FUNAI

DEPARTMENT OF ANATOMY,
FACULTY OF BASIC MEDICAL SCIENCES
COLLEGE OF MEDICINE

LECTURE NOTE ON THE AXILLA AND AXILLARY ARTERY

BY
MR. NWAFOR, JOSEPH A.

COURSE TITLE: GROSS ANATOMY OF THE UPPER AND LOWER

EXTREMITIES (ANA 201)

COURSE LECTURERS: PROF A.O IBEGBU, PROF C.O.O. CHUKWU,

DR. EGWU O.A, DR. U.K EZEMAGU, AKUNNA, GG
2017/2018 SESSION
 INTRODUCTION
The axilla is otherwise called
armpit

It is a pyramidal space situated

between the upper part of the
arm and the chest wall

It lies inferior to the

glenohumeral joint

The shape and size of the axilla

varies, depending on the position
of the arm; it almost disappears
 INTRODUCTION CONT’D
 The axilla could be said
to be a “distribution
center,” or passageway
for the various
neurovascular structures
that serve the upper limb.

The axilla has an apex,

a base
four (4) walls —
anterior, posterior,
medial and lateral
 BOUNDARIES OF THE AXILLA
APEX:
It is directed upwards and medially
towards the root of the neck.

It is truncated and corresponds to a

triangular interval or passage; the
cervicoaxillary canal

This canal is bounded anteriorly by

the clavicle, posteriorly by the
superior border of the scapula, and
medially by the outer border of the
first rib
 BOUNDARIES OF THE AXILLA CONT’D
BASE :
In an oblique disposition like the
apex, The base o the axilla is
directed downwards.

Could be referred to as the

axillary fossa (armpit) formed
by the concave skin,
subcutaneous tissue, and axillary
fascia extending from the arm to
the thoracic wall (approximately
the 4th rib level)
 BOUNDARIES OF THE AXILLA CONT’D
BASE CONT’D
The base of the axilla is
bounded:
Anteriorly by the anterior
axillary folds,

Posteriorly by the
posterior axillary folds

Medially by the thoracic

wall, and the medial aspect
of the arm
 BOUNDARIES OF THE AXILLA CONT’D
ANTERIOR WALL
Has two layers formed by;

The pectoralis major and

its fascia

The Pectoralis minor

subclavius and the and
clavicopectoral fascia
associated with them
 BOUNDARIES OF THE AXILLA CONT’D
ANTERIOR WALL CONT’D
The anterior axillary fold is
the inferiormost part of the
anterior wall that may be
grasped between the fingers

This fold is formed by the

pectoralis major, as it bridges
from thoracic wall to humerus
and the overlying skin.
 BOUNDARIES OF THE AXILLA CONT’D

THE POSTERIOR WALL

Formed chiefly by the scapula

and subscapularis anteriorly

&

The teres major and

latissimus dorsi inferiorly
 BOUNDARIES OF THE AXILLA CONT’D
POSTERIOR WALL CONT’D
The posterior axillary fold is
the inferiormost part of the
posterior wall that may be
grasped

This fold extends farther

inferiorly than the anterior wall

It is formed by the latissimus

dorsi, teres major and overlying
skin.
 BOUNDARIES OF THE AXILLA CONT’D

LATERAL WALL
It is formed by:
The coracobrachialis and
biceps brachii muscles

Upper part of the shaft of the

humerus in the region of the
bicipital groove

It is very narrow bony wall

because the anterior and
posterior walls converge on it.
 BOUNDARIES OF THE AXILLA CONT’D
MEDIAL WALL
It is formed by :
Upper four ribs (1st-4th)
with their intercostal
muscles

Upper part of the overlying

serratus anterior muscle.

The medial wall of the axilla

is avascular, except for a few
small branches from the
superior thoracic artery
 CONTENTS OF THE AXILLA
Axillary artery and its branches

Axillary vein and its tributaries.

Infraclavicular part of the brachial

plexus.
Five groups of axillary lymph

nodes and their associated

lymphatics.
Long thoracic and

intercostobrachial nerves.
 AXILLARY NODES
These are glandular massess scattered in the fibrofatty
connective tissue of the axilla.

They are about 20 to 30 in number, and are arranged in five

groups.

The groups are arranged in a manner that reflects the

pyramidal shape of the axilla

Three groups of the axillary nodes are related to the triangular

base, one group at each corner of the pyramid
 Anterior (pectoral) group of lymph nodes

Consist of 3-5 lymph nodes that lie

along the lateral thoracic vesssels
(i.e lower border of the pectoralis
minor)

They receive lymph from the upper

half of the anterior thoracic wall,
and from the major part of the
breast; superolateral quadrant and
subareolar plexus

These nodes are in direct contact

with the axillary tail of the breast.
 Posterior(subscapular) group of lymph
nodes

Consist of 6 or 7 nodes that

lie along the posterior
axillary fold and subscapular
blood vessels.

These nodes receive lymph

from the posterior aspect of
the thoracic wall and
scapular region.
 Lateral group of axillary lymph nodes

Consist of 4-6 nodes that lie

along the lateral wall of the
axilla, medial and posterior to
the axillary vein.

These nodes receive nearly all

the lymph from the upper
limb, except that carried by the
lymphatic vessels
accompanying the cephalic
vein, which primarily drain
directly to the apical axillary
and infraclavicular nodes.
 Central group of axillary lymph nodes
Consists of 3 or 4 large nodes
situated deep to the pectoralis
minor near the base of the
axilla

They lie in association with the

second part of the axillary
artery

They receive Efferent

lymphatic vessels from the
preceding groups and drain into
the apical group.
 Apical group of axillary lymph nodes
Located at the apex of the
axilla

They lie deep to the

clavipectoral fascia, along the
medial side of the axillary vein
and the first part of the axillary
artery.

They receive lymph from the

central group from all other
groups of axillary nodes
 
 Apical group of axillary lymph nodes
cont’d
Efferent vessels from the apical group traverse the
cervico-axillary canal to ultimately unite to form the
subclavian lymphatic trunk

Once formed, the subclavian lymphatic trunk may be

joined by the jugular and bronchomediastinal trunks on
the right side to form the right lymphatic duct, or the
subclavian trunk may enter the right venous angle
independently.

On the left side, the subclavian trunk commonly joins

 AXILLARY VEIN
 The axillary vein is the continuation
of the basilic vein.

It lies on the medial side of the artery

The axillary vein is joined by the

venae comitantes of the brachial
artery a little above the lower border
of the teres major.

At the outer (lateral) border of the

first rib it becomes the subclavian
vein.
 AXILLARY VEIN CONT’D
It are more abundant than the
arteries, highly variable, and
frequently anastomose.

There is no axillary sheath around

the vein, thus it is free to expand
during times of increased blood
flow.

It receives tributaries that generally

correspond to branches of the
axillary artery
 AXILLARY VEIN CONT’D
However, there are a few major exceptions:

The veins corresponding to the branches of the

thoracoacromial artery do not merge to enter by a common
tributary; some enter independently into the axillary vein, but
others empty into the cephalic vein, which then enters the
axillary vein superior to the pectoralis minor, close to its
transition into the subclavian vein.

The axillary vein receives, directly or indirectly, the

thoracoepigastric vein(s).These veins constitute a collateral
route that enables venous return in the presence of
obstruction of the inferior vena cava.
 AXILLARY ARTERY
Begins at the lateral border of
the 1st rib as the continuation
of the subclavian artery

It passes posterior to the

pectoralis minor into the arm

It then becomes the brachial

artery when it passes the
inferior border of the teres
major
 AXILLARY ARTERY CONT’D
Throughout its course, the artery
is closely related to the cords of
the brachial plexus and their
branches and lies enclosed with
them in the axillary sheath.

For descriptive purposes, the

artery is divided into three parts
by the pectoralis minor

The number of the part s also

indicates the number of its
branches:
 1ST PART OF THE AXILLARY ARTERY
Located between the
lateral border of the 1st
rib and upper border of
the pectoralis minor

It is enclosed in the

axillary sheath and has
one branch—the superior
thoracic artery.
 1ST PART OF THE AXILLARY ARTERY
CONT’D
RELATIONS
Anteriorly: The pectoralis
major and the skin.
Posteriorly: The long
thoracic nerve
Laterally: The three cords
of the brachial plexus
Medially: The axillary
vein
 2ND PART OF THE AXILLARY ARTERY
CONT’D
Lies posterior to pectoralis
minor

It has two branches:

The thoracoacromial
and
lateral thoracic arteries

Both arteries pass medial

and lateral to the muscle,
respectively
 2ND PART OF AXILLARY ARTERY CONT’D

RELATIONS
Anteriorly: The pectoralis minor, the pectoralis major,
and the skin

Posteriorly: The posterior cord of the brachial plexus,

the subscapularis and the shoulder joint

Laterally: The lateral cord of the brachial plexus

Medially: The medial cord of the brachial plexus and the

axillary vein
 3RD PART OF AXILLARY ARTERY
Extends from the lateral
(lower) border of
pectoralis minor to the
inferior border of teres
major

It has three branches viz:

The subscapular
artery (largest branch
of the axillary artery)

The anterior and

posterior circumflex
humeral arteries
 3RD PART OF AXILLARY ARTERY CONT’D

RELATIONS
Anteriorly: The pectoralis
major for a short distance;
lower down the artery, it is
crossed by the medial root
of the median nerve
 3RD PART OF AXILLARY ARTERY CONT’D

RELATIONS
Posteriorly: The
subscapularis, the
latissimus dorsi, and the
teres major. The axillary
and radial nerves also lie
behind the artery
 3RD PART OF AXILLARY ARTERY CONT’D

Laterally: The
coracobrachialis, the
biceps, and the
humerus, the lateral
root of the median and
the musculocutaneous
nerves

Medially: The ulnar

nerve, the axillary
vein, and the medial
cutaneous nerve of the
 CLINICAL ANATOMY OF THE AXILLA
Presence of boils due to infection of the hair abundant hair
follicles and sebaceous glands in the axilla

An infection in the upper limb can cause the axillary nodes to
enlarge and become tender and inflamed, a condition called
lymphangitis. The humeral group of nodes is usually the first to
be involved.

Examination of the lymph node is important in clinical practice

for monitoring metastasis of the breast cancer. An axillary
abscess should be incised through the floor of the axilla, midway
between the anterior and posterior axillary folds, and nearer to
the medial wall in order to avoid injury to the main vessels
 CLINICAL ANATOMY OF THE AXILLA
CONT’D
In clinical testing, the axillary arterial pulsations can be
felt in the lower part of the lateral wall of the axilla.

Next to the popliteal artery, the axillary artery is the

second most common artery of the body to be lacerated
by violent movements.

To check bleeding from the distal part of the limb (in
injuries, operations and amputations) the artery can be
effectively compressed against the humerus in the lower
part of the lateral wall of the axilla
 CLINICAL ANATOMY OF THE AXILLA
CONT’D
The contribution of the subscapular arteries (via the
circumflex scapular) to the arterial anastomoses around the
scapula is significant.

The importance of the collateral circulation made possible by

its anastomoses with other vessels becomes apparent when
ligation of a lacerated subclavian or axillary artery is
necessary or when vascular stenosis of the axillary artery
resulting from an atherosclerotic lesion that causes reduced
blood flow.

In either case, the direction of blood flow in the subscapular

artery is reversed, enabling blood to reach the third part of the
 CLINICAL ANATOMY OF THE AXILLA
CONT’D
The first part of the axillary artery may enlarge (aneurysm
of the axillary artery) and compress the trunks of the
brachial plexus, causing pain and anesthesia in the areas of
the skin supplied by the affected nerves

Aneurysm of the axillary artery may occur in baseball

pitchers because of their rapid and forceful arm movements.

Assessment of the Axillary Vein in Subclavian Vein

Puncture; in which a catheter is placed into the subclavian
vein, has become a common clinical procedure.
BRACHIAL PLEXUS
 OUTLINE
Introduction
Formation of brachial plexus
Variation (types) of the brachial plexus
Parts of the brachial plexus
Branches of the brachial plexus
Description of the side and terminal nerve branches of
the plexus based on:
Origin
Course and relations
Distribution
Clinical and applied Anatomy of the brachial plexus
 INTRODUCTION
The brachial plexus is an organized major network of
the nerve fibers of the five adjacent anterior rami of the
last four cervical (C5–C8) and the first thoracic (T1)
nerves,

 It allows the nerve fibers derived from different

segments of the spinal cord to be arranged and
distributed efficiently in different nerve trunks to the
various parts of the upper limb.

Although, in so doing, their segmental identity is lost

in forming the plexus, however, the original segmental
FORMATION & EXTENT OF BRACHIAL
PLEXUS
The brachial plexus is formed by the union of the
Ventral rami of the last four cervical (C5 - C8) and
the first thoracic (T1) nerves

It extends from the neck to the axilla

It enters the upper limb via the cervico-axillary

canal, providing the innervation to the upper limb
and shoulder region.
 VARIATION /TYPES OF THE BRAHIAL
PLEXUS
The origin of the plexus may shift by one segment either
upward or downward, resulting in a prefixed or post fixed
plexus type respectively.

When the superior-most root (anterior ramus) of the plexus

is C4 and the inferior-most root is C8, it is a prefixed
brachial plexus type. The contribution by C4 is large and
that from T2 is often absent.

When the superior root is C6 and the inferior root is T2, it is

a postfixed brachial plexus type. Here, the contribution by
Tl is large, T2 is always present, C4 is absent, and C5 is
 PARTS OF THE BRACHIAL PLEXUS

 Roots
 Trunks
 Divisions
 Cords
 Branches
 ROOT OF THE BRACHIAL PLEXUS

The roots of the

plexus usually pass
through the gap
between the anterior
and the middle scalene
(L. scalenus anterior
and medius) muscles
with the subclavian
artery
 TRUNKS OF THE BRACHIAL PLEXUS
CONT’D
In the inferior part of the
neck; the posterior
triangle of the neck, lies
the three trunk of the
brachial plexus

 The roots of the plexus

unite to form these trunks
 TRUNKS OF THE BRACHIAL PLEXUS
CONT’D

 A superior trunk,
from the union of the
C5 and C6 roots

 A middle trunk,
which is a
continuation of the
C7 root

 An inferior trunk,
from the union of the
C8 and T1 roots.
 CORDS OF THE BRACHIAL PLEXUS
CONT’D
Each trunk divides into anterior and posterior divisions as the
plexus passes through the cervicoaxillary canal posterior to the
clavicle

The divisions of the trunks form three cords of the brachial plexus

Anterior divisions of the superior and middle trunks unite to form

the lateral cord

Anterior division of the inferior trunk continues as the medial

cord
 BRANCHES OF THE BRACHIAL
PLEXUS

The branches of the

brachial plexus is divided
by the clavicle into:
supraclavicular part
(arising from the roots and
trunks)

Infraclavicular part
(arising from the cords)
 BRANCHES OF THE BRACHIAL
PLEXUS CONT’D
The supraclavicular branches are
mainly:
Dorsal scapular nerve,
long thoracic nerve,
Nerve to subclavius,
Suprascapular nerve

Muscular branches arise from all

5 roots of the plexus to supply the
scaleni and longus colli muscles

The C5 root also give

contribution to the phrenic nerve
 BRANCHES OF THE BRACHIAL
PLEXUS CONT’D
Branches of the
Infraclavicular part of
the brachial plexus
include:

3 branches arise from

the lateral cord

The medial and

posterior cords each
give rise to 5 branches
 BRANCHES CONTD
Branches from the lateral cord
Lateral pectoral nerve
Musculocutaneous nerve
Lateral root of Median nerve

Branches from the medial cord

Medial pectoral nerve
Medial cutaneous nerve of arm
Median cutaneous nerve of forearm
Medial root of median nerve
Ulnar nerve
 BRANCHES CONTD
Branches from the posterior cord

Upper subscapular nerve

Lower subscapular nerve

Thoracodorsal nerve

Axillary nerve

Radial nerve
 DORSAL SCAPULAR NERVE
ORIGIN
Posterior aspect of anterior ramus of C5 with a frequent
contribution from C4

COURSE
Pierces middle scalene; descends deep to levator
scapulae and rhomboids

SUPPLY
Rhomboids; occasionally supplies levator scapulae
 LONG THORACIC NERVE
Origin
Posterior aspect of
anterior rami of C5,
C6, C7

COURSE
Passes through cervico-
axillary canal
descending posterior to
the anterior rami of C8
and T1 roots of the
plexus
LONG THORACIC NERVE
CONT’D

Then runs inferiorly on the superficial surface of

the serratus anterior

SUPPLY
Serratus anterior
 SUPRASCAPULAR NERVE

ORIGIN
Superior trunk, receiving
fibers from C5, C6 and
often C4

COURSE
Passes laterally across the
posterior triangle of neck
superior to brachial plexus;
then through the scapular
notch inferior to superior
transverse scapular ligament
 SUPRASCAPULAR NERVE
SUPPLY
Supraspinatus
infraspinatus
muscles;
Glenohumeral
(shoulder) joint
 NERVE TO SUBCLAVIUS

ORIGIN
Superior trunk, receiving fibers from C5, C6 and often
C4

COURSE
Descends posterior to clavicle and anterior to brachial
plexus and subclavian artery; often giving an accessory
root to the phrenic nerve

SUPPLY
Subclavius and sternoclavicular joint
It innervate the diaphragm via accessory phrenic root
 LATERAL PECTORAL NERVE
ORIGIN
Arises as a side
branch of lateral
cord, receiving
fibers from C5,C6,
C7

COURSE
It pierces the
costocoracoid
membrane to reach
the deep surface of
 LATERAL PECTORAL NERVE CONT’D
In its course, it sends a
communicating branch
to the medial pectoral
nerve by passing anterior
to axillary artery and
vein

SUPPLY
It primarily innervates
the pectoralis major, also
contributes to supply the
Pectoralis minor muscles
 MUSCULOCUTANEOUS NERVE
ORIGIN
Terminal branch of lateral
cord receiving fibers from
C5–C7

COURSE
Exits axilla by piercing
coracobrachialis `to
descend between the
biceps brachii and
brachialis
 MUSCULOCUTANEOUS NERVE
In the cubital fossa, it lies at the
lateral margin of the biceps
tendon where it continues on as
the lateral cutaneous nerve of
the forearm

SUPPLY
Muscles of anterior
compartment of the arm
Coracobrachialis, Biceps
brachii and brachialis

Skin of the lateral aspect of

forearm
 MEDIAN NERVE

ORIGIN
Lateral root of median
nerve, and medial root of
median nerve.

Receive nerve fibres from

C5, C6, C7, C8, T1

COURSE
It exits the axilla, runs a
distance and crosses in
front of the brachial artery
at the middle of the arm
Source ; Clinicaly oriented anatomy, 2006
 MEDIAN NERVE
COURSE CONT’D
 In the cubital fossa, the
median nerve lies medial
to the brachial artery, deep
to the bicipital
aponeurosis and anterior
to brachialis.

• In the forearm, It then

passes between the two
heads of pronator teres
and deep to the fibrous
arch of flexor digitorum
 MEDIAN NERVE
COURSE CONT’D
It emerges on the radial
side of the tendon, deep to
palmaris longus tendon
before passing through the
carpal tunnel under the
retinaculum.

It gives off thhe anterior

interrosseous nerve which
descend on the
interrosseous membrane
to the wrist
 MEDIAN NERVE
COURSE CONT’D
Distal to the flexor
retinaculum the nerve
enlarges, flattens, and
usually divides into five or
six branches in the hand

 Palmar cutaneous branch

 Muscular branch (motor
or recurrent branch)
 Palmar digital branches
 MEDIAN NERVE
SUPPLY
In the arm it gives a sympathetic filament to the brachial
artery

It give a twig to elbow joint which may supply the pronator
teres

It also supplies the superficial flexor muscle of the forearm;

Pronator teres
Palmaris longus
Flexor carpi radialis
Flexor digitorum superficialis
 MEDIAN NERVE CONTD
SUPPLY
The anterior interrosseous branch supplies the deep
flexor muscles;
Radial half of flexor digitorum profundus
Flexor pollicis longus
Pronator quadratus

The palmar cutaneous branch pierces the deep fascia

above the flexor retinaculum and supplies more than
half of the skin on thumb side of the palm
 MEDIAN NERVE CONT’D
SUPPLY
In the hand, it give a muscular (deep) branch to the thenar
muscles;
Abductor pollicis brevis
Flexor pollicis brevis
Opponens pollicis

The palmar digital branches supply the flexor skin of the radial
three and a half digits, the nail beds and distal dorsal skin of
these digits

It also supplies the two radial lumbricals (3 & 4)

 MEDIAL PECTORAL NERVE
ORIGIN
Arise as a side branch of the medial cord, receiving fibers
from C8, T1

COURSE
Passes between axillary artery and the vein; then pierces the
pectoralis minor and enters the deep surface of pectoralis
major

SUPPLY
Pectoralis minor and sternocostal part of the Pectoralis major
ULNAR NERVE
ORIGIN
It is a direct
continuation of medial
cord.
Largest branch of the
medial cord
It nerve root is C7, C8,
T1.

Source ; Clinicaly oriented anatomy, 2006

 ULNAR NERVE CONT’D
COURSE
Ulnar nerve descends
between the axillary artery
and vein, behind the medial
cutaneous nerve of forearm.

It pierces the medial

intermuscular septum, then
runs in a groove behind the
medial epicondyle of the
humerus
 ULNAR NERVE CONT’D
COURSE CONT’D
It then Passes beneath the
fibrous arch of the two
heads of the flexor carpi
ulnaris to enter the
forearm flexor
compartment.

It descends on the flexor

digitorum profundus
under the flexor carpi
ulnaris with the ulnar
 ULNAR NERVE CONT’D

COURSE CONT’D
At the wrist, the ulnar
nerve passes under the
superficial part of the
flexor retinaculum; in the
Guyon's canal lateral to the
pisiform bone in company
with the ulnar artery.

It divides into superficial

and deep terminal branches
ULNAR NERVE CONT’D
COURSE CONT’D
A dorsal branch arises approx.5cm proximal to the
wrist.

It passes distally and dorsally, deep to FCU,

perforates the deep fascia, and descends along the
medial side of the back of the wrist and hand

It then divides into two, or often three, dorsal

digital nerves
 ULNAR NERVE CONT’D
BRANCHES AND SUPPLY
It gives off no branch in the axilla.

It gives off branches as it descends which include;

An articular branch to the elbow joint.

In the forearm, the main nerve fiber supplies the

flexor carpi ulnaris and medial half of flexor
digitorum profundus.
ULNAR NERVE
BRANCHES AND SUPPLY
The first dorsal branch supplies the medial side of
the little finger

The second dorsal branch , supplies the adjacent

sides of the little and ring fingers

The third dorsal branch, when present, supplies

adjoining sides of the ring and middle fingers.
ULNAR NERVE CONT’D

BRANCHES AND SUPPLY CONT’D

In the little finger, the dorsal digital nerves
extend only to the base of the distal
phalanx, and in the ring finger they extend
only to the base of the middle phalanx.
 ULNAR NERVE CONT’D

BRANCHES AND SUPPLY CONT’D

The superficial terminal branch supplies the
The palmaris brevis
The medial aspect of the palmar skin of the little
digit.

This superficial branch divides into two palmar

digital nerves, which can be palpated against the
hook of the hamate bone
 ULNAR NERVE
BRANCHES AND SUPPLY CONT’D
One of the two palmar digital nerves supplies the
medial side of the little finger

The other; common palmar digital nerve sends a

twig to the median nerve and divides into two proper
digital nerves

This two proper digital nerves supply the adjoining

sides of little and ring fingers, (i.e the distal parts of
the little finger and the ulnar side of the ring finger)
ULNAR NERVE CONT’D

BRANCHES AND SUPPLY CONT’D

The deep terminal branch accompanies the deep
branch of the ulnar artery as it passes between
abductor digiti minimi and flexor digiti minimi
before perforating the opponens digiti minimi to
follow the deep palmar arch posterior to the flexor
tendons
 ULNAR NERVE
BRANCHES AND SUPPLY CONT’D
At its origin, the deep terminal branch supplies the
three short muscles of the little finger

As it crosses the hand, it supplies the interossei, 3rd

and 4th lumbricals

It ends by supplying adductor pollicis, the palmar

interosseous and usually flexor pollicis brevis

It sends articular filaments to the wrist joint.

 MEDIAL CUTANEOUS
NERVE OF ARM
ORIGIN
Smallest nerve of plexus that arise as a side branch of
medial cord, receiving fibers from C8, T1

COURSE
It runs along medial side of axillary and brachial veins;
communicates with the intercostobrachial nerve

SUPPLY
Skin of medial side of arm, as far distal as medial epicondyle
of humerus and olecranon of ulna
 MEDIAN CUTANEOUS
NERVE OF FOREARM
ORIGIN
Side branch of the medial cord, receiving fibers from C8, T1

COURSE
Initially runs with ulnar nerve (with which it may be
confused) but pierces the deep fascia with the basilic vein
and enters the subcutaneous tissue, dividing into anterior and
posterior branches

SUPPLY
Skin of medial side of forearm, as far distal as the wrist
 UPPER SUBSCAPULAR NERVE
ORIGIN
Arise as side branch of posterior cord, receiving fibers
from C5

COURSE
Passes posteriorly, entering subscapularis directly

SUPPLY
Superior portion of subscapularis
 LOWER SUBSCAPULAR NERVE
ORIGIN
Side branch of posterior cord, receiving fibers from C6

COURSE
Passes inferolaterally, deep to subscapular artery and vein

SUPPLY
Inferior portion of subscapularis
teres major
 THORACODORSAL NERVE
ORIGIN
Arises as a side branch of posterior cord, receiving
fibers from C6, C7, C8
Arises between upper and lower subscapular nerves

COURSE
Upon originating, it runs inferolaterally along posterior
axillary wall to apical part of latissimus dorsi

SUPPLY
Latissimus dorsi
 AXILLARY NERVE
ORIGIN
Terminal branch of posterior
cord (C5, C6)

COURSE
It is at first lateral to the radial
nerve, posterior to the axillary
artery and anterior to
subscapularis
 AXILLARY NERVE
COURSE
 At the lower border of
subscapularis it curves backward
inferior to the articular capsule of
the GH joint and exits the axillary
fossa, passing through the
quadrangular space with
posterior circumflex humeral
vessels

As it trasverses this space, it

gives rise to anterior and
posterior branches
 AXILLARY NERVE

COURSE CONT’D
The anterior branch
curves round the neck
of the humerus with
the posterior
circumflex humeral
vessels, deep to
deltoid
 AXILLARY NERVE
It reaches the anterior border of the deltoid,
suppyling it and gives off a few small cutaneous
branches which ramify in the skin over its lower part

The posterior branch courses medially and

posteriorly along the attachment of the long head of
triceps, inferior to the glenoid rim

This branch gives off the nerve supply to teres minor

and the upper lateral cutaneous nerve of the arm
 AXILLARY NERVE
SUPPLY
Glenohumeral (shoulder)
joint
Teres minor and deltoid
muscles
Skin over the lower part
of deltoid
`Skin over the upper part
of the long head of
triceps
 RADIAL NERVE

.ORIGIN
Radial nerve arises from
the posterior cord a
direct continuation

Larger terminal branch

of the posterior cord

The nerve root include;

C5, C6, C7, C8, T1
 RADIAL NERVE CONT’D
COURSE
It descends behind the third part of the axillary artery and
the upper part of the brachial artery

With the profunda brachii artery, it inclines dorsally, passing

through the triangular space below the lower border of teres
major, between the long head of triceps and the humerus.

It supplies the long head of triceps, and gives rise to the
posterior cutaneous nerve of the arm which supplies the
skin along the posterior surface of the upper arm
 RADIAL NERVE CONT’D
COURSE
It then spirals obliquely across
the back of the humerus, lying
posterior to the uppermost fibres
of the medial head of triceps
which separate the nerve from
the bone in the first part of the
spiral groove

Here it gives off a muscular

branch to the lateral head of
triceps and a branch which passes
through the medial head of
 RADIAL NERVE CONT’D
COURSE
On reaching the lateral side of the humerus, it pierces the
lateral intermuscular septum to enter the anterior
compartment and descends deep in a furrow between the
brachialis and proximally with the brachioradialis, then
more distally to the extensor carpi radialis longus.

Anterior to the lateral epicondyle it divides into superficial

and deep terminal rami.
 RADIAL NERVE CONTD
COURSE CONT’D
In the forearm,
The superficial terminal branch descends from the lateral
epicondyle anterolaterally in the proximal two-thirds of
the forearm, initially lying on supinator just lateral to the
radial artery.

In the middle third of the forearm, it lies behind the

brachioradialis, close to the lateral side of the artery, and is
successively anterior to pronator teres, the radial head of
flexor digitorum superficialis and flexor pollicis longus.
 RADIAL NERVE CONTD
COURSE CONT’D
It gives off the deep terminal branch; posterior
interosseous nerve

This branch reaches the back of the forearm by passing

round the lateral aspect of the radius under the extensor
carpi radialis and between the two heads of supinator

As it emerges from the supinator, it pierces the deep

fascia and divides into five, sometimes four, dorsal digital
nerves.
 RADIAL NERVE CONTD
COURSE CONT’D
It supplies extensor carpi radialis brevis (beaver muscle)
and supinator before entering supinator

As it emerges from supinator posteriorly, the posterior

interosseous nerve gives off three short branches to
extensor digitorum, extensor digiti minimi and extensor
carpi ulnaris

Sends two longer branches; a medial to extensor pollicis

longus and extensor indicis, and a lateral which supplies
abductor pollicis longus and extensor pollicis brevis.
 RADIAL NERVE CONTD
COURSE , BRANCHES and
SUPPLY CONT’D
Branches of the superficial branch
of the radial nerve reach the hand
by curving around the wrist over
the tendons of abductor pollicis
longus and extensor pollicis brevis.

They divide into dorsal digital

nerves.

On the dorsum of the hand they

usually communicate with the
posterior and lateral cutaneous
nerves of the forearm
 RADIAL NERVE CONTD

COURSE , BRANCHES and SUPPLY CONT’D

There are usually four or five small dorsal digital nerves.

The first supplies the skin of the radial side of the thumb
and the adjoining thenar eminence, and communicates with
branches of the lateral cutaneous nerve of the forearm

The second supplies the medial side of the thumb

 RADIAL NERVE CONTD

COURSE , BRANCHES and SUPPLY CONT’D

The third supplies the lateral side of the index finger;

The fourth supplies the adjoining sides of the index and

middle fingers;

The fifth communicates with a ramus of the dorsal branch

of the ulnar nerve and supplies the adjoining sides of the
middle and ring fingers
 CLINICAL ANATOMY
Erb–Duchenne Palsy
Site of injury:
Occurs at a region of the upper trunk of the brachial
plexus called the Erb's point. Six nerves meet here.

Causes of injury:
Undue separation of the head from the shoulder, which
is commonly encountered in: (i) birth injury, (ii) fall on
the shoulder, and (iii) during anaesthesia.

Nerve roots involved:

Mainly C5 and partly C6.
CLINICAL ANATOMY
 CLINICAL ANATOMY
Erb–Duchenne Palsy
Muscles paralysed: Mainly biceps, deltoid, brachialis
and brachioradialis. Partly supraspinatus, infraspinatus
and supinator.

Deformity (position of the limb)

Arm: Hangs by the side; it is adducted and medially
rotated.
Forearm: Extended and pronated.

This deformity is known as 'policeman's tip hand' or

'porter's tip hand'.
 CLINICAL ANATOMY

Erb–Duchenne Palsy
Disability. The following movements are lost.
Abduction and lateral rotation of the arm(shoulder).
Flexion and supination of the forearm.
Biceps and supinator jerks are lost
 CLINICAL ANATOMY
Klumpke's Paralysis
Site of injury.
Lower trunk of the brachial plexus.

Cause of injury.
Undue abduction of the arm, as in clutching something
with the hands after a fall from a height, or sometimes in
birth injury.

Nerve roots involved.

Mainly Tl and partly C8.
 CLINICAL ANATOMY
Klumpke's Paralysis
Muscles Paralysed
Intrinsic muscles of the hand
Ulnar flexors of the wrist and fingers

Deformity (position of the hand):

Claw hand due to the unopposed action of the long
flexors and extensors of the fingers.

 Here, there is hyperextension at the metacarpophalangeal

joints and flexion at the interphalangeal joints.
 CLINICAL ANATOMY CONT’D

Disability
Claw hand.
Cutaneous anaesthesia and analgesia in a narrow zone
along the ulnar border of the forearm and hand
Horner's syndrome—ptosis, miosis, anhydrosis,
enophthalmos, and loss of ciliospinal maybe
associated
 CLINICAL ANATOMY CONT’D
Injury to the Nerve to Serratus Anterior (Nerve of Bell)

Causes:
Sudden pressure on the shoulder from above.
Carrying heavy loads on the shoulder.

Deformity:
Winging of the scapula, i.e. Excessive prominence of the
medial border of the scapula.
 CLINICAL ANATOMY CONT’D
Normally, the pull of the muscle keeps the medial
border against the thoracic wall.

Disability
1.Loss of pushing and punching actions.
2.Arm cannot be raised beyond 90° (i.e. overhead
abduction which is performed by the serratus anterior
is not possible).
CLINICAL ANATOMY
A superior brachial plexus injury may produce muscle
spasms and a severe disability in hikers (backpacker’s
palsy) who carry heavy backpacks for long periods.

Inflammation of the brachial plexus (brachial neuritis)

is often preceded by some event (e.g., upper respiratory
infection, vaccination, or non-specific trauma).
CLINICAL ANATOMY
Acute brachial plexus neuritis (brachial plexus
neuropathy) is a neurologic disorder of unknown
cause that is characterized by the sudden onset of
severe pain, usually around the shoulder which
typically begins at night and is followed by muscle
weakness and sometimes muscular atrophy

The nerve fibers involved in the above conditions

are usually derived from the superior trunk of the
brachial plexus.
CLINICAL ANATOMY CONT’D

Lesions of the radial nerve at its origin from the

posterior cord in the axilla may be caused by pressure
from a long crutch (crutch palsy).

Compression of the nerve against the humerus occurs

if the arm is rested on a sharp edge such as the back of
a chair (‘Saturday night palsy')
CLINICAL ANATOMY CONT’D
Both of the aforementioned injuries cause
weakness of brachioradialis with wasting and loss
of the reflex. There is both wrist and finger drop
due to weakness of wrist and finger extensors, as
well as weakness of extensor pollicis longus and
abductor pollicis longus
CLINICAL ANATOMY CONT’D

Radial tunnel syndrome is an entrapment neuropathy

of the radial nerve near the elbow,
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