C9: UE NEUROVASCULAR

STRUCTURES
Files

Term

Waiters Tip

problem of the nerves

paralysis of the arm caused by injury to the upper group of the arm's main
nerves

severing C5, C6 nerves

the affected UE manifests:

medially roatted

extended

pronated

hangs by px side in adduction

UE ARTERIAL SYSTEM

C9: UE NEUROVASCULAR STRUCTURES 1

 BLOOD VESSELS

Arteries - sends blood from the heart

Veins - sends blood away from the heart

Capillaries

Nerve - transmit electrical impulses for movement

*Myocardial Infarction occurs when the LEFT VENTRICLE STOPS

HEART

Left Ventricle - pumps blood out of the heart

Aorta - connects left ventricle to the parts of the body

C9: UE NEUROVASCULAR STRUCTURES 2

 3 BRANCHES:

Ascending

Descending

Arch of Aorta

RIGHT: LEFT:

Brachiocephalic Left common carotid artery

Right common carotid artery Left subclavian artery

Right subclavian artery Suprascapular artery

Superficial cervical artery

*Pulse is an artery

Subclavian Artery

main trunk

blood supply to UE

from brachiocephalic to 1st rib

*changes its name after the 1st rib into AXILLARY ARTERY

→ 1st rib to teres major

→ continuation of subclavian artery

→ PARTS

1st part of axillary artery:

Superior Thoracic Artery → upper border of pectoralis minor

2nd part of axillary artery:

Thoracoacromial artery - divides terminal branches

Arterial thoracic artery - lower border of pectoralis minor

3rd part of axillary artery:

C9: UE NEUROVASCULAR STRUCTURES 3

 Anterior circumflex humeral artery

Posterior circumflex humeral artery - front and back of surgical neck

Subscapular artery - lower border of subscapularis

*After teres major is the BRACHIAL ARTERY

→ includes the:
Brachial Artery - main arterial supply of the arm from the lower border of teres
major

Nutrient Artery

Profunda Artery - radial collateral → radial recurrent → radial artery

Superior Ulnar collateral Artery - near and follows Ulnar Artery→

anastamose @ elbow joint

Inferior Ulnar collateral Artery

Radial Artery - lateral side

Arterial radialis indicis

Arterial radialis policis

Ulnar Artery - medial side; enters palm through FR

Anterior ulnar recurrent

Posterior ulnar recurrent

Superior palmar arch

- joining or radial and ulnar artery at the palm

- form an arch at the palm

PULSE

same as rate of heartbeat

an artery

if there's no pulse = LEFT VENTRICLE stopped pumping

CUBITAL FOSSA

C9: UE NEUROVASCULAR STRUCTURES 4

 front of elbow

Lateral: Brachioradialis Base: 2 condyles of humerus

Medial: Pronator Teres Floor: Supinator, Brachialis

UE VENOUS SYSTEM

from muscles/organs to heart and lungs

brings unoxygenated blood

usually blue

SUPERFICIAL VEIN

Cephalic vein

drains blood from lateral side → ascends cubital fossa → lateral from biceps

converges on subclavian vein

Basilic vein

drains blood from medial side → venae comitantes of brachial artery → axillary
vein

converges on subclavian vein and eventually drain to subclavian vein

Subclavian vein

internal

external

Superior vena cava

on medial side or biceps

medial cubital vein → branch of cephalic vein in cubital fossa

→ runs upward and medially → join basilic vein

medial antecubital vein

Dorsal venous network

hand

drains upward to lateral cephalic vein & medial basilic vein

C9: UE NEUROVASCULAR STRUCTURES 5

 LYMPHATIC SYSTEM

drain waste products from your body at lateral

Lymph Nodes

sac thics - of axilla - drain at lateral quadrant

Supraclavicular lymph nodes - above the clavicle

Apical lymph nodes - apex

Central lymph nodes

Humeral lymph nodes

TRansverse cervicla chain lymph nodes

Interpectoral lymph nodes

Cubital lymph nodes

Supratrochlear lymph nodes

NERVES
→ sensory innervation to skin and deep structures

→ motor innervation to muscles

Atlas C1 - carrying the load of the skull

Axis C2
C3

C4
C5

Foramen Transversarium

hole on cervical vertebra

houses vetebral artery

C9: UE NEUROVASCULAR STRUCTURES 6

 Spinal Cord gives out:

Spinal Nerves:
C1

C2

C3

C4
C5

EXITS C - Cervical

CTLS: DUD T - Thoracic

NERVE IMPINGEMENT Ls - Lumbosacral

CTLS: DUU D - Down

U - Up

Nerves of UE

C5 - Superior Trunk

C6 - Superior Trunk
C7 - Middle Trunk

C7 - Inferior Trunk

T1 - Inferior Trunk

Divisions

-Each divides into Anterior Division & Posterior Division

Cords

→ Lateral Cord

→ Posterior Cord

→ Medial Cord

C9: UE NEUROVASCULAR STRUCTURES 7

 MNEMONICS: ROTONDA CUBAO 22355

2 nerves come directly from the ROOT

2 nerves come directly from the TRUNK

3 nerves from LATERAL CORD

5 nerves from POSTERIOR CORD

5 nerves from MEDIAL CORD

UE NEUROVASCULAR STRUCTURE

Two structures: Nerves & Vascular structures

Waiter’s Tip

Problem in the nerves

Nerve palsies or Erb’s duchenne Palsy

Affected upper limb is medially rotated, extended, pronated, and hangs by the
patient’s side in adduction

UE ARTERIAL SYSTEM
“Ugat”

Refers to all in the local dialect

Can be nerves or blood vessels

Nerve

Transmits electrical impulses from brain to muscles to make them move

Blood vessels

Contains blood / container of blood

Arteries, veins, capillaries

To send blood from the heart to bring oxygenated & deoxygenated blood to the
organ and away from the organ & to spread nutrients, oxygen, chemicals, &
other elements to tissues

C9: UE NEUROVASCULAR STRUCTURES 8

 Artery

Blood vessels that sends oxygenated blood from the heart to organs

Color red (contains oxygenated blood)

Heart

Has four chambers (left & right atrium and ventricle)

Left ventricle

Pumps blood out of the heart

When it stops pumping, no more organ that will send blood all over the body

Aorta

From left ventricle, huge blood vessel

connects left ventricle to the rest of the body

shaped like an arch

has 3 branches: Ascending aorta, arch, descemding/thoracic artery

Arch of aorta

or aortic arch

has three main branches; brachiocephalic artery, left common carotid, left
subclavian

Brachiocephalic artery

biggest of the three

right common carotid & right subclavian

a jump off of the right subclavian and right common carotid

Left subclavian & left common carotid

Direct branches of the arch of aorta

in the end we have both right & left subclavian and common carotids

Common carotid artery

as it ascends in front of neck will further divide into external and internal carotid
arteries (both left & right)

left internal/external

C9: UE NEUROVASCULAR STRUCTURES 9

 right internal/external

(LEFT)
Arch of aorta     

Left common carotid     

Eventually branching out into left external & internal carotids

Subclavian Artery

main trunk which will be the blood supply to the upper extremities

left & right subclavians – will be the origin of blood supply to the UE

from brachiocephalic to first rib

Pulse

also an artery

pulsating because of all the blood vessels

pumping of artery (pulse) same as rate of the heartbeat

heart rate is synchronosous w/ arterial pulses as well

To assess if heart is pumping:

a person w/ big breast or large thorax – you can palpate pulse, if there is no
pulse – left ventricle has stopped pumping

B O R D E R S:
Subclavian artery

located in the root of the neck

jumps off the brachiocephalic until the first rib

Axillary artery

from first rib to thee teres major

throughout its course, it is closely related to cords of the brachial plexus and
their branches

C9: UE NEUROVASCULAR STRUCTURES 10

 is enclosed in an axillary sheath

pectoralis minor crosses in front of the axillary artery and divides into three: 1, 2,
3

Axillary sheath

connective tissue sheath

continuous with the pre-vertebral fascia in root of the neck

First part

extends from lateral border of first rib to upper border of pectoralis minor

gives off one branch; superior thoracic artery

Second part

lies deep to the pectoralis muscle(pec minor)

gives off two branches; thoracoacromial artery and lateral thoracic artery

Third part

extends from lower border of pectoralis minor to lower border of teres

major

gives off three branches; posterior & anterior circumflex humeral artery
and subscapuar artery

Brachial artery

from lower border of teres major muscle and continues downward – travels
through anterior compartment of arm

its branches supply both anterior & posterior compartment of arm – supplies
entire arm

terminates opposite the neck of the radius dividing into: radial and ulnar arteries

Radial artery

radial pulse that you can palpate near thumb (on lateral side of wrist)

palpated in the anatomic snuff box

Anatomical Snuff box

also known as radial fossa

a triangular depression found on the lateral aspect of the dorsum of hand

C9: UE NEUROVASCULAR STRUCTURES 11

 located at the level of the carpal bones and best sen when thumb is
extended
B R A N C H E S:

Muscular branch

To anterior compartment of arm

Nutrient artery

To the humerus

Profunda brachii artery/ arteria profunda brachii

Or deep brachial artery

Arises near the origin of the brachial artery

Accompanies radial nerve through radial (spiral) froove of humerus &

supplies triceps muscles

Anastomoses w/ radial recurrent artery (branch of the radial artery) – to

from part of the collateral circulation around elbow joint

Superior ulnar collateral artery

Arises near middle of arm & follows ulnar nerve

Posterior to medial epicondyle

Anastomoses w/ posterior ulnar recurrent artery ( branch of ulnar arter)

– to form part of the collateral circulation around elbow joint

Inferior ulnar collateral artery

Arises near termination of brachial artery & passes anterior to medial

epicondyle

Anstomoses w/ anterior ulnar recurrent artery (branch of ulnar artery) –

to form part of collateral circulation around elbow joint

Ulnar Artery

larger of two terminal branches of the brachial artery

begins in cubital fossa at level of the neck of the radius

forms superficial palmar arch

C9: UE NEUROVASCULAR STRUCTURES 12

 often anastomosing w/ superficial palmar branch of radial artery

In forearm

proximally) lies deep to most of the flexor muscles

(distally) becomes superficial and lies between tendons of flexor carpi

ulnaris & tendons of flexor digitorum superficialis

Forearm Branches
Muscular branches

To neighboring muscles

Anterior & posterior ulnar recurrent branches

Take part in the arterial anastomoses around the elbow joint

Branches taking part in the arterial

Anastomoses around wrist joint

Common interosseous artery

From upper part of ulnar artery and after brief course, divides into anterior and
posterior interosseous arteries

Interosseous arteries

Pass distally on the anterior and posterior surfaces of the interosseous

membrane

Provide nutrient arteries to the radius aand ulna

Supply adjacent muscles in the entrior and posterior compartments

End by taking part in anastomosis around the wrist joint

In Hand

Enters hand superficial to the flexor retinaculum on the lateral side of ulnar nerve
& pisiform bone

Gives off a deep palmar branch then continues into the palm as superficial
palmar arch

Superficial palmar arch

Curves laterally deep to the palmar aponeurosis & superficial to the long flexor
tendons

C9: UE NEUROVASCULAR STRUCTURES 13

 Completed on the lateral side of by anastomosing with the superficial palmar
branch of the radial artery

Curve of arch, lies across the palm, level w/ the distal border of the fully
extended thumb

Gives rise to 3 common palmar digital arteries – each dividing into two proper
palmar digital arteries – supply the adjacent sides of two digits

Deep palmar branch

Of UA, arises superficial to the flexor retinaculum

Passes deep between the abductor digiti minimi & the flexor digiti minimi, and
joins the radial artery to complete the deep palmar arch

Radial Artery

Is the smaller of the two terminal branches of the brachial artery

Begins in the cubital fossa at the level of the neck of the radius and descends
through the lateral (radial) aspect of the anterior compartment of the forearm

Ends by forming the deep palmar arch in hand, often anastomosing with the
deep palmar branch of the ulnar

In forearm

(proximal forearm) radial artery lies deep to the brachioradialis muscle

(middle third of its course) runs medial to the superficial branch of the radial
nerve

(distal forearm) lies on the anterior surface of the radius, between the tendons
of the brachioradialis and flexor carpi radialis muscle

Covered only by the skin and fascia

Ideal site for taking the radial pulse

FOREARM BRANCHES:
Muscular branches

To neighboring muscles

Radial recurrent artery

Takes part in the arterial anastomosis around the elbow joint

C9: UE NEUROVASCULAR STRUCTURES 14

 Superficial palmar branch

Arises just proximal to the wrist

Enters the palm of hand and joins the ulnar artery to complete the superficial
palmar arch

In Hand

Radial artery, leaves the forearm by winding around the lateral aspect of the
wrist to reach the posterolateral surface of the hand

Enters the floor of the anatomic snuffbox, lying on the lateral ligament of the
wrist joint and passing deep to the tendons of the abductor pollicis longus &
extensor pollicis brevis muscles

Continues under the tendon of the extensor pollicis longus to reach the interval
between the two heads of the first dorsal interosseous muscles

Artery divides between the muscle heads to enter the deep aspect of the palm of
the hand

(upon entering the palm), RA curves the medially between the oblique and
transverse heads of the adductor pollicis & continues as the deep palmar arch

Deep Palmar Arch

Curves medially deep to the long flexor tendons & superficial to the metcarpal
bones and interosseous muscles

Completed on the medial side by the deep palmar branch of the ulnar artery

Curve of arch, lies at a level of with the proximal border of the external thumb

Sends branches proximally, which take part in anastomoses with wrist joint and
distally to join the digital branches of the superficial palmar arch

Dorsal carpal arch

On the dorsum of the hand, by the radial artery

Before it dives to form the deep palmar arch

TRACE THE BLOOD FLOW FROM LEFT VENTRICLE TO THE RADIAL PULSE

1. Aorta

Ascending, arch, descending/thoracic

C9: UE NEUROVASCULAR STRUCTURES 15

 1. Arch of aorta

Brachiocephalic, left common carotid, left subclavian

1. Brachiocephalic

Right common carotid & right subclavian

1. Common carotids

Left and right, ascend in front of neck to brain

Further divides into external and internal carotid artery

1. Subclavian

(left & right) blood suppy for the UE

1. Subclavian artery

From brachiocephalic artery to first rib

1. Axillary artery

First rib to teres major; 3 parts (1, 2, 3)

First (1 branch), second (2 branches), & third (3 branches)

1. Brachial artery

Teres major downwards

Also the brachial pulse w/c can be palpated on medial side of forearm

Further divides into radial & ulnar artery forming superficial palmar arch

Ulnar & radial artery, forms superficial palmar arch

UE VENOUS SYSTEM

C9: UE NEUROVASCULAR STRUCTURES 16

 Veins

Travels in the opposite direction from muscles and/or organs will send blood
back to heart to the lungs, so that these blood will exchange CO2 w/ O2 and will
come out again in the form of oxygenated blood

Color blue

Not as complicated as the arterial system; it is simple

Cephalic vein

On lateral side of the dorsal venous rch on the base of hand and winds around
lateral border of foramen

Drains all blood from the lateral side/subclavian

Converge in the area of subclavian vein

Medial cubital vein

A branch of cephalic vein in cubital fossa

Runs forward upward & medially and joins basilica vein

Normally present, but form in w/c it connects cephalic and basilic veins, is
subject to variation

(in cubital fossa) crosses over brachial artery and median nerve, but separated
from them by – bicipital aponeurosis

Basilic & Cephalic vein, likewise will form a network in the hands so that when
on vein is clot the hand will still be drained by the other vein – dorsum venous
network

Veins, always on the medial side

From the subclavian vein it will go down directly into the superior vena cava
(both sides)

In comparison to the arteries which has the brachiocephalic artery in the veins it
is direct

Subclavian Vein      Jugular Vein     Superior Vena C.

Superior Vena Cava

Drains the head up to the upper extremity

C9: UE NEUROVASCULAR STRUCTURES 17

 Ehen there is a clot, there will be congestion and swelling of face, neck, & upper
extremities because blood cannot be drained from finger tips back to the right
atrium

only drains the head through the internal & external jugulars and subclavian vein
(UE) to the superior vena cava

Inferior Vena Cava

From the chest and down

Will drain blood from the top and the legs

Axillary vein

Formed at the lower border of the teres major muscle by the union of the venae
comitantes of the brachial artery & the basilica vein

Runs upward on medial side of axillary artery & ends on lateral border of first rib
becoming the subclavian vei

Receives tributaries, w/c correspond to branches of axillary artery & cephalic

vein

SUMMARY
The venous system is not as complicated as the arterial system, on the lateral side is
the cephalic vein whch goes up & goes to the subclavian vein. On the medial side
is the basilica vein w/c will become an axillary vein & eventually drain in the
subclavian vein – together w/ internal & external jugulars will drain into superior
vena cava

UE LYMPHATIC SYSTEM

Carries debris, waste products, and infections

Chain of structures that will drain all the waste products from the body

Do not go in one single tube, unlike arteries & veins _ lymphatics

Color green

Lymphatic Veins

“pangadlay”

C9: UE NEUROVASCULAR STRUCTURES 18

 If you have a tooth infection you will feel you have nodes under your jaw
because the dirt of tooth will be drine in that area

Ex. punctured self (wound in fingers) – lymph adenopathy is in axilla

Lymph nodes

Does not travel in the same manner as the arteries & veins in one pathway
rather, they can travel in different pathways in a mesh-like structure
Supraclavicular lymph nodes

above the clavicle

Interpectoral lymph nodes

Between pectoralis minor & major

Transverse cervical chain of lymph nodes

Cervical (deep), supraclavicular, subclavicular, upper chest, anterior lateral

neck

Apical lymph nodes

Apex or tip of lungs

Central lymph nodes

Axilla

Humeral lymph nodes

Near humerus

Cubital lymph nodes

Near elbows

Supratrochlear lymph nodes

Above the trochlea

Axillary Lymph Nodes

(20 to 30 in number) collect lymoh from a large territory

Drain lymph vessels from the lateral quadrants of the breast, superficial lymph
vessels form the thoracoabdominal walls above level of umbilicus, skin of the
back above level of the iliac crest, & vessels from the upper limb

ARRANGED IN SIX GROUPS

C9: UE NEUROVASCULAR STRUCTURES 19

 1. Anterior (pectoral) group

Along lower border of the pectoralis minor, deep to the pectoralis minor

Receive lymph vessels from lateral quadrants of breast and superficial vessels
from the anterolateral abdominal wall above levl of umbilicus

1. Posterior (subscapular) group

In front of subscapularis muscle

Receive superficial lymph vessels from the back, down as far as the level of iliac
crests

1. Lateral group

Along medial side of axillary vein

Receive most of the lymph vessels of the upper limb (except those superficial
vessels draining the lateral side – see infraclavicular nodes below)

1. Central group

In center of axilla, in the axxillary fat deep to the pectoralis minor

Receive lymph from the three groups above

1. Infraclavicular (deltopectoral) group

Not strictly axillary nodes because they are located outside axilla

In deltopectoral groove between deltoid & pectoralis major

Receive superficial lymph vessels from the lateral side of the hand, forearm, &
arm

1. Apical group

At apex of axilla, at internal border of first rib

Receive efferent lymph vessels from all the other axillary nodes

Apical Nodes

C9: UE NEUROVASCULAR STRUCTURES 20

 Drain into the subclavian lymph trunk

Subclavian lymph trunks

(left side) drain into the thoracic duct

(right side) drains into right lymph trunk

(alternatively) may drain directly into one of the large veins at the root of the
neck

Superficial lymph vessel

Draining the superficial tissues of the upper limb pass upward to the axilla

Lymph vessels of fingers

Pass along their borders to reach the webs

Vessels ascend onto the dorsum of the hand

Lymph vessels on palm

Form a plexus that is drained by vessels that ascend in front of forearm or

pass around medial and lateral border to join vessels on dorsum of the hand

Lymph vessels, thumb, lateral fingers, and lateral areas of hand,forearm, &
arm – follows the cephalic vein to the infraclavicular group of nodes
Superior vessels from medial fingers & medial areas of hand & forearm

follow basilica vein to cubital fossa

some drain into supratrochlear lymph node, others accompany basilica vein to
the axilla – where they drain into the lateral group of axillary nodes

Supratrochlear lymph nodes

superficial fascia over upper part of the cubital fossa, above the trochlea

Efferent Vessels

also drain into the lateral axillary nodes

C9: UE NEUROVASCULAR STRUCTURES 21

 Deep Lymphatic Vessels

draining the muscles & deep structures of the arm

Deep Structures of arm

drain into lateral group of axillary nodes

Brachial Plexus

the entire nerve supply of the upper limb

a complex nerve network formed when the anterior (ventral) rami of the 5
through the 8 cervical & 1 throracic spinal nerves (C8; T1) intermingle with one
another in the posterior triangle of the neck

I M P O R T A N T  F U N C T I O N S

sensory innervations to skin & deep structures; joints

motor innervations to muscles

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

sympathetic secremotor supply to the sweat glands

C1 – atlas, carrying load of skull ; C2 – axis

Cervical Vertebra

of the spine consist of 7 bony rings that reside in the neck between base of skull
& thoracic vertebrae in trunk

unique because of/ they have foramen transversarium

Foramen Transversarium

hole in the transverse process of cervical vertebra

Houses the vertebral artery

Vertebral artery

Inside hole of vertebra

Die instantaneously if cut because it cuts-off blood supply in the brain

C9: UE NEUROVASCULAR STRUCTURES 22

 Spinal Cord

On neck, inside vertebra

Will give out a nerve: C1, C2, C3, C4 nerves

Spine

divided into; thoracic, cervical, lumbar, & sacral area

Nerve Fibers

originate in single segments of the spinal cords

contribute to the composition of multiple individual nerves

each that branches off, carries fibers from multiplbe segments of the spinal cord

Spinal Root

C5, C6, C7, C8; T1 nerves – brachial plexus

Origin of entire brachial plexus

17 nerves in UE

From roots to trunk

C5 & C6 – superior trunk

C7 – middle trunk

C8 & T1 – inferior trunk

From trunks to divisions

Each trunk is divided into anterior & posterior divisions

From divisions to cords

Lateral cord

All division of superior & middle cord

Posterior cord

All posterior divisions of 3 trunks

Medial cord

Anterior divisions of inferior trunk

C9: UE NEUROVASCULAR STRUCTURES 23

 Named in relation to the axillary artery (point of reference)

Branches of the brachial plexus

17 branches all together

ROTONDA CUBAO (22355)

Roots (2)

Long thoracic nerve (C5, C6, C7)

Dorsal scapular nerve (C5)

Trunks (2)

(both are in the upper/superior trunk)

Suprascapular nerve

Nerve to subclavius

Lateral Cord (3)

Musculocutaneous berve

Lateral pectoral nerve

Median nerve from lateral cord

Posterior Cord (5)

Axillary nerve

Upper subscapular nerve

Lower subscapular nerve

Thoracodorsal nerve

Radial nerve

Medial Cord (5)

Medial pectoral nerve

C9: UE NEUROVASCULAR STRUCTURES 24

 Medial cutaneous of arm

Medial cutaneous nerve of forearm

Median nerve from medial cord

Ulnar nerve

SUBPARTS

Roots

the anterior rami of the spinal nerves

C5 to T1; C5 & 6 (forms upper trunk), C7 (middle trunk), and C8 & T1 (lower
trunk)

Trunks

Upper, middle, & lower trunk

Divisions

Anterior & posterior

Cords

Lateral, medial, & posterior

Lateral cord

Formed when anterior divisions or the upper & middle trunks unite

Gives rise to the musculocutaneous nerve

Contributes to the formation of the median nerve

Medial cord

Anterior division of lower trunk continues

Gives rise to the ulnar nerve

Contributes to the formation of the median nerve

Posterior cord

Formed when posterior divisions of all three trunks join

C9: UE NEUROVASCULAR STRUCTURES 25

 Divides into axillary and radial nerves

Branches

Axillary nerve

Supplies the shoulder region

Supplies teres minor & deltoid muscle

Gives off branches after the shoulder / glenohumeral joint

Can be injured in dislocations of the glenohumeral (shoulder) joint by

compression of the quadrangular space or by pressure of a badly ajudted crutch
pressing upward into armpit

Other four nerves

main branches that distribute through the osseofascial compartment of the upper
limb

Musculocutaneous Nerve

Fisrt muscle it innervates is the coracobracjialis in the axilla down to biceps and
the brachialis (CBB), lower than that has a lateral cutaneous branch – Lateral
cutaneous branch of forearm

Median Nerve

Innervates the wrist flexor muscles in volar surface of arm

Muscles of arm has several layers; upper most – pronator teres

First muscle it innervates is the pronator teres further down it gives off the
muscles in the profundus & flexor pollicis, later on it will supply all the small
muscles of thumb (thenar eminence); flexor pollicis brevis, flexor oponens,
adductor pollicis

Carpal tunnel syndrome

Impingement of median nerve in the wrist

Paralysis of muscle of thethumb

Any condition that decreases size of carpal tunnel & compresses its contets

C9: UE NEUROVASCULAR STRUCTURES 26

 Burning pain or “pins and needles” sensation to the lateral 3 ½ fingers &
weakness of the thenar muscles

Decompressing tunner – receives the syndrome

Ape Hand

Median nerve palsy

Condition in which movements of the thumb are severely limited

Ulnar Nerve

Supplies the medial side of the forearm & in sensory division is the lateral 3 ½ is
median and medial 1 ½ is ulnar

First muscle it innervates is the flexor carpi ulnaris & hypothenar muscles (area
below elbow)

Does not give off branches on axillary area and in upper arm as wel

@ ulnar distribution – if patient complains a tingling sensation in lie with little

figer

@ median nerve – tingling of thumb, index, middle, & half of ring finger

BRANCHES
Superficial branch

Supplies skin of palmar surface of medial 1 ½ fingers including nail beds

Supplies Palmaris brevis muscle

Deep branch

Supplies all small muscles of hand except muscles of the thenar compartment
and first two lumbricals which are supplied by median nerve

Froment’s Sign

Adducting thumb is impossible because the adductor pollicis muscle is paralyzed

Patient is asked to grip piece of paper bet. thumb & index (pinching) he/she does
so, by strongly contracting flexor pollicis longus &flexing the terminal phalanx

C9: UE NEUROVASCULAR STRUCTURES 27

 Papal’s hand

Or main en griffe, “claw hand”

Hand assumes a characteristic claw-like deformity with clawing more

pronounced on medial (ulnar) aspect of hand

Radial Nerve

Supplies the triceps muscle (medial head, innervated twice)

Eventually goes down to supply muscles of dorsal forearm for wrist extension

Radial nerve palsy

Or Saturday night palsy / sweetheart’s palsy

Paralysis of the radial nerve

Path of radial nerve from axilla

Winds around the radial groove of humerus

Radial groove

Area where radial nerve gets impinged

Wrist drop

Radial nerve palsy

May be caused due to trauma to the radial nerve by way of a cut r stab wound

A pathological condition

OTHER PALSIES:

Erb Duchenne’s Palsy

(C5 & C6) or upper brachial plexus plexus palsy

Present with a typical waiter’s tip deformity

Inability to flex elbow (C5) & wrist extension (C6)

Can occur to babies during birth

C9: UE NEUROVASCULAR STRUCTURES 28

 Klumpke’s Palsy

In axillary area

(C8 & T1), or lower brachial plexus injury/palsy

Can be caused by traction – traction injury or stretch injury

“claw like”

ROOTS
Dorsal scapular nerve

C5

Supplies the levator scapula & rhomboid muscles

Long thoracic nerve

C5, 6, 7

arises from the roots of the brachial plexus in the neck and enters the axilla by
passing down over the lateral border of the 1st rib behind the axillary vessels
and brachial plexus

It descends over the lateral surface of the serratus anterior muscle, which it
supplies.

T R U N K S  &  D I V I S I O N S
Nerve to subclavius

C5, 6

Important clinically, it gives a contribution (C5) to the phrenic nerve

If present, referred to as the accessory phrenic nerve

Suprascapular nerve

C5, 6

Arises in the posterior triangle in the neck and runs downward & laterally to
reach the upper edge of the scapua

It passes through the suprascapular notch, beneath the suprascapular ligament,

to reach the supraspinous fossa

C9: UE NEUROVASCULAR STRUCTURES 29

 L A T E R A L  C O R D

Lateral pectoral nerve

Supplies the pectoralis major muscle, primarily its clavicular head

Musculocutaneous nerve

Supplies the coracobrachialis muscle & leaves the axilla by piercing that muscle

Lateral root of the median nerve

is the direct continuation of the lateral cord of the brachial plexus

It is joined by the medial root to form the median nerve trunk, and this passes
downward on the lateral side of the axillary artery

The median nerve gives off no branches in the axilla.

M E D I A L  C O R D

Medial pectoral nerve

supplies and pierces the pectoralis minor muscle, and supplies the pectoralis
major muscle, primarily its sternocostal head

Medial cutaneous nerve of arm

T1

Arises from the medial cord of the brachial plexus and is joined by the
intercostobrachial nerve (lateral cutaneous branch of the 2nd intercostal nerve)

supplies the skin and medial side of the arm

Medial cutaneous nerve of forearm

arises from the medial cord of the brachial plexus and descends in front of the
axillary artery

supplies the skin and medial side of the forearm

Ulnar nerve

C8; T1

arises from the medial cord of the brachial plexus and descends in the interval
between the axillary artery and vein

gives off no branches in the axilla

C9: UE NEUROVASCULAR STRUCTURES 30

 Medial root of the median nerve

arises from the medial cord of the brachial plexus

crosses in front of the third part of the axillary artery to join the lateral root of the
median nerve & form the median nerve trunk

P O S T E R I O R  C O R D
Upper & lower subscapular nerve

Supply the upper and lower parts of the subscapularis muscle

Lower subscapular nerve supplies the teres major muscle

Thoracodorsal nerve

Arise from the posterior cord of the brachial plexus

Runs downward into the axilla and supply the latissimus dorsi muscle

Axillary nerve

(C5, 6)

curves deeply into axilla and passes through the quadrangular space with
posterior circumflex humeral artery

Radial nerve

(C5, 6, 7, 8; T1)

Gives off branches to the heads of the triceps muscle and gives rise to the
posterior cutaneous of the arm

originates from the posterior cord of brachial plexus in the axilla

Named for its pathway along the radial (lateral) side of the upper limb

Is the sole motor nerve to the muscles in the posterior compartments of the arm
and forearm

Also provides extensive cutaneous innervations along the posterior aspect of the
entire limb

Dermatomes of UE

Skin, sensation, sensory contribution in UE

C9: UE NEUROVASCULAR STRUCTURES 31

 Area of the skin of the human anatomy that is mainly supplied by branches of a
single spinal sensory nerve root

Myotomes of UE

For strength, a group of actions supplied by a particular group

Brachial Plexus
- the entire nerve supply of the upper limb
- a complex nerve network formed when the anterior (ventral) rami of the 5th through
the 8th cervical & 1st throracic spinal nerves (C8; T1) intermingle with one another in
the posterior triangle of the neck

IMPORTANT FUNCTIONS
sensory innervations to skin & deep structures; joints
motor innervations to muscles
influence over the diameters of the blood vessels by the sympathetic vasomotor
nerves
sympathetic secremotor supply to the sweat glands

Nerve Fibers
- originate in single sements of the spinal cords
- contribute to the composition of multiple individual nerves
- each that branches off, carries fibers from multiplbe segments of the spinal cord

SUB PARTS
Roots
- the anterior rami of the spinal nerves
- C5 to T1; C5 & 6 (forms upper trunk), C7 (middle trunk), and C8 & T1 (lower trunk)

Trunks
- Upper, middle, & lower trunk

Divisions
- Anterior & posterior

Cords
- Lateral, medial, & posterior

Lateral cord
- Formed when anterior divisions or the upper &
middle trunks unite
- Gives rise to the musculocutaneous nerve
- Contributes to the formation of the median nerve

C9: UE NEUROVASCULAR STRUCTURES 32

 Medial cord
- Anterior division of lower trunk continues
- Gives rise to the ulnar nerve
- Contributes to the formation of the median nerve

Posterior cord
- Formed when posterior divisions of all three trunks join
- Divides into axillary and radial nerves

Branches
Axillary nerve
- Supplies the shoulder region
Other four nerves
- main branches that distribute through the osseofascial compartment of the upper
limb

ROOTS

Dorsal scapular nerve Long thoracic nerve

- C5 - C5, 6, 7
- Supplies the levator scapula & - arises from the roots of the brachial
rhomboid muscles plexus in the neck and enters the axilla
by passing down over the lateral border
of the 1st rib behind the axillary vessels
and brachial plexus
- It descends over the lateral surface of
the serratus anterior muscle, which it
supplies.

TRUNKS & DIVISIONS

Nerve to subclavius Suprascapular nerve

- C5, 6
- Important clinically, it gives a
contribution (C5) to the phrenic nerve
- If present, referred to as the accessory
phrenic nerve
- C5, 6
- Arises in the posterior triangle in the
neck and runs downward & laterally to
reach the upper edge of the scapua
- It passes through the suprascapular
notch, beneath the suprascapular
ligament, to reach the supraspinous
fossa

C9: UE NEUROVASCULAR STRUCTURES 33

 LATERAL CORD

Lateral pectoral nerve Musculocutaneous Lateral root of the median

- Supplies the pectoralis nerve nerve
major muscle, primarily - Supplies the - is the direct continuation
its clavicular head coracobrachialis of the lateral cord of the
muscle & leaves the brachial plexus
axilla by piercing that - It is joined by the medial
muscle root to form the median
nerve trunk, and this
Supplies CBB:
passes downward on the
Coracobrachialis lateral side of the axillary
Biceps Brachii artery
- The median nerve gives
Brachialis
off no branches in the
Elbow joint axilla.
- wrist flexors; volar
surface

CARPAL TUNNEL

gutter converted to
tunnel by flexor
retinaculum

impingement of nerve
at the wrist

paralysis of muscles
of thumb of median
nerve

MEDIAL CORD

Medial pectoral nerve Medial cutaneous Medial cutaneous nerve

- supplies and pierces the nerve of arm of forearm
pectoralis minor muscle, - T1 - arises from the medial
and supplies the - Arises from the cord of the brachial
pectoralis major muscle, medial cord of the plexus and descends in
brachial plexus and is front of the axillary artery

C9: UE NEUROVASCULAR STRUCTURES 34

 primarily its sternocostal joined by the - supplies the skin and
head intercostobrachial medial side of the
nerve (lateral forearm
cutaneous branch of
CARPAL TUNNEL
the 2nd intercostal
nerve) gutter converted to
- supplies the skin and tunnel by flexor
medial side of the arm retinaculum

impingement of nerve
at the wrist

paralysis of muscles
of thumb of median
nerve

Ulnar nerve Medial root of the median nerve

- C8; T1
- arises from the medial cord of the
brachial plexus and descends in the
interval between the axillary
artery and vein
- gives off no branches in the axilla
- medial side of arm
- arises from the medial cord of the
brachial plexus
- crosses in front of the third part of the
axillary artery to join the lateral root of
the median nerve & form the median
nerve trunk
- wrists flexors; volar surface

suplies:

Flexor carpi ulnaris

Flexor digitorum profundus

Ulnar artery

Muscle of hypothenar eminence

POSTERIOR CORD

Upper & lower subscapular nerve Thoracodorsal nerve

- Supply the upper and lower parts of - Arise from the posterior cord of the
the brachial plexus
subscapularis muscle - Runs downward into the axilla and
- Lower subscapular nerve supplies the supply the latissimus dorsi muscle
teres major muscle

C9: UE NEUROVASCULAR STRUCTURES 35

 Axillary nerve
- (C5, 6)
- curves deeply into axilla and passes
through the quadrangular space with
posterior circumflex humeral artery
Radial nerve
- (C5, 6, 7, 8; T1)
- Gives off branches to the heads of the
triceps muscle and gives rise to the
posterior cutaneous of the arm

supplies: supplies:

deltoid triceps (long head)

teres minor triceps (lateral head)

triceps (medial head)

last: extensor carpi

Wrist Drop/ Saturday Night / Sweet Hearts Palsy

radial nerve palsy

paralysis of radial nerve

impingement of radial nerve

Papal Benediction

ulnar nerve palsy (half of 4th & 5th digits)

Ape Hand

injury of median nerve (1st, 2nd, 3rd & half of 4th digits)

Upper Brachial Plexus Palsy/ Erb-duchenne Palsy

C5, C6 palsy

Lower Brachial Plexus Palsy/ Klumpke's Deformity

Dermatomes

C9: UE NEUROVASCULAR STRUCTURES 36

 sensory distribution

strength of muscles

group of actions supplied by a particular nerve/ 1 root

C9: UE NEUROVASCULAR STRUCTURES 37