Upper limb Pectoral region & Axilla 黃敏銓 mchuang@ntu.edu.tw 1
Pectoral region Intercostal nerve Anterior branch of lateral cutaneous branch Lateral cutaneous branch Anterior cutaneous branch Anterior cutaneous branch Sternalis muscle Perforating branch Internal thoracic artery 2
Suspensory ligaments Lactiferous ducts Lactiferous sinus Gland lobules 3
Axilla 4
Anterior wall Inlet (Apex) Axillary sheath Lateral wall Medial wall Posterior wall Floor (Base) 5
Axillary inlet (apex) Middle scalene muscle Anterior scalene muscle 2. Superior border of the scapula 3. Rib 1 1. Clavicle VAN ( 內到外 ) 第 1 肋骨上 Subclavian vein Subclavian artery Inferior trunk 6
Anterior wall Subclavius Pectoralis minor Clavipectoral fascia Pectoralis major 7
Pectoralis major Clavipectoral (Deltopectoral) triangle 1. Act together: powerful adduction, medial rotation 2. Act independently: flexion of arm, extension of flexed arm 3. Inferior part: protract, depress, downward rotate scapula Clavicular head: Medial half of clavicle Pectoralis major Insertion: lateral lip of intertubercular sulcus of humerus Sternocostal head: Sternum 1st~6(7)th costal cartilage Aponeurosis of external oblique Innervation: Medial and lateral pectoral nerves 8
Subclavius Subclavius Origin: 1st rib Insertion: groove on inferior surface of clavicle Sternoclavicular joint 1. Depress clavicle 2. Pull clavicle medially Innervation: nerve to subclavius 9
Pectoralis minor Coracoid process Pectoralis minor Medial pectoral nerve III Origin: 3rd~5th rib Insertion: coracoid process 1. Protract scapula, depress, downward rotate scapula 2. Elevate ribs 3. Landmark IV V Innervation: Medial pectoral nerve 10
Clavipectoral fascia Thoracoacromial artery Cephalic vein Lateral pectoral nerve Clavipectoral fascia Medial pectoral nerve Lateral thoracic artery 11
Medial wall Long thoracic nerve Origin: 1-8(9) ribs Long thoracic nerve Serratus anterior (boxer s muscle) Insertion: costal surface of medial border of scapula 1. Protract, upward rotate and depress scapula 2. Keep scapula opposed to thoracic wall Winged scapula 12
Lateral wall Intertubercular sulcus 13
Posterior wall Subscapularis Teres major Long head of triceps brachii Latissimus dorsi 14
Long head of triceps brachii Origin: infraglenoid tubercle on scapula Insertion: olecranon process of ulna Long head of triceps brachii Arm: adduction, extension Forearm: extension Innervation: radial nerve 15
Subscapularis Origin: subscapular fossa (medial 2/3) Insertion: lesser tubercle of humerus Subscapularis: rotator cuff muscle, medial rotation and adduction of arm Innervation: superior & inferior subscapular nerves 16
Teres major Origin: posterior surface of inferior angle of scapula Insertion: medial lip of intertubercular sulcus Teres major Medial rotation, adduction, and extension of arm Innervation: inferior subscapular nerve 17
Latissimus dorsi Latissimus dorsi Origin: lower 6 thoracic vertebrae, thoracolumbar fascia, iliac crest, lower 3-4 ribs. Insertion: floor of intertubercular sulcus 1. Arm (direct): powerful adduction, medial rotation, extension 2. Scapula (indirect): downward rotation Innervation: thoracodorsal nerve 18
Gateways in the posterior wall Quadrangular space Axillary nerve Posterior circumflex humeral artery & vein Triangular interval Radial nerve Profunda brachii artery Long head of triceps brachii Triangular space Circumflex scapular artery Teres major 19
Floor of the axilla Posterior axillary fold Anterior axillary fold 20
Muscles pass through the axilla Long head of biceps brachii Short head of biceps brachii Coracobrachialis 21
Axillary artery 2 1 Lateral margin of rib I Subclavian artery 3 Lower border of teres major Pectoralis minor Brachial artery 22
Branches of the axillary artery Subscapular artery Anterior circumflex humeral artery Superior thoracic artery Thoracoacromial artery 1 2 3 3 Posterior circumflex humeral artery 3 Circumflex scapular artery Thoracodorsal artery Lateral thoracic artery 2 23
Axillary vein Subclavian vein Cephalic vein Basilic vein Paired brachial veins 24
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Axillary nodes Apical nodes Right subclavian trunk Central nodes Pectoral (anterior) nodes Humeral (lateral) nodes Subscapular (posterior) nodes 2 nd part 1 st part upper limb breast 26
Brachial plexus Middle scalene muscle Roots Trunks C5 Divisions Cords T1 Anterior scalene muscle 27
Brachial plexus 28
Branches of the roots Dorsal scapular nerve Levator scapulae Rhomboid minor Rhomboid major Dorsal scapular nerve Long thoracic nerve Serratus anterior Long thoracic nerve 29
Branches of the trunks Suprascapular nerve Nerve to subclavius Subclavius Supraspinatus Infraspinatus Nerve to subclavius Suprascapular nerve 30
Branches of the lateral cord Pectoralis major Lateral pectoral nerve Flexor muscles of arm Musculocutaneous nerve Median nerve Lateral cutaneous nerve of forearm 31
Branches of the medial cord Pectoralis major and minor Medial pectoral nerve Medial cutaneous nerve of arm Median nerve Medial cutaneous nerve of forearm Ulnar nerve Lateral cutaneous nerve of forearm 32
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Branches of the posterior cord Axillary nerve Radial nerve Subscapularis Superior subscapular nerve Inferior subscapular nerve Teres major Thoracodorsal nerve Latissimus dorsi 34