AT 2

Dr. Maung Myint

 Tutorial 2

• Blood vessels of upper limb

1) Axillary, brachial , radial, ulnar arteries
( branches, and their clinical importance)
2) Superficial and deep palmar arches
( their clinical importance)
3) Superficial and deep veins of the upper limb
(their clinical importance)
• Axilla

• Breast
The axillary artery
• the continuation of the subclavian artrey
• commences at the outer border of the first
rib, and ends at the lower border of the
tendon of the Teres major, where it takes the
name of brachial artery
• divided into three portions;
• the first part lies above,
• the second behind, and
• the third below the Pectoralis minor m.
 From first part
• highest thoracic A

From second part

• Thoracoacromial A
• Lateral thoracic A

From third part

• Subscapular A.
• Posterior circumflex humeral A.
AXILLARY SHEATH
• Anterior circumflex humeral A.
 The brachial artery
• continuation of axillary artery
• commences at the lower margin of the tendon
of the Teres major, and, passing down the arm,
• divides into the radial and ulnar arteries at
the level of neck of the radius.
• At first the brachial artery lies medial to the
humerus but as it runs down the arm it gradually
gets in front of the bone, and at the bend of the
elbow it lies midway between its two epicondyles.
• Median nerve passes the artery, superficially
from lateral to medial
Branches.
• Profunda Brachii A
• Superior Ulnar Collateral A.
• Inferior Ulnar Collateral A.
• Muscular branches to anterior compartment m.
• Nutrient A to the humerus.
 Brachial artery

Measurement of blood pressure

Profunda brachii artery

• arises from the brachial artery

near its beginning

• passes through the triangular

space & wind around the back of
the arm in the spiral groove along
with the radial nerve
 Radial artery
• at the level of the radial neck
• proximally, it lies deep to the
brachioradialis muscle
• distally, it lies superficially between the
tendons of brachioradalis and FCR

In the Forearm
• Radial recurrent A.
• Muscular branches.
At the Wrist
• branches to anastomosis around the wrist.
In the Hand.
• Deep palmar arch
• Princeps pollicis A.
• Radialis indices A.
• Palmar metacarpal A
.
 Ulnar artery
• larger than radial A
• passes deep to flexor muscles arising
from common flexor origin,
• upon FDP
• distally, it lies superficially between
the tendons of FCU & FDS
• enter the palm in front of the flexor
retinaculum.
• ulnar nerve lie on its medial side
In the Forearm
• Anterior recurrent A.
• Posterior recurrent A.
• Common interosseous A ( P&A).
• Muscular branches.

At the Wrist
• branches to anastomosis around
the wrist joint

In the Hand
• Deep branch.
• Superficial palmar arch.
Anastomosis around the elbow
 deep palmar arch

• terminal branch of radial artery & deep

branch of ulnar artery forms complete arch
• 1 cm proximal to the superficial palmar arch
• palmar metacarpal arteries
• princeps pollicis A
• radialis indices A
• branches ( anastomosis around the wrist)
 superficial palmar arch

• incomplete arch
• deep surface of palmar aponeurosis
• level with the border of outstretched
thumb web
• direct continuation of ulnar artery
(superficial palmar branch of radial artery)
• palmar digital As
 Clinical application

Axillary pulse

Brachial pulse

Radial pulse

Ulnar pulse

Measurement of blood pressure

Anatomical snuff box

The concavity formed in

between the extensor tendons
(EPL tendon and EPB,Abd PL)
if the thumb is fully extended.

• roof
beginning of the cephalic vein

• floor
scaphoid, trapezium, base of 1st MC &
radial styloid
Radial artery lies in the base
Superficial veins of the upper extremity
Superficial veins ( in superficial fascia)

• starts from dorsal venous plexus

• radial side – cephalic vein

• fairly constant in the superficial
fascia just posterior to the radial
styloid,
• lies in the deltopectoral groove
• pierce the clavipectoral fascia and
enter the axillary vein

• ulnar side – basilic vein

• pierce the deep fascisa at about
the middle of the arm
• joined by the brachial venae
comitantes to form the axillary vein
 Median cubital vein
• the vein linking the cephalic and
basilic vein just distal to the front of
the elbow
( usually the most prominent ( visible
& palpable ) superficial vein in the
body)

• separated from the underlying

brachial artery by bicipital
aponeurosis.

Care must be taken in administering drugs via median cubital vein.

The needle might inadvertently enter the brachial artery below.
Clinical relevance
( for venepuncture)
Fairly constant sites of superficial veins
( upper limb)

1) Cephalic vein
• immediately posterior to the radial
styloid process
• in the deltopectoral groove

2) Median cubital vein in the cubital fossa

( bicipital aponmeurosis separate it
from the underlying brachial artery)
Clinical relevance
Site for central venous catheterization is
Basilic vein
• Reaches the axillary vein
• Direct in line with axillary vein
• Increases the diameter as it approaches the axillary vein
 Axilla and its lymph nodes

Axilla
• pyramidal space
• between upper part of arm &
side of the chest, anterior &
posterior axillary fold
• pyramidal space
• 4 walls ( anterior, posterior, medial, lateral )
• an apex and Bounded
• in front by clavicle
• a base • behind by upper border of scapula
• medially by outer border of 1st rib

Apex
Posterior wall

Lateral wall

Medial wall

Base

Anterior wall
Posterior wall Subclavius m
Clavipectoral fascia

Subscapularis m P. minor m

P. major m

Teres major m

Latissimas dorsi m Anterior wall

Medial wall
• upper 4 or 5 ribs and intercostal
spaces covered by serratus anterior muscle

Lateral wall
• narrow
• inter-tubercular groove of
humerus, biceps brachii m and
coracobrachialis m
 Clavipectoral fascia clavicle
subclavius

P major P minor

deep fascia of arm pit

strong sheet of connective tissue that is attached

• above to the clavicle.
• below, it splits to enclose the pectoralis minor muscle and then
continues downward as the suspensory ligament of axilla and joins
the fascial floor of the armpit.
 Contents of the axilla

• cords & branches of the brachial plexus

• axillary artery and its branches
• axillary vein and its tributaries
• axillary lymph nodes
• intercosto brachial nerve
• long thoracic nerve ( nerve to serratus anterior )
• fat
 Axillary sheath

• prolongation of the prevertebral fascia

( deep cervical fascia ) into the axilla.

• invest axillary artery, axillary vein and

brachial plexus

Brachial plexus block

Lymph nodes of the axilla

20 to 30 in number, drain lymph from

• the lateral quadrants of the breast

• the superficial lymph vessels from the thoracoabdominal

walls above the level of the umbilicus, and

• the lymph vessels from the upper limb.

Make sure, you know the drainage area.
The lymph nodes are arranged in FIVE groups.

• Anterior group – 4-5 glands

– along the lower border of the pectoralis minor behind the pectoralis major,
lat Th A
– receive lymph vessels from the lateral quadrants of the breast and
superficial vessels from the anterolateral abdominal wall above the level of
the umbilicus.

• Posterior group – 6-7 glands

– in front of the subscapularis muscle,
– receive superficial lymph vessels from the back, down as far as the level of
the iliac crests.

• Lateral group – 4-6 glands

– along the medial side of the axillary vein,
– receive most of the lymph vessels of the upper limb

• Central group – 3-4 glands

– in the center of the axilla in the axillary fat,
– these nodes receive lymph from the above three groups.

• Apical group –
– at the apex of the axilla at the lateral border of the first rib,
– receive the efferent lymph vessels from all the other axillary nodes.
• Deltopectoral group –
– not strictly axillary nodes because they are located outside the axilla
(in the groove between the deltoid and pectoralis major muscles)
– receive superficial lymph vessels from the lateral side of the hand,
forearm, and arm.

• The apical nodes drain into the subclavian lymph trunk.

– on the left side, it drains into the thoracic duct;
– on the right side, it drains into the right lymph trunk.
The breast • Extends from the second rib above to the
(modified sweat gland) sixth rib below, and from the side of the
sternum to near the mid-axillary line.

• Nipple is a cylindrical or conical eminence

situated about the level of the fourth
intercostal space.

• On the summit of the nipple are fifteen to

twenty orifices, the apertures of the
lactiferous ducts.

• The base of the nipple is surrounded by an

pigmented areola.
• numerous large sebaceous glands, the
glands of Montgomery are present on the
areola.

• Axillary tail – part of upper quadrant of the

breast extending into axilla
Structure
The breast consists of glandular and fibrous tissue.

• 15-20 lobules (consisting of compound

tubuloacinar glands) embedded in fat

• lobules are arranged radially, separated

by fibrous septa running from
subcutaneous tissue to the fascia of
chest wall ( Cooper’s ligament)

• each lobule is drained by its lactiferous

duct on to the nipple.

• before opening into the nipple,

lactiferous ducts dilate to form ampulla,
which serve as reservoirs for the milk
Clinical relevance

• Involvement of lactiferous ducts

• Nipple retraction (recent retraction)

• Involvement of suspensory ligaments

• Generalized involvement
– Peau de’ orange appearance of the skin over the
breast
• Localize involvement
– Puckering / dimpling of the skin

• Involvement of ( infilitration into ) deep structures

• fixity

The breast is developed from milk line.

Vessels and Nerves.—

The arteries supplying the breast are derived from

• the lateral thoracic artery

• the acromiothoracic artry

• the internal mammary artery

• the intercostals arteries

The Lymphatic Vessels of the breast
• originate in a plexus in the interlobular spaces, on the walls of the
galactophorous ducts.
• pass to an intricate plexus situated beneath the areola, receives
the lymphatics from the skin, the central part of the gland and
those from the areola and nipple.
• its efferents are collected into two trunks which pass to
• the pectoral group of axillary glands.
• the glands along the thoracic wall

Clinical relevance

Carcinoma of the breast

• staging of carcinoma of the breast ( TNM staging )
Posterior relation:-

• retromammary space
• pectoral fascisa
• pectorlis major muscle
• serratus anterior muscle ( 4 digitations)
• external oblique aponeurosis
• upper part of rectus sheath

Clinical relevance:-
• spread of malignant tumour / mobility
lymphatic drainage of breast

75% drains into anterior group

Thank you !