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01 Natsis.P65 Folia Morphol. Vol. 68, No. 4, pp. 193–200 Copyright © 2009 Via Medica R E V I E W A R T I C L E ISSN 0015–5659 www.fm.viamedica.pl Persistent median artery in the carpal tunnel: anatomy, embryology, clinical significance, and review of the literature K. Natsis1, G. Iordache2, I. Gigis1, A. Kyriazidou1, N. Lazaridis1, G. Noussios3, G. Paraskevas1 1Department of Anatomy, Medical School, Aristotle University of Thessaloniki, Greece 2University of Medicine and Pharmacy of Craiova, Romania 3Laboratory of Anatomy, Department of Physical Education and Sport Sciences (Serres), Aristotle University of Thessaloniki, Greece [Received 5 June 2009; Accepted 16 September 2009] The median artery usually regresses after the eighth week of intrauterine life, but in some cases it persists into adulthood. The persistent median artery (PMA) pas- ses through the carpal tunnel of the wrist, accompanying the median nerve. During anatomical dissection in our department, we found two unilateral cases of PMA originating from the ulnar artery. In both cases the PMA passed through the carpal tunnel, reached the palm, and anastomosed with the ulnar artery, forming a medio-ulnar type of superficial palmar arch. In addition, in both cases we observed a high division of the median nerve before entering the carpal tunnel. Such an artery may result in several complications such as carpal tunnel syndrome, pronator syndrome, or compression of the anterior interosseous nerve. Therefore, the presence of a PMA should be taken into consideration in clinical practice. This study presents two cases of PMA along with an embryological explanation, analysis of its clinical significance, and a review of the literature. The review of the literature includes cases observed during surgical procedures or anatomical dissections. Cases observed by means of imaging techniques were not included in the study. (Folia Morphol 2009; 68, 4: 193–200) Key words: superficial palmar arch, carpal tunnel syndrome, ulnar artery INTRODUCTION artery. After the appearance of the axial artery, which Variations of the usual plan of arrangement of represents the axillary, brachial, and anterior in- the blood vessels are among the most common de- terosseous arteries, the median and the anterior in- velopmental irregularities. They may be due to the terosseous arteries provide the main blood supply choice of unusual paths in the primary vascular plex- to the hand during the first trimester of gestation uses, the persistence of vessels which normally re- [51, 56]. After the eighth week of intrauterine life, gress, the absorption of vessels normally retained, the ulnar and radial arteries develop and the medi- or the incomplete development or fusions and re- an artery usually undergoes retrogression to become gressions of usually distinct parts [3]. a small vessel accompanying the median nerve in The median artery of the forearm is a case of the carpal tunnel, the accompanying artery of the persistence of a blood vessel. It belongs to the ar- median nerve (arteria comes nervi mediani) [54]. teries of the forearm and develops from the axial According to Singer [54], the median artery regresses Address for correspondence: K. Natsis, Associate Professor of Anatomy, Orthopaedic Surgeon, Department of Anatomy, Medical School, Aristotle University of Thessaloniki, P.O. Box: 300, 541 24 Thessaloniki, Greece, tel./fax: 0030 2310 999 681, e-mail: [email protected] 193 Folia Morphol., 2009, Vol. 68, No. 4 when the embryo is approximately 23 mm long, at stage V of development. Another hypothesis pro- poses that a plexus of capillaries develop and form the arterial supply of the upper limb as they pro- gressively differentiate from proximal to distal. The definite arterial pattern is considered the result of persistence, enlargement, and differentiation of these capillaries during 28th–52nd days of intraute- rine life [51]. Kopuz et al. [35] studied the presence of persistent median artery (PMA) in neonatal ca- davers and raised the hypothesis that the median artery regresses at a much later stage, most likely during the perinatal period and early infancy. In their study the incidence of PMA was 20% [35]. MATERIAL, METHODS, AND RESULTS During 36 routine anatomical dissections of 72 upper limbs of adult cadavers performed in our department, we found two cases (2.78%) of a PMA accompanying the median nerve on its route through the carpal tunnel. The first case was a 58-year-old female cadaver and the second case was a 64-year- old male cadaver. The anomaly was unilateral in both cases since it was encountered only on the right upper limb. The artery’s origin was from the trunk of the ulnar artery in both cases and it passed through the carpal tunnel (Fig. 1). On the palm both persistent median arteries gave off the first and the second common digital arteries supplying the thumb, the second finger, and the lateral part of the third finger (Figs. 2, 3). There was an anastomo- sis between the median and the ulnar artery on the palm in both cases forming a medio-ulnar type of superficial palmar arch, according to Lanz [53] and Figure 1. Schematic representation of the reported case: 1 — radial artery; 2 — ulnar artery; 3 — anterior interosseous artery; corresponding to Type C of Group I of Coleman and 4 — persistent median artery. Anson’s classification [15]. There was no anastomo- sis with the superficial palmar branch of the radial artery in both cases. We also found that there was that reduce its area may compress the median nerve no common interosseous artery and the posterior and its branches. and anterior interosseous arteries arose directly from The median artery persists into adulthood in two the ulnar artery (Fig. 1). In both cases the median forms. The first, an antebrachial type, is considered nerve divided into two branches before entering the normal, arises mostly from the anterior interosseous carpal tunnel (Fig. 2). The first branch continued as artery, and does not reach the palm. The second, the first common digital nerve and the second a palmar type, may arise from any of the forearm ar- branch gave off the second and the third common teries and accompanies the median nerve in the car- digital nerves. pal tunnel. It usually terminates as the superficial arch or as the main blood supplier to the index and DISCUSSION long fingers [50]. The term PMA refers to the pal- The structures running through the carpal tun- mar type of the median artery. When present, the nel are the flexor muscle tendons, their sheath, and median artery is the main blood supplier of the the median nerve. Due to the inflexibility of the car- median nerve, corresponding to Types 2 and 3 of pal tunnel walls, any thickening of the components vascularization of the median nerve as described by 194 K. Natsis et al., Persistent median artery in carpal tunnel Figure 3. Second case. Median nerve (arrow) and median artery (arrow head). Figure 2. First case. Persistent median artery running through the carpal tunnel (arrow). be subdivided into four types of incomplete superfi- cial palmar arch. The median artery contributes to Pecket et al. [46]. When a complete superficial pal- the arterial supply of the hand in the third and fourth mar arch is formed, the median nerve receives its type. blood supply from the median artery in the proxi- In Table 1 we present the incidence of the PMA mal part of the forearm and from the superficial found only during anatomical dissection or a surgi- palmar arch in the distal part of the forearm. If the cal procedure, the frequency of the unilateral and median artery does not exist, the blood supply to bilateral cases, and the origin of the artery. All other the median nerve comes from the radial and ulnar cases, studied using imaging techniques, were ex- arteries and the superficial palmar arch when it is cluded from our study. The incidence of the PMA formed [46]. has been reported to range from 0.6% [2] to 44.2% In normal subjects, the radial and the ulnar ar- [24]. The amplitude of the percentage seems to be teries anastomose within the hand to make a su- very wide. This could be the result of absorption of perficial and a deep palmar arch so that occlusion the artery at a later stage, during early infancy or in one forearm vessel will not compromise vascular childhood. Mortality of the neonates that have the supply to the hand [28]. Coleman and Anson [15] artery or disparity between generations could also suggested two groups of superficial palmar arch: be the cause of these differences [24]. Kopuz et al. a complete and an incomplete. Group I can be subdi- [36] found the PMA in 4.5% of forearms, but the vided into five types of complete superficial palmar incidence of PMA in the neonatal cadavers of the arch. The median artery contributes to the third and same study was 12.5%; much higher than the over- fourth type as it anastomoses with the ulnar artery all incidence. The incidence of the PMA can be influ- or with both ulnar and radial arteries. Group II can enced by racial differences. This may be the result 195 Table 1. Overall incidence of persistent median artery. Author (year), references Sample Incidence Percentage Side origin Specimen Method Unilateral Bilateral Ulnar a. Radial a. CIA AIA Tripoid McCormack et al. (1953) [43] 750 31 4.43% – – – – – – – Cadavers Dissection Coleman and Anson (1961) [15] 650 64 9.9% – – – – – – – Cadavers Dissection Keen (1961) [32] 284 27 9.5% – – – – – – – Cadavers Dissection Jackson and Campbell (1970) [29] 1 1 1 – – – – – – Patient Operation Pecket et al. (1973) [46] 60 6 10% – – – – – – – Cadavers Dissection Chalmers (1978) [13] 228 10 4.4% 10 – – – – – – Patients Operation Levy and Pauker (1978) [39] 1 1 1 – – – – – – Patient Operation Boles et al.
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