The Coexistence of an Incomplete Superficial Palmar Arch and a Berrettini Anastomosis: A Case Report.

OBJECTIVE: The aim of this study is to present a relatively rare case of the coexistence of an incomplete superficial palmar arch and a Berrettini anastomosis, identified in a cadaveric specimen, and further discuss the potential clinical implications of such anatomical variations. CASE REPORT: The variation was found in the left hand of a formalin-fixed male cadaver of Greek origin, that was dissected under an operating microscope (×4, ×10 magnification) in our Anatomy Department. In the specimen, we found an incomplete superficial palmar arch, formed only by the superficial branch of the ulnar artery, and a Type 1 Berrettini Anastomosis, originating from the ulnar nerve and joining a branch of the median nerve. CONCLUSION: To avoid iatrogenic damage and permanent loss of sensation, hand surgeons and microsurgeons should be aware of the presence of a BA, and the potential coexistence of this variation with vascular abnormalities in the hand that may complicate surgical procedures.

Bilateral absence of the deep brachial artery.

The aim of the following study was to present and comprehensively describe a case of a bilateral absence of the deep brachial artery (DBA). Furthermore, its embryology and clinical significance will also be discussed. During routine dissection, a 71-year-old male cadaver with a bilateral abnormality in the DBA and its branches was found. The first branch of the brachial artery (BA) was found to be the radial collateral artery, which passed behind the radial nerve. Furthermore, the middle collateral artery originated distal to the radial collateral artery and gave off first a singular, minor muscular branch and then the superior ulnar collateral artery. Later, the preceding nutrient arteries of the humerus and the deltoid branch consecutively branched off from the middle collateral artery. Subsequently, the middle ulnar collateral artery, the inferior ulnar collateral artery, the deltoid artery, the radial artery, and the ulnar artery branched off from the BA, as adapted in the current knowledge regarding the anatomy of the upper extremity. Furthermore, detailed measurements of the distances between the mentioned arteries were carried out. In the present study, a bilateral absence of the DBA was demonstrated. Meta-analysis focusing on the anatomy of this artery has shown how variable its characteristics are. However, our case report is the first in the literature to present this extremely rare variation. Having adequate knowledge regarding the anatomy of the arteries of the proximal arm is of immense importance when performing orthopaedic and reconstructive surgeries in this area.

Variaciones anatómicas de las arterias radial y ulnar en miembros superiores plastinados / Anatomical variations of radial and ulnar arteries in plastinated upper limbs

Los avances en el área de la salud, con el desarrollo de nuevos procedimientos diagnósticos y quirúrgicos, requieren un conocimiento cada vez más preciso de la anatomía humana. La difusión de la disposición variable de la anatomía resulta primordial no sólo en el campo de la especialización o el postgrado, sino por sobre todo, en el pregrado, desde donde se formarán los especialistas que luego desarrollarán esas nuevas prácticas clínicas y quirúrgicas que requerirán una sólida formación anatómica. Es por esto que la aplicación correcta de técnicas anatómicas en las muestras anatómicas es fundamental para que esta enseñanza en el pregrado pueda desarrollarse de manera eficiente, teniendo la plastinación un rol fundamental en este sentido. El objetivo de este trabajo consistió en dar a conocer el hallazgo de variaciones anatómicas arteriales en los miembros superiores de una muestra humana sometida al proceso de plastinación para fomentar, por un lado, la importancia del conocimiento anatómico en el pregrado, el postgrado y las especialidades, como así también la relevancia de la preservación a largo plazo de material biológico para la difusión continua de la anatomía.

SUMMARY: Advances in the area of health with the development of new diagnostic and surgical procedures require an increasingly precise knowledge of human anatomy. The diffusion of the variable arrangement of anatomy is essential not only in the field of specialization or postgraduate, but above all, in the undergraduate, from where the specialists will be trained who will later develop these new clinical and surgical practices that will require a solid anatomical background. This is why the correct application of anatomical techniques in anatomical samples is essential for this undergraduate teaching to be developed efficiently, plastination having a fundamental role in this regard. The aim of this work was to report the discovery of anatomical variations in the upper limbs of a human sample subjected to the plastination process to promote, on one hand, the importance of anatomical knowledge in undergraduate, postgraduate and specialties, as well as the relevance of long- term preservation of biological material for the continued dissemination of anatomy.

Anatomical variations of the superficial palmar arch in human fetuses.

The superficial palmar arch is an important anatomical structure that contributes to the arterial supply of the palmar side of the hand in the upper extremity. However, there is limited information on the embryological morphological structure of the superficial palmar arch in the literature. We studied the types of the superficial palmar arch and determined their variations by dissecting 80 upper extremities of 40 formalin-fixed human fetuses (19 males, 21 females) 18-37 weeks of age. The types and variations of the superficial palmar arch were examined, and the median artery was imaged. The superficial palmar arch type was complete in 58 hands (72.5%) and incomplete in 22 hands (27.5%). The complete group consisted of type A (47.5%), type B (16.25%), type C (3.75%), type D (1.25%), and type E (3.75%). On the other hand, the incomplete group consisted of type F (15%), type G (8.75%), type H (2.5%), and type I (1.25%). A median artery that originated from the ulnar artery and passed through the carpal tunnel during its course was detected in two hands (2.5%). Knowledge of the superficial palmar arch variations will contribute to hand microsurgery particularly in vascular graft and free flap application interventions for arterial bleeding in the palmar region.

Evaluación de las relaciones entre la rama palmar profunda de la arteria ulnar y el ramo profundo del nervio ulnar en la región palmar / Evaluation of the relationship between the deep palmar branch of ulnar artery and the deep branch of the ulnar nerve in the palmar region

RESUMEN: Nos motivó esta presentación los hallazgos observados en la sala de disección sobre las relaciones de la rama palmar profunda de la arteria ulnar y el ramo profundo del nervio ulnar, las diferentes disposiciones de esta rama, el cruzamiento, cuando existe, entre ambos elementos y las pocas referencias sobre el tema, todo con miras a favorecer el abordaje profundo de la palma de la mano y contribuir al conocimiento del área en donde se practican las neurotomías del ramo profundo del nervio ulnar y/ o sus ramas.

SUMMARY: We are motivated by the findings observed in the dissection room on the relationship between the deep palmar branch of ulnar artery and the deep branch of ulnar nerve, the different dispositions of this branch, the crossing, when it exists, between both elements and the few references on the subject, all with a view to favoring the deep approach to the palm and contributing to the knowledge of the area where neurotomies of the deep branch of ulnar nerve and/or its branches are performed.

Recognition of Laceration of an Aberrant Superficial Ulnar Artery With Intraoperative Allen Test and Primary Repair.

There are variations in anatomy that may alter the vasculature of an individual. This case report demonstrates an abnormal branching pattern of a lacerated ulnar artery and its successful surgical repair. Without proper identification, anatomical variations can negatively impact a trauma patient.

Anatomical variations of the superficial ulnar artery: case series observed on historical specimens prepared by Ludwik Karol Teichmann.

BACKGROUND: This report presents a series of cases representing variant origin and course of the ulnar artery, namely the superficial ulnar artery (SUA), observed during the review of collection of historical specimens prepared in the 19th century by the prominent Polish anatomist Ludwik Karol Teichmann and his collaborators, exhibited in the Anatomy Museum of Jagiellonian University Medical College. RESULTS: Three distinct variants of the SUA were found on anatomical specimens of the upper limb with arteries injected by using Teichmann's method. In case no. 1, the SUA originated from the brachial artery slightly above the interepicondylar line of the humerus. This aberrant vessel gave off the common interosseous artery in the upper half of the cubital fossa and then ran superficially to the bicipital aponeurosis and over the muscles arising from the medial epicondyle of the humerus. The cases no. 2 and 3 involved two similar variants of the superficial artery in which the common interosseous artery arose from the radial artery. In the unique case no. 4, the SUA arose from the radial artery. CONCLUSIONS: The SUA shows diverse anatomy regarding its topography and blood supply territory. Orthopaedic, hand, and plastic surgeons should be aware of anatomic variations of the SUA both in planning and in conducting surgeries of the upper limb.

Flow-Through Arterialized Posterior Interosseous Nerve Grafts for Digital Neurovascular Bundle Defects: Anatomical Study.

BACKGROUND: Digital neurovascular bundle defects are often encountered during crush or avulsion injuries and require complex reconstruction. Use of an arterialized nerve graft (neurovascular graft) serving both as an interpositional arterial conduit and as a nerve graft could be a reconstructive option in these cases. In this anatomical study, the authors aimed to describe a neurovascular graft of the posterior interosseous nerve and a branch of the anterior interosseous artery for neurovascular bundle reconstruction of the fingers. METHODS: Eighteen forearms were injected with red latex in order to collect the anatomical characteristics of the posterior interosseous nerve and the artery running near it. RESULTS: In all cases, the posterior interosseous nerve was followed by a branch of the anterior interosseous artery: the distal dorsal branch of the anterior interosseous nerve. The origin of this artery was proximal to the radiocarpal joint, at an average of 56.5 ± 11.1 mm. The proximal and distal diameters of the branch of the anterior interosseous artery were 1.6 ± 0.2 and 1.1 ± 0.2 mm, respectively. The proximal and distal diameters of the posterior interosseous nerve were 1.2 ± 0.3 mm and 1.1 ± 0.3 mm, respectively. CONCLUSIONS: These results show that a potential free neurovascular graft using the posterior interosseous nerve as nerve graft and the anterior interosseous artery as an arterial bypass to reconstruct both the nerve and arterial tree of the finger could be a useful approach. The authors speculate that this graft could be used to reconstruct the neurovascular bundle of amputated or devascularized digits.

Aspectos morfológicos del arco palmar superficial en individuos adultos mayores / Morphological aspects of the surface palmar arch in old adult individuals

RESUMEN: El objetivo de este trabajo consiste en el análisis de la posición del arco palmar superficial en la palma de la mano, con identificación del origen, forma de disposición, anastomosis presentes y terminación del mismo, proporcionando la experiencia propia y comparándola con los referentes del área, sin llevar adelante una comparación de clasificaciones, sino por el contrario, buscando analizar la información desde un punto de vista clínico-quirúrgico, demostrando la importancia del conocimiento de la anatomía real del arco palmar superficial al momento de abordar la anatomía vascular de la mano en todo tipo de situaciones patológicas.

SUMMARY: The objective of this work consists in the analysis of the position of the superficial palmar arch in the palm of the hand, with identification of the origin, form of disposition, present anastomosis and termination of the same, providing the own experience and comparing it with the referents of the area, without carrying out a comparison of classifications, but on the contrary, seeking to analyze the information from a clinical-surgical point of view, demonstrating the importance of knowledge of the real anatomy of the superficial palmar arch when addressing the vascular anatomy of the hand in all kinds of pathological situations.

The ulnar nerve is surrounded by the tendon expansion of the flexor carpi ulnaris muscle at the wrist: an anatomical study of Guyon's canal.

The ulnar tunnel (Guyon's canal) is an osseofibrous tunnel for the ulnar nerve and artery. With regard to the proximal palmar wall (palmar carpal ligament) of the ulnar tunnel, detailed anatomical data such as attachment sites, fibrous continuity to surroundings, and variations have not been clearly described. In this study, topology of Guyon's canal was examined, especially to the palmar side of the ulnar nerve, focusing on the continuity of tendinous structures to reveal a more detailed constitution of Guyon's canal. The palmar wall of Guyon's canal was investigated in 113 forearms of 57 cadavers. The dorsal wall of the canal was also investigated in 25 subjects. The ulnar nerve passed lateral to the pisiform and the flexor carpi ulnaris tendon. At the level of the pisiform, except for one, the ulnar nerve passed dorsal to the aponeurosis expanding from the flexor carpi ulnaris tendon and the periosteum of the pisiform, and this aponeurosis laterally merged with the palmar aspect of the flexor retinaculum. Moreover, the ulnar nerve ran palmar to the pisohamate ligament and the flexor retinaculum extended from the same tendon. The present study suggests that the aponeurosis of palmar side to the ulnar nerve connected with the flexor carpi ulnaris tendon, the periosteum of the pisiform, and the palmar surface of the flexor retinaculum. These findings indicate that the ulnar nerve is surrounded by the aponeurotic portion expanding from the flexor carpi ulnaris tendon at the wrist, which is a new insight of Guyon's canal.

Is the dorsal vascular system sufficient to vascularize the entire teguments of the thumb?

PURPOSE: Simultaneous lesions of both proper digital arteries of the thumb are common in hand trauma surgery. The purpose of this anatomical study was to determine if the dorsal arterial network could be sufficient to ensure the vascularization of the thumb skin sheath. METHODS: We carried out a cadaveric study on 22 hands. The ulnar and radial proper digital arteries of the thumb were ligated at the base of the first phalanx. Red dye was injected into the radial artery and blue dye into the ulnar artery at the wrist level. Visual evaluation of skin staining and systematic photographs was done at 1, 3 and 10 min after injection of dyes. RESULTS: Staining of the thumb sheath was obtained in 100% of the dissections and complete in 91.91% of cases. Staining originated from mixed radial and ulnar artery origins in 81.82% of cases. It was incomplete in 9.09% of cases with a missing on the dorsoradial edge of the proximal phalanx. In one dissection, the whole hand skin was only stained red, and in another dissection only stained blue. CONCLUSION: The dorsal vascular network ensures the substitution of the skin vascularization in more than 90% of cases when ligating the proper digital arteries of the thumb. A clinical impression of good skin vascularization after injury of both proper digital arteries might lead the surgeon not to perform systematic revascularization, but the risk of variable damages of adjacent tissues due to an interruption of one major arterial system requires a palmar arterial anastomosis whenever possible.

Multiple arterial variations in the upper limb: description and clinical relevance.

Although arterial variations in the upper limb are usually found during anatomical dissections and clinical practice, multiple arterial variations associated with nervous variations along the limb is rare and clinically relevant. This paper described a combined anatomical variation involving the neurovasculature in the upper limb. A left upper limb dissection of a male cadaver with approximately 50-60 years of age, fixed in 10% formalin, was performed. During the dissection was observed, the brachial artery ending in the middle third of the arm in three branches: a nutritional branch for the biceps brachii muscle, a "lateral brachial artery" and a "medial brachial artery", which became, after unusual paths crossing over the cubital fossa, the ulnar artery and the radial artery, respectively. Radial and ulnar artery demonstrated several unusual anastomotic branches, respectively, and an anastomotic arch around the biceps brachii muscle tendon. Such combined anatomical variation is unique and relevant for clinical and surgical practice.

Arco palmar superficial: redefiniendo un clásico / Superficial palmar arch: redefining a classic

El arco palmar superficial (APS) resulta de la unión de la arteria ulnar y la rama palmar superficial de la arteria radial. Por su convexidad nacen las arterias digitales comunes. Esta descripción es la única que distintos autores han tomado como válida, por lo que se espera encontrarla durante la disección con mayor frecuencia. Esto no ha sido verificado en nuestra experiencia. Nos proponemos llevar a cabo una revisión de la descripción del APS poniéndolo en contraposición con las disecciones realizadas. Se disecaron y analizaron 61 manos cadavéricas. Estudio del arco palmar superficial: Variante clásica del APS: 23 casos (37,7 %). Variante no clásica del APS: 15 casos (24,6 %). Tipo A: 13 casos (86,7 %). Anastomosis entre arterias ulnar y metacarpiana dorsal del primer espacio. Tipo B: 2 casos (13,3 %). Anastomosis entre arterias ulnar y satélite del nervio mediano. Ausencia del arco: 23 casos (37,7 %) Tipo A: 19 casos (82,6 %). La arteria ulnar es la única estructura en el plano del APS. Tipo B: 3 casos (13 %). La arteria ulnar y la rama palmar superficial de la arteria radial están en el plano del APS sin anastomosarse entre sí. Tipo C: 1 caso (4,4 %). La arteria ulnar y la satélite del nervio mediano están en el plano del APS sin anastomosarse. Estudio de la quinta arteria digital palmar común: La quinta arteria digital palmar común se originó de las distintas variantes en 41 casos (67,2 %). Recomendamos al momento de la disección considerar que: la variante clásica no es la más frecuente de hallar; la ausencia del arco se verifica en el mismo porcentaje que la variante clásica; incluso cuando se comprueba la presencia del APS, el porcentaje de la variante no clásica es contundente; la quinta arteria digital palmar común es una rama colateral constante del APS.

The superficial palmar arch (SPA) is formed by the union of the ulnar artery and the superficial palmar branch of the radial artery. From its convexity four branches emerge, known as the common palmar digital arteries. We propose to carry out a review of the description of the SPA in contrast to the dissections carried out. Sixty-one hands were dissected and studied. Analysis of the SPA: Classic variant of the SPA: 23 cases (37.7 %). Nonclassic variant of the SPA: 15 cases (24.6 %). Type A: 13 cases (86.7 %). Anastomosis between the ulnar artery and the first dorsal metacarpal artery. Type B: 2 cases (13.3 %). Anastomosis between the ulnar artery and the satellite artery of the median nerve. Absence of the arch: 23 cases (37.7 %) Type A: 19 cases (82.6 %). The ulnar artery is the only one present in the plane of the SPA. Type B: 3 cases (13 %). The ulnar artery and the superficial palmar branch of the radial artery are in the plane of the superficial palmar arch, there is no anastomosis between them. Type C: 1 case (4.4 %). The ulnar artery and the satellite artery for the median nerve are in the plane of the SPA, there is no anastomosis between them. Analysis of the fifth common palmar digital artery: The fifth common palmar digital artery originates from the different variants in 41 cases (67.2 %). Based on the results, we recommend at the time of dissecting consider that: The classic variant is not the most frequent to find. The absence of the arch is verified in the same percentage rate as the classic variant. Even when the SPA is present, the percentage rate of the non-classic variant is significant. The fifth common palmar digital artery is a constant collateral branch of the superficial palmar arch.

Description and analysis of the dynamic and morphological flow pattern of the main arteries of the wrist and hand in a healthy spanish population. / Descripción y análisis del patrón de normalidad de flujo dinámico y morfológico de las arterias principales de la muñeca y mano en población sana española.

BACKGROUND AND AIM: The vascular anatomy of the hand has already been widely described macroscopically. However, there are very few papers that study the pattern of normality of in vivo vascularisation that describe and analyse the main arteries of the hand. The aim of this paper was to carry out a study to serve as a reference for the normal values of size and flow of the radial and ulnar artery at the level of the wrist, and the digital radial and ulnar arteries at the level of the fingers. MATERIAL AND METHOD: A descriptive observational cross-sectional study on 200 hands in 100 healthy volunteers aged between 20-30years. Doppler-colour ultrasound was performed on the ulnar and radial arteries in the wrist, as well as on the radial and ulnar digital arteries in each finger. Once the measurements had been taken, a general comparative analysis was performed also taking laterality, dominance and gender into account. RESULTS: It was observed that the radial artery is larger in size than the ulnar at wrist level, however, it was the ulnar artery that showed flow dominance at this level. At finger level, the arteries are greater in size and flow in the areas of the fingers more protected from injury (digital ulnar artery in the first three and radial artery in the fourth and fifth digits).

Anatomical study of the anterior neurovascular interval approach to the elbow: observation of the neurovascular interval and relevant branches.

BACKGROUND: The aim of the study was to investigate the anatomy of the anterior nerve and artery of the elbow joint to provide reference on the relevant surgical approach to the elbow joint, and determine a simple better surgical approach for the treatment of part of the fractures of the elbow joint. MATERIALS AND METHODS: The upper extremities of 10 adult cadavers fixed by formaldehyde and perfused with red latex in the artery were observed to investigate the anatomic structure of the anterior approach to the elbow joint. From the clearance of the brachioradialis and pronator teres muscle to the approach of the neurovascular interval, we observed the states of the median nerve, the brachial, radial and ulnar arteries, and its branches through anatomical layers and measurement methods. RESULTS: Through the anterior neurovascular interval approach to the elbow, nerve and artery can be protected, and the anterior structures of the elbow, such as the ulna coronoid process, humeroulnar joint and trochlea of the humerus, can be exposed. CONCLUSIONS: This study demonstrates that the anterior anatomical structure of the elbow joint including the trochlea of the humerus, coronoid process of the ulna and the front capsule of the elbow can be exposed through the anterior neurovascular approach to the elbow.

Safe zones in volar portals for wrist arthroscopy, evaluation of central portal : a cadaveric study.

The purpose of this cadaveric study is to determine safe zones utilizing volar portals for wrist arthroscopy, by quantitatively describing the neurovascular relationships of a volar radial and a volar ulnar wrist arthroscopy portals in comparison with those of a newly described volar central portal (7) , considering the advantages in visualization of volar portals for wrist arthroscopy over the standard dorsal (19) . The neurovascular structures and the tendons of nine frozen human cadaveric upper limbs were exposed, while the aforementioned volar portal sites were pointed out with pins. The horizontal distance between the portals and the closest neurovascular branch or tendon was measured with a digital caliper, followed by statistical analysis of the data. The median interquartile range distances from portals to structures at risk were measured and safe zones around each portal were established. This study provides a safe approach to the volar radial and ulnar aspects of the radiocarpal and midcarpal joints, while volar radial and ulnar portals should be considered for inclusion in the arthroscopic examination of any patient with radial and ulnar sided wrist pain respectively (17,18) . Regarding the volar central portal, it is reproducible, safe and both the above joints can be inspected through one single incision (7) .

Branches of ulnar artery in human fetuses: anatomical and morphometric study.

PURPOSE: This study was conducted to demonstrate morphological pattern of the ulnar artery and to evaluate morphometrically its anatomical branching pattern in human fetuses. METHODS: Branching pattern of ulnar artery was evaluated on 121 upper limbs of dissected 63 of formalin-fixed fetus cadavers with gestational age ranging from 17 to 40 weeks. In order to obtain second and third trimester data, according to their gestational age, two groups were determined. RESULTS: In 79 of all 121 upper limbs (65%) ulnar artery gave anterior and posterior ulnar recurrent arteries as separate branches. In this study frequency of presence of a median artery was 46.28% among total examined 121 upper limbs. Median arteries originated from ulnar artery (3.57%) and from the common interosseous artery (53.57%) and anterior interosseous artery (42.85%). Mean distances of the measured parameters were demonstrated according to the gestational age and differences between group I (second trimester) and group II (third trimester). No statistical difference for groups was observed for gender and between right and left sides. CONCLUSIONS: Ulnar artery shows predictable patterns during second and third trimester of fetal period and can be suitable access effective alternative for diagnostic and therapeutic coronary interventions. Persistent median artery is important variation and knowledge of its incidence is important for diagnostic difficulties and also during awareness of its injury during surgical approaches.

A cadaveric study for the volar needle approach to the pronator quadratus using the palmaris longus tendon landmark.

INTRODUCTION: Our aim in this work was to determine the safety and accuracy of the volar approach to the pronator quadratus (PQ) through cadaver dissection. METHODS: Twenty upper limbs from 10 fresh cadavers were investigated. At the level 3 cm proximal to the ulnar styloid process (USP), a needle was inserted just medial to the palmaris longus (PL) tendon. Distances of the median nerve (MN) and ulnar artery (UA) from the needle insertion point (IP) were measured using ultrasonography and cadaver dissection. RESULTS: The PQ was located at a depth of 10.8-19.9 mm from the skin and had a median thickness of 9.1 mm, measured 3 cm proximal to the USP. The median distances of the MN and UA from the IP were 7.6 and 13.4 mm, respectively. DISCUSSION: A needle insertion for the volar approach to the PQ was safe at 3 cm proximal to the USP, just medial to the PL tendon.

Newer insights in the anatomy of superficial palmar arch.

PURPOSE: The purpose of the study is to study and classify the superficial palmar arch and its variation based upon the gross dissection and to check the bilateral symmetry of the arches. Specifically, we checked for the presence of the superficial palmar arch as described in the standard textbooks. METHODS: We dissected 55 hands from 28 cadavers of both sexes that include 18 males and 10 females. The superficial palmar arch was carefully dissected and the arteries contributing its formation were traced. It was classified into complete, incomplete arches. Bilateral symmetry of the arches was also studied. RESULTS: The most common pattern of superficial palmar arch observed is complete. And it is further classified into radio-ulnar and predominantly ulnar types. A consistent proportion of radio-ulnar type arch is completed around first web space. None of the dissected hand meets the definition of the classical superficial palmar arch as described in the standard anatomical textbooks. We also encountered few rare variants of the incomplete superficial palmar arch. CONCLUSIONS: Type 1-4 superficial palmar arch is complete and can be utilized for radial artery or ulnar artery cannulation and radial artery harvesting procedure. In type 5 arch, ulnar artery occlusion could lead to severe hand ischemia and at the same time the radial artery in this type can be harvested without ischemic complication. We suggest that the definition of the complete superficial palmar arch should be rechecked and modified as complete superficial palmar or complete superficial first web space arch.