Topographical Anatomy of the Vessels of the Limbs
Basic Anatomical Structures & Principles (syllabus)
Understand the concepts & associated principles, functional & clinical applications of the
topographical anatomy of the vessels of the limbs.
UPPER LIMB
o
ARTERIES
Artery
Source
Branches
Supply
Additional Info
Suprascapular
A.
thyrocervical
trunk
Muscular (to
supraspinatus and
infraspinatus)
supraspinatus &
infraspinatus, shoulder
joint
Anastomoses with the
circumflex scapular a. and
the dorsal scapular a. to form
the scapular anastomosis
Axillary
subclavian
(continuation of
the subclavian
lateral to the
1st rib)
1st part: superior
thoracic; 2nd part:
thoracoacromial, lateral
thoracic; 3rd part: ant. &
post. humeral circumflex,
subscapular
shoulder & upper limb
pectoralis minor crosses the
axillary artery anteriorly and
is used to delineate the 3
parts
Subscapular
axillary, 3rd part circumflex scapular,
thoracodorsal
subscapularis, teres
major, teres minor,
infraspinatus, latissimus
dorsi
anastomoses with
suprascapular, dorsal
scapular & deep br. of
transverse cervical
Anterior
circumflex
humeral
axillary, 3rd part muscular
arm muscles neck of
humerus
Posterior
circumflex
humeral
axillary, 3rd part muscular
arm muscles neck of
humerus
passes through quadrangular
space with axillary nerve
Brachial
axillary
(continuation
distal to teres
major m.)
deep brachial, sup. ulnar
collateral, nutrient, inf.
ulnar collateral; terminal
branches are the radial &
ulnar
arm, forearm & hand
normally terminates at the
level of the elbow, but high
branching may occur
Deep brachial
brachial
ascending br., terminal
branches are the middle
collateral & radial
post. arm
collateral
Arch, superficial
Palmar
ulnar a.,
superficial
palmar br. of
the radial a.
common palmar digital
aa. (3)
superficial palm, palmar
surface of the digits
excluding thumb,
dorsum of the distal
phalangeal segments of
digits 2-5
superficial palmar arterial
arch receives the majority of
its blood supply from the
ulnar a.
Interosseous,
anterior
common
interosseous a.
muscular brs.; a. of the
median nerve
flexor pollicis longus m.,
flexor digitorum
profundus m., pronator
quadratus m., radius,
ulna, carpal bones
anterior interosseous a.
pierces the interosseous
membrane at its distal end to
reach the dorsal carpal
anastomosis
Interosseous,
common
ulnar a.
anterior interosseous a.,
posterior interosseous a.
deep structures of the
forearm
common interosseous a.
supplies the deep forearm
flexor and deep forearm
extensor muscles
Interosseous,
posterior
common
interosseous a.
interosseous recurrent
muscles of the posterior
(extensor) forearm
compartment: supinator
m., abductor pollicis
longus m., extensor
pollicis longus m.,
extensor pollicis brevis
m., extensor indicis m.
posterior interosseous a.
passes proximal to the
interosseous membrane to
reach the extensor
compartment of the forearm
Radial
brachial a.
radial recurrent a.,
palmar carpal br.,
superficial palmar br.,
dorsal carpal br., 1st
dorsal metacarpal a.,
princeps pollicis a.,
radialis indicis a., deep
palmar arterial arch
posterior elbow,
posterior forearm,
posterior hand, deep
portion of palmar side of
the hand, thumb
radial a. provides the
majority of blood supply to
the deep palmar arterial
arch; normally it arises at the
level of the elbow but high
branching of the brachial a.
may result in the radial a.
arising as proximal as the
axilla
Ulnar
brachial a.
anterior ulnar recurrent
a., posterior ulnar
recurrent a., common
interosseous a., palmar
carpal br., dorsal carpal
br., deep palmar br.,
superficial palmar arterial
arch
medial side of the
anterior forearm,
posterior forearm,
superficial palm, fingers
ulnar a. supplies the majority
of blood to the superficial
palmar arterial arch; it
normally arises at the level of
the elbow, but high
branching of the brachial a.
may cause the ulnar a. to
arise as far proximally as the
axilla
Arch, deep
palmar
radial a., deep
br. of ulnar a.
palmar metacarpal aa.
(2nd-4th), perforating
brs.
deep palm, digits
including the dorsum of
the distal phalangeal
segment
deep palmar arterial arch
receives the majority of its
blood supply from the radial
a.
Arch, superficial
palmar
ulnar a.,
superficial
palmar br. of
the radial a.
common palmar digital
aa. (3)
superficial palm, palmar
surface of the digits
excluding thumb,
dorsum of the distal
phalangeal segments of
digits 2-5
superficial palmar arterial
arch receives the majority of
its blood supply from the
ulnar a.
Digital, common
palmar
superficial
palmar arterial
proper palmar digital aa.
(2)
palmar aspect two
adjacent digits
common palmar digital aa.
anastomose with palmar
arch
metacarpal aa.
Digital, proper
palmar
common palmar no named branches
digital a.
palmar aspect of each
digit
proper palmar digital aa.
supply the dorsum of the
distal phalangeal segment
and nail bed
Princeps pollicis
radial a.
two brs. to the thumb
palmar aspect of the
thumb including the
dorsum of the distal
phalangeal segment
arteria princeps pollicis is
similar in function to a
proper digital aa.; this artery
has a large pulse which can
be felt when attempting to
take the pulse of a patient use fingers to feel for the
patient's pulse
Radialis indicis
radial a.
no named branches
lateral (radial) side of the
index finger
Radialis indicis is equivalent
to a proper digital a.
Recurrent,
anterior ulnar
ulnar a.
unnamed muscular brs.
medial side of elbow and anterior ulnar recurrent a.
proximal ends of forearm often arises in common with
flexor mm.
the posterior ulnar recurrent
a.
Superficial ulnar
ulnar a.
no named branches
palm
continues as the superficial
palmar arch
UPPER LIMB
o
Vein
Cephalic v.
VEINS
Tributaries
lateral side of the dorsal
venous arch of the hand;
Drains Into
axillary vein
Regions Drained
superficial parts of
the lateral hand and
Additional Info
median cubital vein usually
shunts some of the blood
superficial veins of the
forearm
lateral forearm
collected by the cephalic v. to
the basilic v.
unites with
brachial vein(s) to
form the axillary
vein
superficial parts of
medial hand &
medial forearm
connects with deep veins of the
forearm via perforating veins
Median cubital cephalic
basilic
superficial parts of
hand & forearm
a median antebrachial vein is
possible and, when present, it
may drain into the median
cubital vein
Dorsal venous
network of
hand
medially into
basilic v. and
laterally into
cephalic v.
superficial, dorsal
aspect of digits
unlike the foot, a distinct arch
may be absent in the hand,
replaced by a dorsal venous
network of veins
Basilic
dorsal veins of hand
medially; superficial veins
of forearm, median
cubital vein
dorsal metacarpal veins
UPPER LIMB
o
Structure
LYMPHATICS
Location
Axillary
nodes
axilla
Pectoral
nodes
lateral border
of pectoralis
major
Lateral
axillary
along distal
axillary v.
Posterior
axillary
anterior to
subscapularis
m.
Central
axillary
along axillary v.
posterior to
pectoralis
minor m.
Apical
axillary
along axillary v.
medial to
pectoralis
minor m. at
apex of axilla
Afferents from
Efferents to
Regions drained
efferents form
subclavian
trunk
upper limb, most
of breast, some
anterolateral
chest wall
most of breast,
anterolateral
chest wall &
muscles
central axillary
nodes
anterolateral
thoracic wall and
muscles, including
most of the
mammary gland
small nodes in
cubital fossa
central axillary
nodes
upper limb
central axillary
nodes
posterior shoulder
lateral, anterior
& posterior
axillary nodes
apical axillary
nodes
upper limb,
breast, posterior
shoulder, lateral
chest wall
central axillary
nodes
subclavian
lymph trunk
upper limb,
breast, posterior
shoulder, lateral
chest wall
Additional Info
axillary nodes are grouped as:
1) pectoral/anterior nodes,
along lower border of pectoralis
major;
2) lateral nodes, distal on axillary
v
3) central nodes, centrally
located along axillary v.;
4) subscapular/ posterior nodes,
along subscapular v. &
tributaries;
5) apical nodes, at apex of axilla,
receiving lymph from all other
groups
LOWER LIMB
o
Artery
ARTERIES
Source
Branches
Supply
Additional Info
Femoral
external iliac
superficial epigastric a.,
superficial circumflex iliac a.,
superficial & deep external
pudendal aa., deep femoral,
descending genicular,
popliteal
thigh, leg & foot
the femoral a. is continuous
with the popliteal a.; the name
change occurs at the adductor
hiatus
Femoral,
deep
femoral
medial & lateral circumflex
femoral aa., perforating aa.
(~3 or 4)
hip joint, proximal thigh,
posterior thigh
the primary blood supply to
muscles of the posterior
compartment of the thigh
Iliac,
external
common
iliac
inferior epigastric, deep
circumflex iliac, femoral
lower limb
external iliac a. is continuous
with the femoral a.; the name
change occurs at the inguinal
ligament; the common iliac
artery bifurcates anterior to the
sacroiliac articulation
Obturator
internal iliac,
anterior
division
pubic br., acetabular br.,
anterior br., posterior br.
medial thigh & hip
anterior & posterior brs. pass
on anterior and posterior sides
of adductor brevis m.
Circumflex
femoral,
medial
deep
femoral (or
femoral)
ascending & descending brs.
medial thigh & hip
Circumflex
femoral,
lateral
deep
femoral (or
femoral)
ascending, transverse &
descending brs.
lateral thigh & hip
Popliteal
femoral
anterior & posterior tibial; 5
genicular brs.
knee, leg & foot
the popliteal a. is the
continuation of the femoral a.;
the name change occurs at the
adductor hiatus
Gluteal,
inferior
internal iliac,
anterior
division
Gluteal,
superior
internal iliac,
posterior
division
superficial br., deep br.
gluteus maximus, medius
& minimus, hip joint
Internal
pudendal
internal iliac
a., anterior
division
inferior rectal a., perineal a.,
artery of the bulb of the
clitoris/penis, urethral a.,
deep clitoral/penile a., dorsal
clitoral/penile a.
anus, muscles of the
superficial and deep
perineal spaces,
clitoris/penis, posterior
aspect of the
scrotum/labium majus
internal pudendal a. is the
primary blood supply to the
perineum
Femoral,
deep
femoral
medial & lateral circumflex
femoral aa., perforating aa.
(~3 or 4)
hip joint, proximal thigh,
posterior thigh
the primary blood supply to
muscles of the posterior
compartment of the thigh
anterior tibial a., posterior
tibial a., 5 genicular brs.
knee, leg and foot
the popliteal a. is the
continuation of the femoral a.;
the name change occurs at the
adductor hiatus
cruciate ligaments &
deep structures of knee
anastomoses with other
genicular brs. of popliteal a.,
circumflex fibular a. & anterior
tibial recurrent a. to form
genicular anastomosis
lateral aspect of knee
anastomoses with other
genicular brs. of popliteal a.,
circumflex fibular a. & anterior
tibial recurrent a. to form
genicular anastomosis
medial aspect of knee
anastomoses with other
genicular brs. of popliteal a.,
circumflex fibular a. & anterior
tibial recurrent a. to form
genicular anastomosis
fibular (peroneal), circumflex
fibular, nutrient a. of tibia,
communicating br., posterior
medial malleolar brs., medial
calcaneal brs., lateral &
medial plantar aa.
posterior & lateral leg,
plantar aspect of foot
posterior tibial bifurcates on
the medial side of the foot to
give rise to the medial and
lateral plantar aa.
nutrient br., lateral malleolar
br., communicating br.,
perforating br.
lateral leg & ankle
anastomoses at ankle with
anterior & posterior tibial aa.
anterior & posterior tibial
recurrent; anterior, medial &
lateral malleolar; dorsalis
pedis
anterior leg, dorsal &
deep foot
anterior tibial a. becomes
continuous with the dorsalis
pedis a.; name change occurs
at the level of the ankle joint
Popliteal
femoral a.
Genicular,
middle
popliteal
Genicular,
superior
lateral
popliteal
Genicular,
superior
medial
popliteal
Tibial,
posterior
Fibular
Tibial,
anterior
gluteus maximus, hip
joint
popliteal
posterior
tibial
popliteal
participates in the formation of
the cruciate anastomoses of
the hip
Plantar,
medial
digital brs. (3)
superficial foot medially
becomes continuous with the
plantar arch; proper plantar
digital a. to lateral side of 5th
digit
deep foot; the plantar
arterial arch and its brs.
supply the toes, including
the distal phalangeal
segment dorsally
plantar metatarsal aa. (4)
deep foot; its plantar
metatarsal brs. and their
brs. supply the toes,
including the distal
phalangeal segment
dorsally
lateral & medial tarsal aa.,
arcuate a., 1st dorsal
metatarsal a., deep plantar a.
dorsal aspect of foot;
the anterior tibial artery
anastomoses with plantar continues as the dorsalis pedis;
arterial arch
the name change occurs at the
level of the ankle
posterior
tibial
Plantar,
lateral
posterior
tibial
Arch,
plantar
arterial
lateral
plantar
Dorsalis
pedis
anterior
tibial a.
Plantar,
deep
deep foot
dorsalis
pedis
anastomoses with plantar
metatarsal aa., but does not
usually participate in formation
of the plantar arch
anastomoses with the deep
plantar br. of the dorsalis pedis
a.
anastomoses with lateral
plantar a. to form the plantar
arterial arch
LOWER LIMB
o
Vein
Dorsal venous
arch of foot
Saphenous,
greater
VEINS
Tributaries
dorsal digital vv. and dorsal
metatarsal vv.
medial end of dorsal venous
arch of foot, perforating
communications, superficial
epigastric, superficial
Drains Into
Regions Drained
great saphenous
v. medially, small
saphenous v.
laterally
dorsum of digits &
superficial
structures of
dorsum of foot
femoral v.
superficial
structures of medial
lower limb; lower
abdominal wall,
Additional Info
frequently used as graft
material in coronary bypass
surgery
circumflex iliac, superficial
external pudendal
Epigastric,
superficial
none
Saphenous,
lesser
Popliteal
perineal region
greater
saphenous v.
superficial fascia
and skin of the
lower abdominal
wall
lateral end of dorsal venous
arch of foot
popliteal v.
superficial lateral
foot & leg
anterior & posterior tibial vv.,
lesser saphenous v.
continues as
femoral v.
foot & leg
superficial epigastric v.
communicates with
paraumbilical vv. and may
enlarge in portal
hypertension, producing the
sign called caput medusae
lies posterior to popliteal a.
within popliteal fossa
UPPER LIMB
o
Structure
Superficial
inguinal
nodes
LYMPHATICS
Location
in superficial fascia
parallel to inguinal
ligament & along
greater saphenous v.
Deep inguinal
nodes
medial to femoral v.
deep to fascia lata &
inguinal ligament
Popliteal
nodes
Afferents from
popliteal fossa along
popliteal vessels
superficial
inguinal &
popliteal nodes
Efferents to
Regions drained
deep inguinal
nodes
external genitalia;
superficial parts of
lower limb
external iliac
nodes
lower limb, external
genitalia, lower
anterior abdominal
wall
deep &
superficial
inguinal nodes
leg & foot
Additional Info
the deep inguinal node
in femoral canal is
called node (or gland)
of Cloquet
Surface & Functional Anatomy (syllabus)
Understand and explain the anatomical basis of the peripheral vascular examination including the
relevant surface anatomy of the peripheral arteries, veins and lymphatics.
Peripheral Vascular Examination
Inspection
o Introduce etc....explain, consent, wash hands
o Expose the patient from the waist down + exposed upper limbs
o Look around the bed for the usual
 ie “does the patient look sick?”, Oxygen, Inhalers/GTN, Catheters, Drains, Fluids,
Dressings, Position, Comfortable
o Vital Signs
o At the end of the bed - Colour of the Limbs (pale/blue/black), Hair Loss, Ulcers, Scars,
Muscle Wasting, skin changes
o Closer inspection of the lower limbs - especially lower medial 1/3 as venous insufficiency
effects this region first
 Any signs of gangrene or pre-gangrene such as missing toes or blackening of the
extremities.
 The presence of any ulcers – ensure you check all around the feet including behind
the ankle and in between the toes. Ulcers may be venous or arterial.
 Any skin changes such as pallor, change in colour (eg purple/black from haemostasis
or brown from haemosiderin deposition), varicose eczema or sites of previous
ulcers.
 Compare size of both legs especially at ankle level for evidence of oedema.
 Venous Stars – minute veins radiating from a single feeding vein.
 Visible sc veins - note distribution, size, tortuosity, any associated erythema or
tenderness
 Presence of any varicose veins – often seen best with the patient standing
o Signs of Chronic Venous Insufficiency – eczema, lipodermatosclerosis, inverted
champagne bottle legs, cutaneous haemosiderin deposits
Palpation
o Palpation of the limbs – paying attention to temperature as well as any abnormalities
identified in inspection
o Check capillary refill by gently pinching the nail bed and counting the return time
(normal is < 3 secs)
o Palpate pulses
 Femoral – feel over the medial aspect of the inguinal ligament.
 Aorta abdominal – placing two fingers either side of umbilicus (expansile)
 Popliteal – ask the patient to flex their knee to roughly 60º keeping their foot on the
bed, place both hands on the front of the knee and place your fingers in the
popliteal space.
 Posterior tibial – felt posterior to the medial malleolus of the tibia.
 Dorsalis pedis – feel on the dorsum of the foot, lateral to the extensor tendon of the
great toe
o Listen for bruits at aorta, iliac and femoral artery
o Check for radio-femoral delay. Palpate both the radial and femoral pulses on one side of
the body. The pulsation should occur at the same time. Any delay may suggest
coarctation of the aorta.
o
o
o
o
o
Fascial Defects - Feel along course of veins (Note tension in vein) and any tender fascial
defects (usually at 5, 10 and 15 cm above medial malleolus)
Pitting Oedema
Sc Tissues - Thickening and tenderness
Vein - Press on vein from above noting presence of retrograde flow
Cough impulses - over saphenofemoral and saphenopopliteal junctions, noting any
bulging with increased transmitted pressure
Trendelenburg Test
o Ask the patient to lie down & raise the leg to empty the veins.
o Place 2 fingers over the saphenofemoral junction.
o Ask the patient to stand up.
o Release pressure at the junction
o If the veins remain empty while standing, the saphenofemoral junction is incompetent.
Tourniquet Tests
Patient Supine with Leg elevated
o Sweep veins empty (Note how easily the veins empty - may give signs of occlusion /
compression)- if fail to empty this suggests high pressure within them
o First place a tourniquet around upper third of thigh to occlude superficial veins
Then Patient Standing
o If veins above tourniquet distend - Saphenofemoral Junction is incompetent
o If veins below tourniquet fill there must be a perforator below level of tourniquet
therefore once again elevate the leg and repeat the procedure with the tourniquet at a
lower position on leg. (Note: Alternatively – one can use multiple tourniquets and simply
release them sequentially)