THE CLINICAL AND DEVELOPMENTAL SIGNIFICANCE OF ULNAR ARTERY VARIATION DURING SURGERIES AND MEDICAL INTERVENTIONS

Background – Ulnar artery is a branch of brachial artery,it descends superficially and vertically between the FCU and FDS in lower two third of forearm. Then it passes above the fiexor retinaculum at wrist later forming superficial palmar arch. During routine dissection in S.N Medical College, Agra, an unusual finding was Case Report- identified in both the upper limb of a 60 year old male cadaver. Ulnar artery runs laterally to ulnar nerve and then passes underneath the fiexor retinaculum. Then it joins with the Superficial Branch of Radial Artery to form Superficial palmar arch. Variation of Ulnar artery is uncommon.It is important in surgical cases of Carpal tunnel release surgery, also can be confused with superficial veins during interventions

Variations of the Lumbrical Muscles in Hands of Koreans / 체질인류학회지

The aim of this study was to classify morphological patterns of the lumbrical muscles and their anatomical variations in the hands. The lumbricals in the hand were investigated in 70 specimens of 45 embalmed Korean adult cadavers. The shapes of the lumbrical muscles were observed in 70 specimens and the distances from the distal border of the flexor retinaculum to the origins of the lumbricals were measured using digital calipers in 52 specimens. The lumbrical muscles were classified into 3 types based on their shapes, and also into 10 types based on their insertion sites. The average distances from the distal border of the flexor retinaculum to the origins of the first, second, third, and fourth lumbricals were +1.8 mm, - 1.4 mm, +5.1 mm, and +11.2 mm, respectively. The results of this study could be useful information for better understanding the function of the lumbrical muscles and for various types of diagnoses and surgery involving the hands.

Higher and Bulkier Origin of the Lumbricals and their Clinical Relevance

Lumbricals are important small intrinsic muscles of the hand, which arise from the tendons of the flexor digitorum profundus in the palm distal to the flexor retinaculum and are inserted on to the dorsal digital expansion. Variations in the unipinnate/bipinnate pattern of lumbricals, absence of one or more muscles, origin from the superficial flexor tendons and flexor retinaculum have been reported earlier. In the present case, all four lumbricals were arising from the tendons of the flexor digitorum profundus, proximal to the flexor retinaculum in the anterior part of the forearm and extending into the palm through the carpal tunnel. However, there was no variation found with regard to their normal unipinnate (first two) and bipinnate (last two) pattern of origin. In the palm all the four lumbricals were found to be bulkier than their normal size, first one being the bulkiest. The bulky and high origin of lumbricals within the carpal tunnel makes the tunnel a compact space. Therefore, such variation is one of the predisposing factors for the carpal tunnel syndrome. Thus, the knowledge of such variant origin of lumbricals is helpful not only during carpal tunnel release but also during the magnetic resonance imaging (MRI) and ultrasound based diagnosis of carpal tunnel and during the flexor tendon repair and reconstruction.

Course pattern of the muscular branch of the median nerve in Sri Lankans hand / Curso del patrón del ramo muscular del nervio mediano de la mano en sri lankenses

Transligamentous variant of the recurrent motor branch is having a higher risk of getting damage during both endoscopic and open carpal tunnel releases. The incidence of the transligamentous variant is about 7 percent to 80 percent world wide. This wide variation of the incidence could be due to the failure of identification of the distal edge of the flexor retinaculum from the obliquely oriented fascia that runs from the distal edge. We used two criteria to identify the distal edge; the abrupt change in the thickness of the flexor retinaculum and its colour change in cross section. The incidence of transligamentous variant is rare and the reported high incidence could be due to an error in identification of the distal edge of the flexor retinaculum as shown by Kosin (1998).

Las variantes transligamentosas del ramo motor recurrente tienen un mayor riesgo de recibir daños durante la endoscopía y liberación abierta del túnel carpiano. La incidencia de la variante transligamentosa es de, aproximadamente, 7 a 80 por ciento en todo el mundo. Esta amplia variación de la incidencia podría deberse a la falla en la identificación del borde distal del retináculo flexor de la fascia de orientación oblicua que va desde el borde distal. Hemos utilizado dos criterios para identificar el borde distal, el brusco cambio en el grosor del retináculo flexor y su cambio de color en la sección transversal. La incidencia de la variante transligamentosa fue rara y el informe de la alta incidencia podría deberse a un error en la identificación del borde distal del retináculo flexor, como lo demuestra Kosin (1998).

Endoscopic release of distal holdfast fibers of the flexor retinaculum for carpal tunnel syndrome / 中国微创外科杂志

Objective To investigate the necessity of releasing the distal holdfast fibers of the flexor retinaculum(DHFFR) during endoscopic carpal tunnel release(ECTR).Methods The Experiment Group included 16 cases.The operation was conducted under brachial plexus anesthesia without the use of tourniquet.A 1 cm skin incision was made.The USE system(Universal Subcutaneous Endoscope System) was employed.Both flexor retinaculum(FR) and distal holdfast fibers of the flexor retinaculum were cut off.Postoperative outcomes were compared with another 16 cases of flexor retinaculum release only(Control Group).Results Follow-up evaluation was carried out at 6 postoperative months.According to the Kelly's criteria,there were 13 cases of excellent results and 3 cases of good results in the Experiment Group,and 8 cases of excellent,5 cases of good,and 3 cases of fair results in the Control Group.Significant difference was obser red in flameda Ⅱ or Ⅲ grade patients between the two groups in carative effects(?~2=6.278,P=0.043).No serious complications or postoperative recurrence occurred.Conclusions Flexor retinaculum is not the only structure existing in the carpal canal to be released.More attention should be paid to complete decompression of both flexor retinaculum and distal holdfast fibers of the flexor retinaculum,especially in those who have serious symptoms.

Variations and Morphometry of the Carpal Tunnel and Its Related Structures

OBJECTIVE: The purpose of this study was to find out diagnostic clue for the carpal tunnel syndrome. So we investigated the postional relationships between the structures, the degree of entrance of the muscle bellies in the carpal tunnel, the location of flexor retinaculum (FR) and the cross sectional area to the tunnel of the tendons, the median nerve and the soft tissues occupied with the wrist. METHOD: Seventy-seven wrists of Korean adults's cadavers were dissected. Fifty-three wrists were examined by posteroanterior view of X-ray. The area of each structure was measured by image analyzer (Optimas Co. WA). The upper and lower borders the FR were confirmed at the sagittal plane after sagittal section. RESULTS: Frequency of the bellies of FDS, FDP and lumbricalis observed in each finger, the length of these bellies entering into the carpal tunnel were obtained. The cases that the third and fourth FDS were located side by side, the second FDS tendon under the third FDS tendon and the fifth tendon under the fourth FDS tendon were most common. The cases that the median nerve was bordered on the third FDS and the second FDS deep inside of the median nerve were most common. Mean length of the FR was 32.1 mm. The cases that the location of the upper margin of the FR was 10 mm and 15 mm from the end of radius were most common (44%). The cases that the margin of FR was 5 mm and 10 mm from the base of the 3rd metacarpal bone were most common (52%). The cross sectional area ratios to the carpal tunnel of the tendon, median nerve and connective tissues were 30%, 4%, 66% at the level of the pisiform bone, 36%, 4%, 60% at the level of the hook of hamate and 28%, 3%, 67% at the level of the lower margin of the FR, respectively. CONCLUSION: These results could help to understand the etiology of the carpal tunnel syndrome and would be a helpful information to the diagnostic imaging of the carpal tunnel.