Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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On Sep 2018




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On Sep 2018




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"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Lucknow
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On Aug 2018




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Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
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Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
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In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
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Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2021 | Month : September | Volume : 15 | Issue : 9 | Page : AC01 - AC06 Full Version

A Cadaveric Study of Superficial Palmar Arch with Surgical Importance


Published: September 1, 2021 | DOI: https://doi.org/10.7860/JCDR/2021/48300.15325
Hemamalini Shetty, K Pushpalatha

1. Associate Professor, Department of Anatomy, JSS Academy of Higher Education and Research, Mysuru, Karnataka, India. 2. Professor and Head, Department of Anatomy, JSS Academy of Higher Education and Research, Mysuru, Karnataka, India.

Correspondence Address :
Hemamalini Shetty,
Associate Professor, Department of Anatomy, JSS Academy of Higher Education and Research, Mysuru, Karnataka, India.
E-mail: shettyhemamalini@gmail.com

Abstract

Introduction: Arterial supply of hand is by two arterial anastomotic arches formed by radial and ulnar arteries and their branches. The anastomoses between the branches of radial and ulnar arteries such as palmar carpal and dorsal carpal arches at the wrist and superficial and deep palmar arches in the palm, maintain a rich arterial supply to the wrist and palm. Effective collateral circulation in palm is essential in peripheral arterial diseases such as Raynaud’s disease and in harvesting radial artery or the ulnar artery for Coronary Artery Bypass Graft (CABG) surgery.

Aim: To observe the variations in the formation of superficial palmar arch.

Materials and Methods: A descriptive study was performed on 45 formalin fixed upper limbs of both sex in the Department of Anatomy, JSS Medical College, Mysuru, Karnataka, India. The study was conducted during routine dissection of upper limbs for undergraduates as per the Cunningham’s manual for practical anatomy. Few rare variations in the formation of superficial palmar arch and the arterial pattern of hand were noticed. The variations found were classified according to Coleman and Anson classification.

Results: Out of 45 limbs, complete arch was found in 36 limbs and incomplete arch in nine limbs. In complete arch type, we found an arterial arcade, bifurcation of ulnar artery and in incomplete arch type, radial-radial anastomosis. Another rare findings of highly tortuous ulnar artery in forearm and in the palm.

Conclusion: The findings in the variations of superficial palmar arch are essential in microvascular surgery, forearm fasciocutaneous flap, radial artery and ulnar artery harvesting in coronary artery bypass graft procedure.

Keywords

Anastomosis, Radial artery, Revascularisation, Ulnar artery, Vascular occlusive disease

The radial and ulnar arteries and their terminal branches in the form of two arterial arches, superficial and deep palmar arches supply the palm (1). Superficial palmar arch is the main arterial supply of palm which is formed by the continuation of ulnar artery in the palm anastomosing with the superficial palmar branch of radial artery, from which the palmar digital arteries arise. Ulnar artery enters palm superficial to the flexor retinaculum along with the ulnar nerve on its medial side lateral to pisiform bone. Then, it turns laterally after passing medial to the hook of the hammate to form the superficial palmar arch (1). The superficial palmar arch is formed entirely by ulnar artery in one-third of cases, in another third it is completed by the superficial palmar branch of radial artery and a third by branches of radial artery, arteria princeps pollicis or arteria radialis indicis or by the median artery (1). It gives one proper palmar digital artery for the ulnar side of the little finger and three common palmar digital arteries. The three common palmar digital arteries which runs on the second to fourth lumbricals, receives palmar metacarpal arteries from the deep palmar arch, and divide into two proper palmar digital arteries.

Proper palmar digital arteries run along the adjacent sides of all digits. Palmar digital arteries supply the metacarpophalangeal joints, interphalangeal joints, nutrient branches to phalanges, soft parts including the matrices of the nails. They are the main digital arteries, since the dorsal digital arteries are small (1). There are extensive connections between the superficial and deep palmar arches and between the dorsal and palmar digital arteries. The formation of superficial palmar arch is highly variable with various types of contributions coming from ulnar, radial and median arteries (2),(3). The variations in the formation of the superficial palmar arch was first reported by Jaschtschinski SN in 1897 and classified into complete and incomplete arches (4).

The main reason for variations in the formation of superficial palmar arch is the radial artery whereas the ulnar artery normally remains constant and variations seem to be more common within the complete type of superficial palmar arch (5),(6),(7),(8),(9).

Several studies have reported that the variations in the formation of superficial palmar arch, being one of the most challenging region and palmar arterial arches has strongly attracted not only clinicians, radiologists even anatomists (10),(11),(12),(13). It is during routine dissection for undergraduate students sometimes that very rare variations in the pattern of superficial palmar arch formation and the distribution of digital branches from the arch supplying the palm were noticed. These variations have to be reported in order to understand the complex but very fine structure of arterial patterns of the palm. Detailed knowledge of which is essential to perform innovative microvascular procedures in reconstructive plastic surgeries of palm, surgical interventions and successful result of the same (14).

The objective of this study was to find out the incidence of anatomical variations in the pattern of superficial palmar arch formation and distribution of digital branches from the arch supplying the palm and describe the variation unknown, which is not reported in the literature so far.

Material and Methods

It was a descriptive study, started in September 2019 for under graduate (2019-2020) batch and completed by November 2020. It was done in JSS Medical College, Anatomy Department, Gross Anatomy Dissection Hall, Mysuru, Karnataka, India. A total of 45 upper limbs of both sex (12 females and 33 males) from embalmed human cadavers, used for routine dissection by undergraduate students, Jagadguru Sri Shivaratheeshwara Medical College, Mysuru were dissected. Ethics Committee Approval was obtained for this study. (JSSMC/IEC/141020/49/NCT/2020-21).

Inclusion criteria: Cadavers which were given to undergraduate students for dissection of upper limbs were included for the study.

Exclusion criteria: Damaged limbs in the region of forearm and palm were excluded from the study.

The dissection of palm was performed according to Cuningham’s manual of practical anatomy volume I (15). The branches of radial and ulnar arteries were traced, cleaned and variations were noted. Photos of the dissected palm were taken and data were classified according to Coleman SS and Anson BJ classification as follow (6):

Complete arch is when there is anastomosis between the arteries that forms the arch.

• Complete arch further divided into:
Type A: Radial-ulnar arch, by ulnar artery and superficial palmar branch of radial artery.
Type B: Ulnar arch arch, formed entirely by ulnar artery.
Type C: Median-ulnar arch, by ulnar artery and persistent median artery.
Type D: Radial-median-ulnar arch, all three arteries ending in the arch.
Type E: Ulnar artery and completed by a large branch from deep arch.
• Incomplete arch is when there is no anastomosis between the arteries forming the arch (4),(6),(7).
Incomplete arch further divided into:
Type F: Mainly by ulnar artery, not supplying thumb and index fingers.
Type G: By ulnar artery and branches of radial artery.
Type H: Persistent median and ulnar arteries
Type I: Radial, median and ulnar artery all giving branches to digits separately.

Statistical Analysis

Results were expressed in terms of frequency and percentages.

Results

Out of 45 limbs, 36 limbs showed complete superficial palmar arch and nine limbs showed incomplete arch (Table/Fig 1).

Complete Types of Arches

A complete type of arch was found in 36 (80%) palms. It was subdivided into four types according to Coleman SS and Anson BJ classification.

1. Type A- Radial-ulnar type: This is classic type formation of superficial palmar arch by ulnar artery and radial artery. This type was observed in 20 hands but showed some modifications than the usual arterial pattern.

Subtype I- the classic type, superficial palmar arch by ulnar artery and superficial palmar branch of radial artery was seen in 15 (33%) hands. In one cadaver, the superficial palmar branch of radial artery was arising in the lower third of forearm, passing superficial to the tendon of flexor carpi radialis and almost same size as ulnar artery completed the arch, bilaterally. In addition to three common palmar and one proper palmar digital arteries, the superficial palmar arch gave another common palmar digital artery to the first web space which divided into two branches for the radial side of the index and thumb representing the arteria radialis indicis and arteria princeps pollicis of the radial artery (Table/Fig 2).

Modification or deviations from the normal pattern: Arterial arcade: In two limbs, the superficial palmar branch of radial artery along with ulnar artery forms the superficial palmar arch, but the anastomosis between the two arteries formed an arterial arcade like the arterial arcades of jejunum and ileum and gave rise to the proper palmar digital arteries like the vasa recta of jejunum and ileum. In one limb, the arterial arcade gave rise to three proper palmar digital arteries to lateral 31/2 digits. The arch gave rise to one common trunk, which divided into one proper palmar digital artery, which supplied the ulnar side of the ring finger and radial side of the little finger and one proper palmar digital artery which supplied the ulnar side of the little finger (Table/Fig 3).

In another limb, the superficial palmar branch of radial artery and ulnar artery formed the arterial arcade, and from the arterial arcade only two common palmar digital arteries, which supplied the middle finger, lateral side of ring finger and medial side of index finger. The common palmar digital branches arising from the arch supplied the medial side of the ring finger and the little finger. But the thumb and radial side of index finger are supplied from the proper palmar digital artery arising from the superficial palmar branch of radial artery before forming the arterial arcade (Table/Fig 4).

Subtype II- Superficial palmar arch was formed by the continuation of ulnar artery in the palm and completed by the first dorsal metacarpal artery. Ulnar artery was anastomosing with the first dorsal metacarpal artery after giving arteria princeps pollicis and arteria radialis indicis branches. This type was seen in five hands (11%). In one specimen, the palmar digital branches from the arch supplied the remaining digits except the medial side of ring finger and lateral side of little finger which was supplied by the palmar metacarpal artery from the deep palmar arch (Table/Fig 5).

In one limb, the ulnar artery bifurcated into two branches in the middle of the palm. The lateral branch continued its lateral course towards the first web space and anastomosed with the first dorsal metacarpal artery after giving arteria princeps pollicis and arteria radialis indicis branches. The medial branch joined a branch coming from the radial artery just proximal to second web space. This branch of radial artery later continued as the proper palmar digital artery supplying the medial side of index and lateral side of middle fingers respectively. The arch gave one common palmar digital artery which supplied the adjacent sides of middle and ring fingers and one common trunk which inturn divided into common palmar digital and proper palmar digital arteries for adjacent sides of ring and little fingers and ulnar side of little finger respectively (Table/Fig 6).

2. Type B- Ulnar type: This type of superficial palmar arch is formed by the continuation of ulnar artery alone. The ulnar artery gave origin to the common palmar digital arteries as well as the arteria princeps pollicis and arteria radialis indicis which are usually branches of radial artery, supplies the radial side of the index and the thumb without any connection with other arteries. This type was observed in 14 hands (Table/Fig 7).

3. Type C- Median-ulnar type: This type of superficial palmar arch is formed by the continuation of ulnar artery in the palm and completed by the persistent median artery. This was observed in one hand.

4. Type D: Radial-median-ulnar type: This type of superficial palmar arch is formed by the anastomosis between the branches of radial artery, persistent median artery and the ulnar artery. This was observed in one hand. The ulnar artery gave origin to two common palmar digital and one proper palmar digital arteries which supplied medial 21/2 digits. Median artery after entering palm divided into two branches. The lateral branch divided into arteria princeps pollicis and arteria radialis indicis in the first web space. Medial branch passed medial to the tendons of index finger and joined a branch coming from the radial artery in the second web space. The medial branch of median artery and branch of radial artery anastomosis supplied the ulnar side of index and radial side of middle fingers (Table/Fig 8). Type E was not found in the present study.

Incomplete Types of Arches

An incomplete type of arch was found in 9 (20%) palms. It was subdivided into two types according to Coleman SS and Anson BJ classification.

1. Type F – mainly by ulnar artery, not supplying the radial side of index and thumb. This type of incomplete arch was formed by the continuation of ulnar artery and superficial palmar branch of radial artery with no anastomosis. This was observed in two hands. The radial side of index and thumb were supplied by the superficial palmar branch of the radial artery (Table/Fig 9).

2. Type G- Ulnar-radial type: This type of incomplete arch is formed by the continuation of ulnar artery in the palm and branches of radial artery with no anastomosis. This was observed in seven hands. In two specimens, the ulnar artery and radial artery branches supplied medial 21/2 and lateral 21/2 digits, respectively with no anastomosis. In two specimens, the ulnar artery and radial artery branches supplied medial 31/2 and lateral 11/2 digits, respectively with no anastomosis. In another three specimens, the palmar continuation of first dorsal metacarpal artery which divided into two branches to index and thumb in the first intermetacarpal space to supply index and thumb (Table/Fig 10).

In one specimen the thin superficial palmar branch of radial artery was anastomosing with a branch of first dorsal metacarpal artery. First dorsal metacarpal artery also gave the arteria princeps pollicis and arteria radialis indicis branches to index finger and thumb. The thenar area, thumb and radial side of index were supplied by this radio-radial anastomosis (Table/Fig 11).

Apart from the complete and incomplete arches we also observed highly tortuous ulnar artery in 19 specimens. The ulnar artery was highly tortuous in the forearm and even in the palm resulting in tortuous superficial palmar arch (Table/Fig 9), ((Table/Fig 9) is common figure for Type F and tortuous ulnar artery).

We did not get Type H and Type I incomplete superficial palmar arches in present study.

Discussion

In the present study, the superficial palmar arch was divided into complete and incomplete arches. Complete superficial palmar arches were observed in 80% and incomplete arches in 20%, respectively (Table/Fig 12).

Presence of complete arch varies from 45-96.4% (16),(17). Incomplete arch included Type F (4.4%) and Type G (15.5%). The presence of an incomplete arch varies from 3-34% in the literature (7),(18).

The most commonly described type of formation of superficial palmar arch is radio-ulnar in the literature or in the textbooks (1),(5). In the present study, this common classical type (Type A) was observed in 44.5% of cases and divided into two subtypes, subtype I (31.1%) and subtype II (11%).

The superficial palmar branch of radial artery and the ulnar artery forming the arterial arcade is one of the rare variations observed in two specimens. This variation has been reported by Madhyastha S et al., but they have not mentioned it as an arterial arcade, instead they have mentioned the formation of superficial palmar arch by superficial palmar branch of radial artery and ulnar artery and a transverse branch proximal to the arch connecting the superficial palmar branch of radial artery and the ulnar artery (10). This type of anastomosis may distribute blood equally to all the digits.

The ulnar artery anatomosing with the first dorsal metacarpal branch of the radial artery (subtype II), which was found in 11% of cases, had rarely been reported in the literature. This subtype II has also been reported by Bilge O et al., (28%) and Fazan VP et al., (26.5%) and Ruengsakulrach P et al., (18%) of cases (12),(13),(18).

Another rare variation observed in the study was bifurcation of the superficial palmar arch or duplication of the superficial palmar arch. Patnaik VVG et al., have reported superficial palmar arch duplication and the arch was formed by the ulnar artery and persistent median artery. They have mentioned it consists of proximal complete arch formed by the median and ulnar arteries with no digital branches arising from it and distal incomplete arch formed by the median and ulnar arteries giving the digital branches (19). Rapotra M et al., also reported the presence of double superficial palmar arch as having proximal and distal arches in their study. Proximal arch is by a thin branch from the lateral side of ulnar artery which terminates by giving arteria princeps pollices and arteria radialis indicis in the first web space. Distal arch is by ulnar artery which gave rise to the three common and one proper palmar digital arteries (20). In present study, also the proximal arch gave arteria princeps pollices and arteria radialis indicis branches in the first web space but it anastomosed with first dorsal metacarpal artery and distal arch gave rise to digital arteries. Both proximal and distal arches were complete, since the bifurcated ulnar artery was anastomosing with the branches of radial artery in the first and second web spaces.

The variant origin of arteria princeps pollicis and arteria radialis indicis from ulnar artery in type B arch, from superficial palmar arch in type A subtype I and from first dorsal metacarpal artery in type A subtype II makes hand surgeries difficult in traumatic situations (8).

Persistent median artery can contribute significantly in the formation of superficial palmar arch, complete or incomplete and arterial supply to the hand. As it passes through the carpal tunnel it has a superficial course and might get damaged during carpal tunnel release (21).

In incomplete arch, type G showed slight deviation than the normal description. The superficial palmar branch of the radial artery was anastomosing with first dorsal metacarpal artery. The thenar region, thumb and radial side of index finger were supplied by the radio-radial anastomosis. This was not reported in the literature.

Present study confirmed the findings of Coleman SS and Anson BJ, they found complete superficial palmar arch in 78.5% of cases (6). We observed the complete superficial palmar arch in 80% of the cases.

The classic type of superficial palmar arch (type A) formed by the superficial palmar branch of the radial artery and ulnar artery was found in 34.5% of hands, in the present study, but it was observed in 15 hands (33.3% of cases). Next commonest type of complete arch was type B in 14 (31.1%), where ulnar artery alone forms the arch.

Superficial palmar arch formed by the ulnar artery alone reaching the space between the thumb and index finger was the main findings as reported by Loukas M et al., (90%) and Bilge O et al., (86%) (2),(12). Even in the present study type B superficial palmar arch (31.1%) was second most common type of variation found in complete arch after radio-ulnar (type A) type (44.5%). This classification does not correlate with Fazan VP et al., Ruengsakulrach P et al., and Lippert H and Pabst R as they classified the superficial palmar arch formed completely by ulnar artery alone as incomplete arch (13),(18),(22).

In case of bifurcation of superficial palmar arch or presence of arterial arcade in the superficial palmar arch, if there is bleeding from any of inter digital branches of ulnar artery the surgeon may ligate the ulnar artery above the proximal superficial palmar arch or the ulnar artery expecting the blood supply to the fourth, third and second inter digital artery to be stopped but because of complete distal superficial palmar arch or arterial arcade, bleeding may continue. So, surgeons should be careful and aware of such type of rare variation of bifurcation of superficial palmar arch and superficial palmar arch with an arterial arcade. In cases of bridging the gap to repair the cut common digital artery, the superficial palmar arch is transferred distally to the common digital artery for revascularisation of the digits (23). The superficial palmar arch is connected directly to the digital arteries of the thumb and digital vein from the index finger were used to revascularise the thumb when there is damage to the arteria princeps pollicis (24). Sometimes superficial palmar branch of radial artery is used in replantation of thumb (25).

The knowledge of formation and variations of superficial palmar arch should be kept in mind during fasciectomy and fasciotomy in Dupuytren’s contracture repair, otherwise damage to the branches forming the arch results in haematoma (26).

Another finding in the present study was tortuous ulnar artery in 19 specimens. Tortuous artery is associated with hypertension, aging, atherosclerosis and other pathological changes in the arteries (27). Artery Tortuosity Syndrome (ATS) is a rare condition caused by an autosomal recessive inheritance and characterised by tortuosity, elongation and aneurysm formation in major arteries due to the disruption of elastic fibres in the tunica media of the arterial wall (28). One of the complications of tortuous ulnar artery is Guyon’s canal syndrome (29),(30).

When compared to other studies by Joshi SB et al., Madhyastha S et al., and Patnaik VVG et al., (3),(10),(19) we got both type A and type B almost in the same proportions similar to the results of Coleman SS and Anson BJ and Tagil SM et al., (6),(31). The (Table/Fig 13) shows table comparing results with previous studies (2),(3),(4),(5),(6),(17),(31),(32),(33),(34),(35).

The presence of loops and tortuosity may result in failure to achieve coronary artery cannulation when ulnar artery is used instead of radial artery for cardiac catheterisation and it is vulnerable to get punctured or perforated during interventional procedures (36).

Limitation(s)

This study is reporting variations in a small set of population (small sample size) and only documented few variations in the anatomy of superficial palmar arch.

Conclusion

It was found that ulnar artery is the main artery forming the superficial palmar arch and variations of patterns are caused by branches of radial artery like first dorsal metacarpal, from deep palmar arch and the median artery. The superficial palmar arch and its digital branches supply medial 31/2 digits normally but can supply more or less than this depending on the pattern of superficial palmar arch formation. Wounds of the palm bleed profusely but heal rapidly because of rich arterial supply. This is the basis for most of the successful reconstructive plastic surgeries of hand.

Acknowledgement

The author extend sincere thanks to Dr. Pushpalatha K, Professor and Head, Department of Anatomy, JSS Academy of Higher Education and Research for giving me an opportunity to carry out this study and support during the study.

References

1.
Susan, Standring. Gray’s Anatomy: The anatomical basis of clinical practice, Wrist and Hand. Fortieth edition. London: Elsevier Churchill Livingstone. 2008;890-94.
2.
Loukas M, Holdman D, Holdman S. Anatomical variations of the superficial and deep palmar arches. Folia Morphol. 2005;4(2):78-83.
3.
Joshi SB, Vatsalaswamy P, Bahetee BH. Variation in formation of superficial palmar arches with clinical implications J Clin Diagn Res. 2014;8(4):AC06-09. [crossref] [PubMed]
4.
Jaschtschinski SN. Morphologie and Topographie des Arcus Volaris sublimes and prefundus des Menchen. Anat Heff. 1897;7:161-88. [crossref]
5.
Gellman H, Botte MJ, Shankwiler J, Gelberman RH. Arterial patterns of the deep and superficial palmar arches. Clin Orthop Relat Res. 2001;(383):41-46. [crossref] [PubMed]
6.
Coleman SS, Anson BJ. Arterial patterns in the hand based upon a study of 650 specimens. Surg Gynecol Obstet. 1961;113:409-24.
7.
Jelicic N, Gajisin S, Zbrodowski A. Arcus palmaris superficialis. Acta Anat. 1988;132:187-90.
8.
Arquez HF, Hurtado DKA. Variations of the superficial palmar arches: A cadaveric study. Journal of Chemical and Pharmaceutical Research. 2016;8:06-14.
9.
Mbaka G, Ejiwunmi AB, Olabiyi O. Pattern of variations in superficial palmar arch in 134 Negro cadaveric hands. Ital J Anat Embryol. 2014;119:153-62.
10.
Madhyastha S, Murlimanju BV, Jiji PJ, Saralaya VV, Rai A, Vadgaonkar R. Morphological variants of the human superficial palmar arch and their clinical implications. J Morphol Sci. 2011;28:261-64.
11.
Srimani P, Saha A. Comprehensive study of superficial palmar arch-A revisit. Italian Journal of Anatomy and Embryology. 2018;123:320-32.
12.
Bilge O, Pinar Y, Ozer MA, Govsa FA. Morphometric study on the superficial palmar arch of the hand. Surg Radiol Anat. 2006;28:343-50. [crossref] [PubMed]
13.
Fazan VP, Borges CT, Da Silva JH, Caetano AG, Filho OA. Superficial palmar arch: An arterial diameter study. J Anat. 2004;204:307-11. [crossref] [PubMed]
14.
Dhar P, Lall K. An atypical anatomical variation of palmar vascular pattern. Singapore Med J. 2008;49:245-49.
15.
Koshi R. Cunnigham’s Mannual of Practical Anatomy. The forearm & Hand. Vol. I, 16th Edn. Oxford: Oxford University Press; 2017;93-102.
16.
Sarkar A, Dutta S, Bal K, Biswas J. Handedness may be related to variations in palmar arterial arches in humans. Singapore Med J. 2012;53:409-12.
17.
Ikeda, Ugava, Kazihara, Hamada. Arterial patterns in the hand based on a three-dimensional analysis of 220 cadaver hands. Am Journal of Hand Surgery. 1988;13:501-09. [crossref]
18.
Ruengsakulrach P, Eizenberg N, Fahrer C, Fahrer M, Buxton BF. Surgical implications of variations in hand collateral circulation: Anatomy revisited. J Thorac Cardiovasc Surg. 2001;122:682-86. [crossref] [PubMed]
19.
Patnaik VVG, Kalsey G, Rajan KS. Superficial palmar arch duplication-a case report. Anat Soc India. 2000;49(1):63-66.
20.
Rapotra M, Sharma A, Sharma M. Pattern of variations in superficial palmar arch and its clinical importance. IJMDS. 2017;6:1483-87. [crossref]
21.
Mitchell R, Chesney A, Seal S, McKnight L, Thoma A. Anatomical variations of the carpal tunnel structures. Can J Plast Surg. 2009;1:03-07. [crossref]
22.
Lippert H, Pabst R. Arterial variations in man: Classification and frequency. J.F. Bergmann. 1985;74-75. [crossref]
23.
Korambayil PM. Use of superficial palmar arch for bridging the gap in digital revascularisation. Indian J Plast Surg. 2011;44:511-16. [crossref] [PubMed]
24.
Korambayil PM, Ambookan PV, Dilliraj VK. Options for thumb revascularisation: Our experience and literature review. Plast Aesthet Res. 2014;1:37-40. [crossref]
25.
Cho H, Bahar AS, Moni, Hyan, Park C. Thumb replantation using the superficial palmar branch of the radial artery. J Hand Microsurg. 2016;8:106-08. [crossref] [PubMed]
26.
Bayat A, McGrouther DA. Management of Dupuytren’s disease-clear advice for an elusive condition. Ann R Coll Surg Engl. 2006;88:03-08. [crossref] [PubMed]
27.
Han HC. Twisted blood vessels: Symptoms, etiology and biomechanical mechanisms. J Vasc Res. 2012;49:185-97. [crossref] [PubMed]
28.
Callewaert BL, Willaert A, Kerstjens-Frederikse WS, De Backer J, Devriendt, K, Albrecht B, et al. Arterial tortuosity syndrome: Clinical and molecular findings in 12 newly identified families. Hum Mutat. 2008;29:150-58. [crossref] [PubMed]
29.
Emel E, Guzey FK, Alatas I. Guyon’s canal syndrome due to tortuous ulnar artery: A case report. Turk Neurosurg. 2003;13:107-10.
30.
Jose RM, Bragg T, Srivastava S. Ulnar nerve compression in Guyon’s canal in the presence of a tortuous ulnar artery. J Hand Surg Br. 2006;31:200-02. [crossref] [PubMed]
31.
Tagil SM, Aynur EC, Tunc CO, Mustafa B, Ahmet S. Variations and Clinical Importance of the Superficial Palmar Arch. SDU Typ Fak Derg. 2007;14(2):11-16.
32.
Jena S, Arora G, Sadananda R, Sahu S, Tudu J. A study on morphological variants of human superficial palmar arch and their clinical importance. Sch J App Med Sci. 2017;5:867-72.
33.
Arrchana S, Arumugan K, Sreevidya J, Seshayyan S. Anatomical study of Superficial palmar arch and its variations with clinical significance. Int J Anat Res. 2018;6:5127-33. [crossref]
34.
Gnanasekaran D, Veeramani R. Newer insights in the anatomy of superficial palmar arch. Surgical and Radiologic Anatomy. 2019;41:791-99. [crossref] [PubMed]
35.
Dawani P, Mahajan A, Mishra S, Vasudeva N. Variations of superficial palmar arch: A clinico-anatomical consideration. Int J Anat Res. 2020;8:7817-22. [crossref]
36.
Mahajan R, Raheja S, Tuli A, Singh S, Agarwal S. Tortuous ulnar artery and Gantzer’s muscle: A rare presentation with clinical implications. IAIM. 2015;2(7):141-46.

DOI and Others

10.7860/JCDR/2021/48300.15325

Date of Submission: Dec 27, 2020
Date of Peer Review: Feb 08, 2021
Date of Acceptance: May 04, 2021
Date of Publishing: Sep 01, 2021

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? NA
• For any images presented appropriate consent has been obtained from the subjects. NA

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