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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

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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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