C9: UPPER LIMB, BREAST AND

AXILLA
Files

Term

Breast
- Are specialized accessory glands of the skin
- Function: milk secretion
- Present in both sexes; male and immature women share the same structures
- Not part of the upper limb but are situated in the pectoral region
- Blood supply & lymphatic drainage are largely related to the armpit

Nipples Areola Ducts

- Are small & surrounded - Colored area of the - Where milk is excreted,
by the areola skin; covers the nipples located in the boundary of
areola

Hemispherical shape

- Comprised of adipose tissues, why it is in the superficial layer

- Pierces through the deep fascial layer through the axillary tail
*if you have infection (abcess of breasts), infection can spread in the deep fascial
layer
*deep fascial layer – passage where infections can spread

Montgomery’s glands
- The same with sebaceous glands – produces oil to moisturize the ducts in the
breast especially for lactation or when a baby needs to suck for
feeding, because it dries up

Breast tissue

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 - Consists of a system of ducts embedded in connective tissue that does not extend
beyond the margin of the areola

Feeding

- Main function
- Baby should latch first – no one should get involved or intervene
- Involvement: examination of breast while examining the axilla

DEVELOPMENT

PUBERTY YOUNG WOMEN

- Breasts gradually enlarge & assume their - Breasts tend to protrude

hemispherical shape under the influence of ovarian forward from a circular base
hormones (progesterone & estrogen)
Increased size of glands
- Mainly from the deposition of fat
Base of breast
- Extends from the 2nd
– 6th rib & from the lateral margin of the sternum to
the mid-axillary line
Greater part of the gland
- Lies in the superficial fascia
Axillary tail
- Extension of the gland, continues upward &
laterally pierces the deep fascia at the lower border
of the pectoralis major muscle & enters
the axilla

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 Lobes
- On each bres, which radiate out from the nipple
- Main duct on each, opens separately on the
summit of the nipple & possess a dilated ampulla
just before its termination
Base of the nipple
- Surrounded by the areola
Suspensory Ligaments
- Fibrous septa that seperates the lobes on the
glands
Retromammary space
- Deep to the breast & superficial to the underlying
pectoral muscles
- Space filled by loose connective tissue

EARLY PREGNANCY LATE PREGNANCY

- Duct system rapidly increases in - 2nd half of pregnancy, growth process
length and branching slows but breast continues to enlarge
Secretory alveoli mostly because of the distention
- Develop at the ends of the smaller (swelling, enlarges) of the secretory
ducts& connective tissue becomes filled alveoli with the fluid secretion
with expanding and budding secretory (colostrums)
alveoli Colostrum
Vascularity of the tissue - Special milk, only released once
- Also increases to provide adequate
- First milk ejected
nourishment for the developing gland - Has antibodies
Nipple *Breast Feeding
- Enlarges - Encouraged, because whatever
Areola
antibodies that the mother has, through
- Becomes darker and more extensive the colustrum it would be carried over or
as a result acquired by the child
of increased deposits of melanin
pigments in the
epidermis
Areola glands
- Enlarges & become more active

POST WEANING POST MENOPAUSE

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 - Breasts return to their inactive state - breasts atrophies after the
once the baby has been weaned menopause; breasts becomes weaker
- In whichever phase or age the mother or sags
stops weaning Secretory Alveoli
- Breasts assumes in its original size - most of it disappear, leaving behind
- Melanin production decreases the ducts
Amount of adipos tissue
Wean
- may increase or decrease
- Stop breastfeeding, usually at age
Breasts
three of child
Remaining milk - tend to shrink in size & become more
- absorbed pendulous
Secretory Alveoli Atrophy after menopause
- caused by the absence of ovarian
- shrink, most of them disappear
estrogen and progesterone
Interlobular Connective Tissue
- thickens
Breasts & Nipples
- shrink, nearly returns to its original size
Pigmentation of the Areola
- fades but area never lightens to its
original color

HOW IS MILK PRODUCED?

- by glands, there is this gland (mammary gland) that produces prolactin that initiates
the production of milk & a hormone (oxcytocin) will be produced in order for the milk
to be ejected

BREASTFEEDING HELPS A CHILD’S SURVIVAL?

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 Nutrients
Antibodies
Healthy BMI
Prevents diabetes & cancer
Unlikely to be obese
Good mental health
Witch’s Milk

- Or neonatal milk
- From babies after a few days or week after birth
- Due to the stimulation of the baby’s breasts by the mother’s hormones that cross
the placenta during pregnancy

Blood supply
- Areas near to it; internal thoracis artery, intercostals artery, & axillary artery
- Where glands are
- Supplies glands responsible for excretion, production, and exportation of milk

Arterial supply to the breasts

- includes the perforating branches of the internal thoracic artery and the intercostal
arteries
Axillary artery

- also supplies the gland via its lateral thoracic and thoracoacromial branches

Veins

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 - correspond to the arteries

Lymph Drainage
- Of the mammary glands is of great clinical importance because of the frequent
development of cancer & subsequent dissemination of the
malignant cells along the lymph vessels to the lymph nodes

Lateral quadrant Medial Quadrant

- Origin into the anterior axillary of the
pectoral group of nodes (posterior to
lower border of the pectoral major
muscle)
- Drain by means of vessel that pierce
the intercostals spaces & enter the
internal thoracic group of nodes (within
thoracic cavity along the
course of the internal thoracic artery)

Complete Radial Mastectomy

- Where breast can be removed totally or a portion of the breast is removed where
the malignant tumor is

Few lymph vessels

- Follow the posterior intercostals arteries & drain posteriorly into the posterior
intercostal nodes (along course of the posterior intercostal arteries)
Some vessels

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 - Communicates with the lymp vessels of the opposite breast and with those of the
anerior abdominal wall

MAIN CONCERN/IDEA
- If there is abcess, infection or signs of tumor, patients complaining of having axillary,
shoulder, & back pain
- Also to assess if there are tumors in underlying areas

WHICH SEX DEVELOPS BREAST CANCER?

- Both sexes can develop breast cancer

In women In men
- more elaborated breasts, easily - non-palpable (sometimes) tumor,
detected difficult to detect
- Complain of other pains but actually
caused by a
tumor
- Gives more time for cancer cells to
spread /
metastisize
Good assessment = good background
in anatomy

TYPICAL WAY OF EXAMINATION

Males
- Easier due to less adipose tissue, if
there is a tumor – easily palpable
Females
- Required to palpate, lying down and
sitting
Breasts are asymmetrical
- One breast is a little bigger / smaller to
the other
Inspect for: tumor, infection, or abcess

UNCOMMON CONGENITAL ANOMALIES

Polythelia Retracted/inverted nipple

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 - Presence of additional nipples, - Red flag for cancer, if there is tumor
polymastia for breasts - or it can be inborn

Micromastia Macromastia Gynecomastia

- Small breasts - Big breasts - Male breasts
- Males are not supposed
to have big breast, but
some would develop
breast-like because of
abnormal production of
hormones (estrogen is
highly produced)

Upper Limbs
- Shoulder, arm, elbow, forearm, wrist, and hand

3 IMPORTANT LANDMARKS OF THE SHOULDER & ARM:

1. Clavicle
2. Scapula
3. Humerus

Sternum
- Flat bone
- Three parts: manubrium, body, xiphoid
process

Jugular Notch
- Or suprasternal notch
- A large depression on the manubrium
Notch – depression ; Process –
protrudes

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 Clavicle

- Long & slender bone – thin

- Concave & convex ends
- Part of the shoulder, ―shoulder complex‖
- (purpose) muscle attachment & transmits forces
- Most commonly fractured bone
- Lateral third, middle third (outer, weakest part), medial third
Articulation
- With the sternum (manubrium) medially & the scapula (acromion process) laterally

Force transmits Middle outer third

- From hand-elbow-shoulder-clavicle - Last area to absorb those forces, thus

it is the most fractured bone

Scapula
- Flat & triangular bone
- In 2nd and 7th ribs, on posterior part
- In contact with the thorax – smooth
part

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 Smooth part Spine of the scapula Acromion process

- In articulation with - Posterior location / on - Very distal part

thorax or rib cage posterior surface

Supraspinous fossa Infraspinous fossa Glenoid fossa

- Upper part - Lower part - Lateral side

Supraglenoid Subscapular Coracoid Crest of the spine

tubercle fossa process
- uppermost
- There is - Anterior part, - Important portion or the
protuberance, important process & summit
important landmark landmarks for
landmark; above palpation
the glenoid fossa *there are
important
landmarks for
identifying /
figure which
has/is a problem

Humerus
- long bone, head of the humerus
articulates with the glenoid cavity of the

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 scapula

Deltoid tuberosity
- when palpated it is pronounced

Axilla
- or armpit, a pyramid-shaped space between the upper part of the arm and side of
the chest
- forms an important passage for nerves, blood vessels, & lymph channels as they
travel between the root of the neck to the upper limb

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 Apex
- the upper neck of the axilla
- directed into the root of the neck and is
rounded by the clavicle in front, behind
by the outer border of the scapula, &
medially by the outer border of the first
rib
Anterior axillary fold
- formed by the lower border of the
pectoralis major muscle
Axillary sheath
- the neurovascular bundle is enclosed in a connective tissue
- continuous with the prevertebral fascia in root of
the neck
MUSCLES IN THE AXILLA
Upper limb – Thoracic Wall
1. Subclavius
- Deeper muscle, Depresses the clavicle
when it pulls
- Origin: 1st costal cartilage
- Insertion: clavicle
- Innervations: nerve to subclavius
- Nerve root: C5, 6
- Action: adducts, flexion, medially
rotates
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Base
- lower end, rounded by the anterior
axillary fold behind the posterior axillary
fold & medially by the chest wall
Posterior Axillary fold
- formed by the tendons of the
latissimus dorsi & teres major muscles
2. Serratus Anterior
- ―Boxer’s Muscle‖
- Origin: first upper ribs
- Insertion: Medial border & inferior
angle of scapula
- Innervations: long thoracic nerve
- Nerve root: C5, 6, 7
- Action: draws the forward anterior
around thoracic wall; rotates scapula
CLINICAL
IMPORTANCE
Long thoracic nerve – if injured, serratus
anterior does not do its function
Medial winging / open book deformity
- Abnormal motion of the scapula,
causing protrusion or prominence of the
scapula
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 Sliding door deformity
- If serratus anterior predominates,
trapezoid & rhomboids (injured), SA
slides

3. Pectoralis Minor 4. Pectoralis Major

- Origin: 3, 4, 5 ribs - Superficial big muscle, deeper than

- Insertion: coracoids process
- Innervation: Medial pectoral nerve
- Nerve root: C6, 7, 8
- Action: depresses point of shoulder, if
fixed (scapula) it elevates the ribs of
origin (3,4,5)
pectoralis minor
- Origin: sternum, clavicle, & upper six
costal cartilages
- Insertion: lateral lip of the bicipital
groove of the humerus
- Innervations: medial & lateral pectoral
nerve
- Nerve root: C5, 6, 7, 8; T1
- Action: flexes, adducts, & medially
rotates arm

Upper Limb – Vertebral Column

1. Latissimus Dorsi
- Big, flat muscle at the back
- Origin: iliac crest, thoracolumbar fascia, spines of lower six thoracic vertebrae, lower
three 0r four ribs, & inferior angle of the scapula
- Insertion: floor of the bicipital groove of humerus
- Innervations: thoracodorsal nerve
- Nerve root: C6, 7, 8
- Action: A-EM (Adducts, extends, medially rotates)
*12 ribs and 12 thoracic vertebra

Scapular – Humerus
1. Subscapularis 2. Teres major
- Origin: subscapular fossa - Origin: lateral lower third of scapula
- Insertion: Lesser tuberosity - Insertion: medial lip of bicipital grove of
- Innervation: upper & lower humerus
subscapular nerve - Innervations: lower subscapular nerve
- Nerve root: C5, 6, 7 - Nerve root: C56,7

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 - Action: medially rotates arm & - Action: SAM (stabilzes shoulder joimt,
stabilizes shoulder joint adducts, medially rotates)

Arm
1. Biceps Brachii 2. Coracobrachialis
- Two heads: short and long - Origin: coracoids process
- Crosses the joints where it iproduces - Insertion: medial surface of humerus
motion - Innervation: Musculocutaneous nerve
- Weak shoulder flexor, weak elbow - Nerve root: C5, 6, 7
flexor, but a strong elbow-forearm - Action: Flexes & adducts arm
supinator
Axillary walls
- Innervations: musculocutaneous nerve
- Nerve root: C5, 6 - There are four wall & two regions

A. REGIONS

Apex
- (anterior) clavicle, (posterior) scapula, (medially) first rib

Base
- Anterior axillary fold (Pectoralis Major), Posterior axillary fold (latissimus dorsi &
teres major), chest wall (medial)

B. WALLS

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 Anterior Posterior Medial Lateral Wall
wall wall wall - Formed by the
- Formed by the - Formed by the - Formed by coracobrachialis &
pectoralis major, subscapularis, the upper four biceps brachii
pectoralis minor, latissimus dorsi, & or five ribs muscles in the
subclavius, and teres major and the bicipital groove
clavipectoral fossa muscles intercostals -Intertubercular
spaces groove (sulcus)
covered by
the serratus
anterior
muscle

C. CONTENTS OF AXILLA

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 Cord & Branches of Brachial Plexus

Lateral Cord Posterior Cord

- Formed by the anterior divion of
superior & middle trunk
Musculocutaneous nerve (C5,6),
Lateral pectoral nerve (C5,6)
Lateral root of median nerve (C5, 6)
- Posterior division of superior, middle, &
inferior
trunk
Upper & lower subscapular nerve
(C5,6)
Thoracodorsal nerve (C6, 7 8)
Axillary nerve (C5, 6)
Radial nerve (C5, 6 , 7, 8; T1)

Medial Cord
- Anterior division of inferior trunk
Medial pectoral nerve (C8; T1)
Medial cutaneous nerve of arm &
forearm (C8; T1)
Medial root of median nerve (C8; T1)

MAJOR BRANCHES

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 Musculocutaneous Nerve
- (C5, 6, 7)
- Origin: lateral cord of the brachial
plexus in the axilla
- arises from the lateral cord of the
brachial plexus, supplies the
coracobrachialis muscle, and leaves the
axilla by piercing that muscle
Axillary nerve
- (C5, 6)
- it divides into anterior and posterior
branches
- is one of the terminal branches of the
posterior cord of the brachial plexus
- curves deeply into axilla and passes
through the quadrangular space with
posterior circumflex humeral artery

Median nerve Ulnar nerve

- C6, 7 , 8; T1 (C5 in some individuals) - (C8 and T1)

- from the medial & lateral cord of the - arises from the medial cord of the
brachial plexus in the axilla brachial plexus
- (named) runs along the median axis of and descends in the interval between
upper limb the axillary
- Has no branches in the arm except for artery and vein
a small vasomotor nerve to the brachial - The ulnar nerve gives off no branches
artery in the axilla
- Lies deep to the bicipital aponeurosis
of cubital fossa

Radial nerve

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 - (C5, 6, 7, 8; T1)
- From the posterior cord of brachial plexus in the axilla
- is the largest branch of the brachial plexus and lies behind the axillary artery
- provides extensive cutaneous innervations along the posterior aspect of entire limb

MINOR BRANCHES

Nerve to the subclavius Long thoracic nerve

- (C5 and 6)
- supplies the subclavius muscle
- It is important clinically because it may
give a contribution (C5) to the phrenic
nerve; this branch, when present, is
referred to as the
accessory phrenic nerve.
- (C5, 6, and 7)
- arises from the roots of the brachial
plexus in the neck and enters the axilla
by passing down over the lateral border
of the 1st rib behind the axillary vessels
and brachial plexus
- It descends over the lateral surface of
the serratus anterior muscle, which it
supplies.

Lateral pectoral nerve Lateral root of the median nerve

- arises from the lateral cord of the
brachial plexus and supplies the
pectoralis major muscle, primarily its
clavicular head
- is the direct continuation of the lateral
cord of the brachial plexus
- It is joined by the medial root to form
the median nerve trunk, and this passes
downward on the lateral side of the

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Medial pectoral nerve
- arises from the medial cord of the
brachial plexus, supplies and pierces
the pectoralis minor muscle, and
supplies the pectoralis major muscle,
primarily its sternocostal head
Medial cutaneous nerve of the
forearm
- arises from the medial cord of the
brachial plexus and descends in front of
the axillary artery
Upper and lower subscapular nerves
- arise from the posterior cord of the
brachial plexus and supply the upper
and lower parts of the subscapularis
muscle
- In addition, the lower subscapular
nerve supplies the teres major muscle
Axillary Artery and its Branches
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axillary artery
- The median nerve gives off no
branches in the axilla.
Medial cutaneous nerve of the arm
- (T1)
- Arises from the medial cord of the
brachial plexus and is joined by the
intercostobrachial nerve (lateral
cutaneous branch of the 2nd intercostal
nerve)
- It supplies the skin on the medial side
of the arm
Medial root of the median nerve
- arises from the medial cord of the
brachial plexus
- crosses in front of the third part of the
axillary artery to join the lateral root of
the median nerve & form the median
nerve trunk
Thoracodorsal nerve
- arises from the posterior cord of the
brachial plexus and runs downward to
supply the latissimus dorsi muscle
19
 Axillary artery
- begins at the lateral border of the 1st rib as a continuation of the subclavian and
ends at the lower border of the teres major muscle, where it continues as the brachial
artery
- supplies the upper limb
- is closely related to the cords of the brachial plexus and their branches and is
enclosed with them in a connective tissue sheath called the axillary sheath
*if sheath is traced upward into the root of the neck, it is seen to be continuous with
the prevertebral fascia
Pectoralis minor muscle

- crosses in front of the axillary artery and divides it into three parts

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 First Part of the Axillary Artery
- extends from the lateral border of the
1st rib to the upper border of the
pectoralis minor
Relations
Anteriorly: The pectoralis major and
the skin. The cephalic vein crosses
the
Posteriorly: The long thoracic nerve
(nerve to the serratus anterior)
Laterally: The three cords of the
brachial plexus
Medially: The axillary vein
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Second Part of the Axillary
Artery
- lies behind the pectoralis minor muscle
Relations
Anteriorly: The pectoralis minor, the
pectoralis major, and the skin
Posteriorly: The posterior cord of the
brachial plexus, the subscapularis
muscle, and the shoulder joint
Laterally: The lateral cord of the
brachial plexus
Medially: The medial cord of the
brachial plexus and the axillary vein
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 Third Part of the Axillary Artery
- extends from the lower border of the pectoralis minor to the lower border of the
teres major
Relations:
Anteriorly: The pectoralis major for a short distance; lower down the artery, it is
crossed by the medial root of the median nerve
Posteriorly: The subscapularis, the latissimus dorsi, and the teres major. The
axillary and radial nerves also lie behind the artery
Laterally: The coracobrachialis, the biceps, and the humerus. The lateral root of
the median and the musculocutaneous nerves also lies on the lateral side
Medially: The ulnar nerve, the axillary vein, and the medial cutaneous nerve of the
arm

BRANCHES
From the first part: From the second part:

Highest thoracic artery Thoracoacromial artery

- is small and extremely variable
- runs along the upper border of the
pectoralis minor to reach area of the first
2 ribs
- Short trunk that immediately divides
into 4 terminal branches that supply
pectoral muscles and the
acromioclavicular region
Lateral thoracic artery
- runs along the lower (lateral) border of
the pectoralis minor along the lateral
chest wall

From the third part:

Subscapular artery
- a large vessel that runs along the lower (axillary) border of the subscapularis
muscle.or scapula

Circumflex scapular artery

- Curls around the axillary border of the scapula to reach infraspinous fossa
Thoracodorsal artery
- Descends along he latissimus dorsi muscle to reach thoracic wall
Anterior & posterior circumflex humeral arteries
- wind around the front and the back of the surgical neck of the humerus,
respectively
Posterior artery

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 - Larger of the two
- Passes the quadrangular space with the axillary nerve to reach scapular region
BRANCHES FROM SUBCLAVIAN
ARTERY
Suprascapular Artery
- Distributed to supraspinous &
infraspinous fossa of scapula
Superficial cervical artery
- Gives off deep branch that runs down
the medial border of scapula
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BRANCHES FROM AXILLARY
ARTERY
Subscapular artery & circumflex
scapular brachii
- Supply the subscapular & infraspinous
fossa of the scapula
Anterior circumflex humeral artery
Posterior circumflex humeral artery
Brachial Artery
- Begins at the lower border of the teres
major muscle as a continuation of the
axillary artery
- Travels through the anterior
compartment of the arm
- Its branches supply both the anterior
and posterior compartments of the arm,
thus supplies the entire arm
- Terminates opposite the neck of the
radius by dividing into radial and ulnar
arteries
Relations
Anteriorly: Vessel is superficial and is
overlapped from the lateral side by the
coracobrachialis and biceps. Medial
cutaneous nerve of the arm lies in front
of the upper part; median crosses its
middle part; & bicipital aponeurosis
crosses its lower part
Posteriorly: The artery lies on the
triceps, coracobrachialis insertion, &
brachialis
Medially: In the upper part of the arm,
ulnar nerve and basilica vein lie medial
to the artery. In lower part, the median
nerve lies on its medial side
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 Laterally: More proximally, the median
nerve and the coracobrachialis and
biceps muscles. More distally, tendon of
the biceps lies lateral to the artery

Ulnar Artery

- The larger of the two terminal branches of the brachial artery

- Begins at the cubital fossa at the level of the neck of the radius
- Descends through the medial (ulnar) aspect of the anterior compartment of the
forearm
- Enters the palm superficial to the flexor retinaculum in company with the ulnar nerve
- Ends by forming the superficial palmar arch, often anastomosing with the superficial
branch of the radial artery

Radial artery
- Is the smaller to three common palmar digital arteries
- Each common artery divides into 2 proper palmar digital arteries that supply the
adjacent sides of two digits

Deep palmar branch

- Arises superficial to the flexor retinaculum’passes deep between the abductor digiti
minimi and the flexor digiti minimi, & joins the radial artery to complete the deep
palmar arch

Axillary Vein & its Tributaries

Axillary Vein
- is formed at the lower border of the teres major muscle by the union of the venae
comitantes of the brachial artery and the basilic vein
- runs upward on the medial side of the axillary artery and ends at the lateral border
of the 1st rib by becoming the subclavian vein
- receives tributaries, which correspond to the branches of the axillary artery, and the
cephalic vein

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 Cephalic Vein Basilic Vein

- arises from the lateral side of the - Arises from the medial side of the
dorsal venous arch on the back of the dorsal venous arch on the back of the
hand and winds around the lateral hand and winds around the medial
border of the forearm border of the forearm
- ascends into the cubital fossa and up - ascends into the cubital fossa and up
the front of the biceps the front of the arm in the superficial
- receives a variable number of fossa on the medial side of the biceps
tributaries from the lateral and posterior
surfaces of the limb
Medial cubital vein
- A branch of the cephalic vein in the
cubital fossa
- Runs upward and medially & joins the
basilica vein

Axillary Lymph Nodes

- (20 to 30 in number) collect lymph from a large territory
- Drain lymph vessels from the lateral quadrants of the breast, superficial lymph
vessels from the thoracoabdominal walls above the level of the

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 umbilicus, skin of the back above the level of the iliac crests, & the vessels from the
upper limb

Arranged in 6 groups
Anterior (pectoral) group: Posterior (subscapular) group:

Lying along the lower border of the Lying in front of the subscapularis
pectoralis minor behind the pectoralis muscle, these nodes receive superficial
major, these nodes receive lymph lymph vessels from the back, down as
vessels from the lateral quadrants of the far as the level of the iliac crests.
breast and superficial vessels from the
anterolateral abdominal wall above the
level of the umbilicus

Lateral group: Central group:

Lying along the medial side of the
axillary vein, these nodes receive most
of the lymph vessels of the upper limb
(except those superficial vessels
draining the lateral side
Lying in the center of the axilla in
theaxillary fat, these nodes receive
lymph from the above three groups.

Infraclavicular Apical group: Subclavian Lymph

(deltopectoral) group:
These nodes are not
strictly axillary nodes
because they are located
Trunk
Lying at the apex of the
axilla at the lateral - Where apical nodes
border of the 1st rib, drain into
these nodes receive the - On the left side, this

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 outside the axilla. They lie
in the groove
between the deltoid and
pectoralis major muscles
and receive superficial
lymph vessels from the
lateral side of the hand,
forearm, and arm.
Axillary Fat
- armpit fat
Loose Connective Tissue
C9: UPPER LIMB, BREAST AND AXILLA
efferent lymph vessels trunk drains into the
from all the other thoracic duct
axillary nodes - On the right side, it
drains into the right lymph
trunk
- may drain directly into
one of the large veins at
the root of the neck
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