Anterior Upper Arm Thorax, Shoulder & Upper Limb Christina Duncan Stacey Fain

Anatomical Landmarks Palpations - Thoracic Jugular Notch Manubrium Body and Xiphoid Process of Sternum Sternal Angle Acromion Nipple

Anatomical Landmarks Palpations – Brachial Median epicondyle Lateral epicondyle Cubital fossa

Incision Lines - Thoracic First Incision: Midline cut from jugular notch to xiphoid process Three lateral incisions will originate from first incision. Upper border of the manubrium to the acromion along the clavicle (A-D). Extend this incision down the arm 5 inches (D-G) and then around the arm. (G,H) From the midline laterally (encircling the pigmented areola) to the midaxillary line about 3 inches below the anterior axillary fold. (B-E) From the xiphisternal junction to the midaxilllary line following the 6th rib. (C-F) Midaxillary Line

Incision Lines - Brachial From first brachial circumferential incision (G,H), continue down arm approximately four inches and make another circumferential cut immediately superior to the cubital fossa (I,J). I J

Reflection of Skin - Thoracic Start at jugular notch. Hold scalpel edge at a slight angle to underlying superficial fascia and proceed laterally. Make an incision in reflected skin for index finger of free hand for purpose of providing traction. GOAL: To have little or no fat adhering to deep surface of the skin, which will show many small pock marks/pits called dermal papillae. Keep 2 skin flaps attached laterally so they can be replaced over chest to prevent drying out. Leave nipple and areola attached to underlying tissue. In males, the nipple is directly attached to anterior thoracic wall. In females, the nipple is completely within the superficial fascia.

Reflection of Skin - Brachial Starting from midline incision, reflect skin medially and distally, respectively. I Distal Medial J

Watch Out! Medial Supraclavicular Nerves Intermediate Supraclavicular Nerves Lateral Supraclavicular Nerves

Watch Out! – Vascular

Cautionary Tales - Nerves Medial Brachial Cutaneous Nerves Intercostobrachial Nerves