AXILLA- BOUNDARIES, AXILLARY ARTERY,AXILLARY VEIN,LYMPH NODES

[SURIYA.KARTHIKEYHAN]

AXILLA- BOUNDARIES, AXILLARY ARTERY,AXILLARY VEIN,LYMPH NODES
  AXILLA OR ARMPIT -  

A PYRAMIDAL SHAPED SPACE BETWEEN THE UPPER ARM AND THE LATERAL THORACIC WALL

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BOUNDARIES - AXILLA

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APEX OF AXILLA

• Cervico Axillary Canal
• Directed upwards and medially
• Allows the structures to pass to and fro from neck & axilla
• Boundaries – Triangle shaped
  • Anteriorly – Posterior surface of clavicle
  • Posteriorly – Superior border of scapula
  • Medially- Outer border of first rib

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SRUCTURES PASSING THROUGH THE APEX

• Axillary Vessels.
• Brachial Plexus Cords.{Enclosed In Axillary Sheath.}
• Long Thoracic Nerve Of Bell.
• Efferent Subclavian Lymph Trunk Extending From Apical Lymph Nodes

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BASE OF AXILLA

FLOOR

• Directed Below
• Anterior Axillary Fold-in Front
• Posterior Axillary Fold-behind
• Chest Wall-medially

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BASE- ANTERIOR AND POSTERIOR AXILLARY FOLD

• ANTERIOR AXILLARY Fold - spirally Arranged Lower Border Of Pectoralis Major.
• POSTERIOR AXILLARY FOLD - Is Slightly Below The Anterior Fold And Formed By Lat.Dorsi In The Medial Part And Teres Major In The Lateral Part.

BASE OF AXILLA-FORMATION

• Skin
• Superficial Fascia
• Axillary Fascia {Deep Fascia Extending From The Anterior Axillary Fold To Posterior Axillary Fold}
• Supported By The Suspensory Ligament Of Axilla

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ANTERIOR WALL

• PECTORALIS MAJOR.-IN SUPERFICIAL PLANE
• PECTORALIS MINOR, SUBCLAVIUS, CLAVIPECTORAL FASCIA,AND SUSPENSORY LIGAMENT OF AXILLA IN DEEPER PLANE

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POSTERIOR WALL

Formed by

• Subscapularis above
• Teres major & Lattismus dorsi below

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ANTERIOR AND POSTERIOR WALL

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MEDIAL WALL

Broad and formed by

• Upper 4 or 5 Ribs And Their Intercostal Muscles.
• Upper Part Of Serratus Anterior Muscle And Overlying Fascia.
• Long Thoracic Nerve Of Bell Passes Downwards Along This Wall Deep To The Fascia And Behind The Mid Axillary Line.

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LATERAL WALL

• Narrow, both Anterior and Posterior Walls converge on It.
• Formed by the Intertubercular Sulcus lodging the Tendon Of Biceps Brachi assisted by Corachobrachialis and Short Head Of Biceps.

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BOUNDARIES OF AXILLA

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CONTENTS OF AXILLA

• Axillary artery
• Axillary vein
• Infraclavicular portion of brachial plexus
• Axillary group of lymph nodes
• Axillary pad of fat
• Axillary tail of Spence
• Long thoracic nerve & Intercostobrachial nerve

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AXILLARY ARTERY

• Origin: Continuation of 3rd part of  subclavian artery
• Extent : outer border of the 1st rib and ends at the lower border of Teres major
• Continues as brachial artery

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DIVISIONS OF AXILLARY ARTERY

• PECTORALIS MINOR CROSSES IN FRONT OF THE ARTERY AND DIVIDES IT INTO 3 PARTS.
• FIRST PART-PROXIMAL TO THE MUSCLE.
• SECOND PART-BEHIND THE MUSCLE.
• THIRD PART- DISTAL TO THE MUSCLE.

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AXILLARY ARTERY- BRANCHES

Gives 6 branches

1. Superior thoracic A,
2. lateral thoracic A
3. Acromio thoracic A
4. Anterior cicumflex humeral A
5. Posterior circumflex humeralA
6. Subscapular A

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RELATIONS

• Throughout the course the artery is accompanied inferomedially by the axillary vein and is closely related to the cords of brachial plexus and their branches.
• Axillary sheath,derived from the pre-vertebral part of deep cervical fascia,encloses the proximal part of the axillary artery and vein together with the brachial plexus.

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FIRST PART-AXILLARY ARTERY(RELATIONS)

ANTERIOR

• Skin, superficial Fascia, platysma, supraclavicular Nerves.
• Pectoral Fascia,pectoralis Major, Clavipectoral Fascia.
• Loop Between The Lateral And Medial Pectoral Nerves.
• Cephalic And Thoraco Acromion Veins Cross.
• Anterior Wall Of Axillary Sheath

POSTERIOR

• 1st & 2nd Digitations Of Serratus Anterior.
• Long Thoracic Nerve, medial Cord Of Brachial Plexus And Medial Pectoral Nerve.
• Posterior wall of Axillary Sheath

LATERAL

• Lateral And Posterior Cords Of Brachial Plexus

MEDIAL

• Axillary Vein

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SECOND PART-AXILLARY ARTERY(RELATIONS)

IN FRONT-

• Pectoralis Minor, Pectoralis Major and its covering fascia and Overlying Skin

BEHIND-

• Posterior Cord of Brachial Plexus and Subscapularis Muscle

LATERAL-

• Lateral Cord of Brachial Plexus

MEDIAL

• Medial Cord of Brachial Plexus
• Axillary Vein              

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THIRD PART-AXILLARY ARTERY(RELATIONS)

IN FRONT

• Pectoralis Major in the Upper part where it is crossed by the Medial root of Median Nerve

BEHIND

• Subscapularis, Latissimus Dorsi & Teres Major
• Axillary & Radial Nerves

LATERALLY

• Lateral root and trunk of Median Nerve.
• Musculocutaneous Nerve & Coracobrachialis Muscle

MEDIALLY

• Axillary Vein,Medial Cutaneous Nerve of Forearm & Ulnar Nerve

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BRANCHES

FIRST PART

• SUPERIOR THORACIC ARTERY

SECOND PART

• THORACO ACROMIAL ARTERY            
• LATERAL THORACIC ARTERY

THIRD PART

• SUBSCAPULAR ARTERY
• ANTERIOR CIRCUMFLEX HUMERAL ARTERY
• POSTERIOR CIRCUMFLEX HUMERAL ARTERY   

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SUPERIOR THORACICARTERY

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THORACO ACROMIAL ARTERY - Pierces The Clavipectoral Fascia.

• Divides Into Four Branches. (1)pectoral. (2)acromial. (3)clavicular. (4)deltoid.

LATERAL THORACIC ARTERY - Provides a large lateral Mammary branches in Females

• Alar Thoracic Artery –Occasionally arises from the 2nd Part & supplies Axillary Lymph Nodes & Fat

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 SUBSCAPULAR ARTERY

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 ANTERIOR CIRCUMFLEX HUMERAL ARTERY

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POSTERIOR CIRCUMFLEX HUMERAL ARTERY

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AXILLARY ARTERY- CLINICAL CORRELATION

• To stop bleeding, Axillary artery – compressed against the humerus
• Aneurysm
• Scapular anastomosis
• Coronary bypass graft

ANASTOMOSIS AROUND SCAPULA

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AXILLARY VEIN

• Origin - Begins as a continuation of basilic vein and a pair of venae commitantes of the brachial artery
• Extent - lower border of teres major and ends at the outer border of the 1st rib
• Termination - contiuous with the subclavian vein.

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AXILLARY VEIN

• Lie on the medial side of axillary artery
• Tributaries
  • Corresponding to the branches of axillary artery
  • Cephalic vein

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AXILLARY VEIN- CLINICAL CORRELATION

• Axillary arch & during abduction of arm(compression by Subclavius) - Spontaneous thrombosis of axillary vein
• During mastectomy →Post operative thrombosis
• Thoraco-epigastric vein
• Communication between Delto - pectoral vein & External jugular vein
• Injury to axillary vein - Air embolism

BRACHIAL PLEXUS

• Cords and branches lie in axilla
• Three cords – lateral, medial and posterior
• Relation of cords – cords lie in relation to axillary artery
  • First part – medial cord posterior to A ,lateral and posterior cord lateral to A
  • Second part – cords lie in respective positions of A
  • Third part – branches will lie around the artery

BRACHIAL PLEXUS

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AXILLARY LYMPH NODES

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LYMPH NODES OF AXILLA

• 20 to 30 nodes lie in axillary fad of fat
• Divided into five groups
  • Anterior or pectoral group
  • Posterior or Subscapular group
  • Lateral or Brachial group
  • Central group
  • Apical group
• Surgeons include interpectoral or Rotter’s nodes as the 6th group 

LYMPH NODES OF AXILLA

• Drain lymphatics from breast, upper limb & superficial lymphatics of upper thoraco abdominal wall
• Lymph nodes also grouped into
  • level I – lateral to the lower border of pectoralis minor
  • Level II - deep to pectoralis minor,
  • level III- medial to the upper border of pectoralis minor
• Sentinel lymph node – nodes first involved in cancer – for Ca breast level 1

AXILLARY LYMPH NODES – CLINICAL CORRELATION

• CA- Axillary tail of breast-misdiagnosed as enlarged lymph node
• LN enlargement - Compression of Intercosto - brachial nerve
• Sentinel lymph node
• Axilla is exposed and lymph nodes are dissected both for staging & treatment for Ca breast after mastectomy
• Axillary nodes are palpated by bimanual examination
• Axillary abscess
• CA – painless enlargement    Infection - painful enlargement