superficial ulnar artery originating from the brachial artery and its clinical importance

Surg Radio1Anat (1998) 20:383-385 Surgical Radiologlc Anatomy Journal of Clinical Anatomy

© Springer-Verlag 1998

Superficial ulnar artery originating from the brachial artery and its clinical importance

T. Nakatani l, S. Tanaka 2 and S. Mizukami 2

1 Department of Anatomy II, School of Medicine, Faculty of Medicine, Kanazawa University, 13-1 Takaramachi, Kanazawa 920-8640, Japan

z Division of Anatomy, College of Nursing, Fukui Prefectural University, 4-1-1 Kenj6jima, Matsuokacy6, Yoshida-gun 910-1145, Japan

Summary: We found a left superficial ulnar artery in the cadaver of a Japanese woman. This anomalous vessel origina- ted from the brachial artery at a site 55 m m distal to the inferior border of the teres major musc le and media l to the median nerve, ran downward and medially supe r f i c i a l to the f o r e a r m f l exo r muscles, and then downward to enter the hand. It formed superficial and deep palmar arches with the radial artery. The clinical importance of the anomalous ulnar artery is discussed.

Art~re ulnaire superficielle naissant de l'art~re braehiale. Importance clinique

R~sum~ : Nous avons trouv6 une art~re u lna i re supe r f i c i e l l e g a u c h e sur le cadavre d 'une japonaise . Cette a t t i re ulnaire anormale naissait de l'art~re bra- chiale, 55 m m distalement au bord infg- rieur du m. grand rond et m6dialement an n. m6dian, se dirigeait d is ta lement et m6dialement, courrait superficiellement aux mm. fl6chisseurs de l ' avant -bras , puis atteignait la main. Elle formait los

Correspondence to: T. Nakatani

arcades palmaires superficielle et profon- de avec l'artbre radiale. L'importance clinique cette art6re ulnaire anormale est discut6e.

Key words: Anomalous ulnar artery - - Forearm flexor muscles - - Radial artery - - Japanese w o m a n

The normal ulnar a. originates from the brachial a. in the cubital fossa, crosses deep under the median nerve and passes obliquely downward and medially, covered by the pronator teres, f lexor carpi radialis, palmaris longus and flexor digi- torum superficialis ram. in the proximal half of the forearm. Then, in the distal half of the forearm, it proceeds between the flexor carpi ulnaris and flexor digito- rum superfcialis ram., being covered by the skin, and ends at the wrist [4, 10]. There are sometimes anomalous cases in which the ulnar a. descends superficial to the forearm flexor mm. and reaches the wrist lateral to the ulnar nerve. Such a case is referred to as a superficial ulnar a. The superficial ulnar a. originates either directly from the axillary a., which Bian- ch [3] called a superficial brachio-ulnar a., or often from the brachial a. in the arm or cubital fossa, or, more rarely, from the superficial brachial a., which continues as

the radial a. [ 1 , 2 , 6 , 7 , 9 , 11, 12, 13, 17]. It runs deep or superfcial to the bicipital aponeurosis and deep or superficial to the deep fascia covering the forearm flexor mm. It is some t imes compl i ca t ed by absence of the palmaris longus m.; if this muscle is present, the artery ties deep to it [6]. Although accidental intra-arterial injection of drugs is rare, if it occurs, amputation of the forearm or fingers is unfortunately sometimes necessary [5]. Since the free forearm flap on the radial a. is often used in reconstructive surgery, if a superficial ulnar a. is present there is a risk that it may be ligated or cut instead of the superficial v., causing disorder of circulation in the hand [8, 16]. Therefore, it is important to know if a patient has a superfcial ulnar a. in the forearm.

Material and methods

Case report

A superficial ulnar a. was found in the left upper limb of an 85-year-old Japane- se woman. This anomaly was observed in i out of 150 arms (0.7%) examined between 1996 and 1997. The left brachial a. divided into the radial and superficial ulnar aa. at a site 55 m m distal to the lower end of the teres ma jo r musc le (Fig. 1). The radial a. ran inferiorly along

384 T. Nakatami, et al.: Superficial ulnar artery

SPA

b

its normal course and branched off the common interosseous a. at the cubital fossa. The superficial ulnar a. ran medial and parallel to the median nerve, over the origins of the forearm flexor mm. and under the bicipital aponeurosis in the cubital fossa, and continued lateral to the flexor carpi ulnaris m., terminating at the wrist on the lateral site of the ulnar nerve, as does the normal ulnar a. It formed superficial and deep palmar arches with the radial a. The superficial vv. were situated superficial to the superficial ulnar a. The left palmaris longus m. was absent. In the right arm, the brachial, radial and ulnar aa. showed normal sites and pathways and the palmaris longus m. was present.

Fig. la-b a Photograph of left arm. Arrow heads indicate the superficial ulnar a. b Drawing of left arm. Arrow indi- cates bifurcation of brachial a. (a and b). BA brachial a. BiA bicipital aponeurosis BV basilic v. CIA common interosseous a. FCR flexor carpi radialis m. FCU flexor carpi ulnaris m. MCV median cubital v. MN median nerve RA radial a. SPA superficial palmar arch SUA superficial ulnar a. TM teres major m. UN ulnar n.

_..~,./A / I x,,,/SUA SBA

RA UA ! PA PA

RA_I ! PA

SU,~

a b c

Fig. 2a-c Diagram of development of principal arteries of the ~ , redrawn from Poteat (1985). a All principal arteries are shown during the development of the arm arteries, b Normal pattern of principal arm arteries: dotted lines indicate arteries that disappear during development, c Abnormal pattern of superficial ulnar a. Dotted lines indicate arteries that disappeared during development. AIA anterior interosseous a.; BA brachial a.; Cl anastomotic connection between brachial and superficial brachial aa.; C2 anastomotic connection between brachial and superficial ulnar aa., MA median a.; PA palmar arch; RA radial a.; SBA superficial brachial a.; SUA superficial ulnar a.; UA ulnar a.

Discussion

Poteat [14] proposed a new model for the sequence of arterial development in the human upper limb to replace the older model of Singer [15]. Poteat reported a patient in whom the radial a. was absent, the superficial ulnar a. and anterior interosseous a. anastomosed with each other in the hand, and a small median a. was present. According to Poteat 's model (Fig. 2), in normal circumstances the superficial ulnar a. originating from the brachial a. develops, the anastomotic connection between the brachial and superficial ulnar aa. forms, and then the portion of the superficial ulnar a. proximal to the anatomic connection disap- pears to form the ulnar a. Applying Poteat's model to the present case, we might conclude that the anastomotic connection between the brachial and superficial tflnar aa. was not formed, and thus the superficial ulnar a. persisted. In the present case as well as in normal cases, the radial a. develops due to the formation of the superficial brachial a. and the anastomosis between the superficial brachial and brachial aa., and the disappearance of the proximal part of the superficial brachial a. However, Bianchi [3] reported f rom the observation of human embryos of 8.5, 10, 15 mm crown-rump (CR) length and guinea pig embryos of 9 mm CR length (correspon- ding to a human embryo of 10 mm CR length) that the brachial a., situated between the ventral and dorsal trunks of the

T. Nakatami, et aI.: Superficial ulnar artery 385

Table 1. Frequency of the superficial ulnar a. References

Author (Year) Country Frequency (%)

Adachi (1928) Japan 0.7

Hazlett (1949) Canada 2.7

4.4 a

McCormack et al. (1953) USA 2.3

Weathersby (1956) USA 2.3

Fadel and Amonoo-Kuofi (1996) Egypt and Saudi Arabia 2.8

Devansh (1996) India 9.4

9.2 b

Present study Japan 0.7

a living arms examined, b living arms at operation

brachial plexus, and the arterial rami branching from the brachial a., were present. On the other hand, no arteries were observed in the area superficial to these nerves, but a venous plexus was found. This may indicate that it is necessary to use modern technology to reexamine whether the superficial a. as described above by Poteat is normally and usually observed in the arm of human embryos during the developmental stage.

The incidence of the superficial ulnar a. ranges from 0.7% to 9.4% (Table 1). This anomaly is relatively rare in Japane- se [1] and relatively corm:non in Indians [6]. The wide variation of incidence may be due to racial factors. Therefore, since a superficial ulnar a. is actually not very rare, there is a fair chance that clinicians may encounter this anomaly. The superficial ulnar a. lies superficial to the forearm flexor mm. and subjacent to the superficial arm vv. This causes the following problems: 1) Intra-arterial injection may be performed instead of intravenous injection in the arm [9]. 2) When a radial forearm flap is raised, the superficial ulnar a. may accidentally be ligated instead of the superficial v., interrupting the circulation of the hand, although Allen's

test shows satisfactory circulation to the hand via the ulnar a. [8, 16]. On the other hand, the presence of a superficial ulnar a. can be advantageous, since it can be used to supply Nood to the forearm flap [6]. While raising a wide forearm flap from the elbow to the wrist and from the radial to the ulnar side, surgeons must not expose the tendons of the brachioradialis and flexor carpi radialis mm., because of the artery's superficial positon, although raising a wide radial flap may expose the tendons.

The superficial ulnar a. is quite easily discovered outlined on the skin surface just below the medial half of the skin crease in front of the elbow, and pulsa- tion is discernible on palpation with l ine difficulty [6, 9]. Therefore, this anomaly must be borne in mind when clinicians or nurses perform intravenous injection or surgery in the arm.

Acknowledgments. We thank Mr. Y. Shiraishi for drawing the illustrations, Mr. T. Nakamura for technical assistance, and Ms I. Koizumi for secre- tarial assistance.

1. Adachi B (1928) Das Arteriensystem der Japaner. Bd. 1. Maruzen Co., Kyoto, pp 326- 374

2. Anil A, Turget HB, Peker TV (1996) A variant of superficial ulnar artery. Surg Radiol Anat 18:237-240

3. Bianchi L (1943) Considerazioni sopra un caso di areria brachio-ulnare superficiale. Anat Anz 93:73-88

4. Clemente CD (1985) Gray's Anatomy. 30th ed. Lea & Febiger, Philadelphia, pp 719-720

5. Cohen S M (1948) Accidental intra-arterial injection of drugs. Lancet 255:361-371 and 409-417

6. Devansh D (1996) Superficial ulnar artery flap. Plast Recons t r Surg 9 7 : 4 2 0 - 4 2 6

7. Fadel RA, Amonoo-Kuofi HS (1996) The superficial ulnar artery: development and surgical significance. Clin Anat 9 :128-132

8. Fatah MF, Nancarrow JD, Murray DS (1985) Rasing the radial artery forearm flap: the superficial ulnar artery "trap." Br J Plast Surg 38:394-395

9. Hazlett JW (1949) The superficial ulnar artery with reference to accidental intra-arterial injection. Can Med Assoc J 61:289-293

10. Hollinshead WH (1958) Anatomy for surgeons. Vol. 3. Paul B. Hoeber, Inc, New York, pp 415-419

l 1. McCormack LJ, Cauldwell EW, Anson BJ (1953) Brachial and antebrachial arterial pat- terns. A study of 750 extremities. Surg Gyne- col Obstet 96:43-54

12. Nakatani T, Tanaka S, Mizukami S, Shiraishi Y, Nakarnura T (1996) The superficial ulnar artery originating from the axillary artery. Ann Anat 178:277-279

I3. Pabst R, Lippert H (1968) Beiderseitiges Vorkommen yon A. brachialis superflcialis, A. ulnaris snperficialis und A. mediana. Anat Anz 123:223-226

14. Poteat WL (1986) Report of a rare human variation: absence of the radial artery. Anat Rec 214:89-95

I5. Singer E (1933) Embryological pattern per- sisting in the arteries of the arm, Anat Rec 55:403-409

16. Thoma A, Young JEM (1992) The superficial ulnar artery "trap" and the free forearm flap. Ann Plast Snrg 28:370-372

17. Weathersby HT (1956) Unusual variation of the ulnar artery. Anat Rec 124:245-248

Received March 6, 1998/Accepted in final form

August 18, 1998

superficial ulnar artery originating from the brachial artery and its clinical importance

Documents