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Anatomy and Physiology in Relation to Compression of the Upper Limb and Thorax

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Anatomy and Physiology in Relation to Compression of the Upper Limb and Thorax Clinical REVIEW anatomy and physiology in relation to compression of the upper limb and thorax Colin Carati, Bren Gannon, Neil Piller An understanding of arterial, venous and lymphatic flow in the upper body in normal limbs and those at risk of, or with lymphoedema will greatly improve patient outcomes. However, there is much we do not know in this area, including the effects of compression upon lymphatic flow and drainage. Imaging and measuring capabilities are improving in this respect, but are often expensive and time-consuming. This, coupled with the unknown effects of individual, diurnal and seasonal variances on compression efficacy, means that future research should focus upon ways to monitor the pressure delivered by a garment, and its effects upon the fluids we are trying to control. More is known about the possible This paper will describe the vascular Key words effects of compression on the anatomy of the upper limb and axilla, pathophysiology of lymphoedema when and will outline current understanding of Anatomy used on the lower limbs (Partsch and normal and abnormal lymph drainage. It Physiology Junger, 2006). While some of these will also explain the mechanism of action Lymphatics principles can be applied to guide the use of compression garments and will detail Compression of compression on the upper body, it is the effects of compression on fluid important that the practitioner is movement. knowledgeable about the anatomy and physiology of the upper limb, axilla and Vascular drainage of the upper limb thorax, and of the anatomical and vascular It is helpful to have an understanding of Little evidence exists to support the differences that exist between the upper the vascular drainage of the upper limb, use of compression garments in the and lower limb, so that the effects of these since the lymphatic drainage follows a treatment of lymphoedema, particularly differences can be considered when using similar course (Figure 1). The venous in relation to the upper body and limbs. compression garments. system of the upper limb consists There is much we do not know about of superficial and deep systems, with the finer details of arterial, venous and numerous ‘perforating’ veins (so-called lymphatic flow in normal, at risk and Box 1 because they pierce the deep fascia lymphoedematous limbs, and how separating the skin from the muscles this is affected by the application of Lymphatic drainage of the axilla and bones) joining the two systems compression. However, despite this, (Moore and Dailey, 2006). the use of compression garments is a It is difficult to get optimum pressure, widely accepted and important part of if any, into the axillary/medial proximal The superficial system arises from treatment (Partsch and Junger, 2006). upper arm area using compression the capillary networks of the skin and garments. This, combined with a likely subcutaneous tissue, which drain into annulus of often inappropriate two major vessels. The anterolateral pressure on the shoulder and lateral tissue of the upper limb drains into the chest provided by the wearer’s bra (in cephalic vein. This vein originates from Colin Carati, Associate Professor; Bren Gannon, Associate Professor, Department of Anatomy/Physiology; Neil Piller, the case of a woman), means that the lateral dorsum of the hand and Professor, Director Lymphoedema Assessment Clinic, there are often very significant issues travels via the lateral border of the wrist Department of Surgery, School of Medicine, Flinders of fluid accumulation (initially) and and forearm, passing through the lateral University and Medical Centre, Bedford Park, South fibre (later) in this area. aspect of the cubital fossa (where it Australia communicates with the basilic vein via 58 Journal of Lymphoedema, 2010, Vol 5, No 1 Piller Review.indd 2 31/03/2010 13:43 Clinical REVIEW the median cubital vein), and ascending The lymphatic drainage of the torso Lymphatic drainage of the upper limb the arm to pass into the axillary region does not follow the venous drainage of The lymphatic drainage of the upper between the deltoid and pectoralis the torso as closely as in the arm. limb also consists of superficial and deep major muscles. The basilic vein drains the However, the venous drainage of the torso systems, which follow similar paths to postero-medial aspect of the dorsum also enters the axillary, subclavian, or that of the vascular system. There are of the hand, travels superficially up the branchiocephalic veins en route to the four major patterns of lymphatic drainage antero-medial aspect of the forearm, superior vena cava, and hence may be which are based on early cadaver, medially through the cubital fossa and relevant to the venous drainage of the lymphography and lymphoscintigraphic about one-third of the way up the arm, arm. The anterior wall of the torso and the investigation (Foeldi et al, 2003). before piercing the deep fascia to then breast drains mainly into the axillary vein, accompany the brachial artery into the and to a lesser extent the internal thoracic The superficial lymphatic drainage axillary region. Both veins connect to veins. The ribcage is drained via intercostal vessels arise as a plexus within the skin of the axillary vein, and then the subclavian and subcostal veins that drain the ribcage the upper limb. Vessels drain from the veins en route to the superior vena posteriorly into the azygous/hemiazygous hand mainly along its palmar surface into cava. Many perforating veins are evident venous system, or anteriorly into the larger lymphatic vessels that converge in the anterior aspect of the forearm, internal thoracic veins. The posterior wall towards the veins draining the forearm, coalescing into the median vein of the of the thorax also drains into the azygous/ especially the basilic vein (Moore and forearm, which then joins the basilic hemiazygous system, which drains directly Dailey, 2006), acquiring new vessels from and/or the cephalic veins (Figure 1). into the superior vena cava. the skin as they travel up the limb (Figure 1). To subclavian lymphatic trunk The lymphatic vessels draining the Apical axillary lymph nodes antero-lateral territory of the arm traverse the upper part of the arm and Deltopectoral lymph nodes the anterior aspect of the shoulder, draining into the uppermost (apical) Central axillary lymph nodes lymph nodes of the axillary lymphatic Pectoralis minor muscle system (Figure 2). Lymph drainage from Humeral (lateral) axillary lymph nodes the postero-medial aspect of the forearm passes through nodes in the medial cubital Pectoral (anterior) axillary lymph nodes region, proximal to the medial epicondyle of the elbow, and then into lateral Subscapular posterior axillary lymph nodes (humeral) lymph nodes of the axilla. Basilic vein The deep lymphatic drainage Cephalic vein originates from the deeper soft tissue, Cubital such as muscles and nerves, joints and the Median cubital vein lymph nodes periosteum of the bones. Vessels converge and travel close to the deep veins of the upper limb, occasionally Cephalic vein passing through a few lymph nodes, Perforator veins before arriving at the lateral (humeral) axillary lymph nodes (Figure 2) (Moore Basilic vein and Dailey, 2006). The cutaneous venous drainage of the upper back (thorax) is via dorsal Superficial palmar perforating (posterior) cutaneous branches venous arch of the posterior intercostal veins and thence to the azygous/hemiazygous system to superior vena cava. Lymphatic plexus of palm Venous drainage of the skin and dermis of the chest anterior to the Digital lymphatic vessels mid-axillary line is largely via the thoraco- Anterior (palmar) view epigastric vein network, to the axillary vein (via the lateral thoracic vein — the Figure 1. Venous and lymphatic systems of the hand and arm. superior part of the thoraco-epigastric Journal of Lymphoedema, 2010, Vol 5, No 1 59 Piller Review.indd 3 31/03/2010 13:43 Clinical REVIEW Supraclavicular lymph nodes Subclavian lymphatic trunk Infraclavicular lymph nodes Internal jugular vein Axillary artery and vein Apical lymph nodes Deep servical lymph nodes Right lymphatic duct Lateral (humeral) lymph nodes Subclavian vein Central lymph nodes Right brachiocephalic vein and artery Pectoral (anterior) lymph nodes Subscapular (posterior) lymph nodes Parasternal lymph nodes Interpectoral lymph nodes Pectoralis minor Pectoralis major To contralateral (left) breast Subareolar lymphatic plexus To abdominal (subdiaphragmatic) (A) Anterior view lymphatics Figure 2. The lymph nodes of the axilla. venous network). Venous drainage of the Lymph drainage of the skin and dermis aspects of the breast medial to the areola, female breast is largely via the lateral of the front of the thorax (chest) anterior drain medially to para-mammary and thoracic vein to the axillary vein, but the to the mid-axillary line is largely from para-sternal nodes (Schuenke et al, 2006), more medial superficial aspects of the individually variable regions (lymphotomes) then to the right or left lymph duct or breast drain to the paired internal thoracic to particular axillary nodes (i.e. the sentinal thoracic duct to the subclavian vein, and venae comitantes, then to subclavian vein node for each region; Suami et al, 2008). on to the superior vena cava. Sentinel and on to the superior vena cava. Much of The area medial to the nipple in both node tracing from non-palpable (deep) the deepest tissue of the breast drains via sexes drains to the parasternal (internal breast tumours (Tanis et al, 2005) suggests perforating veins through the deep fascia mammary) node chain (Figure 3). that much of the deepest tissue of the to the anterior intercostal veins, and then breast is likely to drain via the deep to the internal thoracic veins. Drainage of the well developed lymphatics, which perforate through the lymphatic network of the female breast, deep fascia to join the anterior intercostal The venous drainage of the skin and including the dense sub-areola network, is lymphatics, passing then to the internal dermis of the chest mainly enters the largely via laterally or superiorly directed mammary lymph trunk and chain of nodes.
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