Blood vessels and lymphatics of the upper limb Axillary artery • Course: – It starts at the outer border of the 1st rib as a continuation of the subclavian artery. – It is divided by the covering pectoralis minor muscle into 3 parts: • 1st part, is proximal to pectoralis minor. • 2nd part, is under cover the pectoralis minor. • 3rd part, is distal to the pectoralis minor. • It ends at the lower border of the teres major muscle which it continues as the brachial artery. • Relations: • Anterior: muscles of the pectoral muscles and clavipectoral fascia. • Posterior: muscles of the posterior wall of axilla and posterior cord of the brachial plexus. • Medially: the axillary vein and the medial cord of the brachial plexus. • Laterally: the lateral cord of the brachial plexus. • Branches: – 1st part: (one branch): • The superior thoracic artery: which supplies the upper part of the chest wall. – 2nd part: (two branches): • Thoraco-acromial artery: on the upper border of the pectoralis minor, which supplies the pectoral and shoulder regions. It gives off: Acromial, pectoral, clavicular & deltoid branches. • Lateral thoracic artery: on the lower border of the pectoralis minor, which supplies the pectoral region and the breast. – 3rd part: (three branches): • Subscapular artery: it descends on the lateral border of the scapula and it gives off circumflex scapular artery. It supplies the back of shoulder. • Posterior circumflex humeral artery: it accompanies the axillary nerve on the back of the surgical neck of the humerus. • Anterior circumflex humeral artery: in front of the surgical neck of the humerus.

• Anastmosis related to the axillary artey: – Anastmosis around the scapula: formed by: • Suprascapular artery, form the thyrocervical trunk. • Deep branch of the transverse cervical artery, from the thyrocervical trunk. • Subscapular artery, from the 3rd part of the axillary artery. – Anastmosis around the shoulder: formed by: • Suprascapular artery, form the thyrocervical trunk. • Thoraco-acromial atery, from 2nd part of subclavian artery. • Anterior and posterior circumflex humeral arteries from the 3rd part of axillary artery. Brachial artery • Course: – It starts at the lower border of the teres major as a continuation of the axillary artery. – It is superficial throughout its course. On the upper half of the arm, it is medial to the humerous, while in the lower half of the arm, it is front to the humerus. • Termination: at the level of the neck of the radius as two terminal branches (ulnar and radial arteries). • Relations: – Anterior: skin and fascia. The median nerve is crossing at the middle of the artery from the lateral to the medial side. – Posterior: long head of triceps and brachialis. – Lateral: the tendon of biceps at the lower end of the artery. – Medial: the ulnar nerve, at the upper part of the artery. • Branches: 1. Profunda brachii artery: it arises from the postero-medial aspect of the artery, just below its origin. It accompanies the radial nerve in the spiral groove of the humerus. It ends at the lateral side of the arm as one ascending and two descending branches. 2. Nutrient artery to the humerus, which is directed downwards. 3. Upper and lower ulnar collateral arteries: They accompany the ulnar nerve down to the medial epicondyle. 4. Two terminal branches: ulnar and radial arteries.

• Anastmosis related to the brachial artery: (Anastmosis around the elbow): – Around the lateral epicondyle: formed by: • The two descending branches of the profunda brachii. • Radial recurrent artery. • Interosseous recurrent artery. – Around the medial epicondyle: • The two ulnar collateral arteries. • The two ulnar recurrent arteries (anterior and posterior). Radial artery • Course and relations: 1. In the forearm: the artery starts at the level of the neck of radius and descends on the radial side of the forearm undercover the brachioradialis muscle. It descends over the pronator teres, flexor digitorum superficialis and flexor pollicis longus. It becomes subcutaneous in the lower 1/3 of the forearm. 2. In the dorsum of the hand: the artery winds backwards just below the styloid process to enter the floor of the anatomical snuff box, then it continues to reach the 1st interosseous spcace. 3. In the palm of the hand: the artery passes through the adductor pollicis to reach the palm of the hand and it ends medially as (the deep palmar arch). • Branches: 1. In the forearm: - Recurrent radial artery: it ascends to the front of the lateral epicondyle. - Anterior carpal artery: it passes medially in the front of the wrist joint. - Superficial palmar artery: it passes throuhg the thenar eminence to join the superficial palmar arch. 2. In the back of the hand: - posterior carpal artery: it gives off three dorsal metacarpal arteries to supply the adjacent sides of the medial 4 fingers. - the 1st dorsal metacarpal artery: it gives off 2 dorsal digital arteries to the adjacent sides of thumb & index fingers. - Dorsal digital artery to the radial side of the thumb. 3. In the palm of the hand: - Princeps pollicis artery: to the thumb. - radialis indices artery: to the radial side of the index finger. - deep palamar arch: located on the bases of metacarpal bones. It gives off: a) three palmar metacarpal arteries. b) three perforating arteries to the back of the hand. c) Recurent carpal artery to the anterior carpal arch.

Ulnar artery

• Course and relations: 1. In the forearm: the artery starts at the level of the neck of radius and descends on the ulnar side of the forearm undercover the flexor carpi-ulnaris muscle. It descends over the flexor digitorum profundus, lateral to the ulnar nerve. It becomes subcutaneous in the lower 1/3 of the forearm, lateral to the tendon of the flexor carpi-ulnaris muscle. 2. In the palm of the hand: the artery passes superficial to the flexor retinaculum. It ends by crossing the palm laterally to form (the superficial palmar arch). • Branches: 1. In the forearm: - Anterior recurrent ulnar artery: it ascends to the front of the medial epicondyle. - Posterior recurrent ulnar artery: it ascends to the back of the medial epicondyle. - Common interosseous artery: which is a short trunk (1 cm) appear at the upper border of the interosseous membrane, and ends as: A) Anterior interosseous artery: that descends on the anterior surface of the interosseous membrane to supply muscles of the front of forearm. It gives off the nutrient arteries to the ulna and the radius. B) Posterior interosseous artery: that descends in the posterior compartment of the forearm, to supply muscles of the back of forearm. It gives off the recurrent interosseous artery to the back of the lateral epicondyle. - Anterior carpal artery: it passes laterally in the front of the wrist joint. - Posterior carpal artery: to the back of wrist joint. 2. In the palm of the hand: - Deep branch to join the medial end of the deep palmar arch. - Palmar digital artery to the medial side of the little finger. - suerficial palmar arch: located just beneath the palmar aponeurosis. It gives off three common palmar digital arteries to the adjacent sides of the medial 4 fingers. Venous drainage of the upper limb • Superficial veins: 1. Dorsal venous arch: – It lies in the dorsum of the hand. – It receives: • Dorsal metacarpal veins: drain the middle 3 fingers. • Vein drains the thumb & radial side of the index. • Vein drains the ulnar side of the little finger.

2. Cephalic vein: – It start from the lateral end of the dorsal venous arch. – It ascends on the lateral side of the forearm and the lateral side of the arm. – It ends by piercing the clavipectoral fascia to join the Axillary vein.

3. Basilic vein: – It start from the medial end of the dorsal venous arch. – It ascends on the medial side of the forearm and the medial side of the arm. – It ends by piercing the arm fascia at the point of insertion of coracobrachialis, to join the two venae comitants of the brachial artery to form the Axillary vein. 4. Median cubital vein: – It is present obliquely in the front of the elbow. – It joins the cephalic vein (1 inch below the lateral epicondyle) to the basilic vein (1 inch above the medial epicondyle) • Deep veins: (Axillary vein) – It starts at the lower border of the teres major muscle by the union of the two venae comitants of the brachial artery and the basilic vein. – It ascends in the axilla medial to the axillary artery. – It ends at the outer border of the 1st rib where it continues as subclavian vein. – Tributaries: 1. Circumflex humeral veins. 2. Subscapular vein. 3. Lateral and superior thoracic veins. 4. Cephalic vein.

Lymph nodes of the upper limb

• Axillary lymph nodes: (5 groups) 1. Anterior group (pectoral): – It lies along the lateral thoracic vessels. – It drains the breast & the skin of the anterior abdominal wall above the level of the umbilicus. 2. Posterior group(subscapular): – It lies along the subscapular vessels. – It drains the skin of the back of the trunk above the level of the iliac crest. 3. Lateral group (humeral): – It lies along the lower end of axillary vein. – It drains the upper limb. 4. Central group: – It lies near to the floor of axilla. – It receives afferents from the previous groups of lymph nodes . 5. Apical group: – It lies along the upper end of axillary vein. – It drains the breast and It receives afferents from the previous groups of lymph nodes. – The efferent trunk is the subclavian lymph trunk that ends into thoracic duct on the left side of the body and the right lymphatic duct on the right side.

• Lymphatic drainage of the upper limb: 1. Lymph nodes: – deep lymph nodes: are the lateral axillary lymph nodes. – Superficial lymph nodes: • Infraclavicular LNs: in the deltopectoral groove. • supratrochlear LNs: above the medial epicondyle. 2. Lymph vessels: – Deep vessels: drain the deep tissues of the upper limb & end into the lateral group of axillary nodes. – Superficial vessels: • The minority of these vessels accompany the basilic and cephalic veins to Infraclavicular & supratrochlear LNs. • The majority, pass through the deep fascia with the basilic vein to end into the lateral group of axillary nodes.