Escolar Documentos
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A. Upper Extremity
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IV. Cutaneous Nerves, Superficial Veins, and Lymphatics
1. Cutaneous Nerves:
A. Supraclavicular nerve
a. rises from the cervical plexus (C3, C4)
b. innervates the skin over the upper pectoral, deltoid, and outer trapezius areas.
B. Medial brachial cutaneous nerve:
a. arises from the medial cord of the brachial plexus and innervates the medial side of
the arm
C. Medial antebrachial cutaneous nerve
a. arises from the medial cord of the brachial plexus and innervates the medial side of
the forearm.
D. Lateral brachial cutaneous nerve
a. arises from the axillary nerve and innervates the lateral side of the arm.
E. Lateral antebrachial cutaneous nerve
a. arises from the musculocutaneous nerve and innervates the lateral side of the forearm.
F. Posterior brachial and antebrachial cutaneous nerves
a. arise from the radial nerve and innervate the posterior sides of the arm and forearm
G. Intercostobrachial nerve
a. lateral cutaneous branch of the second intercostal nerve
b. emerges from the second intercostal space by piercing the intercostal and serratus
anterior muscles.
c. may communicate with the medial brachial cutaneous nerve.
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V. Superficial Lymphatics and Axillary Lymph Nodes
A. Lymphatics of the finger
a. drain into the plexus on the dorsum and palm of the hand.
B. Medial group of lymphatic vessels
a. accompanies the basilic vein
C. Lateral group of lymphatic vessels
a. accompanies the cephalic vein and drains into the lateral axillary nodes and into the
deltopectoral (infraclavicular) node, which then drain into the apical nodes.
D. Axillary lymph nodes
1. Central nodes
a. lie near the base of the axilla between the lateral thoracic and subscapular veins;
receive lymph from the lateral, pectoral, and posterior groups of nodes; and drain into the
apical nodes.
2. Lateral (brachial) nodes
a. lie posteromedial to the axillary veins, receive lymph from the upper limb, and drain
into the central nodes.
3. Subscapular (posterior) nodes
a. lie along the subscapular vein, receive lymph from the posterior thoracic wall and the
posterior aspect of the shoulder, and drain into the central nodes.
4. Pectoral (anterior) nodes
a. lie along the inferolateral border of the pectoralis minor muscle
b. receive lymph from the anterior and lateral thoracic walls, including the breast
drain into the central nodes.
5. Apical nodes
a. lie at the apex of the axilla medial to the axillary vein and above the upper border of
the pectoralis minor muscle, receive lymph from all of the other axillary nodes (and
occasionally from the breast), and drain into the subclavian trunks.
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V. A. The Breast
a. consists of mammary gland tissue, fibrous and fatty tissue, blood and lymph vessels, and nerve
b. forms the floor of the axilla attached to the suspensory ligament of the axilla that forms the
hollow of the armpit by traction when the arm is abducted.
c. extends from the second to sixth ribs and from the sternum to the midaxillary line, divided into
the upper and lower lateral and medial quadrants.
d. has mammary glands, which lie in the superficial fascia.
e. supported by the suspensory ligaments (Cooper's ligaments)
f. has a nipple: lies at the level of the fourth intercostal space and areola
g. Blood supply:
1. medial mammary branches of the anterior perforating branches of the internal thoracic
artery
2. lateral mammary branches of the lateral thoracic artery
3. pectoral branches of the thoracoacromial trunk
4. lateral cutaneous branches of the posterior intercostal arteries
h. Innervation:
1. anterior and lateral cutaneous branches of the second to sixth intercostal nerves
C. Clinical correlates
1. Mammography
a. a radiographic examination of the breast to screen for benign and malignant tumors and
cysts
b. plays a part in early detection of breast cancers
2. Breast cancer:
a. occurs in the upper lateral quadrant (about 60% of cases)
b. forms a palpable mass in advanced stages
c. attaches to Cooper's ligaments, and produces shortening of the ligaments, causing
depression or dimpling of the overlying skin
d. inverted nipple: shortening of the lactiferous ducts
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3. Radical mastectomy:
a. extensive surgical removal of the breast, including the pectoralis major and minor
muscles, axillary lymph node sand fascia, and part of the thoracic wall
b. may injure the long thoracic and thoracodorsal nerves
c. may cause postoperative swelling (edema) of the upper limb as a result of lymphatic
obstruction
4. Modified radical mastectomy:
a. involves excision of the entire breast and axillary lymph nodes, with preservation of
the pectoralis major and minor muscles
5. Lumpectomy (tylectomy):
a. surgical excision of only the palpable mass in carcinoma of the breast.
VI. Axilla:
A. Boundaries:
Medial wall: upper ribs and their intercostal muscles and serratus anterior muscle.
Lateral wall: humerus.
Posterior wall: subscapularis, teres major, and latissimus dorsi muscles.
Anterior wall: pectoralis major and pectoralis minor muscles.
Base: axillary fascia.
Apex: interval between the clavicle, scapula, and first rib
B. Contents: axillary vasculature, branches of the brachial plexus, lymph nodes, and areolar tissue
d. Subdivisions:
A. Branches from the roots
1. Dorsal scapular nerve (C5):
a. pierces the scalenus medius muscle
b. innervates the rhomboids and frequently the levator scapulae muscles
2. Long thoracic nerve (C5- C7)
a. supplies the serratus anterior muscle
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B. Branches from the upper trunk
1. Suprascapular nerve (C5- C6)
a. supplies the supraspinatus muscle and the shoulder joint and the infraspinatus muscle.
2. Nerve to subclavius (C5)
a. supplies the subclavius muscle and the sternoclavicular joint
3. Branches from the lateral cord
1. Lateral pectoral nerve (C5- C7):
a. innervates the pectoralis major muscle primarily and the pectoralis minor muscle
2. Musculocutaneous nirve (C5- C7)
a. pierces the coracobrachialis muscle and innervates these three muscles -
coracobrachialis muscle, biceps brachii and brachialis muscles
4. Branches from the medial cord
1. Medial pectoral nerve (C8-T1)
a. supplies the pectoralis minor muscle and the pectoralis major muscle.
2. Medial brachial cutaneous nerve (C8- T1)
a. innervates the skin on the medial side of the arm.
3. Medial antebrachial cutaneous nerve (C8-T1)
a. innervates the skin on the medial side of the forearm
4. Ulnar nerve (C7-T1)
a. runs down the medial aspect of the arm but does not branch in the brachium
5. Branches from the medial and lateral cords:
1. Median nerve (C5-T1)
a. formed by heads from both the medial and lateral cords
6. Branches from the posterior cord
1. Upper subscapular nerve (C5-C6)
a. innervates the upper portion of the subscapularis muscle.
2. Thoracodorsal nerve (C7- C8)
a. Runs behind the axillary artery
accompanies the thoracodorsal artery to enter the latissimus dorsi muscle
3. Lower subscapular nerve (C5- C6)
a. innervates the lower part of the subscapularis and teres major muscles
4. Axillary nerve (C5- C6)
a. innervates the deltoid and teres minor muscles
b. gives rise to the lateral brachial cutaneous nerve
5. Radial nerve (C5-T1)
a. the largest branch of the brachial plexus
b. occupies the musculospiral groove on the back of the humerus with the profunda
brachii artery.
e. Clinical Correlates:
1. Injury to the long thoracic nerve:
Cause: stab wound or during radical mastectomy or thoracic surgery
a. results in paralysis of the serratus anterior muscle and inability to elevate the arm
above the horizontal.
b. produces awinged scapula in which the vertebral (medial) border of the scapula
protrudes away from the thorax
2. Injury to the posterior cord:
a. Cause by the pressure of the crosspiece of a crutch, resulting in paralysis of the arm
called crutch palsy
c. results in loss in function of the extensors of the arm, forearm, and hand and produces
a wrist drop.
3. Injury to the axillary nerve:
a. caused by a fracture of the surgical neck of the humerus or inferior dislocation of the
humerus
b. results in weakness of lateral rotation and abduction of the arm (the supraspinatus can
abduct the arm but not to a horizontal level)
4. Injury to the radial nerve:
a. caused by a fracture of the midshaft of the humerus.
b. results in loss of function in the extensors of the forearm, hand, metacarpals, and
phalanges
c. results in loss of wrist extension, leading to wrist drop , and produces a weakness of
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5. Injury to the musculocutaneous nerve:
a. results in weakness of supination (biceps) and forearm flexion (brachialis and biceps).
6. Injury to the median nerve:
Caused: by a supracondylar fracture of the humerus or a compression in the carpal tunnel.
a. results in loss of pronation, opposition of the thumb, and flexion of the lateral two
interphalangeal joints and impairment of the medial two interphalangeal joints.
b. also produces a characteristic flattening of the thenar eminence, often referred to asape
hand.
7. Injury to the ulnar nerve:
a. caused by a fracture of the medial epicondyle and results in a claw hand , in which the
ring and little fingers are hyperextended at the
metacarpophalangeal joints and flexed at
the interphalangeal joints
b. results in loss of abduction and adduction of the fingers and flexion of the
metacarpophalangeal joints because of paralysis of the palmar and dorsal interossei
muscles and the medial two lumbricals
8. Upper trunk injury (Erb-Duchenne paralysis or Erb palsy):
a. caused by a birth injury during a breech delivery or a violent displacement of the head
from the shoulder such as might result from a fall from a motorcycle or horse
b. results in a loss of abduction, flexion, and lateral rotation of the arm, producing a waiter's
tip hand , in which the arm tends to lie in medial rotation resulting from paralysis of
lateral rotator muscles.
9. Lower trunk injury (Klumpke's paralysis):
a. caused during a difficult breech delivery (birth palsy or obstetric paralysis), by a cervical
rib (cervical rib syndrome), or by abnormal insertion or spasm of the anterior and middle
scalene muscles (scalene syndrome)
b. the injury causes a claw hand
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IX. Axillary vein
a. formed at the lower border of the teres major muscle by the union of the venae comitantes of the
brachial artery and the basilic vein
b. runs upward on the medial side of the axillary artery and ends at the lateral border of the first rib
by becoming the subclavian vein
X. Muscles
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XI. Triangle of Auscultation
a. Boundaries:
the upper border of the latissimus dorsi muscle, the lateral border of the trapezius muscle, and the
medial border of the scapula; its floor is formed by the rhomboid major muscle.
b. the site at whichbreathing sounds are heard most clearly
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XIV. Arteries of the Upper Extremity
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B. Contents of the Lateral Fascial Compartment of the Forearm
The lateral fascial compartment may be regarded as part of the posterior fascial compartment.
Muscles:
1. Brachioradialis and extensor carpi radialis longus
Blood supply: Radial and brachial arteries
Nerve supply to the muscles: Radial nerve
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XVIII. The Region of the Wrist
a. the carpal Tunnel
b. the carpus is deeply concave on its anterior surface and forms a bony gutter.
c. the gutter is converted into a tunnel by the flexor retinaculum
The following structures pass beneath the flexor retinaculum from medial to lateral:
1. Flexor digitorum superficialis tendons and, posterior to these, the tendons of the flexor digitorum
profundus; both groups of tendons share a common synovial sheath.
2. Median nerve
3. Flexor pollicis longus tendon surrounded by a synovial sheath
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Abductor pollicis longus and the extensor pollicis brevis tendons have separate synovial sheaths but
share a common compartment.
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XX. Arteries of the Palm
1. Ulnar Artery
a. enters the hand anterior to the flexor retinaculum on the lateral side of the ulnar nerve and the
pisiform bone
b. gives off a deep branch and then continues into the palm as the superficial palmar arch.
c. superficial palmar arch is a direct continuation of the ulnar artery
d. Four digital arteries arise from the convexity of the arch and pass to the fingers
e. the deep branch of the ulnar artery arises in front of the flexor retinaculum
2. Radial Artery
a. deep palmar arch is a direct continuation of the radial artery
2. Trigger Finger
a. a palpable and audible snapping when a patient is asked to flex and extend the fingers.
b. caused by the presence of a localized swelling of one of the long flexor tendons that catches
on a narrowing of the fibrous flexor sheath anterior to the metacarpophalangeal joint
3. Mallet Finger
a. avulsion of the insertion of one of the extensor tendons into the distal phalanges can occur if
the distal phalanx is forcibly flexed when the extensor tendon is taut.
b. the last 20° of active extension is lost, resulting in a condition known as mallet
4. Boutonnaire Deformity
a. avulsion of the central slip of the extensor tendon proximal to its insertion into the base of the
middle phalanx results in a characteristic deformity
b. results from flexing of the proximal interphalangeal joint and hyperextension of the distal
interphalangeal joint.
c. this injury can result from direct end-on trauma to the finger, direct trauma over the back of
the proximal interphalangeal joint, or laceration of the dorsum of the finger.
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