The pectoral region

This is a region located at the anterior chest wall.

It contains four muscles that exert a force on the upper limb:
1. the pectoralis major,
2. pectoralis minor,
3. serratus anterior and
4. subclavius.
All these muscles are located beneath the breast region

Pectoralis Major
The pectoralis major is the most superficial muscle in the pectoral
region. It is large and fan shaped, and is composed of a sternal
head and a clavicular head:
Attachments:
Clavicular head – originates from the anterior surface of the
medial clavicle.
Sternocostal head – originates from the anterior surface of the
sternum, the superior six costal cartilages and the aponeurosis of
the external oblique muscle.
The distal attachment of both heads is onto the intertubercular
sulcus of the humerus.
Function: Adducts and medially rotates the upper limb and draws
the scapula anteroinferiorly. The clavicular head also acts
individually to flex the upper limb.
Innervation: Lateral and medial pectoral nerves.

Pectoralis Minor
The pectoralis minor lies underneath its larger counterpart muscle,
pectoralis major. Both muscles form part of the anterior wall of the
axilla region.
Attachments: Originates from the 3rd-5th ribs
and inserts into the coracoid process of the scapula.

Function: Stabilises the scapula by drawing it anteroinferiorly

against the thoracic wall.
Innervation: Medial pectoral nerve.

Serratus Anterior
The serratus anterior is located more laterally in the chest wall and
forms the medial border of the axilla region.
Attachments: The muscle consists of several strips, which
originate from the lateral aspects of ribs 1-8. They attach to the
costal (rib facing) surface of the medial border of the scapula.

Function: Rotates the scapula, allowing the arm to be raised over

90 degrees. It also protracts the scapula, holding it against the
ribcage.
Innervation: Long thoracic nerve.

Subclavius
The subclavius is small muscle, which is located directly
underneath the clavicle, running horizontally. It affords some
minor protection to the underlying neurovascular structures (e.g in
cases of clavicular fracture or other trauma).

Attachments: Originates from the junction of the 1st rib and its
costal cartilage. It inserts onto the inferior surface of the middle
third of the clavicle.
Function: Anchors and depresses the clavicle.
Innervation: subclavius Nerve

The shoulder girdle

This is also called the pectoral girdle, is an incomplete bony ring
formed by the clavicle and scapula on each side of the body, joined
anteriorly by the manubrium of the sternum.

The bones of the shoulder girdle articulate with each other and
partake in the formation of 4 joints that include:
The sternoclavicular joint - formed between the sternum and
clavicle.
The acromioclavicular (AC) joint - formed between the scapula and
the clavicle.
The glenohumeral (shoulder) joint - formed between the scapula
and humerus.
The scapulothoracic joint - formed between the scapula and the
posterior thoracic cage.
The shoulder girdle functions as the anchor that attaches the
upper limbs to the axial skeleton. Additionally, the shoulder girdle
allows for a large range of motion, mainly in the highly mobile
scapulothoracic joint.
Vascularization
Suprascapular and thoracoacromial arteries (acromioclavicular
joint)
Internal thoracic and suprascapular arteries (sternoclavicular joint)
Anterior and posterior circumflex humeral arteries (glenohumeral
joint)
Innervation
Subscapular, lateral pectoral, axillary nerves (acromioclavicular
joint)
Medial suprascapular nerve (sternoclavicular joint)
Axillary, suprascapular, lateral pectoral nerves (glenohumeral joint)
Functions
Forms a connection between upper limbs and thoracic cage;
Faciliates movements of the upper limb in the glenohumeral
(shoulder) joint.

Clavicular bone, Os claviculare

The clavicle, or collarbone, is an S-shaped long bone lying
superficial to the skin and is palpable along its entire length. In
conjunction with the scapula, it serves as a connection between
the axial and appendicular skeleton.
The clavicle is composed of a sternal (proximal) end, a shaft
(body) and a acromial (distal) end. The medial end of the clavicle
articulates with the manubrium of sternum (sternoclavicular joint),
while the acromial end articulates with the acromion of the
scapula (acromioclavicular joint).

The acromial and sternal ends of the clavicle contain several bony
landmarks that serve as attachment points for ligaments of their
respective joints. Likewise, the shaft of the clavicle acts as an
attachment site for several muscles, such as the trapezius, deltoid,
pectoralis major, and sternocleidomastoid muscles.
Scapula
The scapula, or shoulder blade, is a triangular flat bone that lies on
the posterolateral aspect of the thorax, overlying the 2nd – 6th or
7th ribs.
The convex posterior surface of the scapula is unevenly divided by
a thick projecting ridge of bone (spine of the scapula) into a small
supraspinous fossa and a much larger infraspinous fossa. The
spine continues laterally as the flat expanded acromion, which
forms the subcutaneous point of the shoulder and articulates with
the acromial end of the clavicle (acromioclavicular joint).

The concave anterior surface of the scapula forms a large

subscapular fossa, which forms a muscular connection with the
posterior thoracic cage (scapulothoracic joint).

Superolaterally, the lateral surface of the scapula contains the

glenoid fossa (Greek word meaning “Socket”), which articulates
with the head of the humerus to form the glenohumeral (shoulder)
joint. The glenoid fossa is a shallow, concave, oval cavity directed
anterolaterally and slightly superiorly, that is considerably smaller
than the ball (head of the humerus) for which it serves as socket.
The beak-like coracoid process is superior to the glenoid fossa
and projects anterolaterally.

The broad bony surfaces of the three fossae provide attachments

for several muscles. The spine and acromion serve as levers for
the attached muscles, particularly the trapezius muscle. The
glenohumeral (shoulder) joint is almost directly inferior to the
acromioclavicular joint, thus the scapula mass is balanced with
that of the free limb, and the suspending structure
(coracoclavicular ligament) lies between the two masses.

Joints
The bones of the shoulder girdle establish connections between
each other and other structures, forming 3 anatomical (true) joints,
and one physiological joint:
1. The sternoclavicular (SC) joint ;formed between the
manubrium of the sternum and the sternal end of the clavicle.
2. The acromioclavicular (AC) joint, formed by the acromion of
scapula and the acromial end of the clavicle.
3. The glenohumeral (shoulder) joint, formed between the
glenoid fossa of the scapula and the head of the humerus.
4. The scapulothoracic joint, formed between the anterior
surface of the scapula and the posterior thoracic cage. This
joint is not a true joint but rather a physiological joint
established by the several muscles, including the trapezius,
rhomboids and serratus anterior.

Clinical notes
Fracture of the clavicle
The clavicle is a long bone and fractures usually occur in its
middle portion. Occasionally, the bone will break where it attaches
at the ribcage (SC joint) or shoulder blade (AC joint). Clavicle
fractures are often caused by a direct blow to the shoulder. This
can happen during a fall onto the shoulder or a car collision. A fall
onto an outstretched arm can also cause a clavicle fracture. In
babies, these fractures can occur during the passage through the
birth canal.

Clavicle fractures can be very painful and may cause difficulty in

moving the arm. Additional symptoms include:
Sagging shoulder (down and forward)
Inability to lift the arm because of pain
A grinding sensation if an attempt is made to raise the arm
A deformity or "bump" over the fracture
Bruising, swelling, and/or tenderness over the collarbone
Fracture of the scapula
Fracture of the scapula is usually the result of severe trauma, as
occurs in pedestrian – vehicle accidents. Usually there are also
fractured ribs. Most fractures require little treatment because the
scapula is covered on both sides by muscles. Most fractures
involve the protruding subcutaneous acromion.

Other clinical conditions

Other clinical conditions of the pectoral girdle include:
Dislocation of the acromioclavicular joint
Dislocation of the glenohumeral joint

THE VENOUS DRAINAGE OF THE UPPER LIMB

THE ARTERIAL SUPPLY TO THE UPPER LIMB
is delivered via five main vessels (proximal to distal): Subclavian
artery, Axillary artery, Brachial artery, Radial artery, Ulnar artery
The venous system of the upper limb drains deoxygenated blood
from the arm, forearm and hand. It can be subdivided into the
superficial system and the deep system
Veins
The venous system of the upper limb drains deoxygenated blood
from the arm, forearm and hand. It can be subdivided into the
superficial system and the deep system.
Superficial Veins
The major superficial veins of the upper limb are the cephalic and
basilic veins. They are located within the subcutaneous tissue of
the upper limb.

Basilic Vein
The basilic vein originates from the dorsal venous network of the
hand and ascends the medial aspect of the upper limb.
At the border of the teres major, the vein moves deep into the arm.
Here, it combines with the brachial veins from the deep venous
system to form the axillary vein.
Cephalic Vein
The cephalic vein also arises from the dorsal venous network of
the hand. It ascends the antero-lateral aspect of the upper limb,
passing anteriorly at the elbow. At the shoulder, the cephalic vein
travels between the deltoid and pectoralis major muscles (known
as the deltopectoral groove), and enters the axilla region via the
clavipectoral triangle. Within the axilla, the cephalic vein empties
into axillary vein.
The cephalic and basilic veins are connected at the elbow by the
median cubital vein.

Deep Veins
The deep venous system of the upper limb is situated underneath
the deep fascia. It is formed by paired veins, which accompany
and lie either side of an artery. In the upper extremity, the deep
veins share the name of the artery they accompany.

The brachial veins are the largest in size, and are situated either
side of the brachial artery. The pulsations of the brachial artery
assist the venous return.
Perforating veins run between the deep and superficial veins of
the upper limb, connecting the two systems.
CLINICAL RELEVANCE
Venepuncture
Venepuncture is the practice of obtaining intravenous access.
This is usually for the purpose of providing intravenous therapy
(e.g. fluids, medications) or for obtaining a blood sample.
The median cubital vein is a common site of venepuncture. It is a
superficial vein that is located anteriorly to the cubital fossa
region. It is thought to be fixed in place by perforating veins, which
arise from the deep venous system and pierce the bicipital
aponeurosis.
Its ease of access, fixed position and superficial position make the
median cubital vein a good site for venepuncture in many
individuals."

LYMPHATIC DRAINAGE OF THE UPPER LIMB

The lymphatic system functions to drain tissue fluid, plasma
proteins and other cellular debris back into the bloodstream and is
also involved in immune defence.
Once this collection of substances enters the lymphatic vessels it
is known as lymph. It is subsequently filtered by lymph nodes,
from which it returns to the circulation via the venous system.

Lymphatic Vessels
Superficial Lymphatic Vessels
The superficial lymphatic vessels of the upper limb initially arise
from lymphatic plexuses in the skin of the hand (networks of
lymphatic capillaries beginning in the extracellular spaces). These
vessels then travel up the arm in close proximity to the major
superficial veins:
The vessels shadowing the basilic vein go on to enter the cubital
lymph nodes. These are found medially to the vein, and proximally
to the medial epicondyle of the humerus. Vessels carrying on from
these nodes then continue up the arm, terminating in the lateral
axillary lymph nodes.
The vessels shadowing the cephalic vein generally cross the
proximal part of the arm and shoulder to enter the apical axillary
lymph nodes, though some exceptions instead enter the more
superficial deltopectoral lymph nodes.
The lymphatic vessels of the hand. They give converge to produce
the superficial lymphatic vessels of the upper limb.
Deep Lymphatic Vessels
The deep lymphatic vessels of the upper limb follow the major
deep veins (i.e. radial, ulnar and brachial veins), terminating in the
humeral axillary lymph nodes. They function to drain lymph from
joint capsules, periosteum, tendons and muscles. Some additional
lymph nodes may be found along the ascending path of the deep
vessels.

Lymph Nodes
The majority of the upper extremity lymph nodes are in the axilla.
They can be divided anatomically into 5 groups:

Pectoral (anterior) – 3-5 nodes, located in the medial wall of the

axilla. They receive lymph primarily from the anterior thoracic wall,
including most of the breast.
Subscapular (posterior) – 6-7 nodes, located along the posterior
axillary fold and subscapular blood vessels. They receive lymph
from the posterior thoracic wall and scapular region.
Humeral (lateral) – 4-6 nodes, located in the lateral wall of the
axilla, posterior to the axillary vein. They receive most of the lymph
drained from the upper limb.
Central – 3-4 large nodes, located near the base of the axilla (deep
to pectoralis minor, close to the 2nd part of the axillary artery).
They receive lymph via efferent vessels from the pectoral,
subscapular and humeral axillary lymph node groups.
Apical – Located in the apex of the axilla, close to the axillary vein
and 1st part of the axillary artery. They receive lymph from efferent
vessels of the central axillary lymph nodes, therefore from all
axillary lymph node groups. The apical axillary nodes also receive
lymph from those lymphatic vessels accompanying the cephalic
vein.
Efferent vessels from the apical axillary nodes travel through the
cervico-axillary canal, before converging to form the subclavian
lymphatic trunk. The right subclavian trunk continues to form the
right lymphatic duct and enters the right venous angle (junction of
the internal jugular and subclavian veins) directly. The left
subclavian trunk drains directly into the thoracic duct.