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Table of Contents
ORIGINAL ARTICLE
Year : 2020  |  Volume : 69  |  Issue : 3  |  Page : 171-177

Evaluation of vascular and neural anatomy of the hand in adult cadavers


1 Department of Anatomy, Faculty of Medicine, Suleyman Demirel University, Isparta, Turkey
2 Department of Anatomy, Faculty of Medicine, Gazi University, Ankara, Turkey
3 Department of Nursing, Aksehir Kadir Yallagoz School of Health, Selcuk University, Konya, Turkey

Date of Submission07-Nov-2019
Date of Acceptance19-Aug-2020
Date of Web Publication30-Sep-2020

Correspondence Address:
Dr. Yadigar Kastamoni
Department of Anatomy, Faculty of Medicine, Suleyman Demirel University, 32260, Isparta
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JASI.JASI_216_19

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  Abstract 


Introduction: We aimed to investigate the vascular and neural anatomy of the hand in adult cadavers and to determine the normal anatomical structure and variations of these structures. Material and Methods: Twenty hands of adult cadavers were examined by the dissection method. After the superficial palmar arch (SPA), the ulnar nerve (UN), median nerve (MN), and deep palmar arch (DPA) were identified, their anatomical structures and variations were evaluated. Then, they were classified according to the number of branches they give off and the course of these branches. Results: When the number of the common palmar digital arteries emerging from the SPA was examined, four branches were observed to emerge from the arch in 80%, and five branches in 20%. When the innervation of the MN and UN was evaluated, 3.5 + 1.5 fingers innervation was observed in 90%, 3 + 1.5 fingers innervation and 3 + 2 fingers innervation were observed in 5% of the samples. When the DPA samples were examined, four metacarpal palmar arteries were observed to emerge from the arch in all of the samples. According to the number of branches they gave off and the course of these branches, the SPA was gathered under seven groups, the nerves were gathered under four groups, and the DPA was gathered under three groups. Discussion and Conclusion: We believe that the data obtained in our study will be used, especially in anatomy education and will guide neurologists, surgeons, orthopedists, radiologists, and anatomists in their studies, diagnosis, and treatments.

Keywords: Classification, deep palmar arch, median nerve, superficial palmar arch, ulnar nerve


How to cite this article:
Kastamoni Y, Anil A, Peker T, Anil F. Evaluation of vascular and neural anatomy of the hand in adult cadavers. J Anat Soc India 2020;69:171-7

How to cite this URL:
Kastamoni Y, Anil A, Peker T, Anil F. Evaluation of vascular and neural anatomy of the hand in adult cadavers. J Anat Soc India [serial online] 2020 [cited 2020 Oct 20];69:171-7. Available from: https://www.jasi.org.in/text.asp?2020/69/3/171/296910




  Introduction Top


The hand plays an important role in the daily life of humans. The hand enables us to position, orient, and grasp objects by touching them and provides our communication with the outside world.[1] In addition to the innervation of the hand and hand-related structures, which take such an essential place in our lives, its nutrition is also vital.

The superficial palmar arch (SPA) and deep palmar arch (DPA), which are formed by the ulnar artery (UA) and radial artery (RA), are the structures feeding the hand.[2] Most of the studies on the SPA have been performed by the anatomical dissection method.[3],[4],[5] Furthermore, there are also studies conducted with angiography [6],[7] and Doppler-ultrasonography [8] methods. In our literature review, few studies on the DPA were encountered.[3],[4],[9] In the Turkish population, there are few studies using the anatomical dissection method concerning the SPA [10],[11] and DPA.[12]

The extrinsic and intrinsic muscles of the hand provide hand movements. The extrinsic muscles of the hand are innervated by the radial nerve (RN), ulnar nerve (UN), and median nerve (MN). The intrinsic muscles of the hand are innervated by the UN and MN.[2] There are many studies on the innervation of the extrinsic muscles [13],[14],[15] and intrinsic muscles [16],[17],[18],[19] of the hand. When the studies on the intrinsic muscles of the hand were examined, it was seen that their dates back to very old times and these studies about the motor innervation of muscles. In our literature review, it was seen that there a few studies about the cutaneous distribution of nerves in the palm.[20],[21],[22] However, no studies about typing these nerves according to the distribution of fingers were found.

This study's goal was to investigate the normal anatomy and variations of the vascular and neural structures of the hand by examining the hands of adult cadavers by the anatomical dissection method.


  Material and Methods Top


Twenty adult cadaver hands, which had been previously fixed in a 10% formaldehyde solution, were examined by the anatomical dissection method. Approval was obtained from the Clinical Research Ethics Committee for this study (Date: October 26, 2015, Decision No: 40).

Dissections were performed under a surgical microscope (Carl Zeiss Opmi Pico, Germany) at × 5 magnification. To remove the skin of each hand, two transverse incisions passing through the wrist fold and finger roots and a vertical incision joining the midpoint of these two incisions were made. After the skin was removed, subcutaneous adipose tissue was cleaned, and the palmar aponeurosis was removed.

Firstly, the presence of the SPA and whether it was a complete arch (complete/incomplete) in case of its presence were evaluated. If the SPA was formed by the UA and superficial palmar branch of the RA, it was evaluated as the “complete” SPA. If it was formed only by the UA, it was evaluated as the “incomplete” SPA. However, according to the definitions in the literature,[3],[4] the SPA formed only by the UA was included in the “complete” SPA category if it reached the first interosseous space. Furthermore, in our study, the number of the common palmar digital arteries emerging from the SPA and the interosseal space of each of these branches were determined. After the measurements of the SPA were completed, the number of branches from the MN and UN, and the interosseal space of each of these branches were recorded. According to the data obtained, the SPA, UN, and MN were classified.

After these procedures, the SPA, UN, and MN were cut from the wrist fold and lifted toward the fingers. The lumbrical muscles and flexor muscle tendons were removed. The DPA was defined, and the number of the metacarpal palmar arteries emerging from the DPA and the interosseal space of these branches were determined. Then, the DPA was classified according to the data obtained.


  Results Top


All of our samples had the SPA. Of the samples, 90% (n = 18) had the “complete” SPA and 10% (n = 2) had the “incomplete” SPA. When the “complete” SPAs were examined, it was revealed that the arch was formed by the UA and superficial palmar branch of the RA (radio-ulnar type) in 83.33% (n = 15) of the samples and only by the UA (ulnar type) in 16.67% (n = 3) of the samples.

When the number of the common palmar digital arteries emerging from the SPA was examined, four branches were observed to emerge from the arch in 80% (n = 16), and five branches emerged from the arch in 20% (n = 4) of the samples. It was detected that 65% (n = 13) of the first branch emerging from the arch ran medially in hand, and 35% (n = 7) ran in the fourth interosseous space. Of the second branch emerging from the arch, 55% (n = 11) was observed to run in the fourth interosseous space and 45% (n = 9) in the third interosseous space. Of the third branch emerging from the arch, 55% (n = 11) was determined to run in the third interosseous space and 45% (n = 9) in the second interosseous space. Of the fourth branch emerging from the arch, 55% (n = 11) was observed to run in the second interosseous space and 45% (n = 9) in the first interosseous space. In the four samples in which the fifth branch emerged, the whole branch was found to run in the first interosseous space.

While classifying the SPA, whether the arch is “complete” or “incomplete,” the type of arteries that formed the arch (radio-ulnar type, ulnar type), the number of the common palmar digital arteries given off by the arch, and the course of these branches were taken into consideration, and the arch was gathered under seven main groups [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5].
Figure 1: Schematic classification of the “complete” superficial palmar arch. UA: Ulnar artery, RA: Radial artery, * common palmar digital artery

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Figure 2: Schematic classification of the “incomplete” superficial palmar arch. UA: Ulnar artery, RA: Radial artery, * common palmar digital artery

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Figure 3: Types of the “complete” superficial palmar arch that gives off four branches. (a) Type I, (b) Type II, (c) Type III. UA: Ulnar artery, RA: Radial artery, * common palmar digital artery

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Figure 4: Types of the “complete” superficial palmar arch that gives off five branches. (a) Type IV, (b) Type V. UA: Ulnar artery, RA: Radial artery, * common palmar digital artery

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Figure 5: Types of the “incomplete” superficial palmar arch. (a) Type VI, (b) Type VII. UA: Ulnar artery, RA: Radial artery, * common palmar digital artery

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When the innervation of the MN and UN was evaluated, 3.5 + 1.5 fingers innervation was observed in 90% (n = 18), 3 + 1.5 fingers innervation was observed in 5% (n = 1), and 3 + 2 fingers innervation was observed in 5% (n = 1) of the samples.

When 18 samples with 3.5 + 1.5 fingers innervation were examined, the MN was determined to be separated into four branches at the terminal in 94.44% (n = 17) and into five branches in 5.56% (n = 1) of the samples. In the samples in which the MN was separated into four branches, the first branch was observed to course laterally in the hand, the second branch coursed in the first interosseous space, the third branch coursed in the second interosseous space, and the fourth branch coursed in the third interosseous space. In the sample in which the MN was separated into five branches at the terminal, the first branch was observed to run laterally in the hand. The second branch was determined to run in the first interosseous space and innervate the thumb medial. The third branch was determined to run in the first interosseous space, but innervate the lateral of the second finger. The fourth branch emerging from the MN was observed to run in the second interosseous space, and the fifth branch ran in the third interosseous space. In all of the 18 samples with 3.5 + 1.5 fingers innervation, the UN was separated into two branches at the terminal. The first branch emerging from the nerve was observed to course in the fourth interosseous space, and the second branch coursed medially in the hand [Figure 6] and [Figure 7].
Figure 6: Schematic classification of the median nerve and ulnar nerve. MN: Median nerve, UN: Ulnar nerve, * terminal branches of the nerves

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Figure 7: Types of the nerves on the hand with 3.5 + 1.5 finger innervation. (a) Type I, (b) Type II. MN: Median nerve, UN: Ulnar nerve, * terminal branches of the nerves

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When the sample with 3 + 1.5 fingers innervation was examined, the MN was determined to be separated into three branches at the terminal. The first one of these branches was observed to course in the first interosseous space, the second branch coursed in the second interosseous space, and the third branch coursed in the third interosseous space. In this sample on the right side, it was noted that there were no branches on the lateral side of the thumb. In the same sample, the UN was observed to be separated into two branches at the terminal. The first branch emerging from the UN was observed to course in the fourth interosseous space, and the second branch coursed medially in hand [Figure 6] and [Figure 8].
Figure 8: (a) Type of the nerves on the hand with 3 + 1.5 finger innervation, Type III. (b) Type of the nerves on the hand with 3 + 2 finger innervation, Type IV. MN: Median nerve, UN: Ulnar nerve, * terminal branches of the nerves

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When the sample with 3 + 2 fingers innervation was examined, the MN was observed to be separated again into four branches. However, when their courses were examined, the branch, which coursed in the third interosseous space, was observed to innervate only the medial of the third finger, i.e., not to innervate the lateral of the 4th finger. The other branches of the MN coursed normally. In this sample, two branches were determined to emerge from the UN. The first one of these branches was observed to run in the fourth interosseous space, and the second branch ran medially in hand. The branch in the fourth interosseous space was determined to be separated into two at the terminal. It was determined that one of these branches innervated the lateral of the fourth finger, the other one continued to run in the fourth interosseous space and innervated the medial of the fourth finger and the lateral of the fifth finger [Figure 6] and [Figure 8].

The MN and UN were classified by considering the distribution of the nerves, the number of branches into which these nerves were separated at the terminal, and the course of these branches. Accordingly, the nerves were gathered under four main groups [Figure 6] and [Figure 8].

When the DPA samples were examined, four metacarpal palmar arteries were observed to emerge from the arch in all of the samples. It was found that 100% (n = 20) of the first branch ran in the first interosseous space, 95% (n = 9) of the second branch ran in the second interosseous space, and 5% (n = 1) ran in the third interosseous space. Of the third branch emerging from the arch, 95% (n = 19) was observed to run in the third interosseous space and 5% (n = 1) ran in the fourth interosseous space. Of the fourth branch, 90% (n = 18) was observed to run in the fourth interosseous space, and 10% (n = 2) ran medially in hand.

The DPA was classified according to the number of the metacarpal palmar arteries given off by the arch and the course of these branches. Accordingly, the DPA was gathered under three main groups [Figure 9] and [Figure 10].
Figure 9: Schematic classification of the deep palmar arch. UA: Ulnar artery, RA: Radial artery, * metacarpal palmar artery

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Figure 10: Types of the deep palmar arch. (a) Type I, (b) Type II, (c) Type III. UA: Ulnar artery, RA: Radial artery, *metacarpal palmar artery

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The frequency and distribution of the SPA types in the right and left hands are presented in [Table 1], the frequency and distribution of the MN and UN types in the right and left hands are presented in [Table 2], and the frequency and distribution of the DPA types in the right and left hands are presented in [Table 3].
Table 1: Frequency of the superficial palmar arch types and their distribution in the right and left hands, n (%)

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Table 2: Frequency of the median nerve and ulnar nerve types and their distribution in the right and left hands, n (%)

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Table 3: Frequency of the deep palmar arch types and their distribution in the right and left hands, n (%)

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  Discussion Top


The vascular structure of the hand, which is a highly complex area, has been investigated in many studies to date. Especially with advances in microsurgery, the vascular structure of the hand has become even more important in reconstructive hand surgery.[10]

The incidence and variations of the SPA were first defined in the 19th century. In 1897, Jaschtschinski described the “complete” and “incomplete” arch together with its different subtypes. Jaschtschinski separated the “complete” SPA into subtypes as the radio-ulnar arch, median-ulnar arch, radio-median-ulnar arch, and ulnar arch.[23]

The SPA and the frequency of its being complete/incomplete are presented in [Table 4].
Table 4: The superficial palmar arch and frequency of its being complete/incomplete in the literature

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Upon examining [Table 4], the results obtained from our study were observed to be consistent with the general average. Moreover, according to the table, the results varied in a wide range. For example, the presence of the “complete” SPA ranged between 45.23% and 95%. We think that this variability may be due to differences, such as ethnicity, gender, the number of samples, study method, and classification.

The studies conducted on the classification of the arch according to the arteries that form the “complete” SPA and their results are presented in [Table 5].
Table 5: Classification of the arch according to the arteries forming the “complete” superficial palmar arch in the literature

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When [Table 5] was examined, the “complete” SPA was detected to be usually formed by the UA and superficial palmar branch of the RA (radio-ulnar type). This was followed by the ulnar type (the formation of the SPA only by the UA). Only in the studies conducted by Singh et al. and Joshi et al.,[4],[24] the ulnar type was found to be more common than the radio-ulnar type. In the studies carried out, the radio-ulnar-median type (the SPA is formed by the UA, the superficial palmar branch of the RA and persistent median artery) was encountered at the lowest rate. When these results were evaluated in terms of types, our study was observed to bear similarities with other studies.

In the studies in [Table 5], it was determined that the SPA was classified according to whether it was complete/incomplete and the type of the arteries forming the arch. However, in our study, in addition to these data, the classification was made by also considering the number of the common palmar digital arteries leaving the arch and the course of these branches [Figure 1] and [Figure 2].

The SPA plays an essential role in microsurgery after hand injuries. The collateral circulation of the hand continues even if any artery in the hand is occluded. Plastic surgeons and hand surgeons should know the normal anatomy and variations of these arteries well before performing surgical procedures such as vascular repair and grafting. Since our study was carried out by considering more data on classification, we believe that our study will constitute a basis for future studies and will shed light on surgical procedures.

Although there are various studies on the sensory innervation of the hand in the literature,[21],[29],[30] there are no studies involving the classification of nerve distribution according to fingers. In our study, the samples were evaluated for innervation by considering the distribution of the MN and UN in hand. Accordingly, 3.5 + 1.5 fingers innervation was observed in 90%, 3 + 1.5 fingers innervation was observed in 5% of the samples, and 3 + 2 fingers innervation was observed in the remaining 5%.

In this study, which we performed by the anatomical dissection method, the MN and UN were classified by considering the distribution of the nerves, the number of branches into which the nerves were separated at the terminal, and the course of these branches [Figure 6]. Our study may be a basic study on this subject. The anatomical dissection method is also known to provide more reliable and accurate results than imaging methods. Therefore, we believe that our study will help to identify and distinguish structures in neurology clinics, neurosurgery, orthopedics, plastic, reconstructive and aesthetic surgery and will provide a basis for studies on the subject.

While there are many studies related to DPA in the literature review,[3],[4],[9] this number is very low when the Turkish population is examined.[12]

In the study conducted by Loukas et al.,[3] the DPA was separated into three types according to the arteries forming the arch. According to this study, if the DPA was formed by the RA and inferior deep palmar branch of the UA, it was defined as “type D-I.” If it was formed by the RA and superior deep palmar branch of the UA, it was defined as “type D-II.” If it was formed by the RA and both deep palmar branches of the UA, it was defined as “type D-III.” In the study, type D-I was found at a rate of 60% (n = 120), type D-II was found at a rate of 30% (n = 60), and type D-III was found at a rate of 10% (n = 20).

In the study performed by Singh et al.,[4] the DPA was separated into five types according to the arteries forming the arch. According to this study, if the DPA was formed by the RA and deep palmar branch of the UA, it was defined as “type G.” If it was formed by the RA, deep palmar branch of the UA and interosseous artery, it was defined as “type H.” If the deep palmar branch of the UA was separated into superior and inferior branches and formed an arch with the RA, it was defined as “type I.” If the deep palmar branch of the UA was separated into superior and inferior branches, and one of these branches formed an arch with the RA, it was defined as “type J.” If the interosseous artery also joined the combination in type “J” and formed an anastomosis with either the arch or the branch of the additional UA, it was defined as “type K.” In the study, type G was found at a rate of 72% (n = 72), type H at a rate of 12% (n = 12), type I at a rate of 8% (n = 8), type J at a rate of 4% (n = 4) and type K was found at a rate of 4% (n = 4).

In both studies, the DPA was observed to be classified according to whether the arch was complete/incomplete and the type of the arteries forming the arch.[3],[4] In our study, during classification, as in the SPA, in addition to the data mentioned above, the number of the metacarpal palmar arteries given off by the arch and the course of these branches were also taken into consideration [Figure 9].

There are some limitations of this study since a smaller number of samples. However, in our study, unlike previous studies, more information was given, especially in terms of the course of the branches given by the arches and nerves and typing was made according to the course of these branches.


  Conclusions Top


Understanding the anatomical structure and variations of the arteries and nerves of the hand is particularly important during the surgical reconstruction of the hand in hand injuries. It is known that the lack of knowledge about the anatomy of the palmar region increases the risk of complications during surgical procedures applied to this region. We think that the data obtained on the vascular and neural anatomy of the hand in our study will be included, especially in anatomy education. At the same time, while determining pathologies and variations related to the structures, these data will contribute to the diagnosis and treatment in orthopedics, surgery, radiology and neurology clinics, and other science branches. Thus, it will guide anatomists and other scientists in studies on the subject.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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