Drainage (Basilic and Cephalic are superficial; venae commitantes are deep)

 Study veins in direction of flow; Start from Dorsal Venous Network

 Basilic vein goes halfway, continue as brachial vein then axillary vein, then subclavian vein
 Median cubital vein (superficial) is over
cubital fossa, at superficial fascia
o Drains to Basilic Vein
o Venipuncture can occur here,
where bicipital aponeurosis
separates vein from cubital fossa
contents
 Brachial veins may be called venae
commitantes (running along with), they
are paired veins, running alongside
arteries (no need to remember specific
names of veins then)
 At the shoulder, the cephalic vein travels
between the deltoid and pectoralis major
muscles (known as the deltopectoral
groove), and enters the axilla region via
the clavipectoral triangle. Within the
axilla, the cephalic vein empties into
axillary vein.
Arterial Supply

Begins as the Subclavian Artery, which then

enters the Axilla at the lateral border of the
first rib, renamed as the Axillary Artery

Axillary Artery branches out, at three

different parts, whereby the second part is
found under/posterior to the pectoralis
minor (landmark).

At the lower border of the teres major

muscle, the axillary artery is renamed the
brachial artery.
Brachial artery descends down the arm. As it moves through the cubital fossa, underneath the
bicipital aponeurosis, the brachial artery terminates by bifurcating into the radial artery and ulna
artery

The ulnar artery enters the hand anteriorly to the flexor retinaculum and laterally to the ulnar nerve.
It gives rise to the deep palmar branch (connection) and continues laterally across the palm as the
superficial palmar ARCH (main contribution).

The radial artery enters the hand dorsally, crossing the floor of the anatomical snuffbox obliquely
(radial pulse can be felt here in addition to radial to flexor carpi radialis). It then turns medially and
travels between the heads of the adductor pollicis muscle. The radial artery supplies a branch to the
thumb, the index finger and to the superficial palmar arch – it then continues as the deep palmar
arch (runs backwards deeply, main contribution).

 After thumb, branches backwards to scaphoid (avascular narcosis)

Scapular Anastomosis – SA and AA give off branches supplying scapular and muscles (anastomose
for collateral circulation when there is resistance to blood flow
Arterial Supply to Posterior of arm

 Profunda Brachii artery accompanies radial nerve in radial groove

o Triceps brachii
 Posterior humeral circumflex artery – branches out from 3rd part of axillary artery,
supplies deltoid, exits from quadrangular space with axillary nerve
Venous Drainage

Superficial – in subcutaneous tissue; Abdomen – Basilic – Cephalic (ABC)

 Basilic Vein
o Arise from dorsal venous network, then ascends
medially
o At border of teres major, the Basilic Vein moves deep
into the arm, combines with the Brachial Vein to form
axillary vein (at level of mid-axilla)
o Axillary vein continues as the subclavian vein when it
crosses over the lateral border of the first rib.

 Cephalic Vein
o Also arise from dorsal venous network, origin of
cephalic vein also passes over anatomical snuffbox
o Passes through the deltopectoral groove, entering axilla
through clavipectoral triangle, by piercing the
clavipectoral fascia (not v important) to terminate as the
axillary vein
o In axilla, cephalic vein empties into axillary vein
 Both veins are connected at Median Cubital Vein
o Could have an M formation, with branch from the cephalic vein too called Median
Cephalic Vein, the other called Median Basilic Vein
o Anterior to cubital fossa

Deep – Underneath deep fascia, formed by vena comitantes

 Shares name with arteries: brachial veins, ulnar veins and radial veins
Lymphatics

Located in Axilla; all drain into Apical Node

 Pectoral (Anterior – drains breast)

 Subscapular (Posterior – drains back)
 Humeral (Lateral – drains upper limb)
o Central
 Apical (at apex of axilla)
Axilla

Area that lie under the Glenohumeral Joint, at the junction of upper limb and thorax, where
muscular and neurovascular structures enter and leave the upper limb.

Pyramidal Shape with a flat apex:

 Lateral Border: Intertubercle Sulcus

 Medial Border: Serratus Anterior and Thoracic Wall
 Anterior Border: Pectoralis Major and Minor
 Posterior Border: Latissimus Dorsi, Teres Major, Scapularis
o Lower border of teres major, marks out brachial artery from axillary
 Apex: Scapula, First Rib (marks Axillary Artery from Subclavian Artery), Clavicle
 Give Location of Change, and Vessels involved
Content found

 Artery: Axillary Artery

o whose Second Part is marked behind
pectoralis minor
o Second part is where ‘M’ is found
 Vein: Axillary Vein
 Nerves: Brachial Plexus
 Lymph Node: Axillary Lymph Node
 Muscles: Short head of Biceps Brachii; Coracobrachialis

Cubital Fossa (TAN)

 TAN/BAN (Lateral to Medial)

o Tendon of Biceps Brachii
o Brachial Artery (which divides into
radial and ulna arteries)
o Median Nerve
 Median Cubital Vein is anterior, and crosses
the cubital fossa
 Triangular Space marked out by the Line
between medial and lateral epicondyles,
Brachioradialis and Pronator Teres (sides of
triangle)
 Bicipital aponeurosis is deep connective tissue protecting structures at cubital fossa
Passageways out the axilla

Quadrangular Space

 Gap of Posterior wall

 Axillary Nerve and posterior circumflex humeral artery (a branch of the axillary artery)

Clavipectoral Triangle

 Anterior Wall, bound by Pec Major, Deltoid and Clavicle

 Cephalic Vein enters, Medial and Lateral Pectoral Nerves leave

 Breast is in superficial fascia

o Anything that cover muscles is deep fascia, which is dense, which blood vessels
cannot travel along through, only send in branches
o Ligaments of cooper in breast are connective tissue, run from pectoralis major to
skin – orange skin appearance
Carpal Tunnel (Osteofascial)

 Passageway found on anterior portion of wrist

 Entrance to the palm for several tendons and median nerve
 scaphoid to pisiform, hook of hamate to trapezium; four corners of flexor retinaculum
 Top border is the flexor retinaculum (Connective tissue)

 9 tendons 4 4 1; + Medial Nerve

o 4 Flexor Digitorum Superficialis
o 4 Flexor Digitorum Profundus
o 1 Flexor Pollicis Longus
o (Flexor Carpi Radialis tendon is WITHIN Flexor Retinaculum)
 Between palmaris longus and flexor carpi ulnaris is medial nerve
o Palmaris longus goes superficial of flexor retinaculum hence prominent
Clinical Relevance: Carpal Tunnel Syndrome

 Any cause decreasing size of carpal tunnel

o Medial nerve’s sensory terminals lead to tingling, diminished sensation, absence of sensation
 Partial numbness, check dermatome
o Wasting of thenar eminence – OAF muscles: opposition in thumb

Ulnar Claw Hand:

 Ulna nerve lesion At Wrist only, Default position at rest

o 4th and 5th Digits
o Extension of Metacarpophalangeal joint
 Due to absence of opposition to extensor muscles by lumbricals or flexors
o Flexion of Interphalangeal joint
 Due to absence of lumbricals to extend, while innervated FDP (functioning Ulna and Median)
and FDS (medial nerve) may flex
 If injury further away from hand, FDP is not innervated, flexion of IP is less; hence paralysis is only in extension
state

Hand of Benediction:

 Median Nerve lesion at wrist or elbow, during Attempts to make a fist

o 2nd and 3rd Fingers
o Inability to flex digits 2 and 3 when asked to make a fist
 Lumbricals and FDP of 2nd and 3rd digits are paralysed and cannot be flexed
 Thumb opposition lost (Ape Hand), Thenar Eminence wasting

Supracondylar Fracture at Elbow: Median Nerve damage (affecting forearm and arm, motor and sensory)

 Forearm supinated, weak wrist flexion with some adduction (by functioning Flexor Carpi Ulnaris)
 Hand of Benediction
Anatomical Snuffbox

(Describing with respect to anatomical position)

 Medial Border: Tendons of Extensor

Pollicis Longus
 Lateral Border: Tendons of Extensor
Pollicis Brevis and Adductor Pollicis Longus
 Proximal Border: Styloid Process of Radius

Content

 Radial Artery
o Crosses the floor to dorsal side,
turning back medially
o [Radial Pulse palpated by placing two fingers on
proximal portion of anatomical snuffbox]
 Superficial branch of radial nerve (Subcutaneous branch)
o Innervates dorsal surface of 3.5 digits on back of
hand (except for fingertips)
 Cephalic Vein
o Arising from dorsal venous network, crossing
snuffbox to travel anteriorly and laterally up the
forearm

Doctor Time

 FOOSH: Scaphoid Fracture

o Scaphoid has blood supply running from distal to
proximal, and fracture can disrupt blood supply to
proximal portion, and hence avascular necrosis