High Level Branching and Very Superficial Course of Radial Artery in the Anatomical Snuffbox: Its Clinical and Surgical Implications

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Case report

High level branching and very superficial course of radial artery in the anatomical snuffbox: its clinical and surgical implications

Anatomy P Jyothsna, SB Nayak , KG Mohandas Rao, N Kumar, P Abhinitha

Abstract It begins 1 cm distal to the elbow the right upper limb of an adult male Introduction joint, at the level of neck of radius. Variation in the origin of radial artery It runs medial to the brachiora- old. The RA had its origin from the is one of the common anomalies dialis throughout its course in the brachialcadaver agedartery approximately in the cubital 65 fossa.years in the upper limb. However, distal forearm. Just above the wrist, it is part of its course shows a constant forearm was normal. It gave its super- pattern. The knowledge of variations radialis medially and anterior bor- The proximal part of its course in the of the radial artery is of importance derpalpable of radius between laterally. the It flexor then turns carpi - in vascular and reconstructive sur- posterolaterally round the wrist ficial palmar branch, 8 cm above the geries. Here, we report the unusual palmarproximal branch border passed of the through flexor retithe the wrist and deep to the abductor thenarnaculum eminence (Figure 1). muscles The superficial before the radial artery in the forearm and superficial to the lateral ligament of thesuperficial dorsum courseof the hand. and branching of brevis muscles. It crosses the scaph- Case report oidpollicis and longustrapezium and extensorbones and pollicis just palmarcompleting arch, thethe RA superficial turned laterally palmar before it passes between the heads arch. After giving the superficial-

The radial artery gave its superficial and passed superficial to the abduc palmar branch 8 cm above the proximal pollicisof the firstlongus dorsal muscle. interosseous Between itthe is tendonstor pollicis (Figure longus, 2). extensor After crossing pollicis onborder to the of dorsalthe flexor aspect retinaculum. of the hand, After by crossed by the tendon of the extensor thesebrevis tendons, and extensor it passed pollicis between longus windinggiving the round superficial the lateral branch, aspect it passed of the crossed by the cephalic vein and digi- - talextensor branches muscles of the ofradial the nerve thumb, which it is interosseous muscle and entered the ing the boundaries of anatomical snuff palm.the two Its headscourse ofand the distribution first dorsal in wrist superficial to the tendons form- passes between the two heads of the the palm were normal. ous space. It passed between the two supply the thumb and index finger. It 1 box and reached the first interosse enters the palm . The common mode Discussion muscle to enter the palm. offirst termination dorsal interosseous of the RA muscleis by form and- The variations in the origin and Conclusionheads of the first dorsal interosseous ing the deep palmar arch. Although The knowledge of this variation of the variations in the origin of the RA are common than its distal course and 2 radial artery is important while per- common, with an incidence of 15% , termination.proximal course RA mayof the originate RA are morefrom forming intravenous cannulations variations in the course are rare, with 4,5, thoracoac- 3 and plastic surgeries. It is also impor- an incidence of only 0.52% . For radi- romial trunk or brachial artery . tant to cardiothoracic surgeons as ological, surgical and routine patient Manners-Smiththe axillary 6 9 artery 7,8- the radial artery is increasingly being care purpose, precise knowledge of tions in the course of the RA into two used for the coronary bypass graft in the course of the RA and its relation to classes according classified to its relation the variato the place of the great saphenous vein. adjacent structures in the distal part tendons forming the anatomical snuff of the forearm and wrist is of great - Introduction importance. We present a rare case The radial artery (RA) is the smaller box. In the first class, the RA is sin terminal branch of the brachial artery. and discuss its clinical and surgical gle and is entirely superficial to the importance.of ‘very superficial course’ of the RA arterytendons of of the the forearm. anatomical In the snuff second box, also known as the superficial dorsal *Corresponding author Case report and deep branches, documented Email: [email protected] During routine dissection classes for asclass, duplication the RA divides of the into RA 9superficial. The cur- Melaka Manipal Medical College (Manipal medical undergraduates, we found Campus), Manipal University, Karnataka, India the following variations of the RA in rent case belongs to the first class of Licensee OA Publishing London 2013. Creative Commons AttributionManners-Smith License classification. (CC-BY) In one

Jyothsna P, Nayak SB, Mohandas Rao KG, Kumar N, Abhinitha P. High level branching and very

For citation purposes: none declared. interests: none declared. Conflict of interests: Competing the final manuscript. as well read and approved design, and preparation of the manuscript, the conception, to All authors contributed rules of disclosure. ethical Ethics (AME) for Medical the Association All authors abide by superficial course of radial artery in the anatomical snuffbox: its clinical and surgical implications. OA Case Reports 2013 Aug 08;2(7):66. Page 2 of 3

Case report

or misinterpreted in contrast13–16 radiographselevation of17 . theHarvesting forearm of flaps the RA is one of the common surgical procedures. Patients with anatomical vari-

lower puncture and success rate in suchations procedures of the RA have. The a significantlyRA is being used for coronary18 artery bypass grafting19 and it has been shown to have a superior perioperative and post-operative course than the saphenous vein grafts20. In the current case,

the superficial palmar branch of the- ulumRA took and itsran origin just undercover 8 cm above of the Figure 1: Dissection of the distal part of the front of the right forearm showing skinproximal in the border distal ofthird the of flexor the forearm. retinac Awareness of this variation is very important as the artery is liable to get branchthe variation (SBRA). of theBranches radial ofartery the radial (RA). nerveNote its (RN) course along superficial with cephalic to the vein tendon and injured in skin incisions in the distal of abductor pollicis longus (APL) and the high origin of its superficial palmar third of the forearm. The very super- - flexor carpi radialis tendon (FCR) can also be seen. theficial cephalic course ofvein the is RA also in thea predispos anatomi- ingcal snufffactor box for andits inadvertent its close relation injuries. to It might get punctured instead of the cephalic vein while setting an intra-

venous line. Superficial cuts in the anatomical snuffbox might result in reportedsignificant here. bleeding when the artery is very superficial as the one being Conclusion The knowledge of this variation of the radial artery is important during intravenous cannulations and plastic surgeries. It is also important to cardiothoracic surgeons as the radial artery is increasingly being used for the Figure 2: Dissection of the lateral side of the right hand showing the anatomi- coronary bypass graft in place of the great saphenous vein. The knowledge dorsalcal snuff interosseous box. Note the (FDI), superficial dorsal relationshipvenous arch of(DVA), the radial branches artery of (RA) the toradial the nerveextensor (RN) pollicis and cephalic brevis (EPB) vein (CV) and canextensor also be pollicis seen. longus (EPL) tendons. First of high origin of superficial palmar bebranch important and very for thesuperficial plastic surgeons,course of cardiologiststhe RA in the anatomicaland radiologists. snuffbox may of the recent studies, the RA passed - References forThe veins, superficial which may arteries become ofa basis the - superficial to the anatomical snuff forupper intraarterial extremity injections may be instead mistaken of tomical basis of clinical practice. 39th ed. musclebox and in crossedone out superficial of 75 specimens to the intended intravenous injections11,12. London:1. Standering Elsevier S. Gray’s Churchill anatomy. Livingstone; The ana studiedtendon 10of. the extensor pollicis longus They may also be encountered during

2005.p883–28. Licensee OA Publishing London 2013. Creative Commons Attribution License (CC-BY)

Jyothsna P, Nayak SB, Mohandas Rao KG, Kumar N, Abhinitha P. High level branching and very

Case report

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Jyothsna P, Nayak SB, Mohandas Rao KG, Kumar N, Abhinitha P. High level branching and very