International Journal of Advances in Science Engineering and Technology, ISSN(p): 2321 –8991, ISSN(e): 2321 –9009 Vol-6, Iss-1, Spl. Issue-2 Mar.-2018, http://iraj.in ADDITIONAL BRANCH OF BRACHIAL ARTERY TERMINATING IN SUPERFICIAL PALMAR ARCH
1BILLAKANTI PRAKASH BABU, 2HUBAN THOMAS
1Associate Professor, Kasturba Medical College/Manipal Academy of Higher Education, Anatomy Department, Kasturba Medical College,Manipal,KARNATAKA-INDIA,576104 2Senior Lecturer, Kasturba Medical College/Manipal Academy of Higher Education, Anatomy Department, Kasturba Medical College,Manipal,KARNATAKA-INDIA,576104 E-mail: [email protected], [email protected]
Abstract - Superficial palmar arch is an arterial arcade in the palm of the hand formed by superficial branch of ulnar artery and can be completed on lateral side by superficial palmar branch of radial artery or any one of these arteries viz. princeps pollicis artery, radialis indicis artery or the median artery. The arch develops as a terminal plexus of axis artery of upper limb which is later joined by median, ulnar and radial arteries as these arteries develop. The present study was conducted in the Department of Anatomy, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, India on 60 formalin fixed adult human cadaver hands. Out of 60 (30 on right and 30 on left side) in one specimen a unique variation was encountered in the arteries taking part in the formation of superficial palmar arch on the right side. Superficial palmar arch formation was normal and in addition an additional branch arose from the medial side of the brachial artery just below the middle of the arm. It descended on the medial side of cubital fossa, superficial to common flexors of forearm and pierced the antebrachial fascia proximal to wrist. It entered the palm by crossing anterior to flexor retinaculum and terminated in superficial palmar arch.The level of termination of brachial artery was normal in cubital fossa and origin of princeps pollicis artery and radialis indicis artery from radial artery were also normal in the hand. The superficial palmar arch on the left side is classical completed on the lateral side by superficial branch of radial artery. The study on variations of superficial palmar arch is helpful in crushing injuries of hand, arterial grafting and injury to blood vessels of the upper limb.Relavant knowledge of anatomy regarding the variations of the superficial palmar arch is significant for the purposes of microvascular repairs and re-implantations during hand
Keywords - Additional branch of brachial artery, Radial artery, Superficial palmar arch, Ulnar artery.
I. INTRODUCTION specimens. Coleman SS, Anson BJ (1961)7 found theincidence of complete SPA formed entirely by UA Anatomically there are two anastomotic arterial in 37% of cases. Mozersky DJ et al (1973)8 noted arches in palm-superficial and deep. These arterial ulnar dominant superficial palmar arch in 88% of arches are the most important circuits because they hands by means of ultrasound evaluation study in 70 provide the principal blood supply to all the structures young volunteers. in the hand1 and collateral circulation in diseases of hand. Superficial palmar arch (SPA) is dominant Knowledge in variation of arterial pattern of hand arterial arch in the palm of hand covered by skin, gained more importance in microsurgical techniques, palmar aponeurosis and lies on digital branches of reconstructive hand surgeries,9 preoperative screening median and ulnar nerves, flexor tendons of digits and of RA harvesting for myocardial revascularization lumbricals.The SPA is formed by superficial branch and also in arterial interventions that include RA of ulnar artery and can be completed on lateral side cannulation and radial artery forearm flap.10 Hence by superficial palmar branch of radial artery or the frequent anatomical variations encountered in the princeps pollicis artery (PPA) or radialis indicis formation of the SPA and increasing incidence of artery (RIA) or median artery.2The SPA develops as a taking radial arterial grafts for coronary bypass terminal plexus of axis artery of upper limb which is surgery has attracted the interest in checking its later joined by median, ulnar and radial arteries as incidence. In the present case an additional branch of these arteries develop3. In ulnar dominant type, brachial artery was taking part in the formation of SPA is completely formed by ulnar artery (UA) and supericial palmar arch on the right side in adult male also supplies thumb and index finger without cadaver communicating with radial artery (RA). In the above cases a potential hazard exists to the fingers including II. MATERIALS AND METHODS index finger and thumb in the case of traumatic injury to the UA.4Due to its superficial position the SPA is A.CADAVERIC SPECIMENS constantly exposed to mechanical injuries.5 The present study was carried in the Department of Anatomy of Kasturba Medical College, Manipal on Jaschtshinski SN (1896)6 in his study on 200 hands 60 formalin fixed adult human cadaver hands. The found the SPA entirely formed by UA, which also age of the cadavers ranged from 35 to 65 years. supplies thumb and index finger in 38% of
Additional Branch of Brachial Artery Terminating in Superficial Palmar Arch
36 International Journal of Advances in Science Engineering and Technology, ISSN(p): 2321 –8991, ISSN(e): 2321 –9009 Vol-6, Iss-1, Spl. Issue-2 Mar.-2018, http://iraj.in Nospecimen with any pathology and abnormality of branch of RA to form SPA. The additional branch of upper limb was included. brachial artery descended on medial side of cubital fossa (Fig.2) and then superficial to common flexor B.DISSECTION PROCEDURE muscles of forearm and pierced antebrachial fascia A horizontal incision was made at the level of wrist proximal to wrist. It crossed anterior to flexor joint and vertical incision from middle of this incision retinaculum, (Fig.1) and entered palm of hand and up to 3rd metacarpophalangeal joint. The skin of the terminated in superficial palmar arch.The termination palm was reflected. The palmar aponeurosis was of brachial artery was normal and origin of princeps resected to see superficial palmar arch and its pollicis artery and radialis indicis artery were also branches. The arch and its branches were clearly normal arising from radial artery in the hand. The demonstrated by removal of surrounding fat. The formation of superficial palmar arch on the left side is complete normal superficial palmar arch formed by normal. superficial branch of ulnar artery and superficial palmar branch of radial artery and additional branch DISCUSSION of brachial artery taking part in superficial palmar arch was noted. The SPA is a dominant arterial arch of the palm but variations in its formation are numerous and well C. RESULTS documented, although the vascular supply to the hand Out of 60 formalin fixed cadavers aged between 35- and digits via the SPA is known to be variable (Al- 65 Years (60 cadavers) (30 on right side and 30 on Turk & Metcalf, 1984; Onderoglu et al, 1997).11, 12 left side), a unique variation was encountered in the The arterial patterns of the hand were first described arteries taking part in the formation of superficial by Jaschtschinski SN, 1892 6 and observed that three palmar arch in one specimen on the right side. SPA arteries ulnar, radial and median arteries taking part formation was normal and in addition an additional in supplying hand with or without anastomosis. The branch arising from brachial artery below the middle SPA is mainly formed by the UA which enters palm of arm on the right side was noted and photographed. of along with the ulnar nerve superficial to flexor UA entered the palm of hand by passing anterior to retinaculum and lateral to pisiform bone passing flexorretinaculum and divided into superficial and medial to hamate and then curving laterally to form deep branches (Fig.1). arch (Williams et al., 1999)13 across the middle 1/3rd of the palm (Massie G, 1944).14Developmental anomalies of blood vessels may be due to: (i) The choice of unusual paths in the primitive vascular plexuses. (ii) The persistence of vessels normally obliterated. (iii) The disappearance of vessels normally retained. (iv) Incomplete development (Vidhya R et al.,).l5 About a third of the SPA is formed by UA alone; and a further third are completed by superficial palmar branch of RA and a
Figure 1: Showing additional branch of brachial artery third either by the radialis indicis artery or princeps terminating into superficial palmar arch pollicis artery or median artery (Coleman and Anson, SPA: Superficial palmar arch; UA: Ulnar artery 1961)7. However there is no report in the available ABBA: Additional branch of brachial artery literature about existence and termination of additional branch of brachial artery into superficial palmar arch. The complete SPA was found in 78.55% of cases and incomplete SPA in 21.5% out of 650 cases in the study of Coleman and Anson7. Ikeda et al.,16 conducted stereoscopic arteriography on 220 cadaver hands and reported SPA in 96.4% cases is complete and 3.6% as incomplete arch. Gellman et al.,17 classified SPA into complete and incomplete types. In complete type there will be an anastomosis between vessels constituting it and in incomplete type there Figure 2: Showing additional branch of brachial artery arising will be an absence of anastomosis between the from brachial artery in arm. BA: Brachial artery; ABBA: Additional branch of brachial arteries constituting it. In 500 cases studied by 18 artery Janevski et al., the complete SPA were seen in 75% and remaining incomplete in 25%. SPA is alone Superficial branch gave rise to one proper digital formed by UA (ulnar dominant type) was reported by artery to ulnar side of little finger and continued Jelicic et al., as 10% 9 and by Ikeda et al., as laterally and joined with the superficial palmar 25.5%.16Tagil et al., 19 noticed that the most
Additional Branch of Brachial Artery Terminating in Superficial Palmar Arch
37 International Journal of Advances in Science Engineering and Technology, ISSN(p): 2321 –8991, ISSN(e): 2321 –9009 Vol-6, Iss-1, Spl. Issue-2 Mar.-2018, http://iraj.in consistent incomplete form was the UA alone The authors declare no conflict of interests forming SPA which was seen in 20% of subjects. Al- Turk & Metcalf 11 showed complete SPA in 84% of REFERENCES cases and incomplete in 16% using Doppler flowmeter. Harvesting RA for use as arterial by-pass [1] Sheetal J, P.Vatasalaswamy and B.H Baheetee. Variation in conduits needs to look superficially for variation in Formation of Superficial Palmar Arches with Clinical Implications, Journal of Clinical and Diagnostic Research, collateral circulation like presence of incomplete 2014 Apr; 8(4): AC06–AC09. SPA. [2] Gajisin S, Zbrodowski A,Local vascular contribution of the superficial palmar arch, Acta. Anat (Basel). 147: 248– 251, Elvan O et al.,20 reported origin of superficial 1993. 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