Cunningham's Manual of Practical Anatomy Vol 1 General Anatomy, Upper and Lower Limbs (17

edn)
Rachel Koshi

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Published: 2024 Online ISBN: 9780198923367 Print ISBN: 9780198923343

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CHAPTER

5 The pectoral region and axilla 

Rachel Koshi

https://doi.org/10.1093/med/9780198923343.003.0005 Pages 55–72

Published: July 2024

Abstract
This chapter on the pectoral region and axilla begins with a description of the surface features of this
region: the scapula, the clavicle, the sternum, and the sternoclavicular joint. It describes the breast,
and its location, structure, extent and deep relations, age-related changes, blood supply, and
lymphatic drainage, as well as applied anatomy of the breast, and provides instructions on how to
dissect the breast. It describes the boundaries and contents of the axilla. It gives detailed, stepwise
instructions on how to dissect the axilla and display the brachial plexus and its branches, the axillary
artery and its branches, and the axillary lymph nodes. It also provides instructions on how to clean and
study the pectoralis major, clavipectoral fascia, serratus anterior, and other muscles and fascia
bounding the axilla. Descriptions and dissections are well illustrated. Some clinical and surgical
aspects of breast disease and examination and lymph node dissection are discussed.

Keywords: breast, pectoralis major, serratus anterior, axillary artery, axillary lymph node, brachial plexus,
sternoclavicular joint, scapula, clavicle, clavipectoral fascia
Subject: Anatomy
Collection: Oxford Medicine Online

Introduction

Muscles covering the front of the chest and holding the free upper limb to the torso, and their vessels and
nerves constitute the pectoral region. The pyramidal space between the upper part of the thorax and the
arm is the axilla.
Overview of the axilla
The axilla is a four-sided pyramidal space between: (1) the upper limb; (2) the muscles connecting the upper
limb to the front of the thorax; (3) the muscles connecting the upper limb to the back of the thorax; and (4)
the lateral wall of the thorax. When the arm is by the side, the axilla is a narrow space. When the arm is
abducted, the volume of the axilla increases and its oor (base) rises, forming a de nite ‘armpit’. Also,
when the arm is abducted, the muscular inferior margin of its anterior wall stands out as the anterior
axillary fold, and the inferior margin of the posterior wall stands out as the posterior axillary fold [Fig. 5.1].

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Fig. 5.1 A pyramidal-shaped hollow—the axilla—is clearly seen between the chest wall and the arm. The anterior and posterior
axillary folds are seen bounding the floor of the axilla.

FotoAndalucia/Shutterstock.com

The superior part of the axilla—the apex—lies lateral to the rst rib and is continuous over its superior
surface, with the superior aperture of the thorax below and the root of the neck above. This continuity
permits blood vessels from the thorax and nerves from the neck to enter the axilla on their way to the upper
limb. (These vessels and nerves pass over the superior surface of the rst rib behind the clavicle [Fig. 5.2].)
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Fig. 5.2 Schematic drawing of the axilla, showing the base, apex, and four walls in relation to the bones of the thorax, pectoral
girdle, and arm.

Surface anatomy of the pectoral region and axilla

All points mentioned in this section should be con rmed on the living body and on specimens of the bones.

The clavicle (collar bone) is palpable throughout its length. It follows a slight curve which is convex
forwards in its medial two-thirds and concave forwards in its lateral one-third [see Fig. 4.1]. Draw a nger
along your clavicle, and note that its ends project above the acromion of the scapula laterally and the
manubrium of the sternum medially. Thus, the positions of these joints are easily identi ed, though the
medial end of the clavicle is somewhat obscured by the attachment of the sternocleidomastoid muscle.

Between the medial ends of the clavicles, feel the jugular notch on the superior margin of the manubrium
p. 56 [Fig. 5.3]. Draw a nger downwards from this notch in the median plane till a blunt transverse ridge is
felt on the sternum. This bony landmark is the sternal angle, a joint between the manubrium and the body
of the sternum. At this level, the cartilage of the second rib articulates with the side of the sternum. The
second rib may be identi ed in this way, even in obese subjects, as the sternal angle is always readily
palpable. The other ribs are identi ed by counting down from the second rib. The anterior part of the rst
rib is hidden by the medial part of the clavicle. Immediately inferior to the lower end of the body of the
sternum is a small median depression—the epigastric fossa—which overlies the xiphoid process, the
lowest piece of the sternum. The cartilages of the seventh ribs lie on either side of this fossa.
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Fig. 5.3 Sternum (anterior view).

The nipple is very variable in position, even in the male, but usually lies over the fourth intercostal space,
near the junction of the ribs with their cartilages. It is just medial to a vertical line passing through the
middle of the clavicle (the mid-clavicular line).

The infraclavicular fossa is a depression inferior to the junction of the lateral and middle thirds of the
clavicle. The pectoralis major muscle on the front of the chest lies medial to the fossa, and the deltoid
muscle, which clasps the shoulder, is lateral to it. The coracoid process of the scapula can be felt just lateral
to the fossa and under cover of the deltoid muscle, 2–3 cm below the clavicle.

Follow the clavicle laterally to its articulation with the acromion—a subcutaneous, attened piece of bone
about 2.5 cm wide, on the top of the shoulder. The acromioclavicular joint can be felt as a slight dip, as the
clavicle projects slightly above the level of the acromion (acron = summit; omos = shoulder).

Raise the arm from the side (i.e. abduct it), and identify the hollow of the axilla, the anterior axillary fold
(containing the pectoralis major muscle), and the posterior axillary fold (containing the latissimus dorsi
and teres major muscles) [Fig. 5.1]. The teres major is a thick, rounded muscle which connects the inferior
angle of the scapula to the humerus, and can be felt in the posterior axillary fold when the arm is raised
above the head. The latissimus dorsi muscle extends from the lower part of the back to the humerus. It can
be made to stand out by depressing the horizontal arm against resistance.

With the arm by the side, push your ngers into the axilla. The anterior and posterior walls are soft and
eshy, but the lateral margin of the scapula can be felt in the posterior wall. The medial wall is formed by
the ribs covered by a sheet-like muscle—the serratus anterior. In the lateral angle, the biceps brachii and
coracobrachialis muscles lie parallel to the humerus. Some of the large nerves in the axilla can be rolled
p. 57 between the ngers and the humer us, and the axillary artery can be felt pulsating. By pushing the ngers
up into the axilla, the head of the humerus can be felt laterally and the lateral border of the rst rib medially.

Pectoral region

Cutaneous nerves
The skin on the anterior and lateral surfaces of the thorax is supplied by:

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1. The supraclavicular nerves from the cervical plexus—principally the fourth cervical ventral ramus

2. The anterior and lateral cutaneous branches of the ventral rami of the second to eleventh thoracic
nerves (intercostal nerves) [Fig. 5.4].
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Fig. 5.4 Dermatomal pattern on the front of the trunk. The areas of skin supplied by the ventral rami are illustrated.

The supraclavicular nerves [Fig. 5.5] arise in the neck from the third and fourth cervical nerves (C. 3, C. 4).
Diverging as they descend, the nerves pierce the deep fascia in the neck. They cross the clavicle to supply the
skin on the front of the chest and shoulder [see Figs. 7.1 and 7.2] down to a horizontal line at the level of the
second costal cartilage. They are named, according to their positions: medial, intermediate, and lateral.

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Fig. 5.5 Course and distribution of the supraclavicular nerves.

The anterior cutaneous branches of the intercostal nerves (except the rst and occasionally the second)
emerge from the intercostal spaces near the lateral border of the sternum, pierce the pectoralis major, and
supply the skin from the anterior median line almost to a vertical line through the middle of the clavicle
(mid-clavicular line). They are accompanied by perforating branches of the internal thoracic artery, an
artery which lies immediately deep to the costal cartilages. In the female, these arterial branches are
enlarged in the second to fourth spaces to supply the mammary gland. The arteries have lymph vessels
running with them from the skin of the anterior thoracic wall and the medial part of the mammary gland
(breast) to parasternal nodes which lie beside the internal thoracic artery.

The lateral cutaneous branches of the intercostal nerves pierce the deep fascia along the mid-axillary line.
Each nerve divides and enters the super cial fascia as anterior and posterior branches. The nerves pierce, or
pass between, the digitations of the serratus anterior but play no part in supplying this muscle, the pectoral
muscles, or the latissimus dorsi over which they run. They supply the part of the skin between the parts
supplied by the anterior cutaneous branches (midline in front to the mid-clavicular line) and the dorsal
ramus (midline of the back to approximately 10 cm from the midline).

There are usually no lateral or anterior cutaneous branches from the rst intercostal nerve. The lateral
cutaneous branch of the second intercostal nerve is the intercostobrachial nerve. It emerges as a large
single branch and communicates with the medial cutaneous nerve of the arm and the lateral cutaneous
branch of the third intercostal nerve. Together, these three nerves supply the skin of the medial side of the
arm and the oor of the axilla.

Dissection 5.1 describes how to re ect the skin of the front and side of chest. [See also Fig. 5.6.]
Dissection 5.1 Skin reflection of the front and side of the chest

Objectives

I. To re ect the skin on the front and side of the chest.

II. To examine the super cial fascia.

III. To nd the cutaneous vessels and nerves.

Instructions

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1. Make the skin incisions 1–4, shown in Fig. 5.6. Make sure to carry incision 4 backwards as far as
the posterior axillary fold.

2. Cut through the super cial fascia in incisions 1, 3, and 4.

3. Start from the midline (incision 1). Re ect the aps of skin and the super cial fascia laterally by
blunt dissection. Do not detach them. Leave the nipple and the surrounding skin in position as a
landmark.

4. As the ap is separated from the skin of the neck along the clavicle, split the super cial fascia
with a blunt instrument. Avoid cutting through the thin sheet of muscle (platysma) and the
supraclavicular nerves [Fig. 5.5]. The supraclavicular nerves pass anterior to the clavicle to
supply the skin of the upper part of the anterior thoracic wall and the shoulder.

5. Identify the medial, intermediate, and lateral branches of the supraclavicular nerves.

6. Note the brous strands connecting the deep fascia to the skin, especially deep to the breast in
the female.

7. Find the anterior cutaneous nerves and vessels which emerge from the anterior ends of the
intercostal spaces. Follow the branches of one of these nerves medially and laterally as far as
possible.

8. Find the lateral cutaneous branches which pierce the chest wall in the mid-axillary line. They
emerge through the deep fascia, one inferior to the other, in a vertical line. Follow the branches
of one of them anteriorly and posteriorly as far as possible.
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Fig. 5.6 Landmarks and incisions. Le forearm pronated, and right forearm supinated.

p. 58 The breast

Location
The mamma, or breast, lies in the super cial fascia of the pectoral region.

Structure
It is made up of: (1) the mammary gland; (2) the fatty super cial fascia in which it is embedded; and (3) the
overlying skin with the nipple and the surrounding pigmented skin—the areola [Fig. 5.7].
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Fig. 5.7 Dissection of the right mammary gland.

In the male, the mammary gland is rudimentary; the nipple is small, and the areola is commonly
surrounded by ne hairs. In the non-lactating female, the breast consists mainly of fatty tissue of the
p. 59 super cial fascia, in which are enclosed 15–20 lobes of rudimentary glandular tissue. These glands

p. 60
radiate outwards from the nipple, giving the gland the shape of a attened cone. Each lobe has a main
lactiferous duct which passes to open separately on the nipple. At the base of the nipple, the duct is dilated
to form a lactiferous sinus. The gland has no capsule, but its lobes are separated by brous strands of the
super cial fascia which pass from the skin to the deep fascia. These brous strands are attached to the gland
and anchor it both to the skin and to the underlying deep fascia.

Extent and deep relations

The base of the mammary gland extends from the margin of the sternum to almost the mid-axillary line,
and from the second to sixth ribs. It lies largely on the pectoralis major muscle. Inferolaterally, it extends on
to the costal origins of the serratus anterior and the external oblique muscle of the abdomen. The ‘axillary
tail’ arises from the superolateral quadrant of the breast and passes into the axilla, up to the level of the
third rib [Fig. 5.7]. The apex of the gland—the nipple—lies a little below the midpoint of the gland,
approximately at the fourth intercostal space in the nulliparous woman. The nipple is free of fat but
contains circular and longitudinal smooth muscle bres which can erect or atten it. The skin of the nipple
and areola contains modi ed sweat and sebaceous glands, particularly at the outer margin of the areola.
These sebaceous glands tend to enlarge in the early stages of pregnancy, and shortly thereafter there is an
increase in pigmentation in both the nipple and areola which never return to their original colour. In the
later stages of pregnancy, the greater part of the fat in the gland is replaced by the proliferation of its ducts
and the growth of many secretory alveoli from their branching ends.

Age changes in the breast

In infancy and early childhood, the breast consists solely of lactiferous ducts. No alveoli or precursors of
alveoli are present. Breast changes occur in the female child at puberty under the in uence of ovarian
hormones. The ducts become branched, and masses of polyhedral cells develop at their ends. The areola
becomes larger and more deeply pigmented. Adipose tissue is laid down in the stroma and the breasts
enlarge and become rounded. The nipple becomes more raised. After menopause, ducts and alveoli atrophy
and fatty tissue replaces the glandular tissue.
During the later stages of pregnancy, the ducts proliferate and alveoli are formed at the ends of the ducts.

Blood supply
The gland receives its blood supply from perforating branches of the intercostal and internal thoracic
arteries medially and from the lateral thoracic artery laterally.

Lymphatic drainage
Lymph vessels drain principally: (1) to the axillary lymph nodes—(a) along the axillary tail to the pectoral

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lymph nodes, and (b) through the pectoralis major and clavipectoral fascia to the apical axillary nodes via
the infraclavicular nodes; (2) to the parasternal nodes along the internal thoracic artery by passing along
the branches of that artery which supply the gland; and (3) some lymph also drains to the posterior
intercostal nodes. Since there is communication of lymph vessels across the median plane, there may be
drainage to the opposite side, especially when some of the pathways are blocked by disease [Fig. 5.8].

Fig. 5.8 Lymph nodes and lymph vessels of the axilla.

The most common breast conditions are painful breasts or mastitis (in ammation of the breast), cysts,
benign tumours, and cancer. Clinical Application 5.1 discusses some of the clinical features of breast cancer.
 Clinical Application 5.1 Breast cancer

The following observations were made during breast examination of a 36-year-old woman with breast
cancer. The right breast was rmly adherent to the underlying tissue.

Study question 1: name the tissue which lies immediately deep to the breast. What does this
immobility/tethering of the breast tell you about the disease process? (Answer: deep fascia, pectoralis
major, and serratus anterior; the breast being xed to the underlying tissue means that the cancer has
invaded the underlying muscle.) The skin over the upper lateral quadrant of the breast is thick and
pitted, resulting in an orange-peel appearance. This appearance is caused by two factors: (1) blockage

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of lymph vessels by cancer cells, resulting in lymphoedema; and (2) the fact that the subcutaneous
tissue is prevented from swelling uniformly by the shortened suspensory ligaments which are also
invaded by disease.

Study question 2: to what structures are the suspensory ligaments attached? (Answer: the suspensory
ligaments run from the glands to the underlying deep fascia and to the overlying skin.)

Study question 3: on examination of the axilla, hard and 3 cm-sized masses were felt immediately deep
to the anterior axillary fold. What are these masses likely to be, and how are they related to the disease
process? (Answer: the masses are most likely enlarged anterior axillary lymph nodes, to which the
cancer cells from the breast have spread.)

p. 61 Dissection 5.2 describes the dissection of the breast.

Dissection 5.2 The breast

Objective

I. To identify the lactiferous ducts and lobes of the mammary gland.

Instructions

1. Attempt to pass a bristle through one of the ducts of the nipple.

2. Attempt to identify one of the lobes of the gland by blunt dissection.

This is not usually very successful in the elderly female and should not be attempted in the male.

Deep fascia of the pectoral region

The deep fascia covering the pectoralis major is continuous with the periosteum of the clavicle and sternum,
and passes over the infraclavicular fossa and deltopectoral groove (between the pectoralis major and the
deltoid) to become continuous with the fascia covering the deltoid. It curves over the inferolateral border of
the pectoralis major to become continuous with the fascia of the axillary oor (axillary fascia). The axillary
fascia stretches between the pectoralis major and the latissimus dorsi. When the arm is abducted, the
axillary fascia rises into the axilla to form the armpit.
The clavipectoral fascia lies in the anterior wall of the axilla, deep to the pectoralis major. It extends from
the clavicle to the axillary fascia, and encloses the pectoralis minor and subclavius muscles [Fig. 5.9].

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Fig. 5.9 Diagram of the clavipectoral fascia shown enclosing the subclavius and pectoralis minor and extending to the axillary
fascia.

See Dissection 5.3 for instructions on dissecting the pectoral region. [See also Fig 5.10.]

Dissection 5.3 Pectoral region-1

Objectives

I. To study the pectoralis major and the deltoid.

II. To identify the cephalic vein.

Instructions

1. Cut the deep fascia in the deltopectoral groove to uncover the cephalic vein passing to the
infraclavicular fossa [Fig. 5.11].

2. Occasional lymph nodes found beside the vein receive lymph from the adjacent super cial
tissues and transmit it through the infraclavicular fossa to the apical nodes of the axilla [Fig.
5.8].

3. Remove the fascia from the anterior parts of the pectoralis major and the deltoid, and de ne the
attachments of these muscles.
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Fig. 5.10 Superficial lymph vessels and lymph nodes of the front of the upper limb.

Pectoralis major
Origin: this powerful, fan-shaped muscle takes origin from: (1) the medial half of the front of the clavicle;
(2) the anterior surfaces of the sternum; (3) the upper six costal cartilages; and (4) the aponeurosis of the
external oblique muscle of the abdomen [Fig. 5.11]. Insertion: it is inserted into the lateral lip of the
intertubercular sulcus or crest of the greater tubercle of the humerus [see Fig. 4.8]. At the insertion, the
abdominal part twists under the sternocostal part to form a U-shaped tendon with it. The lowest abdominal
bres are inserted deep to the upper sternocostal bres, while the intermediate bres form the base of the U
in the anterior axillary fold.
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Fig. 5.11 Muscles of the anterior wall of the trunk. On the le side, the pectoralis major is removed to show the pectoralis
minor and subclavius.

The clavicular part passes inferolaterally, fuses with the anterior layer of the U-shaped tendon, and extends
further inferiorly on the humerus. The clavicular part lies at right angles to the abdominal and lower
sternocostal parts and has di erent actions [Fig. 5.11].

Nerve supply: medial and lateral pectoral nerves. Actions: the clavicular part of the pectoralis major adducts
and medially rotates the humerus. With the arm above the head, the lowest bres act with the latissimus
dorsi to pull down the arm or raise the body, as in climbing a rope. The muscle can also return the extended
humerus to the anatomical position, then continue to ex the shoulder joint with its clavicular part which
passes in front of the shoulder.

Pectoralis minor
Origin: this triangular muscle originates from the third to fth ribs, near their cartilages. Insertion: it
passes superolaterally to the tip of the coracoid process [Fig. 5.11]. Nerve supply: medial pectoral nerve.
Actions: it pulls the scapula (and hence the shoulder) downwards and forwards. It raises the ribs in
inspiration when the scapula is xed.

Dissection 5.4 continues the dissection of the pectoral region.

 Dissection 5.4 Pectoral region-2

Objectives

I. To study the pectoralis minor, subclavius, and clavipectoral fascia.

II. To identify and trace the cephalic vein, thoracoacromial artery, and medial and lateral pectoral
nerves.

III. To explore the continuity of the axillary vessels with the subclavian vessels.

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Instructions

1. Cut across the clavicular head of the pectoralis major below the clavicle, and re ect it towards
its insertion. Identify the branches of the lateral pectoral nerve and thoracoacromial artery that
pierce the clavipectoral fascia to enter the pectoralis major.

2. Cut across the remainder of the pectoralis major about 5 cm from the sternum. Re ect it
laterally. Identify the branch of the medial pectoral nerve which pierces the pectoralis minor to
enter the pectoralis major.

3. Note the entire sheet of the clavipectoral fascia deep to the pectoralis major, and then remove it
from the pectoralis minor.

4. Trace the pectoralis minor to its attachments.

5. Follow the cephalic vein through the upper part of the clavipectoral fascia to the axillary vein,
and the thoracoacromial artery and the lateral pectoral nerve to their origins.

6. Expose the vessels and nerves superior to the pectoralis minor.

7. Cut through the anterior layer of the clavipectoral fascia immediately inferior to, and parallel
with, the clavicle to expose the subclavius muscle.

8. Gently push a nger, inferior to that muscle, along the line of the axillary vessels. It will pass
over the rst rib, deep to the clavicle, into the root of the neck. If the nger is pressed medially
between the axillary artery and vein, a rm resistance of the scalenus anterior muscle can be felt
on the upper surface of the rst rib between the artery and the vein. (Note that the vessels felt on
the rst rib are the subclavian vessels.)

9. Pass a nger deep to the pectoralis minor through the lower part of the axilla. Lift it from the
subjacent structures, but preserve the medial pectoral nerve which enters its deep surface.

Subclavius
Origin: this small muscle arises from the adjacent parts of the upper surfaces of the rst costal cartilage and
rib. Insertion: it passes parallel to the clavicle and is inserted into the groove on the inferior surface of the
clavicle [Figs. 5.9 and 4.2]. Nerve supply: nerve to the subclavius from the upper trunk of the brachial
plexus. Actions: it holds the medial end of the clavicle against the articular disc of the sternoclavicular joint
during movements of the shoulder girdle.
 Sternoclavicular joint
The sternoclavicular joint is a synovial joint between the shallow notch at the superolateral angle of the
p. 62 manubrium of the sternum and the larger medial end of the clavicle. A complete artic ular disc intervenes
between these two articular surfaces. The joint also extends on to the superior surface of the rst costal
cartilage. This is the only articulation of the upper limb bones with the axial skeleton. Thus, the clavicle
forms a support which maintains the scapula in position and transmits forces from the upper limb to the
trunk (e.g. forces generated in falling on an outstretched hand). Functionally, the joint behaves like a ball-
and-socket joint with a wide range of movements, as it has to move with each change in scapular position. It
is subject to considerable force, but the bony surfaces give little intrinsic stability. For this reason, it is

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strengthened by powerful ligaments which are designed to prevent dislocation of the medial end of the
clavicle from the shallow fossa on the sternum. The articular capsule is attached close to the articular
margins of the bones. It is thickened anteriorly and posteriorly to form the anterior and posterior
sternoclavicular ligaments [Fig. 5.12].

Fig. 5.12 Sternoclavicular joint. A coronal section has been made through the anterior surface of the sternum and clavicle on
the right side, opening the right sternoclavicular joint.

The articular disc is a nearly circular plate of brocartilage attached at its margins to the articular capsule. It
divides the joint into two separate synovial cavities. Its strongest attachments are to the upper surface of the
medial end of the clavicle and to the junction of the sternum and rst costal cartilage. It assists the
costoclavicular ligament in preventing the upward displacement of the medial end of the clavicle and acts as
a shock absorber of compression forces applied from the upper limb.

p. 63 The costoclavicular ligament is a powerful band which passes upwards and laterally from the

p. 64
junction of the rst rib and its cartilage to a rough area on the inferior surface of the clavicle near its medial
end. The interclavicular ligament passes between the medial ends of the two clavicles and is fused with the
articular capsules and the jugular notch of the sternum [Fig. 5.12].

p. 65 Dissection 5.5 explains the dissection of the sternoclavicular joint.

 Dissection 5.5 Sternoclavicular joint

Objectives

I. To examine the ligaments of the sternoclavicular joint.

II. To examine the articular disc of the sternoclavicular joint.

Instructions

1. Separate the subclavius from its costal attachment, and turn it laterally to expose the strong

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costoclavicular ligament.

2. Expose the anterior and superior surfaces of the articular capsule of the sternoclavicular joint as
far as possible. Remove the anterior part of the articular capsule, and identify the articular disc
between the clavicle and the sternum, but leave the clavicle in position.

Acromioclavicular joint
The acromioclavicular joint is a plane synovial joint between the facets on the acromial (lateral) end of the
clavicle and the acromion process of the scapula [see Fig. 4.3]. Both surfaces are covered by brocartilage.
An intra-articular brocartilaginous disc may be present. The brous capsule surrounds the articular
margin and is lined by synovial membrane. It is strengthened by superior and inferior acromioclavicular
ligaments, and allows sliding movement between the bones when the shoulder girdle is moved.

Axilla

Boundaries and contents

Start by reviewing the overview of the axilla on p. 55 and in Fig. 5.2. The anterior wall of the axilla extends
from the clavicle to the anterior axillary fold. It consists of the pectoralis major, the pectoralis minor, the
subclavius, and the fascia enclosing them [Fig. 5.11]. The posterior wall consists of the lateral part of the
costal surface of the scapula, covered by the subscapularis superiorly, and the teres major muscle with the
latissimus dorsi winding round its lower border inferiorly. Identify these muscles by using Fig. 5.13. The
anterior and posterior axillary folds are formed by the lower borders of the pectoralis major and the
latissimus dorsi, respectively. The convex medial wall is formed by the lateral wall of the thorax (the rst
ve ribs and intercostal spaces) covered by the serratus anterior. The narrow lateral boundary is formed by
the humerus covered by the upper parts of the biceps and coracobrachialis muscles.
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Fig. 5.13 Contents of the axilla exposed by reflection of the pectoralis major and removal of fat, the fascia, and lymph nodes.
Part of the axillary vein has been removed to display the medial cutaneous nerve of the forearm and the ulnar nerve.

The apex of the axilla is bounded by the clavicle, rst rib, and upper border of the scapula. It is continuous
medially with the superior aperture of the thorax and the root of the neck. Through the apex, vessels from
the thorax and the nerves of the brachial plexus from the neck enter the axilla [Fig. 5.2]. These vessels and
nerves descend through the axilla to the arm and form the contents of the axilla, together with the axillary
lymph nodes and loose fatty tissue. The oor of the axilla is formed by the axillary fascia which stretches
between the anterior and posterior axillary folds. It is pierced by the axillary tail of the breast.

See Dissection 5.6 which begins the dissection of the axilla.

Dissection 5.6 Axilla-1

Objectives

I. To remove the loose connective tissue and fat of the axilla.

II. To remove the fascia overlying the lateral wall of the axilla.

III. To identify and trace the axillary artery, axillary vein, musculocutaneous nerve, median nerve,
ulnar nerve, medial cutaneous nerve of the arm and forearm, intercostobrachial nerve, lateral
cutaneous branches of the upper intercostal nerves, lateral thoracic artery, and long thoracic

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nerve.

Instructions

1. Remove the loose connective tissue, fat, and lymph nodes in the axilla to expose its contents.
Only a few of the large number of lymph nodes will be seen, unless they are enlarged by disease,
so it is not worth trying to dissect them, though they will be felt as slightly rmer structures
among the fat. Lymph vessels will not be seen.

2. Expose the coracobrachialis and short head of the biceps muscles which arise from the tip of the
coracoid process.

3. Find the axillary artery and the median nerve medial to these muscles, and the
musculocutaneous nerve entering the deep surface of the coracobrachialis. Follow this nerve
upwards, and nd its branch to the muscle.

4. Identify the axillary vein medial to the axillary artery.

5. Between the axillary artery and vein, identify the medial cutaneous nerve of the forearm, and
more posteriorly the larger ulnar nerve.

6. Find the medial cutaneous nerve of the arm medial to the vein. Trace it superiorly. A branch
from the intercostobrachial nerve usually joins it. Follow this branch upwards to the emergence
of the intercostobrachial nerve from the second intercostal space in the medial axillary wall.
Trace that nerve down to the axillary oor and the medial side of the arm.

7. Note again the series of lateral cutaneous branches of the third, fourth, fth, and sixth
intercostal nerves, as they emerge in a vertical line inferior to the point of emergence of the
intercostobrachial nerve. Note that the nerves emerge posterior to the pectoralis major and
between the digitations (attachments) of the serratus anterior on each rib.

8. Find the lateral thoracic artery and the long thoracic nerve descending on the lateral surface of
the serratus anterior muscle which they supply [Fig. 5.13].
 Serratus anterior
Origin: the serratus anterior arises from the outer surface of the upper eight ribs. Insertion: its bres pass
posteriorly around the lateral surface of the chest wall, forming the medial wall of the axilla. On the back,
the bres run deep to the scapula and are inserted into the costal surface of the scapula along the medial
border. Nerve supply: long thoracic nerve [Figs. 5.13, 5.14, 4.6]. Actions: (1) it holds the scapula against the
ribs—this action is lost when the long thoracic nerve is injured, resulting in winging of the scapula; (2) it
also protracts the scapula; and (3) the lower bres are powerful lateral rotators of the scapula.

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Fig. 5.14 Serratus anterior. The scapula is drawn away from the side of the chest to show the insertion into the scapula.

Axillary artery
The axillary artery is the main artery of the upper limb. Origin: it is a continuation of the subclavian artery
at the outer border of the rst rib. It passes through the apex and lateral part of the axilla. Termination: it
becomes the brachial artery at the lower border of the teres major, close to the humerus. For the purpose of
description, it is divided into three parts by the pectoralis minor. The rst part lies superior to the pectoralis
minor, the second part deep to it, and the third part inferior to it. Relations: the cords of the brachial plexus
p. 66 lie posterior to the rst part. They are arranged around the second part according to their names. The
main nerves arising from the cords surround the third part.

The axillary artery supplies the structures in, and surrounding, the axilla [Fig. 5.15]: (1) the thoracoacromial
artery arises from the second part of the axillary artery and supplies the anterior axillary wall of the axilla,
including the clavicle, acromion, and anterior part of the deltoid; (2) the superior thoracic artery (a branch
of the rst part) and the lateral thoracic artery (a branch of the second part) supply the medial axillary wall,
the lateral part of the mammary gland, and surrounding structures; (3) the subscapular artery (a branch of
the third part) supplies the posterior axillary wall, including the scapula and muscles covering its posterior
aspect; it gives o two branches—the circum ex scapular and thoracodorsal arteries—which anastomose
with branches from the subclavian artery; and (4) the anterior and posterior circum ex humeral arteries
(branches of the third part) supply the proximal part of the humerus, the muscles covering it, and the
shoulder joint.

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Fig. 5.15 Diagrammatic representation of the axillary artery and its branches.

Axillary vein
The axillary vein lies on the anteromedial aspect of the axillary artery and extends from the lower border of
the teres major to the outer border of the rst rib. It is a continuation of the brachial vein and receives
tributaries corresponding to the branches of the axillary artery. In addition, the axillary vein also receives
the venae comitantes of the brachial artery inferiorly, and the cephalic vein superiorly. It continues as the
subclavian vein at the outer border of the rst rib [Fig. 5.13].

Dissection 5.7 continues the dissection of the axilla.

Dissection 5.7 Axilla-2

Objectives

I. To clean the connective tissue and fascia over the axillary artery, ulnar nerve, radial nerve and
its branches, axillary nerve, and subscapular artery and its branches.

II. To examine the relationship of the cords of the brachial plexus to the axillary artery.

III. To remove the fascia and de ne the posterior wall of the axilla.

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Instructions

1. Expose the axillary artery and vein, and the large nerves surrounding them. If necessary,
remove the smaller tributaries of the vein, in order to get a clear view of the nerves. (Since the
veins follow the branches of the artery, their loss is of little signi cance.)

2. Identify and follow the ulnar nerve. It lies behind and between the axillary artery and vein.

3. Find the median nerve lateral to the axillary artery. Follow its lateral root to the lateral cord of
the brachial plexus, and its medial root to the medial cord of the brachial plexus.

4. Identify the radial nerve which lies behind the artery. Trace the radial nerve proximally and
distally to the lower border of the subscapularis.

5. Find the axillary nerve which passes posteriorly along with the posterior humeral circum ex
artery.

6. Find the posterior cutaneous nerve of the arm.

7. Find the muscular branches of the radial nerve to the long and medial heads of the triceps
muscle.

8. Find the subscapular artery as it arises from the axillary artery close to the axillary nerve. Trace
it and its major branches—the circum ex scapular and thoracodorsal arteries. The
thoracodorsal artery runs along the chest wall parallel to the margin of the latissimus dorsi,
together with the thoracodorsal nerve, to that muscle. (You will study the latissimus dorsi in
further detail later.) The circum ex scapular artery lies close to the nerve (lower subscapular
nerve), entering the teres major.

9. Cut across the pectoralis minor, and follow the axillary vessels to the outer border of the rst
rib. Note that the medial, lateral, and posterior cords of the brachial plexus lie around the
artery posterior to the pectoralis minor. Above the level of the pectoralis minor, all three cords
of the brachial plexus lie posterior to the artery.

10. Expose the anterior surface of the subscapularis, and identify the upper subscapular nerve(s)
entering it. Follow the upper and lower subscapular and thoracodorsal nerves to their origin
from the posterior cord of the brachial plexus [Fig. 5.13].
 Axillary lymph nodes
The axillary lymph nodes drain the lymph vessels of the: (1) upper limb; and (2) super cial vessels of the
p. 67 trunk above the level of the umbilicus and iliac

p. 68
crest. The nodes are scattered throughout the fascia of the axilla and, for the most part, transfer lymph
towards the nodes at its apex (apical nodes). For descriptive purposes, the axillary lymph nodes are divided
into ve groups, four of which lie in one angle of the axillary pyramid and drain a speci c territory. The
lateral nodes lie along the axillary vessels and drain the greater part of the upper limb. The pectoral or
anterior group lies in the anteromedial angle, deep to the pectoralis major, and drains the super cial tissues

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of the anterior and lateral parts of the thoracic and upper abdominal walls, including lymph from the breast.
The subscapular or posterior group lies along the subscapular vessels and drains lymph from the
corresponding region on the back. All these nodes communicate with the more centrally placed central
nodes. The e erent vessels of all these nodes pass to the apical group [Fig. 5.8], which also receives vessels
from nodes on the cephalic vein and in the infraclavicular fossa. The e erent vessels of the apical nodes
form the subclavian lymph trunk which usually drains into the subclavian vein.

Brachial plexus
The brachial plexus is an important nerve plexus that supplies sensory and motor innervation to the upper
limb. The plexus begins in the lower part of the neck (supraclavicular part: roots and trunks) and passes as
divisions behind the middle third of the clavicle into the apex of the axilla [Figs. 5.16, 5.17, 5.18]. The plexus
is formed successively by roots, trunks, divisions, and cords. Nerves supplying the muscles and skin of the
upper limb arise from the roots, trunks, and cords of the plexus.

Fig. 5.16 Diagram showing the route of entry of the nerves and subclavian artery into the upper limb. The fascial sheath which
binds these structures into a narrow bundle is the axillary sheath.
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Fig. 5.17 Horizontal section at the level of the shoulder joint. The chief structures in the axilla and its walls are shown. A =
anterior; P = posterior; L = le ; R = right.

Image courtesy of the Visible Human Project of the US National Library of Medicine.

Fig. 5.18 Diagram of the right brachial plexus. Ventral divisions, light orange; dorsal divisions, yellow. C = cervical; T = thoracic.

Roots of the brachial plexus

The ve roots of the brachial plexus are formed by the ventral rami of the lower four cervical nerves, the
greater part of the ventral ramus of the rst thoracic nerve (C. 5 to T. 1). Small twigs from the ventral rami of
p. 69 the fourth cervical and second tho racic nerves may join the plexus. When the contribution to the brachial
plexus from C. 4 is large and that from T. 1 is small, it is considered as a pre xed brachial plexus. Similarly,
when the contribution from C. 5 is small and that from T. 2 is large, it is considered as a post- xed brachial
plexus.
 Trunks and divisions of the brachial plexus
Three trunks—the superior, middle, and inferior trunks—arise from the roots. The ventral rami of the fth
and sixth cervical nerves unite to form the upper trunk [Fig. 5.18]. The seventh cervical ventral ramus
continues as the middle trunk. The eighth cervical and rst thoracic ventral rami unite to form the lower
trunk.

Just above the clavicle, each of these trunks splits into an anterior and a posterior division, in this way
giving rise to six divisions. The three posterior divisions supply the extensor muscles and the skin on the
back of the limb. The three anterior divisions supply the exor muscles and the skin on the front of the
limb.

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Cords of the brachial plexus
The three posterior divisions unite to form the posterior cord of the plexus. The anterior divisions of the
upper and middle trunks unite to form the lateral cord of the plexus, and the anterior division of the lower
trunk forms the medial cord.

In the axilla (infraclavicular part), the cords rst lie posterior to the rst part of the axillary artery, but
lower down posterior to the pectoralis minor, they surround the second part of the axillary artery in
p. 70 positions which correspond to their names. The plexus ends at the lower border of the pectoralis minor
by dividing into a number of branches.

Each cord of the plexus (and in consequence the nerves which arise from that cord) contains nerve bres
from more than one spinal (segmental) nerve. The lateral cord contains nerve bres from the cervical (C.) 5
to 7 [Fig. 5.18]. The medial cord contains nerve bres from C. 8 and thoracic (T.) 1; and the posterior cord
from C. 5 to T. 1. The root value of a nerve is commonly indicated in brackets, with the name of the nerve.
A knowledge of these segmental, or root values, helps in accurate localization of the injury to the spinal
nerves, or the section of the spinal cord from which they arise.

Branches of the brachial plexus

Branches from the roots

The dorsal scapular nerve (C. 5) supplies the rhomboid major and minor, and the levator scapulae. It will be
seen later on the deep surface of the rhomboid muscles.

The long thoracic nerve (C. 5, 6, 7) arises from the posterior aspect of these ventral rami. It descends behind
the brachial plexus and axillary artery, and then on the lateral surface of the serratus anterior muscle which
it supplies.

Branches from the trunk

The suprascapular nerve (C. 5, 6) arises from the upper trunk, and supplies the supraspinatus and
infraspinatus muscles. It runs inferolaterally behind the clavicle and crosses the superior border of the
scapula to its posterior surface [Fig. 5.19].
 Fig. 5.19 Dissection of the lower part of the posterior triangle of the neck showing the supraclavicular part of the brachial

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plexus.

The nerve to the subclavius (C. 5, 6) also arises from the upper trunk and descends in front of the plexus to
supply the subclavius.

Branches from the cords

The lateral cord gives rise to: (1) the lateral pectoral nerve (C. 5, 6, 7); (2) the musculocutaneous nerve (C. 5,
6); and (3) the lateral root of the median nerve, which joins the medial root to form the median nerve.

p. 71 The medial cord gives rise to: (1) the medial pectoral nerve (C. 8, T. 1); (2) the medial cutaneous nerve of the
arm; (3) the medial cutaneous nerve of the forearm; (4) the medial root of the median nerve; and (5) the
ulnar nerve (C. 8; T. 1).

The posterior cord gives rise to: (1) the upper and (2) lower subscapular nerves (C. 5, 6); (3) the
thoracodorsal nerve; (4) the axillary nerve (C. 5, 6); and (5) the radial nerve (C. 5, 6, 7, 8; occasionally T. 1).

The median nerve (C. 5, 6, 7, 8; T. 1) is formed by one root, each from the medial and lateral cords of the
brachial plexus.

Injuries to the brachial plexus

Injuries to any part of the brachial plexus, or to its branches will lead to sensory and motor loss in the area
supplied by it. Injuries of the brachial plexus are best understood after you have completed the study of the
upper limb, and are described in Chapter 12.

See Clinical Applications 5.1 and 5.2.

 Clinical Application 5.2 Axillary lymph node dissection

Axillary lymph node dissection is a surgical procedure that is used for staging breast cancer. The
surgeon explores the axilla to identify, examine, and remove lymph nodes. Axillary lymph node status
on whether or not they are invaded by cancer cells, and to what extent they are involved, gives valuable
information for planning treatment. Lymph drainage of the upper limb may be impeded after removal
of the axillary nodes.

Study question 1: why is it common for patients who have undergone this procedure to have swelling
of the upper limb? What name is given to swelling due to this cause? (Answer: the upper limb drains

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into the axillary lymph nodes, which have been removed during surgery. As such, the lymph collects in
the limb tissue. Such swelling is called ‘lymphoedema’.) The long thoracic nerve and the thoracodorsal
nerve have a long course in the axilla and may become in ltrated by cancer cells. These nerves may
also be damaged during the surgery. The thoracodorsal nerve lies on the posterior wall of the axilla and
enters the latissimus dorsi near its medial border. The axillary tail of the breast lies close to it.

Study question 2: what would be the result of damage to the thoracodorsal nerve? (Answer: weakened
medial rotation and adduction of the arm.)

p. 72 © Oxford University Press