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Introduction
This article covers the arterial supply and venous drainage of the upper limb, including the clinical relevance.
The arterial blood supply to the upper limb arises from the right and left subclavian arteries, and the venous return drains into the axillary vein.
Arterial supply to the upper limb
The arterial blood supply of the upper limb comes directly from the right and left subclavian arteries, which are a continuation of the brachiocephalic artery on the right side and the aortic arch on the left side.1
The subclavian artery becomes the axillary artery after it passes the lateral border of the first rib to enter the axilla.2
The axillary artery divides into the brachial artery at the level of teres major and further divides into the radial and ulnar arteries at the biceps tendon in the cubital fossa.
The radial and ulnar arteries anastomose in the dorsal and ventral aspects of the hand through the superficial and deep palmar arches to supply the hand and digits.
Subclavian artery
The subclavian artery consists of branches to supply the upper limb and has three parts based on its relation to the anterior scalene muscle of the neck.
The first part arises from the medial border of the anterior scalene muscle and the second part travels posterior to the anterior scalene muscle.
The third part travels from the lateral border of the anterior scalene muscle towards the lateral border of the first rib, where it enters the axilla to form the axillary artery.
Axillary artery
The axillary artery originates from the lateral border of the first rib and ends at the lower border of teres major.2 It has three parts based on its relation to pectoralis minor and is covered by the axillary sheath. This sheath also contains the axillary vein and brachial plexus, forming the neurovascular bundle.
The first part travels proximal to pectoralis minor, branching into the superior thoracic artery, to supply the deep muscles of the first two intercostal spaces.
The second part travels posterior to pectoralis minor, branching into the thoracoacromial artery and the lateral thoracic artery. The thoracoacromial trunk curls around the superiomedial border of pectoralis minor, piercing the costocoracoid membrane and giving off four branches to supply muscles in these regions:
- Pectoral artery
- Clavicular artery
- Acromial artery
- Deltoid artery
The third part of the axillary artery then travels distal to pectoralis minor. It branches into the subscapular artery and thoracodorsal artery. The subscapular artery traverses the lateral border of the scapula and divides into the circumflex scapular artery to supply the subscapularis muscle, and the thoracodorsal artery supplies serratus anterior and latissimus dorsi.
The third part also branches to form the anterior and posterior circumflex arteries, which supply the structures around the neck of the humerus.
Clinical relevance: compression of the axillary artery
If there is diffuse bleeding in the upper limb, the third part of the axillary artery can be compressed against the humerus. The axillary artery can also be compressed at its origin near the first rib in the angle between the clavicle and sternocleidomastoid muscle.
Brachial artery
The axillary artery becomes the brachial artery at the lower border of the teres major.
The brachial artery passes through the cubital fossa to bifurcate into the radial and ulnar arteries beneath the bicipital aponeurosis at the neck of the radius.4 It is the main blood supply of the arm.
It travels lateral to the ulnar nerve in the upper arm and supplies the major muscles of the arm.2 In the proximal arm, the median nerve lies lateral to the brachial artery, then crosses anterior to the artery in the mid-arm. In the cubital fossa and forearm, the median nerve lies medial to the brachial artery.
Clinically, the brachial artery can be palpated medial to the biceps tendon to obtain a pulse.
Near the origin, it branches into the profunda brachii below teres major and travels with the radial nerve posterior to the humerus in the spiral groove to supply the triceps muscle.
The brachial artery also provides a nutrient artery to the humerus and superior and inferior ulnar collateral branches, which anastomose around the elbow.
Radial and ulnar arteries
The radial artery originates at the neck of the radius above the biceps tendon in the cubital fossa and travels along the lateral forearm to supply the posterolateral arm and wrist structures:
- At the distal radius, it passes between flexor carpi radialis and brachioradialis. It can be palpated just before its entry into the anatomical snuffbox at the wrist, where it enters the hand.
- At its terminal end, it forms the deep palmar arch with the deep branch of the ulnar artery.2
The ulnar artery travels along the ulna and medial forearm, passing along the muscles of the common flexor origin to supply the anteromedial structures:
- Medial to the ulnar nerve, it branches into the common interosseous artery, which bifurcates into the anterior and posterior interosseous arteries. These arteries supply the deep muscles of the forearm and accompany the anterior and posterior interosseous nerves (from the median nerve).
- The ulnar artery enters the wrist through the ulnar canal and crosses the flexor retinaculum to form the superficial palmar arch with the superficial branch of the radial artery.2
The superficial and deep palmar arches give off digital branches, which supply the digits.
Clinical relevance: arterial blood gas sampling
As the radial artery is easily palpable at the distal radius, it is an important site for arterial blood sampling. Due to the anastomosis between the radial and ulnar arteries, it is crucial to establish a blood supply through the ulnar artery in the event of damage to the radial artery.4
To test for collateral blood supply, the radial and ulnar arteries are occluded as the patient makes a fist, causing the palm to become pale. The patient then unclenches their fist, and pressure is released on the ulnar artery to assess the collateral blood supply to the hand. This should be visualised by the colour change from pale to pink. This is known as Allen’s test.
Venous drainage of the upper limb
Veins of the upper limb consist of superficial and deep systems.
Superficial veins
The superficial veins lie in the superficial fascia, originate at the dorsal venous arch and ascend along the arm.5
The dorsal venous arch receives the blood supply from the hand via the digital veins and deep veins of the palm to drain into the cephalic vein laterally and basilic vein medially. It accompanies the superficial and deep palmar arches of the arterial system, providing tributaries.5
The cephalic vein ascends along the lateral biceps and passes between the deltoid and pectoralis major and enters the clavipectoral triangle, to drain into the axillary vein at the infraclavicular fossa:
- The basilic vein of the arm ascends along the medial aspect of the biceps, receiving branches from the basilic vein of the forearm, median antebrachial cutaneous vein and perforating veins.
- It drains into the axillary vein by joining the venae comitantes of the brachial artery after piercing the brachial fascia.
- It communicates with the cephalic vein through the median cubital vein, which obliquely crosses the anterior elbow. This is an important site for venepuncture.3, 5
Deep veins
Deep veins consist of venae comitantes, which accompany the upper limb arteries:
- The venae comitantes of the brachial artery form the axillary vein after joining the basilic vein above the posterior wall of the axilla.
- The axillary vein travels medial to the axillary artery before it exits the axilla and continues as the subclavian vein on the superior border of the first rib.
Key points
- The arterial supply to the upper limb originates from the right and left subclavian arteries
- These arteries continue along the arm to anastomose at the superficial and deep palmar arches
- The deep arch is predominantly radial in origin, while the superficial arch is predominantly ulnar in origin, though both receive contributions from the other artery
- The radial artery is easily palpable at the distal radius and is an important site for arterial blood sampling
- The venous system consists of a set of communicating superficial veins, deep veins, and perforating veins
- Superficial veins originate at the dorsal venous arch and continue along the medial and lateral arm to drain into the subclavian vein
- Deep veins, known as venae comitantes, ascend the arm to accompany the arteries. Each major artery has two venae comitantes, which unite to form the axillary vein
Reviewer
Dr Karar Nasser
General Surgery Registrar
Editor
Dr Jess Speller
References
- Whitaker RH, Borley NR. Instant Anatomy. 2nd Ed. Wiley-Blackwell. 2000.
- Ellis H, Mahadevan V. Clinical Anatomy Applied Anatomy for Students and Junior Doctors. 12th Ed. Wiley-Blackwell. 2006.
- Moore KL, Agur AMR, Dalley AF. Moore’s Essential Anatomy. 5th Ed. Lippincott Williams & Wilkins. 2014.
- Abrahams PH, Craven JL, Lumley JSP. Illustrated Clinical Anatomy. 2nd Ed. CRC Press. 2011.
- Snell RS. Clinical Anatomy by Regions. 9th Ed. Lippincott Williams & Wilkins. 2012.
Image references
- Figure 1. OpenStax. Thoracic Upper Limb Arteries. Anatomy and Physiology. License: [CC BY 4.0].
- Figure 2. OpenStax. Thoracic Upper Limb Veins. Anatomy and Physiology. License: [CC BY 4.0].
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