AXILLA
Dr.M.S.ARATHI,M.D.
Professor of Anatomy
CHRI.
OBJECTIVES
• Axilla-boundaries & contents
• Axillary artery-in detail
• Axillary vein
• Axillary lymph nodes
AXILLA
• Axilla ( armpit) --
pyramidal space between
upper part of arm and
chest wall.
• Four sided pyramid
• BOUNDARIES
– Apex
– Base
– Walls – anterior,
posterior, medial,
lateral.
BOUNDARIES OF AXILLA
Boundaries:
• Apex: Cervico-axillary Canal
• Base: Axillary fascia and skin
• Anterior wall: Pectoralis major, Pectoralis minor,
Clavipectoral fascia.
• Posterior wall: Subscapularis, Teres Major, Latissimus
Dorsi
• Medial wall: Upper Ribs And Intercostal Spaces,
Serratus Anterior
• Lateral wall: Humerus
© 2007 Chettinad Hospital & Research Institute
BOUNDARIES OF AXILLA - APEX
Also known as cervico-axillary canal
Boundaries
• Anteriorly- Clavicle,
• Posteriorly-Superior border of scapula
• Medially - outer border of first rib
Structures passing through apex-
• Axillary vessels &
• Cords of brachial plexus - Both enclosed in axillary sheath
( derived from prevertebral fascia)
• Long thoracic nerve/Nerve of Bell
• subclavian lymph trunk from apical axillary lymph nodes-
Efferent
BOUNDARIES OF AXILLA -BASE
• Directed below, presents a concavity
• Bounded
Anteriorly- anterior axillary fold (lower border of Pectoralis
major),
• Posterioly - posterior axillary fold(Lattissimus dorsi -medially
&Teres major- laterally) and
• Medially -chest wall
• Formed by axillary fascia which extends from anterior to
posterior axillary folds &
• is supported from above by suspensory ligament of axilla
BOUNDARIES OF AXILLA - ANTERIOR WALL
Formed by-
• Pectoralis major in superficial
plane
• Pectoralis minor,
• Subclavius,
• Clavipectoral fascia &
• suspensory ligament of axilla in
deep plane
AXILLA
Anterior Wall:
Humerus
Pectoralis major
Pectoralis minor
BOUNDARIES OF AXILLA - POSTERIOR WALL
Formed from above downwards by-
• Subscapularis
• Latissimus dorsi
• Teres major
Posterior Wall:
Subscapularis
Teres major
Latissimus dorsi
BOUNDARIES OF AXILLA - MEDIAL WALL
• Formed by-
• Upper four or five ribs & their
intercostal muscles
• Upper part of serratus anterior
muscle with long thoracic
nerve/Nerve of Bell
• Intercostobrachial nerve
( undivided lateral cutaneous
branch of second intercostal
nerve) pierces medial wall to
supply postero-medial part of
arm
Medial Wall:
Serratus anterior
+ nerve
Upper 4 or 5 ribs + intercostal
muscles
BOUNDARIES OF AXILLA - LATERAL WALL
• Anterior & posterior walls converge on it
• Intertubercular sulcus of shaft of humerus
• Coracobrachialis ,
• Short head of biceps brachii
Lateral Wall:
Inter-tubercular sulcus
Long head of biceps
Short head of biceps
Coracobrachialis
Boundaries:
Apex
Lateral wall
Anterior wall Medial wall
Posterior wall
Base
AXILLA
• Place two fingers of left hand in
hollow of axilla with thumb in front
of pectoralis major
• Anterior wall – between fingers &
thumb
• Medial wall – feel ribs
• Posterior wall – muscle mass in front
of lateral border of scapula
• Lateral wall – feel humerus
CONTENTS OF AXILLA
1. Axillary artery & its
branches
2. Axillary vein & its tributaries
3. Infraclavicular part of
brachial plexus
4. Axillary group of lymph
nodes
5. Long thoracic nerve
6. Intercostobrachial nerve
7. Axillary fat & areolar tissue
CONTENTS OF AXILLA
ARTERY
• ORIGIN
• EXTENT
• TERMINATION
• COURSE
• RELATIONS
• BRANCHES
• APPLED ANATOMY
1.AXILLARY ARTERY
• ORIGIN: Continuation of subclavian artery
• EXTENT:begins from outer border of first rib
to lower border of teres major
• TERMINATION: continues as brachial artery
• Direction of artery depends on the position
of the arm
• Arm at the side – convex upwards & laterally
• Arm abducted to 90°- straight
• Arm above head – concave upwards
AXILLARY ARTERY - PARTS
• Pectoralis minor divides
artery into 3 parts as it
crosses axillary artery
anteriorly
• First part – proximal to
pectoralis minor
• Second part – behind
pectoralis minor
• Third part – distal to
pectoralis minor
AXILLARY ARTERY
RELATIONS
POINTS TO REMEMBER
• ANTERIOR-Skin
-Superficial fascia
-Deep fascia
MEDIAL-Axillary vein
- forms medial relation for all 3 parts
Relations of 1st Part
ANTERIOR
Axillary sheath, cephalic vein,
communication between
lateral and medial pectoral
nerves clavipectoral fascia
LATERAL
Lateral and MEDIAL
posterior cords AXILLARY
of brachial ARTERY Axillary vein
plexus
POSTERIOR
1st and 2nd digitations of
serratus anterior, long thoracic
nerve, medial cord of brachial
plexus
© 2007 Chettinad Hospital & Research Institute
Relations Of 2nd part
ANTERIOR
Pectoralis major
Pectoralis minor
MEDIAL
LATERAL Axillary Axillary vein
Lateral cord Artery MediaL cord
POSTERIOR
Subscapularis,
Posterior cord of
brachial plexus
© 2007 Chettinad Hospital & Research Institute
Relations of 3rd Part
Anterior
Pectoralis major
Medial root
Of median nerve
Lateral Medial
Lateral root & trunk of Axillary vein
Axillary Ulnar nerve
Median nerve Artery
Musculocutaneous nerve Medial cutaneous
Coracobrachialis Nerve of arm &
Posterior Forearm
Axillary, radial
Nerves
Subscapularis,
Teres major
Latissimus dorsi
AXILLARY ARTERY - BRANCHES
• FIRST PART – 1 branch
• Superior Thoracic artery
• SECOND PART – 2 branches
• Lateral Thoracic artery,
• Thoracoacromial artery/Acromiothoracic artery
• THIRD PART – 3 branches
• Subscapular artery
• Anterior circumflex humeral artery
• Posterior circumflex humeral artery
Branches Of Axillary Artery
Superior
Thoracic
Artery
Thoraco
Subscapular Acromial
Artery Artery
Axillary
Artery
Posterior Lateral
Circumflex Thoracic
Artery Artrey
Anterior
Circumflex
Artery
stitute
Research In
Hospital & ttinad
© 2007 Che
Relations:
AXILLARY ARTERY - BRANCHES
1.SUPERIOR THORACIC ARTERY-From first part
• Arises near subclavius
• Downwards, forwards & medially
• Passes between two pectoral muscles
• Ends by supplying these muscles & thoracic wall
2.LATERAL THORACIC ARTERY-From second part
• Emerges at & runs along lower border of pectoralis minor
• in close relation with anterior group of axillary lymph nodes
• In females ,it is large & gives off the lateral mammary
branches to breast
© 2007 Chettinad Hospital & Research Institute
3.THORACOACROMIAL ARTERY-From second part
• Emerges at upper border of pectoralis minor,
• pierces clavipectoral fascia &
• divides into 4 terminal branches
namely
• pectoral – between pectoral muscles, supply them & the
breast
• acromial – anastomosis around acromion process
• clavicular – sternoclavicular joint & subclavius
• deltoid – in deltopectoral groove with cephalic vein
THORACO ACROMIAL ARTERY
4.SUBSCAPULAR ARTERY-From third part
• Largest branch
• Along lower border of subscapularis & terminate near inferior
angle of scapula
• Large branch- Circumflex scapular artery
- passes through triangular intermuscular space
– winds around lateral border of scapula deep to
teres minor &
-gives off branches to anastomosis around scapula
5.ANTERIOR CIRCUMFLEX HUMERAL ARTERY-From third part
• Arises at lower border of subscapularis
• Anastomoses with posterior circumflex humeral artery around
surgical neck of humerus to form an arterial circle
• Gives ascending branch to head of humerus & shoulder joint
6.POSTERIOR CIRCUMFLEX HUMERAL ARTERY-From third part
• Arises at lower borer of subscapularis
• Runs backwards,with axillary nerve
• passes through quadrangular intermuscular space &
• ends by anastomosing with anterior circumflex humeral artery
around surgical neck of humerus to form an arterial circle
• Supplies shoulder joint, deltoid & surrounding muscles
• Gives descending branch which anastomoses with an
ascending branch from profunda brachii artery(branch of
brachial artery-which is a continuation of axillary artery-which
is a contination of subclavian artery.)
© 2007 Chettinad Hospital & Research Institute
APPLIED ANATOMY
• 1.Axillary arterial pulsations can be felt
against lower part of lateral wall of axilla.
• 2.In order to check bleeding from distal part of
limb,artery can be compressed against
humerus in lower part of lateral wall of axilla.
VEIN
• ORIGIN
• TERMINATION
• TRIBUTARIES
• APPLIED ANATOMY
AXILLARY VEIN
• ORIGIN:Continuation of basilic
vein
• It is joined by venae comitantes of
brachial artery
• Lies on medial side of axillary
artery
• TERMINATION:At outer border of
first rib, it continues as subclavian
vein
• Tributaries : Coressponding to
branches of axillary artery
- recieves cephalic vein
• No axillary sheath-free to expand
during increased blood flow
AXILLARY VEIN
Applied anatomy
Part of vein in front of 1st part of axillary artery may get
compressed by subclavius muscle during abduction,
which may account for axillary vein thrombosis when
the arm is held in prolonged abduction above head
during painting of a ceiling.
Occasionally, an axillary arch (muscular band
connecting latissimus dorsi & pectoralis major) may
compress axillary vessels.
Brachial plexus:
Supplies upper limb
Formed by union of
ventral rami of lower 4
cervical & first thoracic
nerve (C5,C6,C7,C8 & T1).
Consists of roots, trunks,
divisions & cords.
AXILLARY LYMPH NODES
• About 20-30 in
number
• Scattered in fibro-
fatty tissue of the
axilla
• Five groups
1) Anterior
2) Posterior
3) Lateral
4) Central
5) Apical
Axillary lymph nodes: Apical nodes
Central group
Area of drainage:
Drain lymphatics from:
i) Upper limb
ii) Most of mammary gland
Subscapular vein
iii) Cutaneous lymphatics from
trunk above level of umbilicus Lateral thoracic
vein
Lateral group
Anterior group
Posterior group
AXILLARY LYMPH NODES
1. Anterior / Pectoral group-
-Along lateral thoracic vessels,
- receive lymph from upper half of anterolateral wall of
chest, upper & lower lateral quadrants & axillary tail of
mammary gland.
2. Posterior / Scapular group-
-Along subscapular vessels,
-lymph from skin and muscles of back of neck and trunk
upto the level of iliac crest.
3. Lateral group-
-Along upper part of humerus, medial to axillary vein,
-lymph from upper limb
AXILLARY LYMPH NODES
4.Central group-
-Close to base of the axilla ,
- Lymph from preceding groups
-drain into apical group
-Intercostobrachial neve passes through this group & its
compression causes pain along medial side of arm
5.Apical group/infraclavicular - -
Along axillary vessels,
-Lymph from central group, upper breast, thumb & its web
(along cephalic vein)
Efferents drain by forming subclavian trunk into junction of
subclavian & internal jugular veins
© 2007 Chettinad Hospital & Research Institute
AXILLARY LYMPH NODES
Classifications according to the
clinicians:
Into 3 levels depending on their relations to
pectoralis minor.
Level I nodes: ( Anterior, posterior and lateral)
located below & lateral to the lower border
of muscle-----
Level II: central – behind. Interpectoral
(Rotter’s nodes)- front of muscle
Level III: Apical- above
Level I first to enlarge in cancer of breast followed
by 2 and 3. Removal of I and II
APPLIED ANATOMY
• Grouping of axillary lymph nodes with respect to pectoralis
minor muscle
• Level 1—Below, Low nodes
• Level 2—Behind, Middle nodes
• Level 3—Above, Upper or Apical nodes
• Rotter’s nodes—interveing between pectoralis major & minor
muscles
APPLIED ANATOMY
• Enlarged apical nodes due to infection or metastatic spread are
palpated as follows:
• Fingers of one hand are pushed upward from base of axilla
towards its apex, while fingers of other hand are approached
from above behind clavicle
• Fascial tent- behind- subscapularis, medially- intercostal
muscles & serratus anterior, apex- where fasciae meet, base-
open & directed below
• block dissection done by keeping fascial tent intact
1.CENTRAL
2.LATERAL
3.PECTORAL
4.APICAL
5.SUBSCAPULAR
AXILLARY LYMPH NODES - APPLIED ANATOMY
• Lymph nodes – infectious or malignant spread
• Carcinoma breast – Apical set becomes adherent to axillary
vein,so while removing tumour, a part of vein is excised.
• Enlargement of central set in carcinoma of breast may press on
intercostobrachial nerve - cause pain on medial side of arm
• Lateral lymph nodes are involved in infections of the hand.
• Enlargement of axillary lymph nodes are observed in
infections of upper limb.
Applied anatomy of Axilla:
• To open a deep axillary abscess,
knife should be placed at base of axilla midway
between anterior & posterior axillary folds, and
more towards thoracic wall in order to
avoid injury to lateral thoracic, subscapular &
axillary vessels in anterior, posterior & lateral
walls of axilla respectively
APPLIED ANATOMY
• Infection of hair follicles –folliculitis
• Suppurations in the axilla are common due to infections of
• hair follicles and sebaceous glands
• Lymph nodes – infectious or malignant spread
• Cold abscess originating from cervical vertebra may track down
along prevertebral sheath as axillary sheath is derived fro i
• Injury to axillary artery
Palpation of the Axilla- any
abnormalities
Grasp the patient's left wrist or elbow
with your left hand and lift their arm
up and out laterally. Then use your
right hand to examine axillary region
as in picture.
This technique permits patient's arm
to remain completely relaxed,
minimizing tension in surrounding
tissues that can mask otherwise
enlarged lymph nodes
Most patients do not have palpable axillary nodes. If you are
able to feel adenopathy (swollen lymph node), make note of the
following characteristics:
Size: Pathologic nodes are generally greater than 1 cm
Firmness: Malignancy makes nodes feel harder
Quantity: The greater the number of nodes, the more likely
true pathology exists
Pain: Often associated with inflammation (e.g. infection)
Relation to other nodes and surrounding tissue: Nodes
fixed to each other or adjacent structures are worrisome for
malignancy
Changes over time: Nodes which regress spontaneously are
obviously of less concern then those that increase in size,
number, or appear to be growing in new locations. Making these
determinations requires multiple evaluations over time.
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