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Rotator Cuff
The rotator cuff is the name given to the tendons of
the subscapularis, supraspinatus, infraspinatus, andteres minor muscles, which are fused to theunderlying capsule of the shoulder joint.
The cuff plays a very important role in stabilizing the
shoulder joint. The tone of these muscles assists in holding the head
of the humerus in the glenoid cavity of the scapuladuring movements at the shoulder joint.
The cuff lies on the anterior, superior, and posterioraspects of the joint.
The cuff is deficient inferiorly, and this is a site ofpotential weakness.
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Clinical Notes
Shoulder Dislocation
The shoulder joint is the most commonly
dislocated large joint, either anterior or
posterior.
Anterior inferior dislocation is the most
common.
Posterior dislocations are rare. It can causedamage to the axillary nerve.
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2- Sternoclavicular joint
Occurs between the sternal end of the
clavicle, the manubrium sterni, and the 1st
costal cartilage.
It is a synovial double plane joint
The joint is innervated by the supraclavicular
nerve and the nerve to subclavius muscle.
Movements are forward and backward,
elevation and depression.
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3- Acromioclavicular joint
Occurs between the acromion process ofscapula and the lateral end of the clavicle.
It is a synovial plane joint.
The joint is innervated by the suprascapularnerve.
Movement is a gliding movement takes place
when the scapula rotates, or when the clavicleis elevated or depressed.
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3
AXILLA
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The axilla, or the armpit, is a pyramid-shapedspace between the upper part of the arm and
the side of the chest.
It forms an important passage of nerves,blood, and lymph vessels as they travel from
the root of the neck to the upper limb.
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We have to discuss:
APEX
BASE
MEDIAL WALL LATERAL WALL
ANTERIOR WALL
POSTERIOR WALL
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Apex
It is the upper end of axilla.
It is directed into the root of the neck and is
bounded in front by the clavicle, behind by the
upper border of the scapula, and medially by
the outer border of the 1st rib.
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Base
It is the lower end of axilla.
It is formed by the skin stretching between the
anterior and posterior walls.
It is bounded in front by the anterior axillary fold (formed by the lower border of pectoralis major
muscle ), behind by the posterior axillary fold
(formed by the tendon of latissimus dorsi and the
teres major muscle ) , and medially by the chest wall.
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Anterior wall
It is formed by the pectoralis major,
subclavius, and pectoralis minor muscles, theclavipectoral fascia, and the suspensory
ligament of the axilla.
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Posterior wall
It is formed by the subscapularis, latissimus
dorsi, and teres major muscles from above
down.
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Medial wall
It is formed by the upper four ribs and the
intercostal spaces covered by the serratus
anterior muscle.
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Lateral wall
It is formed by the coracobrachialis and biceps
muscles in the bicipital groove of the
humerus.
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Contents of the axilla
Axillary artery and its branches.
Axillary vein and its tributaries.
Lymph vessels and lymph nodes
Brachial plexus
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Axillary artery
It begins at the lateral border of the 1st rib as acontinuation of the subclavian, and ends at the lower
border of teres major muscle, where it continues as
the brachial artery.
Throughout its course, the artery is closely related to
the cords of brachial plexus and their branches and is
enclosed with them in a connective tissue sheath,
called the axillary sheath. This sheath is acontinuation of the prevertebral fascia.
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Axillary artery is divided into three parts
according to its relations with pectoralis
minor muscle.
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1st part of axillary artery
It extends from the lateral border of the 1st rib
to the upper border of the pectoralis minor.
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2nd part of axillary artery
It lies behind the pectoralis minor muscle.
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3rd part of axillary artery
It extends from the lower border of the
pectoralis minor to the lower border of teres
major.
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Branches The branches of the axillary artery supply the chest
wall and shoulder.
the 1st, 2nd and 3rd parts give off one, two andthree branches respectively:
1st part: (1) superior thoracic artery2nd part: (1) thoracoacromial trunk
(2) lateral thoracic artery
3rd part: (1) subscapular artery
(2) anterior circumflex humeral artery
(3) posterior circumflex humeral artery
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Axillary vein
It is formed in the region of the lower border of theteres major muscle by the union of the venae
comitantes of the brachial artery and the basilic vein.
It runs upward on the medial side of the axillary
artery and ends at the outer border of the 1st rib bybecoming the subclavian vein.
The vein receives tributaries, which correspond to
the branches of axillary artery, and, in addition, it
receives the cephalic vein.
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4
Brachial Plexus
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Nerves entering the upper limb provides the
following functions:
1- sensory innervation to the skin and deep
structures, such as joints.
2- motor innervation to the muscles.
3- sympathetic vasomotor nerves.
4- sympathetic secretomotor supply to the
sweat glands.
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The brachial plexus is formed in the posterior triangleof the neck by the union of the anterior rami of the
5th
, 6th
, 7th
, and 8th
cervical and the 1st
dorsal spinalnerves.
Roots, trunks and divisions lie in the posteriortriangle.
The roots lie between the anterior and middlescalene muscles.
The trunks traverse the posterior triangle of theneck.
The divisions lie behind the clavicle.
The cords lie in the axilla.
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The plexus is formed as follows:
1- five roots derived from the anterior rami of
C5, 6, 7, 8 and T1; link up into:
2- three trunks formed by the union of
C5 and 6 (upper)C7 alone (middle)
C8 and T1 (lower) ( lower trunk lies behind
the 3rd
part of subclavian artery)trunks split into:
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3- six divisions formed by each trunk dividinginto an anterior and posterior
division; which link up again into:
4- three cords
a lateral, from the fused anterior divisions of
the upper and middle trunks; a medial, from the anterior division of thelower trunk;
a posterior, from the union of all threeposterior divisions.
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The three cords lie above and lateral to the 1st part of
the axillary artery.
The medial cord crosses behind the artery to reach themedial side of the 2nd part of the artery.
The posterior cord lies behind the 2nd part of the artery.
The lateral cord lies on the lateral side of the 2nd part of
the artery.
Thus, the cords of the plexus have the relationship to
the 2nd part of the axillary artery that is indicated by
their names.
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Branches of the different parts of the
brachial plexus
A- Branches of the roots:
1- Dorsal scapular nerve (C5)
2- Long thoracic nerve (C5,6,7)
B- Branches of the upper trunk:
1- Nerve to subclavius (C5,6).
2- Suprascapular nerve (C5,6).
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C- Branches of the lateral cord:
1- Lateral pectoral nerve (C5-7)
2- Musculocutaneous nerve (C5-7)
3- lateral root of median nerve median nerve
gives off no branches in the axilla.
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D- Branches of the medial cord:
1- Medial pectoral nerve (C8-T1).2- Medial cutaneous nerve of arm.
3- Medial cutaneous nerve of forearm.
4- Ulnar nerve it gives off no branches in theaxilla.
5- medial root of median nerve.
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E- Branches of the posterior cord:
1- Upper subscapular nerve.
2- lower subscapular nerve.
3- Thoracodorsal nerve.( N. to Latissimus dorsi
).
4- Axillary nerve (C5,6).
5- Radial nerve the direct continuation, the
largest branch of brachial plexus.
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5
Female Breast and lymph nodes of the
axilla
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The Female Breast
It is a specialized accessory gland of the skinthat is capable of secreting milk.
Its base overlies the 2nd to the 6th rib andfrom the lateral margin of the sternum to themidaxillary line.
Two-thirds of it rests on pectoralis major, one-third on serratus anterior.
Its lower medial edge just overlaps the upperpart of the rectus sheath.
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The greater part of the gland lies in thesuperficial fascia.
A small part the axillary tail extends
upward and laterally, pierces the deep fasciaat the lower border of the P. major muscle,
and comes into close relationship with the
axillary vessels.
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Structure
The breast is made up of 1520 lobules of
glandular tissue embedded in fat.
The latter accounts for its smooth contour and
most of its bulk.
These lobules are separated by fibrous septa,
running from the subcutaneous tissues to the
fascia of the chest wall, serve as suspensory
ligaments (the ligaments of Cooper).
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Each lobule drains by its lactiferous duct on to
the nipple and possesses a dilated ampulla
just prior to its termination.
The nipple is surrounded by the pigmented
areola.
Breasts reach their maximum size during
lactation.
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Blood supply
1- From the axillary artery via its lateralthoracic and acromiothoracic branches.
2- From the internal thoracic (internal
mammary) artery via its perforating branches3- From the intercostal arteries via their lateral
perforating branches.
The venous drainage is to the correspondingveins.