Muscles of UL

Pectoral region; General instructions for dissection; Breast

 Anterior axioappendicular muscles
• The fan-shaped pectoralis major covers the superior part
of the thorax.

• Pectoralis major and adjacent deltoid form the narrow

deltopectoral groove, in which the cephalic vein runs.

• Pectoralis minor lies in the anterior wall of the axilla ;

covered by the pectoralis major.

• Pectoralis minor forms a “bridge” under which vessels

and nerves pass to the arm; anatomical and surgical
landmark.
 Anterior cont’d
• The subclavius lies almost horizontally.

• The serratus anterior overlies the lateral part of the

thorax and forms the medial wall of the axilla.

• This broad sheet of thick muscle was named because

of the sawtoothed appearance of its fleshy slips or
digitations (L. serratus, a saw).
Figure: Anterior axioappendicular muscles
 Table: Anterior Axioappendicular Muscles
Distal
Muscle Proximal Attachment Attachment Innervationa Main Action
Pectoralis Clavicular head: anterior Lateral lip of Lateral and medial Adducts and medially
major surface of medial half of intertubercular pectoral nerves; rotates humerus; draws
clavicle Sternocostal groove of humerus clavicular head scapula anteriorly and
head: anterior surface of (C5, C6), inferiorly
sternum, superior six sternocostal head Acting alone,
costal cartilages, (C7, C8, T1) clavicular head flexes
aponeurosis of external humerus and
oblique muscle sternocostal head
extends it from the
flexed position
Pectoralis 3 to 5 ribs near their Medial border and Medial pectoral nerve Stabilizes scapula by
rd th

minor costal cartilages superior surface of (C8, T1) drawing it inferiorly

coracoid process of and anteriorly against
scapula thoracic wall
Subclavius Junction of 1st rib and its Inferior surface Nerve to sub-clavius Anchors and depresses
costal cartilage of middle third (C5, C6) clavicle
of clavicle
Serratus External surfaces of Anterior surface of Long thoracic nerve Protracts scapula and
anterior lateral parts of 1 – 8
st th
medial border of (C5, C6, C7) holds it against thoracic
ribs scapula wall; rotates scapula
Figure: Pectoralis major
muscle
Figure: Pectoralis minor and
subclavius muscles and
clavipectoral fascia.
Clinical correlation
Paralysis of the Serratus Anterior
• When the serratus anterior is
paralyzed owing to injury to the
long thoracic nerve, the medial
border of the scapula moves
laterally and posteriorly away from
the thoracic wall, giving the scapula
the appearance of a wing,
especially when the person leans
on a hand or presses the upper
limb against a wall.

• When the arm is raised, the medial

border and inferior angle of the
scapula pull markedly away from
the posterior thoracic wall, a
deformation known as a winged
scapula (Fig.).
General instructions for
dissection
Reference: Cunningham’s, Mannual of practical
anatomy , Volume I: Page 1 -19
 Structures met in dissection
1. The skin
8. Joints
2. The superficial fascia
3. Blood vessels 9. Bones
3.1. Arteries
3.2. Capillaries
3.3. Veins
3.4. Lymph vessels
4. Nerves
4.1. Spinal nerves
5. Deep fascia
6. Muscles
7. Bursae and synovial sheaths
 1. Skin
• The skin consists of a superficial layer of avascular, stratified squamous
epithelium, the epidermis and a deeper, vascular dense fibrous tissue,
the dermis, which sends small peg-like protrusions into the epidermis.
• The skin is separated from the deeper structures (muscles and bones) by
two layers of fibrous tissue, the superficial and deep fasciae.
 2. Superficial fascia

• The superficial fascia: The fibrous mesh, filled with fat,

connects the underlying sheet of deep fascia, and is
particularly dense in the scalp, the back of the neck, the
palms of the hands, and the soles of the feet, thus binding the
skin to the deep fascia in these situations.

• In other parts of the body its looseness and elasticity allow

the skin to be moved freely yet return it to its original
position, for example: skin of eyelids, nipples and areolae of
the breasts and in some parts of the external genital organs,
where there is no fat.
 3. Blood vessels
3.1. Arteries: Convey blood from the heart to the tissues at high pressure.
3.2. Blood capillaries: These microscopic tubes form a network through which
the arterioles discharge into the smallest tributaries of the veins.
• The capillary walls consist of a single layer of flattened endothelial cells
through which substances are exchanged between the blood and the tissues.
3.3. Veins: The pumping action of the heart forces the blood through the
arteries and capillaries, but is mostly spent by the time the blood reaches
the veins from the capillaries.
• The more sluggish flow of blood in the veins is aided:
i) By compression from the contracting muscles surrounding them, and
ii) By the fall of pressure in the thorax with each inspiration which draws
blood into the thorax as well as air.
• Lymph vessels: These are fine tubes that contain a clear fluid. They are much
more in tissues adjacent to epithelial surfaces (skin and alimentary and
respiratory tracts) than elsewhere and are absent from the central nervous
system.
 4. Nerves
• These are whitish cords consisting of
large numbers of exceedingly fine
filaments (nerve fibers) of variable
diameter, bound together in bundles
by fibrous tissue.
• Nerve fibers transmit messages (nerve
impulses) either from the central
nervous to the various structures of
the body or from these structures to
the central nervous system.
• Nerves may be classified as:
i) Cranial nerves which are attached
to the brain and emerge from the
skull or cranium;
ii) Spinal nerves which are attached to
spinal medulla ans escape from the
vertebral column through the
intervertebral column.
• Spinal nerves: There are 31 pairs of
these, named after the groups of
vertebrae between which they emerge
– 8 cervical, 12 thoracic, 5 lumbar, 5
sacral and 1 coccygeal.
• Spinal nerves are attached to the spinal
medulla by two roots:
i) Ventral root: efferent (motor) fibers
that arise from spinal medulla
ii) Dorsal root: afferent (sensory) fibers
that arise from the spinal ganglion
on each dorsal root.
• The two roots unite at the ganglion in
the intervertebral foramen the trunk of
the spinal nerve.
• This short trunk divides into a ventral
ramus and a dorsal ramus as it
emerges from the intervertebral
foramen.
Figure 2.58 Basic organization of a spinal nerve
Figure. Spinal nerves (transverse section).
 Clinically, a dermatome is that area of skin
supplied by a single nerve or spinal cord
level. A myotome is that region of skeletal
muscle innervated by a single nerve or spinal
cord level. Most individual muscles of the
body are innervated by more than one spinal
cord level so the evaluation of myotomes is
usually accomplished by testing movements
of joints or muscle groups.
8
A knowledge of dermatomes and myotomes
is absolutely fundamental to carrying out a
neurologic examination. A typical dermatome
map is shown in Fig. 2.10.

Visceral parts of the body are also innervated

in a segmental fashion. For example, pain
fibers from the heart enter the spinal cord at
a more superior level (approximately T1 to
T4) than those from the appendix (T10).

Figure. Dermatomes (anterior view).

 5. Deep Fascia
• Deep Fascia is the dense, inelastic membrane which separates the
superficial fascia from the underlying.
• Fascia reacts readily by laying down collagen fibers parallel to any forces
applied to it. Thus it becomes thickened to form:
i) Glistening aponeurosis where muscles are attached to it;
ii) Retinacula where it is stretched by tendons curving round it;
iii) Ligaments where Ligaments connect bones at joints.there are forces
tending to separate bones.
 6. Muscles
• The muscles are the red flesh of the body and form nearly half of its
weight.
• They produce movement for they can be shortened (contracted) at will
so as to approximate the structures to which they are attached.
• The ends of muscle fibres are attached through the medium fibrous
tissue, more usually the fibrous tissue forms long, inelastic cords
(tendons) or a thin, wider sheet (aponeurosis) depending on the
arrangement of the muscle fibres.
 7. Bursae and synovial sheaths
• Where two structures slide freely over each other, e.g. muscle tendon
or skin over bone or fascia the friction between them is reduced by the
presence of a bursa.
• Bursa is a closed sac lined with a smooth synovial membrane which
normally secretes a small amount of glutinous fluid into the sac.
• Similar synovial sheaths enclose tendons where the range of movement
is considerable, e.g. the tendons sliding in the fingers.
8. Joints
9. Bones
General instructions for dissection
1. Instruments 1. Anatomy of the living
body
2. Removal of the skin
2. Special techniques
3. Deep dissection
2.1. Xray
4. Variation
3. Other special techniques
3.1. Computerized
tomography
3.2. Ultrasound
3.3. Nuclear magnetic
resonance
General instruction
• The dissector requires:
- One scalpel with a solid blade,
- Two pairs of forceps , preferably with rounded
points.
- A strong blunt hook or seeker
Instruments
• Deep to the skin, the body consists of a number of organs in a matrix of
fibrous connective tissue (fascia).
• Dissection is the process of freeing the organs from this tissue. This can
be best done by blunt dissection with a hook or forceps by pulling
these through the loose layers of connective tissue.
• In this way it is possible to free organs without damaging blood vessels
or nerves the knife being reserved for cutting the skin and the dense
layers of deep fascia which enclose many organs and partly conceal
them.
Removal of the skin
• One method is to remove the skin from the superficial fascia in a series
of flaps which can be replaced to obviate drying of the part.
• It is probably better to cut through both skin and superficial fascia and
remove both of them in one layer from the underlying deep fascia by
blunt dissection.
• The blood vessels and nerves entering the superficial fascia through the
deep fascia are easily found in this way and can be traced for some
distance.
• The student should be aware that the distribution of cutaneous nerves
is considerable clinical importance.
• In the superficial fascia. The nerves are almost always accompanied by a
small artery and one or more minute veins.
Deep Dissection
• When the deep fascia has been uncovered and
examined, proceed to remove it.
• This is made more difficult because it sends sheets
between the various muscles enclosing it in a
separate channel.
Variation
• It is obvious even to the causal observer that there are wide variations
between persons. The same type of variation exists in the size, position,
and shape of the various organs of the body indifferent individuals.
• Therefore, no single account of the structure of the body exactly fits
every individual, so the student should expect variations.
Anatomy of the living body
• The student should remember that the purpose of studies on human
cadaver (dead, preserved body) is to allow visualize the living body in
action so that he can appreciate the effects of injury or disease, and can
recognize an abnormality from his knowledge of the normal.
Special techniques
• An increasing number of are being established
whereby the internal structure of of the body can
be assessed during life without surgical
intervention.
Breast
Lecture note
Feb. 22, 2021
Breast
• The breasts consist of mammary glands and associated skin and
connective tissues.
• Mammary glands are modified sweat glands in the superficial fascia.
• Mammary glands consist of a series of ducts and associated secretory
lobules. These converge to form 15 to 20 lactiferous ducts, which open
independently onto the nipple.
• The nipple is surrounded by a circular pigmented area of skin termed the
areola.
• The connective tissue stroma that surrounds the ducts and lobules of the
mammary gland forms a suspensory ligaments of breast that support the
breast.
• Carcinoma of the breast creates tension on the suspensory ligaments,
causing pitting of the skin.
Figure. Sagittal
section of female
breast and anterior
thoracic wall.
The breast consists of glandular
tissue and fibrous and adipose
tissues between the lobes and
lobules of glandular tissue,
together with blood vessels,
lymphatic vessels, and nerves.
The superior two thirds of the
figure demonstrates the
suspensory ligaments and alveoli
of the breast with resting
mammary gland lobules; the
inferior part shows lactating
mammary gland lobules.
Breast cont’d
• In nonlactating women, the predominant component of the breasts is fat,
while glandular tissue is more abundant in lactating women.

• A layer of loose connective tissue (the retromammary space) separates

the breast from the deep fascia of pectoralis muscle and provides some
degree of movement over underlying structures.

• The base, or attached surface, of each breast extends vertically from ribs II
to VI, and transversely from the sternum to as far laterally as the
midaxillary line.
• It is important for clinicians to remember when evaluating the breast for
pathology that the upper lateral region of the breast can project around
the lateral margin of the pectoralis major muscle and into the axilla. This
axillary process (axillary tail) may perforate deep fascia and extend as far
superiorly as the apex of the axilla.
Figure:
Breasts.
 Arterial supply
• The breast is related to the thoracic wall and to structures
associated with the upper limb; therefore, vascular supply
and drainage can occur by multiple routes:
i) Laterally, vessels from the axillary artery-superior thoracic,
thoracoacromial, lateral thoracic, and subscapular arteries;

ii) Medially, branches from the internal thoracic artery;

iii) Second to fourth intercostal arteries via branches that

perforate the thoracic wall and overlying muscle.
 Venous drainage

• Veins draining the breast parallel the arteries and

ultimately drain into the axillary, internal thoracic,
and intercostal veins.
 Innervation
• Innervation of the breast is via anterior and lateral
cutaneous branches of the second to sixth
intercostal nerves.
• The nipple is innervated by the fourth intercostal
nerve
Lymphatic drainage
• Lymphatic drainage of the breast is as follows:
---- approximately 75% is via lymphatic vessels that
drain laterally and superiorly into axillary nodes;
most of the remaining drainage is into parasternal
nodes deep to the anterior thoracic wall and
associated with the internal thoracic artery;
some drainage may occur via lymphatic vessels
that follow the lateral branches of posterior
intercostal arteries and connect with intercostal
nodes situated near the heads and necks of ribs.
Lymphatic cont’d
• Axillary nodes drain into the subclavian trunks;
parasternal nodes drain into the
bronchomediastinal trunks, and intercostal nodes
drain either into the thoracic duct or into the
bronchomediastinal trunks.
 Breast in men
• The breast in men is rudimentary and consists only
of small ducts, often composed of cords of cells,
that normally do not extend beyond the areola.
• Breast cancer can occur in men.
 In the clinic
Breast cancer
• Breast cancer is one of the most common
malignancies in women. In the early stages,
curative treatment may include surgery,
radiotherapy, and chemotherapy.
• Breast cancer develops in the cells of the acini,
lactiferous ducts, and lobules of the breast.
Tumor growth and spread depends on the exact
cellular site of origin of the cancer.
• Breast tumors spread via the lymphatics and
veins, or by direct invasion.
Breast cancer cont’d

• When a patient presents with a lump in the breast, a diagnosis of breast cancer
is confirmed by a biopsy and histologic evaluation. Once confirmed, the
clinician must attempt to stage the tumor.

• Staging the tumor means defining:

--- size of the primary tumor;
--- exact site of the primary tumor;
--- number and sites of lymph node spread;
---- organs to which the tumor may have spread.
Breast cancer cont’d
• Computed tomography (CT) scanning of the body may be carried out to look for
any spread to the lungs (pulmonary metastases), liver (hepatic metastases), or
bone (bony metastases).
• Further imaging may include bone scanning using radioactive isotopes, which
are avidly taken up by the tumor metastases in bone.
Breast cancer cont’d

• Lymph drainage of the breast is complex.

• Lymph vessels pass to axillary, supraclavicular, parasternal, and
abdominal lymph nodes, as well as the opposite breast.
• Containment of nodal metastatic breast cancer is therefore
potentially difficult because it can spread through many lymph
node groups.
• Subcutaneous lymphatic obstruction and tumor growth pull on
connective tissue ligaments in the breast resulting in the
appearance of an orange peel texture (peau d'orange) on the
surface of the breast.
• Further subcutaneous spread can induce a rare manifestation of
breast cancer that produces a hard, woody texture to the skin
(cancer en cuirasse).
Breast cancer cont’d
• A mastectomy (surgical removal of the breast) involves excision of the breast
tissue to the pectoralis major muscle and fascia.
--- Within the axilla the breast tissue must be removed from the medial axillary
wall.
• Closely applied to the medial axillary wall is the long thoracic nerve. Damage to
this nerve can result in paralysis of the serratus anterior muscle producing a
characteristic 'winged' scapula. It is also possible to damage the nerve to the
latissimus dorsi muscle, and this may affect extension, medial rotation, and
adduction of the humerus.
THANK YOU!