Anatomic mapping of the collateral branches of the external carotid artery with regard to daily clinical practice.

BACKGROUND: To identify the anatomical variations of the main branches of the external carotid artery (lingual, facial, occipital, ascending pharyngeal and sternocleidomastoid), giving information about the calibers and origins with the aim of creating a new classification useful in clinical practice. MATERIAL AND METHODS: 193 human embalmed body-donors were dissected. The data collected were analyzed using the Chi² test. The results of previous studies were reviewed. RESULTS: The majority of the anterior arterial branches (superior thyroid, facial and lingual artery) were observed with an independent origin, respectively, classified as pattern I (80.83%, 156/193). In 17.62% (34/193) a linguofacial trunk, pattern II, has been observed, only in 1,04% (2/193) a thyrolingual trunk, pattern III, has been found and in one case (1/193, 0.52%) one thyrolinguofacial trunk, pattern IV, was found. Depending on the posterior branches (occipital and ascending pharyngeal), four different types could be determined: type a, the posterior arteries originated independently, type b, the posterior arteries originated in a common trunk, type c, the ascending pharyngeal artery was absent, type d, the occipital artery was absent. CONCLUSION: Anatomical variations in these arteries are relevant in daily clinical practice due to growing applications, e.g., in Interventional Radiology techniques. Knowledge of these anatomical references could help clinicians in the interpretation of the carotid system.

Art and mental health in Samoa.

OBJECTIVES: To pilot an art and mental health project with Samoan and Australian stakeholders. The aim of this project was to provide a voice through the medium of art for people experiencing mental illness, and to improve the public understanding in Samoa of mental illness and trauma. METHODS: Over 12 months, a series of innovative workshops were held with Samoan and Australian stakeholders, followed by an art exhibition. These workshops developed strategies to support the promotion and understanding of mental health in Samoa. Key stakeholders from both art making and mental health services were engaged in activities to explore the possibility of collaboration in the Apia community. RESULTS: The project was able to identify the existing resources and community support for the arts and mental health projects, to design a series of activities aimed to promote and maintain health in the community, and to pilot these programs with five key organizations. CONCLUSIONS: This project demonstrates the potential for art and mental health projects to contribute to both improving mental health and to lowering the personal and social costs of mental ill health for communities in Samoa.

Cadaveric surgery: a novel approach to teaching clinical anatomy.

INTRODUCTION: Anatomy is an essential basic science for safe and effective medical practice. In 2006 the UK Anatomy Act was changed to allow the use of surgical procedures on cadavers. This has unlocked opportunities for new methods of teaching clinically relevant anatomy. This study explores how surgical procedures may provide a purposeful and memorable way for undergraduates to learn anatomy, compared with conventional teaching methods. METHODS: Under supervision, a group of third-year medical students prepared for and then performed a shoulder hemi-arthroplasty after identifying key anatomical structures and surgical objectives. The procedure was performed in a simulated theatre environment. A focus group was used to collect qualitative data based on the learning experience. RESULTS: The surgical approach and implant insertion were successfully completed, and the educational objectives of identifying and learning surrounding structures were met. The focus group found that the exercise presented a relaxed introduction to surgery, enabled learning by association, and provided a learning experience that was both purposeful and complete. DISCUSSION: The preparation and completion of the procedure enabled the students to focus on the anatomy of the shoulder, by identifying and forming associations with surrounding structures. Uniquely, the surgical nature of this project also allowed undergraduate students to practice key surgical skills and principles. CONCLUSION: The authors believe that learning anatomy via a surgical approach provides a relevant, in-depth, purposeful and enjoyable learning experience. This technique also provided a valuable insight into surgery.

Recurrent laryngeal nerve landmarks revisited.

BACKGROUND: The aim of this work was to evaluate, to prove their reliability, the different surgical landmarks previously proposed as a mean to locate the recurrent laryngeal nerve (RLN). METHODS: The necks of 143 (68 male and 76 female) human adult embalmed cadavers were examined. RLN origin and length and its relationship to different landmarks were recorded and results compared with those previously reported. Statistical comparisons were performed using the chi-square test (significance, p ≤ .05). RESULTS: Mostly, RLN is located anterior to the tracheoesophageal sulcus (41.6%), posterior to the inferior thyroid artery (35.8%), lateral to Berry's ligament (88.1%), below the inferior rim of the inferior constrictor muscle (90.4%), and entering the larynx before its terminal division (54.6%). CONCLUSIONS: The position of the RLN in relation to those structures classically considered as landmarks is highly variable. The most reliable relationships are those with Berry's ligament or the inferior constrictor muscle.

Obturator artery revisited.

INTRODUCTION AND HYPOTHESIS: The aim of this work is to analyse the variability of the obturator artery (oa), unify previous criteria and propose a simple classification for clinical use. METHODS: A sample of 119 adult human embalmed cadavers was used. Origin and course of the oa in relation with the external iliac artery, internal iliac artery and inferior epigastric artery were studied. Chi-squared and t test were used for statistical comparison, and p < 0.05 was considered significant. RESULTS: Based on the number of roots of origin, three different situations were observed. The oa shows a single origin (96.55%). The oa presents a double origin (3.02%), or the oa arises from three roots (0.43%). The first situation was subclassified into six types according to the oa origin. Equal vascular pattern in both hemi-pelvises was observed in 58.93%. CONCLUSIONS: Almost 31% of oa passes over the superior pubic ramus implying an increased risk during some procedures.

Anatomical variations of the superior thyroid and superior laryngeal arteries.

BACKGROUND: There are known to be variations in the origins of the superior thyroid artery (STA), an important surgical landmark, and 1 of its branches, the superior laryngeal artery (SLA). METHODS: Three hundred thirty human embalmed heminecks were dissected. The results of previous studies were reviewed, and a meta-analysis is presented. RESULTS: Four different origins for the STA were found. The most frequent was type I, from the carotid bifurcation (49%). Four different origins were also found for the SLA being the most frequent the type I in which the artery arose from STA (78%). The mean external diameters of STA and SLA were 0.26 and 0.20 cm, respectively, with no statistically significant differences by side or sex. CONCLUSION: Variations in the origin of STA and SLA from the carotid arterial tree and the similarity of their diameters mean that there is a significant possibility of their misidentified during surgery.

Potential structures that could be confused with a nonrecurrent inferior laryngeal nerve: an anatomic study.

OBJECTIVES: Study and detailed description of the large connections between the normally recurrent inferior laryngeal nerve (RILN) and the sympathetic trunk (ST) because these may be mistaken for a nonrecurrent inferior laryngeal nerve (NRILN). STUDY DESIGN: Morphologic study of adult human necks. METHODS: The necks of 144 human, adult, embalmed cadavers were examined (68 males, 76 females). They had been partially dissected by Cambridge preclinical medical students and then further dissected by the authors using magnification. The RILN, the ST, and their branches were identified and dissected. A total of 277 RILNs and STs (137 rights, 140 lefts) were observed. RESULTS: A communicating branch (CB) with a similar diameter to the RILN occurred between the ST and the RILN in 48 of the 277 (17.3%) dissections, 24 from the 137 (17.5%) right dissections, and 24 from the 140 (17%) left dissections. In 12 cases, the CB was bilateral. The CB arose from the superior cervical sympathetic ganglion in 3 of the 48 (6.25%) cases, from the middle ganglion in 10 (21%) cases, from the stellate ganglion in 3 (6.25%) cases, and from the ST in 32 (66.6%) cases. One (0.36%) NRILN associated with a right retro-esophageal subclavian artery (arteria lusoria) was found. CONCLUSIONS: 1) The CB between the RILN and the ST may have a diameter and course similar to an NRILN and may be confused with it. 2) The occurrence of the CB is greater than the occurrence referred to in previous studies. 3) The occurrence of the CB is similar by side and sex. 4) The CB may arise at different levels from the cervical ST and ganglia and end in the thyroid area. 5) Other neural elements may also be confused with an RILN, such as the cardiac nerves and the collateral branches from an NRILN to the trachea and esophagus.

Anatomic study of blood supply of the dorsum of the foot and ankle.

PURPOSE: This project was to study the different patterns of the anterior tibal and dorsalis pedis arteries in relation to the blood supply of the dorsum of the foot and ankle. METHODS: A reliable sample of 150 human embalmed cadavers was dissected. RESULTS: Four different patterns were identified. The dorsalis pedis artery was most frequently (287 cases, 95.7%) found to be the continuation of the anterior tibial artery distal to the ankle, and lay between the tendon of extensor hallucis and the first tendon of extensor digitorum longus. The other 13 cases (4.3%) showed 3 variant patterns of the anterior tibial-dorsalis pedis vascular axis: the anterior tibial artery took a more lateral course, passing in front of the lateral malleolus (6 cases, 2%); the perforating branch of the peroneal artery assumed the expected course of the dorsalis pedis artery (4 cases, 1.3%); the anterior tibal artery gave a lateral branch that replaced the perforating branch of the peroneal artery to supply the lateral aspect of the ankle (3 cases, 1%). CONCLUSION: Arterial variations of the anterior tibial-dorsalis pedis axis occurred in almost 5% of cases. CLINICAL RELEVANCE: An awareness of the existence of such variations is helpful during a preoperative assessment and could prevent injury during surgery.

Neurovascular anatomy and variation in the fourth, fifth, and sixth intercostal spaces in the mid-axillary line: a cadaveric study in respect of chest drain insertion.

Chest drains are normally inserted in the fifth intercostal space in the mid-axillary line. The classical technique for chest drain insertion involves locating the drain in an interspace just superior to the inferior rib, so as to avoid the neurovascular bundle. While teaching thoracic wall anatomy on cadavers, considerable variation was noted in the position of the neurovascular bundles, frequently lying well away from the generally accepted subcostal groove. We endeavoured to perform a comprehensive cadaveric study of the neurovascular relationships in the mid-axillary line in the fifth and adjacent spaces to try to describe a 'Safe Zone' for drain insertion to minimise damage to associated structures. The idea that the neurovascular bundle is safely protected in the subcostal groove should be dispelled, as should the concept that there is nothing to damage in the zone immediately superior to the inferior rib. Clinicians should be aware that the Safe Zone is narrower than hitherto appreciated and should be between 50-70% of the way down an interspace to avoid the variably positioned superior intercostal neurovascular bundle and the inferior collateral artery.

The anatomy of sartorius muscle and its implications for sarcoma radiotherapy.

PURPOSE: Controversy exists as to whether sartorius muscle is completely invested in fascia. If it is, then direct tumour involvement from soft tissue sarcoma of the anterior thigh would be unlikely and would justify omitting sartorius from the radiotherapy volume. SUBJECTS AND METHODS: Eight thighs in six cadavers were examined in the dissecting room. Using a previous case, conformal radiotherapy plans were prepared to treat the anterior compartment of the thigh including and excluding sartorius. The corridor of unirradiated normal tissue was outlined separately. RESULTS: In all cases, sartorius was enclosed within a fascial sheath of its own. In four of the six cadavers, there was clear evidence of a fascial envelope surrounding sartorius, fused to the fascia lata and medial intermuscular septum. In two, sartorius was fully ensheathed in the upper half of the thigh; in the lower half the intermuscular septum became thin, and blended with the tendinous aponeurosis on the surface of vastus medialis in an example case. By excluding sartorius, the volume of the anterior compartment was reduced by 8%, but the volume of the unirradiated normal tissue corridor increased by 134%. With sartorius included, the unirradiated corridor became very small inferiorly, only 6% of the circumference of the whole leg, compared to 27% with sartorius excluded. DISCUSSION: The anatomy suggests that sartorius could be safely omitted from the clinical target volume of anterior compartment soft tissue sarcomas. This substantially increases the size of the unirradiated normal tissue corridor, expressed as a volume and a circumference, which could give a clinical advantage by reducing normal tissue complications.

Supernumerary humeral heads of the biceps brachii muscle revisited.

Supernumerary humeral heads of the biceps brachii muscle were found in 27 (15.4%) of 175 cadavers. They were bilateral in five cadavers and unilateral in 22 (8 left, 14 right), giving a total of 32 examples in 350 arms (9.1%). Depending on their origin and location, the supernumerary heads were classified as superior, infero-medial, and infero-lateral humeral heads. Previous studies were reviewed using this classification. The infero-medial humeral head was observed in 31 of 350 (9%) arms and was therefore the most common variation. The superior humeral head was observed in five (1.5%). The infero-lateral humeral head was the least common variation, observed only in one (0.3%) of 350 arms. A biceps brachii with three heads was observed in 27 of 350 (7.7%) arms and with four heads in five (1.4%) arms.

Extensor digitorum brevis manus: anatomical, radiological and clinical relevance. A review.

The extensor digitorum brevis manus (EDBM) is a supernumerary muscle in the dorsum of the hand frequently misdiagnosed as a dorsal wrist ganglion, exostosis, tendon sheath cyst or synovitis. Its presence in a living subject, confirmed by magnetic resonance imaging (MRI), is presented together with a review of the hitherto reported cases and the results of an anatomical study on 128 adult human cadavers (59 males and 69 females). The EDBM was found in three (2.3%) of the 128 cadavers. It occurred in two (3.4%) of the 59 male cadavers (one bilateral and one unilateral on the right side) and in one (1.5%) of the 69 female cadavers (unilateral on the left side). Consequently, the EDBM was found in four (1.6%) of the 256 upper limbs. It originated from the dorsal wrist capsule within the compartment deep to the extensor retinaculum for the extensor digitorum and inserted into the extensor hood of the index finger in one case and into that of the middle finger in three cases. In both hands of the living subject, the origin was similar but the insertion was into the index and middle fingers. In all cases, it was innervated by the posterior interosseous nerve and its blood supply was provided by the posterior interosseous artery.

Intramuscular Martin-Gruber anastomosis.

The incidence and morphology of the intramuscular Martin-Gruber anastomosis are presented based on the study of 118 human cadavers (55 male, 63 female). The Martin-Gruber anastomosis was found in 25 (21.2%) of the 118 cadavers. It occurred in 11 (20%) of the 55 male cadavers (4 bilateral, 7 unilateral; 5 left and 2 right) and in 14 (22.2%) of the 63 female cadavers (2 bilateral, 12 unilateral; 8 left and 4 right). Therefore, the Martin-Gruber anastomosis was found in 31 (13.1%) of the 236 upper limbs. According to a recent classification (Rodríguez-Niedenführ et al., 2000), pattern I was found in 29 cases (93.5%), corresponding to Type A in 13 (41.9%), Type B in 3 (9.7%) and Type C in 13 (41.9%), whereas pattern II was found in 2 cases (6.5%), both being a duplication of Type IC. Intramuscular Martin-Gruber anastomosis was a single anastomosis that originated in all cases from the anterior interosseous nerve (pattern IC) and then passed through a muscle bundle of the flexor digitorum profundus and behind the ulnar artery to join the ulnar nerve as a single connecting branch. It did not send branches to the flexor digitorum profundus. This intramuscular course was observed in 3 of the 13 cases of Type C anastomosis (23.1%) or 3 cases out of 31 Martin-Gruber anastomoses (10%).

Martin-Gruber anastomosis revisited.

Based on a study of 70 human cadavers (31 male, 39 female) and on cases described previously, we propose a new classification of the Martin-Gruber anastomosis, a neural connection between the median and ulnar nerves in the forearm. The anastomosis was found in 16 (22.9%) cadavers, being bilateral in three (18.7%) and unilateral in 13 (81.3%), five right and eight left. It occurred in eight (25.8%) of the 31 male cadavers and in eight (20.5%) of the 39 females. Therefore, the anastomosis was found in 19 (13.6%) of the 140 forearms. In Pattern I (89.5%) the anastomosis was made by only one branch, whereas in Pattern II (10.5%) it was made by two. The individual branches were classified as Types a, b, and c based on the nature of their origin from the median nerve. Type a (47.3%) arose from the branch to the superficial forearm flexor muscles, Type b (10.6%) from the common trunk, and Type c (31.6%) from the anterior interosseous nerve. Pattern II was a duplication of Type c (10.5%). The anastomotic branch took an oblique or arched course before joining the ulnar nerve, undivided in 15 cases, but divided into two branches in four cases. The anastomosis passed in front of the ulnar artery in four cases, behind it in six, and in nine cases it was related to the anterior ulnar recurrent artery.

Patterns of connections between the musculocutaneous and median nerves in the axilla and arm.

Variations in connections between the musculocutaneous and median nerves in the arm are not as uncommon as was once thought. This opinion led us to perform a study in 138 cadavers (66 male, 72 female). These variations were seen in 64 cadavers (46.4%), 9 bilaterally and 55 unilaterally (26 right and 29 left); in total, therefore, variations were observed in 73 out of 276 arms (26.4%), 42 male and 31 female. No statistically significant differences by gender and side were observed. We classify the variations in three main patterns: Pattern 1, fusion of both nerves (14 arms, 19.2%); Pattern 2, presence of one supplementary branch between both nerves (53 arms, 72.6%); and Pattern 3, two branches (5 arms, 6.8%). Pattern 2 was further subdivided into a sub-group 2a when a single root from the musculocutaneous nerve contributed to the connection (51 arms, 69.9%), and 2b when there were two roots from the musculocutaneous nerve (2 arms, 2.7%). A combination of Patterns 1 and 2a was observed in one case (1.4%). Further variations are described, published classification systems are reviewed and a meta-analysis of previous results is presented. An overall incidence of 33% of variant arms was observed. Of these variant arms, Pattern 1 represented 13.1%, Pattern 2 represented 75.4%, and Pattern 3, 8.5%, similar to our figures.

Extensor carpi radialis accessorius inserting into the abductor pollicis brevis / Inserción del extensor carpi radialis accessorius en el abductor pollicis brevis

A tendinous slip originating from the extensor carpi radialis brevis was found bilaterally in a male cadaver. It passed through an independent compartment under the extensor retinaculum, located ventral to its first compartment, before becoming a muscle belly and inserting into the abductor pollicis brevis. The superficial branch of the radial nerve passed superficial to the tendinous slip (AU)

Se encontró una extensión tendinosa que se originaba procedente del extensor carpi radialis brevis bilateralmente en el cadáver de un hombre. Pasó a través de un compartimiento independiente por debajo del retináculo extensor, localizado ventralmente a su primer compartimento, antes de convertirse en el vientre de un músculo e insertándose en el abductor pollicis brevis. La rama superficial del nervio radial pasaba superficial a la extensión tendinosa (AU)