Original Article
PERSISTENT M EDIAN ARTERY IN THE CARPAL TUNNEL
Raviprasanna.K.H *
1,
Dakshayani K.R
2
.
ABSTRACT
Address for Correspondence: Dr. Raviprasanna. K. H, Assistant Professor, Depart ment of Anat omy, Sree Narayana Inst it ute of M edical Sciences, Nort h Kut hiat hode, Chalakka, Ernakulum, Kerala-683594, India. Phone no- +919496752619 E-M ail: pravi_kh81@yahoo.in
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* 1 AssistantProfessor, Depart ment of Anat omy, Sree Narayana Inst it ute of M edical Sciences, Nort h
Kut hiat hode, Chalakka, Ernakulum, Kerala, India.
2 Professor and HOD, Depart ment of Anat omy, M ysore M edical College and Research Inst it ute,
M ysore, Karnataka, India.
Int roduction: Persist ent m edian art ery originat es from t he ant erior int erosseous art ery in proxim al one-t hird of t he forearm and accom panies m edian nerve. M edian art ery m ay regress in t he forearm or ent er palm t hrough t he carpal t unnel deep t o f lexor ret inaculum of w rist and supply palm by anast om osing w it h t he super ficial palm ar arch.
Objective:In present st udy t he object ive w as t o st udy presence of persist ent m edian ar t ery accom panying m edian nerve and it s t erm inat ion
M aterials and M ethods:The st udy included 50 hum an cadaver upper lim b specim ens at t he Depar t m ent of Anat omy, M ysore M edical College & Research Inst it ut e, M ysore dur ing 2011-13. These specim ens fixed in 10% for m alin w ere finely dissect ed and persist ent m edian art ery w as t raced from origin t o t erm inat ion.
Results:Out of 50 hum an cadaver specim ens, persist ent m edian ar t ery w as present in 4 specim ens (8%). All t he 4 m edian art eries originat ed from ant erior int erosseous art ery and w ere of palm ar t ype w hich reached palm . Out of 4 m edian art er ies, 3 m edian art er ies (6%) t ook part in com plet ion of superficial palm ar arch, supplying t he distal aspect of palm and 1 m edian ar t ery (2%) direct ly supplied radial t w o and half f ingers w it hout form ing arch.
Conclusion:Know ledge of unusual variat ions helps in proper t reat m ent of disorders of t he m edian ner ve. Presence of persist ent m edian art ery usually w ill be asym pt om at ic but m ay cause sym pt om s of carpal t unnel syndrom e or pronat or t eres syndrom e w hen subject ed t o com pression. Rarely t his art ery can be t aken for reconst ruct ion
KEY W ORDS:M edian nerve, Var iat ions, Carpal t unnel, Persist ent M edian art ery, Ant erior Int erosseous art ery.
INTRODUCTION
Int J Anat Res 2014, Vol 2(3):589-93. ISSN 2321- 4287
Received: 30 Aug 2014
Peer Review : 30 Aug 2014 Published (O):30 Sep 2014 Accepted: 15 Sep 2014 Published (P):30 Sep 2014
Internat ional Journal of Anat omy and Research ISSN 2321-4287
w w w.ijmhr.org/ ijar.ht m
Variat ions in t he vascular patterns are common w hich usually result due t o developm ent al anom aly during for m at ion of blood vessels. Persistent median artery usually originates from t he anterior interosseous artery in t he proximal one-t hird of t he forear m and accom panies median nerve. M edian artery may regress in t he forearm or enter palm through t he carpal t unnel
develop and take t he sole responsibilit y of blood supply t o t he forearm and hand [1]. The median ar t er y m i ght also ar i se f r o m co m m o n interosseous, ulnar or radial arteries.
Pecket claimed t hree different t ypes of median ner ve vascular isat i on: (a) radial and ul nar art eries forming superficial and deep palmar arches w it h t he m edian ner ve supplied by superficial palmar arch and by t he anast omoses formed by radial and ulnar and by t he forearm muscular branches (70%). (b) Eit her t rifurcat ion of brachial artery int o radial, ulnar and median artery or bifurcat ion of brachial int o t he radial and ulnar art eries. The median artery t ravels superficially t o t he median nerve and branches out at t he palm t o feed second, t hird and fourt h digits (10%). (c) The median artery is related w it h t he superficial palmar arch (20%). Alt hough t he exi st en ce o f t h e m ed i an ar t er y i s n o t so uncom m on, ranging f rom 1.5 t o 27.1%; it s survival in human adult s show s t he primit ive arterial pattern [2].
In present st udy t he object ive was t o st udy t he p resence of p er si st en t m edi an ar t er y accompanying median nerve in t he carpal t unnel and it s terminat ion.
M ATERIALS AND M ETHODS
RESULTS
The 50 human cadaver upper limb specimens w ere obtained from Depart m ent of Anat omy, M ysore M edical College & Research Inst it ute, M ysore during t ime period of 2011-13. Out of 50 specimens, 25 w ere of right and 25 w ere of left side. These specimens w ere fixed in 10% formalin solut ion. We excluded t hose cadaver specim ens f rom our st udy w hich exhi bit ed previous trauma t o the upper limb, fract ures, any kind of surgical procedures and pat hologies.
The d issect i o n w as p er fo r m ed as per t h e Cunningham’s manual of pract ical anat omy.3 the
m edian nerve w as ident ified in t he forearm bet w een t he heads of pronat or teres and t raced bet w een t endons of f lexor car pi radialis & palmaris longus t ill flexor ret inaculum. Using b l un t di ssect i on t he each m ed i an ar t er y accompanying t he median nerve w ere t raced t o t heir origin and terminat ion. The details w ere not ed.
Out of 50 human cadaver specimens, persistent median artery was present in 4 specimens (8%), 2 on right (4%) and 2 on left side (4%). All t he 4 m ed i an ar t er i es o r i gi nat ed f r om ant er io r interosseous artery and w ere of palmar t ype w hich reached palm. Out of 4 median arteries, 2 m edian art er ies (4%) aft er passing t hrough carpal t unnel along w ith median nerve t ook part in for m at ion of ulnar-m edian-radial t ype of superficial palmar arch by anast omosing w it h ulnar and radial art eries (Fig. 1). 1 m edian artery (2%) anast omosed w ith superficial branch of ulnar art ery t o form ulnar-m edian t ype of palmar arch and supplied distal aspect of palm and fingers (Fig. 2). 1 median artery (2%) direct ly supplied lat eral t w o and half fingers w it hout for m ing arch w it h ulnar ar t er y (incom plet e ulnar-median t ype of arch, Fig. 3).
Fig. 1: Com plet e super f icial palm ar arch for m ed by
Radial, m edian and ulnar art ery.
UA- ulnar art ery, M A-M edian ar t ery, SP br RA- Superficial palmar branch of radial art ery, SPA- superf icial palm ar arch, M N- M edian nerve.
Fig. 2: Com plet e super f icial palm ar arch for m ed by
ulnar and m edian art ery.
UA- u l n ar ar t er y, M A- M ed i an ar t er y, ARI- a r t er i a r ad i al i s indicis,
DISCUSSION
Fig. 3:Incom plet e super ficial palm ar arch form ed by
ulnar and m edian art ery.
UA- ulnar ar t er y, M A- M ed i an ar t er y, ARI- a r t er i a r ad i al i s indicis,
APP- Ar t er i a pr in ceps pollicis.
Table 1: Presence of persist ent m edian ar t er y w it h
m edian nerve.
Total
N % N % %
Persistent median artery w ith
median nerve 2 4 2 4 8
Persistent median artery forms
superficial palmar arch 1 2 2 4 6
Persistent median artery doesn’t
form superficial palmar arch 1 2 - - 2
Total 4 8 4 8 8
Right Left
Other variations Observed in M edian Nerve
Persistence of median artery is a sign of primit ive arterial pattern. It s existence is not uncommon and has been reported in previous literat ures. In 1992 George and Henneberg reported a high incidence (27.1%) of t he median artery among Sout h African cadavers [4]. In 1997, Kopuz et al. studied t he presence of persistent median artery (PM A) in neonat al cadavers and raised t he hypot hesis t hat t he median artery regresses at a m uch lat er st age, m ost li kely dur ing t he perinatal period and early infancy. In t heir st udy t he incidence of PM A w as 20% [5]. In 2009, Nat sis K et al. st udied 72 upper limbs of adult cadavers and found t w o cases (2.78%) of a PM A accom panying t he m edian nerve on it s route t h ro u gh t h e car p al t u n n el [ 6] . In 2009, M ohammad A Abdulla et al. st udied 55 pat ient s w ho underw ent open Carpal Tunnel Release at w rist joint and observed follow ing variat ions. Tw o pat ient s (3.64%) had bif id ner ve w it h persistent median artery running bet w een t he t w o divisions [7]. The percentages of hands in w hich t he median artery made a cont ribut ion
t o t he superficial palmar arch w ere reported t o be 2.2% in Janevskis [8] w ork w hich in present st udy was found t o be 8%. Rodriguez et al [1] confirmed t hat t he median artery may persist in adult life in t w o different patterns - ante brachial an d p alm ar t y p e b ased o n t h ei r vascul ar t er rit ory. In t he ant e brachial t ype w hich is considered norm al, it arises m ost ly from t he anterior interosseous artery and does not reach t he palm. The palmar t ype may arise from any of t he forearm art eries and accompanies t he m edian nerve in t he carpal t unnel. It usually terminates at t he superficial palmar arterial arch or as t he main blood supply t o t he index and long fingers. The term Persistent M edian Artery refers t o t he palmar t ype of t he median artery. In the above st udy all the 4 specimens represent palm ar t ype of variet y. W hen present , t he median artery is t he main blood supply t o t he median nerve, corresponding t o Types 2 and 3 of vascular izat ion of t he m edian ner ve as described by Pecket et al.[2] The incidence of palmar t ype has complicat ions associated w it h p r on at or t er es sy n dr o m e, car p al t u nn el syndrom e and ant er ior int erosseous ner ve syndrome.
Per si st en t m edi an ar t er y an eu r y sm an d thrombosis may develop carpal t unnel syndrome result ing in compression of t he median nerve. A t hrombosed median artery causing carpal t unnel syndrome should be removed surgically w it hout causing furt her vascular crisis and if t he artery is pulsat ing and of considerable size, it can be saved and separated from t he median nerve [9]. In 2013 K.K.Agarwal et al. reported a case of m ed i an ar t er y o r i gi n at i n g f r o m co m m o n interosseous artery in t he left arm of t he cadaver during dissect ion. They also reported absence of superficial palmar arch, median artery mainly supplied index and middle fingers [10].In 2013 Prat hap kumar and Roopa kulkarni reported t he presence of persist ent median artery in bot h upper limbs of a male cadaver w hich was arising from t he ulnar artery. The median artery in each h an d had acco m p an ied m ed i an n er v e t hroughout it s course and was cont ribut ing t o t he superficial palm ar arch along w it h ulnar ar t er y. The m edian ar t er y gave 1st and 2n d
t he persistent median artery accompanying t he median nerve through carpal t unnel w ould have caused compression of median nerve leading t o car pal t unnel syndrom e. The m edian art ery w hich supplied lat eral t w o and half fingers fo r m ed m aj or par t of b loo d supp ly i n t he absence of palmar arch betw een ulnar and radial arteries.
EM BRYOLOGY:
Arey [12] has described developm entally t he anomalies of blood vessels may occur due t o
(a) The choice of unusual pat hs in t he primit ive vascular plexus.
(b) The persistence of vessels norm ally t o be obliterated.
(c) Th e disappearance of v essels nor m ally retained.
(d) Incomplete development and
(e) Fusion & absorpt ion of t he part s usually dist inct .
From t he developmental point of view, t he limb bud appears in the form of small elevations along t he vent rolat eral body w all during t he fourt h w eek and soon acquires a prim it ive capillary p l exu s i n asso ci at io n w i t h b r anch es o f intersegmental arteries arising from t he aorta. The subclavian-axillary artery (t he sole arterial stem of t he upper limb) is ident ifiable in a 5-mm embryo, w here it extends t o t he wrist by dividing int o terminal branches for fingers (Fig. 4a). The primit ive vascular pattern consist s of a primary
Fig. 4:Schem at ic diagram show ing stages in t he developm ent of t he art erial patt ern
of t he upper lim b.
(a) The subclavian-axillar y (SA) ar t er y t raversing t he limb bud and dividing int o digit al art eries (DA); (b) The primar y axial art ery brachial art ery (BA) in t he arm and int erosseous art ery (IA) in t he for earm. Not e t he m edian art ery (M A) arising from t he brachial ar t er y and annexing t he digit al branches.
(c) Ulnar art ery arising f rom t he brachial art ery and communicat ing w it h t he median ar t er y.
(d) Radial ar t ery (RA) ar ising f rom t he brachial art er y and complet ing t he arch form at ion w it h t he ulnar art er y. (e) The final rearrangement of vessels.
CONCLUSION
axial artery (t he brachial artery in t he arm and int erosseous art ery in t he forearm ) w it h t he median artery branching off from t he brachial artery, w hich in t urn annexes t he vessels of hand and corresponds t o stage II (Fig. 4b). In t he 18-m 18-m e18-m br yo, t he ul nar ar t er y (o ne of t he prominent vessels of t he forearm) arising from t he brachial art er y, unit es dist ally w it h t he median artery t o form t he arch pattern (Fig. 4c); t his pattern corresponds t o stage III. Follow ing t his, t he radial artery (anot her prominent vessel of forearm) arises from t he brachial artery and f i nall y t akes ov er t he vessels of t h e hand cor r esp o n di n g t o st age IV (Fi g. 4d). t h i s rearrangem ent (stage V) reaches com plet ion before t he end of t he eight h w eek (Fig. 4e) [12].
Know ledge of variations of vascular patterns has gain ed m o r e i m po r t an ce in m icr o su r gical techniques and reconst ruct ive hand surgeries.
How to cite this article
:
Raviprasanna.K.H,Dakshayani K.R. PERSISTENT M EDIAN ARTERY IN THE CARPAL TUNNEL. Int J Anat Res 2014; 2(3): 589-593. Conflicts of Interests: None
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