PowerPoint Handout: Lab 8, Axilla and Brachial Plexus

Slide Title Slide Number Slide Title Slide Number

Axilla: Introduction Slide 2 Infraclavicular Branches: Medial & Lateral Pectoral &
Slide 14
Subclavian Nerve
Axilla: Contents Slide 3
Infraclavicular Branches: Medial Cutaneous Nerves
Slide 15
Axillary Artery: Review Slide 4 of Arm and Forearm

Axillary Vein Terminal Branches: Musculocutaneous Nerve Slide 16

Slide 5
Axillary Lymph Nodes Terminal Branches: Median Nerve Slide 17
Slide 6
Upper Limb Lymph Drainage Terminal Branches: Ulnar Nerve Slide 18
Slide 7
Brachial Plexus: Introduction Terminal Branches: Axillary Nerve Slide 19
Slide 8
Brachial Plexus: Upper Trunk Injury Surgical Neck Fracture of Humerus Slide 20
Slide 9
Brachial Plexus: Lower Trunk Injury Terminal Branches: Radial Nerve Slide 21
Slide 10
Supraclavicular Branches: Dorsal Scapular, Long
Slide 11
Thoracic, Suprascapular, and Subclavian Nerves
Scapular Winging Slide 12
Infraclavicular Branches Upper Subscapular, Lower
Slide 13
Subscapular, & Thoracodorsal Nerves
 Axilla: Introduction
The axilla is a pyramidal space located between the proximal arm and the lateral
thoracic wall. The walls of the axilla are listed below.
• Anterior wall: pectoralis major, pectoralis minor, and subclavius muscles
• Posterior wall: latissimus dorsi, teres major, and subscapularis muscles
• Medial wall: serratus anterior
• Lateral wall: intertubercular groove on humerus
• Apex (passageway between the neck and axilla): lateral border of 1st rib,
superior border of scapula, posterior border of clavicle

Axillary folds are visible surface features that demarcate the inferior parts of both
the anterior and posterior axillary boundaries.
• The posterior axillary fold is formed by the latissimus dorsi winding around the
lateral border of the teres major muscle. Latissimus dorsi forms much of the
muscle mass underlying the posterior axillary fold extending obliquely upward
from the trunk to the arm.
• The anterior axillary fold is formed by the inferior border of the pectoralis
major muscle.
 Axilla: Contents
The following structures are located within the axilla
• Axillary artery
• Axillary vein
• Brachial plexus cords and branches
• Lymphatic vessels and axillary lymph nodes
• Axillary fat

The prevertebral fascia that surrounds muscles associated with the vertebral column continues as the axillary sheath where the subclavian artery passes through
the interscalene triangle. The first part of the subclavian artery/axillary artery, axillary vein, and the brachial plexus are all enclosed by the axillary sheath.

Prevertebral
Fascia
 Axillary Artery: Review

The axillary artery is a continuation of the subclavian artery at the lateral edge of the first rib. Its distal boundary is at the inferior border of the teres major muscle where it
becomes the brachial artery. It is divided into three parts, with the pectoralis minor muscle defining the separation between the 3 parts. All branches are listed below, but each
of these branches will be explored in detail when we continue our anatomical study further into the axilla.

1. First part is proximal to the pectoralis minor and distal to the lateral edge [Link]
of the first rib. The first part gives off 1 branch.
• Superior thoracic artery (courses to anterior thoracic wall)
2. Second part is posterior to the pectoralis minor muscle and gives off 2
branches.
• The thoracoacromial artery forms four named branches that
ultimately supply the pectoralis major and minor muscles, the
anterior part of the deltoid muscle, and skin overlying
the clavipectoral fascia.
• The lateral thoracic artery supplies the serratus anterior muscle and
the breast. It is accompanied by the long thoracic nerve.
3. Third part is between the pectoralis minor muscle and the lateral border of
the teres major muscle and gives of 3 branches.
• The subscapular artery courses along the anterior aspect of the
subscapularis muscle and forms two branches.
• The thoracodorsal artery courses with the thoracodorsal
nerve to supply the latissimus dorsi muscle.
• The circumflex scapular artery passes through the triangular
space to form collateral circulation with the suprascapular and
dorsal scapular arteries.
• The posterior humeral circumflex artery passes through the
quadrangular space with the axillary nerve to course posteriorly
around the surgical neck of the humerus.
• The anterior humeral circumflex artery courses anteriorly around
the surgical neck of the humerus to anastomose with the posterior
circumflex artery.
 Axillary Vein

• The axillary vein is formed by the

union of the brachial veins (venae
comitantes) and the basilic vein at the
inferior border of teres major.
• The vein has 3 parts that correspond
to the 3 parts of the axillary artery.
 Axillary Lymph Nodes
The axilla contains about 20-30 lymph nodes that can anatomically be divided into five “groups”. Their separation into individual groups is somewhat artificial,
but it facilitates the understanding of regional lymphatic drainage and helps to clarify the location of the nodes. It should be understood, however, that the
axillary nodes are subject to great variations in location, size, and number. In addition, the listed groups have a rich system of anastomoses.
• Pectoral (anterior): located along the lower border of pectoralis minor
• Subscapular (posterior): located on the anterior surface of the subscapularis muscle, on the posterior wall of the axilla
• Humeral (lateral): located along the medial side of the axillary vein
• Central: large and fairly numerous nodes in the fat of the axilla; central nodes
receive lymph from the preceding three outlying groups
• Apical: located at the apex of the axilla; apical nodes receive lymph from
all other axillary groups

Three streams of lymph drain into the axillary nodes from the following regions.
1. The upper extremity (humeral)
2. The adjacent thoracic and upper abdominal wall and breast (pectoral)
3. The back (subscapular region)

These three lymph currents meet and fuse within the central and apical chains.
Efferent vessels from the most apical group converge to form the subclavian
trunk, which ultimately joins the venous circulation.
• On the right side, the subclavian lymphatic trunk joins the venous
circulation at the junction between the right subclavian vein and the right
internal jugular vein (venous angle).
• On the left side, the subclavian trunk usually joins the thoracic duct in the
base of the neck. The thoracic duct then joins the venous circulation at the
junction between the left subclavian vein and the left internal jugular vein
(venous angle).
 Upper Limb Lymph Drainage

Superficial lymphatic vessels of the upper extremity arise from lymphatic plexuses in the
skin of the fingers, palm, and the dorsum of the hand and ascend primarily with the
superficial veins.

• Lymph vessels traveling with the cephalic vein originate from capillaries in the
superficial fascia and skin of the lateral aspects of the hand, forearm and arm. These
vessels drain to the deltopectoral (infraclavicular) nodes, which drain directly to the
apical nodes.
• Lymph vessels traveling with the basilic vein originate from capillaries in the
superficial fascia and skin of the medial three digits, the medial part of the hand and
the medial side of the forearm. These vessels drain first to the supratrochlear
(cubital) nodes which lie in the superficial fascia anterior to the trochlea of the
humerus. These nodes drain to the humeral (lateral) group of axillary lymph nodes.

Deep lymphatic vessels are less numerous than superficial vessels; they accompany the
major deep veins of the upper extremity and terminate in the humeral (lateral) group of
axillary lymph nodes.
 Brachial Plexus: Introduction

• The brachial plexus is created by the joining, separating, and regrouping of the
ventral rami of the spinal nerves.
• The brachial plexus is composed of rami, trunks, divisions, cords, and branches.
• The ventral primary rami of C5 - T1 join into three trunks. Within the
trunks, the sensory and motor components of the rami mix together.
• Superior Trunk is formed by the union of C5 and C6 ventral rami
• Middle Trunk is formed by the ventral ramus of C7
• Inferior Trunk is formed by the joining of C8 and T1 ventral rami
• The trunks divide into divisions, which separate the axons destined for
anterior structures from those destined for posterior structures.
• The anterior divisions contain neurons destined for flexor muscles.
• The posterior divisions contain neurons destined for extensor
muscles.

• The divisions fuse into cords that retain the anterior-posterior segregation but allow further mixing of
axons from different spinal segments. The cords are named for their anatomical relationship relative to the
to the second part of the axillary artery.
• Branches are the named nerves that branch from the brachial plexus. The branches can be described as
organized into different groups.
• Terminal branches are the nerves formed from the distal terminations of the medial, lateral, and
posterior cords (light blue branches on picture).
• Infraclavicular branches are named nerves that branch from the medial, lateral, and posterior cord
(dark blue branches on picture).
• Supraclavicular branches are branches of the rami or trunks (dark purple branches on picture).
 Brachial Plexus: Upper Trunk Injury
Injury to the upper trunk (formed by C5-C6) of the brachial plexus can result in Erb-Duchenne paralysis (palsy). It is caused by a violent distraction (lateral bending) of the head
away from the shoulder. This can occur in trauma, such as from a fall off a motorcycle or horse. In addition, it can occur fr om traction placed on the brachial plexus during a
difficult birth (a common complication of shoulder dystocia) (bottom right figure). The resulting presentation of the upper extremity is described as a “waiter’s tip hand,” in
which the arm rests in medial rotation, the forearm is pronated, and the wrist is flexed (bottom left figure).
• The following nerves are involved in an injury to the upper trunk.
• Axillary nerve:
• Deltoid paralysis results in an inability to laterally rotate and abduct the arm. When at rest, deltoid paralysis results in the arm by the side and medially rotated
(medial rotators are still active).
• Loss of skin sensation from lateral aspect of arm
• Suprascapular nerve:
• Supraspinatus and infraspinatus paralysis results in an inability to laterally rotate and abduct. When at rest, supraspinatus and infraspinatus paralysis results in
the arm being medial rotated (medial rotators are still active).
• Musculocutaneous nerve:
• Biceps brachii, brachialis, and coracobrachialis paralysis results in an inability to flex the elbow and weakened supination of the forearm. When at rest, paralysis
of these muscles results in a pronated forearm with the elbow extended (pronators are still active).
• Loss of skin sensation from lateral aspect of forearm
• Radial nerve (C5-T1): Due to C5 and C6 contributing to the radial nerve, and being the primary innervation of extensor carpi rad ialis longus, weakened extension at the
wrist also occurs, which causes the resting position of the wrist to be flexed. In some situations, C7 can also be involved, which will further weaken wrist extension and
elbow extension.
 Brachial Plexus: Lower Trunk Injury

Injury to nerve roots C8 and T1, or where they combine to form the lower trunk, is called
Klumpke’s paralysis. Injury to only the inferior trunk of the brachial plexus is rare. Klumpke’s
paralysis can be caused by violent hyperabduction of the arm, as when a person is grasping
an object to prevent a fall. It can also be caused by a difficult breech delivery, or by pressure
on the lower trunk by a cervical rib.
• The ulnar nerve and median nerves are the primary nerves involved in an injury to the
lower trunk of the brachial plexus.
• Most importantly, all the intrinsic hand muscles are affected in Klumpke’s paralysis.
• The hand is held in a position known as “total” claw hand, which is when ALL of the
fingers are in flexion when the hand is at rest. Don’t confuse “total” claw hand” with
“ulnar nerve” claw hand in which only digits 4 and 5 are in a flexed position at rest.
• Total claw hand results from the following situation.
• Wrist is slightly extended: loss of some opposition of wrist flexors (total loss of
flexor carpi ulnaris and flexor digitorum profundus, so active flexion of the wrist
will be weak)
• MP joints extended: loss of opposed flexion from lumbricals and interossei
• Flexion of IP joints: loss of opposed extension from lumbricals and interossei
(flexion of of IP joints results from flexor digitorum superficialis still being active
due to receiving innervation from C7)
• At rest, the thumb will retreat posteriorly into the same plane as the fingers. This
due to the loss of innervation to the thenar muscles. This position is described as
“ape hand”.
• In addition to claw hand, the following signs will be present.
• The forearm is supinated due to paralysis of pronator quadratus.
• Loss of skin sensation from the medial aspect of the arm, forearm and ulnar
sensory domain of the hand.
 Supraclavicular Branches: Dorsal Scapular, Long Thoracic, Suprascapular, and Subclavian Nerves
NERVE ORIGIN COURSE STRUCTURES INNERVATED
Posterior aspect of anterior ramus Motor: rhomboids; occasionally
Dorsal scapular Pierces middle scalene; descends deep to levator scapulae and rhomboids
of C5 with a frequent contribution from C4 supplies levator scapulae
Passes through cervico-axillary canal (Fig. 6.14), descends posterior to C8
Posterior aspect of anterior rami of C5,
Long thoracic and T1 roots of plexus (anterior rami); runs inferiorly on superficial surface Motor: serratus anterior
C6, C7
of serratus anterior
Motor: supraspinatus and
Passes laterally across lateral cervical region (posterior triangle of neck),
Superior trunk, receiving fibers from C5, C6 infraspinatus muscles
Suprascapular superior to brachial plexus; then passes through scapular notch inferior to
and often C4 Sensory: glenohumeral (shoulder)
superior transverse scapular ligament
joint
Motor: subclavius and
Subclavian nerve (nerve Superior trunk, receiving fibers from Descends posterior to clavicle and anterior to brachial plexus and subclavian
sternoclavicular joint (accessory
to subclavius) C5, C6 and often C4 artery (Fig. 6.29); often giving an accessory root to phrenic nerve
phrenic root innervates diaphragm)
[Link] [Link]
 Scapular Winging

CLINICAL ANATOMY: Medial winging of the scapula is the result of serratus anterior paralysis from
injury to the long thoracic nerve. The most common etiology is neuropraxia after blunt trauma or a
stretch injury. In addition, surgical procedures in the thoracic region such as radical mastectomy,
resection of the first rib, and transthoracic sympathectomy can expose the long thoracic nerve and
make it susceptible to damage.
To test for medial scapular winging, ask patient to push against a wall and observe the inferior angle
of the scapula. If the nerve is damaged, the inferior angle and medial border will project from the
posterior thoracic wall (medial scapular “winging”). In addition, a person with long thoracic nerve
injury will have difficulty abducting the arm past a horizonal position (90 degrees) due to an inability
to upwardly rotate the scapula.
Two mnemonics that might help remember medial scapular winging:
1. C5,6,7 wings to heaven: The serratus anterior is innervated by the long thoracic nerve (C5-C7),
so damage to the nerve results in (medial) winging of the scapula.
2. SALT on the birds wings: SA=serratus anterior, LT=long thoracic nerve. Damage to the long
thoracic nerve results in (medial) winging of the scapula.

CLINICAL ANATOMY: Lateral winging of the scapula results from a dysfunction in the
trapezius (spinal accessory nerve: CN XI) and/or rhomboid muscles (dorsal scapular nerve).
In lateral winging, the scapula is excessively protracted (abducted) on the thoracic wall.
 Infraclavicular Branches: Upper Subscapular, Lower Subscapular, & Thoracodorsal Nerves
NERVE ORIGIN COURSE STRUCTURES INNERVATED
Side branch of posterior cord,
Upper subscapular Courses posteriorly to enter subscapularis Motor: superior portion of subscapularis muscle
receiving fibers from C5
Side branch of posterior cord, Courses inferolaterally (deep to subscapular artery and vein) to enter Motor: inferior portion of subscapularis and teres
Lower subscapular
receiving fibers from C6 subscapularis and teres major muscles major muscles
• Arises between upper and lower subscapular nerves (aka: middle
Side branch of posterior cord, scapular nerve)
Thoracodorsal Motor: latissimus dorsi muscle
receiving fibers from C6, C7, C8 • Courses inferolaterally along the posterior axillary wall to enter
latissimus dorsi

[Link]
 Infraclavicular Branches: Medial & Lateral Pectoral & Subclavian Nerve
NERVE ORIGIN COURSE STRUCTURES INNERVATED
Side branch of lateral • Pierces costocoracoid membrane to reach deep surface of pectoral muscles Motor: primarily pectoralis major; but some
Lateral pectoral cord, receiving fibers • Forms a communicating branch to the medial pectoral nerve lateral pectoral nerve fibers pass to pectoralis
from C5, C6, C7 • Passes anterior to axillary artery and vein minor via a branch to medial pectoral nerve

• Passes between axillary artery and vein

Side branch of medial
• Pierces pectoralis minor and enters deep surface of pectoralis major Motor: pectoralis minor and sternocostal part of
Medial pectoral cord, receiving fibers
• Although it is called medial for its origin from the medial cord, its anatomical pectoralis major
from C8, T1
position is lateral to the lateral pectoral nerve
Subclavian nerve Superior trunk, receiving • Descends posterior to clavicle and anterior to brachial plexus and subclavian
Motor: subclavius and sternoclavicular joint
(nerve to fibers from C5, C6 and artery
(accessory phrenic root innervates diaphragm)
subclavius) often C4 • Often contributes to accessory root to phrenic nerve

[Link]
 Infraclavicular Branches: Medial Cutaneous Nerves of Arm and Forearm
NERVE ORIGIN COURSE STRUCTURES INNERVATED
• Smallest nerve of brachial plexus Sensory: skin of medial side of arm, as far
Medial cutaneous nerve of arm • Courses along medial side of axillary and brachial veins and distal as medial epicondyle of humerus and
Side branches of medial cord, communicates with intercostobrachial nerve olecranon of ulna
receiving fibers from C8, T1 • Initially runs with ulnar nerve
• Then pierces deep fascia with basilic vein and enters subcutaneous Sensory: skin of medial side of forearm, as far
Medial cutaneous nerve of forearm
tissue, dividing into anterior and posterior branches distal as wrist
• Often confused with ulnar nerve
 Terminal Branches: Musculocutaneous Nerve
NERVE ORIGIN COURSE STRUCTURES INNERVATED
Motor: muscles of anterior compartment of
• Exits axilla by piercing coracobrachialis
Terminal branch of lateral cord, receiving fibers the arm (coracobrachialis, biceps brachii and
Musculocutaneous • Descends through the arm between biceps brachii and brachialis
from C5–C7 brachialis)
• Continues into forearm as lateral cutaneous nerve of forearm
Sensory: skin of lateral aspect of forearm

CLINICAL ANATOMY: Lesions of the [Link]

musculocutaneous nerve can result in
both muscle weakness and
loss/reduction of sensation.
• Weakness of elbow flexion and
supination result. Supination
weakness occurs because the
biceps brachii is major contributor
to supination of the forearm.
• Sensory loss occurs on the lateral
side of the forearm in the domain
of the lateral cutaneous nerve of
the forearm.
 Terminal Branches: Median Nerve
NERVE ORIGIN COURSE STRUCTURES INNERVATED
Motor: muscles of anterior forearm compartment (except flexor carpi
• Lateral and medial roots merge to form median nerve
Lateral root of median nerve is a ulnaris and ulnar half of flexor digitorum profundus), lumbricals of digits 2
(lateral position relative to the axillary artery)
terminal branch of lateral cord (C6, C7) and 3, and thenar muscles (abductor pollicis brevis, opponens pollicis,
Median • Descends through arm adjacent to brachial artery, with
Medial root of median nerve is a flexor pollicis brevis)
nerve gradually crossing anterior to artery to lie medial to
terminal branch of medial cord (C8, T1) Sensory: skin of palm, palmar side of digits 1-3, lateral palmar side of digit
artery in cubital fossa
4, and the distal half on the dorsal surface of digits 1-4

CLINICAL ANATOMY: [Link]

Lesions of the median
nerve (and its branches)
will be explored in
upcoming units when we
study the anatomical area
in which a lesion typically
occurs.
 Terminal Branches: Ulnar Nerve
NERVE ORIGIN COURSE STRUCTURES INNERVATED
Motor: flexor carpi ulnaris and ulnar half of flexor digitorum
• Descends medial arm
Larger terminal branch of medial cord, profundus (forearm); most intrinsic muscles of the hand
Ulnar • Courses posterior to medial epicondyle of humerus
receiving fibers from C8, T1 and often C7 Sensory: skin of hand medial to midline of digit 4, medial half of
• Descends along the ulnar aspect of forearm to hand
digit 4, all of digit 5

CLINICAL ANATOMY:
Lesions of the ulnar
nerve (and its branches)
will be explored in
upcoming units when we
study the anatomical
area in which a lesion
typically occurs.
 Terminal Branches: Axillary Nerve
NERVE ORIGIN COURSE STRUCTURES INNERVATED
• Exits axilla posteriorly by passing through the quadrangular Motor: teres minor and deltoid muscles
Terminal branch of posterior cord, space with posterior circumflex humeral artery Sensory: superolateral arm (skin over inferior
Axillary
receiving fibers from C5, C6 • Gives rise to superior lateral brachial cutaneous nerve part of deltoid muscle), glenohumeral
• Winds around surgical neck of humerus deep to deltoid (shoulder) joint
 Surgical Neck Fracture of Humerus
CLINICAL ANATOMY: Because of their anatomical relationship to the proximal humerus and glenohumeral joint, the axillary nerve and posterior
circumflex humeral vessels are at risk of injury in shoulder dislocations and when the surgical neck of the humerus is fractured.

Case courtesy of [Link] Frank Gaillard,

[Link], rID: 18279
[Link]
 Terminal Branches: Radial Nerve

NERVE ORIGIN COURSE STRUCTURES INNERVATED

• Exits axilla posterior to axillary artery and passes posterior to humerus in radial Motor: all muscles of posterior compartments of
Larger terminal branch of posterior groove with deep brachial artery, between lateral and medial heads of triceps arm and forearm
Radial cord (largest branch of plexus), • Perforates lateral intermuscular septum Sensory: skin of posterior and inferolateral arm,
receiving fibers from C5–T1 • Enters cubital fossa, dividing into superficial (cutaneous) posterior forearm, and dorsum of hand lateral to
and deep (motor) radial nerves axial line of digit 4

CLINICAL ANATOMY: [Link]

Lesions of the radial
nerve (and its
branches) will be
explored in upcoming
units when we study
the anatomical area in
which a lesion
typically occurs.