Axilla

1. Arterial anastomoses around Scapular- Collateral circulation

a. Ligation of lacerated subclavian/axillary artery
i. Axillary artery ligated btwn 1st rib and subscapular artery
ii. Vascular sternosis (artherosclerotic lesion reduce bld flow)
iii. (a & b) reverse direction of bld flow in subscapular artery
b. Surgical ligation of axillary artery btwn subscapular artery and profunda
brachii
i. Bld supply cut frm arm (collateral circulation inadequate although
potential collateral pathways/peri-articular anastomoses exist ard
shoulder joint and elbow joint)
c. Occlusion (slow) => Sufficient time for collateral circulation to develop
i. Ischaemia (loss of bld supply) prevented
d. Occlusion (Sudden) => insuff time for adequate collateral circulation to
develop
i. inadequate bld supply to arm, forearm, hand
2. Dissection of Axillary Lymph Nodes
a. Used to stage breast cancer to determine appropriate treatment
b. Lymphedema (swelling due to accumulated lymph esp in subcutaneous
tissue)
c. Nerves at risk of injury:
i. Long thoracic nerve- supplies serratus anterior
1. nerve identified and maintained against thoracic wall during
surgery
2. Cutting of nerve Winged scapular
ii. Thoracodorsal Nerve- supplies Latissimus Dorsi
1. damage of nerve
a. Weakened medial rotation
b. Weakened adduction
2. No deformity
3. Nerve may have to be sacrificed if nodes around nerve are
obviously malignant. (Nodes resected to incr likelihood of
complete removal of all malignant cells)
d. Recall: Mastectomies may cause damage to thoracodorsal nerve
3. Enlargement of axillary lymph nodes- Lymphangitis (inflammation of lymphatic
vessels,
a. Cause: infection in UL
b. Result:
i. Axillary nodes tender and inflamed (humeral nodes usually first to be
involved)
ii. Warm, tender red streaks in skin of limb
iii. Infectious in:
1. Pectoral region
2. Breast
3. Superior abdomen
iv. Enlargement of axillary nodes
c. In metastatic Cancer of apical group
i. Nodes adhere to axillary vein need to excise tt part of axillary vein
ii. Enlargement of apical nodes obstruction of Cephalic vein superior to
pec minor
4. Role of Axillary Vein in Subclavian Vein Puncture
a. Clinical Significance:
i. Axillary Vein lies anteriorly and inferiorly to axillary artery and brachial
plexus
b. Procedure:

i. Subclavian Vein puncture= Catheter placed into subclavian vein

ii. Punctured (point of entry) is terminal part of axillary vein
c. Risk/ Complications:
i. Pneumothorax (pierces pleura and lung when not done carefully)
5. Brachial Plexus block
a. Enables surgeons to conduct surgeries using local anaesthetic vs generalised
anaesthetic
b. How it works:
i. Anaesthetic solution injected directly into/surrounding axillary sheath
disrupt conduction of impulses of peripheral nerves anaesthesia of
structures supplied by peripheral nerves (branches of cords of plexus)
ii. Sensation blocked in deep structures of UL
iii. Sensation blocked in Skin distal to middle of arm
iv. Combined w occlusive tourniquet to retain anaesthetic agent
c. Methods of procedure/Approach:
i. Interscalene
ii. Supraclavicular
iii. Axillary
6. Variations in Brachial Plexus- Prefixed, postfixed brachial plexus (variations can
occur in all areas/ forms but end roots usually the same for plexuses tt are
functioning normally)
a. Prefixed Brachial Plexus (anterior rami of C4-C8)
b. Postfixed Brachial Plexus (C6-T2)
i. Inferior trunk of plexus may be compressed by first rib
7. Compression of Axillary Artery axillary artery can be palpated in inferior lateral
wall of axilla
a. 3rd part of axillary artery compressed against humerus to stop profusive
bleeding (eg stabbed/ bullet wound)
b. If need to be compressed at more proximal site,1 st part of axillary artery is
compressed
i. Compressed at origin (subclavian artery crosses 1 st rib)
ii. Exert downward pressure in angle btwn clavicle and inferior attachment
of sternocleidomastoid muscle
8. Aneurysm of Axillary Artery (enlargement of first part of axillary artery)
a. Trunks of Brachial Plexus compressed (in all areas of skin supplied by the
affected nerves)
i. Pain
ii. Anesthesia
b. At Risk: (rapid and forceful arm movements)
i. Baseball pitchers
ii. Football quaterbacks
9. Injuries to axillary vein- Air emboli (air bubbles in bld dangerous) or profuse
bleeding
a. Axillary Vein large and exposed
b. Overlaps axillary artery anteriorly when arm fully abducted
10.
Brachial Plexus Injuries(****)
a. Affect:
i. Movements
ii. Cutaneous sensations
b. Causes:
i. Disease
ii. Stretching
iii. Wounds in lateral cervical region (posterior triangle of neck)
c. Result:
i. Paralysis
ii. Anesthesia

d. Test
i. degree of damage:
1. Complete paralysis:
a. No movement detectable
2. Incomplete paralysis:
a. Movements weak vs normal side
ii. Degree of anesthesia- Pinprick of skin
e. Types of Brachial Plexus injury
i. Superior part of Brachial Plexus injured (C5 and C6)
1. Cause: excessive increase in angle btwn neck and shoulder
a. Person lands on shoulder in a way that widely separates
neck and shoulder (think break-dancing)
b. Shoulder usually hits something and stops but head and
trunk continue to move (car accidents as well, T-bone
accidents)
i. Eg thrown off motorcycle/horse and lands on
shoulder
c. Excessive stretching of neck during delivery (in neonates)
2. Result: SUPERIOR roots of plexus avulsed (torn) frm spinal cord
or superior Brachial Plexus stretched/ ruptured
a. Erb-Duchenne Palsy/waiters tip position- Limb hangs by
the side in medial rotation (UL w adducted shoulder,
medially rotated arm and extended elbow)
i. Paralysis of muscles of shoulder supplied by C5 and
C6
1. Deltoid
2. Biceps
3. Brachialis
ii. Loss of sensation in lateral aspect of forearm
b. Backpackers Palsy similar signs of waiters tip
i. Caused by carrying heavy backpack for long period
of time
ii. Results in:
1. Motor sensory deficits in distribution of
musculocutaneous and radial nerve
2. Muscle spasms and severe disability (in
hikers)
c. Acute Brachial Plexus Neuritis (Brachial Plexus Neuropathya neurologic disorder of unknown cause)
i. Onsets after
1. Upper respiratory infection (why you so lazy
Ellen?!)
2. Vaccination
3. Non-specific trauma
ii. Characteristic: Sudden onset of severe pain
1. Around shoulder
2. Pain begins at night
3. Muscle weakness/neurologic amyotrophy
(muscle atrophy) follows after pain
ii. Compression of cords of brachial plexus- Cords compressed btwn
coracoid process of scapular and tendon of pectoralis minor tendon
1. Hyperabduction Syndrome (compression of axillary artery and
vein)
a. Ischaemia (compression decreased blood flow) of UL
b. Distension (enlargement) of superficial veins

2. Caused by: Prolonged hyper abduction of arm (hands raised

above head) eg painting ceiling
3. Neurologic symptoms:
a. Pain radiating down arm
b. Numbness
c. Paresthesia (tingling)
d. Erythema (redness of skin caused by capillary dilation)
e. Weakness of hands
iii. Inferior brachial plexus injury/Klumpke Paralysis- Claw Hand
(C8-T1) (less common)
1. Cause: UL suddenly pulled superiorly
a. Eg person grabs something to
break a fall
b. Eg babys UL pulled excessively
during injury
2. Result:
a. Roots avulsed from spinal cord
short muscles of hand affected
b. Damage to ulnar/median nerve affects literally all fingers.