The upper limb depends on a coordinated vascular and lymphatic network. Arteries deliver oxygenated blood under pressure, veins return blood to the heart and lymphatic vessels return protein-rich interstitial fluid while supporting immune surveillance. Knowledge of these pathways is essential for pulse assessment, wound healing, oedema management, vascular access, dialysis precautions and safe exercise.
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Clinical safety first
Do not massage, compress or exercise an acutely swollen, hot, red or painful limb until serious causes such as infection, arterial compromise or venous thrombosis have been considered. Protect fistulas, grafts, surgical sites and intravenous lines. Compare sides, document objective findings and escalate unexpected vascular changes promptly.
Learning outcomes
- Trace arterial blood flow from the subclavian artery to the hand.
- Describe superficial and deep venous return and clinically important anastomoses.
- Explain superficial/deep lymphatic drainage, axillary node groups and terminal lymph ducts.
- Relate vascular anatomy to pulses, blood pressure, venous access, healing and exercise.
- Recognise red flags for arterial insufficiency, venous thrombosis, infection and lymphoedema.
1. Arterial supply
The arterial pathway is continuous: subclavian → axillary → brachial → radial and ulnar → palmar arches → digital arteries. Arterial branches vary, but the main relationships are predictable enough to guide examination and imaging.
1.1 Subclavian artery
On the right, the subclavian artery arises from the brachiocephalic trunk; on the left, it arises from the aortic arch. It passes laterally over the first rib and becomes the axillary artery at the lateral border of the first rib. The subclavian gives branches to the neck, thoracic wall and scapular region, including the vertebral and thyrocervical systems.
1.2 Axillary artery
The axillary artery extends from the first rib to the inferior border of teres major. Pectoralis minor divides it into three parts.
| Part | Branches | Supply/clinical relevance |
|---|---|---|
| First part, medial to pectoralis minor | Superior thoracic artery. | Upper thoracic wall and first two intercostal spaces. |
| Second part, behind pectoralis minor | Thoracoacromial trunk and lateral thoracic artery. | Pectoral, deltoid and lateral thoracic regions; close to cords of brachial plexus. |
| Third part, lateral to pectoralis minor | Subscapular, anterior circumflex humeral and posterior circumflex humeral arteries. | Scapular and shoulder anastomoses; posterior circumflex artery accompanies axillary nerve. |
1.3 Brachial artery
The brachial artery begins at the lower border of teres major and travels along the medial/anterior arm. It ends in the cubital fossa by dividing into the radial and ulnar arteries. The profunda brachii accompanies the radial nerve in the radial groove; superior and inferior ulnar collateral arteries contribute to elbow anastomoses.
- It is palpable in the medial arm and antecubital fossa.
- It is used for blood-pressure auscultation and is vulnerable in supracondylar humeral fractures.
- Collateral vessels around the elbow help maintain flow during flexion, but do not assume collateral circulation is adequate after trauma.
1.4 Radial and ulnar arteries
| Artery | Course and branches | Clinical landmark |
|---|---|---|
| Radial | Runs along lateral forearm; gives recurrent branch, travels around wrist through anatomical snuffbox and mainly forms deep palmar arch. | Radial pulse at anterior wrist, lateral to flexor carpi radialis tendon. |
| Ulnar | Runs medial forearm with ulnar nerve distally; gives common interosseous artery and mainly forms superficial palmar arch. | Ulnar pulse is deeper and less commonly palpated at wrist. |
| Palmar arches | Superficial and deep arches connect radial and ulnar systems; give common/proper digital arteries. | Support hand perfusion; assess capillary refill, colour and temperature. |
2. Arterial anastomoses and assessment
Anastomoses around the scapula, elbow and wrist provide alternative routes, but their capacity depends on vessel health and the speed of occlusion. Assess perfusion systematically.
- Inspect colour, temperature, skin integrity, hair pattern and nail changes.
- Palpate radial/ulnar pulses where indicated and compare both sides.
- Assess capillary refill, sensation, movement and pain.
- Use Doppler or specialist vascular testing only within training and facility resources.
- Document side, position, time, findings and any exercise-related change.
Sudden pallor, coolness, severe pain, absent pulse, paraesthesia or paralysis is an emergency pattern. Stop treatment and activate the appropriate pathway.
3. Venous drainage
Venous return occurs through superficial veins in subcutaneous tissue and deep veins accompanying arteries. Valves, muscle contraction, respiratory pressure changes and venous tone move blood toward the heart.
3.1 Superficial veins
| Vein | Course | Clinical use |
|---|---|---|
| Dorsal venous network | Receives digital veins on the back of the hand. | Origin of cephalic and basilic pathways; visible with dependency/heat. |
| Cephalic vein | Lateral/radial forearm and arm; ascends in deltopectoral groove and pierces clavipectoral fascia to join axillary vein. | Common venous-access route; protect from injury and recognise variation. |
| Basilic vein | Medial/ulnar hand and forearm; pierces deep fascia and joins brachial veins to form axillary vein near lower teres major. | Used for access and dialysis planning; medial position is close to nerves/arteries after deepening. |
| Median cubital vein | Connects cephalic and basilic veins in cubital fossa. | Common venepuncture site; confirm anatomy and avoid the brachial artery/median nerve beneath. |
| Median antebrachial vein | Variable vein on anterior forearm that may join basilic, cephalic or median cubital vein. | Variation is common; never assume the pattern is identical in every person. |
3.2 Deep veins
Radial and ulnar venae comitantes accompany the arteries and unite as brachial veins. Brachial veins join the basilic vein to form the axillary vein. The axillary vein becomes subclavian at the lateral border of the first rib; subclavian joins internal jugular to form the brachiocephalic vein, and the two brachiocephalic veins form the superior vena cava.
- The upper-limb muscle pump is especially important during movement and gripping.
- Prolonged immobility, dehydration, cancer, surgery and venous injury can increase thrombosis risk.
- Sudden unilateral swelling, warmth, tenderness, colour change or unexplained breathlessness requires urgent medical assessment.
4. Lymphatic drainage
Lymphatic capillaries collect excess interstitial fluid, proteins and cellular debris. Collecting vessels have valves and smooth muscle; lymph is propelled by intrinsic contraction, skeletal-muscle and respiratory pumps, arterial pulsation and external tissue movement.
4.1 Upper-limb lymph pathways
- Superficial lymphatics: accompany superficial veins. Medial-hand/ulnar-side vessels commonly follow basilic pathways toward cubital and humeral (lateral) axillary nodes; lateral/radial-side vessels may follow cephalic pathways toward deltopectoral/infraclavicular and apical nodes.
- Deep lymphatics: accompany deep neurovascular bundles and drain muscles, joints and deep tissues toward axillary nodes.
- Axillary nodes: include humeral/lateral, pectoral/anterior, subscapular/posterior, central and apical groups.
- Terminal drainage: the right upper limb ultimately drains through the right lymphatic duct; the left upper limb through the thoracic duct, both entering the venous angles.
| Axillary node group | Receives | Importance |
|---|---|---|
| Humeral/lateral | Most lymph from upper limb. | First regional filter for limb infection or malignancy. |
| Pectoral/anterior | Anterior thoracic wall and breast; some upper-limb pathways. | Relevant after breast surgery and lymphoedema. |
| Subscapular/posterior | Posterior thoracic wall and scapular region. | Drains posterior tissues and participates in collateral pathways. |
| Central | Receives from pectoral, subscapular and humeral groups. | Passes lymph toward apical nodes. |
| Apical | Receives central and cephalic/infraclavicular routes. | Drains to subclavian trunk and venous angle. |
5. Lymphoedema and physiotherapy
Lymphoedema is abnormal accumulation of protein-rich interstitial fluid after lymphatic overload, damage or obstruction. It may be primary or secondary to surgery, radiotherapy, cancer, infection, trauma, obesity or chronic inflammation.
| Assessment area | What to document |
|---|---|
| History | Onset, surgery/radiation, infection, cancer, trauma, pain, heaviness, tightness and progression. |
| Inspection | Symmetry, skin texture, pitting/non-pitting, folds, papillomatosis, wounds and colour. |
| Measurement | Consistent circumferential points, limb volume method, photographs only with consent. |
| Function | Reach, grip, dressing, work, sleep, self-care and participation. |
| Risk screen | Cellulitis, thrombosis, arterial disease, heart/renal failure, uncontrolled infection and acute inflammation. |
- Education includes skin care, infection prevention, gradual movement and appropriate compression advice by trained clinicians.
- Exercise can support lymph flow through muscle and respiratory pumps but must be dosed to symptoms and comorbidities.
- Manual lymph drainage and compression require specialised assessment; do not apply routine massage to unexplained swelling.
Clinical scenario: swollen arm after breast surgery
A patient develops heaviness and increasing arm circumference weeks after axillary surgery. Inspect the incision and skin, ask about fever and redness, compare measurements and screen function. If cellulitis, thrombosis, acute pain or sudden progression is suspected, seek medical review before compression or exercise. If stable, coordinate a lymphoedema referral and teach skin protection and gentle movement according to the plan.
6. Vascular access and dialysis precautions
- Do not take blood pressure, draw blood or apply tight compression over an arteriovenous fistula/graft unless the renal team directs otherwise.
- Check for a prescribed thrill/bruit only if trained; report absent thrill, pain, swelling, bleeding or colour change urgently.
- Protect PICC lines, cannulas and dressings from traction, kinking and contamination during exercise.
- After vascular surgery or trauma, follow weight-bearing and movement restrictions and monitor distal perfusion.
7. Examination points and revision questions
High-yield points
- Subclavian becomes axillary at the first rib; axillary becomes brachial at the lower border of teres major.
- Brachial divides into radial and ulnar arteries in the cubital fossa.
- Cephalic is lateral; basilic is medial; median cubital connects them in the cubital fossa.
- Most upper-limb lymph drains to axillary nodes; right and left terminal pathways differ.
- Sudden vascular change or unexplained swelling is not a routine physiotherapy finding.
- Trace arterial flow from the subclavian artery to the digital arteries.
- Compare the cephalic, basilic and median cubital veins.
- Describe axillary lymph-node groups and the final ducts.
- Explain the muscle and respiratory pumps in lymph return.
- List signs requiring urgent referral in a swollen or painful upper limb.
- State precautions for an AV fistula, graft, PICC or postoperative axilla.
References for further study
- OpenStax: Circulatory pathways
- NCBI Bookshelf: Brachial artery
- NCBI Bookshelf: Upper-limb veins
- NCBI Bookshelf: Axillary lymph nodes
- TeachMeAnatomy: Upper-limb arteries
- TeachMeAnatomy: Upper-limb veins
Educational note: Vascular and lymphatic assessment and treatment require appropriate training and referral pathways.