ANATOMY OF AXILLA

PROF.Dr. AHMED
ZOLFAKAR
 4- Axilla
It is: the •
pyramidal
intermuscular
space between
the upper part
of medial side
of the arm &
upper part of
side of the
chest

PROF. ZOLFAKAR
 Boundaries:
Apex (cervico-axillary •
canal): - It directs
upwards, medially
towards root of the
neck. - The apex is
bounded by: Anteriorly:
Back of middle third of
the clavicle. "
Posteriorly: Upper
border of scapula.
Medially: Outer border
of first rib.
PROF. ZOLFAKAR
 The base (floor)
- Is formed of:
1- Skin.
2- Superficial fascia.
3- Deep (axillary) fascia:
Upper surface of deep
fascia receives the
attachment of suspensory
ligament of axilla.

PROF. ZOLFAKAR
Anterior wall:

Two layers:
Superficial layer: Pectoralis
major & pectoral fascia.
Deep layer (the axillary
septum):
1- Subclavius.
2- Clavipectoral fascia.
3- Pectoralis minor.
4- Suspensory lIigament of
axilla.
- The anterior axillary fold
(lower border) is formed by
sternocostal head of
pectoralis major. PROF. ZOLFAKAR
 Posterior wall:
It is formed by
subscapularis (medially),
teres major and latissimus
dorsi (laterally).
- Posterior fold (lower
than anterior): Is formed
by teres major, latissimus
dorsi & their triple
relation.
- Medial wall: It is formed by: - The upper 4 or 5 five ribs &
intercostal muscles. - The upper part of serratus anterior. -
The nerve to serratus anterior.
Lateral wall: The narrowest wall, it is formed of
coracobrachialis and short head of biceps.
PROF. ZOLFAKAR
 Contents of the axilla:
Vessels: 1- Axillary artery & its branches.
2- Axillary vein & its tributaries.
Nerves: 1- Cords & branches of the brachial
plexus (infraclavicular part).
Lymph nodes: Axillary lymph nodes.
Special contents: 1- Axillary tail of the breast.
2- Axillary sheath: It contains axillary vessels &
brachial plexus.
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 III-Nerves 1- The Brachial Plexus
It is: the nerve network which
supplies the upper limb.
-Formation lstagesl
= It is formed of several stages.
–Roots: - Are anterior 1ry rami
of C 5,6,7,8 & T1.
- May receive a contribution
from C4 (prefixed brachial
plexus).
- May receive a contribution
from T2 (postfixed brachial
plexus). - The roots lie in the
neck deep to the scalenus
anterior muscle. =.
. •
PROF. ZOLFAKAR
 Trunks: - Are present in the neck
lateral to scalenus anterior in the
posterior triangle. - Upper trunk: Is
formed by the union of C5, 6 roots. -
Middle trunk: Is formed by C7 root
only. - Lower trunk: Is formed by the
union of C8 and T1 roots. .:
Divisions: - Each trunk divides into
anterior & posterior divisions (to
supply flexor, extensor sides). - The
divisions lie behind the clavicle, in
the apex of the axilla.
- Cords: - Are present in the axilla
along the lateral wall.
- Posterior cord: is formed by the
union of the three posterior
divisions.
- Lateral cord: Is formed by the
union of the anterior divisions of
upper & middle trunks.
- Medial cord: Is formed by the
anterior division of lower trunk only
PROF. ZOLFAKAR
Relation to 1st part of
axillary artery:
- Medial cord is posterior to
the artery.
- Lateral & posterior cords
are lateral to the artery.
- Relation to 2nd part of
axillary artery:
- Medial cord is medial to
the artery.
- Lateral cord is lateral to the
artery.
- Posterior cord is posterior
to the artery.

PROF. ZOLFAKAR
 Branches:
1- From the roots
1- Nerve to rhomboids (dorsal scapular nerve) (C5).
2- Nerve to serratus anterior (long thoracic nerve of Bell) (C5,6 &7):
'-3- Branch from C5 to join the phrenic N. (C3, 4, 5).
2- Branches from trunks (upper trunk only) ,-
1- Nerve to subclavius (C5, 6).
2- Suprascapular nerve (C5, 6).
3- Branches from the cords _
- Lateral cord: 1- Lateral pectoral nerve (C5, 6, 7).
2- Lateral root of median nerve (C5, 6, 7).
3- Musculocutaneous nerve (C5, 6, 7). The largest
branch.
- Medial cord: 1- Medial pectoral nerve (C8, T1).
2- Medial root of median nerve (C8, T1).

PROF. ZOLFAKAR
3- Medial cutaneous N. of arm (C8, T1).
4-Medial cutaneous N. of the forearm (C8, T1).
5- Ulnar nerve (C7, 8, T1).
- Posterior cord:
1- & 2- Upper & lower subscapular nerve (C5, 6).
3- Nerve to latissimus dorsi (Thoracodorsal N.)
(C6, 7, 8).
4- Circumflex (axillary) nerve (C5, 6).
5-Radial nerve (C5, 6, 7,8 T1).

PROF. ZOLFAKAR
 Injury of the brachial plexus:
A- Injury of the upper trunk (C5, 6) (Erb's Douchenne
paralysis): -
Cause: Birth injury (excessive displacement of the head to one
side and depression of the shoulder on the other side).
- Results: 1-Motor effect -Erb' paralysis (Porter's tip
deformity): - The shoulder is:
Adducted: due to paralysis of deltoid and supraspinatus. -
- Medially rotated: due to paralysis of infraspinatus & teres -
minor.
- The elbow is extended due to paralysis of biceps and -
brachialis. - The forearm is pronated due to paralysis of
biceps.
2- Sensory effect: Sensory loss in lateral side of the upper
limb.

PROF. ZOLFAKAR
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 B- Injury of the lower trunk (C8, T1):
- Causes:
1- Excessive abduction of the arm as in difficult birth or
traction on the arm.
2- Cervical rib.
3- Malignant lower deep cervical lymph nodes. ~
- Results:
1-Motoreffect -Klumpk's paralysis: - The fibers of T1 are
mainly distributed to lumbricals and interossei in the hand.
Their actions are flexion metacarpophalangeal joints and
extension of interphalangeal joints. Their Paralysis ~ loss of
abduction and adduction of fingers and claw hand
2- Sensory effect: Sensory loss in medial side of the forearm
(T1) & medial 2 fingers (C8).
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 2- Circumflex (Axillary) Nerve
~: It is a mixed nerve. Root value: •
C5, 6. Origin: It is smaller of the 2
terminal branches of the
posterior cord of brachial plexus.
~ Course and Relations: - It passes
downwards & laterally behind
third part of axillary ~ artery and
in front of subscapularis, lateral
to radial nerve. - It runs along the
lower border of subscapularis
muscle to enter the quadrangular
space with the posterior
circumflex r-r humeral artery. - It
winds around back of surgical
neck of humerus where it divides
into anterior & posterior
branches deep to deltoid. ".

PROF. ZOLFAKAR
 Branches:
a) The trunk: Gives articular •
branch to the shoulder
joint.
b) Anterior branch: Supplies •
anterior part of deltoid.
c) Posterior branch: - It •
supplies the teres minor
and the posterior part of
deltoid muscle.
- It gives upper lateral •
cutaneous N. of arm to skin
over upper of lateral side of
arm

PROF. ZOLFAKAR
Injury: It is frequent. - Causes: •
1- Fracture of surgical neck of the humerus. •
2- Downward dislocation of shoulder joint. •
3- Chronic use of axillary crutches. •
- Effects: - Sensory loss:of the skin over the lower •
half of the muscle, as the skin over the upper ~ is
supplied also by lateral supraclavicular nerve.
- Motor effect: - Paralysis of deltoid & teres •
minor.
- Disability: Loss of efficient abduction of the arm •
(15°-90°).
- Late trophic changes(deformity): Flat shoulder & •
prominent acromion due to atrophy of deltoid.

PROF. ZOLFAKAR
 IV- Arteries: - Axillary artery
Origin: It begins at the outer •
border of the first rib as
continuation of the
subclavian A. Termination:
At the lower border of teres
major by becoming the
brachial artery. Course: It is
crossed by the pectoralis
minor muscle, which divides
it into three parts: First part:
Above the muscle. Second
part: Behind the muscle.
Thirdpart: Below the
muscle.

PROF. ZOLFAKAR
 Relations:
First part: - Anteriorly: - •
Pectoralis major. -
Clavipectoral fascia. -
Posteriorly: - 1st
intercostal space. - 1st
digitation of serratus
anterior. - N. to serratus
anterior. - Medial cord of
brachial plexus. ~Laterally
& above: Lat. & posterior
cords of brachial plexus. -
Medially: - Axillary vein.

PROF. ZOLFAKAR
 Second part:
- Anteriorly: - Pectoralis •
minor, major muscles.
- Posteriorly: - Posterior •
cord of brachial plexus. -
Subscapularis muscle.
- Laterally: - Lateral cord of •
brachial plexus. -
Coracobrachialis muscle.
- Medially: - Medial cord of •
brachial plexus.

. •

PROF. ZOLFAKAR
 Third part:
• Anteriorly: •
a) Upper part: - Skin & fasciae. - •
Medial root of median N. - Pectoralis
major. b) Lower part: - Skin & fasciae
only.
- Posteriorly: - •
Axillary and radial nerves (posterior •
cord). - Posterior wall of axilla
(subscapularis, teres major &
latissimus dorsi).
- Laterally: - Median N. & its lateral •
root. - Musclocutaneous N. -
Coracobrachialis & short head of
biceps.
- Medially: •
in order: - Medial cutaneous N. of •
forearm. - Ulnar nerve. - Axillary vein.
- Medial cutaneous nerve of the arm.

PROF. ZOLFAKAR
 Surface anatomy:
The arm is abducted to •
90°. A line is drawn
between the mid
clavicular point and a
point on posterior fold
of the axilla where the
pulsation of the artery
can be felt. - Axillary
vein

PROF. ZOLFAKAR
 Branches: -
First part gives one branch: Superior thoracic •
artery. - It runs forwards, medially on side of
the chest to supply it. r-
- Second part gives two branches: •
1-Acromiothoracic artery - It pierces the •
clavipectoral fascia. - It divides into 4
branches (A, P, C and D):
A- Acromial branch: towards acromion. •
P- Pectoral branch: supplies the 2 pectoral •
muscles & breast.
C- Clavicular branch: To clavicle & •
sternoclavicular joint.
D- Deltoid branch: Runs in deltopectoral •
groove to deltoid.
2- Lateral thoracic artery - It runs along the •
lower border of pectoralis minor. - It
accompanies nerve to serratus anterior. - It
supplies the lateral part of the breast (it is
large in females).

PROF. ZOLFAKAR
 - Third part gives three branches:
1- Anterior circumflex •
humeral artery (smaller) -
It runs in front of surgical
neck of the humerus,
where it divides into: a)
Ascending branch: to
supply the shoulder joint.
b) Transverse branch:
anastomoses with
transverse branch of post.
circumflex humeral
artery.

PROF. ZOLFAKAR
 2- Posterior circumflex humeral artery (larger)

It arises at lower border of •

subscapularis. It enters the
quadrangular space
accompanied by the axillary
nerve. - It passes behind the
surgical neck of humerus,
gives: a) Ascending branch: to
shoulder joint. b) Descending
branch: anastomoses with the
ascending branch of profunda
brachii artery. c) Transverse
branch (continuation):
anastomoses with that of the
anterior.

PROF. ZOLFAKAR
 3- Subscapular artery - The largest of
all branches.
It descends along the lateral •
border of the scapula.
- It runs for about 4 cm, •
divides into its two
terminations:
a) Circumflex scapular A. •
(larger): enters upper
triangular space to share in
anastomosis around scapula.
b) Thoracodorsal A. (smaller): •
Accompanies thoracodorsal N.
- They run along the lateral
border of the scapula as far as
its inferior angle. - They end in
latissimus dorsi muscle.

PROF. ZOLFAKAR
Anastomoses of the axillary artery:
1- Anastomosis around •
the scapula ~ It is
richanastomosis,
between 1st part of
subclavian A. & 3rd part
of axillary A., between:
1· Suprascapular artery:
It is a branch from
thyrocervical trunk of
1st part of the
subclavian artery.

PROF. ZOLFAKAR
It passes to the scapula above •
the suprascapular ligament to
reach the supraspinous fossa.
It traverses the spinoglenoid
notch to reach the
Infraspinous fossa.
2- Deep branch of transverse •
cervical artery: It arises from
thyrocervical trunk of 1st part
of subclavian artery. It runs
along the medial border of the
scapula till the inferior angle.
3- Subscapular artery: It is a •
branch of 3rd part of axillary
artery. It runs along the lateral
border of the scapula, gives
circumflex scapular artery.
4- Lateral & posterior branches •
of posterior intercostal
arteries: From descending
aorta

PROF. ZOLFAKAR
 Clinical significance of anastomosis
around the scapula:
1- It maintains •
circulation to UL if the
axillary artery is
obstructed above the
third part.
2- It maintains •
circulation to the lower
part of the body in case
of coarctation of the
aorta.
PROF. ZOLFAKAR
2- Anastomosis around surgical neck of
the humerus
It is anastomosis between •
branches of:
1 & 2 - Anterior & •
posterior circumflex
humeral arteries of 3rd
part of axillary A.
3- Ascending branch of •
profunda brachii of
brachial A.
4- Descending br. of •
suprascapular of
subclavian A.

PROF. ZOLFAKAR
 V- Veins: Axillary
vein
It begins at lower border of •
teres major by union of the
basilic vein . & 2 venae
comitants of the brachial
artery.. It ascends along the
medial side of axillary artery. It
ends at outer border of the 1st
rib as subclavian vein.
Tributaries: •
1- The two venae comitants of •
brachial artery.
2- The cephalic vein joins it •
above the pectoralis minor.
3- Veins accompany branches •
of the axillary artery.

PROF. ZOLFAKAR
 VI- Axillary lymph nodes
Axillary lymph nodes are •
arranged in 5 groups. ~ Each
group (except central) is related
to a wall of axilla and a vessel.
1- Anterior (pectoral) group: Lies •
along lower border of pectoralis
minor, along lateral thoracic
vessels.
2- Posterior (subscapular) group: •
Lies along subscapular artery on
posterior wall of axilla.
3- Lateral (humeral) group: Lies •
along the axillary vein at lateral
wall of axilla

PROF. ZOLFAKAR
4- Central group: Lying in the •
center of the axilla in the
axillary fat, these nodes receive
lymph from the above three
groups.
■■ Infraclavicular •
(deltopectoral) group: These
nodes are not strictly axillary
nodes because they are located
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.
5- Apical group: Lying at the •
apex of the axilla at the lateral
border of the 1st rib, these
nodes receive the efferent
lymph vessels from all the other
axillary nodes.

PROF. ZOLFAKAR
GOOD LUCK
GOOD LUCK