DISCUSSIONIV. COMMITTEE

kaan yücel11.04.2014

BREAST QUADRANTS

BREAST CANCERmost common cancer among women, other than skin cancersecond leading cause of cancer death in women, after lung cancer

Chance of a woman having an invasive breast cancer some time during her life about 1 in 8

Understanding the lymphatic drainage of the breasts is of practical importance in predicting the metastasis (dispersal) of cancer cells from a carcinoma of the breast (breast cancer).

spreads by means of lymphatic vessels (lymphogenic metastasis), which carry cancer cells from the breast to the lymph nodes, chiefly those in the axilla

MAMMOGRAPHYDigital mammograms replacing conventional film mammography

younger women with dense breast tissue benefit most from this type of mammography.

Surgeons use mammography as a guide when removing breast tumors, cysts, and abscesses.

jagged density in the mammogram. The skin is thickened over the tumor and the nipple is depressed

MASTECTOMY

radical mastectomy more extensive surgical procedureremoval of the breast, pectoral muscles, fat, fascia, and as many lymph nodes as possible in the axilla and pectoral region.

breast excisionsimple mastectomybreast is removed down to the retromammary space.

POLYTHELİAaccessory nipples

POLYMASTİASUPERNUMERARY BREASTS

rudimentary nipple & areola

mistaken for a mole (nevus)

anywhere along a line extending from the axilla to the groin—embryonic mammary crest (milk line) from which the breasts develop.

Polymastia

AMASTİA

There may be a nipple and/or areola, but no glandular tissue.

no breast development

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8. ..the claviopectoral fascia and triangle?Deep to the pectoral fascia & pectoralis major

Descends from the clavicle

Clavipectoral triangle cephalic vein can be found. formed by pectoralis major, deltoid & clavicle

Deltopectoral groove

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Where are the mammary glands?

In the subcutaneous tissue overlying the pectoralis major and minor muscles.

lateral border of the sternum to the midaxillary line vertically from the 2nd through 6th ribs.

sagital T2 MRI slices, shows an ugly posterior dislocation of 6th cervical vertebra, with fracture of the body, and a spinal cord contusion and edema up and down from the compresion.

C2

C8

The patient @ the E.R.!

C7

Tendon Reflexes & Segmental Innervation of Muscles of the Upper Limb

Triceps tendon reflex C6, 7, and 8

extension of the elbow joint by tapping the triceps tendon

The scapular anastomosis system is a system connecting each subclavian artery and the corresponding axillary artery, forming an anastomosis around the scapula. It allows blood to flow past the joint regardless of the position of the arm. Anterior circumflex humeral artery and posterior circumflex humeral artery are both branches of the third part of the axillary artery. The posterior circumflex humeral artery anastomoses with anterior circumflex humeral artery and also with branches from profunda brachii (a branch of brachial artery), suprascapular (a branch of subclavian artery) and thoracoacromial (a branch of axillary artery) arteries, and branches of thoracic aorta as well.All these vessels anastamose or join to connect the first part of the subclavian with the third part of the axillary, providing a collateral circulation. This collateral circulation allows for blood to continue circulating if the subclavian is obstructed.

Principal muscles acting on the shoulder jointAbductorsSupraspinatusDeltoidAdductorsPectoralis majorLattisimus dorsiExtensorsTeres majorLattisimus dorsiDeltoid (posterior fibres)FlexorsPectoralis majorCoracobrachialisDeltoid (anterior fibres) Medial rotatorsPectoralis majorLattisimus dorsiTeres majorDeltoid (anterior fibres)Subscapularis Lateral rotatorsInfraspinatusTeres minorDeltoid (posterior fibres)

Movement of Scapula

Muscles Producing Movementa Nerve to Muscles Range of Movement (AngularRotation; Linear Displacement)

Elevation Trapezius, descending part Levator scapulae Rhomboids

Spinal accessory (CN XI) Dorsal scapular 10-12 cm

Depression Gravity Pectoralis major, inferior sternocostal head Latissimus dorsi Trapezius, ascending part Serratus anterior, inferior part Pectoralis minor

Pectoral nervesThoracodorsalSpinal accessory (CN XI)Long thoracicMedial pectoral

Protraction Serratus anterior Pectoralis major Pectoralis minor

Long thoracicPectoral nervesMedial pectoral

40-45°; 15 cm

Retraction Trapezius, middle part Rhomboids Latissimus dorsi

Spinal accessory (CN XI)Dorsal scapularThoracodorsal

Upward rotationa Trapezius, descending part Trapezius, ascending part Serratus anterior, inferior part

Spinal accessory (CN XI)Long thoracic 60°; inferior angle: 10-12 cm,

superior angle: 5-6 cm

Downward rotationb

Gravity Levator scapulae Rhomboids Latissimus dorsi Pectoralis minor Pectoralis major, inferior sternocostal head

Dorsal scapularThoracodorsal Medial pectoral Pectoral nerves

Movement of Scapula Muscles Producing Movement Nerve to MusclesElevation Trapezius, descending part

Levator scapulae Rhomboids

Spinal accessory (CN XI) Dorsal scapular

Depression Gravity Pectoralis major, inferior sternocostal head

Latissimus dorsi Trapezius, ascending part Serratus anterior, inferior part Pectoralis minor

Pectoral nervesThoracodorsalSpinal accessory (CN XI)Long thoracicMedial pectoral

Protraction Serratus anterior Pectoralis major Pectoralis minor

Long thoracicPectoral nervesMedial pectoral

Retraction Trapezius, middle part Rhomboids Latissimus dorsi

Spinal accessory (CN XI)Dorsal scapularThoracodorsal

Upward rotationa Trapezius, descending part Trapezius, ascending part Serratus anterior, inferior part

Spinal accessory (CN XI)Long thoracic

Downward rotationb Gravity Levator scapulae Rhomboids Latissimus dorsi Pectoralis minor Pectoralis major, inferior sternocostal head

Dorsal scapularThoracodorsal Medial pectoral Pectoral nerves

Clavicular (anterior) part of deltoid muscleflexes and medially rotates armAxillary nerveLateral third of clavicle-Deltoid tuberosity of humerus

Teres majorAdducts and medially rotates armInferior subscapular nerve Posterior surface of inferior angle of scapula-Medial lip of intertubercular sulcus of humerus

Subscapularis Medially rotates arm; as part of rotator cuff, helps hold head of humerus in glenoid cavitySup. & Inf. subscapular nerves Subscapular fossa (most of anterior surface of scapula)-Lesser tubercle of humerus

Latissimus dorsiExtends, adducts, medially rotates humerus (arm)Thoracodorsal nerve Spinous processes of T7 to L5 Sacrum Iliac crest Ribs 10 to 12

Floor of intertubercular sulcus of humerus

Adducts, flexes, and medially rotates the arm.

Clavicular head: Medial half of clavicle Sternocostal head: Anterior surface of sternumSuperior six costal cartilagesAponeurosis of external oblique muscle

Pectoralis major

Lateral and medial pectoral nervesLateral lip of intertubercular sulcus of humerus

Infraspinatus Suprascapular nerve Infraspinous fossa of scapula-Middle facet of greater tubercle of humerus

Teres minor Axillary nerveMiddle part of lateral border of scapula-Inferior facet of greater tubercle of humerus

Deltoid Spinal (posterior) part: Axillary nerveExtends and laterally rotates armSpine of scapula-Deltoid tuberosity of humerus

Coracobrachialis Tip of coracoid process of scapula

Middle third of medial surface of humerus

Musculocutaneous nerve (C5, C6, C7)

Helps flex and adduct arm; resists dislocation of shoulder

Clavicular (anterior) part of deltoid muscleflexes and medially rotates armAxillary nerveLateral third of clavicle-Deltoid tuberosity of humerus

Latissimus dorsiExtends, adducts, medially rotates humerus (arm)Thoracodorsal nerve

Adducts, flexes, and medially rotates the arm.

Pectoralis major

Lateral and medial pectoral nerves

Deltoid Acromial (middle) part: abducts armSupraspinatusSuprascapular nerve Initiates and assists deltoid in abduction of arm and acts with rotator cuff muscles.

Brachialis Distal half of anterior surface of humerus

Coronoid process and tuberosity ulna

Musculocutaneous nerve (C5, C6, C7) and small contribution by the radial nerve at the lateral part

Flexes forearm in all positions

Triceps brachii

Long head: infraglenoid tubercle of scapulaLateral head: posterior surface of humerus, superior to radial grooveMedial head: posterior surface of humerus, inferior to radial groove

Proximal end of olecranon of ulna and fascia of forearm

Radial nerve (C6, C7, C8)

Chief extensor of forearm; long head resists dislocation of humerus; especially important during adduction

Pronator teresPronates and flexes forearm (at elbow)Flexor carpi radialis Flexes and abducts hand (at wrist)Abduction of the wrist= Radial deviation with extensor carpi radialis longus et brevis.Flexor carpi ulnarisFlexes and adducts the wrist joint Adduction of the wrist= Ulnar deviation with extensor carpi ulnarisPalmaris longusFlexes hand (at wrist) and tenses palmar aponeurosis Flexor digitorum superficialisFlexes proximal interphalangeal joints of the index, middle, ring, and little fingers; can also flex metacarpophalangeal joints of the same fingers and the wrist jointFlexor digitorum profundusflexes the distal phalanges of the medial four fingers after the flexor digitorum superficialis has flexed their middle phalanges (i.e., it curls the fingers and assists with flexion of the hand, making a fist). Each tendon is capable of flexing two interphalangeal joints, the metacarpophalangeal joint. Because the tendons cross the wrist, it can flex the wrist joint as well.

BrachioradialisRelatively weak flexion of forearm; maximal when forearm is in midpronated position; an accessory of flexor of the elbow joint

Extensor carpi radialis longusextends and abducts the wristExtensor carpi radialis brevisextends and abducts the wristExtensor digitorummajor extensor of the four fingers (index, middle, ring, and little fingers)Extends medial four digits primarily at metacarpophalangeal joints, secondarily at interphalangeal joints; can also extend the wristExtensor carpi ulnarisExtends and adducts hand at wrist joint (also active during fist clenching)

Biceps brachii Short head: tip of coracoid process of scapulaLong head: supraglenoid tubercle of scapula

Tuberosity of radius and fascia of forearm via bicipital aponeurosis

Musculocutaneous nerve (C5, C6, C7)

Supinates forearm and, when it is supine. flexes forearm; short head resists dislocation of shoulder

pronator quadratus is the prime mover for pronation.

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CASE

The patient is unable to extend the wrist. Loss of sensation on the lateral and

posterior parts of the forearm

A terrible accident in the highway. A public bus involved. Many deaths and injured.

Your patient has the following findings following a thorough neurological exam:

Which nerve(s) injured?

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WHO WANTS TO STUDY ANATOMY?

Innervation of the posterior compartment of the arm 1 POINT

A. Ulnar nerve

B Radial nerve

C. Median nerve

D. Axillary nerve

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WHO WANTS TO STUDY ANATOMY?

Triceps tendon reflex 2 PTS

A. C6

B C6 & C7

C. C6-C7-C8

D. C7

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A branch not from the 3rd part of the axillary artery 3 PTS

A. Subscapular artery

B Anterior circumflex humeral artery

C. Posterior circumflex humeral artery

D. Lateral thoracic artery

WHO WANTS TO STUDY ANATOMY?