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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 69  |  Issue : 2  |  Page : 110-112

Superficial course of the radial artery in the anatomical snuffbox and course of princeps pollicis and first dorsal metacarpal arteries


Department of Anatomy, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India

Date of Submission08-Jun-2019
Date of Acceptance10-Jan-2020
Date of Web Publication30-Jun-2020

Correspondence Address:
Dr. Billakanti Prakash Babu
Department of Anatomy, Kasturba Medical College, Manipal Academy of Higher Education, Manipal - 576 104, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JASI.JASI_72_19

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  Abstract 


Variations of the radial artery (RA), in its course and branching pattern in the anatomical snuffbox, are clinically significant during vascular and reconstructive surgeries of the hand. During the course of routine dissection of RA in the forearm and hand, an important variation was noted. In one of the cadaver RAs, at a short distance above the wrist, it gave superficial palmar artery and turned laterally passed superficial to the tendons to the thumb forming the boundaries of anatomical snuffbox and entered the hand by passing between two heads of the first dorsal interosseous muscle and terminated in the deep palmar arch. At the anatomical snuffbox, RA gave arteria princeps pollicis and first dorsal metacarpal arteries. The knowledge about this variation is to be noted carefully because this artery used as a graft during the cardiac surgery, which when missed might lead to many complications.

Keywords: Anatomical snuffbox, deep palmar arch, origin of arteria princeps pollicis, radial artery


How to cite this article:
Babu BP, Thomas R H. Superficial course of the radial artery in the anatomical snuffbox and course of princeps pollicis and first dorsal metacarpal arteries. J Anat Soc India 2020;69:110-2

How to cite this URL:
Babu BP, Thomas R H. Superficial course of the radial artery in the anatomical snuffbox and course of princeps pollicis and first dorsal metacarpal arteries. J Anat Soc India [serial online] 2020 [cited 2020 Sep 21];69:110-2. Available from: http://www.jasi.org.in/text.asp?2020/69/2/110/288675




  Introduction Top


Accurate and detailed knowledge about the course of the radial artery (RA) and variations in origin and course of its branches has been reported and surgeons should be aware before doing a hand surgery. In addition, iatrogenic trauma due to occurrence of superficial branches of the RA may lead to a life-threatening hemorrhage.

The brachial artery divides into a larger ulnar artery and a smaller RA. From the origin, RA runs superficially downward medial to the brachioradialis. After giving superficial palmar branch, RA winds around the radial aspect of the forearm in the lower part and enters into the anatomical snuffbox.[1] It passes deep to the abductor pollicis longus and extensor pollicis brevis and enters the palm of the hand by passing between the two heads of the first dorsal interosseous muscle. In the anatomical snuffbox, it usually gives off the dorsal carpal branch which ends the dorsal carpal arch. Before its entry to the palm, on the dorsum of the hand, it gives slender branches to the lateral side of the dorsum of the thumb and first dorsal metacarpal artery. In the palm, it lies at first between the first dorsal interosseous and adductor pollicis where it gives off the arteria radialis indicis and arteria princeps pollicis (APP) and becomes continues as the deep palmar arch. According to Hollinshed,[2] the APP may alternatively arise directly from the deep palmar arch or by a common trunk with the arteria radialis indicis both of which are the branches of the RA.

RA is used for common surgical procedures during harvesting. Although there are articles reported the variation in the origin of the RA around 15% as cited by McCormack et al. 1953,[3] there are only very few reports about the variation in its superficial course with about 0.52% incidence.[4] For radiological assessment of the arteries during angiographic procedures, cardiac catheterization, or during the hand surgeries prior to the procedure, a detailed history of the arterial pattern is needed. Entire course of the artery and its relations to the structures in the forearm and hand have to be clearly noted, because when a surgeon misses to note, it would result in complications during hand surgery or after surgery its relation with the adjacent structures in the lower part of the front of the forearm and wrist also has to be noted. In the current report, we present a rare case of “very superficial course” of the RA in anatomical snuffbox and course of APP through thenar muscles and discuss clinical and surgical importance. Anatomical knowledge on the variant branching pattern of RA in the hand is of considerable importance during several surgical approaches and therapeutic practices. During coronary angiography and any coronary interventions, it is important to clearly learn about the RA course.


  Case Report Top


During routine dissection for undergraduate MBBS students at Kasturba Medical College, Manipal, we came across a variation in the course of the RA and the APP in the right upper limb in one male cadaver out of 50 formalin-fixed adult cadavers. Origin of RA was normal. At a short distance above the wrist, it gave superficial palmar artery and turned laterally passed superficial to the tendons to the thumb forming the boundaries of the anatomical snuffbox [Figure 1]. Later, the course of the artery was between the two heads of the first dorsal interosseous muscle in the dorsal aspect and entered the palm of the hand and gave off the arterial radialis indicis and terminated in the deep palmar arch.
Figure 1: Superficial course of the Radial artery and the origin of first dorsal metacarpal artery in the hand from the RA.RA: Radial artery, DM: First dorsal metacarpal artery

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The RA, while passing superficial to the anatomical snuffbox, gave off the princeps pollicis and first dorsal metacarpal arteries [Figure 2]. This variant superficial course of RA and other branches arising at this level were covered only by skin and superficial fascia and were thus very vulnerable to injury.
Figure 2: Dissection of the hand showing radial artery and superficial course of arteria princeps pollicis, first dorsal metacarpal artery and origin of arteria radialis indicis in deeper part of palm of hand. RA: Radial artery;DM: First dorsal metacarpal artery;APP: Arteria princeps pollciis:ARI: Arteria radialis indicis

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  Discussion Top


The brachial artery divided into ulnar and radial arteries. Awareness of RA variation in its origin and branching pattern has great importance in various clinical fields and basic medical studies. Reports on its variant origin and in its proximal course are quite common compared to its distal course in the forearm and termination in the hand.[5] Higher origin of RA associated with its complete superficial course termed as superficial brachioradial artery as cited by Sharmila Bhanu et al.[6] Manners-Smith [7] classified the variations in the course of the RA into two categories in relation with the tendons forming the boundaries of the anatomical snuffbox on the dorsal aspect of the hand. When the RA undergoes a superficial course in relation to these tendons, it was considered one category and named as the superficial dorsal artery of the forearm. In the second category division in the anatomical snuffbox, the RA divides into superficial and deep branches – called the partial duplication of RA [3] or duplication of the RA.[8] The present case belongs to the first class category of Manners-Smith Classification.[7] An extremely superficial course of the RA in the anatomical snuffbox has been reported by Jyothsna et al.[5] Chandni et al.[9] reported a superficial course of RA in the anatomical snuffbox in one of 75 specimens studied. However, an occurrence of anomalous superficial course of APP through the thenar muscles of the hand is seldom reported. Abdullah et al.[10] reported divisions of RA into dorsal and palmar branches 5.5 cm above the styloid process of the radius. Dorsal branch was running superficial to the tendons forming the boundaries of anatomical snuffbox and ended by perforating first dorsal interosseous muscle, while the palmar branch passed superficial to the flexor retinaculum and deep to the abductor pollicis brevis and anastomosed with ulnar artery forming the superficial palmar arch.

The arteries that are superficial in the upper limb may be misinterpreted as veins because of its appearance, which may become a basis for intra-arterial injections instead of intended intravenous injections.[11],[12] It might be also noticed during forearm flaps in plastic surgery [13] or misinterpreted in contrast radiographs.[14] During most of the cardiac surgical procedures, the RA is the most preferred graft [15] because it is easily accessible and arteries always have a greater success rate when compared to veins. Veins such as saphenous graft are also used for cardiac bypass grafting. The very superficial course of the RA in the anatomical snuffbox and its close relation to the cephalic vein are also a predisposing factor for its inadvertent injuries. It might get punctured instead of the cephalic vein while setting an intravenous line. Superficial cuts in the anatomical snuffbox might result in significant bleeding when the artery is very superficial as the one being reported here.


  Conclusion Top


The variations observed in our case with an anomalous superficial course of RA at anatomical snuffbox and course of APP through the thenar muscles may be of significance clinically for microsurgeons in surgeries of the hand and during vascular surgery. The superficial arteries of the upper extremity are thin and might give an appearance like that of veins, and hence, any intravenous injection that is supposed to be given may be misinterpreted and given as an intrarterial injection which may produce complications.

The superficial arteries of the upper extremity are thin and might give the appearance like that of veins, and hence, any intravenous injection that is supposed to be given at that level may be misinterpreted as veins and given as an intrarterial injection which may produce complications later. It is a chance of finding during the routine dissection process. Knowledge of this type of variation is important during surgical procedures of the hand such as cardiac catheterization, arterial grafting, and other angiographic procedures.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Standring S. Gray's Anatomy: The Anatomical Basis of Clinical Practice. 39th ed. London: Elsevier Churchill Livingstone; 2005. p. 883-928.  Back to cited text no. 1
    
2.
Hollinshed WH. Anatomy for Surgeons: The Back and Limbs. 2nd ed. New York: Harper and Row; 1969.  Back to cited text no. 2
    
3.
Mccormack LJ, Cauldwell EW, Anson BJ. Brachial and antebrachial arterial patterns; a study of 750 extremities. Surg Gynecol Obstet 1953;96:43-54.  Back to cited text no. 3
    
4.
Rodríguez-Niedenführ M, Vázquez T, Nearn L, Ferreira B, Parkin I, Sañudo JR. Variations of the arterial pattern in the upper limb revisited: A morphological and statistical study, with a review of the literature. J Anat 2001;199:547-66.  Back to cited text no. 4
    
5.
Jyothsna P, Nayak SB, Rao MK, Kumar N, Abhinitha P. High level branching and very superficial course of radial artery in the anatomical snuffbox: Its clinical and surgical implications. OA Case Reports 2013;2:66.  Back to cited text no. 5
    
6.
Sharmila Bhanu P, Devi Sankar K, Susan PJ. “High origin and superficial course of radial artery”. Int J Anat Var 2010;3:162-4.  Back to cited text no. 6
    
7.
Manners-Smith T. The limb arteries of primates. J Anat Physiol 1912;46:95-172.  Back to cited text no. 7
    
8.
Bumbasirević M, Lesić A, Filipović B. Duplication of the radial artery in the radial forearm flap. Clin Anat 2005;18:305-7.  Back to cited text no. 8
    
9.
Chandni G, Vikram P, Murlimanju BV, Vaishali RS. A morphological study of variations in the origin and course of radial artery. Res J Pharm Biol Chem Sci 2012;3:333-40.  Back to cited text no. 9
    
10.
Abdullah MA, Walid AZ, Hasem HD, Saeed MV, Mujahid MK. An atypical superficial radial artery. Eur J Anat 2010;14:39-41.  Back to cited text no. 10
    
11.
Deligonul U, Gabliani G, Kern MJ, Vandormael M. Percutaneous brachial catheterization: The hidden hazard of high brachial artery bifurcation. Cathet Cardiovasc Diagn 1988;14:44-5.  Back to cited text no. 11
    
12.
Thomas R, Newell R. Anomalous arteries in the upper limb. Clin Anat 1995:7;57.  Back to cited text no. 12
    
13.
Devansh MS. Superficial ulnar artery flap. Plast Reconstr Surg 1996;97:420-6.  Back to cited text no. 13
    
14.
Rodríguez-Niedenführ M, Burton GJ, Deu J, Sañudo JR. Development of the arterial pattern in the upper limb of staged human embryos: Normal development and anatomic variations. J Anat 2001;199:407-17.  Back to cited text no. 14
    
15.
Cohen G, Tamariz MG, Sever JY, Liaghati N, Guru V, Christakis GT, et al. The radial artery versus the saphenous vein graft in contemporary CABG: A case-matched study. Ann Thorac Surg 2001;71:180-5.  Back to cited text no. 15
    


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  [Figure 1], [Figure 2]



 

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