- Venous drainage and Lymphatics of the upper limb Dr.Qudsia sultana
- Why veins are important to us ?
- What is this?
- The veins of upper limb They are divided into two sets, • superficial and • deep which anastomose freely with each other.
- 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).
- 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.
- 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.
- On its medial side ,it receives dorsal digital vein from the ulnar side of the little finger.
- 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.
- Cephalic vein • it then ascends subcutaneously along the lateral side of the biceps in arm .
- 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 .
- Applied anatomy • Internal arterio-venous fistulas for haemodialysis in chronic renal failure is created between cephalic vein and Radial artery.
- 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
- 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.
- Applied • The basilic vein is used for cardiac catheterization.
- 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
- 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
- Lymph nodes of upper limb
- Introduction • Lymphatics • Lymph nodes • Applied anatomy
- Lymphatics of upperlimb. • Superficial Lymphatics. • Deep Lymphatics.
- 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.
- Deep Lymphatics • Follow the arteries • Less numerous. • Drains structures deeper to deep fascia. • End in the lateral group of axillary nodes.
- 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
- 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.
- 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.
- 3.Lateral Group: • Lateral wall of axilla, medial to the axillary vein. • Receive lymph from the medial side of upper limb .
- 4.Central group: • base of the axilla embedded in fat. • Receives lymph from other groups and drains into the apical group.
- 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.
- 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
- 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.
- 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.
- Applied Anatomy • Supratrochlear lymphnodes are enlarged in Syphilis.
- Grouping according to the location of Pectoralis minor
- Rotter’s nodes
- Lymphangitis. • Lymphadenitis. • Lymphedema.
- 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
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.
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
- Pre-axial vein (~great saphenous vein of lower limb).
- Begins: lateral end of dorsal venous arch.
- At elbow:
Most of blood drains into
- basilic vein (through median cubital vein)
- partly into deep veins (through perforator vein).
- Lateral cutaneous nerve of forearm.
- Terminal part of radial nerve.
- Post-axial vein(~short saphenous vein of lower limb).
- Begins: Medial end of dorsal venous arch.
- At elbow:
2.5 cm above medial epicondyle of humerus median cubital vein joins it.
- Medial cutaneous nerve of forearm
- Terminal part of ulnar nerve.
MEDIAN CUBITAL VEIN:
Large communicating vein SHUNTS BLOOD from cephalic to basilic vein.
from cephalic vein (2.5cm below bend of elbow).
obliquely up & medially.
median vein of forearm.
to deep veins through perforator vein(pierces bicipital aponeurosis)
- 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
Palmar venous network.
mostly median cubital vein.
Small VENAE COMITANTES (on each side of digital vein).
venae comitantes of RADIAL & ULNAR arteries join to form BRACHIAL veins (on either side brachial artery). Brachial veins join to form AXILLARY vein.
- 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).
- small bean like structures,
- usually in groups.
- normally not palpable
- palpable in eg: infections or malignancy.
- Superficial cubital or supra trochlear node.
- few (brachial artery, its bifurcation, arteries of fore arm)
Axillary Lymph Nodes
- Upper Limb
- Trunk above umbilicus
Axillary Lymph Nodes
ADDITIONAL LYMPH NODES
Lie – clavipectoral fascia (along cephalic vein).
Drain-breast(upper part). thumb(with its web).
Lie – deltopectoral groove(along cephalic vein).
Superficial cubital or supra trochlear node:
Lie -along basilic vein (above medial epicondyle).
drain-ulnar side of hand &forearm.
- 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
- Inflammation of lymph vessels
-acute lymphangitis skin seen as red, tender streaks.
- lymph nodes (acute or chronic).
- lymph vessel obstruction
- accumulation of tissue fluid.eg: filariasis.
Enlarged central group:
- pressure on intercostobrachial nerve.
- pain along medial side of upper arm.
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
What is Cubital vain ?
Communication between cephalic and basilic vein infront of elbow