INSTRUCTIONS FOR PROSECTING THE UPPER LIMB

PART 1 PECTORAL REGION ARM AND AXILLA First two weeks

DISSECTION GUIDE: EXPOSURE OF PECTORAL REGION AND FRONT OF
ARM
Before commencing the dissection read the Introductory section, pages 1-12 from
Cunninghams manual of practical anatomy.
1.

2.

Make skin incisions (keep these as shallow as possible):

a.

Midline from the suprasternal notch to the xiphisternal joint

b.

Along the line of the clavicle and down the lateral aspect of the arm

c.

Laterally, from the xiphisternal joint to the midaxillary line.

Reflect the skin and superficial fascia laterally from the front of the chest. Look for
a.

The anterior cutaneous nerves

b.

The lateral cutaneous nerves which emerge from the intercostal spaces beside the
sternum and in the mid-axillary
line respectively.

3.

Clean the anterior parts of the deltoid

and pectoralis major muscles; and in the

deltopectoral triangle, between these two
muscles, find the cephalic vein and possibly
an infraclavicular lymph node.
4.

Reflect the skin and superficial fascia

(be sure to leave the deep fascia in place)

from the anterior aspect of the arm (down to
the elbow). Try to leave the cephalic vein
in place. Look for cutaneous nerves emerging through the
deep fascia:
a. Lower lateral cutaneous nerve of the arm - from
between triceps and brachialis
b. Posterior cutaneous nerve of the forearm - from
between triceps and brachialis
c. Medial cutaneous nerve of the arm

d. Medial cutaneous nerve of the forearm (emerges with the basilic vein on the medial
side just above the elbow)
e. Lateral cutaneous nerve of the forearm (emerges in front of the elbow, lateral to
biceps.
5.

Carefully reflect the skin from the floor of the axilla (armpit), but do not disturb the

contents of the axilla.

6.

On the side of the chest, expose parts of serratus anterior and try to preserve the long

thoracic nerve in the mid axillary line.

7.

Look out for the anterior border of latissimus dorsi.

DISSECTION GUIDE:

THE AXILLA AND ARM

This dissection will take considerable time and patience, and it is easiest to follow structures
seen emerging from or entering the axilla. It is not possible to clean and preserve the
structures in the axilla properly in one or two sessions and one dissector will need to continue
with this part while the others continue more distally
1.

Detach pectoralis major from its sternocostal attachment and begin to reflect it laterally

and note the medial pectoral nerves piercing pectoralis minor and supplying the sternal head
of pectoralis major.
2.

Carefully detach pectoralis major from the clavicle; avoid damaging the lateral pectoral

nerve and the thoracoacromial artery which divides into pectoral, clavicular, deltoid and
acromial branches, just below the clavicle.
3.

Identify and then remove the clavipectoral fascia

which splits to enclose the subclavius and pectoralis

minor muscles, and which is continuous inferiorly with
the fascia in the floor of the axilla.
4.

Detach pectoralis minor from its origin on ribs 3, 4

and 5, and reflect it laterally.

5.

Begin removing the fat and lymph nodes from the

axilla and clean:

a)

Coracobrachialis and the short head of biceps arising from the coracoid process

b)

Axillary artery; and the beginnings of the median and musculocutaneous nerves

c)

Ulnar nerve and medial cutaneous nerves of arm and forearm (the medial
cutaneous nerve of the arm is frequently joined by the intercostobrachial nerve
from the 2nd intercostal space)

d)

The lateral thoracic artery and the long thoracic nerve, which descend on the
serratus anterior muscle.

6. Find the posterior cord of the plexus and its branches:

a)

Axillary nerve, passing posteriorly with the posterior circumflex humeral vessels

b)

Upper and lower subscapular nerves trace them to teres major and subscapularis

c)

The thoracodorsal nerve and the subscapular artery trace it to the latissimus
dorsi

d)

The radial nerve; trace it in to the arm for a short distance and find its early
branches (posterior cutaneous nerve of the arm and muscular branches to the long
and medial heads of triceps).

7. Use bone shears or a vibrating saw to cut the clavicle in to thirds so that middle third can
be removed. Expose and clean the roots and trunks and divisions of the brachial plexus.
Preserve their branches:

8.

a.

Dorsal scapular nerve - goes posteriorly to the rhomboids

b.

Suprascapular nerve - heads for the suprascapular notch

c.

Phrenic nerve lies in front of scalenus anterior

d.

Long thoracic nerve

Open the deep fascia on the medial side of the arm and clean and follow the brachial

artery, median and ulnar nerves, and the medial cutaneous nerve of the forearm. Note that the
ulnar nerve pierces the medial intermuscular septum to pass behind the elbow, while the
median nerve and the brachial artery pass into the cubital fossa in front of the elbow.
9.

Remove the deep fascia from the remainder of the arm and clean corachobrachialis and

the short head of biceps and find the musculocutaneous nerve, pull these medially and find
the long
head of
biceps.

PART 2 POSTERIOR ASPECT OF THE SHOULDER & UPPER LIMB weeks 3

and 4
DISSECTION GUIDE: EXPOSURE OF THE SCAPULAR REGION
1.

Make skin incisions (keep these as shallow as possible but note the skin of the back is

quite thick):
a.

Midline from the back of the skull to the lower thorax

b.

From the top of the midline incision to the acromion process

c.

From the bottom of the midline incision to the mid-axillary line

d.

Laterally, from the middle of the midline incision across the posterior axillary fold
to the arm

2. Reflect the skin and superficial fascia from the back to expose and clean the surface of
latissimus dorsi and trapezius. Look for posterior cutaneous neurovascular bundles
beside the midline.
3. On the back of the shoulder clean the surfaces of the deltoid, infraspinatus, teres minor
and teres major muscles.

4. Reflect the skin and superficial fascia from the back of the neck to complete the exposure
of the trapezius muscle.
5. Reflect the remaining piece of skin from the lower part of the posterior triangle of the
neck.
6. Detach the trapezius muscle from the occipital bone and the spinous processes of cervical
and thoracic vertebrae. Reflect it laterally and identify the accessory nerve on its deep
surface.
7. Clean the rhomboids and levator scapulae
muscles.
8. Detach the latissimus dorsi muscle from the
thoracolumbar facsia and reflect it
laterally. Confirm your identification of
the thoracodorsal nerve.
9. Identify the teres major muscle and find its
nerve supply (subscapular nerve).
10. Detach the deltoid muscle from the spine of
the scapula and the acromion process.
Reflect it laterally and find the axillary
nerve and circumflex scapular vessels in
the quadrangular space.
11. Identify the supraspinatus muscle and remove the subacromial bursa to follow its tendon
to the greater tubercle of the shoulder.

DISSECTION GUIDE: POSTERIOR ASPECT OF THE ARM

1.

Reflect the skin and superficial fascia from the

back of the arm (be sure to leave the deep fascia in

place). Look for the following cutaneous nerves as they
pierce the deep fascia:
a.

Upper lateral cutaneous nerve of the arm

from behind deltoid

b.

Lower lateral cutaneous nerve of the arm

and the

c.

Posterior cutaneous nerve of the forearm

both from the lateral side of triceps

2.

Remove the deep fascia and clean and define the

heads of triceps.
3.

Open the gap between the long and lateral heads

of triceps and identify the radial nerve and the profunda

brachii artery in the spiral groove. You can cut the
lateral head of triceps to get a better view of the radial
nerve and profunda brachii artery. Confirm these
structures by finding them again in the lower part of the
axilla.

DISSECTION GUIDE: THE FOREARM AND HAND (with the cadaver in the prone
position)
1.

Make skin incisions (keep them very shallow) down the medial and lateral borders of

the forearm. Be aware that the cadavers forearms are pronated so the ventral aspect of the
forearm is exposed
2.

Reflect the skin and superficial fascia from the front of the forearm but leave the deep

fascia in place.
3.

Try to retain the main superficial veins:

b. The basilic vein runs up the ulna side of the forearm past the medial side of the
elbow, and pierces the deep fascia just above the elbow
c. The cephalic vein runs up the
radial side of the forearm and
continues to the shoulder.

4.

Look for cutaneous nerves accompanying

the veins:
a.

Posterior and lateral cutaneous

nerves of the forearm running with e
cephalic vein

b.

Medial cutaneous nerve of the

forearm running with the basilic
vein.

c.

The superficial branch of the radial

nerve become cutaneous over the
distal radius.

5.

Open the deep fascia to expose the

muscles arising from the medial
epicondyle and common flexor origin:

6.

a.

Flexor carpi ulnaris

b.

Flexor digitorum superficialis

c.

Palmaris longus

d.

Flexor carpi ulnaris

e.

Pronator teres

Clean these muscles and follow them to

the wrist, and identify their tendons.

7.

Remove the skin and the dense lobulated fat from the palm of the hand and expose the
palmar aponeurosis.

8.

Find palmaris brevis arising from the flexor

retinaculum and passing to the skin over the
hypothenar eminence

9.

Clean the muscles of the thenar and

hypothenar eminences and identify the
abductor and flexor muscles of thumb and
little finger.

10.

Locate the ulnar nerve and artery on the ulnar

side of the wrist, and the radial artery on the
radial side of the wrist.

PART 3 FOREARM AND HAND weeks 5 and 6

DISSECTION GUIDE: EXPOSURE OF THE DORSAL FORARM AND HAND
1. Reflect the skin and superficial fascia from the dorsal side of the forearm but leave the
deep fascia in place.
2. Look for the median cubital vein that connects the cephalic and basilic veins over the roof
of the cubital fossa - the bicipital aponeurosis). Confirm the lateral cutaneous nerve of the
forearm as it emerges between biceps and brachioradialis.
3. Clean the deep fascia from the dorsal side of the forearm and hand, but leave the extensor
retinaculum.
4. Identify the dorsal venous arch of the veins on the back of the hand
5. Define muscles arising from the lateral
epicondyle and the common extensor origin.
a.

Brachioradialis

b.

Extensor carpi radialis longus and

brevis

c.

Extensor digitorum

d.

Extensor digiti minimi

e.

Extensor carpi ulnaris.

6. Lift brachioradialis away from the biceps and

brachialis and identify the radial nerve dividing into
superficial and deep branches.
7. Trace the tendons of the extensor muscles to the
wrist and fingers and note how they pass through
compartments in the extensor retinaculum.
8. Identify the outcropping group of extensor
muscles that emerge between extensor carpi radialis
and extensor digitorum
a.

Extensor indicis

b.

Extensor pollicis longus

c.

Extensor pollicis brevis

d.

Abductor pollicis longus.

9. Clean these tendons and locate the anatomical snuffbox at the base of the thumb in the
snuffbox you should be able to find the radial artery, trace it backwards into continuity with
the radial artery where you found it on the front of the wrist. Trace the radial artery distally to

where it pierces the first dorsal interosseous muscle in the web between thumb and index
finger.
10. Trace the extensor digitorum tendons to the fingers and
identify the extensor expansion on the back of at least one finger.
Note also that the 4 tendons are connected to each other on the
back of the hand (tendinous interconections).

DISSECTION GUIDE:

DEEPER STRUCTURES IN THE OF FOREARM AND

HAND
1. Carefully spread the gap between the flex carpi ulnaris and brachioradialis muscles and
identify the 3 deep muscles:
a.

Flexor pollicis longus

b.

Flexor digitorum profundus

c.

Pronator quadratus

d.

Also trace the median nerve, the radial artery and the superficial branch of the
radial nerve through the forearm.

2. You can detach flexor digitorum superficialis from its radial origin to get a clearer view
of the deeper structures in the forearm (especially find and follow the ulna nerve and artery)
3. Identify the supinator muscle and the deep branch of the radial nerve.
4. Look again at the palmar aponeurosis. Distally it divides into slips (one to each finger).
Between these slips look for common palmar digital nerves and vessels dividing into proper
palmar digital nerves and vessels. Remove the skin from at least one finger and confirm that
each finger has four cutaneous nerves (two dorsal and two palmar).
5. Cut the palmaris longus tendon and use it to help reflect the palmar aponeurosis distally.
Note how firmly it is attached to the fibrous flexor sheaths of the long tendons to the fingers.
6. Under palmar aponeurosis you will see the superficial palmar arch. Trace it to the ulnar
artery medially and radial
artery laterally. Also
identify the common palmar
digital branches.
7. Also in this part of the
hand you should follow the
branches of the ulnar and
median nerves, and verify
that the median nerve goes
through the carpal tunnel
and that the ulna nerve goes
over the top of the flexor
retinaculum.

8. Locate the recurrent branch of the median nerve that supplies the thenar muscles.
9. Locate the deep branch of the ulnar nerve that goes deep into the palm and supplies most
of the small muscles of the hand.
10. Deep to the nerves and vessels in the palm of the hand identify the long tendons to the
fingers and the lumbrical muscles arising from the tendons of flexor digitorum profundus.
11. Follow the lumbrical muscles to the extensor expansion of each finger.
12. Open one of the fibrous flexor sheaths down the front of one finger and lift the two
tendons out. Note how the superficial flexor tendon splits to allow the deep tendon to pass
through to the distal phalanx.