Superficial Palmar Arch: an Arterial Diameter Study

J. Anat. (2004) 204, pp307–311

BRIEFBlackwell Publishing, Ltd. COMMUNICATION Superficial palmar arch: an arterial diameter study Valéria Paula Sassoli Fazan,1,2 Celso Teixeira Borges,2 Jefferson Hilário da Silva,2 Abadio Gonçalves Caetano2 and Omar Andrade Rodrigues Filho2 1Department of Surgery and Anatomy, School of Medicine of Ribeirão Preto, University of São Paulo, Brazil 2Department of Biological Sciences, School of Medicine of Triângulo Mineiro, Uberaba, Minas Gerais, Brazil

Abstract

Although anatomical variations in the arterial pattern of the hand have been the subject of many studies, information on the diameter of the superficial palmar arch contributing vessels and its branches are rarely found in the literature. The objective of the current study was to evaluate these arterial variations, with special attention to the diameter of the superficial palmar arch contributing vessels and its major branches. Forty-six hands from male embalmed human cadavers were evaluated, 21 right hands and 25 left hands. Complete arches were present in 43% on the right and in 52% on the left. Arches were completed by the median artery in two cases. Variations were more common at the radial side of the arch and on left hands. Comparison of vessel diameters revealed the radial artery to be significantly larger than the ulnar artery but the ulnar artery to be larger than the superficial branch of the radial artery. The diameters of the common digital arteries were not different with regard to complete or incomplete arches, or with regard to the presence of the median artery. Key words arterial variations; hand; median artery; radial artery, ulnar artery; vascular anatomy.

because, based on anatomical studies, new surgical Introduction procedures can be proposed. Omokawa et al. (2001) The high incidence of anatomical variations in the proposed two different reverse island flaps for large arterial pattern of the hand has been the subject of many palmar defects of the fingers based on a cadaver study anatomical studies (McCormack et al. 1953; Coleman of the arterial branches supplying the midpalmar & Anson, 1961; Jelicic et al. 1988; Gajisin & Zbrodowski, area. In that study, the authors evaluated the arterial 1993; Gellman et al. 2001; Ruengsakulrach et al. 2001). diameter of the cutaneous perforating arteries. The The superficial palmar arch is a dominant vascular objective of the current study was to evaluate the arterial structure of the palm of the hand and, together with variations, with special attention to the diameter of the deep palmar arch, provides the blood supply to all the vessels forming the superficial palmar arch and the fingers. Recent progress in hand surgery has engen- its major branches. The purpose of this study was to add dered a need for precise knowledge of the frequency of new information on the diameter of these vessels anatomical variations in the superficial palmar arch with respect to the presence or absence of a complete and its branches (Jelicic et al. 1988). Very little information superficial palmar arch and to correlate the findings is available in the literature on the diameter of the with laterality information. superficial palmar arch and its branches. Knowledge of the size of these vessels is important in improving Materials and methods microsurgical techniques in reconstructive hand surgery Forty-six hands from 25 male embalmed human cadavers (fixed in 10% formaldehyde solution) were studied. Correspondence Anomalous tortuosities, dilatations, aneurisms or Dr Valéria Paula Sassoli Fazan, MD, PhD, Department of Surgery and atheromatous/occlusive disease tissues were discarded Anatomy, School of Medicine of Ribeirão Preto – USP, Ave. Bandei- rantes 3900, Ribeirão Preto, SP 14049–900, Brazil. T: +55 16 602 2407; at the beginning of the study. An anatomically normal F: +55 16 633 0017; E: [email protected] superficial palmar arch was defined as a direct continuity Accepted for publication 21 January 2004 between the ulnar artery and the superficial branch of

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Fig. 1 (A) Example of a right superficial palmar arch, as classically described in the literature, showing all the branches measured in the current study. A, ulnar artery; B, superficial branch of the radial artery to the superficial palmar arch; C, radial index artery, as a branch of the 1st common digital artery (#); D, princeps policis artery as a branch of the 1st common digital artery (#). Asterisks indicate the 2nd, 3rd and 4th common digital arteries. Arrow indicates the digitus minimus artery. (B) Schematic drawing of a left superficial palmar arch, as classically described in the literature, including all its branches measured in the current study. *, The radial artery continuation, after giving off its superficial branch; **, the deep branch of the ulnar artery, to the deep palmar arch. Letters indicate the site of arterial diameter measurements. A, radial artery; B, superficial branch of the radial artery to the superficial palmar arch; C, ulnar artery to the superficial palmar arch; D, princeps policis artery as a branch of the 1st common digital artery (J); E, radial index artery, as a branch of the 1st common digital artery (J); F, 2nd common digital artery; G, 3rd common digital artery; H, 4th common digital artery; I, digitus minimus artery. (C) The most common variation reported here: note the presence of a small radial artery branch to the arch (dashed line) that arose dorsally and passed into the palm to reach the ulnar artery. (D) An incomplete superficial palmar arch, with contributions from both ulnar and radial arteries. (E) An incomplete superficial palmar arch formed only by the ulnar artery. (F) An incomplete superficial palmar arch in which the median artery substitutes the radial artery vascular territory. (G) A superficial palmar arch in which the median artery substituted the radial artery to complete the arch.

the radial artery (Agur & Lee, 1991; Clemente, 1997; and description of the anatomical variations were Gellman et al. 2001). The main branches of the sup- carried out for the ulnar and radial arteries and for the erficial palmar arch were considered as being the three superficial palmar arch and its branches. common digital arteries (Coleman & Anson, 1961; Ger With the aid of an electronic digital caliper (range et al. 1996) and the proper digital artery to the ulnar of 0–300 mm, resolution 0.01 mm, Gehaka, SP, Brazil), border of the fifth digit (digitus minimus artery) the arterial diameters were measured as represented (Agur & Lee, 1991; Clemente, 1997; Gellman et al. 2001). in Fig. 1(B). If a median artery contributed to the sup- When an arterial trunk, which provided the origin to erficial palmar arch, its diameter at wrist level was also a major vessel to the thumb (princeps policis artery) and measured. Arterial diameters were compared between another vessel to the radial side of the index finger sides (right and left) and between arteries. For this (radial index artery), originated from the superficial comparison, data were tested for normal distribution palmar arch, this was considered as the first common by the Kolmogorov–Smirnov normality test (Ong & digital artery (Al-Turk & Metcalf, 1984; Clemente, 1997). LeClare, 1968; Rosenthal, 1968). If the data presented Therefore, the classical three common digital arteries a normal distribution, comparisons were made by the were named as second to fourth (Fig. 1A). Quantification unpaired Student’s t-test. Otherwise, comparisons were

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made by the Mann–Whitney test (Mann & Whitney, Table 1 Mean diameter of the ulnar and radial artery, at wrist 1947). Differences were considered significant if P < 0.05. level, on the presence of a complete or incomplete superficial palmar arch

Results Complete superficial Incomplete superficial palmar arch palmar arch Forty-six hands were evaluated in total, 21 on the right Right Left Right Left and 25 on the left. A complete superficial palmar arch was present in 43% of the right hands and in 52% of Radial artery 3.1 ± 0.2 3.1 ± 0.2 2.6 ± 0.3* 2.7 ± 0.2* the left hands. In these cases, arches completed by the Ulnar artery 2.5 ± 0.2# 2.6 ± 0.1# 2.6 ± 0.2 2.6 ± 0.2 median artery were included (one case on the right and Data are expressed as mean ± standard error of mean (SEM). one case on the left) (Fig. 1G). Incomplete arches (57% *Significant difference between diameters of the radial arteries on the right and 48% on the left) are represented in on hands with complete and incomplete superficial palmar arches. Fig. 1(D,E). The normal superficial palmar arch, formed #Significant difference between diameters of radial and ulnar arteries on hands with complete superficial palmar arches. by the ulnar artery and the superficial branch of the radial artery (Fig. 1A), was found in 48% of cases on each side. (dorsalis pollicis artery) showed an average diameter The most common variation in superficial palmar of 1.7 ± 0.1 mm, which was not different (Mann–Whitney arch anatomy was the presence of a small radial artery test, P = 0.19) from the superficial branch of the radial branch to the arch, arising dorsally (dorsalis pollicis artery present in the normal complete arches. artery; Agur & Lee, 1991), at the level of origin of the In the two hands in which a complete superficial princeps pollicis artery, which passed into the palm palmar arch was formed by the ulnar and median arteries, to reach the ulnar artery (Fig. 1C). This variation was the mean diameter of the median artery at wrist level found in 33% of the left hands and in 20% of the right was 1.7 ± 0.3 mm, which was significantly smaller than hands. In those hands with incomplete superficial either the radial artery (P = 0.001, Student’s t-test) or palmar arch, this small vessel was present in 33% of the the ulnar artery (P = 0.036, Student’s t-test) at the same left hands and 8% of the right hands. level in those hands with a normal arch. A median artery was found in five out of 46 (10%) The mean average diameter of the classically described hands studied, three left hands and two right hands. common digital arteries (2nd, 3rd and 4th) was 1.6 ± In two of these hands, one on the right and one on the 0.2 mm (values ranged from 1.5 to 2.0 mm). There was left, the median artery substituted the radial artery no significant difference in these diameters when to complete the arch (Fig. 1G). On the other three cases, comparing each of the arteries between left and right the median artery gave off the 1st and 2nd common hands, complete and incomplete arches, or when the digital arteries to the palm, without completing a median artery contributed to the superficial palmar superficial palmar arch (Fig. 1F). One cadaver showed arch. a bilateral median artery, with a symmetric distribution on both hands. Discussion The diameters of the ulnar and radial arteries at wrist level are given in Table 1. When comparing diameters The vascular patterns of the palmar arches and between the arteries that complete the arches on those their interconnecting branches present a complex and hands with a complete superficial palmar arch, the challenging area of study. This anatomy may not accord diameter of the ulnar artery (2.5 ± 0.2 mm on the right with descriptions in standard textbooks and many and 2.6 ± 0.1 mm on the left) was significantly larger attempts have been made to classify these variations. (P < 0.001, Student’s t-test) than the superficial branch One of the first reports that presented a complex of the radial artery (1.7 ± 0.2 mm on the right and classification of the superficial palmar arches was the 1.4 ± 0.1 mm on the left) on both sides. In those hands classic work of Coleman & Anson (1961). Since then, many with an incomplete superficial palmar arch, there other classifications have been suggested by different was no superficial branch of the radial artery. When authors (Karlsson & Niechajev, 1982; Al-Turk & Metcalf, the most common variation reported in this study was 1984; Doscher et al. 1985; Ruengsakulrach et al. 2001; investigated, the small radial artery branch to the arch Gellman et al. 2001). In the current study, the complete/

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incomplete classification was used, despite the literature Gellman et al. (2001) published a description of the controversy, because this basic classification is common vessel lumen diameter of the superficial palmar arch to all and provides the simplest understanding of and its branches. These authors described a radial artery the anatomical distribution of the arches. The variations average diameter of 2.6 mm. Nevertheless, the authors observed in this study were congenital/developmental did not mention any difference between sides or clas- in origin. Although the classical pattern of the superficial sification of the arches. In the current study, the radial palmar arch occurs infrequently, the reported frequency artery diameter was significantly smaller on hands with of the anatomical presence of a complete superficial incomplete superficial palmar arches. The ulnar artery palmar arch varies from 84% to 66% (Coleman & Anson, diameter in the current study was similar to those 1961; Al-Turk & Metcalf, 1984; Ruengsakulrach et al. described by Gellman et al. (2001). These authors also 2001; Gellman et al. 2001). This incidence was lower in described common digital palmar artery diameters with the current study and might be a reflection of the values similar to those reported here. Although formalin- relatively small sample size (46 hands). fixed cadavers were used in the current study, the Despite the wide variety of classifications and varia- vessel diameter data can be considered valid because tions described for the superficial palmar arch, the most they do not differ from those reported in studies common variation found in the current study has only carried out on fresh cadavers (Gajisin & Zbrodowski, 1993; rarely been described. McCormack et al. (1953) found Gellman et al. 2001) or in vivo, with non-invasive methods a small vessel arising dorsally from the radial artery for accessing the arterial diameters (Ikeda et al. 2002; passing into the palm to join the ulnar artery in 51% of Joannides et al. 2002). The current study also shows that the hands studied. In the current study, the frequency there is some variability in the calibre of the common of a similar radial artery branch was 33% on the left digital arteries (2nd, 3rd and 4th) but that this variability side and 20% on the right side. In this situation, the is not great (values ranged from 1.5 to 2.0 mm). superficial palmar arch is completed on the radial side by Arterial diameter is an indicator of blood flow and a small branch of the radial artery. This branch arises is therefore relevant in ensuring good reperfusion of on the dorsal surface of the first dorsal interosseous local structures during reconstructive surgery. Informa- muscle to join the ulnar artery distal to the insertion tion on normal arterial diameters is also important of the adductor pollicis muscle. Allen’s test is widely in relation to changes in response to drugs or different used to assess the ulnar collateral blood supply of the treatments, or alterations in pathologies such as hyper- hand because concerns exist regarding the risk of hand tension and diabetes. ischaemia should there be an inadequate ulnar collateral blood supply (Jarvis et al. 2000). In our observations, Acknowledgements 39% (18/46) of the hands studied showed an important contribution of the radial artery in supplying the dorsal This work was awarded the ‘Prof Renato Locchi’ side of the thumb and index finger. Although 33% of Morphological Sciences Award – Gross Anatomy Category, the left hands and 20% of the right hands studied 2002, from the Brazilian Society of Anatomy. We thank showed the dorsalis pollicis artery, which could be the late Mr Arnaldo Geraldino, from the Human contributing to the local supply to these regions, its Anatomy Discipline, School of Medicine of Triângulo diameter was significantly smaller than the radial artery. Mineiro, for his excellent technical support while the In these cases, acute compression of the radial artery work was carried out. Financial support: CNPq grant may not be a sufficiently discriminatory test, leading no. 501230/2003-3. to a false positive Allen’s test interpretation, because this small vessel may require time for its arterial flow to adjust to the local irrigation of the hand structures. References The median artery was found in 10% of the hands, a Agur AMR, Lee MJ (1991) Grant’s Atlas of Anatomy, 9th edn. similar frequency to that reported by McCormack et al. Baltimore, MD: Williams & Wilkins. (1953). Although O’Sullivan & Mitchell (2002) suggested Al-Turk M, Metcalf WK (1984) A study of the superficial palmar arteries using the doppler ultrasonic flowmeter. J. Anat. that absence of the palmaris longus tendon could be a 138, 27–32. predictor of the pattern of the superficial palmar arch, Clemente CD (1997) Anatomy. A Regional Atlas of the Human this tendon was present in all cases examined here. Body, 4th edn. Baltimore, MD: Williams & Wilkins.

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