DAU

1. AXILLA & Brachial plexus

2. The Axilla
• A pyramidal
shaped space
between the
upper part of the
arm and the side
of the chest
through which
major
neurovascularneurovascular
structures pass
between neck &
thorax and upper
limb.
• Axilla has an
apex, a base and
four walls.

3. Boundaries of the
Axilla
 Apex:
 Is directed upwards
into the root of the
neck
 is bounded, by 3
bones:
• Clavicle anteriorly.
• Upper border of the
scapula
posteriorly.
• Outer border of the
first rib medially.
• It is called cervico-
axillary canal.

4.  Anterior wall:
 Is formed by
• Pectoralis major
• Pectoralis minor
• Subclavius
• Clavipectoral
fascia:
Pectoralis
major
Pectoralis
minor
Clavipectoral fascia

5. • Posterior wall:
• Is formed by:
• Subscapularis
• Latissimus
dorsi
• Teres major
muscles

6.  The medial wall:
 Is formed by:
• Serratus anterior
• Upper 4 or 5 ribs
& Intercostal
muscles .
 The lateral wall:
 Is formed by:
• Coracobrachialis
• Biceps brachii
• Intertubercular
groove of the
humerus.

7.  Base:
 Formed by skin stretching
between the anterior and
posterior walls.
 It is bounded:
• In front by the anterior
axillary fold (formed by
the lower border of the
Pectoralis major
muscle).
• behind by the posterior
axillary fold (formed by
the tendons of
latissimus dorsi and
teres major muscles).
• medially by upper 4 to
5 ribs & the chest wall.

8. Contents of The
Axilla
• Cords and braches
of brachial plexus.
• Axillary artery and
its branches.
• Axillary vein and its
tributaries.
• Axillary lymph
nodes.
• Axillary fat.
• Loose connective
tissue.
The neurovascular bundle is enclosed in connective tissue
sheath, called ‘axillary sheath’
Axillary a. & v.
Brachial
plexus

9. Location & Formation
Brachial Plexus is present in the posterior triangle
of the neck & axilla.
It is formed by the union of the anterior Rami of the
C 5th
, 6th
, 7th
& 8th
and the 1st
thoracic spinal nerve.
What is a Brachial Plexus ?
Brachial Plexus is a network of nerves that present at
the root of the neck to enter the upper limb.
The roots of C5 & C6 unite to form---- Upper trunk
The root of C7 continues as the-------- Middle trunk
The roots of C8 & T1 unite to form---- Lower trunk
9

10. The Plexus can be divided into 5 stages:
Roots: in the posterior∆ of the neck.
Trunks: in the posterior∆ of the neck.
Divisions: behind the clavicle (apex of the axilla).
Cords: in the axilla.
Branches: in the axilla.
NB. The First 2 stages lie in the posterior triangle, while last 2 sages lie in axilla.

11.  The anterior divisions of the upper and middle trunks unite to form the
Lateral cord.
 The anterior division of the lower trunk continues as the Medial cord.
 All the posterior divisions of three trunks join to form the Posterior
cord.
 Cords are named according to there relation to the 2nd
part of the
axillary artery 11

12. B
R
N
C
H
E
S
Lateral cord- 3 Medial cord- 5 Posterior cord- 5
Lateral pectoral nerve. Medial pectoral nerve. Axillary nerve.
Musculocutaneous nerve. Ulnar nerve. Radial nerve.
Median nerve (lateral root). Median nerve (medial root). Upper & lower
subscapular nerves.
Medial cutaneous nerve of
arm & forearm.
Thoracodorsal or N. to
latissimus dorsi.

13. Brachial plexus injuries
• May involve the roots, trunks,
divisions, cords & branches
• Supraclavicular injuries involve
the roots and the trunks,
infraclavicular injuries will affect
the divisions and cords
• Result due to:
– Compression
– Traction
– Stab wounds
• Symptoms depend on the site of
injury & involvement of nerve
fibers

14. Brachial plexus injuries
• Are of two types:
–Upper lesions usually involving C5 & C6
–Lower lesions usually involving (C8), T1

15. Upper Lesions of the Brachial Plexus
(Erb-Duchenne Palsy)
• These are usually the result of
traction & tearing of the 5th and
6th root of the brachial plexus
• This may occur:
• In infants during a difficult
delivery
• In adults following a fall on or
a blow to the shoulder.
• It involves the:
• Nerve to sublavius
• Suprascapular nerve
• Axillary nerve
• Musculocutaneous nerve

16. • The muscles affected are:
– Abductors (supraspinatus &
deltoid) and lateral rotators
(Infraspinatus &teres minor) of
the shoulder
– Subclavius, biceps, brachialis &
coracobrachialis
• Thus:
– The limb hangs limply by the
side, and is medially rotated
– The forearm is pronated and
extended
– There is loss of sensation down
the lateral side of the arm & the
forearm
• Another name for this lesion is
'porters tip'

17. Lower Lesions of the Brachial Plexus
(Klumpke Palsy)
• These are usually caused
by excessive abduction of
the arm as a result of:
– Someone clutching for
an object when falling
from a height
– Difficult delivery in which
baby’s upper limb is
pulled excessively.
– Result of malignant
metastases from the
lungs in the lower deep
cervical lymph nodes
– A cervical rib

18. Person grasping something to prevent a fall

19. Baby’s upper limb is pulled excessively during
delivery

20. • The hand has a clawed
appearance due to:
– Hyperextension of the
metacarpophalangeal joints
(the extensor digitorum is
unopposed by the lumbricals
and interossei and extends
the metacarpophalangeal
joints).
– Flexion of the interphalangeal
joints (the flexor digitorum
superficialis and profundus
are unopposed by the
lumbricals and interossei, the
middle and terminal
phalanges are flexed).
Lower Lesions of the Brachial Plexus
(Klumpke Palsy)

21. Thoracic Outlet syndrome
(TOS)

22. 22
Thoracic Outlet Syndrome
Causes
1. Many factors can induce thoracic outlet
syndrome, including congenital, trauma
and atherosclerotic factors.
2. Bony abnormalities are present in 30%
of patients, such as cervical rib, bifid first
rib, fusion of first and second ribs or
previous thoracoplasty.

23. Thoracic Outlet Syndrome
• Thoracic outlet syndrome results from
compression of the subclavian vessels
and brachial plexus.
• Patients may complain of neck and
shoulder pain with numbness and tingling
in the upper extremity.
• The ulnar side is typically involved.
• Using the extremity in an overhead or
elevated position is difficult.

24. Cervical
Rib
Involves
Inferior
part of
Plexus
Thoracic Outlet
Syndrome

25. 25
Thoracic Outlet Syndrome
ANATOMIC CONSIDERATIONS
1. The subclavian vessels and brachial plexus
transverse the cervico-axillary canal into the
arm.
2. The outer border of the first rib divides the
canal into a proximal and a distal division.
3. The proximal division is composed of the
scalene triangle and the space bounded by the
clavicle and the first rib( costoclavicular
space ).

26. 26
Thoracic Outlet Syndrome
ANATOMIC CONSIDERATIONS
4. The proximal division is the most critical
for neurovascular compression. It is
bounded superiorly by the clavicle and
the subclavius muscle; inferiorly by the
first rib; anteromedially by the sternum,
clavipectal fascia and the costocoracoid
ligament; and posterolaterally the
scalenus media muscle and the long
thoracic nerve.

27. Thoracic Outlet Syndrome
Clinical Signs and Symptoms
• Upper extremity pain.
• Upper extremity paresthesias.
• Grip weakness
• Upper extremity edema.
• Upper extremity coldness.
• Excessive dryness of the arm or hand.
• Excessive sweating of the arm or hand.

28. 28
Thoracic Outlet Syndrome
DIAGNOSIS
1. Physical Exam, history, radiographs of
chest and cervical spine, neuroloical
consultation, NCV (nerve conduction
studies).
2. Pulmonary, esophageal and chest wall
causes must be ruled out.

29. 29
Thoracic Outlet Syndrome
THERAPY
1. Physiotherapy is performed before surgery.
2. Physiotherapy includes heat massage,
active neck exercise, scalenus anterior
muscle stretching, strengthening of the
upper trapezius muscle.
3. Resection of the first rib, and a cervical rib
when present, is best performed through
the trans-axillary approach, with
decompression of 7th and 8th cervical and
1st thoracic root.

30. GOOD LUCK