Download DISCUSSION-IV. Committee

kaan yücel
11.04.2014
most common cancer among women, other than skin cancer
second leading cause of cancer death in women, after lung cancer
Chance of a woman having an invasive breast cancer some time
during her life about 1 in 8
Understanding the lymphatic drainage of the
breasts is of practical importance in predicting the
metastasis (dispersal) of cancer cells from a
carcinoma of the breast (breast cancer).
spreads by means of lymphatic vessels (lymphogenic metastasis),
which carry cancer cells from the breast to the lymph nodes,
chiefly those in the axilla
Digital mammograms replacing conventional film mammography
younger women with dense breast tissue benefit most from this type of mammography.
Surgeons use mammography as a guide when removing breast
tumors, cysts, and abscesses.
jagged density in the
mammogram. The skin is
thickened over the tumor
and the nipple is
depressed
breast excision
simple mastectomy
breast is removed down to the retromammary space.
radical mastectomy more extensive surgical procedure
removal of the breast, pectoral muscles, fat, fascia, and as many
lymph nodes as possible in the axilla and pectoral region.
accessory nipples
rudimentary nipple & areola
mistaken for a mole (nevus)
anywhere along a line
extending from the axilla to the
groin—embryonic mammary
crest (milk line) from which the
breasts develop.
Polymastia
no breast development
There may be a nipple and/or areola, but no glandular tissue.
Deep to the pectoral
fascia & pectoralis major
Descends from the
clavicle
Clavipectoral
triangle
cephalic vein can
be found.
formed by
pectoralis major,
deltoid & clavicle
Deltopectoral groove
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In the subcutaneous
tissue overlying the
pectoralis major and
minor muscles.
lateral border of the
sternum to the
midaxillary line
vertically from the
2nd through 6th ribs.
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sagital T2 MRI slices,
shows an ugly posterior
dislocation of 6th
cervical vertebra, with
fracture of the body,
and a spinal cord
contusion and edema
up and down from the
compresion.
C2
C8
Tendon Reflexes & Segmental Innervation of
Muscles of the Upper Limb
Triceps tendon reflex
C6, 7, and 8
extension of the elbow joint by tapping the triceps tendon
The scapular anastomosis system is 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. Anterior circumflex humeral
artery and posterior circumflex humeral artery are both branches of the third part of the
axillary artery. The posterior circumflex humeral artery anastomoses with anterior
circumflex humeral artery and also with branches from profunda brachii (a branch of
brachial artery), suprascapular (a branch of subclavian artery) and thoracoacromial (a
branch of axillary artery) arteries, and branches of thoracic aorta as well.
All these 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.
Principal muscles acting on the shoulder joint
Abductors
Supraspinatus
Deltoid
Adductors
Pectoralis major
Lattisimus dorsi
Extensors
Teres major
Lattisimus dorsi
Deltoid (posterior fibres)
Flexors
Pectoralis major
Coracobrachialis
Deltoid (anterior fibres)
Medial rotators
Pectoralis major
Lattisimus dorsi
Teres major
Deltoid (anterior fibres)
Subscapularis
Lateral rotators
Infraspinatus
Teres minor
Deltoid (posterior fibres)
Movement of
Scapula
Elevation
Depression
Protraction
Retraction
Upward rotationa
Downward
rotationb
Muscles Producing Movementa
Nerve to Muscles
Trapezius, descending part
Levator scapulae
Rhomboids
Gravity
Pectoralis major, inferior
sternocostal head
Latissimus dorsi
Trapezius, ascending part
Serratus anterior, inferior part
Pectoralis minor
Serratus anterior
Pectoralis major
Pectoralis minor
Trapezius, middle part
Rhomboids
Latissimus dorsi
Trapezius, descending part
Trapezius, ascending part
Serratus anterior, inferior part
Gravity
Levator scapulae
Rhomboids
Latissimus dorsi
Pectoralis minor
Pectoralis major, inferior
sternocostal head
Spinal accessory (CN XI)
Dorsal scapular
Range of Movement (Angular
Rotation; Linear Displacement)
10-12 cm
Pectoral nerves
Thoracodorsal
Spinal accessory (CN XI)
Long thoracic
Medial pectoral
Long thoracic
Pectoral nerves
Medial pectoral
Spinal accessory (CN XI)
Dorsal scapular
Thoracodorsal
Spinal accessory (CN XI)
Long thoracic
Dorsal scapular
Thoracodorsal
Medial pectoral
Pectoral nerves
40-45°; 15 cm
60°; inferior angle: 10-12 cm,
superior angle: 5-6 cm
Movement of Scapula Muscles Producing Movement
Elevation
Depression
Protraction
Retraction
Upward rotationa
Downward rotationb
Trapezius, descending part
Levator scapulae
Rhomboids
Gravity
Pectoralis major, inferior sternocostal head
Latissimus dorsi
Trapezius, ascending part
Serratus anterior, inferior part
Pectoralis minor
Serratus anterior
Pectoralis major
Pectoralis minor
Trapezius, middle part
Rhomboids
Latissimus dorsi
Trapezius, descending part
Trapezius, ascending part
Serratus anterior, inferior part
Gravity
Levator scapulae
Rhomboids
Latissimus dorsi
Pectoralis minor
Pectoralis major, inferior sternocostal head
Nerve to Muscles
Spinal accessory (CN XI)
Dorsal scapular
Pectoral nerves
Thoracodorsal
Spinal accessory (CN XI)
Long thoracic
Medial pectoral
Long thoracic
Pectoral nerves
Medial pectoral
Spinal accessory (CN XI)
Dorsal scapular
Thoracodorsal
Spinal accessory (CN XI)
Long thoracic
Dorsal scapular
Thoracodorsal
Medial pectoral
Pectoral nerves
Clavicular (anterior) part of deltoid muscle
flexes and medially rotates arm
Axillary nerve
Lateral third of clavicle-Deltoid tuberosity of humerus
Teres major
Adducts and medially rotates arm
Inferior subscapular nerve
Posterior surface of inferior angle of scapula-Medial lip of intertubercular
sulcus of humerus
Subscapularis
Medially rotates arm; as part of rotator cuff, helps hold head
of humerus in glenoid cavity
Sup. & Inf. subscapular nerves
Subscapular fossa (most of anterior surface of scapula)-Lesser tubercle of
humerus
Pectoralis major
Adducts, flexes, and medially rotates
Latissimus dorsi
Extends, adducts, medially rotates humerus (arm) the arm.
Lateral and medial pectoral nerves
Thoracodorsal nerve




Spinous processes of T7 to L5
Sacrum
Iliac crest
Ribs 10 to 12
Floor of intertubercular
sulcus of humerus
Clavicular head: Medial half of clavicle
Sternocostal head:
Anterior surface of sternum
Superior six costal cartilages
Aponeurosis of external oblique muscle
Lateral lip of
intertubercular
sulcus of
humerus
Infraspinatus
Suprascapular nerve
Infraspinous fossa of scapula-Middle facet of
greater tubercle of humerus
Teres minor
Axillary nerve
Middle part of lateral border of scapula-Inferior
facet of greater tubercle of humerus
Deltoid
Spinal (posterior) part:
Axillary nerve
Extends and laterally rotates arm
Spine of scapula-Deltoid tuberosity of humerus
Clavicular (anterior) part of deltoid muscle
flexes and medially rotates arm
Axillary nerve
Lateral third of clavicle-Deltoid tuberosity of
humerus
Deltoid Acromial (middle) part: abducts arm
Supraspinatus
Suprascapular nerve
Initiates and assists deltoid in abduction of arm and
acts with rotator cuff muscles.
Coracobrachialis
Tip of coracoid process of
scapula
Latissimus dorsi
Extends, adducts, medially rotates
humerus (arm)
Thoracodorsal nerve
Middle third of medial surface
of humerus
Musculocutaneous nerve
(C5, C6, C7)
Helps flex and adduct arm; resists
dislocation of shoulder
Pectoralis major
Adducts, flexes, and medially rotates the arm.
Lateral and medial pectoral nerves
Triceps
brachii
Brachialis
Distal half of anterior surface
of humerus
Coronoid process and
tuberosity ulna
Long head:
infraglenoid
tubercle of
scapula
Lateral head:
posterior
surface of
humerus,
superior to
radial groove
Medial head:
posterior
surface of
humerus,
inferior to
radial groove
Proximal end
of olecranon of
ulna and fascia
of forearm
Musculocutaneous nerve
(C5, C6, C7) and small
contribution by the
radial nerve at the lateral
part
Radial
nerve
(C6, C7, C8)
Chief extensor of
forearm; long
head resists
dislocation of
humerus;
especially
important during
adduction
Flexes forearm in all positions
Pronator teres
Pronates and flexes forearm (at elbow)
Flexor carpi radialis
Flexes and abducts hand (at wrist)
Abduction of the wrist= Radial deviation with extensor carpi
radialis longus et brevis.
Flexor carpi ulnaris
Flexes and adducts the wrist joint
Adduction of the wrist= Ulnar deviation with extensor carpi
ulnaris
Brachioradialis
Relatively weak flexion of
forearm; maximal when forearm
is in midpronated position; an
accessory of flexor of the elbow
joint
Palmaris longus
Flexes hand (at wrist) and tenses palmar aponeurosis
Flexor digitorum superficialis
Flexes proximal interphalangeal joints of the index,
middle, ring, and little fingers; can also flex
metacarpophalangeal joints of the same fingers and the
wrist joint
Flexor digitorum profundus
flexes the distal phalanges of the medial four fingers
after the flexor digitorum superficialis has flexed their
middle phalanges (i.e., it curls the fingers and assists
with flexion of the hand, making a fist). Each tendon is
capable of flexing two interphalangeal joints, the
metacarpophalangeal joint. Because the tendons cross
the wrist, it can flex the wrist joint as well.
Extensor carpi radialis longus
extends and abducts the wrist
Extensor carpi radialis brevis
extends and abducts the wrist
Extensor digitorum
major extensor of the four fingers (index, middle,
ring, and little fingers)
Extends medial four digits primarily at
metacarpophalangeal joints, secondarily at
interphalangeal joints
; can also extend the wrist
Extensor carpi ulnaris
Extends and adducts hand at wrist joint (also active
during fist clenching)
Biceps brachii
Short head: tip of
coracoid process of
scapula
Long head:
supraglenoid tubercle
of scapula
Tuberosity of radius
and fascia of forearm
via bicipital
aponeurosis
Musculocutaneous
nerve (C5, C6, C7)
pronator quadratus is the prime mover for pronation.
Supinates forearm and,
when it is supine. flexes
forearm; short head resists
dislocation of shoulder
A terrible accident
in the highway.
A public bus
involved.
Many deaths and
injured.
Your patient has the following findings
following a thorough neurological exam:
 The patient is unable to extend the wrist.
 Loss of sensation on the lateral and
posterior parts of the forearm
Which nerve(s) injured?
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Innervation of the posterior compartment of the arm 1 POINT
A. Ulnar nerve
C. Median nerve
B Radial nerve
D. Axillary nerve
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Triceps tendon reflex
2 PTS
A. C6
C. C6-C7-C8
B C6 & C7
D. C7
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A branch not from the 3rd part of the axillary artery
3 PTS
A. Subscapular artery
C. Posterior circumflex humeral artery
B Anterior circumflex humeral
artery
D. Lateral thoracic artery
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