UPPER LIMB-

Blood supply,
lymphatic
drainage and
nerve
supply
 Topic Outcomes
At the end of the lecture, the student should be able to
• explain the extent, course, branches and relations of the
axillary, brachial, radial, and ulnar arteries.
• describe the major veins of the upper limb and its clinical
importance.
• explain the formation, branches, and clinical importance of
the brachial plexus.
• explain the origin, course, branches, distribution, and clinical
importance of musculocutaneous, axillary, median, ulnar,
and radial nerves.
• describe the lymphatic drainage of the upper limb.
 Axilla
• Axilla or armpit - pyramid-shaped space between the
upper part of the arm and the side of the chest.
• It forms passage for nerves, blood, and lymph vessels as
they travel from the root of the neck to the upper limb.

Anterior view
 Axilla

Contents:
1. Axillary artery and its
branches
2. Axillary vein and its
tributaries
3. Brachial nerve plexus
4. Axillary lymph nodes and
lymph vessels
Upper limb - Arteries
 Arch of Aorta
Origin-
Continuation of
ascending aorta.
Branches –
1. Brachiocephalic
artery-2 branches-
Right common
carotid and right
subclavian artery.
2. Left common
carotid artery.
3. Left subclavian artery.
 Upper limb-Arterial supply

• Subclavian artery
• Axillary artery
• Brachial artery
• Radial and ulnar arteries
• Superficial & deep palmar
arches.
 Axillary artery
Origin : Continuation of
subclavian artery.
Extent : Extends from outer
border of 1st rib to lower
border of teres major.
Parts : Pectoralis minor muscle
divides into 3 parts:

1st part – Proximal to pectoralis

minor
2nd part – Posterior to
pectoralis minor
3rd part – Distal to pectoralis
minor insertion.
 Axillary artery-Branches
• First Part - one branch:
1)Superior thoracic artery
• Second Part - two branches:
2)Thoracoacromial artery (with
four smaller branches)
A. Pectoral branch
B. Deltoid branch
C. Acromial branch
D. Clavicular branch
3) Lateral thoracic artery.
• Third Part - three branches:
4) Subscapular artery (circumflex
scapular,thoracodorsal branches).
5) Anterior humeral circumflex
artery.
6) Posterior humeral circumflex
artery.
 Brachial artery

Origin : Continuation of
axillary artery.
Extent : Extends from lower
border of teres major to neck of
radius.
Termination :Terminates into
radial and ulnar arteries.
Course : Median nerve is
lateral in the upper part, cross
over to become medial.
 Brachial artery

Branches:
1.Profunda brachii
2.Nutrient
3.Superior ulnar collateral
4.Middle ulnar collateral
5.Inferior ulnar collateral
6.Muscular
7.Radial
8.Ulnar
 Brachial artery
Branches:
1. Profunda brachii artery:
• Large branch follows the
radial nerve in the spiral
groove.
• It supplies muscular
branches, the nutrient
artery of the humerus, and
finally divides into radial
and middle collateral
branches.
.
 Brachial artery-branches

2. Nutrient artery of humerus -

enters the nutrient canal to
supply humerus.
3. Superior ulnar collateral artery -
supply the medial head of
triceps.
4. Inferior ulnar collateral artery

5. Muscular branches are

distributed to
coracobrachialis, biceps and
brachialis.
6. Radial artery
7. Ulnar artery
Brachial artery injury

• A man was shot

with a high
powered rifle.
• The entrance
wound was on the
lateral aspect of
the left arm.
• He has no pulse at
his wrist and
paralysis and
paresthesia of his
fingers.
 Radial artery
Origin & Course:
• Arises from the brachial
artery at the neck of the
radius.
• It descends along the lateral
side of the forearm,
descends to the wrist, where
it is palpable as it is covered
only by the skin, superficial
and deep fascia.
Branches in the forearm :
1. Radial recurrent artery.
2. Cutaneous branches.
3. Muscular branches.
 Radial artery
Radial artery in the wrist:
• In the wrist the radial artery passes to the dorsal aspect in
the ‘anatomical snuff-box‘.
• At the fifth metacarpal base it anastomoses with the deep
branch of the ulnar artery, completing the deep palmar
arch.
Branches in the wrist:
1. Palmar carpal branch
2. Superficial palmar branch
3. Dorsal carpal branch
4. First dorsal metacarpal artery
5. Second, third and fourth
dorsal metacarpal arteries
6. Arteria princeps pollicis
7. Arteria radialis indicis.
 Ulnar artery

Origin & Course:

• Larger terminal branch of
the brachial artery arises
at the level of neck of
radius.
• Ulnar nerve lies medial to
the distal two-thirds of
the artery.
• Ulnar artery lies
superficial and crosses
the flexor retinaculum.
 Ulnar artery

Branches in the forearm:

1. Anterior ulnar recurrent
artery.
2. Posterior ulnar recurrent
artery.
3. Common interosseous
artery - divides into the
anterior and posterior
interosseous arteries.
4. Cutaneous branches.
5. Muscular branches.
 Ulnar artery

Branches in the wrist:

1. Dorsal cutaneous
branch
2. Palmar carpal branch.
3. Dorsal carpal branch.
4. Deep palmar branch.
5. Superficial palmar
arch - anastomosis
formed mainly by the
ulnar artery .
Superficial & deep palmar arches

• Superficial palmar arch

is formed mainly by
ulnar artery &
completed by radial
artery.
• Deep palmar arch is
formed mainly by radial
artery & completed by
ulnar artery.
• Digital arteries arise
from both arches.
 Superficial palmar arch

Formation:
• An anastomosis formed
mainly by the ulnar artery
and completed by the
superficial palmar branch
of the radial artery.
Branches:
• Common palmar digital
arteries
• Palmar digital artery
• Proper palmar digital
arteries
 Deep palmar arch

Formation:
• Formed by
anastomosis of radial
artery with the deep
palmar branch of the
ulnar artery.
Branches:
1. Palmar metacarpal
artery
2. Perforating branches
3. Recurrent branches
 Pulse

• Radial pulse
• Brachial artery
• Facial artery
• Internal carotid artery
• Femoral artery
• Dorsalis pedis artery
Upper limb - Veins
Upper limb-veins

• Superficial veins:
– Dorsal venous arch
– Median cubital vein
– Cephalic vein
– Basilic vein
• Deep veins:
– Radial and ulnar
veins
– Brachial vein
– Axillary vein
Cephalic vein
Formation: From the lateral
end of dorsal venous arch.
Course: Ascends up through
roof of anatomical snuff box,
lateral border of forearm,
lateral border of biceps
brachii, pierces the deep
fascia at lower border of
pectoralis major to reach the
deltopectoral groove.
Termination: Drains into the
axillary vein.
 Basilic vein

Formation: From the medial

end of dorsal venous arch.
Cephalic
vein
Course: Ascends up along the
medial border of forearm,
medial border of biceps
brachii, pierces the deep fascia
at middle of the arm, runs
along the medial side of
brachial artery.
Termination: Becomes the
axillary vein at the lower
Basilic vein border of teres major.
 Median cubital vein

Cephalic • Large communicating

vein
vein between cephalic &
Basilic basilic veins.
vein
• Situated in the cubital fossa,
separated from the brachial
Median
artery by bicipital
cubital aponeurosis.
vein
• Common site of
intravenous
administration.
Axillary vein
• Starts at the lower border of the
teres major

• Formed by the union of the venae

comitantes of the brachial artery
and the basilic vein.

• Runs on medial side of axillary

artery.

• Ends as subclavian vein at the

lateral border of 1st rib.
• Tributaries: cephalic vein, others
correspond to the branches of
axillary artery
Upper limb - Nerve supply
 Nervous system
• Central nervous system - Brain & spinal cord.
• Peripheral nervous system – Cranial nerves (12 pairs) ,
spinal nerves (31 pairs) and autonomic nerves.
• Spinal nerves:
Spinal nerves
Nerve plexus
Brachial plexus
 Brachial plexus-Formation

• Formed by ventral
rami of spinal nerves
C5-C8 and T1 with
contribution from C4
and T2.
• Pre fixed-contribution
from C4 is large and T2
is absent.
• Post fixed-contribution
from T2 is large and C4
is absent.
 Brachial plexus

• Consists of roots, trunks,

divisions and cords which
provide nerves to the upper
limb.
• Location :
Roots,trunks,divisions - Neck
Cords - Axilla
Branches - Upper limb
 Brachial plexus – Formation

Really Tired? Drink Coffee, Boys!

• Roots (ventral rami)

• Trunks
• Divisions
• Cords
• Branches
 Brachial plexus – Formation
Roots combine forming trunks:

C5
Upper Trunk
C6

C7 Middle Trunk

C8
Lower Trunk
T1
 Brachial plexus – Formation

Trunks split into divisions:

Anterior Division
Upper Trunk
Posterior Division

Anterior Division
Middle Trunk
Posterior Division

Anterior Division
Lower Trunk
Posterior Division
 Brachial plexus – Formation
Divisions form cords:
• Anterior Lateral Cord
• Posterior

• Anterior Medial Cord

• Posterior

• Anterior Posterior Cord

• Posterior
Brachial plexus – Formation
Brachial plexus – Formation
 Brachial plexus - Branches

• Branches from roots:

1. Dorsal scapular nerve (C5)
2. Long thoracic nerve (C5,6,7)

• Branches from upper trunk:

1. Nerve to subclavius (C5,6)

2. Suprascapular nerve (C5,6)
 Brachial plexus –Branches
Branches from cords:
• Lateral Cord(3) Musculocutaneous nerve (C5,6,7)
Lateral pectoral nerve (C5,6,7)
Lateral root of median nerve (C6,7)
• Medial Cord (5) Medial pectoral nerve (C8,T1)
Medial cut.nerve of arm (C8,T1)
Medial cut.nerve of fore arm (C8,T1)
Ulnar nerve (C8,T1)
Medial root of median nerve (C8,T1)
• Posterior Cord(5) Upper subscapular nerve (C5,6)
(ULTRA) Lower subscapular nerve (C5,6)
Thoracodorsal nerve (C5,6,7)
Radial nerve (C6,7,8,T1
Axillary nerve (C5,6)
Brachial plexus – branches
Nerves of upper limb
 1. Axillary Nerve (C5,6):
Origin :
– Arises from posterior
cord(C5,C6) in the axilla.
Course :
– It passes backward and enters
the quadrangular space with the
posterior circumflex humeral
artery.
– As the nerve passes through the
space, it comes into close
relationship with the medial
side of the surgical neck of the
humerus.
– It terminates by dividing into
anterior and posterior branches.
 1. Axillary Nerve (C5,6)
Branches:
• An articular branch to the shoulder joint.
• Anterior terminal branch, which winds around the surgical neck of the
humerus to supply the deltoid and the skin that covers its lower part.
▪Posterior terminal branch, which
gives off a branch to the teres minor
muscle and a few branches to the
deltoid, then emerges from the
posterior border of the deltoid as
the upper lateral cutaneous nerve
of the arm.
Distribution :
Axillary nerve supplies-
- Shoulder joint,
- Two muscles (deltoid,teres minor)
- Skin covering the deltoid
muscle.
Axillary nerve
 2.Musculocutaneous nerve (C5,6,7)
Origin :
▪ Arises from lateral cord in the axilla (C5,6,7).
Course :
▪ It leaves the axilla, pierces the coracobrachialis muscle.
▪Passes downward between the biceps and brachialis muscles.
and pierces the deep fascia just above the elbow.
▪It runs down the lateral aspect of the forearm as the lateral
cutaneous nerve of the forearm.
 2.Musculocutaneous nerve (C5,6,7)

Branches :
▪Muscular branches to the
biceps, coracobrachialis, and
brachialis.
▪Cutaneous branch: Lateral
cutaneous nerve of the forearm
supplies the skin of the front and
lateral aspects of the forearm
down as far as the root of the
thumb.
▪Articular branches to the elbow
joint.
 3. Median Nerve (C5,6,7,8 T1)
Origin :
▪Arises from the medial and
lateral cords of the brachial
plexus in the axilla (C5,6,7,8,T1).
Course :
▪It runs downward on the lateral
side of the brachial artery.
▪In the middle of arm, it crosses
the brachial artery and continues
downward on its medial side.
▪It is superficial, but at the elbow,
it is crossed by the bicipital
aponeurosis.
 3. Median Nerve (C5,6,7,8 T1)
Course :
▪The median nerve leaves the
cubital fossa by passing between
the two heads of the pronator teres.
▪At the wrist, the median nerve
emerges from the lateral border of
the flexor digitorum superficialis
muscle.
▪It enters the palm by passing
behind the flexor retinaculum
through the carpal tunnel. It
immediately divides into lateral and
medial branches.
 3. Median Nerve (C5,6,7,8 T1)
Branches:
▪The median nerve has no branches in the
arm except for a small vasomotor nerve to
the brachial artery.
▪Muscular branches in the cubital fossa to
the pronator teres, the flexor carpi radialis,
the palmaris longus,flexor digitorum
superficialis.
▪ Articular branches to the elbow joint.
▪Articular branches to the wrist and distal
radioulnar joints. It also supplies the joints
of the hand.
▪Palmar cutaneous branch arises in the
lower part of the forearm and is distributed
to the skin over the lateral part of the palm.
 3. Median Nerve (C5,6,7,8 T1)

Branches:
▪Anterior interosseous nerve arises
from the median nerve.
Branches of anterior interosseous
nerve:
1.Muscular branches to the flexor
pollicis longus, the pronator
quadratus,lateral half of the flexor
digitorum profundus.
2.Articular branches to the wrist and
distal radioulnar joints. It also supplies
the joints of the hand.
 3. Median Nerve (C5,6,7,8 T1)

Branches: In the hand:

▪Muscular branch supplies the
muscles of the thenar
eminence - abductor pollicis
brevis,flexor pollicis brevis,
opponens pollicis and the first
lumbrical muscle.
▪Cutaneous branches supply
the palmar aspect of the lateral
three and half fingers and the
distal half of the dorsal aspect
of each finger. One of these
branches also supplies the
second lumbrical muscle.
Median nerve
 4.Ulnar Nerve (C8,T1)

Origin :
▪Arises from the medial cord of
the brachial plexus in the axilla
(C8,T1).
Course : Arm
▪It runs downward on the medial
side of the brachial artery enters
the posterior compartment of the
arm; passes behind the medial
epicondyle of the humerus.
 4.Ulnar Nerve (C8,T1)
Course : Forearm
▪It continues downward to enter
the forearm between the two
heads of origin of the flexor carpi
ulnaris.
▪At the wrist, the ulnar nerve
becomes superficial and enters the
palm of the hand by passing in
front of the flexor retinaculum.
Course : Hand
▪As it crosses the retinaculum, it
divides into a superficial and a deep
terminal branch.
 4.Ulnar Nerve (C8,T1)

Branches : Fore arm

▪The ulnar nerve has no
branches in the arm.
▪Muscular branches to the flexor
carpi ulnaris and to the medial
half of the flexor digitorum
profundus.
▪Articular branches to the elbow
joint.
▪The palmar cutaneous branch is
a small branch that arises in the
middle of the forearm and
supplies the skin over the
hypothenar eminence.
 4.Ulnar Nerve (C8,T1)
Branches in the hand:
▪Superficial branch gives off the
following branches: a muscular
branch to the palmaris brevis and
cutaneous branches to the
palmar aspect of the medial side
of the little finger and the
adjacent sides of the little and
ring fingers.
▪Deep branch supplies abductor
digiti minimi, flexor digiti minimi
and opponens digiti minimi. It
supplies all the palmar and dorsal
interossei, the third and fourth
lumbrical muscles, and both
heads of the adductor pollicis
muscle.
Ulnar nerve
 5.Radial Nerve (C5,6,7,8,T1)
Origin :
▪ Arises from the posterior cord of the brachial
plexus in the axilla (C5,6,7,8,T1).
Course : Arm
▪The nerve winds around the back of the arm in
the spiral groove of the humerus.
▪It continues downward into the cubital fossa in
front of the elbow.In the spiral groove, the nerve is
accompanied by the profunda vessels.
▪It passes downward in front of the lateral
epicondyle of the humerus, divides into superficial
and deep branches.
 5.Radial Nerve (C5,6,7,8,T1)
Branches :
▪Axilla - Branches are given to the long and
medial heads of the triceps and posterior
cutaneous nerve of the arm is given off.
▪Spiral groove – Branches to the lateral and
medial heads of the triceps and to anconeus.
▪The lower lateral cutaneous nerve of the arm
supplies the skin over the lateral and anterior
aspects of the lower part of the arm.
▪The posterior cutaneous nerve of the forearm
runs down the middle of the back of the forearm
as far as wrist.
▪Anterior compartment of the arm - Branches to
the brachialis, brachioradialis and extensor carpi
radialis longus muscles. It also gives articular
branches to the elbow joint.
 5.Radial Nerve (C5,6,7,8,T1)

Branches :
▪Deep branch of radial nerve -
Muscular branches - To extensor
carpi radialis brevis,supinator,
extensor digitorum, extensor
digiti minimi, extensor carpi
ulnaris, abductor pollicis longus,
extensor pollicis brevis, extensor
pollicis longus and extensor
indicis.
▪Articular branches to the wrist
and carpal joints.
 5.Radial Nerve (C5,6,7,8,T1)

Branches :
▪Superficial branch of the radial
nerve - supply the skin on the
lateral two thirds of posterior
surface of hand and the
posterior surface over the
proximal phalanges of the lateral
three and half fingers.

Radial nerve
Radial nerve
 Nerve supply-Intrinsic muscles of hand

• Thenar muscles:
– Abductor pollicis brevis Median nerve
– Flexor pollicis brevis Median nerve
– Opponens pollicis Median nerve
– Adductor pollicis Ulnar nerve
• Hypothenar muscles:
– Abductor digiti minimi Ulnar nerve
– Flexor digiti minimi brevis Ulnar nerve
– Opponens digiti minimi Ulnar nerve
– Palmaris brevis Ulnar nerve
Nerve supply-Intrinsic muscles of hand

• Lumbricals:
– Median nerve (lateral 2).
– Ulnar nerve (medial 2).
• Palmar interossei:
– Ulnar nerve.
• Dorsal interossei:
– Ulnar nerve.
 Cutaneous nerve supply- Hand

Radial nerve

Ulnar nerve

Median nerve

Dorsal aspect Palmar aspect

Brachial plexus & nerves - Clinical
importance
 Brachial plexus injury
• The roots, trunks, and
divisions of the brachial
plexus lie in the neck,
whereas the cords and most
of the branches of the plexus
lie in the axilla.
• Complete lesions involving all
the roots of the plexus are
rare.
• Incomplete injuries are
common and are usually
caused by traction or
pressure; individual nerves
can be injured by stab
wounds.
 Upper lesion of Brachial plexus (Erb-Duchenne Palsy)

Cause:
• Results from excessive displacement of the head to the
opposite side and depression of the shoulder on the same side
causing excessive traction or tearing of C5 and 6 roots.
• Occurs in infants during a difficult delivery or in adults after a
blow to or fall on the shoulder.
Nerves injured:
• Suprascapular nerve, nerve to subclavius,musculocutaneous
and axillary nerves all possess C5 and 6 roots.
Muscles affected:
• Supraspinatus (abductor of the shoulder) and infraspinatus
(lateral rotator of the shoulder); subclavius (depresses the
clavicle); biceps brachii (supinator of the forearm, flexor of the
elbow) greater part of brachialis (flexor of the elbow)
coracobrachialis (flexes the shoulder); deltoid (abductor of the
shoulder) and teres minor (lateral rotator of the shoulder).
• Upper limb will hang by the side, medially rotated;forearm will
be pronated,condition has been likened to that of a porter or
waiter hinting for a tip.
Sensory loss:
• Lateral side of the arm.
 Lower lesion of Brachial plexus (Klumpke Palsy)

Cause:
• Caused by excessive abduction of the arm, when a
person falling from a height clutching at an object to
save himself.
• Also caused by presence of cervical rib or cancer
spread from the lungs in the lower deep cervical
lymph nodes.
Nerves injured:
• T 1 (first thoracic nerve) is injured. Fibers from this
segment run in the ulnar and median nerves.
Muscles affected:
• Hand has a clawed appearance caused by
hyperextension of the metacarpophalangeal joints
and flexion of the interphalangeal joints.
Sensory loss:
• Occur along the medial side of the arm.
 Long thoracic nerve injury

• Long thoracic nerve arises from C5, 6, 7

supplies serratus anterior muscle.
Cause:
• Can be injured by blows to or pressure
on the posterior triangle of the neck or
during the surgical radical mastectomy.
Muscle affected:
• Paralysis of the serratus anterior results
in the inability to rotate the scapula
during the movement of abduction of the
arm above right angle.
• Patient experiences difficulty in raising
the arm above the head.
• The vertebral border and inferior angle
of the scapula not applied to the chest
wall and will protrude
posteriorly,condition known as winged Winging of the right scapula
scapula.
 Radial nerve injury - Axilla
Cause:
• Injured by the pressure of the upper end of a badly fitting crutch pressing up into
the armpit or by a drunkard falling asleep with one arm over the back of a chair.
• Also by fracture and dislocation of the proximal end of the humerus.
Muscles affected- Motor:
• Triceps, anconeus and long extensors of the wrist are paralyzed. The patient is
unable to extend the elbow joint, wrist joint and fingers.
• Wrist drop, or flexion of the wrist occurs as a result of the action of the
unopposed flexor muscles of the wrist.
• Brachioradialis and supinator muscles are also paralyzed, but supination is still
performed well by the biceps brachii.
Sensory loss :
• Posterior surface of the lower part of the arm and down a narrow strip on the
back of the forearm, lateral part of the dorsum of the hand and dorsal surface of
the roots of the lateral three and a half fingers.
 Radial nerve injury – Spiral groove
Cause:
• Injured in fracture of the shaft of
the humerus.
Muscles affected- Motor:
• The injury to the radial nerve
occurs most commonly in the distal
part of the groove, beyond the
origin of the nerves to the triceps
and the anconeus and beyond the
origin of the cutaneous nerves.
• Motor: unable to extend the wrist Wrist drop
and the fingers, wrist drop occurs.
Sensory loss:
• Dorsal surface of the hand and the
dorsal surface of the roots of the
lateral three and a half fingers.
 Radial nerve injury

•Saturday night palsy – Falling asleep with

one's arm hanging over the arm rest of a
chair, compressing the radial nerve at the
spiral groove.
•Honeymoon palsy - Sleeping on and
compressing one's arm overnight.
•Handcuff Neuropathy from tight fitting
handcuffs compressing the superficial
branch of the distal radial nerve.
•Crutch palsy from poorly fitted axillary
crutches.
•Squash palsy associated with the sport
squash, happen to squash players during
prolonged period between matches.
 Musculocutaneous nerve injury
Cause:
• Rarely injured because of its
protected position beneath the
biceps brachii muscle. If it is
injured high up in the arm.
Muscles affected - Motor:
• Biceps and coracobrachialis are
paralyzed and the brachialis
muscle is weakened (the latter
muscle is also supplied by the
radial nerve).
• Flexion of the forearm at the
elbow joint is then produced by
the remainder of the brachialis
muscle and the flexors of the
forearm.
Sensory loss:
• Lateral side of the forearm.
 Median nerve injury
Cause:
• injured occasionally in the elbow region in
supracondylar fractures of the humerus. It is most
commonly injured by stab wounds or broken glass
just proximal to the flexor retinaculum.
Muscles affected - Motor:
• The pronator muscles of the forearm and long
flexor muscles of the wrist and fingers will be
paralyzed.
• No flexion is possible at the inter phalangeal joints
of the index and middle fingers.
• Flexion of the terminal phalanx of the thumb is
lost because of paralysis of the flexor pollicis
longus. The muscles of the thenar eminence are
paralyzed and wasted so that the eminence is
flattened. The thumb is laterally rotated and
adducted. The hand looks flattened and ape like.
Sensory loss :
• Lateral half of the palm of hand,palmar aspect of
the lateral three and a half fingers,distal part of Ape hand
the dorsal surfaces of the lateral three and a half
fingers.
Median nerve palsy
 Carpal tunnel syndrome
• Carpal tunnel, formed by the concave
anterior surface of the carpal bones and
closed by the flexor retinaculum, is tightly
packed with the long flexor tendons of the
fingers and median nerve.
• Clinically, the syndrome consists of a
burning pain or pins and needles along the
distribution of the median nerve to the
lateral three and a half fingers and
weakness of the thenar muscles.
• It is produced by compression of the
median nerve within the tunnel. The exact
cause of the compression is difficult to
determine, but thickening of the synovial
sheaths of the flexor tendons or arthritic
changes in the carpal bones are thought to
be responsible in many cases.
• The condition is relieved by decompressing
the tunnel by making a longitudinal
incision through the flexor retinaculum.
 Ulnar nerve injury
Cause:
• The injuries at the elbow are associated with
fractures of the medial epicondyle.
Muscles affected - Motor:
• The flexor carpi ulnaris and the medial half of the
flexor digitorum profundus muscles are paralyzed.
• The small muscles of the hand will be paralyzed,
except the muscles of the thenar eminence and
the first two lumbricals, which are supplied by the
median nerve.
• The patient is unable to adduct and abduct the
fingers and consequently is unable to grip a piece
of paper placed between the fingers.
• In long-standing cases the hand assumes the
characteristic claw hand deformity. Wasting of the Claw hand
paralyzed muscles results in flattening of the
hypothenar eminence
Sensory loss:
• Anterior and posterior surfaces of the medial third
of the hand and the medial one and a half fingers.
Ulnar nerve palsy

Claw hand
TAKE HOME MESSAGE..
 Muscles-scapular & pectoral region

Levator scapulae, rhomboids Dorsal scapular nerve

Pectoralis minor,major Pectoral nerves

Serratus anterior Long thoracic nerve
Trapezius Accessory nerve

Lattisimus dorsi Thoracodorsal nerve

Subscapularis, teres major Subscapular nerve
Supraspinatus, infraspinatus Suprascapular nerve
Teres minor, deltoid Axillary nerve
 Upper limb-Nerve supply
Arm
• Anterior compartment – Musculocutaneous nerve.
• Posterior compartment – Radial nerve.
Forearm
• Anterior compartment – Median nerve – 6 ½ muscles.
Ulnar nerve – 1 ½ - Flexor carpi ulnaris and medial
part of flexor digitorum profundus.
• Posterior compartment – Radial nerve and its
branches.
Hand
• Ulnar nerve – 15 muscles.
• Median nerve – 5 muscles- lateral 2
lumbricals,abductor pollicis brevis, flexor pollicis
brevis and opponens pollicis.
 Dermatome

Anterior aspect Posterior aspect

Upper limb - Lymphatics
Axillary lymph nodes
• There are 20 to 30 axillary
nodes, which may be
divided into five groups:
1. Lateral
2.Anterior (pectoral)
3.Posterior (subscapular)
4.Central
5.Apical
• Four of the groups are
intermediary, and only the
apical group is terminal.
• Collectively they drain the
entire upper limb, breast
and trunk above the
umbilicus.
 Upper limb lymphatics - Superficial tissue
Forearm and arm:

▪ Superficial vessels run with the superficial veins.

▪ Collecting vessels from the hand pass to the
forearm.

▪Anterior carpal vessels run through the forearm

end in the lateral axillary lymph nodes.

▪Lymph vessels that lie laterally in the forearm

follow the cephalic vein to reach the lateral axillary
nodes and a few continue with the vein and drain
into the infraclavicular nodes.

▪Vessels lying medially in the forearm follow the

basilic vein.
 Upper limb lymphatics - Superficial tissue

Scapular & deltoid region:

▪Lymph vessels from the

deltoid region pass round the
anterior and posterior axillary
folds to end in the axillary
nodes.

▪The scapular skin drains

either to subscapular axillary
nodes or to the inferior deep
cervical nodes.
 Upper limb lymphatics – Deep tissue

▪Deep lymph vessels follow the

main neurovascular bundles
(radial, ulnar, interosseous and
brachial) to the lateral axillary
nodes.
▪A few lymph nodes occur
along the vessels.
▪Scapular muscles drain mainly
to the subscapular axillary
nodes and pectoral muscles
drain mainly to the pectoral,
central and apical lymph nodes.
Thank you