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 mid- dle third of the clavicle into the apex of the axilla [Figs. 3.19, 3.20. 3.21].
Roots of the brachial plexus
The 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 first tho- racic nerve (C5 to T1). Small twigs from the ven- tral rami of the fourth cervical and second thoracic nerves may join the plexus.
DISSECTION 3.7 Axilla-2 Objectives
I. To clean the connective tissue and fascia over the ax- illary 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 define the posterior wall of the axilla.
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 branch- es of the artery, their loss is of little significance.) 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 bra- chial plexus, and its medial root to the medial cord of the brachial plexus.
4. Identify the radial nerve which lies behind the ar- tery. 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 circumflex artery.
6. Find the posterior cutaneous nerve of the arm.
7. Find 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 ax- illary artery close to the axillary nerve. Trace it and its major branches—the circumflex 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 circumflex scapu- lar artery lies close to the nerve (lower subscapular) entering the teres major.
9. Cut across the pectoralis minor, and follow the axil- lary vessels to the outer border of the first 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 pecto- ralis 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 pos- terior cord of the brachial plexus [Fig. 3.15].
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The pectoral region and axilla
artery, but lower down posterior to the pectoralis minor, they surround the second part of the axil- lary artery in positions which correspond to their names. The plexus ends at the lower border of the pectoralis minor by dividing into a number of branches.
of the limb. 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 first lie posterior to the first part of the axillary
Fig. 3.20 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 = left; R = right.
Image courtesy of the Visible Human Project of the US National Library of Medicine.
Scapula
Subscapularis Head of
humerus
Pectoralis major Clavicle
Subclavian artery Cords of brachial plexus
Serratus anterior
L R
A
P
Fig. 3.19 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 cervico-axillary canal.
5th cervical ventral ramus Upper trunk brachial plexus Fascia of cervico-axillary canal Clavicle
Subclavian A.
1st rib Suprascapular N.
Musculocutaneous N.
Outline of pectoralis minor
Ulnar N.
Median N.
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Axilla
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 serra- tus anterior muscle which it supplies.
Branches arising in the axilla
The lateral and medial pectoral nerves pass forwards from the corresponding cords of the bra- chial plexus. They communicate in front of the axillary artery and pass to supply the pectoral mus- cles in the anterior axillary wall. The lateral pecto- ral nerve (C. 5, 6, 7) pierces the clavipectoral fascia to enter the deep surface of the pectoralis major su- perior to the pectoralis minor. The medial pectoral nerve (C. 8, T. 1) supplies and pierces the pectoralis minor to enter the pectoralis major.
The plexus is so arranged that each cord and the nerves which arise from it contain nerve fibres from more than one spinal (segmental) nerve. Thus, the lateral cord contains nerve fibres from the cervical (C.) nerves 5 to 7 [Fig. 3.21], the medial cord from C. 8 and thoracic (T.) 1 (and 2), and the posterior cord from C. 5 to C. 8 (and T. 1). A knowledge of these ‘segmental values’, or root values, is of im- portance in the diagnosis of injuries to the spinal nerves or to the spinal medulla from which they arise.
Branches of the brachial plexus
Branches arising in the neck but distributed to the upper limb
The dorsal scapular nerve (C. 5) supplies the rhomboid major and minor and levator scapulae. It will be seen later on the deep surface of the rhom- boid muscles.
The suprascapular nerve (C. 5, 6) supplies the supraspinatus and infraspinatus muscles. It runs inferolaterally behind the clavicle and crosses the superior border of the scapula to its posterior sur- face [Fig. 3.22].
The nerve to the subclavius (C. 5, 6) descends in front of the plexus to supply the subclavius.
Fig. 3.21 Diagram of the right brachial plexus. Ventral divisions, light orange; dorsal divisions, yellow. C = cervical; T = thoracic.
Dorsal scapular N.
4
C
5 6 7
8
1 2 3
T
Intercostobrachial N. Lateral cutaneous branch 3rd intercostal N.
1st intercostal N.
Long thoracic N.
Phrenic N.
Medial pectoral N.
Suprascapular N.
Lateral pectoral N.
Musculocutaneous N.
Subscapular and thoracodorsal Nn.
Axillary N.
Radial N.
Ulnar N.
Median N.
Medial cutaneous N. of forearm Medial cutaneous N. of arm
N. to subclavius
Fig. 3.22 Dissection of the lower part of the posterior triangle of the neck showing the supraclavicular part of the brachial plexus.
Dorsal scapular N.
External jugular V.
Brachial plexus Suprascapular N.
Sternocleidomastoid
Subclavian V.
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The pectoral region and axilla
CLINICAL APPLICATION 3.1 Breast cancer The following observations were made during breast ex-
amination of a 36-year-old woman with breast cancer.
The right breast was firmly adherent to the underlying tissue.
Study question 1: name the tissue which lies imme- diately 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 ante- rior. The breast being fixed 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: (a) blockage of lymph vessels by cancer cells, resulting in lymphoedema;
and (b) 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 suspen- sory ligaments attached? (Answer: the suspensory liga- ments 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? (An- swer: the masses are most likely enlarged anterior axillary lymph nodes, to which the cancer cells from the breast have spread.)
CLINICAL APPLICATION 3.2 Axillary lymph node dissection Axillary lymph node dissection is a surgical procedure
that is used for staging breast cancer. The surgeon ex- plores 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 treat- ment. Lymph drainage of the upper limb may be imped- ed 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 into the axillary
lymph nodes, which have been removed during surgery.
As such, the lymph collects in the limb tissue. Such swell- ing is called ‘lymphoedema’.) The long thoracic nerve and the thoracodorsal nerve have a long course in the axilla and may become infiltrated by cancer cells. These nerves may also be damaged during the surgery. The thoraco- dorsal nerve lies on the posterior wall of the axilla and enters the latissimus dorsi near its medial border. The ax- illary 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.)
The upper and lower subscapular nerves (C.
5, 6) arise from the posterior cord of the brachial plexus with the thoracodorsal nerve. They supply the muscles of the posterior axillary wall. The upper supplies the subscapularis muscle; the lower supplies the lower fibres of the subscapularis and teres major.
The thoracodorsal nerve passes posteroinferi- orly to supply the latissimus dorsi muscle. It runs with the thoracodorsal artery on the deep surface of the muscle.
The axillary nerve is a terminal branch of the posterior cord of the brachial plexus and is formed near the lower border of the subscapularis. It leaves the axilla by passing back under the subscapularis.
The musculocutaneous nerve arises in the ax- illa from the lateral cord of the brachial plexus and
passes inferolaterally to supply, and then pierce, the coracobrachialis.
The median nerve is formed lateral to the axil- lary artery by one root each from the medial and lateral cords of the brachial plexus. It crosses an- terior to the axillary artery and comes to lie on its medial side.
The ulnar nerve arises from the medial cord of the brachial plexus and runs down between the ax- illary artery and vein.
The radial nerve is the other terminal branch of the posterior cord of the brachial plexus in the axilla. In the axilla, it gives off the nerve to the long head of the triceps—a muscle of the arm.
See Clinical Applications 3.1 and 3.2.
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The iliac crest is the curved bony ridge felt be- low the waist. Trace it forwards to the anterior superior iliac spine and backwards to the pos- terior superior iliac spine. The posterior supe- rior iliac spine is felt in a shallow dimple in the skin above the buttock and about 5 cm from the median plane. Between the left and right dimples is the back of the sacrum. Usually three sacral spines can be palpated in the median plane. The coccyx is the slightly mobile bone felt deep between the buttocks in the median plane.
Feel the tips of the spines of the vertebrae in the median furrow of the back. These are the only parts of the vertebral column which are eas- ily felt. It is difficult to identify individual spines directly, but the seventh cervical spine (vertebra prominens) is the uppermost spine which can be readily felt at the root of your neck. Below this, the approximate levels of other spines are as described in Table 4.1.
Above the vertebra prominens, only the sec- ond cervical spine can be felt easily. It is about 5 cm below the external occipital protuber- ance which is on the lower part of the back of the head where the median furrow of the neck (nuchal groove) meets the skull. The short cervical spines (compare with C7) are separated from the skin by a median fibrous partition—the ligamentum nuchae. The posterior edge of the ligamentum nuchae stretches from the external occipital protuberance to the seventh cervical spine.
The superior nuchal line is a curved ridge on the occipital bone of the skull, extending laterally Turn the body face downwards, and examine the
structures which connect the upper limb to the back of the trunk.