Can palmar creases serve as landmarks for the deeper neuro-vascular structures?

Purpose

The aim of this study was the examination of the superficial anatomy of palmar creases and their relation to deeper neuro-vascular structures.

Methods

Four creases: distal wrist flexion crease, thenar crease, proximal palmar crease and distal palmar crease were evaluated with reference to the following structures: palmar cutaneous branch of median nerve, palmar cutaneous branch of ulnar nerve, the nerve of Henle, transverse palmar branches from ulnar nerve, recurrent motor branch of median nerve, radial proper palmar digital nerve to the index and the ulnar proper palmar digital nerve to the thumb, Berrettini’s communicating branch, ulnar nerve and artery, superficial palmar arch. We performed dissections of 20 cadaveric upper limbs derived from a homogenous Caucasian group. In our study we measured the location of surgically important structures with reference to palmar skin creases.

Results

Among the other observations we noticed that the palmar cutaneous branches of the median and ulnar nerves were located at least 0.5 cm away from the thenar crease. The superficial palmar arch was found between the thenar and proximal palmar crease and never crossed the proximal or distal palmar creases.

Conclusions

These anatomical dissections will provide reference material for further ultrasound studies on the arrangements of neuro-vascular structures in reference to superficial palmar creases.     

A rare anatomical variation of the Berrettini anastomosis and third common palmar digital branch of the median nerve

Variations in the origin and distribution of Berrettini anastomosis between the digital branches of the ulnar and median nerves exist and are well described in the literature. During regular dissections by medical students, we encountered a rare variation in the left hand of an approximately 50-year-old male cadaver. Berrettini anastomosis connecting the third common palmar digital branch of the median nerve with the fourth common palmar and proper palmar digital branches of the ulnar nerve presented a plexiform nature. This communicating branch and the third common palmar digital branch of the median nerve were perforated by the superficial palmar arch. Further, the superficial palmar arch was incomplete, and it was solely formed by the superficial branch of the ulnar artery. The unusual relationship of Berrettini anastomosis with the superficial palmar arch is very rare, and knowledge about such a variation is important when performing carpal tunnel release, flexor tendon surgery, and Dupuytren’s fasciectomy and when dealing with arterial repairs and vascular graft applications in the hand.     

Muscle variations and abnormal branching and course of the ulnar nerve in the forearm and hand

During dissection of the right forearm of a 27-year-old female cadaver, variations in the form and insertion of the palmaris longus muscle were observed. The tendon of the palmaris longus muscle, which demonstrated a centrally placed belly, split into two tendons: one inserted into the palmar aponeurosis and the other into the proximal part of the flexor retinaculum. Additionally, we found an accessory muscle extending between the flexor retinaculum and the tendon of the abductor digiti minimi muscle. This accessory muscle was located deep to the ulnar artery but superficial to the superficial and deep branches of the ulnar nerve at the wrist. Finally, an aberrant branch of the ulnar nerve was identified in the forearm; it traveled distally alongside the ulnar artery and in the palm demonstrated communications with common palmar digital nerves from the ulnar and the median nerves. No variations were observed in the contralateral upper limb.     

Anatomic variations of the median nerve within the carpal tunnel

Two hundred seventy-five consecutive carpal tunnel releases were reviewed to identify anomalies of median nerve anatomy. High division of the median nerve was observed in nine cases; in two of these the nerve divided proximally and then rejoined distally as a “closed loop.” In 42 cases the motor branch passed through the flexor retinaculum. Multiple motor branches were present in 13 cases. The palmar cutaneous branch passed through the flexor retinaculum in seven cases. In three cases, the distal communicating sensory ramus between the medial and ulnar nerves arose proximal to the superficial arch. Median nerve anomalies within the region of the carpal tunnel are common. Knowledge of such anomalies is important to avoid iatrogenic injury.     

Persistent median artery in the hand: a report with a brief review of the literature

We encountered a persistent median artery in the forearms and hands bilaterally in a 78-year-old Japanese male cadaver during dissection practice at Wakayama Medical University. The brachial arteries divided into the ulnar and radial arteries. The ulnar artery gave off the median and posterior interosseous arteries at the same point, although the anterior interosseous artery was not found. The median artery ran along the median nerve and bifurcated in the hand. In the superficial layer of the palm, one branch of the median artery ran to the ulnar side of the thumb, whereas the other passed to the second interdigital space. The ulnar artery reached the third and fourth interdigital spaces and the ulnar side of the little finger, and showed no anastomosis with the median artery in the superficial layer of the palm. The radial artery did not give off the superficial palmar branch. Therefore, the formation of the superficial palmar arch was incomplete. In the deep layer of the palm, the radial artery formed the deep palmar arch with the deep palmar branch of the ulnar artery and gave off the princeps pollicis artery. In the dorsum of hand, the radial artery passed over the first dorsal interosseous muscle to the index finger and communicated with the palmar pollical artery from the median artery in the first interosseous space. The present study reports an unusual variation of the persistent median artery in the hand and briefly reviews the literature about the median artery.     

正中神经返支和掌皮支血供的显微解剖

目的为修复正中神经返支提供带血管蒂神经桥接的有关数据和掌皮支血供的解剖学资料。方法用体视学方法研究了40侧灌注红色乳胶液的返支和掌皮支的营养血管。观察返支营养血管的来源、长度、外径和进入神经干的方式;观察掌皮支营养血管的来源和进入神经的方式。结果返支营养动脉主要发自掌浅弓凹侧筋膜支(称之来源动脉)。来源动脉起点至“零点”距离(11.62±2.30)mm,外径(0.95±0.10)mm,长度(10.12±1.30)mm。营养动脉主干长度(2.84±0.10)mm,外径(0.42±0.15)mm。营养动脉从返支主干近侧1/3段直入式进入神经者占86.5%;从返支中、远侧段伴入式进入神经者占14.5%;掌皮支营养动脉主要发自尺动脉(占52.5%)和桡动脉(占37.5%),以直式、伴入式和肌支式进入神经。结论返支营养动脉可作为血管蒂神经移植的受体血管。     

An unusual variation of the superficial ulnar artery

Anomalous superficial ulnar arteries were found bilaterally during routine dissection of the upper limbs of a 60-year-old male cadaver. In the left arm, the superficial ulnar artery originated from the axillary artery. It crossed the median nerve anteriorly and ran anteromedial to this nerve and the brachial artery. The superficial ulnar artery was also rudimentary and gave rise to only a narrow muscular branch to the biceps brachii. In the hand, it anastomosed with the radial artery, completing the superficial palmar arch. The radial artery was larger than usual and the deep palmar arch was formed only by the radial artery. In the right arm, the superficial ulnar artery originated from the brachial artery at the level of the inter-epicondylar line. Additionally there were “inverse palmaris longus muscles” bilaterally. This was a rare case in which the superficially ulnar artery originated from a different source on each side accompanied by anomalies of the palmar arches on one side.     

Report of a rare human variation: absence of the radial artery

A case of unilateral absence of the radial artery is reported. The arterial system of the specimen was developmentally primitive with the anterior interosseous artery the chief blood supply to the forearm and hand. A "superficial ulnar artery" of small caliber supplemented the supply of the hand. Three large branches of the anterior interosseous artery supplied the hand with the lateral terminal branch replacing the radial artery distal to the wrist. The superficial palmar arch was formed by an anastomosis of the media and lateral terminal branches of the anterior interosseous artery. No deep palmar arch was present, but three palmar metacarpal arteries arose from a perforating artery which branched from a large dorsal branch of the anterior interosseous artery. The median artery was of small caliber and could not be traced beyond the midforearm. Based on this specimen and a review of other forearm and hand arterial variations, it is postulated that the ulnar artery may developmentally precede the median artery.     

Arterial variations of the upper extremities

During the dissection of the right and left upper limbs of a 70-year-old female cadaver, we encountered combined vascular anomalies. On the left side, we observed the presence of a lateral inferior superficial brachial artery, large anterior interosseous artery and an absence of a radial artery, which is quite a rare anomaly. The lateral inferior superficial brachial artery that arose 39 mm distal to the brachial artery descended to the wrist. The anterior interosseous artery originated from the brachial artery at the level of 12 mm distal to the head of the radius and descended on the anterior aspect of the interosseous membrane with the anterior interosseous branch of the median nerve. On the right side, a trifurcation of the brachial artery was observed. It gave off three terminal branches: the radial, ulnar and a muscular artery at the proximal one-third of the humerus. It is obvious that accurate information concerning unusual patterns of the arteries in the upper limbs is relevant clinically, especially in order to avoid accidental injury or intra-arterial injection.     

A rare human variation a major branch of the ulnar artery found in the carpal tunnel

Abstract During a routine anatomic dissection of a 60-year-old female cadaver, a large branch of the ulnar artery in the carpal tunnel was found in the left forearm. This branch crossed the median nerve anteriorly. Guyon’s canal contained another branch of the ulnar artery and the ulnar nerve. There was no superficial palmar arch in the left hand. The right forearm was without any vascular anomalies. This anomaly has considerable consequences for surgeons considering endoscopic carpal release, because there is a significant risk of injury to the ulnar artery branch.     

Definition of a safe-zone in open carpal tunnel surgery: a cadaver study

Carpal tunnel decompression is one of the most common surgical procedures in hand surgery. Cutaneous innervation of the palm by median and ulnar nerves was evaluated to find a suitable incision preserving cutaneous nerves. A morphometric study was designed to define the safe-zone for mini-open carpal tunnel release. Sixteen fresh-frozen (8 right, 8 left) and 14 formalin-fixed (8 right, 6 left) cadaveric hands were dissected. Anatomy of the palmar cutaneous branch of the median and the ulnar nerve, motor branch of the median nerve, superficial palmar arch were evaluated relative to the surgical incision. We also identified the motor branch of the median nerve. Detailed measurements of the whole palmar region are reported in this study. The motor branch of the median nerve was extraligamentous as 60%, subligamentous as 34%, transligamentous as 6%. The palmar cutaneous branches of the median and the ulnar nerves in the palmar region were classified as Type A (34%), Type B (13%), Type C (13%), Type D (none), Type E (40%) according to forms of palmar cutaneous innervation originating from the ulnar and median nerves. Injury to the palmar cutaneous branch of the median nerve (PCBMN) is the most common complication of the carpal tunnel surgery. Various techniques were described to decrease post-operative morbidity. Based on these anatomic findings mini incision between the superficial palmar arch and the most distal part of the PCBMN in the palmar region is the safe-zone for carpal tunnel surgery.     

桡动脉掌浅支蒂腕横纹皮瓣的应用解剖

目的　为临床设计切取腕横纹皮瓣提供解剖学基础。 方法　选取6只新鲜手标本进行红色乳胶灌注,解剖观察桡动脉掌浅支的走行及皮支分布规律和特点。 结果　桡动脉掌浅支于桡骨茎突掌尺侧自桡动脉发出,起始处直径（1.26±0.36）mm,向鱼际肌走行。桡动脉掌浅支于舟骨结节近侧中间腕横纹处发出皮支,皮支发出处直径（0.23±0.06）mm,供养腕横纹皮肤。 结论　以桡动脉掌浅支腕横纹皮支供血,以腕横纹皮肤为供区切取游离皮瓣或带蒂转移可以修复手部皮肤软组织缺损,该术式具有血供可靠、不牺牲主干血管,切取安全等优点。     

An unusual termination of the ulnar nerve in the palm.

During the dissection of the left forearm and hand of a 57-year old male cadaver fixed in 10% formalin, it has been noted that the medial proper palmar digital nerve to the little finger arose from the dorsal branch of the ulnar nerve, instead of the superficial branch of the same nerve. The dorsal branch, given off by the ulnar nerve in the forearm, coursed distally and dorsally deep to the flexor carpi ulnaris muscle. Some 2 cm proximal to the pisiform, it pierced the deep fascia on the posteromedial side of the muscle to become superficial. At this point, one of the three branches given off travelled distally on the palmar-ulnar side of the hand to the skin of the little finger. There were connections between this branch and the branches of the superficial branch of the ulnar nerve which innervated the skin of the hypothenar eminence. Further, another branch of the superficial branch of the ulnar nerve passed under the fibrous arch of the flexor digiti minimi brevis muscle origin and the opponens digiti minimi muscle to re-unite with its parent nerve.     

The superficial ulnar artery: Development and surgical significance

The upper limbs of 72 formalin-fixed human cadavers were examined by dissection for arterial anomalies. In one subject, the ulnar artery was noted to be a branch of the second part of the axillary artery on both right and left sides. It ran a superficial course in the arm, crossed the elbow immediately subjacent to the median cubital vein, and continued its course in the forearm in a subcutaneous position. In the hand it played a dominant role in the formation of the superficial palmar arch. The anomalous ulnar artery was of a smaller caliber than both the radial and common interosseous arteries. Although superficial ulnar arteries have been reported in the literature, the combination of bilateral superficial ulnar arteries originating from the axillary arteries appears to be rare. The developmental and surgical significance of the findings are discussed. © 1996 Wiley-Liss, Inc.     

Relationship of deep structures of the hand and wrist to topographical landmarks

The relationship of topographical landmarks to the deep structures of the wrist and hand has not been clearly defined and would be of benefit to surgeons performing endoscopic carpal tunnel surgery. To this end, 10 fresh cadaveric wrist specimens had radiopaque markers placed adjacent to key anatomic structures within the wrist and hand. A new technique for localizing the hook of the hamate was established. We found that the thick segment of the flexor retinaculum, often defined as the transverse carpal ligament, was 2.2 cm in length. Its distal border was 1 cm distal to the distal aspect of the hook of the hamate. The proximal ligamentous portion had a mean length of 1.2 cm, whereas the distal aponeurotic portion (distal to the hook of the hamate) had a mean length of 1.0 cm. The position of the superficial palmar arch was 2.7 cm distal to the hook of the hamate or at a line bisecting three-fourths of the distance from the distal flexor wrist crease to the proximal palmar crease. The relationship of the superficial palmar arch to topographical landmarks was more consistent than it was when the standard reference of Kaplan's cardinal line was used. © 1993 Wiley-Liss, Inc.     

Unusual vascularization and nerve supply of the fifth finger.

During a dissection course, an unusual variation in vascularization and nerve supply of the fifth finger of the right hand was found in a 73-year-old human male cadaver. The proper digital palmar artery arose from the superficial branch of the ulnar artery distel to the Guyon's canal. The proper digital palmar artery coursed first palmar to the ulnar nerve then between the abductor minimi and flexor digiti minimi muscles to reach the ulnar side of the fifth finger. Besides this, the ulnar border of the fifth finger was supplied on its palmar side by the dorsal branch of the ulnar nerve, which gave off two tiny twigs for the sensory innervation on the dorsal side of the same finger.     

Persistent median artery: cadaveric study and review of the literature

The persistent median artery (PMA) may compress the median nerve (MN) and may be a significant supply of blood to the hand. Two cases of unilateral PMA (4%) were detected during the dissection of 50 upper limbs. The first case was a 75-year-old, right-handed male who suffered from chronic pain in both upper limbs, especially the left side. A dissection of his left upper limb revealed a PMA piercing both the MN and the medial branch of the anterior interosseous nerve. This artery coursed distally, deep to the transverse carpal ligament (TCL), forming a median-ulnar pattern for the superficial palmar arch (SPA). The PMA was superficial to two nerves at the distal edge of the TCL; the extraligamentous recurrent thenar (RT) branch of the MN and the third common digital nerve (TCDN). The second case was from the left side of an 80-year-old female found to have a high origin of the radial artery with trifurcation of the latter into PMA, common interosseous, and ulnar arteries. The PMA passed deep to the TCL forming a radial-median-ulnar pattern of SPA. Both the transligamentous RT branch of the MN and the TCDN passed deep to the PMA inside the carpal tunnel, before the abnormal crossing of the latter nerve ventral to the SPA on its way to the digits. The relationships of the PMA to various MN branches may have important implications regarding the diagnosis and treatment of MN compressive neuropathies.     

A variant course of the superficial palmar branch of the radial artery

The objective of this report was to present a case of superficial palmar branch of the radial artery (SPBRA) with a variant course, which to the best of our knowledge, has not been reported in the literature. During anatomical dissections that were carried out in the Department of Anatomy of Suleyman Demirel University School of Medicine to demonstrate the superficial palmar arch, a variation in the course of the SPBRA was noted in the right hand of an adult cadaver. This variant branch ran superficial to, and in contact with, the flexor retinaculum, and ran transversely to join the ulnar artery.     

Median artery revisited

This study confirms that the median artery may persist in adult life in 2 different patterns, palmar and antebrachial, based on their vascular territory. The palmar type, which represents the embryonic pattern, is large, long and reaches the palm. The antebrachial type, which represents a partial regression of the embryonic artery is slender, short, and terminates before reaching the wrist. These 2 arterial patterns appear with a different incidence. The palmar pattern was studied in the whole sample (120 cadavers) and had an incidence of 20%, being more frequent in females than in males (1.31), occurring unilaterally more often than bilaterally (41) and slightly more frequently on the right than on the left (1.11). The antebrachial pattern was studied in only 79 cadavers and had an incidence of 76%, being more frequent in females than in males (1.61); it was commoner unilaterally than bilaterally (1.51) and was again slightly more prevalent on the right than on the left (1.21). The origin of the median artery was variable in both patterns. The palmar type most frequently arose from the caudal angle between the ulnar artery and its common interosseous trunk (59%). The antebrachial pattern most frequently originated from the anterior interosseous artery (55%). Other origins, for both patterns, were from the ulnar artery or from the common interosseous trunk. The median artery in the antebrachial pattern terminated in the upper third (74%) or in the distal third of the forearm (26%). However, the palmar pattern ended as the 1st, 2nd or 1st and 2nd common digital arteries (65%) or joined the superficial palmar arch (35%). The median artery passed either anterior (67%) or posterior (25%) to the anterior interosseous nerve. It pierced the median nerve in the upper third of the forearm in 41% of cases with the palmar pattern and in none of the antebrachial cases. In 1 case the artery pierced both the anterior interosseous and median nerves.     

Vascular branches from cutaneous nerve of the forearm and hand: Application to better understanding raynaud's disease

Cutaneous nerves have branches called vascular branches (VBs) that reach arteries. VBs are thought to be involved in arterial constriction, and this is the rationale for periarterial sympathectomy as a treatment option for Raynaud's disease. However, the branching patterns and distribution areas of the VBs remain largely unclear. The aim of the present study was to investigate the anatomical structures of the VBs of the cutaneous nerves. Forty hands and forearms were examined to assess the branching patterns and distribution areas of the VBs of the superficial branch of the radial nerve (SBRN), the lateral antebrachial cutaneous nerve (LACN), the medial antebrachial cutaneous nerve (MACN), and the palmar cutaneous branch of the ulnar nerve (PCUN). VBs reaching the radial and ulnar arteries were observed in all specimens. The branching patterns were classified into six types. The mean distance between the radial styloid process and the point where the VBs reached the radial artery was 34.3 ± 4.8 mm in the SBRN and 38.5 ± 15.8 mm in the LACN. The mean distance between the ulnar styloid process and the point where the VBs reached the ulnar artery was 60.3 ± 25.9 mm in the MACN and 43.8 ± 26.0 mm in the PCUN. This study showed that the VBs of the cutaneous nerves have diverse branching patterns. The VBs of the SBRN had a more limited distribution areas than those of the other nerves. Clin. Anat. 31:734–741, 2018. © 2017 Wiley Periodicals, Inc.