LEVEL 1 – Basic Anatomy (Foundation)

1. Describe the Pectoralis Major muscle under the following headings: a) Origin and Insertion
b) Nerve Supply c) Actions of its two heads d) Clinical testing of the muscle (AN 34.2)
2. Enumerate the layers of the breast. Describe the structure of the Mammary Gland covering
its location, extent, and detailed description of the Stroma and Parenchyma. (AN 34.2)
3. Describe the Clavipectoral Fascia. Give its vertical and lateral extent, list the structures it
encloses, and enumerate the four structures that pierce it. (AN 34.1)
4. Describe the Serratus Anterior muscle including its origin, complex insertion, nerve supply,
and primary action. (AN 34.2)
5. Outline the anatomical location of the Pectoral Region. Enumerate and locate the key surface
landmarks used for orientation on the anterior chest wall, specifically detailing the Sternal Angle
and the Nipple. (AN 34.1)
B. Short Notes (Focused Subtopics)
1. Origin and Insertion of Pectoralis Minor
2. Axillary Tail of Spence (and Foramen of Langer)
3. Cutaneous Innervation/Dermatomes of the Pectoral Region (mentioning C4-T2 skip)
4. Suspensory Ligaments of Cooper
5. Nerve Supply of Pectoralis Major and Minor (Mnemonic: All five segments of the brachial
plexus)
6. Clavicular and Sternocostal Heads of Pectoralis Major
7. Structures Piercing the Clavipectoral Fascia (Mnemonic: LiTtle Can Lose: Lateral pectoral N.,
Thoraco-acromial A., Cephalic V., Lymphatics)
8. Role of Fat in Mammary Gland
9. Nipple and Areola
10. The thick upper part of the Clavipectoral Fascia (Costocoracoid Ligament)
C. Viva Questions (Identification and Recall)
1. What is the largest muscle of the pectoral region?
2. Which rib articulates at the Sternal Angle (Angle of Louis)?
3. In males, in which intercostal space does the nipple typically lie?
4. Name the nerve supplying the Serratus Anterior.
5. What is the term for the thick fascial sheet deep to Pectoralis Major?
6. The Pectoralis Major muscle inserts onto which lip of the bicipital groove?
7. What is the name given to the enlarged sebaceous glands on the areola during pregnancy?
8. What percentage of lymph from the breast drains into the axillary nodes?
9. Which structure keeps the dome of the axillary fascia pulled up, maintaining the concavity of
the axilla?
10. Name the condition where the male breast becomes enlarged.
11. Which part of the Pectoralis Major tendon is formed by the clavicular fibers?
12. What structure is felt 2.5 cm below the clavicle in the infraclavicular fossa?
13. Which ribs give rise to the Pectoralis Minor muscle?
14. Name the plexus of lymph vessels deep to the areola.
15. The clavicular head of Pectoralis Major primarily performs which action of the arm?

--------------------------------------------------------------------------------

LEVEL 2 – Conceptual & Applied Anatomy

A. Essay Questions (Integration and Understanding-based)
1. Discuss the functional anatomy of the Serratus Anterior. Explain why it is famously known
as the “Boxer’s Muscle”. (AN 34.3)
2. Explain the structural role of the connective tissue of the breast (Stroma). How do the
Suspensory Ligaments of Cooper contribute to the shape of the breast, and what is the
consequence of their atrophy or infiltration? (AN 34.3)
3. Discuss the topographical relationship of the Pectoralis Minor muscle to the overlying
Pectoralis Major and the Clavipectoral Fascia. Describe how the fascia related to these two
muscles creates the suspensory ligament of the axilla. (AN 34.2)
4. Describe the twisting of fibers in the Pectoralis Major insertion. Explain how this twisting
helps form the rounded axillary fold and outline the respective positions of the clavicular and
sternocostal fibers upon insertion. (AN 34.2)
B. Short Notes (Conceptual Topics)
(Attempt 6 out of 8)
1. Mechanism and Clinical Presentation of Winging of the Scapula
2. Congenital anomaly of Pectoralis Major (focusing on the sternocostal head)
3. Pectoralis Major and Pectoralis Minor supply by all five spinal segments of the brachial plexus
4. The role of the suspensory ligament of the axilla in maintaining axillary concavity
5. Why the skin area supplied by C4 meets the area supplied by T2
6. The Subareolar Plexus of Sappey and its function in deep lymphatic drainage
7. The significance of the Axillary Tail of Spence in pathology
8. Developmental anomaly: Gynecomastia (including cause and common timing)
C. Viva Questions (“Why-type” Conceptual Viva)
(Answer 10 out of 15)
1. Why is the sternal angle a crucial surface landmark?
2. Why does injury to the Long Thoracic nerve lead to weakness in protraction of the scapula?
3. Why are the lower fibres of Pectoralis Major inserted highest?
4. Why does an infiltration of the suspensory ligaments of Cooper cause the breast to become
fixed and immobile?
5. Why is the serratus anterior essential for overhead abduction of the arm?
6. Why does the Pectoralis Major tendon have a U-shaped or bilaminar structure?
7. Why is the nipple richly innervated by sensory nerve endings?
8. Why might a unilateral breast malignancy become bilateral?
9. Why does the areola become darker and enlarged during pregnancy?
10. Why is the clavicular head of Pectoralis Major prominent when lifting a heavy rod?
11. Why is the knowledge of lymphatic drainage of the breast of great clinical importance?
12. Why is the Subclavius muscle enclosed by the split laminae of the clavipectoral fascia?
13. Why is the nipple the most sensitive part of the breast to tactile stimulation?
14. Why is the Axillary Tail of Spence a site of a high percentage of breast tumors?
15. Why might a retracted nipple be prone to infection?

--------------------------------------------------------------------------------

LEVEL 3 – Clinical & Diagnostic Anatomy

A. Essay Questions (Clinically Oriented)
(Attempt 3 out of 4)
1. Discuss the lymphatic drainage of the Mammary Gland in detail. Outline the percentage of
lymph draining into the primary node groups (axillary, internal mammary, posterior intercostal)
and describe the drainage pathways from the lateral and medial quadrants. (AN 34.4)
2. Carcinoma of the Breast is a common malignancy in females. Describe the common
origin of this cancer and list the key clinical presentations, providing the anatomical basis for
each sign (e.g., retraction of skin/nipple, peau d’orange appearance). (AN 34.4)
3. Define Winging of the Scapula. Explain the cause of this condition and describe the steps
required for a patient to demonstrate this clinical sign. (AN 34.3)
4. Discuss the significance of the deep lymphatics of the breast in the spread of cancer.
Describe the specific pathway that leads to the formation of Krukenberg’s Tumor. (AN 34.4)
B. Short Notes (Applied/Surgical Anatomy)
(Attempt 6 out of 8)
1. Peau d’orange appearance (Orange peel sign)
2. Role of mammography and self-examination in early detection of breast cancer
3. Anatomical basis of Nipple Retraction in Carcinoma
4. Metastasis of breast cancer to the opposite side and abdomen
5. Clinical correlations of Polythelia and Polymastia
6. Vulnerability of the Long Thoracic nerve (stab injury, surgical removal of breast tumor)
7. Krukenberg’s Tumor (definition and pathway)
8. Radical Mastectomy (classical operation and structures removed)
C. Viva Questions (Case-based and Applied Anatomy Viva)
(Answer 10 out of 15)
1. A patient presents with a painless, hard lump in the upper lateral quadrant of the breast. Which
group of lymph nodes is most likely involved first?
2. If breast lymphatics communicate with the subperitoneal lymph plexus, what secondary tumor
might develop?
3. During overhead arm movements, a patient’s medial border of the scapula protrudes
posteriorly. Which nerve is likely injured?
4. A pregnant woman shows small nodular elevations around the nipple. What are these
elevations, and what gland forms them?
5. You note significant dimpling of the skin over a breast lump. Which fibrous structures are being
infiltrated by the carcinoma?
6. In a suspected case of breast cancer, the surgeon wants to assess the apical group of lymph
nodes. The deep lymphatics reach these nodes by piercing which two structures?
7. A vertical sheet of muscle passes superficial to the Pectoralis Major, extending from the neck
to the abdomen. What is this occasional muscle called?
8. A patient has Polythelia. Along which embryonic line would you expect to find these extra
nipples?
9. Why must the Pectoralis Minor be removed in a classical radical mastectomy?
10. If 20% of the lymph from the breast drains into the internal mammary nodes, where are these
nodes located?
11. What structure serves as a useful landmark to help count the ribs?
12. A patient cannot suckle their infant due to an anatomical anomaly of the breast. What
developmental anomaly might this be?
13. If cancer cells spread along posterior intercostal arteries from the breast, which lymph nodes
will they drain into?
14. What common site is the Pectoral region carcinoma most likely to arise from within the breast
parenchyma?
15. If the lower sternocostal part of Pectoralis Major is congenitally absent, which specific actions
of the arm will be weakened?
Mnemonics-
Lateral Less, Medial More
The Lady Between Two Majors
SALT:
◦ Serratus Anterior = Long Thoracic
C5-6-7 raise your arms up to heaven