The Axilla

Dr Bismarck A. Hottor
 Objectives
1. By the end of this session and the dissection of the
axillary region the student will:
1. Discuss the location, shape and size of axilla
2. Describe the boundaries of the axilla
3. Enumerate and describe the relevant contents
of the axilla such as axillary artery and its
branches, axillary vein and its tributaries,
cords and branches of the brachial plexus

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 Axilla: Introduction
• Pyramidal space b/n
upper thoracic wall and
the arm.
• It below the shoulder
joint and superior to
axillary fascia
• It is the gateway and
Distribution centre for
neurovascular bundle of
the upper limb
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 Shape and size of axilla
• Varies depending on the position of the arm
– Disappears when arm is abducted

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 Axilla-Boundaries

• Apex
• A floor (Base)
• 4 sides
– Anterior
– posterior
– Medial
– Lateral

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 Axilla (cervico-axillary canal) Inlet
• Is oriented horizontally
• It is triangular in shape
• Bounded by the:
– first rib medially
– Superior border of scapula
posteriorly
– Clavicle anteriorly
• Major vessels and nerves
pass to and from the arm

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 Base/Floor
• Formed by skin
subcutaneous fascia and
axillary (deep) fascia
• Broad at the chest and
narrow at the arm
• Extends from the arm to
chest wall along rib 4
• Virtual
• Convex upwards. By courtesy Dr David
Morton, University of Utah

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 Anterior wall
• It is in 2 layers
• Formed by
– Pectoralis major and
deep pectoral fascia
– Pectoralis minor and
clavipectoral fascia
• Anterior axillary fold

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 Posterior wall
• Formed by
– Scapula
– Subscapularis
– Teres major
– Latissimus dorsi
• Posterior axillary fold
• Intermuscular gaps for
the passage of structures
between axilla and
Lateral view of sagittal section of the
posterior scapular region shoulder
and arm
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 Medial Wall
• Formed by upper thoracic wall (first 4 ribs
and associated intercostal muscles) and
upper part of serratus anterior muscle.

Inferior view of
transverse section

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 Lateral wall
• Formed by the intertubercular
sulcus of humerus
• Lat wall is narrow and bony

Inferior view of
transverse section
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 Contents
• Axillary artery and its branches
• Axillary vein and its tributaries
• Lymph vessels
• Lymph nodes
• Cords and branches of brachial plexus
• Proximal portions of biceps brachii and
coracobrachialis
• Axillary tail of the breast
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 Axillary artery
 Main artery of Upper
limb
 Continuation of
subclavian aa
 Beginning and ending

 Has 3 parts
• Relations 17
 Axillary artery: Branches
• First part
– Superior thoracic
• Second part
– Thoracoacromial
– Lateral thoracic
• Third part
– Subscapular
– Anterior circumflex humeral
– Posterior circumflex humeral
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 Axillary vein
• Formed by basilic and venae
comitantes of brachial artery
• Begin at lower border T.
Major and end at the first rib
• Anteromedial to artery
distally
• Anteroinferior to artery
proximally
• Has three parts like the artery
• Tributaries
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 Axillary Lymph nodes

• Pectoral (anterior)
• Posterior
(Subscapular)
• Lateral (humeral)
• Central nodes
• Apical

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 Axillary lymphadenopathy
• Infection in the arm
• Infection in the pectoral region and upper
anterior abdominal wall
• Lymphoedema of the arm

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Cords and Branches of Brachial plexus

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 Brachial Plexus (BP)

Dr Bismarck A. Hottor, MB ChB; PhD

 Objectives
• By the end of this session student should be
able to:
– Discuss the location and relations of the various
parts of plexus
– Describe the formation of the brachial plexus
– List the branches from the roots, trunks and cords
– Discuss the variations of BP and their clinical
significance
– Describe BP injuries and their manifestation

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 Introduction
• Most nerves of the upper limb arise from the
brachial plexus.
• It is the major network of nerves that supply
the upper limb
• It begins in the neck and extend into the axilla
• Most of its branches are infraclavicular

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 Spinal nerves

• Conduct information to and from the CNS

• 31 pairs
• Dorsal root (afferent or sensory) and ventral root
(efferent or motor)
• Dorsal and ventral roots form spinal nerves
• Division into large ventral ramus and smaller dorsal
ramus
• Ventral ramus innervates the limbs, the muscles and
skin of the anterior part of the trunk.
• The dorsal ramus innervates the post-vertebral
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 General principles of limb innervation
• Limb muscles are innervated by spinal
nerves (ventral rami of spinal nerves)
• Nerves first form plexuses
• Segmentation in muscular and cutaneous
innervations

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 Brachial plexus: Introduction
• It is found in the root of the neck and axilla
• It is made up of:
– Roots
– Trunks
– Divisions
– Cords
– Terminal branches

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 Formation of the brachial plexus
• BP is formed by the union of the ventral rami of
the lower 4 (C5- C8) cervical spinal nerves and
the 1st thoracic nerve (T1)
• These form the ROOTS
• The roots unite and some continue to form the
TRUNKS-superior, middle and inferior trunks
• Each trunk divides into anterior and posterior
DIVISIONS
• The divisions of the trunks form 3 CORDS
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BP Formation

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33
 BP: Parts, Location and Relations
Roots (5)-B/n scalene mm

Trunks(3)- Posterior triangle

Divisions(6)-behind the clavicle

Cords (3)- in the axilla

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 Branches of brachial plexus
• Supraclavicular branches arise from roots or
from trunks
• Infraclavicular branches come from the cords

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 Supraclavicular branches

1. Dorsal scapular nerve C5

From roots
2. Long thoracic nerve C5, 6 7)

3. Nerve to subclavius C5, 6

From superior trunks
4. Suprascapular nerve C5, 6

1. Nerves to scaleni and longus colli

C5, 6, 7, 8
2. Branch to phrenic nerve
C5 36
 Infraclavicular branches
Lateral pectoral C5, 6, 7
Musculocutaneous C5, 6 7
Lateral cord
Lateral root of median C(5), 6, 7
medial pectoral C8, T1
Medial cutaneous of
C8, T1
forearm
Medial cord Medial cutaneous of arm C8, T1
Ulnar C(7), 8, T1
Medial root of median C8, T1
Upper subscapular C5, 6
Thoracodorsal C6, 7,8
Posterior cord Lower subscapular C5, 6
Axillary C5, 6
Radial C5, 6, 7, 8, (T1)
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 Variations of Brachial plexus
• Prefixed BP(C4-8)
• Postfixed BP(C6-8, T1 & 2)
• Variation may occur in the formation of the
trunk, divisions and the cords
• Trunk divisions and cord formations may be
absent in some individuals

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 Brachial plexus injury
• May result from disease, stretch and wound in
the neck or axilla
• Injuries result in paralysis of limb movement
or loss of sensation
• Manifestation depends on the part of the
plexus damaged

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 Brachial plexus lesions
• Upper plexus , i.e. C5 and C6 roots and the
upper trunk
– usually traumatic
• lower plexus, i.e. C8 and T1 roots and the
lower trunk.
– Trauma
– Malignant infiltration
– Thoracic outlet syndrome.
• Severe trauma may affect the whole plexus
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 Upper plexus palsies
• Causes:
– Excessive increase in the angle b/n head and
shoulder of an infant during birth
– Severe fall on the side of the head and the
shoulder in adults e . g. motor cycle injuries
• Deformity:
– Waiter hinting for a tip (Erb–Duchenne paralysis).
– There is sensory loss over the lateral aspect of the
upper arm.
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 Lower plexus palsies-Causes

• Upward traction on the arm causing excessive

increase in the angle b/n trunk and arm e.g. in
a forcible breech delivery ((Klumpke's
paralysis)
• An associated Horner's syndrome (ptosis and
constriction of the pupil)
• Malignant infiltration (from apical lung cancer-
Pancoast tumor)

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 Lower plexus palsies-Causes

• Metastatic carcinoma of the breast

• Radiotherapy for breast carcinoma
• Thoracic surgery involving a sternal split
• Thoracic outlet syndrome

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 Lower plexus palsies-Clinical Features
• Clawed hand (unopposed action of the long
flexors and extensors of the fingers -Klumpke's
paralysis).
• Sensory loss along the medial aspect of the
forearm
• Often an associated Horner's syndrome (ptosis
and constriction of the pupil) which occurs as
a result of traction on the cervical sympathetic
chain.
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