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Platysma
sheetlike muscle in the neck
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Intercostal nerves
lateral and anterior cutaneous branches travel along with the intercostal artery and vein along the groove in the ribs
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Supraclavicular nerves
dervied from ventral rami of spinal nerve C3 and C4, descend deep into platysma to supplement innervation of the superior part of the pectoral region
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Cephalic vein
ascends along the anteriolateral aspect of the arm, passing through the deltopectoral triangle (between deltoid, clavicle, and pec major), courses deep to pec major to drain in axillary vein
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Glandualar tissue of breast
embedded within fat and connective tissue, extends from 2-6th rib and from sterum to mid axillary line, composed of 16 lobes
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Axillary tail of breast
gladular tissue extending into axilla
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Lactiferous sinus
expandsion of lactiferous duct that hold reservoir of milk during lactation
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Lactiferous duct
duct that milk travels through, exits at the nipple
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Suspensory ligaments (of Cooper)
Supportive cnnective tissue bands within the superficial fascia, extend from membranous layer of superficial fascia to skin of breast
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Morphological Effects of Breast carcinoma
Carcinoma can produce fibrosis or shortening of the suspensory ligaments, can produce characteristic orange peel appearance, dimpling of skin
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Retromammry space
Between deep membranous layer of superficial fascia and the deep facia covering pectoralis major, filled with loos connective tissue, provides for significant breast motility
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Nipple
cylindrical projection at the level of the 4th intercostal space
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Blood supply of breast
multiple sources: perforatng branches of internal thoracis artery, anterior and posterior intercostal arteries, lateral thoracic artery (corresponding venous drainage)
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Lymphatic drainage of breast
Most lymph drains to axillary lymph nodes, some following the internal thoracic artery to drainin the parasternal nodes
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Deep fascia of pectoral region
Envelops muscles of pectoral region, covering superficial and deep surfaces
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Clavipectoral fascia
deep fascia ensheathing the pectoralis minor
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Pectoralis major (origin/insertion)
clavicular head (midline of clavicle), sternocostal head (sternum and costal cartilage of ribs 1-6)/both insert at the crest of the greater tubercle of the humerus
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Pec mjor (action)
ADDUCTION, medial rotation, flexion (clavicular and sternocostal parts)
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Pec major (innervation)
medial and lateral pectoral nerves
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Pectoralis minor (origin/insertion)
Ribs 3-5 near costochondral joints/coracoid process of scapula
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Pectoralis minor (function)
downward rotation, protraction, depression of the scapula
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Pectoralis minor (innervation)
medial pectoral nerves
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Subclavius muscle (origin/insertion)
first rib in costochondral joint/ groove for subclavius on inferior surface of clavicle
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Subclavius clinical correlate
May projectclavian vessels and brachial plexu ffrom the adjacent sharp broken clavicle
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Serratus anterior (origin/insertion)
upper nine ribs/costal surface of scapula, along medial border
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Serratus anterior (action)
upward rotation, protraction, and depression (lower fibers only) of scapula
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Serratus anterior (innervation)
long thoracic nerve
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Clinical correlate long thoracic nerve injury
results in wingged scapcula, perhaps during mastectomy this could happen
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Lateral pectoral nerve
branches form lateral cord of brachial plexus, innervates pectoralis major
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Medial pectoral nerve
Branches from medial cord of brachial plexus, pierces through and innervates pec minor and pec major
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Nerve to subclavius
branches from superior trunk of brachial plexus
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Long thoracic nerve
innervates serratus anterior
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Superior thoracic artery
small branch from proximal part of axillary artery, supplies superior part of the pectoral region
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Thoracoacromial artery
arises form axillary artery posterior to pec minor, emerges through clavipectoral fascia medial to pectoralis minor and deep to pec major and gives rise to 4 branches
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Branches of thoracoacromial artery
clavicular branch (courses medially), pectoral branch ( descend on the deep surface of pec major), deltoid branch (courses laterally and emerges from deltopectroal triangle), acromial branch (courses towards acromion, deep to deltoid)
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Lateral thoracic artery
arises from axillary artery, posterior to pectoralis minor, distal to the origin of thoracoacrmoial artery, descends on the lateral thoracic wall
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What does shoulder movement generally result from (2)
glenohumeral (glenoid in scapula and head of humerus) and scapulothoracic (between scapula and ribcage)
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What two muscles are responsible for first 90 deg of should abduction
deltoid and supraspinatus
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What muscles allow should abduction greater than 90 deg?
serratus and rhomboids
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What are the scapular fixator muscles?
serratus and rhomboids
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What muscles make up the rotator cuff?
(SITS) supraspinatus, infraspinatus, teres minor, subscapularis
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What joints make up the shoulder?
Scapulo thoracic, acromio clavicular (3 ligaments), sternoclavicular
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What ligaments make up the acromio clavicular joint (acromion process, coracoid process, clavicle)?
coraco acromial ligament, coracoclavicular ligament, acromioclavicular ligament
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What joints make up the elbox?
humero-ulnar joint/ulnar collateral ligament (throchlea and olecranum), radio humeral joint/radial collateral ligament (between capitulum and radial head), proximal ulner joint (annular ligament)
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Bursa
a sac lined by synovial membrane, filled with synovial fluid it is like a cushion
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Bursitis:
inflamed burse, causes pain with motion
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Bursa in shoulder joint
subacromial bursa, subdeltoid bursa
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Bursa in elbow
olecranon bursa (a subcutaneous bursa)
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Supraspinatus muscle (origin/insertion)
supraspinatus fossa/greater tuberosity of humerus
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Infraspinatus muscle (origin/insertion)
Infra spinous fossa/greatere tuberosity of humerus
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Teres major (origin/insertion)
inferior angle of scapula/lesser tuberosity
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Pectoralis major (origin/insertion)
clavicle, sternum, ribs/humerus
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Pectoralis minor (origin/insertion)
ribs 3,4,5/coracoid process of scapula
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Deltoid (origin/insertion)
clavicle/humerus
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Subscapularis (origin/insertion)
anterior fossa of scapula/lesser tuberosity of humerus
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Biceps short head (origin/insertion)
coracoid process os scapula/radius
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Biceps long head (origin/insertion)
glenoid/radius
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Where is the ascultaroy triangle?
On back, bordered by the medial border of the Scapula, Latissimus dorsi, Trapezius
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Function of pectoralis major
Adduction of arm
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Function of Pectoralis minor?
Depression of shoulder
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Function of deltoid
Abduction of arm
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Function of biceps?
Flexion of forearm, supinates arm
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Function of Coracobrachialis
Felxion of the forearm, adduction
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Function of triceps?
Extension of arm
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Nerve roots that make up the Brachial Plexus
- C5-T1
- Denervation of this muscle as a result of suprascapular nerve injury results in elimination of external rotation of shoulder
- infraspinatus
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What muscle does shoulder adduction? What is it innervated by?
latissimus dorsi, thoracodorsal nerve
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What nerve supplies the Trapezius?
Spinal accessory (not in brachial plexus)
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What muscle supplies the Levator Scapula?
Dorsal scapular
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What nerve supplies the Rhomboid major and Rhomboid minor?
Dorsal scapular
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What nerve supplies the Serratus anterior?
Long thoracic
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What nerve supplies the Supraspinatus?
suprascapular nerve
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What nerve supplies the infraspinatus?
suprascapular
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What nerve supplies the Deltoid?
Axillary
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What nerve supplies the Teres minor?
Axillary
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What nerve supplies the Pectoralis major?
Medial and Lateral Pectoral nerves
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What nerve supplies the Pectoralis minor?
Medial Pectoral
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What nerve supplies the Latissimus Dorsi?
Thoracodorsal
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What nerve supplies the Teres Major?
Subscapularis
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What nerve supplies the Subscapularis muscle?
Subscapularis nerve
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What nerve supplies the Coracobrachialis?
Musculocutaneous
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What nerve supplies Brachialis?
Musculocutaneous
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What nerve supplies the Biceps?
Musculocutaenous
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What nerve supplies the Triceps?
Radial nerve
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Complete destruction of the brachial plexus denervates all 14 muscles except?
Trapezius and Levator Scapular
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Muscles responsible for Abduction of shoulder (predominant first)
Supraspinatues (Suprascapular n.), Deltoid (Axillary n.), Trapezius (Spinal accessory n.)
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Muscles responsible for Adduction of shoulder (predominant first)
Latissimus dorsi (Thoracodorsal n.), Teres major (Subscapular n.), Subscapularis (Subscapular n.)
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Muscles responsible for Anterior flexion of shoulder
Combined effort, several muscles involved
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Muscles responsible for External rotation of shoulder (predominant first)
Infraspinatus (Suprascapular nerve), Teres minor (Axillary n.)
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Muscles responsible for internal rotation of shoulder (predominant first)
Latissimus dorsi (Thoracodorsal n.), Subscapularis (Subscapular n.), Pectoralis major (Lat/Med Pectoral Nerves)
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Muscles responsible for Extension of shoulder (predominant first)
Latissimus dorsi (Thoracodorsal n.), Triceps (Radial n.)
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Muscles responsible for Scapulothoracic motion of shoulder
Rhomboids (Dorsal scapular n.), Levator (Dorsal scapular), Serratus (Long thoracic n.), Pectoralis minor (Medial pectoral nerve)
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Muscles responsible for Elbow flexion
Biceps brachii (Musculocutaneous n.), Brachialis (Musculocutaneous n.)
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Muscles responsible for Elbow Extension
Triceps (Radial n.)
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Axilla
Pyramidal space Anterior and Posterior walls created by Clavicle, 1st ribs, Scapula, Ribs of thorax, arm
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Lateral wall of the axilla
Humerus
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Medial Wall of the axilla
Ribs (thorax)
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Base of the axilla
Axillary fossa
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What passes through the axilla
Axillary vein, axillary artery, Portions of the brachial plexus, Axillary lymphatic nodes (involved in hand infection and breast cancer)
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What is the differences between the right and left subclavian arteries?
On the right, the brachiocephalic trunk comes off of the Aorta and gives rise to the right subclavian artery, on the left the subclavian comes directly off the aorta
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Where does the Axillary artery begin?
The Subclavian Artery turns into the Axillary artery at the level of the 1st rib
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Where does the Axillary artery end?
The Axillary artery ends at the Teres Major muscle and becomes the Brachial artery
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How many parts are there on the Axillary artery?
3
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How many branches come off the Axillary artery?
5
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What branches off the first part of the Axillary artery?
Supreme thoracic
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What branches off the second part of the Axillary artery?
thoracoacromial, lateral thoracic
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What branches off the third part of the Axillary artery?
Posterior humeral circumflex, anterior humeral circumflex, subscapular
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Apex of the axilla
Passage from axilla to neck (area between clavicle, first rib, scapula)
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What provides collateral circulation to the upper extremity?
branches from the subclavian artery
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What artery supplies the humeral head and is usually damaged in fractures of the surgical neck of the humerus?
Anterior humeral circumflex
- How many trunks are in the brachial plexus? What are they formed by?
- 3 trunks (C5-T1); upper (C5 and C6), middle (C7), lower (C8, T1)
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What are the three important nerves that branch off the brachial plexus but within the axilla?
Suprascapular, axillary nerve, musculocutaneous
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What are the main terminal branches of the brachial plexus?
Ulnar, Radial, Median
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Where does the suprascapular nerves arise from?
upper trunk of the brachial plexus
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Where does the Dorsal scapular nerve arise from?
C5
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What are the "roots" (C5-T1) formed by?
The anterior primary ramus from the mixed spinal nerve
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What forms the mixed spinal nerve?
the dorsal and ventral roots from the spinal cord
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Are plexus roots extravertebral or intravertebral?
extravertebral
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Are spinal nerve roots extravertebral or intravertebral?
intravertebral
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What are the 2 nerves that branch of the roots in the brachial plexus?
Dorsal scapular and long thoracic
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What is the important nerve that branches off a trunk in the brachial plexus?
suprascapular branches off the upper trunk
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What do the trunks of the brachial plexus divide into?
anteriior and posterior divisions
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Does anything branch off the divisions in the Brachial Plexus?
No
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What do the divisons form in the Brachial Plexus?
3 cords, lateral, medial and posterior (named with respect to their position in respect to the axillary artery)
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What forms the Posterior Cord of the Brachial Plexus?
Posterior divisions of the Superior, middle and Inferior trunks
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What forms the Lateral Cord of the Brachial Plexus?
Anterior divisions of the Superior and Middle trunk
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What forms the Medial Cord of the Brachial Plexus?
The Anterior division of the Inferior trunk
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What are the main branches from the Lateral Cord (3)?
Lateral pectoral nerve (to pec major), terminal branch: Musculocutaneous nerve (to biceps and brachialis), terminal branch: Lateral componet of median nerve
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What are the main branches from the Medial Cord (5)?
Medial pectoral nerve (to pec major and minor), Medial brachial cutaneous, Medial antebrachial cutaneous, terminal branch: Medial component of median nerve, terminal branch: Ulnar nerve
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What are the main branches from the Posterior Cord (5)?
Subscapular lower, SUbscapular upper, Thoracodorsal (Latissimus dorsi), terminal branch: Axillary (deltoid, teres minor), terminal branch: Radial nerve
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What are the nerves that emerge from the Axilla?
Ulnar, Radial, Median- control remaining upper extremity (arm, forearm, hand)
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What is the Ulnar the terminal branch of?
Medial cord
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What is the Radial nerve the terminal branch of?
Posterior cord
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What does total inury to the brachial plexus result in?
flail insensate arm
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What does upper plexus injury (C5, C6, C7) result in?
Supraclavicular, upper plexus controls shoulder and elbow - "bad shoulder, good hand"
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What does lower plexus injury result in (C8, T1)?
infraclavicular, controls hand motions, has little effect on should- "band hand, good shoulder" **RARE** usually would involved whole plexus
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How many paravertebral ganglion are in the sympathetic cervical chain?
3 (inferior, middle, superior)
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Stellate ganglion
cervico thoracic ganglion, fusion of the inferior cervical ganglion at the 7th cervical vertebra with the first thoracic ganglion
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Horner's syndrome
Caused by total lower plexus injury, first order sympathetic fibers terminate in the intermediolateral cell column at the level of C8-T2, second otder preganglionic pupillomotor fibers exit the spinal cord at T1, damage results in Miosis (pupillary constriction)
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Rotator cuff borders
above: Teres minor, lateral: Humerus, medial: Long Head of Triceps, Below: Teres major
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What passes through the rotator cuff?
Axillary nerve, Posterior Humeral Circumflex artery
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