|Year : 2021 | Volume
| Issue : 1 | Page : 21-24
Cadaveric Study of Topographical Location and Arterial Diameter of Superficial Palmar Arch with its Clinical Implication
Associate Professor, Department of Anatomy, MVJ Medical College and Research Hospital, Hoskote, Bengaluru, Karnataka, India
|Date of Submission||28-Aug-2020|
|Date of Decision||05-Oct-2020|
|Date of Acceptance||17-Dec-2020|
|Date of Web Publication||27-Jan-2021|
K L Varalakshmi
Department of Anatomy, MVJ Medical College and Research Hospital, Hoskote, Bengaluru - 562 114, Karnataka
Source of Support: None, Conflict of Interest: None
Background: During the surgical exposure of carpal tunnel, it is possible to injure neurovascular structures, especially the superficial palmar arch (SPA) due to its proximity to the flexor retinaculum. Hence, the topographical location of SPA is necessary to avoid iatrogenic injuries. Size of the vessels forming SPA is important to carry out new procedures in the microsurgical techniques in reconstructive surgeries. Materials and Methods: The present study was conducted on 40 cadaveric hands obtained from AJ Institute of Medical science, Mangalore. The distance between the SPA and distal wrist crease (DWC) and Kaplan's cardinal line (KCL) were measured. Diameters of arteries which are mainly contributing in the formation of SPA and its branches were measured with a digital caliper, and mean and standard deviation were calculated. Results: The distance of SPA, from DWC was 44.22 ± 4.98 mm and from KCL along the lateral and medial border of ring fingers was 8.32 ± 1.01 mm and 9.54 ± 0.95 mm, respectively. The average diameter of the ulnar artery was 2.84 mm; radial artery was 2.79 mm; the superficial palmar branch of the radial artery, princeps pollicis artery, and the median artery was 1.5 mm, 1.24 mm, and 2.025 mm, respectively. Conclusion: The results of the present study on the location of the SPA as well as arterial diameters will be of great help for the surgeons and radiologists. Advances in reconstructive surgeries of the hand, especially microsurgeries has entailed a better understanding of arterial variations, in-depth knowledge of which is necessary for the positive outcome of surgical procedures.
Keywords: Arterial diameter, carpal tunnel release, distal wrist crease, Kaplan's cardinal line, reconstructive surgeries, superficial palmar arch
|How to cite this article:|
Varalakshmi K L. Cadaveric Study of Topographical Location and Arterial Diameter of Superficial Palmar Arch with its Clinical Implication. Natl J Clin Anat 2021;10:21-4
|How to cite this URL:|
Varalakshmi K L. Cadaveric Study of Topographical Location and Arterial Diameter of Superficial Palmar Arch with its Clinical Implication. Natl J Clin Anat [serial online] 2021 [cited 2021 May 12];10:21-4. Available from: http://www.njca.info/text.asp?2021/10/1/21/308114
| Introduction|| |
Superficial palmar arch (SPA) is a convex arcade of arteries formed predominantly by the anastomosis between the ulnar artery and radial artery (superficial palmar branch). In some individuals, the ulnar artery may show anastomosis with arteria radialis indices or median artery or arteria princeps pollicis. The formation of SPA and their interconnecting branches shows extensive variations and its one of the highly demanding areas of study in the palmar region. Although literature shows numerous studies on the arterial pattern and its variations, very few studies are available regarding the topographical location and arterial diameter.
The SPA is located in the center and superficial aspects of the palm. Due to its location, it is commonly involved in hand injuries and many surgical interventions. It is one of the most common structures which are susceptible to injury during carpal tunnel release surgeries (both endoscopic and open). Such iatrogenic injuries are more so with endoscopic carpal tunnel release due to limited visual fields; hence, it is important to plan a precise incision to avoid damage to this highly vulnerable anatomical structure. There is consistent distance between the SPA and easily identifiable palpable bony landmarks. Hence, distal wrist crease (DWC), carpometacarpal joint of the ring finger, and Kaplan's cardinal line (KCL) are used to as a predictable landmark to locate the SPA to avoid iatrogenic injuries. KCL was proposed by E.B. Kaplan in 1953; according to Kaplan “a horizontal line drawn from the apex of the interdigital fold between the thumb and index finger, extending toward the ulnar side of the palm.” In open or endoscopic carpal tunnel release surgeries, KCL can be considered as the most distal extent of incision to keep the SPA out of danger. The DWC is the constant reliable topographical landmark which guides the surgeon while planning the surgeries. Knowledge of SPA and its relations to anatomical landmarks would reduce the possibilities of iatrogenic injuries, helps in the effective handling of vascular occlusive conditions, and helps to interpret the abnormalities in arteriograms correctly.
Comprehensive knowledge of incidence of anatomical variations in the SPA and its branches has become essential with the progressive development in the hand surgeries. The success of reconstructive surgeries of the hands depends on the good reperfusion of local structures and arterial diameter is one of good indicator of blood flow. Precise information about normal dimensions of arteries is vital to distinguish the alterations in the arterial diameter caused due to diseases such as hypertension/diabetes or drugs or any other treatment. Okawa et al. conducted a cadaveric study on arterial branches which supply mid palmar area and had planned two different reverse island flaps to treat large palmar defects of palm. Thus, knowledge of SPA is important for anatomists, orthopedicians, radiologists, and microvascular surgeons. The study of a SPA with special emphasis on topographical location and arterial diameter assumes great importance to prevent and avoid possible complications and achieve the best operative results as well as diagnostic interventions.
| Materials and Methods|| |
A total of 40 cadaveric hands (20 right and 20 left) from 20 embalmed cadavers (19 male and 1 female) were procured from the anatomy department of AJ Institute of Medical science, Mangalore. Since it was a cadaveric study, Ethical clearence was exempted for our institution. SPA was dissected as per the classical incision and dissection procedures of Cunningham's manual of practical Anatomy Volume 1. Formation of SPA and its branching patterns were noted. Damaged and traumatised upper limbs or arterial arch with abnormal tortuosity, dilatations, or aneurysms were not included in the study. After exposing the SPA, the following measurements were taken.
- The measurement from DWC:
- The average distance between the SPA and DWC was measured along the longitudinal axis extending from the lateral aspect of the ring finger. A thread was placed along the lateral border of the ring finger to mark the longitudinal axis.
Measurement of the arch from KCL.
Using the digital caliper, in each cadaveric hand, the distance between the SPA and the meeting point of KCL and the longitudinal lines from the ulnar and the radial border of ring finger was measured. The mean and standard deviations of measured distances were calculated. While taking measurement, these lines were represented by placing the thread at the KCL and longitudinal line along the medial and lateral border of the ring finger [Figure 1].
|Figure 1: (a) Measurement of an arch from distal wrist crease along line 1 (longitudinal line along the lateral border of the ring finger). (b) Measurement between the junction point of Kaplan's cardinal line and the superficial palmar arch along the lateral (line 1) and medial border (line 2) of the ring finger. (Distance is marked by arrow)|
Click here to view
Measurement of diameters of vessels
Using electronic digital caliper (0–150 mm, 0.01 mm resolution), the external diameters of arteries forming the arch and its branches were measured. Diameters of main arteries of the hand such as radial, ulnar, and median were measured at wrist level. Superficial palmar branch of the radial artery and common palmar digital arteries were measured at the site of their origin. Mean and standard deviation was calculated for the measured diameters and represented in the form of a table. Since in the present study, the radialis indicis artery was not contributed in the formation of SPA, the diameter of radialis indicis artery was not included.
| Results|| |
Measurement of distance of the superficial palmar arch from surface landmarks
In the current study, the mean distance of SPA from DWC was 44.22 ± 4.98 mm. Distance of SPA from the junction point of KCL along the radial (KCL-RB) and ulnar borders (KCL-UB) of the ring finger was 8.32 ± 1.01 mm and 9.54 ± 0.95 mm, respectively. The arch lies distal to these lines in all specimens [Table 1].
The external diameter of the ulnar artery (2.84 mm) was more than the external diameter of the radial artery (2.79 mm). In the present study, the median artery was seen in two hands (one right and one left) out of 40 hands, constituting about 5% of total study samples and the average diameter of median artery was 2.025 ± 0.21 mm.
| Discussion|| |
Any type of surgeries either open or endoscopic release of carpal tunnel, the situation of SPA is of utmost importance. The statistics from the previous studies have reported that chances of injury to the SPA are 1.5% and 3.7% in open and endoscopic interventions, respectively. The reasons for such injuries are mainly due to inadequate visualization and identification of SPA with reference to surface landmarks. Majority of complications were in the form of postoperative hematoma, aneurysmal dilation leading to delayed healing, and symptoms of ischemia due to poor reperfusion. The deep branch of the ulnar nerve, motor branch of the median nerve, the distal end of the transverse carpal ligament, and SPA all lie deep to the KCL, and therefore, KCL is considered as one of the important surface landmarks to localize these important anatomical structures.
In the present study, the distance of SPA from the junction point of KCL-RB and KCL-UB of the ring finger was 8.32 ± 1.01 mm and 9.54 ± 0.95 mm, respectively. Panchal and Trzeciak had done a study on 60 formalin-fixed hands and measured the distance between the SPA and KCL along the radial and ulnar borders of the ring finger. In their study, the SPA was present at a distance of 10.4 ± 4 mm and 11.8 ± 4 mm from the radial and ulnar borders of the ring finger. Vasiliadis et al. measured the distance between SPA and KC L with respect to the axis of 3rd web space as the longitudinal reference line, and the mean distance was 10.4 ± 5 mm. The result of our study is in range with the above studies. Vella et al., in their study on clinical applications of KCL, evaluated the relationships between KCL and structures lying deep to it. The distance between the original Kaplan's line and the SPA was 14 ± 5 mm slightly higher compared to our study.
In the current study, the distance of SPA from DWC was 44.23 ± 4.98 mm. A morphometric study on the safe zone for mini-open carpal tunnel release was conducted by Ozcanli et al. and observed that the distance of SPA from DWC was 46 ± 3.9 mm. McLean et al. in their study on 48 cadaveric hands recorded the distance of SPA and DWC as 48 mm. In the same study, SPA was present at an average of 15.3 ± 8.60 mm distance from KCL and 32 ± 6.33 mm distal to the carpometacarpal joint of ring finger. In case of patients with first carpometacarpal arthritis, the movements of the thumb will be restricted and the location of KCL may differ; then DWC can be used as a reliable landmark to avoid neurovascular damage. The differences between the results are possibly due to age, gender, racial, and geographic variations in the studied populations. This may be one of the limitations of our study which can be overcome by doing an ultrasound examination of palmar hand surface.
In this modern era, with drastic advances in microsurgeries in reconstructive hand surgery, knowledge about vascular patterns and diameters of arteries of the hands have gained more importance. Although numerous studies have been conducted on anatomical variations in the arterial pattern of the hand and its anatomical variations, very few studies are available with respect to the diameter of vessels contributing to SPA and its branches. The study on the diameter of vessels is clinically important in reconstructive hand surgeries as based on the results from these studies new surgical procedures can be established. Fazan et al. dissected 46 embalmed hands and compared the diameter of the vessels contributing to the SPA and its important branches. In their study, the average diameter of the radial and ulnar artery was 2.5 mm and 2.6 mm, respectively. The proper digital palmar digital artery and common palmar digital artery showed diameter of 1.6–1.8 mm and 1.5–2 mm, respectively. The diameter of superficial palmar branch of the radial artery was 1.7 mm2. Gellman et al. performed a detailed study of SPA including the diameters of arteries and observed that the average diameter of ulnar artery was 2.5 mm and the radial artery was 2.6 mm. The common palmar digital arteries showed average diameter of 1.6 mm. There was no difference in the diameter between sides and types of arches. In the present study, we have used formalin-fixed cadavers, results of our study does not show much difference from those studies which is conducted on the fresh cadavers (Gellman et al.). James Doyle et al. showed the diameter of the ulnar artery was 1.8–2 mm, radial artery was 2–2.4 mm, the common palmar digital arteries in the range of 1.5–1.7 mm, and the proper palmar digital artery was 0.8–1.2 mm. The results of the present study correlate with these studies. The measurement of median artery diameter at the level of wrist is important as it may compress the structures resulting in carpal tunnel syndrome. The diameter of >2 mm can compress the structures of carpal tunnel. In the present study, mean diameter of the median artery was 2.025 mm. Nayak et al. conducted a study on diameter of the median artery which was varied between 0.8 mm and 2.6 mm. The median artery can increase in caliber due to thrombosis, aneurysm, and calcifications which may lead to carpal tunnel syndrome.
| Conclusion|| |
The present study suggests that there is a consistent distance between the SPA and surface and bony landmarks. During carpal tunnel release surgeries (open or endoscopic), the DWC and KCL can be considered as reliable landmarks to plan a proper incision to avoid pseudoaneurysm and hematoma of SPA and to obtain the good surgical outcome. The size of the vessels contributing in the formation of SPA is vital to assessing radiologists and treating surgeons for better microsurgical interventions and flap designing.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Standring S. Gray's anatomy. The anatomical basis of clinical practice. 40th
ed., Edinburgh: Elsevier Churchill Livingstone; 2005. P
Fazan VP, Borges CT, Da Silva JH, Caetano AG, Filho OA. Superficial palmar arch: An arterial diameter study. J Anat 2004;204:307-11.
Houdek MT, Wagner ER, Shin AY. The cup of diogenes: A fixed anatomical landmark for carpal tunnel surgery. Hand (N Y) 2015;10:712-6.
Hazani R, Elston J, Brooks D, Wilhelmi BJ. Bridging the gap in hand replantation: Use of the common digital artery for completion of the superficial palmar arch. Plast Reconstr Surg 2010;126:2037-42.
Kwiatkowska M, Jakutowicz T, Ciszek B, Czubak J. Can palmar creases serve as landmarks for the deeper neuro-vascular structures? Surg Radiol Anat 2014;36:495-501.
Bilge O, Pinar Y, Ozer MA, Gövsa F. A morphometric study on the superficial palmar arch of the hand. Surg Radiol Anat 2006;28:343-50.
Omokawa S, Tanaka Y, Ryu J, Suzuki J, Vincent L, Kish AS. Anatomy of the ulnar artery as it relates to the transverse carpal ligament. J Hand Surg 2002;27A:101-4.
Romanes GJ. Cunningham's Manual of Practical Anatomy. 15th ed., Oxford: Oxford University Press; 2005. p. 76-7.
Benson LS, Bare AA, Nagle DJ, Harder VS, Williams CS, Visotsky JL. Complications of endoscopic and open carpal tunnel release. Arthroscopy 2006;22:919-24, 924.e1-2.
Panchal AP, Trzeciak MA. The clinical application of kaplan's cardinal line as a surface marker for the superficial palmar arch. Hand (N Y) 2010;5:155-9.
Vasiliadis HS, Tokis AV, Andrikoula SI, Kordalis NV, Beris AE, Xenakis T, et al
. Microsurgical dissection of the carpal tunnel with respect to neurovascular structures at risk during endoscopic carpal tunnel release. Arthroscopy 2006;22:807-12.
Vella JC, Hartigan BJ, Stern PJ. Kaplan's cardinal line. J Hand Surg 2006;31(A):912-18.
Ozcanli H, Coskum NK, Cengiz M, Oguz N, Sindel M. Definition of A safe zone in open carpal tunnel surgery: A cadaveric study. Surg Radiol Anat 2009;0498:1-8.
McLean KM, Sacks JM, Kuo YR, Wollstein R, Rubin JP, Lee WP. Anatomical landmarks to the Superficial and deep palmar arches. Plast Reconstr Surg 2008;121:181-5.
Cobb TK, Cooney WP, An KN. Clinical location of hook of hamate: A technical note for endoscopic carpal tunnel release. J Hand Surg Am 1994;19:516-8.
Gellman H, Botte MJ, Shankwiler J, Gelberman RH. Arterial patterns of the deep and superficial palmar arches. Clin Orthop Relat Res 2001; 383:41-6.
Doyle JR, Botte MJ. Surgical anatomy of the hand and upper extremity. Lippincott: Williams and Wilkins; 2003. p. 38-45.
Nayak SR, Krishnamurthy A, Ramanathan L, Prabhu LV. The median-radial type of superficial palmar arch: A case report and review of the literature. Clinics (Sao Paulo) 2008;63:409-10.