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Compression of Axillary Artery The axillary artery can be palpated in the inferior part of the lateral wall of the

axilla. Compression of the third part of this artery against the humerus may be necessary when profuse bleeding occurs (e.g., resulting from a stab or bullet wound in the axilla). If compression is required at a more proximal site, the axillary artery can be compressed at its origin (as the subclavian artery crosses the 1st rib) by exerting downward pressure in the angle between the clavicle and the inferior attachment of the sternocleidomastoid. Aneurysm of Axillary Artery The first part of the axillary artery may enlarge (aneurysm of the axillary artery) and compress the trunks of the brachial plexus, causing pain and anesthesia (loss of sensation) in the areas of the skin supplied by the affected nerves. Aneurysm of the axillary artery may occur in baseball pitchers because of their rapid and forceful arm movements. Injuries to Axillary Vein Wounds in the axilla often involve the axillary vein because of its large size and exposed position. When the arm is fully abducted, the axillary vein overlaps the axillary artery anteriorly. A wound in the proximal part of the axillary vein is particularly dangerous, not only because of profuse bleeding but also because of the risk of air entering it and producing air emboli (air bubbles) in the blood. Role of Axillary Vein in Subclavian Vein Puncture

Subclavian vein puncture, in which a catheter is placed into the subclavian vein, has become a common clinical procedure (see blue box Subclavian Vein Puncture in Chapter 8). The axillary vein becomes the subclavian vein as the first rib is crossed. Because the needle is advanced medially to enter the vein as it crosses the rib, the vein actually punctured (the point of entry) in a subclavian vein puncture is the terminal part of the axillary vein. However, the needle tip proceeds into the lumen of the subclavian vein almost immediately. Thus it is clinically significant that the axillary vein lies anterior and inferior (i.e., superficial) to the axillary artery and the parts of the brachial plexus that begin to surround the artery at this point. Enlargement of Axillary Lymph Nodes An infection in the upper limb can cause the axillary nodes to enlarge and become tender and inflamed, a condition called lymphangitis (inflammation of lymphatic vessels). The humeral group of nodes is usually the first to be involved. Lymphangitis is characterized by the development of warm, red, tender streaks in the skin of the limb. Infections in the pectoral region and breast, including the superior part of the abdomen, can also produce enlargement of axillary nodes. In metastatic cancer of the apical group, the nodes often adhere to the axillary vein, which may necessitate excision of part of this vessel. Enlargement of the apical nodes may obstruct the cephalic vein superior to the pectoralis minor. Dissection of Axillary Lymph Nodes Excision and pathologic analysis of axillary lymph nodes are often necessary for staging and determining the appropriate treatment of a cancer such as breast cancer (see p. 104).

Because the axillary lymph nodes are arranged and receive lymph (and therefore metastatic breast cancer cells) in a specific order, removing and examining the lymph nodes in that order is important in determining the degree to which the cancer has developed and is likely to have metastasized. Lymphatic drainage of the upper limb may be impeded after the removal of the axillary nodes, resulting inlymphedema, swelling as a result of accumulated lymph, especially in the subcutaneous tissue. During axillary node dissection, two nerves are at risk of injury. During surgery, the long thoracic nerve to the serratus anterior is identified and maintained against the thoracic wall. As discussed earlier in this chapter, cutting the long thoracic nerve results in a winged scapula. If the thoracodorsal nerve to the latissimus dorsi is cut, medial rotation and adduction of the arm are weakened, but deformity does not result. If the nodes around this nerve are obviously malignant, sometimes the nerve has to be sacrificed as the nodes are resected to increase the likelihood of complete removal of all malignant cells. Variations of Brachial Plexus Variations in the formation of the brachial plexus are common (Bergman et al., 1988). In addition to the five anterior rami (C5C8 and T1) that form the roots of the brachial plexus, small contributions may be made by the anterior rami of C4 or T2. When the superiormost root (anterior ramus) of the plexus is C4 and the inferiormost root is C8, it is a prefixed brachial plexus.Alternately, when the superior root is C6 and the inferior root is T2, it is a postfixed brachial plexus. In the latter type, the inferior trunk of the plexus may be compressed by the 1st rib, producing neurovascular symptoms in the upper limb. Variations may also occur in the formation of trunks, divisions,

and cords; in the origin and/or combination of branches; and in the relationship to the axillary artery and scalene muscles. For example, the lateral or medial cords may receive fibers from anterior rami inferior or superior to the usual levels, respectively. In some individuals, trunk divisions or cord formations may be absent in one or other parts of the plexus; however, the makeup of the terminal branches is unchanged. Because each peripheral nerve is a collection of nerve fibers bound together by connective tissue, it is understandable that the median nerve, for instance, may have two medial roots instead of one (i.e., the nerve fibers are simply grouped differently). This results from the fibers of the medial cord of the brachial plexus dividing into three branches, two forming the median nerve and the third forming the ulnar nerve. Sometimes it may be more confusing when the two medial roots are completely separate; however, understand that although the median nerve may have two medial roots the components of the nerve are the same (i.e., the impulses arise from the same place and reach the same destination whether they go through one or two roots). Brachial Plexus Injuries Injuries to the brachial plexus affect movements and cutaneous sensations in the upper limb. Disease, stretching, and wounds in the lateral cervical region (posterior triangle) of the neck (see Chapter 8) or in the axilla may produce brachial plexus injuries. Signs and symptoms depend on the part of the plexus involved. Injuries to the brachial plexus result in paralysis andanesthesia. Testing the persons ability to perform movements assesses the degree of paralysis. In complete paralysis, no movement is detectable.

In incomplete paralysis, not all muscles are paralyzed; therefore, the person can move, but the movements are weak compared with those on the normal side. Determining the ability of the person to feel pain (e.g., from a pinprick of the skin) tests the degree of anesthesia. Injuries to superior parts of the brachial plexus (C5 and C6) usually result from an excessive increase in the angle between the neck and the shoulder. These injuries can occur in a person who is thrown from a motorcycle or a horse and lands on the shoulder in a way that widely separates the neck and shoulder (Fig. B6.12A). When thrown, the persons shoulder often hits something (e.g., a tree or the ground) and stops, but the head and trunk continue to move. This stretches or ruptures superior parts of the brachial plexus or avulses (tears) the roots of the plexus from the spinal cord.

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