Case Report Original Article

Archives of Clinical Experimental Surgery

Increased of Langerhans Cells in Smokeless ATobacco-Associated Variant Accessory Belly Oral of Extensor Mucosal Indicis Lesions Muscle: An Anatomical Variation

Srinivasa Rao Sirasanagandla1, Bhagath Kumar Potu2, Satheesha Nayak B1, SN Somayaji1, Narendra Pamidi1 Érica Dorigatti de Ávila1, Rafael Scaf de Molon2, Melaine de Almeida Lawall1, Renata Bianco 1 Department of Anatomy 1 1 Melaka Manipal Medical College ConsolaroAbstract , Alberto Consolaro Manipal University Madhav Nagar Muscular variations of the extensor compartment of the are generally encountered during sur- Manipal, Karnataka, India gical and dissection procedures. Additional bellies, extra tendons, and abnormal attachment are such 1 2Department of Anatomy reported variations. Knowledge of these kinds of variation are important for surgeons to plan Bauru Dental School Faculty of Medicine and Abstract University of São Paulo Health Sciences the surgical procedure and modify their approach to that case, or the surgeon can take the advantage Bauru–SP, Brazil UCSI University ofObjective: these variations To evaluate during musclethe changes graft inand the tendon number transplantation of Langerhans procedures. Cells (LC) Here observed we report in a thecase epithelium of School of Medicine 2Araraquara Dental School Cheras, Kuala Lumpur, Malaysia ofsmokeless an additional tobacco belly (SLT-induced) of the extensor indicislesions. muscle. The additional belly arose from the . Its tendon passed through the fourth compartment deep into the extensor retinaculum and São Paulo State University Received: June 16, 2012 Methods: Microscopic sections from biopsies carried out in the buccal mucosa of twenty patients, who were Araraquara-SP, Brazil divided into two tendinous slips on the dorsum of the hand. One of these slips attached to the ulnar Accepted: July 23, 2012 chronic users of smokeless tobacco (SLT), were utilized. For the control group, twenty non-SLT users of SLT Arch Clin Exp Surg 2014;3:64-65 side of the tendon of the extensor digitorum for the middle finger; the other slip was merged with with normal mucosa were selected. The sections were studied with routine coloring and were immunostained Received: February 05, 2012 DOI:10.5455/aces.20120723021445 over the dorsum of the hand. The additional belly was supplied by the posterior interosseous . Accepted: February 29, 2012 for S-100, CD1a, Ki-67 and p63. These data were statistically analyzed by the Student’s t-test to investigate the Corresponding author: Arch Clin Exp Surg 2012;X: X-X Key words: Additional bellies, extensor indicis, muscle grafts, tendon transplantation, clinical importance Dr. Bhagath Kumar Potu, Ph.D differences in the expression of immune markers in normal mucosa and in SLT-induced leukoplakia lesions. DOI: 10.5455/aces.20120229052919 UCSI University Results: There was a significant difference in the immunolabeling of all markers between normal mucosa School of Medicine Corresponding author Jalan Menara Gadin andIntroduction SLT-induced lesions (p<0.001). The leukoplakiaCase lesions report in chronic SLT users demonstrated a significant Érica Dorigatti de Avila Taman Connaught Cheras, Kuala Lumpur, Malaysia increaseThe inextensor the number indicis of Langerhans (EI) muscle cells and- be in the Anabsence anomalous of epithelial additional dysplasia. belly of EI Departamento de Estomatologia [email protected] da Faculdade de Odontologia de longsConclusion: to the deep The set increase of muscles in the ofnumber the exof -thesewas cells found represents in the the right initial forearm stage of leukoplakia. of approxi - Bauru tensorKey words:compartment Smokeless of tobacco, the forearm, leukoplakic which lesions, cancer,mately langerhans a 50-year-old cells, chewing male tobacco. cadaver dur- Universidade de São Paulo (USP) lies medial and parallel to extensor pollicis ing routine dissection classes for Phase-I Avenida Alameda Octávio Pinheiro Brizola, 9-75, 17012-901 longusIntroduction (EPL). It originates from the poste- undergraduatecontact with medical the students.oral mucosa The and EI creates a Bauru–SP, Brasil rior surface of the , distal to the origin originatedmore from alkaline the posterior environment, surface itsof theproducts may [email protected] of EPLAmong and from tobacco the adjacent users, there interosseous is a false beulna- and adjacent interosseous membrane, even be more aggressive to tissue [5]. The membrane.lief that SLT Its is tendonsafe because passes it underis not theburned, passed through the fourth compartment extensorwhich leads retinaculum many people in the fourthto quit dorsal cigarettes deep topercentage the extensor of retinaculum,SLT users is and lower in- compared compartment,and start using along SLT with[1]. However, tendons of SLT the conserted- to in cigarette the ulnar users; side ofhowever, the tendon usage of is increasing extensortains higher digitorum concentrations (ED). It joins of nicotinethe ulnar thanthe extensoramong digitorum young individuals (ED) for the and index it is therefore a side of the tendon of the extensor digito- finger.significant In the present and case,disturbing we observed danger an [6,7]. rumcigarettes for the indexand, in finger addition, opposite nearly the head30 carciadditional- belly, which arose from the in- ofnogenic the second substances, metacarpal such bone as [1].tobacco-specificterosseous membraneInitial studies partially on the fused effects with of SLT on the N-nitrosamines (TSNA), which is formed oral mucosa demonstrated the formation of during the aging process of the tobacco, [2-4] white lesions induced by chronic exposure to and which presents high carcinogenic poten- tobacco, characterized by epithelial thicken- tial. Moreover, because the tobacco has direct ing, increased vascularization, collagen altera- Variation of extensor indicis muscle 65

the tendon of ED for the middle finger; in contradic- tion to this, our case demonstrated two tendons with two different sites of insertion. If the additional bellies are small, they are asympto- matic and may go unnoticed. Such muscles are found during surgeries or dissection procedures. The addi- tional bellies can be used for the muscle graft purpose without sacrificing the normal muscle. If the muscle is large, it may confuse clinicians during diagnosis of vari- ous soft tissue conditions or it may also lead to some Figure 1. Photograph showing the additional belly of extensor in- confusion for surgeons operating in the forearm exten- dicis muscle and its mode of insertion (EI: extensor indicis; AB: sor and hand regions. Knowledge about the presence additional belly; TS: tendinous slip; *: extensor digitorum tendon). of multiple tendons of extensors is useful in identifying the muscle belly of EI. The tendon of this additional and planning tendon transfer or graft surgeries. If the belly passed through the fourth compartment deep to tendon of the additional belly is thick, it may decrease the extensor retinaculum, along with tendons of ED the space in the respective compartment and may in- and EI. On reaching the dorsum of the hand, the ten- crease the risk of tenosynovitis. Extension of a bulky, don of the additional belly divided into two tendinous musculotendinous portion of extensor indicis proprius slips. One of these slips attached to the ulnar side of the into the fourth dorsal compartment of the may tendon of ED for the middle finger; the other slip was lead to extensor indicis proprius syndrome [6]. There- very thin and merged with fascia over the dorsum of fore, clinicians must be aware of these variations for a the hand (Figure 1). The additional belly was supplied successful diagnosis and treatment. by a branch from the posterior interosseous nerve. The Conflict of interest statement opposite limb of the same cadaver did not reveal any The authors have no conflicts of interest to declare. variation. References Discussion 1. Williams PL, Bannister LH, Berry MM, Collins P, Presence of an anomalous muscle belly, occurrence Dyson M, Dussek JE, Ferguson MWJ (eds.) Gray’s of an extra tendon and variation in its insertions are the Anatomy. Churchill Livingstone, Edinburgh, Lon- reported variations of EI. In the present case, we are re- don, 1995: 851. porting a unique variation of the EI. Earlier, Yoshida et 2. Yoshida Y. Anatomical study on the extensor digi- al. [2] classified the variations of the extensor indicis torum profundus muscle in the Japanese. Okajimas muscle into four types: a) extensor indicis radialis, b) Folia Anat Jpn 1990;66:339-53. extensor indicis ulnaris, c) extensor pollicis etindicis 3. el-Badawi MG, Butt MM, al-Zuhair AG, Fadel RA. accessories, and d) extensor mediiproprius. El-Badawi Extensor tendons of the fingers: arrangement and et al. [3] described a variation of extensor medii brevis. variations--II. Clin Anat 1995;8:391-398. Mohandas KG et al. [4] reported a small muscle on the 4. Rao Mohandas KG, Vollala VR, Bhat SM, Bolla S, dorsum of the hand inserted into the (in Samuel VP, Narendra P. Four cases of variations addition to normal EI) and termed this extensor indicis in the forearm extensor musculature in a study of brevis. Kosugi et al. [5] observed that the EI could be hundred limbs and review of literature. Indian J absent in 0.6 to 3% of specimens. Our case is in con- Plast Surg 2006;39:141-147 formity with the extensor mediiproprius (EMP), but 5. Kosugi K, Meguri S, Fukushima O, Koda M. Ana- the tendon of the muscle belly was divided into two tomical study on the variation of the extensor mus- tendinous slips. One of these slips attached to the ul- cles. 1. M. extensor indicis. Tokyo Jikeikai Medical nar side of the tendon of ED for the middle finger; the Journal 1984a;99:867-876. other slip was very thin and merged with the fascia over 6. Ritter MA, Inglis AE. The Extensor Indicis Proprius the dorsum of the hand. In a report by Yoshida et al. Syndrome. J Bone Joint Surg Am, 1969;51:1645- [2], the EMP had two slips and both were attached to 1648. © GESDAV This is an open access article licensed under the terms of the Creative Commons Attribution Non-Commercial DOI:10.5455/aces.20120723021445 License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted, non-commercial use, www.acesjournal.org distribution and reproduction in any medium, provided the work is properly cited.