Windsor University School of Medicine Vasculature of the upper limb The natural desire of good men is knowledge.  Leonardo da Vinci Lecture Idara C. Eshiet

Vasculature of the arm Relationship of the upper limb to the neck Right posterior scapula region Arteries associated with gateways in the posterior scapular region Arterial anastomoses around the shoulder Posterior wall of the axilla Axillary artery Branches of the axillary artery Brachial artery & branches

Relationship of the upper limb to the neck

Spaces in posterior scapula region Quadrangular space Superior: teres minor inferior: teres major Medial: long head of triceps Lateral: humerus Quadrangular space Triangular space

Triangular Space Superiorly: teres minor, subscapularis Inferior : teres major Lateral : long head of triceps

Triangular Interval Medially long head of the triceps brachii Laterally shaft of the humerus Superiorly teres major

Contents Quadrangular space Triangular space The axillary nerve & posterior circumflex humeral artery. Triangular space Circumflex scapular branch of subscapular artery 1 2 3

Posterior wall of the axilla Triangular interval Radial nerve Profunda brachii artery Triangular space Circumflex scapular artery

Arteries and nerves associated with gateways in the posterior scapular region

Axillary artery The subclavian artery in the neck becomes the axillary artery at the lateral margin of rib1 Becomes the brachial artery at the inferior margin of the teres major muscle. The axillary artery is separated into 3 parts by the pectoralis minor muscle. 1 2 3 Pectoralis minor m.

Branches of the axillary artery The axillary artery is separated into three parts by the pectoralis minor muscle, which crosses anteriorly to the vessel. First part is proximal to pectoralis minor Second part is posterior to pectoralis minor Third part is distal to pectoralis min.

Branches of the axillary artery 1st part gives 1branch : superior thoracic artery 2nd part gives 2 branches: thoraco-acromial artery & lateral thoracic artery 3rd part gives 3 branches : subscapular artery, anterior circumflex humeral artery, and posterior circumflex humeral artery 2a 1 3b.c 3a 2b

Arterial Anastomoses around the Scapula Collateral circulation: Subclavian artery-----Suprascapular artery--------circumflex scapular artery----subscapular artery----axillary artery

Axillary vein The axillary vein begins at the lower margin of the teres major muscle and is the continuation of the basilic vein. The axillary vein passes through the axilla medial and anterior to the axillary artery and becomes the subclavian vein. Tributaries of the axillary vein generally follow the branches of the axillary artery. Other tributaries include brachial veins that follow the brachial artery, and the cephalic vein.

Brachial Artery This is a continuation of Axillary artery beyond lower border of Teres major. It is Superficial and palpable throughout its course. It ends opposite the neck of the radius in the cubital fossa under cover the bicipital aponeurosis. It terminally divides into Radial & Ulnar Arteries

Branches: 1-Muscular : muscles of flexor compartment 2-Nutrient: to the humerus 3-the Deep Brachial Artery (profunda brachii artery) -arises near the beginning of brachial artery -follows the Radial Nerve into the spiral groove 4- Superior& inferior Ulnar collateral Arteries -Arises from the middle of the B.A and follows the Ulnar Nerve Ist brach is the deep brachial art. (goes posteriorly) Then comes the superior and inferior ulnar arteries because they follow the ulnar nerve.

Collateral and Recurrent arteries make very efficient anastomoses around the ELBOW

Veins of the arm 1. Deep veins: 2. Subcutaneous veins: Paired brachial veins pass along the medial & lateral sides of the brachial a. 2. Subcutaneous veins: Basilic vein Cephalic vein Axillary v. Cephalic v. Basilic v. deep v.

Vasculature of the forearm Cubital fossa Radial artery Ulnar artery Deep veins

Cubital fossa The brachial artery normally bifurcates into radial & ulnar a. in the apex of the fossa. The ulnar n. does not pass through the cubital fossa Radial a. Median c.v. Ulnar a.

Radial Artery Begins in the cubital fossa as a smaller terminal branch of the brachial artery at the level of the neck of the radius. It passes downwards & laterally , beneath brachioradialis muscle In the distal part of the forearm, it lies b/w brachioradialis tendon laterally & FCR tendon medially. It is covered only by the skin and fascia(site for taking the radial pulse). It leaves the forearm by winding around the lateral aspect of the wrist

Branches of the Radial Artery Muscular branches Recurrent Branch Superficial palmar branch – this arises just above the wrist and joins the Ulna a. to form the superficial palmar arch

Ulnar artery Begins in the cubital fossa at the level of the neck of the radius. It is larger than the radial artery. Descends deep to the flexor muscles Becomes superficial in lower part of forearm and lies b/w FCU and FDS tendons Ulnar a.

In the Palm It enters the palm Superficial to the flexor retinaculum in company with ulnar nerve. It ends by forming the Superficial Palmar arch anastomosing with the superficial palmar branch of the radial artery

ULNAR ARTERY RADIAL ARTERY IMP Superficial palmer arch Superfical branch of RA Deep palmer arch Deep branch Of UA ULNAR ARTERY RADIAL ARTERY

Branches of the ulnar artery 1. Muscular branches 2. Ulnar recurrent a. with anterior & posterior branches 3. Common interroseous a. –branches are anterior & posterior interosseous arteries). 4. 2 small carpal a. ( dorsal carpal branch & palmar carpal branch).

Collateral and Recurrent arteries make very efficient anastomoses around the ELBOW

IMP

veins Deep veins of the anterior compartment generally accompany the arteries & ultimately drain into brachial veins associated with the brachial artery in the cubital fossa.

Blood supply to the hand Ulnar artery & Superficial Palmar arch Radial artery & Deep Palmar arch Dorsal Venous arch

Arteries & Veins The blood supply to the hand is by the radial & ulnar arteries, which form 2 interconnected vascular arches (superficial & deep) in the palm. Vessels to the digits, muscles, & joints originate from the 2 arches & the parents arteries: The radial artery contributes substantially to the supply of the thumb & the lateral side of the index finger; The remaining digits & the medial side of the index finger are supplied mainly by the ulnar artery.

Radial artery VS. Ulnar artery in the Hand The radial artery contributes substantially to the supply of the thumb & the lateral side of the index finger; The remaining digits & the medial side of the index finger are supplied mainly by the ulnar artery.

Ulnar artery & superficial palmar arch A palmar digital artery to medial side of little finger 3 large, common palmar digital arteries, which are joined by the palmar metacarpal arteries from the deep palmar arch before bifurcating into the proper palmar digital arteries, which enter the fingers.

Radial artery & Deep Palmar arch 2 vessels, the princeps pollicis artery & the radialis indicis artery, arise from the radial artery. The princeps pollicis artery is the major blood supply to the thumb. The radialis indicis artery supplies the lateral side of the index finger.

Deep Palmar arch The deep palmar arch gives rise to : 3 palmar metacarpal arteries, which join the common palmar digital arteries from the superficial palmar arch; 3 perforating branches, which anastomose with the dorsal metacarpal arteries from the dorsal carpal arch.

Dorsal venous arch of the hand The deep veins follow the arteries; the superficial veins drain into a dorsal venous network on the back of the hand over the metacarpal bones.

Dorsal venous arch The cephalic vein originates from the lateral side of the dorsal venous network & passes over the anatomical snuffbox into the forearm. The basilic vein originates from the medial side of the dorsal venous network & passes into the dorsomedial aspect of the forearm.

Snuffbox The base of the triangle is at the wrist & the apex is directed into the thumb The lateral border is formed by the tendons of the abductor pollicis longus & extensor pollicis brevis The medial border is formed by the tendon of the extensor pollicis longus The floor is formed by the scaphoid & trapezium, & distal ends of the tendons of the extensor carpi radialis longus & extensor carpi radialis brevis.

Anatomical snuffbox The radial artery passes obliquely through the anatomical snuffbox, deep to the extensor tendons of the thumb & lies adjacent to the scaphoid & trapezium

Surface Anatomy

Surface Anatomy.2

Radial p. in anatomical snuff box Surface Anatomy.3 Axillary pulse Brachial p. cf. brachial p. Radial pulse Ulnar pulse Radial p. in anatomical snuff box

POWER REVIEW1. 1. What are the borders of the triangular spaces? Superior: teres minor m. / Inferior: Teres major m. Lateral: Long head of triceps. 2. what are the borders of the quadrangular space? Superior : teres minor / Inferior: Teres major Medial: Long head of triceps/ Lateral: Humerus 3. which nerve & vessel run in the spiral groove on the posterior humerus, & are therefore susceptible to damage following fracture of the humeral shaft? The radial nerve & the deep brachial artery

POWER REVIEW2. 4. Which nerve passes posterior to the medial humeral epicondyle (“funny bone”)? The ulnar nerve 5. Which structures pass through the carpal tunnel? The median nerve, the flexor pollicis longus tendon, the 4 flexor digitorum profundus tendons, and the 4 flexor digitorum superficialis tendons.

POWER REVIEW3. 6. What structures pass through the quadrangular space? The axillary nerve & posterior circumflex humeral artery 7. what structure passes through the triangular space? Circumflex scapular artery

POWER REVIEW 4. 8. which nerve innervates the flexors of the upper limb? The musculocutaneous nerve 9. which nerve innervate the extensors of the upper limb? The radial nerve 10. the median nerve lies in close proximity to which artery? The brachial artery (the median nerve is located just anterior to it)

POWER REVIEW 5. 11. In the hand, which nerve innervates the thenar muscles? Median nerve 12. In the hand, which nerve innervates the hypothenar muscles? Ulnar nerve 13.The ulnar artery lies btwn which 2 muscles? The flexor digitorum superficialis & the flexor digitorum profundus

POWER REVIEW QUESTIONS1. 14. The common interosseous artery (a branch of the ulnar artery) divides into which 2 arteries? The anterior interosseous artery & the posterior interosseous artery 15. Which artery runs with the superficial branch of the radial nerve under the brachioradialis muscle? Radial artery

REVIEW QUESTIONS1 The deep artery of the arm accompanies which of the following before passing around the body of the humerus? Which of the following is true regarding the quadrangular space? Which of the following is derived from the radial artery?

unknown Quality is never an accident. It is always the result of high intention, sincere effort and skillful execution. It represents the wise choice of many alternatives. ……………References……………………….. Gray’s Anatomy for students, 2nd edition Anatomy Recall, 2nd edition