UNILATERAL INCOMPLETE SUPERFICIAL PALMAR ARCH: A CASE REPORT

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Int J Anat Res 2015, 3(4):1638-41. ISSN 2321-4287 1638

Case Report

UNILATERAL INCOM PLETE SUPERFICIAL PALM AR ARCH: A CASE

REPORT

Subhankar Chakraborty

1

**_{, Subhra M andal *}**

2

_.

ABSTRACT

Address for Correspondence: Dr.(M rs) Subhra M andal, M D (Anat omy), Associate Professor, M edical College Kolkata, West Bengal, India. M obile no.:+919477458100

E-M ail: drsuvramandal@gmail.com

The f unct ional im por t ance of hand is r evealed by it s rich vascularit y cont ribut ed by superf icial and deep palm ar arches (SPA and DPA).Superficial palm ar arch is locat ed superf icial t o flexor t endons, and deep palm ar arch deep t o lum brical m uscles. Variat ions are found m ore of t en in SPA t han DPA, lat er being m ore or less constant . During rout ine undergraduat e dissect ion, w e observed, unilat eral incom plet e SPA being form ed by superficial palm ar branches of ulnar and radial ar t ery in t he right hand of a m ale cadaver. These t w o art er ies rem ained independent w it hout anast om osis form ing incom plet e arch (SPA).The super ficial branch of ulnar ar t er y ent ered hand superf icial t o flexor ret inaculum and supplied m iddle, ring and lit t le f inger by t hr ee branches. The superficial branch of radial ar t ery via it s t w o br anches supplied index f inger and t hum b. Classical SPA form at ion w as seen on left side.

The presence of an incom plet e SPA as in t his case is a pot ent ial danger in RA harvest ing for CABG.Variat ions in SPA play a pivotal role in m icrovascular surgical procedures of hand, RAint er vent ions and ar t er ial graf t appl icat io ns.

KEY W ORDS: Super f icial palm ar arch, Deep palm ar ar ch, Lum br ical, Anast om osis, Ret inaculum , CABG, M icrovascular surgery.

INTRODUCTION

Int ernat ional Journal of Anatomy and Research, Int J Anat Res 2015, Vol 3(4):1638-41. ISSN 2321- 4287 DOI: ht t p:/ / dx.doi.org/10.16965/ ijar.2015.302

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Received: 24 Oct 2015 Accept ed: 24 Nov 2015 Peer Review : 24 Oct 2015 Published (O): 31 Dec 2015 Revised: None Published (P): 31 Dec 2015

Int ernat ional Journal of Anat omy and Research ISSN 2321-4287

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DOI: 10.16965/ ijar.2015.302

1 ₂nd_{yr Post-Graduate Trainee, *}2 _{Associate Professor}

Depart ment of Anat omy, M edical College and Hospital, Kolkata, West Bengal, India.

(M A) accom panying t he m edian nerve. The median art ery is t he axial art ery of t he superior ext r em i t y d u r in g ear l y em br y o ni c li f e. It m aint ains t he SPA w hile t he RA and UA are developing. W hen t he UA and RA are fully developed, t he M A disappears. The M A m ay persist in adult life as ant ebrachial or palm ar median artery, based on t heir vascular territ ory. The palm ar t ype is int imat ely relat ed t o t he median nerve, reaches t he w rist and ent ers t he p al m af t er p assi n g b eneat h t h e f l exo r ret inaculum (FR) and m ay t ake par t in t he format ion of SPA [2]. A classical t ype of SPA is Superficial palmar arch (SPA) is an im port ant

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Subhankar Chakrabort y, Subhra M andal. UNILATERAL INCOM PLETE SUPERFICIAL PALM AR ARCH: A CASE REPORT.

described as direct cont inuit y bet w een UA and t he superficial branch of RA [3]. This ensures t he presence of collat eral supply in hand. UA ent ers t he palm w it h t he ulnar nerve, ant erior t o t he f lexor ret inaculum and lat eral t o t he pisiform bone. It passes medial t o t he hook of t he hamat e, then curves laterally t o form an arch t hat is convex dist ally and level w ith a t ransverse line t hr ough t he dist al bor der of t he f ully ext ended pollicial base [4]. Thereaft er it usually communicates wit h t he superficial branch of the radial art ery to complete t he arch. In incomplet e variet y of SPA, no anast omosis is seen bet w een t he ulnar and radial art eries [5]. Coleman and Anson (1961) classified incomplete SPA int o four subt ypes, namely t ypeA, t ype B, t ype C and type D [6]. Type A incomplete SPA poses vulnerabilit y t o digit al ischemic changes aft er t rauma or aft er any intervent ion related t o t he radial artery. This v ar i at i o n al so assu m es i m po r t an ce i n obst ruct ion of art eries at t he level of w rist occurring in “ Hypot henar Hammer Syndrome” an d i n co n nect iv e t i ssue d iseases [ 6] . Know ledge of t he f r equency of anat om ical variat ions of t he art erial pat t erns of t he hand is crucial for safe and successful reconst ruct ive hand surgeries [7], preoperat ive screening for radial art ery (RA) har vest ing for m yocar dial revascularizat ion procedures and also in art erial int ervent ions t hat include RA cannulat ion and forearm flaps based on RA. Therefore w e report a case of incom plet e SPA in a m idd le aged f or m alin f ixed m ale cadaver t hat w e cam e across during rout ine dissect ion classes f or undergraduat e st udent s, in t he Depart ment of Anat omy, M edical College Kolkata, India.

Fig.1: Classical SPA

Photo 1: Norm al SPA (left palm ).

Case Report

We m ade t he skin incisions, dissect ed t he palm ar aponeurosis, f lexor ret inaculum and deep fascia covering t he t henar and hypot henar muscles according t o t he guidelines prescribed in Grant ’s Dissect or- 15t h edit ion. After t his w e encountered an incomplete t ype of SPA in t he right hand of t he cadaver. The hist ory of t he in-dividual and t he cause of deat h w ere not known. We found t he superficial branch of UA entering t he hand, superficial t o t he flexor ret inaculum. Thereaft er it gave off one proper digit al branch t o the ulnar side of t he lit t le finger and t w o com-mon digital branches to supply the adjacent sides of middle, ring and lit t le fingers. The superficial palmar branch of radial art ery ent ered t he hand superficial t o t he t henar muscles and t hen gave off one proper digit al branch t o t he radial side of t he t humb and one common digit al branch supplying t he ulnar side of t he t humb and radial side of t he index finger. The adjacent sides of index and middle fingers receive t heir blood supply from t he palmar met acarpal branch of t he deep palmar arch. On t he left side t he SPA w as complet e as t he t radit ional cont inuit y be-t w een be-t he superficial branches of be-t he UA and t he RA w as maint ained.

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Photo 3: Superficial branch of ulnar art ery.

Photo 4: Superf icial branch of radial art ery.

Fig. 2: schem at ic diagram of super ficial palm ar arch observed in our case.

DISCUSSION

Superficial art eries of t he hand present many diverse pat t erns t hat permit t heir w ell defined cat egorizat ion. Colem an and Anson st udied t hese diversit ies in 1961 and classified complet e SPAs int o 5 groups. These aut hors again t ypified t he incomplete SPAs int o 4 categories, namely, Type A, Type B, Type C and Type D [6]. Type A h ad n o an ast o m osi s b et w een su p er f i ci al branches of RA and UA. In Type B, t he SPAs w ere

solely formed by UA. Type C SPAs w ere formed b y u l nar an d m ed i an ar t er ies w i t h ou t anast omosis. Type D variet ies w ere cont ributed by ulnar, median and radial arteries, w it hout any anast omosis bet w een t hem. In our st udy w e observed an incomplet e arch belonging t o t he ‘ Type A variet y of Incomplete Palmar Arches’ of Coleman and Anson’s classificat ion.

Fig. 3: Colem an and Anson’s classificat ion of incom -plet e SPAs.

In a 500 hand st udy by Janevsky et al. , t he com p l et e ar ch es w er e seen i n 75% an d incomplet e arches in 25% of cases [8]. About a t hird SPA are formed by t he UA alone; a furt her is com plet ed by t he superficial branch of RA, and a t hird eit her by ARI or by APP or by M A [4]. The t radit ional classificat ion has been report ed t o be evident in as many as 55.9% of specimens in t he research of Ikeda et al. [9], or as few as 10% of specimens according t o Ruengsakulrach et al. [10] SPA alone formed by UA was reported by Coleman and Anson as 37% [6], by Jelicic et al as 10% [7] and by Ikeda et al as 25.5% [9]. The incidence of incomplete SPAs reported are 10%, 16%, 16% and 21.47% of cases in st udies of Loukas et al (2005), Pat naik et al (2002), Al t urk and M et calf (1984) and Coleman and Anson (1961) respect ively [6,11-14]. Tagil et al not iced t hat t he most consist ent incomplet e form w as t he UA alone forming SPA w hich was seen in about 20% of subject s [15].

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Int J Anat Res 2015, 3(4):1638-41. ISSN 2321-4287 1641 Conflicts of Interests: None

REFERENCES

cont ribut ing t o t he format ion of SPA [16]. These arterial variat ions have enormous import ance for vascular graft harvest ing, graft applicat ions, free/ pedicled flap harvest ing in hand surgeries. Therefore prior det ermination of intact collateral supply of t he hand is an essent ial prerequisit e for perf or m ing t hese procedures. M odif ied Allen’s t est , Ar t er ial An giograp hy, Dop pler Ultrasound, Photo-plethysmography, can be used t o det ermine t he vascular pat t ern in t he palm. The lat est report s of Johnson et al [17] on coronary art ery bypass graft (CABG) favors t he use of an art erial graft , part icularly t he radial art ery as compared t o t he saphenous vein. The RA cont ribut es great ly to t he circulat ion of hand but in many cases it can be removed as a non-essential vessel, w ith adequat e circulat ion being p r o vi ded b y t he u ln ar an d i n so m e cases persist ent median art ery [18]. In t his case w e are present ing, t he only major communicat ion bet w een t he radial and t he ulnar art ery w as t he format ion of deep palmar arch. Therefore in this case, harvest ing a graft based on ulnar art ery w ould pose a risk of compromised circulat ion t o most of t he palm. These variat ions should be kept in m ind w hile considering any operat ive procedure involving t his region; ot herwise t hese may result in fut ile surgical out come.

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UNILATERAL INCOMPLETE SUPERFICIAL PALMAR ARCH: A CASE REPORT