Definition
It is a pyramid shaped space between the upper part of the arm and the side of the chest Important Nerves, Blood and Lymph vessels travel through it from root of the neck to the upper limb
BOUNDARIES
BOUNDARIES :
APEX : DIRECTED UPWARD AND MEDIAL WARD, ENDING IN THE CERVICOAXILLARY CANAL, WHICH LEADS INTO POSTERIOR TRIANGLE OF NECK.
BOUNDARIES :
Anterior wall: By the pectoralis major, Subclavius and pectoralis minor muscles Posterior wall: By the subscapularis, Latissimus dorsi and teres major muscles
BOUNDARIES :
Medial wall: By the upper 4 or 5 ribs and intercostal spaces covered by serratus anterior muscle Lateral wall: By the coracobrachialis and biceps muscles in the bicipital groove of humerus
BOUNDARIES :
Base : The Base of axilla is formed by the axillary fascia and the skin stretching between the anterior and posterior walls
Contents of Axilla
Axillary artery and its branches Axillary vein and its tributaries
Lymph vessels and lymph nodes
Important nerve plexus the Brachial Plexus which innervates the upper limb
Axillary Artery
Is a continuation of subclavian artery Begins at the lateral border of the 1st rib Ends at the lower border of teres major It continues as the brachial artery Closely related to brachial plexus cords Enclosed with them in the axillary sheath Axillary sheath is continuous with the prevertebral fascia Pectoralis minor divides it into 3 parts Branches of axillary artery supply the thoracic wall and the shoulder region
1st Part of Axillary Artery
Extends from the lateral border of the 1st rib to the upper border of pectoralis minor Branches : Highest thoracic artery = superior thoracic artery
Relation
Anterior: Pectoralis major, covering fascia, skin, cephalic vein Posterior: Long thoracic nerve Lateral: Three cords of brachial plexus Medial: Axillary vein
2nd Part of Axillary Artery
Lies behind the pectoralis minor muscle Branches : Thoracoacromial and lateral thoracic arteries
Relation
Anterior: Pectoralis minor and major, covering fascia and skin Posterior: Posterior cord of brachial plexus Lateral: Lateral cord of brachial plexus Medial: medial cord of brachial plexus and axillary vein
3rd Part of Axillary Artery
Extends from lower border of pectoralis minor to the lower border of teres major Branches : Subscapular artery, anterior and posterior circumflex humeral arteries
Relation
Anterior: Pectoralis major, medial root of the median nerve Posterior: subscapularis, latissimus dorsi and teres major Lateral: Coracobrachialis, biceps, humerus Medial: Ulnar nerve, axillary vein, medial cutaneous nerve of the arm
Branches of the axillary artery
1 2 3
Send - Superior thoracic artery
The - Thoraco-acromial artery Lord to - Lateral thoracic artery Say - Subscapular artery A - Anterior circumflex humeral artery Prayer - Posterior circumflex humeral artery
AXILLARY VEIN
BEGINS AT UNION OF BASILIC AND BRACHIAL VEINS AND TERMINATES AT 1ST RIB AS SUBCLAVIAN VEIN. LIES MEDIAL TO AND PARTLY OVERLAPS AXILLARY ARTERY WITH MEDIAL CORD AND ITS BRANCHES. RECEIVES TRIBUTARIES CORRESPONDING TO BRANCHES OF ARTERY PLUS THE CEPHALIC VEIN.
AXILLARY LYMPH NODES
1. ANTERIOR(PECTORAL) AXILLARY N - receive afferens from ant & lat thorax, central & lat mammary gland - efferents go to 4 &5 2. LATERAL (BRACHIAL) AXILLARY NODES: - receive afferens from all upper extremity except those nodes around cephalic vein - efferents go to 4 & 5 3. POST(SUBSCAPULAR) AXILLARY NODES : - receive afferens from lower back of neck and posterior wall of thorax - efferents go to 4 4. CENTRAL AXILLARY NODES : - receive afferens from all the above nodes - efferents go to 5 5. APICAL (SUBCLAVICULAR) AXILLARY NODES: - receive afferens from all the above nodes - efferents go to trunci subclaviiangulus venosus jugulum
2
3
Brachial Plexus
Brachial Plexus
Roots
C5 C6 C7 C8 T1
Divisions
Anterior primarily flexors Posterior primarily extensors
Trunks
Upper 5,6 Middle 7 Lower 8,1
Cords
Lateral C5,6,7 Posterior C5,6,7,8 Medial C8,T1
Parts of Brachial Plexus
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R = ROOTS (ventral rami) T = TRUNKS D = DIVISIONS C = CORDS B = BRANCHES
Roots join to form Trunks! (in neck)
Ventral Rami Trunks
C5 C6 C7 C8 T1
Upper Trunk Middle Trunk Lower Trunk
Trunks Split to form Divisions! (in neck)
Trunks Divisions
Upper
Middle Lower
Anterior Posterior
Anterior Posterior Anterior Posterior
Divisions Join to form Cords! (in axilla)
Trunks Divisions Cords
U M
A P A P A P
LATERAL CORD
MEDIAL CORD
POSTERIOR CORD
Cords Give off Branches!! (in axilla)
Lateral Musculocutaneous
Median Medial Ulnar
Posterior
Radial Axillary (thoracodorsal) (subscapular)
Relation of Spinal N. Roots to Vertebrae
1st cervical nerve exits ABOVE C1 vertebra
2nd through 7th nerves exit above corresponding vertebrae
8th cervical nerve exits BELOW C7 vertebra Note: There are 7 cervical vertebrae There are 8 cervical nerves
Brachial Plexus and its branches :
(1) Roots
C5 C6 C7 C8 T1
(2) Long thoracic nerve : Spinal Cord Segments C5, C6, C7 Muscles Innervated Serratus
(3) Dorsal scapular nerve : Spinal Cord Segment C5 (C4 is variable) Muscles Innervated Levator Rhomboids
TRUNCUS SUPERIOR
(4) Nerve to subclavius : Spinal Cord Segments C5, C6 Muscles Innervated
SC
(5) Suprascapular nerve :
Spinal Cord Segments
C4, C5, C6
(6) Anterior Divisions
Innervates volar aspect of U.E. Spinal Cord Segments
C5 C6 C7 C8 T1
(7) Posterior Divisions
Innervates the dorsal aspect of the U.E. Spinal Cord Segments
C5 C6 C7 C8 T1
(9) Lateral Cord
Gives rise to 2 nerves Spinal Cord Segments: C5, C6 &C7. (8) Lateral pectoral nerve Spinal Cord Segments C5, C6, C7 Muscles Innervated Pec. Maj. (21) Musculocutaneous Spinal Cord Segments C5, C6, C7 Muscles Innervated BB, CB, Brachialis
(11) Medial Cord
Gives rise to 5 nerves Spinal Cord Segments:C8-T1 (12)Medial pectoral nerve (13)Muscles Innervated Pec. Maj. Pec. Min. (16)Medial brachial cutaneous (17) Medial antebrachial cutaneous (18) Ulnar nerve Muscles Innervated FCU, FDP (4,5), PB, ADM, ODM, FDM, ADD POL, FPB (deep head), Lum (4,5) DI, PI
Branches of Brachial Plexus Medial Cord:
Money Makes Many Men Unhappy Medial pectoral nerve Medial branch of median nerve Medial cutaneous nerve of arm
Medial cutaneous nerve of forearm
Ulnar nerve
(22) Median nerve
Spinal Cord Segments
C5, C6, C7, C8, T1
Muscles Innervated
PT, FCR, PL, FDS, FDP (2,3), FPL, FPB, APB, OP, PQ, LUM (2,3).
(10) Posterior Cord
Gives rise to 5 nerves Spinal Cord Segments: C5 T1 (13) Upper subscapular nerve Spinal Cord Segments : C5, C6 Muscles Innervated Subscapularis (14) Thoracodorsal nerve Spinal Cord Segments : C6-C8 Muscles Innervated Lat. D. (15) Lower subscapular nerve Spinal Cord Segments: C5, C6 Muscles Innervated T. Maj. Subscapularis
(10) Posterior Cord
(19) Axillary nerve Spinal Cord Segments: C5, C6 Muscles Innervated T. Min. Deltoid (20)Radial nerve Spinal Cord Segments C5, C6, C7, C8, T1 Muscles Innervated Triceps, Anconeous, BR, Brachialis, ECRL
Brief Overview of Injuries
Due to traction Traumatic injuries
Contusion Disruption of blood supply Laceration
Injuries (Median)
Fracture Dislocation Compression Sites Low lesion Ant. Interosseous lesion Lesion proximal to elbow
Injuries (Median)
Fracture Dislocation Compression Sites Low lesion Ant. Interosseous lesion Lesion proximal to elbow
Median Nerve: Common Sites of Compression
Ape hand Deformity
Wasting of the thenar eminence and unable to oppose the thumb
Ulnar Nerve Injuries
Fractures Lacerations Low Lesions High Lesions
Ulnar Nerve: Compression Sites
Cubital tunnel
Guyons canal
Midpalm
Bishops or Benediction Hand
Wasting of hypothenar muscles, interossei, and two medial lumbricals
Radial Nerve Injuries
Fractures Dislocations Posterior Interosseous Lesions Mid-humeral Lesion High Lesion Sensory Loss
Anatomy of the Radial Nerve
Deltoid tuberosity
Radial Groove (Spiral Groove)
Drop Wrist Deformity
Wrist, thumb, and finger extensors weakness
Summary
Brachial plexopathies require thorough understanding of anatomy Specialized sensory and motor testing can help localize the pathology
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