|Year : 2015 | Volume
| Issue : 2 | Page : 140-144
A morphological study of variations in superficial palmar arches of the hand
Chandni Gupta1, Sneha Guruprasad Kalthur1, Narga Nair2, Shakuntala R Pai3
1 Department of Anatomy, Kasturba Medical College, Manipal University, Manipal, India
2 Department of Anatomy, Amala Institute of Medical Sciences, Thrissur, Kerala, India
3 Department of Anatomy, Srinivasan Medical College, Mangalore, Karnataka, India
|Date of Web Publication||16-Mar-2015|
Department of Anatomy, Kasturba Medical College, Manipal University, Manipal - 576 104, Karnataka
Source of Support: None, Conflict of Interest: None
Objectives: Arterial arches of the hand are very important for orthopedic surgeons as well as microvascular surgeons while doing surgeries on hand. The greatest risk associated with harvesting the radial artery for coronary artery bypass grafting is ischemia of the soft tissues of the hand. There may be numerous variations in the formation of these arterial arches which will be important for the surgeons. So, for the above-mentioned reasons the following study was undertaken to look for the pattern of superficial arches in hands and its variations. Materials and Methods: The study was done on 75 formalin fixed upper limbs from the Department of Anatomy. Incision was given according to Cunningham manual of anatomy and superficial palmar arch was exposed, and its formation from different branches was noted down. The variations were noted down in the formation of superficial palmar arch to provide a database of the normal and variant anatomy. Results: In 77.3% of specimens superficial palmar arch was complete and in 22.6% of specimens it was incomplete. Conclusion: The variations found in this study will help not only the anatomists, but also orthopedics and microvascular surgeons who do surgery on hands. Current progress in the microsurgical procedures for reconstructive hand operations needs the understanding of variant arterial arches, the comprehensive knowledge of which is vital for the surgical interventions and successful outcome of the surgeries.
Keywords: Complete, formation, incomplete, radial artery harvesting, superficial palmar arch
|How to cite this article:|
Gupta C, Kalthur SG, Nair N, Pai SR. A morphological study of variations in superficial palmar arches of the hand. CHRISMED J Health Res 2015;2:140-4
|How to cite this URL:|
Gupta C, Kalthur SG, Nair N, Pai SR. A morphological study of variations in superficial palmar arches of the hand. CHRISMED J Health Res [serial online] 2015 [cited 2019 Nov 15];2:140-4. Available from: http://www.cjhr.org/text.asp?2015/2/2/140/153259
| Introduction|| |
Superficial palmar arch is formed mainly by the ulnar artery, which enters the palm along with ulnar nerve, anterior to the flexor retinaculum and lateral to the pisiform, passing medial to the hamate's hook, then curving laterally to form the arch. The arch is convex distally across the middle 1/3 of the palm and in the level with a transverse line through the distal border of the fully extended pollex base. 
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 the remaining third either by the arteria radialis indicis, or a branch of arteria princeps pollicis or by the median artery. 
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. Accepting the fact that extensive arterial anastomosis in the hand leads to profuse bleeding from its wounds; but because of the same reasons, healing is also very rapid. While making incisions to evacuate the pus from the hand, we should take care of termination of the ulnar artery and superficial palmar arch because of their superficial position. Some authors asserted the importance of understanding variations of the superficial palmar arch for the purpose of microvascular repair and re-implantation. 
Although the classic type of superficial palmar arch occurs relatively infrequently, there is always a significant anastomosis between the radial and the ulnar artery in the hand. This anatomic study confirms the presence of a collateral supply in the hand. In the absence of vascular disease, harvesting the radial artery should be regarded as a safe procedure. The Radial artery and ulnar artery provide most of the blood supply to the hand. Further circulation may come from the median artery or the interosseous arterial system. The Radial artery and ulnar artery form four circuits in the hand, the anterior and posterior carpal arch at the level of the carpal bones and the superficial and deep palmar arch at the mid palmar level. These arches form three circuits on the palmar side and one circuit on the dorsal side of the hand. The superficial and deep palmar arches are the chief circuits because they provide the blood supply to all of the fingers. Standard anatomy textbooks lack evidence about crucial variations in the arterial supply of the hand. Numerous studies have described the variations of the intricate anatomy of the hand and forearm. However, these studies are inadequate by the fact that none of them look precisely for variations of the collateral circulation that might affect the decision to remove the Radial artery, such as the presence of both an incomplete superficial palmar arch and an incomplete deep palmar arch in the same hand. Such information is very significant when considering Radial artery harvesting. 
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 the orthopedics and microvascular surgeons.
| Materials and methods|| |
In this study, 75 (40 left, 35 right side) formalin fixed upper limbs from the Department of Anatomy were dissected.
Exposure of superficial palmar arches was achieved following classical incisions and dissection procedures provided by Cunningham's Manual of Practical Anatomy. Palmar aponeurosis was exposed and separated from the flexor retinaculum, divided proximally and reflected distally cutting the septae that pass backward from its edges. This exposed the superficial palmar arch which was cleaned to study the pattern and its formation by different arteries.
Statistical analysis of the results was done.
| Results|| |
In 58 specimens out of 75 specimens superficial palmar arch was complete, and it was divided into five types [Table 1] and [Figure 1].
|Figure 1: Complete superficial palmar arch which is formed by branch of radial artery that was giving princeps pollicis and radialis indicis. UA - Ulnar artery, RAB - Radial artery branch|
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|Table 1: Completion of superficial palmar arch by different arteries in percentage|
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- Formed by superficial palmar branch of radial artery and ulnar artery in 13 specimens
- Formed by princeps pollicis, radialis indices artery branch of radial artery and ulnar artery in 41 specimens
- Formed by median artery and ulnar artery in 1 specimens
- Formed by a branch to the thumb of radial artery and ulnar artery in 2 specimens
- Formed by deep branch of radial artery and ulnar artery in 1 specimen.
Incomplete arch was found in 17 specimens out of 75 specimens [Figure 2], 8 in the right hand and 9 in the left hand.
| Discussion|| |
Variations in the arterial pattern of the upper limb have frequently been observed both in routine dissections and in clinical practice.
Comparison of the result of this study with other studies is shown in [Table 2]. In this study, it was found that superficial palmar arch was complete in 58 specimens out of 75 specimens that is, in 77.3% of specimens and incomplete in 17 specimens out of 75 specimens that is, in 22.6% of specimens, 8 in right hand and 9 in left hand it was similar to the study done by Coleman and Anson.  They found that superficial volar arch was complete in 80% of cases and incomplete superficial palmar arch in 21.5% of cases. They divide the complete arch into five types - Type A-radio ulnar arch (34.5% of cases), Type B-formed entirely by ulnar artery (37% of cases), Type C-medio ulnar arch (3.8% of specimens), Type D-radio medio ulnar intercommunication (1.2% of cases), Type E-arch is formed mainly by ulnar artery and completed by a large vessel derived from deep palmar arch (2% of cases).  In this study, Type A was seen in 22.4% of specimens, Type C in 1.72% of specimens.
Ikeda et al., Patnaik et al. found that the superficial palmar arch was complete in 96.4, 78% and incomplete in 3.6, 16% of cases. , Patnaik et al. also found in 6% of limbs, a double superficial palmar arch.  The results of this study were almost similar to Patnaik et al. study. 
Doscher et al. also found that the superficial palmar arch was incomplete in 11% of the hands. 
Dhar and Lall found a case in which there was no communication between the superficial palmar branches of the radial and ulnar arteries (incomplete superficial palmar arch). 
Ramakrishnan et al. found incomplete arch in 4 hands (8%, 1 right and 3 left) and persistent median artery supplying the radial side of the palm and digits in one hand (2%) and in this study incomplete arch was seen in 22.6% of cases and there was also one case in which median artery was forming the superficial palmar arch but it was complete arch. 
Fazan et al. found complete superficial palmar arches in 43% on the right and in 52% on the left side. They found arch was incomplete in 57% on the right and 48% on the left side. They found the normal superficial palmar arch, formed by the ulnar artery and the superficial branch of the radial artery in 48% of cases on each side. The most common variation in superficial palmar arch anatomy in their study was the presence of a small radial artery branch to the arch which was arising dorsally at the level of origin of the princeps pollicis artery, and passed into the palm to reach the ulnar artery to form the superficial palmar arch. They got this variation in 33% of the left hands and in 20% of the right hands. In incomplete superficial palmar arch, this small vessel was present in 33% of the left hands and 8% of the right hands in their study. Arches were completed by the median artery in two cases in their study. In the present study median artery was seen in 1 case. 
Madhyastha et al. found that 45 (93.75%) hands had the usual morphology of the superficial palmar arch, and they found the variant morphological patterns in only 3 (6.25%) hands. In one of the hands, they found the absence of formation of the arch; in the other hand the arch was formed only by the ulnar artery. In the third case, though the arch was formed by the anastomosis between ulnar and radial arteries, there was variation in its branching pattern. 
Gharravi et al. found one case in which superficial palmar arch was absent. They found that there was no anastomosis between radial and ulnar arteries in the palm of the hand. Ulnar artery gave three palmar digital arteries; proper palmar digital artery and two common palmar digital arteries. Radial artery gave proper palmar digital artery and arteria princeps pollicis. In this study, there were incomplete arches in 22.6% of cases. 
Suman and Jayanthi found in 50% of cases an ulnar dominant superficial palmar arch where ulnar artery was forming the superficial palmar arch, and it terminates by supplying the thumb and index finger. There was no such case seen in the present study. 
Anitha et al. found that in six upper limbs the median artery took part in the formation of superficial palmar arch. They found that out of six upper limbs, the median artery anastomosed with the ulnar artery in four cases and in two cases the median artery formed incomplete arch with the ulnar artery. In this study, median artery was seen in 1 case. 
Taðýl et al. found that superficial palmar arch was complete in 15 (75%) and incomplete in 5 (25%) of the hands. Their results are similar to the present study 77.3% complete arch and incomplete in in 22.6% of specimens. 
Vijaya Lakshmi and Rao found a case in which superficial palmar arch was formed by superficial branch of ulnar artery and is completed by the two arterial loops on the radial side unlike the normal contribution of a single branch of radial artery or a branch from arteria princeps pollicis or a branch from arteria radialis indicis.  There was no such case seen in the present study.
In this study, there were some new findings which other studies have not mentioned like the arch is formed by princes pollicis, radialis indices artery branch of radial artery and ulnar artery in 41 specimens that is, in (70.68% of specimens), formed by a branch to the thumb of radial artery and ulnar artery in two specimens that is, in (3.44%) and formed by deep branch of radial artery and ulnar artery in one specimen that is, (1.72%).
Variations seen in superficial palmar arch can be medio ulnar type of superficial palmar arch that we got in 1 case in our study. The embryological reason behind this may be because median artery is the axis artery of the upper limb during early embryonic life. It maintains the superficial palmar arch when the radial and ulnar arteries are developing. When the ulnar and radial arteries are completely developed the median artery vanishes. But it may persist in adult life as palmar median artery. This is closely related to the median nerve and reaches the wrist and enters the palm by passing deep to the flexor retinaculum and may take part in the formation 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. In cases of blood loss from palm, if ulnar artery is ligated at its origin close to the division of the 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 significance. The radial artery is being used for transplant surgery in cases of coronary artery disease so one should be careful under such situations that if radial artery is removed then ulnar artery cannot be ligated as then the blood supply to hand will be totally jeopardized. 
Current progress in the microsurgical techniques for reconstructive hand surgeries has demanded a clear understanding of these arterial variations. 
Damage to superficial palmar arch can affect the arterial supply of the fingers, mainly if there is an incomplete superficial palmar arch. Therefore, it is necessary to do the investigations like Allen test, angiography and color Doppler studies of the hand before doing any invasive procedures on the hand like using a radial artery for coronary artery bypass grafting. The information about these variant arches is vital for the safe and fruitful result of the hand operations. 
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[Figure 1], [Figure 2]
[Table 1], [Table 2]