State establishment "DnEpropetrovsk Medical Academy of health Ministry of Ukraine"
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- The Anticubital Fossa.
- Peculiarities of the Brachial Artery as Regards its Course.
- As Regards its Division.
- Varieties in Muscular Relations.
- Practice class 35. The arteries of the pelvic region and lower extremity: relations, branches, supplement, anastomoses. The aim
- Professional orientation
- The Common Iliac Arteries (Aa. Iliacae Communes)
- 1. The Hypogastric Artery (A. Hypogastrica; Internal Iliac Artery)
- As Regards its Place of Division.
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. THE BRACHIAL ARTERY commences at the lower margin of the tendon of the Teres major, and, passing down the arm, ends about 1 cm. below the bend of the elbow, where it divides into the radial and ulnar arteries. At first the brachial artery lies medial to the humerus; but as it runs down the arm it gradually gets in front of the bone, and at the bend of the elbow it lies midway between its two epicondyles. Relations.—The artery is superficial throughout its entire extent, being covered, in front, by the integument and the superficial and deep fasciae; the lacertus fibrosus (bicipital fascia) lies in front of it opposite the elbow and separates it from the vena mediana cubiti; the median nerve crosses from its lateral to its medial side opposite the insertion of the Coracobrachialis. Behind, it is separated from the long head of the Triceps brachii by the radial nerve and a. profunda brachii. It then lies upon the medial head of the Triceps brachii, next upon the insertion of the Coracobrachialis, and lastly on the Brachialis. Laterally, it is in relation above with the median nerve and the Coracobrachialis, below with the Biceps brachii, the two muscles overlapping the artery to a considerable extent. Medially, its upper half is in relation with the medial antibrachial cutaneous and ulnar nerves, its lower half with the median nerve. The basilic vein lies on its medial side, but is separated from it in the lower part of the arm by the deep fascia. The artery is accompanied by two venae comitantes, which lie in close contact with it, and are connected together at intervals by short transverse branches. The Anticubital Fossa.—At the bend of the elbow the brachial artery sinks deeply into a triangular interval, the anticubital fossa. The base of the triangle is directed upward, and is represented by a line connecting the two epicondyles of the humerus; the sides are formed by the medial edge of the Brachioradialis and the lateral margin of the Pronator teres; the floor is formed by the Brachialis and Supinator. This space contains the brachial artery, with its accompanying veins; the radial and ulnar arteries; the median and radial nerves; and the tendon of the Biceps brachii. The brachial artery occupies the middle of the space, and divides opposite the neck of the radius into the radial and ulnar arteries; it is covered, in front, by the integument, the superficial fascia, and the vena mediana cubiti, the last being separated from the artery by the lacertus fibrosus. Behind it is the Brachialis which separates it from the elbow-joint. The median nerve lies close to the medial side of the artery, above, but is separated from it below by the ulnar head of the Pronator teres. The tendon of the Biceps brachii lies to the lateral side of the artery; the radial nerve is situated upon the Supinator, and concealed by the Brachioradialis. Peculiarities of the Brachial Artery as Regards its Course.—The brachial artery, accompanied by the median nerve, may leave the medial border of the Biceps brachii, and descend toward the medial epicondyle of the humerus; in such cases it usually passes behind the supracondylar process of the humerus, from which a fibrous arch is in most cases thrown over the artery; it then runs beneath or through the substance of the Pronator teres, to the bend of the elbow. This variation bears considerable analogy with the normal condition of the artery in some of the carnivora; it has been referred to in the description of the humerus. As Regards its Division.—Occasionally, the artery is divided for a short distance at its upper part into two trunks, which are united below. Frequently the artery divides at a higher level than usual, and the vessels concerned in this high division are three, viz., radial, ulnar, and interosseous. Most frequently the radial is given off high up, the other limb of the bifurcation consisting of the ulnar and interosseous; in some instances the ulnar arises above the ordinary level, and the radial and interosseous form the other limb of the division; occasionally the interosseous arises high up. Sometimes, long slender vessels, vasa aberrantia, connect the brachial or the axillary artery with one of the arteries of the forearm, or branches from them. These vessels usually join the radial. Varieties in Muscular Relations.—The brachial artery is occasionally concealed, in some part of its course, by muscular or tendinous slips derived from the Coracobrachialis, Biceps brachii, Brachialis, or Pronator teres. Collateral Circulation.—After the application of a ligature to the brachial artery in the upper third of the arm, the circulation is carried on by branches from the humeral circumflex and subscapular arteries anastomosing with ascending branches from the profunda brachii. If the artery be tied below the origin of the profunda brachii and superior ulnar collateral, the circulation is maintained by the branches of these two arteries anastomosing with the inferior ulnar collateral, the radial and ulnar recurrents, and the dorsal interosseous. Branches.—The branches of the brachial artery are: Profunda Brachii. Superior Ulnar Collateral. Nutrient. Inferior Ulnar Collateral. Muscular. 1. The arteria profunda brachii (superior profunda artery) is a large vessel which arises from the medial and back part of the brachial, just below the lower border of the Teres major. It follows closely the radial nerve, running at first backward between the medial and lateral heads of the Triceps brachii, then along the groove for the radial nerve, where it is covered by the lateral head of the Triceps brachii, to the lateral side of the arm; there it pierces the lateral intermuscular septum, and, descending between the Brachioradialis and the Brachialis to the front of the lateral epicondyle of the humerus, ends by anastomosing with the radial recurrent artery. It gives branches to the Deltoideus and to the muscles between which it lies; it supplies an occasional nutrient artery which enters the humerus behind the deltoid tuberosity. A branch ascends between the long and lateral heads of the Triceps brachii to anastomose with the posterior humeral circumflex artery; a middle collateral branch descends in the middle head of the Triceps brachii and assists in forming the anastomosis above the olecranon; and, lastly, a radial collateral branch runs down behind the lateral intermuscular septum to the back of the lateral epicondyle of the humerus, where it anastomoses with the interosseous recurrent and the inferior ulnar collateral arteries. 2. The nutrient artery (a. nutricia humeri) of the body of the humerus arises about the middle of the arm and enters the nutrient canal near the insertion of the Coracobrachialis. 3. The superior ulnar collateral artery (a. collateralis ulnaris superior; inferior profunda artery), of small size, arises from the brachial a little below the middle of the arm; it frequently springs from the upper part of the a. profunda brachii. It pierces the medial intermuscular septum, and descends on the surface of the medial head of the Triceps brachii to the space between the medial epicondyle and olecranon, accompanied by the ulnar nerve, and ends under the Flexor carpi ulnaris by anastomosing with the posterior ulnar recurrent, and inferior ulnar collateral. It sometimes sends a branch in front of the medial epicondyle, to anastomose with the anterior ulnar recurrent. 4. The inferior ulnar collateral artery (a. collateralis ulnaris inferior; anastomotica magna artery) arises about 5 cm. above the elbow. It passes medialward upon the Brachialis, and piercing the medial intermuscular septum, winds around the back of the humerus between the Triceps brachii and the bone, forming, by its junction with the profunda brachii, an arch above the olecranon fossa. As the vessel lies on the Brachialis, it gives off branches which ascend to join the superior ulnar collateral: others descend in front of the medial epicondyle, to anastomose with the anterior ulnar recurrent. Behind the medial epicondyle a branch anastomoses with the superior ulnar collateral and posterior ulnar recurrent arteries. 5. The muscular branches (rami musculares) three or four in number, are distributed to the Coracobrachialis, Biceps brachii, and Brachialis.
Students are supposed to identify the following anatomical structures on the samples:
Practice class 35. The arteries of the pelvic region and lower extremity: relations, branches, supplement, anastomoses. The aim: to learn the topography of the arteries of the lower extremity, branches that spring from them; to define muscles that are supplied by these arteries. Professional orientation: knowledge of this topic is necessary for doctors of all the specialities, especially therapeutisis, traumatologists, surgeons. The plan of the practice class:
The Common Iliac Arteries (Aa. Iliacae Communes) The abdominal aorta divides, on the left side of the body of the fourth lumbar vertebra, into the two common iliac arteries. Each is about 5 cm. in length. They diverge from the termination of the aorta, pass downward and lateralward, and divide, opposite the intervertebral fibrocartilage between the last lumbar vertebra and the sacrum, into two branches, the external iliac and hypogastric arteries; the former supplies the lower extremity; the latter, the viscera and parietes of the pelvis. The right common iliac artery is somewhat longer than the left, and passes more obliquely across the body of the last lumbar vertebra. In front of it are the peritoneum, the small intestines, branches of the sympathetic nerves, and, at its point of division, the ureter. Behind, it is separated from the bodies of the fourth and fifth lumbar vertebrae, and the intervening fibrocartilage, by the terminations of the two common iliac veins and the commencement of the inferior vena cava. Laterally, it is in relation, above, with the inferior vena cava and the right common iliac vein; and, below, with the Psoas major. Medial to it, above, is the left common iliac vein. The left common iliac artery is in relation, in front, with the peritoneum, the small intestines, branches of the sympathetic nerves, and the superior hemorrhoidal artery; and is crossed at its point of bifurcation by the ureter. It rests on the bodies of the fourth and fifth lumbar vertebrae, and the intervening fibrocartilage. The left common iliac vein lies partly medial to, and partly behind the artery; laterally, the artery is in relation with the Psoas major. Branches.—The common iliac arteries give off small branches to the peritoneum, Psoas major, ureters, and the surrounding areolar tissue, and occasionally give origin to the iliolumbar, or accessory renal arteries. Peculiarities.—The point of origin varies according to the bifurcation of the aorta. In three-fourths of a large number of cases, the aorta bifurcated either upon the fourth lumbar vertebra, or upon the fibrocartilage between it and the fifth; the bifurcation being, in one case out of nine, below, and in one out of eleven, above this point. In about 80 per cent. of the cases the aorta bifurcated within 1.25 cm. above or below the level of the crest of the ilium; more frequently below than above. The point of division is subject to great variety. In two-thirds of a large number of cases it was between the last lumbar vertebra and the upper border of the sacrum; being above that point in one case out of eight, and below it in one case out of six. The left common iliac artery divides lower down more frequently than the right. The relative lengths, also, of the two common iliac arteries vary. The right common iliac was the longer in sixty-three cases; the left in fifty-two; while they were equal in fifty-three. The length of the arteries varied, in five-sevenths of the cases examined, from 3.5 to 7.5 cm.; in about half of the remaining cases the artery was longer, and in the other half, shorter; the minimum length being less than 1.25 cm., the maximum, 11 cm. In rare instances, the right common iliac has been found wanting, the external iliac and hypogastric arising directly from the aorta.
The hypogastric artery supplies the walls and viscera of the pelvis, the buttock, the generative organs, and the medial side of the thigh. It is a short, thick vessel, smaller than the external iliac, and about 4 cm. in length. It arises at the bifurcation of the common iliac, opposite the lumbosacral articulation, and, passing downward to the upper margin of the greater sciatic foramen, divides into two large trunks, an anterior and a posterior. Relations.—It is in relation in front with the ureter; behind, with the internal iliac vein, the lumbosacral trunk, and the Piriformis muscle; laterally, near its origin, with the external iliac vein, which lies between it and the Psoas major muscle; lower down, with the obturator nerve. In the fetus, the hypogastric artery is twice as large as the external iliac, and is the direct continuation of the common iliac. It ascends along the side of the bladder, and runs upward on the back of the anterior wall of the abdomen to the umbilicus, converging toward its fellow of the opposite side. Having passed through the umbilical opening, the two arteries, now termed umbilical, enter the umbilical cord, where they are coiled around the umbilical vein, and ultimately ramify in the placenta. At birth, when the placental circulation ceases, the pelvic portion only of the artery remains patent and constitutes the hypogastric and the first part of the superior vesical artery of the adult; the remainder of the vessel is converted into a solid fibrous cord, the lateral umbilical ligament (obliterated hypogastric artery) which extends from the pelvis to the umbilicus. Peculiarities as Regards Length.—In two-thirds of a large number of cases, the length of the hypogastric varied between 2.25 and 3.4 cm.; in the remaining third it was more frequently longer than shorter, the maximum length being about 7 cm. the minimum about 1 cm. The lengths of the common iliac and hypogastric arteries bear an inverse proportion to each other, the hypogastric artery being long when the common iliac is short, and vice versa. As Regards its Place of Division.—The place of division of the hypogastric varies between the upper margin of the sacrum and the upper border of the greater sciatic foramen. The right and left hypogastric arteries in a series of cases often differed in length, but neither seemed constantly to exceed the other. Collateral Circulation.—The circulation after ligature of the hypogastric artery is carried on by the anastomoses of the uterine and ovarian arteries; of the vesical arteries of the two sides; of the hemorrhoidal branches of the hypogastric with those from the inferior mesenteric; of the obturator artery, by means of its pubic branch, with the vessel of the opposite side, and with the inferior epigastric and medial femoral circumflex; of the circumflex and perforating branches of the profunda femoris with the inferior gluteal; of the superior gluteal with the posterior branches of the lateral sacral arteries; of the iliolumbar with the last lumbar; of the lateral sacral with the middle sacral; and of the iliac circumflex with the iliolumbar and superior gluteal. Branches.—The branches of the hypogastric artery are: From the Anterior Trunk. From the Posterior Trunk. Superior Vesical. Iliolumbar. Middle Vesical. Lateral Sacral. Inferior Vesical. Superior Gluteal. Middle Hemorrhoidal. Obturator. Internal Pudendal. Inferior Gluteal. Uterine
In the Female. Vaginal
The superior vesical artery (a. vesicalis superior) supplies numerous branches to the upper part of the bladder. From one of these a slender vessel, the artery to the ductus deferens, takes origin and accompanies the duct in its course to the testis, where it anastomoses with the internal spermatic artery. Other branches supply the ureter. The first part of the superior vesical artery represents the terminal section of the pervious portion of the fetal hypogastric artery. The middle vesical artery (a. vesicalis medialis), usually a branch of the superior, is distributed to the fundus of the bladder and the vesiculae seminales. The inferior vesical artery (a. vesicalis inferior) frequently arises in common with the middle hemorrhoidal, and is distributed to the fundus of the bladder, the prostate, and the vesiculae seminales. The branches to the prostate communicate with the corresponding vessels of the opposite side. The middle hemorrhoidal artery (a. haemorrhoidalis media) usually arises with the preceding vessel. It is distributed to the rectum, anastomosing with the inferior vesical and with the superior and inferior hemorrhoidal arteries. It gives offsets to the vesiculae seminales and prostate. The uterine artery (a. uterina) springs from the anterior division of the hypogastric and runs medialward on the Levator ani and toward the cervix uteri; about 2 cm. from the cervix it crosses above and in front of the ureter, to which it supplies a small branch. Reaching the side of the uterus it ascends in a tortuous manner between the two layers of the broad ligament to the junction of the uterine tube and uterus. It then runs lateralward toward the hilus of the ovary, and ends by joining with the ovarian artery. It supplies branches to the cervix uteri and others which descend on the vagina; the latter anastomose with branches of the vaginal arteries and form with them two median longitudinal vessels—the azygos arteries of the vagina—one of which runs down in front of and the other behind the vagina. It supplies numerous branches to the body of the uterus, and from its terminal portion twigs are distributed to the uterine tube and the round ligament of the uterus. The vaginal artery (a. vaginalis) usually corresponds to the inferior vesical in the male; it descends upon the vagina, supplying its mucous membrane, and sends branches to the bulb of the vestibule, the fundus of the bladder, and the contiguous part of the rectum. It assists in forming the azygos arteries of the vagina, and is frequently represented by two or three branches. The obturator artery (a. obturatoria) passes forward and downward on the lateral wall of the pelvis, to the upper part of the obturator foramen, and, escaping from the pelvic cavity through the obturator canal, it divides into an anterior and a posterior branch. In the pelvic cavity this vessel is in relation, laterally, with the obturator fascia; medially, with the ureter, ductus deferens, and peritoneum; while a little below it is the obturator nerve.
The anterior branch runs forward on the outer surface of the obturator membrane and then curves downward along the anterior margin of the foramen. It distributes branches to the Obturator externus, Pectineus, Adductores, and Gracilis, and anastomoses with the posterior branch and with the medial femoral circumflex artery. The posterior branch follows the posterior margin of the foramen and turns forward on the inferior ramus of the ischium, where it anastomoses with the anterior branch. It gives twigs to the muscles attached to the ischial tuberosity and anastomoses with the inferior gluteal. It also supplies an articular branch which enters the hip-joint through the acetabular notch, ramifies in the fat at the bottom of the acetabulum and sends a twig along the ligamentum teres to the head of the femur.
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