Anat. Soc. India 49(1) 63-66 (2000)
Superficial Palmar Arch Duplication-A Case Report
Patnaik V.V. Gopichand, Kalsey G., Singla Rajan K. Departmet of Anatomy, Govt. Medical Collage, Amritsar, Punjab INDIA.
Abstract : In this paper, a case of persistent median artery with double superficial palmar arch is reported. The inter-communique betwixt ulnar artery and persistent median artery has resulted in this case to an entity aptly christened as double superficial palmar arch, constituted by the proximal component forming a complete arch situated topographically where a superficial palmar arch is usually described & a distal component which is sub serving the purpose of providing necessary interdigital branches which normally are given off by a superficial palmar arch; incomplete in this case between Ist & 2nd intermetacarpal space.
Keywords : Double superficial palmar arch, persistent median artery
Case Report During the dissections being done in the Anatomy Department of Government Medical College, Amritsar under the project of "Arterial pattern of Superior Extremity of human adult- a morphological study", a case of double superficial palmar arch was encountered with proximal one being complete and distal one being incomplete. The limb belonged to the right side of a 50 years old male cadaver. The brachial artery was found to be dividing normally in radial and ulnar arteries 2.5 cms distal to the intercondylar line opposite the head of radius. The ulnar artery was going to the palm normally while radial artery was going to dorsal aspect of wrist after passing through anatomical snuff box to dip into 1st intermetacarpal space to take part in formation of deep palmar arch. No superficial palmar branch, arteria princeps pollicis or arteria radialis indicis was arising from it. The median artery was arising from common interosseous artery and was persistent. It was going into the palm superficial to the thenar muscles and taking place of radial artery and its branches there giving arteria princeps pollicis and arteria radialis indicis supplying the respective areas. The ulnar artery was very big in caliber and giving fourth and third interdigital branches and ending as second interdigital branch. At this level there was no communication between median and ulnar arteries. However, proximally at the level of heads of metacarpals there was found a very thin anastomosis between persistent median artery and the ulnar artery. The caliber of this anastomosis was approximately one third of that of persistent median artery, thus making a mediano-ulnar type of complete superficial palmar arch (Group I, Type C of Coleman and Anson, 1961), while the distal one being an incomplete superficial palmar arch of mediano-ulnar type (Group II, Type C of Coleman and Anson, 1961). Thus, there were found 2 superficial palmar arches, proximal complete mediano ulnar type giving no interdigital branch and distal incomplete mediano ulnar type giving the interdigital branches. (See Photographs 1 and 2). 
Photograph. 1. Double superficial palmar arch (pa - proximal complete arch; m - median artery; u-ulnar artery; I-IV - Interdigital bb.) 
Photograph. 2. Persistent median artery (pma) passing through median nerve (m) (b - brachial artery; r-radial artery; u - ulnar artery) Discussion : The superficial palmar arch is fed mainly by the ulnar artery, entering the palm with the ulnar nerve anterior to the flexor retinaculum and lateral to pisiform, passing medial to the hamateﾁfs hook, then curving laterally to form the arch, convex distally (Williams et al, 1999) across the middle 1/3 of the palm (Massie, 1944) and in level with transverse line through the distal border of the fully extended pollicial base (Boyd, 1956, Williams et al, 1999). About 1/3rd of the superficial palmar arches are formed by the ulnar artery alone; a further 1/3rd are completed by superficial palmar branch of radial artery and a 1/3rd either by the arteria radialis indicis, a branch of arteria princeps pollicis or by persistent median artery (Coleman and Anson, 1961). The persistent median artery going to the palm and taking part in the formation of superficial palmar arch is reported in different percentages by different workers (Table1). However, none of them have commented upon the double superficial palmar arch. Table I Prevelance of Persistent median artery | Sr. No. | Author and year | %age | 1.
2.
3.
4.
5.
6.
7. | Tandler et al (1887)
Adachi (1928)
Misra (1955)
Coleman and Anson (1961)
Keen (1961)
Anson (1966)
Karlsson (1982) | 16%
8%
8.4%
9.9%
9.5%
8.0%
4.0% |
Coleman and Anson (1961) classified the superficial palmar arch in 2 groups. Group 1: Complete arch (Found in 78.5% cases) is further divided into five types : Type A : The classical radio ulnar arch formed by superficial palmar branch of radial artery and the larger ulnar artery (34.5%). Type B : This arch is formed entirely by ulnar artery (37%). Type C : Mediano- ulnar arch is composed of ulnar artery and an enlarged median artery (3.8%) (8% by Anson, 1966). Type D : Radio-mediano-ulnar arch in which 3 vessels enter into formation of the arch (1.2%). Type E : It consists of a well formed arch initiated by ulnar artery and completed by a large sized vessel derived from deep arch (2%). Group II : Incomplete arch?When the contributing arteries to the superficial palmar arch donﾁft anastomose and when the ulnar artery fails to reach the thumb and index finger, the arch is incomplete. It can be further divided into 4 types : Type A : Both superficial palmar branch of the radial artery and ulnar artery take part in supplying the palm and fingers but in doing so fail to anastomose (3.2%). Type B : Only the ulnar artery forms the superficial palmar arch but the arch is incomplete in the sense that it does not supply the thumb and the index finger (13.4%). Type C : Superficial vessels receive contribution from both median and ulnar arteries but without anastomosis (3.8%). Type D : Radial, median and ulnar arteries all give origin to superficial vessels but donﾁft anastomose (1.1%). In the above classification they did not make a mention of double superficial palmar arch as was found in the present case. The proximal one of our case fits into group I type C, while distal one fits into group II type C. The proximal arch was giving no interdigital branch directly which were given by distal arch only, whereby the median artery was continuing as 1st interdigital artery supplying 1st interdigital cleft (corresponding to the areas supplied by arteria princeps pollicis and arteria radialis indicis) and ulnar artery was giving 4th, 3rd and 2nd interdigital branches. It fits into type 1 of 7 different patterns of common volar digital arteries observed by Coleman and Anson, 1961) (See original article for details). Developmental aspect of superficial palmar arch : Arey (1957) is of the view that the anomalies of blood vessels may be due to : (1) the choice of unusual paths in the primitive vascular plexuses .
(ii) The persistence of vessels normally obliterated
(iii) The disappearance of vessels normally retained (iv) Incomplete development (v) Fusion and absorption of the parts usually distinct. Muller (1903) has advocated the idea of a capillary plexus ancestory for vascular trunks in contrast to notions which had earlier prevailed (Keibal and Mall, 1912). According to Bhargva (1956) the blood vessels arise from angioblastic tissue of mesenchyme which forms the blood islands. These islands become hollowed out and acquire a lining of flattened endothelial cells ; these isolated spaces unite to form vascular plexuses. Arteries and veins are differentiated from these capillary plexuses by enlargement of one channel and retrogression of the other. Keibel and Mall (1912) opine that the earliest channels of an arterial source into the anterior limb buds are doubtless capillaries which arise directly from the lateral aortic wall at many points and anastomose profusely in early limb tissue. These are named as 5 early subclavians by Goppert (1908). Out of all these only a single member remains to constitute definitive subclavian artery, the vessel of 7th segment. It now forms the sole supply of the capillary plexus formerly nourished by multiple vessels. Further development of arteries of upper limb is described by Senior (1926) in the following five stages : Stage I : Originally the subclavian artery extends to the wrist, where it terminates by dividing into terminal branches for the fingers. The distal portion of the artery becomes the interosseous artery of the adult. Stage II : The median artery arises from the interosseous artery and becomes larger while interosseous artery subsequently undergoes retrogression. During this process the median artery fuses with the lower portion of interosseous artery and ultimately forms the main channel for the digital branches becoming the principle artery of the forearm. Stage III : In embryos of 18mm, the ulnar artery arises from brachial artery and unites distally with the median artery to form superficial carpal arch. Digital branches arise from this arch. Stage IV : In embryo of 21mm length, the superficial brachial artery develops in the axillary region and traverses the medial surface of the arm and runs diagonally from the ulnar to the radial side of the forearm to the posterior surface of the wrist. There it divides over the carpus into branches for the dorsum of the thumb and index finger. Stage V : Finally three changes occur. When the embryo reaches the length of 23 mm the median artery undergoes retrogression becoming a small slender structure, now known as arteria comes nervi mediani. The superficial brachial artery gives off a distal branch which anastomoses with the superficial palmar arch already present. At the elbow an anastomotic branch between brachial artery and superficial brachial artery becomes enlarged sufficiently to form with the distal portion of the latter, the radial artery, as a major artery of the forearm; the proximal portion of the superficial brachial artery atrophies correspondingly (From Singer, 1933). Thus the axis artery of the upper limb gives rise to the sub-clavian, axillary, brachial and interosseous artery and to deep palmar arch. Other arteries of the upper limb develop as sprouts of the axis artery (Arey, 1966; Patten, 1968; Allan, 1969; Hamilton and Mossman, 1972). According to Vare and Bansal (1969) the superficial palmar arch develops as a terminal plexus of axial artery which is later joined by median, ulnar and radial arteries as these arteries develop. Some of these arteries retain communication with the plexus while others lose it. Accordingly arch may be of different varieties. In the present case we assume that the median artery arose normally as a branch of common interosseous artery and joined the capillary plexus in the palm while the anterior interosseous artery regressed. Meanwhile the ulnar artery also developed normally to go upto palm and proximal superficial palmar arch was formed. However, it remained too amall in caliber to supply interdigital branches so the ulnar artery itself continued to supply 4th, 3rd and 2nd interdigital branches while the median artery which had to regress, did not do so and continued to supply 1st interdigital cleft because the proximal superficial palmar arch did not develop properly to supply these interdigital branches. So it seems to be a failure on the part of superficial palmar arch to develop fully and feed interdigital branches, thus forming a thin proximal complete mediano ulnar type of superficial palmar arch and a failure on the part of median artery and ulnar artery to retrogress giving rise to distal incomplete mediano ulnar type of superficial palmar arch. This is in consonance with Areyﾁfs (1957) views that anomalous blood vessels may be due to: (i) Persistence of vessels normally obliterated (Persistent median artery which should have obliterated) and (ii) Haemodynamically incomplete development of proximal superficial palmar arch which was so unable to give rise to interdigital branches the later being given off thus from another incomplete superficial palmar arch formed distally by persistent median artery and continuation of ulnar artery. Clinical Significance : The superficial and deep palmar arches account for a rich anastomosis between arteries of the palm. Wounds of the palm bleed profusely but heal rapidly because of these anastomosis. However, for arresting the bleeding from the palm, one may have to ligate the radial or ulnar artery or even brachial artery especially in cases of persistent median artery as was in this case. In case, there is bleeding from any of interdigital branches of ulnar artery the surgeon may ligate the ulnar artery above the proximal superficial palmar arch expecting the blood supply to the 4th, 3rd and 2nd interdigital artery to be cut off because of incomplete distal superficial palmar arch, whereas actually it is still not cut off completely because of an alternative route via proximal complete superficial palmar arch. The situation may be thus very embarassing and trying one. So one should be familiar with such type of rare variation of double superficial palmar arch. Similarly in case of injury to 1st interdigital branch of median artery, its ligation above the proximal superficial palmar arch may not be sufficient to arrest this bleeding because then ulnar artery may feed it via proximal superficial palmar arch though distally there is no anastomosis between 1st and 2nd interdigital branches. References : 1. Adachi : Das Arterien system des japaner, Kyoto, Vol 1, (1928)
2. Anson, B. J. : Morrisﾁf Human anatomy, In: CVS-arteries and veins; Mc Graw Hill Book Co., New York, Toronto: pp. 708-24(1966)
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17. Vare, A. M. and Bansal, P.C. (1969) : A case of anomalous brachial artery and other associated vascular anomalies in a single upper limb. Journal of the anatomical society of India. [18 (2)] : pp. 50-53.
8. Williams, P. L. et al : Grayﾁfs anatomy. In : Arteries of the limbs 38th Ed., Churchill Livingstone, New York, London, p. 1544 (1999) .
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