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 Borders Superior: teres minor inferior: teres major Medial: long head of triceps Lateral: humerus Contents The axillary nerve & posterior circumflex humeral artery. Quadrangular space Triangular space

Triangular Space Borders Superiorly: teres minor, subscapularis Inferior : teres major Lateral : long head of triceps Contents Circumflex scapular artery branch of subscapular artery

Triangular Interval Medially long head of the triceps brachii Laterally shaft of the humerus Superiorly teres major Contents: Radial nerve Profunda brachii 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 : a. subscapular artery, b. anterior circumflex humeral artery, and c. posterior circumflex humeral artery

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 branch is the deep brachial art. (goes posteriorly) Then comes the superior and inferior ulnar arteries because they follow the ulnar nerve.

The Deep Artery of the arm ( profunda Brachii artery) Is the largest branch of the brachial artery and has the most superior origin. It accompanies the radial nerve along the radial groove as it passes posteriorly around the shaft of the humerus. It terminates by dividing into middle and radial collateral arteries, which participate in the periarterial anastomoses around the elbow.

Superior Ulna Collateral Artery Arises from the medial aspect of the brachial artery near the middle of the arm and accompanies the ulna nerve posterior to the medial epicondyle of the humerus. It anastomoses here with the Posterior ulna recurrent artery and inferior ulna collateral artery, participating in the periarterial anastomoses of the elbow.

Inferior Ulna Collateral Artery It arises from the brachial artery 5cm proximal to the elbow crease. It then passes inferomedially anterior to the medial epicondyle of the humerus and joins the anastomoses of the elbow region by anastomosing with the Anterior Ulna Recurrent Artery.

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.

The cephalic vein The cephalic vein ascends in the subcutaneous tissue from the lateral part of the dorsal venous network, running along the lateral border of the wrist and anterolateral surface of the proximal forearm and arm. Anterior to the elbow, it communicates with the median cubital vein, which passes obliquely across cubital fossa. It runs superiorly between the deltoid and pectoralis major muscles and enters the clavipectoral triangle where it joins the terminal part of the Axillary vein.

The Basilic Vein It ascends in the subcutaneous tissue from the medial end of the dorsal venous network along the medial side of the forearm and inferior part of the arm. It is often visible through the skin. It passes deeply near the junction of the middle and inferior 3rds of the arm running parallel to the Brachial artery and medial cutaneous nerve of forearm merging with the brachial vein to become the axillary vein at the inferior border of Teres major.

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 Radial Recurrent artery- anastomose with the radial collateral a., branch of the deep artery of the arm. palmar and dorsal branches- which participate in the periarterial anastomoses around the wrist by anastomosing with the corresponding branches of the ulna artery and terminal branches of the anterior and posterior interroseous arteries, forming the palmar and dorsal carpal 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. Anterior and posterior Ulnar recurrent aa. 3. Common interroseous a. –branches are anterior & posterior interosseous arteries). 4. 2 small carpal a. ( dorsal carpal branch & palmar carpal branch).

The anterior and posterior ulnar recurrent arteries anastomose with the inferior and superior ulna collateral arteries, respectively. They therefore participate in the periarterial anastomoses around the elbow. The palmar and Dorsal carpal branches form the palmar and dorsal carpal arches respectively.

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.

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 REVIEW 1. 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 arm ? 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 carpi ulnaris?

POWER REVIEW 6. 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 QUESTIONS 7. 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