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Pectoral Region and Axilla Important

Doctors Notes
Notes/Extra explanation
Editing File
Objectives
By the end of the lecture the students should be able to :
Identify and describe the muscles of the pectoral region.
I. Pectoralis major.
II. Pectoralis minor.
III. Subclavius.
IV. Serratus anterior.
Describe and demonstrate the boundaries and contents of the axilla.
Describe the formation of the brachial plexus and its branches.
 The movements of the upper limb
Note: differentiate between the different regions

Flexion & extension of Flexion & extension of Flexion & extension of

wrist = hand elbow = forearm shoulder = arm = humerus
 I. Pectoralis Major
Origin 2 heads
Clavicular head: From
Medial ½ of the front of the clavicle.
Sternocostal head: From;
Sternum.
Upper 6 costal cartilages.
Aponeurosis of the external oblique muscle.

Insertion Lateral lip of bicipital groove (humerus)*

Costal cartilage (hyaline
Nerve Supply Medial & lateral pectoral nerves. cartilage that connects the
ribs to the sternum)
Action Adduction and medial rotation of the arm. Recall what we took in foundation:
Only the clavicular head helps in flexion of arm Muscles are attached to bones /
(shoulder). ligaments / cartilage by
1) tendons
* 3 muscles are attached at the bicipital groove: 2) aponeurosis
Latissimus dorsi, pectoral major, teres major 3) raphe
Extra
Extra picture for understanding
 II. Pectoralis Minor
Origin From 3rd ,4th, & 5th ribs close to their costal
cartilages.

Insertion Coracoid process (scapula)*

3
Nerve Supply Medial pectoral nerve. 4
Action 1. Depression of the shoulder. 5
2. Draw the ribs upward and outwards during
deep inspiration.

*Don’t confuse the coracoid process on the

scapula with the coronoid process on the ulna
Extra
 III. Subclavius
Origin From 1st rib at its junction with the 1st costal
cartilage
Insertion Subclavian groove in the middle 1/3 of the
inferior surface of clavicle.

Nerve Supply Nerve to subclavius from upper trunk of

brachial plexus

Action Fixes the clavicle during movement of shoulder

joint.
(pulls the clavicle medially to stablize sternoclavicular joint)
 Clavipectoral Fascia

o It is thickened membrane of deep fascia*

(between subclavius & pectoralis minor).

o It is pierced (‫ )مثقوب‬by :
1- Lateral pectoral nerve.
2- Thoraco-acromial artery.
3- Cephalic vein.
4- Few lymph vessels.
*(fascia = connective tissue)

Extra picture for

understanding
IV. Serratus anterior
Origin Upper eight ribs.

Insertion anterior aspect of the medial border and

inferior angle of scapula (the blue part).

Nerve Supply Long thoracic nerve (from roots of brachial plexus,C5,6,7).

(also called nerve of Bell / nerve to serratus anterior)
Action 1. Draws the scapula forward in boxing (protrusion or
protraction)*. "boxer's muscle"
2. Rotates scapula outwards in raising the arm above 90
degree (Abduction above 90) with trapezius.
*Don’t confuse protraction and retraction.
Retraction (when you wake up and are yawning)
Protraction (when you extend your arm like when punching someone or boxing
hence the name boxers muscle)
Causes of Winging of Scapula:
1) Dislocation of shoulder joint.
2) Lesion of long thoracic nerve and paralysis of Serratus anterior muscle (The long thoracic nerve runs on the
anterolateral chest wall usually. It is damaged in radical mastectomy operations or injury of chest wall).
Radical mastectomy is a surgical procedure in which the breast, underlying chest muscle, and
lymph nodes of the axilla are removed as a treatment for breast cancer.
Axilla
o A pyramid-shaped space between the upper part
of the arm and the side of the chest (‫)منطقة اإلبط‬
o It’s the space through which major
neurovascular structures pass between neck &
thorax and upper limbs.

The Axilla has:

A. Apex
B. Base
C. Four Walls:
1.Anterior,
2. Posterior,
3.Medial,
4.Lateral wall Extra picture
for understanding
Boundaries of The Axilla:
A. Apex:
o It’s called Cervicoaxillary canal (through which the
neurovascular structures pass)

o It is directed upwards and medially into the

root of the neck.

o The Apex is bounded by 3 bones:

1. Clavicle anteriorly.
2. Upper border of the scapula posteriorly.
3. Outer border of the first rib medially.

The picture in the previous slide shows the exact

location of the apex (cervicoaxillary canal)
Boundaries of The Axilla:

B. Base:
o Formed by skin stretching between the anterior
and posterior walls. 1

o The base is bounded:

1. In front by the anterior axillary fold (formed
by the lower border of the Pectoralis major).
2. Behind by the posterior axillary fold (formed
by the tendons of latissimus dorsi and teres
major muscles).
3. Medially by upper 4 or 5 ribs and the chest 2 Formed by

wall.
 Boundaries of The Axilla:
C. Four Walls:
1. Anterior wall 2. Posterior wall
It is formed by: It is formed by:
1) Pectoralis major 1) Subscapularis
2) Pectoralis minor 2) Latissimus dorsi
3) Subclavius 3) Teres major muscles
4) Clavipectoral fascia

Clavipectoral
fascia.

subclavius Pectoralis major

Pectoralis
minor
Boundaries of The Axilla:
C. Four Walls:
3. Medial wall 4. Lateral wall
It is formed by: It is formed by:
1) Serratus anterior 1) Coracobrachialis
2) Upper 4-5 ribs and 2) Biceps brachii
intercostal muscle 3) Bicipital/ intertubercular
groove of the humerus
Contents of The Axilla
o Cords and branches of brachial plexus
o Axillary artery and its branches
o Axillary vein and its tributaries
o Axillary lymph nodes
o Axillary fat
o Loose connective tissue

 The neurovascular bundle is enclosed in

loose connective tissue sheath, called
axillary sheath

Extra picture for understanding

Brachial Plexus
What is a brachial plexus?
Brachial Plexus is a network of nerves that
present at the root of the neck to enter the
upper limb.

Location & Formation:

o It is present in the posterior triangle of
the neck & axilla.

o It is formed by the union of the anterior

Rami of the C 5th, 6th, 7th, 8th, and the 1st
thoracic spinal nerve.

The posterior triangle consists of: 1) clavicle Remember in the spine we only have 7 cervical
2) sternocleidomastoid muscle 3) trapezius vertebra BUT there are 8 cervical spinal nerves.
Brachial Plexus Note:
The first 2 stages lie in
the posterior triangle,
while the last 2 stages
lie in the axilla.
Brachial Plexus
Stages:-
Roots of C5 & C6 unite to form Superior trunk

Roots of C7 continues as the Middle trunk

Roots of C8 & T1 unite to form Inferior trunk

Each trunk will branch into anterior and posterior division

-The anterior divisions of the upper and middle trunks

unite to form the Lateral cord.
-The anterior division of the lower trunk continues as
the Medial cord.
-All the posterior divisions of three trunks join to form the
Posterior cord.
Cords are named according to their relation to the 2nd part
of the axillar artery.
Brachial Plexus
The brachial plexus branches from the

Cords
Roots Trunks
Lateral cord (3) Medial Cord (5) Posterior Cord (5)

Dorsal scapular nerve (C5) Suprascapular nerve (C5,C6) Lateral pectoral nerve Medial pectoral nerve Axillary nerve.

Long thoracic nerve To subclavius muscle (C5,C6) Musculocutaneous nerve Ulnar nerve Radial nerve

Note: what is in the boxes should be Median nerve (lateral Median nerve (medial Upper & lower subscapular
memorized root). root) nerves

Medial cutaneous Thoracodorsal or N. to

nerve of arm & latissimus dorsi
forearm

Mnemonic (Team 433)

Lateral Cord Branches: LLM "Lucy Loves Me“
Lateral pectoral, Lateral root of the median nerve,
Musculocutaneous.
Medial Cord Branches: MMUM "Most Men Use Morphine“
Medial pectoral, Medial cutaneous nerve of arm and forearm,
Ulnar, Medial root of the median nerve.
Posterior cord branches STAR
Subscapular (upper and lower), Thoracodorsal, Axillary, Radial
Questions
1- Which of the following statements is NOT correct: 5- Which wall is formed (partly) by the clavipectoral fasica?
A- The base of axilla is bounded posteriorly by the pectoralis A- Anterior
major. B- Posterior
B- The base of axilla is bounded medially by the 4 or 5th rib. C- Medial
C- The apex of the axilla is bounded by 3 bones (clavicle, scapula D- Lateral
and the 1st rib).
D- The apex is called cervicoaxillary canal. 6- In the brachial plexus all the posterior divisions of the three
trunks join to form ______.
2- The lateral wall of the axilla does not contain: A- Lateral cord
A- biceps brachii B- Posterior cord
B- upper 4-5 ribs and intercostal muscles C- Lateral root
C- bicipital groove of the humerus D- Posterior root
D- coracobrachialis
7- Which cord gives rise to the musculocutaneous nerve?
3- Which of the following is located between subclavius and A- Anterior cord
pectoralis minor? B- Posterior cord
A- Serratus anterior C- Medial cord
B- Axilla D- Lateral cord
C- Clavipectoral Fascia
D- Brachial Plexus 8- A patient presents to the ER with inability to depress his Answers:
shoulders. The physician suspects nerve involvement ,which 1- A
2- B
4- What is the nerve supply of Serratus anterior? nerve is most likely damaged?
3- C
A- Lateral pectoral nerve. A- Medial pectoral nerve
4- B
B- Long thoracic nerve. B- Lateral pectoral nerve
5- A
C- Musculocutaneous nerve. C- Anterior pectoral nerve
6- B
D- Ulnar nerve. D- Posterior pectoral nerve 7- D
8- A
Questions
9- List the main terminal nerves of the brachial plexus.

10- A boxer presented to the ER with inability to punch. Which muscle is most likely affected and what
nerve supplies this muscle?

11- Name one muscle responsible for depression of the shoulder, and mention its origin and insertion.

12- What are the contents of the axilla?

13- A Soldier was shot on the chest and the shot has effected a nerve , what might happen to him?
Answers:
9- Median, ulnar, radial, axilla and musculocutaneous.
10- Serratus anterior supplied by long thoracic nerve.
11- Pectoralis minor. Origin (Close to the costal cartilage of ribs 3, 4, 5) Insertion (coracoid process)
12- 1) Cords and branches of brachial plexus
2) Axillary artery and its branches
3) Axillary vein and its tributaries
4) Axillary lymph nodes
5) Axillary fat
6) Loose connective tissue
13- Winging of scapula
Summary (Pectoral Region)
Muscle Origin Insertion Nerve supply Action

Pectoralis Clavicular head: From; Lateral lip of bicipital Medial & lateral (1) Adduction of the arm
Major (1) Medial ½ of the front of the groove (Humerus). pectoral nerves (2) medial rotation of the arm.
clavicle. (3) Clavicular head helps in flexion of
Sternocostal head: From; arm (shoulder).
- Sternum.
- Upper 6 costal cartilages.
- Aponeurosis of the external oblique
muscle.
Pectoralis From 3rd ,4th, & 5th ribs close to their Coracoid process Medial pectoral (1) Depression of the shoulder.
Minor costal cartilages. (scapula). nerve (2) Draw the ribs upward and
outwards during deep inspiration.

Subclavius From 1st rib at its junction with 1st Subclavian groove in Nerve to subclavius (1) Fixes the clavicle during
costal cartilage. the middle 1/3 of the from upper trunk of movement of shoulder joint
inferior surface of brachial plexus.
clavicle.
Serratus Upper eight ribs. (1) anterior aspect of Long thoracic nerve (1) Draws the scapula forward in
anterior the medial border of (from roots of boxing, (protrusion or protraction).
inferior angle of brachial "boxer's muscle"
scapula. plexus,C5,6,7). (2) Rotates scapula outwards in
raising the arm above 90 degree
(Abduction above 90)
Summary (Axilla)
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