Week 2 - Severson Flashcards
What are the major dermatomes associated with the Pectoral/Breast/Axilla/Arm/Elbow region of the body?
C5 - Shoulder
T4 - Nipple
Where are the superficial veins of the upper extremity located?
- Between the two layers of superficial fascia
- Upper limb used for venipuncture (drawing blood)
- median cubital (basilic veins)
Where are the lymphatic vessels located?
- superficial lymphatic vessels are located in the superficial fascia
- Lymph nodes:
- cubital (supratrochlear)
- axillary nodes
Define a neurovascular bundle.
- Term applied to the body nerves, arteries, veins and lymphatics that tend to travel together in the body.
- Neuro: Nerve
- Vascular: Veins, Lymph vessels and arteries
At what intercostal space is the nipple of the mammary gland usually located?
Approximately the 4th intercostal space
At what intercostal space is the axillary tail of the mammary gland found?
- 1st and 2nd intercostal space
- Superolateral part frequently projects toward axilla as an AXILLARY TAIL (of Spence) in relation to pectoralis major muscle and pectoral axillary lymph nodes.
In what layer of the skin is the mammary gland located?
- The entire gland lies in the superficial fascia
- glands embedded in fat (round contour)
What are the suspensory ligaments?
- Suspensory ligaments (of Cooper)
- run from dermis of skin, ertically through gland to deepest part of superficial fascia
- well developed over upper breast
- support
***The breast is not directly attached to the underlying muscle.
What are areolar glands and what do they secrete?
- Areolar glands of Montgomery
- sebaceous glands that enlarge in pregnancy and secrete an oily substance to provide a protective lubricant for areola and nipple
- Produce little irregularities or small projections in areolae.
Describe the arterial supply of the breast.
- Axillary artery branches to include:
- Superior thoracic
- Pectoral branch of thoracoacromial
- Lateral thoracic arteries
- Intercostal arteries
- cutaneous branches in 3rd to 5th intercostal spaces
- Internal thoracic artery
- perforating branches in 2nd to 4th intercostal spaces
Describe the venous supply of the breast.
- Form anastomotic circle around papilla
- Branches pass peripherally from this to:
- Axillary vein
- Internal thoracic vein
- Lateral thoracic vein
- Upper intercostal vein
- Branches pass peripherally from this to:
Describe the lymphatic drainage of the breast.
- Originates from an extensive perilobar plexus
-
Principal drainage:
- lymph follows the lactiferous ducts to the areolar where a subareolar plexus is found
- lymph then drains by two trunks into the pectoral group of axillary nodes
-
Secondary drainage:
- Medial: Parasternal nodes
- Upper: Apical axillary nodes or Supraclavicular nodes
- Lower: Abdominal lymph nodes
-
Principal drainage:
Where do most breast cancers develop?
Epithelial cells of the lactiferous ducts in the mammary gland lobules.
What course does most lymph from the breast follow?
- *Axillary lymph nodes → Subclavian lymphatic trunk → Venous system
- *Pectoral nodes → *Central nodes → *Apical nodes → Clavicular nodes
What groups of lymph nodes receive breast lymph?
- Axillary Lymph Nodes
- Pectoral nodes
- Central nodes
- Apical nodes
- Subscapular nodes
- Humeral nodes
- Parasternal Lymph Nodes
- Clavicular nodes → Lumphatic duct → Subclavian Vein
What is colostrum?
A form of milk produced by the mammary glands of mammals (including humans) in late pregnancy.
Most species will generatecolostrum just prior to giving birth.
What are the four quadrants of the breast?
- Superior lateral
- Superior medial
- Inferior lateral
- Inferior media
Within what quadrant is the axillary tail (of Spence) associated?
Superior lateral
What is the difference between Simple and Radical Mastectomy?
Simple = removal of the breast down to the retrommammary space
Radical = removal of the primary tumor, underlying fascia, fat, pectoral muscles, and as many lymph nodes as possible (basically the entire breast)
What is a lumpectomy?
Removal of the tumor and it’s surrounding tissues only.
What nerve is important to be preserved with radical mastectomy?
***
What happens with paralysis of the serratus anterior muscle?
***Winged scapula***
Why do polymastia, polythelia, or amastia occur?
- Embryonic Mammary Crests (ridges) or “milk lines” are common in mammals with multiple breasts and can arise in humans
- Polymastia = supernumerary breasts
- Polythelia = accessory nipples
- Amastia = no breast development
What is gynecomastia?
Gynecomastia is the growth of abnormally large breasts in males. It is due to the excess growth of breast tissue, not excess fat tissue.
What muscle forms the bulk of the anterior chest wall?
Pectoralis major
What muscles serve to medially rotate and adduct the upper extremity?
Adduct: Pectoralis major, latissimus dorsi, teres major
Medially rotate: Pectoralis major, teres major, subscapularis
What forms the boundaries of the axilla?
- Apex: directed upward and medialward, ending in the cervicoaxillary canal, which leads into the posterior triangle of the neck
- Base: formed by axillary fascia and skin
- Anterior wall: pectoralis major and minor muscles, clavipectoral fascia
- Poterior: subscapularis, teres major, and latissimus dorsi muscles
- Medial wall: first 4 ribs and intercostal muscles, upper part of serratus anterior muscle
- Lateral wall: humerus, coracobrachialis and biceps muscles
What three major structures are located in the axilla?
- Axillary vessels and there branches
- Brachial plexus and its branches
- Lymph nodes embedded in fat
What is the axillary sheath?
At the apex of the axilla, fascia of the first two ribs in the first interspace becomes continuous with the scalene fascia. Here this fascia forms a tubular sheath for vessels and nerves entering the axilla.
From which artery does the axillary artery originate from?
Subclavian artery
Continuation of the Axillary artery is called what?
Brachial artery
Where does the axillary artery begin and end?
Begin: lateral margin of the first rib
End: lower margin of teres major
What are the six major branches of the axillary artery?
- Superior (supreme) Thoracic artery
- Thoracoacromial artery
- Lateral thoracic artery
- Anterior circumflex humoral artery
- Posterior circumflex humoral artery
- Subscapular artery
(Part 1: #1, Part 2: #2-3, Part 3: #4-6)
Where does the Axillary vein begin and end?
Begin: at union of basilic and brachial veins
End: terminates at the first rib as subclavian vein
What groups of nodes (5) constitute the axillary lymph nodes?
- Pectoral
- Subscapular
- Humeral
- Central
- Apical
What ventral rami contribute to the brachial plexus?
C5, C6, C7, C8, & T1 = Roots of brachial plexus
What is the relationship of the ventral rami to the scalene muscles?
The roots of the plexus usually pass through the gap between the anterior and the middle scalene muscles with the subclavian artery.
What are the five sections of the brachial plexus network?
- Roots (C5-T1 anterior/ventral rami)
- Trunks (Superior, Middle, Inferior)
- Divisions (3 Anterior, 3 Posterior)
- Cords (Lateral, Posterior, Medial)
- Terminal branches (5 Peripheral nerves)
What ventral rami join to make the Superior Trunk of the brachial plexus?
C5 & C6
What ventral rami makes up the Middle Trunk of the brachial plexus?
C7
What ventral rami join to make the Inferior Trunk of the brachial plexus?
C8 & T1
What two things does each Trunk split into in the brachial plexus?
Anterior and Posterior Division
What Divisions join to make up the Lateral Cord?
the Anterior Divisions of the Superior and Middle Trunks
What Divisions join to make up the Posterior Cord?
the Posterior Divisions of the Superior, Middle, and Inferior Trunks
What Division makes up the Medial Cord?
the Anterior Division of the Inferior Trunk
What two peripheral nerves does the Posterior Cord split into?
- Axillary Nerve
- Radial Nerve
What three peripheral nerves make up the “M” of the brachial plexus?
Musculocutaneous Nerve,
Median Nerve,
Ulnar Nerve
What clinical deficit is manifest with axillary nerve injury?
What muscles does the Musculocutaneous Nerve innervate?
Anterior compartment of arm:
- coracobrachialis
- biceps brachii
- brachialis
- skin of lateral aspect of arm
What muscles does the Radial Nerve innervate?
All muscles of the posterior compartments of the arm and forearm.
***EXTENSORS***
What muscles does the Ulnar Nerve innervate?
forearm FLEXORS
What spinal nerves are involved with upper brachial plexus injuries?
C5 & C6
What clinical manifestations would be evident in an individual with injury to the upper plexus?
- Limb hangs by side in medial rotation (pronated)
- Upper limb with adducted shoulder
- Extended elbow
What types of physical activity may injure the brachial plexus?
- Carrying a heavy backpack
- Backpacking (hiking)
- Painting a ceiling
- Hanging from one arm
What spinal nerves are involved with lower brachial plexus injuries?
C8 & T1
What muscles are affected with lower brachial plexus injuries?
Ulnar Nerve - Intrinsinc hand muscles
(result in “claw hand”)
What nerve is involved with “wrist drop”?
Radial Nerve
What part of the brachial plexus is affected by crutches that are too long?
Consequently affecting what muscles?
Radial Nerve
All posterior muscles of arm and forearm.
EXTENSORS
What clinical deficit is manifest with axillary nerve injury?
- Atrophy of deltoid
- Flattened shoulder
- Slight hollow inferior to the acromion
- Loss of sensation over the lateral side of the proximal part of the arm
Where is a brachial plexus block performed?
into or immediately surrounding the axillary sheath
What spinal nerves are involved in cervical rib syndrome?
C8 & T1
What blood vessel is involved with costoclavicular syndrome?
Subclavian artery
What nerves supply the Biceps brachii?
Musculocutaneous nerve (C5, C6, C7)
What nerve supplies the Coracobrachialis?
Musculocutaneous nerve (C5, C6, & C7)
What nerves supply the Brachialis?
Musculocutaneous nerve (C5 & C6)
and
Radial nerve (C5 & C7)
What nerve supplies the Triceps brachii?
Radial nerve (C6, C7, & C8)
What muscle of the arm supinates the forearm?
Biceps brachii
Which muscle of the arm extend across two joints?
Biceps brachii
-spans the glenohumeral joint, elbow, & radio-ulnar joints
What structures are found in the Quadrangular space?
Axillary nerve
Posterior circumflex artery
(Formed by: teres minor, long head of triceps, teres major, and medial surface of humerus)
What structures are found in the Triangular interval?
Deep brachial artery
Radial nerve
(Formed by: teres major and the long and lateral heads of the triceps)
Where is the tendon of the long head of the biceps located?
Lateral humeral head, covered by the Transverse humeral ligament
Attaches at the Supraglenoid tubercle of scapula
What forms the bicipital aponeurosis?
Triangular membranous band that runs from the biceps tendon across the cubital fossa, and merges with the antebrachial (deep) fascia covering the flexor muscles in the medial side of the forearm
What is the relationship between the bicipital aponeurosis and the brachial artery?
bicipital aponeurosis is superficial to the brachial artery in the cubital fossa
What tendon of the biceps brachii is affected with biceps tendinitis?
Long head of the biceps brachii
Where does the tendon of the long head of the biceps brachii rupture?
Intertubercular sulcus of the humerus
Where does the short head originate?
Tip of coracoid process of scapula
Where do most fractures of the humerus occur?
Surgical neck
When fractures occur at various humeral sites, what nerves may be affected?
Surgical neck - Musculocutaneous nerve
Midhumeral fracture - Radial nerve
Supraepicondylar - Radial, Musculocutaneous, Median, or Ulnar nerves
What are the clinical manifestations of radial nerve injuries?
Radial:
- superior to the origin of its branches to the triceps brachii results in paralysis of the triceps, brachioradialis, supinator, and extensor muscles of the wrist and fingers
- loss of sensation in areas of skin supplied by this nerve also occurs
What are the clinical manifestations of Musculocutaneous nerve injuries?
Musculocutaneous:
- axilla: paralysis of the coracobrachialis, biceps, and brachialis
- weak flexion of glenohumeral joint
- weak flexion of elbow joint and supination of the forearm
- loss of sensation may occur on the lateral surface of the forearm
What are the clinical manifestations of the ulnar nerve?
What are the clinical manifestations of the median nerve?
What are the major branches of the brachial artery?
- Profunda brachii artery
- Humeral nutrient artery
- Superior ulnar collateral artery
- Inferior ulnar collateral artery
What nerve accompanies the Profunda brachii artery branch of the brachial artery?
Radial nerve
What nerve accompanies the Superior ulnar collateral artery branch of the brachial artery?
Ulnar nerve
What is the best place to compress the brachial artery?
Medial to the humerus near the middle of the arm
What is Volkmann’s ischemic contracture?
Ischemic compartment syndrome
after 6 hours of ischemia necrotic tissue of the muscles and nerves is replaced with fibrous scar tissue and causes the involved muscles to shorten permanently, producing a flexion deformity
What are the boundaries of the antecubital fossa?
- Superiorly: line connecting the medial and latearl epicondyles
- Medially: mass of flexor muscles of the forearm arising from the common flexor attachment on the medial epicondyle (pronator teres)
- Laterally: mass of the extensor muscles of the forearm arising from the lateral epicondyle and supra-epicondylar ridge (brachioradialis)
What vein is usually used for venipuncture?
Median Antebrachial Vein
(Median basilic vein & Median cephalic vein)
What structures are found deep in the fossa?
Biceps brachii tendon, forearm extensors (laterally), forearm flexors (medially), Median nerve, Deep branch of the Radial nerve
What are the two bony joints between the upper limb and the trunk?
Acromioclavicular joint (AC)
&
Sternoclavicular joint
What is the synovial joint between the upper limb and the trunk?
Glenohumeral joint
What is the function of the clavicle?
- Serves as a moveable, crane-like strut (rigid support) from which the scapula and free limb are suspended, keeping them away from the trunk so that the limb has maximum freedom of motion.
- forms one of the bony boundaries of the cervico-axillary canal, protection of neurovascular bundle
- transmits shocks (traumatic impacts) from the upper limb to the axial skeleton
What is the most common site of fracture of the clavicle in children and adults?
junction of the medial and lateral thirds
What is a “greenstick” fracture?
Incomplete fracture in which one side of the bone is broken and the other is bent.
What joint is involved with “shoulder separation”?
AC joint
What happens with “shoulder separation”?
AC joint dislocation when both the AC and coracoclavicular ligaments are torn
How does using the term AC “shoulder separation” differ from using the term AC “shoulder dislocation”?
- AC shoulder separation
- dislocation of AC joint with coracoclavicular ligament torn/ruptured
- AC shoulder dislocation
- dislocation of AC joint without ligament rupture
What tendon becomes calcified and is involved with subacromial bursitis?
Supraspinatus tendon
When is pain with calcific bursitis most intense?
Why is the pain intense?
Abduction (50°-130°)
calcium in the supraspinatus tendon causes increased local pressure and irritates the overlying subacromial bursa → results in inflammatory reaction = subacromial bursitis
Which muscles form the rotator cuff?
- S: Supraspinatus
- I: Infraspinatus
- T: Teres minor
- S: Subscapularis
What muscle of the rotator cuff is most likely to rupture when lifting an object?
Supraspinatus
What role do the rotator cuff muscles and glenohumeral ligaments plain in supporting the glenohumeral joint?
- Stabilize humeral head
- Move the humerus
- Flexion/Extension
- Abduction/Adduction
- Medial/Lateral rotation
- Circumduction
- Compress humeral head within glenoid cavity
What is the most common direction for dislocation of the glenohumeral joint?
Inferior
What nerve is most often injured with shoulder dislocation?
Axillary nerve
What is the clinical manifestation of nerve injury with shoulder dislocation?
Axillary nerve injury: paralysis of the deltoid and loss of sensation in a small area of skin covering the central part of the deltoid
(inability to abduct the arm to or above the horizontal level)
What is “frozen shoulder” or adhesive capsulitis?
Adhesive fibrosis and scarring between the inflamed joint capsule of the glenohumeral joint, rotator cuff, subacromial bursa, and deltoid
