Traumatic injury of radial and ulnar artery with perfusion of the hand through the median artery: a case report / Lesión traumática de arteria radial y ulnar con perfusión de la mano a través de la arteria mediana: reporte de caso

Abstract Case description: A young male patient with a complete section of the ulnar and radial arteries preserved the perfusion of the hand through an anatomical variant, the median artery, identified by angiotomography. Clinical Findings: A wound in the distal third of the left forearm with present pulses and adequate hand coloration. An angiotomography of the upper left limb showed a median artery originating as a continuation of the anterior interosseous artery and ending in the palm of the hand with an incomplete superficial palmar arch. Treatment and Outcomes: Ligation of both radial and ulnar arteries was performed. It was not possible to follow up the patient. Clinical Relevance: Forming the superficial and deep palmar arches, the irrigation of hand comes from the ulnar and radial arteries, which can compromise the viability of the limb when injured. The median artery is present in 0.6-21.1% of the population, originates from the anterior interosseous artery (branch of the ulnar), accompanies the median nerve in its path and ends in the palm joining the superficial palmar arch. Diagnostic imaging is a key tool for assessing arterial circulation and characterizing upper limb vascular lesions. Knowledge of the anatomical variations of the arterial supply of the hand, including variability of the superficial palmar arch, is crucial for the safety and success of hand surgeries.

Resumen Descripción del caso: Un paciente joven de sexo masculino con sección completa de las arterias cubital y radial conservó la perfusión de la mano a través de una variante anatómica, la arteria mediana, identificada por angiotomografía. Hallazgos clínicos: Herida en el tercio distal del antebrazo izquierdo con pulsos presentes y coloración adecuada de la mano. Una angiotomografía del miembro superior izquierdo mostró una arteria mediana que se originaba como continuación de la arteria interósea anterior y terminaba en la palma de la mano con un arco palmar superficial incompleto. Tratamiento y resultados: Se realizó la ligadura de las arterias radial y cubital. No fue posible realizar un seguimiento del paciente. Relevancia clínica: La irrigación de la mano proviene de las arterias cubital y radial, que forman los arcos palmar superficial y profundo, comprometiendo la viabilidad de la extremidad cuando se lesionan. La arteria mediana está presente en el 0.6-21.1% de la población, se origina en la arteria interósea anterior (rama del cubital), acompaña al nervio mediano en su recorrido y termina en la palma uniéndose al arco palmar superficial. El diagnóstico por imagen es una herramienta clave para evaluar la circulación arterial y caracterizar las lesiones vasculares del miembro superior. El conocimiento de las variaciones anatómicas de la irrigación arterial de la mano, incluida la variabilidad del arco palmar superficial, es de importancia crucial para la seguridad y el éxito de las cirugías de la mano.

Anatomical basis of transition from eleven to twelve meridians in Han dynasty / 中国针灸

The discovery of modern evolutionary anatomy shows that the persistent median artery in the upper arm is a common variant with an increasing trend. This phenomenon can explain well the transition from the eleven meridians described in the Han silk and bamboo slips to the twelve meridians finalized in

The Superficial Palmar Arch: A Morphological Study

Background: The functional importance of hand is revealed by its rich vascularity contributed by superficial anddeep palmar arches (SPA and DPA). The efficiency of collateral circulation in hand by SPA and DPA is essential incertain peripheral vascular diseases like Raynaud’s disease and in harvesting radial artery for coronary arterybypass graft (CABG). Knowledge of variations in the arterial supply of hand is important while performingmicrosurgical procedures like arterial repair, vascular graft and flap application.Objective: To study the morphology of the Superficial Palmar Arch and variation in its formation.Materials and methods: We have dissected 30 cadaveric hands at Department of Anatomy of Medical Collegeand Hospital, Kolkata.Result and conclusion: Out of 30 specimens, variations were observed in 14 specimens. Out of 14 specimens in 11specimens SPA was formed alone by Ulnar Artery, in two specimens SPA was incomplete formed by superficialpalmar branches of Ulnar and Radial Artery, in one specimen there was presence of Persistent Median Arterywith incomplete SPA. All the variations found were present unilaterally. In rest 16 specimens SPA was completeclassical radio-ulnar type.

Thrombosed Fusiform Dilatation of Persistent Median Artery with Normal Median Nerve

Carpal tunnel syndrome can be produced by abnormal mass effect due to trauma, ganglion cysts, various soft tissue tumors, musculotendinous variants, and aberrant vascular structures. Persistent median artery is one of the causes of the carpal tunnel syndrome. Thrombosed persistent median artery usually accompanies the anomaly of the median nerve and causes a sudden onset of severe pain and paresthesia. In contrast to previous literature, we report the rare case of gradual onset and mild symptom of a 53-year-old man with a thrombosed persistent median artery but without anomaly of the median nerve and abnormal finding of electrophysiologic study.

Clinically Relevant Morphometric Study Of Left Coronary Artery In Adult Human Cadavers

Background: The anatomical variations of left coronary artery [LCA] determine the course in the pathogenesis ofatherosclerosis, mechanical stress and hemodynamic change.Aim: To study the gross anatomy of left coronary artery [LCA] in terms of its origin, termination, branchingpattern, dominance pattern, external diameter at origin, length of main trunk of left coronary artery, variationsand/ anomalies if present.Materials and Methods: After an ethical approval, 150 adult human cadaveric hearts were collected fromDepartment of Anatomy, B.V.D.U. Medical College and Hospital, Sangli and Pune. The careful dissection wascarried out to note details about left coronary artery and data was analyzed using SPSS software.Results: The origin of left coronary artery was observed in the left posterior aortic sinus 100%. The incidence ofbifurcation, trifurcation and quadrifurcation was 69.33, 28% and 2.67% respectively. SA nodal artery was directlyarising from main trunk of left coronary artery in 2 hearts (1.33%). Circumflex branch of left coronary artery gaveSA nodal artery, AV nodal artery and posterior interventricular artery in 18.66%, 16% and 16% hearts respectively.In one case (0.66%), we found a hyperdominant left anterior descending artery which continued as posteriorinterventricular artery [PDA] occupying entire posterior interventricular sulcus and terminated at crux of theheart by giving AV nodal artery. Hence left dominance was observed in total 16.66% cases. The mean externaldiameter of left coronary artery at its origin was 5.02 ±1.0328. Length of main trunk of left coronary artery wasranging from 4 mm to 22 mm with mean length of 11.66±3.529 mm.Conclusion: Short or long main trunk of left coronary artery, small diameter of main trunk, additional terminalbranches of left coronary artery, left coronary artery dominance, Mouchet’s posterior recurrent interventricularartery, hyperdominanant left anterior descending artery are the significant anatomical factors which decide theextent of coronary insufficiency, its functional impact and may create challenges during the interventionalcoronary care.

Anatomical Study Of Superficial Palmar Arch And Its Variations With Clinical Significance

Background: Superficial Palmar Arch (SPA) is an arterial arcade usually formed by the continuation of ulnarartery and the superficial branch of radial artery. Variations can occur in the vessels contributing to the formationof SPA. Knowledge of such variations will be very much helpful to microvascular surgeons, plastic surgeons andorthopaedicians to bring a better outcome in their surgical procedures. Also, it will be useful to the cardiovascularsurgeons to carryout radial artery harvesting procedures for the purpose of Coronary Artery Bypass Grafting. Themain objective is to study the different patterns of formation of the superficial palmar arch with an emphasis ontheir clinical importance.Materials and methods: This study was done in 40 upper limb specimens from 20 embalmed human adultcadavers at the Institute of Anatomy, Madras Medical College, Chennai. In every upper limb specimen, the palmwas dissected as per the steps described in the Cunningham’s Manual of Practical Anatomy. The SuperficialPalmar Arch was exposed and the vessels taking part in its formation were studied. Variations in the formationof Superficial Palmar Arch were noted and analysed.Results: Out of 40 specimens, the Superficial Palmar arch was found to be complete in 29 specimens (72.5%) andincomplete in 11 specimens (27.5%).Conclusion: Information about the different patterns in the formation of the Superficial Palmar Arch will beextremely useful for hand surgeons, microvascular surgeons, plastic surgeons and orthopaedicians to bring outa successful and beneficial postoperative outcome. Awareness about these variations will also help in appropriateinterpretation of investigations prior to radial artery harvesting for the purpose of Coronary Artery BypassGrafting.

Sonographic Findings of the Bifid Median Nerve and Persistent Median Artery in Carpal Tunnel: A Preliminary Study in Chinese Individuals

OBJECTIVE: The aim of this study was to investigate the prevalence of anatomic variations of the bifid median nerve, persistent median artery and persistent median vein in Chinese individuals and their relationship with carpal tunnel syndrome. METHODS: One hundred and sixty median nerves were examined using ultrasonography and colour Doppler ultrasonography. The location, shape, and size of the bifid median nerve, persistent median artery and persistent median vein were recorded. The cross-sectional area of the bifid median nerve (two trunks) was measured at the level of the pisiform. RESULTS: Among the 160 wrists examined, a bifid median nerve was observed in 15 (9.4%) wrists, and a persistent median artery was observed in 12 (7.5%) wrists. These two variations either coexisted or were observed independently, and the probability of coexistence (6.3%) was higher than the probability of existing independently (bifid median nerve only 3.1%, persistent median artery only 1.3%). The cross-sectional area of the radial trunk was greater than (13 in 15, 86.7%) the cross-sectional area of the ulnaris trunk. Persistent median vein was observed in 9 wrists (5.6%). CONCLUSIONS: The persistent median artery and bifid median nerve tend to coexist, and the persistent median vein sometimes runs parallel to the persistent median artery. Their positional relationship in carpal tunnel is uncertain, and thus, preoperative ultrasound is necessary. These three variations do not present any additional risk for the development of carpal tunnel syndrome.

Pattern of Variations in Superficial Palmar Arch and its Clinical Importance

Background: Superficial palmar arch (SPA) is an important arterial anastomotic arcade which is the dominant vascular supply to the majority of the palmar muscles. Objectives: Keeping the importance of these variations in mind this study was designed to find out the pattern of superficial palmar arterial arches. Materials and Methods: A total of 40 adults upper limbs of unknown sex were observed for the variations in the pattern of superficial palmar arches on right and left side and were compared with the previous data. Results: A complete superficial palmar arch was encountered in 72.5% (n=29/40) of specimens and an incomplete SPA was observed in 27.5% (n=11/40) of specimens. Conclusion: Knowledge of the variations in the arterial supply of hand is essential in advent of microvascular surgery for revascularisation, replantation and composite tissue transfers

Coupled multiple musculo-neurovascular variations in same upper limb: a case report and clinical significances / Múltiples variaciones músculo-neurovasculares conectados en el mismo miembro superior: reporte de un caso y significados clínicos

Variants of the median nerve, extra forearm flexor muscles heads are relationships of the persistent median artery (PMA) that have been extensively reported. We report the findings of a PMA (diam. 3.25 mm), a pierced median nerve, and accessory heads of the flexor digitorum profundus (FDP) and flexor policis longus (FPL) muscles coexisting with a brachioradial artery (BRA) (diam.1.8mm) in the left upper limb of a 65 year-old male cadaver. The median nerve provided a ring for the passage of the PMA about the junction of the proximal and middle thirds of the forearm. Both accessory muscles were placed anterior to the ulnar artery, with the brachioradial artery coursing superficially in the brachium and antebrachium. The notable diameter of the PMA may be etiological in the causation of a carpal tunnel syndrome, while the hypoplastic BRA may pose some challenges inits selection as good conduit for catheterization and other surgical interventions like CABG in the upper limb. Additional clinical interest include the possible reduction in blood supply to the hand from the compressive effect of the 2 accessory muscles on the ulnar artery and possible inadvertent drug injection due to the superficial placement of the brachioradial artery close to veins.

Variantes del nervio mediano y cabezas adicionales de los músculos flexores del antebrazo, se relacionan con la arteria mediana persistente (AMP). Presentamos los resultados de una AMP (diámetro 3,25 mm), un nervio mediano pinzado y cabezas accesorias de los músculos flexor profundo de los dedos (FPD) y flexor largo del pulgar (FLP) que coexisten con una arteria braquiorradial (ABR) (diámetro 1,8 mm) en el miembro superior izquierdo de un cadáver de sexo masculino de 65 años. El nervio mediano proporciona un anillo para el paso de la AMP sobre la unión de los tercios proximal y medio del antebrazo. Ambos músculos accesorios se colocaron por delante de la arteria ulnar, con la arteria braquiorradial ubicada superficialmente en el brazo y en el antebrazo. El diámetro notable de la AMP puede ser la causa del síndrome del túnel carpiano, mientras que la ABR hipoplásica puede plantear algunos desafíos en su selección como buen conducto para la cateterización y otras intervenciones quirúrgicas como la cirugía de revascularización coronaria a partir del miembro superior. De interés clínico se considera la posible reducción en el suministro de sangre debido a la compresión de los 2 músculos accesorios a la arteria ulnar y la posible inyección fallida de drogas debido a la ubicación superficial de la arteria braquiorradial, cercana a las venas.

Study of Palmar Type of Median Artery and its Fate.

Background: The median artery is a transitory vessel that represents the arterial axis of the forearm during early embryonic life. When present, it appears mainly as two types: antebrachial and palmar. Context and purpose of the study: In the present study the objective was to investigate the occurrence and fate of palmar type of median artery. The study was conducted on 40 cadaveric upper extremities dissected in the department of Anatomy, Guru Gobind Singh Medical College, Faridkot, India. Results: In the present study, persistent median artery (palmar type) was seen in 2.5% of the limbs dissected. It was originating from the posterior aspect of the ulnar artery approximately 3.2 cm distal to the elbow joint. It pierced the median nerve (traversing from its medial to its lateral aspect) in the proximal third of the forearm. The artery then travelled lateral to the median nerve in rest of the forearm. Subsequently, it accompanied the median nerve into the palm passing deep to the flexor retinaculum. Finally, the artery terminated by completing the superficial palmar arch. In addition to the above described variant blood vessel, we also observed high division of median nerve into its medial and lateral branches. Clinical implications: When median artery is patent and reaches the hand, it forms the only arterial supply to the median nerve and damage to this artery could have serious effects. The aim of our study was to provide additional information about anomalous palmar type of median artery and its clinical implications.

Anatomical variations of coronary artery and frequency of median artery: A cadaveric study from Northern India.

Introduction: Clinicians and anatomists have been examining coronary artery variations for a long time. However, there is still no consensus on the normality or abnormality of coronary arteries. The present survey was therefore conducted to find out the variations in left coronary artery (LCA) and right coronary artery (RCA) branches, the existence and occurrence of the median artery in northern Indian population.Material and methods: The present study was planned and conducted during March 2012 to September 2014 at Department of Anatomy, Major S. D. Singh Medical College, Fatehgarh; a tertiary care teaching hospital. The hearts of 40 adult northern Indian cadavers fixed with 10% formaldehyde were used. To determine the dominant circulation, the artery that supplies the posterior inter ventricular sulcus was investigated. Dissections were performed under a dissection microscope and photographed. Results: LCA branched out of the aortic sinus in all the hearts and had an average diameter of 4.44 ± 1.79 mm. In 45% hearts, the LCA was separated into the anterior inter ventricular branch and the circumflex branch (bifurcation). In 42.5% hearts, in addition to the anterior inter ventricular branch and the circumflex branch; there was a median artery that coursed on the front wall of the left ventricle (trifurcation). In 10% hearts, branching occurred as in trifurcation but with two median arteries emerging from the LCA (quadrifurcation). Myocardial bridges were found on the LCA branches in 19 of the 24 hearts in which the median artery existence of the median artery and myocardial bridges. The median artery might be important as it may not result in any clinical symptom for many years in a large number of subjects. Knowledge of individual and racial variations in coronary arteries is essential for the diagnosis and treatment of coronary artery patients.

Persistent Median Artery In the Carpal Tunnel.

Introduction: Persistent median artery originates from the anterior interosseous artery in proximal one-third of the forearm and accompanies median nerve. Median artery may regress in the forearm or enter palm through the carpal tunnel deep to flexor retinaculum of wrist and supply palm by anastomosing with the superficial palmar arch. Objective: In present study the objective was to study presence of persistent median artery accompanying median nerve and its termination Materials and Methods: The study included 50 human cadaver upper limb specimens at the Department of Anatomy, Mysore Medical College & Research Institute, Mysore during 2011-13. These specimens fixed in 10% formalin were finely dissected and persistent median artery was traced from origin to termination. Results: Out of 50 human cadaver specimens, persistent median artery was present in 4 specimens (8%). All the 4 median arteries originated from anterior interosseous artery and were of palmar type which reached palm. Out of 4 median arteries, 3 median arteries (6%) took part in completion of superficial palmar arch, supplying the distal aspect of palm and 1 median artery (2%) directly supplied radial two and half fingers without forming arch. Conclusion: Knowledge of unusual variations helps in proper treatment of disorders of the median nerve. Presence of persistent median artery usually will be asymptomatic but may cause symptoms of carpal tunnel syndrome or pronator teres syndrome when subjected to compression. Rarely this artery can be taken for reconstruction.

Persistent palmar pattern of Median artery bilaterally.

Persistent median artery and distribution in both hands, was observed in formalin fixed superior extremities of adult cadaver in the department of Anatomy, Dr. B.R.Ambedkar Medical College, Bangalore. The persistent median arteries on both sides were arising from ulnar artery, accompanied the median nerve and contributed to the superficial palmar arch which supplied the lateral 2 ½ fingers. Persistent median artery may be present asymptomatically in most of the individuals but it may lead to compression symptoms of median nerve when artery is subjected to compression. Therefore this kind of anomaly is of clinical importance.

Arteria mediana persistente (AMP) bilateral de gran calibre en sujeto asintomático / High-caliber persistent bilateral median artery in asymptomatic

Se describe hallazgo en hombre de 22 años, asintomático, sano, de Arteria Mediana Persistente (AMP) bilateral de gran calibre asociada a un nervio median bífido (NMB) en una de las muñecas. La arteria mediana puede persistir hasta la adultez, acompañando al nervio por el túnel carpiano. Es una variante frecuente, suele ser bilateral y se asocia usualmente a NMB. La presencia de AMP puede asociarse a STC agudo secundario a trombosis y a STC crónicos por conflicto espacial. Sorprende el carácter asintomático de nuestro paciente a pesar del gran calibre de sus AMP. Sugerimos realizar, previo a cirugía o infiltración por STC, una ultrasonografía para adaptar tratamiento y evitar complicaciones.

We describe two high-caliber persistent median arteries (MPA) in an asymptomatic 22 year old healthy man, one of them between a bifid median nerve (BMN). The median artery may persist into adulthood, accompanying the median nerve through the carpal tunnel. It is a frequent anatomic variant, usually bilateral, regularly associated to BMN. The presence of MPA may be associated with acute carpal tunnel syndrome (CTS) secondary to thrombosis and chronic CTS probably due to spatial conflict. In this case, calls attention the lack of symptomatology despite the great size of MPA. We suggest performing prior to any surgery or infiltration of corticosteroids for CTS, an ultrasonographic study to avoid surgical complications.

The Ultrasonographic Findings of Bifid Median Nerve

PURPOSE: We wanted to evaluate the ultrasonographic findings of bifid median nerve and its clinical significance. MATERIALS AND METHODS: We retrospectively reviewed five cases (three men and two women, mean age: 54 years) of incidentally found bifid median nerve from 264 cases of clinically suspected carpal-tunnel syndrome that were seen at our hospital during last 6 years. Doppler sonography was performed in all five cases and MR angiography was done in one case for detecting a persistent median artery. The difference (deltaCSA) between the sum of the cross-sectional areas of the bifid median nerve at the pisiform level (CSA2) and the cross-sectional area proximal to the bifurcation(CSA1) was calculated. RESULTS: The incidence of a bifid median nerve was 1.9%. All the patients presented with a tingling sensation on a hand and two patients had nocturnal pain. All the cases showed bifurcation of the nerve bundle proximal to the carpal tunnel. The margins appeared relatively smooth and each bundle showed a characteristic fascicular pattern. A persistent median artery was noted between the bundles in four cases. deltaCSA was more than 2 mm2 in four cases. CONCLUSIONS: Bifid median nerve with a persistent median artery is a relatively rare normal variance and these are very important findings before performing surgical intervention to avoid potential nerve injury and massive bleeding. We highly suggest that radiologists should understand the anatomical characteristics of this anomaly and make efforts to detect it.