PT Extras 2

Suspensory/Cooper’s ligament

Fibroglandular mass anteriorly through superficial fascia to attach breasts to dermis

Lateral mammary vessels source

Lateral thoracic artery from second part of axillary artery

Medial mammary vessels source

Anterior perforating artery from internal thoracic artery (branch of subclavian artery)

Blood supply of breasts

Lateral mammary vessels, medial mammary vessels, additional supply from pectoral branch of thoracoacromial trunk

Breast venous drainage

Towards the axilla to the axillary vein, also via internal thoracic vein, lateral thoracic vein, 3rd-5th intercostal veins

Breast lymphatic drainage

Starts in deep lymphatic plexi around lobes and ducts, passes through body of breast to axillary and parasternal nodes (medial/upper and lower inner quadrants)

Subcutaneous breast lymphatics

Start from subareolar plexus to midline to anastamose with other side; upward over clavicle and downward in abdominal wall

Level 1 axillary nodes

Brachial, subscapular, pectoral nodes (lateral to pec minor)

Level 2 axillary nodes

Central nodes (under pec minor)

Level 3 axillary nodes

Apical between pec minor and 1st rib

Anterior cutaneous pectoral innervation

Medial and lateral branches of anterior cutaneous branch of intercostal nerve

Lateral cutaneous pectoral innervation

Anterior branches of lateral cutaneous branch of intercostal nerves

Superior cutaneous pectoral innervation

Supraclavicular nerve (C3, C4)

Deltopectoral triangle borders

Medially: clavicle

Superiorly: deltoid
Inferiorly: pectoralis major

Deltopectoral triangle contents

Cephalic vein that joins the axillary vein

Axilla apex border

Cervicoaxillary canal; between first rib, clavicle, superior edge of subscapularis

Axilla anterior wall

Pectoral muscles, clavipectoral and pectoral fascia, inferiorly by anterior axillary fold

Axilla posterior wall

Anterior surface: scapulae and subscapularis

Inferior border: teres major and latissimus dorsi

Axilla medial wall

Thoracic wall (ribs 1-4), overlying serratus anterior

Axilla lateral wall

Intertubercular groove

Axilla base/floor

Skin, subcutaneous tissue, deep fascia from arm laterally to thorax medially

Axillary artery first part location

Lateral border of 1st rib to medial border of pec minor, within axillary sheath with trunks and cords of brachial plexus

Axillary artery first part branches

Superior/supreme thoracic artery exiting inferior to subclavius and posterior to axillary vein, supplies first and second intercostal spaces and subclavius

Axillary artery second part location

Deep to pectoralis minor

Axillary artery second part first branch

Thoracoacromial trunk splitting into acromial branch (supplies deltoid at level of acromion), clavicular branch (supplies SC joint and subclavius), deltoid branch (supplies deltoid, part of pectoralis major, travels with cephalic vein in deltopectoral groove), pectoral branch (supplies pectorals via 4 smaller branches deep to clavicular head of pec major and breasts)

Axillary artery second part second branch

Lateral thoracic artery, lateral to lateral border of pec minor, supplies pectoral muscles, serratus anterior, breasts

Axillary artery third part location

Extends from lateral border of pectoralis minor to inferior border of teres major

Axillary artery third part first branch

Subscapular artery, follows margin of subscapularis and divides into thoracodorsal artery (supplies latissimus dorsi) and scapular circumflex artery (passes through triangular space, pierces teres minor to enter infraspinatus fossa, anastomoses with dorsal scapular artery for scapula collateral circulation)

Axillary artery third part second branch

Anterior humeral circumflex artery, passes anterior to surgical neck of humerus, anastomoses with posterior humeral circumflex artery and supplies glenohumeral joint and head of humerus

Axillary artery third part third branch

Posterior humeral circumflex artery, passes through quadrangular space, wraps posterior to surgical neck of humerus, supplies glenohumeral joint and surrounding tissues

Axillary vein location

Begins at lower margin of teres major, continuation of basilic vein, medial to axillary artery, becomes subclavian vein at lateral border of first rib, receives tributaries corresponding to branches of axillary artery

Brachial plexus roots

Ventral rami of C5-T1, pass through gap between anterior and middle scalenes (scalene interval), accompanied by subclavian artery

Brachial plexus trunks

Superior trunk: union of C5 and C6

Middle trunk: continuation of C7

Inferior trunk: union of C8 and T1

Brachial plexus divisions

Anterior divisions: supply anterior compartment of upper limb (flexors)
Posterior divisions: supply posterior compartment of upper limb (extensors)

Brachial plexus cords

Lateral cord: anterior divisions of superior and middle trunks

Posterior cord: union of posterior divisions of all three trunks

Medial cord: continuation of anterior division of inferior trunk

Dorsal scapular nerve

Branches off brachial plexus roots, arises from posterior aspect of C5 ventral ramus with contribution of C4, pierces scalene, innervates levator scapula and rhomboids

Long thoracic nerve

Branches off brachial plexus roots, arises off posterior aspect of C5, C6, C7 ventral rami, passes through apex of axilla, supplies serratus anterior

Nerve to subclavius

Branches off brachial plexus trunks (C4, C5, C6), arises from anterior aspect of superior trunk, receives fibers from anterior aspect of superior trunk and primarily C5 with some C6

Suprascapular nerve

Branches off brachial plexus trunks (C4, C5, C6), arises from posterior surface of superior trunk, receives fibers from C5, C6, sometimes C4, innervates infraspinatus, supraspinatus, and GH joint

Lateral cord branches

Lateral pectoral nerve (C5, C6, C7), musculocutaneous nerve (C5-C7), lateral communicating branch of median nerve, median nerve (C5-T1)

Lateral pectoral nerve

Primarily supplies pectoralis major, sends a branch to medial pectoral nerve

Musculocutaneous nerve

Exits axilla by piercing coracobrachialis, passes between biceps and brachialis, supplies all anterior arm muscles, becomes cutaneous in the forearm (lateral antebrachial cutaneous nerve)

Lateral communicating branch/root of median nerve

Joins medial root of median nerve to form median nerve

Median nerve

Arises by medial and lateral roots from medial and lateral cords, supplies anterior compartment in forearm and some hand and skin

Branches off medial cord

Medial communicating branch of median nerve, medial pectoral nerve (C8, T1), medial brachial cutaneous nerve (C8, T1), medial antebrachial cutaneous nerve (C8, T1), ulnar nerve (C8, T1, sometimes C7)

Medial communicating branch/root of median nerve

Joins lateral root of median nerve to form median nerve

Medial pectoral nerve

Pierces pectoralis minor, supplies pectoralis minor and major, lateral to lateral pectoral nerve

Medial brachial cutaneous nerve

Supplies skin on medial arm

Medial antebrachial cutaneous nerve

Supplies skin on medial forearm

Ulnar nerve

Does not branch in the forearm, supplies some of anterior forearm and continues to medial hand

Branches off posterior cord

Upper subscapular nerve (C5, C6), thoracodorsal/middle subscapular nerve (C6, C7, C8), lower subscapular nerve (C6, C7), axillary nerve (C5, C6), Radial nerve (C5-T1)

Upper subscapular nerve

Supplies superior part of subscapularis

Thoracodorsal/Middle subscapular nerve

Supplies latissimus dorsi

Lower subscapular nerve

Supplies inferior part of subscapularis and teres major

Axillary nerve

Terminal branch of posterior cord, passes through quadrangular space and winds around surgical neck, supplies teres minor and deltoid, continues distally as superior lateral cutaneous nerve of the arm to supply skin over inferior half of deltoid

Radial nerve

Terminal branch of posterior cord, supplies musculature in posterior compartment of arm and skin on posterior aspect of arm and forearm, runs in triangular interval

Carrying angles

Women: 10-15 degrees

Men: 5 degrees

Transverse humeral ligament function

Holds the tendon of long head of biceps in intertubercular groove

Bicipital aponeurosis location

Distal continuation of common biceps tendon, connects biceps tendon to deep fascia of forearm

Bicipital aponeurosis function

Provides protection for brachial artery and median nerve in cubital fossa and alters the force distribution to decrease pressure on biceps tendon on radial tuberosity

Branches of brachial artery

Brachial profunda/deep brachial artery, superior and inferior ulnar collateral arteries, radial artery, ulnar artery

Brachial profunda/deep brachial artery supply

Blood to posterior compartment of arm

Superior and inferior ulnar collateral arteries supply

Participate in elbow anastomoses

Radial artery supply

At or near cubital fossa, under bicipital aponeurosis

Ulnar artery supply

At or near cubital fossa, under bicipital aponeurosis

Elbow anastomoses

Superior ulnar collateral to posterior ulnar recurrent

Inferior ulnar collateral to anterior ulnar recurrent

Middle collateral to interosseous recurrent

Radial collateral to radial recurrent

Elbow anastomoses branches

Superior ulnar collateral and inferior ulnar collateral branch from brachial artery

Middle collateral and radial collateral branch from deep brachial artery

Radial recurrent artery branches from radial artery

Anterior ulnar recurrent and posterior ulnar recurrent branch from ulnar artery

Interosseous recurrent from common interosseous artery

Cephalic vein location

Travels with deltoid branch of thoracoacromial trunk in deltopectoral groove on lateral surface of arm

Basilic vein location

Ascends into inferior medial arm, passes deeply, piercing brachial fascia to merge with accompanying veins of brachial vein to form axillary vein

Median cubital vein location

Communication between the cephalic vein and basilic vein

Musculocutaneous nerve location

Pierces coracobrachialis, travels between biceps and brachialis, becomes lateral antebrachial cutaneous nerve

Median nerve location

Initially lateral to brachial artery, crosses anterior to travel with brachial artery, becomes medial to brachial artery in cubital fossa

Ulnar nerve location

Medial to brachial artery, around middle of arm, pierces medial intermuscular septum with superior ulnar collateral artery, passes posterior to medial epicondyle

Radial nerve location

Initially posterior to brachial artery, medial to humerus, and anterior to long head of triceps

Travels inferolateral in spiral/radial groove on posterior humerus

Pierces lateral intermuscular septum and enters anterior compartment of arm between brachialis and brachioradialis

Radial nerve branches

Branches at level of lateral epicondyle

Deep branch: entirely muscular and articular, pierces supinator muscle

Superficial branch: cutaneous

Radial nerve innervation

Muscles in posterior arm, motor innervation to long and lateral head of triceps prior to spiral line, medial head of triceps from spiral line

Cubital fossa borders

Superiorly: imaginary line connecting medial and lateral epicondyles

Medially: pronator teres

Laterally: brachioradialis

Floor: brachialis and supinator

Roof: deep fascia reinforced with bicipital aponeurosis

Cubital fossa contents

Terminal part of brachial artery, beginning of radial and ulnar arteries, biceps brachii tendon, median nerve

Elbow joint type

Ginglymoid/hinge, uniaxial (flexion and extension)

Humeroulnar joint type

Modified sellar

Humeroradial joint type

Modified ovoid

Proximal radioulnar joint

Uniaxial diarthrodial, trochoid or pivot, modified ovoid, allows for supination and pronation

Elbow joint capsule contents

Humeroulnar, humeroradial, proximal radioulnar joint

Elbow joint anterior proximal attachment

Superior to radial and coronoid fossae

Elbow joint anterior distal attachment

Inserts onto ulna at margin or coronoid process, attaches onto radius at annular ligament

Elbow joint lateral attachment

Blends with fibers of lateral collateral ligament

Elbow joint medial attachment

Blends with fibers of medial collateral ligament

Elbow joint posterior attachment

Upper edge of olecranon fossa

Anterior medial collateral ligament location

Attaches from the tip of the medial epicondyle of the humerus to coronoid process of the ulna

Anterior medial collateral ligament function

Limits extension and valgus stress

Posterior medial collateral ligament location

Attaches from posterior surface of medial epicondyle to olecranon and coronoid process of ulna

Posterior medial collateral ligament function

Limits flexion and valgus stress

Transverse/oblique ligament function

Limits valgus stress

Lateral collateral ligament location

Fan shaped; extends from inferior lateral epicondyle to annular ligament and lateral aspect of the olecranon process

Lateral collateral ligament function

Limits varus force