Armpit

Axillary region& brachial

plexus
M. & A. Page 423-429
 Objectives
• Identify bone structures and landmarks around axilla.
• Describe boundaries of axilla.
• Outline axillary artery and vein with their branches.
• Appreciate the importance of collateral circulation
around scapula.
• Review distribution of axillary lymph nodes.
• Describe in detail the brachial plexus (trunks, divisions,
cords and branches)
• Predict the result of injury to different parts of the
plexus.
Bones of upper limb
 The clavicle
• The medial end articulates with the manubrium
• The lateral end articulates with the acromion of
the scapula
• Cylindrical and S-shaped with the medial 2/3
being convex anteriorly
• The large vessels & nerves of the upper
extremity pass posterior to it
• Most frequently fractured in the middle third
portion the"most"common"fractured"bone"of"the"body
The clavicle
Fracture of clavicle
pulls"this"part"up
 Scapula
• Triangular flat bone overlying 2nd-7th ribs
• The spine divides the posterior surface into a
small supraspinoussupraspinatous"muscle
fossa and a much larger
infraspinous fossa
infraspinatous"muscle
• The costal surface has a large subscapular
fossa subscapularis"muscle
• The spine continues laterally as a flat expanded
acromion can"feel"it"bcz"it"projects"anteriorly
• The beak-like coracoid process is superior to the
glenoid cavity and project anterolaterally
 Scapula

much"larger
 Fascia of the upper limb
• The pectoral fascia is continuous with the
fascia of the abdominal wall
• Laterally it becomes the axillary fascia
• Clavicopectoral fascia between the first rib
and the coracoid process is the
costocoracoid membrane with"4"branches:"it"pierces"the"fascia
• It is pierced by the thoracoacromial artery,
the cephalic vein, and the lateral pectoral
nerve
lateral+less:+pectoralis+major
medial+more:+major+and+minor

• The axillary fascia is a continuation of the

prevertebral layer of the deep cervical fascia
 Axilla
Axilla is a pyramidal area at the junction of
the upper extremity and the trunk
(underarm)
Boundaries:
• Medially: Ribs 1-4, the intercostal muscles,
and the serratus anterior m.
greater"and"lesser"tubercle:"btwn"them"is"the"intertubercular"groove
• Laterally: The humerus(Specifically, the
floor of the intertubercular groove)
 Axilla
• Anteriorly: The pectoralis major and minor
mm.
• Posteriorly: The scapula and the
subscapularis, teres major, and latissimus
dorsi mm.
• Base: the axillary fascia and skin
• Apex: The interval between the clavicle,
scapula, and first rib
 Axilla
has"to"pass"through"axilla"to"reach
the"arm

• Structures within axilla: Axillary a. &v.,

Axillary lymph nodes, Branches of the +"nerves"must"pass
too
brachial plexus, Bicep brachii m.,
+"these"2"muscles
coracobrachialis m.
the"muscles"are"outside"the"sheath

• Structures in the axillary sheath: Axillary a.

& v., and the brachial plexus
Axilla
 Axillary artery
• The subclavian a. becomes the axillary a.
at the lateral border of the first rib. The
axillary a. becomes the brachial a. at the
inferior border of the teres major m.
• The pectoralis minor m. divides it into
three parts
 Axillary artery
• Branches of first part: Superior thoracic a.
• Branches of second part (Deep to
pactoralis minor m.): Thoracoacromial &
Lateral thoracic aa.
biggest branch

• Branches of third part: Subscapular a.,

Anterior & Posterior circumflex humeral
aa.
1"2"3"is"the"pneumonic

Eirst"part"1"division
2nd"part"2"divisions
3rd"part"3"divisions
 Axillary vein
• Originate at the inferior border of teres
major m. As a termination of the basilic
vein
• The vein lies superficial to the arteryimp"for"catheter
placement"etc…
Axillary artery
Axillary artery
 Collateral circulation
each"of"these"arteries"come"from"different"areas

• Around third"part
scapula: Suprascapular a.,
subscapular a. ( Circumflex scapular
branch), Dorsal scapular a.,Transverse
cervical
from"subclavian"a.
a., and intercostal aa.
• Ligation of a lacerated subclavian or
axillary may be done if necessary circulation
bcz"have"collateral

• Around the surgical neck of the humerus:

Anterior and Posterior circumflex humeral
aa. if"one"of"them"not"both
 Axillary lymph nodes
5 groups of axillary L.N.
• Pectoral (Receives lymph from anterior thoracic
wall including most of the breast)
• Subscapular (Posterior)
• Humeral (Lateral)
• Central
• Apical the  lateral  is  more  common  
the  medial

The lateral,pectoral,and subscapular drain into the

central nodes, which in turn drain into the apical.
The apical nodes drain into the subclavian trunk
medial:"internal"thoracic"drainage

they"are"in"order"of"severity"if"related"to"cancer
Axillary Lymph nodes
 Brachial plexus Question

• A large network of nerves that originate in

the neck and extends into the axilla, giving
rise to most of the nerves that supply the
upper extremity it"is"mainly"somatic an"exception"that"is"rare

• Ventral Rami C5, C6, C7,C8,and T1is"from"C4

• Rami pass between anterior & middle
scalene mm.
• 2 nerves branch off rami: Dorsal scapular
n. ( C5), Long thoracic n. ( C5,C6,and C7)
for"serratus"anterior
 Ron"Tailor"drinks"cold"beer

Brachial plexus
becomes
starts"as

• Rami – Trunk – Divisions – Cords –

Branches
• 2 nerves branch off the superior trunk of
the brachial plexus
• The Suprascapular nerve (C5and C6) imp
• The nerve to the subclavius
muscle"is"not"imp
(C5) not"imp"at"all"!!!

• Each trunk divides into anterior & posterior

division
 Brachial plexus
The divisions of the trunk form three cords
that are named for their position in relation
of the second part of the axillary a.
• Anterior division of the superior & middle
trunks unite to form lateral cord
• Anterior division of the inferior trunk
continues as the medial cord
• Posterior division of all the three trunks
unite to form posterior cord
Long thoracic supplies the serratus anterior
Musculocutaneous+nerve:+from+lateral+cord

Median+nerve:+lateral+root+from
lateral+cord+and+medial+root+from+
medial+cord
Brachial plexus
Ulnar+nerve:+lateral+root+of+medial+cord

know"each"from"which"rami"is"coming
3"trunks

5"rami"!

Terminal"nerve
 Terminal branches
part"is"muscular"and"part"is"cutaneous

• Lateral cord: Musculocutaneous n.(

C5,C6,and C7)
• Medial cord: Ulnar n. (C8,and T1)
• Medial & Lateral cord branches: Median
n.( C5,C6,C7,C8,And T1) largest"branch

• Posterior cord: Axillary (C5, C6) & radial (

C5,C6, C7, C8,T1)nn.
• The radial nerve is the largest branch of
the plexus
Cutaneous nerves of the upper
limb

C6,"C7,"C8"

Thumb:"C6
First"2"Eingers:"C7
last"2"Eingers:"C8
Cutaneous innervation

nah:"you"will"learn"it
dermatome"much"more"imp
 Myotome
• Biceps C5 efferent, C6 afferent.
• Tricep C7
• Brachioradialis C6
 Brachial plexus injury
• Injuries to the plexus affect movement and
cutaneous sensations in the upper limb
• Signs and symptoms depends which part
is involved
• Erb-Duchene Palsy: Injury to the superior
part of the brachial plexus ( C5,& C6),
Waiter’s  tip  posture.arm"medially"rotated"and"hand"pointed"backwards
• Klumpke pulsy: Lower brachial plexus
involvement (C8, &T1) Claw hand posture
Brachial plexus injury

head"is"up"and"plexus"is"injured"
due"to"falling"down