SURGICAL ANATOMY OF THE HAND AND UPPER EXTREMITY part 03

 

the carpal tunnel. Clin Anat 1:23–31, 1988.

Distal Branching of the Median Nerve

Distal branching of the median nerve is a pattern where the

recurrent motor branch leaves the median nerve more distally in the palm, distal to the carpal tunnel. The nerve

branch then loops back proximally to reach the thenar muscles, extending in a retrograde fashion.

Recurrent Motor Branch Arising from the Ulnar

Aspect of the Median Nerve

The recurrent motor branch arises in or distal to the carpal

tunnel, but the branch point usually is on the ulnar aspect

of the median nerve trunk. In addition, the motor branch

can arise from the central, anterior surface of the median

nerve, then pass ulnarly and distally until it clears the transverse carpal ligament, where it turns and passes radially and

somewhat retrograde over the ligament to reach the thenar

muscle mass (36,150). A variation of this anomaly was

reported by Papathanassiou, who noted one clinical case

and one dissection specimen in which the motor branch

arose from the ulnar, anterior aspect of the radial division of

the median nerve (149). This anomaly was found in 16 of

20 dissections by Mumford et al. (134). The anomaly also

was encountered once by Lanz (138,146).

Ulnar-sided Exit of the Recurrent Motor Branch with

Hypertrophy of the Flexor Pollicis Brevis or Palmaris

Brevis

An associated concomitant hypertrophy of the flexor pollicis brevis or palmaris brevis has been noted to occur commonly with the aberrant origin of the recurrent motor

branch arising from the ulnar side of the nerve rather than

from the radial aspect (150). The hypertrophied flexor pollicis brevis lies anterior to the flexor retinaculum. Spinner

emphasizes that when this muscle variant is found, it is safer

to identify the median nerve in the carpal tunnel, and locate

the motor branch by opening the carpal tunnel on the

medial side. The motor branch can then be traced distally

as it recurs through the superficial hypertrophied muscle

(6,150).

Recurrent Motor Branch Arising Anteriorly

Recurrent motor branch can arise anteriorly, then pass

over the surface of the transverse carpal ligament. The

recurrent motor branch arises in the carpal tunnel, more

proximally than normal, originating from the palmar

aspect of the nerve. The nerve extends distally, around the

distal edge of the transverse carpal ligament, and loops

back proximally to reach the thenar muscles in a retrograde fashion.

Recurrent Motor Branch and Median Nerve Passing

Anterior to the Transverse Carpal Ligament

A rare pattern noted by Sunderland involves the entire

median nerve passing superficial to the transverse carpal ligament (44).

Absence of the Recurrent Motor Branch to the Thenar

Muscles

Complete absence of the recurrent motor branch to the

thenar muscles has been described (6,41,140). This is

observed in the all-ulnar hand, in which all of the thenar

muscles are innervated by the ulnar nerve through various

communicating branches (41,140).

High Division of the Median Nerve (Bifid Median

Nerve)

Branching of the median nerve proximal to the wrist is well

described, and often presents as a bifid median nerve

(135,141,144). The bifid median nerve can be discovered

in the carpal canal during carpal tunnel release or in the

forearm during operative exploration (138,141,144,146).

There usually is a larger, more radial component and a

smaller ulnar component that travels parallel to the larger

component.

This anomaly has been described by Gruber, who noted

four cases in which the median nerve branch to the third

web space originated in the proximal forearm. Amadio

found high branching of the median nerve in 3% of cases

(70). Hartmann and Winkelman and Spinner also have

reported high branching of the median nerve in the forearm

(71,72). In most of the cases studied by Amadio, the bifid

median nerve had two branches that remained independent

of one another. However, two of nine cases had a loop communication in which one or the other median nerve branch

received a communicating branch from the other in or just

distal to the carpal canal (70). This communicating loop

also was noted in 3 of 29 cases reported in the literature at

the time of Amadio’s study (70).

A median artery also may be present with the bifid

median nerve. The median artery is an anomalous artery

that is a persistent extension of the anterior interosseous

artery. The median artery can result from persistence of an

embryonic artery known as the forearm axis artery.

Anomalous muscles such as aberrant flexor digitorum

superficialis or lumbricals also have been associated with a

high division of the median nerve.

Riche-Cannieu Anastomosis

Nerve communication between the median nerve recurrent

motor branch and the ulnar nerve deep branch is referred to

as a Riche-Cannieu communication or anastomosis. In 1897,

Riche and Cannieu independently described a connection

between these nerves occurring between the fibers of the

median nerve recurrent motor branch traveling to the superficial head of the flexor pollicis brevis and the fibers of the

deep ulnar branch going to the deep head of the flexor pollicis brevis (151,152). Mannerfelt drew additional attention to

this important anastomosis (46,150). The communicating

fibers pass radially from the deep ulnar branch between the

heads of the adductor pollicis, then pass deep to the flexor

3 Nerve Anatomy 197

pollicis longus tendon. The fibers continue proximally to

the radial side of the flexor pollicis longus tendon as they

approach the median nerve recurrent motor branch. This

communication was found in 77% of cadaver specimens

studied, and was found in virtually all fresh cadaver hands

(153). Riche described two other anatomic median–ulnar

nerve communications. In one, the communication

occurred between a thumb digital nerve (derived from the

median nerve) and fibers en route to the adductor pollicis

(derived from the deep ulnar nerve branch). The communicating fibers were found in the adductor muscle on the

medial side of the flexor pollicis longus tendon. In another

pattern, the communicating fibers passed through the first

lumbrical, which was innervated by the ulnar nerve

(36,152). It is now assumed that the Riche-Cannieu connection usually carries motor fibers only (36,150,153),

although early investigators thought it carried sensory

fibers (154). Foerster, as a result of war-injury studies, and

Harness and Sekeles, as a result of anatomic dissections,

believed that the anastomosis was of the motor type

(153,155,156). Because Harness and Sekeles found that

most of the preserved specimens studied (77%) and virtually all of the fresh specimens contained the Riche-Cannieu

communication, they concluded that this nerve anastomosis is common and normal, and may represent the more

usual innervation pattern of the thenar muscles (153).

Additional clinical and electromyographic studies have

supported this consideration (36,153). However, Mannerfelt has noted that the nature (sensory, motor, or mixed),

incidence, and direction of the fiber passage (i.e., median

to ulnar nerve, or ulnar to median nerve) remain unresolved (36,150). Either way, the communication provides

a potential pathway for double innervation of the intrinsic

muscles anywhere in the hand. A variation of the RicheCannieu anastomosis has been noted by Harness and Sekeles and by Hovelacque, in which a branch from the deep

ulnar nerve communicates with a thumb digital nerve.

This presents the possibility that median motor fibers destined for the thenar muscles were traveling in the digital

nerve (36,157).

Basic Patterns of the Riche-Cannieu

Anastomosis

Spinner has summarized the basic patterns of the RicheCannieu anastomosis (6):

n An anastomosis in the substance of the adductor pollicis

between the median and ulnar nerves

n A communicating branch from the motor branch of the

median nerve coursing anterior to the radial head of the

flexor pollicis brevis and the ulnar component passing

deep to the ulnar head of this muscle

n Anastomosis between the two motor nerves across the

first lumbrical

n Anastomosis between the branch of the deep ulnar nerve

to the adductor pollicis or flexor pollicis brevis and the

median nerve digital branch to the thumb or index finger

Palmar Ulnar–Median Communicating Branch

of Berrettini

As noted previously, the Riche-Cannieu anastomosis usually carries motor fibers and occurs in the region of the

adductor pollicis and thenar muscles. However, a distal

communicating branch between the ulnar and median

sensory nerves is not uncommon; in fact, the presence of

a communicating branch may be the most common (and

normal) nerve pattern. Classically, palmar sensation in the

fingers is described as divided between ulnar and median

nerves at the midline of the ring finger. Berrettini

described and illustrated this communicating branch in

1741 (158). More recently, Meals and Shaner found a

communicating branch between the ulnar and median

nerves in the palm in 40 of 50 dissected specimens. Several studies have confirmed the common presence of this

communicating branch (44,46,52,159). The communicating branch usually passes immediately deep to the

superficial palmar arch; however, in some specimens the

branch courses just distal to the transverse carpal ligament

(70,157).

Innervation of the Lumbricals and Associated

Flexor Digitorum Profundus

In general, the belly of the flexor digitorum profundus of

the index finger and the first lumbrical muscle nearly always

are supplied by branches of the median nerve. However,

innervation of the other flexor digitorum profundus muscle

bellies and their corresponding lumbricals is quite variable.

The lumbrical usually is supplied by the same major nerve

(median or ulnar) that supplies the corresponding belly of

the flexor digitorum profundus. However, in 50% of cases,

there are variations from the classic pattern of innervation

(in which the median nerve innervates the radial two bellies

and the ulnar nerve innervates the ulnar two bellies) (36).

The variation usually involves the median nerve encroaching on the ulnar nerve distribution. However, the ulnar

nerve also can encroach laterally to innervate the long finger belly partially or exclusively (36).

Clinical Correlations: Median Nerve in the

Wrist and Hand

As the median nerve passes through the carpal tunnel, it is

the most palmarly located structure, with the transverse

carpal ligament adjacent to its palmar surface. The median

nerve is therefore at inherent risk for injury during carpal

198 Systems Anatomy

tunnel release. Scarring or adhesions add to the risk of

injury if the median nerve is adherent to the ligament. This

risk is especially significant when repeat or revision carpal

tunnel release is performed (160,161).

Anatomic Aspects of Carpal Tunnel Syndrome

Several causes of carpal tunnel syndrome have been recognized (6,142,160–177). Specific anatomic abnormalities

that can be factors in carpal tunnel syndrome include the

following:

n A palmaris profundus muscle. The palmaris profundus

is a muscle that originates from the radius, ulna, and

interosseous ligament in the forearm, and passes through

the carpal tunnel to insert onto the dorsal surface of the

palmar fascia. It can produce symptoms if its tendon is

large or if the musculotendinous junction extends into

the carpal tunnel (6,127)

n An anomalous flexor digitorum superficialis, especially

that with a muscle belly that extends distally into the

carpal tunnel (178–184)

n Anomalous lumbrical muscles that extend proximally

into the carpal tunnel (185)

n An enlarged, inflamed, thrombosed, or calcified median

artery in the carpal tunnel (186,187)

n A hypertrophied palmaris longus (160)

High Division of the Median Nerve (Bifid

Median Nerve)

The high division of the median nerve results in two

nerves entering the carpal tunnel. This variant can subject

the nerve to potential injury during carpal tunnel release,

especially if one of the two branches is not recognized. An

unrecognized branch is particularly vulnerable during

flexor tenosynovectomy or flexor tendon repair in the

carpal tunnel. Spinner notes that in carpal tunnel syndrome with atypical findings such as sensibility abnormalities isolated only to the third web space or only to the

more lateral aspect of the hand (sparing the third web

space), the examiner should consider the bifid median

nerve as a potential finding (6). Similarly, laceration of the

forearm associated with numbness of the third web space

and its accompanying digital manifestation in the ulnar

half of the long finger and radial half of the ring finger

suggest the occurrence of a bifid median nerve (or perhaps

a partial laceration of a normal median nerve) (6). When

a bifid median nerve is encountered or a median nerve

found with high branches originating in the forearm, special care is required during carpal tunnel release or median

nerve exploration, both for nerve protection and for adequate decompression. Release of the median nerve

branches from separate fascial channels in the transverse

carpal ligament may be needed (36,135).

The Recurrent Motor Branch of the Median

Nerve

The most common pattern of the recurrent branch of the

median nerve is the course where the nerve exits the nerve

trunk distal to the transverse carpal ligament, then curves

back proximally in a retrograde fashion to reach the

thenar muscles. This common pattern also is relatively

safe because the nerve branch does not penetrate or lie

within the ligament that is transected. The presence of

variations in number and patterns of the recurrent branch

of the median nerve should be kept in mind during operative exploration of hand lacerations with loss of thenar

muscle function.

The Transretinacular Pattern

The transretinacular pattern of the recurrent motor branch,

in which the recurrent branch penetrates the transverse

carpal ligament, is the second most common pattern, and is

potentially problematic. The motor branch that travels in

the ligament is at risk for injury when the ligament is transected during carpal tunnel release. Injury to the nerve with

this pattern can be minimized by an appreciation of the

anatomy, as well as by transection of the transverse carpal

ligament carried out toward the ulnar side of the canal.

When the transligamentous pattern is encountered during

carpal tunnel release, the nerve branch should be decompressed throughout its tunnel through the ligament. This

pattern has been thought to be potentially responsible for

carpal tunnel syndrome that presents with more motor or

even pure motor dysfunction, compared with sensory

abnormalities (6,188).

Palmar Ulnar–Median Communicating Branch

of Berrettini

The communicating sensory branch between the ulnar and

median nerves (palmar ulnar–median communicating

branch of Berrettini; see earlier) may course between the

nerves just distal to the transverse carpal ligament

(70,157). It is vulnerable to injury during carpal tunnel

release or palmar exploration for operative procedures such

as flexor tendon repair or partial palmar fasciectomy for

Dupuytren’s contracture, especially along the axis of ring

finger ray (36).

Common and Proper Digital Nerves and

Arteries

During nerve and artery exploration in the palm or digits,

an appreciation of the relationship between the common

and proper digital nerves and arteries is emphasized. In the

palm, the median nerve branches usually are located deep to

the associated arterial structures. These nerve branches pass

3 Nerve Anatomy 199

deep to the superficial palmar arterial arch and usually pass

deep to the common digital arteries as the nerves and arteries course distally. At the approximate level of the

metacarpal necks, the nerves course more palmarly, and

come to lie palmarly at the base and along the digits. In the

digits, the digital nerves are palmar to the digital arteries.

Thus, it is possible (and not uncommon) to encounter a

clinical situation where both digital nerves are lacerated in

the digit, but the digit remains vascularized. The deeperlying arteries are more protected, and can therefore more

often survive penetrating trauma.

All Ulnar Nerve–Innervated Hand

In the all ulnar nerve–innervated hand, there is absence

of a thenar branch from the median nerve. With a complete median nerve laceration at the wrist, operative

exploration reveals only a small median nerve in the

carpal tunnel. The only deficit noted may be loss of sensibility to the palmar aspect of the index finger. The ulnar

nerve provides the remaining motor and sensory fibers

(6).

ULNAR NERVE

Origin of the Ulnar Nerve

The ulnar nerve arises from the medial cord of the brachial

plexus, and is composed of fibers from the anterior rami of

C8, and T1 (1–4,11) (see Fig. 3.1).

Ulnar Nerve in the Axilla and Arm

At the level of the pectoralis minor muscle, the medial

cord divides into two branches. One branch courses

slightly laterally to join a branch from the lateral cord to

form the median nerve. The other branch of the medial

cord continues distally to form the ulnar nerve (see Fig.

3.1). In the axilla and arm, the ulnar nerve remains the

most medially positioned major nerve. In the axilla, the

ulnar nerve is medial and adjacent to the axillary artery.

The axillary vein is located medial to the ulnar nerve. At

the inferior border of the subscapularis muscle, the ulnar

nerve may receive additional fibers of the C7 nerve root

through the “lateral root of the ulnar nerve” (189). This

supplemental nerve arises from either the lateral cord or

middle trunk (8). The ulnar nerve continues distally from

the medial cord deep (posterior) to the pectoralis minor

and pectoralis major and anterior to the subscapularis,

latissimus dorsi, and teres major. Along this course, it

remains medial or posteromedial to the axillary artery and

subsequent brachial artery. At the inferior border of the

pectoralis major, the ulnar nerve continues and diverges

medially from the brachial artery (as the artery courses

slightly anteriorly). The ulnar nerve pierces the medial

intermuscular septum approximately 8 cm proximal to the

medial epicondyle (13). As the nerve passes from the anterior compartment to the posterior compartment through

the medial intermuscular septum, it passes deep to the

arcade of Struthers, if present (see later, under Anomalies

and Variations: Ulnar Nerve in the Axilla and Arm). In

this vicinity, the brachial artery gives off the superior ulnar

collateral artery, which also pierces the medial intermuscular septum and continues distally along with the nerve.

The nerve remains to the medial aspect of the superior

ulnar collateral artery. Both nerve and artery continue distally and medially on the anterior surface of the medial

head of the triceps muscle. The artery is then joined by a

branch of the inferior ulnar collateral artery at the medial

supracondylar ridge. These arteries continue in close proximity to the nerve as the nerve enters the interval between

the medial epicondyle of the humerus and the olecranon.

The nerve passes into the ulnar groove on the dorsal

aspect of the medial epicondyle. The ulnar nerve does not

normally innervate any muscles of the arm, although a

muscular branch to the flexor carpi ulnaris may branch

from the ulnar nerve proper 1 cm proximal to the medial

epicondyle (189) (Table 3.2 and Fig. 3.3).

The Medial Antebrachial Cutaneous Nerve

The medial antebrachial cutaneous nerve (medial cutaneous nerve of the forearm) is a sensory nerve with several

branches that innervates the medial forearm (discussed in

detail later, under Medial Antebrachial Cutaneous Nerve;

Fig. 3.4). It is mentioned here because of its close anatomic

200 Systems Anatomy

TABLE 3.2. ORDER OF INNERVATION OF MUSCLES

SUPPLIED BY THE ULNAR NERVE

Muscle

Flexor carpi ulnaris

Flexor digitorum profundus

Abductor digiti minimi

Flexor digiti minimi

Opponens digiti minimi

Fourth web space interossei

Third web space interossei

Second web space interossei

Fourth lumbrical

Third lumbrical

Adductor pollicis (oblique head)

Adductor pollicis (transverse head)

First web space interosseous

From Sunderland S, Ran LJ. Metrical and non-metrical features of

the muscular branches of the median nerve. J Comp Neurol 85:191,

1946.

3 Nerve Anatomy 201

FIGURE 3.3. Schematic illustration of the ulnar nerve and associated branches and innervated

muscles.

202 Systems Anatomy

FIGURE 3.4. Cutaneous nerves of the upper extremity. A: Anterior aspect.

A

3 Nerve Anatomy 203

FIGURE 3.4 (continued). B: Posterior aspect.

B

proximity to the ulnar nerve. The medial antebrachial cutaneous nerve originates from the lower trunk or medial cord

of the brachial plexus, just proximal to the actual origin of

the ulnar nerve (190). It contains fibers from C8 and T1. In

the axilla, the nerve runs with the ulnar nerve between the

axillary artery and vein. A small branch leaves the nerve to

supply the skin over the biceps muscle and the elbow flexion crease (along with branches of the medial cutaneous

nerve of the arm, discussed in further detail later) (191).

The medial antebrachial cutaneous nerve descends along

the medial surface of the brachial artery. It pierces the antebrachial fascia in the middle third of the arm with the

basilic vein. The nerve divides into anterior and posterior

branches approximately 15 cm proximal to the medial epicondyle. The anterior branch passes anterior to the median

cubital vein between the medial epicondyle and biceps tendon, and innervates the mediopalmar skin of the forearm

(Fig. 3.4A-B). The terminal branches join the palmar cutaneous branches of the ulnar and median nerves in the hand.

The posterior branch of the medial cutaneous nerve of the

forearm often crosses the ulnar nerve from approximately 6

cm distal to the medial epicondyle. It descends along the

medial side of the basilic vein, supplying the dorsomedial

skin of the forearm. Distally, the nerve joins the dorsal cutaneous branch of the ulnar nerve (189,190) (Fig. 3.4A-B).

Anomalies and Variations: Ulnar Nerve in

the Axilla and Arm

The ulnar nerve normally originates from the medial cord

of the brachial plexus. It may, however, receive fibers from

several other sources, including the lateral cord, the middle

trunk, and the anterior division of the middle trunk. These

neural elements are collectively referred to as the lateral root

of the ulnar nerve. The lateral root of the ulnar nerve joins

the ulnar nerve proper at or distal to the inferior border of

the subscapularis muscle. The lateral root nerve fibers may

provide innervation to the flexor carpi ulnaris (8).

Arcade of Struthers

As the ulnar nerve passes from the anterior to the posterior

muscle compartment of the arm, it may encounter a myofibrous or fasciomyofibrous tunnel, the arcade of Struthers.

This common structure, first described by Struthers in

1854 (18), should not be confused with the rare (1%) unrelated anatomic structure, the ligament of Struthers (which

is seen in association with a supracondylar process and can

result in median neuropathy in the arm; see earlier, under

Median Nerve in the Axilla and Arm). The arcade of

Struthers is common, and has been shown to occur in 70%

of specimens (192,193). The arcade of Struthers is a fibrous

or fascial sheet located in the distal third of the medial

aspect of the humerus. When the arm is in the anatomic

position, the roof of the arcade faces medially. It is formed

by a thickening of the deep investing fascia of the distal part

of the arm, by superficial muscular fibers of the medial head

of the triceps, and by attachments of the internal brachial

ligament (6). (The internal brachial ligament is a relatively

long, longitudinal ligament originating from the region of

the coracobrachialis tendon.) The anterior border of the

arcade of Struthers is the medial intermuscular septum. The

lateral border of the arcade is formed by the medial aspect

of the humerus covered by deep muscular fibers of the

medial head of the triceps. Spinner has noted that the presence of the arcade of Struthers should be suspected if, at the

time of operative exposure of the proximal portion of the

ulnar nerve, the muscle fibers of the medial head of the triceps are seen crossing obliquely, superficial to the nerve.

This is in the area where the nerve traverses from the anterior to posterior compartment. When no muscular fibers

can be seen crossing the ulnar nerve approximately 5 to 7

cm proximal to the medial epicondyle, the arcade probably

is not present (193). The arcade of Struthers may be a

potential area of ulnar nerve compression. If decompression

or transposition of the ulnar nerve is performed, awareness

of this structure is important for through decompression.

Compression of the ulnar nerve can occur above the elbow

at the arcade at the level of the medial epicondylar groove,

or distally as the nerve passes between the ulnar and

humeral heads of the flexor carpi ulnaris (17,78,193).

The First Branch

The first branch of the ulnar nerve usually originates in

the cubital tunnel. However, variation in the articular

and first muscular branches is common. The articular

branch, normally the first branch of the nerve, exits from

the main trunk in the ulnar groove and passes horizontally into the joint. One or several articular branches may

originate in the arm, up to approximately 1 cm proximal

to the medial epicondyle. The first muscular branch, usually to the flexor carpi ulnaris, usually exits immediately

distal to the articular branch. However, division as high

as 4 cm proximal to the medial epicondyle has been

reported (189,194).

The Medial Antebrachial Cutaneous Nerve

and the Ulnar Nerve

The medial antebrachial cutaneous nerve may arise from

several slightly different points. It usually arises from the

medial cord of the brachial plexus, just proximal to the origin of the ulnar nerve. It usually arises just distal to the origin of the medial brachial cutaneous nerve, which is the

smallest branch of the brachial plexus (194) (see Fig. 3.1).

The medial antebrachial cutaneous nerve also may arise

from the lower trunk of the brachial plexus, from the first

thoracic nerve root (T1), or from the ulnar nerve itself. The

medial antebrachial cutaneous nerve commonly communi204 Systems Anatomy

cates with the intercostobrachial nerve in the axilla and the

medial cutaneous nerve of the arm proximally (195).

Clinical Correlations: Ulnar Nerve in the

Axilla and Arm

Arcade of Struthers

During exploration of the ulnar nerve at the elbow for

neuropathy, awareness of the possible presence of an

arcade of Struthers is important because this may be a

potential area of nerve compression (see earlier). The

nerve should be explored proximally to the level of where

the nerve passes from the anterior to posterior compartments. Muscle fibers of the medial head of the triceps

that cross obliquely superficial to the nerve usually indicate the presence of an arcade of Struthers. If present, the

fascial sheet of the arcade of Struthers should be incised.

If the nerve is transposed anteriorly, it should be confirmed that an arcade of Struthers is not present or is not

causing tethering or compression of the proximal aspect

of the transposed nerve.

The Arcade and the Ligament of Struthers

The arcade of Struthers should not be confused with the

ligament of Struthers. The arcade of Struthers, present in

approximately 70% of studied specimens, is located at the

medial intermuscular septum, and can cause compression

of the ulnar nerve. The ligament of Struthers, in contrast, is

rare, occurring in only 1%, and consists of a ligament or

extension of the pronator teres muscle from the medial epicondyle to an (anomalous) supracondylar process. The ligament of Struthers is a possible site of compression of the

medial nerve (6,17,18,20–22,78,192).

Ulnar Nerve in the Elbow and Forearm

Ulnar Nerve in the Cubital Tunnel

The cubital tunnel at the elbow is a fibroosseous tunnel

(189,196,197). The lateral border consists of the humerus,

ulna, and elbow joint. The medial and inferior border consists of a fascial sheath confluent with the brachial and antebrachial fascia of the adjacent muscles. The distal medial

border consists of the aponeurosis or fascia between the two

heads of the flexor carpi ulnaris (6,17,78). As noted by

Siegel and Gelberman, the tunnel can be divided geographically into three parts (189).

Ulnar Nerve in the First Part of the Cubital Tunnel

The first part of the cubital tunnel is the entrance of the tunnel, formed by the ulnar groove in the medial epicondyle. At

this entrance, the ulnar nerve lies in the extensor side of the

arm. In the first part, the ulnar nerve usually provides one

branch or several small articular branches to the elbow joint.

These branches usually are proximal to the branches given

off to innervate the flexor carpi ulnaris (189).

Ulnar Nerve in the Second Part of the Cubital Tunnel

The second and middle part of the tunnel consists of a fascial arcade. (This arcade should not be confused with the

arcade of Struthers, which is a separate fascial arcade located

more proximally in the arm; see earlier.) The fascial arcade

of the second part of the cubital tunnel attaches to the

medial epicondyle and to the olecranon. It connects the

ulnar and humeral heads of the origin of the flexor carpi

ulnaris muscle. In this area, the nerve crosses the medial

surface of the elbow. It lies on the posterior and oblique

portions of the ulnar collateral ligament. The nerve usually

gives off two branches to innervate the flexor carpi ulnaris.

One branch usually supplies the humeral head and one supplies the ulnar head. The first branch exits the main nerve

trunk horizontally. The second branch continues distally for

several centimeters before entering the flexor carpi ulnaris.

Up to four motor branches to the flexor carpi ulnaris may

be given off, exiting the main nerve at a point between 4 cm

proximal and 10 cm distal to the medial epicondyle (13).

The motor branches enter the flexor carpi ulnaris on its

deep surface. The first motor branch of the flexor carpi

ulnaris divides in 5% of limbs to supply the flexor digitorum

profundus as well (63) (see Table 3.2). In the second portion

of the cubital tunnel, the distance between the medial

humeral epicondyle and the olecranon is shortest with elbow

extension. This distance increases with elbow flexion (198).

The roof of the cubital tunnel is formed by the fascial

arcade, which becomes taut with elbow flexion (189).

Ulnar Nerve in the Third Part of the Cubital Tunnel

The third and most distal part of the tunnel consists of the

muscle bellies of the flexor carpi ulnaris. The flexor carpi

ulnaris provides a portion of the roof in this area. Although

the ulnar nerve enters the cubital tunnel on the extensor

side of the arm (in the first part of the tunnel), it comes to

lie on the flexor surface on exiting the tunnel in the third

part. The nerve courses through the interval between the

humeral and ulnar heads of the flexor carpi ulnaris or

between the flexor carpi ulnaris and flexor digitorum profundus muscles (189).

The volume of the tunnel decreases with elbow flexion,

and the pressure within it increases, even in the normal

elbow when the aponeurotic arch or surrounding soft tissues are not thickened.

The nerve then continues distally in the forearm

between the flexor digitorum profundus, located dorsally

and laterally to the nerve, and the flexor carpi ulnaris,

located anteriorly and medially. The nerve maintains this

relationship with the muscles through the proximal to middle forearm. In general, the nerve runs a straight course

through the forearm from the level of the medial epicondyle

of the distal humerus to the pisiform–hamate groove in the

3 Nerve Anatomy 205

carpus. In the distal third of the forearm, the ulnar nerve

courses more superficially, lying just radial and deep (dorsal) to the flexor carpi ulnaris muscle (6,189).

Motor Branches of the Ulnar Nerve in the

Forearm

In the forearm, and distal to the exit of the motor branches

to the flexor carpi ulnaris, the ulnar nerve usually has three

additional main branches. These are (a) the motor branch

to the flexor digitorum profundus (to the ring and small

fingers), (b) the palmar cutaneous portion of the ulnar

nerve, and (c) the dorsal branch of the ulnar nerve

(189,199).

Motor Branch to the Flexor Digitorum Profundus (to

the Ring and Small Fingers)

The motor branch to the flexor digitorum profundus from

the ulnar nerve usually innervates the ulnar half of the muscle, which includes the muscle bellies to the ring and small

fingers. (The anterior interosseous nerve from the median

nerve usually innervates the radial half of the flexor digitorum profundus, including the muscle bellies to the long

and index fingers, as well as the flexor pollicis longus.) The

motor branch from the ulnar nerve is located proximally in

the forearm. It arises approximately 3 cm distal to the

medial epicondyle and usually exits the ulnar nerve trunk

just distal to the branches to the flexor carpi ulnaris. The

motor branch passes distally for approximately 2.5 cm, usually lying on the anterior surface of the flexor digitorum

profundus (1–4,11,13,189,191). It then enters the muscle

at approximately 6 cm distal to the medial epicondyle (6),

whereas the anterior interosseous nerve enters the flexor

digitorum profundus to the index and long fingers approximately 4 to 7 cm more distally (6). In 80% of upper limbs,

a single branch from the ulnar nerve supplies the flexor digitorum profundus. In approximately 20%, two or more

branches supply the muscle. There may not be a direct

branch from the main ulnar nerve trunk that supplies the

flexor digitorum profundus. In these specimens, the flexor

digitorum profundus may by innervated by the branch of

the ulnar nerve to the flexor carpi ulnaris or by a branch

from the median nerve.

In the forearm, the ulnar nerve lies medial and adjacent

to ulnar artery.

Traditionally, the ulnar nerve is described as innervating

the flexor digitorum profundus to the ring and small fingers, and the anterior interosseous nerve from median nerve

is described as innervating the flexor digitorum profundus

to the index and long fingers. This pattern, however, has

been noted actually to comprise only 50% of upper limbs

(32). In several studied specimens, the median nerve or

derived branches was found to innervate the flexor digitorum to the ring and little fingers. In addition, the ulnar

nerve was found occasionally to supply the flexor digitorum

profundus to the long finger (32,189). The flexor digitorum profundus to the index finger, however, does seem to

be innervated consistently by the median nerve.

Sympathetic Fibers from the Ulnar Nerve in

the Forearm

In the middle forearm, the ulnar nerve supplies the accompanying ulnar artery with a segmental sympathetic nerve.

This is the nerve of Henle (200–202) (Fig. 3.3).

Palmar Cutaneous Branch of the Ulnar Nerve

The palmar cutaneous branch of the ulnar nerve is not as

consistent as its median nerve counterpart, the palmar cutaneous branch of the median nerve. When present, the palmar cutaneous branch of the ulnar nerve arises at variable

levels from the ulnar nerve in the distal forearm, usually in

the vicinity of the junction of the middle and distal thirds

of the forearm. It courses distally on or in the epineurium

of the ulnar nerve on the palmar surface of the ulnar artery.

The nerve then perforates the antebrachial fascia just proximal to the distal wrist flexion crease, and innervates the

skin in the hypothenar eminence, the ulnar artery, and,

occasionally, the palmaris brevis muscle (6) (see Figs. 3.3

and 3.4A).

Dorsal Cutaneous Branch of the Ulnar Nerve

The dorsal cutaneous branch of the ulnar nerve arises from

the medial aspect of main ulnar nerve trunk in the distal

forearm and curves dorsally to supply cutaneous innervation to the dorsal aspect of the small finger and ulnar ring

finger (199,203,204) (see Fig. 3.4B). Its point of origin is

an average of 6.4 cm from the distal aspect of the head of

the ulna and 8.3 cm from the proximal border of the pisiform. The cross-sectional shape of the nerve at its origin

usually is round or slightly oval, with a mean diameter of

approximately 2.4 mm. The point of nerve origin corresponds to a point located at the distal 26% of the total

length of the ulna (199). The nerve extends distally and

medially, passing dorsal to the flexor carpi ulnaris, and

pierces the deep antebrachial fascia. The nerve emerges at

the dorsomedial border of the flexor carpi ulnaris at a mean

distance of 5 cm from the proximal edge of the pisiform. At

this point, the nerve pierces the deep antebrachial fascia to

become subcutaneous on the medial aspect of the distal

forearm. Proximal to the wrist, the nerve provides two to

three branches. A branch piercing the capsule of the ulnocarpal joint usually is present. With the forearm in supination, the nerve branch passes along and close to the medial

aspect of the head of the ulna near the widest diameter of

the ulnar head (equator of the ulnar head). With the fore206 Systems Anatomy

arm pronated, the nerve branches displace slightly palmarly

to pass along the palmoulnar aspect of the ulnar head. In

the hand, an additional one or two branches usually are

given off. The total number of branches averages five, with

a range from three to nine. Two branches typically extend

to the small finger, one to the dorsoulnar aspect of the ring

finger, and one or two branches to the dorsoulnar aspect of

the carpus and hand. The diameters of the branches range

from 0.7 to 2.2 mm (199). The branches of the dorsal

branch of the ulnar nerve continue to the level of the proximal interphalangeal joints, where the nerves arborize and

become difficult to trace. There are no apparent further

communications between the dorsal branch of the ulnar

nerve and the ulnar nerve proper, with the palmar cutaneous branch of the ulnar nerve, or with the nerve of Henle

(200).

In the proximal forearm, the posterior ulnar recurrent

artery, which arises from the ulnar artery close to the bifurcation of the radial artery, courses ulnarly and proximally to

continue in proximity to the ulnar nerve and motor

branches to the flexor digitorum profundus, along the ulnar

border of the nerves (1–4,11).

The superior ulnar artery accompanies the ulnar nerve

into the cubital tunnel. In the cubital tunnel, the superior

ulnar collateral artery joins the posterior ulnar recurrent

artery to form one of the vascular collateral pathways

around the elbow and bypassing the distal portion of the

brachial artery (1,4).

In the region of the junction of the proximal and middle

thirds of the forearm, the ulnar artery joins the ulnar nerve

and continues on the radial aspect of the nerve. This relationship is maintained as the nerve and artery emerge from

the radial edge of the flexor carpi ulnaris tendon, coursing

slightly radial to pass radial to the pisiform and enter

Guyon’s canal at the wrist.

Anomalies and Variations: Ulnar Nerve in

the Elbow and Forearm

Anomalous Connections between the Ulnar

and Median Nerve

In the distal forearm, a crossing of nerve fibers from the

ulnar nerve to the median nerve can occur, although with

less frequency than the more common crossing of fibers in

the opposite direction from median nerve or anterior

interosseous nerve to ulnar nerve (the Martin-Gruber anastomosis). These anomalous connections between the ulnar

nerve and median nerve in the forearm are discussed in

detail earlier, under Nerve Anomalies and Variations:

Median Nerve in the Forearm. In general, from the elbow

to the wrist, the ulnar nerve shows relatively few anomalies

or deviations from its normal course. The division of its

branches is relatively consistent.

Variations in Innervation of the Flexor Carpi

Ulnaris

The flexor carpi ulnaris usually receives two or three motor

branches. Up to five branches have been noted (6). In isolated case reports, the flexor carpi ulnaris was found to have

a motor branch from the median nerve (6).

Variations in Innervation of the Flexor

Digitorum Profundus Muscle

Variations in the innervation of the flexor digitorum profundus muscle have been reported (205). Traditionally, the

ulnar nerve is thought to innervate the flexor digitorum

profundus to the ring and small fingers, and the median

nerve innervates the index and long fingers. However, this

pattern was found in only 50% of upper limbs (32). In several specimens, the median nerve was found to innervate

the ring and little fingers and the ulnar nerve was found to

supply the long finger (32,189). It is more common for the

median nerve to innervate muscles traditionally supplied by

the ulnar nerve than for the ulnar nerve to innervate muscles usually supplied by the median nerve (32,35,63). This

may occur in the all–median nerve hand.

Many of the variations in branching occur in the muscle

belly of the flexor digitorum profundus, and therefore are

difficult to identify by superficial visualization and examination of the muscle. The flexor digitorum profundus to

the index finger, however, does seem to be innervated most

consistently by the median nerve. Sunderland has noted

only one case in which the flexor digitorum profundus to

the index finger was innervated by the ulnar nerve (44).

Sensory Variations of the Dorsal Branch of the

Ulnar Nerve in the Forearm

The dorsal branch of the ulnar nerve usually arises from the

ulnar nerve trunk at approximately 6 to 8 cm from the wrist

joint (mean distance of 6.4 cm from the distal aspect of the

head of the ulna and 8.3 cm from the proximal border of

the pisiform) (199). Several variations can occur. The

branch may arise from the ulnar nerve as far proximal as the

elbow and continue subcutaneously along the entire length

of the forearm (206). Alternatively, an entire nerve loop has

been noted to form around the pisiform between the ulnar

nerve and a branch from the dorsal cutaneous nerve. This

branch of the dorsal cutaneous nerve appeared to contribute additional fibers to the ulnar digital nerve to the

small finger (207).

Absence of the Dorsal Cutaneous Branch of

the Ulnar Nerve

In 1 of 24 specimens, the dorsal branch of the ulnar nerve

was found to be absent (199). With complete absence of the

3 Nerve Anatomy 207

dorsal cutaneous branch of the ulnar nerve, sensibility to

the dorsum of the ulnar hand can be supplied by the superficial radial nerve (208), the musculocutaneous nerve (6), or

the posterior cutaneous nerve of the forearm.

Ulnar Nerve Compression by Anomalous

Anconeus Epitrochlearis

The ulnar nerve may be compressed at the elbow by an

anomalous muscle, the anconeus epitrochlearis. The

anconeus epitrochlearis originates from the medial border

of the olecranon and adjacent triceps tendon and inserts

into the medial epicondyle of the elbow. The muscle

appears as an auxiliary extension of the medial portion of

the triceps. The muscle crosses the ulnar nerve posterior to

the cubital tunnel. When present, it forms a portion of the

cubital tunnel, reinforcing the aponeurosis of the two heads

of the origin of the flexor carpi ulnaris (6).

The Posterior Cutaneous Nerve

The posterior cutaneous nerve of the forearm usually is a

branch of the radial nerve. Rarely, the posterior cutaneous

nerve may arise from the ulnar nerve (189).

Clinical Correlations: Ulnar Nerve in the

Elbow and Forearm

The ulnar nerve is at risk for compression or stretch at the

cubital tunnel of the elbow. Panas in 1878 described a condition now known as tardy ulnar palsy (209). Several

anatomic and mechanical etiologic factors have been

described (6,17,78,189,208,210–218) (Table 3.3).

Neuropathy of the ulnar nerve as it passes through the

cubital tunnel posterior to the medial epicondyle of the

humerus may be associated with recurrent dislocation of

the nerve. This condition was described by Collinet in

1896, followed by reports by Cobb and Momberg (both in

1903) (219–221).

In 1926, Platt discussed the pathogenesis of neuritis of

the ulnar nerve in the cubital tunnel, specifically in the

postcondylar groove (79,215).

The ulnar nerve also is subject to compression in the

cubital tunnel by the overlying fascia at the level of the

medial condyle, as well as by the fascia between the heads

of the flexor carpi ulnaris and in the muscle itself

(222–225). Spinner has suggested that the most common

cause for an idiopathic type of ulnar nerve paralysis is

entrapment of the nerve at the distal cubital tunnel where

the ulnar nerve enters the forearm posteriorly between the

two heads of the flexor carpi ulnaris. A fascial connection is

present between the two, and the proximal edge may at

times be thickened and act as a compressing band (6).

In the cubital tunnel, an articular branch (or branches)

is (are) usually given off by the ulnar nerve, followed by a

motor branch to the flexor carpi ulnaris (which exits the

nerve trunk just distal to the articular branch). Appreciation

of these two nerves and their respective functions and destinations is relevant for ulnar nerve exploration in the

cubital tunnel. In performing an anterior transposition of

the ulnar nerve, the articular branch in the cubital tunnel

may tether the nerve trunk and prevent mobilizing the

ulnar nerve for transposition. This branch often is sacrificed

to allow anterior mobilization of the nerve, and causes minimal morbidity. Occasionally, a branch to the flexor carpi

ulnaris also is a limiting structure to anterior transposition.

Obviously, protection and preservation of this nerve is optimal because morbidity may be substantial if the flexor carpi

ulnaris has no additional motor nerves and becomes denervated by sacrifice of the motor branch. To mobilize the

ulnar nerve, distal nerve dissection and mobilization to

allow transposition is preferred over sacrifice of the motor

branch of the flexor carpi ulnaris.

With elbow flexion, the cubital tunnel decreases in volume and the aponeurosis becomes taut over the ulnar nerve

(196,198,213,214,226). During elbow flexion, the nerve

stretches and elongates approximately 4.7 mm. During flexion, the medial head of the triceps has been noted to push

the ulnar nerve anteromedially 0.73 cm (227). When there

is fixation of the nerve, a traction neuritis can develop (6).

The ulnar nerve may be compressed at the elbow by an

anomalous muscle, the anconeus epitrochlearis (6). The

anconeus epitrochlearis is a muscle variant that originates

from the medial border of the olecranon and adjacent triceps tendon and inserts into the medial epicondyle of the

elbow. The muscle appears as an auxiliary extension of the

medial portion of the triceps. The muscle crosses the ulnar

nerve posterior to the cubital tunnel. When present, it

forms a portion of the cubital tunnel, reinforcing the

aponeurosis of the two heads of the origin of the flexor carpi

ulnaris (6). It has been found to be a factor in producing

208 Systems Anatomy

TABLE 3.3. ANATOMIC AND MECHANICAL

FACTORS CONTRIBUTING TO CUBITAL TUNNEL

SYNDROME

Idiopathic

Ganglion

Anomalous muscle (anconeus epitrochlearis)

Arcade of Struthers

Hypertrophic arthritis

Fracture malunion, nonunion

Fracture callus

Traumatic heterotopic ossification

Neurogenic heterotopic ossification

Cubitus valgus

Rheumatoid synovitis of elbow joint

Supracondylar process

Translocation, subluxation, or snapping of the triceps

Translocation, subluxation, or dislocation of ulnar nerve

Trauma (contusion, stretch, friction, repetitive traction)

ulnar compressive neuritis posterior to the elbow. Excision

of the muscle mass without translocation of the nerve has

relieved symptoms when it was the single factor in the

pathogenesis (6).

The flexor carpi ulnaris was found, in an isolated case, to

have a motor branch from the median nerve (6). With this

variant, weak action of the muscle could be observed when

a complete high ulnar lesion was present (6).

The flexor carpi ulnaris sometimes may receive an additional inconsistent motor branch from the ulnar nerve in

the mid-forearm.

Compression of the Dorsal Cutaneous Branch

of the Ulnar Nerve

The dorsal cutaneous branch of the ulnar nerve is vulnerable to compression by external pressure in individuals who

write with their left hand. Often, these individuals write

with the ulnar border of the wrist against the firm writing

surface. If the dorsal cutaneous branch of the ulnar nerve

passes from its volar position to the dorsum of the hand

over the prominence of the distal ulna, external pressure can

cause symptoms of pain in the wrist and numbness of the

dorsoulnar aspect of the hand (6).

Absence of the Dorsal Cutaneous Branch of

the Ulnar Nerve

Complete absence of the dorsal cutaneous branch of the

ulnar nerve can occur (see earlier, under Anomalies and

Variations: Ulnar Nerve in the Elbow and Forearm). Sensibility to the dorsoulnar hand can then be supplied by the

superficial radial nerve (208), by a dorsal division of the

musculocutaneous nerve (6), or by the posterior cutaneous

nerve of the forearm. With this variation, an injury or lesion

of the ulnar nerve at the elbow does not produce sensory

loss of the dorsum of the hand, but presents with sensory

findings similar to those of a low ulnar nerve lesion. This

variation should be suspected if electromyographic localization of the nerve lesion is at the elbow when clinical findings suggest a lesion at the wrist (6). The presence of this

variation can be evaluated by local anesthetic block of the

superficial radial nerve or the musculocutaneous nerve,

which produces anesthesia over the dorsoulnar hand.

Ulnar Nerve at the Wrist and Hand

Ulnar Nerve in the Ulnar Tunnel

The ulnar nerve and ulnar artery enter the ulnar tunnel

(Guyon’s canal) at the wrist. The artery usually is located

radial to the nerve (228). The nerve and artery pass radial

to the pisiform, anterior (superficial) to the transverse

carpal ligament (flexor retinaculum), and dorsal to the

superficial palmar carpal ligament. The ulnar nerve divides

into deep terminal and superficial palmar branches at the

base of the hypothenar eminence.

The ulnar nerve extends approximately 4 cm in its path

through the ulnar tunnel. The tunnel originates at the proximal edge of the palmar carpal ligament and extends distally

to the fibrous arch of the hypothenar muscles. The tunnel

has been described in terms of having a floor (dorsal surface), a roof (palmar surface), and two walls (medial and lateral). The boundaries change from proximal to distal, and

the four walls are not distinct through the entire course.

The roof of the tunnel is composed of the palmar carpal ligament, the palmaris brevis, and hypothenar fat and fibrous

tissue. The floor of the tunnel consists of tendons of the

flexor digitorum profundus, the transverse carpal ligament,

the pisohamate and pisometacarpal ligaments, and the

opponens digiti minimi. The medial wall consists of the

flexor carpi ulnaris, the pisiform, and the abductor digiti

minimi. The lateral wall is composed of the tendons of the

extrinsic flexors, the transverse carpal ligaments, and the

hook of the hamate (229,230). The distal ulnar tunnel has

been divided in three zones based on topography of the

nerve and its relationship to the surrounding structures

(230). Zone I consists of the portion of the tunnel proximal

to the bifurcation of the ulnar nerve. Zone II encompasses

the deep motor branch of the nerve and surrounding structures. Zone III includes the superficial branch and adjacent

distal and lateral tissues.

Ulnar Nerve in Zone I of the Ulnar Tunnel

In zone I, the nerve continues for approximately 3 cm,

stretching from the proximal edge of the palmar carpal ligament to the nerve’s bifurcation. The palmar carpal ligament, lying superficial (anterior to the ulnar nerve), is actually a thickening of the superficial forearm fascia that

becomes distinct approximately 2 cm proximal to the pisiform. The ligament arises ulnarly from the tendon of the

flexor carpi ulnaris and inserts radially on the palmaris

longus tendon and the transverse carpal ligament, forming

the roof (palmar surface of the proximal part of zone I). The

ulnar nerve, along with the ulnar artery, passes deep to the

palmar carpal ligament to enter the ulnar tunnel. At this

level, the ulnar artery lies slightly superficial and radial to

the nerve. The deep (dorsal) surface of zone I consists of

tendons of the flexor digitorum profundus and the ulnar

portion of the transverse carpal ligament. The lateral wall is

formed by the most distal fibers of the palmar carpal ligament, which curve radially and posteriorly to wrap around

the neurovascular bundle and merge with the fibers of the

transverse carpal ligament. The pisiform and tendon of the

flexor carpi ulnaris comprise the medial wall of the tunnel

at this level (229,230). Distal to the palmar carpal ligament,

the roof of the ulnar tunnel consists of the palmaris brevis

muscle. This muscle originates from the distal palmar

aspect of the pisiform and hypothenar muscle fascia and

inserts on the ligament. The length of the palmaris brevis

3 Nerve Anatomy 209

from the proximal to distal border is approximately 2.5 cm

(229,230). In this area, deep to the palmaris brevis, the

ulnar nerve bifurcates into the deep motor branch and the

superficial branch of the ulnar nerve. The point of nerve

branching is approximately 1 cm distal to the proximal edge

of the pisiform. Three to 7 mm distal to the bifurcation of

the nerve, the ulnar artery divides into two branches. The

larger of the arterial branches accompanies the superficial

branch of the nerve and becomes the superficial palmar

arch. The smaller arterial branch continues with the motor

branch into the deep space of the palm and terminates in

the deep palmar arch. Both arteries remain superficial and

radial to the nerves they accompany (230). The distal extent

of zone I terminates at the level of the bifurcation of the

ulnar nerve. At this level, the roof of the tunnel is formed

by the palmaris brevis and the floor formed by the pisohamate and pisometacarpal ligaments. The pisohamate ligament arises from the distal, radial, and dorsal aspects of the

pisiform and inserts on the proximal, ulnar, and palmar

aspects of the hook of the hamate. Ulnar to the pisohamate

ligament, the pisometacarpal ligament arises from the distal

aspect of the pisiform and inserts on the palmar radial

aspect of the base of the fifth metacarpal. The divergence of

these ligaments leaves an opening in the floor of the tunnel

that is filled with fibrofatty tissue overlying the capsule of

the triquetrohamate joint (229,230).

In zone I, the ulnar nerve carries both motor and sensory

fibers. The nerve fibers are arranged in two distinct groups

of fascicles. The palmar-radial fibers contain the fascicles

that become the superficial branch of the ulnar nerve,

whereas the dorsal-ulnar fibers become the deep motor

branch. Thus, in zone I, the ulnar nerve actually is two

nerves contained in a common epineurial sheath

(229–231).

Ulnar Nerve in Zone II of the Ulnar Tunnel

Zone II encompasses the portion of the ulnar tunnel distal

to the bifurcation, in the region where the deep (motor)

branch of the ulnar nerve passes. This zone usually is

located in the dorsoradial portion of the ulnar tunnel. The

palmar (superficial) aspect of zone II is bordered by the palmaris brevis and the superficial branch of the ulnar nerve.

The lateral border of zone II consists of transverse carpal ligament, which forms a wall that merges with the floor of the

tunnel. The floor of zone II consists of the pisohamate and

the pisometacarpal ligaments. At the distal extent of zone

II, the fibrous arch of the hypothenar muscles lies palmar to

the nerve, the opponens digiti minimi lies posterior, the

hook of the hamate and flexor digiti minimi are located laterally, and the abductor digiti minimi lies on the medial

aspect (230). The deep branch of the ulnar nerve passes

deep to the fibrous arch and between the muscles as it exits

the tunnel. The nerve to the abductor digiti minimi usually

is given off just proximal to its entrance into these muscles.

The motor branch innervates the opponens digiti minimi as

it continues radially and posteriorly around the hook of the

hamate. The nerve then continues deeply across the palm

(229,230). The ulnar artery enters zone II radially and palmarly, just distal to the level of the bifurcation of the nerve.

The artery follows the nerve, lying palmar and slightly

radial. Both structures continue distally and pass deep to

the arch of the origin of the hypothenar muscles. In zone II,

the deep branch of the ulnar carries motor fibers.

Ulnar Nerve in Zone III of the Ulnar Tunnel

Zone III encompasses the portion of the ulnar tunnel distal

to the bifurcation, in the region of the superficial branch of

the ulnar nerve, also referred to as the superficial palmar

branch (189). At the entrance to zone III, the palmaris brevis comprises the palmar boundary, the abductor digiti

minimi comprises the medial border, and the

pisometacarpal ligament and capsule of the triquetrohamate

joint comprise the dorsal border. The lateral and dorsal borders are formed by zone II. As the superficial branch of the

ulnar nerve continues distally, it gives off two small

branches that innervate the palmaris brevis. This occurs

either in the ulnar tunnel or just distal to exiting it

(189,230). Distal to this point, the nerve usually contains

only sensory fibers. The nerve emerges from zone III by

passing over the fibrous arch of the hypothenar muscles.

The ulnar artery continues with the nerve throughout zone

III, remaining superficial and radial to the nerve. At the distal end of the zone, the superficial palmar branch of the

ulnar nerve lies between the hypothenar fascia posteriorly

and the artery and a fibrofatty layer deep to the subcutaneous tissues palmarly (229,230). The superficial palmar

branch in zone III contains mostly sensory fibers along with

motor fibers to the hypothenar muscles. Lesions in this

zone should produce primarily sensory deficits with possible motor weakness of the hypothenar muscles.

Superficial Palmar Branch of the Ulnar Nerve

The superficial palmar branch exits the distal ulnar tunnel

with the superficial terminal branch of the ulnar artery. The

nerve then provides several small twigs to innervate the skin

on the medial side of the hand. The motor branches to the

palmaris brevis may leave the nerve at this point (if not

branched more proximally in the ulnar tunnel). The nerve

continues distally and radially and divides into the proper

digital nerve to the ulnar side of the little finger and the

common palmar digital nerve to the fourth web space. At

the level of the metacarpal shafts, the common digital nerve

divides into two proper digital nerves, one each to supply

adjacent aspects of the fourth web space between the small

and ring fingers (see Fig. 3.3). In the palm, the nerves lie

dorsal to the superficial palmar arch and palmar to the

flexor tendons. Immediately after division, in the region of

the metacarpal necks, the proper digital nerves course anteriorly to lie palmar (superficial) to the digital arteries. The

210 Systems Anatomy

neurovascular bundles are stabilized in the digits by the

retaining skin ligaments, Cleland’s ligaments located dorsal

to the neurovascular bundle, and Grayson’s ligaments

located palmarly. The proper palmar digital nerves supply

the palmar skin of the digits, and the skin distal to the distal interphalangeal joints on the dorsal surface (189).

Deep Terminal Branch of the Ulnar Nerve

The deep terminal branch of the ulnar nerve exits from

zone II of the ulnar tunnel dorsoulnar to the deep terminal

branch of the ulnar artery (1,3,159,232). The nerve passes

medial to the hook of the hamate, deep to the fibrous arch

of the hypothenar muscle origin. The nerve continues

between the abductor digiti minimi and flexor digiti minimi muscles, supplying motor branches to each. The nerve

then pierces and innervates the opponens digiti minimi

(41). The deep branch then crosses the palm with the ulnar

artery (which now forms the deep palmar arch). Along its

course, the nerve is deep to the extrinsic flexor tendons and

deep to the mid-palmar and thenar fascial clefts, but palmar to the interossei (11). At the level of the third

metacarpal, the deep branch of the ulnar nerve and the

deep palmar arch cross between the oblique and transverse

heads of the adductor pollicis. Along its deep course, the

nerve innervates each of the seven interossei, the third and

fourth lumbricals, the adductor pollicis, the flexor pollicis

brevis and the hypothenar muscles (see Table 3.2 and Fig.

3.3). The deep terminal branch provides sensory afferent

nerves to the ulnocarpal, intercarpal, and carpometacarpal

joints (191).

Sympathetic Fibers from the Ulnar Nerve in

the Hand

At the wrist, sympathetic fibers arise from the distal ulnar

nerve and supply the proximal ulnar portions of the

superficial and deep vascular arches of the hand. The

deep vascular arch is segmentally innervated by fibers

from the ulnar nerve and the superficial radial nerve (the

median nerve and the superficial radial nerve also give

segmental supply to the superficial vascular arch in the

palm of the hand) (6).

Anomalies and Variations: Ulnar Nerve in

the Wrist and Hand

The Riche-Cannieu Communication

The Riche-Cannieu communication consists of a communication between the deep terminal branch of the ulnar

nerve and the motor branch of the median nerve (see earlier, under Anomalies and Variations: Median Nerve in the

Wrist and Hand). Because it occurs in 50% to 77% of

hands (194), it can be argued whether this is a normal pattern or a variation. The communication occurs at the terminal portion of the deep branch of the ulnar nerve in the

radial aspect of the palm (41,233). The communicating

fibers pass radially from the deep ulnar branch between the

heads of the adductor pollicis, then pass deep to the flexor

pollicis longus tendon. The fibers continue proximally to

the radial side of the flexor pollicis longus tendon as they

approach the median motor branch. The communication

often occurs in the substance of the flexor pollicis brevis

(41). Through the Riche-Cannieu communication, the

median nerve may innervate the third lumbrical, or, rarely,

all of the lumbrical muscles (35,63). Conversely, the second

lumbrical may be innervated by the ulnar nerve (see earlier

under Anomalies and Variations: Median Nerve in the

Wrist and Hand). There is some question as to whether

there is a crossing of sensory fibers as well (39).

Variations of Innervation of the Flexor Pollicis

Brevis

Considerable variation exists as to the innervation of the

flexor pollicis brevis. Reports have suggested the muscle is

innervated by the ulnar nerve in 50%, the median nerve in

35%, and both in 15%. Each head may receive a different

contribution, with the deep head more commonly innervated by the ulnar nerve and the superficial head more commonly innervated by the median nerve (11).

Variations of Innervation of the Abductor

Pollicis Brevis

The abductor pollicis brevis is innervated by the median

nerve in 95%, the ulnar nerve in 2.5%, and by both nerves

in 2.5% (9,41,189).

Variation of Innervation of the Opponens

Pollicis

The opponens pollicis muscle is innervated by the median

nerve alone in 83%, the ulnar nerve in 10%, and by both

nerves in 7% (153).

Variations in Sensory Innervation of the Ulnar

Nerve Proper in the Hand

Several variations in the sensory innervation of the ulnar

nerve have been noted. Distal to the wrist, the ulnar nerve

proper usually innervates the palmar aspect of the small finger and ulnar aspect of the ring finger. The pattern is variable, and the area of ulnar innervation includes the volar

aspect of the entire ring finger, the ulnar aspect of the long,

or the entire long finger. Conversely, the ulnar nerve may

innervate only the volar aspect of the small finger. The ulnar

supply to the fourth web space (to the space between the

ring and small finger), instead of arising in its usual location

3 Nerve Anatomy 211

at the distal end of the ulnar tunnel, has been observed to

arise in the mid-forearm and continue on an aberrant

course superficial to the transverse carpal ligament and the

palmar aponeurosis (234).

A communicating branch may exist between the superficial branch of the ulnar nerve and the common digital

nerve of the third web space (common digital nerve of the

median nerve to supply adjacent sides of the long and ring

finger). This is a relatively common finding (189,191) and

leads to dual innervation to the adjacent sides of the long

and ring fingers.

Variations in Sensory Innervation of the

Dorsal Cutaneous Branch of the Ulnar Nerve

in the Hand

The dorsal aspect of the hand usually is innervated by the

dorsal branch of the ulnar nerve. However, this area may be

supplied partially or entirely by the radial nerve or by the

posterior cutaneous nerve of the forearm. Complete

absence of the dorsal branch of the ulnar nerve has been

found in 1 of 24 specimens (199). In these cases, the radial

nerve or posterior cutaneous nerve of the forearm supplies

the dorsoulnar hand sensibility. The dorsal branch of the

ulnar nerve may deviate palmarly at the pisiform, join the

superficial (sensory) branch, and supply the palmar surface

of the little finger. A nerve connection may exist between

the dorsal sensory branches of the ulnar nerve and the

superficial radial nerves. This communication between the

dorsal branch of the ulnar nerve and a subcutaneous

branch from the superficial branch of the radial nerve was

observed in 1 of 24 specimens. The communication was

noted on the dorsal aspect of the hand (199). An additional variation is the presence of a third dorsal digital

branch from the ulnar nerve. When present, this branch

from the ulnar nerve supplies the third web space in conjunction with the radial digital nerve, providing dual

innervation (6).

Variations of Division and Recommunication

of the Ulnar Nerve into Deep and Superficial

Branches

Variations exist as to the point of division of the ulnar nerve

into its deep and superficial branches. The deep motor

branch may divide proximal to the hook of the hamate. The

radial division may enter the carpal tunnel (radial to the

hook of the hamate) and rejoin the ulnar division distal to

the hamate (235,236). Less commonly, the deep motor

branch may divide proximal to the pisiform, communicate

with the dorsal sensory branch, or rejoin the nerve distal to

the pisiform. In the event of nerve injury distal to an anomalous division, function is partially preserved. The ulnar

digital nerve to the ring finger may arise in the forearm,

passing superficial to the ulnar tunnel. Similarly, the dorsal

cutaneous branch may arise near the elbow, passing distally

in the subcutaneous tissue to reach the hand (41,189).

An anomalous terminal branch of the ulnar nerve has

been observed at the distal end of Guyon’s canal, which

joined the digital sensory branch to the medial aspect of the

small finger (237,238).

The Ulnar Palmar Cutaneous Nerve

The ulnar palmar cutaneous nerve is not a consistent

branch, as is its adjacent counterpart, the median palmar

cutaneous nerve (6,239) (see Fig. 3.4A). When present, it

arises at variable levels from the ulnar nerve in the distal half

of the forearm.

Clinical Correlations: Ulnar Nerve in the

Wrist and Hand

In zone I of the ulnar tunnel, the ulnar nerve carries both

motor and sensory fibers. A compression or traumatic

lesion in zone I has a high likelihood of producing both

motor and sensory deficits. If the lesion is in zone I, or in

the area just proximal to the entrance of the ulnar tunnel,

the dorsal sensor branch (which exits the ulnar nerve more

proximally in the distal forearm) is spared. Therefore, sensibility to the dorsal aspect of the small and ulnar side of the

ring finger is spared. These findings, of palmar sensibility

loss (to the small and ulnar side of the ring) with intrinsic

motor loss and with sparing of dorsal sensibility, help localize the area of compression or dysfunction (229,240–242).

In zone I of the ulnar tunnel, the ulnar nerve fibers are

arranged in two distinct groups of fascicles, with the palmar-radial fibers containing fascicles that become the superficial branch of the ulnar nerve (mostly sensory fibers),

whereas the dorsal-ulnar fibers become the deep branch

(motor branch). A lesion in zone I that involves the palmarradial aspect or the dorsal-ulnar aspect of the nerve may

involve mostly sensory or mostly motor fibers, respectively,

and thus produce an associated clinical presentation

(229–231).

In zone II of the ulnar tunnel, the deep branch of the

ulnar nerve carries motor fibers. A lesion in zone II should

produce only motor deficits. Conversely, if an occult lesion

or penetrating injury produces only motor loss, zone II

should be suspected as a site of the lesion.

In zone III of the ulnar tunnel, the superficial branch of

the ulnar nerve carries mostly sensory fibers, along with

motor fibers to the palmaris brevis and hypothenar muscles.

Therefore, it is technically incorrect to refer to this branch

at this point as the sensory branch of the ulnar nerve. The

superficial branch of the ulnar nerve is preferred.

In zone III of the ulnar tunnel, the superficial branch

contains mostly sensory fibers along with motor fibers to

the hypothenar muscles. Lesions in this zone should produce primarily sensory deficits with possible motor weak212 Systems Anatomy

ness of the hypothenar muscles. Conversely, if an occult

lesion or penetrating injury produces mostly sensory loss

(or concomitant weakness of the hypothenar muscles), zone

II should be suspected as the site of the lesion.

In carpal tunnel syndrome, the etiology often is

unknown, and it is attributed to an idiopathic cause. However, in ulnar nerve compression in the ulnar tunnel, a cause

more commonly is found. These include tumors in the

ulnar tunnel (ganglions, lipomas, giant cell tumor, desmoid

tumors, rheumatoid synovial cysts), anatomic abnormalities

that encroach on the ulnar nerve (anomalous muscles,

thickened ligaments, anomalous hamulus), trauma with

associated inflammation, edema, or hematoma (fractures,

repetitive trauma, edema after burns), vascular pathology,

or inflammatory conditions (rheumatoid arthritis or degenerative arthritis) (6,243–267) (Table 3.4). Ganglions are the

most common tumor related to ulnar tunnel syndrome,

accounting for 29% to 45% of reported caused of ulnar

tunnel syndrome. Other more common related factors

include anomalous muscles (see later), fractures, and vascular abnormalities (230,268–273).

Anomalous muscles reported to cause ulnar tunnel syndrome include the several variations of the palmaris longus

(274–276), an accessory flexor digiti minimi (262,277), an

accessory abductor digiti minimi (198,278), an accessory

muscle from the flexor carpi ulnaris tendon, and various

anomalous muscles located in the canal (see later) (279,

280).

Several variations of the palmaris longus have been

related to ulnar variations in Guyon’s canal and to ulnar

tunnel syndrome. These include a reversed muscle–tendon

relationship with a distal muscle belly and proximal tendon

(275), an anomalous extension into Guyon’s canal, an

accessory palmaris longus, and a duplicated palmaris longus

(6,9,274,275).

An anomalous palmaris longus may have a reversal of its

normal muscle relationship, with the tendon arising proximally from the medial epicondyle, and the muscle belly

attaching distally to the flexor retinaculum at the wrist.

There may be an associated accessory musculotendinous

slip, approximately 1 cm thick, which inserts into the pisiform (275). This anomalous palmaris can create an arch

that reinforces the roof of the tunnel. However, the ulnar

nerve and artery must penetrate through this arch to reach

the wrist, and thus are more vulnerable to compression. The

nerve and artery run their normal course deep to the palmaris brevis (275). Spinner has referred to this anatomic

arrangement as the variant canal of Guyon (6).

An anomalous accessory palmar longus has been noted

in the ulnar tunnel. Thomas described a 1-cm-wide muscle

arising from the palmaris longus tendon. The muscle

inserted into the soft tissues of the region of the hypothenar

muscles and into the pisiform. This muscle passed through

the ulnar tunnel, and was thought to be responsible for

clinical symptoms of fatigability of the hand (274).

King and O’Rahilly reported a duplication of the palmaris longus with either a separate muscular slip (accessory

palmaris) or a separate tendon that originated from the

duplicated palmaris and extended to the abductor digiti

quinti or the flexor digiti quinti. The accessory muscle

passed volar to the ulnar nerve and ulnar artery. The muscle appeared to form part of the roof of the ulnar tunnel. An

associated tendinous slip that extended between the ulnar

artery and nerve also was noted to occur. The artery crossed

anterior to the slip.

As early as 1864, anomalies of the palmaris longus were

noted, and associated with variations of the ulnar tunnel

(276). A palmaris longus with a double origin was described

by Wood. From this palmaris longus tendon, there was an

associated anomalous flexor digiti quinti with a high origin

from the palmaris longus.

Besides the palmaris longus, other aberrant muscles have

been noted in the ulnar tunnel or its vicinity that place the

ulnar nerve at risk for compression.

Schjelderup described an anomalous muscle 4 mm wide

that extended in the canal and crossed over the ulnar nerve

before the nerve divided (279).

Turner and Caird also noted an anomalous muscle in the

ulnar tunnel. The muscle originated from the pisiform,

crossed through the ulnar tunnel passing between the deep

and superficial branches, and inserted into the transverse

carpal ligament. This muscle passed between the motor and

sensory branches of the ulnar nerve (280).

3 Nerve Anatomy 213

TABLE 3.4. COMMON CAUSES OF ULNAR NERVE

COMPRESSION AT THE WRIST BASED ON 135

REPORTED CASES

Cause Number

Tumors

Ganglion 46

Lipoma 3

Giant cell tumor 2

Desmoid tumor 1

Anatomic abnormalities

Anomalous muscles 22

Thickened ligaments 4

Anomalous hamulus 3

Trauma

Fractures 19

Repetitive trauma 8

Edema after burns 10

Other trauma 3

Vascular pathology 9

Arthritis

Rheumatoid 4

Degenerative 1

Other

Dupuytren’s contracture 1

136 total

From Botte MJ, Gelberman RH. Ulnar nerve compression at the

wrist. In: Szabo RM, ed. Nerve compression syndromes: diagnosis

and treatment. Thorofare, NJ: Slack, 1989:121–136.

Jeffery described an accessory hypertrophied abductor

digiti quinti that arose from the fascia of the distal forearm.

The muscle was thought responsible for isolated paralysis of

the intrinsic muscles without sensibility loss. The patient’s

symptoms improved after excision of the abnormal muscle

(6,278).

An accessory muscle arising from the tendon of the

flexor carpi ulnaris was noted by Kaplan. This muscles

inserted into the volar carpal ligament. It formed a thickened roof of the ulnar tunnel, possibly increasing the vulnerability to the ulnar nerve (6,9; personal communication

to Spinner).

Swanson identified an accessory flexor digiti quinti arising from the forearm fascia. The muscle inserted into the

flexor digitorum brevis and caused symptoms of ulnar nerve

compression (6,277).

Hayes et al. described a ligamentous band that attached

to the pisiform and extended to the hook of the hamate.

The band was located anterior to the deep branch of the

ulnar nerve (6,281). The flexor and abductor digiti minimi

muscles arose in part from the ligamentous band.

In the vicinity of the ulnar tunnel, Lipscomb reported a

case of duplication of the hypothenar muscles (282). The

duplicated muscle simulated a tumor of the hand. The muscle originated from the pisiform and the hook of the

hamate. The palmaris brevis was noted to be six times the

normal size. Proximally, these anomalous muscles formed

part of the ulnar tunnel (6), and potentially increased the

risk of nerve compression.

Harrelson and Newman described ulnar tunnel syndrome caused by a hypertrophied flexor carpi ulnaris muscle in close proximity to the ulnar tunnel (283).

Most ganglia that cause ulnar tunnel syndrome arise

from the palmar aspect of the carpus and present in zone I

or II.

Although the deep terminal branch of the ulnar nerve

consists mostly of motor fibers, it also contains sensory

afferent nerves to the ulnocarpal, intercarpal, and carpometacarpal joints. It is thus not a purely motor nerve,

although it sometimes incorrectly is referred to as the deep

motor branch of the ulnar nerve. The correct names include

deep branch of the ulnar nerve and deep terminal branch of the

ulnar nerve (189,229,284).

The deep branch of the ulnar nerve and the deep palmar

arch cross between the interval between the oblique and

transverse heads of the adductor pollicis at the level of the

third metacarpal. This interval is useful in identifying the

neurovascular bundle during exploration for deep or severe

trauma. The neurovascular bundle also requires isolation

and protection in adductor pollicis recession, as often is performed for correction of thumb-in-palm deformities in

spastic muscle disorders. Compression of the deep branch

of the ulnar nerve by the adductor pollicis also has been

noted (285).

Because the ulnar nerve on occasion may innervate the

third lumbrical muscle, a high ulnar nerve lesion can produce clawing in three fingers instead of two.

Although ulnar neuropathy is a relatively common cause

of intrinsic muscle atrophy, several other etiologies are possible: Charcot-Marie-Tooth disease, thoracic outlet syndrome, C8 to T1 root level impingement, anterior horn cell

disorders, and even compression at the foramen magnum

level (foramen magnum meningioma) (45,46,196,213,240,

241,273,286–289).

The ulnar supply to the fourth web space (to the space

between the ring and small fingers), instead of arising in its

usual location at the distal end of the ulnar tunnel, has been

observed to arise in the mid-forearm and continue on an

aberrant course superficial to the transverse carpal ligament

and the palmar aponeurosis (280). When present, it can be

vulnerable to injury during carpal tunnel decompression

(6).

RADIAL NERVE

Origin of the Radial Nerve

The radial nerve arises from the posterior cord of the

brachial plexus, posterior to the third portion of the axillary

artery (1–4,11) (see Fig. 3.1). It contains fibers from C5

through C8 (and occasionally T1) and is the largest terminal branch of the brachial plexus. The lower trunk contributes fibers from T1 in 8% of upper limbs (13).

Radial Nerve in the Axilla and Arm

In the proximal portion of the arm, the radial nerve courses

posterior to the brachial artery, anterior to the subscapularis

muscle, the teres major and latissimus dorsi muscle tendons, and the long head of the triceps. At the junction of

the proximal and middle thirds of the humerus, the nerve

courses dorsolaterally, passing posterior to the medial head

of the triceps and anterior to the long head. The radial

nerve is accompanied by the profunda brachii artery, and

continues distally close to the posterior cortex of the

humerus (290). The nerve and artery pass through the

extensor compartment of the arm, between the medial and

lateral heads of the triceps muscle. The nerve continues distally, coursing slightly anteriorly as it spirals around the

humerus to reach the lateral intermuscular septum. The

nerve is separated from the humeral cortex by the medial

head of the triceps, which lies adjacent to but not in the spiral groove of the humerus (291,292). The radial nerve

leaves the extensor compartment of the arm at the lateral

border of the medial head of the triceps muscle, sequentially

providing motor branches to the triceps long head, medial

head, and lateral head (Table 3.5 and Fig. 3.5). The nerve

enters the flexor compartment of the arm, piercing the lat214 Systems Anatomy

eral intermuscular septum approximately 10 cm proximal

to the lateral humeral epicondyle (6). The radial collateral

artery (the terminal branch of the profunda brachii artery)

accompanies the radial nerve in this area. The radial nerve

continues deep in the intermuscular interval between the

brachialis and brachioradialis muscles. It continues distally,

and extends in the interval between the extensor carpi radialis longus muscle and brachialis. The nerve exits the arm

anterior to the tip of the lateral epicondyle, dividing into

the superficial and deep terminal branches as it enters the

forearm (13,291,292). In the arm, the radial nerve sequentially innervates the three heads of the triceps and the

anconeus. In the distal third of the arm proximal to the

elbow epicondylar line, the radial nerve innervates the brachioradialis and extensor carpi radialis longus (see Table 3.5

and Fig. 3.5). Occasionally, the radial nerve provides a

motor branch to the radial portion of the brachialis (6,293),

which usually is supplied by the musculocutaneous nerve.

The motor branch to the extensor carpi radialis brevis can

have a variable source. In most limbs (58%), motor innervation to the extensor carpi radialis brevis arises from the

sensory division of the radial nerve in the forearm, the

superficial radial nerve (294).

3 Nerve Anatomy 215

TABLE 3.5. LEVEL AND ORDER OF INNERVATION

OF MUSCLES SUPPLIED BY THE RADIAL NERVE

Range in cm from

Tip of Acromion

Muscle (Shortest to Longest)

Triceps

Long head 7.1

Medial head 9.5–11.2

Lateral head 10.1

Anconeus

Range in cm from

Humerus (from 10 cm

above Lateral Epicondyle)

Brachioradialis 8.2–10.0

Extensor carpi radialis longus 10.5–12.3

Extensor carpi radialis brevis 14.7–16.5

Range in cm from

Lateral Epicondyle

Extensor carpi ulnaris 10.2–10.6

Extensor digitorum communis 10.2–12.5

Extensor digiti minimi 11.7–12.0

Abductor pollicis longus 11.4–14.2

Extensor pollicis longus 13.9–17.6

Extensor pollicis brevis 15.9–16.4

Extensor indicis proprius 16.9–18.0

From Sunderland S, Hughes ESR. Metrical and non-metrical features

of the muscular branches of the ulnar nerve. J Comp Neurol

85:113–120, 1946; and Linnell EA. The distribution of nerves in the

upper limb, with reference to variabilities and their clinical

significance. J Anat 55:79, 1921.

FIGURE 3.5. Schematic illustration of the radial nerve and associated branches and innervated muscles.

Clinical Correlations: Radial Nerve in the

Axilla and Arm

Holstein-Lewis Fracture

The close proximity of the radial nerve to the surface of the

humeral diaphysis places the nerve at risk for injury with

humeral fractures (295–301). Transient nerve injury is the

most common type of complication associated with

humeral shaft fractures. Most nerve injuries are associated

with transverse or short oblique fractures. Transection of the

radial nerve is rare and associated most commonly with

open fractures, penetrating injuries, or spiral oblique fractures (301).

Radial nerve compression in the arm has been attributed

to impingement by the triceps muscle (302,303).

Radial Nerve in the Forearm and Hand

The radial nerve passes anterior to the lateral epicondyle to

enter the forearm. At approximately the level of the elbow,

the radial nerve divides into the superficial and deep terminal branches deep to the brachioradialis and extensor carpi

radialis longus and brevis (6,291) (see Fig. 3.5). The point

of bifurcation usually is at the level of the radiocapitellar

joint, but it may divide 2 to 5 cm proximal or distal to this

joint (6,13,304). The superficial branch passes anterior

(superior) to the supinator muscle in the proximal third of

the forearm and continues along the deep surface of the

brachioradialis muscle. Proximally, the nerve is adjacent to

the anterior third of the brachioradialis, but as it descends

distally, it courses laterally and anteriorly. The radial artery

passes palmar to the insertion of the pronator teres muscle

and comes to lie on the ulnar border of the brachioradialis

muscle in the middle third of the forearm. The superficial

branch, which descends more laterally, is lateral to the radial

artery, palmar to the origins of the radial head of the flexor

digitorum superficialis and flexor pollicis longus muscle.

The superficial branch continues distally on the deep surface of the brachioradialis, crossing and descending along

the radius. The superficial branch pierces the antebrachial

fascia on the ulnar side of the brachioradialis tendon,

(between the tendons of the brachioradialis and extensor

carpi radialis longus). The nerve thus becomes subcutaneous at approximately 9 cm proximal to the wrist (291).

Superficial Branch of the Radial Nerve

Several patterns of the superficial branch of the radial nerve

have been noted (305,306). The superficial branch of the

radial nerve arose from the radial nerve at the level of the

lateral humeral epicondyle in 8 of 20 specimens, and within

2.1 cm of the lateral epicondyle in the remaining 12. The

superficial branch courses distally deep to the brachioradialis muscle until it emerges between the tendons of the brachioradialis and extensor carpi radialis longus to pierce the

antebrachial fascia. In 10% of specimens, the superficial

branch became subcutaneous by actually piercing the tendon of the brachioradialis. Table 3.6 shows relationships of

the superficial branch of the radial nerve to specific landmarks. The superficial branch of the radial nerve becomes

subcutaneous at a mean of 9 cm proximal to the radial styloid [range, 7 to 10.8 cm, standard deviation (SD) 1.4 cm].

When the nerve initially enters the subcutaneous tissue, its

mean width is 3 mm (SD 0.5 mm). The superficial branch

of the radial nerve continues distally and usually divides

into two branches (85% of specimens) or three branches

(15% of specimens). The first major branch point occurs at

a mean distance of 5.1 cm (range, 3.2 to 7.1 cm, SD 1.8

cm) proximal to the radial styloid. The point at which the

superficial branch of the radial nerve becomes subcutaneous

is, on average, the distal 36% of the distance from the lateral humeral epicondyle to the radial styloid. The first

branch point of the superficial branch of the radial nerve

after it enters the subcutaneous tissue is, on average, the distal 20% of that distance. At the level of the extensor retinaculum, the width of the palmar and dorsal major

branches averages 2 mm (SD 0.4 mm) and 2 mm (SD 0.2

mm), respectively. The nearest branch to the center of the

216 Systems Anatomy

TABLE 3.6. RELATIONSHIPS OF THE SUPERFICIAL BRANCH OF THE RADIAL NERVE TO SPECIFIC

LANDMARKS

Forearm SBRN-SQa to RS Branch to RSc Distance to Center Distance of Closest Branch

Length (cm) (cm/% Forearmb) (cm/% Forearm) of First DC (cm) to Lister’s Tubercle (cm)

Mean 25.5 9.0/36% 5.1/20% 0.4 1.6

Min. 21.5 6.1/25% 2.7/11% 0.0 0.5

Max. 11.6/40% 10.5/38% 1.6 2.9

DC, dorsal compartment; RS, radial styloid.

aSBRN-SQ is the distance from the RS to where the superficial branch of the radial nerve (SBRN) became subcutaneous.

b% forearm indicates the percentage of the distal forearm length at which the SBRN became subcutaneous or had its first major branch point. c

Branch to RS is the distance from the RS to the first major branch point.

From Abrams RA, Brown RA, Botte MJ. The superficial branch of the radial nerve: an anatomic study with surgical implication. J Hand Surg

[Am] 17:1037–1041, 1992.

first dorsal wrist compartment is within a mean transverse

distance of 0.4 cm (SD, 0.4 cm), and in 35% of specimens,

there is a branch lying directly over the center of the first

dorsal wrist compartment. All branches pass radial to Lister’s tubercle by a mean distance of 1.6 cm (SD 0.05 cm).

No branches pass closer than 0.5 cm to the tubercle (305).

In all specimens studied, the major palmar branch continues distally to become the dorsoradial digital nerve of the

thumb. In half of the specimens, before it reached the

thumb, the palmar branch divides into other smaller cutaneous branches that extend to the palmar radial thenar eminence. In 35%, there were connections between these

branches of the superficial branch of the radial nerve and

branches from the lateral antebrachial cutaneous nerve. The

major dorsal branch, with numerous branching configurations, continues distally, branching into the dorsoulnar digital nerve to the thumb and the dorsoradial digital nerve to

the index finger, and a third branch continues distally to

become the dorsoulnar and dorsoradial digital nerves of the

index and long fingers, respectively. The dorsoulnar digital

nerve to the long finger arises from the dorsal sensory

branch of the ulnar nerve in 90% of specimens (305). The

dorsoulnar digital nerve to the thumb parallels the thumb

metacarpal running superficial to the first dorsal

interosseous muscle, passing dorsoulnar to the metacarpophalangeal joint. The widths of the dorsoradial and dorsoulnar digital nerves to the thumb at the level of the

metacarpophalangeal joints are 1.5 mm (SD 0.5 mm) and

1.4 mm (SD 0.3 mm), respectively (305). Despite pattern

variations, discernible features were as follows: The palmar

branch from the first major branch point always became the

dorsoradial digital nerve to the thumb. In 65%, the dorsoulnar digital nerve to the thumb and the dorsoradial digital nerve to the index finger came from the same branch,

which emanated from the first main dorsal branch. In 30%,

the dorsoulnar nerve to the thumb and the dorsoradial

nerve to the index finger came from different branches off

the main dorsal branch, and in 1 specimen of 20, the dorsoulnar nerve to the thumb was noted to arise from a trifurcating branch at the first major branch paint. In all specimens, the continuation of the main dorsal branch

bifurcated distally, usually near the metacarpal heads, into

the dorsoulnar digital nerve to the index finger and the dorsoradial digital nerve to the long finger (305).

Posterior Interosseous Nerve

The posterior interosseous nerve, the deep terminal branch

of the radial nerve, innervates the extensor muscles of the

forearm and contains sensory afferent fibers to the wrist

joint (307,308) (Table 3.7, and see Fig. 3.5). The posterior

interosseous nerve is one of the main continuing branches

after the bifurcation of the radial nerve (291,307,309). The

bifurcation usually occurs at approximately the level of the

radiocapitellar joint. The posterior interosseous nerve continues a few centimeters to enter the supinator muscle. Just

before entering the supinator, the motor branch to the

extensor carpi radialis brevis is given off. The motor branch

to the extensor carpi radialis brevis usually exits off the lateral aspect of the posterior interosseous nerve. The extensor

carpi radialis brevis usually receives its innervation at the

level of the radial head or distal to it (6).

The supinator muscle, arising from the lateral epicondyle, radial collateral ligament, and the proximal ulna, is

divided into deep and superficial heads. The muscle is

approximately 5 cm broad. The posterior interosseous nerve

gives off one or more branches to the supinator muscle

before entering it; however, additional fibers may remain

within the epineurium of the main trunk for several centimeters, supplying the muscle between its two heads. The

posterior interosseous nerve enters the supinator muscle at

the muscle’s proximal end, through a teardrop-shaped

opening in the superficial head of the muscle. The opening

leads the plane between the deep and superficial heads. The

opening in the superficial head contains a fibrous or muscular thickening along its margin, referred to as the arcade

of Frohse (Frohse, 1908). The nerve enters the arcade of the

Frohse and continues distally to pass obliquely between the

superficial and deep muscle bellies. In its course through

the supinator, the nerve usually is somewhat perpendicular

to the direction of the line of the muscle fibers. The nerve

continues dorsolaterally around the neck of the radius and

innervates the supinator while coursing through it. The

nerve is separated from the radius by the deep head of the

supinator muscle, but may come into contact with the

bone, especially when the fibers of the deep head parallel

the course of the nerve (291,310). The nerve crosses the

proximal radius to exit the distal portion of the supinator

approximately 8 cm distal to the elbow joint (6). The nerve

thus emerges dorsally to enter the extensor compartment of

the forearm. As the nerve emerges from the supinator, it

divides into multiple branches, dividing in a somewhat

radial pattern resembling a cauda equina. There is a basic

pattern to the multiple branches, consisting of two major

components. These include those branches that supply the

3 Nerve Anatomy 217

TABLE 3.7. THE POSTERIOR INTEROSSEOUS

NERVE: ORDER OF MUSCLE INNERVATION AND

DISTANCE FROM THE DISTAL EDGE OF THE

SUPINATOR TO THE POINT OF MUSCLE

PENETRATION OF INNERVATED MUSCLE

Extensor carpi ulnaris 1.25 cm

Extensor digitorum communis 1.23–1.8 cm

Extensor digiti quinti 1.8 cm

Abductor pollicis longus 5.6 cm

Extensor pollicis brevis 6.5 cm

Extensor indicis proprius 6.8 cm

Extensor pollicis longus 7.5 cm

From Spinner M. Injuries to the major branches of peripheral nerves

of the forearm, 2nd ed. Philadelphia: WB Saunders, 1978.

superficial layer of muscles (extensor digitorum communis,

extensor digiti quinti, and extensor carpi ulnaris) and those

branches coursing deep to the outcropping muscles (abductor pollicis longus, extensor pollicis longus and brevis, and

extensor indicis proprius). The branch pattern may be quite

variable. After leaving the supinator muscle, the nerve lies

between the abductor pollicis longus muscle (located

deeply) and the extensor carpi ulnaris, extensor digiti minimi, and extensor digitorum communis muscles (all located

superficially). The posterior interosseous nerve is joined on

the extensor surface of the forearm by the posterior

interosseous artery, a branch of the common interosseous

artery. Coursing distally in the forearm, the nerve passes

superficial to the extensor pollicis brevis and deep to the

extensor pollicis longus muscles (291). It penetrates deeply,

either over or through the extensor pollicis brevis muscle,

and comes to lie on the interosseous membrane between the

radius and ulna. Continuing distally on the interosseous

membrane, it divides into terminal branches that provide

sensory innervation to the wrist (291). The extensor carpi

radialis brevis muscle may be innervated by the radial nerve,

its superficial branch, or the posterior interosseous nerve.

Branches to this muscle most commonly originate 2 cm distal to the tip of the lateral epicondyle, but may arise

between 2 and 5 cm distal to it (35,291).

As noted previously, the branch pattern of the posterior

interosseous nerve is variable after it exits the supinator, and

variations exist as to the order and distance that muscles are

innervated (44) (see Fig. 3.5). In general, the nerve gives off

three short and two long motor branches after it leaves the

muscle (291). The general order of muscle innervation and

the distance from the distal edge of the supinator to the

point of innervation of the associated muscle is as follows:

extensor carpi ulnaris, innervated approximately 1.25 cm

distal to the supinator; extensor digitorum communis,

innervated approximately 1.25 to 1.8 cm distal to the

supinator; extensor digiti quinti, innervated approximately

1.8 cm distal to the supinator; abductor pollicis longus,

innervated approximately 5.6 cm distal to the supinator;

extensor pollicis brevis, innervated approximately 6.5 cm

distal to the supinator; extensor indicis proprius, innervated

approximately 6.8 cm distal to the supinator; and extensor

pollicis longus, innervated approximately 7.5 cm distal to

the supinator (6,291,311) (see Tables 3.5 and 3.7).

There are three short branches given off after the posterior interosseous nerve exits the supinator. These innervate

the extensor digitorum communis, followed by the extensor

digiti minimi and the extensor carpi ulnaris muscles, and

arise in close succession and travel a variable distance before

entering their respective muscles (see distances above, Fig.

3.5). Although variation exists, there is a relatively constant

pattern in that the extensor carpi ulnaris and extensor digitorum communis muscles are innervated proximal to the

abductor pollicis longus and extensor pollicis brevis. One to

three terminal branches of the posterior interosseous nerve

supply the extensor carpi ulnaris. These branches pass horizontally in a medial direction to reach the muscle. These

branches arise from the posterior interosseous nerve at

approximately the level just distal to the most distal portion

of the insertion of the anconeus (6). The branches then run

proximally and distally within the muscle. The extensor

digiti minimi is supplied by a branch of the posterior

interosseous nerve just radial to the innervation of the

extensor carpi ulnaris. These motor branches are vulnerable

to injury if the interval between the extensor carpi ulnaris

and the extensor digiti minimi, or between the extensor digiti minimi and extensor digitorum communis in the midforearm, is explored (6).

A long lateral branch supplies the abductor pollicis

longus 5.6 cm distal to the division and ends in the extensor

pollicis brevis, 6.8 cm distal to the division (311). Multiple

branches to these muscles are common (291) (Fig. 3.5).

A final long medial muscular branch provides innervation to the extensor indicis proprius 6.8 cm distal to the

nerve division and to the extensor pollicis longus 7.5 cm

distal to the division (see earlier). This medial branch may

divide and innervate both the extensor pollicis longus and

the extensor indicis proprius, or two separate nerves can

exist that each exit the posterior interosseous nerve, with

each muscle receiving its separate nerve (291).

After innervation of the extensor pollicis longus, the

nerve exits from the muscle belly or from its course superficial to this muscle. The nerve comes to lie on the dorsal

aspect of the interosseous membrane between the radius

and ulna. The nerve continues distally on the interosseous

membrane, where it divides into terminal branches that

provide sensory innervation to the wrist (291). Specific

branches innervate the ligaments of the radiocarpal, intercarpal, and carpometacarpal joints (291,312).

The radial nerve and its branches also carry sympathetic

nerve fibers. The main trunk of the radial nerve, which

divides into several branches in the proximal forearm, supplies sympathetic fibers to the radial artery at the elbow or

in the proximal forearm. More distally in the forearm, the

radial artery is supplied segmentally in the middle and distal portions by sympathetic nerve fibers from the superficial

radial nerve (313).

Anomalies and Variations: Radial Nerve

in the Forearm and Hand

Three patterns of variability are recognized in the course of the

radial nerve in the forearm. The first pattern concerns the terminal branching of the radial nerve trunk. Most commonly,

the nerve bifurcates into superficial and deep branches at the

level of the tip of the lateral epicondyle. The level of division

may vary from 4.5 cm proximal to 4 cm distal to the epicondyle; the distal division is more common (205).

A second pattern of variability concerns the level of

innervation of the forearm muscles. The extensor carpi radi218 Systems Anatomy

alis brevis muscle may be innervated directly from the radial

nerve trunk, from its bifurcation, from the posterior

interosseous nerve, or from the superficial branches. The

supinator muscle usually receives a single branch from the

posterior interosseous nerve before it enters the muscle and

several short branches within the muscle. However, several

branches have been noted to divide proximally to supply

the supinator muscle (17,35,44). As the posterior

interosseous nerve leaves the supinator, several branches

arise to supply the superficial and deep forearm extensor

muscles. Although the level of innervation and branching

described usually is adhered to, significant variation exists

among individuals. All of the branches may arise from one

common nerve, or may divide much like the cauda equina

(2,3,6,11,13,25,44,191,291).

Rarely, as noted by Linell, the motor branch to the

extensor carpi radialis longus can arise from the posterior

interosseous nerve and penetrate the supinator muscle to

reach its destination (205). In this situation, a lesion or

compression of the posterior interosseous nerve may present not only with loss of digital extension, but also with

complete loss of wrist extension. The hand has no sensory

abnormalities, and there is no dysfunction of the brachioradialis muscle.

The posterior interosseous nerve has been shown to have

variable patterns. The nerve may pass superficial to the

supinator, rather than through it. Distally, the nerve may

pass under, over, or through the extensor pollicis brevis

muscle before coming in contact with the interosseous

membrane. Krause and von Luschka have described the

motor branch to the abductor pollicis longus and extensor

pollicis brevis, extensor pollicis longus, and extensor indicis

proprius passing superficial to the superficial head of the

supinator, while the remaining major portion of the posterior interosseous nerve, supplying the extensor digitorum

communis, extensor digiti quinti proprius, and extensor

carpi ulnaris, follows its usual course (6,314,315).

Froment-Rauber Nerve

The posterior interosseous nerve rarely may continue distally to innervate the first, second, and third dorsal

interosseous muscles. This was first described by Froment

in 1846 (316), and further noted by Rauber in 1865

(317,318), and by Shevkunenko in 1949 (312). Spinner has

referred to the anomaly as the Froment-Rauber nerve (6).

Froment-Rauber Anastomosis

An anastomosis may exist between the terminal branches of

the posterior interosseous nerve and the deep branch of the

ulnar nerve in the dorsal interosseous muscles of the hand.

Although originally described by Bichat in 1802 (319) and

again by Hovelacque in 1927 (73,74), the anastomosis usually is referred to as the Froment-Rauber anastomosis. Spinner suggests that the name of Bichat should be added to the

eponym because of Bichat’s early description.

Anterior Interosseous Nerve to Posterior

Interosseous Nerve Anastomosis

Rauber described a communication between the anterior

interosseous nerve and the posterior interosseous, passing

through a foramen in the interosseous ligament. The anterior interosseous nerve usually is divided into three long

branches. The main branch supplies the flexor pollicis

longus, the flexor profundus muscles to the index and long

fingers, and the pronator quadratus. The other two

branches pass adjacent to the interosseous membrane,

where they innervate the interosseous ligament and the

periosteum of the radius and ulna (6). Some of the branches

that travel along the interosseous ligament penetrate the ligament to communicate with terminal branches of the posterior nerve. In the distal forearm, a terminal branch of the

main anterior interosseous nerve branches posterior to the

pronator quadratus and passes through a foramen in the

interosseous ligament to anastomose with branches of the

posterior interosseous nerve. The latter communication can

occur at the distal border of the interosseous ligament. This

is a potential pathway for communication of nerve fibers

between the median nerve and radial nerve. It also is possible that the median nerve fibers that join the posterior

nerve actually may continue to reach the intrinsic muscles

of the hand (6). Spinner notes that this is an example of

neural plexification that occurs throughout the entire

peripheral nervous system.

The Superficial Branch of the Radial Nerve

The superficial branch of the radial nerve may wind around

the brachioradialis and continue on the superficial surface

of the muscle, rather than along the deep surface. It can

thus course from the elbow to the hand in the subcutaneous

tissue on the dorsolateral surface of the forearm (6,194).

Rarely, the brachioradialis and extensor carpi radialis

longus muscles share a common muscle belly, or have a conjoined muscle. In these cases, the superficial branch of the

radial nerve has been reported to perforate a conjoined tendon that is shared by the two muscles (6).

Absence of the Superficial Branch of the

Radial Nerve

Complete absence of the superficial branch of the radial

nerve has been described (320). In this case, the area normally supplied by the radial nerve was supplied by the musculocutaneous nerve (which extended more distally than

normal), and an enlarged ulnar dorsal cutaneous nerve

(320) was found to supply the autonomous zone of the

thumb.

3 Nerve Anatomy 219

The superficial branch of the radial nerve may supply

sensibility to the thenar eminence in the region (normally

innervated by the palmar cutaneous branch of the median

nerve), and to the palmar aspect of the thumb (normally

innervated by the common digital nerves of the thumb

originating from the median nerve). Thus, it is possible for

an injury to the superficial branches of the radial nerve to

produce numbness or anesthesia of both the dorsal and palmar aspects of the thumb.

The superficial branch of the radial nerve may supply the

entire dorsum of the hand. Learmonth has reported an

anatomic specimen in which the entire dorsal cutaneous

branch of the ulnar nerve was absent. The region normally

supplied by the ulnar nerve was supplied by an enlarged

superficial radial nerve, which had additional branches (208).

The Musculocutaneous Nerve

Spinner and colleagues noted several specimens and clinical

cases where the musculocutaneous nerve extended more

distally than traditionally depicted. The nerve can continue

into the hand to supply the anterior palmar aspect of the

thumb or thenar eminence (in the region of the thumb

metacarpal between the sensory region of the medial palmar

cutaneous nerve area and the more dorsal superficial radial

autonomous zone) (6).

The musculocutaneous nerve also may supply sensibility

to the dorsum of the thumb in the area usually supplied by

the superficial branch of the radial nerve (6).

It is not uncommon for there to be a communicating

branch between the superficial branch of the radial nerve

and the musculocutaneous nerve (205).

Spinner has pointed out that communicating branches

between the median and musculocutaneous nerves in the

arm and between the median and ulnar nerves in the intrinsic muscles probably pass distally through the posterior cord

to the posterior interosseous nerve rather than through the

usual medial cord to the ulnar nerve path (6).

Clinical Correlations: Radial Nerve in the

Forearm and Hand

Radial Tunnel Syndrome

The radial nerve may be compressed or develop neuritis along

its course in the radial tunnel, frequently between the head or

neck of the radius and the supinator muscle (321,322). The

radial nerve is particularly at risk at its entrance into the

supinator, at the arcade of Frohse. The arcade of Frohse is a

fibrous or fascial band resembling an oval-shaped window at

the proximal aspect of the supinator muscle. The nerve also

may be compressed in the muscle itself (see discussion of paralysis of the posterior interosseous nerve, later). Mass lesions

such as synovial cysts, synovitis, or lipomas also can impinge

on the radial nerve and associated branches (323–326).

The radial nerve is at risk in the radial tunnel during

radial head excision or fixation of fractures (327–344).

During operative exposure of the radial head and neck,

rotation of the forearm in pronation rotates the nerve away

from and slightly more distal to the operative site, and provides additional safety. With the elbow in supination, the

posterior interosseous nerve passes the neck of the radius

with a minimal distance of approximately 2.2 cm (mean,

3.3 cm) distal to the radiocapitellar articulation. With the

elbow pronated, this minimal distance increases to 3.8 cm

(mean 5.2 cm), thus moving the nerve away from the operative area (345).

The Presence or Absence of the Wrist

Extensors

The presence or absence of the active wrist extension

(extensor carpi radialis longus and brevis and extensor carpi

ulnaris) is helpful in determining the level of nerve injury or

dysfunction. A high radial nerve injury that is above the

elbow usually results in loss of wrist and digital extension.

If wrist extension and radial deviation are present (indicating function of the extensor carpi radialis longus), the lesion

is distal to the branching of this nerve. A lesion of the posterior interosseous nerve usually preserves the branch to the

extensor carpi radialis brevis, which branches from the

superficial branch of the radial nerve or from its own

branch proximal to the supinator muscle.

Posterior Interosseous Nerve Paralysis

A hand with a posterior interosseous nerve paralysis usually

dorsiflexes in a radial direction because of preservation of

the extensor carpi radialis longus (and brevis). On occasion,

the wrist may dorsiflex more neutrally. This can be due to

variation of the insertion of the radial extensors of the wrist.

The extensor carpi radialis longus can have a tendinous

attachment to the brevis tendon. The extensor carpi radialis

longus also can insert not only to the base of the index

metacarpal, but to the base of the long metacarpal. Either

of these conditions helps produce a more neutral wrist

extension with complete paralysis of the posterior

interosseous nerve.

Spontaneous Neuropathy of the Posterior

Interosseous Nerve

The most frequent cause of spontaneous neuropathy of the

posterior interosseous nerve probably is entrapment of the

nerve as it enters the supinator muscle at the arcade of

Frohse (346,347). Spontaneous neuropathy is well documented in the historical literature (73,111,208,316,327,

346,348–361). Two clinical pictures are described. The first

is a complete paralysis of all innervated muscles (the extensor carpi radialis brevis often is spared because it often arises

220 Systems Anatomy

separately from the superficial branch of the radial nerve, or

from the posterior interosseous nerve proximal to the

arcade of Frohse, and does not penetrate the muscle). The

second clinical picture is a slow, progressive paralysis of the

posterior interosseous nerve, usually commencing with

paralysis of one or several muscles. If untreated, it frequently progresses to a complete paralysis.

Pseudoulnar Claw Hand

When there is an incomplete, spontaneous neuropathy of

the posterior interosseous nerve, the ring and small fingers

initially may be involved. There is lack of extension of these

digits, which assume a position of flexion at the metacarpophalangeal joints and the proximal and distal interphalangeal joints. The hand with these flexed digits may resemble a claw hand (similar to ulnar neuropathy, without the

extension at the metacarpophalangeal joints). This partial,

spontaneous neuropathy of the posterior interosseous has

been described as a pseudoulnar claw hand (362).

Additional partial paralysis of the posterior interosseous

nerve includes loss of extension at the metacarpophalangeal

joints of single digits, combinations of digits, or the thumb

(350,351,354,356,357,363).

Differential Diagnosis in Loss of Digital

Extension

Loss of digital extension can occur from several etiologies,

especially in the patient with inflammatory arthritis. The

causes of digital extensor function loss include posterior

interosseous nerve paralysis, spontaneous rupture of extrinsic extensor tendon(s), extensor tendon subluxation into

the valley between metacarpal heads (such as can occur with

inflammatory arthritis that results in incompetence of the

sagittal bands for tendon centralization and stabilization),

and metacarpophalangeal joint subluxation (in inflammatory arthritis). Partial posterior interosseous nerve paralysis

can be distinguished from the other causes by clinical examination, as follows:

Neuropathy of the Posterior Interosseous Nerve

Partial or complete posterior interosseous nerve paralysis

results in loss of active digital extension specifically at the

metacarpophalangeal joint. Active digital extension function remains intact at proximal and distal interphalangeal

joints because of ulnar nerve–innervated intrinsic muscles.

The tenodesis effect is intact (with digital extension occurring when the wrist is passively flexed), and thus helps rule

out extensor tendon rupture. Radiographs help determine if

metacarpophalangeal joint subluxation is present.

Extensor Tendon Rupture

There is loss of active digital extension at the metacarpal

joints. The tenodesis effect is absent (showing no digital

extension occurring when the wrist is passively flexed). The

patient is unable to maintain digital extension at the

metacarpophalangeal joint when the joint is passively

placed in an extended position (helping to rule out extensor

tendon subluxation between the metacarpal heads). Radiographs help determine if metacarpophalangeal joint subluxation is present (364).

Extensor Tendon Subluxation

With extensor tendon subluxation, there is weakness or

inability actively to extend the digit at the metacarpophalangeal joint. However, the patient is able to maintain digital

extension when the digits are passively placed in extension.

This is possible because the tendon often centralizes when the

metacarpophalangeal joint is passively placed in extension.

The patient is able momentarily to maintain the extended

position. However, when the digit is flexed, the tendon

resubluxates, and digital extension no longer is possible.

Metacarpophalangeal Joint Subluxation

With metacarpophalangeal joint subluxation, as can

develop with rheumatoid arthritis, the patient is unable

fully to extend the digits. Passive extension of the digit may

not be possible, and this helps distinguish the condition

from tendon subluxation. Radiographs show metacarpophalangeal joint subluxation, and help distinguish the

condition from nerve palsy.

Innervation of the Posterior Interosseous

Nerve

There is clinical relevance to the order and distance of

innervation of the posterior interosseous nerve (see Table

3.7). These can be used in identifying the portion or level

of nerve injured from penetrating trauma. The order and

distances also have predictive usefulness post-nerve repair in

the evaluation of nerve regeneration success and expectations. After successful neurorrhaphy or neurolysis of the

posterior interosseous nerve, the earliest clinical sign of

impending recovery is the ability of the wrist to dorsiflex in

a neutral, or even ulnar, direction. This indicates recovery of

function of the extensor carpi ulnaris (and, to some extent,

of the extensor digitorum communis).

Safe and Unsafe Internervous Planes

Because of the transverse or horizontal branching of the

posterior interosseous nerve in the mid-forearm, motor

branches are vulnerable to injury if the intervals between

the extensor carpi ulnaris and the extensor digiti minimi, or

between the extensor digiti minimi and extensor digitorum

communis, are explored (6). Relatively safe internervous

planes in this area are between the anconeus and the extensor carpi ulnaris and between the extensor digitorum communis and the extensor carpi radialis brevis.

3 Nerve Anatomy 221

Communication Between the Anterior

Interosseous Nerve and the Posterior

Interosseous

As noted earlier, Rauber described a communication

between the anterior interosseous nerve and the posterior

interosseous, passing through a foramen in the interosseous

ligament. When present, this explains the retained function

of the intrinsic muscles in a hand when the ulnar nerve has

been severed (6,317,318).

The Superficial Branch of the Radial Nerve

The superficial branch of the radial nerve may be compressed distal to its exit from the radial tunnel and along its

course in the forearm and wrist. It may be impinged at its

passage from the subfascial to the subcutaneous level, where

its exits into the subcutaneous tissues between the brachioradialis and extensor carpi radialis longus. Dysfunction of

the superficial branch of the radial was described by

Wartenberg in 1932, and his name often is used in association with the clinical syndrome (365,366).

The superficial branch of the radial nerve usually passes

dorsally from the deep surface of the brachioradialis to

become subcutaneous approximately 10 cm proximal to the

radial styloid. The nerve is especially vulnerable to external

injury or compression from this point distally. The nerve

has been compressed by external objects, such as tight wristwatches, bracelets, handcuffs, gloves, and casts (6,367). The

nerve also may be injured from iatrogenic causes, including

laceration from release of the first dorsal compartment in

De Quervain’s disease, from injury from a cutdown procedure of a vein in the distal forearm, or from laceration from

tendon lengthening procedures involving the extensor carpi

radialis or longus (6).

Injury to the superficial branch of the radial nerve can

result in considerable pain and disability, and a full causalgia syndrome can develop (368). Neuromas or associated

regional pain syndromes from sympathetic-mediated nerve

dysfunction are particularly troublesome.

A communication branch between the superficial branch

of the radial nerve and the musculocutaneous nerve in the

distal forearm is not uncommon (205). Because of this, laceration of the superficial branch of the radial nerve in the

proximal forearm (proximal to the communicating branch)

may not present clinically with the classic sensory loss

expected for superficial radial nerve injury.

MUSCULOCUTANEOUS NERVE

Origin of the Musculocutaneous Nerve

The musculocutaneous nerve originates from the lateral

cord of the brachial plexus and is derived from the ventral

rami of C5, C6, and C7. It branches from the lateral cord at

the level of and deep to the pectoralis minor (see Fig. 3.1).

Musculocutaneous Nerve in the Axilla

and Arm

The nerve extends distally on a course lateral to the remaining brachial plexus and medial to the proximal humerus.

The nerve pierces the coracobrachialis and continues distally, in a lateral course between the biceps and brachialis to

the lateral side of the arm. The course of the nerve in this

part of the arm has been delineated by Williams and Latarjet et al., noting that the nerve projects along a line drawn

from the lateral side of the third part of the axillary artery

across the coracobrachialis and biceps to the lateral side of

the biceps tendon (3). The course is varied by its point of

entry into the coracobrachialis (369). The musculocutaneous nerve supplies the coracobrachialis, both heads of the

biceps, and most of the brachialis (see Fig. 3.2). The branch

to the coracobrachialis exits the musculocutaneous nerve

before it enters the muscle. The fibers from this branch (to

the coracobrachialis) are derived from the ventral ramus of

C7. This nerve may branch directly from the lateral cord.

The branches to the biceps and brachialis leave the musculocutaneous after the nerve pierces the coracobrachialis.

The nerve branch to the brachialis also sends a branch to

the elbow joint for innervation. The nerve also supplies a

small branch to the humerus, where it enters the cortex

with the nutrient artery.

At a point just distal to the elbow, the musculocutaneous

nerve pierces the deep fascia lateral to the tendon of the

biceps. From this point, it continues as the lateral antebrachial cutaneous nerve (lateral cutaneous nerve of the

forearm).

Lateral Antebrachial Cutaneous Nerve

(Lateral Cutaneous Nerve of the Forearm)

The lateral antebrachial cutaneous nerve originates as a continuing branch of the musculocutaneous nerve (see Figs. 3.2

and 3.4). The musculocutaneous nerve in the arm passes deep

to the biceps and superficial to the brachialis, in a medial-tolateral direction. As the musculocutaneous nerve passes distally and laterally, it reaches the approximate level of the elbow

joint, and exits from the deep surface of the biceps to become

cutaneous. At this point, the musculocutaneous nerve

becomes the lateral antebrachial cutaneous nerve. The lateral

antebrachial cutaneous nerve continues distally in the forearm, deep to the cephalic vein, and descends along the radial

border of the forearm to reach the wrist. In the forearm, the

nerve sends out small cutaneous branches to provide sensibility to the skin of the anterolateral forearm. The nerve may

have anastomoses distally with either the posterior cutaneous

nerve of the forearm or with the superficial branch of the

radial nerve (3). The nerve may give rise to a slender recurrent

branch that extends along the cephalic vein as far as the middle third of the arm, giving off several small branches to provide sensibility to the skin over the distal third of the anterolateral surface of the upper arm (370,371). This recurrent

222 Systems Anatomy

branch rarely is mentioned in most descriptions of the nervous anatomy in the upper extremity (3).

At the level of the wrist joint, the lateral antebrachial

cutaneous nerve is located anterior to the radial artery and

may have several small branches that pierce the deep fascia

and accompany the radial artery to the dorsum of the wrist.

The nerve then passes to the base of the thenar eminence

and ends in multiple small cutaneous rami. The nerve often

connects with the superficial branch of the radial nerve and

the palmar cutaneous branch of the median nerve.

Anomalies and Variations:

Musculocutaneous Nerve and Lateral

Antebrachial Cutaneous Nerve

Several variations of the lateral antebrachial cutaneous

nerve have been described.

n The musculocutaneous nerve may pass behind the coracobrachialis (instead of passing through the muscle) (3).

n The musculocutaneous nerve may accompany or actually adhere to the median nerve in its course in the arm.

n The musculocutaneous usually supplies motor innervation to the coracobrachialis. The muscle, however, may

be innervated by its own nerve, and branch directly from

the lateral cord of the brachial plexus.

n Small branches of the median nerve may pass to the musculocutaneous nerve and continue with the musculocutaneous nerve. Conversely, small branches of the musculocutaneous nerve may pass to the median nerve, and

continue with the median nerve.

n The distal branches of the lateral antebrachial cutaneous

nerve may have anastomoses with the superficial branch

of the radial nerve or with the palmar cutaneous branch

of the median nerve.

n The lateral antebrachial cutaneous nerve may, through

these small distal branches, innervate or help innervate

the pronator teres.

n The lateral antebrachial cutaneous nerve may have small

branches that extend to the dorsum of the thumb and

supply sensibility to the overlying skin (replacing the

innervation of the terminal portion of the superficial

branch of the radial nerve) (3).

Clinical Correlations: Musculocutaneous

Nerve and Lateral Antebrachial

Cutaneous Nerve

Injury to the musculocutaneous nerve can occur from

fractures of the proximal humerus. Clinical findings

include weakness of elbow flexion (from paresis of the

biceps and brachialis) and sensory loss on the lateral aspect

of the forearm. Pain and paresthesia may be aggravated by

elbow extension, which can stretch the musculocutaneous

nerve.

The lateral antebrachial cutaneous nerve can be used as

a donor nerve for nerve grafting. However, because of

donor site morbidity with numbness on the lateral aspect of

the forearm, other donor nerves (such as the sural nerve)

usually are selected.

MEDIAL BRACHIAL CUTANEOUS NERVE

(MEDIAL CUTANEOUS NERVE OF THE ARM,

NERVE OF WRISBERG)

The medial brachial cutaneous nerve, often referred to as

the medial cutaneous nerve of the arm, or as the nerve of

Wrisberg (3,11), is a sensory nerve that supplies the medial

aspect of the arm from the axilla to the medial elbow. It is

considered the smallest true nerve branch that originates

from the brachial plexus.

Origin of the Medial Brachial Cutaneous

Nerve

The medial brachial cutaneous nerve originates from the

medial cord of the brachial plexus. It comprises mostly fibers

from the ventral rami of C8 and T1 (see Fig. 3.1). The nerve

branches from the medial cord at a point slightly proximal to

the point of origin of the medial antebrachial cutaneous nerve.

Medial Brachial Cutaneous Nerve in the

Axilla and Arm

From its origin from the medial cord, the medial brachial

cutaneous nerve passes through the axilla deep to the pectoralis insertion and anterior to the latissimus dorsi. In its

proximal course, it is located dorsal to the axillary artery

and vein. As it continues distally, it comes to lie medial to

these vessels. The nerve may pass posterior to the axillary

vein. In the axilla, it may anastomose with the intercostal

nerves. The medial brachial nerve may branch early and

consist of several branches as it exits the axilla. The nerve

and associated branches continue distally medial to the

brachial artery and basilic vein. The nerve descends distally

along the medial aspect of the arm and pierces the deep

brachial fascia to become cutaneous in the mid-portion of

the arm. It continues to branch and provides sensibility to

the medial aspect of the arm as far distally as the medial epicondyle and olecranon (11) (see Fig. 3.4).

Anomalies and Variations: Medial

Brachial Cutaneous Nerve

n The medial brachial cutaneous nerve may communicate

with the medial antebrachial cutaneous nerve through

the ulnar branch of the latter nerve.

n The medial brachial cutaneous nerve may originate as a

branch of the medial antebrachial cutaneous nerve (11).

n The anastomoses with the intercostal nerve in the proximal axilla may have so many branches that the connections assume a plexiform pattern in the axilla.

3 Nerve Anatomy 223

n The intercostobrachial nerve communication may be

large (between the medial brachial cutaneous nerve and

the intercostal nerves) and may be reinforced by a part of

the lateral cutaneous branch of the third intercostal

nerve. When there is a large contribution or component

from the lateral cutaneous branch of the third intercostal

nerve, it may replace the medial cutaneous nerve of the

arm (3).

Clinical Correlations: Medial Brachial

Cutaneous Nerve

The medial brachial cutaneous nerve contains only sensory

fibers. Injury to the medial brachial cutaneous nerve results

in loss of sensibility to the medial aspect of the arm.

MEDIAL ANTEBRACHIAL CUTANEOUS

NERVE (MEDIAL CUTANEOUS NERVE OF

THE FOREARM)

The medial antebrachial cutaneous nerve, often referred to

as the medial cutaneous nerve of the forearm, is a sensory

nerve that supplies the medial aspect of the forearm from

the elbow to the wrist. It also supplies sensibility to the skin

overlying a portion of the anterior arm anterior to the

biceps muscle.

Origin of the Medial Antebrachial

Cutaneous Nerve

The medial antebrachial cutaneous nerve originates from the

medial cord of the brachial plexus. It comprises mostly fibers

from the ventral rami of C8 and T1 (see Fig. 3.1 and Appendix 3.1). The nerve branches from the medial cord at a point

slightly distal to the point of origin of the medial brachial

cutaneous nerve.

Medial Antebrachial Cutaneous Nerve in

the Axilla, Arm, and Forearm

From its origin from the medial cord, the medial antebrachial cutaneous nerve passes through the axilla deep to

the pectoralis insertion and anterior to the latissimus dorsi.

In its proximal course, it lies medial to the axillary artery,

much closer to the artery than the medial brachial cutaneous nerve. It often is situated between the axillary artery

and vein. In the proximal portion, just distal to the axilla,

the nerve gives off a small branch that pierces the fascia over

the proximal and anterior aspect of the biceps muscle. This

branch supplies sensibility to the skin overlying the anterior

biceps muscle from the axilla to the level of the elbow. The

main nerve continues distally along the medial aspect of the

arm medial to the brachial artery. It pierces the deep fascia

with the basilic vein to become cutaneous in the mid-portion of the arm. The nerve divides into an anterior and a

posterior (ulnar) branch (Fig. 3.4).

Anterior Branch of the Medial Antebrachial

Cutaneous Nerve

The anterior branch of the medial antebrachial cutaneous

nerve usually is a larger branch than the posterior (ulnar)

branch of the medial antebrachial nerve. The anterior

branch continues distally along the anteromedial aspect

of the forearm. Proximally in the forearm, it usually

passes superficial to the median basilic vein. The nerve

then continues on the anterior part of the ulnar forearm,

supplying the skin of the anteromedial forearm as far distally as the wrist. It often has an anastomosis with the palmar cutaneous branch of the ulnar nerve (3,11) (see Fig.

3.4).

Posterior (Ulnar) Branch of the Medial

Antebrachial Cutaneous Nerve

The posterior (ulnar) branch of the medial antebrachial

cutaneous nerve continues obliquely distally along the

medial side of the basilic vein, anterior to the medial epicondyle of the humerus but curving posteriorly, and spiraling around the ulnar aspect of the forearm to reach the dorsal portion of the medial forearm. It continues distally along

the ulnar aspect of the forearm as far distal as the wrist, supplying the overlying skin as it extends distally (see Fig. 3.4).

It often has anastomoses with the medial brachial cutaneous

nerve (in the proximal forearm), with the dorsal antebrachial cutaneous nerve, and with the dorsal branch of the

ulnar nerve (3,11).

Anomalies and Variations: Medial

Antebrachial Cutaneous Nerve

The anterior branch of the medial antebrachial nerve

descends anteromedially in the forearm to reach the wrist.

In this area it often has an anastomosis with the palmar

cutaneous branch of the ulnar nerve.

The posterior branch of the medial antebrachial nerve

descends distally and posterior to the dorsal aspect of the

forearm, to reach the medial border of the wrist. Along its

course, it may have several anastomoses, including those

with the medial brachial cutaneous (in the proximal forearm), or with the posterior cutaneous nerve of the forearm

or the dorsal branch of the ulnar nerve.

Clinical Correlations: Medial Antebrachial

Cutaneous Nerve

The medial antebrachial cutaneous nerve contains only sensory fibers. Injury to the medial antebrachial cutaneous

nerve results in loss of sensibility to the medial aspect of the

224 Systems Anatomy

forearm and a portion of the anterior arm overlying the

anterior biceps.

Injury to the medial cord or to the C8 or T1 nerve

roots results in dysfunction of the medial antebrachial

cutaneous nerve (as well as ulnar neuropathy), and is associated with numbness along the medial aspect of the forearm and a portion of the anterior arm overlying the anterior biceps.

SENSORY ORGANELLES

Several sensory nerve endings (organelles) terminate in the

skin, usually in relatively high concentrations in the hand.

These are innervated by the sensory nerve endings of the

median, ulnar, and radial nerves. The nerve endings are

encapsulated and exhibit considerable variety in size, shape,

and distribution, but all share in common the feature of an

axon terminal encapsulated by nonexcitable cells. The

major end organelles include the pacinian corpuscles,

Meissner corpuscles, Ruffini nerve endings, and Merkel

receptors (3,372,373) (Fig. 3.6).

Pacinian Corpuscles

Pacinian corpuscles (corpuscles of Vater-Pacini) are relatively

large, lamellated structures located in the subcutaneous tissue.

They occur in high concentrations on the palmar surface of

the hand and digits (as well as in the plantar foot, periostea,

interosseous membranes, and periarticular areas). These are

rapidly adapting receptors, and their function usually is considered to be detection of vibration, pressure, or coarse touch

(3,373). They are oval, spherical, or irregular firm masses,

smooth and glistening white or yellow in color, up to 2 to 4

mm in size (approximately 100 to 500 µm across) (373), and

are easily seen with (or without) loupe magnification during

operative procedures on the palmar surface of the hand or digits. Each has a capsule, an intermediate growth zone, and a

3 Nerve Anatomy 225

FIGURE 3.6. Sensory organelles.

central core containing an axon terminal. The capsule is

formed by approximately 30 concentrically arranged lamellae

of flat cells. The axon terminal consists of an unbranched terminal of a peripheral nerve, and is in contact with the innermost core lamellae (3,372,373).

Meissner Corpuscles

Meissner corpuscles (tactile corpuscles of Meissner) are found

in the dermis, usually in the superficial layers very close to the

epidermis. They are in relatively high concentrations in all

parts of the hand (and foot), especially in the distal digits

(373). They also are rapidly adapting and highly sensitive to

fluctuating mechanical forces acting on the surface of the skin.

Meissner corpuscles are particularly sensitive to vibration at

certain frequencies. The structures are somewhat cylindrical in

shape, with their long axes perpendicular to the skin surface.

They are much smaller than the pacinian corpuscles, measuring approximately 80 µm long and 30 µm across. The

organelle has a connective tissue capsule and a central core, the

capsule being loosely attached to the core. Like the pacinian

corpuscle, the Meissner corpuscle has an axon terminal ending inside of the capsule (3) (Fig. 3.6).

Ruffini Nerve Endings

Ruffini endings (type II slowly adapting cutaneous mechanoreceptors) occur in the dermis of hairy skin. These are

slowly adapting (compared with the rapidly adapting

pacinian and Meissner corpuscles) and responsive to continuous forces such as maintained stress or stretch of the

skin. They consist of highly branched nerve endings that

are distributed among bundles of collagen fibers in a

spindle-shaped structure. The structure is enclosed partly

by a fibrocellular sheath derived from the perineurium of

the nerve (3) (Fig. 3.6).

Merkel Receptors

Merkel receptors basically are nerve endings (type I slowly

adapting cutaneous mechanoreceptors), and occur in the

skin in the vicinity of the dermal–epidermal junction. The

nerve ending is located in the basement membrane and keratinocytes of the epidermis, or near the hair follicle. The

Merkel receptors are sensitive to perpendicular pressure or

indentation of the skin, or to the bending of the hair follicle (3,373).

226 Systems Anatomy

APPENDIX 3.1. DERMATOMES OF THE UPPER EXTREMITY

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49:1605, 1967.

Wood VE, Frykman GK. Unusual branching of the median nerve at

the wrist: a case report. J Bone Joint Surg Am 60:267–268, 1978.

Zoega H. Fracture of the lower end of the radius with ulnar nerve

palsy. J Bone Joint Surg Br 48:514, 1966.

236 Systems Anatomy

4

VASCULAR SYSTEMS

MICHAEL J. BOTTE

This chapter discusses vascular systems of the upper extremity. Included are separate sections on the major arteries,

veins, lymphatics, and lymph nodes. Similar to the other

systems chapters (Chapters 1 to 3), this chapter is provided

as a reference for specific vascular structures. The discussion

of each vascular structure contains a gross anatomic description, followed by a description of the associated branches

and the area or structures supplied. The intraosseous vascular supply to the skeletal structures is covered in the chapter

on Skeletal Anatomy (Chapter 1). The vascular contributions to specific muscles are listed under each separate muscle in the chapter on Muscle Anatomy (Chapter 2). Discussions of variations and clinical correlations of the described

anatomy follow each section.

ARTERIAL ANATOMY

AXILLARY ARTERY

Gross Anatomic Description: Axillary

Artery

The axillary artery begins at the distal edge of the first rib

and ends at the distal edge of the teres major tendon (Figs.

4.1 and 4.2). It is formed as the continuation of the subclavian artery. The subclavian artery crosses deep to the clavicle and superior to the first rib to become the axillary artery

(1–10). Some authors consider the axillary artery to begin

at the distal edge of the clavicle (11,12). The axillary artery

is the central structure of the axilla and continues across the

axilla to the distal edge of the teres major tendon. At that

point, where it leaves the axilla, the axillary artery becomes

the brachial artery (1–12). From its beginning at the first

rib, the axillary artery continues in a distal and inferior

direction (when the arm is at the side) to reach the inferior

aspect of the proximal arm. The artery initially lies deep in

the axilla, inferior to the anterior border of the deltoid and

covered in part by the pectoralis minor and more distally by

the pectoralis major. As it crosses anterior to the teres major,

it becomes superficial and palpable in the axilla, just before

it becomes the brachial artery. In its most distal part, the

axillary artery is covered only by skin and fascia (1,2,3,6).

The axillary vein lies parallel to the axillary artery and is

positioned anterior or inferior to the artery along the

artery’s course through the axilla.

The axillary artery is conventionally divided into three

parts, based on its relationship to the pectoralis minor

(Table 4.1; see Fig. 4.2). The first part of the axillary artery,

also called the proximal part, is proximal to the pectoralis

minor. The second or posterior part is posterior to the muscle. The third part, also called the distal part, is distal to the

pectoralis minor (3,4,11).

The First (Proximal) Part of the Axillary Artery

The first (proximal) part of the axillary artery is approximately 2.5 cm long and extends from the lateral border of

the first rib to the medial border of the pectoralis minor

(7,8,11). It is bordered superiorly by the anterior deltoid

muscle and covered anteriorly by the skin, superficial fascia, platysma, supraclavicular nerves, deep fascia, a portion of the clavicular part of the pectoralis major, and the

clavipectoral fascia. Anterior to the first part of the artery

lie the lateral pectoral nerve, the loop of communication

between the lateral pectoral nerve and the medial pectoral

nerve, and the thoracoacromial and cephalic veins. Posterior to the first part of the artery are the first intercostal

space, the corresponding external intercostal muscle, the

first and second digitations of the serratus anterior, the

long thoracic and medial pectoral nerves, and the medial

cord of the brachial plexus. Lateral to the first part of the

artery are the posterior and lateral cords of the brachial

plexus, separated from the artery by the areolar tissue.

Medial to the first part of the artery lie the axillary vein

and a portion of the medial cord of the brachial plexus.

The first part of the axillary artery is enclosed with the

axillary vein and brachial plexus in a fibrous axillary

sheath that is continuous with the prevertebral layer of the

deep cervical fascia (1–4,8,12). The first part of the axillary artery gives off the superior (supreme) thoracic artery

(see under Main Branches: Axillary Artery, later) (11)

(Table 4.2).

238 Systems Anatomy

FIGURE 4.1. The main arterial trunks of the upper extremity.

The Second (Posterior) Part of the Axillary

Artery

The second (posterior) part of the axillary artery is approximately 3 cm long and consists of the portion of the artery

that lies deep to the pectoralis minor (7,8,11). This part

courses anterior to the subscapularis muscle and is surrounded by the cords of the brachial plexus. Anterior to the

artery lie the skin, superficial and deep fascia, the pectoralis

major muscle, and, immediately anterior to the artery, the

4 Vascular Systems 239

FIGURE 4.2. The axillary artery and its six associated branches. From proximal to distal, these

include the superior (supreme) thoracic artery arising from the first part of the axillary artery; the

thoracoacromial and lateral thoracic arteries arising from the second part of the axillary artery;

and the subscapular artery and the anterior and posterior humeral circumflex arteries arising

from the third part of the axillary artery.

pectoralis minor. Posterior to the second part of the artery

are the posterior cord of the brachial plexus and the areolar

tissue that separates the posterior cord from the deeperlying subscapularis. Lateral to the second part of the artery

are the lateral cord of the brachial plexus and the coracobrachialis. Medial to the second part of the artery are the

axillary vein, the medial cord of the brachial plexus, and the

medial pectoral nerve. The cords of the brachial plexus

therefore surround the second part of the axillary artery on

three sides (posterior, lateral, and medial), with the relative

positions implied by their names, and separate the artery

from the axillary vein and adjacent muscles (1–4,8,12). The

second part of the axillary artery gives off the thoracoacromial and lateral thoracic arteries (see later, under Main

Branches: Axillary Artery) (11) (see Table 4.1).

The Third (Distal) Part of the Axillary Artery

The third (distal) part of the axillary artery is approximately

7.5 cm long and extends from the lateral border of the pectoralis minor to the distal border of the tendon of the teres

major (7,8,11). Anterior to the proximal portion of this

third part is the pectoralis major muscle. Anterior to the

distal portion of the third part, the artery is covered only by

skin and superficial fascia. It is palpable in this subcutaneous location. Posterior to the third part of the artery are

the inferior part of the subscapularis muscle and the tendons of the latissimus dorsi and teres major. Lateral to the

third part of the artery is the coracobrachialis muscle.

Medial to the third part of the artery is the axillary vein.

The branches of the brachial plexus have the following relationships to the third part of the axillary artery: On the lateral aspect are the lateral root and trunk of the median

nerve, and, for a short distance, the musculocutaneous

nerve. On the medial aspect (between the axillary vein and

artery) lie the ulnar nerve and (to the medial aspect of the

vein) the medial brachial cutaneous nerve. Anterior to the

third part of the artery are the medial root of the median

nerve and the medial antebrachial cutaneous nerve. Posterior to the third part of the axillary artery are the radial and

axillary nerves. The axillary nerve extends only as far as the

distal border of the subscapularis (1,2). The third part of

the axillary artery gives off the subscapular artery and the

anterior and posterior humeral circumflex arteries (see later,

under Main Branches: Axillary Artery) (11) (see Table 4.1).

The direction and shape of the axillary artery varies with

the position of the arm (3,4). When the arm is at the side,

the axillary artery becomes convex superiorly. In this position, the third part of the artery is “clasped” by the two

heads of the median nerve (11). When the arm is raised

above the head, the axillary artery becomes concave superiorly. When the arm is abducted 90 degrees, the artery is

basically straight, and the two roots of the median nerve lie

loosely around the third part (3,4,11).

Main Branches: Axillary Artery

The first part of the axillary artery gives off the superior

(supreme) thoracic artery. The second part gives off the thoracoacromial and lateral thoracic arteries. The third part

gives off the subscapular artery and the anterior humeral

and posterior humeral circumflex arteries (see Table 4.1 and

Figs. 4.1 and 4.2).

Superior Thoracic Artery

The superior (supreme) thoracic artery arises from the proximal part of the first part of the axillary artery (see Figs. 4.1

and 4.2). It is a small branch that usually originates just distal to the clavicle, but variations include its origin from the

thoracoacromial artery or its complete absence (1–4,11).

The artery extends downward or medially, usually posterior

to the axillary vein, and continues along the chest wall in

the first and possibly second intercostal spaces (see Fig. 4.1).

The superior thoracic artery pierces the clavipectoral fascia

and courses between the pectoralis minor and pectoralis

major, supplying both muscles. It continues along the chest

wall and anastomoses with the internal thoracic and upper

one or two intercostal arteries. It also reaches and supplies

the sternoclavicular joint (8). Besides supplying the pectoralis major and minor, the superior thoracic artery supplies the associated intercostal muscles and the upper portion of the serratus anterior (7).

Thoracoacromial Artery

The thoracoacromial artery, arising from the second part of

the axillary artery, is a short arterial trunk with several

240 Systems Anatomy

TABLE 4.1. BRANCHES OF THE THREE PARTS THE

AXILLARY ARTERY

First (proximal) part of the axillary artery

Superior thoracic artery

Second (posterior) part of the axillary artery

Thoracoacromial artery

Clavicular branch

Pectoral branch

Deltoid branch

Acromial branch

Acromial rete

Lateral thoracic artery

Lateral (external) mammary branches

Third (distal) part of the axillary artery

Subscapular artery

Circumflex scapular artery

Thoracodorsal artery

Posterior humeral circumflex artery

Acromial rete (anastomosis)

Anterior humeral circumflex artery

Bicipital branch

Pectoral branch

branches of its own (3,4) (see Figs. 4.1 and 4.2). It originates deep to or just proximal to the proximal edge of the

pectoralis minor. Near the artery’s origin, it branches into

four terminal branches: the clavicular, humeral, acromial,

and pectoral branches. The artery or its separate branches

pierce the clavipectoral fascia and the branches radiate away

from each other to reach their respective destinations. The

thoracoacromial artery may initially divide into two short

trunks, one of which descends inferiorly and medially to

form the clavicular and pectoral branches, the other of

which ascends superiorly and laterally to form the acromial

and humeral branches.

The Clavicular Branch

The clavicular branch of the thoracoacromial artery usually

is relatively small and ascends or descends medially in a retrograde direction between the clavicular part of the pectoralis major and the clavipectoral fascia. The branch supplies the sternoclavicular joint, the subclavius muscle, and a

part of the thoracic wall (1,2,8). It may send a nutrient vessel to the clavicle (7).

The Pectoral Branch

The pectoral branch of the thoracoacromial artery is the

largest branch of the thoracoacromial artery. It descends

with the lateral pectoral nerve between the pectoralis minor

and pectoralis major muscles. It supplies both muscles, as

well as the breast. The pectoral branch then forms anastomoses with the intercostal branches of the internal thoracic

and lateral thoracic arteries (2). It may send a deep branch

posterior to the pectoralis minor that may supply the adjacent part of the thoracic wall (7).

The Deltoid Branch

The deltoid branch of the thoracoacromial artery also is a

relatively large branch, and often arises with the acromial

branch. It crosses anterior to the pectoralis minor but deep

to the clavicular head of the pectoralis major as it ascends

toward the lateral aspect of the shoulder. The branch continues along with the cephalic vein between the pectoralis

major and deltoid. It may give branches that pass through

the interval between the pectoralis major and deltoid to

become superficial to both muscles. The deltoid branch

supplies both the pectoralis major and the deltoid as it continues along the deltopectoral groove (3,4,8).

The Acromial Branch

The acromial branch of the thoracoacromial artery is a relatively small branch that often arises with the deltoid

branch. It ascends toward the superior aspect of the shoulder. The branch crosses over in the vicinity of the coracoid

process deep to the deltoid muscle. It either perforates the

deltoid or crosses through the interval between the deltoid

and the clavicular head of the pectoralis major. The acromial branch supplies the deltoid and continues superiorly

toward the acromion. At the acromion, the artery forms

anastomoses with the branches of the suprascapular artery,

the deltoid branches of the thoracoacromial artery, and the

posterior humeral circumflex arteries. The anastomosis over

the acromion is called the acromial rete (from the Latin rete,

which means “net”) (8).

Lateral Thoracic Artery

The lateral thoracic artery arises most commonly from the

second part of the axillary artery, but may have several common variations (see Figs. 4.1 and 4.2). It originates from the

second part of the axillary artery in approximately 50% of

individuals, from the subscapular artery in approximately

30%, from the first part of the axillary artery in approximately 11%, and from the thoracoacromial artery in 7%

(7). It passes deep to the pectoralis minor and descends

along the lateral border of the muscle to reach the thoracic

wall, passing anterior to the lateral cutaneous branches of

the thoracic segmental nerves. It continues downward along

the superficial aspect of the serratus anterior. It usually has

a branch that extends laterally across the axilla to reach the

anterior surface of the subscapularis and the axillary lymph

nodes. The lateral thoracic artery forms anastomoses with

the internal thoracic, subscapular, and intercostal arteries

and the pectoral branch of the thoracoacromial artery. The

artery supplies the pectoralis minor and major, the serratus

anterior, the subscapularis, the second to fifth intercostal

spaces, and the axillary lymph nodes. In women, the lateral

thoracic artery is large and also forms the lateral mammary

branches (sometimes referred to as the external mammary

branches). These branches can be of considerable size, and

curve around the free lateral border of the pectoralis major

to supply the breast (1–4).

Subscapular Artery

The subscapular artery usually is the largest branch of the

axillary artery (see Figs. 4.1 and 4.2). It arises from the third

part of the axillary artery at the distal border of the subscapularis muscle. It descends along the anterior surface of

the subscapularis muscle, deep to the latissimus dorsi. It

usually lies adjacent to the lower subscapular and thoracodorsal nerves. The subscapular artery usually is accompanied by several veins, which unite and communicate with

the circumflex scapular vein and continue to either the axillary vein or the medial brachial vein. At approximately 2.5

to 4 cm from its origin point from the axillary artery, the

subscapular artery divides into the circumflex scapular and

thoracodorsal arteries (3,4).

The Circumflex Scapular Artery

The circumflex scapular artery usually is larger than the

thoracodorsal artery, and courses posteriorly and then

medially. It curves around the lateral border of the scapula

4 Vascular Systems 241

to pass through the triangular space (bordered by the teres

minor and subscapularis superiorly, the teres major inferiorly, and the long head of the triceps laterally) (3,4). The

circumflex scapular artery then enters the infraspinous fossa

between the teres minor and the scapula, and remains close

to the posterior surface of the scapula. The artery then

forms anastomoses with the several intercostal arteries and

with the deep branch of the transverse cervical artery or

with the descending branch of the descending scapular

artery. The posterior portion of circumflex scapular artery

supplies the infraspinatus muscle. As the artery passes

through the triangular space, it usually gives a branch to the

subscapularis muscle. The circumflex scapular artery usually

also has another large branch that continues along the lateral border of the scapula between the teres major and teres

minor. This branch may form anastomoses with the deep

branch of the transverse cervical artery (or descending

branch of the descending scapular at the inferior angle of

the scapula). The vessel supplies the teres major and minor

muscles as well as the long head of the triceps and the deltoid (1,3,4). There also may be additional anastomoses with

other arteries in the shoulder region, and branches originating from the suprascapular artery may contribute to vascularity of the rotator cuff (13) (Table 4.1 and Fig. 4.2).

The Thoracodorsal Artery

The thoracodorsal artery is the continuation of the scapular

artery and courses inferiorly across the axilla along the anterior border of the latissimus dorsi muscle. The artery lies adjacent to the thoracodorsal nerve. The thoracodorsal artery

forms anastomoses with the circumflex scapular artery and

with the deep branch of the transverse cervical artery (or

descending branch of the descending scapular artery). The

thoracodorsal artery supplies the subscapularis as well as providing the principal vascular supply to the latissimus dorsi.

One or two large branches cross the axilla to supply the serratus anterior and intercostal muscles. These branches may

form anastomoses with the intercostal, lateral thoracic, and

thoracoacromial arteries. When the lateral thoracic artery is

small or absent, a branch of the thoracodorsal may supply the

associated muscles (1,3,4) (Table 4.1 and Fig. 4.2)

Additional subscapular branches may arise from the second or third part of the axillary artery and descend to supply the subscapularis. One branch that usually is consistent

accompanies the upper subscapular nerve (7).

Anterior Humeral Circumflex Artery

The anterior humeral circumflex artery, along with the posterior humeral circumflex artery, are the most distal arterial

branches from the axillary artery (see Table 4.1 and Figs. 4.1

and 4.2). It is much smaller than the posterior humeral circumflex artery and originates from the third part of the axillary artery near the inferior border of the subscapularis muscle. The posterior humeral circumflex artery also originates at

the same level on the axillary artery. The anterior humeral circumflex artery may arise from a common trunk with the posterior humeral circumflex or consist of several small branches.

The anterior humeral circumflex artery leaves the axillary

artery along the superior or lateral margin of the arterial

trunk and ascends upward or laterally deep to the coracobrachialis muscle and short head of the biceps brachii. It

curves anterior to the neck of the humerus. As it reaches the

intertubercular sulcus of the humerus, the anterior humeral

circumflex artery gives off a branch, the bicipital branch of

the anterior humeral circumflex, that ascends in the sulcus to

supply the tendon of the long head of the biceps, the head of

the humerus, and the shoulder joint. A pectoral branch of the

anterior humeral circumflex artery may descend along the

tendon of insertion of the pectoralis major. This branch contributes to the vascular supply of the pectoralis major tendon.

The main branch of the artery continues laterally, in close

proximity to the humerus, deep to the long head of the

biceps brachii and the deltoid. It forms an anastomosis with

the posterior humeral circumflex artery (3,4).

Posterior Humeral Circumflex Artery

The posterior humeral circumflex artery, along with the anterior humeral circumflex artery, are the most distal arterial

branches from the axillary artery (see Table 4.1 and Figs. 4.1

and 4.2). It originates from the third part of the axillary

artery near the inferior border of the subscapularis muscle,

and is much larger than the anterior humeral circumflex

artery. The posterior humeral circumflex artery courses deep

and posteriorly, to pass through the quadrangular space (bordered by the teres minor and subscapularis superiorly, the

long head of the triceps brachii medially, the teres major inferiorly, and the surgical neck of the humerus laterally). The

artery curves around the surgical neck of the humerus and

forms anastomoses with the anterior humeral circumflex

artery, the deltoid branch of the profunda brachii artery, and

the acromial branches of the suprascapular and thoracoacromial arteries. The posterior humeral circumflex artery provides branches to the deltoid, the teres major and minor, the

long and lateral heads of the triceps brachii, the greater

tuberosity of the humerus, and the shoulder joint. The posterior humeral circumflex may have anastomoses with the

acromial rete (3,4).

Anomalies and Variations: Axillary Artery

The axillary artery has considerable variations in its branch

patterns (14–18). The branches described previously may

arise together, or their subsequent smaller branches may be

given off directly by the main axillary artery. Instead of 6

branches, the axillary artery may have a total of 5 to 11 (8).

The axillary artery has been noted to pass posterior to the

medial cord of the brachial plexus (19).

Bilateral double axillary arteries have been noted (20).

242 Systems Anatomy

A thoracoepigastric artery is a rare variation of a branch

that arises from the axillary artery (14). The branch leaves

the axillary artery and passes as a common trunk between

the roots of the median nerve, and divides into two

branches. The lateral one gives rise to muscular branches

that supply the shoulder and fasciae, whereas the medial

one descends on the anterior aspect of the axillary fossa,

reaching the hypogastric region. The artery forms an anastomosis with the superficial epigastric artery, which is a

branch of the femoral artery (14).

An alar thoracic artery is a branch, usually from the second part of the axillary artery, that specifically supplies the

fat and lymph nodes in the axilla (3).

The vascular supply to the serratus anterior muscle usually originates from the thoracodorsal artery and vein.

Goldberg et al. noted that the artery to the serratus anterior

could originate directly from the subscapular artery (21).

The thoracodorsal pedicle arose directly from the axillary

artery and separately from the subscapular vascular pedicle

in 3% of cases. This has implications for dissection and

transfer of the serratus anterior (21).

The lateral thoracic artery arises most commonly from

the second part of the axillary artery and is conventionally

illustrated as such in anatomy textbooks. This, however, is

observed only in approximately 50% of individuals. Its origin is variable, and includes the subscapular artery in

approximately 30%, from the first part of the axillary artery

in approximately 11%, and from the thoracoacromial

artery in 7% (7). The lateral thoracic artery has been noted

to originate proximal to the origin of the superior thoracic

artery (instead of its usual more distal origin point) (15).

The subscapular artery usually arises from the third part

of the axillary artery. Variations include point of origin from

the second part of the axillary in approximately 15%, or

from a common trunk with the posterior humeral circumflex artery in approximately 15% (7).

The subscapular, anterior and posterior humeral circumflex

arteries, and the profunda brachii artery may arise from a

common branch. The branches of the brachial plexus can

surround this anomalous artery instead of the axillary artery

(3,4,7). The posterior humeral circumflex and the subscapular arteries may share a common trunk in approximately 15%

(7). The posterior humeral circumflex artery may originate

from the profunda brachii artery, passing inferior to the teres

major instead of through the quadrangular space (3,4).

The axillary artery may give rise directly to the radial and

ulnar arteries in the axilla, sometimes referred to as the high

division axillary anomaly (22–34). The high origin of the

radial artery is among the most common of all vascular variations in the upper extremity (23,24). Celik and colleagues

noted this anomaly in 7 of 81 (8.6%) of arteriograms, and it

represented 86% of all variations noted in their series (24).

The radial artery can be connected to the axillary artery (or

occasionally to the brachial artery) through a long, slender

anastomotic artery, referred to as the vasa aberrantia (25).

High division of the ulnar artery from the axillary is rare

compared with the anomaly in the radial artery (24,26).

This has been observed in only approximately 1% to 2% of

cases (22,24,29), originating from the second part of the

axillary artery. High division of the ulnar artery can occur

concomitantly with a high division of the radial artery (22).

The high division involving the ulnar artery has been

referred to as a superficial ulnar artery (27–34). The superficial ulnar artery has been noted to cross ventral to the medial

root of the median nerve before continuing toward the

medial part of the arm (27,33,34). The superficial ulnar

artery may cross superficial to the median nerve and brachial

artery. In general, the anomalous ulnar artery is smaller than

the radial artery or interosseous arteries. When the ulnar

artery originates directly from the axillary artery, it has been

noted that the common interosseous artery (which usually

originates from the ulnar artery) originates from the radial

artery (30). These anomalies of the radial and ulnar arteries

may be bilateral (23,27,31).

The axillary artery also may give rise directly to an anterior

interosseous artery. Similarly, the axillary artery may divide in

the axilla into two main branches. The branches continue into

the arm, where one usually runs more superficially and may

represent the radial or ulnar arteries; the deeper branch usually

corresponds to the brachial artery proper (8).

Clinical Correlations: Axillary Artery

The axillary artery is easily palpable in its third (distal) part,

as it crosses anterior to the teres major and is covered on the

lateral axillary surface only by skin and fascia. This is a useful landmark for the administration of local anesthesia for

the placement of an axillary block regional anesthetic

(35–38). The more proximal portions of the artery can be

mapped out, when the arm is raised, by a line drawn from

the point of artery palpation (distal part) to the mid-clavicle (area of the proximal part). Although it is used as a landmark to identify the brachial plexus, pseudoaneurysm or

obliteration of the axillary artery can occur from injury to

the artery from axillary block (39,40).

In anatomic and operative dissections of the axilla, the

coracoid process and pectoralis minor are key landmarks for

identification of the axillary artery and surrounding

brachial plexus. The second part of the axillary artery lies

deep to the pectoralis minor. From this second part of the

axillary artery, the specific designation of the cords of the

brachial plexus has been made [the lateral cord lies lateral to

the axillary artery (second part), the medial cord lies medially, and the posterior cord lies posteriorly] (1–4,11). Thus,

the pectoralis minor can help with identification of the second part of the axillary, and this also corresponds to the

level of the brachial plexus that contains the cords.

The second part of the axillary artery lies inferior to the

coracoid process, deep to the pectoralis minor. Risk of

injury to the artery may be lessened if the arm is adducted

4 Vascular Systems 243

while performing operative procedures involving the coracoid process (6,8).

An appreciation of the relatively high incidence (8.6%) of

the anomalous radial artery or, less commonly, the ulnar

artery originating high in the axilla directly from the axillary

artery, is important during the operative exposure of the axilla

or forearm or in the interpretation of arteriograms (23,24).

These variations also may be relevant in the dissection for

pedicle and free flaps that are based on the forearm arteries.

The axillary artery is vulnerable to injury from a variety

of well documented trauma events. These include proximal

humeral fractures or dislocations, which can cause thrombosis (from torn intima), pseudoaneurysm, or rupture

(41–52). Clavicle fractures are a less common cause of axillary artery injury (48). Penetration of the artery by the

proximal locking screws of humeral intramedullary nails

has been reported (50). In addition, chronic, incorrect use

of crutches has been associated with axillary artery stenosis,

aneurysm formation, and secondary axillobrachial thromboembolic disease (51,52).

Of all upper extremity emboli, up to 20% arise from an

arterial, not a cardiac source (51). Axillary artery thromboses contribute to a substantial number of these cases.

Sports-related trauma, especially that involving professional baseball pitchers, is well known to cause injury to the

axillary artery (53–57). Arterial aneurysm, thrombosis, or

occlusion can lead to hand ischemia from insufficiency or

emboli (57,58).

Several muscles or related structures can compress the

axillary artery. Thrombosis of the axillary artery has

occurred from compression by the pectoralis minor or from

an anomalous muscle in the axillary fossa (58–60).

Quadrilateral Space Syndrome

Quadrilateral space syndrome consists of compression of

the posterior humeral circumflex artery and the axillary

nerve by fibrotic bands as the artery and the nerve traverse

the quadrilateral space (61). Symptoms often are secondary

to compression of the axillary artery, not the posterior

humeral circumflex artery. Because of the vague, often nonspecific clinical presentation of patients with quadrilateral

space syndrome, diagnosis is challenging and requires a

high index of suspicion. Subclavian arteriography confirms

the diagnosis. Conservative treatment has been successful;

operative management is reserved for selected, refractory

patients (61).

BRACHIAL ARTERY

Gross Anatomic Description: Brachial

Artery

The brachial artery, which is a continuation of the axillary

artery, begins at the distal margin of the teres major and

continues approximately 1 cm distal to the elbow, where it

ends to form the radial and ulnar arteries (7,11) (Fig. 4.3;

see Figs. 4.1 and 4.2). It passes down the medial aspect of

the arm and becomes more anteriorly located as it descends

so that it is along the anteromedial aspect of the elbow

joint. It is superficial and palpable along its course, covered

only by skin and superficial and deep fascia. The artery

passes deep to the bicipital aponeurosis. In the proximal

part of the arm, the median nerve lies anterior to the

brachial artery. The median nerve crosses the brachial artery

in the mid-portion of the arm so that the nerve lies medial

to the artery at the elbow. The ulnar nerve lies immediately

medial to the brachial artery in the proximal part of the

arm. The brachial artery then curves anteriorly away from

the ulnar nerve so that the two structures are separated from

each other at the elbow.

In the proximal arm, located posterior to the brachial

artery, is the radial nerve and the profunda brachii artery,

and the long head of the triceps. The brachial artery then

passes along the medial head of the triceps, along the insertion of the coracobrachialis, and then continues along the

brachialis. In the proximal arm, lateral to the brachial

artery, is the median nerve and coracobrachialis. More distally, the biceps brachii lies lateral to the artery. On the

medial aspect of the artery, in the proximal arm, are the

medial antebrachial cutaneous nerve and ulnar nerves.

More distally, the median nerve is located medially after it

crosses the artery. The basilic vein also lies along the medial

aspect of the brachial artery, but is separated from the artery

in the distal part of the arm by fascia. The brachial artery

usually is accompanied by two venae comitantes, which lie

in close contact to the artery and are interconnected at

intervals by short transverse branches (1–6,11).

At the elbow, the brachial artery courses anteriorly to

cross the mid-portion of the cubital fossa. It is covered anteriorly by skin, superficial fascia, and the median cubital

vein. At the level of the radial neck, the brachial artery

divides into the radial and ulnar arteries. In the cubital

fossa, the brachialis lies posterior and lateral to the brachial

artery. The median nerve lies medial to the artery as it

divides into the radial and ulnar arteries (3).

244 Systems Anatomy

TABLE 4.2. BRANCHES OF THE BRACHIAL ARTERY

Profunda brachii (deep brachial artery)

Deltoid (ascending) branch

Radial collateral artery

Middle collateral artery

Nutrient (accessory) branch to the humerus

Principal nutrient artery of the humerus

Superior ulnar collateral artery

Inferior ulnar collateral artery

Posterior branch

Anterior branch

Muscular branches

Main Branches: Brachial Artery

The brachial artery gives off the profunda brachii artery, the

superior and inferior ulnar collateral arteries, as well as a

principal nutrient artery of the humerus and several muscular branches (3) (see Figs. 4.2 and 4.3 and Table 4.2).

Profunda Brachii Artery

The profunda brachii artery (deep brachial artery) is the

largest and most proximal branch of the brachial artery (see

Figs. 4.2 and 4.3). It arises from the posteromedial aspect of

the brachial artery just distal to the distal border of the teres

major. The profunda brachii artery initially spirals backwards into the posterior compartment of the arm between

the long and lateral heads of the triceps brachii. Proximally,

the profunda brachii gives off the deltoid ascending branch.

The profunda brachii artery then continues distally along

with the radial nerve in the spiral groove of the humerus

between the lateral and medial heads of the triceps. The

nerve and artery continue posterior to the humerus. The

profunda brachii artery divides into the radial collateral and

the middle collateral arteries. The profunda brachii also

gives off a nutrient branch to the humerus (3).

4 Vascular Systems 245

FIGURE 4.3. The brachial artery and major branches,

including the collateral circulation of the elbow.

The Deltoid Ascending Branch

The deltoid ascending branch of the profunda brachii is a

small artery that leaves the profunda brachii artery proximally and ascends between the long and lateral heads of the

triceps brachii. It anastomoses with a descending branch of

the posterior humeral circumflex artery (arising from the

axillary artery). In 7%, the anastomosis to the posterior

humeral circumflex artery may be the major or sole source

of the profunda brachii. In addition, this anastomosis may

be the major or sole source of the posterior humeral circumflex from the profunda brachii in 16% (7). The deltoid

ascending branch helps supply the brachialis and deltoid

muscles (1,3,7) (Table 4.2).

The Radial Collateral Artery

The radial collateral artery of the profunda brachii is one

of the terminal distal divisions of the profunda brachii

artery. [The middle collateral artery of the profunda is the

other terminal division (see later).] The radial collateral

artery, frequently described as the terminal portion of the

profunda brachii, continues along with the radial nerve,

along the humerus and on the surface of the lateral head of

the triceps brachii. It continues distal to the elbow to enter

the forearm, still in association with the radial nerve. The

artery lies deep to the lateral head of the triceps to the level

of the lateral supracondylar ridge of the humerus. Here it

courses anteriorly to cross through the lateral intermuscular septum into the flexor compartment of the arm, and

continues distally between the brachioradialis and the

brachialis muscles to the palmar aspect of the lateral epicondyle. The radial collateral artery terminates as it anastomoses with the radial recurrent artery. Other branches

may follow the posterior antebrachial cutaneous nerve and

continue with the nerve to reach the skin. Before the radial

collateral artery pierces the intermuscular septum, it may

give a branch that continues distally to the posterior aspect

of the lateral epicondyle and contributes to the anastomoses around the elbow. The radial collateral artery usually

contributes to the intraosseous circulation of the capitellum and the lateral aspect of the trochlea as well (62)

(Table 4.2 and Fig. 4.3).

The Middle Collateral Artery

The middle collateral artery of the profunda brachii usually

is larger than the radial collateral artery. Along with the

radial collateral, the middle collateral artery is the terminal

division of the profunda brachii artery. The middle collateral artery passes through the long and medial heads of the

triceps muscle and continues distally posterior to the

humeral diaphysis and lateral epicondyle. At the distal

humerus, the middle collateral artery forms an anastomosis

with the interosseous recurrent artery and contributes to the

anastomoses around the elbow (3,4). This anastomosis has

been referred to as the olecranon articula rete (7) (Table 4.2

and Fig. 4.3).

An Accessory Nutrient Artery

An accessory nutrient artery of the profunda brachii usually

is given off of the profunda brachii artery, which supports

the principal nutrient artery from the brachial artery. This

accessory nutrient artery usually enters the humerus

through a nutrient canal located posterior to the deltoid

tuberosity. This branch may be absent (3,4) (Table 4.2).

Principal Nutrient Artery of the Humerus

The humerus has one main or principal nutrient artery.

This artery arises directly from the brachial artery in the

mid-portion of the arm, often near the origin of the superior ulnar collateral artery or, less frequently, from the superior ulnar collateral artery itself (7). The nutrient artery

enters the humerus through a nutrient canal located near

the insertion of the coracobrachialis, near or distal to the

middle of the humerus but anterior to the proximal end of

the medial supracondylar ridge (3,4,7) (Table 4.2).

Superior Ulnar Collateral Artery

The superior ulnar collateral artery arises from the brachial

artery at a level just distal to the mid-portion of the arm (see

Table 4.2 and Figs. 4.2 and 4.3). It also may originate from

the proximal part of the profunda brachii in up to 22% (7).

It is a long, slender vessel that pierces the medial intermuscular septum to reach the posterior compartment of the

arm. The artery joins the ulnar nerve and both structures

continue distally along the medial head of the triceps

brachii. The artery and nerve course posteriorly behind the

medial epicondyle in the interval between the epicondyle

and the olecranon. The vessel continues deep to the flexor

carpi ulnaris. Traditional textbooks usually show or discuss

an anastomosis of the superior ulnar collateral artery with

the posterior ulnar recurrent artery (1–4); however, recent

studies demonstrated no identifiable direct anastomosis

between these arteries in 20 of 22 specimens (62). There

usually is a more proximal anastomosis with the inferior

ulnar collateral artery just proximal to the medial epicondyle (Fig. 4.2). The superior ulnar collateral artery also

may anastomose with the anterior ulnar recurrent artery

and may provide a branch to the medial epicondyle (1,2).

The superior ulnar collateral artery (along with the inferior

ulnar collateral and the posterior ulnar recurrent arteries)

provides a segmental extraneural and intraneural vascular

supply to the ulnar nerve (62–64).

Inferior Ulnar Collateral Artery

The inferior ulnar collateral artery originates from the

medial side of the brachial artery approximately 5 cm proximal to the medial epicondyle (see Table 4.2 and Figs. 4.2

and 4.3). It continues medially on the surface of the

brachialis and divides into anterior and posterior branches.

246 Systems Anatomy

The posterior branch crosses through the medial intermuscular septum to the posterior compartment of the arm. This

branch passes laterally on the dorsal aspect of the distal

humerus, deep to the triceps brachii to reach the lateral

aspect of the posterior humerus. This branch anastomoses

with the middle collateral branch of the profunda brachii at

the lateral margin of the humerus. By this junction with the

middle collateral branch, the inferior ulnar collateral artery

forms an arterial arch just proximal to the olecranon fossa.

At the medial margin of the humerus, the posterior branch

also may provide a branch that communicates with the superior ulnar collateral and the posterior ulnar recurrent arteries

(posterior to the medial epicondyle). The anterior branch of

the inferior ulnar collateral artery, which leaves the trunk at

the medial aspect of the humerus, continues distally and

passes anterior to the distal humerus and medial epicondyle

to communicate with the anterior ulnar recurrent artery.

The inferior ulnar collateral also contributes to the vascular

supply to the medial aspect of the trochlea through a circumferential vascular ring that originates from the inferior

ulnar collateral artery at the level of the elbow (62).

Recent studies have shown that the inferior ulnar collateral artery (along with the superior ulnar collateral and the

posterior ulnar recurrent arteries) provides a segmental

extraneural and intraneural vascular supply to the ulnar

nerve (63). The inferior ulnar collateral artery provides the

only direct vascularization to the nerve in the region just

proximal to the cubital tunnel (62–64).

Muscular Branches

There are usually three or four muscular branches that originate from the brachial artery to supply the coracobrachialis,

biceps brachii, and the brachialis muscles (Table 4.2).

Anastomoses of the Brachial Artery

The branches of the brachial artery form an anastomotic

network posterior and anterior to the elbow, with interconnections to branches from the radial and ulnar arteries (see

Fig. 4.3). These have been described individually previously. For descriptive purposes and to summarize, these

have been divided by Clemente into those that pass anterior

and those that pass posterior to the medial and lateral epicondyles of the humerus (3).

The branches that anastomose anterior to the medial epicondyle include the anterior branch of the inferior ulnar collateral, the anterior ulnar recurrent, and (possibly) an anterior branch of the superior ulnar collateral. The branches

that anastomose posterior to the medial epicondyle include

the inferior ulnar collateral, the posterior ulnar recurrent,

and the posterior branch of the superior ulnar collateral.

The branches that anastomose anterior to the lateral epicondyle include the radial recurrent and the radial collateral

branch of the profunda brachii artery.

The branches that anastomose posterior to the lateral

epicondyle include the middle collateral branch of the profunda brachii, the interosseous recurrent artery, and the terminal portion of the inferior ulnar collateral artery as it

reaches the lateral aspect of the humerus.

A transverse arch is formed on the posterior aspect of the

humerus proximal to the olecranon fossa. This arch is

formed by the anastomoses of the inferior ulnar collateral,

posterior ulnar recurrent, the middle collateral branch of

the profunda brachii, and the interosseous recurrent arteries (1).

Yamaguchi and colleagues have divided the extraosseous

vascular patterns of the elbow into three vascular arcades:

medial, lateral, and posterior. The medial arcade is formed

by the superior and inferior ulnar collateral arteries and the

posterior ulnar recurrent artery. The lateral arcade is formed

by the radial and middle collateral, radial recurrent, and the

interosseous recurrent arteries. The posterior arcade is

formed by the medial and lateral arcades and the middle

collateral artery (62).

Anomalies and Variations: Brachial

Artery

High (proximal) divisions of the brachial artery: Several

anomalous branches or variations of branches of the

brachial artery have been described (22,33,65–85). Most

common are the more proximal divisions of the brachial

artery, occurring in 12% to 15% (7,83). These are often

referred to as high divisions. (See also earlier discussion of

high division of the axillary artery, which includes several

analogous branches from the axillary artery.) The superficial

brachial artery is an anomalous artery that originates from

a high division of the brachial artery (1,7,73–75,78), usually proximal in the arm, and has been observed to occur in

as low as 1% and as high as 17% of individuals (66–69,

72,83). It can continue into the forearm as the superficial

antebrachial artery or may rejoin the brachial artery distally

(66,69). In addition, a high division of the brachial artery

can form the radial, ulnar, and common interosseous arteries more proximally, at the level of the arm. Considered to

be among the most frequent of the high divisions, the radial

artery can branch high in the arm, occurring in up to 7%

to 15% (7,22,65,70,76,78,79,81). When the radial artery

arises high from the brachial artery, the other limb of the

bifurcation consists of the ulnar and common interosseous

arteries. In some cases, the ulnar artery can arise more proximally than normal, and the radial and common

interosseous form the other limb of the bifurcation (33,

80,81,86,87). The incidence of the high division of the

ulnar artery is much less than that of the radial artery,

occurring only in approximately 2% (7). Occasionally the

common interosseous arises at a more proximal level (1), or

may be absent in the presence of a high radial artery division (77).

4 Vascular Systems 247

A distal division of the radial and ulnar arteries has been

noted to occur 8 cm distal to the antecubital fossa (82).

This distal division has implications in preparing the radial

forearm flap.

Absent brachial artery and branches: Agenesis of the

brachial artery, profunda brachii artery, and superior and

inferior ulnar collateral arteries has been noted. The axillary

artery supplies collateral circulation to the forearm (88).

Vasa aberrantia: The vasa aberrantia is an anomalous

series of long slender vessels that anastomose with the

brachial or axillary artery and radial or ulnar arteries (or one

of their branches). Interconnections with the radial artery

are more common (1–4).

If there is a supracondylar process present with the commonly associated ligament of Struthers, the brachial artery

(with the median nerve) often passes deep to the ligament

(the ligament often is a proximal extension of the pronator

teres). The brachial artery, along with the median nerve,

takes a medial course along the border of the biceps toward

the medial supracondylar area. The structures then pass

deep to the pronator teres to reach the elbow region. [Note:

In the presence of the ligament of Struthers, the median

nerve may pass deep to the ligament, accompanied by the

inferior ulnar collateral artery (with the brachial artery

assuming its usual course) (1–4,7,89)].

The profunda brachii has considerable variation in its

origin. It exists as the classic artery as described earlier only

in approximately 55%, in which it arises as a single trunk

from the posteromedial aspect of the brachial artery. The

site of origin is at or slightly distal to the level of the teres

major (1,2,7). Variations include the vessel originating as a

common trunk with the superior ulnar collateral artery in

22%, from the axillary artery in 16%, or as a branch of the

posterior humeral circumflex artery in 7% (7).

Clinical Correlations: Brachial Artery

Collateral Circulation

As described previously, there is a well established series of

anastomoses around the elbow and shoulder. This provides

a substantial collateral circulation. If there is laceration or

mechanical block (e.g., from a ligature) of the brachial

artery in the proximal third of the arm (proximal to the origin of the profunda brachii), blood can possibly flow

through branches from the anterior and posterior humeral

circumflex and subscapular arteries to communicate with

the ascending branches of the profunda brachii artery. If the

main trunk of the brachial artery is blocked distal to the

level of the profunda brachii and the superior ulnar collateral arterial origins, circulation may possibly be maintained

by branches through these vessels, which anastomose with

the inferior ulnar collateral, posterior ulnar recurrent, the

radial recurrent, and the interosseous recurrent arteries (3).

Brachial Artery, Supracondylar Process, and

the Ligament of Struthers

In the presence of a supracondylar process and associated

ligament of Struthers, the median nerve and brachial artery

often pass deep to the ligament. Although median nerve

compression under the ligament is discussed more commonly, potential arterial compromise also is possible (89).

The brachial artery usually takes a more medial course

along the medial aspect of the biceps if it passes deep to the

ligament of Struthers. It then passes deep to the pronator

teres at the level of the elbow.

ULNAR ARTERY

Gross Anatomic Description: Ulnar Artery

The ulnar artery is formed as one of the two main terminating branches of the brachial artery (Fig. 4.4; see Fig.

4.3). The brachial artery bifurcates approximately 1 cm distal to the elbow joint into the ulnar and radial arteries. The

ulnar artery usually is the larger of the two, originating on

the ulnar side of the brachial artery at the level of the radial

neck and distal base of the coronoid process. From its point

of origin it courses distally and medially, and reaches the

ulnar margin of the forearm approximately midway

between the elbow and wrist joints. The ulnar nerve joins

the ulnar artery in the proximal quarter of the forearm, with

the nerve located ulnar to the artery. The nerve accompanies the ulnar artery through the forearm to the wrist. From

the mid-forearm distally, the artery continues along the

ulnar margin of the distal half of the forearm. The artery

and nerve cross the wrist superficial to the flexor retinaculum, with both structures on the radial side of the pisiform.

The artery supplies a portion of the flexor retinaculum as it

continues distally (90). The artery and nerve pass through

the ulnar tunnel (Guyon’s canal), and the distal part of the

ulnar artery forms the superficial palmar arch (1–4,7,11).

In the proximal half of the forearm, the ulnar artery is

located deep to the pronator teres, flexor carpi radialis, palmaris longus, and flexor digitorum superficialis muscles. It

lies superficial to the brachialis for a short distance, and

continues distally throughout the forearm superficial to the

flexor digitorum profundus muscles. Proximally, the

median nerve is located medial to the artery for a short distance. At approximately 2 to 3 cm distal to the origin point

of the ulnar artery, the median nerve crosses superficial to

the ulnar artery (separated from the artery by the ulnar half

of the pronator teres). The median nerve then continues on

the lateral side of the artery (1–4,11).

In the distal half of the forearm, the ulnar artery lies

superficial to the flexor digitorum profundus, between the

flexor digitorum superficialis (located radially) and the

flexor carpi ulnaris (located ulnarly). The ulnar nerve

248 Systems Anatomy

remains ulnar to the artery throughout the distal forearm

and gives off the palmar cutaneous branch of the ulnar

nerve, which continues distally along the distal ulnar artery

to reach the palm. The ulnar artery has a superficial course

in the distal forearm, covered anterior by the deep and

superficial fascia, and skin. The ulnar artery usually has two

adjacent venae comitantes (1–4,11). Proximal to the wrist,

the ulnar artery forms anastomoses with the anterior

interosseous artery, and both provide vascularity to the distal ulna and associated soft tissues (91,92).

4 Vascular Systems 249

FIGURE 4.4. The main arteries of the

palmar forearm and hand.

At the level of the wrist, the ulnar artery crosses superficial to the flexor retinaculum, with the ulnar nerve continuing on the dorsoulnar aspect of the artery. Both structures

pass radial to the pisiform.

The ulnar artery and nerve enter the ulnar tunnel

(Guyon’s canal), covered anteriorly by fascia, skin, and the

palmaris brevis muscle (1–4).

Main Branches: Ulnar Artery

The main branches of the ulnar artery can be divided into

three groups: those in the forearm, wrist, and palm (Table

4.3). The forearm branches include the anterior ulnar recurrent artery, the posterior ulnar recurrent artery, the common

interosseous artery (which divides in the anterior and posterior interosseous arteries), and several muscular branches.

The wrist branches include the palmar carpal and dorsal

carpal arteries. The branches in the hand include the deep

palmar arch and the superficial arch (which give rise to the

common palmar digital arteries).

Anterior Ulnar Recurrent Artery

The anterior ulnar recurrent is the most proximal branch of

the ulnar artery, arising from the medial aspect of the ulnar

artery just distal to the ulnar artery origin from the brachial

artery (see Figs. 4.3 and 4.4). The artery passes anteriorly

and proximally between the brachialis and the pronator

teres. It continues anterior to the medial epicondyle to anastomose with the interior ulnar collateral artery. The anterior

ulnar recurrent artery supplies the brachialis and pronator

teres muscles.

Posterior Ulnar Recurrent Artery

The posterior ulnar recurrent usually is the second main

branch of the ulnar artery (see Figs. 4.3 and 4.4). The posterior ulnar recurrent artery usually is larger than the anterior ulnar recurrent artery and arises more distally from the

medial aspect of the ulnar artery. The posterior ulnar recurrent artery passes posteriorly and proximally between the

flexor digitorum superficialis and flexor digitorum profundus, and continues in a proximal direction posterior to the

medial epicondyle. As the artery ascends, it passes through

the interval between the medial epicondyle and the olecranon, with the artery passing adjacent to the ulnar nerve in

this region. The artery continues either deep to or between

the heads of the flexor carpi ulnaris. The posterior ulnar

recurrent artery continues proximally to anastomose with

the superior and inferior ulnar collateral and the

interosseous recurrent arteries. The posterior ulnar recurrent artery supplies the flexor digitorum superficialis, flexor

digitorum profundus, flexor carpi ulnaris, and elbow joint,

as well as extending to several of the other neighboring

muscles (1–4). The artery also contributes to the vascular

supply to the olecranon (along with vessels from the

interosseous recurrent artery) from vessels given off that

course along the medial and lateral aspect of the distal end

of the humerus (62). In addition, the posterior ulnar recurrent artery (with the superior and inferior ulnar collateral

arteries) provides a segmental extraneural and intraneural

vascular supply to the ulnar nerve (62–64).

Common Interosseous Artery

The common interosseous usually is the third main branch

from the ulnar artery (see Figs. 4.3 and 4.4). It is a short, thick

vessel, only approximately 1 cm long (93–96). The common

interosseous artery arises from the posterolateral aspect of the

ulnar artery from a point approximately 1 cm distal to the

branch point of the posterior ulnar recurrent artery. Its branch

point corresponds to the level of the radial tuberosity. A rare

high division of the common interosseous artery has been

noted, arising from the brachial artery in the proximal or distal third of the arm (77,96) (see later, under Anomalies and

Variations: Ulnar Artery and Its Branches). The artery divides

250 Systems Anatomy

TABLE 4.3. BRANCHES OF THE ULNAR ARTERY

Branches in the forearm

Anterior ulnar recurrent artery

Posterior ulnar recurrent artery

Common interosseous artery

Anterior interosseous artery

Median artery

Muscular branches to forearm

Nutrient vessels to radius and ulna

Palmar carpal branch

Palmar radiocarpal arch

Palmar intercarpal arch

Palmar carpal network

Dorsal carpal network

Dorsal carpal branch

Dorsal radiocarpal arch

Dorsal intercarpal arch

Basal metacarpal arch

Posterior interosseous artery

Interosseous recurrent artery

Dorsal carpal network

Muscular branches

Branches at the wrist

Palmar carpal artery

Transverse arches at the carpus

Palmar radiocarpal arch

Palmar intercarpal arch

Dorsal carpal artery

Branches in the hand

Deep palmar artery

Superficial palmar arch

Common palmar digital arteries

Proper palmar digital arteries

Dorsal branches (to the dorsal digital arteries)

Vinculum longum superficialis

Vinculum brevis superficialis

Vinculum longum profundus

Vinculum brevis profundus

into two main branches, the anterior and posterior

interosseous arteries. Both of these arteries have received

attention in anatomic studies because of their relevance in

pedicle or free tissue flaps or grafts of the forearm (97–127).

The Anterior Interosseous Artery (Proximal Part)

The anterior interosseous artery arises a few centimeters

distal to the level of the radial tuberosity (see Fig. 4.4).

The diameter of the artery at its origin varies from 0.9 to

1.5 mm (101). It passes through the deep flexor compartment of the forearm along the anterior interior

interosseous ligament. The anterior interosseous artery is

accompanied by the anterior interosseous nerve. Along its

course in the forearm, the artery passes deep to or through

the flexor digitorum profundus and flexor pollicis longus,

and gives off a small, inconsistent vessel of variable size,

the median artery, as well as several muscular branches

(3,4,7,8) (Table 4.3). The anterior interosseous artery

appears to be the main periosteal and endosteal supply of

the ulna, with its branches supplying the distal one-fourth

of both the ulnar and radius (91,92,128,129). [Other

contributing arteries that supply the ulna include the

ulnar artery proper, the ulnar recurrent artery, and the

recurrent interosseous artery (128).] The anterior

interosseous artery also gives off five to seven cutaneous

branches that reach the overlying skin in the posterior

aspect of the distal two-thirds of the forearm (101).

At the proximal border of the pronator quadratus,

branches separate from the anterior interosseous artery to

supply a portion of the triangular fibrocartilage and the distal radioulnar joint (100,130). These branches arborize in a

fanlike fashion around the distal radioulnar joint. Small vessels are given off that penetrate and supply the capsule and

the triangular fibrocartilage from the palmar, dorsal, and

medial sides (130,131). These terminal branches of the anterior interosseous artery are joined by the posterior

interosseous artery (101). The terminal branches of the anterior interosseous artery usually also are joined by a small

branch of the ulnar artery to give the direct peridiscal vessels

that supply the palmar, medial, and dorsal margins of the triangular fibrocartilage. These small vessels arborize and anastomose with each other and form a terminal capillary network that ends at the peripheral segments of the triangular

fibrocartilage. The small arteries are arranged radially in a

series of terminal capillary loops. The outer 15% to 20% of

the triangular fibrocartilage is vascularized, leaving the central

segments of the fibrocartilage devoid of vessels (130,131).

The dorsal branch of the anterior interosseous artery gives off

a terminal branch that forms an anastomosis with the posterior interosseous artery at the distal part of the forearm, and

both continue to contribute to the vascular supply of the dorsal capsule of the distal radioulnar joint (100,130).

At its distal end, the anterior interosseous artery divides

into palmar and dorsal branches that continue distally to

supply the palmar and dorsal aspects of the carpus, respectively. The palmar branch continues deep to the pronator

quadratus and bifurcates 5 to 8 mm proximal to the radiocarpal arch (discussed later, under Radial Artery). The palmar branch of the anterior interosseous artery usually contributes at least one branch to the palmar radiocarpal arch

to supply the ulnar aspects of the lunate and triquetrum

(132–136). The palmar branch then terminates by anastomosing with the recurrent vessels from the deep arch

(132,133) (Table 4.3 and Fig. 4.6).

The dorsal branch of the anterior interosseous artery

continues distally on the interosseous membrane to reach

the carpus, where it contributes to the dorsal radiocarpal

arch in 89% of studied specimens (discussed later, under

Radial Artery) (132). Small branches extend radially to supply the lunate and anastomose with several branches from

the radial artery that supply the dorsal ridge of the scaphoid

(137–140). The dorsal branch of the anterior interosseous

artery bifurcates at the intercarpal level, with each branch

contributing to the intercarpal arch (in 83% of specimens)

(132,133). The dorsal branch of the anterior interosseous

artery terminates by forming an anastomosis with the recurrent vessels from the basal metacarpal arch at the third and

fourth interosseous spaces (in 70% of specimens) (132)

(Table 4.3 and Fig. 4.5).

The Median Artery

The median artery is a long, thin vessel that usually arises in

the proximal part of the anterior interosseous artery and

passes anteriorly to reach the median nerve (141–172)

(Table 4.3). It is variable in size and occurrence, with a diameter ranging from 0.7 to 2.7 mm (167). The incidence of a

substantial median artery has been suggested to be approximately 8% to 10% (7); however, reported incidences have

varied from 2% to 23% (158,161,167). It often is visible as

a small vessel in continuity with or adjacent to the median

nerve in the forearm or extending into the carpal canal.

Although it usually arises from the anterior interosseous

artery, it also can arise from the common interosseous trunk

directly from the ulnar artery (2%) (141,142,150). The

median artery continues along with the median nerve and

supplies the nerve in their course through the forearm. In

2%, the median artery has been noted to penetrate or split

the median nerve (141). The median artery is of variable

size, sometimes barely visible along the nerve or, conversely,

greatly enlarged and continuing through the carpal tunnel

into the palm to anastomose with the superficial palmar arch

(149). When enlarged or thrombosed, the median artery can

contribute to the formation of carpal tunnel syndrome or

can penetrate the median nerve in the forearm and produce

pronator syndrome (151–172). The median artery occasionally contributes to the carpal arches, especially if the superficial and deep arches are absent or poorly developed (7,145).

The incidence appears higher in neonatal cadavers compared

with those of adults. It has been proposed that the median

artery may undergo regression even after birth (142).

4 Vascular Systems 251

The Anterior Interosseous Artery (Distal Part)

The anterior interosseous artery continues distally along the

anterior surface of the interosseous ligament to reach the

proximal edge of the pronator quadratus. At this point, the

anterior interosseous artery gives off a small vessel, the palmar carpal branch of the anterior interosseous artery, that

continues deep to the pronator quadratus to help form the

palmar carpal network. The palmar carpal network is a collection of anastomosing vessels on the anterior surface of

the wrist (on the deep surface of the carpal canal) that

receives interconnections from the palmar carpal branches

of the anterior interosseous artery, ulnar artery, and radial

artery, and a retrograde branch from the deep palmar arch.

The anterior interosseous artery, after giving off the palmar

carpal branch, passes through a small foramen in the anterior interosseous ligament to reach the extensor compartment of the forearm. The anterior interosseous artery continues for a short distance along the posterior aspect of the

anterior interosseous ligament to form an anastomosis with

the radial artery and the posterior interosseous artery, and

contributes to the formation of the dorsal carpal network

(Fig. 4.5). These anastomosing branches between the anterior and posterior interosseous arteries and ulnar artery contribute to the vascular supply of the distal ulnar and dorsal

capsule of the distal radioulnar joint (91,92,130). Anastomoses with the anterior and posterior interosseous arteries

and the radial artery help supply vascularity to the distal

radius. These anastomoses form vessels used for the harvest

of distal radius vascularized bone grafts (91,92) (see later

discussion of vascularized bone grafts, under Clinical Correlations: Radial Artery).

The terminal part of the anterior interosseous artery

continues distally on the posterior aspect of the anterior

interosseous ligament along with the terminal portion of

the posterior interosseous nerve to reach the dorsum of the

wrist and contribute to the dorsal carpal network (Fig. 4.5).

The Posterior Interosseous Artery

The posterior interosseous artery arises as the other terminal branch of the common interosseous artery (along with

the anterior interosseous artery), and is formed at the level

of the radial tuberosity (Fig. 4.5; see Fig. 4.4). The posterior interosseous artery usually is smaller than the anterior

interosseous artery, and passes dorsally between the

oblique cord and the proximal border of the interosseous

ligament to reach the posterior compartment of the forearm. The posterior interosseous artery passes between the

adjacent borders of the supinator and the abductor pollicis longus. It then passes distally in the posterior compartment of the forearm between the superficial and deep layers of the extensor muscles, and provides branches to both

groups of muscles. The posterior interosseous artery continues along the dorsal surface of the abductor pollicis

longus and the extensor pollicis brevis, and is accompanied by the posterior interosseous nerve. In the distal forearm, the posterior interosseous artery forms an anastomosis with the terminal branches of the anterior interosseous

artery, the radial and ulnar artery, and the dorsal carpal

network. These anastomosing branches between the anterior and posterior interosseous arteries and ulnar artery

contribute to the vascular supply of the distal ulnar and

dorsal capsule of the distal radioulnar joint (91,92,130).

Anastomoses with the radial artery and anterior

interosseous artery help supply the vascularity of the distal radius. These anastomoses form vessels used for the

harvest of distal radius vascularized bone grafts (91,92)

(see later discussion of vascularized bone grafts, under

Clinical Correlations: Radial Artery).

The Interosseous Recurrent Artery

The interosseous recurrent artery is one of the few main

branches of the posterior interosseous artery (see Table 4.3

and Figs. 4.3 and 4.5). It arises proximally from the posterior interosseous artery, near its origin from the common

interosseous artery. At times, the interosseous recurrent

artery may arise directly from the common interosseous

artery. The interosseous recurrent artery passes on or

through the supinator muscle, then posteriorly between the

radius and ulna, and continues proximally in a retrograde

fashion posterior to the radial head to reach the interval

between the lateral epicondyle and the olecranon. Its course

is deep to the anconeus muscle. In the distal posterior compartment of the arm, the interosseous recurrent artery

forms an anastomosis with the middle collateral branch of

the profunda brachii artery, and the posterior ulnar recurrent and the inferior ulnar collateral arteries (1) (Fig. 4.3).

Besides muscular branches to neighboring muscles, the

interosseous recurrent artery usually contributes to the

intraosseous circulation to the radial head, capitellum, and

the lateral aspect of the trochlea through posterior perforating vessels (62). The vessels that supply the radial head penetrate the elbow capsular insertion at the neck of the radius.

(Note: The radial head has a dual blood supply through

both the interosseous recurrent artery and the radial recurrent artery.) The interosseous recurrent artery also contributes to the vascularity of the olecranon (along with vessels from the posterior ulnar recurrent artery) from vessels

that course along the lateral and medial aspect of the

humerus (62) (Fig. 4.3).

Muscular Branches of the Ulnar Artery in the

Forearm

The ulnar artery supplies many of the muscles of the flexor

forearm, giving off multiple muscular branches as the artery

descends distally. These branches supply most of the ulnar

muscles of the flexor forearm, including the pronator teres,

flexor carpi radialis, flexor digitorum superficialis, flexor digitorum profundus, flexor carpi ulnaris, and brachialis (173).

252 Systems Anatomy

4 Vascular Systems 253

FIGURE 4.5. The main arteries of the

dorsal forearm and hand.

Palmar Carpal Branch of the Ulnar Artery

The palmar carpal branch of the ulnar artery is a small

branch that arises from the radial aspect of the ulnar artery

at the level of the wrist or near the distal border of the

pronator quadratus, just proximal to the carpal tunnel. It

courses radially toward the midline, deep to the flexor digitorum profundus on the palmar aspect of the proximal

wrist. It forms an anastomosis with the corresponding palmar carpal branch of the radial artery (see Fig 4.4) (1). This

branch may correspond to the palmar radiocarpal arch,

described by Gelberman and colleagues in their classic

descriptions of the extraosseous vascular patterns of the carpus (see later) (132) (Fig. 4.6).

Palmar Radiocarpal Arch

The palmar radiocarpal arch is one of three vascular transverse arches that provide vascularity to the carpus (132)

(Fig. 4.6). The other two arches include the palmar intercarpal arch and the deep palmar arch. The palmar radiocarpal arch spans the radiocarpal joint, arising on the ulnar

side from the radial aspect of the ulnar artery, and on the

radial side from the ulnar aspect of the radial artery. It usually receives a central contribution from the distal end of

the anterior interosseous artery. The palmar radiocarpal

arch is the most proximal of the transverse arches, and it

extends 5 to 8 mm proximal to the radiocarpal joint at the

level of the distal metaphysis of the radius and the ulna. The

artery lies in the wrist capsule. It usually has an anastomosis with the palmar intercarpal arch through a longitudinal

interconnection branch. The palmar radiocarpal arch was

found to be consistently present by Gelberman and colleagues, formed by branches from the ulnar, radial, and

interosseous arteries in 87% of specimens, and by the ulnar

and radial arteries alone in 13% (132). The palmar radiocarpal arch supplies the palmar surface of the lunate and triquetrum.

Palmar Intercarpal Arch

The palmar intercarpal arch is one of three vascular transverse arches that provide vascularity to the carpus (132)

(see Fig. 4.6). The other two include the palmar radiocarpal arch (more proximally; see earlier) and the deep

palmar arch (located distally; see later, under Radial

Artery). The palmar intercarpal arch is located between

the proximal and distal carpal rows, and arises from the

radial aspect of the ulnar artery and from the ulnar aspect

of the superficial palmar branch of the radial artery. It usually receives a contribution from the distal end of the anterior interosseous artery. It is variable in occurrence. Gelberman and associates found it to be present in 53% of

specimens, formed by branches of the ulnar, radial, and

anterior interosseous arteries in 75%, and formed by the

ulnar and radial arteries alone in 25%. The arch is small,

and is not considered a major contributor of nutrient vessels to the carpus (132,133).

Dorsal Carpal Branch of the Ulnar Artery

The dorsal carpal branch of the ulnar artery arises proximal

to the pisiform, between 1.6 and 4.4 cm proximal to the

ulnar styloid, and curves medially and dorsally to wind

around the wrist, crossing deep to the flexor carpi ulnaris

tendon (174) (see Fig. 4.4). The artery passes to the ulnar,

then dorsal aspect of the wrist and continues toward the

midline of the dorsal wrist, deep to the extensor tendons. It

forms an anastomosis with the corresponding dorsal carpal

branch of the radial artery (and dorsal radiocarpal arch,

Figs. 4.5 and 4.6). The dorsal carpal branch of the ulnar

artery supplies an area of skin overlying the ulnar

metacarpals and the ulnar hypothenar region (174). Just

distal to its origin, the dorsal carpal branch also gives a small

branch that courses along the ulnar aspect of the fifth

metacarpal to supply the ulnar aspect of the dorsal surface

of the small finger (1–4).

Deep Palmar Branch of the Ulnar Artery

The deep palmar branch of the ulnar artery is a small branch

that arises from the ulnar aspect of the distal ulnar artery at

the level of the carpal canal. It courses ulnarly a short distance on the anterior surface of the flexor retinaculum and

anterior to the ulnar nerve to reach the hypothenar muscles.

The arterial branch then continues between the abductor

digiti minimi and flexor digiti minimi brevis and through

the origin of the opponens digiti minimi. The vessel curves

laterally into the palm, along with the deep branch of the

radial nerve. The deep palmar branch of the ulnar artery

then forms an anastomosis with the radial artery to complete

the deep palmar arch (1) (Fig. 4.1). In 14% of cases, the

deep palmar branch of the ulnar artery gives rise to the perforating branch of the fourth interspace (175).

Superficial Palmar Arch

The superficial palmar branch is formed mainly by the terminal portion of the ulnar artery, and often is completed

with contributions from the superficial branch of the radial

artery or, less frequently, from a branch of the princeps pollicis or by the radialis indicis; rarely, it is completed with

contributions from the median artery (11) (see Figs. 4.4

and 4.6). Several variations exist in the formation of the

superficial palmar arterial arch (176–201). The ulnar artery

enters the palm through Guyon’s canal with the ulnar nerve,

usually on the lateral aspect of the pisiform and superficial

to the flexor retinaculum. Initially, the artery usually is

located radial and deep to the ulnar nerve, although 

several

variations exist (176–183,202–212). The structures pass

through the ulnar tunnel (Guyon’s canal), deep to the pal254 Systems Anatomy

maris brevis, and continue medial to the hook of the

hamate. The artery remains superficial to the base of the

flexor digiti minimi brevis and opponens digiti minimi.

The artery then curves laterally, convex distally to cross the

palm deep to the palmar fascia. This corresponds to the

level of the metacarpal diaphysis, roughly at the level

slightly proximal to the distal transverse palmar crease

(2,4,41). As the superficial palmar arch crosses the palm

transversely, it usually is located at a level distal to the deep

palmar arch; however, it passes at a level proximal to the

level of deep arch in 14% (175). Its mean lumen diameter

is 1.8 mm (range, 1 to 3 mm) (191) (Table 4.4). As the

superficial palmar arch continues across the palm in a radial

direction, it remains superficial to the tendons of the flexor

digitorum superficialis and flexor digitorum profundus, the

lumbrical muscles, and the branches of the median and

ulnar nerves. The superficial palmar arch, along with its

common palmar digital arteries, supplies the superficial

4 Vascular Systems 255

FIGURE 4.6. The arteries of the palmar wrist. Note the transverse carpal arches: the palmar

radiocarpal arch, palmar intercarpal arch, and deep palmar arch.

flexor tendons, flexor retinaculum, median and ulnar

nerves, flexor pollicis longus tendon, lumbrical muscles,

palmar aponeurosis, and the skin of the palm of the hand

(204–206,208,209). A terminal branch of the superficial

palmar arch helps supply the thumb as well, although most

of the thumb’s supply comes from the princeps pollicis

artery with contributions from the first dorsal metacarpal

artery (usually originating from the radial artery; see later,

under Radial Artery) (189,203,204,207). Erbil and colleagues noted in five cases that the first web space of the

hand and the associated portion of the thumb received

arteries only from the superficial palmar arch. None of the

branches was large enough to be considered a “princeps pollicis artery” (207).

Vascular contributions to the superficial (and deep) arch

are variable, and have been the subject of several investigations (145,146,184–200) (see earlier discussion of the

median artery, under Common Interosseous Artery). Several authors have indicated that the superficial palmar arch

usually communicates with (or is completed by) the superficial palmar branch of the radial artery (6,8,11,12).

Williams notes that in approximately one-third, the superficial arch is formed by the ulnar artery alone; in an additional third, it is formed by the ulnar artery with significant

contributions from the superficial palmar branch of the

radial artery, and in the final third, the superficial arch is

formed by the ulnar artery with contributions from a

branch of the princeps pollicis or the radialis indicis, or,

more rarely, from the median artery (4). Tountas and

Bergman describe the contributions to the superficial arch

as those formed by the ulnar artery and completed by the

radial artery in 30%, completed by the union with the deep

palmar arch through the princeps pollicis artery in 42%,

and completed by a median artery in 8% (7).

Wilgis and Kaplan have presented an extensive classification of the arterial patterns of the superficial palmar arch

(185). Three general patterns (or variants) are noted, each

with several subtypes.

In the first variant, the ulnar artery is responsible for the

formation of the superficial palmar arch, and this occurs in

approximately 66%. Seven subtypes of the first variant are

noted:

Type I: The ulnar artery is responsible for the formation

of all the digital arteries.

Type II: The ulnar artery ends as the radial collateral of

the index finger; the two collaterals of the thumb are

formed by the first palmar metacarpal artery of the radial

artery.

Type III: In this, the most frequent variation, the ulnar

artery ends in the second intermetacarpal space; the two

palmar collaterals of the thumb and the collateral radial of

the index are furnished by the radial artery.

Type IV: The ulnar artery runs vertically from the pisiform bone to the third intermetacarpal space. It supplies the

five collateral arteries to the fingers; the other five collateral

arteries are furnished by the first and the second palmar

metacarpal branches of the radial artery.

Type V: The ulnar artery runs vertically and reaches the

fourth intermetacarpal space, furnishing only three collateral arteries for the fingers; the other seven are supplied by

the metacarpal branches of the radial artery.

Type VI: The ulnar artery, reduced in size, supplies only

the ulnar collateral to the fifth finger.

Type VII: The ulnar artery gives only insignificant

branches to the digital arteries, and the main supply is from

the radial artery.

In the second variant of the superficial arch, the superficial palmar radial artery participates in the formation of

the arch, and this occurs in approximately 30%. This second variant has five subtypes:

Type I: In this type, which occurs very frequently, it is

noted that before the anastomosis with the ulnar artery, one

or two collaterals for the thumb are furnished by the radial

artery.

Type II: In addition to the collateral of the thumb, there

are one or two collaterals from the radial artery to supply

the index finger.

Type III: In this, the most frequent type, there are regular anastomoses between the superficial radial palmar artery

and the ulnar artery.

Type IV: The superficial palmar radial artery supplies the

thumb, the index finger, and the radial side of the long finger, terminating directly in the radial branch of the long finger. It supplies the five digital branches (two to the thumb,

two to the index finger, and one to the long finger). The

ulnar artery supplies the remaining five digital arteries (two

to the small, two to the ring, and one to the long finger). It

ends as the ulnar branch to the long finger.

Type V: The ulnar artery either supplies only the ulnar

two digits, or none at all. If the ulnar artery does not supply the small or ring finger, the superficial branch of the

radial artery supplies all the fingers, and the ulnar artery

supplies mostly the hypothenar muscles.

256 Systems Anatomy

TABLE 4.4. VESSEL LUMEN DIAMETERS OF

ARTERIES OF THE WRIST AND HAND

Vessel Diameter (Range)

Radial artery 2.6 mm (2.3–5 mm)

Ulnar artery 2.5 mm (1.4–4.5 mm)

Superficial palmar arch 1.8 mm (1–3 mm)

Deep palmar arch 1.5 mm (1–2.3 mm)

Common palmar digital arteries 1.6 mm (1–2 mm)

(of superficial palmar arch)

Common metacarpal arteries 1.2 mm (1–2 mm)

(of deep palmar arch)

From Gellman H, Botte MJ, Shankwiler J, et al. Arterial patterns of

the deep and superficial palmar arches. Clin Orthop 383:41–46,

2001, with permission.

In the third variant of the superficial arch, the median

artery contributes to the formation of the arch, and this was

seen in only 4%. In this variant, types similar to those previously described can occur, in which arteries participate in

the formation of the arch. Very infrequently, an additional

subcutaneous transverse anastomosis with the subcutaneous

branch of the superficial branch of the ulnar artery is found.

If present, it is located superficial to the palmar arch, and

may be mistaken for the superficial palmar arch if its position is not properly assessed (185).

Coleman and Anson, in their classic study evaluating

650 limbs, noted the superficial arch to be complete in 80%

and incomplete in 20% (184). In the complete arch group,

five patterns (or types) were described.

Type I indicated an arch formed by the superficial palmar branch of the radial artery and the (larger) ulnar artery.

This was found in 34.5%.

Type II (37%) indicated an arch formed entirely by the

ulnar artery.

Type III (4%) indicated an arch formed by an enlarged

median artery.

Type IV (1.2%) indicated an arch formed by the radial

artery, median artery, and the ulnar artery.

Type V indicated an arch formed by the ulnar artery

joined by a large vessel from the deep palmar arch joining the

superficial arch at the base of the thenar eminence (184). The

incomplete arch was divided into four patterns or (types).

Koman et al. have noted that the superficial palmar arch

is completed by branches from the deep palmar arch (39%),

the radial artery (34.5%), or the median artery (5%) (212).

Overall, the ulnar arch had communications with these arterial contributions, and the superficial arch was considered to

have adequate collateral flow in a total of 78.5% of patients.

In the remaining 21.5%, the arch was “incomplete,” and collateral flow was thought to be inadequate (212).

Gellman and colleagues also classified the superficial arch

as complete or incomplete in a study of 45 cadavers (191).

Complete superficial palmar arches were seen in 84.4% of

specimens. The complete arch was subdivided into five subtypes (types A through E), and the incomplete arches were

subdivided into two subtypes (types F and G). In the complete arches, the type A pattern was the most common, seen

in 35.5% of specimens, and consisted of a superficial arch

formed by anastomosis between the continuation of the ulnar

artery and the superficial palmar branch of the radial artery.

This is the variant most commonly described in anatomic

textbooks (1–4). In type B, the superficial arch was formed by

a continuation of the ulnar artery with formation of common

digital vessels to the thumb and index web space. It was considered a complete arch because it reached all the digits; however, it was formed entirely by the ulnar artery. This pattern

was seen in 31.1% of the specimens. In type C, the arch was

complete but formed by the continuation of the ulnar artery

with a contribution from the median artery. This pattern was

seen in 13.3% of the specimens. The type D pattern consisted

of a complete arch formed from contributions from all three

arteries (ulnar, radial, and median). This pattern was seen in

only 2.2% of the specimens. The last complete arch pattern,

type E, consisted of an arch formed largely by the continuation of the ulnar artery, with a communication with the deep

palmar arch (instead of the more common anastomosis with

the superficial palmar branch of the radial artery). This variation was seen in 2.2% of the specimens. Gellman et al. also

noted two patterns designated as incomplete arches (types F

and G), where the ulnar artery failed to reach the thumb and

first web space, and there was a lack of anastomosis of the

radial or median artery with the ulnar artery. In type F, the

ulnar artery comprised most of the arch but did not reach or

contribute to the arterial supply to the thumb and index fingers. This was the most commonly encountered type of

incomplete arch, seen in 11.1% of specimens. In type G, the

other type of incomplete arch, the ulnar artery supplied the

ulnar digits and the superficial palmar branch of the radial

nerve supplied the radial digits and thumb, and there were no

anastomoses between the two arteries. This type was seen in

4.4% of the specimens (191).

In 80 cadaver hands, Ozkus and colleagues (145) demonstrated a superficial palmar arch formed by anastomosis of

both the ulnar and radial arteries in 80%, and a superficial

arch formed by the ulnar artery alone in 17%. In two specimens, the arches were supplied by a median artery (145).

In Lippert’s study, a complete arch with contributions from

both the radial and ulnar arteries was found in 42%. In 58%,

there was no connection between the two arteries (213).

Further variation in the arches was demonstrated by

Ruengsakulrach and colleagues (146). In a study of 50

cadaver limbs, a superficial palmar arch was found to be

continuous with the radial artery in 34%, although every

hand had at least one major branch connecting the radial

and ulnar arteries.

Ikeda and colleagues conducted an investigation using

stereoscopic arteriographs of 220 cadaver hands (189). The

authors grouped the superficial palmar arch into complete

(96.4%) and incomplete (3.6%) types (189). Using the

Doppler flowmeter, Al-Turk and Metcalf showed the superficial arch to be complete in 84% and incomplete in 14%

of cases (192). Similarly, using ultrasound techniques,

Doscher and colleagues noted the arch to be incomplete in

11% of 200 normal hands (193).

The lumens of the superficial arch and associated

branches are listed in Table 4.4 (191).

Branches of the Superficial Palmar Arch:

Common Palmar Digital Arteries and Proper

Digital Artery to the Ulnar Small Finger

Three common palmar digital arteries and the proper digital artery to the ulnar aspect of the small finger are usually

4 Vascular Systems 257

given off by the superficial palmar arch as it crosses the

palm from medial to lateral (1–4,11,191) (Fig. 4.6).

The first branch usually is the proper palmar digital

artery for the ulnar aspect of the small finger, which arises

as far proximal as the level of and deep to the palmaris brevis. This palmar digital artery continues superficial to and

in line with the fibers of the hypothenar muscles. It courses

in a fairly straight line to reach the ulnar aspect of the base

of the small finger. Proximal to the level of the metacarpal

neck, the artery usually is superficial to the associated digital nerve. As the artery continues distally, it becomes deep

to the proper digital nerve (usually at approximately the

level of the metacarpal neck). The artery continues in this

relationship dorsal to the nerve through the digit. In the

digits, the artery passes deep to Grayson’s ligaments and

superficial to Cleland’s ligaments (214–217).

After giving off the proper palmar digital artery for the

ulnar aspect of the small finger, the superficial palmar arch

gives rise to three common palmar digital arteries (see Figs.

4.4 and 4.6). These vessels leave the arch on its converse

side, cross superficial to the lumbricals, and continue distally toward the fourth, third, and second web spaces. Each

vessel receives a contribution from the corresponding palmar metacarpal artery from the deep palmar arch. Proximal

to the level of the metacarpal neck, the common palmar

digital artery usually is superficial to the associated common digital nerve. As the artery continues distally, it

becomes deep to the proper digital nerve (usually at

approximately the level of the metacarpal neck). This relationship is maintained, with the artery remaining dorsal to

the nerve through the digit. Although the vascular supply

to the radial aspect of the index finger usually is not

described as being supplied by the branches of the superficial palmar arch (1–4,7,8,11), Gellman et al. noted that the

superficial arch actually did supply the radial border of the

index finger and radial aspect of the thumb as a common

pattern, occurring in 83% of specimens (191). The common palmar digital arteries, along with direct branches

from the superficial palmar arch, supply the superficial

flexor tendons, flexor retinaculum, median and ulnar

nerves, flexor pollicis longus tendon, lumbrical muscles,

palmar aponeurosis, and the skin of the palm of the hand

(204). The lumen size of the common palmar digital arteries varies from 1 to 2 mm, with an average of 1.6 mm (191)

(see Table 4.4).

Each common palmar digital artery then divides into

two proper palmar digital arteries (see Figs. 4.4 and 4.8). In

the fourth web space, the common digital artery divides to

provide proper palmar digital arteries to the radial side of

the small finger and the ulnar side of the ring finger. In the

third web space, the common palmar digital artery divides

to provide proper palmar digital arteries to the radial side of

the ring finger and the ulnar side of the long finger. In the

second web space, the common digital artery divides to provide proper palmar digital arteries to the radial side of the

long finger and the ulnar side of the index finger. [Note:

The proper digital artery to the radial side of the index finger is usually a continuation of the radial index artery (arteria radialis indicis), a branch from the radial artery, and the

palmar digital arteries to the thumb are supplied by the

princeps pollicis artery (arteria princeps pollicis), also

derived from the radial artery (1–4,218–232)].

The proper palmar digital arteries continue to the distal

aspect of each respective digit. The artery remains dorsal to

the corresponding proper digital nerve in the digit. The

artery also passes deep to Grayson’s ligament and superficial

to Cleland’s ligament. The digital arteries send several small

vessels throughout the digit to supply the soft tissues and

osseous structures, including the digital nerves and flexor

tendons (218) (discussed later and in Chapter 2). Vascularization of the digital nerves is supplied by numerous anastomotic vessels connecting the digital arteries, epineurial

vessels, and the periarterial network (venae comitantes and

vasa vasorum) (218–232).

The proper palmar digital arteries give rise to the vincular system, which provides the segmental vascular supply of the extrinsic tendons in the flexor sheath

(233–249). The vincular system consists of long and short

vincular connections. The vincula, which attach directly

to the dorsal surface of the flexor tendons in the sheath,

are vessels in a mesentery that is flexible to allow movement of the tendons. The vincula comprise the vinculum

brevis superficialis, the vinculum brevis profundus, the

vinculum longum superficialis, and the vinculum longum

profundus.

The vinculum longum superficialis arises as small branches

from the proper palmar digital arteries at the level of the

base of the proximal phalanx. The branches course anterior

toward the midline, deep to the tendons. The branches then

interconnect anterior to the phalanx, still deep (dorsal) to

the tendons. From these branches the vinculum longum

superficialis arises at the floor of the digital sheath. The vinculum longum superficialis passes anteriorly, then splits to

allow passage of the flexor digitorum profundus. The vinculum then passes anteriorly to attach directly to the dorsal

surface of the flexor digitorum superficialis (233–249).

The vinculum brevis superficialis is a small, triangular

mesentery that arises near the insertion of the flexor digitorum superficialis. The vinculum brevis superficialis arises

from the proper palmar digital artery, at the level of the

neck of the proximal phalanx. It supplies the flexor digitorum superficialis tendon near its insertion into the middle

phalanx. A portion of the vinculum brevis superficialis continues anteriorly, at the level of the proximal interphalangeal joint, toward the flexor digitorum profundus to

form the vinculum longum profundus. The vinculum

longum profundus also may arise as a separate vessel. The

vinculum longum profundus attaches to and supplies the

flexor digitorum profundus in the region of the middle phalanx (233–249).

258 Systems Anatomy

The vinculum brevis profundus also is a small mesentery

that arises from interconnecting branches that arise from

the proper palmar digital arteries at the level of the middle

phalanx. The branches interconnect dorsal to the flexor digitorum profundus, form a mesentery, and attach to the dorsal surface of the tendon near its insertion into the distal

phalanx (249).

Because the vincula enter the tendon on the dorsal surface, the vascularity of the dorsal half of the tendon in the

digits is richer than the palmar half. The vincula often are

variable in presence and configuration (249). In addition to

the vascular supply, the tendons in the synovial sheath

receive nutrition through synovial fluid diffusion.

The proper palmar digital arteries continue along the

palmar aspects of the radial and ulnar borders of each digit.

The diameters of the digital arteries have been evaluated

with arteriograms, clinical measurements, and high-frequency ultrasound (219–220). The index and long fingers

have been shown usually to have a larger digital artery on

the ulnar border, whereas the ring and small fingers usually

have a larger digital artery on the radial border (220). Each

proper digital artery also usually gives off two dorsal cutaneous branches that form anastomoses with the dorsal digital arteries (derived from the dorsal metacarpal arteries; see

later, under Radial Artery) (221). These branches contribute to the vascular supply of the soft tissues on the dorsum of the middle and distal phalanges, including the proximal and distal interphalangeal joints (222).

The proximal interphalangeal joint is supplied chiefly by

small vessels that leave the proper digital artery on the

artery’s dorsal surface, although additional vascularity is

supplied by smaller vessels that leave the proper digital

artery on its palmar surface, or from vessels derived from

the dorsal digital arteries. The vessels that leave that proper

digital artery on its dorsal surface arise 1.5 to 2.5 cm proximal to the proximal interphalangeal joint and divide into

branches to the dorsal skin, branches to the proximal phalanx, those continuing to the vincular system, and those

supplying the lateral surface of the joint and the palmar

plate. Other branches arise distal to the proximal interphalangeal joint and provide branches to the palmar aspect of

the distal interphalangeal joint and to the vincular system

(223).

The proper digital arteries arborize in the distal phalanx

region to supply the matrix of the fingernail, and form the

complex anastomosis of the subcutaneous pulp of the digital tip (224).

Anomalies and Variations: Ulnar Artery

and Its Branches

The ulnar artery may arise more proximally than the standard bifurcation of the brachial artery in the proximal forearm (3,24,25,29–34,68,76,80,81,250–259). This may

occur in the arm from a high division of the brachial artery,

or in the axilla from a high division of the axillary artery

(see earlier, under Anomalies and Variations for both the

brachial and the axillary arteries). The incidence of high

division of the ulnar artery is much less than that of the

radial artery, occurring in only approximately 2% (7). With

a high division of the ulnar artery, the artery may take a

more superficial course, and has been referred to as a superficial ulnar artery (27–34). The superficial ulnar artery has

been noted to cross ventral to the medial root of the median

nerve before continuing toward the medial part of the arm

(27,33,34). The superficial ulnar artery may cross superficial to the median nerve and brachial artery. The anomalous

ulnar artery usually is smaller than the radial artery or

interosseous arteries. When the ulnar artery originates

directly from the axillary artery, the common interosseous

artery (which usually originates from the ulnar artery) has

been noted to originate from the radial artery (30). These

anomalies of the radial and ulnar arteries may be bilateral

(23,27,31).

A distal division of the radial and ulnar arteries has been

noted to occur 8 cm distal to the antecubital fossa (82).

This distal division has implications in preparing the radial

forearm flap.

Variations of the superficial palmar arch: The superficial

palmar arch shows several patterns and variations. These are

so common and numerous that they are described previously in the discussion of the anatomy of the superficial palmar arch.

Although the radial index artery (radialis indicis arteria)

usually arises from the deep palmar arch, it may originate

independently from the superficial palmar arch in approximately 13% and in combination with the deep arch in

42%. When it arises in combination with the deep arch, the

superficial component is usually the larger of the two. The

princeps pollicis artery also may arise from the superficial

arch (7).

The common interosseous artery can arise more proximal than its normal origin from the ulnar artery. A high

division has been noted where the common interosseous

artery originated from the brachial artery, either in the

proximal third of the arm (96) or at the level of the humeral

intercondylar line (95). When arising from the proximal

arm, the common interosseous artery continued distally

and followed the brachial artery. It supplied muscular

branches, then formed the ulnar recurrent arteries, and in

the distal part of the cubital fossa it divided into anterior

and posterior interosseous arteries. The brachial artery

passed medially to the median nerve, gave off superior and

inferior ulnar collateral arteries, and, proximal to the superior border of the pronator teres muscle, the artery divided

into the ulnar and radial arteries (96).

The common palmar digital arteries usually arise separately from the superficial palmar arch (1–4,11,213). There

usually are three common palmar digital arteries, given off

to the fourth, third, and second web spaces. The first and

4 Vascular Systems 259

second common palmar digital arteries may arise as a common trunk from the superficial palmar arch (210).

Clinical Correlations: Ulnar Artery and Its

Branches

Thrombosis of the Ulnar Artery

The ulnar artery is among the most common upper extremity

arteries involved with occlusion or thrombosis (260–284).

The more common site for thrombosis is in the hypothenar

eminence, either in or just distal to the ulnar tunnel, although

thrombosis has been noted in several sites from the mid-forearm to the digits (266). Associated factors include blunt

trauma (260,275,278) and anomalous muscles (267,270,

283), but it may occur spontaneously (274). Cases associated

with carpal tunnel syndrome (277) as well as bilateral symmetric thrombosis have been reported (276). The venae comitantes to the ulnar artery also may be involved with thrombosis (285). A variation of thrombosis of the ulnar artery is the

hypothenar hammer syndrome (212,286–338). This syndrome involves a posttraumatic aneurysmal dilatation with

associated thrombosis, and subsequent vascular insufficiency

or emboli to the ulnar digits. It is associated with repetitive

blunt trauma to the hypothenar eminence. Symptoms,

including pain, cold intolerance, numbness, and weakness,

develop secondary to thrombosis or occlusion. The etiology

responsible is repetitive trauma with disruption of the internal

elastic lamina, producing dilatation with mural thrombi,

complete occlusion, or distal emboli (212). The arterial dilatation may take on a corkscrew configuration, seen by angiography or at operative exposure.

True and False Aneurysm of the Ulnar Artery

Along with thrombosis, the ulnar artery is afflicted relatively

frequently with aneurysm (339–373). A true or false

aneurysm may result. A true aneurysm usually is the result of

repetitive trauma that leads to intimal damage to the media,

disruption of the internal elastic lamina, exposure of

endothelial collagen, and aneurysmal dilatation or thrombosis (212). The wall of the vessel thus dilates to produce the

pulsatile mass that contains a true endothelium and the normal layers of an arterial wall. A true aneurysm usually is fairly

uniform in shape. A false aneurysm usually occurs after penetrating trauma, in which local hemorrhage and extravasation

cause the surrounding soft tissues to organize, undergo fibrosis, and recanalize. The lumen of a false aneurysm is in continuity with a true vessel, but it lacks a true endothelial layer

(in contrast to the true aneurysm, which contains an

endothelial layer). The false aneurysm may not be uniform in

shape. There appears to be a similar incidence of true and

false aneurysms involving the ulnar artery (339).

Allen Test

The Allen test is a clinical test used to evaluate the patency

of the radial and ulnar arteries in the forearm and wrist

(374–386). The test consists of compressing both the radial

and ulnar arteries at the distal forearm or wrist, and then

emptying the hand of blood by the patient’s active flexion

and extension of the digits. The pressure is then removed

from the radial artery, and the hand is allowed to fill

(demonstrating flow from the radial artery). The test is

repeated by releasing the pressure to the ulnar artery, and

again the hand is allowed to fill (now showing flow from the

ulnar artery). If one of the two arteries is occluded or if one

of the palmar aches is incomplete, the compromised circulation becomes evident. Gelberman and Blasingame have

evaluated a timed Allen test in 800 hands (378). The

authors found that the average ulnar artery fill time was 2.3

± 1.0 seconds, and the average radial artery fill time was 2.4

± 1.2 seconds. Seven percent of ulnar arteries and 2% of

radial arteries did not fill completely within 6 seconds.

Ninety-one percent of the hands tested were considered

complete, with uniform brisk refill (378). The Allen test is

valuable in the routine evaluation of the vasculature of the

hand, but is particularly valuable in preoperative assessment

before procedures that involve the vasculature or those performed in the vicinity of these structures. It also is helpful

in posttraumatic vascular evaluation. The Allen test is difficult to perform in the setting of acute fracture or trauma.

Arterial Dominance

Arterial dominance in the hand has been the subject of several anatomic studies (387–393). Authors continue to disagree as to which artery, the ulnar or radial, is the major or

“dominant” artery of the hand, although most studies support the radial artery. In a study evaluating dynamic values

of vessel diameter, blood velocity, and flow rate in vivo,

Trager and colleagues found variability between individuals

in artery dominance, noting 11 with the ulnar artery dominant, 7 with the radial dominant, and 2 with equal values

(388). With radionucleotide flow studies and anatomic dissections, Tonks and colleagues found no difference in the

anatomic dimensions of the vessels, but that the radial

artery appeared to be the dominant vessel compared with

the ulnar (389). Using arterial pressure measured simultaneously in the thumb and in the contralateral arm by straingauge plethysmography in 100 healthy subjects, Husum

and Palm showed radial artery dominance in 110 hands

(55%), ulnar artery dominance in 24 (12%), and neither

artery dominant in 66 (33%) (390). Patsalis et al. found a

ratio of radial artery dominance to ulnar artery dominance

of 13:4 by studying 164 hands in vivo using digital pulse

electronic oscillography and the Allen test (391). Kleinert

and associates studied 200 hands using pulse-volume

plethysmography amplitudes during radial or ulnar artery

260 Systems Anatomy

compression. In their study, only 5% were found to have

ulnar artery dominance (i.e., pulse-volume plethysmography amplitude larger during radial artery compression) in

all digits, and 28% were found to have complete radial

artery dominance. Ulnar artery dominance in three or more

digits was seen in 22%, compared with 57% with radial

artery dominance. Overall, 87% of thumbs and 71% of

index, 60% of long, 52% of ring, and 52% of small fingers

were found to be radial artery dominant (393). From lumen

diameters alone, the radial artery is slightly larger at the

wrist (mean, 2.6 mm; range, 2.3 to 5 mm) compared with

the ulnar (mean, 2.5 mm; range, 1.4 to 4.5 mm) (191) (see

Table 4.4).

Ulnar Artery Repair

In an evaluation of repair of injuries to the ulnar or the

radial artery, or both, it was shown that the overall success

rate for all repairs was 54%. It appears that, besides operative technique, back pressure in the distal arterial stump and

the extent of original ischemia of the hand relative to its

normal blood supply (a function of the completeness of the

palmar arches) are important factors influencing vessel

patency after repair (132).

Forearm Flaps and the Ulnar Artery

For soft tissue coverage and hand reconstructive procedures,

several forearm flaps are available, usually vascularized from

a distally based inflow from either the radial or ulnar artery

(252–254,266,386–404). The forearm flap also may be elevated as a free flap, based on a proximal radial artery inflow

(402,403). For harvest of distally or proximally based radial

artery forearm flaps, an intact ulnar artery and a superficial

palmar arch that provides a strong contribution to the vascularity of all the digits are prerequisite. Conversely, for harvest of a distally based ulnar artery forearm flap, an intact

radial artery to provide circulation to the hand is prerequisite. Clinical examination with the Allen test, Doppler

examination, or an arteriogram helps confirm these data.

Because several variations and anomalies of the ulnar and

radial arteries exist (as noted earlier, under Anomalies and

Variations), these have potential implications in the harvest

of the forearm flaps.

Persistent Median Artery and Carpal Tunnel

Syndrome or Pronator Syndrome

A persistent and enlarged median artery that extends into

the carpal canal is a known cause of median nerve compression, especially if associated with thrombosis,

aneurysm, or calcification (151–170). The incidence of a

persistent median artery is approximately 2.2% to 4.4%,

with an overall incidence of related carpal tunnel syndrome

of 1.1% to 1.8% (161). A median artery also has been associated with pronator syndrome (171), and has been noted

to pass through the substance of the median nerve in the

forearm just proximal to the origin of the anterior

interosseous nerve (172). The persistent median artery in

the forearm can give rise to a vascular leash to the flexor

muscles that can compress the median nerve (171).

Other Anomalies and Variations

Similar to the ulnar artery in Guyon’s canal and in the

hypothenar region, the superficial palmar artery is vulnerable to several lesions. Besides trauma (sometimes associated

with carpal tunnel release), reports have noted aneurysm,

occlusion, or thrombosis (405–412). Its anatomic position

and vulnerability has become of greater interest with the

advent of endoscopic carpal tunnel release (410).

Compared with the ulnar artery in the palm, aneurysm

of the common and proper digital arteries is rare. True and

false aneurysms have been reported, usually as isolated cases

(413–434).

For soft tissue coverage in a digit, several local flaps have

been described, many based on a distal digital artery

(reverse digital artery flap) (435–442).

Spinner and colleagues have described a patient with

neurovascular symptoms due to penetration of a proper digital nerve by a common digital artery. The authors consider

this an underrecognized but possibly relatively common

anatomic variation (443).

Relationships Between the Digital Arteries

and Digital Nerves

In the region of the metacarpal shaft, the common digital

arteries are positioned palmar to the associated common

digital nerves. At approximately the level of the metacarpal

necks, this relationship is reversed, so that the digital

artery in the digit is located dorsal to the associated digital nerve.

RADIAL ARTERY

Gross Anatomic Description: Radial

Artery

The brachial artery bifurcates into the radial and ulnar

arteries at approximately the level of the neck of the radius,

usually approximately 1 cm distal to the elbow joint (see

Figs. 4.3 and 4.4). The radial artery appears to be a continuing extension of the brachial artery because of its slightly

lateral direction. The radial artery may be slightly smaller

in diameter than the ulnar artery. The radial artery continues along the radial aspect of the forearm to the wrist to

reach the dorsum of the wrist, deep to the tendons of the

4 Vascular Systems 261

abductor pollicis longus and the extensor pollicis longus

and extensor pollicis brevis. The radial artery continues distally and dorsally to the space between the dorsal bases of

the thumb and index metacarpals. The artery then passes

between the two heads of the first dorsal interosseous muscle into the palm of the hand, joining the deep palmar

branch of the ulnar artery to form the deep palmar arch.

The radial artery has been divided into three parts for

descriptive purposes. These include the radial artery in the

forearm, in the wrist, and in the hand (3) (Table 4.5).

The radial artery in the forearm extends from the neck

of the radius to the anterior aspect of the styloid process. It

passes along the medial aspect of the radius in the proximal

forearm, and passes anterior to the radius in the middle and

distal portions (1–4,444). It is deep to the brachioradialis

proximally, then exits the deep surface of the muscle along

the medial border of the muscle. The radial artery then

becomes superficial, covered anteriorly by skin and superficial and deep fascia. Along its course in the forearm, the

artery passes superficial to the biceps tendon, the supinator

muscle, the pronator teres muscle, the radial origin of the

flexor digitorum superficialis muscle, the flexor pollicis

longus, the pronator quadratus muscle, and the distal end

of the radius. In the proximal third of its course, the artery

lies between the brachioradialis and the pronator teres muscles. In the distal third of its course, it lies between the brachioradialis and flexor carpi radialis muscles or associated

tendons. The superficial branch of the radial nerve joins the

radial artery in the proximal third of the forearm and

remains adjacent and lateral to the artery in the middle

third of the forearm. Small branches of the lateral antebrachial cutaneous nerve may run along the distal part of

the artery as it winds around the wrist. The radial artery is

accompanied by a pair of venae comitantes through its

course. In the distal forearm, the radial artery lies on the

distal anterior aspect of the radius and is positioned superficially, covered only by skin and antebrachial fascia. The

flexor carpi radialis is located medial to the artery at the distal forearm (3).

In the proximal forearm, the radial artery gives off the

radial recurrent artery. Throughout its course, it gives off

several small muscular branches. In the distal forearm, a

small palmar carpal branch arises. The radial artery forms

anastomoses with the anterior and posterior interosseous

arteries (which in turn form anastomoses with the ulnar

artery) in the distal forearm, which contribute to the vascularity of the distal radius (91,92,129). Branches of these

anastomoses are used for harvest of distal radius–vascularized bone grafts (91,92) (see discussion of vascularized

bone grafts, under Clinical Correlations: Ulnar Artery and

Its Branches, earlier). Just proximal to the wrist, the radial

artery gives off a branch that contributes to the palmar

radiocarpal arch, which contributes to the vascularity of

the carpus (132) (Figs. 4.6 and 4.8). A relatively small

branch, the superficial palmar branch (of the radial

artery), also is given off just distal to the carpus. This

branch continues into the palmar aspect of the wrist and

usually helps form the radial aspect of the superficial palmar arch. The superficial branch of the radial artery also

contributes to form the palmar intercarpal arch (along

with contributions from the anterior interosseous artery

and the ulnar artery). The palmar intercarpal arch contributes to the vascularity of the carpus. These branches

are discussed separately later (3) (see Tables 4.5 and 4.6).

At the wrist, the radial artery curves dorsally and distally to wind around the lateral aspect of the wrist to reach

the dorsal surface. It passes between the capsule of the

wrist and deep the tendons of the abductor pollicis longus

and extensor pollicis brevis. This interval, referred to as

the anatomic snuff-box, lies just distal to the extensor retinaculum, between the extensor pollicis longus and extensor pollicis brevis. The radial artery crosses the snuff-box

superficial to the scaphoid and trapezium and deep to

both the extensor tendons. It also remains deep to the distal branches of the superficial radial nerve as the nerve

branches continue distally to the thumb and index finger.

The radial artery exits the distal edge of the extensor pollicis longus and continues distally toward the first dorsal

web space (1,2,445). The artery then dives abruptly

through the interval between the two heads of the first

dorsal interosseous muscle (3).

In the hand, the radial artery passes between the heads of

the first dorsal interosseous to reach the deep palmar surface

262 Systems Anatomy

TABLE 4.5. BRANCHES OF THE RADIAL ARTERY

Branches in the forearm

Radial recurrent artery

Muscular branches

Superficial palmar branch

Palmar carpal branch

Palmar radiocarpal arch

Branches at the wrist

Palmar intercarpal arch

Dorsal carpal branch

Dorsal radiocarpal arch

Artery to the dorsal ridge of the scaphoid

Dorsal intercarpal arch

Basal metacarpal arch

Dorsal metacarpal branches

Branches in the hand

Dorsal metacarpal branches (from the basal metacarpal arch)

First dorsal metacarpal artery

Princeps pollicis

Radial index artery

First palmar metacarpal artery

Deep palmar arch

Palmar metacarpal arteries

Perforating branches

Radial recurrent artery of the deep palmar arch

Ulnar recurrent artery of the deep palmar arch

Accessory ulnar recurrent artery of the deep palmar arch

(variable)

of the hand. The artery crosses the deep palm transversely

between the oblique and transverse heads of the adductor

pollicis muscle. The continuing artery pierces the transverse

head and reaches the base of the small finger metacarpal,

where it forms a variable anastomosis with the deep palmar

branch of the ulnar artery, completing the deep palmar arch

(446–451) (Figs. 4.4, 4.6, and 4.8).

Main Branches: Radial Artery

The branches of the radial artery can be roughly divided

into three groups for descriptive purposes (3). These groups

are the radial artery branches in the forearm, wrist, and

hand, although many of the arteries span more than one

region (see Table 4.5).

Radial Recurrent Artery

The radial recurrent artery is the first major branch of the

radial artery. It arises just distal to the radiocapitellar joint or

in the region of the neck of the radius (see Fig. 4.3). It originates from the lateral aspect of the artery and ascends proximally between the branches of the radial nerve. It passes

superficial to the supinator and continues between the brachioradialis and brachialis muscles. The artery supplies these

adjacent muscles and the elbow joint, including vessels to the

radial head, capitellum, and the lateral aspect of the trochlea

(supplied by posterior perforating vessels arising from the

radial recurrent artery) (62,444). The artery continues proximally, anterior to the elbow joint, to form an anastomosis

with the radial collateral artery branch of the profunda

brachii artery. Other branches may follow the posterior antebrachial cutaneous nerve and continue with the nerve to

reach the skin. Before the radial collateral artery pierces the

intermuscular septum, it may give a branch that continues

distally to the posterior aspect of the lateral epicondyle and

contributes to the anastomoses around the elbow. The radial

collateral artery usually also assists the radial recurrent artery

in supplying the intraosseous circulation to the capitellum

and the lateral aspect of the trochlea (62).

Muscular Branches of the Radial Artery

The radial artery provides several small muscular branches

to the brachioradialis and pronator teres muscles, and to a

portion of the superficial and deep flexor pronator muscles

located on the radial aspect of the forearm.

Superficial Palmar Branch (Artery) of the

Radial Artery

The superficial palmar branch arises in the distal forearm

from the radial artery proximal to the wrist (see Figs. 4.4,

4.6 and 4.8). It leaves the radial artery 5 to 8 mm proximal

to the radial styloid, usually from the medial or anterior

aspect of the radial artery (132,133). Because of its direction, it occasionally may appear as a small continuation of

the radial artery (as the main trunk of the radial artery continues distally, curving dorsally and laterally). The superficial palmar branch passes between the flexor carpi radialis

and the brachioradialis, and curves anteriorly and slightly

medially to pass superficial to the radial aspect of the transverse carpal ligament. It reaches the base of the thenar muscles. It then crosses the radial aspect of the carpus and forms

communications with the palmar intercarpal arch, which in

turn supplies the tubercle of the scaphoid and the radiopalmar surface of the trapezium. The superficial palmar branch

usually passes through the thenar muscles, but occasionally

may continue superficial to these muscles. It supplies the

thenar muscles and then, to a variable degree, forms an

anastomosis with the terminal portion of the ulnar artery,

completing the superficial palmar arch (see Superficial Palmar Arch, under Main Branches: Ulnar Artery, earlier). The

superficial palmar branch of the radial artery is variable in

size and configuration. When small, it may not complete

the anastomosis with the superficial palmar arch, and can

terminate at the level of the thenar muscles. Conversely, it

may remain large and appear as a palmar continuation of

the radial artery (3).

Palmar Carpal Branch of the Radial Artery and

Palmar Radiocarpal Arch

The palmar carpal branch of the radial artery arises in the

distal part of the forearm, usually near the distal border of

the pronator quadratus and approximately 5 mm distal to

the point where the superficial palmar branch is given off.

The palmar carpal branch is a small artery and passes across

the palmar aspect of the wrist toward the ulna. It forms an

anastomosis with the palmar carpal branch of the ulnar

artery. The palmar carpal branches of the radial and ulnar

arteries are joined by the anterior interosseous artery, to

form the palmar radiocarpal arch (see earlier under Ulnar

Artery; see Fig. 4.6). The palmar radiocarpal arch is the

most proximal of three transverse vascular arches that provide vascularity to the carpus (132,133,452–458). The

other two arches include the palmar intercarpal arch and

the deep palmar arch (Fig. 4.6 and see later). The palmar

radiocarpal arch crosses the anterior aspect of the proximal

wrist at the level of the distal metaphysis of the radius and

the ulna. It lies in the wrist capsule and usually has an anastomosis with the palmar intercarpal arch through a longitudinal interconnection. The palmar radiocarpal arch was

found to be consistently present by Gelberman and colleagues, formed by branches from the radial, ulnar, and

interosseous arteries in 87% of specimens, and by the radial

and ulnar arteries alone in 13% (132). The palmar radiocarpal arch (along with the palmar intercarpal arch and the

ulnar recurrent branch of the deep arch) contributes to the

4 Vascular Systems 263

palmar vascular supply of the lunate (452). It also supplies

the palmar surface of the triquetrum (132).

Palmar Intercarpal Arch of the Radial Artery

The palmar intercarpal arch is a small branch that usually

arises from the superficial palmar branch of the radial artery

(or anastomoses with it), usually at the level of the scaphotrapezial joint (see Fig. 4.6). It spans the palmar carpus

between the proximal and distal carpal rows. It is the most

variably occurring of the palmar carpal arches, and is found

in 53% of specimens studied (132). It is formed by

branches of the radial, ulnar, and anterior interosseous

arteries in 75%, and by the radial and ulnar arteries alone

in 25%. The arch is small and is not thought to be a major

contributor of vascularity to the carpus, although it does

contribute to the vascular supply to the lunate, capitate, and

triquetrum (132,133).

Dorsal Carpal Branch of the Radial Artery and

the Dorsal Radiocarpal Arch

The dorsal carpal branch of the radial artery usually originates at the level of the radiocarpal joint and runs dorsally

and ulnarly, penetrating the radiocarpal ligament deep to

the extensor tendons. It commonly forms an anastomosis

with the ulnar artery on the dorsum of the wrist. It contributes to a dorsal carpal network of several small vessels

or vascular arches (see later) that supply the dorsal carpus.

It crosses the carpus transversely and supplies or forms the

dorsal radiocarpal arch, which also receives contributions

from the ulnar artery and from the dorsal branch of the

anterior interosseous artery (see earlier, under Ulnar

Artery; Fig. 4.7). The dorsal radiocarpal arch, studied in

detail by Gelberman and associates, was found to be present in 80% of specimens, and is the most proximal of the

three dorsal carpal arches (the other two arches, the dorsal

intercarpal arch and the basal metacarpal arch, are

described later) (132). The dorsal radiocarpal arch is

located at the level of the radiocarpal joint, and lies deep to

the extensor tendons. The dorsal radiocarpal arch provides

the main vascular supply to the lunate and the triquetrum

(132). Although the dorsal radiocarpal arch usually is

formed by anastomosing branches of the radial and ulnar

arteries and the dorsal branch of the anterior interosseous

artery, it occasionally is formed by the radial and ulnar

arteries alone or by the radial and anterior interosseous

arteries (132,133).

Artery to the Dorsal Ridge of the Scaphoid

The artery to the dorsal ridge of the scaphoid is a direct

branch of the radial artery in 75% of specimens or originates

as a branch from the radiocarpal or intercarpal arch in 25%

of specimens (132) (Fig. 4.7). It arises at or near the level of

the scaphoid waist or distal scaphoid, usually at a level

between the dorsal radiocarpal arch (discussed previously)

and the dorsal intercarpal arch (discussed later), and takes an

ulnar retrograde course to reach the dorsal surface of the

scaphoid. In 70% of specimens studied, the dorsal ridge vessel arose directly from the radial artery. In 23%, the dorsal

ridge vessels had their origin from the common stem of the

intercarpal artery. In 7%, the dorsal ridge vessels originated

from both the intercarpal artery and the radial artery. There

are consistent, well developed anastomoses between the dorsal ridge vessels of the scaphoid (from the radial artery) and

the dorsal branch of the anterior interosseous artery. On the

dorsum of the scaphoid, an oblique ridge lies between the

articular surfaces of the radius and of the trapezium and

trapezoid. The major dorsal vessels to the scaphoid are

attached to the scaphoid by a soft tissue leash. The vessels

enter the bone through small foramina located on this dorsal ridge, usually at the level of the scaphoid waist (although

occasionally vessels enter slightly proximal or distal to the

waist) (132,133,138,139). The artery to the dorsal ridge of

the scaphoid supplies 70% to 80% of the scaphoid in the

proximal and central portions. The remaining 20% to 30%

in the distal portion is supplied by several palmar vessels

from the radial artery that enter the scaphoid through the

region of the tubercle. These are the palmar scaphoid

branches, discussed in the following section (138,139).

Palmar Scaphoid Branches

The palmar scaphoid branches are small arteries that arise

directly from the radial artery (or, less commonly, from the

superficial palmar branch of the radial artery). These vessels

supply the distal palmar aspect of the scaphoid in the tubercle region. When the branches arise directly from the radial

artery, the origin is just distal to that of the superficial palmar branch of the radial artery. The palmar scaphoid

branches consist of several small branches that course

obliquely and distally over the palmar aspect of the

scaphoid to enter the bone through the region of the tubercle (138,139) (Fig. 4.6). The small arteries further branch

into several smaller branches just before penetrating the

scaphoid. In 75% of specimens studied, these arteries arose

directly from the radial artery (138). In the remaining 25%,

they arose from the superficial palmar branch of the radial

artery. Consistent anastomoses exist between the palmar

division of the anterior interosseous artery and the palmar

scaphoid branch of the radial artery, when the latter arises

from the superficial palmar branch of the radial artery.

There are no apparent communicating branches between

the ulnar artery and the palmar branches of the radial artery

that supply the scaphoid. The palmar scaphoid branches

enter the palmar aspect of the tubercle and divide into several smaller branches to supply the distal 20% to 30% of

264 Systems Anatomy

the scaphoid. There are no apparent anastomoses between

the palmar and dorsal vessels (132).

Dorsal Intercarpal Arch

The dorsal intercarpal arch is the largest of the dorsal transverses, and is consistently present (see Fig. 4.7). It arises

from the radial artery approximately 5 mm distal to the

branch point of the artery to the dorsal ridge of the

scaphoid (132), usually at the level of the distal carpal row

or between the proximal and distal carpal rows. It runs

transversely across the dorsal carpus either between the

proximal and the distal carpal rows, or across the trapezoid

and capitate. The dorsal intercarpal arch supplies the distal

carpal row and forms an anastomosis with the radiocarpal

arch to supply the lunate and triquetrum. Branches also

contribute to the vascular supply of the trapezoid, capitate,

and hamate. Like the radiocarpal arch, the dorsal intercarpal arch usually is formed by various contributions from

the radial, ulnar, and anterior interosseous arteries. It

receives contributions from all three arteries (radial, ulnar,

and anterior interosseous) in 53% of cadavers studied

(132). Alternatively, it may be formed by the radial and

ulnar arteries alone in 20%, by the radial and anterior

interosseous arteries in 20%, and by the ulnar and anterior

interosseous arteries in 7% (see also under Ulnar Artery,

earlier) (132).

4 Vascular Systems 265

FIGURE 4.7. The arteries of the dorsal wrist. Note the transverse carpal arches: the dorsal radiocarpal arch, dorsal intercarpal arch, and basal metacarpal arch.

Basal Metacarpal Arch

The basal metacarpal arch is the most distal of the dorsal

transverse arches and is located at the base of the

metacarpals, just distal to the carpometacarpal joints (see

Fig. 4.7). It is the smallest and most variable of the dorsal

transverse arches and actually is considered a series of vascular retia. It is complete in 27% of specimens, and present

in its radial aspect alone in 46% (132). It is formed by interconnecting branches of the radial and ulnar arteries, from

perforating arteries from the second, third, and fourth

intraosseous spaces, as well as from anastomoses with the

dorsal intercarpal arch. It contributes to the vascularity of

the distal carpal row through anastomoses with the intercarpal arch (132,133).

Dorsal Metacarpal Branches

The dorsal metacarpal branches (with the exception of the

first dorsal metacarpal artery) arise from the dorsal carpal

network or from contributions from the basal metacarpal

arch (see Fig. 4.7). (Note: The first dorsal metacarpal arises

directly from the radial artery and is described later.) Three

thin dorsal metacarpal arteries usually are present but variable, and run distally on the second, third, and fourth dorsal interosseous muscles (3,459–464). At the level of the

second, third, and fourth digital web spaces, the dorsal

metacarpal arteries bifurcate into dorsal digital branches,

supplying adjacent dorsal sides of the index, middle, ring,

and small fingers. Each dorsal metacarpal artery has four to

eight cutaneous branches (459). The dorsal digital branch

vessels form anastomoses with the proper palmar digital

branches of the superficial arch. The dorsal metacarpal

branches also form anastomoses with the deep palmar

branch through the (proximal) perforating branches,

located proximally at the bases of the metacarpal. Further

anastomoses are formed with the dorsal metacarpal

branches near their points of bifurcation, where communications are formed with the common palmar digital vessels

of the superficial palmar arch by the (distal) perforating

arteries (3,4) (Figs. 4.5 and 4.7).

First Dorsal Metacarpal Artery

The first dorsal metacarpal artery arises separately at the

base of the thumb and index metacarpal just before the

radial artery passes anteriorly between the two heads of the

first dorsal interosseous muscle. The artery then forms two

branches, one of which continues along the index

metacarpal to supply the dorsoradial aspect of the index finger. The other branch continues distally along the dorsoradial aspect of the thumb to approximately the level of the

thumb metacarpal head. It then further divides into two

branches, one directed radially and one ulnarly to supply

the dorsal aspect of the thumb. The radial aspect of the dorsal thumb may receive a separate branch that arises directly

from the radial artery (3,4,189,459,462) (Fig. 4.7).

Princeps Pollicis Artery

The princeps pollicis artery arises from the radial artery or

from the most radial part of the deep palmar arch (Fig. 4.8).

As the radial artery passes between the heads of the first dorsal interosseous to enter the deep palm, it then turns medially to form the deep palmar arch. The princeps pollicis

forms from the anterolateral aspect of the radial artery (or

deep arch), and then continues distally toward the thumb

along the ulnar aspect of the thumb metacarpal (465). It

passes between the first dorsal interosseous muscle and the

oblique head of the adductor pollicis, crossing deep to the

tendon of the flexor pollicis longus. The princeps pollicis

then divides into the two proper palmar digital arteries of

the thumb. These branches continue distally toward the

thumb, with the ulnar proper digital artery passing to the

ulnar side of the insertion of the adductor pollicis and the

radial proper digital artery passing to the radial aspect of the

muscle. The proper palmar digital arteries continue to reach

the pulp of the thumb, supplying branches to the soft tissues and interphalangeal joint (202,203,466). Similar to

the digits, complex anastomoses occur between the two digital arteries at the level of the distal phalanx (3). The princeps pollicis is one of the principal arteries to supply the

thumb; however, variations are common (189,192,207,

210,467). The vascular supply to the thumb also may come

from the superficial branch of the radial artery (8%), the

first palmar metacarpal artery (18%), and the dorsal

metacarpal artery (8%) (467).

Radial Index Artery (Arteria Radialis Indicis)

The radial index artery usually is the second branch from

the radial artery as the radial artery enters the deep palm.

The radial index artery arises just ulnar and in close proximity to the princeps pollicis artery, usually originating

between the first dorsal interosseous muscle and the transverse head of the adductor pollicis muscle. The radial index

artery continues distally along the radial aspect of the index

finger to reach the level of the distal phalanx. The radial

index artery then forms a complex anastomosis with the

ulnar-sided proper palmar digital artery. Although the

radial index artery usually arises directly from the radial

artery (or deep arch), variations are common, and it also

may originate from a common trunk shared by the proximal portion of the princeps pollicis artery (3,4,192,202,

203,210). This trunk is then called the first palmar metacarpal artery (3,4,202,203,468).

266 Systems Anatomy

Deep Palmar Arch

The deep palmar arch is the terminal part of the radial artery,

which crosses transversely across the deep palm (11) (see Figs.

4.4, 4.6 and 4.8). It is located at the level of the metacarpal

bases, 5 to 10 mm distal to the palmar carpometacarpal

joints. The deep palmar arch is located proximal to the superficial palmar arch in 83%, but is distal to the superficial arch

in 15% (201). The lumen diameter of the deep palmar arch

varies between 1 and 2.3 mm, with an average of 1.5 mm

(191) (see Table 4.4). It is nearly consistently present and

usually forms an anastomosis with the deep palmar branch of

the ulnar artery, although variations in vascular patterns are

not uncommon. The most frequent variations are with the

complete or incomplete formation of the deep arch, with or

without anastomoses of the radial artery with the deep

branches of the ulnar artery (see later under Anomalies and

Variations: Radial Artery) (3,4,7,198,201,208,209,213,446,

448,450). The deep palmar arch is deeply situated in the

palm, superficial to the interosseous muscles, but deep to the

extrinsic flexor tendons, lumbricals, and the oblique head of

the adductor pollicis (8). In approximately two-thirds of

cases, the deep palmar arch lies deep to the ulnar nerve; in

one-third, the deep arch lies superficial to the nerve (to the

palmar side) (3). The deep palmar arch rarely may be doubled, and encircle the ulnar nerve. The deep palmar arch

crosses the palm in a radial-to-ulnar direction. It gives off

three (or four) palmar metacarpal arteries, several perforating

branches, and two recurrent branches (Fig. 4.8).

4 Vascular Systems 267

FIGURE 4.8. The arteries of the palmar hand. S, superficial palmar arch;

D, deep palmar arch.

The three or four palmar metacarpal arteries arise from

the distal convex edge of the deep palmar arch. These vessels course distally, usually toward the intermetacarpal

spaces of the index and long, the long and ring, and the ring

and small fingers. The palmar metacarpal arteries, like the

deep arch, are deeply situated, superficial to the interosseous muscle but deep to the extrinsic flexor tendons and

associated lumbrical muscles. The palmar metacarpal arteries reach the web spaces of the digits and form an anastomosis with the common palmar digital arteries (which are

derived from the superficial palmar arch) (3).

The deep palmar arch gives rise to the perforating

branches. Three perforating branches pass directly from the

deep palmar arch in a dorsal direction, through the second,

third, and fourth interosseous muscle spaces. The perforating branches form an anastomosis with the dorsal metacarpal arteries.

The deep palmar arch also gives rise to the radial and

ulnar recurrent branches (arteries). These branches originate

from the proximal concave aspect of the deep arch, and continue in a proximal direction along the anterior aspect of the

wrist. These vessels supply the carpal bones (mainly distal

carpal row), intercarpal articulations, and end in the palmar

carpal network. The radial recurrent branch contributes to

the vascular supply of the trapezoid and trapezium (132).

The ulnar recurrent branch contributes to the vascular supply of the capitate, hamate, and lunate (132). Theses

branches also send perforating branches to the dorsal basal

metacarpal arch and the palmar metacarpal arteries (3,132).

In 27% of specimens studied, an accessory ulnar recurrent

artery was present. It originates from the deep arch 5 to 10

mm medial to the ulnar recurrent artery and supplies the

medial aspect of the hook of the hamate. When this vessel is

not present, the medial aspect of the hamate is supplied by

direct branches from the ulnar artery (132) (Fig. 4.8).

Anomalies and Variations: Radial Artery

The radial artery may arise more proximal than usual, either

proximal to the elbow, or from various locations directly

from the brachial or axillary artery (23,79,95,469–471).

This may occur in as much as 12% of specimens (3), can be

associated with a high origin of the common interosseous

artery in the same extremity (95), and has been noted to be

bilateral (79). In the forearm, variations of the radial artery

are less frequent than those of the ulnar artery.

Various anomalies in the configuration of the radial

artery in the forearm have been noted, including tortuous

configurations (5.2%), hypoplasia (1.7%), and a radioulnar

loop (0.9%) (472).

In the region of the anatomic snuff-box, the radial artery

has been noted to pass superficial to the extensor tendons of

the thumb (instead of deep to these structures) (3,473–475).

The anomaly has occurred bilaterally (474). The superficial

radial artery at the wrist has been referred to as the arteria

antebrachialis superficialis dorsalis (476) or the arteria radialis

superficialis (473).

Absence of the Radial Artery

In its absence, a normal ulnar artery or an enlarged anterior

interosseous or median artery can replace the radial artery.

The anterior interosseous and median artery can contribute

directly to the formation of the palmar arches (3,477–480).

Absence of the radial artery also is observed in radial preaxial hemimelia, and in specific genetic and chromosomal disorders (Fanconi’s anemia, Holt-Oram syndrome) (480).

Anomalous Course of the Superficial Branch

Anomalous course of the superficial branch of the radial

artery: An abnormal course of the superficial branch of the

radial artery passing through the carpal tunnel was noted in

2 of 70 (2.85%) cadaver extremities studied (481). This

anomaly can potentially cause or contribute to carpal tunnel syndrome (481).

Accessory Radial Artery

In the arm and forearm, an accessory radial artery has been

noted that had a high division, passed lateral to the brachial

artery and lateral to the radial artery, and ultimately formed

an anastomosis with the princeps pollicis artery in the hand

(482).

The radial artery has been noted to pass along the forearm superficial to the deep fascia, as opposed to the normal

position deep to the antebrachial fascia (3).

The radial artery has been noted to pass superficial to the

brachioradialis instead of deep to its medial border (3).

Variations of the Deep Palmar Arch

Although consistent data indicate that the deep palmar arch

is less variable than the superficial arch, several variations

have been described. The incidence of a complete arch

(with contributions from both the radial artery and the

deep branch or branches of the ulnar artery) varies from

79% to 100% (175,213,448–450). Wilgis and Kaplan note

the most frequent pattern is the deep palmar arch existing

as an anastomosis between the radial artery and the deep

branch of the ulnar artery (185). The anterior interosseous

artery may participate in the formation of the deep palmar

arch with the radial artery alone or with the ulnar artery

alone (185). Mezzogiorno and associates noted the deep

arch formed from contributions from both the radial and

ulnar arteries in 89%, with formation by the radial artery

alone in 8% and by the ulnar artery alone in 3% (448).

Gellman and associates found less variability in the deep

palmar arch than in the superficial palmar arch; however, in

their study, the deep arch was complete and anastomosed

268 Systems Anatomy

with the ulnar artery in all specimens (191). Three general

patterns were noted in the communication of the radial

artery with the ulnar artery, with the radial artery communicating with the inferior deep branch of the ulnar artery in

44%, with the superior deep branch of the ulnar artery in

33%, or with both deep branches of the ulnar artery in

20% (191).

Olave and Prates noted in a study of 60 cadaver hands

that although the radial artery usually passed through the

first interosseous space to form the deep arch (85% of specimens), an anomalous route of the radial artery passing

through the second interosseous space was noted in as

much as 13% of specimens (449).

Absence of the Princeps Pollicis

In the absence of the princeps pollicis (noted in 2.4% of

220 cadavers), the vascular supply for the thumb was provided by the terminal branches of the superficial palmar

arch or the first dorsal metacarpal artery, both of which

originate from the radial artery (189).

Clinical Correlations: Radial Artery

Soft Tissue Forearm Flaps and the Radial

Artery

For soft tissue coverage and hand reconstructive procedures,

several forearm flaps are available, usually vascularized from

a distally based inflow from either the radial or ulnar arteries, or associated branch arteries (483–502). The forearm

flap also may be elevated as a free flap, based on a proximal

radial artery inflow (117,402,403). For harvest of a distally

or proximally based radial artery forearm flap, an intact

ulnar artery and superficial palmar arch that provides a

strong contribution to the vascularity of all the digits are

prerequisite. Conversely, for harvest of a distally based ulnar

artery forearm flap, an intact radial artery to provide circulation to the hand is prerequisite. Recent investigations have

led to the development of forearm flaps that do not sacrifice

a major forearm artery (483,487). Clinical examination

with the Allen test, Doppler examination, or an arteriogram

helps confirm these data. Several variations and anomalies

of the ulnar and radial arteries exist (as noted in the previous section) and have potential implications for the harvest

of forearm flaps.

Vascularized Bone Grafts and the Radial

Artery

The use of pedicled vascularized bone grafts for reconstruction of carpal nonunions or dysvascular conditions has

become more popular and feasible, especially in the last two

decades (503–524). These usually are based on the ulnar,

radial, or anterior or posterior interosseous arteries, or their

branches. Roy-Camille described the transfer of the

scaphoid tubercle with attached abductor pollicis brevis

muscle to assist healing of a scaphoid fracture (91,92,522).

Beck transferred a decorticated pisiform on a vascular pedicle in the revascularization of the lunate in a patient with

Kienböck’s disease (91,92,523,524). Braun used a distal

radius bone graft based on the pronator quadratus muscle

and anterior interosseous artery pedicle to successfully treat

five established scaphoid nonunions (504). Detailed and

concise descriptions of several reverse-flow, pedicled, vascularized bone grafts from the dorsal distal radius have now

been applied to difficult scaphoid fractures, nonunions, or

avascular necrosis of carpal bones. These and related techniques have shown significant potential. Shin and Bishop

have summarized the harvest of several of these distal radius

vascularized bone grafts based on anastomosing vessels

between the radial artery, the anterior and posterior

interosseous arteries, and carpal arch vessels. The radial

artery and posterior division of the interosseous artery usually are the primary sources. When harvested with retrograde anastomosing vessels, a vascularized graft of greater

reach is provided (91,92). These have been used for

scaphoid nonunion and Kienböck’s disease.

Radial Artery and Aneurysm, Thrombosis, and

Emboli

Although not as common as in the ulnar artery, aneurysm

(true and false), thrombosis, and embolization of the radial

artery are well reported (523–534). These have been noted

at the level of the forearm or wrist (525,528,530) or at the

anatomic snuff-box (534). The most common cause of true

aneurysm is blunt trauma (526). Other reported causes of

true and false aneurysm have been idiopathic, iatrogenic

(528,529), and penetrating trauma (530). In the region of

the anatomic snuff-box, the radial artery passes deep to the

extensor pollicis longus tendon. Compression of the artery

against the proximal epiphysis of the first metacarpal was

thought to be the etiology of emboli that resulted in

ischemic changes of the thumb and index finger (534).

Approximately 25% of those with true aneurysms of the

extremity have shown secondary problems with thromboembolism (526).

Metacarpal Arteries and Soft Tissue or Bone

Tissue Transfers

Anatomic studies have evaluated the dorsal metacarpal

arteries and anastomosing branches with regard to soft tissue and bone transfer procedures. The first or second dorsal

metacarpal artery can be used for an axial or retrograde

nutrient supply to vascularize a pedicled soft tissue flap for

hand reconstruction (221,222,440, 460,463,464). The second metacarpal has been described as a vascularized graft

for thumb reconstruction (461,513).

4 Vascular Systems 269

VENOUS ANATOMY

The veins of the upper extremity are divided into two

groups, superficial and deep (535–547). The superficial

veins are subcutaneous in the superficial fascia. Both

groups exhibit substantial variability, and disagreement

exists in the described patterns and names of veins. Many

of the superficial veins remain unnamed. The deep veins

accompany the arteries, including the palmar arches and

the dorsal arterial arch, and pass deep to the deep fascia

to continue between the muscles. The deep veins include

the venae comitantes. The deep veins often are doubled,

and the larger veins often are named after their corresponding artery, but usually are slightly smaller in caliber

than the artery. The deep veins not only run parallel with

the arteries, but often cross the arteries at various angles

(185). Both the superficial and deep veins have extensive

interconnections, and often form several parallel channels

of drainage from any single region. Both groups have

valves, but valves are more numerous in the deep veins

(4,185).

For descriptive purposes, the superficial veins are

described first, followed by the deep veins. The veins are

discussed from distal to proximal, in the direction of

blood flow. Because variations of the venous system are so

common, only the few well established variations are discussed.

SUPERFICIAL VEINS

Gross Anatomic Description: Superficial

Veins

The superficial veins include the venous network on the

dorsum of the hand, the superficial venous palmar arch, the

cephalic and accessory cephalic vein, the basilic vein, the

median antebrachial and cubital vein, and their associated

branches (Table 4.6).

Venous Network of the Dorsal Hand

The venous network of the dorsal hand forms initially from

venules of the distal digits and dorsal digital venous arches

that coalesce to form the dorsal digital veins (535,537,541)

(Fig. 4.9). The dorsal digital veins pass along the sides of the

digits and are joined to one another by additional oblique

communicating branches. There are frequent communications between the superficial and deep venous arches, and

between the palmar and lateral vessels (541). The digital

veins from the adjacent sides of the digits coalesce and also

receive interconnections from the palmar digital veins

through the intercapitular veins located in the digital web

space (see Fig. 4.10) (537). The dorsal digital veins and

intercapitular veins coalesce to form three dorsal metacarpal

veins, which end in the venous network on the dorsum of

the hand (3,4,537). The radial part of the network is joined

by the dorsal digital vein from the radial side of the index

finger and by the dorsal digital veins of the thumb. These

eventually coalesce to form the distal aspect of the cephalic

vein (which arises on the radial aspect of the hand. The

ulnar part of the network receives the dorsal digital vein of

the ulnar side of the small finger and hand to contribute to

the formation of the basilic vein. An additional venous

interconnection often forms with either the cephalic or

basilic vein in the forearm (3,537).

These digital veins have valves that prevent the flow of

blood from the dorsum to the palmar aspect, from proximal

to distal, and from the ulnar to radial digits in the proximal

venous arches (537).

270 Systems Anatomy

TABLE 4.6. VEINS OF THE UPPER EXTREMITY

Superficial veins

Venous network of the dorsal hand

Dorsal digital veins

Intercapitular veins

Dorsal metacarpal veins

Superficial venous palmar arch

Palmar digital veins

Intercapitular veins

Transverse anastomoses

Cephalic vein

Accessory cephalic vein

Basilic vein

Median antebrachial vein

Median cubital vein

Deep veins

Deep veins of the hand

Common palmar digital veins

Palmar metacarpal veins

Dorsal metacarpal veins

Superficial palmar venous arch

Deep palmar venous arch

Deep veins of the forearm

Venae comitantes of the radial artery

Venae comitantes of the ulnar artery

Venae comitantes of the posterior interosseous artery

Venae comitantes of the anterior interosseous artery

Brachial veins

Axillary veins

Brachial vein

Basilic vein

Posterior humeral circumflex vein

Circumflex scapular vein

Long thoracic vein

Subscapular vein

Thoracodorsal vein

Thoracoepigastric vein

Lateral thoracic vein

Superior thoracic vein

Cephalic vein

Superficial Venous Palmar Arch

The superficial venous palmar arch is a more delicate network than the venous network of the dorsal hand. It is initially formed by the palmar digital veins that drain into

venous networks located over the palmar digits and thenar

and hypothenar eminences (Fig. 4.10). The palmar digital

veins interconnect with the dorsal digital veins and dorsal

metacarpal veins through the intercapitular veins located

in the digital web spaces (see Fig. 4.9). There are transverse anastomoses between the intercapitular veins at the

base of the digits on the palmar side. The palmar digital

vessels with their interconnections in turn drain proximally over the palmar surface of the wrist and contribute

to the median antebrachial vein (centrally in the palmar

forearm) and the cephalic vein (on the radial aspect) and

the basilic vein (on the ulnar aspect) (3,4) (see Figs. 4.10

and 4.11).

Cephalic Vein

The cephalic vein is formed on the radial aspect of the wrist,

often in the region of the anatomic snuff-box. It arises from

the lateral contributions of the dorsal venous networks and

the superficial venous palmar arch (Figs. 4.9 through 4.11). It

courses proximally and winds along the radial aspect of the

forearm, receiving contributions from both the palmar and

dorsal surfaces of the hand and forearm (548–550). In the

palmar forearm, the cephalic veins communicate with the

median antebrachial vein (median cubital vein) and subsequently with the basilic vein. The main trunk of the cephalic

vein continues proximally along the radial side of the antecubital fossa in the groove between the brachioradialis and the

biceps brachii muscles (Fig. 4.12) . Here it crosses superficial

to the lateral antebrachial cutaneous branch of the musculocutaneous nerve. The cephalic vein enters the arm and continues proximally in the groove along the lateral border of the

4 Vascular Systems 271

FIGURE 4.9. The veins of the dorsal hand

and digits.

biceps brachii. In the proximal third of the arm, the cephalic

vein passes between the pectoralis major and deltoid muscles,

where it lies adjacent to the thoracoacromial artery (Fig.

4.13). From the interval between the pectoralis major and deltoid muscles and the clavicle (the deltopectoral triangle), the

cephalic vein passes deep to the clavicular head of the pectoralis major muscle to pierce the clavipectoral fascia. It

crosses anterior to the axillary artery, coursing in a medial

direction to reach the axillary vein. It connects with the axillary vein just inferior to the clavicle. The cephalic vein usually

has a valve near its junction with the axillary vein. The

cephalic vein may communicate with the external jugular vein

by a connection that ascends anteriorly to the clavicle (3,4).

Accessory Cephalic Vein

The accessory cephalic vein is located on the radiopalmar

forearm (see Fig. 4.11). It arises from the small vessels on

the dorsum of the forearm or from the ulnar side of the dorsal venous network in the hand. The accessory cephalic vein

continues proximally, remaining on the radial aspect of the

cephalic vein, and joins the cephalic vein in the proximal

forearm just distal to the elbow. The accessory cephalic vein

may arise form the cephalic vein, proximal to the wrist, and

then join it again in the proximal forearm. A large oblique

anastomosis often connects the cephalic and basilic veins on

the dorsum of the forearm (3,4).

Basilic Vein

The basilic vein arises on the dorsoulnar aspect of the hand,

initially formed from contributions of the dorsal venous network (see Figs. 4.9 and 4.10). The basilic vein continues proximally on the dorsal surface of the ulnar side of the forearm. It

curves toward the medial aspect of the forearm in the middle

third of the forearm to reach the anterior medial forearm just

272 Systems Anatomy

FIGURE 4.10. The veins of the palmar hand and digits.

4 Vascular Systems 273

FIGURE 4.11. The veins of the palmar forearm. Variation exists as to the venous patterns.

proximal to the elbow (551–561) (Fig. 4.11). Here the basilic

vein receives the median antebrachial vein. The basilic vein

then continues obliquely in a proximal direction in the groove

between the biceps brachii and the pronator teres. The vein

crosses the brachial artery, separated by the bicipital aponeurosis. Small nerve branches of the medial antebrachial cutaneous

nerve pass both anteriorly and posteriorly to the basilic vein in

this area. The basilic vein continues proximally in the anteromedial arm, along the medial aspect of the biceps brachii (Fig.

4.12). The vein perforates the deep fascia in the middle third

of the arm, usually slightly distal to the mid-portion. The vein

then continues proximally on the medial side of the brachial

artery to the distal border of the teres major. It joins the

brachial vein to help form the axillary vein (3,4) (Fig. 4.13).

Median Antebrachial and Median Cubital

Veins

The median antebrachial vein drains the central part of

the venous plexus on the palmar surface of the hand (see

Fig. 4.11). It continues proximally toward the ulnar side

of the anterior forearm. The median antebrachial vein

reaches the proximal forearm and either empties into the

basilic vein or forms the median cubital vein. It may

divide into two vessels, one of which joins the basilic vein

and the other joining the cephalic vein distal to the antecubital fossa (545–547). The median antebrachial vein

also has interconnections with the deep veins of the forearm (3).

274 Systems Anatomy

FIGURE 4.12. The veins of the anterior elbow.

DEEP VEINS

Gross Anatomic Description: Deep Veins

The deep veins of the upper extremity consist of the deep

veins of the hand and forearm, the brachial veins, and the

axillary vein (see Table 4.6). In general, the deep veins follow the associated arteries as the venae comitantes. These

veins often are arranged in pairs along both sides of the

artery. There usually are several short transverse or diagonal

intercommunicating branches between the veins.

Deep Veins of the Hand

The superficial palmar arch and the deep palmar arch of the

hand usually are accompanied by a pair of venae comitantes

that form the superficial and deep palmar venous arches.

These venous arches receive the veins corresponding to the

branches of the arterial arches.

Interestingly, the proper palmar digital arteries usually

are not accompanied by double venae comitantes (185).

The proper digital artery may be accompanied by a single

palmar digital vein, but this is not consistent. Frequently,

small veins unrelated to the palmar digital arteries are found

in the subcutaneous layers of a digit. These drain either into

the superficial system or into the deep veins of the palmar

arches. The superficial system, which is more abundant,

collects into lateral veins over the dorsum of the digits and

is then directed toward the interdigital spaces to form the

venous network over the dorsum of the hand (see earlier,

under Superficial Veins).

The common palmar digital veins drain into the superficial venous arch and the palmar metacarpal veins flow into

the deep palmar venous arch. The dorsal metacarpal veins

receive perforating branches from the palmar metacarpal

veins and end in the radial veins and the superficial veins on

the dorsum of the wrist (3,4).

Deep Veins of the Forearm

The deep veins of the forearm consist of the venae comitantes of the radial and ulnar arteries. The deep veins of the

palm, including the superficial and deep palmar venous

4 Vascular Systems 275

FIGURE 4.13. The veins of the axilla, including the brachial, cephalic, and axillary veins.

arches, drain into these veins. The deep palmar venous arch

drains principally into the radial veins. The superficial palmar arch drains into the ulnar veins. The radial and ulnar

venae comitantes coalesce at the level of the elbow to form

the brachial veins. The radial veins usually are smaller than

the ulnar veins, and usually receive the dorsal metacarpal

veins. The ulnar veins receive small connections from the

deep palmar venous arch and communicate with the superficial veins at the wrist. At the level of the elbow, the ulnar

veins receive the anterior and posterior interosseous veins.

There also usually is a communicating branch to the

median cubital vein.

Brachial Veins

There usually are two brachial veins, located on the medial

and lateral aspects of the brachial artery (see Figs. 4.12 and

4.13). The brachial veins usually are formed by the union

of the radial and ulnar venae comitantes near the level of the

elbow. These brachial veins receive branches that correspond to the branches given off by the artery. Near the distal margin of the subscapularis muscle, these veins join the

axillary vein. The medial brachial vein often flows into the

basilic vein. The basilic vein may take the place of the

medial brachial accompanying vein. These deep veins have

numerous anastomoses (with each other and with the

superficial veins); there are frequent variations, and the

nomenclature of the veins is not consistent among textbooks or studies (1–11).

Axillary Vein

The axillary vein begins at the union of the basilic and

brachial veins, usually located at the distal border of the

teres major muscle (see Fig. 4.13). The axillary vein terminates to become the subclavian vein at the distal outer border of the first rib. The branches of the axillary vein are variable, but roughly correspond to the associated branches of

the axillary artery. These branches include the circumflex

scapular vein, long thoracic vein, subscapular vein, thoracodorsal vein, thoracoepigastric vein, and superior thoracic

vein (see Table 4.6 and Fig. 4.13). In addition, the cephalic

vein joins the axillary vein proximal in the axilla, near the

first rib. The axillary vein is located on the medial aspect of

the axillary artery. In the proximal axilla, between the axillary vein and the axillary artery, are the medial cord of the

plexus and the medial pectoral nerve. More distally in the

axilla, between the axillary vein and artery, are the median

and ulnar nerves and the medial cutaneous nerve of the

forearm. The medial cutaneous nerve of the arm is located

medial to the vein. The lateral group of the axillary lymph

nodes is located posteromedial to the axillary vein. The axillary vein has a pair of valves near its distal end, at the border of the subscapularis muscle. Valves also are located near

the ends of the subscapular veins. As with the brachial

veins, there are frequent variations in the descriptions of the

axillary vein, and the nomenclature, branching, and patterns depicted between the veins are not consistent among

reports or textbooks (1–11).

Anomalies and Variations: Superficial

and Deep Veins

Absence of the Cephalic or Basilic Veins

Because of the substantial variation of the superficial veins

of the forearm, there often is a reciprocal relationship in the

size of the cephalic and basilic veins. Either one may predominate or be lacking. Absence of the cephalic vein has

been observed in 3% of men and 1% of women in a study

of 170 men and 96 women (546). With absence of the

cephalic vein, the median antebrachial vein usually is

enlarged to drain the area of the cephalic vein (3,4).

Absence of communication between the cephalic and

basilic veins has been noted in 9% of men and 7% of

women (546)

Absence of the Median Antebrachial Vein

The median antebrachial vein may be absent (1,2).

Median Cephalic Vein and Median Basilic Vein

The median cubital vein may be split into a distinct “Y”

pattern, with one arm of the Y draining into the cephalic

and the other into the basilic vein. In this case, one branch

is called the median cephalic vein and the other the median

basilic vein (3,4).

Clinical Correlations: Superficial and

Deep Veins

In the elbow region, the basilic vein passes in the groove

between the biceps brachii and the pronator teres. In this

area, small nerve branches of the medial antebrachial cutaneous nerve pass both anteriorly and posteriorly to the

basilic vein, and are vulnerable to injury if the vein is mobilized, explored, or harvested for venous graft.

The cephalic, basilic, and median cubital veins are clinically important from the standpoint of venipuncture, formation of arteriovenous fistulas for vascular access, the use

of pedicled flaps on the upper extremity, and the pathologic

formation of hemangiomas or aneurysms (551–571). The

median cubital vein is commonly used for venipuncture.

Because it has substantial anastomosing branches with the

deep veins, it is “anchored down,” and this helps facilitate

placement of a needle by preventing the vein from slipping

or rolling away.

276 Systems Anatomy

LYMPHATIC VESSELS AND

NODES

The lymphatic system is a widely dispersed network of thinwalled lymphatic vessels, larger lymph vessels, and associated nodes. The system drains fluid formed in the interstitial spaces and the tissue spaces of most organs. The lymph

fluid is then returned to the venous system for recirculation.

Peripherally, the lymphatic vessels do not communicate

with the blood vessels, but the lymph eventually empties in

to the venous system at the junction of the jugular and subclavian veins at both sides of the neck. The endothelium at

this point is continuous with that of the lymphatic vessels

(3,4).

Lymph fluid consists of an ultrafiltrate of blood that

contains plasma proteins. On its way to the venous system,

the lymph fluid is circulated through lymphatic tissue and

lymph nodes. The lymph nodes contain phagocytes that

function to remove foreign matter. Lymphocytes also enter

the lymphatic fluid at the nodes, as well as immunoglobulins or antibodies, playing a role in immunologic protection

(3,4,8).

In the upper extremity, lymphatic drainage is directed

along the routes of the major vascular channels. The lymphatic vessels are divided into superficial and deep lymphatic vessels. The superficial lymph vessels are present in

greater numbers than the deep (572). The lymph nodes are

similarly divided into superficial and deep lymph nodes.

The superficial lymphatics generally follow the veins,

whereas the deep lymphatics usually follow the arteries.

Most of the lymph from the upper limbs drains to the axillary nodes; in addition, two groups of superficial lymph

nodes, the supratrochlear node(s) located proximal to the

medial elbow and the deltopectoral node(s) located at the

deltopectoral grove, assist with lymph drainage. In general,

the hand, forearm, and arm have very few lymph nodes,

and those present are very small (3,4,572,573).

SUPERFICIAL AND DEEP LYMPHATIC

VESSELS

Gross Anatomic Description: Superficial

Lymphatic Vessels

The superficial lymphatic vessels include the digital

plexuses, the palmar plexus, and the radial, median, and

ulnar channels (3,4,572,573) (Table 4.7). The superficial

vessels arise in a complex lymphatic plexus that courses

throughout the skin of the entire limb (Figs. 4.14 and

4.15). Commencing in the each digit, vessels arise distally

and course in a proximal direction along the sides of each

finger to form a digital plexus. The meshes of vessels are

denser on the palmar aspect of the digit, but head in a

slightly dorsal direction to reach the dorsum of the hand.

In addition, fine but dense meshes of plexuses form in the

palm to form the palmar plexus. The lymph in the palmar

plexus courses in different directions, proximally toward

the wrist, distally to join the digital vessels, medially to

join the vessels on the ulnar border of the hand, and laterally to the vessels of the thumb (3). In addition, a palmar trunk is formed from several vessels that arise in the

central part of the palmar plexus and unite to pass around

the metacarpal of the index finger to join the vessels on

the back of the index finger and thumb. Continuing in a

proximal direction, lymphatic vessels at the wrist form

three roughly parallel channels, the radial, median, and

ulnar lymphatic vessels. These vessels course, respectively,

along the cephalic, median, and basilic veins in the forearm. Some of the ulnar lymph vessels end or pass through

the small supratrochlear node(s), located on the medial

elbow, proximal to the joint level (see Fig. 4.15). Some of

the radial lymph vessels continue proximally to form a

trunk that ascends with the cephalic vein to reach the deltopectoral nodes. [Some of these vessels may continue

with the cephalic vein to penetrate the clavipectoral fascia

to enter the apical group of the axillary nodes in the infraclavicular region, or may ascend as far as the lower deep

cervical nodes proximal to the clavicle (3,572,573).] Most

of the superficial lymph vessels of the upper extremity,

however, continue proximally to reach the lateral group of

axillary nodes (see Figs. 4.15 and 4.16).

4 Vascular Systems 277

TABLE 4.7. LYMPHATIC VESSELS AND LYMPH

NODES OF THE UPPER EXTREMITY

Superficial lymphatic vessels

Digital plexus

Palmar plexus

Radial vessels

(Some to deltopectoral nodes)

Median lymph vessels

Ulnar lymph vessels

(Some to supratrochlear nodes)

Deep lymphatic vessels

Deep radial lymphatic vessels

Deep ulnar lymphatic vessels

Deep anterior interosseous lymphatic vessels

Deep posterior interosseous lymphatic vessels

Deep brachial lymphatic vessels

Superficial lymph nodes

Supratrochlear lymph nodes

Deltopectoral lymph nodes

Deep lymph nodes

Axillary lymph nodes

Lateral group

Pectoral (anterior) group

Subscapular (posterior) group

Central group

Apical (subclavicular) group

Gross Anatomic Description: Deep

Lymphatic Vessels

The deep lymphatic vessels include the deep radial, deep

ulnar, deep anterior and posterior interosseous, and deep

brachial lymphatic vessels (see Table 4.7). The deep lymphatic vessels accompany the deep blood vessels. In the

forearm, there are four sets, which correspond to and follow

the radial, ulnar, and anterior and posterior interosseous

arteries. These deep lymphatic vessels communicate at

intervals with the superficial lymphatic vessels, and some

may end in the associated nodes. In the arm, these deeper

lymphatic vessels follow the brachial artery. Some vessels

terminate in small nodes along the artery, but most continue proximally to reach the axillary nodes (3,4,574,575)

(see Figs. 4.15 and 4.16).

Gross Anatomic Description: Superficial

Lymph Nodes

Although most of the lymph nodes of the upper extremity

are grouped in the axillary nodes, several nodes exist along

the superficial vessels. These include the supratrochlear and

deltopectoral nodes (see Table 4.7).

The supratrochlear nodes consist of one to five small

nodes located on the medial distal arm, just proximal to the

medial epicondyle of the elbow (see Fig. 4.15). Located in

the superficial fascia, these nodes usually are medial to the

basilic vein. The supratrochlear nodes receive lymph flow,

usually through the (superficial) ulnar lymphatic vessels

that follow the basilic vein, to drain fluid from the middle,

ring, and small fingers, the medial portion of the hand, and

the superficial areas over the ulnar side of the forearm.

Because these vessels intercommunicate with the other

lymph vessels of the digits and fingers, it is conceivable that

the supratrochlear nodes can receive fluid from other parts

of the upper extremity as well.

The deltopectoral nodes consist of only a few nodes

located along the cephalic vein in the deltopectoral grove,

between the pectoralis major and deltoid muscles, just inferior to the clavicle (Fig. 4.16; see Fig. 4.15). The deltopectoral nodes can receive lymph flow from the (superficial)

radial lymph vessels, which follow the cephalic vein (3,4,8,

575).

278 Systems Anatomy

FIGURE 4.14. Schematic illustration of the fine superficial lymph vessels on the dorsum of the digits and

hand.

4 Vascular Systems 279

FIGURE 4.15. Schematic illustration of the fine superficial lymph vessels on the palmar hand and

forearm. The supratrochlear, deltopectoral, and axillary nodes are shown.

Gross Anatomic Description: Deep Lymph

Nodes

The deep lymph nodes are located and mainly comprise the

axillary lymph nodes. There are, however, sporadic, variable, isolated deep lymph nodes in the forearm along the

course of the radial, ulnar, and interosseous arteries, and in

the arm along the medial side of the brachial artery (3).

The axillary nodes are relatively large, and vary from 20

to 30 in number. These are divided into several groups,

including the lateral, pectoral (anterior), subscapular (posterior), central, and apical (subclavicular) nodes (3,4,575,576)

(see Table 4.7 and Fig. 4.16).

Lateral Group of the Axillary Lymph Nodes

The lateral group consists of four to six axillary nodes

located medial and posterior to the axillary vein (575,576)

(see Fig. 4.16). This group includes among the most distal

of the axillary nodes and receives lymph vessels from nearly

the entire upper limb (with the exception of those vessels

that accompany the cephalic vein, some of which drain into

the deltopectoral nodes). The lymph vessels also pass to the

central and apical group of the axillary nodes (located deep

and proximal to the lateral group) (3,4,8).

Pectoral (Anterior) Group of the Axillary

Lymph Nodes

The pectoral group of lymph nodes is located inferior to the

lateral group and consists of four or five nodes that lie along

the lateral border of the pectoralis minor muscle, close to

the lateral thoracic artery (see Fig. 4.16). The lymph vessels

that drain into the pectoral group arise in the skin and muscles of the anterior and lateral thoracic walls, and from the

central and lateral parts of the mammary gland. These vessels also connect to the central and apical groups of lymph

nodes (3,4,8).

Subscapular (Posterior) Group of the Axillary

Lymph Nodes

The subscapular lymph nodes are located along the lower

margin of the posterior wall of the axilla, close to the subscapular artery (576,577) (see Fig. 4.16). These usually are

280 Systems Anatomy

FIGURE 4.16. The several groups of lymph nodes comprising the axillary nodes.

inferior to the central and lateral groups of nodes. The subscapular group consists of six or seven axillary nodes. The

lymph vessels that drain into the subscapular group arise in

the skin and muscles of the posterior neck and the posterior

thoracic wall. The lymph vessels then continue to the central group of nodes (3,4,8).

Central Group of the Axillary Nodes

The central group of lymph nodes is located deep in the

axilla, in the adipose tissue (576,577) (see Fig. 4.16). The

central group consists of three or four nodes. Because of its

central location, this group does not drain a specific part of

the upper extremity directly, but does receive vessels from

the lateral, pectoral, and subscapular groups of nodes. Vessels that enter the central group may continue proximally

and superiorly to reach the apical nodes (3,4,8)

Apical (Subclavicular) Group of the Axillary

Nodes

The apical group of nodes is located superiorly and proximally in the axilla, and consists of 6 to 12 nodes (576)

(see Fig. 4.16). The nodes lie partly deep to the superior

part of the pectoralis minor and partly in the apex of the

axilla, medial and superior to the superior border of the

muscle. The lymph vessels that drain into the apical

nodes follow the cephalic vein. The apical lymph nodes

usually receive a few vessels from those draining the superior part of the mammary gland. The apical nodes also

receive communicating vessels from the other axillary

nodes. The vessels from the apical nodes unite to form

the subclavian trunk, which continues either directly into

the junction of the internal jugular and subclavian veins

or into the jugular lymphatic trunk. On the left side, the

subclavian trunk may end in the thoracic duct. A few vessels from the apical nodes also may pass to the inferior

deep cervical nodes (3,4,8).

Anomalies and Variations: Lymphatic

Vessels and Nodes

Because of the normal variations in the lymphatic system,

these are described in the sections on normal anatomy of

the vessels and nodes (see the Gross Anatomic Description

sections for the superficial and deep lymph vessels and

nodes, earlier).

Clinical Correlations: Lymphatic Vessels

and Nodes

Unilateral upper extremity lymphedema is a well recognized

potential occurrence after operative axillary node dissection

(i.e., performed with mastectomy for breast carcinoma)

(573,577,578).

Palpable enlargement and possible tenderness of the axillary or supratrochlear nodes can follow infection or

metastatic disease, an important finding in the clinical evaluation of these problems.

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577. Mellor RH, Stanton AW, Azarbod P, et al. Enhanced cutaneous

lymphatic network in the forearms of women with postmastectomy oedema. J Vasc Res 37:501–512, 2000.

578. Milanov NO, Abalmasov KG, Lein AP. Changes in the lymphatic vessels of the upper extremity following a radical mastectomy (based on lymphographic data). Vopr Onkol 32(2):

23–28, 1986.

4 Vascular Systems 293

6

ARM

JAMES R. DOYLE

Compared with the anatomic and functional complexities

of the shoulder region, forearm, wrist, and hand, the arm is

remarkably less complex. The arm in large part is presented

exclusive of the shoulder and the elbow, which are discussed

elsewhere. This arbitrary division is meant to facilitate the

presentation of the necessary information for the region and

should not be taken as a failure to recognize the important

interactions among all parts of the upper extremity. As with

all such divisions, there may be omissions or additions

made for the sake of clarity and the descriptive process.

DESCRIPTIVE ANATOMY

Contents

Bone: The humerus.

Blood Vessels: The cephalic and basilic veins and the

brachial artery and its branches.

Nerves: The median, musculocutaneous, ulnar, radial,

and superficial cutaneous nerves.

Muscles and Septa: The biceps, brachialis, coracobrachialis, and triceps muscles and medial and lateral intermuscular septa.

External Landmarks

Lateral Arm

Useful lateral landmarks include the prominent deltoid

muscle covering the proximal half of the arm, the lateral

biceps groove that contains the cephalic vein, the lateral and

long heads of the triceps, and the lateral epicondyle and

olecranon (Fig. 6.1).

Posterior Arm

Posteriorly, the long and lateral heads of the triceps that

cover the deep medial head form a bulky muscle mass over

the shaft of the humerus. The olecranon process of the ulna

is a prominent bony landmark, as is the posterior aspect of

the acromion process and the medial and lateral humeral

condyles (Fig. 6.2).

Anteromedial Arm

Useful anteromedial landmarks include the coracoid

process of the scapula inferior to the outer aspect of the

clavicle, the long head of the biceps tendon, and the greater

tuberosity of the humerus palpable just lateral and superior

to the biceps tendon (Fig. 6.3). The deltopectoral groove is

marked by the cephalic vein. The biceps is the prominent

and relatively mobile muscle mass on the front of the arm

that overlies the brachialis. The medial biceps groove, which

contains the basilic vein, marks the medial margin of the

biceps and defines the interval between the anterior and

posterior compartments of the arm.

Skeletal Anatomy

Humerus

The humerus is the longest and largest bone in the upper

extremity, with expanded proximal and distal articular ends

joined by a long shaft.

Humeral Shaft

The humeral shaft is almost round in its proximal aspect

and becomes triangular (apex anterior) in its distal aspect.

Proximal and Anterior Surface of the Humerus

The proximal and anterior surface demonstrates two

prominent ridges or crests flanking the bicipital or intertubercular groove that are distal continuations of the greater

and lesser tuberosities (Fig. 6.4A). The crest from the

greater tuberosity, which is lateral, provides an insertion for

the pectoralis major, and the crest of the lesser tubercle,

which is medial, receives the insertion of the teres major.

The intertubercular groove contains the tendon of the long

316

FIGURE 6.1. A: Lateral arm. B: external landmarks and

muscles.

A

head of the biceps and also provides a point of attachment

for the latissimus dorsi.

The deltoid tuberosity is a laterally situated prominence at

approximately the mid-portion of the shaft that is the insertion point of the deltoid muscle. Just distal to the deltoid

tuberosity and beginning posteriorly and spiraling distally

and laterally is a groove for the radial nerve. At approximately

the level of the deltoid tuberosity, the cross-sectional shape of

the humerus begins to change from circular to triangular,

with the apex of the triangle being anterior. As this triangular configuration continues distally, it begins to narrow in the

anteroposterior plane while simultaneously widening in the

medial and lateral aspects to form the medial and lateral

supracondylar ridges. The anteriorly situated ridge of the triangular configuration courses between the coronoid and

radial fossae to end between the trochlea and capitellum.

Hueter’s line, also known as the interepicondylar line, is a

straight line drawn from the tips of the humeral epicondyles

in the coronal plane (1). It is a useful landmark for locating

the possible site of division of the radial nerve into motor and

sensory components at the elbow (see discussion of distal

radial nerve division, later).

6 Arm 317

FIGURE 6.2. A: Posterior arm. B: external landmarks and muscles.

A B

Posterior Surface of the Humerus

The posterior aspect of the humerus is relatively flat from the

region of the deltoid tuberosity to the distal articulation (see

Fig. 6.4B). Posteriorly, a prominent oblique ridge begins

medially just distal to the surgical neck and runs laterally to

end near the deltoid tuberosity. This ridge represents the

point of origin of the lateral head of the triceps (2).

Humeral Torsion

When the humerus is viewed along its longitudinal axis

from proximal to distal, the proximal and distal articular

axes are divergent by approximately 15 degrees (see Fig.

6.4C). The articular axis of the proximal humerus looks

posteriorly by 15 degrees in relationship to the distal intercondylar axis, which is in the coronal plane (2).

318 Regional Anatomy

FIGURE 6.3. A: Anteromedial arm. B: external landmarks and muscles.

A

B

6 Arm 319

FIGURE 6.4. A: Anterior view of humerus

with external landmarks and cross-sectional

anatomy. Observe the changes in the

medullary canal, external shape, and cortical

thickness from proximal to distal. B: Posterior

humerus, external landmarks. C: Humeral torsion. The proximal and distal axes of the

humerus are divergent by approximately 15

degrees. The articular axis of the proximal

humerus looks posteriorly by 15 degrees in

relationship to the distal intercondylar axis,

which is in the coronal plane.

ANATOMIC RELATIONSHIPS

Veins of the Arm

Two major veins are present in the arm: the cephalic and

the basilic, which run in the biceps groove on each side of

the arm (Fig. 6.5). The cephalic continues proximally to

the deltopectoral groove, where it acts as a useful landmark for identification of the interval between the deltoid

and pectoralis muscles (3). At the deltopectoral triangle

(the infraclavicular fossa) just inferior to the clavicle, the

cephalic vein perforates the clavipectoral fascia and empties into the axillary vein. The cephalic vein in the deltopectoral groove is accompanied by the deltoid branch

of the thoracoacromial artery, which exits from the deltopectoral triangle and gives muscular branches to the

deltoid and clavicular head of the pectoralis major. In

contrast to the more superficial course of the cephalic

vein, the basilic vein pierces the brachial fascia at approximately the mid-aspect of the arm, where it ascends

medial to the brachial artery in the neurovascular bundle

to the lower margin of the teres major, where it becomes

the axillary vein (2).

320 Regional Anatomy

FIGURE 6.5. Veins of the arm and forearm, anterior view. The cephalic and basilic veins mark the

division between the flexor and extensor compartments of the arm and the location of the medial

and lateral intermuscular septa. The cephalic vein

continues proximally to the deltopectoral groove,

where it may act as a useful landmark to identify

the interval between the deltoid and the pectoralis

muscles. In the forearm, the cephalic and basilic

veins flank the median antebrachial vein in the

forearm. Note the median cubital vein in the region

of the antecubital fossa.

Cutaneous Nerves of the Upper Extremity

Lateral Antebrachial Cutaneous Nerve

The musculocutaneous nerve from the lateral cord of the

brachial plexus pierces the coracobrachialis, which it innervates, and descends laterally between the biceps and

brachialis, which it also innervates, to exit from the lateral

margin of the biceps, where it becomes the lateral antebrachial cutaneous nerve (LACN) of the forearm (Fig. 6.6).

The LACN is discussed in detail in Chapter 8.

Medial Antebrachial Cutaneous Nerve

The counterpart of the LACN on the medial aspect of the

arm, the medial antebrachial cutaneous nerve (MACN),

was studied by Masear et al. in 50 cadavers (4) (Fig. 6.7).

They found that the MACN arises in the axilla from the

medial cord in 78% and from the lower trunk in 22%. In

54%, the MACN and medial brachial cutaneous nerve

(MBCN) had a common origin from either the medial cord

or the lower trunk. When a common origin was present,

the MBCN divided from the MACN an average of 6 cm

(range, 1 to 20 cm) distal to the origin from the medial cord

or lower trunk. Twenty-six percent (13 of 50) had a second

MBCN branch off the MACN. In 8 of these 13, the highest medial brachial branch arose from the plexus separate

from the origin of the MACN. Four percent had three

MBCN branches of the MACN in the proximal two-thirds

of the arm. One specimen had no MBCN, and a thoracic

nerve sent cutaneous branches to the posteromedial arm

into the distribution ordinarily supplied by the MBCN. In

two specimens, the MBCN, MACN, and medial pectoral

nerve had a common trunk off the medial cord. The

MACN communicated with the medial brachial nerve in

4% and with the ulnar nerve in 6%. No communication

was found with the palmar cutaneous branch of the ulnar

nerve in the distal forearm. This nerve is adjacent to the

basilic vein as it descends along the medial side of the

brachial artery and then pierces the brachial fascia to

become superficial at the middle or distal arm. The relationship of the nerve to the basilic vein is variable because

half of the nerves cross deep and the other half superficial

to the median cubital vein at the elbow. In the distal arm,

the MACN divides into anterior and posterior branches at

an average of 14.5 cm (range, 1 to 31 cm) proximal to the

medial humeral epicondyle, with most (92%) branching

between 7 and 22 cm proximal to the medial epicondyle.

The anterior branch traverses the elbow between the medial

epicondyle and the biceps tendon, usually lying 2 to 3 cm

anterolateral to the epicondyle but sometimes crossing

directly over it. The anterior branch gives off variable cutaneous branches (two to five) to the antecubital fossa and the

proximal and distal anterior arm. Most of these branches

arose 6 cm proximal and 5 cm distal to the elbow. The main

anterior branch then continues distally superficial to the

flexor carpi ulnaris (FCU) and is traceable to an average of

5.6 cm from the wrist flexion crease. The posterior branches

(one to four) were found to course posteriorly from 6 cm

proximal to 4 cm distal to the epicondyle. Most (90%)

crossed at or proximal to the epicondyle. Anteromedial

articular branches were found in 34% (17 of 50), with 6

from the anterior and 11 from the posterior branches (3,4).

Clinical Significance

The MACN is a useful nerve graft for brachial plexus reconstruction (4). The MACN is a long nerve, similar in diameter to the sural, and is readily accessible in the surgical exposure of the plexus. If the length of only one sural nerve is

needed, the MACN usually suffices, and surgical time may

be shortened. In the 50 dissected specimens of Masear et al.,

the average graft length was 18.7 cm (range, 10 to 26 cm)

(4). Graft diameter proximally averaged 3.15 mm with 10.2

groups of fascicles, and in the mid-brachium near the bifurcation, the average diameter was 2 mm with 7 fascicular

groups. If the MACN is selected as a graft for a digital or

cutaneous nerve of the hand or wrist, a good size match is

obtained by using the anterior branch just proximal to the

elbow. Graft diameter may be increased or decreased by

moving proximally or distally as needed (4). Masear et al.

advise against taking the posterior branch because this

results in numbness over the olecranon, and the resulting

neuroma is in an area subjected to trauma (4). Cheney has

noted the MACN is a branching nerve of appropriate length

and diameter that matches the surgical requirements for cranial nerve reconstruction in head and neck surgery (5). He

noted that the MACN closely resembles the distal facial

nerve in terms of diameter and branching (5).

Medial Brachial Cutaneous Nerve

The other major medial cutaneous nerve of the arm is the

MBCN. It arises from the medial cord of the brachial

plexus and passes medial and posterior to the ulnar nerve as

it courses distally. Two to 3 cm proximal to the medial epicondyle, the nerve arborizes into two to five branches that

terminate over the medial epicondyle in 80% of specimens;

in the remaining 20%, the branches end in the mid-portion

of the medial arm (6).

Clinical Significance

Both the MACN and the MBCN send multiple branches

to the medial side of the elbow, which is the location of the

standard incision for ulnar nerve transposition. Race and

Saldana noted that 100% of the terminal branches of the

posterior arborization of the MACN and 80% of the

MBCN are in the fascia directly over the medial epicondyle

and the flexor pronator mass (7). The authors note that

unless these three to seven branches are carefully dissected,

any incision placed over the medial cubital tunnel will transect these nerves and result in anesthesia over the medial

6 Arm 321

322 Regional Anatomy

FIGURE 6.6. Palmar (A) and Dorsal (B) views of the cutaneous nerves of the arm and forearm.

All but one (the axillary) of the five terminal branches of the brachial plexus contribute branches

to the hand. The musculocutaneous nerve ends in the lateral antebrachial cutaneous nerve

(LACN); the median nerve ends as a major component of sensibility to the palmar and radial

aspect of the hand; the ulnar nerve ends as its medial counterpart; and the radial nerve ends by

sharing innervation of the dorsum of the hand with the median and ulnar nerves. The cutaneous

branch of the axillary nerve is the upper lateral brachial cutaneous nerve, which innervates the

skin over the outer and inferior aspect of the deltoid and upper aspect of the arm.

6 Arm 323

FIGURE 6.6. (continued) The posterior cord of the plexus is represented by five cutaneous

nerves, including the axillary nerve branch already mentioned. The remaining four are the posterior brachial cutaneous, the lower lateral brachial cutaneous, the posterior antebrachial cutaneous, and the superficial branch of the radial nerve. The LACN and medial antebrachial cutaneous (MACN), as well as the medial brachial cutaneous (MBCN), are the most significant nerves

on the anterior and medial aspects of the arm. The LACN, the distal sensory continuation of the

musculocutaneous nerve, innervates the skin on the flexor and radial one-half of the forearm.

The LACN is useful as a digital nerve graft and the MACN as a nerve graft for brachial plexus

reconstruction. Both the MACN and the MBCN send multiple branches to the medial side of the

elbow that may be at risk during surgery in this region (see text).

324 Regional Anatomy

FIGURE 6.7. A: Origin and distribution of

medial antebrachial cutaneous nerve

(MACN). This nerve arises most often from

the medial cord of the brachial plexus in the

axilla and descends adjacent to the basilic

vein to become superficial at the middle or

distal arm, where it divides into anterior and

posterior branches. The anterior branch traverses the elbow between the medial epicondyle and the biceps tendon, usually lying

1 to 3 cm anterolateral to the epicondyle,

where it gives off branches to the antecubital

fossa and proximal forearm. It then continues distally to innervate the flexor and ulnar

one-half of the forearm. The posterior

branch continues distally to innervate the

skin over the ulnar and dorsal aspect of the

forearm.

epicondyle and olecranon (7). Review of the authors’

patients with the standard incision for ulnar nerve transposition revealed a number with dense anesthesia over the olecranon and posteromedial aspect of the forearm. Painful

neuromas were not encountered, but this problem has been

reported by others (8). Because of their anatomic studies

and the findings on their patients who had undergone ulnar

nerve transposition, the authors now use a posterior

approach that affords better protection to the branches of

the MACN and MBCN (7).

Intercostobrachial Cutaneous Nerve

The intercostobrachial cutaneous nerve from the lateral

cutaneous branch of the second thoracic nerve is joined by

the MBCN from the medial cord of the brachial plexus to

innervate the skin on the proximal posteromedial aspect of

the arm. The intercostobrachial cutaneous nerve may be

sacrificed as part of the axillary portion of a modified radical mastectomy.

Muscles and Intermuscular Septa of the

Arm

Biceps Brachii

The biceps brachii is a fusiform muscle that derives its name

from its two proximal parts or heads: a long head that arises

by means of a tendon from the supraglenoid tubercle of the

scapula, and a short head that arises from the apex of the

coracoid process of the scapula (2,9) (Fig. 6.8). The long

head starts in the shoulder joint capsule as a long, round

tendon and arches over the humeral head to descend in the

intertubercular groove, where it is retained by the transverse

humeral ligament and a fibrous expansion of the pectoralis

major tendon. The tendon is surrounded by a synovial

sheath in the groove. The two heads lead into the muscle

bellies that, although closely applied, may be separated to

within 7 cm of the elbow joint (2). The muscle ends in a

flattened tendon that attaches to the rough posterior aspect

of the radial tuberosity. The bicipitoradial bursa separates

the tendon from the smooth portion of the radial tuberosity. As it approaches its insertion, the biceps tendon spirals

or twists, with its anterior surface becoming lateral. The

biceps is covered proximally by the pectoralis major and the

deltoid. Its medial margin touches the coracobrachialis and

it covers the brachial artery and median nerve. The lateral

border is adjacent to the deltoid proximally and the brachioradialis distally. The biceps is the main supinator of the

forearm and an elbow flexor, and it may play a role in preventing proximal migration of the humerus with contraction of the deltoid during abduction.

Brachialis

This muscle arises from the anterior and distal half of the

humerus, beginning in a “U”-shaped fashion from around

6 Arm 325

FIGURE 6.7. (continued) B: Fresh cadaver dissection of the MACN in the right arm. Note the

size and distribution of this cutaneous nerve.

B

the deltoid insertion (Fig. 6.9). It also arises from the intermuscular septa, more from the medial than the lateral

because it is separated from the lateral septum by the brachioradialis and the extensor carpi radialis longus. Although

it begins under cover of the biceps in its mid-portion, it is

uncovered anterolaterally. Its insertion is by a broad tendon

to the ulnar tuberosity on the anterior aspect of the coronoid process. The brachialis is a flexor of the elbow.

Coracobrachialis

This muscle arises from the coracoid process of the scapula,

which it shares as a point of origin with the short head of

the biceps (see Fig. 6.9). The muscle also arises from the

proximal 10 cm of the short head of the biceps. Insertion is

into an impression, 3 to 5 cm in length, on the medial

aspect of the mid-portion of the humerus between the triceps and brachialis (2). The coracobrachialis flexes the arm

forward and medially, and in abduction it acts with the

anterior deltoid (2).

Triceps

This muscle, like the biceps, takes its name from the number of heads of origin: the long, lateral, and medial (9). The

long and lateral heads are superficial and cover the deep

medial head; thus, the triceps may be considered to have

two layers (Fig. 6.10).

326 Regional Anatomy

FIGURE 6.8. Anterior arm muscles, the biceps. Note

the relationship of the biceps to the brachialis, the

coracobrachialis, and the medial intermuscular septum.

Long Head

The long head arises by a flat tendon from the infraglenoid

tubercle of the scapula (see Fig. 6.10A). Its muscle fibers

descend medial to the lateral head and superficial to the

medial or deep head to join them to form a large, common

posterior tendon.

Lateral Head

The lateral head arises from a long, narrow ridge that begins

medially and distal to the surgical neck and continues distally and laterally to end posterior to the deltoid tuberosity

(see Fig. 6.10A).

Medial Head

The medial head, which is covered in large part by the long

and lateral heads, arises from the proximal and posterior

shaft of the humerus just distal to the teres major and follows the medial margin of the radial groove to continue its

broad origin on the remainder of the posterior humeral

shaft down to the region of the elbow joint capsule (see Fig.

6.10B). It also arises from the medial intermuscular septum

and from the distal part of the lateral intermuscular septum.

The tendon of the triceps begins near the middle of the

muscle and has two layers, one superficial in the distal half

of the muscle and one deep in the substance of the muscle.

However, after receiving all the muscle fibers distally, the

two layers become one and insert on the olecranon. The triceps is the major extensor of the forearm. The medial head

is active in all forms of extension, whereas the lateral and

long heads are minimally active except in extension against

resistance.

Intermuscular Septa

The distal half of the arm is divided into anterior and posterior compartments by the lateral and medial intermuscular septa (Fig. 6.11). The lateral intermuscular septum arises

from the lateral epicondyle and epicondylar ridge of the

humerus and ends at the insertion of the deltoid. The

medial intermuscular septum, located in the distal twothirds of the arm, begins at the medial epicondyle and epicondylar ridge and blends proximally with the fascia of the

coracobrachialis near its insertion, to end at the medial lip

of the intertubercular sulcus distal to the teres major. The

radial and ulnar nerves pierce the lateral and medial septa,

respectively, as they change compartments in the middle

third of the arm.

Neurovascular Structures

Brachial Artery/Neurovascular Bundle

The brachial artery, a continuation of the axillary, which by

definition begins at the lower border of the teres major

muscle, continues distally to the neck of the radius, where

it bifurcates into the radial and ulnar arteries (3) (Fig. 6.12).

In the proximal arm, the artery is deep and medial and

gradually migrates to an anterior and central position as it

reaches the antecubital fossa. At this level, in the proximal

arm, the neurovascular bundle contains the brachial artery

and the median, ulnar, radial, medial antebrachial cutaneous, and medial brachial cutaneous nerves, as well as the

basilic vein. Spatial orientation at this level places the

median nerve anterior to the artery, the ulnar nerve medial,

and the radial nerve posterior. The median nerve gradually

crosses over the brachial artery as it descends so that it lies

medial to it in the antecubital fossa. The brachial artery is

flanked by brachial veins on either side. The anterior

6 Arm 327

FIGURE 6.9. Anterior arm muscles, brachialis and coracobrachialis. Note the relationship of the coracobrachialis and the

brachialis.

branches of the brachial artery are depicted in Figure 6.12B.

The brachial artery gives off numerous muscular branches

in the arm, mainly from its lateral side, and its major

branch is the deep brachial artery (its largest branch), from

the posteromedial aspect and arising distal to the teres

major (see Fig. 6.12C). This artery accompanies the radial

nerve through the spiral groove. On the posterior aspect of

the humerus, an ascending deltoid branch is given off that

communicates proximally with the posterior humeral circumflex artery. The deep brachial divides into the radial and

the middle collateral arteries. The middle collateral

descends in the substance of the medial head of the triceps

and participates in an anastomosis posteriorly in the supracondylar region between the laterally placed radial collateral

and a branch from the medially placed inferior ulnar collateral artery, and then continues distally to anastomose with

the interosseous recurrent artery posteriorly in the proximal

forearm. The radial collateral artery continues distally

between the brachialis and brachioradialis anterior to the

lateral epicondyle to anastomose with the radial recurrent

artery. The superior ulnar collateral arises from the medial

side of the brachial artery in the mid-humeral region and

accompanies the ulnar nerve, piercing the medial intermuscular septum with that nerve to descend between the medial

328 Regional Anatomy

FIGURE 6.10. A, B: Triceps. This muscle, like the biceps, derives its name from the number of

heads of origin; the long, lateral, and the medial. Note that the medial or deep head is covered

by the long and lateral heads.

6 Arm 329

FIGURE 6.11. A: Intermuscular septa. The distal aspect of the arm is divided into anterior and

posterior compartments by the medial and lateral intermuscular septa. The lateral septum arises

from the lateral epicondyle and epicondylar ridge of the humerus and ends at the deltoid insertion. The medial septum is located in the distal two-thirds of the arm and has similar but medial

epicondylar origins; it ends proximally by blending with the fascia of the coracobrachialis near its

insertion. B: Cross-section of the arm through the medial and lateral intermuscular septa. Note

the division of the distal arm into anterior and posterior compartments by the septa, and the

relationships of the various neurovascular structures to the septa.

FIGURE 6.12. A: The axilla and medial aspect of the arm. Note the brachial artery and its relationship to the nerves in the axilla and medial aspect of the arm (see text). (continued on next page)

A

330 Regional Anatomy

FIGURE 6.12. (continued) B: Anterior

branches of the brachial artery. Note the

course and branching of the brachial artery

and its subsequent division into the radial

and ulnar arteries in the forearm.

6 Arm 331

FIGURE 6.12. (continued) C: Posterior

branches of the brachial artery. Note the relationship of the posterior branches of the

brachial artery to the deltoid and triceps muscles.

epicondyle and the olecranon and ending deep to the FCU

by anastomosing with the posterior ulnar recurrent and

inferior ulnar collateral arteries. The inferior ulnar collateral

artery arises 3 to 4 cm proximal to Hueter’s line, passes

medially over the median nerve, and soon divides into a

posterior and a descending branch. The posterior branch

penetrates the medial intermuscular septum and anastomoses with the middle collateral artery posteriorly. The

descending branch anastomoses with the anterior ulnar

recurrent artery.

Intraosseous Arterial Supply of the Humerus

The following information is based on an injection study of

30 adult humeri performed by Laing (10) (Fig. 6.13). The

discussion of the intraosseous blood supply of the humerus

excludes the rich blood supply from the periosteum and the

muscular and ligamentous attachments, and the practical

relationship between these two sources is discussed later

under the section on Clinical Significance.

Arteries of the Humeral Head

A constant anterolateral artery from the ascending branch

of the anterior humeral circumflex enters the proximal

humerus either at the upper end of the bicipital groove or

by branches entering the greater and lesser tuberosities.

After entering the bone, this vessel (which may be multiple)

curves posteromedially just below the obliterated epiphyseal

line of the humeral head, and has been called the arcuate

artery. Additional contributions to the blood supply of the

humeral head were noted from the posterior humeral circumflex as posteromedial arteries. Inconsistent arteries also

were noted to enter the head posteriorly and anteriorly from

the attachment of the rotator cuff.

Arteries of the Humeral Shaft

Main Nutrient Artery

The main nutrient artery of the humeral shaft usually

arose directly from the brachial artery, and in this series

of 30 humeri was single in 28 and double in 2 instances.

In two-thirds of the specimens, this artery entered the

humerus anteromedially, medially in six cases, anteriorly

in five, and posteromedially in one case. The point of

entry of the main nutrient artery was at the junction of

the middle and distal thirds or in the lower part of the

middle third of the humerus in 24 cases, approximately

the mid-portion in 4 cases, and at the junction of the

third and fourth quarters in 2 bones. In all cases, the

course of the artery through the cortex was distalward,

and the length of the intracortical canal varied from 0.25

to 2 inches. When the nutrient artery was single it

divided into ascending and descending branches either in

the intracortical canal or in the medullary canal. In two

cases, the division took place outside the bone, and each

branch had its own canal and nutrient foramen. The

superior branch became the ascending artery of the shaft

and the inferior branch, the descending artery. The

ascending branch courses up the medullary canal and

anastomoses with any accessory nutrient arteries that may

be present. In some specimens this intramedullary artery

anastomosed with the periosteal arteries by small

transcortical vessels. The descending branch usually was

smaller than the ascending branch, and usually immediately divided into many fine arteries and continued distally in the intramedullary canal to reach the supracondylar and epicondylar regions.

Accessory Nutrient Arteries of the Humeral Shaft

One to four accessory nutrient arteries of the shaft were

found in almost all specimens, but were never as large as the

main nutrient artery.

Accessory Arteries from the Profunda Brachii. In seven

specimens, one or several arteries from the profunda brachii

artery entered the posterior surface of the humerus in the

spiral groove. These vessels were all small and no nutrient

foramen was visible on the surface.

Accessory Arteries from the Humeral Circumflex. In nine

specimens, an accessory nutrient vessel from the descending

branch of the anterior humeral circumflex artery entered

the upper end of the shaft anterolaterally. In one specimen,

a branch from the posterior humeral circumflex entered the

proximal humerus posteromedially. Only one specimen

demonstrated a sizable accessory nutrient vessel laterally.

Thus, most of the accessory nutrient arteries entered the

upper third of the humeral shaft anteriorly or anteromedially. Also, no true accessory nutrient vessels were seen

between the site of the main nutrient artery and the epicondylar region.

Arteries of the Distal Humerus

In addition to the descending branch of the main humeral

nutrient artery that reached the epicondylar region, on each

side there were arteries that entered the epicondyles medially, laterally, and posteriorly. Arterial branches were noted

to enter the trochlea, capitellum, and olecranon fossa, but

no vessels were noted anteriorly.

Clinical Significance of the Blood Supply to the

Humerus

Fractures of the Shaft. Although the periosteum represents

a rich source of blood supply to the humerus, the intraosseous supply also is important and both sources of blood

332 Regional Anatomy

6 Arm 333

FIGURE 6.13. Interosseous arterial supply to the humerus.

Note the arterial supply to the humeral head from the

humeral circumflex arteries, and the main nutrient artery

from the brachial artery entering the humerus anteromedially at the junction of the middle and distal thirds and dividing into ascending and descending branches and medial and

lateral branches to the epicondyles (see text).

supply must be respected and preserved. Fractures of the

shaft at the junction of the middle and distal thirds most

likely will destroy the main nutrient artery, and the upper

margin of the distal component of the humerus then

depends on vessels from the periosteum and those intramedullary vessels ascending from the epicondyles. Extensive stripping of the periosteum of the distal fragment in

open reductions in this region should be avoided to preserve the remaining components of the blood supply. This

concept is illustrated by the potential for compromise of the

blood supply of the shaft of the humerus by insertion of an

intramedullary device in conjunction with an open reduction of the fracture. The intramedullary device has the

potential to compromise the intramedullary blood supply,

and in combination with extensive periosteal stripping at

the fracture site, may diminish the blood supply to the fracture site.

Fractures of the Humeral Head/Metastatic Deposits.

The upper half of the humerus has an excellent blood

supply from the ascending branch of the main nutrient

artery and the accessory arteries, which may explain the

predilection of metastatic deposits for this part of the

humerus. Fractures of the surgical neck of the humerus

occur below the main blood supply of the humeral head

and above the main blood supply to the proximal shaft,

and thus both sides of the fracture interface have an excellent blood supply. This may account for the rapid union

of these fractures. When operating in this region, it is

appropriate to remember that the main blood supply of

the humeral head enters it through the upper end of the

bicipital groove or from the adjacent parts of the greater

and lesser tuberosities.

Fractures of the Distal Humerus. The importance of preserving the muscular and ligamentous attachments when

operating on the lower end of the humerus is well known.

Excessive stripping of soft tissues should be avoided to preserve the periosteal blood supply to the distal humerus and

associated fracture fragments.

Nerves

Radial Nerve

The radial nerve arises from the posterior cord and is the

largest branch of the brachial plexus. The radial nerve leaves

the medial side of the arm accompanied by the deep

brachial artery and passes laterally between the long and

medial heads of the triceps to a shallow groove beneath the

lateral head. The radial nerve comes in contact with the

humerus in the spiral groove approximately 3 cm proximal

to the deltoid tuberosity. It continues in this groove laterally

and distally to pierce the lateral intermuscular septum and

enters the anterior compartment at approximately the junction of the middle and distal thirds of the humerus. It then

continues to descend toward the forearm in a groove

between the brachialis and brachioradialis. It is between

these two muscles that it enters the forearm.

Radial Nerve Division and Branches

Medial Branches. Muscular branches from the radial are

given off in medial, posterior and lateral locations. Medial

branches (Fig. 6.14A) include a branch to the long head of

the triceps and a branch to the medial half of the medial or

deep head of the triceps. The branch to the medial head is

a long, slender nerve that arises in the axilla and enters the

medial head two handbreadths distal to the acromion. It lies

close to the ulnar nerve as far as the distal third of the arm,

and is called the ulnar collateral nerve because of this proximity (9).

Posterior Branches. Two posterior branches may be

found; the most proximal leaves the posterolateral aspect of

the radial nerve in a more transverse course than its parent

and enters the lateral head of the triceps (see Fig. 6.14A and

B). The second and more distal branch leaves the radial

nerve posteriorly to enter the lateral half of the medial or

deep head of the triceps. This nerve also may send a branch

to the lateral head. This branch to the medial head continues distally through the substance of the lateral half of the

medial head to end in the anconeus.

Clinical Significance. The fact that two parallel and sufficiently separated radial nerve branches (the medially situated ulnar collateral and the laterally placed posterior

branch) innervate the medial or deep head of the triceps

results in a useful gap between the two nerves that allows

the surgeon to split the medial head to expose the posterior

aspect of the humerus without denervating the muscle (9).

Lateral Branches. These arise anterior to the lateral intermuscular septum and supply the lateral one-third or less of

the brachialis and all of the brachioradialis and extensor

carpi radialis longus (see Fig. 6.14C).

Distal Radial Nerve Division. At the elbow, the radial

nerve may divide into its motor and sensory branch at any

level within a 5.5-cm segment, from 2.5 cm above to 3 cm

below Hueter’s line (a line drawn through the tips of the

epicondyles of the humerus) (1) (see Fig. 6.14C).

Ulnar Nerve

The ulnar nerve arises from the medial cord, and after leaving the axilla continues distally medial to the brachial artery

until it reaches the midarm, where it pierces the medial inter334 Regional Anatomy

6 Arm 335

FIGURE 6.14. A: Medial and posterior branches of the radial nerve.

Note the medial and posterior

branches to the triceps. The main

stem of the radial nerve penetrates

the lateral intermuscular septum to

enter the anterior aspect of the

arm at approximately the junction

of the middle and distal thirds of

the arm. (continued on next pag

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