Palmar Arterial Arches - A Morphological Study
Author(s): Patnaik, V.V.G; *Kalsey, G., *Singla Rajan, K.
Vol. 51, No. 2 (2002-07 - 2002-12)
Department of Anatomy, Govt. Medical College, Patiala, *Amritsar. INDIA
Abstract
Arterial arches of hand are very important for orthopaedicians as well as microvascular surgeons. Variations encountered
in these are so numerous that Poirier finds it difficult to establish a type. The present study was conducted in 50 upper limbs at Govt.
Medical College, Amritsar to find out the pattern of arterial arches of hand. Variations are found more often in superficial palmar arch than
the deep one, later being more or less constant. SPA was found to be single in 94% limbs (complete in 78%, & incomplete in 16%.) In 6%
of limbs, a double SPA was encountered, proximal complete (radio ulnar in 4% & mediano-ulnar in 2%) & distal incomplete. Amongst the
DPAs, all were complete but in one case (2%), it was limited upto 2nd intermetacarpal space only with no contribution further laterally.
In general, it was confirmed that size of the 2 arches is inversally proportional to each other.
All the variations encountered have an ontogenic basis which has been discussed along with their clinical implications.
Key words: Superficial Palmar arch, Deep palmar arch, Palmar arterial arches.
Introduction:
Arterial supply to the man's hand, his most
important earning tool is derived from two
anastomotic arches, superficial et deep formed by
the anastomosis between two main arteries of
forearm i.e. radial, ulnar & their branches; in the
palm. These were studied as early as 1753, by
Haller, a swiss anatomist & poet while notable
variations were described by Tiedman (1831) which
were explained later, on ontogenic basis by Meyer
(1881) & Singer (1933). It was Manners Smith
(1910) who made a comparative study of arteries of
hands in primates & concluded that many of the
variations noted in man represent a retention or
reappearance of primitive patterns. Tandler (1897);
Jaschtschinski (1897); Adachi (1928); Fracassi,
(1945) Coleman & Anson (1961) are the few among
those to name, who have worked on arteries of
hand.
Superficial Palmar Arch - This anastomosis is
fed mainly by the ulnar artery, entering the palm
with the ulnar nerve, anterior to the flexor
retinaculum and lateral to the pisiform, passing
medial to the hamate's hook, then curving laterally
to form an arch, convex distally (Williams et al,
1999) across the middle 1/3 of the palm (Massie,
1944), and in level with a transverse line through the
distal border of the fully extended pollicial base
(Boyd et al, 1956 and Williams et al, 1999). About a
third of the superficial palmar arches are formed by
the ulnar artery alone; a further third are completed
by the superficial palmar branch of the radial artery and a third either by the arteria radialis indicis, a
branch of arteria princeps pollicis or by the median
artery (Coleman & Anson, 1961). It is covered by
the palmaris brevis and palmar aponeurosis and it is
superficial to the flexor digiti minimi, branches of the
median nerve and to the long flexor tendons and
lumbrical muscles (Anson and Maddok, 1952;
Williams et al, 1999).
This arch shows a number of variations as
reported by Dubreuil chambardel (1926); Huber,
(1930); Coleman & Anson, (1961) & Mozersky et al
(1973). According to Poirier (1886), Variations in
SPA are so numerous that it is difficult to establish a
type.
Deep Palmar Arch: It is formed by
anastomosis of the end of the radial with the deep
palmar branch of the ulnar artery. It forms a flatter
curve than the superficial arch (Spalteholz). The
radial artery typically emerges between 2 heads of
adductor pollicis in its course across the palm, Then
it crosses the bases of metacarpal bones and
interossei (Williams, et al, 1999).
This arch is found to be comparatively less
variable than SPA (Coleman & Anson, 1961;
Karlsson & Niechajev, 1982).
Apart from these two main arches two more
arches Palmar & Dorsal Carpal arches give twigs to
the palm & dorsum of hand. All these arches
anastomose freely with each other so much so that
wounds of palmar or carpal arches can be source of
severe bleeding, difficult to achieve haemostasis. It
is also because of occasional difficulty in finding & securing both ends of divided vessel (Huber, 1930;
Treves & Rogers, 1947).
Accepting the fact that extensive arterial
anastomosis in the hand leads to profuse bleeding
from its wounds; Lockhart et al (1959) emphasize
that for the same reasons, healing is also very rapid.
They further call for paying particular attention to the
superficial position of termination of ulnar artery and
superficial palmar arch while making incisions to
evacuate pus from the hand.
Dubreuil (1926) and Mozersky et al (1973)
asserted the importance of understanding variations
of the superficial palmar arch for the purpose of
microvascular repair and re-implantation.
Keeping the importance of these variations in
mind, this study was designed to find out the pattern
of palmar arterial arches in the region which may
help not only the anatomists but also
orthopaedicians & microvascular surgeons.
Materials & Methods:
50 Upper limbs belonging to 25 cadavers
(M.F.: 19:6) of the Anatomy Department, of Govt.
Medical College, Amritsar, comprised the material
for study. These were embalmed with an embalming
fluid containing lead oxide to colour the arteries red
& labelled from 1-25 with letters (R) or (L)
corresponding to right or left limb respectively &
letters (M) or (F) corresponding to male or female
respectively. Exposure of different palmar arches
was achieved following classical incisions &
dissection procedures provided by Cunningham's
Manual of Practical Anatomy, (Romanes, 1999).
Palmar aponeurosis was exposed and
separated from flexor retinaculum, divided
proximally and reflected distally cutting the septae
which pass backwards from its edges. This exposed
the superficial palmar arch which was cleaned to
study the pattern. All other branches of radial and
ulnar arteries in the palm were also studied.
The tendons of flexor digitorum superficialis
were divided at the level of heads of metacarpals
and reflected proximally upto wrist. This exposed
the deep palmar arch which was cleaned to study
the pattern.
Any variation from the normal patterns were
observed, noted and where required, photographed.
Observations:
Superficial Palmar arch: Out of the 50 limbs,
single SPA are found in 47 (94%) limbs which
included 39 limbs (78%) with a complete arch & 8
limbs (16%) with an incomplete one. In the former
group classical radio ulnar type was encountered in
38 (76%) limbs while one (2%) limb had ulnar type
of arch. In the later (incomplete arch) group, 6 limbs
(12%) had a blood supply from both ulnar artery &
superficial palmar branch of radial artery but without
an anastomosis with each other (Photograph 1)
while in 2 limbs, instead of superficial palmar branch
of radial, it was median artery which was a source of
blood supply along with ulnar artery again without
anastomosis with each other (Photograph 2).
The arrangement of intercommunications
betwixt ulnar artery and radial or median artery as
the case may be; (radio-ulnar in limb number 1ML
and 12 MR; mediano-ulnar in limb no. 11 MR) and
branching out of palmar interdigital arteries has set
apart 3 cases deviant from normal which are
christened as double superficial palmar arch. All the
3 double superficial palmar arches had 2
constitutent components - a proximal and a distal
where proximal arch was invariably complete and
situationally where superficial palmar arch is
expected, the distal component was incomplete in
all the 3 cases, but was responsible for palmar
interdigital arteries to emnate from and so
considered as an incomplete superficial palmar
arch, the 2 component arches together constituted
double superficial palmar arch.
Deep Palmar arch: It is found to be less
variable as compared to superficial palmar arch. In
all the 50 dissections, it was a complete arch. The
ulnar artery gave 2 deep palmar branches in all
cases but both of these contributed to formation of
deep palmar arch only in 10% instances. In majority
of specimens i.e. 52% it was only inferior deep
palmar branch of ulnar artery which formed deep
palmar arch, the superior being lost in hypothenar
eminence. In 36% of dissections, it was superior
ramus which contributed to formation of deep
palmar arch.
In one limb the radial artery dipped in 2nd
intermetacarpal space and took part in formation of
deep palmar arch with superior deep palmar branch
of ulnar artery.
Discussion:
Superficial Palmar arch:
Owing to a large number of variations in SPA,
Poirier (1886) had found it extremely difficult to
establish a type, while Adachi (1928) has described
3 types of superficial palmar arch.
- Ulnar type: in which contribution by radial artery is absent or minimal. It is seen in 59%
dissections (64% by Karlsson and Niechajev, 1982).
- Radioulnar type: Seen in 32% dissections (32% by Karlsson and Niechajev, 1982).
- Mediano ulnar type: seen in 9% dissections (4% by Karlsson and Niechajev, 1982).
Huber (1930) groups the superficial palmar arch into
2 classes:
- Those in which additional branches from the
forearm participate in the formation of the arch
or replace the radial in its composition.
- Those in which there is no true arch, the
arteries which should participate in its
formation and in some cases the additional
ones also, failing to anastomose and each
giving rise independently to a certain number
of digital branches in a somewhat fan like
manner.
Coleman and Anson (1961) elaborated more
on superficial palmar arch and reclassified it as
follows :
Group I: Complete arch (Found in 78.5% cases). It can be further divided into five types:
Type A: The classical radio ulnar arch is
formed by superficial palmar branch
of radial artery and the larger ulnar
artery. It was found in 34.5%
dissections (36% by Weathersby,
1954; and 30% by Anson, 1966).
Type B: This arch is formed entirely by ulnar
artery. It was found in 37% cases.
Type C: Mediano ulnar arch is composed of
ulnar artery and an enlarged median
artery. It was found in 3.8%
specimens (8% by Anson, 1966).
Type D: Radio-mediano-ulnar arch in which 3
vessels enter into the formation of
arch. It was found in only 1.2%
dissections.
Type E: It consists of a well formed arch
initiated by ulnar artery and completed
by a large sized vessel derived from
deep arch. The latter vessel comes to
superficial level at the base of the
thenar eminence of join the ulnar
artery. It was found in 2% cases.
Group II: Incomplete arch :
When the
contributing arteries to the superficial
arch do not anastomose or when the
ulnar artery fails to reach the thumb
and index finger, the arch is
incomplete, Such type of arch was
found in 21.5% cases. It can be
further divided into 4 types.
Type A: Both superficial palmar branch of
radial artery and ulnar artery take part
in supplying palm and fingers but in
doing so, fail to anastomose. It was
found in 3.2% cases.
Type B: Only the ulnar artery forms superficial
palmar arch. The arch is incomplete
in the sense that the ulnar artery does
not take part in the supply of thumb
and index finger. It was found in
13.4% dissections.
Type C: Superficial vessels receive
contributions from both median and
ulnar arteries but without
anastomosis. It was found in 3.8%
specimens.
Type D: Radial, median and ulnar artery all
give origin to superficial vessels but
do not anastomose. It was found in
1.1% cases.
If the results of present study are compared
with earlier authors, (Table I) it is seen that in 38
cases (76%) out of 39 (78%) the complete SPA was
of type A i.e. radio ulnar type whereas in Coleman &
Anson (1961) series it was found in 34.5%
dissections with type B in another 37%. In this
context, comments of Adachi (1928) are worth a
mention who commented that differentiation
between these two types is very difficult as it
depends upon observer's estimate as to what
constitutes a minimal contribution by radial artery. It
may probably explain part of discrepancy in this
observation.
Incomplete arch (group II) was encountered in
8 limbs (16%) of the present study. While it was of
type A in 12% & type C in 4%, Coleman & Anson
(1961) found it to be of type B in majority (13.4%)
(See Table 1).
TABLE I: COMPARISON OF PREVALENCE OF TYPES OF SINGLE SUPERFICIAL PALMAR ARCH
S.
No.
Coleman & Anson (1961)
Weathers by (1954)
Anson (1966)
Present study
1
Group I
78.5%
-
78.0%
Type A
34.5%
36.0%
30.0%
76.0%
Type B
37.0%
2.0%
Type C
3.8%
8.6%
-
Type D
1.2%
-
-
-
Type E
2.0%
-
2.
Group II
21.5%
-
-
16.0%
Type A
3.2%
-
-
12.0%
Type B
13.4%
-
-
-
Type C
3.8%
-
-
4.0%
Type D
.0%
-
-
-
3.
Total
100.0%
-
-
*94.0%
* In the rest of 6%, the superficial palmar arch was double
In 3 of the limbs (6%) double SPA was
encountered (radioulnar in two & mediano ulnar in
one limb) out of these one has been already
reported by Patnaik et al (2000 a).
Ontogenesis of Double SPA:
The superficial palmar branch of radial artery
failed to develop fully consequent upon median
artery persistance as in one case. So only a very
small superficial palmar arch developed between persistent median artery and ulnar artery or the
radial and ulnar arteries and this superficial palmar
arch was insufficient to supply palmar interdigital
branches. In all 3 cases, the proximal component of
double superficial palmar arch remained
rudimentary. So the first interdigitial was still being
supplied by median or radial artery (as is the case)
while the ulnar artery continued to supply 4th, 3rd and
2nd interdigital spaces as a major chunk giving the
appearance of 2nd superficial palmar arch which is
incomplete and falls in Type B or C of Group II of
Coleman and Anson (1961). This is in consonence
with Arey's (1957) views that anomalous blood
vessels may be due to:
- Persistence of vessels normally obliterated
(median artery which should have obliterated;
as in majority of cases but persistent in limb
no. 11 MR).
- Hydrodynamically incompetent development of
proximal superficial palmar arch which was so
unable to give rise to interdigital branches, the
later being given off thus from incomplete
distal superficial palmar arch.
Clinical Significance:
Double superficial palmar arch is very
important clinically in cases of bleeding from any of
the interdigital branches of ulnar artery. The surgeon
may ligate the ulnar artery at a point proximal to
usual level of superficial palmar arch expecting the
blood supply through 4th, 3rd, 2nd interdigital arteries
to be cutt off as an incomplete distal superficial
palmar arch was encountered. Because of an
alternate route via proximal complete superficial
palmar arch, the result in such a case is bound to be
different. The situation may be thus very
embarrasing and trying one.
Another variation seen in superficial palmar
arch was mediano ulnar type of superficial palmar
arch. It is to be noted that the source for both the
feeding vessel in this type of arch is ulnar artery
proper. In cases of bleeding from palm, if ulnar
artery is ligated at its origin close to the bifurcation
of brachial artery, the blood flow in this arch via both
these routes gets completely cut off. Then the only
source of blood supply is via radial artery, deep
palmar arch and then through perforating arteries
indicating their importance. The radial artery is being used for transplant surgery in cases of
coronary artery disease so one should be careful
under such circumstances that if radial artery is
removed then ulnar artery cannot be ligated as then
the blood supply to hand will be totally
jeopardized.
Deep Palmar arch: Coleman & Anson (1961)
had classified deep palmar arch as follows :
Group I: Complete arch: It was found in 97% cases and further divided into 4 types:
Type A: The deep palmar arch is formed by
the deep palmar branch of the radial
artery which anastomoses with
superior deep palmar branch of ulnar
artery. The latter follows the deep
branch of ulnar nerve into the palm. It
was found in 34.5% dissections.
Type B: The deep palmar branch of radial
artery anastomoses with the inferior
deep palmar branch of ulnar artery.
This is the commonest pattern
encountered in 49% of dissections.
Type C: Here both deep palmar branches of
ulnar artery join the deep palmar
branch of radial artery to complete the
arch. It was found in 13% of
specimens.
Type D: It is formed by superior deep palmar
branch of the ulnar artery which
anastomoses with an enlarged
superior perforating artery of the 2nd
interspace. There is also a
contribution from the Ist interspace
which despite its small size helps to
complete the arch. It was found only
in 0.5% cases.
Group II: Incomplete arch: It was found in 3%
cases only and can be further divided
into:
Type A: The inferior deep branch of ulnar
artery anastomoses with the
perforating artery of the 2nd
interspace. The deep supply to the
thumb and radial border of index
finger is derived from deep palmar
branch of radial artery. It was found in 1.5% dissections.
Type B: The deep arterial supply to thumb and
the index finger are derivatives of
deep palmar branch of radial artery
which in turn anastomosis with a
perforating artery of 2nd space. The
arch is incomplete because the deep
branch of ulnar artery ends in an
anastomosis with perforating artery of
3rd interspace. It was found in 1.5% of
cases.
TABLE II: PERCENTAGE FREQUENCY OF VARIOUS TYPES OF DEEP PALMAR ARCH
Sr. No.
Type of deep palmar arch
Coleman & Anson (1961)
Percentage frequency
(Coleman & Anson, 1961)
Present Study (2000)
1
Type A
34.5%
36.0%
2
Type B
49.0%
52.0%
3
Type C
13.0%
10.0%
4
Type D
0.5%
0.0%
5
Deviant from, Coleman & Anson (1961) classification
0.0
2.0%
6
Total
97.0%*
100.0%
*In rest of their 3% dissections, it was of incomplete type (group II).
Table 2 shows that finding of present study are
comparable to those of Coleman & Anson (1961)
except that no arch of incomplete type (Group II)
was encountered in the present study. Rather one
entirely different type of arch was found in one limb
(2%) i.e. limb No 13ML, where radial artery dipped
in 2nd intermetacarpal space to form DPA with
superior deep palmar branch of ulnar artery.
(Patnaik et al, 2000 b) This type of DPA doesn't fall
in any of Coleman & Anson's classification but is a
classical retention of atavistic pattern where the
main artery dipped in the 2nd intermetacarpal space
as part of catella volaris proximalis of primates &
contributed to the small DPA in a typical primate
fashion of archus volaris profundus. (Patnaik et al,
2000b).
In group I, Type A, B and C of their
classification, the radial artery passes through first
inter metacarpal space,. while here it was passing through 2nd intermetacarpal space. In Type D, the
superior deep palmar branch of ulnar artery
anastomoses with enlarged superior perforating
artery of 2nd intermetacarpal space with a small
contribution from first interspace to complete the
arch. Contribution from the first intermetacarpal
space was not found in the present case, and it was
the radial artery proper and not an enlarged superior
perforating artery which passed through 2nd
intermetacarpal space. In group II type A of
Coleman and Anson (1961), it is inferior deep
palmar branch of ulnar artery which anastomoses
with perforating artery of 2nd space and deep supply
to thumb and radial border of index finger is from
deep palmar branch of radial artery, whereas in the
present case, it was superior deep palmar branch of
ulnar artery completing the arch and the deep
supply to thumb and radial border of index finger
was from superficial palmar branch of radial artery.
In group II type B, deep arterial supply to thumb and
radial border of index finger are derivatives of deep
palmar branch of radial which anastomoses with
perforating artery of 2nd space, deep palmar branch
of ulnar anastomosing with perforating artery of 3rd
space. This is also entirely different from the present
case.
Thus the deep palmar arch in limb number
13ML, does not fall in any of the types of Coleman
and Anson (1961) and the limb is unique in itself
exhibiting a different type of deep palmar arch
not described earlier.
In none of the cases, deep palmar arch was
absent unlike the earlier reported prevalence of
0.5% by Jaschtschinski (1897) and a report by
Poteat (1986) where it was absent.
Summary & Conclusions:
To conclude, hand is supplied by SPA & DPA,
SPA is found as a single entity in 94% of limbs while
in the other 6% limbs a definable double superficial
palmar arch is observed, the term christened by
Patnaik et al, 2000a. It is seen that all the variations
observed have some ontogenic basis and are
clinically important.
On the other hand DPA was found to be more
or less constant with little variations, except for one limb in which it was strikingly different from the rest
being limited laterally upto 2nd intermetacarpal
space only with no communication or contribution
whatsoever further laterally. In toto, it is better
developed in limbs with incomplete SPA & vice
versa & the size of the 2 arches is inversaly
proportional to each other.
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Photograph 1: Incomplete radio ulnar type of superficial palmar arch (Group II, Type A) (r-radial artery; u-ulnar artery; I to IV - interdigital branches)
Photograph 2: Incomplete mediano-ulnar type of superficial palmar arch (Group II, Type C) (r-radial artery; ma-median artery;
mn-median nerve; u-ulnar artery)
Department of Anatomy, Govt. Medical College, Patiala, *Amritsar. INDIA
Abstract
Arterial arches of hand are very important for orthopaedicians as well as microvascular surgeons. Variations encountered in these are so numerous that Poirier finds it difficult to establish a type. The present study was conducted in 50 upper limbs at Govt. Medical College, Amritsar to find out the pattern of arterial arches of hand. Variations are found more often in superficial palmar arch than the deep one, later being more or less constant. SPA was found to be single in 94% limbs (complete in 78%, & incomplete in 16%.) In 6% of limbs, a double SPA was encountered, proximal complete (radio ulnar in 4% & mediano-ulnar in 2%) & distal incomplete. Amongst the DPAs, all were complete but in one case (2%), it was limited upto 2nd intermetacarpal space only with no contribution further laterally.
In general, it was confirmed that size of the 2 arches is inversally proportional to each other.
All the variations encountered have an ontogenic basis which has been discussed along with their clinical implications.
Key words: Superficial Palmar arch, Deep palmar arch, Palmar arterial arches.
Introduction:
Arterial supply to the man's hand, his most important earning tool is derived from two anastomotic arches, superficial et deep formed by the anastomosis between two main arteries of forearm i.e. radial, ulnar & their branches; in the palm. These were studied as early as 1753, by Haller, a swiss anatomist & poet while notable variations were described by Tiedman (1831) which were explained later, on ontogenic basis by Meyer (1881) & Singer (1933). It was Manners Smith (1910) who made a comparative study of arteries of hands in primates & concluded that many of the variations noted in man represent a retention or reappearance of primitive patterns. Tandler (1897); Jaschtschinski (1897); Adachi (1928); Fracassi, (1945) Coleman & Anson (1961) are the few among those to name, who have worked on arteries of hand.
Superficial Palmar Arch - This anastomosis is fed mainly by the ulnar artery, entering the palm with the ulnar nerve, anterior to the flexor retinaculum and lateral to the pisiform, passing medial to the hamate's hook, then curving laterally to form an arch, convex distally (Williams et al, 1999) across the middle 1/3 of the palm (Massie, 1944), and in level with a transverse line through the distal border of the fully extended pollicial base (Boyd et al, 1956 and Williams et al, 1999). About a third of the superficial palmar arches are formed by the ulnar artery alone; a further third are completed by the superficial palmar branch of the radial artery and a third either by the arteria radialis indicis, a branch of arteria princeps pollicis or by the median artery (Coleman & Anson, 1961). It is covered by the palmaris brevis and palmar aponeurosis and it is superficial to the flexor digiti minimi, branches of the median nerve and to the long flexor tendons and lumbrical muscles (Anson and Maddok, 1952; Williams et al, 1999).
This arch shows a number of variations as reported by Dubreuil chambardel (1926); Huber, (1930); Coleman & Anson, (1961) & Mozersky et al (1973). According to Poirier (1886), Variations in SPA are so numerous that it is difficult to establish a type.
Deep Palmar Arch: It is formed by anastomosis of the end of the radial with the deep palmar branch of the ulnar artery. It forms a flatter curve than the superficial arch (Spalteholz). The radial artery typically emerges between 2 heads of adductor pollicis in its course across the palm, Then it crosses the bases of metacarpal bones and interossei (Williams, et al, 1999).
This arch is found to be comparatively less variable than SPA (Coleman & Anson, 1961; Karlsson & Niechajev, 1982).
Apart from these two main arches two more arches Palmar & Dorsal Carpal arches give twigs to the palm & dorsum of hand. All these arches anastomose freely with each other so much so that wounds of palmar or carpal arches can be source of severe bleeding, difficult to achieve haemostasis. It is also because of occasional difficulty in finding & securing both ends of divided vessel (Huber, 1930; Treves & Rogers, 1947).
Accepting the fact that extensive arterial anastomosis in the hand leads to profuse bleeding from its wounds; Lockhart et al (1959) emphasize that for the same reasons, healing is also very rapid. They further call for paying particular attention to the superficial position of termination of ulnar artery and superficial palmar arch while making incisions to evacuate pus from the hand.
Dubreuil (1926) and Mozersky et al (1973) asserted the importance of understanding variations of the superficial palmar arch for the purpose of microvascular repair and re-implantation.
Keeping the importance of these variations in mind, this study was designed to find out the pattern of palmar arterial arches in the region which may help not only the anatomists but also orthopaedicians & microvascular surgeons.
Materials & Methods:
50 Upper limbs belonging to 25 cadavers (M.F.: 19:6) of the Anatomy Department, of Govt. Medical College, Amritsar, comprised the material for study. These were embalmed with an embalming fluid containing lead oxide to colour the arteries red & labelled from 1-25 with letters (R) or (L) corresponding to right or left limb respectively & letters (M) or (F) corresponding to male or female respectively. Exposure of different palmar arches was achieved following classical incisions & dissection procedures provided by Cunningham's Manual of Practical Anatomy, (Romanes, 1999).
Palmar aponeurosis was exposed and separated from flexor retinaculum, divided proximally and reflected distally cutting the septae which pass backwards from its edges. This exposed the superficial palmar arch which was cleaned to study the pattern. All other branches of radial and ulnar arteries in the palm were also studied.
The tendons of flexor digitorum superficialis were divided at the level of heads of metacarpals and reflected proximally upto wrist. This exposed the deep palmar arch which was cleaned to study the pattern.
Any variation from the normal patterns were observed, noted and where required, photographed.
Observations:
Superficial Palmar arch: Out of the 50 limbs, single SPA are found in 47 (94%) limbs which included 39 limbs (78%) with a complete arch & 8 limbs (16%) with an incomplete one. In the former group classical radio ulnar type was encountered in 38 (76%) limbs while one (2%) limb had ulnar type of arch. In the later (incomplete arch) group, 6 limbs (12%) had a blood supply from both ulnar artery & superficial palmar branch of radial artery but without an anastomosis with each other (Photograph 1) while in 2 limbs, instead of superficial palmar branch of radial, it was median artery which was a source of blood supply along with ulnar artery again without anastomosis with each other (Photograph 2).
The arrangement of intercommunications betwixt ulnar artery and radial or median artery as the case may be; (radio-ulnar in limb number 1ML and 12 MR; mediano-ulnar in limb no. 11 MR) and branching out of palmar interdigital arteries has set apart 3 cases deviant from normal which are christened as double superficial palmar arch. All the 3 double superficial palmar arches had 2 constitutent components - a proximal and a distal where proximal arch was invariably complete and situationally where superficial palmar arch is expected, the distal component was incomplete in all the 3 cases, but was responsible for palmar interdigital arteries to emnate from and so considered as an incomplete superficial palmar arch, the 2 component arches together constituted double superficial palmar arch.
Deep Palmar arch: It is found to be less variable as compared to superficial palmar arch. In all the 50 dissections, it was a complete arch. The ulnar artery gave 2 deep palmar branches in all cases but both of these contributed to formation of deep palmar arch only in 10% instances. In majority of specimens i.e. 52% it was only inferior deep palmar branch of ulnar artery which formed deep palmar arch, the superior being lost in hypothenar eminence. In 36% of dissections, it was superior ramus which contributed to formation of deep palmar arch.
In one limb the radial artery dipped in 2nd intermetacarpal space and took part in formation of deep palmar arch with superior deep palmar branch of ulnar artery.
Discussion:
Superficial Palmar arch:
Owing to a large number of variations in SPA, Poirier (1886) had found it extremely difficult to establish a type, while Adachi (1928) has described 3 types of superficial palmar arch.
- Ulnar type: in which contribution by radial artery is absent or minimal. It is seen in 59% dissections (64% by Karlsson and Niechajev, 1982).
- Radioulnar type: Seen in 32% dissections (32% by Karlsson and Niechajev, 1982).
- Mediano ulnar type: seen in 9% dissections (4% by Karlsson and Niechajev, 1982).
Huber (1930) groups the superficial palmar arch into 2 classes:
- Those in which additional branches from the forearm participate in the formation of the arch or replace the radial in its composition.
- Those in which there is no true arch, the arteries which should participate in its formation and in some cases the additional ones also, failing to anastomose and each giving rise independently to a certain number of digital branches in a somewhat fan like manner.
Coleman and Anson (1961) elaborated more on superficial palmar arch and reclassified it as follows :
Group I: Complete arch (Found in 78.5% cases). It can be further divided into five types:
Type A: The classical radio ulnar arch is formed by superficial palmar branch of radial artery and the larger ulnar artery. It was found in 34.5% dissections (36% by Weathersby, 1954; and 30% by Anson, 1966).
Type B: This arch is formed entirely by ulnar artery. It was found in 37% cases.
Type C: Mediano ulnar arch is composed of ulnar artery and an enlarged median artery. It was found in 3.8% specimens (8% by Anson, 1966).
Type D: Radio-mediano-ulnar arch in which 3 vessels enter into the formation of arch. It was found in only 1.2% dissections.
Type E: It consists of a well formed arch initiated by ulnar artery and completed by a large sized vessel derived from deep arch. The latter vessel comes to superficial level at the base of the thenar eminence of join the ulnar artery. It was found in 2% cases.
Group II: Incomplete arch :
When the contributing arteries to the superficial arch do not anastomose or when the ulnar artery fails to reach the thumb and index finger, the arch is incomplete, Such type of arch was found in 21.5% cases. It can be further divided into 4 types.
Type A: Both superficial palmar branch of radial artery and ulnar artery take part in supplying palm and fingers but in doing so, fail to anastomose. It was found in 3.2% cases.
Type B: Only the ulnar artery forms superficial palmar arch. The arch is incomplete in the sense that the ulnar artery does not take part in the supply of thumb and index finger. It was found in 13.4% dissections.
Type C: Superficial vessels receive contributions from both median and ulnar arteries but without anastomosis. It was found in 3.8% specimens.
Type D: Radial, median and ulnar artery all give origin to superficial vessels but do not anastomose. It was found in 1.1% cases.
If the results of present study are compared with earlier authors, (Table I) it is seen that in 38 cases (76%) out of 39 (78%) the complete SPA was of type A i.e. radio ulnar type whereas in Coleman & Anson (1961) series it was found in 34.5% dissections with type B in another 37%. In this context, comments of Adachi (1928) are worth a mention who commented that differentiation between these two types is very difficult as it depends upon observer's estimate as to what constitutes a minimal contribution by radial artery. It may probably explain part of discrepancy in this observation.
Incomplete arch (group II) was encountered in 8 limbs (16%) of the present study. While it was of type A in 12% & type C in 4%, Coleman & Anson (1961) found it to be of type B in majority (13.4%) (See Table 1).
TABLE I: COMPARISON OF PREVALENCE OF TYPES OF SINGLE SUPERFICIAL PALMAR ARCH
| S. No. |
Coleman & Anson (1961) | Weathers by (1954) | Anson (1966) | Present study | |
|---|---|---|---|---|---|
| 1 | Group I | 78.5% | - | 78.0% | |
| Type A | 34.5% | 36.0% | 30.0% | 76.0% | |
| Type B | 37.0% | 2.0% | |||
| Type C | 3.8% | 8.6% | - | ||
| Type D | 1.2% | - | - | - | |
| Type E | 2.0% | - | |||
| 2. | Group II | 21.5% | - | - | 16.0% |
| Type A | 3.2% | - | - | 12.0% | |
| Type B | 13.4% | - | - | - | |
| Type C | 3.8% | - | - | 4.0% | |
| Type D | .0% | - | - | - | |
| 3. | Total | 100.0% | - | - | *94.0% |
* In the rest of 6%, the superficial palmar arch was double
In 3 of the limbs (6%) double SPA was encountered (radioulnar in two & mediano ulnar in one limb) out of these one has been already reported by Patnaik et al (2000 a).
Ontogenesis of Double SPA:
The superficial palmar branch of radial artery failed to develop fully consequent upon median artery persistance as in one case. So only a very small superficial palmar arch developed between persistent median artery and ulnar artery or the radial and ulnar arteries and this superficial palmar arch was insufficient to supply palmar interdigital branches. In all 3 cases, the proximal component of double superficial palmar arch remained rudimentary. So the first interdigitial was still being supplied by median or radial artery (as is the case) while the ulnar artery continued to supply 4th, 3rd and 2nd interdigital spaces as a major chunk giving the appearance of 2nd superficial palmar arch which is incomplete and falls in Type B or C of Group II of Coleman and Anson (1961). This is in consonence with Arey's (1957) views that anomalous blood vessels may be due to:
- Persistence of vessels normally obliterated (median artery which should have obliterated; as in majority of cases but persistent in limb no. 11 MR).
- Hydrodynamically incompetent development of proximal superficial palmar arch which was so unable to give rise to interdigital branches, the later being given off thus from incomplete distal superficial palmar arch.
Clinical Significance:
Double superficial palmar arch is very important clinically in cases of bleeding from any of the interdigital branches of ulnar artery. The surgeon may ligate the ulnar artery at a point proximal to usual level of superficial palmar arch expecting the blood supply through 4th, 3rd, 2nd interdigital arteries to be cutt off as an incomplete distal superficial palmar arch was encountered. Because of an alternate route via proximal complete superficial palmar arch, the result in such a case is bound to be different. The situation may be thus very embarrasing and trying one.
Another variation seen in superficial palmar arch was mediano ulnar type of superficial palmar arch. It is to be noted that the source for both the feeding vessel in this type of arch is ulnar artery proper. In cases of bleeding from palm, if ulnar artery is ligated at its origin close to the bifurcation of brachial artery, the blood flow in this arch via both these routes gets completely cut off. Then the only source of blood supply is via radial artery, deep palmar arch and then through perforating arteries indicating their importance. The radial artery is being used for transplant surgery in cases of coronary artery disease so one should be careful under such circumstances that if radial artery is removed then ulnar artery cannot be ligated as then the blood supply to hand will be totally jeopardized.
Deep Palmar arch: Coleman & Anson (1961)
had classified deep palmar arch as follows :
Group I: Complete arch: It was found in 97% cases and further divided into 4 types:
Type A: The deep palmar arch is formed by the deep palmar branch of the radial artery which anastomoses with superior deep palmar branch of ulnar artery. The latter follows the deep branch of ulnar nerve into the palm. It was found in 34.5% dissections.
Type B: The deep palmar branch of radial artery anastomoses with the inferior deep palmar branch of ulnar artery. This is the commonest pattern encountered in 49% of dissections.
Type C: Here both deep palmar branches of ulnar artery join the deep palmar branch of radial artery to complete the arch. It was found in 13% of specimens.
Type D: It is formed by superior deep palmar branch of the ulnar artery which anastomoses with an enlarged superior perforating artery of the 2nd interspace. There is also a contribution from the Ist interspace which despite its small size helps to complete the arch. It was found only in 0.5% cases.
Group II: Incomplete arch: It was found in 3% cases only and can be further divided into:
Type A: The inferior deep branch of ulnar artery anastomoses with the perforating artery of the 2nd interspace. The deep supply to the thumb and radial border of index finger is derived from deep palmar branch of radial artery. It was found in 1.5% dissections.
Type B: The deep arterial supply to thumb and the index finger are derivatives of deep palmar branch of radial artery which in turn anastomosis with a perforating artery of 2nd space. The arch is incomplete because the deep branch of ulnar artery ends in an anastomosis with perforating artery of 3rd interspace. It was found in 1.5% of cases.
TABLE II: PERCENTAGE FREQUENCY OF VARIOUS TYPES OF DEEP PALMAR ARCH
| Sr. No. | Type of deep palmar arch Coleman & Anson (1961) |
Percentage frequency | |
|---|---|---|---|
| (Coleman & Anson, 1961) | Present Study (2000) | ||
| 1 | Type A | 34.5% | 36.0% |
| 2 | Type B | 49.0% | 52.0% |
| 3 | Type C | 13.0% | 10.0% |
| 4 | Type D | 0.5% | 0.0% |
| 5 | Deviant from, Coleman & Anson (1961) classification | 0.0 | 2.0% |
| 6 | Total | 97.0%* | 100.0% |
*In rest of their 3% dissections, it was of incomplete type (group II).
Table 2 shows that finding of present study are comparable to those of Coleman & Anson (1961) except that no arch of incomplete type (Group II) was encountered in the present study. Rather one entirely different type of arch was found in one limb (2%) i.e. limb No 13ML, where radial artery dipped in 2nd intermetacarpal space to form DPA with superior deep palmar branch of ulnar artery. (Patnaik et al, 2000 b) This type of DPA doesn't fall in any of Coleman & Anson's classification but is a classical retention of atavistic pattern where the main artery dipped in the 2nd intermetacarpal space as part of catella volaris proximalis of primates & contributed to the small DPA in a typical primate fashion of archus volaris profundus. (Patnaik et al, 2000b).
In group I, Type A, B and C of their classification, the radial artery passes through first inter metacarpal space,. while here it was passing through 2nd intermetacarpal space. In Type D, the superior deep palmar branch of ulnar artery anastomoses with enlarged superior perforating artery of 2nd intermetacarpal space with a small contribution from first interspace to complete the arch. Contribution from the first intermetacarpal space was not found in the present case, and it was the radial artery proper and not an enlarged superior perforating artery which passed through 2nd intermetacarpal space. In group II type A of Coleman and Anson (1961), it is inferior deep palmar branch of ulnar artery which anastomoses with perforating artery of 2nd space and deep supply to thumb and radial border of index finger is from deep palmar branch of radial artery, whereas in the present case, it was superior deep palmar branch of ulnar artery completing the arch and the deep supply to thumb and radial border of index finger was from superficial palmar branch of radial artery. In group II type B, deep arterial supply to thumb and radial border of index finger are derivatives of deep palmar branch of radial which anastomoses with perforating artery of 2nd space, deep palmar branch of ulnar anastomosing with perforating artery of 3rd space. This is also entirely different from the present case.
Thus the deep palmar arch in limb number 13ML, does not fall in any of the types of Coleman and Anson (1961) and the limb is unique in itself exhibiting a different type of deep palmar arch not described earlier.
In none of the cases, deep palmar arch was absent unlike the earlier reported prevalence of 0.5% by Jaschtschinski (1897) and a report by Poteat (1986) where it was absent.
Summary & Conclusions:
To conclude, hand is supplied by SPA & DPA, SPA is found as a single entity in 94% of limbs while in the other 6% limbs a definable double superficial palmar arch is observed, the term christened by Patnaik et al, 2000a. It is seen that all the variations observed have some ontogenic basis and are clinically important.
On the other hand DPA was found to be more or less constant with little variations, except for one limb in which it was strikingly different from the rest being limited laterally upto 2nd intermetacarpal space only with no communication or contribution whatsoever further laterally. In toto, it is better developed in limbs with incomplete SPA & vice versa & the size of the 2 arches is inversaly proportional to each other.
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Photograph 1: Incomplete radio ulnar type of superficial palmar arch (Group II, Type A) (r-radial artery; u-ulnar artery; I to IV - interdigital branches)
Photograph 2: Incomplete mediano-ulnar type of superficial palmar arch (Group II, Type C) (r-radial artery; ma-median artery; mn-median nerve; u-ulnar artery)
