Upper Limbs Blood Supply And Nerves

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

a. b.

subscapular – biggest (along border of subscapular muscle) ant. humeral circumflex

I. Arterial Supply - blood supply of the upper limbs leaves the aortic arch through the brachiocephalic trunk; which divides into a right/left common carotid and right/left subclavian arteries (only called subclavian arter until before the outer border of the first rib.)

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A. Axillary Artery– Closely related to the cords of the brachial plexus – Enclosed with a thin connective tissue called the axillary sheath (continuous to prevertebral facia) – Continuation of subclavian – Lateral border of 1st rib to lower border of teres major ms. – Divided into 3 parts by pectoralis 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. Highest/superior thoracic – blood supply to the superior chest wall (upper border of the pectoralis minor) nd 2 part – covered by the pectoralis minor a. thoracoacromial –divides into 2 branches b. lateral thoracic – lower border of pectoralis minor 3rd 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. Brachial Artery – Continuation of axillary a. – Anterior fascial compartment of upper arm – Main arterial supply for the arm  In case of bleedings in forearm or hand : compression of brachial artery is an effective temporal hemostasis – Lower border of teres major to neck of radius – Brachial pulse : medial side of midway of upper arm – Important branches: 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 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

C. Radial Artery – Forms part of superficial and deep palmar arterial arches(mainly deep arterial arch) – Smaller than ulnar artery – Begins at the cubital fossa at the level of neck of humerus – Leaves forearm by winding around lateral aspect of the wrist to reach posterior surface of arm – Passes between tendons of flexor 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. Muscular a. – to neighboring muscles b. Radial recurrent a. – arterial anastomoses around elbow joint c. Palmar carpal a. d. Dorsal carpal a. e. Superficial palmar a. f. Princeps pollicis a. – principal artery of thumb g. Radial indicis proprius a. – radial side of index finger

c. Common interosseous a. – divides into anterior and posterior interosseous arteries d. Muscular a. e. Dorsal carpal a. f. Palmar carpal a. g. Deep palmar a. E. A. – – B. – –

Palmar Arterial Arches SUPERFICIAL formed principally by ulnar a. supplies medial 3 ½ digits DEEP formed principally by radial a. Supplies lateral 1 ½ digits

F. Arterial anastomoses (for collateral circulation) A. SCAPULAR – Axillary system with subclavian system – Shoulder level B. ELBOW JOINT – Branches of brachial a. with branches of radial and ulnar aa. C. ANASTOMOSES WRIST & PALM – Branches of radial and ulnar arteries G. Metacarpal and Digital Arteries II. Venous Drainage – Superior vena cava  brachiocephalic vein subclavian vein  axillary vein A. Deep Set – accompany arteries B. Superficial Set – mostly outside the deep fascia 1. Palmar arch –digits 2. Cephalic vein – Lateral/ radial side of dorsal venous arch – Drain into axillary artery – Deltopectoral groove then pierces clavipectoral fascia

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

Ulnar Artery Larger of the two terminal arteries Begins at the cubital fossa Anterior compartment of arm Enters from in front of the flexor retinaculum – Lateral to ulnar nerve – Forms part of superficial and deep palmar arterial arches (mainly superficial) – Impt. Branches a. Anterior ulnar recurrent a. b. Posterior ulnar recurrent a.

3. Median cubital – Connection between cephalic and basilic at the cubital fossa – Varies between persons 4. Basilic vein – radial side – Brachial + basilic vein = axillary – Venae comitantes with brachial artery III. Lymphatic Drainage – Axillary lymph nodes  subclavian lymph trunk  right lymph trunk/left thoracic duct – Usually follow the veins A. Deep Set -parallel arteries in the hand and 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 and vessels from the upper limb 1. Lateral – Along medial side of the axillary vein – Receives most of the lymph vessels of the upper limb (except superficial vessels draining the lateral side) 2. Pectoral (Anterior) – Lower border of pectoralis muscle – Lateral quadrant of breast and superficial vessels from the anterolateral abdominal wall above level of umbilicus 3. Subscapular(Posterior) – In front of subscapularis muscle – Lymph vessels from the back as far as level of the iliac crest 4. Central – Center of axilla in the axillary fat – Receive lymph from the above three groups 5. Infraclavicular (deltopectoral) group – not strictly axillary nodes because they are located outside the axilla – Groove between deltoid and pectoralis major muscle – Receive superficial lymph vessels from the lateral side of the hand and forearm 6. Apical – Apex of the axilla at the lateral border of the first rib – Reveive efferent lymph vessels from all other axillary nodes B. Superficial Set – Begins around the fingers as digital lymphatic plexus; goes around radial and ulnar channels; encounter cubital (supratrochlear) and deltopectoral nodes before reaching axillary nodes.

1. Cubital nodes above the medial epicondyle 2. Infraclavicular nodes 3. Deltopectoral nodes

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 – Lateral Head of median nerve

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Nerve Supply of Upper Extremities A. Brachial Plexus Brachial Plexus – Formed by the union of the ventral primary rami of the lower four cervical nerves and the greater part of the ventral primary ramus of T1. – Parts : Roots (5), Trunks (3), Divisions (6), Cords (3), Terminal Branches (5) A. Roots : – C5 – dorsal scapular nerve (rhomboids); phrenic nerve Long thoracic (serratus anterior)nerve – C6- Long thoracic nerve – C7- Long thoracic nerve – C8 – T1 B. Trunks a. Upper Trunk (C5 and C6) – suprascapular nerve (supra and infraspinatus) – Nerve to subclavius b. Middle Trunk (C7) c. Lower Trunk (C8 and T1) C. Divisions – Anterior and posterior divisions of each trunk – Have no branches

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b. Medial Cord (anterior of lower trunk) Medial pectoral nerve – pectoralis minor and major (together with lateral pectoral nerve) Medial cutaneous nerve of arm Medial Cutaneous nerve 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) Medial Head of medial Nerve c. Posterior Cord (all posterior cords) Upper subscapularis nerve (subscapularis) Middle Subscapularis or thoracodorsal nerve (latissimus dorsi) Axillary or circumflex humeral nerve (deltoid and teres minor)

Radial Nerve (all the muscles in the posterior arm and forearm compartments)

After the axilla it immediately enters the posterior compartment of the upper arm *** Median Nerve is formed by the joining of the medial and lateral cords – Runs lateral to the brachial artery (upperarm) and then crosses halfway to continue on its medial side – Emerges from the lateral border of the flexor digitorum superficialis muscle and lies behind the flexor retinaculum – No branches in the upper arm – Supplies most of the muscles of the anterior forearm compartment (except 1 ½ muscles which are supplied by the ulnar nerve) – In the hand the thenar compartment muscles (opponens, flexor and abductor pollicis brevis) – Two lumbricals 1. Injury to the Roots

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Winging of scapula results from the damage of the long thoracic nerve Commonly occurs during breast surgery

b. Lower trunk injury – (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 to the cords Posterior cord injury – Saturday night palsy or crutch palsy – Loss of extensors of forearm, wrist and hand (ulnar nerve innervates most intrinsic muscles of the hand and anterior compartment muscles) Terminal Branches a. Musculocutaneous Nerve b. Median Nerve – Median nerve palsy (carpal tunnel syndrome) c. Ulnar Nerve – Ulnar nerve palsy (numbness and tingling in ulnar nerve distribution in the hand such as little finger and middle half of the ring finger) d. Radial Nerve – Radial Nerve Palsy (wrist drop) 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

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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 WHAT ARE THE TERMINAL BRANCHES OF THE BRACHIAL ARTERY? Radial and Ulnar Artery WHAT ARTERY SUPPLIES THE TRICEPS BRACHII MUSCLE? Brachial artery specifically profunda artery RADIAL ARTERY IS FOUND BETWEEN THE TENDONS OF WHAT MUSCLES? flexor carpi radialis and brachioradialis muscle THE DEEP PALMAR ARTERIAL ARCH ARISES MAINLY FROM WHAT ARTERY? Radial Artery (DR SU) WHAT SUPERFICIAL VEIN PASSES THRU THE DELTOPECTORAL GROOVE? Cephalic vein SUPERFICIAL LYMPH VESSELS ON THE MEDIAL SIDE OF THE UPPER LIMBS WILL DRAIN INTO WHICH GROUP OF AXILLARY NODES? Lateral Axillary node  Central Axillary node WHAT CARPAL BONE WILL BE OF HELP IN LOCATING FOR THE PULSATION OF YOUR ULNAR ARTERY? Pisiform

10. THE SUPERFICIAL PALMAR ARTERIAL ARCH ARISE

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MAINLY FROM WHAT ARTERY? Ulnar Artery 8.

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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 nerve. (BBC, Brachialis, biceps brachii, coracoradialis)

3.

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

4.

Give 2 nerves coming from the posterior cord of the brachial plexus – radial nerve, axillary/ circumflex humeral nerve, middle subscapularis, upper subscapularis

5.

What nerve will innervate the posterior arm compartment? Radial nerve

6.

What nerve will provide cutaneous innervation to the tips of 3 ½ fingers of the dorsal surface of the hand? Median nerve

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