Nerve and blood supply of the upper limb

This material was developed This material was developed for use by students of OTPT 102, AY 09-10, College of Allied Medical Professions, University of the Philippines, Manila. Please obtain permission before use.

Enrico C. Aguila, OTRPAugust 7, 2009

OTPT 102: Applied Anatomy and KinesiologyCollege of Allied Medical ProfessionsUniversity of the Philippines Manila

Nerve and Blood Supply of the Upper

Extremities

This material was developed This material was developed for use by students of OTPT 102, AY 09-10, College of Allied Medical

Professions, University of the Philippines, Manila. Please obtain permission before use.

Learning Objectives:

At the end of the SGD and didactics, the student should be able to:

Describe brachial plexus in terms of:– Roots, trunks, divisions, cords and branches– Pathway– Motor distribution – Sensory distribution

Describe the arterial and venous circulation of the upper extremity in terms of:– Vessels– Pathway– Distribution– Function

Describe the lymphatic circulation of the upper extremity.



Brachial Plexus - Collection of nerves that enter the upper extremities



Lies partly in the neck and partly in the axilla



Gives rise to the nerves that innervate the UE



Functions

Sensory innervation of skin and deep structures such as joints

Motor innervation of the muscles of the UE

Influence over the diameters of the blood vessels by the sympathetic vasomotor nerves

Sympathetic secretomotor supply to the sweat glands



Parts

Really Tired? Drink Coffee Buddy!

R = ROOTS (ventral rami) (5)T = TRUNKS (3)D = DIVISIONS (2)C = CORDS (3)B = BRANCHES (Many!!)



Nerve roots

C5

C6

C7

C8

T1



Trunks (formed by the roots in the neck)

C5

C6

C7

C8

T1

Upper Middle

Lower



Divisions (neck)

Upper

Middle

Lower

TRUNKS DIVISIONSAnterior

Anterior

Anterior Posterior

Posterior

Posterior



Cords – formed by the joining of the divisions in the axilla

T D CORDS

U

M

L

A

A

A

P

P

P

Lateral

Medial

Posterior



Cords – give off branches (axilla)

Lateral

Medial

Posterior

Musculocutaneous

Median

Ulnar

Axillary

Radial

Thoracodorsal

Upper and lowerSubscapular

C5

C6

C7

C8

T1

MC

M

U

R

Ax

LTN

DSNSupSN

LPN

USSN

TDN

LSSN

MP

MBC

MABC

Upper

Middle

Lower

Anterior

Ante

rior

Anterior

Posterior

PosteriorPost

eri

or

Posterior

Lateral

Medial

Brachial Plexus



Nerves of the Brachial Plexus

RootsDorsal scapular (C5)Long thoracic (C5, C6, C7)

Upper trunkNerve to subclavius (C5, C6)Suprascapular

Lateral CordLateral pectoral MusculocutaneousLateral root of median nerve

Medial Cord

Medial pectoralMedial cutaneous nerve of armMedial cutaneous nerve of forearmUlnar Medial root of median

Posterior Cord

Upper subscapularLower subscapularThoracodorsalAxillaryRadial



Dorsal scapular (C5)

Rhomboids minorRhomboids major



Long thoracic C5, C6, C7

Serratus anterior



Nerve to subclavius C5, C6

SubclaviusMay give branch to the phrenic nerve (accessory phrenic nerve)



Suprascapular C5, C6

Supraspinatusinfraspinatus



Lateral pectoral C5, C6, C7

Pectoralis major



Medial pectoral

Pectoralis majorPectoralis minor



Musculocutaneous C5, C6, C7

CoracobrachialisBrachialisBiceps



Upper subscapular C5, C6

Subscapularis



Lower subscapular C5, C6

SubscapularisTeres major



Thoracodorsal C6, C7, C8

Latissimus dorsi



Medial cutaneous nerve of arm

Skin on medial side of distal one third of arm



Medial cutaneous nerve of forearm

Skin on medial side of forearm



Axillary C5, C6

Motor–Teres minor–Deltoid

Sensory–Skin over lateral part

of upper arm



Radial C5, C6, C7, C8, T1

Motor•Triceps•Anconeus•Small part of brachialis•Brachioradialis•ECRL•ECRB•Supinator•EDC•EDM•ECU•EPL•APL•EPB•EIP

Sensory•Posterior aspect of the arm•Posterior aspect the forearm•Lower lateral aspect of the arm•Dorsal lateral surface of the hand



Median nerve C5, C6, C7, C8, T1

Motor•Pronator teres•FCR•PL•FDS•FPL•FDP 1 and 2•Pronator quadratus•OP•FPB•APB•Lumbricales 1 and 2

Sensory

•Palmar side of lateral 3 ½ fingers•Lateral side of palm•Lateral side of wrist



Ulnar C8, T1

Motor•Abductor Digiti Minimi•Adductor Pollicis•Dorsal Interossei•Flexor Carpi Ulnaris•Flexor Digiti Minimi•Flexor Digitorum Profundus (Med. 2)•Flexor Pollicis Brevis (Med.)•Lumbricals (Med. 2)•Opponens Digiti Minimi•Palmar Interossei

Sensory•Palmar surface of medial 1 ½ fingers •Medial palm and wrist•Dorsal surface of medial 1 ½ fingers



Innervation of Joints

SHOULDER AXILLARY

ELBOW ULNAR

WRIST RADIAL, MEDIAN, ULNAR



Sensorty innervation of the UE



Sensory innervation of the hand

This material was developed This material was developed for use by students of OTPT 102, AY 09-10, College of Allied Medical Professions, University of the Philippines, Manila. Please obtain permission before use.

Arterial supply of the UE



Subclavian artery

Passes laterally deep to the clavicle.

Becomes the axillary artery as it passes into the axillary region.



Axillary artery

Starts at the lateral border of the first rib, as a continuation of the subclavian, and ends at the lower border of the axilla (i.e. the lower border of teres major) to become the brachial artery



Branches of the axillary

1st part:

• superior thoracic artery

2nd part:

• acromiothoracic trunk• lateral thoracic artery

3rd part:

• subscapular artery• anterior circumflex humeral artery• posterior circumflex humeral artery



First Part of the Axillary Artery

between the lateral border of the first rib and the superior border of the pectoralis minor muscle

enclosed in the axillary sheath along with the axillary vein.

has only one branch, the supreme thoracic artery.

This artery helps to supply the first two intercostal spaces and the superior part of the serratus anterior muscle.



Second Part of the Axillary Artery

This part of the artery lies deep to the pectoralis minor muscle.

The lateral, medial and posterior cords of the brachial plexus are so named respective to this part of the axillary artery.

This part of the axillary artery has two branches, the thoracoacromial and lateral thoracic arteries.



The Thoracoacromial Artery

This is a short, wide trunk that arises from the axillary artery deep to the pectoralis minor muscle.

It pierces the costocoracoid membrane, which is part of the clavipectoral fascia.

It then divides into 4 branches (acromial, deltoid, pectoral, and clavicular) deep to the clavicular head of the pectoralis major muscle.



The Lateral Thoracic Artery

This nerve descends along the axillary border of the pectoralis minor muscle.

It supplies the pectoral muscles and the axillary lymph nodes.

The lateral thoracic artery is large in women, and is an important source of blood to the lower part of the mammary glands.



Third Part of the Axillary Artery

This part extends from the inferior border of the pectoralis minor muscle to the inferior border of the teres major muscle.

It has three branches, the anterior and posterior circumflex humeral arteries and the subscapular artery.



Circumflex Humeral Arteries

These arteries pass around the surgical neck of the humerus and anastomose with each other.

The anterior circumflex humeral artery passes laterally, deep to the coracobrachialis and the biceps brachii muscles.

It gives off an ascending branch that supplies the shoulder, but the main artery winds around the surgical neck of the humerus.

The larger posterior circumflex humeral artery passes through the posterior wall of the axilla through the quadrangular space.

It is accompanied by the axillary nerve to supply the surrounding muscles.



The Subscapular Artery

This is the largest branch of the axillary artery. It descends along the lateral border of the subscapularis muscle and divides into the circumflex scapular artery and the thoracodorsal artery.

The circumflex scapular artery passes around the lateral border of the scapula to supply muscles on the dorsum of the scapula.

The thoracodorsal artery continues the general course of the subscapular artery to supply adjacent muscles, principally, the latissimus dorsi muscle.



Subclavian A.

Axillary A.

3rd Axillary A.

2nd Axillary A.

1st Axillary A.

Superior thoracic A.

Thoracoacromial A.

lateral thoracic A.

Subscapular A.

anterior circumflex humeral A

posterior circumflex humeral A

Axillary Artery



Brachial artery

This artery begins at the inferior border of the teres major muscle as the continuation of the axillary artery.

It runs inferiorly and slightly laterally on the medial side of the biceps brachii muscle to the cubital fossa, where it ends opposite the neck of the radius.

It is superficial and palpable throughout its whole length.



At first it lies medial to the humerus and then anterior to it.

It lies anterior to the triceps brachii and brachialis muscles, and is overlapped by the biceps brachii and coracobrachialis muscles.

It accompanies the median nerve, which crosses it anteriorly at the middle of the arm.

Under the cover of the bicipital aponeurosis, the brachial artery divides into the radial and ulnar arteries.



Branches of the brachial artery

The brachial artery gives rise to many unnamed muscular branches, mainly from its lateral side.

The named branches of the brachial artery are the profunda brachii artery, the nutrient humeral artery, and the ulnar collateral arteries (superior and inferior).



Profunda Brachii Artery

This is the largest branch of the brachial artery, and has the most superior origin.

It accompanies the radial nerve in its posterior course in the radial groove.

Posterior to the humerus, the profunda brachii artery (or deep brachial artery) divides into anterior and posterior ascending branches.

These help form the arterial anastomoses of the elbow region.



Ulnar collateraal arteries

Superior Ulnar Collateral ArteryThis arises from the brachial artery near the middle of the arm.

It accompanies the ulnar nerve posterior to the medial epicondyle of the humerus.

Here, it anastomoses with the posterior ulnar recurrent branch of the ulnar artery and the inferior ulnar collateral artery.

Inferior Ulnar Collateral Artery

This arises from the brachial artery about 5 cm proximal to the elbow crease.

It then passes inferomedially, anterior to the medial epicondyle of the humerus.

Here, it joins the anastomoses of the elbow region.



Branches of the brachial artery

profunda (accompanying the radial nerve);superior ulnar collateral (accompanying the ulnar nerve);

nutrient (to the humerus); inferior ulnar collateral.



Radial and ulnar arteries

brachial artery bifurcates proximal to the cubital fossa into the radial and ulnar arteries.

supply the blood to the forearm and a portion of the hand and digits.



Radial artery

The radial artery courses down the lateral side of the arm where it sends many small branches to the forearm.

The radial recurrent artery is the first and largest major branch of the radial artery which serves the region of the elbow.



Ulnar artery

The ulnar artery extends down the ulnar side of the forearm and serves the medial side of the forearm through many small branches.

The first large branch of the ulnar nerve is the ulnar recurrent artery which arises from the proximal portion near the elbow.



Veins of the Upper extremityNote: The veins of the upper extremity are classified as either deep or superficial veins. The superficial veins are highly variable and form an extensive network just below the skin. The deep veins accompany the arteries of the same region and bear similar names. A brief summary of the two types of veins follows.

Deep Veins of the Upper Extremity The radial vein on the lateral side of the forearm and the ulnar vein on the medial side drain blood form the deep and superficial palmar arches of the hand. The radial and ulnar veins join in the cubital fossa to form the brachial vein which continues up the medial side of the brachium. The brachial then becomes the axillary vein draining portion of the biceps and trips. Finally the axillary vein becomes the subclavian vein.



Superficial Veins of the Upper Extremity The main superficial vessels of the upper extremity are the basilic and cephalic veins. The basilic vein passes on the ulnar side of the forearm and the medial side of the arm. Near the head of the humerus, the basilic vein merges with the brachial vein and forms the axillary vein. The cephalic vein drains the superficial portion of the hand and forearm on the radial side and continues p the lateral side of the arm. In the shoulder region the cephalic vein pierces the fascia and joins the axillary vein. Another portion of the superficial vein is the median vein. It ascends from the cephalic vein on the lateral side to connect with the basilic vein on the medial side.

Superficial Veins Deep Veins

Nerve and blood supply of the upper limb

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