解剖學科 李亭輝老師 Axilla - Transition area between the neck and the arm An irregularly shaped pyramidal space: ➢ four sides (walls) ➢ apex ➢ base 圖片版權為 出版商所有，禁止任意傳播 Axilla - All major structures passing into and out of the upper limb pass through the axilla, include (anterior → posterior): 。Axillary v. 。Axillary a. 。Brachial plexus - Axillary sheath: surrounding arteries, veins and nerves 圖片版權為 出版商所有，禁止任意傳播 Apex of the axilla - Cervico-axillary canal The margins of the canal: 。Medial: the lateral border of rib I 。Anterior: the posterior surface of the clavicle 。Posterior: the superior border of the scapula 圖片版權為 出版商所有，禁止任意傳播 Base - formed by concave skin, subcutaneous tissue, and axillary (deep) fascia ➛ axillary fossa AF: axillary fossa 圖片版權為 出版商所有，禁止任意傳播 Anterior wall - Formed by: 。pectoralis major muscle 。pectoralis minor 。subclavius muscle Subclavius m. Clavipectoral fascia Pectoralis major Pectoralis minor 圖片版權為 出版商所有，禁止任意傳播 - Anterior axillary fold: the inferiormost part of the anterior wall AX: anterior axillary fold 圖片版權為 出版商所有，禁止任意傳播 Posterior wall - Formed by: 。 costal surface of the scapula 。 subscapularis muscle 。 latissimus dorsi and teres major muscles 圖片版權為 出版商所有，禁止任意傳播 - Posterior axillary fold: the inferiormost part of the posterior wall PX: Posterior axillary fold 圖片版權為 出版商所有，禁止任意傳播 Medial wall - Formed by 。upper thoracic wall (the ribs and related intercostal tissues) 。serratus anterior muscle 圖片版權為 出版商所有，禁止任意傳播 Lateral wall - narrow and formed entirely by the intertubercular sulcus of the humerus 圖片版權為 出版商所有，禁止任意傳播 Contents of the axilla - axillary artery axillary vein brachial plexus ensheathed in axillary sheath 圖片版權為 出版商所有，禁止任意傳播 Axillary artery - begin at lateral border of 1st rib and end at inferior border of teres major m. - subclavian artery → axillary artery → brachial artery - separated into 3 parts by the pectoralis minor 1st part: between 1st rib and pectoralis minor m. 2nd part: posterior to pectoralis minor m. 3rd part: from pectoralis minor to inferior border of teres major 圖片版權為 出版商所有，禁止任意傳播 Axillary artery - - Arteries originates from the 1st part: 。superior thoracic artery Arteries originates from the 2nd part 。thoraco-acromial artery 。lateral thoracic artery Arteries originates from the 3rd part 。subscapular artery 。anterior circumflex humeral artery 。posterior circumflex humeral artery 圖片版權為 出版商所有，禁止任意傳播 Axillary artery - Superior thoracic artery (from the 1st part) 。 Supply: upper regions of the medial and anterior axillary walls (1st & 2nd intercostal spaces & serratus anterior m) Superior thoracic artery 圖片版權為 出版商所有，禁止任意傳播 Axillary artery - Thoraco-acromial artery (from the 2nd part) 。four branches 。supply: anterior axillary wall and related regions 圖片版權為 出版商所有，禁止任意傳播 Axillary artery - Lateral thoracic artery (from the 2nd part) 。follows the margin of the pectoralis minor muscle to the thoracic wall 。supply: the medial and anterior walls of the axilla 圖片版權為 出版商所有，禁止任意傳播 圖片版權為 出版商所有，禁止任意傳播 Axillary artery - Subscapular artery (from the 3rd part) 。the largest branch of the axillary artery 。originates from the posterior surface of the third part of the axillary artery 。2 terminal branches: circumflex scapular artery and thoracodorsal artery 圖片版權為 出版商所有，禁止任意傳播 Axillary artery - Circumflex scapular artery - Thoracodorsal artery ➛ anastomotic network of vessels around the scapula 圖片版權為 出版商所有，禁止任意傳播 Axillary artery - Anterior circumflex humeral artery (from the 3rd part) 。passes anterior to the surgical neck of the humerus 。anastomoses with the posterior circumflex humeral artery 。supply: glenohumeral joint and the head of the humerus 圖片版權為 出版商所有，禁止任意傳播 Axillary artery - Posterior circumflex humeral artery (from the 3rd part) 。curves around the surgical neck of the humerus 。 anastomotic network of vessels around the scapula 圖片版權為 出版商所有，禁止任意傳播 Arterial Anastomoses Around Scapula - collateral circulation of shoulder 圖片版權為 出版商所有，禁止任意傳播 Axillary vein - union of the accompanying brachial veins and the basilic vein - end at lateral border of 1st rib where it becomes subclavian vein cephalic vein: join the axillary vein 圖片版權為 出版商所有，禁止任意傳播 Axillary vein - The veins of the axilla are more abundant than the arteries, are highly variable, and frequently anastomose. 圖片版權為 出版商所有，禁止任意傳播 Axillary Lymph Nodes - in the axillary fat 5 groups ➢ pectoral ➢ subscapular ➢ humeral ➢ central ➢ apical 圖片版權為 出版商所有，禁止任意傳播 ➢ Pectoral (anterior) nodes o 3-5 nodes o lie along the medial wall of the axilla, around the lateral thoracic vein and inferior border of the pectoralis minor o receive lymph from the anterior thoracic wall (breast) 圖片版權為 出版商所有，禁止任意傳播 ➢ Subscapular (posterior) nodes o 6-7 nodes o lie along the posterior axillary fold, subscapular vessels o receive lymph from the posterior aspect of the thoracic wall and scapular region 圖片版權為 出版商所有，禁止任意傳播 ➢ Humeral (lateral) nodes o 4-6 nodes o lie along the lateral wall of the axilla, medial and posterior to the axillary vein o receive nearly the lymph from the upper limb 圖片版權為 出版商所有，禁止任意傳播 ➢ Central nodes o 3-4 large nodes o deep to the pectoralis minor o efferent lymphatic vessels from the pectoral, subscapular, and humeral nodes➛ central nodes ➛ apical nodes 圖片版權為 出版商所有，禁止任意傳播 ➢ Apical nodes o at the apex of the axilla along the medial side of the axillary vein and artery o receive lymph from all other groups of axillary nodes o form subclavian lymphatic trunk ➛ right lymphatic duct ➛ thoracic duct 圖片版權為 出版商所有，禁止任意傳播 Brachial plexus - somatic plexus formed by the anterior rami of C5-C8, and T1 The parts of the brachial plexus (medial → lateral) roots, trunks, divisions, and cords 圖片版權為 出版商所有，禁止任意傳播 圖片版權為 出版商所有，禁止任意傳播 Brachial plexus - Roots 。 Union of the anterior rami of C5 to C8, and most of T1 圖片版權為 出版商所有，禁止任意傳播 圖片版權為 出版商所有，禁止任意傳播 Brachial plexus - Trunks 。superior : C5 & C6 roots 。middle : C7 root 。inferior : C8 & T1 roots 圖片版權為 出版商所有，禁止任意傳播 圖片版權為 出版商所有，禁止任意傳播 Brachial plexus - Divisions 。each of the three trunks divides into an anterior and a posterior division 。3 anterior divisions: anterior compartments of the arm and forearm 3 posterior divisions: posterior compartments 。no peripheral nerves originate directly from the divisions of the brachial plexus 圖片版權為 出版商所有，禁止任意傳播 Brachial plexus - Cords 。lateral : anterior divisions of superior & middle trunks 。medial : anterior division of inferior trunk 。posterior : posterior divisions of 3 trunks anterior compartments of the upper limb: medial and lateral cords posterior compartments of the upper limb: posterior cord 圖片版權為 出版商所有，禁止任意傳播 Brachial plexus - Branches: divided into supraclavicular and infraclavicular parts by the clavicle 圖片版權為 出版商所有，禁止任意傳播 Brachial plexus o Supraclavicular part: ➢ 4 branches ➢ from the roots and trunks 圖片版權為 出版商所有，禁止任意傳播 Brachial plexus ➢ Branches of the supraclavicular part: ① Dorsal scapular nerve: Origin: C5 root Course: travel along the medial border of the scapula Function: motor ➛rhomboid major, rhomboid minor 圖片版權為 出版商所有，禁止任意傳播 Brachial plexus ② Long thoracic nerves: Origin: C5 to C7 roots Course: runs inferiorly on superficial surface of serratus anterior Function: motor ➛serratus anterior 圖片版權為 出版商所有，禁止任意傳播 圖片版權為 出版商所有，禁止任意傳播 Brachial plexus ③ Suprascapular nerve Origin: superior trunk Course: passes laterally to enter the posterior scapular region Function: motor ➛ supraspinatus, infraspinatus 圖片版權為 出版商所有，禁止任意傳播 圖片版權為 出版商所有，禁止任意傳播 Brachial plexus ④ Nerve to subclavius muscle (subclavian nerve) Origin: superior trunk Course: passes anteroinferiorly over the subclavian artery and vein Function: motor ➛ subclavius 圖片版權為 出版商所有，禁止任意傳播 Brachial plexus o Infraclavicular part -- Lateral cord (C5-C7) Lateral pectoral Musculocutaneous Median -- lateral root -- Medial cord (C8-T1) Medial pectoral Medial brachial cutaneous Medial antebrachial cutaneous Ulnar Median -- medial root -- Posterior cord (C5-T1) Upper subscapular Thoracodorsal Lower subscapular Axillary Radial 圖片版權為 出版商所有，禁止任意傳播 Brachial plexus o Infraclavicular part ➢ Branches of the infraclavicular part ① Lateral pectoral nerve Origin: lateral cord (C5 to C7) Course: accompanies with the thoraco-acromial artery Function: motor ➛ pectoralis major 圖片版權為 出版商所有，禁止任意傳播 Brachial plexus ② Musculocutaneous nerve Origin: lateral cord (C5 to C7) Course: penetrate the coracobrachialis muscle and pass between the biceps brachii and brachialis muscles in the arm ➛ terminates as lateral cutaneous nerve of forearm Function: motor ➛ all muscles in the anterior compartment of the arm Function: sensory ➛skin on lateral side of forearm 圖片版權為 出版商所有，禁止任意傳播 圖片版權為 出版商所有，禁止任意傳播 Brachial plexus ③ Medial pectoral nerve Origin: medial cord (C8, T1) Course: penetrate and supply the pectoralis minor muscle Function: motor ➛pectoralis major, pectoralis minor 圖片版權為 出版商所有，禁止任意傳播 Brachial plexus ④ Medial cutaneous nerve of arm (medial brachial cutaneous nerve) Origin: medial cord (C8, T1) Course: descends medial to brachial artery and basilic vein to innervate skin of distal medial arm Function: sensory ➛ skin on medial side of distal one-third of arm 圖片版權為 出版商所有，禁止任意傳播 圖片版權為 出版商所有，禁止任意傳播 Brachial plexus ⑤ Medial cutaneous nerve of forearm (medial antebrachial cutaneous nerve) Origin: medial cord (C8, T1) Course: Pierces deep fascia with basilic vein in midarm Function: sensory ➛ Skin on medial side of forearm 圖片版權為 出版商所有，禁止任意傳播 圖片版權為 出版商所有，禁止任意傳播 Brachial plexus ⑥ Median nerve Origin: medial and lateral cords (C6 to T1) Course: descends through arm adjacent to brachial artery, with nerve gradually crossing anterior to artery to lie medial to artery in cubital fossa Function: motor a. all muscles in the anterior compartment of the forearm (except flexor carpi ulnaris and medial half of flexor digitorum profundus) b. 3 thenar muscles of the thumb and two lateral lumbrical muscles Function: sensory ➛ skin over the palmar surface of the lateral three and one-half digits and over the lateral side of the palm and middle of the wrist 圖片版權為 出版商所有，禁止任意傳播 Fig 6.28 圖片版權為 出版商所有，禁止任意傳播 Brachial plexus ⑦ Ulnar nerve Origin: medial cord ((C7) C8, T1) Course: descends medial arm; passes posterior to medial epicondyle of humerus; then descends ulnar aspect of forearm to hand Function: motor a. All intrinsic muscles of the hand (except three thenar muscles and two lateral lumbricals) b. Flexor carpi ulnaris and the medial half of flexor digitorum profundus in the forearm Function: sensory ➛ Skin over the palmar surface of the medial one and one-half digits and associated palm and wrist, and skin over the dorsal surface of the medial one and one-half digits Brachial plexus 圖片版權為 出版商所有，禁止任意傳播 圖片版權為 出版商所有，禁止任意傳播 Brachial plexus ⑧ Upper subscapular nerve Origin: posterior cord (C5, C6) Course: passes posteriorly, entering subscapularis directly Function: motor ➛ subscapularis 圖片版權為 出版商所有，禁止任意傳播 Brachial plexus ⑨ Thoracodorsal nerve Origin: posterior cord (C6 to C8) Course: inferolaterally along posterior axillary wall to apical part of latissimus dorsi Function: motor ➛ latissimus dorsi 圖片版權為 出版商所有，禁止任意傳播 Brachial plexus ⑩ Lower subscapular nerve Origin: posterior cord (C5, C6) Course: passes inferolaterally, deep to subscapular artery and vein Function: motor ➛ subscapularis, teres major 圖片版權為 出版商所有，禁止任意傳播 Brachial plexus ⑪ Axillary nerve Origin: posterior cord (C5, C6) Course: passes posteriorly around the surgical neck of the humerus , accompanied by the posterior circumflex humeral artery Function: motor ➛deltoid, teres minor Function: sensory ➛skin over upper lateral part of arm 圖片版權為 出版商所有，禁止任意傳播 Brachial plexus ⑫ Radial nerve Origin: posterior cord (C5 to C8, (T1)) Course: passes out of the axilla to the posterior arm (with profunda brachii artery) Function: motor ➛ All muscles in the posterior compartments of arm and forearm Function: sensory ➛skin on the posterior aspects of the arm and forearm, the lower lateral surface of the arm, and the dorsal lateral surface of the hand 圖片版權為 出版商所有，禁止任意傳播 Brachial Plexus Injuries - result in loss of muscular movement (paralysis) and loss of cutaneous sensation (anesthesia) injuries to superior parts of the brachial plexus (C5 and C6) o an excessive increase in the angle between the neck and the shoulder o excessive stretching of the neck occurs during delivery 圖片版權為 出版商所有，禁止任意傳播 Brachial Plexus Injuries o the characteristic position of the upper limb: waiter’s tip position ➛ adducted shoulder, medially rotated arm, and extended elbow 圖片版權為 出版商所有，禁止任意傳播 Brachial Plexus Injuries o muscles affected: C5: shoulder muscles and elbow flexors C6: wrist extensors supraspinatus, infraspinatus, teres minor deltoid biceps brachii brachialis o Erb-Duchenne palsy Brachial Plexus Injuries o sensory loss: C5 and C6 innervated area C5: lateral arm C6: lateral forearm and the thumb 圖片版權為 出版商所有，禁止任意傳播 - Injuries to inferior parts of the brachial plexus (C8, T1) o Klumpke paralysis o less common o an excessive increases in the angle between the trunk and the upper limb o a baby's limb is pulled excessively during delivery 圖片版權為 出版商所有，禁止任意傳播 - Injuries to inferior parts of the brachial plexus (C8, T1) o muscle affected: short muscles of the hand o the characteristic position of the upper limb: claw hand 圖片版權為 出版商所有，禁止任意傳播 Brachial Plexus Injuries o sensory loss: C8: the little finger, the medial side of the hand, and the forearm T1: the middle of the forearm to the axilla 圖片版權為 出版商所有，禁止任意傳播 Upper Limb Lab II 1. Axillary artery 1) Arteries originates from the 1st part:: • superior thoracic artery 2) Arteries originates from the 2nd part: • thoraco-acromial artery • lateral thoracic artery 3) Arteries originates from the 3rd part: • subscapular artery • anterior circumflex humeral artery • posterior circumflex humeral artery 2. Brachial plexus 1) Supraclavicular part o Dorsal scapular nerve o Long thoracic nerves o Suprascapular nerve 2) Infraclavicular part o Lateral pectoral nerve o Medial pectoral nerve o Musculocutaneous nerve o Median nerve o Ulnar nerve o Thoracodorsal nerve o Upper subscapular nerve o Lower subscapular nerve o Axillary nerve o Radial nerve
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