue and own fascia were removed from the lateral region of the neck, deltoid, subclavian and scapular regions. The clavicle is dissected at the acromioclavicular joint and, with the muscles attached to it, is retracted anteriorly. The acromial process and the upper end of the humerus are removed, and the muscles attached to them are laid aside. Vessels and nerves were dissected.

Rice. 19. Options for dividing the axillary artery into branches.
1-a. axillaris; 2-a. circumllexa humeri anterior; 3-a. circumllexa humeri posterior; 4-rr. subscapulares; 5-a. thoracoacromialis; 6-r. deltoideus; 7-r. acromialis; 8-a. thoracica suprema; 9-rr. pectorales; 10-a. thoracica lateralis; 11-a. subscapularis; 12-a. thoracodorsalis; 13-a. circumflexa scapulae; 14-a. profunda brachii; 15-a. suprascapularis; 16-a. collateral is ulnaris superior; 17-a. transversa colli.

The lymph nodes in the armpit drain lymph from upper limb, from a significant part of the chest and from the superficial layers of the upper part of the anterior abdominal wall. The axillary nodes are located in loose fatty tissue and are separated from the neurovascular bundle by its vagina.

Among the nodi lymphatici axillares, there are five groups. In the middle of the base of the armpit there are 1-10 (average 3) nodi lymphatici axillares centrales. Some of these nodes may be located superficial to the axillary fascia under the subcutaneous tissue. The superficial lymphatic vessels of the upper limb, chest, back and mammary gland flow into the central nodes.

Rice. 20. View of the armpit, subclavian and scapular regions on the sagittal cut, made medial to the coracoid process of the scapula through the lateral edge of the II rib. View from the right, outside (1/1,1).

Lateral to the central nodes along the medial surface of the neurovascular bundle under the lower edge of the pectoralis major muscle lie 3-7 nodi lymphatici axillares laterales, which receive lymph from the upper limb. On the back wall of the armpit along the subscapular vessels are 2-12 nodi lymphatici axillares subscapulares. The lymphatic vessels of the scapular and subscapular regions flow into them, shoulder joint and part of the vessels of the back of the neck. On the medial and anterior walls of the armpit to the level of the upper edge of the pectoralis minor along a. thoracica lateralis lie from 5 to 19 nodi lymphatici axillares pectorales, which receive lymph from the mammary gland, pectoral muscles and from the integument of the anterolateral surface of the chest and upper abdomen. At the top of the armpit in the trigonum clavipectorale, respectively, the first and second intercostal spaces, along the neurovascular bundle lie 1-9 nodi lymphatici axillares apicales.
Lymph flows into these lymph nodes from all previous groups of nodes, as well as from the pectoralis major and minor muscles and the mammary gland. From the nodes of the armpit, lymph flows along the truncus subclavius. The last one on the left in half of the cases flows into the thoracic duct, and in the other half - independently into the left venous angle or left subclavian vein. On the right, in 4/5 of all cases, the subclavian trunk with one, rarely with two mouths independently flows into the veins of the right venous angle and in 1/5 cases merges with the jugular trunk, forming ductus lymphaticus dexter.

Rice. 21. View of the armpit, subclavian and scapular regions on a sagittal cut made through the coracoid process of the scapula. Right side view, outside.

Rice. 22. View of the armpit on the sagittal cut, made at the level of the shoulder joint with the arm somewhat laid aside. Right side view, outside.
The head of the humerus was removed from the articular capsule.

The spaces between the neurovascular bundle and the walls of the axillary fossa are filled with fiber. The latter can be the object of surgical interventions: firstly, it is removed along with the lymph nodes and vessels located in it during operations for breast cancer, and secondly, during operations for suppurative processes developing in it (phlegmon, adenophlegmon, abscesses and etc.). With wounds and injuries in the fiber of the armpit, hematomas can form. On the other hand, contacts of the axillary fiber with neighboring cellular spaces are of practical interest, since pus (blood) can spread to neighboring areas and form streaks.

The fiber of the armpit communicates widely with the tissue of neighboring areas both along the neurovascular bundles of the area and by direct transition to the tissue of neighboring areas. In the course of the axillary, and then the subclavian arteries and veins and the brachial plexus, the fiber of the armpit is connected with the fiber of the lateral region of the neck and the fiber of the prescalene and interscalene spaces. Down and laterally along the brachial vessels and the median and ulnar nerves, the fiber of the armpit is connected with the fiber of the anterior region of the shoulder, along the radial nerve and deep artery of the shoulder - with the fiber of the posterior region of the shoulder. Through the quadrilateral and trilateral openings located in the posterior wall of the armpit, along the posterior artery surrounding the shoulder, the axillary nerve and the artery surrounding the scapula, the fiber of the armpit is connected to the fiber of the subdeltoid space, rear surface scapular region and fiber lying under the broad muscle of the back. The fiber of the armpit at the back wall directly passes into the fiber located between the subscapularis muscle at the back and the serratus anterior muscle at the front. Along the branches a. thoracoacromialis, n. pectoralis medialis and v. cephalica, perforating the clavicular-thoracic fascia, the fiber of the apex of the armpit communicates with the fiber located under the pectoralis major muscle, as well as with the fiber located in the fascial sheaths of the pectoralis minor and major muscles.

The canal of the radial nerve.

radial nerve canal, or brachial canal,canalis nervous radialis, s. canalis humeromuscularis, located on the back surface of the shoulder, between the bone and the triceps muscle of the shoulder along the furrow of the radial nerve. The inlet (upper) opening of the canal is located on the medial side at the level of the border between the upper and middle thirds of the body of the humerus. It is limited to bone, lateral and medial heads triceps muscle of the shoulder.

The outlet (lower) of the canal is located on the lateral side of the shoulder, between the brachial and brachioradialis muscles, at the level of the border between the middle and lower thirds of the humerus. The radial nerve passes through this canal along with the deep arteries and veins of the shoulder.

In the anterior region of the shoulder, on the sides of the biceps muscle of the shoulder, there are two grooves: medial and lateral sulcus bicipitalis medialis et sulcus bicipitalis lateralis. These furrows separate the anterior region of the shoulder (regio brachii anterior) from the posterior region (regio brachii posterior).