Neurovasculature of the upper limb (brachial plexus, cubital fossa) PDF

ANATOMY. NEUROVASCULATURE OF THE UPPER LIMB. CUBITAL FOSSA. Dr Viktoriia Yerokhina, Lecturer in Medical Sciences [email protected]  SUBCLAVIAN ARTERY – REVISION SLIDE Arises from the brachiocephalic trunk (2) on the right side (2.1) and directly...

ANATOMY. NEUROVASCULATURE OF THE UPPER LIMB. CUBITAL FOSSA. Dr Viktoriia Yerokhina, Lecturer in Medical Sciences [email protected]  SUBCLAVIAN ARTERY – REVISION SLIDE Arises from the brachiocephalic trunk (2) on the right side (2.1) and directly from the aortic arch on the left side (4). It supplies: inferior part of the neck, posterior part of the brain, anterior and lateral thoracic walls, anterior abdominal wall, upper extremity. Right Left  AXILLARY ARTERY – ARTERIA AXILLARIS Axillary artery is a direct continuation of the subclavian artery. It gives off branches in the axillary fossa and then continues as the brachial artery. Axillary artery supplies the muscles of the shoulder joint, muscles bordering the axillary fossa, deltoid, lateral thoracic wall including its muscles and the mammary gland.  AXILLARY ARTERY – ARTERIA AXILLARIS Axillary artery can be divided into three parts according to its relationship with the pectoralis minor. First part – proximal to pectoralis minor Second part – posterior to pectoralis minor Third part – distal to pectoralis minor  AXILLARY ARTERY - BRANCHES AND AREAS SUPPLIED 1. Superior thoracic artery (a. thoracis superior) – supplies the pectoral muscles and the mammary gland 2. Thoraco-acromial artery (a. thoracoacromialis) – runs through the clavipectoral triangle 3. Lateral thoracic artery (a. thoracica lateralis) – descends on the serratus anterior, which it supplies  AXILLARY ARTERY - BRANCHES AND AREAS SUPPLIED 4. Subscapular artery (a. subscapularis) 4.1 Circumflex scapular artery (a. circumflexa scapulae) –supplies the posterior scapular muscles 4.2 Thoracodorsal artery (a. thoracodorsalis) – passes over the latissimus dorsi, which it supplies 5. Anterior circumflex humeral artery (a. circumflexa humeri anterior) – smaller artery located on the anterior surface of the surgical neck of the humerus 6. Posterior circumflex humeral artery (a. circumflexa humeri posterior) – larger artery that supplies the deltoid ARTERIAL SUPPLY TO THE UPPER LIMB  BRACHIAL ARTERY – ARTERIA BRACHIALIS Continuation of the axillary artery, past the lower border of the teres major. It supplies the whole arm and elbow joint. It terminates in the cubital fossa where it bifurcates into the ulnary and radial arteries. Its collaterals terminate in the cubital articular anastomosis.  BRACHIAL ARTERY – BRANCHES AND AREAS SUPPLIED 1. Profunda brachii artery / deep artery of arm (a. profunda brachii) – runs between lateral and medial heads of the triceps brachii and then passes in the radial canal with the radial nerve, Supplies the humeral shaft and the muscles of the posterior compartment of the arm: Shoulder – deltoid Posterior arm – triceps brachii Proxima forearm – anconeus, brachialis, brachioradialis Intermuscular septum 2. Humeral nutrient artery (a. nutritia humeri)  BRACHIAL ARTERY – BRANCHES AND AREAS SUPPLIED 3. Superior ulnar collateral artery (a. collateralis ulnaris superior) – terminates in the cubital articular anastomosis 4. Inferior ulnar collateral artery (a. collateralis ulnaris inferior) – arises just above the cubital fossa – enters the cubital articular anastomosis 5. Cubital articular anastomosis (rete articulare cubiti) – vascular plexus of the elbow joint – formed by the brachial, radial, and ulnar arteries  RADIAL AND ULNAR ARTERIES Radial and ulnar arteries are formed by the bifurcation of the brachial artery within the cubital fossa. Both arteries continue to the palm, but neither of them pass in the carpal tunnel. Radial artery – supplies the posterolateral aspect of the forearm. It contributes to anastomotic networks surrounding the elbow joint and carpal bones. Radial pulse can be palpated in the distal forearm, immediately lateral to the prominent tendon of the flexor carpi radialis muscle.  ULNAR ARTERY Ulnar artery – supplies the anteromedial aspect of the forearm. It contributes to an anastomotic network surrounding the elbow joint. Also gives rise to the anterior and posterior interosseous arteries, which supply deeper structures in the forearm. These two arteries anastomose in the hand by forming two arches: superficial palmar arch, deep palmar arch.  BRANCHES OF THE RADIAL ARTERY 1.1 Radial recurrent artery (a. recurrens radialis) 1.2 Palmar carpal branch (r. carpalis palmaris) 1.3 Superficial palmar branch (r. palmaris superficialis) 1.4 Dorsal carpal branch (r. carpalis dorsalis) 1.5 First dorsal metacarpal artery (a. metacarpalis dorsalis prima) 1.6 First palmar metacarpal artery (a. metacarpalis palmaris prima)  BRANCHES OF THE ULNAR ARTERY 2.1 Ulnar recurrent artery (a. recurrens ulnaris) 2.2 Common interosseous artery (a. interossea communis) 2.2.1 Anterior interosseous artery (a. interossea anterior) 2.2.2 Posterior interosseous artery (a. interossea posterior) 2.3 Palmar carpal branch (r. carpalis palmaris) 2.4 Dorsal carpal branch (r. carpalis dorsalis) 2.5 Deep palmar branch (r. palmaris profundus) – anastomoses with the radial artery and forms the deep palmar arch RADIAL AND ULNAR ARTERY  SUPERFICIAL AND DEEP PALMAR ARCHES (ARCUS PALMARIS SUPERFICIALIS ET PROFUNDUS) 3. Superficial palmar arch (arcus palmaris superficialis) – is formed by an anastomosis between the larger trunk of the ulnar artery and the smaller superficial palmar branch of the radial artery 4. Deep palmar arch (arcus palmaris profundus) – is formed by an anastomosis between the larger terminal branch of the radial artery and the smaller deep palmar branch of the ulnar artery.  VEINS OF THE UPPER LIMB Veins of the upper limb form two systems: 1. Superficial venous system Located within the subcutaneous tissue, drain into deep venous system 2. Deep venous system Located below the deep fascia accompanying the arteries of the upper limb as venae comitantes. Deep veins communicate with superficial veins via perforator veins. Perforating veins run between the deep and superficial veins of the upper limb, connecting the two systems.  VEINS OF THE UPPER LIMB - SUPERFICIAL SYSTEM 1. Intercapitular veins (vv. intercapitulares) – connections draining venous blood from the palm to the dorsal venous network of the hand 2. Dorsal venous network of hand (rete venosum dorsale manus) – a venous plexus on the dorsum of the hand 3. Basilic vein (vv. basilica) – arises at the dorsal venous network of the hand – courses on the medial side of the forearm  VEINS OF THE UPPER LIMB - SUPERFICIAL SYSTEM 4. Cephalic vein (v. cephalica) – arises at the dorsal venous network of the hand – courses on the lateral side of the forearm, 5. Median cubital vein (v. mediana cubiti) – connects the cephalic vein with basilic vein across the cubital fossa  COMMON VENOUS PATTERNS IN FRONT OF THE ELBOW The veins in front of the elbow commonly form two patterns: 1. H-shaped pattern. 2. M-shaped pattern.  VEINS OF THE UPPER LIMB - DEEP SYSTEM The veins of the deep system follow the course of the arteries; two veins accompany each artery up to the armpit. 6. Deep venous palmar arch (arcus venosus palmaris profundus) – drains the fingers and metacarpals 7. Radial veins (vv. radiales) – thin veins draining the area supplied by the radial artery 8. Ulnar veins (vv. ulnares) – thin veins draining the area supplied by the ulnar artery 9. Brachial veins (vv. brachiales) – drain the area supplied by the brachial artery VEINS OF THE UPPER LIMB  ANTERIOR BRANCHES OF THE SPINAL NERVES 1. Cervical plexus (plexus cervicalis) – C1 to C4 2. Brachial plexus (plexus brachialis) – C5 to T1 3. Thoracic nerves (nervi thoracici) – T1 to T12 4. Lumbar plexus (plexus lumbalis) – T12 to L4 5. Sacral plexus (plexus sacralis) – L4 and L5 and S1 to S4 6. Coccygeal plexus (plexus coccygeus) – S5 and Co THE SPINAL NERVE ROOTS AND PLEXUSES, Posterior view  BRACHIAL PLEXUS (PLEXUS BRACHIALIS) Brachial plexus is formed predominantly by the anterior rami of nerves C5 to T1 (C4 and T2 make small contributions). It passes over the first rib into the axilla and innervates the upper limb and some muscles of the neck and shoulder. Plexus is well known for its conspicuous M or W shape seen in cadaver dissections. Subdivisions of this plexus are called roots, trunks, divisions, cords, and braches A good mnemonic for this is: Read That Damn Cadaver Book Or Remember To Drink Cold Beer  BRACHIAL PLEXUS (PLEXUS BRACHIALIS) As the body is dissected from the anterior surface of the shoulder inward, the posterior divisions are found behind the anterior ones.  BRACHIAL PLEXUS (PLEXUS BRACHIALIS) Five roots are the anterior rami of C5 through T1. Roots C5 and C6 converge to form the upper trunk; C7 continues as the middle trunk; and C8 and T1 converge to form the lower trunk. Each trunk divides into an anterior and posterior division. Finally, the six divisions merge to form three large fiber bundles - the lateral, posterior, and medial cords. From these cords arise the following major nerves: 1. Axillary nerve 2. Musculocutaneous nerve 3. Radial nerve 4. Median nerve 5. Ulnar nerve BRACHIAL PLEXUS (PLEXUS BRACHIALIS) BRACHIAL PLEXUS (PLEXUS BRACHIALIS)  MAJON NERVES OF THE BRACHIAL PLEXUS Musculocutaneous, median, and ulnar nerves contain anterior division fibers and innervate muscles in the anterior arm, anterior forearm, and palmar compartments that function mainly as flexors. Axillary and radial nerves contain posterior division fibers and innervate muscles in the posterior arm and posterior forearm compartments that function mainly as extensors. BRACHIAL PLEXUS (PLEXUS BRACHIALIS) EFFECTS OF LESIONS TO BRANCHES OF THE BRACHIAL PLEXUS  EFFECTS OF LESIONS TO BRANCHES OF THE BRACHIAL PLEXUS Radial nerve – ‘wrist drop’ Wrist drop is a condition where a patient is unable to extend their wrist and fingers, causing the hand to hang down loosely. This is often due to damage or compression of the radial nerve, which controls the muscles responsible for wrist and finger extension. Common causes: direct injury, prolonged pressure on the nerve (such as from using crutches), or fractures of the humerus that impact the nerve. Treatment: physical therapy, splinting, and in some cases, surgery if the nerve damage is severe.  EFFECTS OF LESIONS TO BRANCHES OF THE BRACHIAL PLEXUS Ulnar Nerve – ‘claw hand’ Claw hand is a condition where a patient’s fourth and fifth fingers are hyperextended at the metacarpophalangeal (MCP) joints and flexed at the interphalangeal (IP) joints, giving a "clawed" appearance. Cause: damage or compression of the ulnar nerve, which innervates the intrinsic muscles of the hand responsible for flexing and extending the fingers. Common causes: ulnar nerve injury from trauma (such as a fracture near the elbow or wrist), long-term pressure on the nerve, or nerve damage from conditions like leprosy. Treatment: management includes physical therapy, splinting to support hand function, and in severe cases, surgical intervention to release pressure on the ulnar nerve or restore muscle function. CUBITAL FOSSA – ANTECUBITAL FOSSA Cubital fossa - triangular space on the anterior aspect of the elbow joint  CUBITAL FOSSA – BOUNDARIES 1. Cubital fossa 2. Proximally: biceps brachii - horizontal line drawn between the epicondyles of the humerus. 3. Laterally: brachioradialis 4. Medially: pronator teres 5. Bottom: brachialis  CONTENT OF CUBITAL FOSSA From lateral to medial: radial nerve, biceps tendon, brachial artery, and median nerve Epitrochlear lymph nodes (cubital lymph nodes) Located in the subcutaneous fat just above the medial epicondyle of the humerus Drains the ulnar side of the forearm and hand “Really Need Beer To Be At My Nicest:” the contents of the cubital fossa are (from lateral to medial) Radial Nerve, Biceps Tendon, Brachial Artery, and Median Nerve. REFERENCES