AXILLARY ARTERY AND BRACHIAL PLEXUS Valentin C. Dones III, MSPT, PTRP, COMT, DMS, IMPT Masters of Science in Orthopedic Physical Therapy Certified Dorn Teacher Certified Dorn Specialist Certified in Orthopedic Manual Therapy Mulligan Practitioner Functional Fascial Taping Practitioner Integrated NeurMuscular Taping Therapist

AXILLA Floor Fascia and a dome of skin Anterior axillary fold > posterior axillary fold Continuous with the anterior compartment of the arm

Contents of the Axilla Proximal parts of biceps brachii and coracobrachialis Axillary process of the breast Collections of lymph nodes Major vessels and nerves

Biceps Brachii Origin Insertion Action Innervation Short head: apex of coracoid process Long head: Supraglenoid tubercle Insertion Radial tuberosity in the forearm Action Flexor of the forearm Supinator of the forearm Accessory flexor of GHJ Prevents superior movement of the humerus on the glenoid cavity Innervation Musculocutaneous nerve

Coracobrachialis Origin Insertion Action Innervation Apex of the coracoid process Insertion Small linear roughening on the medial aspect of the humerus, midshaft Action Flexes the arm at the GHJ Innervation Musculocutaneous nerve

Axillary artery Subclavian artery  lateral border of rib 1  axillary artery  inferior margin of teres major  brachial artery Pectoralis minor  3 parts of the axillary artery

Axillary artery First part Second part Third part Superior thoracic artery Second part Thoraco-acromial artery Lateral thoracic artery Third part Subscapular artery Anterior circumflex humeral artery Posterior circumflex humeral artery

Superior thoracic artery From the anterior surface of the first part of the axillary artery Upper regions of the medial and anterior axillary walls

Thoraco-acromial artery From the anterior surface of the second part of the axillary artery Pierces the clavipectoral fascia Four branches Pectoral Deltoid Accompanies the cephalic vein Clavicular Acromial

Lateral Thoracic Artery Posterior to the inferior margin of pectoralis minor Supplies the medial and anterior walls Supplies breast

Subscapular artery Largest branch of the axillary artery To the posterior wall of the axilla in the posterior scapular region From the posterior surface of the third part of the axillary artery Follows inferior margin of the subscapular artery

Subscapular artery Circumflex Scapular Artery Thoracodorsal Artery Enters the infraspinous fossa Thoracodorsal Artery Follows the lateral border of the scapula to the inferior angle Vascular supply of the posterior and medial walls of the axilla

Anterior Circumflex Humeral Artery Small compared to the posterior circumflex humeral artery Passes anterior to the surgical neck of the humerus

Posterior Circumflex Humeral Artery From the lateral surface of the third part of the axillary artery Leaves the quadrangular space with the axillary nerve

Axillary Vein Begins at the lower border of the teres major Continuation of the basilic vein Drains the posteromedial surface of the hand Penetrates the deep fascia in the middle of the arm Axillary vein  subclavian vein at lateral border of rib 1 Tributaries Brachial veins Cephalic vein

Cephalic Vein Drains the lateral and posterior parts of the hand, the forearm, and the arm Enters the clavipectoral triangle

Brachial Plexus Anterior rami of C5-C8, T1 Roots, trunks, divisions and cords Proximal parts of the brachial plexus are posterior to the subclavian artery More distal regions of the plexus surround the axillary artery

Roots Receives gray rami communicantes In the posterior triangle of the neck Between the anterior and middle scalenes Superior and posterior to the subclavian artery

Trunks Superior trunk – C5 and C6 Middle trunk – C7 root Inferior trunk – C8 – T1 Lies on rib 1 posterior to the subclavian artery

Divisions Anterior Posterior Anterior divisions  peripheral nerves  anterior compartments of the arm and forearm Posterior divisions  peripheral nerves  posterior compartments

Cords Related to the second part of the axillary artery Lateral cord Union of upper and middle trunks Lateral to the axillary artery (2nd part) Medial cord Continuation of the anterior division of the inferior trunk Medial to the axillary artery (2nd part)

Cords Posterior cord Posterior to the axillary artery (2nd part) Union of all three posterior divisions

Branches of the Roots

Dorsal Scapular Nerve Originates from C5 Pierces the middle scalene Travels the medial border of the scapula Innervates Rhomboid major Rhomboid minor

Long Thoracic Nerve Anterior rami of C5 to C7 Down the medial wall of the axilla On the superficial aspect of the serratus anterior muscle

LONG THORACIC NERVE C5, C6, C7 Enters the axilla by passing down over the lateral border of the first rib behind the axillary vessels and brachial plexus Descends over the lateral surface of the serratus anterior, which it supplies

Suprascapular Nerve C5 and C6 From the superior trunk of the brachial plexus Passes laterally through the posterior triangle of the brachial plexus Through the suprascapular foramen  posterior scapular region Innervates Supraspinatus Infraspinatus

Nerve to the subclavius From the superior trunk of the brachial plexus Passes anteroinferiorly over the subclavian artery and vein Innervates the subclavius muscle

Lateral Pectoral Nerve Most proximal Penetrates the pectoral branch of the thoraco-acromial artery Innervates the pectoralis major

Musculocutaneous nerve Large terminal branch of the lateral cord Penetrates the coracobrachialis muscle Passes between the biceps brachii and brachialis muscles Lateral cutaneous nerve of the forearm

Lateral Root of the Median Nerve Largest terminal branch of the lateral cord Joins the medial root of the medial cord  Median Nerve

Medial Pectoral Nerve Supplies the pectoralis minor Supplies the pectoralis major Most proximal branch Passes in between the axillary artery and axillary vein

Medial cutaneous nerve of the arm Medial brachial cutaneous nerve Supplies the skin over the medial side of the arm In the axilla, communicates with the intercostobrachial nerve (T2)

Medial Cutaneous Nerve of the Forearm Medial antebrachial cutaneous nerve Just distal to the origin of the medial cutaneous nerve of the arm Gives off a branch to the skin over the biceps brachii muscle Penetrates the deep fascia with the basilic vein

Medial Root of the Median Nerve With the lateral root forms the lateral cord of the brachial plexus Median nerve is formed anterior to the third part of the axillary artery

Ulnar Nerve Large terminal branch of the medial cord

Median Nerve Formed anterior to the third part of the axillary artery Union of lateral and medial roots Passes anterior to the brachial artery Innervates Thenar muscles Two lateral lumbricals Palmar surface of the lateral three and ½ digits and over the lateral side of the palm and middle of the wrist

Median Nerve M over the third part of the axillary artery Musculocutaneous nerve Lateral root of the median nerve Medial root of the median nerve Ulnar nerve

Median Nerve M over the third part of the axillary artery Musculocutaneous nerve piercing the coracobrachialis muscle

Branches of the Posterior Cord Superior subscapular nerve Thoracodorsal nerve Inferior subscapular nerve Axillary nerve Radial nerve

Superior subscapular nerve Short Supplies the Subscapularis muscle

Thoracodorsal nerve Longest Passes vertically along the posterior axillary wall Innervates the latissimus dorsi

Inferior subscapular nerve Supplies Subscapularis Teres major

Axillary Nerve Exits the axilla through the quadrangular space Innervates the deltoid and teres minor Superior lateral cutaneous nerve of the arm passes through the quadrangular space Accompanied by the posterior circumflex humeral artery

RADIAL NERVE Continues downward into the cubital fossa in front of the elbow Between the brachialis and brachioradialis In the spiral groove, accompanied by the profunda vessels I/C with the shaft of the humerus

RADIAL NERVE: BRANCHES IN THE AXILLA Long head of the triceps Medial head of the triceps Posterior cutaneous nerve of the arm

RADIAL NERVE: In the spiral groove Lateral head of the triceps Medial head of the triceps Anconeus Lower lateral cutaneous nerve of the arm supplies the skin over the lateral and anterior aspects of the lower part of the arm Posterior cutaneous nerve of the forearm runs down the middle of the back of the forearm as far as the wrist

RADIAL NERVE: In the anterior compartment After the nerve has pierced the lateral fascial septum Gives off branches to the brachialis, brachioradalis and extensor carpi radialis longus muscles Gives articular branches to the elbow joint

NERVE OF THE LATERAL COMPARTMENT OF THE FOREARM Pierces the lateral intermuscular septum in the lower part of the arm Passes forward into the cubital fossa Passes downward in front of the lateral epicondyle of the humerus

NERVE OF THE LATERAL COMPARTMENT OF THE FOREARM Lies between the brachialis on the medial side and brachioradialis and extensor carpi radialis longus on the lateral side At the level of the lateral epicondyle, it divides into superficial and deep branches

BRANCHES Muscular branches Articular branches to the elbow joint Brachioradialis Extensor carpi radialis longus Small branch to the lateral part of the brachialis muscle Articular branches to the elbow joint Deep branch of the radial nerve Winds around the neck of the radius Within the supinator muscle Enters the posterior compartment of the forearm Superficial branch of the radial nerve

Radial Nerve Posterior cutaneous nerve of the arm Posterior brachial cutaneous nerve Innervates the posterior surface of the arm

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