Shoulder/Arm Group #3 (Rhomboid Major and minor, levator scapula, serratus anterior, pec major and minor, subclavius)

Lymphatic drainage of the breast

- Axillary lymph nodes - medial portion of Breast drains into parasternal nodes and superficial lymphatic pathways talk w/ app breast and abdominal lymphatics

Deltopectoral triangle

AKA clavipectoral triangle -Deltoid, pectoralis Major, and clavicle form triangle - Contains cephalic (enters with deltoid branch of thoracromial artery) - it and medial/lateral pectoral nerves exit

Actions of Serratus Anterior

Abducts scapula Upward scapular rotation Depresses scapula Holds medial border of scapula to rib cage

Actions of Rhomboid Major (AED)

Adduct Scapula Downward scapular Rotation

Action of Pec Major

Adduct Shoulder IR Elevate thorax during inhalation Flex shoulder (upper fibers) -clavicular head Horizontally adduct (upper fibers) Extends shoulder (lower fibers) -Sternocostal head

Action of rhomboid minor

Adduct scapula Scapular downward rotation

Breast fat

Amount determines size of breast Upper right: 60% Upper left: 15% Lower right: 10% Lower left: 5% Nipple: 10%

Intercostal Nerve

Anterior and lateral cutaneous branches

Intercostobrachial Nerve

Branches from 2nd and 3rd lateral cutaneous branches extend into the axilla and medial arm - Joints with medial brachial cutaneous Nn

Innervation of levator scapulae

Cervical Nerve (C3-C4) Dorsal scapular Nerve(C5)

Insertion of Subclavius

Clavicle (inferior surface, middle 1/3)

Pectoralis Major Origin

Clavicle (medial 1/2) - anterior surface Sternum -Anterior surface Costal Cartilage of ribs 1-6 Aponeurosis of external oblique muscle

Blood supply to subclavius

Clavicular branch of thoracoacromial artery

Pec Minor Insertion

Coracoid process -medial border and superior surface

Acromial Branch of Thoracromial Artery

Courses around the coracoid process beneath deltoid - Provides br. to deltoid musc. and ends on acromion

Pectoral fascia

Covers pec major - inferior with anterior abdominal wall fascia - leaves lateral border of pec major to become axillary fascia

Clavipectoral fascia

Covers subclavius and pec minor

Deltoid branch of Thoracromial Artery

Crosses pec minor to run along the cephalic vein b/t deltoid and pectoralis major

clavipectoral fascia

Deep to pectoral fascia and descends from clavicle - Encloses subclavius m. and then the pectoralis minor and is inferior with the axillary fascia as well

Actions of Pec Minor

Depresses Scapula -inferior and anterior Abducts Scapula Downward Scapular Rotation

Actions of Subclavius

Depresses clavicle Elevates clavicle Stabilizes SC joint

Actions of Serratus posterior Inferior

Depresses ribs 9-12 (expiration) - Aerobic activity

Actions of Serratus posterior inferior

Depresses scapula

lactiferous sinuses

Dilated portion of lactiferous ducts

Innervation of Rhomboid Major

Dorsal Scapular (C5)

Innervation of rhomboid minor

Dorsal scapular (C5)

Blood Supply to Rhomboid Major

Dorsal scapular Artery

Blood supply of Levator scapulae

Dorsal scapular Artery

lactiferous ducts

Drain lobules; opens onto nipple

Actions of Serratus Posterior Superior

Elevates scapula

Serratus Posterior superior Action

Elevates superior ribs - inspiration

Serratus anterior Origin

External (lateral) surfaces of lateral parts of ribs 1-8

(Breast Composition: Glandular tissue)

Glandular tissue (modified sweat gland) 15-20 lobules

Serratus posterior inferior insertion

Inferior border of ribs 9-12

Medial Winging

Injured Nerve: Long Thoracic Muscle palsy: Serratus Anterior Physical Exam: Arm Flexion; Push-up motion against a wall Postion of scapula: Entire scapula displaced more medial and superior

Lateral Winging

Injured Nerve: Spinal accessory Muscle palsy: Trapezius Physical Exam: Arm abduction; ER against resistance Position of scapula: Superior angle more laterally displaced

Subclavius Origin

Junction of 1st rib and its costal cartilage (surrounded by clavipectoral fascia)

Lateral pectoral nerve

Larger than medial - Arises from lateral brachial plexus (C5-C7_ - Course on undersurface of pec major - pierces clavipectoral fascia

Blood Supply of Serratus Anterior

Lateral Thoracic Artery (upper part) Thoracodorsal artery (lower part)

Pec Major insertion

Lateral lip of inter tubercular sulcus of humerus

Innervation of Pec Major

Lateral/medial pectoral( C5, C6, C7, C8, T1)

Deep Muscles

Levator Scapulae Rhomboid major and minor Triceps Brachii

Innervation of Serratus Anterior

Long Thoracic Nerve (C5-C7)

Rhomboid Major Insertion

Medial border of scapula - Between spine and inferior border

Insertion of Serratus Anterior

Medial border of scapula (anterior surface) - same as rhomboids

Levator Scapulae Insertion

Medial border of scapula (superior angle)

Innervation of Pec minor

Medial pectoral nerve (C8-T1) - PIERCES and lies lateral

boundaries of breast

Medial: Lateral border of sternum lateral: midaxillary line Superior: 2nd rib inferior: 6th rib Posterior: deep fascia of pectoralis mm and Serratus anterior

Scapular Winging

Most common cause is damage to the long thoracic nerve

Thoracromial artery (atlas pg 379-381)

One fo 2 branches of 2nd part of Axillary Aa - courses pec minor area of upper chest - pierces clavipectorla fascia into 4 branches

Blood supply of Pectoralis major

Pectoral branch of Thoracromial artery

Levator scapulae Origin

Posterior tubercles of the Tranverse Processes of C1-C4

Pectoralis Minor Origin

Ribs 3-5 -near costal cartilages (surrounded by clavipectoral fascia)

Actions of Levator scapulae

Scapular elevation Downward scapular rotation Lateral flexion of neck Rotates neck Extends neck

Rhomboid Minor Origin

Spinous Processes of C6,C7 Nuchal Ligament

Serratus Posterior Superior Origin

Spinous processes of C7-T3 vertebrae

Rhomboid Major Origin

Spinous processes of T1-T4

Serratus posterior inferior origin

Spinous processes of T11-L2 vertebrae

Innervation of Subclavius

Subclavian nerve (C5-C6)

Insertion of Serratus posterior superior

Superior border of ribs 2-4

Arterial supply of the breast

Superolaterally branches from the lateral thoracic Aa - Long thoracic Nn accompanies this artery

Internal thoracic Artery

Supplies breast superomedially

Superficial Muscles

Trapezius Infraspinatus Deltoid Teres Minor and major Serratus Anterior

Innervation of Serratus posterior superior

Ventral rami of intercostal nerve (T2-T5)

Innervation of Serratus posterior inferior

Ventral rami of intercostal nerve (T9-T12)

Medial pectoral nerve

arise from medial Brachial plexus (C8,T1) - goes behind axillary Aa and around to unite in front with the lateral Nn - Enters pec minor and some branch into major

Lateral thoracic artery of Thoracromial Artery

Other of the 2 branches of 2nd part of Axillary Artery (Thoracoacromial 1st branch) - descends along axillary border of pec minor - follows onto thoracic wall and supplies lateral aspect of breast and serratus anterior

Blood Supply to Pec minor

Pectoral branch of thoracromial artery

Superficial to deep structures of pectoral region structures

Pectoral fascia Pectoralis major Clavipectoral fascia Pectoralis minor - More superficial to deep

Scapular winging and purpose of Serratus Anterior

Serratus Anterior protracts, upwardly rotates scapula and keeps it closely opposed to thoracic wall - Optomizes position of glenoid and helps max ROM

Clavicular branch of Thoracromial Artery

Serves sternoclavicular joint - Courses b/t the clavicular head of pec major and clavipectoral fascia ** supplies subclavius Mm

Blood supply to serratus posterior inferior

Superior intercostal Artery

Blood supply to Serratus Posterior Superior

Superior intercostal artery

Quadrants of the breast

Superolateral Superomedial Inferolateral Inferomedial - Superolateral segment contains axillary tail and 50% of breast cancer occurs here

Insertion of Rhomboid Minor

root of scapular spine