Collateral Circulation after Ligature of the Axillary Artery

Highest Thoracic.

Thoracoacromial.

Lateral Thoracic.

From third part

Subscapular.

Posterior Humeral Circumflex.

Anterior Humeral Circumflex.

1. The highest thoracic artery (a. thoracalis suprema; superior thoracic artery) is a small vessel, which may arise from the thoracoacromial. Running forward and medialward along the upper border of the Pectoralis minor, it passes between it and the Pectoralis major to the side of the chest. It supplies branches to these muscles, and to the parietes of the thorax, and anastomoses with the internal mammary and intercostal arteries.

2. The thoracoacromial artery (a. thoracoacromialis; acromiothoracic artery; thoracic axis) is a short trunk, which arises from the forepart of the axillary artery, its origin being generally overlapped by the upper edge of the Pectoralis minor Projecting forward to the upper border of this muscle, it pierces the coracoclavicular fascia and divides into four branches—pectoral, acromial, clavicular, and deltoid. The pectoral branch descends between the two Pectorales, and is distributed to them and to the mamma, anastomosing with the intercostal branches of the internal mammary and with the lateral thoracic. The acromial branch runs lateralward over the coracoid process and under the Deltoideus, to which it gives branches; it then pierces that muscle and ends on the acromion in an arterial network formed by branches from the transverse scapular, thoracoacromial, and posterior humeral circumflex arteries. The clavicular branch runs upward and medialward to the sternoclavicular joint, supplying this articulation, and the Subclavius. The deltoid (humeral) branch, often arising with the acromial, crosses over the Pectoralis minor and passes in the same groove as the cephalic vein, between the Pectoralis major and Deltoideus, and gives branches to both muscles.

3. The lateral thoracic artery (a. thoracalis lateralis; long thoracic artery; external mammary artery) follows the lower border of the Pectoralis minor to the side of the chest, supplying the Serratus anterior and the Pectoralis, and sending branches across the axilla to the axillary glands and Subscapularis; it anastomoses with the internal mammary, subscapular, and intercostal arteries, and with the pectoral branch of the thoracoacromial. In the female it supplies an external mammary branch which turns round the free edge of the Pectoralis major and supplies the mamma.

4. The subscapular artery (a. subscapularis) the largest branch of the axillary artery, arises at the lower border of the Subscapularis, which it follows to the inferior angle of the scapula, where it anastomoses with the lateral thoracic and intercostal arteries and with the descending branch of the transverse cervical, and ends in the neighboring muscles. About 4 cm. from its origin it gives off a branch, the scapular circumflex artery.

The Scapular Circumflex Artery (a. circumflexa scapulæ; dorsalis scapulæ artery) is generally larger than the continuation of the subscapular. It curves around the axillary border of the scapula, traversing the space between the Subscapularis above, the Teres major below, and the long head of the Triceps laterally, it enters the infraspinatous fossa under cover of the Teres minor, and anastomoses with the transverse scapular artery and the descending branch of the transverse cervical. In its course it gives off two branches: one (infrascapular) enters the subscapular fossa beneath the Subscapularis, which it supplies, anastomosing with the transverse scapular artery and the descending branch of the transverse cervical; the other is continued along the axillary border of the scapula, between the Teres major and minor, and at the dorsal surface of the inferior angle anastomoses with the descending branch of the transverse cervical. In addition to these, small branches are distributed to the back part of the Deltoideus and the long head of the Triceps brachii, anastomosing with an ascending branch of the a. profunda brachii.

5. The posterior humeral circumflex artery (a. circumflexa humeri posterior; posterior circumflex artery) arises from the axillary artery at the lower border of the Subscapularis, and runs backward with the axillary nerve through the quadrangular space bounded by the Subscapularis and Teres minor above, the Teres major below, the long head of the Triceps brachii medially, and the surgical neck of the humerus laterally. It winds around the neck of the humerus and is distributed to the Deltoideus and shoulder-joint, anastomosing with the anterior humeral circumflex and profunda brachii.

6. The anterior humeral circumflex artery (a. circumflexa humeri anterior; anterior circumflex artery), considerably smaller than the posterior, arises nearly opposite it, from the lateral side of the axillary artery. It runs horizontally, beneath the Coracobrachialis and short head of the Biceps brachii, in front of the neck of the humerus. On reaching the intertubercular sulcus, it gives off a branch which ascends in the sulcus to supply the head of the humerus and the shoulder-joint. The trunk of the vessel is then continued onward beneath the long head of the Biceps brachii and the Deltoideus, and anastomoses with the posterior humeral circumflex artery.

Peculiarities.—The branches of the axillary artery vary considerably in different subjects. Occasionally the subscapular, humeral circumflex, and profunda arteries arise from a common trunk, and when this occurs the branches of the brachial plexus surround this trunk instead of the main vessel. Sometimes the axillary artery divides into the radial and ulnar arteries, and occasionally it gives origin to the volar interosseous artery of the forearm.
7. Methodic of class work:

a) interrogation of the students on the home task;

b) study of samples (topic according to the plan);

c) fill in the protocol of current lesson;

d) checking and signing the protocols by teacher.
8. Forms and methods of the self-checking.

Questions:

10. Sources of the information: Human anatomy

11. The program of self-preparation of students:

1. To learn the appropriate sections under the textbook

2. To consider preparations and to study them according to the plan of practical class.

3. To fill in the report of practical class.

4. To be able to show on a preparation of the Brachial Artery, the Axillary Artery.

.

Methodical elaboration for practice class on human anatomy

1. The topic: The arteries of the hand.

2. The place: classroom of the department of human anatomy.

3. The aim: to know the structure of the arteries of the carps.

4. The professional orientation of students: The knowledge of this topic are necessary for doctors of all specialities, it represents special interest for therapists.

5. The basic of knowledge:

6. The plan of the practice class:

A. Checking of the home task: interrogation or the test control – 30 min

B. Summary lecture on the topic by teacher – 20 min

а) The anterior ulnar carpal artery;

b) The dorsal carpal branch;

c) The superficial volar arch;

4. 
   The anterior radial carpal artery;
   
5. 
   The superficial volar branch;
   

Working plan:

The volar carpal branch (ramus carpeus volares; anterior ulnar carpal artery) is a small vessel which crosses the front of the carpus beneath the tendons of the Flexor digitorum profundus, and anastomoses with the corresponding branch of the radial artery.

The dorsal carpal branch (ramus carpeus dorsalis; posterior ulnar carpal artery) arises immediately above the pisiform bone, and winds backward beneath the tendon of the Flexor carpi ulnaris; it passes across the dorsal surface of the carpus beneath the Extensor tendons, to anastomose with a corresponding branch of the radial artery. Immediately after its origin, it gives off a small branch, which runs along the ulnar side of the fifth metacarpal bone, and supplies the ulnar side of the dorsal surface of the little finger.

The deep volar branch (ramus volaris profundus; profunda branch) passes between the Abductor digiti quinti and Flexor digiti quinti brevis and through the origin of the Opponens digiti quinti; it anastomoses with the radial artery, and completes the deep volar arch.

The superficial volar arch (arcus volaris superficialis; superficial palmar arch) is formed by the ulnar artery, and is usually completed by a branch from the a. volaris indicis radialis, but sometimes by the superficial volar or by a branch from the a. princeps pollicis of the radial artery. The arch passes across the palm, describing a curve, with its convexity downward.

Three Common Volar Digital Arteries (aa. digitales volares communes; palmar digital arteries) arise from the convexity of the arch and proceed downward on the second, third, and fourth Lumbricales. Each receives the corresponding volar metacarpal artery and then divides into a pair of proper volar digital arteries (aa. digitales volares propriæ; collateral digital arteries) which run along the contiguous sides of the index, middle, ring, and little fingers, behind the corresponding digital nerves; they anastomose freely in the subcutaneous tissue of the finger tips and by smaller branches near the interphalangeal joints. Each gives off a couple of dorsal branches which anastomose with the dorsal digital arteries, and supply the soft parts on the back of the second and third phalanges, including the matrix of the finger-nail. The proper volar digital artery for medial side of the little finger springs from the ulnar artery under cover of the Palmaris brevis.

The superficial volar branch (ramus volaris superficialis; superficialis volœ artery) arises from the radial artery, just where this vessel is about to wind around the lateral side of the wrist. Running forward, it passes through, occasionally over, the muscles of the ball of the thumb, which it supplies, and sometimes anastomoses with the terminal portion of the ulnar artery, completing the superficial volar arch. This vessel varies considerably in size: usually it is very small, and ends in the muscles of the thumb; sometimes it is as large as the continuation of the radial

The dorsal carpal branch (ramus carpeus dorsalis; posterior radial carpal artery) is a small vessel which arises beneath the Extensor tendons of the thumb; crossing the carpus transversely toward the medial border of the hand, it anastomoses with the dorsal carpal branch of the ulnar and with the volar and dorsal interosseous arteries to form a dorsal carpal network. From this network are given off three slender dorsal metacarpal arteries, which run downward on the second, third, and fourth Interossei dorsales and bifurcate into the dorsal digital branches for the supply of the adjacent sides of the middle, ring, and little fingers respectively, communicating with the proper volar digital branches of the superficial volar arch. Near their origins they anastomose with the deep volar arch by the superior perforating arteries, and near their points of bifurcation with the common volar digital vessels of the superficial volar arch by the inferior perforating arteries.

The first dorsal metacarpal arises just before the radial artery passes between the two heads of the first Interosseous dorsalis and divides almost immediately into two branches which supply the adjacent sides of the thumb and index finger; the radial side of the thumb receives a branch directly from the radial artery.

The arteria princeps pollicis arises from the radial just as it turns medialward to the deep part of the hand; it descends between the first Interosseous dorsalis and Adductor pollicis obliquus, along the ulnar side of the metacarpal bone of the thumb to the base of the first phalanx, where it lies beneath the tendon of the Flexor pollicis longus and divides into two branches. These make their appearance between the medial and lateral insertions of the Adductor pollicis obliquus, and run along the sides of the thumb, forming on the volar surface of the last phalanx an arch, from which branches are distributed to the integument and subcutaneous tissue of the thumb.

The arteria volaris indicis radialis (radialis indicis artery) arises close to the preceding, descends between the first Interosseus dorsalis and Adductor pollicis transversus, and runs along the radial side of the index finger to its extremity, where it anastomoses with the proper digital artery, supplying the ulnar side of the finger. At the lower border of the Adductor pollicis transversus this vessel anastomoses with the princeps pollicis, and gives a communicating branch to the superficial volar arch. The a. princeps pollicis and a. volaris indicis radialis may spring from a common trunk termed the first volar metacarpal artery.

The deep volar arch (arcus volaris profundus; deep palmar arch) is formed by the anastomosis of the terminal part of the radial artery with the deep volar branch of the ulnar. It lies upon the carpal extremities of the metacarpal bones and on the Interossei, being covered by the Adductor pollicis obliquus, the Flexor tendons of the fingers, and the Lumbricales. Alongside of it, but running in the opposite direction—that is to say, toward the radial side of the hand—is the deep branch of the ulnar nerve.

The volar metacarpal arteries (aa. metacarpeæ volares; palmar interosseous arteries), three or four in number, arise from the convexity of the deep volar arch; they run distally upon the Interossei, and anastomose at the clefts of the fingers with the common digital branches of the superficial volar arch.

The perforating branches (rami perforantes), three in number, pass backward from the deep volar arch, through the second, third, and fourth interosseous spaces and between the heads of the corresponding Interossei dorsalis, to anastomose with the dorsal metacarpal arteries.

The recurrent branches arise from the concavity of the deep volar arch. They ascend in front of the wrist, supply the intercarpal articulations, and end in the volar carpal network.

a) interrogation of the students on the home task;

b) study of samples (topic according to the plan);

c) fill in the protocol of current lesson;

d) checking and signing the protocols by teacher.
8. Forms and methods of the self-checking.

Questions:

10. Sources of the information: Human anatomy

11. The program of self-preparation of students:

1. To learn the appropriate sections under the textbook

2. To consider preparations and to study them according to the plan of practical class.

3. To fill in the report of practical class.

4. To be able to show on a preparation of the arteries of the carps.

.

1. The topic: The Arteries of the Lower Extremity.

2. The place: classroom of the department of human anatomy.

3. The aim: to know the structure of the Common Iliac Arteries, the External Iliac Artery, the Anterior Tibial Artery, the Posterior Tibial Artery, the Popliteal Artery, the Arteria Dorsalis Pedis.

4. The professional orientation of students: The knowledge of this topic are necessary for doctors of all specialities, it represents special interest for therapists.

5. The basic of knowledge:

6. The plan of the practice class:

A. Checking of the home task: interrogation or the test control – 30 min

B. Summary lecture on the topic by teacher – 20 min

а) The Common Iliac Arteries;

b) The External Iliac Artery;

c) The Anterior Tibial Artery;

4. 
   The Posterior Tibial Artery;
   
5. 
   The Popliteal Artery;
   
6. 
   The Arteria Dorsalis Pedis;
   

Working plan:

The artery which supplies the greater part of the lower extremity is the direct continuation of the external iliac. It runs as a single trunk from the inguinal ligament to the lower border of the Popliteus, where it divides into two branches, the anterior and posterior tibial. The upper part of the main trunk is named the femoral, the lower part the popliteal.

The femoral artery begins immediately behind the inguinal ligament, midway between the anterior superior spine of the ilium and the symphysis pubis, and passes down the front and medial side of the thigh. It ends at the junction of the middle with the lower third of the thigh, where it passes through an opening in the Adductor magnus to become the popliteal artery. The vessel, at the upper part of the thigh, lies in front of the hip-joint; in the lower part of its course it lies to the medial side of the body of the femur, and between these two parts, where it crosses the angle between the head and body, the vessel is some distance from the bone. The first 4 cm. of the vessel is enclosed, together with the femoral vein, in a fibrous sheath—the femoral sheath. In the upper third of the thigh the femoral artery is contained in the femoral triangle (Scarpa’s triangle), and in the middle third of the thigh, in the adductor canal (Hunter’s canal).

The femoral sheath (crural sheath) is formed by a prolongation downward, behind the inguinal ligament, of the fasciæ which line the abdomen, the transversalis fascia being continued down in front of the femoral vessels and the iliac fascia behind them. The sheath assumes the form of a short funnel, the wide end of which is directed upward, while the lower, narrow end fuses with the fascial investment of the vessels, about 4 cm. below the inguinal ligament. It is strengthened in front by a band termed the deep crural arch (page 419). The lateral wall of the sheath is vertical and is perforated by the lumboinguinal nerve; the medial wall is directed obliquely downward and lateralward, and is pierced by the great saphenous vein and by some lymphatic vessels. The sheath is divided by two vertical partitions which stretch between its anterior and posterior walls. The lateral compartment contains the femoral artery, and the intermediate the femoral vein, while the medial and smallest compartment is named the femoral canal, and contains some lymphatic vessels and a lymph gland imbedded in a small amount of areolar tissue. The femoral canal is conical and measures about 1.25 cm. in length. Its base, directed upward and named the femoral ring, is oval in form, its long diameter being directed transversely and measuring about 1.25 cm. The femoral ring is bounded in front by the inguinal ligament, behind by the Pectineus covered by the pectineal fascia, medially by the crescentic base of the lacunar ligament, and laterally by the fibrous septum on the medial side of the femoral vein. The spermatic cord in the male and the round ligament of the uterus in the female lie immediately above the anterior margin of the ring, while the inferior epigastric vessels are close to its upper and lateral angle. The femoral ring is closed by a somewhat condensed portion of the extraperitoneal fatty tissue, named the septum femorale (crural septum), the abdominal surface of which supports a small lymph gland and is covered by the parietal layer of the peritoneum. The septum femorale is pierced by numerous lymphatic vessels passing from the deep inguinal to the external iliac lymph glands, and the parietal peritoneum immediately above it presents a slight depression named the femoral fossa.

The femoral triangle (trigonum femorale; Scarpa’s triangle) corresponds to the depression seen immediately below the fold of the groin. Its apex is directed downward, and the sides are formed laterally by the medial margin of the Sartorius, medially by the medial margin of the Adductor longus, and above by the inguinal ligament. The floor of the space is formed from its lateral to its medial side by the Iliacus, Psoas major, Pectineus, in some cases a small part of the Adductor brevis, and the Adductor longus; and it is divided into two nearly equal parts by the femoral vessels, which extend from near the middle of its base to its apex: the artery giving off in this situation its superficial and profunda branches, the vein receiving the deep femoral and great saphenous tributaries. On the lateral side of the femoral artery is the femoral nerve dividing into its branches. Besides the vessels and nerves, this space contains some fat and lymphatics.

The adductor canal (canalis adductorius; Hunter’s canal) is an aponeurotic tunnel in the middle third of the thigh, extending from the apex of the femoral triangle to the opening in the Adductor magnus. It is bounded, in front and laterally, by the Vastus medialis; behind by the Adductores longus and magnus; and is covered in by a strong aponeurosis which extends from the Vastus medialis, across the femoral vessels to the Adductores longus and magnus; lying on the aponeurosis is the Sartorius muscle. The canal contains the femoral artery and vein, the saphenous nerve, and the nerve to the Vastus medialis.

Relations of the Femoral Artery.—In the femoral triangle the artery is superficial. In front of it are the skin and superficial fascia, the superficial subinguinal lymph glands, the superficial iliac circumflex vein, the superficial layer of the fascia lata and the anterior part of the femoral sheath. The lumboinguinal nerve courses for a short distance within the lateral compartment of the femoral sheath, and lies at first in front and then lateral to the artery. Near the apex of the femoral triangle the medial branch of the anterior femoral cutaneous nerve crosses the artery from its lateral to its medial side.

Behind the artery are the posterior part of the femoral sheath, the pectineal fascia, the medial part of the tendon of the Psoas major, the Pectineus and the Adductor longus. The artery is separated from the capsule of the hip-joint by the tendon of the Psoas major, from the Pectineus by the femoral vein and profunda vessels, and from the Adductor longus by the femoral vein. The nerve to the Pectineus passes medialward behind the artery. On the lateral side of the artery, but separated from it by some fibers of the Psoas major, is the femoral nerve. The femoral vein is on the medial side of the upper part of the artery, but is behind the vessel in the lower part of the femoral triangle.

In the adductor canal the femoral artery is more deeply situated, being covered by the integument, the superficial and deep fasciæ, the Sartorius and the fibrous roof of the canal; the saphenous nerve crosses from its lateral to its medial side. Behind the artery are the Adductores longus and magnus; in front and lateral to it is the Vastus medialis. The femoral vein lies posterior to the upper part, and lateral to the lower part of the artery.