ANA 211

DR. MFON AKPASO

DERMATOMES OF THE UPPER LIMB
• DEFINITION: The area of skin supplied by one spinal segment
• A typical dermatome extends from the posterior median line to the
anterior median line around the trunk
• However, in the limbs the dermatomes have migrated rather
irregularly, so that the original uniform pattern is disturbed
• There are two dermatome maps in common use.
• One has gained popular acceptance because of its more intuitive
aesthetic qualities, corresponding to concepts of limb development
(Keegan and Garrett, 1948);
• the other is based on clinical findings and is generally preferred by
neurologists (Foerster, 1933).
• Both maps are approximations, delineating dermatomes as distinct
zones when actually there is much overlap between adjacent
dermatomes and much variation (even from side to side in the same
individual)
• Embryological Basis: The early human embryo shows regular segmentation of the
body.
• Each segment is supplied by the corresponding segmental nerve.
• In an adult, all structures, including the skin, developed from one segment are
supplied by their original segmental nerve
• The limb may be regarded as an extension of the body wall, and the segments
from which they are derived can be deduced from the spinal nerves supplying
them.
• The limb buds arise in the area of the body wall supplied by the lateral branches
of anterior primary rami. The nerves to the limbs arise from these branches
• Important features: The cutaneous innervation of the upper limb is derived:
• a. Mainly from segments C5-C8 and T1 of the spinal cord, and b. Partly from the
overlapping segments from above (C3, C4) as well from below (T2, T3).
• Since the limb bud appears on the ventrolateral aspect of the body wall, it is
invariably supplied by the anterior primary rami of the spinal nerves. Posterior
primary rami do not supply the limb.
• There is varying degree of overlapping of adjoining dermatomes, so that the area
of sensory loss following damage to the cord or nerve roots is always less than
the area of distribution of the dermatomes
• Each limb bud has a cephalic and a caudal border, known as preaxial and
postaxial borders, respectively
• In the upper limb, the thumb and radius lie along the preaxial border, and the
little finger and ulna along the postaxial border.
• The dermatomes of the upper limb are distributed in an orderly numerical
sequence:
• a. Along the preaxial border from above downward, by segments C3-C6 with
overlapping of the dermatomes.
• b. The middle three digits (index, middle and ring fingers) and the adjoining area
of the palm are supplied by segment C7.
• c. The postaxial border is supplied (from below upwards) by segments C8, T7, T2.
• There is overlapping of the dermatomes.
Spinal Description of Dermatome(s)
Segment/Nerve(s)
C3, C4 Region at base of neck, extending laterally over shoulder
C5 Lateral aspect of arm (i.e., superior aspect of abducted
arm)
C6 Lateral forearm and thumb
C7 Middle and ring fingers (or middle three fingers) and center
of posterior aspect of forearm

C8 Little finger, medial side of hand and forearm (i.e., inferior

aspect of abducted arm)

T1 Medial aspect of forearm and inferior arm

T2 Medial aspect of superior arm and skin of axilla
CUTANEOUS NERVES OF THE UPPER
LIMB
• Most cutaneous nerves of the upper limb are derived from the brachial plexus, a
major nerve network formed by the anterior rami of the C5–T1 spinal nerves.
• The nerves to the shoulder, however, are derived from the cervical plexus, a
nerve network consisting of a series of nerve loops formed between adjacent
anterior rami of the first four cervical nerves.
• The cervical plexus lies deep to the sternocleidomastoid muscle on the antero
lateral aspect of the neck.
Cutaneous Nerve Contributing Spinal Source Course and Distribution
Nerves
Supraclavicular nerves C3, C4 Cervical plexus Pass anterior to clavicle,
immediately deep to platysma,
and supply skin over clavicle
and superolateral aspect of
pectoralis major
Superior lateral C5, C6 Terminal branch of Emerges from beneath
cutaneous nerve of arm axillary nerve posterior margin of deltoid and
supplies skin over lower part of
this muscle and on lateral side
of midarm
Inferior lateral C5, C6 Radial nerve (or posterior Perforates lateral head of
cutaneous nerve of arm cutaneous nerve of arm) triceps, passing close to
cephalic vein to supply skin
over inferolateral aspect of
arm
Posterior cutaneous C5–C8 Radial nerve (in axilla) Crosses posterior to and
nerve of arm communicates with
intercostobrachial nerve and
supplies skin on posterior arm
as far as olecranon
Posterior cutaneous C5-C8 Radial nerve (with Perforates lateral head of
nerve of forearm . inferior lateral triceps, descends
cutaneous nerve of laterally in arm, then
arm) runs along and supplies
posterior forearm to
wrist
Lateral cutaneous C6–C7 Musculocutaneous Emerges lateral to biceps
nerve of forearm nerve (terminal tendon deep to cephalic
branch) vein, supplying skin of
anterolateral forearm to
wrist
Medial cutaneous C8–T2 Medial cord of Communicates with
nerve of arm brachial plexus (in intercostobrachial nerve,
axilla) continuing to supply skin
of medial aspect of distal
arm
Medial cutaneous nerve C8, T1 Medial cord of brachial Descends medial to brachial
of forearm plexus (in axilla) artery, pierces deep fascia
with basilic vein in midarm,
dividing into anterior and
posterior branches that enter
forearm and supply skin of
anteromedial aspect to wrist

Medial cutaneous nerve C8–T2 Medial cord of brachial Communicates with

of arm plexus (in axilla) intercostobrachial nerve,
continuing to supply skin of
medial aspect of distal arm
Intercostobrachial nerve T2 Second intercostal nerve Extends laterally,
(as its lateral cutaneous communicating with posterior
branch) and medial cutaneous nerves
of arm, supplying skin of axilla
and medial aspect of proximal
arm
CLINICAL ANATOMY
• The area of sensory loss of the skin, following injuries of the spinal
cord or of the nerve roots, conforms to the dermatomes.
• Therefore, the segmental level of the damage to the spinal cord can
be determined by examining the dermatomes for touch, pain and
temperature.
• Note that injury to a peripheral nerve produces sensory loss
corresponding to the area of distribution of that nerve
• The spinal segments do not lie opposite the corresponding vertebrae.
• In estimating the position of a spinal segment in relation to the
surface of the body, it is important to remember that a vertebral
spine is always lower than the corresponding spinal segment.
• As a rough guide it maybe stated that in the cervical region there is a
difference of one segment, e.g. the 5th cervical spine overlies the 6th
cervical spinal segment.
VEINS OF THE UPPER LIMBS
• The main superficial veins of the upper limb, the cephalic and basilic
veins, originate in the subcutaneous tissue on the dorsum of the hand
from the dorsal venous network.
• Perforating veins form communications between the superficial and
deep veins
The cephalic vein
• The cephalic vein (G. kephalé, head) ascends in the subcutaneous
tissue from the lateral aspect of the dorsal venous network,
proceeding along the lateral border of the wrist and the anterolateral
surface of the proximal forearm and arm; it is often visible through
the skin.
• Anterior to the elbow, the cephalic vein communicates with the
median cubital vein, which passes obliquely across the anterior aspect
of the elbow in the cubital fossa (a depression in front of the elbow),
and joins the basilic vein.
• The cephalic vein courses superiorly between the deltoid and
pectoralis major muscles along the deltopectoral groove, then enters
the clavipectoral tri angle.
• It then pierces the costocoracoid membrane and part of the
clavipectoral fascia, joining the terminal part of the axillary vein.
The basilic vein
• The basilic vein ascends in the subcutaneous tissue from the medial
end of the dorsal venous network along the medial side of the
forearm and the inferior part of the arm; it is often visible through the
skin.
• It then passes deeply near the junction of the middle and inferior
thirds of the arm, piercing the brachial fascia and running superiorly
parallel to the brachial artery and the medial cutaneous nerve of the
forearm to the axilla, where it merges with the accompanying veins
(L. venae comitantes) of the axillary artery to form the axillary vein.
The median antebrachial vein
• The median antebrachial vein (median vein of the forearm) is highly
variable.
• It begins at the base of the dorsum of the thumb, curves around the
lateral side of the wrist, and ascends in the middle of the anterior
aspect of the forearm between the cephalic and the basilic veins.
• The median antebrachial vein sometimes divides into a median basilic
vein, which joins the basilic vein, and a median cephalic vein, which
joins the cephalic vein.
Dorsal venous arch
• Dorsal venous Arch: Dorsal venous arch lies on the dorsum of the
hand.
• Its afferents (tributaries) include:
• i. Three dorsal metacarpal veins.
• ii. A dorsal digital vein from the medial side of the little finger.
• iii. A dorsal digital vein from the radial side of the index finger.
• iv. Two dorsal digital veins from the thumb.
• V. Most of the blood from the palm courses through veins passing
around the margins of the hand and also by perforating veins passing
through the interosseous spaces.
• Pressure on the palm during gripping fails to impede the venous
return due to the mode of drainage of the palm into the dorsal
venous arch.
• Its efferents are the cephalic and basilic veins.
Deep veins
• Deep veins lie internal to the deep fascia, and—in contrast to the
superficial veins—usually occur as paired accompanying veins that
travel with, and bear the same name as, the major arteries of the
limb
• Deep veins start as small venae comitantes running on each side of
digital veins.
• These continue proximally as superficial and deep palmar arches.
Joining to form the brachial vein.
• Brachial veins lie on each side of brachial artery. They join the axillary
vein at the lower border of teres major.
CLINICAL ANATOMY
• The median cubital vein is the vein of choice for intravenous
injections, for collecting blood, and for cardiac catheterisation,
because it is fixed and does not slip away during piercing.
• When the median cubital vein is absent, the basilic is preferred over
the cephalic because it is a more efficient channel.
• Basilic vein runs along straight path, whereas cephalic vein bends
acutely to drain into the axillary vein.
• The cephalic vein frequently communicates with the external jugular
vein by means of a small vein which crosses in front of the clavicle.
• In operations for removal of the breast (in carcinoma), the axillary
lymph nodes are also removed, and it sometimes becomes necessary
to remove a segment of the axillary vein also.
• In these cases/ the communication between the cephalic vein and the
external jugular vein enlarges considerably and helps in draining
blood from the upper limb.
• In case of fracture of the clavicle, the rupture of the communicating
channel may lead to formation of a large haematoma, i.e. collection
of blood.
LYMPHATIC DRAINAGE
• When circulating blood reaches the capillaries, part of its fluid content
passes through them into the surrounding tissue as tissue fluid.
• Most of this tissue fluid re-enters the capillaries at their venous ends.
• Some of it is, however, returned to the circulation through a separate
set of lymphatic vessels.
• These vessels begin as lymphatic capillaries which drain into larger
vessels. Along the course of these lymph vessels there are groups of
lymph nodes.
• Lymph nodes are small bean-like structures that are usually present in
groups.
• These are not normally palpable in the living subject.
• However, they often become enlarged in disease, particularly by
infection or by malignancy in the area from which they receive lymph.
• They then become palpable and examination of these nodes provides
valuable information regarding the presence and spread of disease.
• The main lymph nodes of the upper limb are the axillary lymph nodes.
• These comprise anterior, posterior, lateral, central and apical groups.
Other nodes are as follows.
• 1. The infraclavicular nodes lie in or on the clavipectoral fascia along
the cephalic vein. They drain the upper part of the breast, and the
thumb with its web.
• 2. The deltopectoral node lies in the deltopectoral groove along the
cephalic vein. It is a displaced node of the infraclavicular set, and
drains similar structures.
• 3. The superficial cubital or supratrochlear nodes lie just above the
medial epicondyle along the basilic vein.
• They drain the ulnar side of the hand and forearm.
• 4. A few other deep lymph nodes lie in the following regions.
• i. Along the medial side of the brachial artery.
• ii. At the bifurcation of the brachial artery (deep cubital lymph node).
• iii. Occasionally along the arteries of the forearm.
• Superficial lymphatics are much more numerous than the deep
lymphatics.
• They collect lymph from the skin and subcutaneous tissues.
• Most of them ultimately drain into the axillary nodes, except for:
• i. A few vessels from the medial side of the forearm which drain into
the superficial cubital nodes.
• ii. A few vessels from the lateral side of the forearm which drain into
the deltopectoral or infraclavicular nodes.
• The dense palmar plexus drains mostly into the lymph vessels onto the
dorsum of the hand, where these continue with the vessels of the
forearm.
• Deep lymphatics are much less numerous than the superficial
lymphatics.
• They drain structures lying deep to the deep fascia.
• They run along the main blood vessels of the limb, and end in the
axillary nodes.
• Some of the lymph may pass through the deep lymph nodes present
along the axillary vein
CLINICAL ANATOMY
• Inflammation of lymph vessels is known as lymphangitis, In acute
lymphangitis, the vessels may be seen through the skin as red, tender
(painful to touch) streaks
• Inflammation of lymph nodes is called lymphandenitis.
• It may be acute or chronic.
• The nodes enlarge and become palpable and painful.
• Obstruction to lymph vessels can result in accumulation of tissue
fluid in areas of drainage.
• This is called lymphoedema and may be caused by carcinoma,
Infection with some parasites like filaria, or because of surgical
removal of lymph nodes.
• Pain along the medial side of upper arm is due to pressure on the
intercostobrachial nerve by enlarged central group of axillary lymph
nodes.