Check List 2

1. Muscles underneath the breast and their nerve supply

Muscles: Pectoralis Major, Pectoralis Minor, and Subclavian.
• Pectoralis Major Innervation- Medial and lateral pectoral nerves. (largest and most
superficial of the 3.)
• Subclavian- Nerve to Subclavius
• Pectoralis Minor- Medial Pectoral Nerve

2. Quadrants of the breast? Which quadrant has the maximum chance of getting cancer? (Google)

Upper outer quadrant, Upper inner quadrant, Lower-outer quadrant, Lower inner quadrant

Upper outer quadrant has the highest chance of breast cancer.

3. What is gynecomastia? What are causes of gynecomastia? Is cancer possible in a male breast?
• Cancer is possible in the male breast.
• Gynecomastia is swollen male breast tissue
• It is caused by a hormonal imbalance: estrogen and testoteron
• Caused by genetic Klinfelter. (XXY; XXXY); Contain barr bodies.
4. Suspensory ligament of Cooper- Connective tissue that surrounds the ducts that condenses to
form ligaments that support the breast and are continuous with the skin.
Lactiferous duct- The mammary glands branch into these ducts and associated lobules. 15-20 of
them. Open independently to the nipple.
Lactiferous sinus- ??? Potentially this is the lactiferous ducts when they dilate in which milk
accumulates b/t breastfeeding. (IDK though) . @the base of the nipple.

5. Blood supply and lymphatic drainage of the breast

Blood Supply:
Laterally- Vessels from the axillary artery: This includes the following
• Superior Thoracic
• Thoracic-Acromial
• Lateral Thoracic
• Subscapular arteries
Medially- Branches from the internal thoracic artery
2nd and 4th intercostal arteries via branches that perforate the thoracic wall &
overlying muscle

Venous Drainage: The veins parallel the arteries and drain into the axillary, internal
thoracic, and intercostal veins

Lymphatic Drainage:
• 75% drain laterally and superiorly to AXILLARY nodes
• Most remaining goes to parasternal nodes that are deep to the anterior thoracic
wall and are associated to the internal thoracic artery.
• Some (a really small amount) may drain via lymphatic vessels that follow lateral
branches of the posterior intercostal arteries that go to the head and neck of ribs.

6. What is winged scapula?

This occurs when there is damage to the long thoracic nerve. Damage to this causes
paralysis of the serratus anterior muscle producing a winged scapula.
7. What is thoracostomy?
A small incision made for the purpose to place a tube in between the lungs and the chest wall
to relieve air or trapped fluid. (Context from Thoracic chest tube insertion)

8. What is median sternotomy?

This is a vertical incision made from the sternal notch (atop the manubrium of the sternum) to
the distal end of the xiphoid process. Allow to access to the heart

9. What are the indications of thoracostomy? Where is the location of thoracostomy tube?
 Indications: ??? pneumothorax, hemothorax, hemopneumothorax, malignant pleural effusion
empyema, hydrothorax, and chylothorax, and also after thoracic surgery.

Location: Between the anterior axillary and midaxillary anatomical lines from front t* o back
(Anterior to posterior) and in either the fourth or fifth anatomical space.

10. What are other regions of the body is innervated by the intercostal nerve in addition to the
thoracic wall?
• Brachial plexus (Contributions from the anterior ramus of T1
• Medial Surface of the upper arm
• Muscles, skin, and peritoneum of abdominal wall.
11. What is the intercostobrachial nerve?
Only major structure that passes directly through the medial wall & into the axilla.
This is the lateral cutaneous branch of the 2nd intercostal nerve. It communicates with a
branch of the brachial plexus in the axilla to supply skin on the upper arm.

12. What are flail chest, slipping rib syndrome, and separation of ribs?
• Flail Chest: After severe trauma, ribs may be broken in two or more places. If enough ribs
are broken, a loose segment of chest wall, a flail segment is produced
• Slipping Rib Syndrome: caused by hypermobility of the anterior false ribs that allows the 8-
10th ribs to slip as the cartilaginous rib tip slips under the rib above. Pain in upper abdomen

• Separation of Ribs: When a rib separates at the costochondral joint. Cause pain and popping
noise
13. What is the clinical importance of sternal bone marrow study?
• The clinical importance of this study is so when it is drawn under a microscope a clinician
can diagnose a certain blood disease like leukemia.
14. What is the arrangement of the vein, artery, and neve in the intercostal space and costal
groove?
Intercostal nerve and associated major arteries and veins lie in the costal groove.
- Vein is the most superior structure => highest position in the costal groove
- Artery is inferior to the vein
- Nerve is inferior the artery => often not protected by the costal groove
• Picture is down below.

15. What is thoracic outlet syndrome?

• Describes symptoms resulting from abnormal compression of the brachial plexus of nerves
as it passes over the first rib and through the axillary inlet into the upper limb
• The cervical band from a cervical rib is one of this syndrome by putting upward stresses on
the lower parts of the brachial plexus as they pass over the cervical band and related
cervical rib.
16. What is the articulation of the cervical rib?
• Cervical Rib: only present in about 1% of the population.
- Accessory rib that articulates with vertebra CVII, the anterior end attaches to the
superior border of the anterior aspect of rib I
- often not appreciated by clinicians that a fibrous band commonly extends from the
anterior tip of the small cervical ribs to rib I, producing a “cervical band”
17. What is intercostal nerve block? How is it done?
• Local anesthesia of intercostal nerves produce excellent analgesia in patients w/ chest
trauma.
• The nerve block may be undertaken using a “blind” technique or under direct imaging
guidance.
1.) patient is placed in the appropriate position to access the rib. Typically, under
ultrasound guidance
2.) needle may be advanced into the region of the subcostal groove, followed by an
injection with a local anesthetic.

18. What are the complications of intercostal nerve block?

• May include…
- puncture of the parietal pleura and an ensuing pneumothorax.
- Bleeding may also occur if the artery or vein is damaged during the procedure.
19. Injuries to the brachial plexus and trauma to the roots of the brachial plexus?
• When the brachial plexus is damaged it requires meticulous clinical history taking and
examination.
• Usually are the result of blunt trauma producing nerve avulsions and disruption
 ➢ Devastating for the function of the upper limb and require months of rehabilitation for a
small amount of function to be regained.
• Spinal cord injuries in the cervical region and direct pulling injuries tend to affect the roots
of the brachial plexus.
- Trunks affected by severe trauma to the 1st rib.
- Divisions and cords of the Brachial plexus can be injured by dislocation of glenohumeral
joint.
20. Erb-Duchenne paralysis
• Form of brachial plexus palsy
• 1/1,000 babies have this condition.
• Cause arm weakness and loss of motion.

21. Klumpke paralysis

• Affects the movement of the lower arm and hand

•
22. Saturday night palsy
• Radial nerve compression; think of when your arm falling asleep
• Wrist drop
23. What are the blood supply and nerve supply of the diaphragm, hemidiaphragm, and paradoxical
movement of the diaphragm?
• Diaphragm
➢ Blood Supply:
- Superior
+ the musculophrenic and pericardiaco-phrenic arteries, both branches of the internal
thoracic artery
+ the superior phrenic artery, a branch of the thoracic aorta
- Inferior
+ inferior phrenic arteries, branches of the abdominal aorta
➢ Nerve Supply/ Innervation:
+ Primarily by the phrenic nerves (C3-C5 spinal cord levels)
+ pass through the thoracic cavity, between the mediastinal pleura and the
pericardium, to the superior surface of the diaphragm
+ the right phrenic nerve accompanies the inferior vena cava through the diaphragm
+ the left phrenic nerve passes through the diaphragm by itself
• Paradoxical movement of the Diaphragm:
➢ An abnormal sign scene during respiration in which the diaphragm moves opposite to
the normal directions of the movements
- During inspiration the normal diaphragm would down and upwards in expiration.
- During a paradoxical movement the diaphragm would do the opposite.
- Seen during flail chest as well
+ When the patient takes a deep inspiration, the flail segment moves in the opposite
direction to the chest wall, preventing full lung expansion and creating a paradoxically
moving segment.