venous & lymphatic drainage of upper limb

VENOUS & LYMPHATIC DRAINAGE OF UPPER LIMB

Dr.I.Dinesh Reddy. MD. Senior resident,SVMC.

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 utilised for i.v

injections.

INDIVIDUAL VEINSDORSAL VENOUS ARCH

Location- dorsum of hand. Afferents-a) 3 dorsal metacarpal veins.b) 1 dorsal digital vein medial side of little finger.c) 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 ANATOMYCardiac 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

1.Infraclavicular.2.Deltopectoral.3.Superficial cubital or supra trochlear

node.4.few (brachial artery ,

its bifurcation,arteries of fore arm)

AXILLARY LYMPH NODES Drains1.Upperlimb.2.Breast.3.Trunk above umbilicus.

AXILLARY LYMPH NODES

AXILLARY LYMPH NODESAnterior Posterior Lateral

Lie • Lat.thorasic vein.• Pect.minor lower

border

• Subscapular vessels

• subscapularis

• p/m axillary vein

afferents • Ant.trunk (up. ½)• Breast major

• Post.trunk (as far as iliac crest)• Axillary tail of

breast

• Upper limb(except cephalic vein )

efferentsImp. • Axillary tail in

contact(cancer misdiagnosed)

AXILLARY NODES-AFFERENTS&EFFERENTS:

AXILLARY LYMPH NODESCentral Apical or

infraclavicularLie • Axilla upper part Axillary vein (apex of

axilla deep to clavipectoral fascia)

afferents Other lymph nodes Breast upper part&rest of nodes

efferents apical Left—thorasic ductRight—subclavian lymph trunk

Imp. Intercostobrachial nerve passes

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 nodesExcept few vessels - medial side of forearm (drain superficial cubital nodes),- Lateral side of fore arm. (drain to deltopectoral nodes

SUPERFICIAL LYMPHATICS Dense palmar plexus

Dorsum of hand

vessels of forearm&arm

Reach floor of axilla

VERTICAL AREA of lymph shed(middle of forearm & arm)

SUPERFICIAL LYMPHATICS

DEEP LYMPHATICS Less numerous Drain--deep to deep fascia

run-main blood vessels

End-axillary nodes

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

QUESTIONS1.Cephalic vein drains intoa) Axillary vein in lower part of armb) Axillary vein in upper part of armc) Basilic vein in fore armd) Brachial vein

Lymph shed lies on a) Lateral side of armb) Medial side of armc) Anterior aspect of armd) Posterior aspect of arm

QUESTION A female patient of 60 years felt two nodular

swellings in her right axilla.-what parts of the body have to be examined?

ANSWERExamine- both mammary glands, axilla of both sides, supraclavicular & infraclavicular lymph nodes, abdomen and pelvis

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CLINICAL CASE A 30 year old female went to doctor for

routine blood examination. The doctor asked technician to collect blood sample of lady. While attempting to collect blood sample from median cubital vein the technician noticed that the blood in the syringe is bright red. He immediately withdrew the needle.

In second attempt ,he inserted the needle slightly medial to the previous puncture. The lady felt sharp pain, which radiates to lateral three digits

QUESTION What is median cubital vein?

ANS Communication between cephalic and basilic

vein infront of elbow

QUESTION Name the fascial structure which separates

median cubital vein from brachial artery and median nerve?

ANS Bicipital aponeurosis

QUESTION Mention cause of sharp pain that radiated to

lateral 3 ½ digits

ANS Median nerve injury

QUESTION What does the bright red colour in syringe

indicate during collection of blood sample from the median cubital vein?

ANS Brachial artery puncture

Thank you