Venous & Lymphatic Drainage of Upper Limb Lecture – Anatomy & MBBS Lectures

1. Venous drainage and Lymphatics of the upper limb Dr.Qudsia sultana
2. Why veins are important to us ?
3. What is this?
4. The veins of upper limb They are divided into two sets, • superficial and • deep which anastomose freely with each other.
5. Deep veins of the upper limb • Follow the course of arteries. • Arranged in pairs on either side of the arteries of upper limb and are called as venae commitants (except the axillary Artery).
6. The superficial veins of upper limb • placed immediately under the skin, in the superficial fascia. • Communicate with deep veins and finally drain in axillary vein. • They are • Cephalic, • Basilic and • Median cubital vein.
7. Dorsal venous arch • It drains the blood from back of the hand. • Formed by the union of three dorsal metacarpal veins. Which in return formed by the union of dorsal digital veins. • On its lateral side it receives, dorsal digital veins from the radial side of index finger and both the sides of the thumb.
8. On its medial side ,it receives dorsal digital vein from the ulnar side of the little finger.
9. Cephalic vein • Formed in the anatomical snuff box. • Begins –lateral side of dorsal venous arch. • winds upwards round the radial border of the forearm to its anterior surface in the cubital fossa, where it is connected to basilic vein through median cubital vein.
10. Cephalic vein • it then ascends subcutaneously along the lateral side of the biceps in arm .
11. It lies in the groove between the pectoralis major and deltoid • It pierces the clavipectoral fascia with right angled bend to end in the axillary vein .
12. Applied anatomy • Internal arterio-venous fistulas for haemodialysis in chronic renal failure is created between cephalic vein and Radial artery.
13. Basilic vein • Begins in the ulnar side of the dorsal venous arch of the hand. • It runs up for some distance on the posterior surface of the ulnar side of the forearm. • Inclines forwards to the anterior surface of medial epicondyle where it is connected to the cephalic vein by median cubital vein
14. It then ascends medial to biceps • perforates the deep fascia a little below the middle of the arm and • join with the venae commitantes of the brachial artery to form the axillary vein.
15. Applied • The basilic vein is used for cardiac catheterization.
16. Median cubital vein • It is given off from the cephalic vein about 2.5cms below and front of the elbow , and passes medially to join the basilic vein about 2.5cms above the elbow. • It rests on bicipital aponeurosis which seperates it from brachial artery and median nerve. • Receives tributaries from forearm- median antebrachial vein
17. As it is fixed to deep veins with perforators it is used: • Blood sampling • Blood transfusion • Intravenous injection in general, are often performed at the bend of the elbow( the median cubital vein) . • Cardiac catheterization
18. Lymph nodes of upper limb
19. Introduction • Lymphatics • Lymph nodes • Applied anatomy
20. Lymphatics of upperlimb. • Superficial Lymphatics. • Deep Lymphatics.
21. Superficial Lymphatics • Collect lymph from skin and subcutaneous tissue and accompany superficial veins. • Drain into axillary nodes • Medial three fingers, medial side of the arm and forearm –along the basilic vein- Supratrochlear lymphnodes – lateral group of axillary lymph nodes. • Index and thumb finger, Lateral side of the arm and forearm – along the cephalic vein- infraclavicular nodes-apical group of axillary nodes.
22. Deep Lymphatics • Follow the arteries • Less numerous. • Drains structures deeper to deep fascia. • End in the lateral group of axillary nodes.
23. Lymph nodes • Axillary Lymph Node (Pectoralis group). • Scattered in the fibro-fatty tissue of the axilla. • Five groups • Anterior group • Posterior group • Lateral group • Central group • Apical group
24. 1.Anterior Group: • Along the lateral thoracic vessels. (lower border of the pectoralis minor). • Receives lymph from the upper half of the anterior wall of the trunk and from the major part of the breast.
25. 2.Posterior Group (Scapular group). • Along the subscapular vessels, on the posterior fold of the axilla. • Receive lymph from the posterior wall of the of the trunk upto the iliac crest.
26. 3.Lateral Group: • Lateral wall of axilla, medial to the axillary vein. • Receive lymph from the medial side of upper limb .
27. 4.Central group: • base of the axilla embedded in fat. • Receives lymph from other groups and drains into the apical group.
28. Applied • Intercosto brachial nerve passes through the central nodes. • If central nodes are enlarged due to ca breast – compresses the nerve – referred pain along the medial side of arm.
29. 5. Apical/ Infraclavicular: • Lie deep to the clavipectoral fascia along the axillary vessels. • Receive lymph from all the groups of axillary lymphnodes, • Lmphatics along the cephalic vein(thumb and its web) • upper part of the breast. • Drains into subclavian trunk
30. Lymph nodes • Deltopectoral nodes: • Lies in the deltopectoral groove along the cephalic vein. • Superficial cubital / supratrochlear nodes. • Lie above the medial epicondyle. • Drains the ulnar side of the hand and forearm.
31. Lymph nodes • Deep lymph nodes: • Medial side of the brachial artery. • At the bifurcation of the brachial artery. • Occasionally along the arteries of the forearm.
32. Applied Anatomy • Supratrochlear lymphnodes are enlarged in Syphilis.
33. Grouping according to the location of Pectoralis minor
34. Rotter’s nodes
35. Lymphangitis. • Lymphadenitis. • Lymphedema.

GENERAL

• Most superficial veins join to form two large veins – CEPHALIC & BASILIC vein.
• CEPHALIC (PRE-AXIAL)vein.
• BASILIC (POST-AXIAL) vein.
• CEPHALIC is LONGER than basilic & drain into AXILLARY vein

GENERAL
Load on cephalic vein reduced by
basilic vein through Median cubital vein& partly perforating deep vein. Superficial veins accompanied by
cutaneous nerves & superficial lymphatics.
Superficial veins best utilized for i.v injections.

INDIVIDUAL VEINS

DORSAL VENOUS ARCH

Location- dorsum of hand. Afferents-

a) 3 dorsal metacarpal veins.

b) 1 dorsal digital vein medial side of little finger.

1 dorsal digital vein lateral side of index finger. d) 2 dorsal digital vein of thumb. Efferents- 1. Cephalic vein.

2. Basilic vein.

Dorsal Venous Arch

CEPHALIC VEIN:

• Pre-axial vein (~great saphenous vein of lower limb).
• Begins: lateral end of dorsal venous arch.
• Course:
• At elbow:

Most of blood drains into

• basilic vein (through median cubital vein)
• partly into deep veins (through perforator vein).

Nerves accompanying:

• Lateral cutaneous nerve of forearm.
• Terminal part of radial nerve.

BASILIC VEIN:

• Post-axial vein(~short saphenous vein of lower limb).
• Begins: Medial end of dorsal venous arch.
• Course:
• At elbow:

2.5 cm above medial epicondyle of humerus median cubital vein joins it.

Nerves accompanying:

• Medial cutaneous nerve of forearm
• Terminal part of ulnar nerve.

MEDIAN CUBITAL VEIN:

Large communicating vein SHUNTS BLOOD from cephalic to basilic vein.

• Begins:

from cephalic vein (2.5cm below bend of elbow).

• Direction:

obliquely up & medially.

• Tributaries:

median vein of forearm.

• Connections:

to deep veins through perforator vein(pierces bicipital aponeurosis)

CLINICAL ANATOMY:

• Median cubital vein vein of choice for i.v. injections.
• MCV used to withdrawl blood from donors & in cardiac catheterisation.

Reason for choice:

• Fixed by perforator.
• Doesn’t slip away during piercing.

MEDIAN VEIN OF FORE ARM

• Begins:

Palmar venous network.

• Ends:

mostly median cubital vein.

DEEP VEINS:

• Begins:

Small VENAE COMITANTES (on each side of digital vein).

• Course:

venae comitantes of RADIAL & ULNAR arteries join to form BRACHIAL veins (on either side brachial artery). Brachial veins join to form AXILLARY vein.

CLINICAL ANATOMY

• Cardiac catheterisation:

basilic vein preferrable (continuity with axillary vein).

• Internal arterio-venous fistulae: between cephalic vein & radial artery (for repeated vene puncture access).
• Cephalic communicates frequently with EJV

Lie – infront of clavicle.

Imp – Helps drain blood from upper limb (axillary vein removed).

LYMPHATIC SYSTEM

Lymph nodes

• small bean like structures,
• usually in groups.

Palpability:

• normally not palpable
• palpable in eg: infections or malignancy.

Lymph nodes:

A. Axillary(main)

B. Additional

• Infraclavicular.
• Deltopectoral.
• Superficial cubital or supra trochlear node.
• few (brachial artery, its bifurcation, arteries of fore arm)

Axillary Lymph Nodes

Drains

1. Upper Limb
2. Breast
3. Trunk above umbilicus

Axillary Lymph Nodes

ADDITIONAL LYMPH NODES

Infraclavicular nodes:

Lie – clavipectoral fascia (along cephalic vein).

Drain-breast(upper part). thumb(with its web).

Deltopectoral node:

Lie – deltopectoral groove(along cephalic vein).

Drain–infraclavicular node(displaced).

Superficial cubital or supra trochlear node:

Lie -along basilic vein (above medial epicondyle).

drain-ulnar side of hand &forearm.

LYMPHATICS:

SUPERFICIAL LYMPHATICS:

• More numerous (than deep).
• Collect lymph-skin & subcutaneous tissue.
• Ultimately drain —-axillary nodes

Except few vessels

medial side of forearm (drain superficial cubital nodes),

Lateral side of fore arm. (drain to deltopectoral nodes

Superficial Lymphatics

Deep Lymphatics

CLINICAL ANATOMY

Lymphangitis:

• Inflammation of lymph vessels

-acute lymphangitis skin seen as red, tender streaks.

Lymphadenitis:

• lymph nodes (acute or chronic).

Lymphoedema:

• lymph vessel obstruction
• accumulation of tissue fluid.eg: filariasis.

Enlarged central group:

• pressure on intercostobrachial nerve.
• pain along medial side of upper arm.

Clinical classification:

Level 1 (low nodes)-lie below pect.minor.

Level 2 (middle nodes)-lie behind pect.minor.

Level 3 (upper or apical)- lie above muscle & upto lower surface of clavicle.

Rotters nodes- intervene between pect.minor & pect.major

Question

What is Cubital vain ?

Answer

Communication between cephalic and basilic vein infront of elbow