Upper Limbs Blood Supply and Nerves

Upper Limbs: Blood Supply Nerves and Lymphatics Dr. Elma July 2, 2009

a.

b.

subsc subs capul apula ar – bigg bigges estt (along border of subscapular muscle) ant. ant. hum humer eral al cir circu cumf mfle lex x

I. Arterial Supply - blood supply of the upper limbs leaves the aortic arch through the brachiocephalic brachiocephalic trunk ; whic which h divi divide des s into a right/left common carotid and right right/le /left ft subcl subclav avian ian arter arteries ies (only called called subcla subclavia vian n arter arter until until befor before e the outer border of the first rib.)

c.

A. Axillary Artery– Clos losely ely rel relat ated ed to the the cords of the brachial plexus – Encl Enclos osed ed with with a thi thin n con conne nect ctiv ive e tissue called the axillary sheath (continuous to prevertebral facia) – Cont Contin inua uati tion on of of subc subcla lavi vian an st – Lateral bo border of of 1 rib to lower border of teres major ms. – Divi Divide ded d int into o 3 part parts s by by pec pector toral alis is minor ms. (the part number corresponds to the number of branches ) 1st part – lateral border of first rib to the upper border of pectoralis minor muscle a. Highes Highest/su t/super perior ior thorac thoracic ic – blood supply to the superior chest wall (upper border of the pectoralis minor) nd 2 part – covered by the pectoralis minor a. thorac thoracoac oacro romia miall –div –divide ides s into 2 branches b. latera laterall thor thoraci acic c – lower lower border of pectoralis minor rd 3 part – lower border of pectoralis minor to lower border of teres major

– wind around front of surgical neck of the humerus (triangular space) post. humeral circumflex- wind around back of the surgical neck of the humerus (quadrangular space together with axillary nerve)

B. Brachi Brachial al Artery Artery – Cont Contin inua uati tion on of axil axilla lary ry a. – An Ante teri rior or fasc fascia iall com compa part rtme ment nt of upper arm – Main Main arte arteri rial al su supp pply ly for for the the arm arm  In case of bleedings in forearm or hand : compression of brachial artery is an effective temporal hemostasis – Lowe Lowerr bor borde derr of of ter teres es maj major or to neck neck of radius – Brac Brachi hial al pul pulse se : med media iall si side de of of midway of upper arm – Import portan antt bran branc ches: hes: a. Profunda brachii – deep biceps brachii b. Superior ulnar collateral a . – arises near the middle of the arm and follows the ulnar nerve c. Inferior ulnar collateral a. – arises near the termination of the artery and takes part in the elbow el bow anastomosis d. Radial a termination; contribute to the e. Ulnar a. formation of superficial and deep palmar arches * collateral /recurrents – contribute to a certain anastomosis

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C. Radi Radial al Art Arter ery y – Forms orms par partt of su supe perf rfic icia iall and and deep deep palmar arterial arches(mainly deep arterial arch) – Smal Smalle lerr tha than n ulna ulnarr art arter ery y – Begi Begins ns at the the cub cubit ital al fossa fossa at the the level of neck of humerus – Leav Leaves es for forea earm rm by wind windin ing g aro aroun und d lateral aspect of the wrist to reach posterior surface of arm – Passe asses s bet betwe ween en tend tendon ons s of of fle flex xor carpi radialis and brachioradialis muscle, continues to deep palmar ligament, into the floor of the anatomical snuff box bounded by tendons of extensor pollicis brevis and longus muscles – Impt. Branches a. Muscu Muscular lar a. – to neighb neighbori oring ng muscles b. Radia Radiall recur recurre rent nt a. – arte arteria riall anastomoses around elbow joint c. Palma almarr car carpa pall a. a. d. Dors Dorsal al car carpa pall a. e. Supe Superf rfic icia iall palm palmar ar a. f. Princ Princeps eps pollic pollicis is a. – prin princip cipal al artery of thumb g. Radial Radial indicis indicis propr proprius ius a. – radial radial side of index finger

c. Common Common inter inteross osseou eous s a. – divi divides des into anterior and posterior interosseous arteries d. Mus usc cular lar a. a. e. Dors Dorsal al carp carpal al a. f. Palmar lmar carpa arpall a. a. g. Deep Deep palm palmar ar a.

E. A. – – B. – –

Palm Palmar ar Arter Arterial ial Arc Arches hes SUPE SUPERF RFIC ICIA IAL L form formed ed prin princi cipa pally lly by ulna ulnarr a. supp su ppli lies es medi medial al 3 ½ digi digits ts DEEP form formed ed prin princi cipa pally lly by radi radial al a. Supp Suppli lies es late latera rall 1 ½ dig digit its s

F. Arterial anastomoses (for collateral circulation) A. SCAPULA LAR R – Ax Axil illar lary y sys syste tem m with with su subc bcla lavi vian an system – Shoulder level B. ELB ELBOW JOIN JOINT T – Bran Branch ches es of brac brachi hial al a. with with branches of radial and ulnar aa. C. ANASTO ANASTOMO MOSES SES WRIST WRIST & PALM PALM – Bran Branch ches es of radi radial al and and uln ulnar ar arteries

G. Metaca Metacarpal rpal and Digita Digitall Arteries Arteries II. Venous Drainage – Superior ve vena ca cava  brachiocephalic vein subclavian vein  axillary vein A. Deep Set – accompany arteries B. Superficial Set – mostly outside the deep fascia 1. Palma almarr arch arch –di –digi gits ts 2. Ceph Cephal alic ic vein vein – Late Latera ral/ l/ rad radia iall si side de of of dor dorsa sall veno venous us arch – Drai Drain n int into o axi axill llar ary y art arter ery y – Delt Deltop opec ector toral al gro groov ove e then then pie pierc rces es clavipectoral fascia

DR SU – Deep Radial; Superficial Ulnar D. – – – – – –

Ulnar Artery Larg Larger er of of the the two two term termin inal al art arter erie ies s Begi Begins ns at the the cub cubit ital al foss fossa a Ante An teri rior or com compa part rtme ment nt of of arm arm Ente Enters rs fro from m in in fro front nt of of the the flex flexor or retinaculum Late Laterral to ulnar lnar ner nerve Forms orms par partt of su supe perf rfic icia iall and and deep deep



3. Medi Median an cubi cubita tall – Conn Connec ecti tion on betw betwee een n ceph cephal alic ic and and basilic at the cubital fossa – Varie aries s betw betwee een n pers person ons s 4. Basili Basilic c vein vein – radi radial al sid side e – Brac Brachi hial al + basi basili lic c vein vein = axi axill llar ary y – Venae enae com comit itan ante tes s wit with h bra brach chia iall artery

III. Lymphatic Drainage – Ax Axil illa larry lymph ymph node odes  subclavian lymph trunk  right lymph trunk/left thoracic duct – Usu Usually ally fo follow llow the the vein veins s A. Deep Set -parallel arteries in the hand and forearm forearm of hand; drain into lateral and central group of axial nodes. a. axillary lymph nodes– drain lymph vessels from the lateral quadrants of the breast, the superficial lymph vessels, and thoracoabdominal walls above the level of the umbilicus umbilicus and vessels from the upper limb 1. Lateral – Alon Along g med media iall sid side e of of the the axil axilla lary ry vein – Recei eceive ves s mos mostt of of the the lymp lymph h ves vesse sels ls of the upper limb (except superficial vessels draining the lateral side) 2. Pecto ectora rall (Ante (Anteri rior or)) – Lowe Lowerr bor borde derr of of pec pecto tora rali lis s mus muscl cle e – Late Latera rall quad quadra rant nt of brea breast st and and superficial vessels from the anterolateral abdominal wall above level of umbilicus 3. Subsca Subscapul pular( ar(P Posteri osterior) or) – In fron frontt of of sub subsc scap apul ular aris is muscl muscle e – Lymph ymph vess vessel els s from from the the back back as far far as level of the iliac crest 4. Central – Cent Center er of of axi axill lla a in in the the axi axill llar ary y fat fat – Recei eceive ve lym lymph ph fr from the the abov above e three groups 5. Infrac Infraclav lavicu icular lar (delt (deltope opecto ctoral ral)) group – not not stri strict ctly ly axil axilla lary ry node nodes s bec becau ause se they are located outside the axilla – Groo Groove ve betw betwee een n del delto toid id and and pectoralis major muscle – Recei eceive ve sup super erfi fici cial al lym lymph ph vesse vessels ls from the lateral side of the hand and forearm 6. Apical – Ap Apex ex of the the axi axill lla a at at the the late latera rall border of the first rib – Revei eveive ve effer efferen entt lym lymph ph vess vessel els s from all other axillary nodes B. Superf Superfici icial al Set Set

1. Cubita Cubitall nodes nodes above above the the medi medial al epicondyle 2. Infrac Infraclav lavicu icular lar nodes nodes 3. Delt Deltop opec ector toral al nod nodes es



D. Cords (relationship to second part of axillary artery) a. Lateral Cord ( anterior of upper and middle trunk ) – Lateral pectoral nerve (pectoralis major and minor) – Musculucutaneous nerve (anterior arm compartment muscles); pierces the coracobrachialis muscle; “musculo” – refers to the BBC, “cutaneous” refers to the lateral cutaneous nerve of the forearm – Late Latera rall Hea Head d of of med media ian n ner nerve ve

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Nerve Supply of Upper Extremities A. Brachi Brachial al Plexu Plexus s

Brachial Plexus – Forme ormed d by by the the unio union n of of the the ven ventr tral al primary rami of the lower four cervical nerves and the greater part of the ventral primary ramus of T1. – Parts arts : Roots oots (5) (5),, Tru Trunk nks s (3), (3), Divisions Division s (6), Cords (3), Terminal Branches (5) A. Roots : – C5 – dorsal scapular nerve (rhomboids); (rhomboids); phrenic nerve Long thoracic (serratus anterior)nerve – C6- Long thoracic nerve – C7- Long thoracic nerve – C8 – T1 B. Trunk runks s a. Upper Upper Trunk Trunk (C5 and C6) – su supr prasc ascap apul ular ar nerv nerve e (sup (supra ra and and infraspinatus) – Nerve to to su subclavius b. Middl Middle e Trun Trunk k (C7) (C7) c. Lo Lower wer Trun Trunk k (C8 (C8 and and T1) T1)

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b. Medial Cord (anterior of lower trunk) Medial pectoral nerve – pectoralis minor and major (together with lateral pectoral nerve) Medi Medial al cuta cutane neou ous s ner nerve ve of arm arm Medi Medial al Cuta Cutane neou ous s ner nerve ve of forearm Ulnar nerve – runs to the medial side of the brachial artery (Anterior forearm compartments, flexor carpi ulnaris, ulnar half of flexor digitorum profundus, adductor pollicis brevis and most of intrinsic muscles of hand except for thenar compartment and first two lumbricals) Medi Medial al Head Head of medi medial al Nerv Nerve e

c. Posteri Posterior or Cord (all posterio posterior r cords) Upper subscapularis nerve (subscapularis) Middle Subscapularis or thoracodorsal nerve (latissimus dorsi) Axillary or circumflex humeral nerve (deltoid and teres minor)



After After the axilla it immediately enters the posterior compartment c ompartment of the upper arm *** Median Nerve is formed by the joining of the medial and lateral cords – Runs uns late latera rall to the the brac brachi hial al art arter ery y (upperarm) and then crosses halfway to continue on its medial side – Emer Emerge ges s fro from m the the late latera rall bord border er of of the flexor digitorum superficialis muscle and lies behind the flexor retinaculum – No bran branch ches es in the the upp upper er arm arm – Supp Suppli lies es mos mostt of of the the musc muscle les s of the the anterior forearm compartment (except 1 ½ muscles which are supplied by the ulnar nerve) – In the the han hand d the the the then nar compartment muscles (opponens, flexor and abductor pollicis brevis) – Two lumbricals

b. Lower Lower trunk trunk inju injury ry – (Klumpke’s paralysis) – loss of ulnar flexion of the wrist and the use of many of the intrinsic muscles of the hand results in the claw like position – Scalene syndrome – may be produced by spasms of anterior and middle scalene muscles or by a cervical rib involving commonly the lower trunk causing pain along the median border of arm and atrophy of some mall muscles of hand; or compress subclavian artery causing ischemia of the heart 3. Injury Injury to the cords cords Posterior cord injury – Satu Saturd rday ay nigh nightt pals palsy y or or crut crutch ch palsy – Loss Loss of of ext exten ensor sors s of fore forear arm, m, wri wrist st and hand (ulnar nerve innervates most intrinsic muscles of the hand and anterior compartment muscles)

1. Injur Injury y to to tthe he Roo Roots ts a. b. – c. –

d. – –

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Winging of scapula results from the damage of the long thoracic nerve Comm Common only ly occu occurs rs duri during ng brea breast st surgery

Cutaneous Innervation of the Upper Extremeties

1. 2. Injury to the Trunks a. Injury to upper trunk (Erb’s Duchenne paralysis) or waiter’s tip position – upper limbs hangs by the side in internal rotation

Terminal Branches Muscu Musculo locu cutan taneo eous us Nerve Nerve Medi Median an Nerv Nerve e Median ne nerve pa palsy (carpal tunnel syndrome) Ulnar nar Ne Nerve rve Ulna Ulnarr ner nerve ve pals palsy y (num (numbn bnes ess s and and tingling in ulnar nerve distribution in the hand such as little finger and middle half of the ring finger) Radi Ra dial al Nerv Nerve e Radi Radial al Nerv Nerve e Pal Palsy sy (wri (wrist st drop drop)

2.

On Blood Supply and Lymphatics WHAT MUSCLE MARKS THE TERMINATION OF THE AXILLARY ARTERY? Teres Major GIVE 1 ARTERY ARISING FROM THE 3RD PART OF THE AXILLARY ARTERY – Subscapular/Anterior or Posterior humeral circumflex artery

3.

WHAT ARE THE TERMINAL BRANCHES OF THE BRACHIAL ARTERY? Radial and Ulnar Artery

4.

WHAT ARTERY SUPPLIES THE TRICEPS BRACHII MUSCLE? Brachial artery specifically specifically profunda artery

5.

RADIAL ARTERY IS FOUND BETWEEN THE TENDONS OF WHAT MUSCLES? flexor carpi radialis and brachioradialis muscle

6.

THE DEEP PALMAR ARTERIAL ARCH ARISES MAINLY FROM WHAT ARTER A RTERY? Y? Radial Artery (DR SU)

7.

WHAT SUPERFICIAL VEIN PASSES PASSES THRU THE



10. THE SUPERFICIAL PALMAR ARTERIAL ARCH ARISE

7.

MAINLY FROM WHAT ARTER A RTERY? Y? Ulnar Artery 8.

9.

11. THE AXILLARY VEIN IS FORMED BY THESE TWO VEINS? Brachial and Basilic Veins

12. LYMPH VESSELS OF THE UPPER LIMBS WILL DRAIN MAINLY INTO WHICH GROUP OF AXILLARY NODES? Lateral Axillary node central axillary node

On Innervation

1.

From what roots will the long thoracic nerve originate? C5, C6, C7

2.

Give one muscle supplied by the musculocutaneous musculocutaneous nerve. (BBC, Brachialis, biceps brachii, coracoradialis) coracoradialis)

3.

Cord/s of origin of the median nerve. Lateral and medial cord

4.

Give 2 nerves coming from the posterior cord of

What nerve injury will produce claw hand deformity? Lower trunk injury (Klumpke’s paralysis) The ulnar ulnar nerv nerve e will will come come from from what what cord? cord? Medial cord The opponens pollicis muscle is innervated by what nerve? Median nerve

Upper Limbs Blood Supply and Nerves

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