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Upper Limbs: Blood Supply Nerves and a.

subscapular – biggest
Lymphatics (along border of
Dr. Elma subscapular muscle)
July 2, 2009 b. 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.)

– wind around front of


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

A. Axillary Artery- B. Brachial Artery


– Closely related to the cords of the – Continuation of axillary a.
brachial plexus – Anterior fascial compartment of
– Enclosed with a thin connective upper arm
tissue called the axillary sheath – Main arterial supply for the arm 
(continuous to prevertebral facia) In case of bleedings in forearm or
– Continuation of subclavian hand : compression of brachial
– Lateral border of 1st rib to lower artery is an effective temporal
border of teres major ms. hemostasis
– Divided into 3 parts by pectoralis – Lower border of teres major to neck
minor ms. (the part number of radius
corresponds to the number of – Brachial pulse : medial side of
branches ) midway of upper arm
1st part – lateral border of first rib – Important branches:
to the upper border of pectoralis a. Profunda brachii – deep biceps
minor muscle brachii
a. Highest/superior thoracic b. Superior ulnar collateral a. –
– blood supply to the arises near the middle of the arm
superior chest wall and follows the ulnar nerve
(upper border of the c. Inferior ulnar collateral a. –
pectoralis minor) arises near the termination of the
nd
2 part – covered by the pectoralis artery and takes part in the elbow
minor anastomosis
a. thoracoacromial –divides d. Radial a termination;
into 2 branches contribute to the
b. lateral thoracic – lower e. Ulnar a. formation of
border of pectoralis minor superficial and deep palmar
3rd part – lower border of pectoralis arches
minor to lower border of teres
major * collateral /recurrents – contribute to
a certain anastomosis
C. Radial Artery c. Common interosseous a. – divides
– Forms part of superficial and deep into anterior and posterior
palmar arterial arches(mainly deep interosseous arteries
arterial arch) d. Muscular a.
– Smaller than ulnar artery e. Dorsal carpal a.
– Begins at the cubital fossa at the f. Palmar carpal a.
level of neck of humerus g. Deep palmar a.
– Leaves forearm by winding around
lateral aspect of the wrist to reach
posterior surface of arm E. Palmar Arterial Arches
– Passes between tendons of flexor A. SUPERFICIAL
carpi radialis and brachioradialis – formed principally by ulnar a.
muscle, continues to deep palmar – supplies medial 3 ½ digits
ligament, into the floor of the B. DEEP
anatomical snuff box bounded by – formed principally by radial a.
tendons of extensor pollicis brevis – Supplies lateral 1 ½ digits
and longus muscles
– Impt. Branches F. Arterial anastomoses (for
a. Muscular a. – to neighboring collateral circulation)
muscles A. SCAPULAR
b. Radial recurrent a. – arterial – Axillary system with subclavian
anastomoses around elbow joint system
c. Palmar carpal a. – Shoulder level
d. Dorsal carpal a. B. ELBOW JOINT
e. Superficial palmar a. – Branches of brachial a. with
f. Princeps pollicis a. – principal branches of radial and ulnar aa.
artery of thumb C. ANASTOMOSES WRIST & PALM
g. Radial indicis proprius a. – radial – Branches of radial and ulnar
side of index finger 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
1. Cubital nodes above the medial
and central group of axial nodes.
epicondyle
a. axillary lymph nodes– drain lymph
2. Infraclavicular nodes
vessels from the lateral quadrants of
3. Deltopectoral nodes
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.
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

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
Nerve Supply of Upper Extremities pollicis brevis and most of
intrinsic muscles of hand except for
A. Brachial Plexus thenar compartment and first two
lumbricals)
– Medial Head of medial Nerve
Brachial Plexus
– Formed by the union of the ventral c. Posterior Cord (all posterior
primary rami of the lower four cords)
cervical nerves and the greater – Upper subscapularis nerve
part of the ventral primary ramus (subscapularis)
of T1. – Middle Subscapularis or
– Parts : Roots (5), Trunks (3), thoracodorsal nerve (latissimus
Divisions (6), Cords (3), Terminal dorsi)
Branches (5) – Axillary or circumflex humeral
A. Roots : nerve (deltoid and teres minor)
– 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 – Radial Nerve (all the muscles in
each trunk the posterior arm and forearm
– Have no branches compartments)
After the axilla it immediately b. Lower trunk injury
enters the posterior compartment – (Klumpke’s paralysis) – loss of
of the upper arm ulnar flexion of the wrist and the
*** Median Nerve is formed by the use of many of the intrinsic
joining of the medial and lateral muscles of the hand results in the
cords claw like position
– Runs lateral to the brachial artery – Scalene syndrome – may be
(upperarm) and then crosses produced by spasms of anterior
halfway to continue on its medial and middle scalene muscles or by a
side cervical rib involving commonly the
– Emerges from the lateral border of lower trunk causing pain along the
the flexor digitorum superficialis median border of arm and atrophy
muscle and lies behind the flexor of some mall muscles of hand; or
retinaculum compress subclavian artery
– No branches in the upper arm causing ischemia of the heart
– Supplies most of the muscles of the
anterior forearm compartment 3. Injury to the cords
(except 1 ½ muscles which are Posterior cord injury
supplied by the ulnar nerve) – Saturday night palsy or crutch
– In the hand the thenar palsy
compartment muscles (opponens, – Loss of extensors of forearm, wrist
flexor and abductor pollicis and hand (ulnar nerve innervates
brevis) most intrinsic muscles of the hand
– Two lumbricals and anterior compartment
muscles)

1. Injury to the Roots 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)

– Winging of scapula results from Cutaneous Innervation of the Upper


the damage of the long thoracic Extremeties
nerve
– Commonly occurs during breast
surgery
On Blood Supply and Lymphatics
1. WHAT MUSCLE MARKS THE TERMINATION OF
2. Injury to the Trunks THE AXILLARY ARTERY? Teres Major

a. Injury to upper trunk (Erb’s 2. GIVE 1 ARTERY ARISING FROM THE 3RD PART OF
THE AXILLARY ARTERY – Subscapular/Anterior
Duchenne paralysis) or waiter’s or Posterior humeral circumflex artery
tip position – upper limbs hangs 3. WHAT ARE THE TERMINAL BRANCHES OF THE
by the side in internal rotation BRACHIAL ARTERY? Radial and Ulnar Artery
4. WHAT ARTERY SUPPLIES THE TRICEPS BRACHII
MUSCLE? Brachial artery 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 ARTERY? Radial Artery
(DR SU)
7. WHAT SUPERFICIAL VEIN PASSES THRU THE
DELTOPECTORAL GROOVE? Cephalic vein
8. 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
9. WHAT CARPAL BONE WILL BE OF HELP IN
LOCATING FOR THE PULSATION OF YOUR ULNAR
ARTERY? Pisiform
10. THE SUPERFICIAL PALMAR ARTERIAL ARCH ARISE 7. What nerve injury will produce claw hand
MAINLY FROM WHAT ARTERY? Ulnar Artery deformity? Lower trunk injury (Klumpke’s
paralysis)
8. The ulnar nerve will come from what cord?
Medial cord
9. The opponens pollicis muscle is innervated by
what nerve? Median nerve

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