Enigma of scapular foramen and tunnels: an untold story.

PURPOSE: The study was undertaken to make a qualitative and quantitative assessment of unnamed foramen and tunnels in adult human scapulae with aid of plain and contrast radiographs. MATERIALS AND METHODS: A total of 120 dry bones, 60 each of the right and the left side were included in the study. Distribution of these foramina and tunnels was noted for their number, side, location, course and communication. Their morphometry was done using Vernier's caliper. RESULTS: Incidence of scapular foramina was 7.5% (R > L), whereas scapular tunnels were seen in 15.8% cases. Incidence of the sinuous, curved, and straight tunnels was found to be 50, 39, and 10.7% respectively. Left-sided tunnels were longer than the right ones. Plain and contrast radiographs were taken to confirm the findings. CONCLUSION: Anatomy literature describes only two scapular foramina, namely, nutrient foramen and suprascapular foramen/notch in a great zeal; occurrence of such anonymous foramina is hardly discussed. Through this study, there is an endeavor towards unfolding the mystery of scapular foramina in terms of their morphometry and distribution, the knowledge of which will aid clinicians, forensic experts, and surgeons in better diagnosis and management of clinical cases.

Unusual Branching Pattern of the Lateral Cord of the Brachial Plexus Associated with Neurovascular Compression: Case report.

The brachial plexus consists of a network of nerves that innervates the upper limbs and its musculature. We report a rare formation of the lateral cord of the brachial plexus observed during the dissection of a 47-year-old male cadaver at the Department of Anatomy, Vardhman Mahavir Medical College, New Delhi, India, in 2016. The lateral cord was exceptionally long with twin lateral pectoral nerves and twin lateral roots of the median nerve. The proximal lateral root of the median nerve was thin in comparison to the medial root of the median nerve. The distal lateral root of the median nerve was thicker and followed an unusual course through the coracobrachialis muscle. In the lower third of the arm, the median nerve and the brachial artery-along with its vena comitans-spanned through the brachialis muscle. Surgeons, anaesthesiologists, radiologists and anatomists should be aware of such anatomical variations as they may result in neurovascular compression.

Absence of Posterior Triangle: Clinical and Embryological Perspective.

Sternocleidomastoid (SCM) and Trapezius (TM) muscle present in the cervical region serves as an important landmark in forming boundaries of posterior triangle of neck. This case reports a continuous muscle sheet obscuring the left posterior triangle in the neck of a 60-year-old Indian male cadaver. An unfamiliar oval gap was observed in its posterosuperior portion. Description of such a variant in anatomical literature is rare and is scarcely reported. An attempt has been made to portray its embryological and phylogenetic basis. In addition authors have endeavoured to discuss its clinical implications. Awareness of such anatomical variations is relevant for the operating surgeons in their endeavour to perform various reconstruction surgeries of head and neck, radiologists while concluding various levels in Computed Tomography (CT) and Magnetic Resonance Images (MRI) of the region and to the anaesthetists in their search for nerves and vessels while attempting various anaesthetic procedures.

Aberrant pancreatic ductal organisation: a case report.

Anomalous pancreatic ductal system has always enthralled the anatomists, surgeons, gastroenterologists and radiologists alike. With the growing use of MRCP, ERCP and endoscopic and surgical procedures, the knowledge of anatomical aberrations of pancreaticobiliary tract becomes extremely important. Moreover, the anomalous pancreatic duct morphology may be responsible for atypical gastrointestinal complains. We report an exceptionally rare case of two accessory ventral pancreatic ducts opening separately into the common bile duct proximal to the hepato pancreatic ampulla. Concomitant occurrence of an ectopic major duodenal papilla, 3.8 cm distal to the pyloric end of stomach was also seen. Moreover, the accessory pancreatic duct and the minor duodenal papilla were absent. Clinical implications and embryological description of these rare anomalies are discussed. Awareness of such rare morphological variants can go a long way in assisting effective patient management.

Peripheral communications of intercostobrachial nerve Peripheral communications of the intercostobrachial nerve in relation to the alar thoracic artery.

The intercostobrachial nerve (ICBN) is often encountered during axillary dissection for axillary lymph node dissection (ALND) for diagnostic and therapeutic surgery for mastectomy. The present report is a case observed in the Department of Anatomy at Vardhman Mahavir Medical College, Delhi during routine dissection of the upper extremity of a male cadaver for first year undergraduate medical students. On the right side, the medial cord of brachial plexus gave two medial cutaneous nerves of arm. Both the nerves were seen communicating with the branches of the ICBN. The ICBN and one of its branches were surrounding the termination of an alar thoracic artery. These peripheral neural connections of the ICBN with the branches of the medial cord can be a cause of sensory impairment during axillary procedures done for mastectomy or exploration of long thoracic nerves. The alar thoracic artery found in relation to the ICBN could further be a cause of vascular complications during such procedures.

Unduly extensive uncinate process of pancreas in conjunction with pancreatico-duodenal fold.

Anatomical variations of pancreatic head and uncinate process are rarely encountered in clinical practice. These variations are primarily attributed to the complex development of the pancreas. An unduly enlarged uncinate process of the pancreas overlapping the third part of duodenum was discovered during dissection. This malformation of the pancreatic uncinate process was considered to be due to excessive fusion between the ventral and dorsal buds during embryonic development. On further dissection, an avascular pancreatico-duodenal fold guarding the pancreatico-duodenal recess was observed. The enlarged uncinate process can cause compression of neurovascular structures and also cause compression of adjoining viscera. The pancreatico-duodenal recess becomes a potential site for internal herniation. This case is of particular interest to the gastroenterologists and surgeons performing surgical resections. Precise knowledge of embryogenesis of such pancreatic anomalies is necessary for understanding and thus treating many diseases of the pancreas.

Unusual disposition of lateral circumflex femoral artery: Anatomical description and clinical implications.

The anatomical knowledge of arterial variations of lower limb is of utmost significance for the present day surgeons and interventional radiologists for minimizing complications during vascular reconstructive procedures, catheterization procedures and surgical intervention for embolism. Lateral Circumflex Femoral Artery (LCFA) is an important branch of Profunda Femoris artery and precise knowledge of its variations can be of great relevance during surgical and radiological procedures in femoral region. The present study reports a unique case of anomalous route taken by LCFA posterior to femoral nerve associated with a prominent muscular branch from Femoral artery mimicking the course of LCFA. Documentation of such variations is highly significant. It may serve as guideline for surgeons in reducing the incidence of postoperative complications where LCFA is used as a long vascular pedicle in anterolateral perforator thigh flap and in breast reconstruction after mastectomy. Ignorance of such variations can lead to fatal intraoperative haemorrhage and incapacitating sensory and motor deficit due to injury to femoral nerve branches which are closely related to these vessels.

Morphometric analysis of upper end of tibia.

INTRODUCTION: The present study aims to assess different morphometric parameters of condylar and intercondylar surface of tibia and to compile the results, analyze and formulate a baseline data for future studies with relevance to Indian population and also to compare the current data with accessible literature for pertinent surgical utilities. Morphometric parameters of upper end of tibia can be used to guide treatment and monitor outcome of total knee replacement surgeries. Information regarding morphometry of upper end of the tibia is vital as it provides reliable method of assessing knee deformity. MATERIALS AND METHODS: The study group comprised of 50 male and 50 female adult human tibiae. Morphometric measurements of medial condyle, lateral condyle and intercondylar area of tibiae were meticulously recorded with digital Vernier calipers with a least count of 0.01 mm. Student's t-test was used with significant level of p-value < 0.05 and 95% confidence interval. RESULTS: All measurements were found to be statistically significant when compared between the two sexes on both sides (p-value<0.05). Anteroposterior measurements were found to be greater than transverse measurements for both medial and lateral condyles. Furthermore, both anteroposterior and transverse measurements were greater in medial condyle than in lateral condyle on both sides and sexes. CONCLUSION: The present study is an endeavor to provide a base line data pertaining to morphometric details of upper end of tibia with reference to unicompartmental and total knee arthroplasty in Indian population. The results of the study assume special importance in view of the technical advancements in reconstructive surgical procedures in orthopedic practice.

Multiple unilateral variations in medial and lateral cords of brachial plexus and their branches.

During routine dissection of the upper extremity of an adult male cadaver, multiple variations in branches of medial and lateral cords of brachial plexus were encountered. Three unique findings were observed. First, intercordal neural communications between the lateral and medial cords were observed. Second, two lateral pectoral nerves and one medial pectoral nerve were seen to arise from the lateral and medial cord respectively. The musculocutaneous nerve did not pierce the coracobrachialis. Finally, the ulnar nerve arose by two roots from the medial cord. Knowledge of such variations is of interest to anatomists, radiologists, neurologists, anesthesiologists, and surgeons. The aim of our study is to provide additional information about abnormal brachial plexus and its clinical implications.

Human tibial torsion--morphometric assessment and clinical relevance.

BACKGROUND: Tibial torsion is an important anatomical parameter in clinical practice and displays variability among individuals. These variations are extremely significant in view of alignment guides such as those related to rotational landmarks of tibia in total knee arthroplasty. Further, precise knowledge and information pertaining to angle of tibial torsion also helps in correction of traumatic malunion or congenital maltorsion of tibia. METHODS: The present study was carried out to determine the angle of tibial torsion in 100 adult dry tibia bones in the Department of Anatomy, Government Medical College, Amritsar. The study group comprised 50 males and 50 females with equal number of right- and left-sided bones. The measurements were meticulously recorded and the data were subjected to statistical analysis. The results were analyzed and discussed in the light of existing literature. RESULTS: On the right side, it was found to be 29.84° ± 4.86°° (range = 22.00° -38.00°) in males and 28.92° ± 5.10°° (range = 15.00°-38.00°) in females. On the left side, it was found to be 28.00° ± 4.94°° (range = 20.00°-40.00°°) in males and 28.12° ± 4.28°° (range = 20.00°-37.00°°) in females. CONCLUSION: The present study is an endeavor to provide baseline data with reference to the angle of tibial torsion in the Indian population. The results of the study assume special importance in view of the technical advancements in reconstructive surgical procedures in orthopedic practice.

Quadrifurcation of the hepatic artery proper in conjunction with double right gastric arteries.

Descriptions of the variant hepatic arterial pattern are common and frequently reported in anatomy archives. We describe a noteworthy deviation from the usual branching pattern in a single cadaver. There was a unique division of the hepatic artery proper into two right gastric arteries (RGAs), apart from the usual branches. Furthermore, an arterial loop was formed by these two RGAs, giving off another RGA, which we termed 'right gastric proper'. This report attempts to evaluate the embryological basis of the anomaly. The significance of this anomalous hepatic arterial pattern is appreciated while performing liver transplantations, hepatic artery infusion of chemotherapeutic drugs and Doppler angiographic procedures. We advocate meticulous familiarisation with the anatomy of the coeliac trunk and its topographic relationship to vital viscera for the operating hepatobiliary surgeon and radiologist.

Anomalous composition of musculature of the first dorsal fibro-osseous compartment of the wrist.

The anomalous orientation of musculature of the first dorsal fibro-osseous compartment of the wrist is clinically relevant to De Quervian's stenosing tenosynovitis and reconstructive surgeries. Split insertion of the abductor pollicis longus (APL) is commonly found in chimpanzees, gorillas and gibbons. A comparable identical pattern of anomalous slips in humans is of anthropological and phylogenetic importance and could be a result of atavism. This case report describes an unusual fused muscle belly of the APL and extensor pollicis brevis (EPB), which split into three slips--medial, intermediate and lateral. Further, the medial slip was seen to divide into two tendons, inserting on the base of the first metacarpal along with the intermediate slip. The lateral slip divided into three tendons, inserting into the base of the proximal phalanx, base of the first metacarpal and abductor pollicis brevis muscle. The fusion and unusual insertion pattern of the APL and EPB merits documentation for reconstructive procedures such as tendon transfer and interposition arthroplasty.

Unusual topography of posterior antebrachial musculature in the first osseofibrous compartment of wrist: clinicomorphological appraisal / Topografía inusual de la musculatura antebraquial posterior en el primer compartimento osteofibroso de la muñeca: valoración clínico-morfológica

Anatomical variations of abductor pollicis longus and extensor pollicis brevis are important in clinical assessment of diseased and traumatized hand. The present case reports an unusual fusion of muscle bellies of abductor pollicis longus and extensor pollicis brevis with two separate tendons of insertion, the medial tendon inserted into the base of first metacarpal and the lateral tendon into the abductor pollicis brevis muscle. Knowledge of such anatomical variations is of utmost importance in the management of De Quervain's disease and reconstructive surgeries of hand.

Las variaciones anatómicas de los músculos abductor largo del pulgar y extensor corto del pulgar son importantes en la evaluación clínica de la mano enferma y traumatizada. El presente caso informa una inusual fusión de los vientres musculares de los Mm. abductor largo del pulgar y extensor corto del pulgar con dos tendones de inserción separados, el tendón medial se insertó en la base del primer metacarpiano y el tendón lateral en el músculo abductor corto del pulgar. El conocimiento de estas variaciones anatómicas es de importancia en el manejo de la enfermedad de De Quervain y cirugía reconstructiva de la mano.

Bipartite clavicular attachment of the sternocleidomastoid muscle: a case report.

Morphological variations of the sternocleidomastoid (SCM) muscle assume relevance during attempted surgical interventions in the cervical region. The present study reports bipartite clavicular attachment of the SCM in the neck of an adult male cadaver during performance of a routine anatomy demonstration. The anomaly was unilaterally observed on the left side of the neck. The clavicular head of the muscle exhibited two bellies, one medial and one lateral. While the medial belly was fused with the sternal head, the lateral belly appeared to blend with the medial. Cranially, the SCM attached to the mastoid process and superior nuchal line. We have attempted to elucidate the embryological basis of the above muscular variant. Additionally, we discuss its clinical relevance, highlighting the utility of the SCM in various reconstructive procedures. We assert that detailed anatomical knowledge of such SCM variants is of utility not only to the gross anatomist, but also for neck and orthopaedic surgeons and anaesthetists. Moreover, radiologists require familiarity with such aberrations to decipher magnetic resonance imaging scans of the cervical region.

Anomalous superior thyroid artery.

The variations in the pattern of distribution of superior thyroid artery assume paramount importance for neck surgeons, in view of its vital topographical relationship to the external laryngeal nerve. In this study, we report an unusual variation in the arterial supply of the thyroid gland, which was detected during a routine dissection of an adult male cadaver. The right superior thyroid artery was absent whereas the left superior thyroid artery took origin from the left common carotid artery and showed a dominant pattern of distribution supplying the superior aspect of both the left and right lobes of the thyroid gland. It exhibited a usual relationship with the left external laryngeal nerve. The inferior thyroid arteries did not show any unusual distribution. Knowledge of such arterial variations related to the thyroid gland is immensely helpful for surgeons in order to put ligature on anomalous artery and to avoid damage to vital structures in this area, such as the external laryngeal nerve.

Unilateral quadripartite composition of pectoral major muscle: anatomical description and clinical implications / Composición unilateral cuadripartita del músculo pectoral mayor: descripción anatómica e implicancias clínicas

A unilateral anomalous disposition of the muscular slips of pectoralis major was observed in an adult male cadaver during routine gross anatomy teaching session. The pectoralis major muscle displayed unusual configuration and comprised of four parts delineated by three intramuscular clefts. Further, the sternocostal part was found to divide into two fasciculi. The origin and insertion of pectoralis major muscle was as usual and unremarkable. Interestingly, the innervation of the muscle was observed to bear an important variation. The clavicular and sternocostal slips of pectoralis major muscle received a direct branch from the lateral cord of brachial plexus in addition to its usual innervation from the lateral and medial pectoral nerves. The multiplicity of innervation of pectoralis major as encountered in the present study would presumably augment its suitability for its use in reconstructive procedures. An additional anomalous attachment of the pectoralis minor muscle was also observed emanating from the second rib, apart from the usual third, fourth and fifth ribs. These variants of the pectoral muscles may also have implications in biomechanical studies, as they may alter the kinematics.

Una disposición anómala unilateral de los vientres musculares del músculo pectoral mayor se observó en un cadáver adulto de sexo masculino durante una clase de rutina de anatomía. El músculo pectoral mayor mostró una configuración inusual y presentaba cuatro partes delimitadas por tres depresiones intramusculares. Además, la parte esternocostal se encontraba dividdida en dos fascículos. El origen y la inserción del músculo pectoral mayor era normal. Curiosamente, la inervación de los músculos, presentaba una importante variación anatómica. Los fascículos clavicular y esternocostal del músculo pectoral mayor recibieron una rama directa del fascículo lateral del plexo braquial, además de su inervación normal de los nervios pectoral lateral y medial. La múltiple inervación del músculo pectoral mayor como se encuentró en el presente estudio, probablemente, haga aumentar su idoneidad para el uso en procedimientos reconstructivos. También se observó un fascículo adjunto anómalo adicional del músculo pectoral menor, que se originaba de la segunda costilla, además de su origen en la tercera, cuarta y quinta costillas. Estas variaciones de los músculos pectorales también puede tener implicancias en estudios biomecánicos, ya que probablemente alteran la cinemática.

An assembly of anomalous extensor tendons of the hand--anatomical description and clinical relevance.

Innumerable descriptions about variations in the pattern of extensor tendons are recorded in the literature. The dorsum of the hand in an adult male cadaver revealed an unusual pattern of extensor arrangement during a gross anatomical practical session. The extensor digitorum, extensor indicis and extensor digiti minimi tendons displayed a variant pattern. Extensor digitorum contributed tendons only to the middle and ring fingers, with junctura tendinum present between the extensor digitorum for the ring finger and extensor digiti minimi. Interestingly, an accessory muscle was observed arising from the common extensor origin passing to the index finger, in addition to the usual extensor indicis. The origin and insertion of extensor digiti minimi was as usual with an accessory slip contributed from the extensor carpi ulnaris to the proximal phalanx of the fifth finger. The plethora of variations in this region is of paramount importance for the reconstructive surgeon, who may utilize the accessory tendons to restore functional capacity of the fingers.

An Assembly of Anomalous Extensor Tendons of the Hand - Anatomical Description and Clinical Relevance.

Innumerable descriptions about variations in the pattern of extensor tendons are recorded in the literature. The dorsum of the hand in an adult male cadaver revealed an unusual pattern of extensor arrangement during a gross anatomical practical session. The extensor digitorum, extensor indicis and extensor digiti minimi tendons displayed a variant pattern. Extensor digitorum contributed tendons only to the middle and ring fingers, with junctura tendinum present between the extensor digitorum for the ring finger and extensor digiti minimi. Interestingly, an accessory muscle was observed arising from the common extensor origin passing to the index finger, in addition to the usual extensor indicis. The origin and insertion of extensor digiti minimi was as usual with an accessory slip contributed from the extensor carpi ulnaris to the proximal phalanx of the fifth finger. The plethora of variations in this region is of paramount importance for the reconstructive surgeon, who may utilize the accessory tendons to restore functional capacity of the fingers.