Superficial ulnar artery: Curse or blessing in harvesting fasciocutaneous forearm flaps

Superficial ulnar artery diagnosed by vascular ultrasound: case report

The largest branch of the terminal division of the brachial artery is the ulnar artery, which arises after the cubital fossa. This artery usually has a deep path in the muscles of the anterior forearm and is responsible for vascularization of the superficial and deep musculature on the ulnar side of the forearm and hypothenar area of the hand. We report an anatomical variant diagnosed by Doppler ultrasound in which the ulnar artery had a superficial position in the forearm. Occurrence of a superficial ulnar artery is rare, but it is an important fact for clinicians, surgeons, and nursing professionals.

Isolated Ulnar Artery Injury: Indications for and Timing of Operative Intervention

Background. Penetrating ulnar artery injury at the wrist is typically treated with immediate operative repair. This study reports a missed iatrogenic ulnar artery injury that resulted in the development of an ulnar artery pseudoaneurysm that was later managed with elective operative repair. The diagnosis and treatment of distal upper extremity pseudoaneurysms and the approach to suspected ulnar artery injury are discussed. Suspected isolated ulnar artery injuries without hard signs of bleeding can be managed with close follow-up and elective repair, should complications such as pseudoaneurysm occur.

An unusual topographic relationship between high origin of superficial ulnar artery and bitendinous palmaris longus

The ulnar artery usually arises from the brachial artery at the cubital fossa. It descends beneath the flexor carpi ulnaris in the forearm and then terminates at the wrist joint by forming the superficial palmar arch with the contributory radial artery. In the present study, we report a more proximal origin of ulnar artery presenting a superficial course in the lower portion of the upper extremity, termed superficial ulnar artery. Interestingly, this artery lies superficially to a bitendinous palmaris longus, a variant muscle in the forearm. The relation between arterial and muscular variations may be useful during clinical procedures such as angiography, forearm flap and tendon grafting as well as avoiding accidental intra-arterial injection.

Upper limb principal arteries variations: A cadaveric study with terminological implication

Although the variability of the upper limb arteries is a clinically important problem, the prevalence is varying across the existing studies and classification is rather complicated, not well established and sometimes even unclear for simple and direct understanding and usage. Multiple case reports appearing in the last years apply incorrect, inappropriate, and sometimes misleading terminology. We performed an anatomical cadaveric study of the variability of the arteries of the upper limb, namely, the axilla, arm, and forearm, in 423 upper limbs embalmed with classical formaldehyde method (Central European population). We proposed to apply the Equality system based on the common trunks for denomination of the axillary artery branches principal variations: Truncus subscapulocircumflexus (22.9%), truncus profundocircumflexus (13.75%), and truncus bicircumflexus (13.95%). Further, we proposed the terminology system developed by Rodríguez-Niedenführ et al. for the free upper limb principal arterial trunk variations based on the origin, location (in the arm only, or in the arm and forearm), and course (related to the forearm flexor muscles) of the involved artery: Arteria brachialis superficialis (9.5%), arteria brachioradialis superficialis (6.4%), arteria brachioulnaris superficialis (1.9%), arteria brachiomediana superficialis (0.5%), and arteria comitans nervi mediani manus (3.3%). Extensive development of the catheterization methods via the arteria radialis et ulnaris as well as surgical procedures using flaps based on perforating branches of these arteries (including arteria brachioradialis superficialis et brachioulnaris superficialis) necessitate thorough data on prevalence of the variant vessels for safe performance of these procedures to prevent any unexpected situations or to react adequately in such.

Branches of ulnar artery in human fetuses: anatomical and morphometric study

PURPOSE

This study was conducted to demonstrate morphological pattern of the ulnar artery and to evaluate morphometrically its anatomical branching pattern in human fetuses.

METHODS

Branching pattern of ulnar artery was evaluated on 121 upper limbs of dissected 63 of formalin-fixed fetus cadavers with gestational age ranging from 17 to 40 weeks. In order to obtain second and third trimester data, according to their gestational age, two groups were determined.

RESULTS

In 79 of all 121 upper limbs (65%) ulnar artery gave anterior and posterior ulnar recurrent arteries as separate branches. In this study frequency of presence of a median artery was 46.28% among total examined 121 upper limbs. Median arteries originated from ulnar artery (3.57%) and from the common interosseous artery (53.57%) and anterior interosseous artery (42.85%). Mean distances of the measured parameters were demonstrated according to the gestational age and differences between group I (second trimester) and group II (third trimester). No statistical difference for groups was observed for gender and between right and left sides.

CONCLUSIONS

Ulnar artery shows predictable patterns during second and third trimester of fetal period and can be suitable access effective alternative for diagnostic and therapeutic coronary interventions. Persistent median artery is important variation and knowledge of its incidence is important for diagnostic difficulties and also during awareness of its injury during surgical approaches.

Superficial Ulnar Artery Crossing Over the Palmaris Longus Tendon at the Wrist in a Cadaver: A Case Report

Superficial ulnar artery (SUA) is defined as arterial variation of an ulnar artery of high origin that lies superficially in the forearm. Because an SUA may be mistaken for a superficial vein, there is a risk of arterial damage. During routine dissection of the cadaver, we incidentally detected a case of unilateral SUA in the left arm. SUA arose from the axillary artery and descended superficial to the axillary artery and median nerve. At the wrist, the SUA crossed over palmaris longus (PL) tendon from the radial side to the ulnar side. In this cadaver, the PL tendon was located on the ulnar side and was thicker than the flexor carpi radialis tendon. Clinicians should check for the presence of SUA before any technical procedure, because lack of awareness of its presence can have serious consequences.

Anomalous Radial Artery as an Incidental Finding During a Routine Carpal Tunnel Release

BACKGROUND

Compression of the median nerve at the wrist, or carpal tunnel syndrome, is the most commonly recognized nerve entrapment syndrome. Carpal tunnel syndrome is usually caused by compression of the median nerve due to synovial swelling, tumor, or anomalous anatomical structure within the carpal tunnel.

METHODS

During a routine carpal tunnel decompression, a large vessel was identified within the carpal tunnel.

RESULTS

The large vessel was the radial artery. It ran along the radial aspect of the carpal tunnel just adjacent to the median nerve.

CONCLUSIONS

The unusual presence of the radial artery within the carpal tunnel could be a contributing factor to the development of carpal tunnel syndrome. In this case, after surgical carpal tunnel release, all symptoms of carpal tunnel syndrome resolved.

Variations in the Anatomical Structures of the Guyon Canal

BACKGROUND

Compression neuropathy of the ulnar nerve at the Guyon canal is commonly seen by hand surgeons. Different anatomical variations of structures related to the Guyon canal have been reported in the literature. A thorough knowledge of the normal contents and possible variations is essential during surgery and exploration.

OBJECTIVES

To review the recognized anatomical variations within and around the Guyon canal.

METHODS

This study is a narrative review in which relevant papers, clinical studies, and anatomical studies were selected by searching electronic databases (PubMed and EMBASE). Extensive manual review of references of the included studies was performed. We also describe a case report of an aberrant muscle crossing the Guyon canal.

RESULTS

This study identified several variations in the anatomical structures of the Guyon canal reported in the literature. Variations of the ulnar nerve involved its course, branching pattern, deep motor branch, superficial sensory branch, dorsal cutaneous branch, and the communication with the median nerve. Ulnar artery variations involved its course, branching pattern, the superficial ulnar artery, and the dorsal perforating artery. Aberrant muscles crossing the Guyon canal were found to originate from the antebrachial fascia, pisiform bone, flexor retinaculum, the tendon of palmaris longus, flexor carpi ulnaris, or flexor carpi radialis; these muscles usually fuse with the hypothenar group.

CONCLUSION

The diverse variations of the contents of the Guyon canal were adequately described in the literature. Taking these variations into consideration is important in preventing clinical misinterpretation and avoiding potential surgical complications.

Superficial ulnar artery perforator flap

Superficial ulnar artery is a rare finding but shows significant surgical implications. Its thinness and pliability make this flap an excellent solution for soft tissue reconstruction, especially in the head and neck region. We hereby report a successful free superficial ulnar artery perforator forearm flap transfer for tongue reconstruction. A 64-year-old man presenting with a squamous cell carcinoma of the left tongue underwent a wide resection of the tumor, left radical neck dissection, and reconstruction of the tongue and the left tonsillar pillar with the mentioned flap. No complications were observed postoperatively. The flap survived completely; no recurrence at 6 months of follow-up was detected. Superficial ulnar artery perforator flap has shown to be a safe alternative to other free tissue flaps in specific forearm anatomic conditions.

[Superficial ulnar artery while harvesting a radial forearm flap]

Forearm vascular anatomical variations are common and may have complications during flaps harvesting. This article describes the presence of an ulnar superficial artery, revealed while harvesting a radial forearm flap. The prevalence of this anatomical variation is between 0.7 and 9.4%. It may have important consequences while covering loss of substance with a radial forearm flap. Unknown, there is a risk of vascular injury which may lead to distal ischemia of the upper limb. Preoperative diagnosis can anticipate this risk and harvest a fascio-cutaneous flap centered on a perforator of this artery.

Ulnar forearm free flaps in head and neck reconstruction: systematic review of the literature and a case report

OBJECTIVE

Under the assumption that the ulnar artery is the predominant blood supply to the hand, radial forearm free flaps (RFFF) generally have been preferred over ulnar forearm free flaps (UFFF) in head and neck reconstruction. The objective of this study is to create the first and only systematic review of the literature regarding UFFF in head and neck reconstruction, assessing the usage, morbidity, complications, and rationale of its use.

METHODS

A systematic review of the literature was conducted using PubMed, including Mesh terms and manual searches. Articles not in English were excluded.

RESULTS

Seventeen articles of the 80 articles identified by our search criteria met inclusion criteria; a total of 682 cases of UFFF were identified, including our patient case. Fifty-five percent of the cases involved use of the Allen's test. Mean flap size was 6.1 × 10.5 cm. Of the 432 cases reporting flap survival, 14 (3.2%) flap losses were reported, 13 total (3.0%), and one partial (0.2%). The UFFF was preferred to the RFFF due to decreased hirsutism (61%), better cosmetic outcomes (91%), and better post-operative hand function with reduced donor site morbidity (73%). For the case report, an UFFF was used successfully for lid reconstruction and resurfacing in a 72-year-old man who presented with late ectropion and exposure keratopathy following maxillary resection for leiomyosarcoma.

CONCLUSIONS

This is the first and only systematic review of the literature to date of UFFF in head and neck reconstruction. Our review demonstrates that the UFFF rarely results in flap loss, donor site morbidity, or hand ischemia, instead providing enhanced outcomes. With its many surgeon-perceived advantages and minimal morbidity, the UFFF may become a preferred forearm flap for head and neck reconstruction.

Superficial ulnar artery: a contraindication to radial forearm free tissue transfer

OBJECTIVES

Superficial ulnar artery is a vascular anomaly that may be encountered during elevation of forearm flaps for head and neck reconstruction. This anomaly should be considered in patients with a positive Allen's test.

STUDY DESIGN

Case report and retrospective review of forearm flaps performed at our institution.

METHODS

A 72-year-old man with a history of total laryngectomy presented for closure of a pharyngocutaneous fistula with radial forearm flap. A positive Allen's test and undetectable Doppler over the thenar eminence with radial artery occlusion was noted. An ulnar flap was felt to be the best alternative. A superficial ulnar artery was discovered upon elevation of the ulnar flap. Despite its anomalous course, the artery provided several fasciocutaneous branches, and the flap was successfully used to repair the patient's fistula. A retrospective review of forearm flaps and the incidence of superficial ulnar artery at our institution is presented.

RESULTS

A total of 690 forearm flaps (571 radial, 51 ulnar, and 68 osteocutaneous radial) were performed from 1998 to 2010. Superficial ulnar artery was encountered three times, yielding an incidence of 0.43%. In each case, the preoperative Allen's test suggested a dominant radial artery circulation. In all cases, a fasciocutaneous ulnar flap was successfully used.

CONCLUSIONS

Superficial ulnar artery should be considered with a positive Allen's test. An ulnar fasciocutaneous flap based on the superficial ulnar artery is a safe alternative to the radial fasciocutaneous flap in this setting.

Anatomical variations of the carpal tunnel structures

There are many anatomical variations in and around the carpal tunnel that affect the nerves, tendons and arteries in this area. Awareness of these variations is important both during the clinical examination and during carpal tunnel release. The purpose of the present review is to highlight recognized anatomical variations within the carpal tunnel including variation in nerve anatomy, tendon anatomical variants, vascular anatomical variations and muscle anatomical variations.

The superficial ulnar artery: Incidence and calibre in 95 cadaveric specimens

The superficial ulnar artery (SUA) is an anatomical variation of the upper limb vasculature with a prevalence of 0.7-9.4% in the population. The importance of this variant is that it may be cannulated inadvertently by an unsuspecting physician, leading to possible ischemia of the hand. With the growing use of radial forearm flaps, the surgeon needs to be aware of its presence during surgery and be able to adapt the procedure accordingly. The aims of the study focus on the incidence and calibre of the SUA. Ninety-five cadaveric limbs were dissected and the calibre of the different arteries measured. Four SUAs (4.2%) were found, all in male cadavers. Two of these were from the same cadaver. Measurements of the calibre of the vessels showed that the SUA was smaller than the ulnar artery. Of the limbs dissected, 4.2% had an SUA, which is a similar prevalence to other studies in Western Europe. It is most commonly found in males, unilaterally and in the right upper limb. It is extremely rare to experience consequences from intra-arterial cannulation and the SUA may have more of a beneficial role in reconstructive fasciocutaneous forearm flaps.