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Superficial muscles of the back: Arranged in two layers: First layer: 1. Trapezius 2. Latissimus dorsi Second layer: 1. Levator scapulae 2. Rhomboideus major and minor 1.Trapezius: Origin: ᴥ Superior nuchal line of occipital bone ᴥ ligamentum nuchae ᴥ Spinous process and supraspinous ligaments of all thoracic vertebra Insertion: ᴥ Posterior border of the lateral one third of the clavicle ᴥ Medial border of acromion and upper lip of the crest of spine of scapula ᴥ Deltoid tubercle Actions: ☻Upper and lower fibers – rotate the scapula ☻ Upper fibers along with levator scapulae elevate the scapula ☻ Middle fibres of trapezius and the rhomboids together retract the scapula Nerve supply: Spinal part of accessory nerve 2.Latissimus dorsi: Origin: ᴥ lower six thoracic spines and supraspinous ligaments ᴥ Spines and supraspinous ligaments of all lumbar and sacral vertebra ᴥ Outer lip of iliac crest Insertion: ᴥ Floor of intertubercular sulcus of humerus Nerve supply: Thoracodorsal Actions: ☻Extension of shoulder joint ☻ In combination with the pectoralis major it is powerfull adductor 3.Levator scapulae: Origin: ᴥ Transverse process of upper four cervical vertebra Insertion: ᴥ Dorsal aspect of vertebral border of scapula Nerve supply: Ventral rami of C3 and C4 Actions: Elevates the scapula in combination with upper part of trapezius 4.Rhomboideus major: Origin: ᴥ Spinous process of T2 to T5 Insertion: ᴥ Dorsal aspect of medial border of scapula Nerve supply: Dorsal scapular nerve 5.Rhomboideus minor: Origin: ᴥ Ligamentum nuchae ᴥ Spinous process of C7 and T1 Nerve supply: Dorsal scapular nerve Actions: ♥ Combined with middle fibres of tapezius retract the scapula ♥ With levator scapula depress the shoulder THE BREAST / MAMMARY GLAND: It is present in both sexes It is a modified sweat gland Situation: 1 It lies in the superficial fascia 2 3 Extent: 4 5 Vertical: 6 Second to sixth rib Horizontal: Later border of sternum to the mid axillary line Axillary tail of spence Relations: ☻ Pectoral fascia ☻ Pectoralis major muscle ☻ Serratus anterior muscle ☻ External oblique muscle Retro-mammary Mammary bed space External oblique Serratus anaterior Features in the skin: Nipple: It lies at the level of fourth intercostal space in nulliparous females Areola: It is a circular area of skin around the base of the nipple Arterial supply: Venous Drainage: Azygous vein Internal vertebral venous plexus Posterior intercostal vein Axillary vein Internal thoracic vein Intracranial saggital & transverse sinus CIRCULUS VENOSUS Clavicle and humerus Lymphatic drainage: It consists of two sets: ◙ Those draining the parenchyma of the breast including areola and nipple ◙Those draining the overlying skin excluding areola and nipple First set: ◙ Those draining the parenchyma of the breast including areola and nipple: From the parenchyma: Subareolar plexus of sappey Drainage: Posterior group Intercostal nodes Parasternal lymph nodes Anterior group Central group Apical group Second set: Those draining the overlying skin excluding areola and nipple Infraclavicular nodes Axillary nodes Sub diaphragmatic lymph nodes Supraclavicular nodes Parasternal nodes Subperitoneal lymph plexus Krukenberg’s tumour Hepatic nodes Drainage Applied anatomy: The breast is the frequent site of carcinoma Peau d’ orange Muscles of Pectoral Region: It Includes: ┼ Pectoralis minor ┼ Subclavius ┼ Serratus anterior ┼ Pectoralis major Pectoralis major: Origin: ♣ Clavicular head ♣ Sternocostal head Insertion: Lateral lip of intertuberculus sulcus of humerus Nerve supply: Medial and lateral pectoral nerve Actions: ♥ Medial rotation and adduction of the shoulder joint ♥ Clavicular head produces flexion of shoulder joint ♥ Sterno-costal head helps in extension to bring flexed humerus to the side as in climbing Pectoralis minor: Origin: Third to fifth ribs Insertion: Medial border and upper surface of the coracoid process Nerve supply: Medial and lateral pectoral nerve Action: Assisted by serratus anterior muscle protracts the scapula Along with levator scapulae and rhomboideus it depresses the shoulder Subclavius: Origin: Junction of first rib and its costal cartilage Insertion: Groove on the undersurface of the middle third of the clavicle Nerve supply: Nerve to subclavius Action: Stabilise the calvicle during the shoulder movements Clavipectoral fascia It is a strong sheet of fascia which stretches from the pectoralis minor to clavicle Structures piercing the fascia: Cephalic vein Lymphatics Lateral pectoral nerve Thoraco-acromial vessels Serratus anterior: Origin: Eight fleshy digitations from outer surface and upper border of upper eight ribs Insertion: Costal surface along the medial border of scapula Nerve supply: Long thoracic nerve Action: Along with pectoralis minor protracts the scapula With upper and lower fibers of trapezius it rotates the scapula forward and upwards AXILLA /ARMPIT: Situation: It is a pyramidal shaped space present between upper end of arm and lateral thoracic wall 1 Boundaries: 1. Apex 3 2. Base 3.Anterior wall 4. Posterior wall 5 6 4 5. Medial wall 6. Lateral wall 2 1. APEX: It is also called as cervico-axillary canal 2. Base: Infront : Anterior axillary fold Behind: Posterior axillary fold 3. Anterior wall 4. Posterior wall 5. Medial wall 6. Lateral wall Contents: 1. Axillary artery and its branches 2. Axillary vein and its tributaries 3. Cords of brachial plexus and their branches, long thoracic and intercosto brachial nerve 4. Axillary lymph nodes 5. Axilary fat and occasionally axillary tail of the breast Axillary artery: It is a continuation of third part of subclavian artery at the outer border of first rib Branches: First part: Superior thoracic artery Second part: Thoraco acromial artery Lateral thoracic artery Third part: Subscapuar artery Anterior circumflex scapular artery Posterior circumflex artery Quadrangular space Scapular anastomosis: In each of subscapular, supraspinous and infraspinous fossae Suprascapular Deep branch of transverse cervical arteries With Circumflex scapular artery Over the Acromion Process: Acromial branch of Suprascapular artery Thoraco-acromial artery With Posterior circumflex humeral arteries Brachial plexus: ♥ Muscles of upper limb receive innervation from nerves of the brachial plexus Formation: Lower four cervical nerves and the first thoracic nerve (C5-8) and T1 Parts of Brachial Plexus: It consists of R = ROOTS (Ventral rami) T = TRUNKS D = DIVISIONS C = CORDS B = BRANCHES Roots join to form Trunks! (in neck) • Ventral Rami • • • • • C5 C6 C7 C8 T1 Trunks Upper trunk Middle trunk Lower trunk Trunks Split to form Divisions! (in neck) • Trunks Divisions Anterior • Upper Posterior Anterior • Middle • Lower Posterior Anterior Posterior Divisions Join to form Cords! (in axilla) Trunks U Divisions A MEDIAL CORD P A L LATERAL CORD P A M Cords P POSTERIOR CORD Cords Give off Branches!! (in axilla) LATERAL CORD LATERAL PECTORAL NERVE MUSCULOCUTANEOUS LATERAL ROOT OF MEDIAN NERVE MEDIAL PECTORAL NERVE MEDIAL CORD MEDIAL ROOT OF MEDIAN NERVE MEDIAL CUTANEOUS NERVE OF ARM MEDIAL CUTANEOUS NERVE OF FOREARM ULNAR NERVE UPPER SUBSCAPULAR POSTERIOR CORD THORACODORSAL LOWER SUBSCAPULAR AXILLARY NERVE RADIAL NERVE APPLIED ANATOMY: 1. ERB’S PARALYSIS: Site of injury: Upper Trunk of Brachial plexus Cause of injury: Undue separation of the head from shoulder Nerves roots involved: C5 – C6 Muscles paralysed: Biceps, Deltoid, Brachialis & Brachioradialis. Partly supraspinatus, infraspinatus and supinator Deformity: (Position of the limb) Arm: Adducted and Medially rotated Forearm: Extended and Pronated The deformity is known as Policeman’s tip hand or Porter’s tip paralysis Disability: 1. Abduction and lateral rotation of the arm is lost 2. Flexion and supination of the forearm is lost 2. Klumke’s Paralysis: Site of injury: Lower trunk of brachial plexus Cause of injury: Undue abduction of arm Nerves roots involved: T1 and partly C8 Muscles paralysed: Intrinsic muscles of the hand (T1) Ulnar flexors of the wrist and fingers (C8) Deformity: (Position of hand) Claw hand 3.Injury to the nerve to serratus anterior muscle: Cause: Sudden pressure on the shoulder from above Carrying heavy loads on the shoulder Deformity: Winging of scapula Disability: Loss of pushing and punching movements Arm cannot be raised beyond 90o