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ADDITIONAL BRANCH OF BRACHIAL TERMINATING IN

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 and can be completed on lateral side by superficial palmar branch of or any one of these viz. , radialis indicis artery or the median artery. The arch develops as a terminal plexus of axis artery of 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 . It descended on the medial side of , superficial to common flexors of 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 theincidence of complete SPA formed entirely by UA in 37% of cases. Mozersky DJ et al (1973)8 noted Anatomically there are two anastomotic arterial ulnar dominant superficial palmar arch in 88% of arches in palm-superficial and deep. These arterial hands by means of ultrasound evaluation study in 70 arches are the most important circuits because they young volunteers. provide the principal blood supply to all the structures in the hand1 and collateral circulation in diseases of Knowledge in variation of arterial pattern of hand hand. Superficial palmar arch (SPA) is dominant gained more importance in microsurgical techniques, arterial arch in the palm of hand covered by skin, reconstructive hand surgeries,9 preoperative screening palmar aponeurosis and lies on digital branches of of RA harvesting for myocardial revascularization median and ulnar nerves, flexor tendons of digits and and also in arterial interventions that include RA lumbricals.The SPA is formed by superficial branch cannulation and radial artery forearm flap.10 Hence of ulnar artery and can be completed on lateral side the frequent anatomical variations encountered in the by superficial palmar branch of radial artery or formation of the SPA and increasing incidence of princeps pollicis artery (PPA) or radialis indicis taking radial arterial grafts for coronary bypass artery (RIA) or median artery.2The SPA develops as a surgery has attracted the interest in checking its terminal plexus of axis artery of upper limb which is incidence. In the present case an additional branch of later joined by median, ulnar and radial arteries as brachial artery was taking part in the formation of these arteries develop3. In ulnar dominant type, supericial palmar arch on the right side in adult male SPA is completely formed by ulnar artery (UA) and cadaver also supplies thumb and index finger without communicating with radial artery (RA). In the above II. MATERIALS AND METHODS cases a potential hazard exists to the fingers including index finger and thumb in the case of traumatic injury A.CADAVERIC SPECIMENS to the UA.4Due to its superficial position the SPA is The present study was carried in the Department of constantly exposed to mechanical injuries.5 Anatomy of Kasturba Medical College, Manipal on 60 formalin fixed adult human cadaver hands. The Jaschtshinski SN (1896)6 in his study on 200 hands age of the cadavers ranged from 35 to 65 years. found the SPA entirely formed by UA, which also Nospecimen with any pathology and abnormality of supplies thumb and index finger in 38% of upper limb was included. specimens. Coleman SS, Anson BJ (1961)7 found

Proceedings of 39th IRF International Conference, 28th January, 2018, Bengaluru, India 1

Additional Branch of Brachial Artery Terminating in Superficial Palmar Arch B.DISSECTION PROCEDURE fossa (Fig.2) and then superficial to common flexor A horizontal incision was made at the level of wrist muscles of forearm and pierced antebrachial fascia joint and vertical incision from middle of this incision proximal to wrist. It crossed anterior to flexor up to 3rd metacarpophalangeal joint. The skin of the retinaculum, (Fig.1) and entered palm of hand and palm was reflected. The palmar aponeurosis was terminated in superficial palmar arch.The termination resected to see superficial palmar arch and its of brachial artery was normal and origin of princeps branches. The arch and its branches were clearly pollicis artery and radialis indicis artery were also demonstrated by removal of surrounding fat. The normal arising from radial artery in the hand. The complete normal superficial palmar arch formed by formation of superficial palmar arch on the left side is superficial branch of ulnar artery and superficial normal. palmar branch of radial artery and additional branch of brachial artery taking part in superficial palmar DISCUSSION arch was noted. The SPA is a dominant arterial arch of the palm but C. RESULTS variations in its formation are numerous and well Out of 60 formalin fixed cadavers aged between 35- documented, although the vascular supply to the hand 65 Years (60 cadavers) (30 on right side and 30 on and digits via the SPA is known to be variable (Al- left side), a unique variation was encountered in the Turk & Metcalf, 1984; Onderoglu et al, 1997).11, 12 arteries taking part in the formation of superficial The arterial patterns of the hand were first described palmar arch in one specimen on the right side. SPA by Jaschtschinski SN, 1892 6 and observed that three formation was normal and in addition an additional arteries ulnar, radial and median arteries taking part branch arising from brachial artery below the middle in supplying hand with or without anastomosis. The of arm on the right side was noted and photographed. SPA is mainly formed by the UA which enters palm UA entered the palm of hand by passing anterior to of along with the superficial to flexor flexorretinaculum and divided into superficial and retinaculum and lateral to pisiform bone passing deep branches (Fig.1). medial to hamate and then curving laterally to form 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

Figure 1: Showing additional branch of brachial artery completed by superficial palmar branch of RA and a terminating into superficial palmar arch third either by the radialis indicis artery or princeps SPA: Superficial palmar arch; UA: Ulnar artery pollicis artery or median artery (Coleman and Anson, ABBA: Additional branch of brachial artery 1961)7. However there is no report in the available 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 from brachial artery in arm. will be an absence of anastomosis between the BA: Brachial artery; ABBA: Additional branch of brachial arteries constituting it. In 500 cases studied by artery Janevski et al., 18 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 branch of RA to form SPA. The additional branch of consistent incomplete form was the UA alone brachial artery descended on medial side of cubital forming SPA which was seen in 20% of subjects. Al-

Proceedings of 39th IRF International Conference, 28th January, 2018, Bengaluru, India 2

Additional Branch of Brachial Artery Terminating in Superficial Palmar Arch 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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