International Journal of Current Research and Review
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IJCRR - 4(3), February, 2012

Pages: 46-52

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BILATERAL VARIATION IN THE VASCULAR PATTERN OF PALM- A CASE REPORT

Author: A.Himabindu, B.Narasing Rao

Category: Healthcare

Abstract:A bilateral variation in the pattern of arterial supply of the palm was observed during routine dissection of a 65 years old male cadaver. The right hand received blood supply by ulnar, radial and median arteries, with an arch of communication between radial and median arteries. In the left hand superficial palmar arch was formed mainly by ulnar artery and completed by first dorsal metacarpal branch of radial artery. In both hands deep branch of radial artery and a branch from ulnar proper digital branch of little finger formed the deep palmar arch. Knowledge of arterial variations provides an important source of information for vascular surgeons for safe surgical procedures in the hand.

Keywords: superficial palmar arch, deep palmar arch, ulnar artery, radial artery, median artery.

Full Text:

INTRODUCTION
Arterial supply to the human hand is derived from two main anastomotic channels, superficial and deep palmar arches. They are formed by radial and ulnar arteries, which account for high vascularity of the palm. So wounds of the palm bleed profusely but heal rapidly because of this rich anastomosis. Superficial palmar arch is mainly fed by ulnar artery alone or completed by superficial branch of radial artery, by the arteria radialis indicis, a branch of arteria princeps pollicis or by the persistent median artery1 . Very rarely it is formed by anastomosis of median artery with radial artery. This type of arch was described as median –radial type of superficial palmar arch2 . SPA shows a number of variations that it is difficult to establish a type3 . Deep palmar arch is formed by anastomosis of the deep palmar branch of the radial artery with the deep palmar branch of the ulnar artery. Jaschtschinski4 and Coleman and Anson1 described its variations. Variations of deep palmar arch are less common compared to superficial palmar arch1,5. So an injury to the ulnar artery or the superficial palmar arch may compromise the arterial supply of the fingers, particularly if there is an insufficient anastomosis between the superficial and deep palmar arches6 . Thus familiarity of the possible variations in arterial pattern of hand is especially important for the vascular surgeons while performing reconstructive hand surgeries for restoration of the normal function of the hand. 

Case report During regular dissection for undergraduate medical students, bilateral variations of superficial palmar arch and deep palmar arch were identified in a 65-year-old male cadaver. In the right hand, beneath the palmar aponeurosis there were three vessels. From medial to lateral side they were ulnar, median and radial arteries respectively. Ulnar artery gave one proper and two common digital arteries, which supplied the medial 2½ fingers. Arteria nervi mediana, a branch of ulnar artery, accompanied by the median nerve passing deep to flexor retinaculum was found to be giving a common digital branch that supplied radial side of the middle finger and ulnar side of the index finger. Superficial palmar branch of the radial artery gave a common digital branch that supplied the radial side of index finger and the ulnar side of the thumb. A loop of communication existed between the radial artery and the arteria nervi mediana(median artery) but not with the ulnar artery.(Fig:1) In the left hand, one proper and four common digital arteries were branched out from the ulnar artery. Through these branches, the ulnar artery supplied entire palm except radial side of thumb, which got its nutrition from the radial artery. The superficial palmar arch was completed by the first dorsal metacarpal artery in the first digital web space. First dorsal metacarpal artery was a branch of radial artery, before it pierced 1st dorsal interossei muscle. These variant types of arterial anastamosis should be kept in mind while performing hand surgeries. (Fig.1),(Fig.2) Deep palmar arch in both the upper limbs was formed between deep branch of radial artery, which entered the palm through 1st dorsal metacarpal space piercing the 1st dorsal interosseus muscle and inferior deep branch arising from ulnar proper palmar digital artery of little finger. Deep branch of ulnar nerve accompanied the arch and supplied interossei and adductor pollices muscles. (Fig.3)

DISCUSSION The arterial supply to the hand and its variations were being reported since a long time. Jaschtschinski4 in his study on 200 subjects, classified superficial palmar arch into complete and incomplete types based on the anastomosis between the vessels. Complete SPA was ulnar type (38%), radioulnar type (27%) and mediano ulnar type (3%) and radio-mediano-ulnar (0.5%). He also mentioned the absence of superficial palmar arch. A very rare type of superficial palmar arch termed median –radial type existed between median artery and radial artery2 . Superficial palmar arch was classified into Group I (Complete arch) and Group II (Incomplete arch)1 Group I was further divided into five types: Type A: The classical radio ulnar arch formed by superficial branch of radial artery with large superficial branch of ulnar artery. Type B: This arch is formed entirely by ulnar artery supplying thumb and index finger. Type C: Mediano ulnar arch formed between ulnar artery and median artery. Type D: Radio-mediano-ulnar arch, in which three vessels enter into the formation of arch. Type E: It consists of a well-formed arch initiated by ulnar artery and completed by a large vessel derived from deep arch. Group II: An incomplete arch exists when the arteries forming superficial arch do not anastomose or when the ulnar artery fails to reach the thumb and index finger. It was subdivided into Type A: No anastomosis between superficial palmar branch of radial artery and ulnar artery Type B: Only the ulnar artery forms superficial palmar arch. Type C: Superficial vessels receive contributions from both median and ulnar arteries but without anastomosis. Type D: Radial, median and ulnar artery all give origin to superficial vessels but do not anastomose. The median artery forming superficial palmar arch may arise from ulnar, anterior interosseous, common interosseous and from radial arteries7 . This persistent median artery has an embryological correlation. The ante brachial pattern of median artery ends at the level of forearm and the palmar pattern where the artery accompanying the median nerve in the forearm and extending down to the palm supplying the digits8 . A dorsally arising small radial artery branch, coined as dorsalis pollicis artery by Agur and Lee9 might complete superficial palmar arch. McCormack et al. 10 also reported a small vessel arising dorsally from the radial artery passing into the palm to join the ulnar artery in 51% of the hands studied. First dorsal metacarpal artery often had a fascial course on the dorsal surface of the index head of first interosseus muscle, this artery can be easily injured in an intervention over the carpometacarpal joint of the thumb, when approached from the dorsum of this joint11 . In the present case, right hand showed a complete radio-median type of superficial palmar arch as described by Keen2 .Along with this rare arch, ulnar artery was also present in the hand without any communication with the other two vessels. In the left hand, an ulnar-radial type of complete arch existed between ulnar artery and first dorsal metacarpal artery of radial artery coming from the dorsum. An arch was seen in the first digital web space. Eventhough it was not falling in any of the major classifications of superficial palmar arch, a dorsal artery completing the arch was described by Agur and Lee9 McCormack et al10 Deep palmar arch: Coleman and Anson1 had classified deep palmar arch as follows: Group I: Complete arch, further divided into 4 types. Type A: The deep palmar arch is formed by the deep palmar branch of the radial artery, which anastomoses with superior deep palmar branch of ulna artery. The latter follows the deep branch of ulnar nerve into the palm. Type B: The commonest pattern of deep palmar arch that existed between deep palmar branch of radial artery with the inferior deep palmar branch of ulnar artery. Type C: Both (superior andinferior) deep palmar branches of ulnar artery join the deep palmar branch of radial artery to complete the arch. Type D: It is formed by superior deep palmar branch of the ulnar artery, which anastomoses with an enlarged superior perforating artery of the 2nd inter metacarpal space. Group II: Incomplete arch, further divided into: Type A: The inferior deep branch of ulnar artery anastomoses with the perforating artery of the 2nd interspace without any communication with deep palmar branch of radial artery. Type B: The deep branch of ulnar artery ends in an anastomosis with perforating artery of 3rd interspace as deep palmar branch of radial artery anastomoses with the perforating artery of the 2nd interspace. Mezzogiorno12 identified the deep palmar arch patterns as radioulnar (66.7%),) radialanastomotic (21.67%), radial (8.33%), and ulnar (3.33%). Olave13 explained two groups of deep palmar arches. In group I the radial artery passed through the first interosseous space anastomosing with one or two deep palmar branches. These deep palmar branches originated from the ulnar artery, ulnar proper palmar digital artery of the little finger or the common palmar digital artery of the fourth interosseous space. In group II, the artery passed through the second interosseous space, anastomosing with one deep palmar branch, rarely with two deep palmar branches. In the present case both limbs showed the commonest variety of complete deep palmar arch (type B). This complete radioulnar type of deep palmar arch existed between deep palmar branch of radial artery, which passed through the first dorsal interosseous muscle anastomosing with deep palmar branch of ulnar artery. This deep palmar branch of ulnar artery was arising from proper digital branch of little finger as explained by Olave.13

Embryology Shin Matsumoto14 explained the arterial supply of the early upper limb bud as subclavian-axillary-brachial trunk. The main arterial supply to the developing hand consisted of the brachial and interosseous arteries that terminated in a capillary plexus. A branch of the trunk- median artery, temporarily replaced interosseous artery in supplying the hand. The connection between superficial brachial artery and median artery became the main route of blood supply for the finger arteries up to the adult stage. Subsequently ulnar and then radial arteries are formed from the axis artery at the end of arterial development and median artery regresses. Ulnar artery joined the ulnar end of the superficial palmar arch, radial artery with deep palmar arch. Persistence of any of these vessels leads to variations.

Conclusion: The detailed knowledge of arterial arches of the human hand, a prehensile organ, is important to vascular surgeons while correcting any traumatic events in the hand. Success of surgical procedures depends on the healthy function of the arterial arch that exists between radial and ulnar arteries in order to maintain normal blood flow to the hand and digits. Otherwise it leads to ischemia of soft tissues of the hand which is the earn tool of mankind.

ACKNOWLEDGEMENTS: Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.

References:

1. Coleman,s.andAnson,j.(1961):Arterial pattern in hand–based upon a studyon650specimens.surgery.gynaec ology.obstetrics.,(113(4))pp409-24.

2. Keen JA. Study of the arterial variations in the limbs with special reference to symmetry of vascular pattern. Am J Anat. 1961; 108: 245- 61.

3. Poirier,P:Traite d‘Anatomie Humaine L. BattlleandCo.Paris:pp 833 (1886)

4. Jaschtscinski SN(Morphologie und Topographie des Arcus volaris sublimes und profundus desMenschen)Anat.Hefte 1897;7: 161-88

5. Karlsson,S.andNiechajev ,I.A.(1982): Arterial anatomy of the upper extremity.Acta Radiologica Diagnosis.23: 115-121

6. Calenoff,L.Angiography of the hand:guidelines for interpretation.Radiology,102(2):331- 5,1972

7. Sujatha D‘costa,kilarkaje Narayana,Prasanthi Narayana,Jiji,Soubhagya R.Nayak,SJ Madhan Occurance and fate of palmar type of medaian artery.ANZ J SURG 2006;76,484-487

8. Rodriguez- NiedenfuhrM; Sando,J.R; Vazquez,T;Nearn,L;Logan,BandParkin, I. Median artery revisited.J.Anat., 195(1):57-63,1999

9. Agur AMR, Lee MJ. Grant‘s Atlas of Anatomy. 9th Ed., Baltimore, Williams and Wilkins. 1991; 434

10. McCormack LJ, Cauldwell EW, Anson BJ. Brachial and antebrachial arterial patterns: a study of 750 extremities. Surg Gynecol Obstet. 1953; 96: 43–54.

11. Wilgis EFS, Kaplan EB. The blood and the nerve supply of the hand. In: Morton Spinner, ed. Kaplan‘s Functional and Surgical Anatomy of the Hand. 3rd Ed., Philadelphia, J.B. Lippincott Company. 1984; 206.

12. Mezzogiorno A.Passiatore C. Mezzogiorno v. Anatomic variations of deep palmar arteries in man. Acta Anat,1994,149(3):221-4

13. Olave E.Prates JC. Deep palmar arch patterns in Brazilian individuals. Surg Radiol.Anat.1999:(21)267-71

14. Shin Matsumoto1 , Hans-Jürg Kuhn2 ,Hermann Vogt3 , Michael Gerke3 Embryological development of the arterial system of the forelimb in Tupaia,Article first published online: 26 JAN 2005DOI: 10.1002/ar.1092400314

ABBREVIATIONS
ANM- ARTERIA NERVI MEDIANA
FR- FLEXOR RETINACULUM
FDMA- FIRST DORSAL METACARPAL ARTERY
DPA- DEEP PALMAR ARCH
IDP.Br- INFERIOR DEEP PALMAR BRANCH OF ULNAR
ARTERY RA- RADIAL ARTERY SPA- SUPERFICIAL PALMAR ARCH
UA- ULNAR ARTERY



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One article from every issue is selected for the ‘Best Article Award’. Authors of selected ‘Best Article’ are rewarded with a certificate. IJCRR Editorial Board members select one ‘Best Article’ from the published issue based on originality, novelty, social usefulness of the work. The corresponding author of selected ‘Best Article Award’ is communicated and information of award is displayed on IJCRR’s website. Drop a mail to editor@ijcrr.com for more details.

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A study by Alice Alice entitled \"Strengthening of Human Milk Banking across South Asian Countries: A Next Step Forward\" is awarded Best article of Vol 14 issue 20
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A study by Singh R. et al. entitled \"A Prospective Study to Find the Association of Astigmatism in Patients of Vernal Keratoconjunctivitis (VKC) in a Tertiary Health Care Centre in India (Vindhya Region MP)\" is awarded Best Article for Vol 14 issue 15
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A Study by Mohita Ray et al. entitled "Accuracy of Intra-Operative Frozen Section Consultation of Gastrointestinal Biopsy Samples in Correlation with the Final Histopathological Diagnosis" is awarded Best Article for Vol 13 issue 01
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A Study by Sindhu Priya E S et al. entitled "Neuroprotective activity of Pyrazolone Derivatives Against Paraquat-induced Oxidative Stress and Locomotor Impairment in Drosophila melanogaster" is awarded Best Article for Vol 12 issue 23
A Study by Habiba Suhail et al. entitled "Effect of Majoon Murmakki in Dysmenorrhoea (Usre Tams): A Standard Controlled Clinical Study" is awarded Best Article for Vol 12 issue 22
A Study by Ghaffar UB et al. entitled "Correlation between Height and Foot Length in Saudi Population in Majmaah, Saudi Arabia" is awarded Best Article for Vol 12 issue 21
A Study by Siti Sarah Binti Maidin entitled "Sleep Well: Mobile Application to Address Sleeping Problems" is awarded Best Article for Vol 12 issue 20
A Study by Avijit Singh"Comparison of Post Operative Clinical Outcomes Between “Made in India” TTK Chitra Mechanical Heart Valve Versus St Jude Mechanical Heart Valve in Valve Replacement Surgery" is awarded Best Article for Vol 12 issue 19
A Study by Sonali Banerjee and Mary Mathews N. entitled "Exploring Quality of Life and Perceived Experiences Among Couples Undergoing Fertility Treatment in Western India: A Mixed Methodology" is awarded Best Article for Vol 12 issue 18
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A Study by Sudha Ramachandra & Vinay Chavan entitled "Enhanced-Hybrid-Age Layered Population Structure (E-Hybrid-ALPS): A Genetic Algorithm with Adaptive Crossover for Molecular Docking Studies of Drug Discovery Process" is awarded Best article for Vol 12 issue 15
A Study by Varsha M. Shindhe et al. entitled "A Study on Effect of Smokeless Tobacco on Pulmonary Function Tests in Class IV Workers of USM-KLE (Universiti Sains Malaysia-Karnataka Lingayat Education Society) International Medical Programme, Belagavi" is awarded Best article of Vol 12 issue 14, July 2020
A study by Amruta Choudhary et al. entitled "Family Planning Knowledge, Attitude and Practice Among Women of Reproductive Age from Rural Area of Central India" is awarded Best Article for special issue "Modern Therapeutics Applications"
A study by Raunak Das entitled "Study of Cardiovascular Dysfunctions in Interstitial Lung Diseas epatients by Correlating the Levels of Serum NT PRO BNP and Microalbuminuria (Biomarkers of Cardiovascular Dysfunction) with Echocardiographic, Bronchoscopic and HighResolution Computed Tomography Findings of These ILD Patients" is awarded Best Article of Vol 12 issue 13 
A Study by Kannamani Ramasamy et al. entitled "COVID-19 Situation at Chennai City – Forecasting for the Better Pandemic Management" is awarded best article for  Vol 12 issue 12
A Study by Muhammet Lutfi SELCUK and Fatma entitled "Distinction of Gray and White Matter for Some Histological Staining Methods in New Zealand Rabbit's Brain" is awarded best article for  Vol 12 issue 11
A Study by Anamul Haq et al. entitled "Etiology of Abnormal Uterine Bleeding in Adolescents – Emphasis Upon Polycystic Ovarian Syndrome" is awarded best article for  Vol 12 issue 10
A Study by entitled "Estimation of Reference Interval of Serum Progesterone During Three Trimesters of Normal Pregnancy in a Tertiary Care Hospital of Kolkata" is awarded best article for  Vol 12 issue 09
A Study by Ilona Gracie De Souza & Pavan Kumar G. entitled "Effect of Releasing Myofascial Chain in Patients with Patellofemoral Pain Syndrome - A Randomized Clinical Trial" is awarded best article for  Vol 12 issue 08
A Study by Virendra Atam et. al. entitled "Clinical Profile and Short - Term Mortality Predictors in Acute Stroke with Emphasis on Stress Hyperglycemia and THRIVE Score : An Observational Study" is awarded best article for  Vol 12 issue 07
A Study by K. Krupashree et. al. entitled "Protective Effects of Picrorhizakurroa Against Fumonisin B1 Induced Hepatotoxicity in Mice" is awarded best article for issue Vol 10 issue 20
A study by Mithun K.P. et al "Larvicidal Activity of Crude Solanum Nigrum Leaf and Berries Extract Against Dengue Vector-Aedesaegypti" is awarded Best Article for Vol 10 issue 14 of IJCRR
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A study by Karanpreet et al "Pregnancy Induced Hypertension: A Study on Its Multisystem Involvement" is given Best Paper Award for Vol 10 issue 09

List of Awardees

A Study by Ese Anibor et al. "Evaluation of Temporomandibular Joint Disorders Among Delta State University Students in Abraka, Nigeria" from Vol 13 issue 16 received Emerging Researcher Award


A Study by Alkhansa Mahmoud et al. entitled "mRNA Expression of Somatostatin Receptors (1-5) in MCF7 and MDA-MB231 Breast Cancer Cells" from Vol 13 issue 06 received Emerging Researcher Award


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International Journal of Current Research and Review (IJCRR) provides platform for researchers to publish and discuss their original research and review work. IJCRR can not be held responsible for views, opinions and written statements of researchers published in this journal

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