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Belbl M, Steyerova P, Kachlik D. Two arterial variations of the hand and wrist present bilaterally (persistent median artery and superficial dorsal branch of the radial artery): ultrasound findings. Surg Radiol Anat 2024; 46:85-89. [PMID: 38006408 DOI: 10.1007/s00276-023-03262-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 10/25/2023] [Indexed: 11/27/2023]
Abstract
PURPOSE Arterial variations of the upper limb may bear high importance for many clinical procedures, including the use of flaps in plastic surgery. We present a feasible way for visualization and confirmation of presence of these variations. METHODS All variations were detected by ultrasonography and confirmed by Color Doppler Imaging. Proper documentation was taken in order to present our findings. RESULTS We report a case of a 19-year-old female who showed two concomitant arterial variations of the forearm and the hand bilaterally. These two variations were the persistent median artery and the superficial dorsal branch of the radial artery which both significantly contributed to the blood supply of the hand. All examinations were performed by the same investigator and all findings were reviewed by an experienced sonographist. CONCLUSION An unusual arrangement of the arterial system can be easily detected. We present a feasible way to prevent iatrogenic injuries and increase utilization of anatomical variants knowledge in surgery by using ultrasound prior to planning surgical procedures.
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Affiliation(s)
- Miroslav Belbl
- Department of Anatomy, Second Faculty of Medicine, Charles University, V Uvalu 84, 150 06, Prague 5-Motol, Czech Republic.
- Second Faculty of Medicine, Center for Endoscopic, Surgical and Clinical Anatomy (CESKA), Charles University, Prague, Czech Republic.
| | - Petra Steyerova
- Second Faculty of Medicine, Center for Endoscopic, Surgical and Clinical Anatomy (CESKA), Charles University, Prague, Czech Republic
- Department of Radiology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - David Kachlik
- Department of Anatomy, Second Faculty of Medicine, Charles University, V Uvalu 84, 150 06, Prague 5-Motol, Czech Republic
- Second Faculty of Medicine, Center for Endoscopic, Surgical and Clinical Anatomy (CESKA), Charles University, Prague, Czech Republic
- Department of Health Care Studies, College of Polytechnics, Jihlava, Czech Republic
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Schwabl C, Hörmann R, Strolz CJ, Drakonaki E, Zimmermann R, Klauser AS. Anatomical Variants of the Upper Limb Nerves: Clinical and Preoperative Relevance. Semin Musculoskelet Radiol 2023; 27:129-135. [PMID: 37011614 PMCID: PMC10069954 DOI: 10.1055/s-0043-1761952] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Abstract
Profound knowledge of nerve variations is essential for clinical practice. It is crucial for interpreting the large variability of a patient's clinical presentation and the different mechanisms of nerve injury. Awareness of nerve variations facilitates surgical safety and efficacy. Clinically significant anatomical variations can be classified into two main groups: variability in the course of the nerve and variability of structures surrounding the nerve. In this review article we focus on the most common nerve variants of the upper extremity and their clinical relevance.
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Affiliation(s)
- Christoph Schwabl
- Radiology Department, Medical University of Innsbruck, Innsbruck, Austria
| | - Romed Hörmann
- Department of Anatomy, Histology and Embryology, Institute of Clinical and Functional Anatomy, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Elena Drakonaki
- Independent MSK Radiology Practice, Heraklion, Crete, Greece
| | - Robert Zimmermann
- Department of Surgery, University Hospital for Plastic, Reconstructive and Aesthetic Surgery, Medical University of Innsbruck, Innsbruck, Austria
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Arnauw S, De Wachter G. Thrombosis of persistent median artery as a cause of carpal tunnel syndrome : case report. Acta Orthop Belg 2021. [DOI: 10.52628/87.3.19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Carpal tunnel syndrome (CTS) is a common peripheral neuropathy, caused by compression of the median nerve. Symptoms usually are present for months and aggravate over time. Acute onset of complaints and symptoms, like coldness of the hand, should raise awareness of a possible vascular cause of CTS.Persistent median artery (PMA) is a very rare anatomical variant of the blood supply of the upper limb. The presence of a thrombosed PMA is an extremely rare cause of CTS. In this article a case is presented in which the patient has carpal tunnel syndrome of his left hand, caused by a thrombosed persistent median artery.
Conservative treatment, consisting of rest, ice applica- tion and non-steroidal anti-inflammatory drugs, failed. Surgical excision of the thrombosis and open exploration of the carpal tunnel was performed, with complete relief of symptoms. In literature different treatment options, like conservative treatment with antiplatelet therapy or surgical excision of the throm- bosis and decompression of the nerve, are described with good results. However up until now, no consensus exists about the golden standard in treatment of a thrombosed persistent median artery.
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AlModumeegh AS, AlOtaibi NA, AlYamani AA, AlDossari AA, AlAmmari AS, AlQattan MM. Persistent median artery in carpal tunnel syndrome for a patient with end stage renal disease after thrombosis of the left radiocephalic AV forearm loop graft: A case report. Int J Surg Case Rep 2021; 87:106439. [PMID: 34602365 PMCID: PMC8523786 DOI: 10.1016/j.ijscr.2021.106439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 09/19/2021] [Accepted: 09/19/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION & IMPORTANCE Carpal tunnel syndrome (CTS) is the most common neuropathy in the world and is caused by compression of the median nerve. It has many known risk factors, including hemodialysis and a persistent median artery (PMA), which can be an incidental finding during carpal tunnel release (CTR). CASE PRESENTATION A 65-year-old woman with end-stage renal disease (ESRD) on dialysis for seven months presented with typical signs and symptoms of carpal tunnel syndrome. Nerve conduction studies (NCS) displayed severe neuropathy. Upon carpal tunnel release (CTR) a rare superficial non-calcified persistent median artery critical to the circulation of the hand was found. The patient's symptoms resolved completely within four weeks of the operation. CLINICAL DISCUSSION The PMA is a relatively common anomaly and could cause carpal tunnel syndrome by: directly pressing the median nerve, thrombosing, or in the setting of an aneurysm. Although usually found deep to the flexor retinaculum, the PMA could also be found superficially. It can be critical to the blood supply of the hand and should therefore be dealt with carefully. CONCLUSION Surgeons should be aware of the possibility of finding a PMA when performing CTR. The PMA could be deep or superficial to the transverse carpal ligament. Where possible, the PMA should be preserved. Especially if its contributions to the blood supply of the hand are undetermined.
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Affiliation(s)
- Abdulaziz S AlModumeegh
- Plastic Surgery Department, Medical College Al-Imam Muhammad Ibn Saud Islamic University, Riyadh, Saudi Arabia.
| | - Nouf A AlOtaibi
- College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | | | | | - Ali S AlAmmari
- College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Mohammed M AlQattan
- Division of Plastic Surgery and Hand Surgery, Department of Surgery, King Saud University, Riyadh, Saudi Arabia
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Konarik M, Musil V, Baca V, Kachlik D. Upper limb principal arteries variations: A cadaveric study with terminological implication. Bosn J Basic Med Sci 2020; 20:502-513. [PMID: 32343941 PMCID: PMC7664784 DOI: 10.17305/bjbms.2020.4643] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Accepted: 04/04/2020] [Indexed: 11/16/2022] Open
Abstract
Although the variability of the upper limb arteries is a clinically important problem, the prevalence is varying across the existing studies and classification is rather complicated, not well established and sometimes even unclear for simple and direct understanding and usage. Multiple case reports appearing in the last years apply incorrect, inappropriate, and sometimes misleading terminology. We performed an anatomical cadaveric study of the variability of the arteries of the upper limb, namely, the axilla, arm, and forearm, in 423 upper limbs embalmed with classical formaldehyde method (Central European population). We proposed to apply the Equality system based on the common trunks for denomination of the axillary artery branches principal variations: Truncus subscapulocircumflexus (22.9%), truncus profundocircumflexus (13.75%), and truncus bicircumflexus (13.95%). Further, we proposed the terminology system developed by Rodríguez-Niedenführ et al. for the free upper limb principal arterial trunk variations based on the origin, location (in the arm only, or in the arm and forearm), and course (related to the forearm flexor muscles) of the involved artery: Arteria brachialis superficialis (9.5%), arteria brachioradialis superficialis (6.4%), arteria brachioulnaris superficialis (1.9%), arteria brachiomediana superficialis (0.5%), and arteria comitans nervi mediani manus (3.3%). Extensive development of the catheterization methods via the arteria radialis et ulnaris as well as surgical procedures using flaps based on perforating branches of these arteries (including arteria brachioradialis superficialis et brachioulnaris superficialis) necessitate thorough data on prevalence of the variant vessels for safe performance of these procedures to prevent any unexpected situations or to react adequately in such.
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Affiliation(s)
- Marek Konarik
- Department of Anatomy, Second Faculty of Medicine, Charles University, Prague, Czech Republic; Department of Histology and Embryology, Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Vladimir Musil
- Centre of Scientific Information, Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Vaclav Baca
- Department of Health Care Studies, College of Polytechnics Jihlava, Jihlava, Czech Republic
| | - David Kachlik
- Department of Anatomy, Second Faculty of Medicine, Charles University, Prague, Czech Republic; Department of Histology and Embryology, Third Faculty of Medicine, Charles University, Prague, Czech Republic; Department of Health Care Studies, College of Polytechnics Jihlava, Jihlava, Czech Republic
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Hinchcliff KM, Ho CN, Meamar P, Irwin CS. Maintained Hand Perfusion in the Setting of Radial and Ulnar Artery Transections: A Report of 2 Cases. JBJS Case Connect 2020; 10:e1900365. [PMID: 32910601 DOI: 10.2106/jbjs.cc.19.00365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE Two otherwise healthy male patients presented with lacerations to the volar distal forearm. Both patients had capillary refill at the fingertips and intact Doppler signals of the palmar arch. Computed tomography angiography revealed cessation of flow in the major forearm arteries at the level of the lacerations, with distal reconstitution from the anterior interosseous artery in both cases and from a branch off the ulnar artery in 1 case. The patients underwent operative exploration, where complete transections of the radial and ulnar arteries were found and repaired. CONCLUSIONS In patients without arterial disease, contributions from minor forearm arteries can be sufficient for hand perfusion in the setting of radial and ulnar artery transection.
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Jeon SY, Lee K, Yang WJ. Carpal tunnel syndrome caused by thrombosed persistent median artery - A case report. Anesth Pain Med (Seoul) 2020; 15:193-198. [PMID: 33329813 PMCID: PMC7713818 DOI: 10.17085/apm.2020.15.2.193] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 10/01/2019] [Accepted: 10/02/2019] [Indexed: 11/17/2022] Open
Abstract
Background A rare case of carpal tunnel syndrome caused by a thrombosed persistent median artery is presented here. Case The diagnosis was delayed due to the overlapping cervical radiculopathy. Acute severe pain and nocturnal paresthesia were chief complaints. Ultrasonography, magnetic resonance imaging, and computed tomography angiography revealed that the median nerve was compressed by the occluded median artery. Instead of surgery, conservative therapy was tried. It worked well for six months. Conclusions The importance of using modalities for decision making of diagnosis and treatment is emphasized in this report.
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Affiliation(s)
- Sang Yoon Jeon
- Department of Anesthesiology and Pain Medicine, Dongkang Medical Center, Ulsan, Korea
| | - Kwangmin Lee
- Department of Anesthesiology and Pain Medicine, Cheju Halla General Hospital, Jeju, Korea
| | - Weon-Joon Yang
- Department of Anesthesiology and Pain Medicine, Cheju Halla General Hospital, Jeju, Korea
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Haładaj R, Wysiadecki G, Dudkiewicz Z, Polguj M, Topol M. Persistent Median Artery as an Unusual Finding in the Carpal Tunnel: Its Contribution to the Blood Supply of the Hand and Clinical Significance. Med Sci Monit 2019; 25:32-39. [PMID: 30600313 PMCID: PMC6327784 DOI: 10.12659/msm.912269] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Knowledge of the variable relation of the persistent median artery (PMA) to the median nerve and its contribution to the formation of the superficial palmar arch is of great clinical significance. This study presents a proposal of specific variables which might be introduced to characterize the PMA in the wrist region. MATERIAL AND METHODS One hundred and twenty-five randomly selected, isolated upper limbs fixed in 10% formalin solution were subjected to anatomical dissection. RESULTS Of the 125 upper limbs, PMA was found in 5 specimens (4% of the total number of limbs). In the carpal tunnel, the artery occupied the anterolateral position (2 cases), the anterior position (2 cases) or the anteromedial position (1 case) in relation to the median nerve. Two types of superficial palmar arches with significant contributions from the PMA were observed in the studied material: complete medio-ulnar arch and an incomplete arch without a connection between the territories of the ulnar and median arteries. The mean ratio of the diameter of the PMA to the diameter of ulnar artery at the level of the wrist was 0.59 (min.=0.38, max=0.83, SD=0.19). CONCLUSIONS Orthopedic and hand surgeons should be aware of the probability of occurrence of the PMA in both planning and conducting surgeries within the wrist region and within the carpal tunnel, as this anomalous vessel might present significant contributions to the arterial blood supply of the hand and might potentially play an important role in the presence of notable clinical symptoms and presentations.
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Affiliation(s)
- Robert Haładaj
- Department of Normal and Clinical Anatomy, Interfaculty Chair of Anatomy and Histology, Medical University of Łódź, Łódź, Poland
| | - Grzegorz Wysiadecki
- Department of Normal and Clinical Anatomy, Interfaculty Chair of Anatomy and Histology, Medical University of Łódź, Łódź, Poland
| | - Zbigniew Dudkiewicz
- Clinic of Hand Surgery, Chair of Traumatology and Orthopedics, Medical University of Łódź, Łódź, Poland
| | - Michał Polguj
- Department of Angiology, Interfaculty Chair of Anatomy and Histology, Medical University of Łódź, Łódź, Poland
| | - Mirosław Topol
- Department of Normal and Clinical Anatomy, Interfaculty Chair of Anatomy and Histology, Medical University of Łódź, Łódź, Poland
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