Download Anterior

Anatomy Of Shoulder And Arm II
Axilla and Its Contents
Dr. Fadel Naim
Orthopedic Surgeon
Faculty of Medicine
IUG-Gaza
SURFACE ANATOMY

Anteriorly
–
–
–
–
–
–
–

Clavicle
Tip of coracoid process of scapula
Greater tubercle of humerus
Deltoid contour
axilla and its folds
Medial epicondyle shows head of humerus direction
Lateral epicondyle show greater tuberosity direction
Posteriorly
– Scapula
• acromian,crest of spine [T3]
• medial and lateral borders,
• inferior angle
Surface anatomy
Anterior aspect
Posterior aspect
Axilla (Arm pit)
AXILLA

A pyramid-shaped
space between the
upper part of the arm
and the side of the
chest through which
major neurovascular
structures pass
between neck & thorax
and upper limbs.
Axilla
4
Sided pyramid
 Apex connected to the neck=Inlet
 Base Arm pit= Outlet
 Anterior wall
 Posterior wall
 Medial wall
 Lateral wall
Axillary Walls
Bones
Anterior
Posterior
Medial
Lateral
Clavicle
Scapula
Ribs
Humerus
Muscles
Anterior
Posterior
Medial
Lateral
Pectoralis
Subscapularis
teres minor
teres major
latissimus dorsi
Serratus
anterior
Tendon of long
head of biceps
major
pectoralis minor
subclavius

Anterior wall:

Is formed by
• Pectoralis major
• Pectoralis minor
• Subclavius
• Clavipectoral fascia
•Clavipectoral
fasciac
•subclavius
•Pectoralis
major
•Pectoralis
minor
Muscles
Anterior
Posterior
Medial
Lateral
Pectoralis major
pectoralis minor
subclavius
Subscapularis
Serratus
anterior
Tendon of long
head of biceps
teres
minor
teres major
latissimus dorsi
Muscles
Anterior
Posterior
Medial
Lateral
Pectoralis major
pectoralis minor
subclavius
Subscapularis
teres minor
teres major
latissimus dorsi
Serratus
Tendon of long
head of biceps
anterior
Muscles
Anterior
Posterior
Medial
Lateral
Pectoralis major
pectoralis minor
subclavius
Subscapularis
teres minor
teres major
latissimus dorsi
Serratus
anterior
Tendon
of long
head of biceps
Coracobarchialis
Apex Of Axilla



The entrance from neck to axilla
The superior opening of the axilla to reach the arm
Boundaries:
– 1st rib medially
– Clavicle anteriorly
– Upper border of the scapula posteriorly

The arteries, veins, lymphatics, and nerves pass from
the neck to the axilla through the cervico-axillary
canal
Base Of Axilla




Anterior axillary fold ( pectorails major )
Posterior axillary fold ( latissimus dorsi )
Chest wall ( medially )
Formed by:
– The concave skin
– Subcutaneous tissue
– Axillary (deep) fascia extending from the arm to the
thoracic wall
Pectoralis Major

Origin
– Clavicular head:
• Medial half clavicle.
– Sternocostal head:
•
•
•
•

Lateral manubrium
Sternum
Six upper costal cartilages
External oblique aponeurosis
INSERTION
– Lateral lip of bicipital groove of humerus

Action
– Clavicular head:
• Flexes and adducts arm.
– Sternal head:
• Adducts and medially rotates arm .
• Accessory for inspiration

Nerve
– Medial pectoral nerve (from medial cord)
– Lateral pectoral nerve (from lateral cord)
Absent Pectoralis Major


Deficiency or absence of the
sternocostal part is not
uncommon.
No disability usually results
– The anterior axillary fold is
absent on the affected side
– The nipple is more inferior than
usual.
Poland syndrome

The classic ipsilateral features of Poland syndrome
include the following:
– Absence of sternal head of the pectoralis major
muscle
– Hypoplasia and/or aplasia of breast or nipple
– Deficiency of subcutaneous fat and axillary hair
– Abnormalities of rib cage
– Upper extremity anomalies;
• short upper arm, forearm, or fingers
The Clavipectoral Fascia


A fascial envelope extends from the
axillary fascia, encloses the
pectoralis minor and subclavius
muscles, and then attaches to the
clavicle
The costocoracoid membrane:
– The part of the clavipectoral fascia
superior to the pectoralis minor is
pierced by the lateral pectoral nerve
that primarily supplies the pectoralis
major.

The suspensory ligament of the
axilla:
– The part of the clavipectoral fascia
inferior to the pectoralis minor supports
the axillary fascia and pulls it and the
skin inferior to it upward during
abduction of the arm, forming the axilla
Clavipectoral fascia
•Encloses
•subclavius
• Pectoralis Minor.
•It is pierced by :
•Cephalic vein.
• Lymph nodes from pectoral
region to apical group of
axillary lymph nodes
•Lateral pectoral nerve.
•Thoraco- acromial artery
•Clavicle
•Clavipectoral
fascia
•Subclavius
•Pectoralis major
•Subscapularis
•Pectoralis minor
•Teres major
•Latissimus
•dorsi
Subclavius

Origin
– Costochondral junction of 1st rib

INSERTION
– Subclavian groove on inferior surface of middle third of
clavicle

Action
– Depresses clavicle and steadies it during shoulder
movements

Nerve
– Nerve to subclavius (upper trunk of brachial plexus)
Pectoralis Minor


Origin
3, 4, 5 ribs
INSERTION
– Medial and upper surface of coracoid process of scapula

Action
– Elevates ribs if scapula fixed
– Pulls shoulder downward and forward

Nerve
– Medial pectoral nerve (from medial cord of brachial plexus)

Important
 The pectoralis minor muscle is covered by the clavipectoral fascia.
 The medial pectoral nerve pierces the pectoralis minor .
 Axillary artery is divided into three parts by pectoralis minor.
Subscapularis

Origin
– Medial two thirds of subscapular fossa

INSERTION
– Lesser tuberosity of humerus
– Upper medial lip of bicipital groove
– Capsule of shoulder joint

Action
– Medially rotates arm
– Stabilizes shoulder joint

Nerve
– Upper and lower subscapular nerves (from posterior cord of brachial
plexus)
Teres Major

ORIGIN
– Lower third of lateral side of inferior angle of scapula below teres minor

INSERTION
– Medial lip of bicipital groove of humerus

ACTION
– Medially rotates and adducts arm.
– Stabilizes shoulder joint

NERVE
– Lower subscapular nerve (from posterior cord of brachial plexus)
Latissimus Dorsi

ORIGIN
– Spine T7
• spinous processes and supraspinous
ligaments
of all lower thoracic, lumbar and sacral
vertebrae
– lumbar fascia
– posterior third iliac crest
– last four ribs (interdigitating with external
oblique abdominis)
– inferior angle of scapula

INSERTION
– Floor of bicipital groove of humerus after
spiraling around teres major
Latissimus Dorsi

ACTION
– Extends, adducts and medially rotates arm.
– Costal attachment helps with deep inspiration
and forced expiration

NERVE
– Thoracodorsal nerve (from posterior cord of brachial
plexus)
Serratus Anterior
 ORIGIN
– Upper 8 ribs and anterior intercostal
membranes from midclavicular line.
 INSERTION
– Inner medial border scapula
• 1 and 2: upper angle
• 3 and 4: length of costal surface
• 5-8: inferior angle
Serratus Anterior

Action
– A strong protractor of the scapula that is used when
punching or reaching anteriorly ("boxer's muscle")
– Inferior part rotates the scapula, elevating its glenoid cavity
so the arm can be raised above the shoulder
– Holds the scapula against the thoracic wall when doing
push ups or when pushing against resistance

Nerve
– Long thoracic nerve
Contents of axilla
1.
2.
3.
4.
5.
6.
The three cords of the
brachial plexus and their
branches
The axillary arteries and
its branches
The axillary vein and its
tributaries
The axillary lymph
nodes
Fibro-fatty tissue
The axillary tail of
Spence of mammary
gland in females
•Axillary a.
•Axillary v.
•Axillary
lymph nodes
•Fat
AXILLARY ARTERY
Beginning
It begins as a continuation of
the subclavian artery at outer
border of 1st rib.
Termination
It ends at the lower border of
teres major and continues as
brachial artery.
Parts
The artery is divided into 3
parts by pectoralis minor
muscle.
Parts of the Axillary Artery
st
1 part:
st
From lateral border of 1 rib to
upper border of pectoralis
minor
2
nd
part:
Behind pectoralis minor
rd
3 part:
From lower border of
pectoralis minor to lower
border of teres major
Boundaries of the 1st
Portion

Anteriorly
– Clavicular portion of the pectoralis
major
– The coracoclavicular fascia
– Crossed by cephalic vein

Posteriorly:
– The long thoracic nerve

Lateral:
– The 3 cords of the brachial plexus

Medial:
– The axillary vein which overlaps the
artery.

It is enclosed, together with the
axillary vein and the brachial
plexus, in the axillary sheath
Boundaries of the 2nd
Portion

Anteriorly:
– The pectorales major and minor

Posteriorly
– The posterior cord of the brachial plexus and the
subscapularis muscle and shoulder joint

Medially
– The axillary vein, separated from the artery by the
medial cord of the brachial plexus

Laterally
– The lateral cord of the brachial plexus
Boundaries of the 2nd
Portion

The brachial plexus thus surrounds the
artery on three sides, and separates it from
direct contact with the vein and adjacent
muscles.
Boundaries of the 3rd
Portion

Anteriorly:
– The lower part of the pectoralis major above
– Fascia below
– The medial head of the median nerve

Posteriorly
– The lower part of the subscapularis,
– The tendons of the latissimus dorsi and teres major
– The radial and axillary nerves

On its lateral side:
– Coracobrachialis, biceps and humerus
– Lateral head and the trunk of the median, and the musculocutaneous

On its medial side:
– The axillary vein
– The ulnar nerve
– Medial brachial cutaneous nerve
Relations

To remember the branches easily,
– The number of branches from each part
═ The same as the number of the part
– 1st had 1 branch
– 2nd has 2 branches
– 3rd had 3 branches
1st =1
2nd =2
3rd =3
Some Times Life
Seems A Pain

The axillary artery branches
into the following arteries:
1.
2.
3.
4.
5.
6.
Superior thoracic artery
Thoracicoacromial artery
Lateral thoracic artery
Subscapular artery
Anterior humeral circumflex
artery
Posterior humeral circumflex
artery
Branches Of Axillary Artery
First part
(1 branch)
Second part
(2 branches)
Third part
(3 branches)
1 superior thoracic a.
(Highest thoracic a.)
The
superior thoracic artery (highest thoracic artery) is a
small vessel that arises from the first part of the axillary
artery, just inferior to the subclavius
It runs inferomedially posterior to the axillary vein
and supplies muscles in the 1st and 2nd intercostal
spaces and the serratus anterior.
It anastomoses with the intercostal arteries
Branches Of Axillary Artery
First part
(1 branch)
Second part
(2 branches)
Third part
(3 branches)
2 thoracoacromial a.
3 lateral thoracic a.
The
thoracoacromial artery:
A short wide trunk, deep to the pectoralis minor.
Divides into 4 branches deep to the clavicular head of
the pectoralis major.
Acromial
Deltoid
Pectoral
 Clavicular
Branches Of Axillary Artery
First part
(1 branch)
Second part
(2 branches)
Third part
(3 branches)
2 thoracoacromial a.
3 lateral thoracic a.
The
lateral thoracic artery
Descends along the lateral border of the pectoralis minor
Supplies:
the pectoral muscles
the axillary lymph nodes
 the breast
An important source of blood to the lateral part of
the mammary gland in women.
Branches Of Axillary Artery
Third part (3 branches)
4 subscapular a.
5 anterior humeral circumflex a.
6 posterior humeral circumflex a.
The subscapular artery:
The largest branch of the axillary artery
Descends along the lateral border of the
subscapularis on the posterior axillary wall.
Divides into the
circumflex scapular artery
thoracodorsal artery
Supplies
Subscapularis
teres major
serratus anterior
latissimus dorsi muscles
Branches Of Axillary Artery
Third part (3 branches)
4 subscapular a.
5 anterior humeral circumflex a.
6 posterior humeral circumflex a.
Anterior and posterior humeral circumflex a :
These arteries anastomose to form a circle
around surgical circumflex humeral neck of
humerus;
larger posterior circumflex humeral artery
passes through quadrangular space with axillary
nerve
Arterial Anastomoses Around the Shoulder


Many arterial anastomoses occur
between the subclavian and
axillary artery around the
scapula.
Several vessels join to form
networks on the anterior and
posterior surfaces of the scapula
and around the humeral neck
– The Suprascapular artery
– The dorsal scapular artery
– The Superficial and deep branch of
transverse cervical artery
– The Subscapular (via the
circumflex scapular) artery
– The Anterior and posterior
circumflex humeral artery
Scapular anastomosis





A system connecting each subclavian artery and the
corresponding axillary artery, forming an anastomosis around
the scapula.
It allows blood to flow past the joint regardless of the position
of the arm.
It includes:
1. transverse cervical artery.
2. transverse scapular artery.
3. branches of subscapular artery.
4. branches of thoracic aorta.
vessels anastamose or join to connect the first part of
the subclavian with the third part of the axillary, providing
a collateral circulation.
This collateral circulation allows for blood to continue
circulating if the subclavian is obstructed.

The extreme mobility of the shoulder joint may
result in kinking of the axilllary artery and occlusion
of its lumen

The importance of the collateral circulation
becomes apparent when ligation of a lacerated
subclavian or axillary artery is necessary.

In either case, the direction of blood flow in the
subscapular artery is reversed, enabling blood to
reach the third part of the axillary artery.
Arterial Anastomoses Around the Shoulder

Slow occlusion of the axillary artery (resulting from
disease or trauma) often enables sufficient
collateral circulation to develop, preventing
ischemia

Sudden occlusion usually does not allow sufficient
time for a good collateral circulation to develop
– An inadequate supply of blood flow to the arm, forearm,
and hand.
Ligation of the axillary artery distal to the subscapular
artery and proximal to the deep artery of the arm cuts off
the blood supply to the arm because the collateral circulation
is inadequate
Compression of the Axillary Artery

The axillary artery can be palpated in the inferior
part of the lateral wall of the axilla

Compression of the third part of this artery against
the humerus may be necessary when profuse
bleeding occurs

If compression is required at a more proximal site,
the axillary artery can be compressed at its origin
by exerting downward pressure in the angle
between the clavicle and the attachment of the
sternocleidomastoid.
Axillary Vein

Formation :
– Basilic vein + venae comitantes of the
brachial artery

Beginning :
– Lower border of teres major

Course :
– It runs along the medial side of the axillary
artery.

Trmination :
– At outer border of the 1st rib.
– It becomes the subclavian vein.

The cephalic v. joins the axillary v. just
before it becomes the subclavian.
Injuries to the Axillary Vein




Wounds in the axilla often involve the
axillary vein because of its large size and
exposed position.
It may be injured in sports as well as when
a person uses a crutch.
When the arm is fully abducted, the axillary
vein overlaps the axillary artery
anteriorly.
A wound in the proximal part of the axillary
vein is particularly dangerous not only
because of profuse bleeding but also
because of the risk of air entering the vessel
and producing air emboli
The veins of the right axilla,
viewed from in front
Axillary Vein Thrombosis




An uncommon condition that may be regarded as the
upper limb equivalent of a deep venous thrombosis
Commonly follows excessive use of the arm
Less frequently, the vein is compressed by
musculoskeletal abnormalities or enlarged lymph
nodes.
It may also follow mastectomy, radiotherapy, or venous
cannulation, or may result from underlying visceral
malignancy
Lymph Nodes of the Axilla
The axillary lymph nodes
are arranged in five
principal groups:
Apical
Anterior (pectoral)
Posterior
(subscapular)
Lateral ( humeral)
Central
•The 20-30 axillary nodes
are divided into
•5 groups - on the basis of
location•The groups are arranged in a
manner that reflects the pyramidal
•shape of the axilla.
•Humeral (lateral) nodes
•Pectoral (anterior) nodes
•Subscapular (posterior) nodes
•
Central nodes
•
Apical nodes
•Efferent vessels from the apical group
traverse the cervico-axillary canal.
The Apical Group

Located along the
medial side of the
axillary vein and the
first part of the axillary
artery.

Receives lymph from
all other groups of
axillary lymph nodes
as well as from
lymphatics
accompanying the
proximal cephalic vein
The Pectoral (Anterior) Group




3 – 5 lymph nodes
Lie along the medial wall of the
axilla, around the lateral
thoracic vein and the inferior
border of the pectoralis minor
Receives lymph mainly from
the anterior thoracic wall
including the breast.
Efferent lymphatic vessels from
these nodes pass to the central
and apical groups of axillary
lymph nodes.
The Subscapular (Posterior) Group



Consists of 6-7 lymph nodes that lie
along the posterior axillary fold
and subscapular blood vessels.
Receives lymph from the
posterior aspect of the thoracic
wall and scapular region.
Efferent lymphatic vessels pass
from these nodes to the central
and apical groups of axillary
lymph nodes.
The Humeral (Lateral) Group


Consists of four to six lymph
nodes that lie along the lateral
wall of the axilla, medial and
posterior to the axillary vein.
This group of lymph nodes
receives nearly all the lymph
from the greater part of upper
limb
– Except that carried by lymphatic
vessels accompanying the
cephalic vein, which drains to the
central and apical axillary nodes.
The Central Group



Consists of three or four large
lymph nodes situated deep to
the pectoralis minor near the
base of the axilla, in
association with the second
part of the axillary artery
Receives lymph from the
pectoral, subscapular, and
humeral groups of axillary
lymph nodes.
Efferent vessels from the
central group pass to the
apical group of lymph nodes.
Enlargement of the Axillary Nodes

The axillary lymph nodes enlarge and become tender
when infections of the upper limb occur

Infections in the pectoral region and breast, including
the superior part of the abdomen, can also produce
enlargement of axillary lymph nodes

The humeral group of nodes is the first one to be
involved in lymphangitis (inflammation of lymphatic
vessels) resulting from a hand infection

In carcinoma of the apical group, the lymph nodes often
adhere to the axillary vein, which may necessitate
excision of part of this vessel

Enlargement of the apical group of lymph nodes may
obstruct the cephalic vein superior to the pectoralis
minor.
lymphangitis (inflammation of lymphatic vessels)
Palpation of the Axillary Lymph Nodes
– Axillary nodes are palpated at deep
pressure using a circular motion with
the pads of the three middle fingers
of the examining hand
– in all five aspects of the axilla are
examined.
– Patient standing or sitting with the
hand of the examined side on the hip
pushing hard medially

Start palpating the central nodes deep in the
apex of the axilla between the pectoralis and
subscapular muscles

Proceeding down the mid-axillary chestwall,
gently move the pads of the fingers medially and
inside the border of the pectoral muscle and the
pectoral node group

Continue by palpating the subscapular nodes.
Sweep back up and return to the axilla with the
palm facing laterally, feeling inside the muscle of
the posterior axillary fold (subscapular muscle).

Check the lateral nodes with the palm of the
hand facing the humeral head pressing on
subclavian vein and the pulsating axillary artery.

By placing the finger tips high up in the axilla to
the outer border of 1st rib the apical group con
be palpated
DRAINAGE

On right side :
– The trunk drains into right
lymph trunk.

On left side :
– It drains into thoracic duct.