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02 Neck Axilla Back
02 Neck Axilla Back
nerves
and rotates cervical part of vertebral column Medius Transverse processes of C1-C6
1st rib
Elevates 1st rib, laterally flexes
Anterior Transverse processes of C3-C6 C4-C6
and rotates cervical part of vertebral column Scalenus Anterior muscles
1. Key muscle in understanding the root of the neck and its relation to many neurovascular structures identified
in the posterior triangle 2. Important relations:
• Anteriorly – related to carotid arteries, vagus nerve, IJV, and deep cervical lymph nodes
• Posteriorly – related to the pleura, origin of the brachial plexus, and 2 nd part of the subclavian artery
• Medially – related to the vertebral artery and vein, sympathetic trunk, and thoracic duct (on the left side)
• Laterally - related to the emerging branches of the cervical plexus, roots of the brachial plexus, and the 3 rd
part of the subclavian artery 3. Divides the subclavian artery into 3 parts
Phrenic Nerve Spinal Accessory Nerve (XI) Fibers Motor, Sensory Motor
Course
CRANIAL ROOT
1. Arises in the neck from the 3rd, 4th,
and 5th cervical nerves of the cervical plexus (C3-C5) 2. Runs vertically downward across the front of the
scalenus anterior muscle 3. Enters the thorax by passing in front
of the subclavian artery
1. Emerges from anterior surface of the medulla oblongata 2. Nerve runs laterally in the posterior cranial
fossa and joins the spinal root SPINAL ROOT
1. Emerges from nerve cells in the anterior gray horn of the upper 5 segments of the cervical part of
the spinal cord 2. Nerve ascends alongside the spinal cord and enters the skull through the foramen magnum
–
turns lateral to join cranial root
4. Further courses in the thorax
terminating at the diaphragm
Cranial and Spinal root leave the skull through the jugular foramen and eventually separate:
• Cranial root – joins vagus nerve; distributed to soft palate, pharynx, and larynx muscles
• Spinal root – runs downward and laterally and enters SCM and over to the trapezius Areas of distribution
Diaphragm Soft palate, pharynx, larynx, sternocleidomastoid, trapezius muscles
Subclavian arteries Left Subclavian Right Subclavian Origin Arch of the aorta Brachiocephalic artery
Commencement Behind manubrium sterni Behind right sternoclavicular joint
Course
Ascends to the root of the neck Arches upward and laterally over the pleura between the scalenus anterior and
medius muscles Termination Outer border of the 1st rib
Scalenus anterior divides the subclavian artery into 3 parts
Posterior
Vertebral artery Basilar artery cerebral artery
Inferior thyroid artery
First Part of Subclavian Artery Extends from the origin of the subclavian artery to the medial border of
scalenus anterior Thyrocervical
Superficial cervical 1st
trunk
artery
• Vertebral artery - ascends in the neck through foramina in the transverse processes of the upper 6 cervical
vertebrae ,ascends into the skull through the foramen magnum;
Suprascapular artery
Forms the basilar artery at the anterior surface of the medulla oblongata at the level of the lower border of the
pons
• Basilar artery - gives branches to the pons, cerebellum, and internal ear; contributes Superior epigastric
to the formation of the Circle of Willis
Internal thoracic
artery
artery
Musculophrenic artery
• Posterior cerebral artery - curves laterally and backward around the midbrain
Subclavian artery
• Thyrocervical trunk
• Inferior thyroid artery - closely related to recurrent laryngeal nerve; gives branches to thyroid and inferior
parathyroid glands
• Superficial cervical artery - crosses the brachial plexus
Costocervical
2nd
trunk
Superior intercostal artery
• Suprascapular artery - follows the suprascapular nerve onto the back of the scapula
• Internal thoracic artery – descends into the thorax behind the 1st costal cartilage and in front of the pleura
3rd
Deep cervical artery • Superior epigastric artery - supplies anterior abdomen
• Musculophrenic artery - supplies 7th-9th intercostal spaces and diaphragm
Anatomy 1C Joshua Montelibano 1st shift 2015-2016
Second Part of Subclavian Artery Lies behind the scalenus anterior
Third Part of Subclavian Artery Extends from the lateral border of the scalenus anterior across the
posterior triangle to the lateral border of the 1st rib
Lymph Drainage Superficial Cervical Lymph Nodes Deep Cervical Lymph Nodes
• Situated along the course of the External 1. Jugulodigastric node – located below the
Jugular Vein angle of the jaw
• Receive lymph from: • Drainage of the tonsil and tongue 2. Jugulo-
1. The skin over the angle of the jaw 2. Skin over omohyoid node – close to the omohyoid muscle
the apex of the parotid gland 3. Lobe of the ear • Drainage of the tongue
• Efferent lymph vessels drain into the deep • Efferent lymph vessels join to form jugular trunk
cervical lymph nodes – drains into thoracic duct (right lymph duct)
• Form a vertical chain along the course of the Anatomy 1C Joshua Montelibano 1st shift
Internal Jugular Vein within the carotid sheath 2015-2016
• Receive lymph from regional nodes:
CERVICAL PLEXUS
Formed by the anterior rami of 1st 4 cervical nerves Joined by connecting branches – form loops that lie in
front of the origins of the levator scapulae and scalenus medius
Covered in front by the prevertebral layer of deep cervical fascia Related to the Internal Jugular Vein in the
carotid sheath Supplies the skin and muscles of the head, neck, and shoulders
Branches of the Cervical Plexus Branches Nerve Root Distribution CUTANEOUS BRANCHES
Lesser Occipital nerve C2 Back of the scalp and
auricle Greater auricular nerve
C2, 3 Skin over the angle of the mandible Transverse cervical nerve
Skin over the front of the neck Supraclavicular nerve C3, 4 Skin over the shoulder
region MUSCULAR BRANCHES TO THE NECK MUSCLES Proprioceptive, C2, 3 Prevertebral muscles, SCM
C3, 4 Levator scapulae Proprioceptive C3, 4 Trapezius Branch of C1 joins with hypoglossal nerve Some C1
fibers leave as a descending branch – unites with descending cervical nerve (C2, 3) C1 descending branch +
descending cervical nerve = ansa cervicalis Ansa cervicalis – innervates Sternohyoid, Omohyoid,
Sternothyroid
MUSCULAR BRANCH TO THE DIAPHRAGM Phrenic nerve C3, 4, 5 Diaphragm
CERVICAL PART OF THE SYMPATHETIC TRUNK Extends upward to the base of the skull below
the neck of the 1st rib Directly behind the internal and common carotid arteries, embedded in deep fascia
Three Ganglia of the Sympathetic Trunk and its Branches
Superior Cervical Ganglion
Internal carotid nerve Postganglionic fibers; accompanies ICA Gray rami communicantes To the upper 4
anterior rami of cervical nerves Arterial branches To the common and external carotid arteries Cranial nerve
brances Join the 9th, 10th, and 12th cranial nerves Phrayngeal branches Unite with glossopharyngeal and vagus
nerves Superior cardiac branch Descends in the neck; ends in cardiac plexus Middle Cervical Ganglion
Gray rami communicantes To the anterior rami of 5 th and 6th cervical nerves Thyroid branches Pass along
inferior thyroid artery; to thyroid gland Middle cardiac branch Descends in the neck; ends in cardiac plexus
Inferior Cervical Ganglion
Stellate ganglion Fused inferior cervical with 1st thoracic ganglion Gray rami communicantes To the anterior
rami of the 7th and 8th cervical nerve Arterial branches To the subclavian and vertebral arteries Inferior Cardiac
branch Descends to join the cardiac plexus
Anatomy 1C Joshua Montelibano 1st shift 2015-2016
AXILLA, PECTORAL REGION, and MAMMARY GLAND BREAST (Mammary gland)
Specialized accessory glands of the skin that secrete milk Present in both sexes (similar structures in males
and immature females)
Superior: 2nd rib Inferior: 6th rib Medial: Lateral margin of the sternum Anterior: Skin Posterior: Deep pectoral
fascia
Nipples (at level of 4th intercostal space) are small and surrounded by a colored area of the skin – areola
Areolar glands – produces tiny tubercles in the areola Darkening of areola – increased deposits of melanin in
the epidermis
Axillary tail of Spence
• Extension upward and laterally piercing the deep fascia at lower border of pectoralis major
• Enters the axilla
Each breast consist of 15-20 lobes – radiate out from the nipple
• Main duct of each lobe opens separately on the summit of the nipple – each possess a dilated ampulla
(before termination)
• Lobes are separated by fibrous septa – serves as suspensory ligaments of Cooper Retromammary space
- space behind the breast filled by loose connective tissue
Arterial supply
Perforating branches of internal thoracic artery,
Medial
Axillary artery via
intercostal arteries Lateral
lateral thoracic and thoracoacromial arteries Venous supply (correspond to arteries)
Lymph drainage
Medial Into the internal thoracic group of nodes Lateral Into the anterior axillary or pectoral group of nodes
Posterior Into the posterior intercostal nodes Innervation 4th-6th intercostal nerves
Anatomy 1C Joshua Montelibano 1st shift 2015-2016
Muscles of the Pectoral Region Origin Insertion Innervation Nerve Roots Action
Pectoralis major
• Clavicle
• Sternum
• Upper 6 costal cartilages
Lateral lip of bicipital Medial groove of humerus
and lateral pectoral nerves from brachial plexus
Adducts arm and rotates it medially
C5, 6, 7, 8, T1
Clavicular fibers also flex arm
Coracoid process of
Pectoralis minor 3rd, 4th, and 5th ribs
scapula
C6, 7, 8 Depresses point of shoulder
Medial pectoral nerve from brachial plexus
if fixed scapula – elevates ribs of origin
Subclavius 1st costal cartilage Clavicle
Nerve to subclavius from upper trunk of brachial plexus
Depresses clavicle and steadies this C5, 6
bone during movements of the shoulder girdle
Medial border and inferior
Serratus anterior Upper 8 ribs
Long thoracic nerve C5, 6, 7
border of scapula
Draws the forward anterior around the thoracic wall Rotates the scapula
The Axilla Axilla (armpit)
• Pyramid-shaped space between the upper part of the arm and side of the chest
• Forms an important passage for nerves, blood, and lymph vessels as they travel from root of the neck to the
upper limb
Apex – upper end of the axilla
• Directed into the root of the neck
• Bounded in front by the clavicle, behind by the upper border of the scapula, and medially by the outer
border of the 1st rib Base – lower end of the axilla
• Bounded in front by anterior axillary fold (lower border of pectoralis major), behind by posterior axillary fold
(tendon of latissimus dorsi and teres major), medially by the chest wall
Contents:
• Axillary artery and its branches – supply blood to upper limb
• Axillary vein and tributaries – drains blood from upper limb
• Lymph vessels and lymph nodes - drain lymph from upper limb and breast
• Brachial plexus – innervates the upper limb
Anatomy 1C Joshua Montelibano 1st shift 2015-2016
Walls of the Axilla
Base is formed by the skin stretching between anterior and posterior walls Axilla contains principal vessels and
nerves to upper limb and lymph nodes
Key Muscle in Axilla Pectoralis minor
• Crosses axillary artery and brachial plexus of nerves
• Used in describing the axillary artery to divide into 3 parts
BRACHIAL PLEXUS Complicated plexus allowing nerve fibers from different segments of the spinal cord
to be arranged and distributed efficiently in nerve trunks to the various parts of the upper limbs Formed in the
posterior triangle of the neck – union of anterior rami of the 5th to 8th cervical and 1st thoracic spinal
nerves
Important functions:
1. Sensory innervation to the skin and deep structures 2. Motor innervation to the muscles 3. Influence over the
diameters of the blood vessels by the sympathetic vasomotor nerves 4. Sympathetic secretomotor supply to
the sweat glands
Divided into roots, trunks, divisions, and cords Roots, trunks, divisions – reside in lower part of posterior
triangle of the neck Cords and its branches – arranged around the axillary artery in the axilla; enclosed in
axillary sheath
Lateral cord – Upper (C5, 6) + middle (C7) Posterior cord – Upper (C5, 6) + middle (C7) + lower (C8, T1)
Medial cord – Lower (C8, T1)
Anatomy 1C Joshua Montelibano 1st shift 2015-2016
Branches of the Brachial Plexus Branches Roots Distribution ROOTS Dorsal Scapular nerve C5
Rhomboid minor, Rhomboid major,
Levator scapulae muscles Long Thoracic nerve C5, 6, 7 Serratus anterior UPPER (SUPERIOR) TRUNK
Suprascapular nerve
C5, 6
Supraspinatus and infraspinatus Nerve to subclavius (Accessory phrenic nerve)
Subclavius *Gives contribution to phrenic nerve LATERAL CORD Lateral Pectroal nerve Musculocutaneous
of median nerve
Termination: Lateral border of the 1st rib Drains into subclavian vein Posterior: Subscapularis, latissimus
dorsi, teres Anterior circumflex
major, axillary and radial nerves
Formed from union of: humeral artery
Lateral: Coracobrachialis, biceps, humerus, lateral
venae comitantes of the brachial artery and basilic vein
Posterior circumflex humeral artery
Vein receives tributaries corresponding to branches of the axillary artery root of median and musculocutaneous
nerve Medial: Ulnar nerve, axillary vein, medial
cutaneous nerve of the arm
Anatomy 1C Joshua Montelibano 1st shift 2015-2016
ARM and CUBITAL FOSSA Skin Superficial Sensory Nerves
• Cutaneous nerves on lateral surface
1. Supraclavicular nerves (C3, 4)
• Nerve supply to skin over the point of the shoulder halfway down the deltoid 2. Upper lateral cutaneous
nerve of the arm (branch of axillary nerve C5, 6)
• Nerve supply to skin over the lower half of the deltoid 3. Lower lateral cutaneous nerve of the arm (branch
of radial nerve C5, 6)
• Nerve supply to skin over lateral surface of arm below the deltoid
• Cutaneous nerves on medial surface
1. Medial Cutaneous nerve of the arm (T1)
• Nerve supply of skin of the armpit and medial side of the arm 2. Intercostobrachial nerves (T2) 3. Posterior
cutaneous nerve of the arm (branch of radial nerve C8)
• Nerve supply of skin of the back of the arm
Veins of upper limb
Deep veins Comprises the venae comitantes – accompany large arteries and the axillary vein
Superficial veins Lie in the superficial fascia
Cephalic vein Basilic vein
Commencement
Subcutaneous tissue from the lateral aspect of the dorsum of the hand (lateral of the wrist)
Medial border of the wrist
Joins venae comitantes
Termination Deltopectoral groove Lower border of teres major Drainage Axillary vein
of brachial artery
Roof: skin and fascia reinforced by the bicipital aponeurosis Floor: Brachialis Base of the triangle: Imaginary
line between the humeral Lateral: brachioradialis Medial: Pronator teres
ELBOW JOINT
Articulation: between trochlea and capitulum of the humerus and the trochlear notch of the ulna and head of
the radius
articular surfaces covered with hyaline cartilage
Capsule: Anterior: attached above to the humerus along upper margins of coronoid and radial fossae
to the front of the medial and lateral epicondyles and below to the margin of the coronoid process of the ulna
and to the annular ligament Posterior: attached above to margins of olecranon fossa of the humerus and below
to the upper margin and sides of the olecranon process
Ligaments: Lateral ligament – triangular; attached by its apex to lateral epicondyle of humerus
Medial ligament – triangile; with 3 strong bands: anterior band, posterior band, transverse band
Synovial membrane : lines the capsule and covers fatty pads in the floors of the coronoid, radial, and
olecranon fossae
Nerve supply: Branches from median, ulnar, musculocutaneous, and radial nerves
Anatomy 1C Joshua Montelibano 1st shift 2015-2016
BACK, SHOULDER, & SCAPULAR MUSCLES Bony Prominences
• External occipital protuberance – lies at junction of head and neck
• Seventh (7th) cervical vertebrae (vertebra prominens) – most prominent spinous process that can be felt in
the neck
• First (1st) thoracic vertebra
• Scapula
Crest of the spine – can be palpated at level of 3rd thoracic spine Medial border Superior angle – can be
palpated opposite the 1st thoracic spine Inferior angle – can be palpated opposite the 7th thoracic spine
• Iliac crest – lie at the level of 4th lumbar spine
Superficial part of the back
Sensory nerve supply
Posterior rami of spinal nerves (1st and 8th cervical nerves does not supply the skin) Arterial supply
Posterior branches of the:
Intercostal Nerves
Raises ribs Inspiratory muscle Serratus Posterior Inferior
Upper spines lumber and lower thoracic
Lower ribs Depresses ribs
Lumbar Triangle Site where pus may emerge from the abdominal wall (pus accumulation may
occur)
Inferior: Iliac crest Medial: Inferior border of latissimus dorsi Lateral: posterior border of the external oblique of
the abdomen
Suboccipital Triangle
Medial: Rectus capitis posterior major Lateral: Oblique capitis superior
Oblique capitis inferior
Triangular space
Superior: Teres minor Inferior: Teres major Lateral: Long head of triceps brachii Contains circumflex
scapular artery
Quadrangular space
Superior: Subscapularis Inferior: Teres major Medial: Long head of triceps brachii Lateral: surgical neck of
humerus Contains Axillary nerve and Posterior circumflex humeral artery
Anatomy 1C Joshua Montelibano 1st shift 2015-2016
Arterial anastomosis around the shoulder joint
• Anastomosis between the branches of the subclavian artery and axillary artery
• Ensures adequate blood flow in upper limb irrespective of arm positioning
SHOULDER JOINT
Articulation: between rounded head of the humerus and shallow, pear-shaped glenoid cavity of the scapula
articular surfaces covered by hyaline cartilage; glenoid cavity deepened by glenoid labrum (fibrocartilaginous
rim) Type: Synovial ball-and-socket joint Capsule: surrounds the joint and attached medially to the margin of
the glenoid cavity outside the labrum
Thin and lax – allows movement; strengthened by fibrous slips from the tendons of the subscapularis,
supraspinatus, infraspinatus, and teres minor
Ligaments: Glenohumeral ligaments – 3 weak bands of fibrous tissue, strengthen front of the capsule
Transverse humeral ligament – strengthens the capsule and bridges the gap between 2 tuberosities
Coracohumeral ligament – strengthens capsule above and stretches from the root of the coracoid process to
the greater tuberosity of the humerus
Synovial membrane : lines the capsule and attached to margins of the cartilage covering the articular surfaces
extends through anterior wall of the capsule – forms subscapularis bursa beneath subscapularis Nerve supply:
Axillar and suprascapular nerves
Anatomy 1C Joshua Montelibano 1st shift 2015-2016
TOPOGRAPHIC ANATOMY
Anatomy 1C Joshua Montelibano 1st shift 2015-2016
MUSCLE ATTACHMENT and INSERTION
Anatomy 1C Joshua Montelibano 1st shift 2015-2016
CLAVICLE, SCAPULA and HUMERUS
Anatomy 1C Joshua Montelibano 1st shift 2015-2016