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    Rotator Cuff

    The rotator cuff is the name given to the tendons of

    the subscapularis, supraspinatus, infraspinatus, andteres minor muscles, which are fused to theunderlying capsule of the shoulder joint.

    The cuff plays a very important role in stabilizing the

    shoulder joint. The tone of these muscles assists in holding the head

    of the humerus in the glenoid cavity of the scapuladuring movements at the shoulder joint.

    The cuff lies on the anterior, superior, and posterioraspects of the joint.

    The cuff is deficient inferiorly, and this is a site ofpotential weakness.

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    Clinical Notes

    Shoulder Dislocation

    The shoulder joint is the most commonly

    dislocated large joint, either anterior or

    posterior.

    Anterior inferior dislocation is the most

    common.

    Posterior dislocations are rare. It can causedamage to the axillary nerve.

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    2- Sternoclavicular joint

    Occurs between the sternal end of the

    clavicle, the manubrium sterni, and the 1st

    costal cartilage.

    It is a synovial double plane joint

    The joint is innervated by the supraclavicular

    nerve and the nerve to subclavius muscle.

    Movements are forward and backward,

    elevation and depression.

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    3- Acromioclavicular joint

    Occurs between the acromion process ofscapula and the lateral end of the clavicle.

    It is a synovial plane joint.

    The joint is innervated by the suprascapularnerve.

    Movement is a gliding movement takes place

    when the scapula rotates, or when the clavicleis elevated or depressed.

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    3

    AXILLA

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    The axilla, or the armpit, is a pyramid-shapedspace between the upper part of the arm and

    the side of the chest.

    It forms an important passage of nerves,blood, and lymph vessels as they travel from

    the root of the neck to the upper limb.

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    We have to discuss:

    APEX

    BASE

    MEDIAL WALL LATERAL WALL

    ANTERIOR WALL

    POSTERIOR WALL

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    Apex

    It is the upper end of axilla.

    It is directed into the root of the neck and is

    bounded in front by the clavicle, behind by the

    upper border of the scapula, and medially by

    the outer border of the 1st rib.

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    Base

    It is the lower end of axilla.

    It is formed by the skin stretching between the

    anterior and posterior walls.

    It is bounded in front by the anterior axillary fold (formed by the lower border of pectoralis major

    muscle ), behind by the posterior axillary fold

    (formed by the tendon of latissimus dorsi and the

    teres major muscle ) , and medially by the chest wall.

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    Anterior wall

    It is formed by the pectoralis major,

    subclavius, and pectoralis minor muscles, theclavipectoral fascia, and the suspensory

    ligament of the axilla.

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    Posterior wall

    It is formed by the subscapularis, latissimus

    dorsi, and teres major muscles from above

    down.

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    Medial wall

    It is formed by the upper four ribs and the

    intercostal spaces covered by the serratus

    anterior muscle.

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    Lateral wall

    It is formed by the coracobrachialis and biceps

    muscles in the bicipital groove of the

    humerus.

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    Contents of the axilla

    Axillary artery and its branches.

    Axillary vein and its tributaries.

    Lymph vessels and lymph nodes

    Brachial plexus

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    Axillary artery

    It begins at the lateral border of the 1st rib as acontinuation of the subclavian, and ends at the lower

    border of teres major muscle, where it continues as

    the brachial artery.

    Throughout its course, the artery is closely related to

    the cords of brachial plexus and their branches and is

    enclosed with them in a connective tissue sheath,

    called the axillary sheath. This sheath is acontinuation of the prevertebral fascia.

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    Axillary artery is divided into three parts

    according to its relations with pectoralis

    minor muscle.

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    1st part of axillary artery

    It extends from the lateral border of the 1st rib

    to the upper border of the pectoralis minor.

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    2nd part of axillary artery

    It lies behind the pectoralis minor muscle.

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    3rd part of axillary artery

    It extends from the lower border of the

    pectoralis minor to the lower border of teres

    major.

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    Branches The branches of the axillary artery supply the chest

    wall and shoulder.

    the 1st, 2nd and 3rd parts give off one, two andthree branches respectively:

    1st part: (1) superior thoracic artery2nd part: (1) thoracoacromial trunk

    (2) lateral thoracic artery

    3rd part: (1) subscapular artery

    (2) anterior circumflex humeral artery

    (3) posterior circumflex humeral artery

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    Axillary vein

    It is formed in the region of the lower border of theteres major muscle by the union of the venae

    comitantes of the brachial artery and the basilic vein.

    It runs upward on the medial side of the axillary

    artery and ends at the outer border of the 1st rib bybecoming the subclavian vein.

    The vein receives tributaries, which correspond to

    the branches of axillary artery, and, in addition, it

    receives the cephalic vein.

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    4

    Brachial Plexus

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    Nerves entering the upper limb provides the

    following functions:

    1- sensory innervation to the skin and deep

    structures, such as joints.

    2- motor innervation to the muscles.

    3- sympathetic vasomotor nerves.

    4- sympathetic secretomotor supply to the

    sweat glands.

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    The brachial plexus is formed in the posterior triangleof the neck by the union of the anterior rami of the

    5th

    , 6th

    , 7th

    , and 8th

    cervical and the 1st

    dorsal spinalnerves.

    Roots, trunks and divisions lie in the posteriortriangle.

    The roots lie between the anterior and middlescalene muscles.

    The trunks traverse the posterior triangle of theneck.

    The divisions lie behind the clavicle.

    The cords lie in the axilla.

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    The plexus is formed as follows:

    1- five roots derived from the anterior rami of

    C5, 6, 7, 8 and T1; link up into:

    2- three trunks formed by the union of

    C5 and 6 (upper)C7 alone (middle)

    C8 and T1 (lower) ( lower trunk lies behind

    the 3rd

    part of subclavian artery)trunks split into:

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    3- six divisions formed by each trunk dividinginto an anterior and posterior

    division; which link up again into:

    4- three cords

    a lateral, from the fused anterior divisions of

    the upper and middle trunks; a medial, from the anterior division of thelower trunk;

    a posterior, from the union of all threeposterior divisions.

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    The three cords lie above and lateral to the 1st part of

    the axillary artery.

    The medial cord crosses behind the artery to reach themedial side of the 2nd part of the artery.

    The posterior cord lies behind the 2nd part of the artery.

    The lateral cord lies on the lateral side of the 2nd part of

    the artery.

    Thus, the cords of the plexus have the relationship to

    the 2nd part of the axillary artery that is indicated by

    their names.

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    Branches of the different parts of the

    brachial plexus

    A- Branches of the roots:

    1- Dorsal scapular nerve (C5)

    2- Long thoracic nerve (C5,6,7)

    B- Branches of the upper trunk:

    1- Nerve to subclavius (C5,6).

    2- Suprascapular nerve (C5,6).

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    C- Branches of the lateral cord:

    1- Lateral pectoral nerve (C5-7)

    2- Musculocutaneous nerve (C5-7)

    3- lateral root of med