The Axilla The space between shoulder and chest wall'

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The Axilla The space between shoulder and chest
wall.

• Kristen Blake Bruzzini, Ph.D.

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Overview

• The Axilla Where is it?
• The Axillary Vessels
• The Brachial Plexus
• Injuries to the Brachial Plexus
• Axillary Lymph Nodes

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Boundaries

• Apex
• Anterior Wall
• Medial Wall
• Posterior Wall
• Lateral Wall
• Base/Floor

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Surface Anatomy
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Muscles that Form the Boundaries

• Pectoralis Major and Minor
• Subscapularis
• Teres Major
• Latissimus Dorsi
• Serratus Anterior
• Long and Short Heads of Biceps Brachii
• Coracobrachialis

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Muscles that Form Boundaries of Axilla

• 1. pectoralis major and minor muscles
• 2. subscapularis muscle
• a. Origin - arises from subscapular fossa of
  scapula
• b. Insertion - passes directly IN FRONT of the
  shoulder joint, fuses with its capsule and
  inserts on the lesser tubercle of the humerus
• c Action - medial rotator of the arm
• d. Innervation - upper and lower subscapular
  nerves
• e. Blood Supply - subscapular vessels

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• 3. teres major muscle
• a. Origin - arises from the inferior angle and
  adjacent axillary border of the scapula
• b. Insertion - passes anterior to the long head
  of the triceps brachii muscle and anatomical
  neck of the humerus to insert on the lesser
  tubular ridge
• c. Action - adductor and medial rotator of the
  arm
• d. Innervation - lower subscapular nerve
• e. Blood supply - subscapular vessels

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• 4. latissimus dorsi muscle
• a. crosses inferior angle of scapula and the
  origin of the teres major muscle, then turns
  under the same muscle to reach its anterior
  position
• b. rotation of the muscle fibers causes most
  superior of fibers of origin to insert on the
  humerus at the most inferior position
• c. Origin spinous processes of lower thoracic
  vertebrae, spinous processes of lumbar
  vertebrae, dorsum of sacrum, iliac crest and
  lower ribs
• d. Inserts on crest of lesser tubercle and
  intertubercular sulcus
• e. Action - exends, adducts, and medially rotates
  the arm
• d. Innervation - thoracodorsal nerve (also called
  middle scapular nerve)

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• 5. serratus anterior muscle
• a. Origin - upper eight ribs
• b. Insertion - vertebral border of scapula
• c. Action -prevents retraction of the scapula
  and shoulder when lower fibers contract, it
  can assist the trapezius muscle in rotating the
  scapula or shoulder
• (1) loss of nerve supply can result in winged
  scapula
• d. innervation long thoracic nerve
• e. blood supply superior thoracic artery

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• 6. long and short head of biceps brachii and
  coracobrachialis muscles
• a. origin from supraglenoid tubercle (long
  head) and coracoid process (short head)
• b. insertion radial tuberosity
• c. action -flexes shoulder, flexes forearm at
  elbow and supinates forearm

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Axillary Artery

• Divided into three parts by the pectoralis minor
• First part has one branch
• Second part has two branches
• Third part has three branches

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• 1st part has one branch
• superior thoracic artery - supplies the first two
  intercostal spaces superficially

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• 2nd part has two branches

thoracoacromial trunk - arises behind the upper
margin of the pectoralis minor muscle and quickly
divides into four branches i. acromial artery -
supplies region of the acromion process of the
scapula ii. pectoral arteries - pierce the
costocoracoid membrane and supply the
pectoralis major and minor muscles iii.
clavicular artery - small branch that goes to
region of the subclavius muscle iv. deltoid
artery - enters deltopectoral triangle and
travels distally with the cephalic vein lateral
thoracic artery i. arises behind the lower
border of the pectoralis minor muscle ii.
supplies the lower anterior and medial aspects
of the axilla and the mammary gland
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• 3rd part has three branches

subscapular artery - largest branch off axillary
artery i. circumflex scapular artery (i) goes
around scapula, between the scapula and teres
muscles (ii) gives off branches, which pass
through the triangular space (iii) ends
deep to the infraspinatus muscle, where it
joins with the suprascapular artery, forming
a collateral route for blood from the first
part of the subclavian artery to the third
part of the axillary artery ii. thoracodorsal
artery - travels with nerve of same name to
latissimus dorsi muscle iii. anterior humeral
circumflex artery - small and passes anterior
to the humerus posterior humeral circumflex
artery larger and passes posterior to the
humerus, accompanies axillary nerve
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Axillary Vein
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Brachial Plexus

• formed from anterior primary rami of spinal
  nerves C5-T1 in the posterior triangle of the
  neck
• Basic Parts
• Rami
• Trunks
• Divisions
• Cords
• Nerves

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Nerves

• dorsal scapular nerve to rhomboid muscles - from
  anterior primary
• ramus of C5 - pierces scalenus medius muscle
• long thoracic nerve to serratus anterior - from
  anterior primary rami of CS, 6, 7 - pierces
  scalenus medius muscle
• 3. suprascapular nerve to supraspinatus and
  infraspinatus muscles - from upper trunk - goes
  through scapular notch
• 4. nerve to subclavius - from upper trunk
• 5. lateral pectoral nerve to pectoralis major
  muscle - from lateral cord - goes through
  costocoracoid membrane
• 6. medial pectoral nerve to pectoralis major and
  minor muscles - from medial cord
• 7. medial brachial cutaneous - from medial cord
• 8. medial antebrachial cutaneous - from medial
  cord
• 9. upper subscapular nerve to subscapularis
  muscle - from posterior cord

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• 10. thoracodorsal nerve to latissimus dorsi
  muscle - from posterior cord
• 11. lower subscapular nerve to subscapularis and
  teres major muscles - from posterior cord
• 12. axillary nerve to deltoid and teres minor
  muscles- from posterior cord
• 13. radial nerve to all dorsal muscles of upper
  limb - from posterior cord
• 14. musculocutaneous nerve to anterior
  compartment of arm - from lateral cord
• 15. median nerve - major nerve to anterior
  forearm, minor nerve to hand - from both medial
  and lateral cords
• 16. ulnar nerve - minor nerve to anterior
  forearm, major nerve to hand - from medial
  cord

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Dermatomes and Myotomes of the Upper Limb
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Injuries to the Brachial Plexus

• Difficult to diagnose because the symptoms of
  each injury can appear to be similar.
• More than one of the conditions can occur
  simultaneously.
• Generally two types
• Erb Palsy (more common)
• Klumpke Palsy

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Types of Brachial Plexus Injuries

• Stretch
• Neuroma
• Rupture
• Avulsion

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Injuries to Brachial Plexus
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Classic Erbs Palsy (waiters tip) arm extended,
adducted, internally rotated.
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Note that he is not using his right arm, has poor
biceps flexion, is left hand dominant.
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Injuries to Brachial Plexus
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Horners Syndrome

• Suspected T1 involvement
• Note droopy mouth in addition to other signs

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Injury Anatomy
http//www.drnathbrachialplexus.com/injury/brachia
l_skeleton.php
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Lymph Nodes

• divided into five regional groups
• pectoral nodes
• brachial nodes
• subscapular nodes
• central nodes
• apical nodes

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Thank You!
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Elbow Tendonitis(tennis elbow, lateral
epicondylitis)