Give me a flowchart if nerve supply, arterial supply and venous supply of the upper limb till the hand. Also mention the associated clinicals or related deformities caused by nerve or vessel injury

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Nerve, Arterial & Venous Supply of the Upper Limb - Flowcharts with Clinical Correlates

Part 1 - NERVE SUPPLY (Brachial Plexus → Terminal Nerves → Hand)

Brachial Plexus Schematic

From Gray's Anatomy for Students:

Brachial Plexus - Components in neck and axilla

Brachial Plexus full detail - terminal nerves, cords, divisions, trunks, roots

NERVE SUPPLY FLOWCHART

ANTERIOR RAMI (Roots)
├── C5 ──┐
├── C6 ──┤ → SUPERIOR TRUNK
├── C7 ────→ MIDDLE TRUNK
├── C8 ──┐
└── T1 ──┘ → INFERIOR TRUNK
            (all 3 trunks split into ANTERIOR + POSTERIOR divisions)

ANTERIOR DIVISIONS → LATERAL & MEDIAL CORDS
POSTERIOR DIVISIONS → POSTERIOR CORD

          ┌──────────────────────────────────────────────────────────┐
          │             3 CORDS (around 2nd part of axillary artery) │
          └──────────────────────────────────────────────────────────┘
                 │                    │                   │
          LATERAL CORD          MEDIAL CORD         POSTERIOR CORD
          (C5, C6, C7)          (C8, T1)             (C5-T1)
                │                    │                   │
     ┌──────────┤          ┌─────────┤          ┌────────┤
     │          │          │         │          │        │
  Lateral    Medial      Medial    Ulnar     Axillary  Radial
  pectoral   root of     root of   nerve     nerve    nerve
  nerve      median      median
             nerve       nerve
                \         /
                 MEDIAN NERVE
                 (C5, C6, C7, C8, T1)

LATERAL CORD (C5, C6, C7) Branches:

Nerve	Root	Muscles Supplied	Sensory Area
Lateral pectoral nerve	C5-C7	Pectoralis major	-
Musculocutaneous nerve	C5-C7	Coracobrachialis, Biceps brachii, Brachialis	Lateral forearm (as lateral cutaneous n. of forearm)
Lateral root of Median	C5-C7	(joins medial root)	-

MEDIAL CORD (C8, T1) Branches:

Nerve	Root	Muscles Supplied	Sensory Area
Medial pectoral nerve	C8-T1	Pectoralis minor + major	-
Medial cutaneous n. of arm	T1	-	Medial arm
Medial cutaneous n. of forearm	C8-T1	-	Medial forearm
Medial root of Median nerve	C8-T1	(joins lateral root)	-
Ulnar nerve	C8, T1	Flexor carpi ulnaris, medial half FDP, hypothenar muscles, all interossei, 3rd+4th lumbricals, adductor pollicis	Medial 1.5 fingers, medial hand

POSTERIOR CORD (C5-T1) Branches:

Nerve	Root	Muscles Supplied	Sensory Area
Superior subscapular n.	C5-C6	Subscapularis (upper)	-
Thoracodorsal n.	C6-C8	Latissimus dorsi	-
Inferior subscapular n.	C5-C6	Subscapularis (lower), Teres major	-
Axillary nerve	C5-C6	Deltoid, Teres minor	Lateral arm (regimental badge area)
Radial nerve	C5-T1	Triceps, Brachioradialis, all wrist/finger extensors (via posterior interosseous nerve)	Posterior arm, forearm, lateral 3.5 fingers dorsally

TERMINAL NERVES TO THE HAND (flowchart)

MEDIAN NERVE (C5-T1)
├── Arm: no muscular branches (only vascular to brachial artery)
├── Forearm: Pronator teres, FCR, Palmaris longus, FDS
│           → Anterior Interosseous N.: Lat. half FDP, FPL, Pronator quadratus
├── At wrist: passes through CARPAL TUNNEL under flexor retinaculum
└── Hand:
    ├── Recurrent (thenar) branch → ABductor pollicis brevis, Opponens pollicis, Flexor pollicis brevis
    ├── 1st & 2nd lumbricals
    └── Sensory: Thumb, index, middle, lateral ½ ring finger (palmar); same digits nail beds

ULNAR NERVE (C8-T1)
├── Arm: no muscular branches
├── Elbow: passes posterior to medial epicondyle (cubital tunnel)
├── Forearm: Flexor carpi ulnaris, medial half FDP (ring + little)
├── Wrist: passes through GUYON'S CANAL (ulnar canal)
└── Hand:
    ├── Deep branch: hypothenar muscles (AbDM, FDM, OpDM)
    │              → all interossei (4 dorsal + 3 palmar), 3rd & 4th lumbricals, Adductor pollicis
    └── Sensory: Little finger, medial half ring finger (palmar + dorsal)

RADIAL NERVE (C5-T1)
├── Arm (in radial groove): Triceps, Brachioradialis, ECRL
├── Divides at lateral epicondyle into:
│   ├── Superficial radial n. (sensory): Dorsum of lateral 3.5 fingers + 1st web space
│   └── Posterior interosseous n. (deep motor branch):
│       → ECRB, Supinator, ED, EDM, ECU, APL, APB, EPL, EPB, EIP
└── No intrinsic hand muscles supplied

Part 2 - ARTERIAL SUPPLY (Subclavian → Hand)

Arterial supply of forearm and hand (Netter illustration from Sabiston)

ARTERIAL SUPPLY FLOWCHART

SUBCLAVIAN ARTERY
    │
    │ (crosses 1st rib, passes lateral border of 1st rib)
    ▼
AXILLARY ARTERY (1st–3rd parts, relative to pectoralis minor)
    ├── 1st part: Superior thoracic artery
    ├── 2nd part: Thoracoacromial, Lateral thoracic
    ├── 3rd part: Subscapular, Anterior + Posterior circumflex humeral arteries
    │
    │ (at lower border of teres major)
    ▼
BRACHIAL ARTERY
    ├── Profunda brachii (deep brachial) → radial groove → elbow anastomosis
    ├── Superior ulnar collateral artery
    ├── Inferior ulnar collateral artery
    │
    │ (bifurcates ~1 cm distal to elbow crease / neck of radius)
    ├──────────────────┬────────────────────────
    │                  │
RADIAL ARTERY         ULNAR ARTERY
    │                      │
    ├── Radial recurrent    ├── Anterior ulnar recurrent
    ├── Muscular branches   ├── Posterior ulnar recurrent
    ├── Palmar carpal       ├── Common interosseous artery
    ├── Superficial palmar  │       ├── Anterior interosseous a.
    │   branch              │       └── Posterior interosseous a.
    ├── Dorsal carpal       ├── Muscular branches
    │   branch              ├── Palmar carpal branch
    │                       └── Dorsal carpal branch
    │
    │ (at wrist, radial travels through "anatomical snuffbox")
    ▼
DEEP PALMAR ARCH (mainly RADIAL) ──── deep branch of ULNAR
    ├── Palmar metacarpal arteries (to common palmar digitals)
    └── Princeps pollicis → thumb
        Radialis indicis → index (radial side)

SUPERFICIAL PALMAR ARCH (mainly ULNAR) ──── superficial branch of RADIAL
    ├── Common palmar digital arteries (3)
    └── → Proper palmar digital arteries (radial + ulnar side of each finger)

Key summary:

Superficial palmar arch = completed mainly by ulnar artery + superficial branch of radial
Deep palmar arch = completed mainly by radial artery + deep branch of ulnar
Each digit receives 2 proper digital arteries (one on each side of the flexor sheath)

Part 3 - VENOUS DRAINAGE (Hand → Axilla)

VENOUS DRAINAGE FLOWCHART

HAND
    │
    ├── Dorsal venous network of hand
    │       └── Digital veins → dorsal metacarpal veins → dorsal venous arch
    │
    │──────────────────────────────────────
    ▼                          ▼
CEPHALIC VEIN            BASILIC VEIN
(radial/lateral side)    (ulnar/medial side)
    │                          │
    │ runs lateral forearm      │ runs medial forearm
    │ → passes antecubital      │ → passes medially
    │   fossa                   │
    │                   MEDIAN CUBITAL VEIN
    │                (connects cephalic ↔ basilic
    │                  at antecubital fossa —
    │                  commonest venipuncture site)
    │                          │
    │ continues up lateral      │ pierces deep fascia
    │ arm                       │ at mid-arm
    │                           ▼
    │                    AXILLARY VEIN
    │                    (joins at lower axilla)
    │──────────────────────────▶│
                         AXILLARY VEIN
                               │
                               ▼
                        SUBCLAVIAN VEIN → BRACHIOCEPHALIC VEIN

DEEP VENOUS SYSTEM:
    Venae comitantes (2 per artery) accompany every major artery
    → Radial vv., Ulnar vv., Brachial vv. → drain into axillary vein
    (These run alongside arteries under deep fascia)

Part 4 - CLINICAL CORRELATES & DEFORMITIES

A. NERVE INJURIES

Nerve	Common Site/Cause of Injury	Deformity / Deficit	Clinical Test
Axillary nerve (C5-C6)	Fracture surgical neck of humerus; anterior shoulder dislocation	- Deltoid paralysis → inability to abduct arm beyond 15° - Loss of sensation "regimental badge" area (lateral arm)	Test deltoid contraction; check lateral arm sensation
Radial nerve - Axilla	Crutch palsy; fracture/dislocation upper humerus	Complete wrist drop + loss of triceps reflex + sensory loss posterior arm/forearm	Can't extend wrist or MCP joints
Radial nerve - Radial groove (mid-humerus)	Humeral shaft fracture; "Saturday night palsy" (arm draped over chair after intoxication)	Wrist drop (triceps spared, triceps reflex preserved); sensory loss dorsum of hand/lateral 3.5 fingers	Test brachioradialis (elbow flexion in mid-prone = tests above radial groove)
Posterior interosseous nerve	Radial head fracture/dislocation; arcade of Frohse entrapment	Finger drop without wrist drop (ECRL spared); no sensory loss	MCP extension loss; wrist deviates radially
Median nerve - Elbow	Supracondylar fracture of humerus (children); anterior interosseous nerve syndrome	"Hand of Benediction" (high lesion): on making a fist, index + middle can't flex (FDS/FDP fail) → looks like a blessing hand - Anterior interosseous n.: can't flex distal phalanx of thumb + index ("O-sign" negative)	OK sign test; resisted pronation
Median nerve - Wrist (Carpal Tunnel Syndrome)	Carpal tunnel syndrome (most common compressive neuropathy)	Ape hand deformity (thenar wasting, thumb cannot oppose); sensory loss lateral 3.5 fingers and palm; nocturnal pain/tingling (Phalen's/Tinel's positive)	Phalen's test, Tinel's sign, thenar wasting
Ulnar nerve - Elbow (cubital tunnel)	Medial epicondyle fracture; prolonged elbow flexion/leaning; tardy ulnar palsy	Claw hand (ring + little fingers): MCP hyperextension + IP flexion (more pronounced = low lesion at wrist = "ulnar paradox") - Wasting of hypothenar, interossei, 1st dorsal interosseous	Froment's sign (adductor pollicis); card test (palmar interossei); interosseous wasting
Ulnar nerve - Wrist (Guyon's canal)	Hook of hamate fracture; cyclist's palsy	Intrinsic hand paralysis (hypothenar + interossei), but FCU + medial FDP spared; sensory loss ulnar 1.5 fingers	Same as above but FCU intact
Upper brachial plexus (C5-C6) - Erb-Duchenne palsy	Excessive depression of shoulder/lateral neck traction; birth injury; motorcycle fall	"Waiter's tip" / "Policeman accepting a tip": arm internally rotated, extended at elbow, pronated; deltoid, biceps, brachialis, brachioradialis, supinator paralysed; sensory loss lateral arm and forearm	Clinical inspection; absent biceps + brachioradialis reflexes
Lower brachial plexus (C8-T1) - Klumpke's palsy	Forcible hyperabduction of arm (falling person grabs overhead object; breech delivery with arms overhead)	Claw hand with intrinsic paralysis (combined median + ulnar); sensory loss medial forearm + hand + medial 1.5 fingers; Horner's syndrome (ptosis, enophthalmos, miosis, anhidrosis) if T1 sympathetics involved	Intrinsic wasting; check for Horner's

B. VASCULAR INJURIES / CLINICAL POINTS

Vessel	Injury/Condition	Clinical Significance
Axillary artery	Anterior shoulder dislocation; proximal humeral fractures	Limb ischemia; axillary nerve often co-injured
Brachial artery	Supracondylar fracture (children); anterior elbow dislocation; Volkmann's ischemic contracture	Volkmann's contracture: forearm compartment syndrome from brachial artery compromise → ischemic contracture of flexors → wrist flexed, fingers semiflexed/extended at IPs
Radial artery	Wrist lacerations; radial artery cannulation (Allen's test required)	Allen's test: compresses both radial + ulnar → release one to check palmar arch patency
Ulnar artery	Hook of hamate fracture; hypothenar hammer syndrome	Thrombosis → ischemia of ulnar digits; check Allen's test
Palmar arches	Incomplete arch variants (~20%); radial artery harvesting for bypass	If incomplete arch, radial artery harvest may compromise thumb/index blood supply
Cephalic/Basilic veins	IV access, PICC lines, venipuncture	Median cubital vein over antecubital fossa is preferred IV access; basilic vein used for PICC line placement

Quick Memory Aids

RADIAL nerve injured → Wrist drop (Saturday night palsy, spiral groove fracture)
MEDIAN nerve injured at wrist → Ape hand (thenar wasting, no opposition)
MEDIAN nerve injured at elbow → Benediction hand (on making fist)
ULNAR nerve injured → Claw hand (ring + little worst affected)
Ulnar paradox: claw MORE pronounced with LOW ulnar lesion (at wrist) because FDP to ring/little is intact and pulls strongly
ERB's palsy = C5-C6 = Waiter's tip
KLUMPKE's palsy = C8-T1 = Claw hand + Horner's
Brachial artery injury at elbow → Volkmann's ischemic contracture

Sources: Gray's Anatomy for Students (9780323934237); S. Das Manual on Clinical Surgery 13th Ed (9788190568104); Sabiston Textbook of Surgery (9780443124341); General Anatomy & Musculoskeletal System - THIEME Atlas (9781626237186)

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