Consequently, Trendelenburg position should be employed whenever feasible, the carotid artery should not be palpated during venipuncture, and the head should be rotated to the contralateral side only so far as to provide access to the neck. The position of the radial artery in the forearm is represented by a line from the lateral margin of the Biceps tendon in the center of the anticubital fossa to the medial side of the front of the styloid process of the radius when the limb is in the position of supination. On physical examination, the clinician may note signs of digital ischemia, such as ulcers, sluggish capillary refill of the digits, coolness to the affected extremity, and tenderness about the pectoralis minor. More medial cannulation may be impeded by calcification of the costoclavicular ligament. The suprascapular nerve passes under the ligament. This ligament runs from the pubic tubercle medially to the anterior superior iliac spine laterally. The deep lymphatic vessels of the upper limb accompany the major arteries to also end in the lateral and central axillary lymph nodes.
Also, surgical ligatures can be placed on the suprascapular, axillary or subscapular arteries without damaging the muscles of the shoulder. The thoracoacromial artery is a short trunk arising anteriorly and passing medial to the pectoralis minor muscle. The junction of the two lines indicates the origin of the superior vena cava, the line of which is continued vertically down to the level of the third right costal cartilage. ? The pectoral branch skirts medial to the pectoralis minor muscle and descends on the deep surface of the sternocostal portion of the pectoralis major muscle and serves as its main blood supply. It courses obliquely through the axilla behind the pectoralis minor, which divides it into three parts as blood flows, before-behind-after the muscle for parts one-two-three, respectively. Here, the axillary vein can be recognized as a compressible structure lying anterior to the noncompressible, pulsating axillary artery.
Todd and associates 60 have reported on two major league pitchers with symptomatic aneurysms of the axillary artery at the origin of the circumflex humeral arteries who were successfully treated with resection and reversed saphenous vein interposition graft. The situation of the distal portion of the artery is indicated by continuing this line around the radial side of the wrist to the proximal end of the first intermetacarpal space. This represents a possible route of collateral drainage if the inferior vena cava is obstructed for some reason. Lower subscapular nerve accompanies circumflex scapular artery into the triangular space. Investing tissues The adventitia of the subclavian vein becomes invested with the connective tissue of the clavicular periosteum, the costoclavicular ligament, and the fascia of the subclavius and anterior scalene muscles. Lymph from the axillary lymph nodes subsequently drains into the subclavian lymph trunk.
The right border of the heart lies posterior to it. If the introducer sheath lies too far medially relative to the lumen of the superior vena cava, lines may either kink as they pass into the superior vena cava or be passed into the contralateral subclavian and axillary veins. William Ignace Wei, Yu-wai Chan, in , 2009 Arterial anatomy of the region The axillary artery, a continuation of the subclavian artery, enters the region behind the clavicle see Figures 17. The external intermuscular septum extends upwards from the external condyle to the insertion of the deltoid, and is pierced a third of the way down by the musculo-spiral nerve. The risk of subclavian arterial puncture increases as the probing needle is aimed progressively posteriorly. The anterior superior rotator cuff insertion supraspinatus can be palpated on the humeral head lateral to the anterolateral aspect of the acromion and localized pain in this area can be indicative of cuff pathology.
Identify the muscles of the posterior shoulder and describe the rotator cuff muscles, together with their neurovascular supply. The Kidneys The upper limit of the is indicated by a line drawn transversely at the level of the eleventh dorsal spine, the lower limit by one at the level of the third spine. As the pectoralis major muscle has part of its origin from the anterior wall of the sternum and the second to sixth costal cartilages, the muscle also contributes some vascular supply to these structures. Describe the brachial plexus, including its parts and branches, and their functions. The diagnosis may be difficult as the visual or palpable size of the hematoma may not correlate with the severity of the neurologic deficit and it may evolve up to 2 days post-procedure. The most important internal gross features are glandular, namely secretory glands, lactiferous ducts, and lactiferous sinuses.
These help support the lobules of the gland and attach it to the dermis of the overlying skin. Note a hollow in the posterolateral aspect of the extended elbow distal to the lateral epicondyle; this lies over the head of the radius, which can be felt to rotate during pronation and supination. The position of the radial artery in the forearm is represented by a line from the lateral margin of the Biceps tendon in the center of the anticubital fossa to the medial side of the front of the styloid process of the radius when the limb is in the position of supination. The anastomotic network surrounding the scapula provides an alternate path for collateral circulation to the arm from arteries including the and. Furthermore, reverse Trendelenburg position may be contraindicated by hemodynamic instability accompanying volume depletion. Anatomy of the axillary artery. Then, the remainder of deltoid, both clavicular and acromial heads were divided close to the origin and turned it downwards.
Less easily identified is the coracoid process of the scapula, lying immediately below the clavicle at the Junction of the middle and outer thirds, and covered by the anterior fibres of the deltoid. The two lines indicating the borders of Pectoralis minor begin at the coracoid process of the scapula and extend to the third and fifth ribs respectively, just lateral to the corresponding costal cartilages. And the mean distance between the origins of the anterior and posterior branches of the axillary nerve was 5. It runs in the bicipital groove between the insertions of latissimus dorsi and pectoralis major on the proximal humerus. Contralateral head rotation increases the angle between the subclavian and internal jugular vein normally at least 90°.
Advancing the full length of the dilator through the subcutaneous tract and into the vein risks venous injury. Anatomic complications Beginning at the axillary-subclavian junction, the posterior relationships of the subclavian vein are first the anterior scalene muscle with the phrenic nerve lying on its anterior face, followed by the subclavian artery, and then the brachial plexus. Latham lays down the following rule as a sufficient practical guide for the definition of the area of superficial dulness. The upper border of Latissimus dorsi is almost horizontal, running from the spinous process of the seventh thoracic vertebra to the inferior angle of the scapula and thence somewhat obliquely to the intertubercular sulcus of the humerus; the lower border corresponds roughly to a line drawn from the iliac crest about 2 cm. At the wrist Figs 113-115 it is convenient to commence at the radial pulse. All pitchers were able to continue pitching for 3 to 9 more years of competition.
These measurements are useful guides, but long-term catheters should be positioned precisely under fluoroscopy, and the position of short-term lines should be confirmed with a postprocedure chest x-ray. Quadrangular Space Dimensions Distance of Axillary Nerve from Vertical Distance Horizontal Distance Midpoint Deltoid insertion Antero-medial tip of Coracoid process Postero-lateral aspect of Acromion process Midpoint of vertical distance of Deltoid muscle Ant. A dilator should never be given the opportunity to cause such venous injury. The position of the wrist-joint can be indicated by drawing a curved line, with its convexity upward, between the styloid processes of the radius and ulna; the summit of the convexity is about 1 cm. The patient should be placed in the Trendelenburg position to maximize venous filling and minimize risk of air embolus; the head and neck position should be neutral.