AXILLARY POLE

From Big Medical Encyclopedia

AXILLARY POLE [fossa axillaris (PNA, JNA, BNA); synonym axillary pole] — deepening in axillary area between proximal department of a shoulder and a verkhnelateralny surface of a chest wall, a cut without skin, a fascia and cellulose is considered as an axillary (axillary) cavity (cavum axillare).

Anatomy

P. I. at the taken-away upper extremity has the form of the quadrangular truncated pyramid turned by the basis from top to bottom, and top up — in an interval between the I edge and a clavicle. Its lower bounds, i.e. borders of the basis of a pyramid, serve: in front — bottom edge of a big pectoral muscle (m. pectoralis major), behind — bottom edge of the broadest muscle of a back (t. latissimus dorsi), from the medial party — the conditional line on a chest wall and from the lateral party — the conditional line on an inner surface of a shoulder connecting edges of these muscles. Front wall of P. I. the clavicular and chest fascia (fascia clavi-pectoralis), big and small pectoral muscles make (mm. pectorales major et minor); back — the broadest muscle of a back, big round and infrascapular muscles (mm. teres major et subscapularis); lateral — an inner surface of a humeral bone with a short head of a biceps of a shoulder (caput breve m. bicipitis brachii) and coronoid and humeral muscle (m. coracobrachialis); medial — a sidewall of a thorax to the level V of an edge with a front gear muscle (m. serratus anterior). Basis of a pyramid of P. I. it is tightened by an axillary fascia (fascia axillaris), edges it is covered with skin with hypodermic cellulose and a superficial fascia. At the top of P. I. it is reported with kletchatochny spaces necks (see).

P.'s skin I. thin, is covered with hair, in it there is a lot of grease and sweat glands.

Fig. 1. The diagrammatic representation of axillary area with the vessels located in it: 1 — a biceps of a shoulder, 2 — the big pectoral muscle (is cut), 3 — a lateral saphena of a hand, 4 — a small pectoral muscle, 5 — a front gear muscle, 6 — an infrascapular artery and a vein, 7 — the broadest muscle of a back, 8 — medial and lateral roots of a median nerve, 9 — an axillary artery, 10 — an axillary vein, 11 — humeral veins.
Fig. 2. The diagrammatic representation of axillary area with the bunches of a brachial plexus and vessels located in it: 1 — a musculocutaneous nerve, 2 — a lateral root of a median nerve, 3 — an axillary artery, 4 — a lateral bunch of a brachial plexus, 5 — a medial bunch of a brachial plexus, 6 — an axillary vein, 7 — a medial saphena of a hand, 8 — a medial root of a median nerve, 9 — a median nerve, 10 — an elbow nerve, 11 — a medial cutaneous nerve of a shoulder, 12 — a medial cutaneous nerve of a forearm, 13 — a biceps of a shoulder.

The axillary pole is filled with cellulose, in a cut the neurovascular bunch is located. It includes an axillary artery with its branches and a vein (and. et v. axillares) with its inflows (fig. 1) and a brachial plexus — plexus brachialis (see. Brachial plexus ), presented here by three secondary bunches — lateral, medial and back (but to the relation to an axillary artery) with their branches (fig. 2), and also axillary limf, nodes and limf, vessels. In the field of a clavicular and chest triangle (trigonum clavi-pectorale) in P. I. lie: first piece of an axillary artery; kpered from it the clavicular and chest fascia, to-ruyu probodat a lateral saphena of a hand (v. cephalica) and a grudoakromialny artery (and. thoracoacromialis), medial and lateral chest nerves (nn. pectorales medialis et lateralis); kzad from it — a medial bunch of a brachial plexus (fasciculus medialis plexus brachialis), a front gear muscle and intercostal muscles of the first mezhreberye; knaruzh and from above from it — lateral and back bunches of a brachial plexus (fasciculi lateralis et posterior plexus brachialis); from top to bottom and medially from it — an axillary vein. In the same place branches of the first (upper) piece of an axillary artery — an upper chest artery (a. thoracica superior) and a grudoakromialny artery are located, branches a cut supply a deltoid muscle, a shoulder joint and pectoral muscles.

In the field of a chest triangle (trigonum pectorale) in an axillary pole lie: second piece of an axillary artery; kpered from it — a small pectoral muscle (m. pectoralis minor); kzad — a back bunch of a brachial plexus and an infrascapular muscle; lateralno — a lateral bunch of a brachial plexus; medially — an axillary vein, a medial bunch of a brachial plexus and a branch of the second piece of an axillary artery — a lateral chest artery (a. thoracica lateralis).

At the level of a subchest triangle (trigonum subpectorale) in an axillary pole lie: lateralno — a musculocutaneous nerve (item musculocutaneus), a short head of a biceps of a shoulder, a klyuvovidnoplechevy muscle; in front — medial and lateral roots of a median nerve (n. medianus); medially — an elbow nerve, medial cutaneous nerves of a shoulder and forearm (nn. cutanei brachii et antebrachii mediales), axillary vein; behind — beam (n. radialis) and axillary nerves. In the same place there are branches of the third piece of an axillary artery: an infrascapular artery (a. subscapularis), the front and back arteries which are bending around a humeral bone (aa. circumflexae humeri anterior et posterior).

The axillary artery (a. axillaris) is continuation of subclavial (a. subclavia) and further passes into a humeral artery; as its proximal border serves the I edge, distal — bottom edge of the broadest muscle of a back. Axillary and subclavial arteries anastomose among themselves within a shovel by means of a nadlopatochny artery (a. suprascapularis), a cross artery of the neck and an artery which is bending around a shovel (aa. transversa colli et circumflexa scapulae).

The axillary vein is formed at merge of two humeral veins (vv. brachiales) at bottom edge of a big pectoral muscle also proceeds in a subclavial vein (v. subclavia).

Limf, nodes P. I. lie in the form of five groups — apical, central, lateral, chest, infrascapular (see. Lymph nodes ); inflow of a lymph to them goes on superficial and deep limf. to vessels of a hand, mammary gland, a sidewall of a chest cavity, outflow is carried out in the right and left subclavial trunks (trunci subclavii dexter et sinister).

A brachial plexus within P. I. gives rise to large nerves of an upper extremity: the musculocutaneous nerve and a lateral root depart from a lateral bunch median nerve (see); from a medial bunch — a medial root of a median nerve, elbow nerve (see), medial cutaneous nerves of a shoulder and forearm; from a back bunch — an axillary nerve and beam nerve (see).

Pathology

To to malformations axillary pole the additional mammary glands which are occasionally found here located in hypodermic cellulose belong. As a rule, these glands do not function, however before periods, during pregnancy and a lactation they can bulk up, causing to the woman considerable inconveniences. Sometimes malignant tumors develop in them. For these reasons, and also for cosmetic reasons additional mammary glands are subject to operational removal (see. Mammary gland ).

Injuries axillary pole happen closed and opened, to damage or without damage of a neurovascular bunch. The closed damages — bruises (see), stretchings (see. Distortion ) fabrics of axillary area — a thicket proceed without damage of large axillary vessels and nerves. At dislocation of a shoulder, a fracture of a surgical or anatomic neck of a humeral bone disturbance of an integrity of a neurovascular bunch in P. I is quite often observed. The most often neurovascular bunch is damaged at gunshot wounds.

Clinically closed injury of an axillary artery is characterized by emergence in P. I. the pulsing swelling, over a cut it is possible to listen to noise, easing or disappearance of a peripheric pulse and a cold snap of an extremity. At injury of an axillary vein there is cyanosis, and also puffiness of a brush and distal third of a forearm. At open damage of vessels arises bleeding (see) with the phenomena of acute blood losses (see). Open injury of an axillary vein can be followed by air embolism (see) since the vein is fixed to an axillary fascia and at wound it is not fallen down owing to what at a breath in it air is sucked in.

The symptomatology of damage of a brachial plexus is very various and depends on the place of damage and extent of defeat of conduction paths. At damage of all texture sluggish paralysis of a hand develops, tendon and periosteal jerks are absent, there comes anesthesia of skin of all extremity (except for the interior of a shoulder innervated boundaries - costal and humeral nerves, and an upper part of the deltoid area innervated by supraclavicular nerves), the muscular and joint feeling to radiocarpal, and sometimes and to an elbow joint inclusive drops out (see. Paralyses, paresis ).

Specification of nature of an injury of P. I. it is based on data a wedge, researches. In doubtful cases conduct angiographic, elek-trodiagnostichesky and other researches.

Treatment of injuries of P. I. at the kept neurovascular bunch and absence of wounds generally conservative (rest, cold, an immobilization of an extremity); in the presence of wounds make their primary surgical treatment (see. Surgical treatment of wounds ). At disturbance of an integrity of axillary vessels and a brachial plexus the immediate surgery is necessary for recovery of blood supply and an innervation of an extremity with sewing together of vessels (see. Vascular seam ) and a nerve (see. Nervous seam ), plastics of vessels (see. Plastic surgeries ). Bandaging of the main vessels (see Bandaging of blood vessels) is admissible only when in connection with a condition of the victim or lack of the minimum conditions reconstructive operation is impossible. Also reposition and fixing of fragments, an immobilization of an extremity, etc. are obligatory.

Fig. 3. The diagrammatic representation of an exposure of vessels and nerves of an axillary pole on a projection of an axillary artery: 1 — a median nerve (will delay kpered and up), 2 — a musculocutaneous nerve, 3 — an axillary artery, 4 — an axillary vein (it is delayed kzad and knutr), 5 — a medial cutaneous nerve of a forearm.

Vessels and P.'s nerves I. can be bared by the section which is carried out on their projection (fig. 3) or vneproyek-tsionny cuts. In particular, the projection of an axillary artery passes on border between a front and average third of P. I., what corresponds to front border of growth of hair.

Thanks to existence of a set of the anastomosis between axillary, subclavial and humeral arteries located in muscles, fastion and cellulose of axillary area, bandaging of an axillary artery, especially in its upper part, and an axillary vein usually does not cause serious violations of blood supply of an extremity. Feature of deep burns (see) in the area P. I. the fact that they lead to formation of the rough hems which are fixing a shoulder to a breast and sharply limiting the movements in a shoulder joint is. In this regard at treatment of patients with burns apply preventive fixing of a hand in the relevant provision. Treatment of such cicatricial contractures (see) demands quite difficult, sometimes multi-stage plastic surgery.

Diseases. From pyoinflammatory diseases of P. I. the most frequent is hydradenitis (see) — an inflammation of sweat glands with formation of the typical slowly abscessing cone-shaped infiltrates of crimson and gray coloring. Less often furuncles meet (see. Furuncle ) and an anthrax (see. Anthrax ).

As the complication of the pyoinflammatory processes which are localized in an upper extremity is more rare in a mammary gland, and also at the infected grazes and superficial wounds in axillary area acute or chronic axillary lymphadenitis is quite often observed (see). At acute lymphadenitis in P. I. it is possible to probe 2 — 3 increased painful limf, a node; accession limfangiita (see) on an extremity on the course limf, vessels it is found education dense painful tyazhy and a dermahemia over them. In case of suppuration limf, nodes it is formed abscess (see) or phlegmon (see) axillary area. Pus can spread to a deltoid muscle, a shovel, to area of a neck, shoulder. At distribution of process on big and small pectoral muscles the deep (subpektoralny) phlegmon which is characterized heavy a wedge, a current is formed. Pain and a swelling of the corresponding half of a thorax, a smoothness of a subclavial pole, restriction of movements in a shoulder joint are noted. Even at rather small local manifestations high temperature of a body from oznoba, change of a blood count, other phenomena of heavy intoxication of an organism are observed.

At hron, lymphadenitis in P. I. the condensed, increased, slightly painful nodes are probed; the general condition of the patient is usually not broken.

Diagnosis of pyoinflammatory diseases of P. I. the wedge, researches is based on data. Hron, lymphadenitis needs to be differentiated with system malignant new growths (see. Leukoses , Lymphogranulomatosis , Lymphosarcoma , Reticulosarcoma ), metastasises of a breast cancer and specific (is more often tubercular) defeat limf, nodes (see Tuberculosis extra pulmonary). Results biopsies (see), as a rule, allow to specify the diagnosis.

is carried out by Fig. 4. Diagrammatic representation of subpektoralny phlegmon, its opening and drainage: 1 — accumulation of pus under pectoral muscles (is shaded), 2 — a section on bottom edge of a big pectoral muscle through which the fenestrated drainage is carried out to a cavity of an abscess (3). Through two additional sections at an upper pole of an abscess (counteropening) by means of a packer (4) the second drainage tube is carried out

Treatment of lymphadenitis shall be directed first of all to elimination of a basic disease. At purulent lymphadenitis opening of an abscess, an immobilization of an extremity is shown. In complex treatment of deep (subpektoralny) phlegmon the basic is early broad opening of an abscess a section on the outer edge of a big pectoral muscle, if necessary with imposing of counteropenings (see) and its adequate drainage (fig. 4).

Some patol, processes in P. I., the blockade of absorbent or venous vessels causing emergence, lead to development is long not falling down puffiness, sometimes elephantiasis of an upper extremity (see Elephantiasis). More often these phenomena are observed after radical mastectomies (see) and other operations connected with removal axillary limf, nodes; in these cases also long lymphorrhea (see) with the subsequent formation limf, fistula can take place. Blockade limf, vessels and veins can be caused by tumoral process in P. I., thrombosis of a venous trunk in the place of transition of an axillary vein in subclavial (see. Pedzheta — Schröter a syndrome ), the thrombosis of subclavial and axillary veins sometimes complicating catheterization of a subclavial vein and other reasons. A contrast research limf, ways (see. Limfografiya ) and veins (see. Flebografiya ) helps to establish the reason and localization of the block of vessels and to choose option of treatment.

Aneurisms of axillary vessels are a consequence of an injury more often, diseases (syphilis, atherosclerosis) are more rare. Existence in P. I. the pulsing swelling, over a cut systolic noise can be listened, and data of angiographic researches allow to make the correct diagnosis. Treatment of aneurisms — operational (see. Aneurism ).



Bibliography: Vedeno A. N. Plastic and reconstructive surgeries on the main veins, L., 1979; Misnik V. P. Anatomy of the lymph nodes close to an axillary pole at the adult, Arkh. annate., gistol, and embriol., t. 77, No. 7, page 34, 1979; The Multivolume guide to surgery, under the editorship of B. V. Petrovsky, t. 11, page 127, M., 1960; Operational surgery and topographical anatomy, under the editorship of V. V. Kovanov, page 13, M., 1978; Pokrovsky A. V. Clinical angiology, M., 1979; Popkirov S. It is purulent - septic surgery, the lane with bolg., Sofia, 1977; Borghouts J. M of N. of Surgical treatment of chronic suppurative hidradenitis, Arch. chir, neerl., v. 26, p. 201, 1974; Page R. E. Treatment of axillary abscesses by incision and primary suture under antibiotic cover, Brit. J. Surg., v. 61, p. 493, 1974; Schulz H. G. Rontgenbefunde bei der Achselvensperre, Dtsch. Gesundh. - Wes., S. 1312, 1966.


And. H. Belov; M. M. Pavlova (An.).

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