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major muscle, where v. cephalica is located. V. cephalica 
penetrates fascia clavipectorale and goes into v. axillaris. 
Sulcus 
deltoideopectoralis 
goes 
up 
to 
trigonum 
deltoideopectorale 
(or 
fossa 
deltoideopectorale, 
Mohrenheim’s fossa). 
Between the deep lamina of fascia pectoralis and deeper is 
located fascia clavipectorale. There is superficial subpectoral 
space, filled with adipose tissue, where we see 
branches of 
a. 
thoracoacromialis, nn. pectorales medialis et lateralis and 
Rotter’s lymph nodes (nodi lymphoidei interpectorales). 
Fascia clavipectorale is located between scapula coracoid 
process, clavicle and the 3rd – 5th ribs. It forms the sheath for m. 
pectoralis minor, m. subclavius, a. et v. axillaris and plexus 
brachialis. 
Between the posterior surface of m. pectoralis minor and 
thoracic wall is located a deep subpectoral space, where axilla 
neurovascular fascicle passes (Fig. A. 1). 
Superfacial and deep subpectoral spaces join together via 
cellular tissue, which surrounds the neurovascular fascicle, 
with axilla, cellular tissue of lateral cervical region and 
subdeltoid cellular space. 
Subpectoral phlegmons should be cut through the line 
which goes along the posterior edge of pectoralis major 
muscle. 
Two triangles can be considered in this segment: 
1. Trigonum clavipectorale – between the clavicle and 
upper edge of m. pectoralis minor. 
2. Trigonum pectorale – complies with the position of m. 
pectoralis minor. 
These triangles have neurovascular fascicle: a. et v. axillaris 
and plexus brachialis, which come here from the lateral 
cervical segment while passing between the clavicle and the 

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1st rib, and move to axilla. 
V. axillaris passes in trigonum clavipectorale downward, up 
to the middle and forward from a. axillaris. It is bedded to 
fascia clavipectorale and attaches to it. That is why air epiboly 
occurs
 
(frequent and dangerous complication of clavicle 
fracture).
The axillary vein (v. axillaris) is followed by a group of lymph 
nodes, which are amputated in mastectomy. The v. subclavia is 
a direct continuation of v. axillaris. 
The surgical anatomy of subclavian vein is very important, 
because it is often needled and catheterized for introducing 
medications, vein blood pressure measuring, and diagnostic 
manipulation in the heart cavity. 
The border between v. axillaris and v. subclavia is located 
on the inferior margin of the 1st rib. The vein lays on the 
upper surface of the 1st rib in spatium antescalenum, then 
goes to the level of sternoclavicular joint, where it combines 
with internal jugular vein while creating a brachiocephalic 
vein. 
Subclavian vein goes in obliquity from down to top and 
from outside to inside. It does not change its position when 
we move upper limbs, because it is solidly connected to 
surrounding tissues. 
As a result of adhesion of subclavian vein sheath with 
clavicle periosteum, the 1st rib and fascia clavipectoral, its 
lumen remains constant even in case of acute fall of circulating 
blood volume (CBV), when all other circumferential veins are 
stuck together. 
The subclavian vein can be divided into three segments. 
First segment is located in trigonum clavipectorale, second – 
behind the clavicle, and third – in spatium antescalenum. 
Postclavicular segment of
 
v. subclavia is located on upper 

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surface of the 1st rib, which separates the vein from cupula of 
the pleura. Here the vein is located between the clavicle and 
anterior scalene muscle, which separates it from a. subclavia 
and trunk of brachial plexus. 
Then v. subclavia goes to spatium antescalenum, passes 
above cupula of pleura while covering a. subclavia.
V. cephalica, v. suprascapularis, v. transversa colli, v. 
jugularis externa, v. cervicalis profunda, v. vertebralis, and 
chest or jugular lymphatic trunk fall into v. subclavia from 
above. 
If long-standing fluid maintenance is necessary (peritonitis, 
major combustion, craniocerebral trauma, heavy loss of blood, etc) 
when superficial veins are absent, we use a puncture and 
catheterization of v. subclavia according to the method of 
Seldinger.
The puncture of v. subclavia is performed by means of 
subclavian or supraclavicular approach. The vein puncture 
according to Abanіak technique (1 cm down from the border 
of middle and internal third of the clavicle) is more useful at 
subclavian approach. The angle formed by upper edge of the 
clavicle and lateral crus of sternocleidomastoid muscle is a 
reference point during the vein puncture when using 
supraclavicular approach. The needle enters Ioffe’s point, a bit 
upper from the top of the angle. 
The puncture of the right vein with subclavian access is 
more dangerous, because: 
a) large veins and lymphatic trunks fall into upper wall of 
v. subclavia; 
b) above the clavicle the vein is located near to cupula of the 
pleura, and damage of the latter could result in pneumothorax. 
Below the clavicle the vein is separated from pleura with the 1st 
rib;

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c) in the middle parts of infraclavicular region the vein 
covers a. subclavia and protects it. 
The choice of v. subclavia for catheterization can be 
explained by its anatomic-functional peculiarities:
1) the vein has its permanent position and clear 
topographic-anatomical points of reference; 
2) the vein lumen is big enough (12 – 25 mm in adults); 
3) the vein’s wall is fixed with muscular-fascial formations, 
what ensures its relative immovability and prevents it from 
collapse even in unexpected hypovolemia (decrease of blood 
circulation); 
4) the high speed of blood circulation is a factor which 
prevents thrombosis. 
Compression of v. subclavia in spatium costoclavicularis on 
exertion induces hypertrophy of valve wall and results in vein 
thrombosis. Thus Paget – Schroetter syndrome occurs. The 
symptoms of Paget – Schroetter syndrome are: progressive 
limb edema, sharp pain, cyanosis and affection of blood 
circulation in the limb.
There is a valve in the part of v. subclavia passage, between 
clavicle and the
 
1st rib. The damage of cups of the valve results in 
their thickening and parafunction. The balloon dilatation causes 
the destruction of thickened cups and improves the vein blood 
circulation. Thus, the Paget – Schroetter syndrome is successfully 
treated by means of endovascular surgery (thrombolytic therapy, 
balloon dilatation and aspiration thrombectomy). 
A. thoracica superior springs from a. axillaris in trigonum 
clavipectorale and provides blood supply of the 1st and the 2nd 
intercostal spaces, and of a. thoracoacromialis, which penetrates 
fascia clavipectorale near the internal edge of m. pectoralis minor 
and gives off: 
● rr. pectorales – provide blood supply of major and minor 
pectoralis muscles;

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● r. acromialis – provides blood supply of acromioclavicular 
joint and participates in forming rete acromiale; 
● r. deltoideus – provides blood supply of m. deltoideus.
V. axillaris is located downwards and up to the middle in 
trigonum pectorale, and a. axillaris is located upwards and 
outwards.
At this level plexus brachialis bifurcates into 3 fascicles. 
Fasciculus lateralis is located outwards and upwards from the 
arteria, fasciculus posterior – behind the arteria, fasciculus 
medialis – up to the middle and downwards from the arteria, 
and behind the vein. 
Plexus brachialis is formed by anterior branches of four 
lower cerebrospinal nerves (С5 – С8). The part of anterior 
branch (C4 and Th1) also participates in forming plexus 
brachialis. They join together like this: the anterior branch of 
C5 joins with anterior branch of C6 while forming a truncus 
superior; the anterior branch of C8 joins with anterior branch 
of Th1 while forming a truncus inferior; and between them the 
anterior branch of C7 is located. The anterior branch of C7 
forms a truncus medius. Superior, inferior and middle trunks 
with their short branches form pars supraclavicularis of 
brachial plexus (Fig. A.2). 
Each of abovementioned trunks bifurcate into 2 branches: 
anterior and posterior one. Due to these branches the fascicles 
of plexus brachialis are formed at the level of inferior edge of 
the clavicle, or just in trigonum clavipectorale. 
The process of their formation is explained by 
K. A. Hryhorovych the next way: the posterior divarications are 
joined together in one trunk and form a posterior cord of brachial 
plexus (fasciculus posterior). The frontal divarications of upper 
trunk are joined together with frontal divarications of the middle 
trunk and form a lateral cord of brachial plexus (fasciculus 
lateralis). 

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The frontal divarications of inferior trunk form a medial 
fascicle of brachial plexus (fasciculus medialis). Fasciculus 
posterior gives off n. axillaris and then passes into n. radialis. 
Fasciculus lateralis and fasciculus medialis bifurcate into 
2 branches. The middle branch of fasciculus lateralis and lateral 
branch of fasciculus medialis join almost at the right angle, 
encircling a. axillaris and forming n. medianus. The outer branch 
of fasciculus lateralis forms n. musculocutaneus, which enters m. 
coracobrachialis. Medial branch of fasciculus medialis forms n. 
ulnaris, n. cutaneus antebrachii medialis and n. cutaneus brachii 
medialis. 
The damage of plexus brachialis in adults is observed as 
complication from inflammation in the result of direct trauma, 
or during the treatment of dislocation of glenohumeral joint. 
The damage of plexus brachialis quite often occurs in obstetric 
practice during childbirth: in case of fetus head, hand or leg 
traction, when fetus is overweight (more than 4000 g), or if fetus 
is in abnormal position (pelvic presentation, breech birth).
Depending on the level of brachial plexus damage we can 
distinguish the following types of paralysis: 
Erb – Duchenne paralysis (superior type) – С5 – С6 – С7 
rami or trunks of plexus brachialis;
Dejerine-Klumpke paralysis (inferior type) – С8 – Th1 rami 
or inferior trunk formed by them.
In case of Erb – Duchenne paralysis the function of m. 
deltoideus, m. biceps brachii and m. brachioradialis is affected, 
i. e. n. axillaris and n. musculocataneus are damaged. A patient 
is not able to lift and shift his shoulder back, or bend his 
brachium in elbow joint. 
In case of Dejerine – Klumpke paralysis we can observe 
paralysis phenomena, sensory anesthesia, and pupillary 
disorders. Dysfunction and atrophy of small muscles of the 
hand (thenar and hypothenar muscles, musculi interossei 

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dorsales, 
musculi 
interossei 
palmares 
and 
musculi 
lumbricales). Sensory anesthesia of skin of the hand 
(cutaneous branches of n. radialis, ulnaris et medianus), 
medial surface of shoulder and brachium (n. cutaneus brachii 
medialis, n. cutaneus antebrachii medialis) occur. 
A. thoracica lateralis originates from a. axillaris in trigonum 
pectorale and follows n. thoracicus longus till m. serratus anterior. 
Anteriorly a. axillaris is crossed by nn. intercostobrachiales. Having 
reached the exterior surface of m. serratus anterior, a. axillaris 
supplies this muscle with blood, and gives off lateral rami 
(rr. mammarii laterales).
Compression of neurovascular fascicle is possible within 
trigonum pectorale, which results in syndrome of pectoralis 
minor muscle (Wright syndrome). The symptoms of Wright 
syndrome are muscle-tonic neurodystrophic disorders of the 
pectoralis minor muscle and compression of neurovascular 
fascicle which passes below the muscle. Neurovascular fascicle 
is pressed behind the pectoralis minor muscle below the 
processus coracoideus to caput humeri. Compression of these 
formations may appear in cases of excessive shoulder 
abduction (immobilization after humerus fracture, sleeping 
with arms put behind the head). A patient complains of pain in 
pectoralis minor muscle area when he raises or abducts his 
arm. We can observe paresthesia, weakness of arm muscles, 
skin blanching, hand swelling, decrease of pulse in a. radialis.
The axillary vessels and plexus brachialis are surrounded by 
cellular tissue and located in fascial compartment formed by 
fascia clavipectorale. The cellular tissue of trigonum 
clavipectorale while the neurovascular fascicle upwards, joins the 
deep cellular tissue of trigonum cervicalis lateralis, and fissure 
anterscalenum. Downwards it joins the cellular tissue of axilla, 
and along a. et v. axillaris and nerves of plexus brachialis – with 

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subpectoral cellular space. 

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