26/03/07

HUBS1105L8
Blood Vessels and Nerves of the Upper Limb

Learning Objectives:
1. Understand the formation & distribution of the brachial plexus
Identify roots, trunks and cords of brachial plexus
Identify named nerves: axillary, radial, musculocutaneous, median & ulnar
Illustrate the structure of the brachial plexus diagrammatically
Describe the distribution of axillary, radial, musculocutaneous, median & ulnar nn.
Describe the major courses & relations of these nerves
Describe segmental innervation of upper limb - dermatomes & myotomes
State major effects of damage to:axillary, radial, musculocutaneous, median & ulnar
nn.
Describe the motor & sensory nerve supply to the hand
Describe methods of testing nerve integrity
2. Understand the structure of blood vessels to the upper limb
Identify arteries: subclavian, axillary, brachial, radial, ulnar, superficial & deep
palmar arches
Identify superficial veins: cephalic. basilic, median cubital
Identify deep veins: brachial, venae comitantes
Identify main features of arteriograms or venograms
Describe the course & relations of major arteries & veins
Describe the pattern of superficial & deep venous return (including valves)
Describe the surface markings of major vessels
Describe & explain the function of collateral arterial anastomoses
Explain the hazard of injection in the cubital fossa
Demonstrate & describe the palpation of pulses of the subclavian, axillar, brachial,
radial & ulnar arteries
The Nervous System
The nervous system is organized into the central nervous system (brain and spinal
chord) and the peripheral nervous system (nerve fibres that carry information
between the CNS and the rest of the body).
The spinal chord only goes as far as the lumbar region of the spine. After this
point the spinal nerves dangle downwards in a large lead.
NERVES OF THE UPPER LIMB
The Peripheral Nervous System

The link between the neurons of the central nervous system and the rest of the
body.
Nerve cell bodies are clustered into groups called ganglia
Nerve cell axons are bundled together and wrapped in connective tissue to for the
peripheral nerves. These axons carry sensory and motor commands.

Afferent Nerves: These come from the dorsal roots of the spinal chord. They send
information about the internal and external environment to the CNS. Visceral afferents
carry subconscious input, whereas sensory afferents carry conscious input. Sensory
information is categorised as either somatic (arising from the bodys surface) or special
(including vision, hearing, taste and smell) sensation.
Efferent Nerves: These come from the ventral roots of the spinal chord and are the
communication link by which the CNS controls the activities of muscles and glands, the
effector organs that carry out actions. The CNS regulates these organs by initiating action
potentials in the cell bodies of efferent neurons, whose axons terminate on these organs.
The autonomic nervous system innervates the involuntary branch of the peripheral
efferent division (smooth and cardiac muscle and glands) and the somatic nervous system
innervates voluntary control (skeletal muscle). The autonomic nervous system is further
divided into the sympathetic and parasympathetic nervous systems.

Nerves can either arise from the brain stem (12 cranial nerves mainly control the
structures of the head) or the spinal chord (31 pairs of spinal nerve come off the
spinal chord through openings between vertebrae)
The spinal chord has two functions. It is the neuronal link between the brain and
the peripheral nervous system, being organised into ascending and descending
tracts for communication in both directions. It is also the integrating center for
spinal reflexes including the basic protective and postural reflexes.
Afferent and efferent fibres are bundled together into spinal nerves, which supply
specific body regions and are attached to the spinal chord in a paired fashion
throughout its length.
After the spinal nerves emerge from the spinal chord they progressively branch to
form a network of peripheral nerves that supply the tissues. The posterior branch*
supplies the deep muscles of the back and skin, whilst the ventral branch is larger
and forms plexuses (nerve networks) and supplies the superficial back,
extremities and the lateral and ventral trunk, except in the thoracic region where it
forms the intercostal nerve. => * Must remember posterior branch for exam.

Root Value: The spinal nerve from which a nerve is derived (may be more than one). The
spinal chord segments to which sensory and motor neurons attach.
Motor Distribution: The efferent distribution from the CNS to the muscle (The
information going from the brain to the muscles). The list of muscles supplied by a nerve.

Sensory Distribution: The afferent distributions, from the body to the CNS. The
peripheral nerve. Afferent information is received from the muscle, connective tissue and
joints
Cutaneous Distribution: The afferent distribution of a peripheral nerve to the skin.
Brachial Plexus
The brachial plexus is composed of spinal nerves C5 to T1.
It is the sensory and motor supply to the upper limb, except for the tip of the
shoulder (these are derived from the cervical plexus)
It is an arrangement of nerve fibres running from the spine through the neck and
the axilla and into the arm.
The brachial plexus elements consist of roots, trunks, divisions, cords and
branches (collateral/preterminal and terminal branches)
- Roots The roots are the five anterior rami of the spinal nerves after they have
given off thioer segmental supply to the muscles of the neck.
- Trunks The roots form three trunks:
Superior (upper) trunk From C5 and C6
Middle trunk formed by C7
Inferior (lower) trunk formed by C8 and T1
Each trunk then splits into two, an anterior and posterior division, to form six
divisions
- Cords The six divisions regroup to become three cords. These are named by
their position with respect to the axillary artery:
Posterior cord formed by the posterior divisions of the three trunks
Lateral cord formed by the anterior divisions of the superior and middle
trunks
Medial cord continuation of the inferior trunk

The posterior cord branches into 2 terminal branches of the brachial plexus, the
small axillary nerve and the large radial nerve
The anterior branches of the brachial plexus (lateral and medial cords) form an M
shape. This M gives rise to 3 terminal branches of the brachial plexus. The
musculocutaneous nerve branches off the lateral cord. The ulnar nerve is a
continuation of the medial cord and the median nerve is formed by the joining of
the medial and lateral cords.
There are also lots of little branches of the brachial plexus before the terminal
branches. These go to the shoulder region.

Posterior Brachial Plexus

Axillary Nerve
A small branch of the posterior brachial plexus
The roots are C5 and C6
Goes straight through to the axilla

Supplies the deltoid and teres minor muscles (all other rotator cuff muscles are
supplied by the suprascapula nerve)

Radial Nerve
A large branch of the posterior brachial plexus
The roots are C5 T1
Innervates all muscles at the back of the arm and the back of the forearm,
including the supinator (the posterior compartments of the arm)
Cutaneous distribution is the posterior arm, posterior forearm and the lateral part
of the back of the hand
It is the most vulnerable at three points, high in the axilla, against the humerus
(sits on back of humerus) and at the neck of the radius.

AXILLARYNERVE
C5,6

Deltoid
Teres
minor
Triceps

RADIALNERVE
C5,6,7,8,T1

Anconeus
Brachioradialis
Allextensors

ALLposterior
Arm&Forearm
Muscles

Supinator
Sensory

Anterior Brachial Plexus

Musculocutaneous Nerve
Roots are C5 C7
Supplies all of the anterior arm muscles (the BBC)
Cutaneous distribution is the anterolateral skin of the forearm

C5,6,7
Coracobrachialis
Anterior
Compartment
OfArm

Bicepsbrachii
Brachialis

Sensory
(Lateralcutaneous
Nerveofthigh)

Median Nerve
Roots are C6 - T1
Bypasses the arm to reach the forearm where it supplies the anterior forearm
muscles (flexors and pronators) except the medial half of the flexor digitorum
profundus and the flexor carpi ulnaris. It then goes on to supply the lateral two
lumbricals and the thenar muscles of the hand
Cutaneous distribution if the skin on the lateral 3 fingers on the palmar surface
and just over the nail beds.

C6,7,8,T1

Pronators
Allflexors
(exceptFCU&
MedialhalfFDP)

Anterior
Compartment
ofForearm

Thenarmuscles
Sensory

Lumbricals(2lateral)

Ulnar Nerve
Roots values are C7 - T1
Ulnar nerve basically supplies everything the radial nerve does not. It too
bypasses the arm to supply the medial half of the flexor digitorum profundus, the
flexor carpi ulnaris and everything in the hand except the lateral two lumbricals
and the thenar
Supplies the skin on the medial 1 fingers on the front and back of the hand.

C7,8,T1

Pectoralmuscles
Sensory

Flexorcarpiulnaris

Sensory

Flexordigitorumprofundus
(ulnarhalf)

Anterior
Forearm
Muscles

Hypothenarmuscles
Adductorpollicis
Sensory

Lumbricals(2medial)

Mostsmall
Handmuscles

Interossei

* Note: All nerves can be described in terms of the peripheral nerve of supply or of the
segmental origin of those fibres.
Motor Segmental Distribution: Spinal roots that supply a particular group of muscles
involved in a specific movement (e.g. elbow flexion is supplied by C5, C6 and elbow
extension by C7, C8)
Myotomes: A group of muscles supplied by a single spinal cord segment (consists of
muscles not nerves). Myotomes are named from the segment giving origin to motor
neurons supplying its muscles (e.g. T1 myotome is the intrinsic muscles of the hand. The
T1 neurons are received via the median and ulnar nerves)
Dermatomes: The region of skin that receives sensory innervation from a single spinal
cord segment (consists of skin, not nerves). Named in reference to spinal cord segment
which gives attachment to sensory neurons that supply it.

DERMATOMES

ANTERIOR

C5

POSTERIOR

T2
T2
T1

AXILLARY

C8
RADIAL

RADIAL

C6
T1

C6

AXILLARY

C5

C8

C7

C7

MUSCULO
CUTANEOUS

MUSCULO
CUTANEOUS

RADIAL
MEDIAN

ULNAR

CUTANEOUSNERVE
DISTRIBUTION

Nerve Lesions
* Note: Need to know for exam

Lesions of the brachial plexus are quite common due to the region and the
abundance of compressions, trauma, dislocations and fractures.
Wherever the point of damage is, effects will be distal to that point

Afferent (sensory) lesions

Lesions lead to sensory defects, as impulses are unable to reach the spinal cord
(there is a loss of cutaneous sensation)
There is a loss of spinal reflexes as these are also dependent on afferent impulses
(e.g. pain withdrawal reflex)
Damage or pressure of the nerve can cause impulses from the site and result in
tingling, itching or pain (e.g. pain when the funny bone is hit, due to the ulnar
nerves positioning on the elbow)
Efferent (motor) lesions

If impulses are unable to reach the muscles then paralysis results. This can be
either complete or incomplete
There is a loss of spinal reflexes
Muscle will become flaccid and atrophy if no nerve regeneration occurs

NERVE

PARALYSIS

MOTOR LOSS

Axillary

SITE OF
INJURY
axilla

deltoid

humeral abduction

Musculocutaneous

axilla

arm flexors

Radial

axilla

supinator &
extensors

weak forearm flex

(due to the
brachioradialis) &
supination
weak supination
lat. dorsum of
(biceps brachii is a hand
powerful supinator,
therefore supination
is not lost), loss of
extension, the wrist
will drop

cubital fossa

all except triceps

elbow

pronators, flexors
exc. FCU/med.
FDP, thenar,
lat 2 lumbricals
(paralysis of most
of the forearm
muscles)

wrist

thenar mm.

Median

as above except
triceps
loss/impaired
flexion of wrist
& digits
loss of opposition
& precision grip

loss opposition &

precision grip

SENSORY
LOSS
over lower
deltoid
lateral forearm

lat. 3 1/2 digits

lat. 3 1/2 digits

Ulnar

above elbow

FCU, med. FDP,

hypothenar, add.
poll., med. 2
lumbricals,
interossei
(paralysis of the
medial forearm
muscles and
intrinsic hand
muscles)

impaired hand
function;
claw hand - loss
of power grip

at wrist

as above, except
FDP

unimpaired flexion
of digits 4, 5 at IP
joints

palm & dorsal 1

1/2 digits

BLOOD VESSELS OF THE UPPER LIMB

Blood vessels can be distinguished from nerves because they are hollow. Arteries
are firm, viens are thin and flimsy and nerves feel like calamari.
Arteries
The aorta is the artery through which blood leaves the heart. It has three branches,
the brachiocephalic (which forms the right common carotid and the right
subclavian), the left common carotid and the left subclavian.
The subclavian arches across the 1st rib and becomes the axillary, which goes
through the axilla and becomes the brachial artery when it reaches the humerus.
The axillary artery begins medially and comes around to the middle of the
humerus and down into the middle of the cubital fossa. The brachial artery then
comes across the head of the radius and divides into two terminal branches, the
radial artery (small) and the ulnar artery (large)
The radial artery begins at the cubital fossa and runs down the lateral side of the
forearm. It sits lateral to the flexor carpi radialis tendon, running down the
forearm to sit in the floor of the anatomical snuffbox. It pierces the 1st dorsal
interosseous muscle then goes deep into the palm to form the deep palmar arch.
The Ulnar artery becomes more superficial as it travels to the wrist. It sits on the
lateral side of the pisiform on top of the flexor retinaculum. As it reaches the palm
it forms the superficial palmar arch, which extends more distally than the deep
palmar arch.
Each of the superficial and deep palmar arches are completed from a branch of the
other.
The arches give off digital branches. The superficial arch gives off branches to the
medial 3 fingers only and the deep arch gives off branches to the lateral 1
fingers only.

1.Axillary
2.Brachial
3.Radial
4.Ulnar
5.Superficialpalmar
arch

6
5

6.Deeppalmararch
DigitialAa.

Arterial Anastomoses
The arteries of the arm have a collateral circulation. These are small indirect
branches through which blood can flow if the main vessel is obstructed. They
occur in areas where compression of the arteries is likely (e.g. when grasping
objects or clenching the fist). They are also present in the palm between the
superficial and deep palmar arches and around joints (periarticular anastomoses).
Pulse
Can be palpated at:
The clavicle
The axilla
The brachial artery
- Bicipital groove
- wy down the humerus
- Cubital fossa (used to take blood pressure)
- Flexor carpi radialis tendon
- The base of the anatomical snuffbox
- Superficial to the flexor retinaculum

Veins
Veins are described according to the direction of blood flow. Therefore the origin
is distal and the insertion is proximal, since the blood flows back to the heart.
Veins have valves to prevent the reverse flow of blood because the blood flow is
against gravity and therefore it is harder for the blood to get up through them. The
valves are formed by folds (1-3 cusps). The circumference of the vein is thicker at
points where there is a valve.
Veins have a wiggly appearance
There are two sets of veins, superficial and deep.
Superficial Veins
These are just under the superficial fascia of the skin
They are very variable
They are very large
Superficial veins sit on top of the muscles
Superficial veins must drain into deep veins before the blood can drain into the
heart.
The back of the hand houses the dorsal venous arch, a network of veins that
continues on as two veins, the basilic vein on the medial side and the cephalic
vein on the lateral side. The basilic vein comes up the medial side of the forearm
and goes deep to joint the brachial vein somewhere between the elbow and the
axilla. The cephalic vein comes up the lateral side of the forearm and goes into the
gap between the deltoid and the pectoralis major where it goes deep to join the
axillary vein.
The medial cubital vein travels laterally across the cubital fossa. This is the vein
that blood samples are usually taken from. A median antebrachial vein exists in
the area of the cubital fossa. Its position can vary, either stemming from the
median cubital vein or the cephalic vein.
Other veins may also be present.

1.Dorsalvenousarch
2.Cephalicvein
3.Basilicvein
4.Mediancubital
5.Medianantebrachial
6.Mediancephalic
&medianbasilic

Deep Veins
Also known as Venae comitantes they are very small
These are always found in pairs
They are the approximately the size of the brachial vein or smaller
Have similar names to the arteries
There are two radial, two ulnar, two brachial and two axillary veins that drain into
one axillary vein that then drains into the subclavian vein. The blood then drains
into the internal jugular, the brachiocephalic vein and eventually the superior vena
cava and the heart.
* Note: The veins are tied up with fascia and the arteries. Need to know this for an
exam. It is often not just the artery that needs to be identified, but the artery and the
vien.