Surface Anatomy from Anterior Side.

The surface of the axilla (known as the "armpit" in layman's terms) is defined by an anterior axillary fold and a
posterior axillary fold; the axillary fossa lies between these.

The anterior axillary fold is formed by skin overlying the lower border of the pectoralis major muscle.

The posterior axillary fold is formed by skin overlying the tendons of the latissimus dorsi and teres major muscles.
The axilla is a pyramidal -shaped space between the upper limb and the thoracic wall.

The Apex of the axilla, through which vessels and nerves pass from the neck, is formed by the convergence of
first rib, clavicle, and scapula.

Borders/Walls: The axilla has anterior (A), medial (M), posterior (P) and lateral (L) borders.

The lower border of the teres major muscle defines the lower border of the axilla.
Walls of the axilla

Anterior wall: the pectoralis major m. and pectoralis minor m. In this cadaver view, the pectoralis major has been
reflected and a glimpse of the axillary contents can be obtained. Note that the lateral border of pectoralis major
muscle (when covered with skin) makes the palpable anterior axillary fold.

Posterior wall: the subscapularis m, tendons of teres major and latissimus dorsi m. The teres major m. and
latissimus dorsi m. tendons, along with overlying skin make up the palpable posterior axillary fold.

Medial wall of the axilla - the serratus anterior m.

Lateral wall: intertubercular groove of humerus.

Axillary Vein:
In the cadaver, the Axillary vein is typically the largest element in the axilla. This vein drains into the subclavian
vein above and receives venous blood from a number of major veins arriving from the upper extremity: the
cephalic vein, the basilic vein as well as veins of named arteries (e.g. subscapular, lateral thoracic).

Axillary lymph nodes. These are large and of clinical importance because of their frequent invasion by cancer
cells from the breast. Lymph from the upper extremity as well as the breast drains into the axillary nodes.
Lymphatics:

Most of the lymphatic drainage from the breast is into the axillary lymph nodes with a small portion draining into
the parasternal nodes. The general direction of lymphatic drainage is shown by the red arrows.

The axillary nodes are important during breast cancer since metastatic cells typically invade these lymph nodes
before entering the circulatory system. These nodes are often surgically sampled and assessed in the staging of
breast cancer.

Lymphatic fluid from the upper extremity also empties into the axillary nodes. Loss (removal) of axillary lymph
nodes during breast cancer surgery can lead to the condition of lymphedema, which is a swelling and hardening
of the upper extremity as lymph collects in interstitial spaces.
The axillary artery is a named artery that from the clavicle to the lower border of teres major m. It arises from the
subclavian a. and ends as the brachial a.
Branches of the axillary artery. The overlying pectoralis minor m. defines three divisions of the axillary artery:

1st part: gives off the superior thoracic a.

2nd part: (located deep to pec minor m tendon): gives off 2 branches: the thoracoacromial a. and the lateral
thoracic a. (in the female, the lat. thoracic a. is large and supplies lateral part of the mammillary gland).

3rd part: gives off 3 branches: the subscapular a. (largest branch!); anterior humeral circumflex a., posterior
humeral circumflex a.

***Remember that, because of extensive anastomoses around the scapula, in order to cut off all blood supply to
the upper extremity the ligation must be placed distal to the subscapular branch of the axillary art. Ligation of the
axillary a. above that point can result in a reversal of blood flow direction in the subscapular artery (from the
collateral scapular circulation arriving via the suprascapular, transverse cervical and intercostal arteries) and
thereby enable arterial blood to enter the brachial artery.
Brachial plexus in the axilla consists of Cords and Terminal Branches. The three cords are named according to
their position relative to the axillary artery:

 Lateral (L)
 Medial (M)
 Posterior (P)

The terminal branches of the lateral and medial cords form the classical sideways "M" that is your guide to
dissecting the plexus.
Overview of plexus. The brachial plexus begins in the neck as ventral rami of nerves C5 - C8 and T1. These are
called the Roots of the plexus. (note these are not ventral or dorsal roots but ventral rami!!!)
The roots form 3 Trunks of the plexus: superior trunk (C5 & C6); middle trunk (C7) and inferior trunk (C8
and T1).

Each trunk splits into 2 Divisions: anterior and posterior. Functional significance: Generally, the anterior
divisions supply flexors and posterior divisions supply extensors of upper limb.

The divisions form the Cords of the plexus: The three posterior divisions join to form the posterior cord (C5-T1).
The Anterior divisions of the superior and middle trunks join to form the lateral cord (C5-C7). The anterior division
of the inferior trunk forms the medial cord (C8T1).

Each of the 3 cords of the plexus end as 2 terminal branches.

(The plexus parts are named like a tree's parts (roots, trunks, divisions, cords and branches).
Schematic showing the organization of the plexus and the "Robert Taylor Drinks Cold Beer" mnemonic (roots,
trunks, divisions, cords, branches).
In addition to the terminal branches, other named nerves also arise from each of the cords of the plexus.

Lateral cord: gives off the lateral pectoral nerve, before splitting into its 2 terminal branches (musculocutaneous
and lateral root of median nerve).
Medial cord: gives off the medial pectoral nerve; medial brachial cutaneous nerve; the medial antebrachial
cutaneous nerve and then ends as its 2 terminal branches (ulnar nerve; medial root of median nerve).

Posterior cord: gives off the upper subscapular n; thoracodorsal nerve; lower subscapular nerve before splitting
into its 2 terminal branches (axillary nerve; radial nerve).
Schematic showing the musculocutaneous nerve's course and its sensory map.
Medial cord terminal branches and the course of the median and ulnar nerves in the arm.

Neither of these nerves innervate structures in the arm; the main target of the median nerve is the anterior
compartment of the forearm, while the main target of the ulnar nerve are the intrinsic muscles of the hand.
Posterior cord schematic. The axillary artery and the medial and lateral cords have been reflected in the
schematic to show the terminal branches (axillary and radial nerve) and other nerves (upper and lower
subscapular and thoracodorsal nerves) that arise from this cord.
"Upper plexus injuries"- Superior Trunk Injury.

These injuries can result from stab or bullet wounds of neck; trauma that separates shoulder and neck (i.e. pulling
on face mask in football, landing on shoulder after a fall such as from a motorcycle and more commonly -
stretching an infant's neck too much during a normal vaginal delivery.

Superior trunk injuries disrupt the upper plexus feed to the extremity (the superior trunk carries C5-6 neural feed).

This affects scapular muscles - rhomboids, levator scapulae, supra- and infraspinatus (lateral rotator), as well as
muscles innervated by the musculocutaneous nerve (flexors of elbow and arm). The patient with superior trunk
injury presents with the limb in the "waiter's tip position" (hanging extended (flexors are paralyzed), in medial
rotation (lateral rotators are paralyzed).

This is also called Erb-Duchenne's paralysis or Erb's palsy (or waiter's tip palsy).
"Lower plexus injuries" (Inferior Trunk injury)

These are less common than upper plexus injuries. They can occur by suddenly pulling the upper limb superiorly
(e.g. pulling on an infant's limb during a breech delivery, grabbing to break a fall (from a tree). These injuries
interrupt the feed from the C8-T1 spinal cord segments and affect the distal parts of the upper extremity - i.e.
crippling of the hand.

Neurovascular compression (thoracic outlet - or inlet syndrome) can also produce lower plexus injury. The
compression can be due to an extra rib associated with the C7 vertebrae (present in 1% of people), or by a very
broad tendinous, overdeveloped, or spastic anterior scalene muscle in the neck.

A patient with inferior trunk injury presents with anesthesia on the medial surface of arm and hand and
paralysis/atrophy of muscles innervated by the ulnar nerve. Claw hand that is crippling is present. This is also
called Klumpke's paralysis (or palsy).
Injury to the posterior cord of the plexus can result from poorly fitting (too long) crutches, undue compression
due to falling asleep with arm over a chair - "Saturday Night palsy"). This affects mainly the radial nerve terminal
branch of the posterior cord. The patient presents with paralysis of the extensors of the elbow, wrist, digits - wrist
drop.
The Arm or the Brachium contains a single bone - the humerus.

There are 2 muscle compartments in the arm: Anterior and Posterior. The muscles in the anterior compartment
are flexors while those in the posterior compartment are extensors.

All anterior compartment muscles (3) are innervated by the musculocutaneous nerve. All posterior compartment
muscles (2) are innervated by the radial nerve.
Elbow joint (humerus with radius and ulna):

Note that the head of the radius articulates with the capitulum of the humerus.
The proximal ulna has two prominent projections - the olecranon (posterior) and the coronoid process (anterior).
Together, these processes form the walls of the trochlear notch (resembles the jaws of a crescent wrench). The
trochlea of the humerus fits into the trochlear notch of the ulna.

On the posterior side, the large olecranon of the ulna articulates in the olecranon fossa of the humerus. The
olecranon is the palpable "back of the elbow".

While the head of the radius is at the elbow, the smaller "head" of the ulna is distal (not shown on this slide). The
radial tuberosity is located just distal to the neck of the radius.
Ligaments of the elbow region:

Radial collateral ligament, Ulnar collateral ligament and the Joint capsule.
Note that the insertion tendon of the triceps brachii muscle to the olecranon contributes stability to the back of the
elbow joint.

There are several bursae around the elbow joint; the subcutaneous olecranon bursae are clinically important.

The Annular Ligament is NOT part of the elbow joint. This ligament wraps around the head of the radius and
stabilizes the proximal radio-ulnar joint.
Two common clinical problems:

Bursitis of the elbow: The subcutaneous bursae of the olecranon can become problematic when they are
inflamed and produce bursitis. This can occur after injury, or as a result of excessive pressure and friction on the
olecranon region (e.g. "student's elbow").

Posterior dislocation of elbow. The x-ray shows a common type of dislocation which results from forcible
hyperextension of the elbow or falls on the hands with the elbows flexed; the trauma moves the ulna posteriorly.
This can cause the ligaments to rupture, and sometimes a fracture will result. If the displaced bones compress
nerves and blood vessels around the elbow, immediate reduction (repositioning) of the dislocation to relieve
pressure is required.
BONES OF FOREARM

Radius: This is the shorter bone located on the lateral or **thumb side** (to find the radius, look for the thumb!).
The head of the radius and the radial tuberosity are proximal; the styloid process is distal.

Ulna: This is a larger bone than the radius ; it has a prominent olecranon (back of the elbow). Other parts of the
ulna to know: coronoid process (anterior lip), trochlear notch, ulnar tuberosity, head and styloid process (both
distal).

Note that radius extends about 1 cm more distal than the ulna). There is an articular disc between the distal end
of the ulna and the carpal bones.

The tough interosseous membrane is located between the radius and ulna and divides the forearm into
anterior and posterior compartments.
Breaks of the distal radius (from breaking falls with an outstretched hand) are very common. This is called Colle's
fracture. The distal part of the radius can be displaced dorsally, leading to an appearance referred to as a "dinner
fork" abnormality.
Very often, the scaphoid bone (a proximal row carpal bone - thumb side) is also fractured in this type of injury. In
addition, the lunate bone can undergo anterior dislocation with such an injury, a situation that may lead to carpal
tunnel syndrome in the future.
MOVEMENTS AT THE ELBOW

The elbow is a hinge joint: Only flexion (anterior movement of the forearm) and extension (return to anatomical
position) are possible - NO Abduction or Adduction is done at this joint. Hyperextension is not normal.

The front of the elbow is called the cubital region.

Coracobrachialis: This crosses only the shoulder joint; the musculocutaneous nerve pierces this muscle. It
flexes the arm at the shoulder joint. It does NOT act at the elbow.

Biceps brachii: This crosses both the shoulder and the elbow joints; the musculocutaneous nerve lies deep to it.
The short head of biceps is more medially located than the long head of biceps.

The tendon of the long head of the biceps tendon wraps the head of humerus and carries a synovial sheath with
it through the intertubercular groove ("bicipital groove").

The biceps is a flexor of the elbow and a powerful supinator of the radioulnar joints; it is also a weak flexor of the
shoulder joint.
Deep compartment of Anterior arm

This contains the brachialis muscle, which is the main flexor of the elbow joint. In the schematic, the biceps has
been removed and the musculocutaneous nerve is shown emerging from the coracobrachialis muscle.

In the arm, the targets of the musculocutaneous nerve are motor, however the nerve continues into the forearm
as a purely sensory nerve (here it is also called the lateral antebrachial cutaneous nerve).

Injury of musculocutaneous nerve in the axilla weakens flexion at elbow joint, weakens supination, and produces
a loss of sensation on the lateral surface of the forearm.
Summary of Posterior Musculature of the Arm

The extensor compartment of the arm contains 2 muscles (the triceps brachii and the anconeus ); all
musculature here is innervated by the radial nerve.
Radial nerve: Enters the arm from the axilla and passes inferolaterally around the humerus in the radial groove.
It passes between the lateral and medial heads of the triceps brachii muscle.
Above the elbow on the lateral side, the radial nerve moves anteriorly and divides into deep and superficial
branches.
Because of its proximity to the humerus, the radial nerve is frequently damaged when fractures of the humerus
occur. If the injury is proximal, paralysis of all extensors in the upper extremity occurs. However, if the radial
nerve is injured at or below the radial groove, the triceps is not completely paralyzed.
The classic presentation of radial nerve injury is "wrist drop", as shown. This is due to paralysis of the wrist
extensor muscles in the forearm.

Other major nerves that are present in the arm (median and ulnar) pass through the arm but do not innervate any
brachial muscles.
Arterial supply.

The axillary artery becomes the brachial artery distal to the lower border of the teres major muscle. The first
branch of the brachial artery in the arm is the profunda brachii (deep brachial artery). The profunda brachii splits
into radial collateral and medial collateral branches at the elbow.

The brachial artery gives rise to the superior ulnar collateral artery (middle of arm) and the inferior ulnar
collateral artery (just above the elbow). At the cubital region, the brachial artery ends by splitting into the radial
and ulnar arteries.

Note: the brachial artery is occasionally double; when this occurs, one artery lies superficial to the medial nerve
and is called the superficial brachial artery. This ("high bifurcation" of the brachial artery) is not uncommon.

When taking arterial blood pressure: the sphygmomanometer is typically used to compress the brachial art
against the humerus and a stethoscope is placed over the brachial artery in the cubital fossa just medial to the
biceps tendon.
It is not uncommon to find a high division of the brachial artery in the arm. In that case, the radial and ulnar
arteries can begin in the superior or middle part of the arm. Variations are important to consider when performing
venous injections or blood draws.