UPPER EXTREMITY:

Axilla & its boundaries, structures,

vessels & nerves; Brachial plexus &
its terminal branches & area of
supply

AXEL LANGUIDO ELISES, MD, FPSGS, FPALES, FPCS, PATOS

PRETEST
1. The Anterior Axillary Fold is formed by:
A. biceps brachii
B. pectoralis minor
C. teres major
D. none of the above
2. The Posterior Axillary Fold is formed by:
A. anterior
B. posterior
C. superior
D. inferior
3. The Brachial plexus is partly formed by which of the following
spinal roots:
A. C1, C2, C3, C4
B. C5, C6, C7, C8
C. C9, T1, T2, T3
D. all of the above
PRETEST
4. The posterior cord of the brachial plexus is formed by:
A. anterior division of superior trunk
B. anterior division of superior & inferior trunks
C. posterior division of superior, middle & inferior trunks
D. anterior division of superior trunk & posterior division of inferior trunk
5. Injury to the median nerve will lead to :
A. Police tip deformity
B. Wrist Drop deformity
C. Claw Hand deformity
D. Ape Hand deformity
6. Injury to the musculocutaneous nerve will cause loss of skin
sensation at the:
A. lateral aspect of upper arm
B. lateral aspect of foream
C. medial aspect of upper arm
D. lateral aspect of forearm
PRETEST
7. Radial nerve is a branch of the :
A. anterior cord
B. posterior cord
C. medial cord
D. lateral cord
8. Injury to the ulnar nerve will lead to :
A. Police tip deformity
B. Wrist Drop deformity
C. Claw Hand deformity
D. Ape Hand deformity
9. Klumpke’s palsy:
A. C1, C2
B. C4, C5
C. C5, C6
D. C8, T1
PRETEST
10. Axillary vein is formed by the union of:
A. cephalic and basilica veins
B. cephalic and brachial veins
C. brachial veins and basilic vein
D. subclavian vein and cephalic vein
Learning Objectives
Objectives
 Define the boundaries & contents of the
axilla
 Explain the parts of the brachial plexus
 Describe the motor and sensory
innervation from each main branch of
the brachial plexus

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Objectives
 Predict the type of condition/impairment
caused by nerve damage to main
branches of brachial plexus

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Course Outline
 Axilla
 Boundaries
 Contents
 Brachial plexus
 Axillary artery

 Axillary vein

 Lymph nodes

 Axillary tail (of Spence)

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Course Outline
 Brachial plexus (5-3-6-3-4/12)
 Ventral rami/ Roots  Divisions (6)
 C5  Anterior
 C6  Posterior

 C7  Cords (3)
 C8  Lateral
 T1  Medial

 Trunks  Posterior

 Superior
 Middle

 Inferior
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Course Outline
 Branches
 Infrascapular
 Suprascapular  Lateral pectoral n.
 Dorsal Scapular n.  Musculocutaneous n.
 Long Thoracic n.
 Median n.
 Suprascapular n.
 Medial pectoral n.
 Subclavian n.
 Medial cutaneous n. of arm

 Medial cutaneous n. of forearm

 Ulnar n.

 Upper subscapular n.

 Lower subscapular n.

 Thoracodorsal n.

 Axillary n.

 Radial n.
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Course Outline
 Nerve Damage
 Ulnarnerve
 Median nerve
 Radial nerve

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Axilla

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Axilla
 pyramid shaped space between the upper
thoracic wall & arm

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Axilla: Borders
 borders:
 medial wall
 lateral wall
 posterior wall
 anterior wall
 base
 apex

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Axilla: Borders
medial wall
 formed by:
 4 upper ribs & its intercostal muscles
 serratus anterior

lateral wall
 intertubercular groove, humerus

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Axilla: Borders
posterior wall
 formed by:
 scapula

 subscapularis

 teres major forms the

posterior axillary fold
 latissimus dorsi

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Axilla: Borders
anterior wall
 formed by:
 pectoralis major forms the
posterior axillary fold
 pectoralis minor

 pectoral fascia

 clavipectoral fascia

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Axilla: Borders
base
 formed by concave skin & subcutaneous
tissue, & axillary fascia  extends from
upper arm to lateral chest, 4th rib
 forms the axillary fossa

 bounded by:
 anterior : anterior axillary fold
 posterior : posterior axillary fold
 medial : external thoracic wall
 lateral : medial aspect, upper arm
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Axilla: Borders
apex
 interval between the:
 clavicle
 1st rib

 upper border of scapula

 forms a passage way between the cervical

neck & the upper extremity = cervicoaxillary
canal

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Axilla: Contents
 contents:
1. Brachial plexus & branches
 a somatic nerve plexus
 formed by anterior rami of C5, C6, C7, C8, T1
(roots)
 responsible for:
 innervation of all muscles of upper extremity,
EXCEPT:
 trapezius
 levator scapulae

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Axilla: Contents
 supplies all cutaneous innervation of upper
limb, EXCEPT:
 axilla - supplied by supraclavicular
nerve (C3,C4)
 dorsal scapular area
- supplied cutaneous branches
of dorsal rami

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Axilla: Contents
 communicates with sympathetic trunk via gray
rami communicantes  joins the roots of the
plexus
 derived from the middle & inferior cervical
sympathetic ganglia & the 1st thoracic
sympathetic ganglion

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Axilla: Contents
 subdivided into:
 Roots (5)
 Trunks (3)
 Divisions (6)
 Cords (3)
 Branches (16)

Robert Taylor Drinks Cold Beer

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Axilla: Contents
Brachial Plexus
Anterior Rami Trunks Divisions Cords Branches

Musculocutaneous
Anterior Lateral
C5 Superior Posterior
Trunk Median
C6
C7 Middle Anterior
Medial Medial cutaneous n’s.
Trunk Posterior
Medial pectoral
Ulnar
C8
T1 Inferior Anterior Posterior Radial
Trunk Posterior
Axillary
Thoracodorsal
Subscapulars
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Axilla: Contents
 Branches
 Suprascapular
 Dorsal Scapular n. Branches from the
Roots
 Long Thoracic n.

 Suprascapular n. Branches from the

Trunk
 Subclavian n.

 Infrascapular
 Musculocutaneous n. Branches from
 Median n., lateral head Lateral Cord
 Lateral pectoral n.

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Axilla: Contents
 Medial pectoral n. Branches from
 Medial cutaneous n. of arm Medial Cord
 Medial cutaneous n. of forearm

 Ulnar n.

 Upper subscapular n. Branches from

Posterior Cord
 Lower subscapular n.

 Thoracodorsal n.

 Axillary n.

 Radial n.

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Property of Axel L. Elises, MD, FPSGS, FPALES, FPCS, PATOS
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Property of Axel L. Elises, MD, FPSGS, FPALES, FPCS, PATOS
Total Brachial Plexus Palsy
 usually due to severe trauma
 manifestations:
 entire arm is paralyzed
 arm’s musculature will go into rapid atrophy
 complete anesthesia of arm distal to a line
extending obliquely from tip of shoulder to
medial arm half way to elbow
 entire upper limb is areflexic

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Upper Plexus Palsy
 Erb – Duchenne Palsy
 due to damage to C5, C6
roots/upper trunk
 causes by forceful separation or
increase in the angle between
head & shoulder :
 forceful extraction of fetal head
during childbirth
 pressure on shoulder (e.i. rifle
recoil, backpacker’s palsy)
 also caused by idiopathic plexitis
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Upper Plexus Palsy
 paralysis of (corresponding actions):
 deltoid & supraspinatus (shoulder abduction)
 infraspinatus (external rotation of arm)

 biceps (forearm supination, elbow flexion)

 brachioradialis (elbow flexion)

 brachialis (elbow flexion)

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Upper Plexus Palsy
 sensation is usually intact
 reflexes of biceps & brachioradialis are
depressed or absent
 “policeman’s/ waiter’s tip”

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Upper Plexus Palsy
 Acute Brachial Plexus Neuritis
 idiopathic
 maybe due to URTI, recent vaccination
 sudden onset of severe pain around the
shoulder especially at night
 later, associated with muscle weakness & atrophy

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Middle Plexus Palsy
 C7 root damage/injury
 rarely occurrence, usually due to trauma
 Extensors are affected:
 Triceps
 Anconeus
 Extensor carpi radialis & ulnaris
 Extensor digitorum & indices
 Extensor pollicis longus & brevis
 Abductor pollicis longus
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Middle Plexus Palsy
 Triceps reflex is absent
 sensory deficit is patchy &
inconsistent over the surface of
the extensors of forearm & radial
aspect of the dorsum of the hand

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Lower Plexus Palsy
 Dejerine-Klumpke Palsy
 injuryto C8, T1 roots
 often due to trauma:
 arm traction in abducted position
 surgical procedures for lung tumors

 aneurysm of the aortic arch

 lost of sensation:
 medial arm & forearm
 ulnar aspect of the hand

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Lower Plexus Palsy
 weakness of & finger flexion, & intrinsic
muscles of the hand 
Claw hand deformity
 Hoffmann’s reflex/ Finger Flexor reflex is
absent
 sympathetic fibers of T1 destined for superior
cervical ganglion are interrupted  Horner’s
Syndrome:
 ptosis
 miosis

 anhydrosis
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Specific Nerve Palsy
 Median Nerve Palsy
 loss of the ability to abduct & oppose
the thumb due to thenar muscles
paralysis
 Sensory loss in the thumb, index
finger, long finger, & the radial aspect
of the ring finger
 Weakness in forearm pronation, wrist
& finger flexion
 “Ape hand” deformity
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Specific Nerve Palsy
 Ulnar Nerve Palsy
 “Claw hand” deformity
 Radial Nerve Palsy
 “Wrist drop” deformity

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Axilla: Contents
2. Axillary artery
 continuation of subclavian artery
 from 1st rib, lateral border, to inferior border of
teres major
 passes behind the pectoralis minor  3 parts

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Axilla: Contents
 First Part:
 between the 1st rib & medial
border of pectoralis minor
1. Superior thoracic artery
 supplies:
 subclavius
 1st & 2nd intercostal muscles & spaces
 superior part of serratus anterior
 pectoralis muscles
 anastomoses with intercostals & internal thoracic
arteries

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Axilla: Contents
 Second Part:
 posterior to pectoralis minor
1. Thoracoacromial artery
 pierces costocoracoid of
clavipectoral fascia  branches:
 Acromial (superomedial)
 Deltoid (superolateral)
 Clavicular (inferomedial)
 Pectoral (inferolateral)

All Dogs Can Pee

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Axilla: Contents
2. Lateral Thoracic artery
 descends along the lateral
 border of pectoralis minor
 supplies:
 pectoralis muscles
 serratus anterior
 intercostal arteries
 lateral aspect, breast

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Axilla: Contents
 Third Part:
 between the lateral aspect of
pectoralis minor & inferior border
of teres major
1. Subscapular artery
 largest branch of axillary artery
 along the lateral border of subscapularis muscle
 branches:
a. circumflex scapular artery
 lateral border of scapula to infraspinous
fossa; anastomoses with suprascapular
artery
b. thoracodorsal artery
 along latissimus dorsi, with thoracodorsal
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nerve
Axilla: Contents
2. Anterior Circumflex
Humeral artery
 smallest of the circumflex
runs anterolateral to the humerus,
behind the coracobrachialis &
biceps
3. Posterior Circumflex Humeral artery
 passes medially & posteriorly thru the
quadrangular space on posterior wall of axilla
 anastomoses with anterior circumflex humeral
artery

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Axilla: Contents
Branches of
Axillary Artery:
Save Superior Thoracic artery
The Thoracoacromial artery
Lions Lateral Thoracic artery
And Anterior Circumflex Humeral a.
Protect Posterior Circumflex Humeral a.
Species Subscapular artery

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Axilla: Contents

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Axilla: Contents
3. Axillary vein
 anteromedial to axillary artery
 from the union of brachial vein & basilic vein at
the inferior border of teres major
 ends at the lateral aspect of 1st rib 
commencement of subclavian vein
 has three parts

 cephalic vein is a tributary

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Axilla: Contents
4. Lymph nodes
 5 principal groups:
 Pectoral nodes (3-5)
 Anterior axillary nodes
 medial wall of axilla
 around lateral thoracic vein, inferior border
of pectoralis minor
 drains:
 anterior thoracic wall
 upper outer quadrant of breast
 subareolar plexus

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Axilla: Contents
 Subscapular nodes (6-7)
 Posterior axillary nodes
 medial wall of axilla
 around subscapular vessels, along
posterior axillary fold
 drains:
 posterior thoracic wall
 scapular area

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Axilla: Contents
 Humeral nodes (4-6)
 Brachial or Lateral axillary nodes
 lateral wall of axilla
 medial & posterior to axillary vein
 drains:
 lymph nodes from upper limb
 Central nodes (3-4)
 near the base of axilla
 along the 2nd part of the axillary artery

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Axilla: Contents
 Apical nodes (4-6)
 Medial or Subclavicular nodes
 apex of axilla
 along 1st part of axillary artery & vein
 crosses the cervicoaxillary canal

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Axilla: Contents
3. Axillary tail (of Spence)
 extension of breast tissue to the axilla

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Axilla: Contents
 canals & passage way:
1. Cervicoaxillary canal
 communicates superiorly to the root of cervical
neck
 most neurovascular bundle passes thru
2. Clavipectoral triangle
 communicates anteriorly to pectoral region
3. Quadrangular space
4. To the upper arm
5. To the thoracic wall
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