Neurovascular Systems: Forms and Relations

4 Neurovascular Systems: Forms and Relations

4.1 The Arteries


A Course of the different segments of the arteries supplying the shoulder and arm

Subclavian artery: The right subclavian artery arises from the brachiocephalic trunk (as shown here), and the left arises directly from the aortic arch. The vessel runs over the first rib between the anterior and middle scalene (interscalene space, scalene interval) and continues as the axillary artery (see below) on reaching the lateral border of the rib. Unlike the other arteries pictured here, the subclavian artery supplies blood not only to the upper limb (i. e., the shoulder girdle and arm) but also to

a portion of the neck,

the cerebral circulation, and

the anterior chest wall.

Axillary artery: The continuation of the subclavian, the axillary artery runs from the lateral border of the first rib to the inferior border of the teres major muscle.

Brachial artery: The brachial artery is the continuation of the axillary artery. It ends at the elbow joint by dividing into the radial and ulnar arteries.

Radial artery: The radial artery runs distally on the radial side of the forearm from the division of the brachial artery, passing between the brachioradialis and flexor carpi radialis muscles on its way to the wrist. It terminates in the deep palmar arch.

Ulnar artery: This second division of the brachial artery runs below the pronator teres on the ulnar side of the forearm, under cover of the flexor carpi ulnaris, to the superficial palmar arch.

B Overview of the arteries of the shoulder and arm

The arteries of the shoulder and arm vary considerably in their origins and branching patterns (the principal variants are reviewed in Chapter 5, Neurovascular Systems: Topographical Anatomy). The branches are listed below in the order in which they arise from the parent vessels.

Branches of the subclavian artery

Vertebral artery

Internal thoracic artery (internal mammary artery)

Thyrocervical trunk

Inferior thyroid artery

Ascending cervical artery

Suprascapular artery

Transverse cervical artery

Costocervical trunk

Deep cervical artery

Supreme intercostal artery

Branches of the axillary artery

Superior thoracic artery

Thoracoacromial artery

Acromial branch

Clavicular branch

Deltoid branch

Pectoral branch

Lateral thoracic artery

Subscapular artery

Thoracodorsal artery

Circumflex scapular artery

Anterior circumflex humeral artery

Posterior circumflex humeral artery

Branches of the brachial artery

Deep artery of the arm (deep brachial artery)

Medial collateral artery

Radial collateral artery

Superior ulnar collateral artery (arterial network of the elbow)

Inferior ulnar collateral artery (arterial network of the elbow)

Branches of the radial artery

Radial recurrent artery (arterial network of the elbow)

Palmar carpal branch (palmar carpal network)

Superficial palmar branch (superficial palmar arch)

Dorsal carpal branch (dorsal carpal network)

Dorsal metacarpal arteries

Dorsal digital arteries

Princeps pollicis artery

Radialis indicis artery

Deep palmar arch

Palmar metacarpal arteries

Perforating branches

Branches of the ulnar artery

Ulnar recurrent artery (arterial network of the elbow)

Common interosseous artery

Posterior interosseous artery

Recurrent interosseous artery

Anterior interosseous artery

Palmar carpal branch (palmar carpal network)

Dorsal carpal branch (dorsal carpal network)

Deep palmar branch (deep palmar arch)

Superficial palmar arch

Common palmar digital arteries

Proper palmar digital arteries


D Arteries of the right hand

Posterior view.


E Main arterial branches in the right forearm (perforating branches)

a From the radial artery and ulnar artery (forearm supinated, anterior view).

b From the posterior interosseous artery (forearm pronated, posterior view).

Fasciocutaneous flaps with an excellent vascular pedicle can be harvested from the thin skin of the forearm. Composed of skin, subcutaneous tissue, and fascia, these flaps are supplied by branches of the major arteries and their accompanying veins. The skin flaps carry this vascular supply with them when they are transferred to the recipient site.

4.2 The Veins


B Cubital fossa of the right arm: variable course of the subcutaneous veins

a M-shaped venous pattern above the median antebrachial vein.

b Presence of an accessory cephalic vein from the venous plexuses on the extensor side of the forearm.

c Absence of the median cubital vein.

All of the illustrated variants are common.


D Superficial veins of the right upper limb

Anterior view. The main longitudinal trunks of the subcutaneous venous network of the arm are the median antebrachial vein, the basilic vein, and the cephalic vein.

Median antebrachial vein: This vein, unlike the cephalic and basilic, receives blood mainly from the cutaneous veins on the dorsum of the hand, draining the flexor side of the forearm. The variable median antebrachial vein opens into the corresponding longitudinal veins at the elbow, usually by way of the median cephalic vein and median basilic vein (see p. 379).

Basilic vein: This vein begins at the elbow, first ascending in the epifascial plane in the medial bicipital groove to the basilic hiatus, where it pierces the fascia in the middle of the arm. It terminates in a subfascial plane at the ulnar brachial vein.

Cephalic vein: In the arm the cephalic vein first ascends on the lateral side of the biceps brachii, then enters a groove between the deltoid and pectoralis major muscles (the deltopectoral groove). It finally opens into the axillary vein in the clavipectoral triangle (see p. 380).


E Superficial veins of the dorsum of the right hand

F Overview of the main superficial and deep veins of the upper limb

Numerous connections exist between the deep and superficial veins of the arm—the perforator veins. Valves are incorporated into the veins at regular intervals, increasing the efficiency of venous return (see p. 65).

Deep veins of the upper limb

Subclavian vein

Axillary vein

Brachial veins

Ulnar veins

Radial veins

Anterior interosseous veins

Posterior interosseous veins

Deep palmar venous arch

Palmar metacarpal veins

Superficial veins of the upper limb

Cephalic vein

Accessory cephalic vein

Basilic vein

Median cubital vein

Median antebrachial vein

Median cephalic vein

Median basilic vein

Dorsal venous network of the hand

Superficial palmar venous arch

4.3 The Lymphatic Vessels and Lymph Nodes


A Lymph vessels of the upper limb (after Schmidt and Lanz)

a Posterior view, b anterior view. The lymph vessels (lymphatics) in the upper limb are of two types:

Superficial (epifascial) lymphatics

Deep lymphatics

While the deep lymphatics of the upper limb accompany the arteries and deep veins, the superficial lymphatics lie in the subcutaneous tissue. In the forearm, they are most closely related to the cephalic and basilic veins. Numerous anastomoses exist between the deep and superficial systems. The arrows in the diagrams indicate the main directions of lymphatic drainage. Inflammations and infections of the hand generally incite a painful swelling of the axillary lymph nodes. When the lymph vessels are also involved, they are visible as red streaks beneath the skin (lymphangitis).


B Lymphatic drainage of the thumb, index finger, and dorsum of the hand (after Schmidt and Lanz)

The thumb, index finger, and part of the middle finger are drained by a radial group of lymph vessels that pass directly to the axillary lymph nodes. The other fingers are drained by an ulnar group of lymphatics (not shown here) that end at the cubital lymph nodes.

D The axillary lymph nodes, grouped by levels

(after Henne-Bruns, Dürig, and Kremer)

Level I: lower axillary group

(lateral to pectoralis minor)

Pectoral axillary lymph nodes

Subscapular axillary lymph nodes

Humeral axillary lymph nodes

Paramammary lymph nodes

Level II: middle axillary group

(along the pectoralis minor)

Interpectoral axillary lymph nodes

Central axillary lymph nodes

Level III: upper, infraclavicular group

(medial to pectoralis minor)

Apical axillary lymph nodes


E Classification of axillary lymph nodes by level

The axillary lymph nodes have major clinical importance in breast cancer. A malignant breast tumor will metastasize (seed tumor cells) to the axillary nodes as it grows. As a guide for surgical removal, the axillary lymph nodes can be segregated into groups arranged in three levels, based on their relationship to the pectoralis minor muscle (see p. 211).

Level I: all the lymph nodes lateral to the pectoralis minor.

Level II: all the lymph nodes along the pectoralis minor.

Level III: all the lymph nodes medial to the pectoralis minor (see p. 302).

4.4 The Brachial Plexus: Structure


A Schematic representation of the structure of the brachial plexus

a Names and sequence of the various components of the brachial plexus.

b Relationship of the lateral, medial, and posterior cords of the brachial plexus to the axillary artery.

c Subdivision of the brachial plexus cords into their main branches.

B Number and location of the main components of the brachial plexus




1. Plexus roots (anterior rami of the spinal nerves from cord segments C5–T1)


Between anterior and middle scalene (interscalene space)

2. The primary trunks: upper, middle, and lower


Lateral to the interscalene space and above the clavicle

3. The three anterior and three posterior divisions


Posterior to the clavicle

4. The lateral, medial, and posterior cords


In the axilla, posterior to the pectoralis minor

Jul 25, 2021 | Posted by in ANATOMY | Comments Off on Neurovascular Systems: Forms and Relations
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