Chapter 10
Back
Textbook of
Human Anatomy
Volume 1: Upper Limb
Author: Dr Yogesh Sontakke, JIPMER, Pondicherry
©CBS Publishers & Distributors Pvt Ltd, New Delhi
As per:
Competency based Undergraduate
curriculum
• AN10.8
• Describe, identify, and demonstrate position, attachment,
nerve supply, and actions of trapezius and latissimus dorsi
• AN10.9
• Describe arterial anastomosis around scapula and mention
boundaries of triangle of auscultation
• AN13.7
• ………,Testing of muscles: Trapezius, latissimus dorsi,
………………
Medical Council of India, Competency based Undergraduate curriculum for the Indian Medical Graduate,
2018. Vol. 1; pg 1-80. 2
Human Anatomy/Yogesh Sontakke
Back
• Posterior axio-appendicular muscles
connect appendicular skeleton of
upper limb with axial skeleton
• Connect pectoral girdle and humerus
with vertebral column
• Clinical examination, knowledge of
structures lying –back is very
important
Human Anatomy/Yogesh Sontakke 3
Human Anatomy/Yogesh Sontakke 4
SURFACE
LANDMARKS
Scapula
• Lies posterolateral on chest wall
• Extends vertically from 2nd to 7th rib
• Scapula – covered by muscles, only
following parts can be felt easily:
• Inferior angle: Lies – 7th rib, level
of 7th thoracic vertebra
• Medial border: Extends from T2 to
T7 vertebral level
Human Anatomy/Yogesh Sontakke 5
SURFACE
LANDMARKS
Scapula
• Root of spine: Lies opposite – spine
of T3 vertebra
• Acromion: Can be felt at top of
shoulder
• Crest of spine: Runs downward and
medially from acromion – root of
spine
Human Anatomy/Yogesh Sontakke 6
SURFACE
LANDMARKS
• Eighth rib
• Lies just below inferior angle of scapula
• Iliac crest
• Curved bony crest of hipbone that lies
below waist
• Anterior superior iliac spine
• Anterior end of iliac crest
• Posterior superior iliac spine
• Posterior end of iliac crest
• Can be felt in shallow dimple above
buttock, about 5 cm from median plane
Human Anatomy/Yogesh Sontakke 7
SURFACE
LANDMARKS
• External occipital protuberance
• Bony projection – skull felt in midline
–back of head
• Nuchal furrow or groove
• Midline shallow groove extends from
external occipital protuberance –
spine of C7 vertebra
Human Anatomy/Yogesh Sontakke 8
SURFACE
LANDMARKS
• Spines of vertebrae
• Spine of C7 vertebra can be felt –
root of neck, at lower end of nuchal
furrow
• Spine of T2 lies – superior angle of
scapula
• Spine of L4 lies – level of highest
point of iliac crest
• Spine of S2 lies – level of posterior
superior iliac spine
Human Anatomy/Yogesh Sontakke 9
CUTANEOUS INNERVATION
• Skin of back – supplied by posterior primary rami of spinal
nerve
• Some peculiarities of dorsal or posterior primary rami:
• C1, C7, C8, L4, and L5 spinal nerves: Their posterior
primary rami do not supply skin
• Medial divisions of posterior rami:
Upto T6, they supply skin
Below T6, lateral divisions of posterior rami supply skin
• L1, L2, L3 and S1–S3: posterior primary rami supply of
gluteal region
Human Anatomy/Yogesh Sontakke 10
Some Interesting
Facts
• Skin of back – thicker (not histologically thick variety
of skin) and adhered – underlying fascia
• Difficult – separate skin of back from underlying fascia
• Muscles of back present – form of layers of thin sheets
• Careful dissection – required to visualize these
muscles
Human Anatomy/Yogesh Sontakke 11
MUSCLES OF
THE BACK
• Called posterior axio-
appendicular muscles
• Connect appendicular skeleton
of upper limb –axial skeleton
• Grouped as follows
• Superficial layer
• Trapezius
• Latissimus dorsi
Human Anatomy/Yogesh Sontakke 12
MUSCLES OF
THE BACK
• Deep layer
• Levator scapulae
• Rhomboid major
• Rhomboid minor
• Superficial Posterior Axio-
appendicular Muscles include
• Trapezius muscle
• Latissimus dorsi muscle
Human Anatomy/Yogesh Sontakke 13
Human Anatomy/Yogesh Sontakke 14
Trapezius
Muscle
• Flat triangular muscle
• Right and left trapezius muscles
together form trapezium shape
(trapezium = four-sided irregular figure,
in Greek)
• Covers back of neck and upper part of
thorax
Human Anatomy/Yogesh Sontakke 15
Trapezius
Muscle
Origin
• Originates from
• Superior nuchal line (medial one-
third)
• External occipital protuberance
• Ligamentum nuchae
• Spine of C7 vertebra
• Spines of T1 to T12 vertebrae
Human Anatomy/Yogesh Sontakke 16
Human Anatomy/Yogesh Sontakke 17
Trapezius Muscle
Insertion
• Inserts as follows
• Upper fibers – posterior border of lateral one-
third of clavicle
• Middle fibers – medial border of acromion
process and upper lip of crest of spine of
scapula
• Lower fibers – apex of triangular area at
medial end of spine of scapula
Innervations (nerve supply)
• Supplied by
• Spinal part of spinal accessory nerve
• Proprioception by ventral primary rami of
Human Anatomy/Yogesh C3
Sontakke 18
Trapezius Muscle
Actions
• Steadies scapula and performs following
action
• Upper fibers
• Along with levator scapulae –
elevation of scapula (shrugging of
shoulder)
• Middle fibers
• Along with rhomboid major and minor
– retraction of scapula
• Lower fibers:
• Along with serratus anterior – rotates
Human Anatomy/Yogesh Sontakke 19
Human Anatomy/Yogesh Sontakke 20
Latissimus Dorsi
• Wide, thin sheet-like muscle covers wide area of back
(latissimi = wide, dorsi = back, in Latin)
• Large fan-shaped muscle connects humerus with
trunk
Origin
• Originates from
• Spines of lower six thoracic vertebrae (deep to
origin of trapezius)
• Thoracolumbar fascia
• Outer lip of iliac crest
• Lower four ribs
Human Anatomy/Yogesh Sontakke 21
•
Latissimus Dorsi
Direction of fibers
• Fibers ascend upward and laterally
(lowest fibers almost vertical and
uppermost fibers are nearly horizontal)
• Fibers turn around inferolateral border
of teres major muscle – form posterior
axillary fold
Human Anatomy/Yogesh Sontakke 22
Latissimus Dorsi
Insertion
• Muscle inserts in floor of
bicipital groove
(intertubercular sulcus)
• Lowest fibers insert – higher
levels and higher fibers insert
in lower levels
Innervation
• Thoracodorsal nerve (nerve –
latissimus dorsi) (C6–C8)
• Branch of posterior cord of
brachial plexus Human Anatomy/Yogesh Sontakke 23
Latissimus Dorsi
Actions
• Helps – swimming, rowing,
climbing, and pulling
• Movements require adduction,
extension, and medial rotation of
shoulder
• Violent expiration: coughing and
sneezing
• Climbing on rope: this action,
humeral attachment (proximal
attachment of the muscle) – fixed
and trunk moves upward
• Pectoralis major muscle also helps –
climbing
Human Anatomy/Yogesh Sontakke 24
Latissimus Dorsi
Clinical testing
• Ask to adduct abducted
arm (at 90°) against
resistance
• Accentuates posterior
axillary fold or contracted
muscle can be felt in
posterior axillary fold
Human Anatomy/Yogesh Sontakke 25
Human Anatomy/Yogesh Sontakke 26
Clinical
Integration
• Musculocutaneous flap for breast reconstruction
• Case of carcinoma of breast, breast reconstruction
surgery – required after mastectomy (removal of
breast)
• Musculocutaneous flap of latissimus dorsi with
thoracodorsal nerve and thoracodorsal artery
(branch of subscapular artery) and venae
comitantes may be used for breast reconstruction
Human Anatomy/Yogesh Sontakke 27
Clinical
Integration
• Cardiac support
• Patients with low cardiac output but not suitable for
heart transplant, latissimus dorsi is wrapped
around the heart and this muscle is stimulated
electrically using pacemaker along with heart
• Procedure is called cardiomyoplasty
Human Anatomy/Yogesh Sontakke 28
Clinical
Integration
• Injury to thoracodorsal nerve
• May occur during mastectomy as axillary tail
reaches up to nerve
• Results in paralysis of latissimus dorsi muscle and
inability – raise trunk during climbing
• Latissimus dorsi – useful in breast reconstruction
surgeries and for filling back defects
Human Anatomy/Yogesh Sontakke 29
Deep Posterior Axio-appendicular Muscles
Deep posterior axio-
appendicular muscles are
• Levator scapulae
• Rhomboid major
• Rhomboid minor
• Levator Scapulae
• Strap-like muscle situated –
back of neck
• Elevates the scapula, called
levator scapulae
Human Anatomy/Yogesh Sontakke 30
Deep Posterior Axio-appendicular Muscles
Origin
• Originates from
• Transverse processes of
C1–C2 vertebrae
• Posterior tubercles of
transverse processes of
C3–C4 vertebrae
Direction of fibers
• Runs obliquely downward
and laterally
Human Anatomy/Yogesh Sontakke 31
Deep Posterior Axio-appendicular Muscles
Insertion
• Inserts on
• Superior angle of scapula
• Posterior surface of medial border of scapula (between
superior angle and root of the spine)
Innervations (nerve supply)
• Innervated by
• Dorsal scapular nerve (C5)
• Branches from C3 and C4 nerves
Action
• Elevates and steadies scapula
Human Anatomy/Yogesh Sontakke 32
Some Interesting
Facts
• Upper part of levator scapulae – covered by
sternocleidomastoid and lower part – covered
by trapezius
• Reflect trapezius and observe oblique muscle
fibers near superior angle and medial border
of scapula – identify levator scapulae muscle
Human Anatomy/Yogesh Sontakke 33
Rhomboid
Minor
Small rhomboid-shape lies under cover
of trapezius
Origin
• Originates from
• Lowest part of ligamentum nuchae
• Spine of C7 and T1 vertebrae
• Supraspinous ligament intervening
between C7 and T1 vertebrae
Direction
• Muscle fibers run downward and
Human Anatomy/Yogesh Sontakke 34
Rhomboid
Minor
Insertion
• Inserts on medial border of
scapula on triangular area –
root of spine
Innervation
• Dorsal scapular nerve (C5)
Action
• Retracts scapula Human Anatomy/Yogesh Sontakke 35
Rhomboid Major
Quadrilateral sheet of muscle lies
deep – trapezius and inferior –
rhomboid minor
Origin
• Originates from spines of T1 – T5
vertebra and intervening
supraspinous ligaments
Insertion
• Inserts on posterior aspects of
medial border of scapula below
root of spine Human Anatomy/Yogesh Sontakke 36
Rhomboid Major
Innervation
• Dorsal scapular nerve (C5)
Actions
• Rhomboid minor and major,
and middle fibers of trapezius
retract scapula
• Rhomboids steady scapula
with help of serratus anterior
muscle
Human Anatomy/Yogesh Sontakke 37
DORSAL SCAPULAR NERVE
(NERVE TO RHOMBOIDS)
• Dorsal scapular nerve arises from ventral primary ramus of
C5 spinal nerve in neck
• Enters in posterior triangle of neck between scalenus anterior
and scalenus medius muscles (in neck)
• Nerve passes laterally for short distance and pierces scalenus
medius muscle
• Then, passes downward on the anterior surface of the levator
scapular muscle
• (Note: dissection of posterior triangle of neck, seeing from
posterior aspect, spinal accessory nerve and superficial
branch of transverse cervical artery lie between trapezius
and levator scapulae Human Anatomy/Yogesh Sontakke 38
DORSAL SCAPULAR NERVE
(NERVE TO RHOMBOIDS)
• Dorsal scapular nerve and deep branch of transverse
cervical artery lie deep – levator scapulae muscle
Structures supplied
• Dorsal scapular nerve supplies
• Levator scapulae
• Rhomboid minor
• Rhomboid major
Human Anatomy/Yogesh Sontakke 39
Some Interesting
Facts
• Near origin trapezius, latissimus dorsi, levator scapulae,
rhomboid minor and major are aponeurotic (whitish sheets)
• Try identify these muscles away from origin
• Spinal accessory nerve runs – deep surface of trapezius muscle
along with superficial branch of transverse cervical artery
• Dorsal scapular nerve and deep branch of transverse cervical
artery lies – deep surface of levator scapular, rhomboid minor
and major
• Three muscles insert – posterior aspect at medial border of
scapula – above downward are levator scapulae, rhomboid
minor, and rhomboid major
Human Anatomy/Yogesh Sontakke 40
Human Anatomy/Yogesh Sontakke 41
Thank you………….
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