the carpal tunnel. Clin Anat 1:23–31, 1988.
Distal Branching of the Median Nerve
Distal branching of the median nerve is a pattern where the
recurrent motor branch leaves the median nerve more distally in the palm, distal to the carpal tunnel. The nerve
branch then loops back proximally to reach the thenar muscles, extending in a retrograde fashion.
Recurrent Motor Branch Arising from the Ulnar
Aspect of the Median Nerve
The recurrent motor branch arises in or distal to the carpal
tunnel, but the branch point usually is on the ulnar aspect
of the median nerve trunk. In addition, the motor branch
can arise from the central, anterior surface of the median
nerve, then pass ulnarly and distally until it clears the transverse carpal ligament, where it turns and passes radially and
somewhat retrograde over the ligament to reach the thenar
muscle mass (36,150). A variation of this anomaly was
reported by Papathanassiou, who noted one clinical case
and one dissection specimen in which the motor branch
arose from the ulnar, anterior aspect of the radial division of
the median nerve (149). This anomaly was found in 16 of
20 dissections by Mumford et al. (134). The anomaly also
was encountered once by Lanz (138,146).
Ulnar-sided Exit of the Recurrent Motor Branch with
Hypertrophy of the Flexor Pollicis Brevis or Palmaris
Brevis
An associated concomitant hypertrophy of the flexor pollicis brevis or palmaris brevis has been noted to occur commonly with the aberrant origin of the recurrent motor
branch arising from the ulnar side of the nerve rather than
from the radial aspect (150). The hypertrophied flexor pollicis brevis lies anterior to the flexor retinaculum. Spinner
emphasizes that when this muscle variant is found, it is safer
to identify the median nerve in the carpal tunnel, and locate
the motor branch by opening the carpal tunnel on the
medial side. The motor branch can then be traced distally
as it recurs through the superficial hypertrophied muscle
(6,150).
Recurrent Motor Branch Arising Anteriorly
Recurrent motor branch can arise anteriorly, then pass
over the surface of the transverse carpal ligament. The
recurrent motor branch arises in the carpal tunnel, more
proximally than normal, originating from the palmar
aspect of the nerve. The nerve extends distally, around the
distal edge of the transverse carpal ligament, and loops
back proximally to reach the thenar muscles in a retrograde fashion.
Recurrent Motor Branch and Median Nerve Passing
Anterior to the Transverse Carpal Ligament
A rare pattern noted by Sunderland involves the entire
median nerve passing superficial to the transverse carpal ligament (44).
Absence of the Recurrent Motor Branch to the Thenar
Muscles
Complete absence of the recurrent motor branch to the
thenar muscles has been described (6,41,140). This is
observed in the all-ulnar hand, in which all of the thenar
muscles are innervated by the ulnar nerve through various
communicating branches (41,140).
High Division of the Median Nerve (Bifid Median
Nerve)
Branching of the median nerve proximal to the wrist is well
described, and often presents as a bifid median nerve
(135,141,144). The bifid median nerve can be discovered
in the carpal canal during carpal tunnel release or in the
forearm during operative exploration (138,141,144,146).
There usually is a larger, more radial component and a
smaller ulnar component that travels parallel to the larger
component.
This anomaly has been described by Gruber, who noted
four cases in which the median nerve branch to the third
web space originated in the proximal forearm. Amadio
found high branching of the median nerve in 3% of cases
(70). Hartmann and Winkelman and Spinner also have
reported high branching of the median nerve in the forearm
(71,72). In most of the cases studied by Amadio, the bifid
median nerve had two branches that remained independent
of one another. However, two of nine cases had a loop communication in which one or the other median nerve branch
received a communicating branch from the other in or just
distal to the carpal canal (70). This communicating loop
also was noted in 3 of 29 cases reported in the literature at
the time of Amadio’s study (70).
A median artery also may be present with the bifid
median nerve. The median artery is an anomalous artery
that is a persistent extension of the anterior interosseous
artery. The median artery can result from persistence of an
embryonic artery known as the forearm axis artery.
Anomalous muscles such as aberrant flexor digitorum
superficialis or lumbricals also have been associated with a
high division of the median nerve.
Riche-Cannieu Anastomosis
Nerve communication between the median nerve recurrent
motor branch and the ulnar nerve deep branch is referred to
as a Riche-Cannieu communication or anastomosis. In 1897,
Riche and Cannieu independently described a connection
between these nerves occurring between the fibers of the
median nerve recurrent motor branch traveling to the superficial head of the flexor pollicis brevis and the fibers of the
deep ulnar branch going to the deep head of the flexor pollicis brevis (151,152). Mannerfelt drew additional attention to
this important anastomosis (46,150). The communicating
fibers pass radially from the deep ulnar branch between the
heads of the adductor pollicis, then pass deep to the flexor
3 Nerve Anatomy 197
pollicis longus tendon. The fibers continue proximally to
the radial side of the flexor pollicis longus tendon as they
approach the median nerve recurrent motor branch. This
communication was found in 77% of cadaver specimens
studied, and was found in virtually all fresh cadaver hands
(153). Riche described two other anatomic median–ulnar
nerve communications. In one, the communication
occurred between a thumb digital nerve (derived from the
median nerve) and fibers en route to the adductor pollicis
(derived from the deep ulnar nerve branch). The communicating fibers were found in the adductor muscle on the
medial side of the flexor pollicis longus tendon. In another
pattern, the communicating fibers passed through the first
lumbrical, which was innervated by the ulnar nerve
(36,152). It is now assumed that the Riche-Cannieu connection usually carries motor fibers only (36,150,153),
although early investigators thought it carried sensory
fibers (154). Foerster, as a result of war-injury studies, and
Harness and Sekeles, as a result of anatomic dissections,
believed that the anastomosis was of the motor type
(153,155,156). Because Harness and Sekeles found that
most of the preserved specimens studied (77%) and virtually all of the fresh specimens contained the Riche-Cannieu
communication, they concluded that this nerve anastomosis is common and normal, and may represent the more
usual innervation pattern of the thenar muscles (153).
Additional clinical and electromyographic studies have
supported this consideration (36,153). However, Mannerfelt has noted that the nature (sensory, motor, or mixed),
incidence, and direction of the fiber passage (i.e., median
to ulnar nerve, or ulnar to median nerve) remain unresolved (36,150). Either way, the communication provides
a potential pathway for double innervation of the intrinsic
muscles anywhere in the hand. A variation of the RicheCannieu anastomosis has been noted by Harness and Sekeles and by Hovelacque, in which a branch from the deep
ulnar nerve communicates with a thumb digital nerve.
This presents the possibility that median motor fibers destined for the thenar muscles were traveling in the digital
nerve (36,157).
Basic Patterns of the Riche-Cannieu
Anastomosis
Spinner has summarized the basic patterns of the RicheCannieu anastomosis (6):
n An anastomosis in the substance of the adductor pollicis
between the median and ulnar nerves
n A communicating branch from the motor branch of the
median nerve coursing anterior to the radial head of the
flexor pollicis brevis and the ulnar component passing
deep to the ulnar head of this muscle
n Anastomosis between the two motor nerves across the
first lumbrical
n Anastomosis between the branch of the deep ulnar nerve
to the adductor pollicis or flexor pollicis brevis and the
median nerve digital branch to the thumb or index finger
Palmar Ulnar–Median Communicating Branch
of Berrettini
As noted previously, the Riche-Cannieu anastomosis usually carries motor fibers and occurs in the region of the
adductor pollicis and thenar muscles. However, a distal
communicating branch between the ulnar and median
sensory nerves is not uncommon; in fact, the presence of
a communicating branch may be the most common (and
normal) nerve pattern. Classically, palmar sensation in the
fingers is described as divided between ulnar and median
nerves at the midline of the ring finger. Berrettini
described and illustrated this communicating branch in
1741 (158). More recently, Meals and Shaner found a
communicating branch between the ulnar and median
nerves in the palm in 40 of 50 dissected specimens. Several studies have confirmed the common presence of this
communicating branch (44,46,52,159). The communicating branch usually passes immediately deep to the
superficial palmar arch; however, in some specimens the
branch courses just distal to the transverse carpal ligament
(70,157).
Innervation of the Lumbricals and Associated
Flexor Digitorum Profundus
In general, the belly of the flexor digitorum profundus of
the index finger and the first lumbrical muscle nearly always
are supplied by branches of the median nerve. However,
innervation of the other flexor digitorum profundus muscle
bellies and their corresponding lumbricals is quite variable.
The lumbrical usually is supplied by the same major nerve
(median or ulnar) that supplies the corresponding belly of
the flexor digitorum profundus. However, in 50% of cases,
there are variations from the classic pattern of innervation
(in which the median nerve innervates the radial two bellies
and the ulnar nerve innervates the ulnar two bellies) (36).
The variation usually involves the median nerve encroaching on the ulnar nerve distribution. However, the ulnar
nerve also can encroach laterally to innervate the long finger belly partially or exclusively (36).
Clinical Correlations: Median Nerve in the
Wrist and Hand
As the median nerve passes through the carpal tunnel, it is
the most palmarly located structure, with the transverse
carpal ligament adjacent to its palmar surface. The median
nerve is therefore at inherent risk for injury during carpal
198 Systems Anatomy
tunnel release. Scarring or adhesions add to the risk of
injury if the median nerve is adherent to the ligament. This
risk is especially significant when repeat or revision carpal
tunnel release is performed (160,161).
Anatomic Aspects of Carpal Tunnel Syndrome
Several causes of carpal tunnel syndrome have been recognized (6,142,160–177). Specific anatomic abnormalities
that can be factors in carpal tunnel syndrome include the
following:
n A palmaris profundus muscle. The palmaris profundus
is a muscle that originates from the radius, ulna, and
interosseous ligament in the forearm, and passes through
the carpal tunnel to insert onto the dorsal surface of the
palmar fascia. It can produce symptoms if its tendon is
large or if the musculotendinous junction extends into
the carpal tunnel (6,127)
n An anomalous flexor digitorum superficialis, especially
that with a muscle belly that extends distally into the
carpal tunnel (178–184)
n Anomalous lumbrical muscles that extend proximally
into the carpal tunnel (185)
n An enlarged, inflamed, thrombosed, or calcified median
artery in the carpal tunnel (186,187)
n A hypertrophied palmaris longus (160)
High Division of the Median Nerve (Bifid
Median Nerve)
The high division of the median nerve results in two
nerves entering the carpal tunnel. This variant can subject
the nerve to potential injury during carpal tunnel release,
especially if one of the two branches is not recognized. An
unrecognized branch is particularly vulnerable during
flexor tenosynovectomy or flexor tendon repair in the
carpal tunnel. Spinner notes that in carpal tunnel syndrome with atypical findings such as sensibility abnormalities isolated only to the third web space or only to the
more lateral aspect of the hand (sparing the third web
space), the examiner should consider the bifid median
nerve as a potential finding (6). Similarly, laceration of the
forearm associated with numbness of the third web space
and its accompanying digital manifestation in the ulnar
half of the long finger and radial half of the ring finger
suggest the occurrence of a bifid median nerve (or perhaps
a partial laceration of a normal median nerve) (6). When
a bifid median nerve is encountered or a median nerve
found with high branches originating in the forearm, special care is required during carpal tunnel release or median
nerve exploration, both for nerve protection and for adequate decompression. Release of the median nerve
branches from separate fascial channels in the transverse
carpal ligament may be needed (36,135).
The Recurrent Motor Branch of the Median
Nerve
The most common pattern of the recurrent branch of the
median nerve is the course where the nerve exits the nerve
trunk distal to the transverse carpal ligament, then curves
back proximally in a retrograde fashion to reach the
thenar muscles. This common pattern also is relatively
safe because the nerve branch does not penetrate or lie
within the ligament that is transected. The presence of
variations in number and patterns of the recurrent branch
of the median nerve should be kept in mind during operative exploration of hand lacerations with loss of thenar
muscle function.
The Transretinacular Pattern
The transretinacular pattern of the recurrent motor branch,
in which the recurrent branch penetrates the transverse
carpal ligament, is the second most common pattern, and is
potentially problematic. The motor branch that travels in
the ligament is at risk for injury when the ligament is transected during carpal tunnel release. Injury to the nerve with
this pattern can be minimized by an appreciation of the
anatomy, as well as by transection of the transverse carpal
ligament carried out toward the ulnar side of the canal.
When the transligamentous pattern is encountered during
carpal tunnel release, the nerve branch should be decompressed throughout its tunnel through the ligament. This
pattern has been thought to be potentially responsible for
carpal tunnel syndrome that presents with more motor or
even pure motor dysfunction, compared with sensory
abnormalities (6,188).
Palmar Ulnar–Median Communicating Branch
of Berrettini
The communicating sensory branch between the ulnar and
median nerves (palmar ulnar–median communicating
branch of Berrettini; see earlier) may course between the
nerves just distal to the transverse carpal ligament
(70,157). It is vulnerable to injury during carpal tunnel
release or palmar exploration for operative procedures such
as flexor tendon repair or partial palmar fasciectomy for
Dupuytren’s contracture, especially along the axis of ring
finger ray (36).
Common and Proper Digital Nerves and
Arteries
During nerve and artery exploration in the palm or digits,
an appreciation of the relationship between the common
and proper digital nerves and arteries is emphasized. In the
palm, the median nerve branches usually are located deep to
the associated arterial structures. These nerve branches pass
3 Nerve Anatomy 199
deep to the superficial palmar arterial arch and usually pass
deep to the common digital arteries as the nerves and arteries course distally. At the approximate level of the
metacarpal necks, the nerves course more palmarly, and
come to lie palmarly at the base and along the digits. In the
digits, the digital nerves are palmar to the digital arteries.
Thus, it is possible (and not uncommon) to encounter a
clinical situation where both digital nerves are lacerated in
the digit, but the digit remains vascularized. The deeperlying arteries are more protected, and can therefore more
often survive penetrating trauma.
All Ulnar Nerve–Innervated Hand
In the all ulnar nerve–innervated hand, there is absence
of a thenar branch from the median nerve. With a complete median nerve laceration at the wrist, operative
exploration reveals only a small median nerve in the
carpal tunnel. The only deficit noted may be loss of sensibility to the palmar aspect of the index finger. The ulnar
nerve provides the remaining motor and sensory fibers
(6).
ULNAR NERVE
Origin of the Ulnar Nerve
The ulnar nerve arises from the medial cord of the brachial
plexus, and is composed of fibers from the anterior rami of
C8, and T1 (1–4,11) (see Fig. 3.1).
Ulnar Nerve in the Axilla and Arm
At the level of the pectoralis minor muscle, the medial
cord divides into two branches. One branch courses
slightly laterally to join a branch from the lateral cord to
form the median nerve. The other branch of the medial
cord continues distally to form the ulnar nerve (see Fig.
3.1). In the axilla and arm, the ulnar nerve remains the
most medially positioned major nerve. In the axilla, the
ulnar nerve is medial and adjacent to the axillary artery.
The axillary vein is located medial to the ulnar nerve. At
the inferior border of the subscapularis muscle, the ulnar
nerve may receive additional fibers of the C7 nerve root
through the “lateral root of the ulnar nerve” (189). This
supplemental nerve arises from either the lateral cord or
middle trunk (8). The ulnar nerve continues distally from
the medial cord deep (posterior) to the pectoralis minor
and pectoralis major and anterior to the subscapularis,
latissimus dorsi, and teres major. Along this course, it
remains medial or posteromedial to the axillary artery and
subsequent brachial artery. At the inferior border of the
pectoralis major, the ulnar nerve continues and diverges
medially from the brachial artery (as the artery courses
slightly anteriorly). The ulnar nerve pierces the medial
intermuscular septum approximately 8 cm proximal to the
medial epicondyle (13). As the nerve passes from the anterior compartment to the posterior compartment through
the medial intermuscular septum, it passes deep to the
arcade of Struthers, if present (see later, under Anomalies
and Variations: Ulnar Nerve in the Axilla and Arm). In
this vicinity, the brachial artery gives off the superior ulnar
collateral artery, which also pierces the medial intermuscular septum and continues distally along with the nerve.
The nerve remains to the medial aspect of the superior
ulnar collateral artery. Both nerve and artery continue distally and medially on the anterior surface of the medial
head of the triceps muscle. The artery is then joined by a
branch of the inferior ulnar collateral artery at the medial
supracondylar ridge. These arteries continue in close proximity to the nerve as the nerve enters the interval between
the medial epicondyle of the humerus and the olecranon.
The nerve passes into the ulnar groove on the dorsal
aspect of the medial epicondyle. The ulnar nerve does not
normally innervate any muscles of the arm, although a
muscular branch to the flexor carpi ulnaris may branch
from the ulnar nerve proper 1 cm proximal to the medial
epicondyle (189) (Table 3.2 and Fig. 3.3).
The Medial Antebrachial Cutaneous Nerve
The medial antebrachial cutaneous nerve (medial cutaneous nerve of the forearm) is a sensory nerve with several
branches that innervates the medial forearm (discussed in
detail later, under Medial Antebrachial Cutaneous Nerve;
Fig. 3.4). It is mentioned here because of its close anatomic
200 Systems Anatomy
TABLE 3.2. ORDER OF INNERVATION OF MUSCLES
SUPPLIED BY THE ULNAR NERVE
Muscle
Flexor carpi ulnaris
Flexor digitorum profundus
Abductor digiti minimi
Flexor digiti minimi
Opponens digiti minimi
Fourth web space interossei
Third web space interossei
Second web space interossei
Fourth lumbrical
Third lumbrical
Adductor pollicis (oblique head)
Adductor pollicis (transverse head)
First web space interosseous
From Sunderland S, Ran LJ. Metrical and non-metrical features of
the muscular branches of the median nerve. J Comp Neurol 85:191,
1946.
3 Nerve Anatomy 201
FIGURE 3.3. Schematic illustration of the ulnar nerve and associated branches and innervated
muscles.
202 Systems Anatomy
FIGURE 3.4. Cutaneous nerves of the upper extremity. A: Anterior aspect.
A
3 Nerve Anatomy 203
FIGURE 3.4 (continued). B: Posterior aspect.
B
proximity to the ulnar nerve. The medial antebrachial cutaneous nerve originates from the lower trunk or medial cord
of the brachial plexus, just proximal to the actual origin of
the ulnar nerve (190). It contains fibers from C8 and T1. In
the axilla, the nerve runs with the ulnar nerve between the
axillary artery and vein. A small branch leaves the nerve to
supply the skin over the biceps muscle and the elbow flexion crease (along with branches of the medial cutaneous
nerve of the arm, discussed in further detail later) (191).
The medial antebrachial cutaneous nerve descends along
the medial surface of the brachial artery. It pierces the antebrachial fascia in the middle third of the arm with the
basilic vein. The nerve divides into anterior and posterior
branches approximately 15 cm proximal to the medial epicondyle. The anterior branch passes anterior to the median
cubital vein between the medial epicondyle and biceps tendon, and innervates the mediopalmar skin of the forearm
(Fig. 3.4A-B). The terminal branches join the palmar cutaneous branches of the ulnar and median nerves in the hand.
The posterior branch of the medial cutaneous nerve of the
forearm often crosses the ulnar nerve from approximately 6
cm distal to the medial epicondyle. It descends along the
medial side of the basilic vein, supplying the dorsomedial
skin of the forearm. Distally, the nerve joins the dorsal cutaneous branch of the ulnar nerve (189,190) (Fig. 3.4A-B).
Anomalies and Variations: Ulnar Nerve in
the Axilla and Arm
The ulnar nerve normally originates from the medial cord
of the brachial plexus. It may, however, receive fibers from
several other sources, including the lateral cord, the middle
trunk, and the anterior division of the middle trunk. These
neural elements are collectively referred to as the lateral root
of the ulnar nerve. The lateral root of the ulnar nerve joins
the ulnar nerve proper at or distal to the inferior border of
the subscapularis muscle. The lateral root nerve fibers may
provide innervation to the flexor carpi ulnaris (8).
Arcade of Struthers
As the ulnar nerve passes from the anterior to the posterior
muscle compartment of the arm, it may encounter a myofibrous or fasciomyofibrous tunnel, the arcade of Struthers.
This common structure, first described by Struthers in
1854 (18), should not be confused with the rare (1%) unrelated anatomic structure, the ligament of Struthers (which
is seen in association with a supracondylar process and can
result in median neuropathy in the arm; see earlier, under
Median Nerve in the Axilla and Arm). The arcade of
Struthers is common, and has been shown to occur in 70%
of specimens (192,193). The arcade of Struthers is a fibrous
or fascial sheet located in the distal third of the medial
aspect of the humerus. When the arm is in the anatomic
position, the roof of the arcade faces medially. It is formed
by a thickening of the deep investing fascia of the distal part
of the arm, by superficial muscular fibers of the medial head
of the triceps, and by attachments of the internal brachial
ligament (6). (The internal brachial ligament is a relatively
long, longitudinal ligament originating from the region of
the coracobrachialis tendon.) The anterior border of the
arcade of Struthers is the medial intermuscular septum. The
lateral border of the arcade is formed by the medial aspect
of the humerus covered by deep muscular fibers of the
medial head of the triceps. Spinner has noted that the presence of the arcade of Struthers should be suspected if, at the
time of operative exposure of the proximal portion of the
ulnar nerve, the muscle fibers of the medial head of the triceps are seen crossing obliquely, superficial to the nerve.
This is in the area where the nerve traverses from the anterior to posterior compartment. When no muscular fibers
can be seen crossing the ulnar nerve approximately 5 to 7
cm proximal to the medial epicondyle, the arcade probably
is not present (193). The arcade of Struthers may be a
potential area of ulnar nerve compression. If decompression
or transposition of the ulnar nerve is performed, awareness
of this structure is important for through decompression.
Compression of the ulnar nerve can occur above the elbow
at the arcade at the level of the medial epicondylar groove,
or distally as the nerve passes between the ulnar and
humeral heads of the flexor carpi ulnaris (17,78,193).
The First Branch
The first branch of the ulnar nerve usually originates in
the cubital tunnel. However, variation in the articular
and first muscular branches is common. The articular
branch, normally the first branch of the nerve, exits from
the main trunk in the ulnar groove and passes horizontally into the joint. One or several articular branches may
originate in the arm, up to approximately 1 cm proximal
to the medial epicondyle. The first muscular branch, usually to the flexor carpi ulnaris, usually exits immediately
distal to the articular branch. However, division as high
as 4 cm proximal to the medial epicondyle has been
reported (189,194).
The Medial Antebrachial Cutaneous Nerve
and the Ulnar Nerve
The medial antebrachial cutaneous nerve may arise from
several slightly different points. It usually arises from the
medial cord of the brachial plexus, just proximal to the origin of the ulnar nerve. It usually arises just distal to the origin of the medial brachial cutaneous nerve, which is the
smallest branch of the brachial plexus (194) (see Fig. 3.1).
The medial antebrachial cutaneous nerve also may arise
from the lower trunk of the brachial plexus, from the first
thoracic nerve root (T1), or from the ulnar nerve itself. The
medial antebrachial cutaneous nerve commonly communi204 Systems Anatomy
cates with the intercostobrachial nerve in the axilla and the
medial cutaneous nerve of the arm proximally (195).
Clinical Correlations: Ulnar Nerve in the
Axilla and Arm
Arcade of Struthers
During exploration of the ulnar nerve at the elbow for
neuropathy, awareness of the possible presence of an
arcade of Struthers is important because this may be a
potential area of nerve compression (see earlier). The
nerve should be explored proximally to the level of where
the nerve passes from the anterior to posterior compartments. Muscle fibers of the medial head of the triceps
that cross obliquely superficial to the nerve usually indicate the presence of an arcade of Struthers. If present, the
fascial sheet of the arcade of Struthers should be incised.
If the nerve is transposed anteriorly, it should be confirmed that an arcade of Struthers is not present or is not
causing tethering or compression of the proximal aspect
of the transposed nerve.
The Arcade and the Ligament of Struthers
The arcade of Struthers should not be confused with the
ligament of Struthers. The arcade of Struthers, present in
approximately 70% of studied specimens, is located at the
medial intermuscular septum, and can cause compression
of the ulnar nerve. The ligament of Struthers, in contrast, is
rare, occurring in only 1%, and consists of a ligament or
extension of the pronator teres muscle from the medial epicondyle to an (anomalous) supracondylar process. The ligament of Struthers is a possible site of compression of the
medial nerve (6,17,18,20–22,78,192).
Ulnar Nerve in the Elbow and Forearm
Ulnar Nerve in the Cubital Tunnel
The cubital tunnel at the elbow is a fibroosseous tunnel
(189,196,197). The lateral border consists of the humerus,
ulna, and elbow joint. The medial and inferior border consists of a fascial sheath confluent with the brachial and antebrachial fascia of the adjacent muscles. The distal medial
border consists of the aponeurosis or fascia between the two
heads of the flexor carpi ulnaris (6,17,78). As noted by
Siegel and Gelberman, the tunnel can be divided geographically into three parts (189).
Ulnar Nerve in the First Part of the Cubital Tunnel
The first part of the cubital tunnel is the entrance of the tunnel, formed by the ulnar groove in the medial epicondyle. At
this entrance, the ulnar nerve lies in the extensor side of the
arm. In the first part, the ulnar nerve usually provides one
branch or several small articular branches to the elbow joint.
These branches usually are proximal to the branches given
off to innervate the flexor carpi ulnaris (189).
Ulnar Nerve in the Second Part of the Cubital Tunnel
The second and middle part of the tunnel consists of a fascial arcade. (This arcade should not be confused with the
arcade of Struthers, which is a separate fascial arcade located
more proximally in the arm; see earlier.) The fascial arcade
of the second part of the cubital tunnel attaches to the
medial epicondyle and to the olecranon. It connects the
ulnar and humeral heads of the origin of the flexor carpi
ulnaris muscle. In this area, the nerve crosses the medial
surface of the elbow. It lies on the posterior and oblique
portions of the ulnar collateral ligament. The nerve usually
gives off two branches to innervate the flexor carpi ulnaris.
One branch usually supplies the humeral head and one supplies the ulnar head. The first branch exits the main nerve
trunk horizontally. The second branch continues distally for
several centimeters before entering the flexor carpi ulnaris.
Up to four motor branches to the flexor carpi ulnaris may
be given off, exiting the main nerve at a point between 4 cm
proximal and 10 cm distal to the medial epicondyle (13).
The motor branches enter the flexor carpi ulnaris on its
deep surface. The first motor branch of the flexor carpi
ulnaris divides in 5% of limbs to supply the flexor digitorum
profundus as well (63) (see Table 3.2). In the second portion
of the cubital tunnel, the distance between the medial
humeral epicondyle and the olecranon is shortest with elbow
extension. This distance increases with elbow flexion (198).
The roof of the cubital tunnel is formed by the fascial
arcade, which becomes taut with elbow flexion (189).
Ulnar Nerve in the Third Part of the Cubital Tunnel
The third and most distal part of the tunnel consists of the
muscle bellies of the flexor carpi ulnaris. The flexor carpi
ulnaris provides a portion of the roof in this area. Although
the ulnar nerve enters the cubital tunnel on the extensor
side of the arm (in the first part of the tunnel), it comes to
lie on the flexor surface on exiting the tunnel in the third
part. The nerve courses through the interval between the
humeral and ulnar heads of the flexor carpi ulnaris or
between the flexor carpi ulnaris and flexor digitorum profundus muscles (189).
The volume of the tunnel decreases with elbow flexion,
and the pressure within it increases, even in the normal
elbow when the aponeurotic arch or surrounding soft tissues are not thickened.
The nerve then continues distally in the forearm
between the flexor digitorum profundus, located dorsally
and laterally to the nerve, and the flexor carpi ulnaris,
located anteriorly and medially. The nerve maintains this
relationship with the muscles through the proximal to middle forearm. In general, the nerve runs a straight course
through the forearm from the level of the medial epicondyle
of the distal humerus to the pisiform–hamate groove in the
3 Nerve Anatomy 205
carpus. In the distal third of the forearm, the ulnar nerve
courses more superficially, lying just radial and deep (dorsal) to the flexor carpi ulnaris muscle (6,189).
Motor Branches of the Ulnar Nerve in the
Forearm
In the forearm, and distal to the exit of the motor branches
to the flexor carpi ulnaris, the ulnar nerve usually has three
additional main branches. These are (a) the motor branch
to the flexor digitorum profundus (to the ring and small
fingers), (b) the palmar cutaneous portion of the ulnar
nerve, and (c) the dorsal branch of the ulnar nerve
(189,199).
Motor Branch to the Flexor Digitorum Profundus (to
the Ring and Small Fingers)
The motor branch to the flexor digitorum profundus from
the ulnar nerve usually innervates the ulnar half of the muscle, which includes the muscle bellies to the ring and small
fingers. (The anterior interosseous nerve from the median
nerve usually innervates the radial half of the flexor digitorum profundus, including the muscle bellies to the long
and index fingers, as well as the flexor pollicis longus.) The
motor branch from the ulnar nerve is located proximally in
the forearm. It arises approximately 3 cm distal to the
medial epicondyle and usually exits the ulnar nerve trunk
just distal to the branches to the flexor carpi ulnaris. The
motor branch passes distally for approximately 2.5 cm, usually lying on the anterior surface of the flexor digitorum
profundus (1–4,11,13,189,191). It then enters the muscle
at approximately 6 cm distal to the medial epicondyle (6),
whereas the anterior interosseous nerve enters the flexor
digitorum profundus to the index and long fingers approximately 4 to 7 cm more distally (6). In 80% of upper limbs,
a single branch from the ulnar nerve supplies the flexor digitorum profundus. In approximately 20%, two or more
branches supply the muscle. There may not be a direct
branch from the main ulnar nerve trunk that supplies the
flexor digitorum profundus. In these specimens, the flexor
digitorum profundus may by innervated by the branch of
the ulnar nerve to the flexor carpi ulnaris or by a branch
from the median nerve.
In the forearm, the ulnar nerve lies medial and adjacent
to ulnar artery.
Traditionally, the ulnar nerve is described as innervating
the flexor digitorum profundus to the ring and small fingers, and the anterior interosseous nerve from median nerve
is described as innervating the flexor digitorum profundus
to the index and long fingers. This pattern, however, has
been noted actually to comprise only 50% of upper limbs
(32). In several studied specimens, the median nerve or
derived branches was found to innervate the flexor digitorum to the ring and little fingers. In addition, the ulnar
nerve was found occasionally to supply the flexor digitorum
profundus to the long finger (32,189). The flexor digitorum profundus to the index finger, however, does seem to
be innervated consistently by the median nerve.
Sympathetic Fibers from the Ulnar Nerve in
the Forearm
In the middle forearm, the ulnar nerve supplies the accompanying ulnar artery with a segmental sympathetic nerve.
This is the nerve of Henle (200–202) (Fig. 3.3).
Palmar Cutaneous Branch of the Ulnar Nerve
The palmar cutaneous branch of the ulnar nerve is not as
consistent as its median nerve counterpart, the palmar cutaneous branch of the median nerve. When present, the palmar cutaneous branch of the ulnar nerve arises at variable
levels from the ulnar nerve in the distal forearm, usually in
the vicinity of the junction of the middle and distal thirds
of the forearm. It courses distally on or in the epineurium
of the ulnar nerve on the palmar surface of the ulnar artery.
The nerve then perforates the antebrachial fascia just proximal to the distal wrist flexion crease, and innervates the
skin in the hypothenar eminence, the ulnar artery, and,
occasionally, the palmaris brevis muscle (6) (see Figs. 3.3
and 3.4A).
Dorsal Cutaneous Branch of the Ulnar Nerve
The dorsal cutaneous branch of the ulnar nerve arises from
the medial aspect of main ulnar nerve trunk in the distal
forearm and curves dorsally to supply cutaneous innervation to the dorsal aspect of the small finger and ulnar ring
finger (199,203,204) (see Fig. 3.4B). Its point of origin is
an average of 6.4 cm from the distal aspect of the head of
the ulna and 8.3 cm from the proximal border of the pisiform. The cross-sectional shape of the nerve at its origin
usually is round or slightly oval, with a mean diameter of
approximately 2.4 mm. The point of nerve origin corresponds to a point located at the distal 26% of the total
length of the ulna (199). The nerve extends distally and
medially, passing dorsal to the flexor carpi ulnaris, and
pierces the deep antebrachial fascia. The nerve emerges at
the dorsomedial border of the flexor carpi ulnaris at a mean
distance of 5 cm from the proximal edge of the pisiform. At
this point, the nerve pierces the deep antebrachial fascia to
become subcutaneous on the medial aspect of the distal
forearm. Proximal to the wrist, the nerve provides two to
three branches. A branch piercing the capsule of the ulnocarpal joint usually is present. With the forearm in supination, the nerve branch passes along and close to the medial
aspect of the head of the ulna near the widest diameter of
the ulnar head (equator of the ulnar head). With the fore206 Systems Anatomy
arm pronated, the nerve branches displace slightly palmarly
to pass along the palmoulnar aspect of the ulnar head. In
the hand, an additional one or two branches usually are
given off. The total number of branches averages five, with
a range from three to nine. Two branches typically extend
to the small finger, one to the dorsoulnar aspect of the ring
finger, and one or two branches to the dorsoulnar aspect of
the carpus and hand. The diameters of the branches range
from 0.7 to 2.2 mm (199). The branches of the dorsal
branch of the ulnar nerve continue to the level of the proximal interphalangeal joints, where the nerves arborize and
become difficult to trace. There are no apparent further
communications between the dorsal branch of the ulnar
nerve and the ulnar nerve proper, with the palmar cutaneous branch of the ulnar nerve, or with the nerve of Henle
(200).
In the proximal forearm, the posterior ulnar recurrent
artery, which arises from the ulnar artery close to the bifurcation of the radial artery, courses ulnarly and proximally to
continue in proximity to the ulnar nerve and motor
branches to the flexor digitorum profundus, along the ulnar
border of the nerves (1–4,11).
The superior ulnar artery accompanies the ulnar nerve
into the cubital tunnel. In the cubital tunnel, the superior
ulnar collateral artery joins the posterior ulnar recurrent
artery to form one of the vascular collateral pathways
around the elbow and bypassing the distal portion of the
brachial artery (1,4).
In the region of the junction of the proximal and middle
thirds of the forearm, the ulnar artery joins the ulnar nerve
and continues on the radial aspect of the nerve. This relationship is maintained as the nerve and artery emerge from
the radial edge of the flexor carpi ulnaris tendon, coursing
slightly radial to pass radial to the pisiform and enter
Guyon’s canal at the wrist.
Anomalies and Variations: Ulnar Nerve in
the Elbow and Forearm
Anomalous Connections between the Ulnar
and Median Nerve
In the distal forearm, a crossing of nerve fibers from the
ulnar nerve to the median nerve can occur, although with
less frequency than the more common crossing of fibers in
the opposite direction from median nerve or anterior
interosseous nerve to ulnar nerve (the Martin-Gruber anastomosis). These anomalous connections between the ulnar
nerve and median nerve in the forearm are discussed in
detail earlier, under Nerve Anomalies and Variations:
Median Nerve in the Forearm. In general, from the elbow
to the wrist, the ulnar nerve shows relatively few anomalies
or deviations from its normal course. The division of its
branches is relatively consistent.
Variations in Innervation of the Flexor Carpi
Ulnaris
The flexor carpi ulnaris usually receives two or three motor
branches. Up to five branches have been noted (6). In isolated case reports, the flexor carpi ulnaris was found to have
a motor branch from the median nerve (6).
Variations in Innervation of the Flexor
Digitorum Profundus Muscle
Variations in the innervation of the flexor digitorum profundus muscle have been reported (205). Traditionally, the
ulnar nerve is thought to innervate the flexor digitorum
profundus to the ring and small fingers, and the median
nerve innervates the index and long fingers. However, this
pattern was found in only 50% of upper limbs (32). In several specimens, the median nerve was found to innervate
the ring and little fingers and the ulnar nerve was found to
supply the long finger (32,189). It is more common for the
median nerve to innervate muscles traditionally supplied by
the ulnar nerve than for the ulnar nerve to innervate muscles usually supplied by the median nerve (32,35,63). This
may occur in the all–median nerve hand.
Many of the variations in branching occur in the muscle
belly of the flexor digitorum profundus, and therefore are
difficult to identify by superficial visualization and examination of the muscle. The flexor digitorum profundus to
the index finger, however, does seem to be innervated most
consistently by the median nerve. Sunderland has noted
only one case in which the flexor digitorum profundus to
the index finger was innervated by the ulnar nerve (44).
Sensory Variations of the Dorsal Branch of the
Ulnar Nerve in the Forearm
The dorsal branch of the ulnar nerve usually arises from the
ulnar nerve trunk at approximately 6 to 8 cm from the wrist
joint (mean distance of 6.4 cm from the distal aspect of the
head of the ulna and 8.3 cm from the proximal border of
the pisiform) (199). Several variations can occur. The
branch may arise from the ulnar nerve as far proximal as the
elbow and continue subcutaneously along the entire length
of the forearm (206). Alternatively, an entire nerve loop has
been noted to form around the pisiform between the ulnar
nerve and a branch from the dorsal cutaneous nerve. This
branch of the dorsal cutaneous nerve appeared to contribute additional fibers to the ulnar digital nerve to the
small finger (207).
Absence of the Dorsal Cutaneous Branch of
the Ulnar Nerve
In 1 of 24 specimens, the dorsal branch of the ulnar nerve
was found to be absent (199). With complete absence of the
3 Nerve Anatomy 207
dorsal cutaneous branch of the ulnar nerve, sensibility to
the dorsum of the ulnar hand can be supplied by the superficial radial nerve (208), the musculocutaneous nerve (6), or
the posterior cutaneous nerve of the forearm.
Ulnar Nerve Compression by Anomalous
Anconeus Epitrochlearis
The ulnar nerve may be compressed at the elbow by an
anomalous muscle, the anconeus epitrochlearis. The
anconeus epitrochlearis originates from the medial border
of the olecranon and adjacent triceps tendon and inserts
into the medial epicondyle of the elbow. The muscle
appears as an auxiliary extension of the medial portion of
the triceps. The muscle crosses the ulnar nerve posterior to
the cubital tunnel. When present, it forms a portion of the
cubital tunnel, reinforcing the aponeurosis of the two heads
of the origin of the flexor carpi ulnaris (6).
The Posterior Cutaneous Nerve
The posterior cutaneous nerve of the forearm usually is a
branch of the radial nerve. Rarely, the posterior cutaneous
nerve may arise from the ulnar nerve (189).
Clinical Correlations: Ulnar Nerve in the
Elbow and Forearm
The ulnar nerve is at risk for compression or stretch at the
cubital tunnel of the elbow. Panas in 1878 described a condition now known as tardy ulnar palsy (209). Several
anatomic and mechanical etiologic factors have been
described (6,17,78,189,208,210–218) (Table 3.3).
Neuropathy of the ulnar nerve as it passes through the
cubital tunnel posterior to the medial epicondyle of the
humerus may be associated with recurrent dislocation of
the nerve. This condition was described by Collinet in
1896, followed by reports by Cobb and Momberg (both in
1903) (219–221).
In 1926, Platt discussed the pathogenesis of neuritis of
the ulnar nerve in the cubital tunnel, specifically in the
postcondylar groove (79,215).
The ulnar nerve also is subject to compression in the
cubital tunnel by the overlying fascia at the level of the
medial condyle, as well as by the fascia between the heads
of the flexor carpi ulnaris and in the muscle itself
(222–225). Spinner has suggested that the most common
cause for an idiopathic type of ulnar nerve paralysis is
entrapment of the nerve at the distal cubital tunnel where
the ulnar nerve enters the forearm posteriorly between the
two heads of the flexor carpi ulnaris. A fascial connection is
present between the two, and the proximal edge may at
times be thickened and act as a compressing band (6).
In the cubital tunnel, an articular branch (or branches)
is (are) usually given off by the ulnar nerve, followed by a
motor branch to the flexor carpi ulnaris (which exits the
nerve trunk just distal to the articular branch). Appreciation
of these two nerves and their respective functions and destinations is relevant for ulnar nerve exploration in the
cubital tunnel. In performing an anterior transposition of
the ulnar nerve, the articular branch in the cubital tunnel
may tether the nerve trunk and prevent mobilizing the
ulnar nerve for transposition. This branch often is sacrificed
to allow anterior mobilization of the nerve, and causes minimal morbidity. Occasionally, a branch to the flexor carpi
ulnaris also is a limiting structure to anterior transposition.
Obviously, protection and preservation of this nerve is optimal because morbidity may be substantial if the flexor carpi
ulnaris has no additional motor nerves and becomes denervated by sacrifice of the motor branch. To mobilize the
ulnar nerve, distal nerve dissection and mobilization to
allow transposition is preferred over sacrifice of the motor
branch of the flexor carpi ulnaris.
With elbow flexion, the cubital tunnel decreases in volume and the aponeurosis becomes taut over the ulnar nerve
(196,198,213,214,226). During elbow flexion, the nerve
stretches and elongates approximately 4.7 mm. During flexion, the medial head of the triceps has been noted to push
the ulnar nerve anteromedially 0.73 cm (227). When there
is fixation of the nerve, a traction neuritis can develop (6).
The ulnar nerve may be compressed at the elbow by an
anomalous muscle, the anconeus epitrochlearis (6). The
anconeus epitrochlearis is a muscle variant that originates
from the medial border of the olecranon and adjacent triceps tendon and inserts into the medial epicondyle of the
elbow. The muscle appears as an auxiliary extension of the
medial portion of the triceps. The muscle crosses the ulnar
nerve posterior to the cubital tunnel. When present, it
forms a portion of the cubital tunnel, reinforcing the
aponeurosis of the two heads of the origin of the flexor carpi
ulnaris (6). It has been found to be a factor in producing
208 Systems Anatomy
TABLE 3.3. ANATOMIC AND MECHANICAL
FACTORS CONTRIBUTING TO CUBITAL TUNNEL
SYNDROME
Idiopathic
Ganglion
Anomalous muscle (anconeus epitrochlearis)
Arcade of Struthers
Hypertrophic arthritis
Fracture malunion, nonunion
Fracture callus
Traumatic heterotopic ossification
Neurogenic heterotopic ossification
Cubitus valgus
Rheumatoid synovitis of elbow joint
Supracondylar process
Translocation, subluxation, or snapping of the triceps
Translocation, subluxation, or dislocation of ulnar nerve
Trauma (contusion, stretch, friction, repetitive traction)
ulnar compressive neuritis posterior to the elbow. Excision
of the muscle mass without translocation of the nerve has
relieved symptoms when it was the single factor in the
pathogenesis (6).
The flexor carpi ulnaris was found, in an isolated case, to
have a motor branch from the median nerve (6). With this
variant, weak action of the muscle could be observed when
a complete high ulnar lesion was present (6).
The flexor carpi ulnaris sometimes may receive an additional inconsistent motor branch from the ulnar nerve in
the mid-forearm.
Compression of the Dorsal Cutaneous Branch
of the Ulnar Nerve
The dorsal cutaneous branch of the ulnar nerve is vulnerable to compression by external pressure in individuals who
write with their left hand. Often, these individuals write
with the ulnar border of the wrist against the firm writing
surface. If the dorsal cutaneous branch of the ulnar nerve
passes from its volar position to the dorsum of the hand
over the prominence of the distal ulna, external pressure can
cause symptoms of pain in the wrist and numbness of the
dorsoulnar aspect of the hand (6).
Absence of the Dorsal Cutaneous Branch of
the Ulnar Nerve
Complete absence of the dorsal cutaneous branch of the
ulnar nerve can occur (see earlier, under Anomalies and
Variations: Ulnar Nerve in the Elbow and Forearm). Sensibility to the dorsoulnar hand can then be supplied by the
superficial radial nerve (208), by a dorsal division of the
musculocutaneous nerve (6), or by the posterior cutaneous
nerve of the forearm. With this variation, an injury or lesion
of the ulnar nerve at the elbow does not produce sensory
loss of the dorsum of the hand, but presents with sensory
findings similar to those of a low ulnar nerve lesion. This
variation should be suspected if electromyographic localization of the nerve lesion is at the elbow when clinical findings suggest a lesion at the wrist (6). The presence of this
variation can be evaluated by local anesthetic block of the
superficial radial nerve or the musculocutaneous nerve,
which produces anesthesia over the dorsoulnar hand.
Ulnar Nerve at the Wrist and Hand
Ulnar Nerve in the Ulnar Tunnel
The ulnar nerve and ulnar artery enter the ulnar tunnel
(Guyon’s canal) at the wrist. The artery usually is located
radial to the nerve (228). The nerve and artery pass radial
to the pisiform, anterior (superficial) to the transverse
carpal ligament (flexor retinaculum), and dorsal to the
superficial palmar carpal ligament. The ulnar nerve divides
into deep terminal and superficial palmar branches at the
base of the hypothenar eminence.
The ulnar nerve extends approximately 4 cm in its path
through the ulnar tunnel. The tunnel originates at the proximal edge of the palmar carpal ligament and extends distally
to the fibrous arch of the hypothenar muscles. The tunnel
has been described in terms of having a floor (dorsal surface), a roof (palmar surface), and two walls (medial and lateral). The boundaries change from proximal to distal, and
the four walls are not distinct through the entire course.
The roof of the tunnel is composed of the palmar carpal ligament, the palmaris brevis, and hypothenar fat and fibrous
tissue. The floor of the tunnel consists of tendons of the
flexor digitorum profundus, the transverse carpal ligament,
the pisohamate and pisometacarpal ligaments, and the
opponens digiti minimi. The medial wall consists of the
flexor carpi ulnaris, the pisiform, and the abductor digiti
minimi. The lateral wall is composed of the tendons of the
extrinsic flexors, the transverse carpal ligaments, and the
hook of the hamate (229,230). The distal ulnar tunnel has
been divided in three zones based on topography of the
nerve and its relationship to the surrounding structures
(230). Zone I consists of the portion of the tunnel proximal
to the bifurcation of the ulnar nerve. Zone II encompasses
the deep motor branch of the nerve and surrounding structures. Zone III includes the superficial branch and adjacent
distal and lateral tissues.
Ulnar Nerve in Zone I of the Ulnar Tunnel
In zone I, the nerve continues for approximately 3 cm,
stretching from the proximal edge of the palmar carpal ligament to the nerve’s bifurcation. The palmar carpal ligament, lying superficial (anterior to the ulnar nerve), is actually a thickening of the superficial forearm fascia that
becomes distinct approximately 2 cm proximal to the pisiform. The ligament arises ulnarly from the tendon of the
flexor carpi ulnaris and inserts radially on the palmaris
longus tendon and the transverse carpal ligament, forming
the roof (palmar surface of the proximal part of zone I). The
ulnar nerve, along with the ulnar artery, passes deep to the
palmar carpal ligament to enter the ulnar tunnel. At this
level, the ulnar artery lies slightly superficial and radial to
the nerve. The deep (dorsal) surface of zone I consists of
tendons of the flexor digitorum profundus and the ulnar
portion of the transverse carpal ligament. The lateral wall is
formed by the most distal fibers of the palmar carpal ligament, which curve radially and posteriorly to wrap around
the neurovascular bundle and merge with the fibers of the
transverse carpal ligament. The pisiform and tendon of the
flexor carpi ulnaris comprise the medial wall of the tunnel
at this level (229,230). Distal to the palmar carpal ligament,
the roof of the ulnar tunnel consists of the palmaris brevis
muscle. This muscle originates from the distal palmar
aspect of the pisiform and hypothenar muscle fascia and
inserts on the ligament. The length of the palmaris brevis
3 Nerve Anatomy 209
from the proximal to distal border is approximately 2.5 cm
(229,230). In this area, deep to the palmaris brevis, the
ulnar nerve bifurcates into the deep motor branch and the
superficial branch of the ulnar nerve. The point of nerve
branching is approximately 1 cm distal to the proximal edge
of the pisiform. Three to 7 mm distal to the bifurcation of
the nerve, the ulnar artery divides into two branches. The
larger of the arterial branches accompanies the superficial
branch of the nerve and becomes the superficial palmar
arch. The smaller arterial branch continues with the motor
branch into the deep space of the palm and terminates in
the deep palmar arch. Both arteries remain superficial and
radial to the nerves they accompany (230). The distal extent
of zone I terminates at the level of the bifurcation of the
ulnar nerve. At this level, the roof of the tunnel is formed
by the palmaris brevis and the floor formed by the pisohamate and pisometacarpal ligaments. The pisohamate ligament arises from the distal, radial, and dorsal aspects of the
pisiform and inserts on the proximal, ulnar, and palmar
aspects of the hook of the hamate. Ulnar to the pisohamate
ligament, the pisometacarpal ligament arises from the distal
aspect of the pisiform and inserts on the palmar radial
aspect of the base of the fifth metacarpal. The divergence of
these ligaments leaves an opening in the floor of the tunnel
that is filled with fibrofatty tissue overlying the capsule of
the triquetrohamate joint (229,230).
In zone I, the ulnar nerve carries both motor and sensory
fibers. The nerve fibers are arranged in two distinct groups
of fascicles. The palmar-radial fibers contain the fascicles
that become the superficial branch of the ulnar nerve,
whereas the dorsal-ulnar fibers become the deep motor
branch. Thus, in zone I, the ulnar nerve actually is two
nerves contained in a common epineurial sheath
(229–231).
Ulnar Nerve in Zone II of the Ulnar Tunnel
Zone II encompasses the portion of the ulnar tunnel distal
to the bifurcation, in the region where the deep (motor)
branch of the ulnar nerve passes. This zone usually is
located in the dorsoradial portion of the ulnar tunnel. The
palmar (superficial) aspect of zone II is bordered by the palmaris brevis and the superficial branch of the ulnar nerve.
The lateral border of zone II consists of transverse carpal ligament, which forms a wall that merges with the floor of the
tunnel. The floor of zone II consists of the pisohamate and
the pisometacarpal ligaments. At the distal extent of zone
II, the fibrous arch of the hypothenar muscles lies palmar to
the nerve, the opponens digiti minimi lies posterior, the
hook of the hamate and flexor digiti minimi are located laterally, and the abductor digiti minimi lies on the medial
aspect (230). The deep branch of the ulnar nerve passes
deep to the fibrous arch and between the muscles as it exits
the tunnel. The nerve to the abductor digiti minimi usually
is given off just proximal to its entrance into these muscles.
The motor branch innervates the opponens digiti minimi as
it continues radially and posteriorly around the hook of the
hamate. The nerve then continues deeply across the palm
(229,230). The ulnar artery enters zone II radially and palmarly, just distal to the level of the bifurcation of the nerve.
The artery follows the nerve, lying palmar and slightly
radial. Both structures continue distally and pass deep to
the arch of the origin of the hypothenar muscles. In zone II,
the deep branch of the ulnar carries motor fibers.
Ulnar Nerve in Zone III of the Ulnar Tunnel
Zone III encompasses the portion of the ulnar tunnel distal
to the bifurcation, in the region of the superficial branch of
the ulnar nerve, also referred to as the superficial palmar
branch (189). At the entrance to zone III, the palmaris brevis comprises the palmar boundary, the abductor digiti
minimi comprises the medial border, and the
pisometacarpal ligament and capsule of the triquetrohamate
joint comprise the dorsal border. The lateral and dorsal borders are formed by zone II. As the superficial branch of the
ulnar nerve continues distally, it gives off two small
branches that innervate the palmaris brevis. This occurs
either in the ulnar tunnel or just distal to exiting it
(189,230). Distal to this point, the nerve usually contains
only sensory fibers. The nerve emerges from zone III by
passing over the fibrous arch of the hypothenar muscles.
The ulnar artery continues with the nerve throughout zone
III, remaining superficial and radial to the nerve. At the distal end of the zone, the superficial palmar branch of the
ulnar nerve lies between the hypothenar fascia posteriorly
and the artery and a fibrofatty layer deep to the subcutaneous tissues palmarly (229,230). The superficial palmar
branch in zone III contains mostly sensory fibers along with
motor fibers to the hypothenar muscles. Lesions in this
zone should produce primarily sensory deficits with possible motor weakness of the hypothenar muscles.
Superficial Palmar Branch of the Ulnar Nerve
The superficial palmar branch exits the distal ulnar tunnel
with the superficial terminal branch of the ulnar artery. The
nerve then provides several small twigs to innervate the skin
on the medial side of the hand. The motor branches to the
palmaris brevis may leave the nerve at this point (if not
branched more proximally in the ulnar tunnel). The nerve
continues distally and radially and divides into the proper
digital nerve to the ulnar side of the little finger and the
common palmar digital nerve to the fourth web space. At
the level of the metacarpal shafts, the common digital nerve
divides into two proper digital nerves, one each to supply
adjacent aspects of the fourth web space between the small
and ring fingers (see Fig. 3.3). In the palm, the nerves lie
dorsal to the superficial palmar arch and palmar to the
flexor tendons. Immediately after division, in the region of
the metacarpal necks, the proper digital nerves course anteriorly to lie palmar (superficial) to the digital arteries. The
210 Systems Anatomy
neurovascular bundles are stabilized in the digits by the
retaining skin ligaments, Cleland’s ligaments located dorsal
to the neurovascular bundle, and Grayson’s ligaments
located palmarly. The proper palmar digital nerves supply
the palmar skin of the digits, and the skin distal to the distal interphalangeal joints on the dorsal surface (189).
Deep Terminal Branch of the Ulnar Nerve
The deep terminal branch of the ulnar nerve exits from
zone II of the ulnar tunnel dorsoulnar to the deep terminal
branch of the ulnar artery (1,3,159,232). The nerve passes
medial to the hook of the hamate, deep to the fibrous arch
of the hypothenar muscle origin. The nerve continues
between the abductor digiti minimi and flexor digiti minimi muscles, supplying motor branches to each. The nerve
then pierces and innervates the opponens digiti minimi
(41). The deep branch then crosses the palm with the ulnar
artery (which now forms the deep palmar arch). Along its
course, the nerve is deep to the extrinsic flexor tendons and
deep to the mid-palmar and thenar fascial clefts, but palmar to the interossei (11). At the level of the third
metacarpal, the deep branch of the ulnar nerve and the
deep palmar arch cross between the oblique and transverse
heads of the adductor pollicis. Along its deep course, the
nerve innervates each of the seven interossei, the third and
fourth lumbricals, the adductor pollicis, the flexor pollicis
brevis and the hypothenar muscles (see Table 3.2 and Fig.
3.3). The deep terminal branch provides sensory afferent
nerves to the ulnocarpal, intercarpal, and carpometacarpal
joints (191).
Sympathetic Fibers from the Ulnar Nerve in
the Hand
At the wrist, sympathetic fibers arise from the distal ulnar
nerve and supply the proximal ulnar portions of the
superficial and deep vascular arches of the hand. The
deep vascular arch is segmentally innervated by fibers
from the ulnar nerve and the superficial radial nerve (the
median nerve and the superficial radial nerve also give
segmental supply to the superficial vascular arch in the
palm of the hand) (6).
Anomalies and Variations: Ulnar Nerve in
the Wrist and Hand
The Riche-Cannieu Communication
The Riche-Cannieu communication consists of a communication between the deep terminal branch of the ulnar
nerve and the motor branch of the median nerve (see earlier, under Anomalies and Variations: Median Nerve in the
Wrist and Hand). Because it occurs in 50% to 77% of
hands (194), it can be argued whether this is a normal pattern or a variation. The communication occurs at the terminal portion of the deep branch of the ulnar nerve in the
radial aspect of the palm (41,233). The communicating
fibers pass radially from the deep ulnar branch between the
heads of the adductor pollicis, then pass deep to the flexor
pollicis longus tendon. The fibers continue proximally to
the radial side of the flexor pollicis longus tendon as they
approach the median motor branch. The communication
often occurs in the substance of the flexor pollicis brevis
(41). Through the Riche-Cannieu communication, the
median nerve may innervate the third lumbrical, or, rarely,
all of the lumbrical muscles (35,63). Conversely, the second
lumbrical may be innervated by the ulnar nerve (see earlier
under Anomalies and Variations: Median Nerve in the
Wrist and Hand). There is some question as to whether
there is a crossing of sensory fibers as well (39).
Variations of Innervation of the Flexor Pollicis
Brevis
Considerable variation exists as to the innervation of the
flexor pollicis brevis. Reports have suggested the muscle is
innervated by the ulnar nerve in 50%, the median nerve in
35%, and both in 15%. Each head may receive a different
contribution, with the deep head more commonly innervated by the ulnar nerve and the superficial head more commonly innervated by the median nerve (11).
Variations of Innervation of the Abductor
Pollicis Brevis
The abductor pollicis brevis is innervated by the median
nerve in 95%, the ulnar nerve in 2.5%, and by both nerves
in 2.5% (9,41,189).
Variation of Innervation of the Opponens
Pollicis
The opponens pollicis muscle is innervated by the median
nerve alone in 83%, the ulnar nerve in 10%, and by both
nerves in 7% (153).
Variations in Sensory Innervation of the Ulnar
Nerve Proper in the Hand
Several variations in the sensory innervation of the ulnar
nerve have been noted. Distal to the wrist, the ulnar nerve
proper usually innervates the palmar aspect of the small finger and ulnar aspect of the ring finger. The pattern is variable, and the area of ulnar innervation includes the volar
aspect of the entire ring finger, the ulnar aspect of the long,
or the entire long finger. Conversely, the ulnar nerve may
innervate only the volar aspect of the small finger. The ulnar
supply to the fourth web space (to the space between the
ring and small finger), instead of arising in its usual location
3 Nerve Anatomy 211
at the distal end of the ulnar tunnel, has been observed to
arise in the mid-forearm and continue on an aberrant
course superficial to the transverse carpal ligament and the
palmar aponeurosis (234).
A communicating branch may exist between the superficial branch of the ulnar nerve and the common digital
nerve of the third web space (common digital nerve of the
median nerve to supply adjacent sides of the long and ring
finger). This is a relatively common finding (189,191) and
leads to dual innervation to the adjacent sides of the long
and ring fingers.
Variations in Sensory Innervation of the
Dorsal Cutaneous Branch of the Ulnar Nerve
in the Hand
The dorsal aspect of the hand usually is innervated by the
dorsal branch of the ulnar nerve. However, this area may be
supplied partially or entirely by the radial nerve or by the
posterior cutaneous nerve of the forearm. Complete
absence of the dorsal branch of the ulnar nerve has been
found in 1 of 24 specimens (199). In these cases, the radial
nerve or posterior cutaneous nerve of the forearm supplies
the dorsoulnar hand sensibility. The dorsal branch of the
ulnar nerve may deviate palmarly at the pisiform, join the
superficial (sensory) branch, and supply the palmar surface
of the little finger. A nerve connection may exist between
the dorsal sensory branches of the ulnar nerve and the
superficial radial nerves. This communication between the
dorsal branch of the ulnar nerve and a subcutaneous
branch from the superficial branch of the radial nerve was
observed in 1 of 24 specimens. The communication was
noted on the dorsal aspect of the hand (199). An additional variation is the presence of a third dorsal digital
branch from the ulnar nerve. When present, this branch
from the ulnar nerve supplies the third web space in conjunction with the radial digital nerve, providing dual
innervation (6).
Variations of Division and Recommunication
of the Ulnar Nerve into Deep and Superficial
Branches
Variations exist as to the point of division of the ulnar nerve
into its deep and superficial branches. The deep motor
branch may divide proximal to the hook of the hamate. The
radial division may enter the carpal tunnel (radial to the
hook of the hamate) and rejoin the ulnar division distal to
the hamate (235,236). Less commonly, the deep motor
branch may divide proximal to the pisiform, communicate
with the dorsal sensory branch, or rejoin the nerve distal to
the pisiform. In the event of nerve injury distal to an anomalous division, function is partially preserved. The ulnar
digital nerve to the ring finger may arise in the forearm,
passing superficial to the ulnar tunnel. Similarly, the dorsal
cutaneous branch may arise near the elbow, passing distally
in the subcutaneous tissue to reach the hand (41,189).
An anomalous terminal branch of the ulnar nerve has
been observed at the distal end of Guyon’s canal, which
joined the digital sensory branch to the medial aspect of the
small finger (237,238).
The Ulnar Palmar Cutaneous Nerve
The ulnar palmar cutaneous nerve is not a consistent
branch, as is its adjacent counterpart, the median palmar
cutaneous nerve (6,239) (see Fig. 3.4A). When present, it
arises at variable levels from the ulnar nerve in the distal half
of the forearm.
Clinical Correlations: Ulnar Nerve in the
Wrist and Hand
In zone I of the ulnar tunnel, the ulnar nerve carries both
motor and sensory fibers. A compression or traumatic
lesion in zone I has a high likelihood of producing both
motor and sensory deficits. If the lesion is in zone I, or in
the area just proximal to the entrance of the ulnar tunnel,
the dorsal sensor branch (which exits the ulnar nerve more
proximally in the distal forearm) is spared. Therefore, sensibility to the dorsal aspect of the small and ulnar side of the
ring finger is spared. These findings, of palmar sensibility
loss (to the small and ulnar side of the ring) with intrinsic
motor loss and with sparing of dorsal sensibility, help localize the area of compression or dysfunction (229,240–242).
In zone I of the ulnar tunnel, the ulnar nerve fibers are
arranged in two distinct groups of fascicles, with the palmar-radial fibers containing fascicles that become the superficial branch of the ulnar nerve (mostly sensory fibers),
whereas the dorsal-ulnar fibers become the deep branch
(motor branch). A lesion in zone I that involves the palmarradial aspect or the dorsal-ulnar aspect of the nerve may
involve mostly sensory or mostly motor fibers, respectively,
and thus produce an associated clinical presentation
(229–231).
In zone II of the ulnar tunnel, the deep branch of the
ulnar nerve carries motor fibers. A lesion in zone II should
produce only motor deficits. Conversely, if an occult lesion
or penetrating injury produces only motor loss, zone II
should be suspected as a site of the lesion.
In zone III of the ulnar tunnel, the superficial branch of
the ulnar nerve carries mostly sensory fibers, along with
motor fibers to the palmaris brevis and hypothenar muscles.
Therefore, it is technically incorrect to refer to this branch
at this point as the sensory branch of the ulnar nerve. The
superficial branch of the ulnar nerve is preferred.
In zone III of the ulnar tunnel, the superficial branch
contains mostly sensory fibers along with motor fibers to
the hypothenar muscles. Lesions in this zone should produce primarily sensory deficits with possible motor weak212 Systems Anatomy
ness of the hypothenar muscles. Conversely, if an occult
lesion or penetrating injury produces mostly sensory loss
(or concomitant weakness of the hypothenar muscles), zone
II should be suspected as the site of the lesion.
In carpal tunnel syndrome, the etiology often is
unknown, and it is attributed to an idiopathic cause. However, in ulnar nerve compression in the ulnar tunnel, a cause
more commonly is found. These include tumors in the
ulnar tunnel (ganglions, lipomas, giant cell tumor, desmoid
tumors, rheumatoid synovial cysts), anatomic abnormalities
that encroach on the ulnar nerve (anomalous muscles,
thickened ligaments, anomalous hamulus), trauma with
associated inflammation, edema, or hematoma (fractures,
repetitive trauma, edema after burns), vascular pathology,
or inflammatory conditions (rheumatoid arthritis or degenerative arthritis) (6,243–267) (Table 3.4). Ganglions are the
most common tumor related to ulnar tunnel syndrome,
accounting for 29% to 45% of reported caused of ulnar
tunnel syndrome. Other more common related factors
include anomalous muscles (see later), fractures, and vascular abnormalities (230,268–273).
Anomalous muscles reported to cause ulnar tunnel syndrome include the several variations of the palmaris longus
(274–276), an accessory flexor digiti minimi (262,277), an
accessory abductor digiti minimi (198,278), an accessory
muscle from the flexor carpi ulnaris tendon, and various
anomalous muscles located in the canal (see later) (279,
280).
Several variations of the palmaris longus have been
related to ulnar variations in Guyon’s canal and to ulnar
tunnel syndrome. These include a reversed muscle–tendon
relationship with a distal muscle belly and proximal tendon
(275), an anomalous extension into Guyon’s canal, an
accessory palmaris longus, and a duplicated palmaris longus
(6,9,274,275).
An anomalous palmaris longus may have a reversal of its
normal muscle relationship, with the tendon arising proximally from the medial epicondyle, and the muscle belly
attaching distally to the flexor retinaculum at the wrist.
There may be an associated accessory musculotendinous
slip, approximately 1 cm thick, which inserts into the pisiform (275). This anomalous palmaris can create an arch
that reinforces the roof of the tunnel. However, the ulnar
nerve and artery must penetrate through this arch to reach
the wrist, and thus are more vulnerable to compression. The
nerve and artery run their normal course deep to the palmaris brevis (275). Spinner has referred to this anatomic
arrangement as the variant canal of Guyon (6).
An anomalous accessory palmar longus has been noted
in the ulnar tunnel. Thomas described a 1-cm-wide muscle
arising from the palmaris longus tendon. The muscle
inserted into the soft tissues of the region of the hypothenar
muscles and into the pisiform. This muscle passed through
the ulnar tunnel, and was thought to be responsible for
clinical symptoms of fatigability of the hand (274).
King and O’Rahilly reported a duplication of the palmaris longus with either a separate muscular slip (accessory
palmaris) or a separate tendon that originated from the
duplicated palmaris and extended to the abductor digiti
quinti or the flexor digiti quinti. The accessory muscle
passed volar to the ulnar nerve and ulnar artery. The muscle appeared to form part of the roof of the ulnar tunnel. An
associated tendinous slip that extended between the ulnar
artery and nerve also was noted to occur. The artery crossed
anterior to the slip.
As early as 1864, anomalies of the palmaris longus were
noted, and associated with variations of the ulnar tunnel
(276). A palmaris longus with a double origin was described
by Wood. From this palmaris longus tendon, there was an
associated anomalous flexor digiti quinti with a high origin
from the palmaris longus.
Besides the palmaris longus, other aberrant muscles have
been noted in the ulnar tunnel or its vicinity that place the
ulnar nerve at risk for compression.
Schjelderup described an anomalous muscle 4 mm wide
that extended in the canal and crossed over the ulnar nerve
before the nerve divided (279).
Turner and Caird also noted an anomalous muscle in the
ulnar tunnel. The muscle originated from the pisiform,
crossed through the ulnar tunnel passing between the deep
and superficial branches, and inserted into the transverse
carpal ligament. This muscle passed between the motor and
sensory branches of the ulnar nerve (280).
3 Nerve Anatomy 213
TABLE 3.4. COMMON CAUSES OF ULNAR NERVE
COMPRESSION AT THE WRIST BASED ON 135
REPORTED CASES
Cause Number
Tumors
Ganglion 46
Lipoma 3
Giant cell tumor 2
Desmoid tumor 1
Anatomic abnormalities
Anomalous muscles 22
Thickened ligaments 4
Anomalous hamulus 3
Trauma
Fractures 19
Repetitive trauma 8
Edema after burns 10
Other trauma 3
Vascular pathology 9
Arthritis
Rheumatoid 4
Degenerative 1
Other
Dupuytren’s contracture 1
136 total
From Botte MJ, Gelberman RH. Ulnar nerve compression at the
wrist. In: Szabo RM, ed. Nerve compression syndromes: diagnosis
and treatment. Thorofare, NJ: Slack, 1989:121–136.
Jeffery described an accessory hypertrophied abductor
digiti quinti that arose from the fascia of the distal forearm.
The muscle was thought responsible for isolated paralysis of
the intrinsic muscles without sensibility loss. The patient’s
symptoms improved after excision of the abnormal muscle
(6,278).
An accessory muscle arising from the tendon of the
flexor carpi ulnaris was noted by Kaplan. This muscles
inserted into the volar carpal ligament. It formed a thickened roof of the ulnar tunnel, possibly increasing the vulnerability to the ulnar nerve (6,9; personal communication
to Spinner).
Swanson identified an accessory flexor digiti quinti arising from the forearm fascia. The muscle inserted into the
flexor digitorum brevis and caused symptoms of ulnar nerve
compression (6,277).
Hayes et al. described a ligamentous band that attached
to the pisiform and extended to the hook of the hamate.
The band was located anterior to the deep branch of the
ulnar nerve (6,281). The flexor and abductor digiti minimi
muscles arose in part from the ligamentous band.
In the vicinity of the ulnar tunnel, Lipscomb reported a
case of duplication of the hypothenar muscles (282). The
duplicated muscle simulated a tumor of the hand. The muscle originated from the pisiform and the hook of the
hamate. The palmaris brevis was noted to be six times the
normal size. Proximally, these anomalous muscles formed
part of the ulnar tunnel (6), and potentially increased the
risk of nerve compression.
Harrelson and Newman described ulnar tunnel syndrome caused by a hypertrophied flexor carpi ulnaris muscle in close proximity to the ulnar tunnel (283).
Most ganglia that cause ulnar tunnel syndrome arise
from the palmar aspect of the carpus and present in zone I
or II.
Although the deep terminal branch of the ulnar nerve
consists mostly of motor fibers, it also contains sensory
afferent nerves to the ulnocarpal, intercarpal, and carpometacarpal joints. It is thus not a purely motor nerve,
although it sometimes incorrectly is referred to as the deep
motor branch of the ulnar nerve. The correct names include
deep branch of the ulnar nerve and deep terminal branch of the
ulnar nerve (189,229,284).
The deep branch of the ulnar nerve and the deep palmar
arch cross between the interval between the oblique and
transverse heads of the adductor pollicis at the level of the
third metacarpal. This interval is useful in identifying the
neurovascular bundle during exploration for deep or severe
trauma. The neurovascular bundle also requires isolation
and protection in adductor pollicis recession, as often is performed for correction of thumb-in-palm deformities in
spastic muscle disorders. Compression of the deep branch
of the ulnar nerve by the adductor pollicis also has been
noted (285).
Because the ulnar nerve on occasion may innervate the
third lumbrical muscle, a high ulnar nerve lesion can produce clawing in three fingers instead of two.
Although ulnar neuropathy is a relatively common cause
of intrinsic muscle atrophy, several other etiologies are possible: Charcot-Marie-Tooth disease, thoracic outlet syndrome, C8 to T1 root level impingement, anterior horn cell
disorders, and even compression at the foramen magnum
level (foramen magnum meningioma) (45,46,196,213,240,
241,273,286–289).
The ulnar supply to the fourth web space (to the space
between the ring and small fingers), instead of arising in its
usual location at the distal end of the ulnar tunnel, has been
observed to arise in the mid-forearm and continue on an
aberrant course superficial to the transverse carpal ligament
and the palmar aponeurosis (280). When present, it can be
vulnerable to injury during carpal tunnel decompression
(6).
RADIAL NERVE
Origin of the Radial Nerve
The radial nerve arises from the posterior cord of the
brachial plexus, posterior to the third portion of the axillary
artery (1–4,11) (see Fig. 3.1). It contains fibers from C5
through C8 (and occasionally T1) and is the largest terminal branch of the brachial plexus. The lower trunk contributes fibers from T1 in 8% of upper limbs (13).
Radial Nerve in the Axilla and Arm
In the proximal portion of the arm, the radial nerve courses
posterior to the brachial artery, anterior to the subscapularis
muscle, the teres major and latissimus dorsi muscle tendons, and the long head of the triceps. At the junction of
the proximal and middle thirds of the humerus, the nerve
courses dorsolaterally, passing posterior to the medial head
of the triceps and anterior to the long head. The radial
nerve is accompanied by the profunda brachii artery, and
continues distally close to the posterior cortex of the
humerus (290). The nerve and artery pass through the
extensor compartment of the arm, between the medial and
lateral heads of the triceps muscle. The nerve continues distally, coursing slightly anteriorly as it spirals around the
humerus to reach the lateral intermuscular septum. The
nerve is separated from the humeral cortex by the medial
head of the triceps, which lies adjacent to but not in the spiral groove of the humerus (291,292). The radial nerve
leaves the extensor compartment of the arm at the lateral
border of the medial head of the triceps muscle, sequentially
providing motor branches to the triceps long head, medial
head, and lateral head (Table 3.5 and Fig. 3.5). The nerve
enters the flexor compartment of the arm, piercing the lat214 Systems Anatomy
eral intermuscular septum approximately 10 cm proximal
to the lateral humeral epicondyle (6). The radial collateral
artery (the terminal branch of the profunda brachii artery)
accompanies the radial nerve in this area. The radial nerve
continues deep in the intermuscular interval between the
brachialis and brachioradialis muscles. It continues distally,
and extends in the interval between the extensor carpi radialis longus muscle and brachialis. The nerve exits the arm
anterior to the tip of the lateral epicondyle, dividing into
the superficial and deep terminal branches as it enters the
forearm (13,291,292). In the arm, the radial nerve sequentially innervates the three heads of the triceps and the
anconeus. In the distal third of the arm proximal to the
elbow epicondylar line, the radial nerve innervates the brachioradialis and extensor carpi radialis longus (see Table 3.5
and Fig. 3.5). Occasionally, the radial nerve provides a
motor branch to the radial portion of the brachialis (6,293),
which usually is supplied by the musculocutaneous nerve.
The motor branch to the extensor carpi radialis brevis can
have a variable source. In most limbs (58%), motor innervation to the extensor carpi radialis brevis arises from the
sensory division of the radial nerve in the forearm, the
superficial radial nerve (294).
3 Nerve Anatomy 215
TABLE 3.5. LEVEL AND ORDER OF INNERVATION
OF MUSCLES SUPPLIED BY THE RADIAL NERVE
Range in cm from
Tip of Acromion
Muscle (Shortest to Longest)
Triceps
Long head 7.1
Medial head 9.5–11.2
Lateral head 10.1
Anconeus
Range in cm from
Humerus (from 10 cm
above Lateral Epicondyle)
Brachioradialis 8.2–10.0
Extensor carpi radialis longus 10.5–12.3
Extensor carpi radialis brevis 14.7–16.5
Range in cm from
Lateral Epicondyle
Extensor carpi ulnaris 10.2–10.6
Extensor digitorum communis 10.2–12.5
Extensor digiti minimi 11.7–12.0
Abductor pollicis longus 11.4–14.2
Extensor pollicis longus 13.9–17.6
Extensor pollicis brevis 15.9–16.4
Extensor indicis proprius 16.9–18.0
From Sunderland S, Hughes ESR. Metrical and non-metrical features
of the muscular branches of the ulnar nerve. J Comp Neurol
85:113–120, 1946; and Linnell EA. The distribution of nerves in the
upper limb, with reference to variabilities and their clinical
significance. J Anat 55:79, 1921.
FIGURE 3.5. Schematic illustration of the radial nerve and associated branches and innervated muscles.
Clinical Correlations: Radial Nerve in the
Axilla and Arm
Holstein-Lewis Fracture
The close proximity of the radial nerve to the surface of the
humeral diaphysis places the nerve at risk for injury with
humeral fractures (295–301). Transient nerve injury is the
most common type of complication associated with
humeral shaft fractures. Most nerve injuries are associated
with transverse or short oblique fractures. Transection of the
radial nerve is rare and associated most commonly with
open fractures, penetrating injuries, or spiral oblique fractures (301).
Radial nerve compression in the arm has been attributed
to impingement by the triceps muscle (302,303).
Radial Nerve in the Forearm and Hand
The radial nerve passes anterior to the lateral epicondyle to
enter the forearm. At approximately the level of the elbow,
the radial nerve divides into the superficial and deep terminal branches deep to the brachioradialis and extensor carpi
radialis longus and brevis (6,291) (see Fig. 3.5). The point
of bifurcation usually is at the level of the radiocapitellar
joint, but it may divide 2 to 5 cm proximal or distal to this
joint (6,13,304). The superficial branch passes anterior
(superior) to the supinator muscle in the proximal third of
the forearm and continues along the deep surface of the
brachioradialis muscle. Proximally, the nerve is adjacent to
the anterior third of the brachioradialis, but as it descends
distally, it courses laterally and anteriorly. The radial artery
passes palmar to the insertion of the pronator teres muscle
and comes to lie on the ulnar border of the brachioradialis
muscle in the middle third of the forearm. The superficial
branch, which descends more laterally, is lateral to the radial
artery, palmar to the origins of the radial head of the flexor
digitorum superficialis and flexor pollicis longus muscle.
The superficial branch continues distally on the deep surface of the brachioradialis, crossing and descending along
the radius. The superficial branch pierces the antebrachial
fascia on the ulnar side of the brachioradialis tendon,
(between the tendons of the brachioradialis and extensor
carpi radialis longus). The nerve thus becomes subcutaneous at approximately 9 cm proximal to the wrist (291).
Superficial Branch of the Radial Nerve
Several patterns of the superficial branch of the radial nerve
have been noted (305,306). The superficial branch of the
radial nerve arose from the radial nerve at the level of the
lateral humeral epicondyle in 8 of 20 specimens, and within
2.1 cm of the lateral epicondyle in the remaining 12. The
superficial branch courses distally deep to the brachioradialis muscle until it emerges between the tendons of the brachioradialis and extensor carpi radialis longus to pierce the
antebrachial fascia. In 10% of specimens, the superficial
branch became subcutaneous by actually piercing the tendon of the brachioradialis. Table 3.6 shows relationships of
the superficial branch of the radial nerve to specific landmarks. The superficial branch of the radial nerve becomes
subcutaneous at a mean of 9 cm proximal to the radial styloid [range, 7 to 10.8 cm, standard deviation (SD) 1.4 cm].
When the nerve initially enters the subcutaneous tissue, its
mean width is 3 mm (SD 0.5 mm). The superficial branch
of the radial nerve continues distally and usually divides
into two branches (85% of specimens) or three branches
(15% of specimens). The first major branch point occurs at
a mean distance of 5.1 cm (range, 3.2 to 7.1 cm, SD 1.8
cm) proximal to the radial styloid. The point at which the
superficial branch of the radial nerve becomes subcutaneous
is, on average, the distal 36% of the distance from the lateral humeral epicondyle to the radial styloid. The first
branch point of the superficial branch of the radial nerve
after it enters the subcutaneous tissue is, on average, the distal 20% of that distance. At the level of the extensor retinaculum, the width of the palmar and dorsal major
branches averages 2 mm (SD 0.4 mm) and 2 mm (SD 0.2
mm), respectively. The nearest branch to the center of the
216 Systems Anatomy
TABLE 3.6. RELATIONSHIPS OF THE SUPERFICIAL BRANCH OF THE RADIAL NERVE TO SPECIFIC
LANDMARKS
Forearm SBRN-SQa to RS Branch to RSc Distance to Center Distance of Closest Branch
Length (cm) (cm/% Forearmb) (cm/% Forearm) of First DC (cm) to Lister’s Tubercle (cm)
Mean 25.5 9.0/36% 5.1/20% 0.4 1.6
Min. 21.5 6.1/25% 2.7/11% 0.0 0.5
Max. 11.6/40% 10.5/38% 1.6 2.9
DC, dorsal compartment; RS, radial styloid.
aSBRN-SQ is the distance from the RS to where the superficial branch of the radial nerve (SBRN) became subcutaneous.
b% forearm indicates the percentage of the distal forearm length at which the SBRN became subcutaneous or had its first major branch point. c
Branch to RS is the distance from the RS to the first major branch point.
From Abrams RA, Brown RA, Botte MJ. The superficial branch of the radial nerve: an anatomic study with surgical implication. J Hand Surg
[Am] 17:1037–1041, 1992.
first dorsal wrist compartment is within a mean transverse
distance of 0.4 cm (SD, 0.4 cm), and in 35% of specimens,
there is a branch lying directly over the center of the first
dorsal wrist compartment. All branches pass radial to Lister’s tubercle by a mean distance of 1.6 cm (SD 0.05 cm).
No branches pass closer than 0.5 cm to the tubercle (305).
In all specimens studied, the major palmar branch continues distally to become the dorsoradial digital nerve of the
thumb. In half of the specimens, before it reached the
thumb, the palmar branch divides into other smaller cutaneous branches that extend to the palmar radial thenar eminence. In 35%, there were connections between these
branches of the superficial branch of the radial nerve and
branches from the lateral antebrachial cutaneous nerve. The
major dorsal branch, with numerous branching configurations, continues distally, branching into the dorsoulnar digital nerve to the thumb and the dorsoradial digital nerve to
the index finger, and a third branch continues distally to
become the dorsoulnar and dorsoradial digital nerves of the
index and long fingers, respectively. The dorsoulnar digital
nerve to the long finger arises from the dorsal sensory
branch of the ulnar nerve in 90% of specimens (305). The
dorsoulnar digital nerve to the thumb parallels the thumb
metacarpal running superficial to the first dorsal
interosseous muscle, passing dorsoulnar to the metacarpophalangeal joint. The widths of the dorsoradial and dorsoulnar digital nerves to the thumb at the level of the
metacarpophalangeal joints are 1.5 mm (SD 0.5 mm) and
1.4 mm (SD 0.3 mm), respectively (305). Despite pattern
variations, discernible features were as follows: The palmar
branch from the first major branch point always became the
dorsoradial digital nerve to the thumb. In 65%, the dorsoulnar digital nerve to the thumb and the dorsoradial digital nerve to the index finger came from the same branch,
which emanated from the first main dorsal branch. In 30%,
the dorsoulnar nerve to the thumb and the dorsoradial
nerve to the index finger came from different branches off
the main dorsal branch, and in 1 specimen of 20, the dorsoulnar nerve to the thumb was noted to arise from a trifurcating branch at the first major branch paint. In all specimens, the continuation of the main dorsal branch
bifurcated distally, usually near the metacarpal heads, into
the dorsoulnar digital nerve to the index finger and the dorsoradial digital nerve to the long finger (305).
Posterior Interosseous Nerve
The posterior interosseous nerve, the deep terminal branch
of the radial nerve, innervates the extensor muscles of the
forearm and contains sensory afferent fibers to the wrist
joint (307,308) (Table 3.7, and see Fig. 3.5). The posterior
interosseous nerve is one of the main continuing branches
after the bifurcation of the radial nerve (291,307,309). The
bifurcation usually occurs at approximately the level of the
radiocapitellar joint. The posterior interosseous nerve continues a few centimeters to enter the supinator muscle. Just
before entering the supinator, the motor branch to the
extensor carpi radialis brevis is given off. The motor branch
to the extensor carpi radialis brevis usually exits off the lateral aspect of the posterior interosseous nerve. The extensor
carpi radialis brevis usually receives its innervation at the
level of the radial head or distal to it (6).
The supinator muscle, arising from the lateral epicondyle, radial collateral ligament, and the proximal ulna, is
divided into deep and superficial heads. The muscle is
approximately 5 cm broad. The posterior interosseous nerve
gives off one or more branches to the supinator muscle
before entering it; however, additional fibers may remain
within the epineurium of the main trunk for several centimeters, supplying the muscle between its two heads. The
posterior interosseous nerve enters the supinator muscle at
the muscle’s proximal end, through a teardrop-shaped
opening in the superficial head of the muscle. The opening
leads the plane between the deep and superficial heads. The
opening in the superficial head contains a fibrous or muscular thickening along its margin, referred to as the arcade
of Frohse (Frohse, 1908). The nerve enters the arcade of the
Frohse and continues distally to pass obliquely between the
superficial and deep muscle bellies. In its course through
the supinator, the nerve usually is somewhat perpendicular
to the direction of the line of the muscle fibers. The nerve
continues dorsolaterally around the neck of the radius and
innervates the supinator while coursing through it. The
nerve is separated from the radius by the deep head of the
supinator muscle, but may come into contact with the
bone, especially when the fibers of the deep head parallel
the course of the nerve (291,310). The nerve crosses the
proximal radius to exit the distal portion of the supinator
approximately 8 cm distal to the elbow joint (6). The nerve
thus emerges dorsally to enter the extensor compartment of
the forearm. As the nerve emerges from the supinator, it
divides into multiple branches, dividing in a somewhat
radial pattern resembling a cauda equina. There is a basic
pattern to the multiple branches, consisting of two major
components. These include those branches that supply the
3 Nerve Anatomy 217
TABLE 3.7. THE POSTERIOR INTEROSSEOUS
NERVE: ORDER OF MUSCLE INNERVATION AND
DISTANCE FROM THE DISTAL EDGE OF THE
SUPINATOR TO THE POINT OF MUSCLE
PENETRATION OF INNERVATED MUSCLE
Extensor carpi ulnaris 1.25 cm
Extensor digitorum communis 1.23–1.8 cm
Extensor digiti quinti 1.8 cm
Abductor pollicis longus 5.6 cm
Extensor pollicis brevis 6.5 cm
Extensor indicis proprius 6.8 cm
Extensor pollicis longus 7.5 cm
From Spinner M. Injuries to the major branches of peripheral nerves
of the forearm, 2nd ed. Philadelphia: WB Saunders, 1978.
superficial layer of muscles (extensor digitorum communis,
extensor digiti quinti, and extensor carpi ulnaris) and those
branches coursing deep to the outcropping muscles (abductor pollicis longus, extensor pollicis longus and brevis, and
extensor indicis proprius). The branch pattern may be quite
variable. After leaving the supinator muscle, the nerve lies
between the abductor pollicis longus muscle (located
deeply) and the extensor carpi ulnaris, extensor digiti minimi, and extensor digitorum communis muscles (all located
superficially). The posterior interosseous nerve is joined on
the extensor surface of the forearm by the posterior
interosseous artery, a branch of the common interosseous
artery. Coursing distally in the forearm, the nerve passes
superficial to the extensor pollicis brevis and deep to the
extensor pollicis longus muscles (291). It penetrates deeply,
either over or through the extensor pollicis brevis muscle,
and comes to lie on the interosseous membrane between the
radius and ulna. Continuing distally on the interosseous
membrane, it divides into terminal branches that provide
sensory innervation to the wrist (291). The extensor carpi
radialis brevis muscle may be innervated by the radial nerve,
its superficial branch, or the posterior interosseous nerve.
Branches to this muscle most commonly originate 2 cm distal to the tip of the lateral epicondyle, but may arise
between 2 and 5 cm distal to it (35,291).
As noted previously, the branch pattern of the posterior
interosseous nerve is variable after it exits the supinator, and
variations exist as to the order and distance that muscles are
innervated (44) (see Fig. 3.5). In general, the nerve gives off
three short and two long motor branches after it leaves the
muscle (291). The general order of muscle innervation and
the distance from the distal edge of the supinator to the
point of innervation of the associated muscle is as follows:
extensor carpi ulnaris, innervated approximately 1.25 cm
distal to the supinator; extensor digitorum communis,
innervated approximately 1.25 to 1.8 cm distal to the
supinator; extensor digiti quinti, innervated approximately
1.8 cm distal to the supinator; abductor pollicis longus,
innervated approximately 5.6 cm distal to the supinator;
extensor pollicis brevis, innervated approximately 6.5 cm
distal to the supinator; extensor indicis proprius, innervated
approximately 6.8 cm distal to the supinator; and extensor
pollicis longus, innervated approximately 7.5 cm distal to
the supinator (6,291,311) (see Tables 3.5 and 3.7).
There are three short branches given off after the posterior interosseous nerve exits the supinator. These innervate
the extensor digitorum communis, followed by the extensor
digiti minimi and the extensor carpi ulnaris muscles, and
arise in close succession and travel a variable distance before
entering their respective muscles (see distances above, Fig.
3.5). Although variation exists, there is a relatively constant
pattern in that the extensor carpi ulnaris and extensor digitorum communis muscles are innervated proximal to the
abductor pollicis longus and extensor pollicis brevis. One to
three terminal branches of the posterior interosseous nerve
supply the extensor carpi ulnaris. These branches pass horizontally in a medial direction to reach the muscle. These
branches arise from the posterior interosseous nerve at
approximately the level just distal to the most distal portion
of the insertion of the anconeus (6). The branches then run
proximally and distally within the muscle. The extensor
digiti minimi is supplied by a branch of the posterior
interosseous nerve just radial to the innervation of the
extensor carpi ulnaris. These motor branches are vulnerable
to injury if the interval between the extensor carpi ulnaris
and the extensor digiti minimi, or between the extensor digiti minimi and extensor digitorum communis in the midforearm, is explored (6).
A long lateral branch supplies the abductor pollicis
longus 5.6 cm distal to the division and ends in the extensor
pollicis brevis, 6.8 cm distal to the division (311). Multiple
branches to these muscles are common (291) (Fig. 3.5).
A final long medial muscular branch provides innervation to the extensor indicis proprius 6.8 cm distal to the
nerve division and to the extensor pollicis longus 7.5 cm
distal to the division (see earlier). This medial branch may
divide and innervate both the extensor pollicis longus and
the extensor indicis proprius, or two separate nerves can
exist that each exit the posterior interosseous nerve, with
each muscle receiving its separate nerve (291).
After innervation of the extensor pollicis longus, the
nerve exits from the muscle belly or from its course superficial to this muscle. The nerve comes to lie on the dorsal
aspect of the interosseous membrane between the radius
and ulna. The nerve continues distally on the interosseous
membrane, where it divides into terminal branches that
provide sensory innervation to the wrist (291). Specific
branches innervate the ligaments of the radiocarpal, intercarpal, and carpometacarpal joints (291,312).
The radial nerve and its branches also carry sympathetic
nerve fibers. The main trunk of the radial nerve, which
divides into several branches in the proximal forearm, supplies sympathetic fibers to the radial artery at the elbow or
in the proximal forearm. More distally in the forearm, the
radial artery is supplied segmentally in the middle and distal portions by sympathetic nerve fibers from the superficial
radial nerve (313).
Anomalies and Variations: Radial Nerve
in the Forearm and Hand
Three patterns of variability are recognized in the course of the
radial nerve in the forearm. The first pattern concerns the terminal branching of the radial nerve trunk. Most commonly,
the nerve bifurcates into superficial and deep branches at the
level of the tip of the lateral epicondyle. The level of division
may vary from 4.5 cm proximal to 4 cm distal to the epicondyle; the distal division is more common (205).
A second pattern of variability concerns the level of
innervation of the forearm muscles. The extensor carpi radi218 Systems Anatomy
alis brevis muscle may be innervated directly from the radial
nerve trunk, from its bifurcation, from the posterior
interosseous nerve, or from the superficial branches. The
supinator muscle usually receives a single branch from the
posterior interosseous nerve before it enters the muscle and
several short branches within the muscle. However, several
branches have been noted to divide proximally to supply
the supinator muscle (17,35,44). As the posterior
interosseous nerve leaves the supinator, several branches
arise to supply the superficial and deep forearm extensor
muscles. Although the level of innervation and branching
described usually is adhered to, significant variation exists
among individuals. All of the branches may arise from one
common nerve, or may divide much like the cauda equina
(2,3,6,11,13,25,44,191,291).
Rarely, as noted by Linell, the motor branch to the
extensor carpi radialis longus can arise from the posterior
interosseous nerve and penetrate the supinator muscle to
reach its destination (205). In this situation, a lesion or
compression of the posterior interosseous nerve may present not only with loss of digital extension, but also with
complete loss of wrist extension. The hand has no sensory
abnormalities, and there is no dysfunction of the brachioradialis muscle.
The posterior interosseous nerve has been shown to have
variable patterns. The nerve may pass superficial to the
supinator, rather than through it. Distally, the nerve may
pass under, over, or through the extensor pollicis brevis
muscle before coming in contact with the interosseous
membrane. Krause and von Luschka have described the
motor branch to the abductor pollicis longus and extensor
pollicis brevis, extensor pollicis longus, and extensor indicis
proprius passing superficial to the superficial head of the
supinator, while the remaining major portion of the posterior interosseous nerve, supplying the extensor digitorum
communis, extensor digiti quinti proprius, and extensor
carpi ulnaris, follows its usual course (6,314,315).
Froment-Rauber Nerve
The posterior interosseous nerve rarely may continue distally to innervate the first, second, and third dorsal
interosseous muscles. This was first described by Froment
in 1846 (316), and further noted by Rauber in 1865
(317,318), and by Shevkunenko in 1949 (312). Spinner has
referred to the anomaly as the Froment-Rauber nerve (6).
Froment-Rauber Anastomosis
An anastomosis may exist between the terminal branches of
the posterior interosseous nerve and the deep branch of the
ulnar nerve in the dorsal interosseous muscles of the hand.
Although originally described by Bichat in 1802 (319) and
again by Hovelacque in 1927 (73,74), the anastomosis usually is referred to as the Froment-Rauber anastomosis. Spinner suggests that the name of Bichat should be added to the
eponym because of Bichat’s early description.
Anterior Interosseous Nerve to Posterior
Interosseous Nerve Anastomosis
Rauber described a communication between the anterior
interosseous nerve and the posterior interosseous, passing
through a foramen in the interosseous ligament. The anterior interosseous nerve usually is divided into three long
branches. The main branch supplies the flexor pollicis
longus, the flexor profundus muscles to the index and long
fingers, and the pronator quadratus. The other two
branches pass adjacent to the interosseous membrane,
where they innervate the interosseous ligament and the
periosteum of the radius and ulna (6). Some of the branches
that travel along the interosseous ligament penetrate the ligament to communicate with terminal branches of the posterior nerve. In the distal forearm, a terminal branch of the
main anterior interosseous nerve branches posterior to the
pronator quadratus and passes through a foramen in the
interosseous ligament to anastomose with branches of the
posterior interosseous nerve. The latter communication can
occur at the distal border of the interosseous ligament. This
is a potential pathway for communication of nerve fibers
between the median nerve and radial nerve. It also is possible that the median nerve fibers that join the posterior
nerve actually may continue to reach the intrinsic muscles
of the hand (6). Spinner notes that this is an example of
neural plexification that occurs throughout the entire
peripheral nervous system.
The Superficial Branch of the Radial Nerve
The superficial branch of the radial nerve may wind around
the brachioradialis and continue on the superficial surface
of the muscle, rather than along the deep surface. It can
thus course from the elbow to the hand in the subcutaneous
tissue on the dorsolateral surface of the forearm (6,194).
Rarely, the brachioradialis and extensor carpi radialis
longus muscles share a common muscle belly, or have a conjoined muscle. In these cases, the superficial branch of the
radial nerve has been reported to perforate a conjoined tendon that is shared by the two muscles (6).
Absence of the Superficial Branch of the
Radial Nerve
Complete absence of the superficial branch of the radial
nerve has been described (320). In this case, the area normally supplied by the radial nerve was supplied by the musculocutaneous nerve (which extended more distally than
normal), and an enlarged ulnar dorsal cutaneous nerve
(320) was found to supply the autonomous zone of the
thumb.
3 Nerve Anatomy 219
The superficial branch of the radial nerve may supply
sensibility to the thenar eminence in the region (normally
innervated by the palmar cutaneous branch of the median
nerve), and to the palmar aspect of the thumb (normally
innervated by the common digital nerves of the thumb
originating from the median nerve). Thus, it is possible for
an injury to the superficial branches of the radial nerve to
produce numbness or anesthesia of both the dorsal and palmar aspects of the thumb.
The superficial branch of the radial nerve may supply the
entire dorsum of the hand. Learmonth has reported an
anatomic specimen in which the entire dorsal cutaneous
branch of the ulnar nerve was absent. The region normally
supplied by the ulnar nerve was supplied by an enlarged
superficial radial nerve, which had additional branches (208).
The Musculocutaneous Nerve
Spinner and colleagues noted several specimens and clinical
cases where the musculocutaneous nerve extended more
distally than traditionally depicted. The nerve can continue
into the hand to supply the anterior palmar aspect of the
thumb or thenar eminence (in the region of the thumb
metacarpal between the sensory region of the medial palmar
cutaneous nerve area and the more dorsal superficial radial
autonomous zone) (6).
The musculocutaneous nerve also may supply sensibility
to the dorsum of the thumb in the area usually supplied by
the superficial branch of the radial nerve (6).
It is not uncommon for there to be a communicating
branch between the superficial branch of the radial nerve
and the musculocutaneous nerve (205).
Spinner has pointed out that communicating branches
between the median and musculocutaneous nerves in the
arm and between the median and ulnar nerves in the intrinsic muscles probably pass distally through the posterior cord
to the posterior interosseous nerve rather than through the
usual medial cord to the ulnar nerve path (6).
Clinical Correlations: Radial Nerve in the
Forearm and Hand
Radial Tunnel Syndrome
The radial nerve may be compressed or develop neuritis along
its course in the radial tunnel, frequently between the head or
neck of the radius and the supinator muscle (321,322). The
radial nerve is particularly at risk at its entrance into the
supinator, at the arcade of Frohse. The arcade of Frohse is a
fibrous or fascial band resembling an oval-shaped window at
the proximal aspect of the supinator muscle. The nerve also
may be compressed in the muscle itself (see discussion of paralysis of the posterior interosseous nerve, later). Mass lesions
such as synovial cysts, synovitis, or lipomas also can impinge
on the radial nerve and associated branches (323–326).
The radial nerve is at risk in the radial tunnel during
radial head excision or fixation of fractures (327–344).
During operative exposure of the radial head and neck,
rotation of the forearm in pronation rotates the nerve away
from and slightly more distal to the operative site, and provides additional safety. With the elbow in supination, the
posterior interosseous nerve passes the neck of the radius
with a minimal distance of approximately 2.2 cm (mean,
3.3 cm) distal to the radiocapitellar articulation. With the
elbow pronated, this minimal distance increases to 3.8 cm
(mean 5.2 cm), thus moving the nerve away from the operative area (345).
The Presence or Absence of the Wrist
Extensors
The presence or absence of the active wrist extension
(extensor carpi radialis longus and brevis and extensor carpi
ulnaris) is helpful in determining the level of nerve injury or
dysfunction. A high radial nerve injury that is above the
elbow usually results in loss of wrist and digital extension.
If wrist extension and radial deviation are present (indicating function of the extensor carpi radialis longus), the lesion
is distal to the branching of this nerve. A lesion of the posterior interosseous nerve usually preserves the branch to the
extensor carpi radialis brevis, which branches from the
superficial branch of the radial nerve or from its own
branch proximal to the supinator muscle.
Posterior Interosseous Nerve Paralysis
A hand with a posterior interosseous nerve paralysis usually
dorsiflexes in a radial direction because of preservation of
the extensor carpi radialis longus (and brevis). On occasion,
the wrist may dorsiflex more neutrally. This can be due to
variation of the insertion of the radial extensors of the wrist.
The extensor carpi radialis longus can have a tendinous
attachment to the brevis tendon. The extensor carpi radialis
longus also can insert not only to the base of the index
metacarpal, but to the base of the long metacarpal. Either
of these conditions helps produce a more neutral wrist
extension with complete paralysis of the posterior
interosseous nerve.
Spontaneous Neuropathy of the Posterior
Interosseous Nerve
The most frequent cause of spontaneous neuropathy of the
posterior interosseous nerve probably is entrapment of the
nerve as it enters the supinator muscle at the arcade of
Frohse (346,347). Spontaneous neuropathy is well documented in the historical literature (73,111,208,316,327,
346,348–361). Two clinical pictures are described. The first
is a complete paralysis of all innervated muscles (the extensor carpi radialis brevis often is spared because it often arises
220 Systems Anatomy
separately from the superficial branch of the radial nerve, or
from the posterior interosseous nerve proximal to the
arcade of Frohse, and does not penetrate the muscle). The
second clinical picture is a slow, progressive paralysis of the
posterior interosseous nerve, usually commencing with
paralysis of one or several muscles. If untreated, it frequently progresses to a complete paralysis.
Pseudoulnar Claw Hand
When there is an incomplete, spontaneous neuropathy of
the posterior interosseous nerve, the ring and small fingers
initially may be involved. There is lack of extension of these
digits, which assume a position of flexion at the metacarpophalangeal joints and the proximal and distal interphalangeal joints. The hand with these flexed digits may resemble a claw hand (similar to ulnar neuropathy, without the
extension at the metacarpophalangeal joints). This partial,
spontaneous neuropathy of the posterior interosseous has
been described as a pseudoulnar claw hand (362).
Additional partial paralysis of the posterior interosseous
nerve includes loss of extension at the metacarpophalangeal
joints of single digits, combinations of digits, or the thumb
(350,351,354,356,357,363).
Differential Diagnosis in Loss of Digital
Extension
Loss of digital extension can occur from several etiologies,
especially in the patient with inflammatory arthritis. The
causes of digital extensor function loss include posterior
interosseous nerve paralysis, spontaneous rupture of extrinsic extensor tendon(s), extensor tendon subluxation into
the valley between metacarpal heads (such as can occur with
inflammatory arthritis that results in incompetence of the
sagittal bands for tendon centralization and stabilization),
and metacarpophalangeal joint subluxation (in inflammatory arthritis). Partial posterior interosseous nerve paralysis
can be distinguished from the other causes by clinical examination, as follows:
Neuropathy of the Posterior Interosseous Nerve
Partial or complete posterior interosseous nerve paralysis
results in loss of active digital extension specifically at the
metacarpophalangeal joint. Active digital extension function remains intact at proximal and distal interphalangeal
joints because of ulnar nerve–innervated intrinsic muscles.
The tenodesis effect is intact (with digital extension occurring when the wrist is passively flexed), and thus helps rule
out extensor tendon rupture. Radiographs help determine if
metacarpophalangeal joint subluxation is present.
Extensor Tendon Rupture
There is loss of active digital extension at the metacarpal
joints. The tenodesis effect is absent (showing no digital
extension occurring when the wrist is passively flexed). The
patient is unable to maintain digital extension at the
metacarpophalangeal joint when the joint is passively
placed in an extended position (helping to rule out extensor
tendon subluxation between the metacarpal heads). Radiographs help determine if metacarpophalangeal joint subluxation is present (364).
Extensor Tendon Subluxation
With extensor tendon subluxation, there is weakness or
inability actively to extend the digit at the metacarpophalangeal joint. However, the patient is able to maintain digital
extension when the digits are passively placed in extension.
This is possible because the tendon often centralizes when the
metacarpophalangeal joint is passively placed in extension.
The patient is able momentarily to maintain the extended
position. However, when the digit is flexed, the tendon
resubluxates, and digital extension no longer is possible.
Metacarpophalangeal Joint Subluxation
With metacarpophalangeal joint subluxation, as can
develop with rheumatoid arthritis, the patient is unable
fully to extend the digits. Passive extension of the digit may
not be possible, and this helps distinguish the condition
from tendon subluxation. Radiographs show metacarpophalangeal joint subluxation, and help distinguish the
condition from nerve palsy.
Innervation of the Posterior Interosseous
Nerve
There is clinical relevance to the order and distance of
innervation of the posterior interosseous nerve (see Table
3.7). These can be used in identifying the portion or level
of nerve injured from penetrating trauma. The order and
distances also have predictive usefulness post-nerve repair in
the evaluation of nerve regeneration success and expectations. After successful neurorrhaphy or neurolysis of the
posterior interosseous nerve, the earliest clinical sign of
impending recovery is the ability of the wrist to dorsiflex in
a neutral, or even ulnar, direction. This indicates recovery of
function of the extensor carpi ulnaris (and, to some extent,
of the extensor digitorum communis).
Safe and Unsafe Internervous Planes
Because of the transverse or horizontal branching of the
posterior interosseous nerve in the mid-forearm, motor
branches are vulnerable to injury if the intervals between
the extensor carpi ulnaris and the extensor digiti minimi, or
between the extensor digiti minimi and extensor digitorum
communis, are explored (6). Relatively safe internervous
planes in this area are between the anconeus and the extensor carpi ulnaris and between the extensor digitorum communis and the extensor carpi radialis brevis.
3 Nerve Anatomy 221
Communication Between the Anterior
Interosseous Nerve and the Posterior
Interosseous
As noted earlier, Rauber described a communication
between the anterior interosseous nerve and the posterior
interosseous, passing through a foramen in the interosseous
ligament. When present, this explains the retained function
of the intrinsic muscles in a hand when the ulnar nerve has
been severed (6,317,318).
The Superficial Branch of the Radial Nerve
The superficial branch of the radial nerve may be compressed distal to its exit from the radial tunnel and along its
course in the forearm and wrist. It may be impinged at its
passage from the subfascial to the subcutaneous level, where
its exits into the subcutaneous tissues between the brachioradialis and extensor carpi radialis longus. Dysfunction of
the superficial branch of the radial was described by
Wartenberg in 1932, and his name often is used in association with the clinical syndrome (365,366).
The superficial branch of the radial nerve usually passes
dorsally from the deep surface of the brachioradialis to
become subcutaneous approximately 10 cm proximal to the
radial styloid. The nerve is especially vulnerable to external
injury or compression from this point distally. The nerve
has been compressed by external objects, such as tight wristwatches, bracelets, handcuffs, gloves, and casts (6,367). The
nerve also may be injured from iatrogenic causes, including
laceration from release of the first dorsal compartment in
De Quervain’s disease, from injury from a cutdown procedure of a vein in the distal forearm, or from laceration from
tendon lengthening procedures involving the extensor carpi
radialis or longus (6).
Injury to the superficial branch of the radial nerve can
result in considerable pain and disability, and a full causalgia syndrome can develop (368). Neuromas or associated
regional pain syndromes from sympathetic-mediated nerve
dysfunction are particularly troublesome.
A communication branch between the superficial branch
of the radial nerve and the musculocutaneous nerve in the
distal forearm is not uncommon (205). Because of this, laceration of the superficial branch of the radial nerve in the
proximal forearm (proximal to the communicating branch)
may not present clinically with the classic sensory loss
expected for superficial radial nerve injury.
MUSCULOCUTANEOUS NERVE
Origin of the Musculocutaneous Nerve
The musculocutaneous nerve originates from the lateral
cord of the brachial plexus and is derived from the ventral
rami of C5, C6, and C7. It branches from the lateral cord at
the level of and deep to the pectoralis minor (see Fig. 3.1).
Musculocutaneous Nerve in the Axilla
and Arm
The nerve extends distally on a course lateral to the remaining brachial plexus and medial to the proximal humerus.
The nerve pierces the coracobrachialis and continues distally, in a lateral course between the biceps and brachialis to
the lateral side of the arm. The course of the nerve in this
part of the arm has been delineated by Williams and Latarjet et al., noting that the nerve projects along a line drawn
from the lateral side of the third part of the axillary artery
across the coracobrachialis and biceps to the lateral side of
the biceps tendon (3). The course is varied by its point of
entry into the coracobrachialis (369). The musculocutaneous nerve supplies the coracobrachialis, both heads of the
biceps, and most of the brachialis (see Fig. 3.2). The branch
to the coracobrachialis exits the musculocutaneous nerve
before it enters the muscle. The fibers from this branch (to
the coracobrachialis) are derived from the ventral ramus of
C7. This nerve may branch directly from the lateral cord.
The branches to the biceps and brachialis leave the musculocutaneous after the nerve pierces the coracobrachialis.
The nerve branch to the brachialis also sends a branch to
the elbow joint for innervation. The nerve also supplies a
small branch to the humerus, where it enters the cortex
with the nutrient artery.
At a point just distal to the elbow, the musculocutaneous
nerve pierces the deep fascia lateral to the tendon of the
biceps. From this point, it continues as the lateral antebrachial cutaneous nerve (lateral cutaneous nerve of the
forearm).
Lateral Antebrachial Cutaneous Nerve
(Lateral Cutaneous Nerve of the Forearm)
The lateral antebrachial cutaneous nerve originates as a continuing branch of the musculocutaneous nerve (see Figs. 3.2
and 3.4). The musculocutaneous nerve in the arm passes deep
to the biceps and superficial to the brachialis, in a medial-tolateral direction. As the musculocutaneous nerve passes distally and laterally, it reaches the approximate level of the elbow
joint, and exits from the deep surface of the biceps to become
cutaneous. At this point, the musculocutaneous nerve
becomes the lateral antebrachial cutaneous nerve. The lateral
antebrachial cutaneous nerve continues distally in the forearm, deep to the cephalic vein, and descends along the radial
border of the forearm to reach the wrist. In the forearm, the
nerve sends out small cutaneous branches to provide sensibility to the skin of the anterolateral forearm. The nerve may
have anastomoses distally with either the posterior cutaneous
nerve of the forearm or with the superficial branch of the
radial nerve (3). The nerve may give rise to a slender recurrent
branch that extends along the cephalic vein as far as the middle third of the arm, giving off several small branches to provide sensibility to the skin over the distal third of the anterolateral surface of the upper arm (370,371). This recurrent
222 Systems Anatomy
branch rarely is mentioned in most descriptions of the nervous anatomy in the upper extremity (3).
At the level of the wrist joint, the lateral antebrachial
cutaneous nerve is located anterior to the radial artery and
may have several small branches that pierce the deep fascia
and accompany the radial artery to the dorsum of the wrist.
The nerve then passes to the base of the thenar eminence
and ends in multiple small cutaneous rami. The nerve often
connects with the superficial branch of the radial nerve and
the palmar cutaneous branch of the median nerve.
Anomalies and Variations:
Musculocutaneous Nerve and Lateral
Antebrachial Cutaneous Nerve
Several variations of the lateral antebrachial cutaneous
nerve have been described.
n The musculocutaneous nerve may pass behind the coracobrachialis (instead of passing through the muscle) (3).
n The musculocutaneous nerve may accompany or actually adhere to the median nerve in its course in the arm.
n The musculocutaneous usually supplies motor innervation to the coracobrachialis. The muscle, however, may
be innervated by its own nerve, and branch directly from
the lateral cord of the brachial plexus.
n Small branches of the median nerve may pass to the musculocutaneous nerve and continue with the musculocutaneous nerve. Conversely, small branches of the musculocutaneous nerve may pass to the median nerve, and
continue with the median nerve.
n The distal branches of the lateral antebrachial cutaneous
nerve may have anastomoses with the superficial branch
of the radial nerve or with the palmar cutaneous branch
of the median nerve.
n The lateral antebrachial cutaneous nerve may, through
these small distal branches, innervate or help innervate
the pronator teres.
n The lateral antebrachial cutaneous nerve may have small
branches that extend to the dorsum of the thumb and
supply sensibility to the overlying skin (replacing the
innervation of the terminal portion of the superficial
branch of the radial nerve) (3).
Clinical Correlations: Musculocutaneous
Nerve and Lateral Antebrachial
Cutaneous Nerve
Injury to the musculocutaneous nerve can occur from
fractures of the proximal humerus. Clinical findings
include weakness of elbow flexion (from paresis of the
biceps and brachialis) and sensory loss on the lateral aspect
of the forearm. Pain and paresthesia may be aggravated by
elbow extension, which can stretch the musculocutaneous
nerve.
The lateral antebrachial cutaneous nerve can be used as
a donor nerve for nerve grafting. However, because of
donor site morbidity with numbness on the lateral aspect of
the forearm, other donor nerves (such as the sural nerve)
usually are selected.
MEDIAL BRACHIAL CUTANEOUS NERVE
(MEDIAL CUTANEOUS NERVE OF THE ARM,
NERVE OF WRISBERG)
The medial brachial cutaneous nerve, often referred to as
the medial cutaneous nerve of the arm, or as the nerve of
Wrisberg (3,11), is a sensory nerve that supplies the medial
aspect of the arm from the axilla to the medial elbow. It is
considered the smallest true nerve branch that originates
from the brachial plexus.
Origin of the Medial Brachial Cutaneous
Nerve
The medial brachial cutaneous nerve originates from the
medial cord of the brachial plexus. It comprises mostly fibers
from the ventral rami of C8 and T1 (see Fig. 3.1). The nerve
branches from the medial cord at a point slightly proximal to
the point of origin of the medial antebrachial cutaneous nerve.
Medial Brachial Cutaneous Nerve in the
Axilla and Arm
From its origin from the medial cord, the medial brachial
cutaneous nerve passes through the axilla deep to the pectoralis insertion and anterior to the latissimus dorsi. In its
proximal course, it is located dorsal to the axillary artery
and vein. As it continues distally, it comes to lie medial to
these vessels. The nerve may pass posterior to the axillary
vein. In the axilla, it may anastomose with the intercostal
nerves. The medial brachial nerve may branch early and
consist of several branches as it exits the axilla. The nerve
and associated branches continue distally medial to the
brachial artery and basilic vein. The nerve descends distally
along the medial aspect of the arm and pierces the deep
brachial fascia to become cutaneous in the mid-portion of
the arm. It continues to branch and provides sensibility to
the medial aspect of the arm as far distally as the medial epicondyle and olecranon (11) (see Fig. 3.4).
Anomalies and Variations: Medial
Brachial Cutaneous Nerve
n The medial brachial cutaneous nerve may communicate
with the medial antebrachial cutaneous nerve through
the ulnar branch of the latter nerve.
n The medial brachial cutaneous nerve may originate as a
branch of the medial antebrachial cutaneous nerve (11).
n The anastomoses with the intercostal nerve in the proximal axilla may have so many branches that the connections assume a plexiform pattern in the axilla.
3 Nerve Anatomy 223
n The intercostobrachial nerve communication may be
large (between the medial brachial cutaneous nerve and
the intercostal nerves) and may be reinforced by a part of
the lateral cutaneous branch of the third intercostal
nerve. When there is a large contribution or component
from the lateral cutaneous branch of the third intercostal
nerve, it may replace the medial cutaneous nerve of the
arm (3).
Clinical Correlations: Medial Brachial
Cutaneous Nerve
The medial brachial cutaneous nerve contains only sensory
fibers. Injury to the medial brachial cutaneous nerve results
in loss of sensibility to the medial aspect of the arm.
MEDIAL ANTEBRACHIAL CUTANEOUS
NERVE (MEDIAL CUTANEOUS NERVE OF
THE FOREARM)
The medial antebrachial cutaneous nerve, often referred to
as the medial cutaneous nerve of the forearm, is a sensory
nerve that supplies the medial aspect of the forearm from
the elbow to the wrist. It also supplies sensibility to the skin
overlying a portion of the anterior arm anterior to the
biceps muscle.
Origin of the Medial Antebrachial
Cutaneous Nerve
The medial antebrachial cutaneous nerve originates from the
medial cord of the brachial plexus. It comprises mostly fibers
from the ventral rami of C8 and T1 (see Fig. 3.1 and Appendix 3.1). The nerve branches from the medial cord at a point
slightly distal to the point of origin of the medial brachial
cutaneous nerve.
Medial Antebrachial Cutaneous Nerve in
the Axilla, Arm, and Forearm
From its origin from the medial cord, the medial antebrachial cutaneous nerve passes through the axilla deep to
the pectoralis insertion and anterior to the latissimus dorsi.
In its proximal course, it lies medial to the axillary artery,
much closer to the artery than the medial brachial cutaneous nerve. It often is situated between the axillary artery
and vein. In the proximal portion, just distal to the axilla,
the nerve gives off a small branch that pierces the fascia over
the proximal and anterior aspect of the biceps muscle. This
branch supplies sensibility to the skin overlying the anterior
biceps muscle from the axilla to the level of the elbow. The
main nerve continues distally along the medial aspect of the
arm medial to the brachial artery. It pierces the deep fascia
with the basilic vein to become cutaneous in the mid-portion of the arm. The nerve divides into an anterior and a
posterior (ulnar) branch (Fig. 3.4).
Anterior Branch of the Medial Antebrachial
Cutaneous Nerve
The anterior branch of the medial antebrachial cutaneous
nerve usually is a larger branch than the posterior (ulnar)
branch of the medial antebrachial nerve. The anterior
branch continues distally along the anteromedial aspect
of the forearm. Proximally in the forearm, it usually
passes superficial to the median basilic vein. The nerve
then continues on the anterior part of the ulnar forearm,
supplying the skin of the anteromedial forearm as far distally as the wrist. It often has an anastomosis with the palmar cutaneous branch of the ulnar nerve (3,11) (see Fig.
3.4).
Posterior (Ulnar) Branch of the Medial
Antebrachial Cutaneous Nerve
The posterior (ulnar) branch of the medial antebrachial
cutaneous nerve continues obliquely distally along the
medial side of the basilic vein, anterior to the medial epicondyle of the humerus but curving posteriorly, and spiraling around the ulnar aspect of the forearm to reach the dorsal portion of the medial forearm. It continues distally along
the ulnar aspect of the forearm as far distal as the wrist, supplying the overlying skin as it extends distally (see Fig. 3.4).
It often has anastomoses with the medial brachial cutaneous
nerve (in the proximal forearm), with the dorsal antebrachial cutaneous nerve, and with the dorsal branch of the
ulnar nerve (3,11).
Anomalies and Variations: Medial
Antebrachial Cutaneous Nerve
The anterior branch of the medial antebrachial nerve
descends anteromedially in the forearm to reach the wrist.
In this area it often has an anastomosis with the palmar
cutaneous branch of the ulnar nerve.
The posterior branch of the medial antebrachial nerve
descends distally and posterior to the dorsal aspect of the
forearm, to reach the medial border of the wrist. Along its
course, it may have several anastomoses, including those
with the medial brachial cutaneous (in the proximal forearm), or with the posterior cutaneous nerve of the forearm
or the dorsal branch of the ulnar nerve.
Clinical Correlations: Medial Antebrachial
Cutaneous Nerve
The medial antebrachial cutaneous nerve contains only sensory fibers. Injury to the medial antebrachial cutaneous
nerve results in loss of sensibility to the medial aspect of the
224 Systems Anatomy
forearm and a portion of the anterior arm overlying the
anterior biceps.
Injury to the medial cord or to the C8 or T1 nerve
roots results in dysfunction of the medial antebrachial
cutaneous nerve (as well as ulnar neuropathy), and is associated with numbness along the medial aspect of the forearm and a portion of the anterior arm overlying the anterior biceps.
SENSORY ORGANELLES
Several sensory nerve endings (organelles) terminate in the
skin, usually in relatively high concentrations in the hand.
These are innervated by the sensory nerve endings of the
median, ulnar, and radial nerves. The nerve endings are
encapsulated and exhibit considerable variety in size, shape,
and distribution, but all share in common the feature of an
axon terminal encapsulated by nonexcitable cells. The
major end organelles include the pacinian corpuscles,
Meissner corpuscles, Ruffini nerve endings, and Merkel
receptors (3,372,373) (Fig. 3.6).
Pacinian Corpuscles
Pacinian corpuscles (corpuscles of Vater-Pacini) are relatively
large, lamellated structures located in the subcutaneous tissue.
They occur in high concentrations on the palmar surface of
the hand and digits (as well as in the plantar foot, periostea,
interosseous membranes, and periarticular areas). These are
rapidly adapting receptors, and their function usually is considered to be detection of vibration, pressure, or coarse touch
(3,373). They are oval, spherical, or irregular firm masses,
smooth and glistening white or yellow in color, up to 2 to 4
mm in size (approximately 100 to 500 µm across) (373), and
are easily seen with (or without) loupe magnification during
operative procedures on the palmar surface of the hand or digits. Each has a capsule, an intermediate growth zone, and a
3 Nerve Anatomy 225
FIGURE 3.6. Sensory organelles.
central core containing an axon terminal. The capsule is
formed by approximately 30 concentrically arranged lamellae
of flat cells. The axon terminal consists of an unbranched terminal of a peripheral nerve, and is in contact with the innermost core lamellae (3,372,373).
Meissner Corpuscles
Meissner corpuscles (tactile corpuscles of Meissner) are found
in the dermis, usually in the superficial layers very close to the
epidermis. They are in relatively high concentrations in all
parts of the hand (and foot), especially in the distal digits
(373). They also are rapidly adapting and highly sensitive to
fluctuating mechanical forces acting on the surface of the skin.
Meissner corpuscles are particularly sensitive to vibration at
certain frequencies. The structures are somewhat cylindrical in
shape, with their long axes perpendicular to the skin surface.
They are much smaller than the pacinian corpuscles, measuring approximately 80 µm long and 30 µm across. The
organelle has a connective tissue capsule and a central core, the
capsule being loosely attached to the core. Like the pacinian
corpuscle, the Meissner corpuscle has an axon terminal ending inside of the capsule (3) (Fig. 3.6).
Ruffini Nerve Endings
Ruffini endings (type II slowly adapting cutaneous mechanoreceptors) occur in the dermis of hairy skin. These are
slowly adapting (compared with the rapidly adapting
pacinian and Meissner corpuscles) and responsive to continuous forces such as maintained stress or stretch of the
skin. They consist of highly branched nerve endings that
are distributed among bundles of collagen fibers in a
spindle-shaped structure. The structure is enclosed partly
by a fibrocellular sheath derived from the perineurium of
the nerve (3) (Fig. 3.6).
Merkel Receptors
Merkel receptors basically are nerve endings (type I slowly
adapting cutaneous mechanoreceptors), and occur in the
skin in the vicinity of the dermal–epidermal junction. The
nerve ending is located in the basement membrane and keratinocytes of the epidermis, or near the hair follicle. The
Merkel receptors are sensitive to perpendicular pressure or
indentation of the skin, or to the bending of the hair follicle (3,373).
226 Systems Anatomy
APPENDIX 3.1. DERMATOMES OF THE UPPER EXTREMITY
REFERENCES
1. Anderson JE. Grant’s atlas of anatomy. Baltimore: Williams &
Wilkins, 1983.
2. Clemente CD. Anatomy: a regional atlas of the human body.
Philadelphia: Lea & Febiger, 1975.
3. Williams PW. Gray’s anatomy: the anatomical basis of medicine
and surgery, 38th ed. New York: Churchill Livingstone, 1995:
425–736.
4. Basmajian JV, Slonecker CE. Grant’s method of anatomy: a clinical problem-solving approach. Philadelphia: Williams &
Wilkins, 1989.
5. Borchardt M, Wjasmenski H. Der Nervus Medianus. Beitr F
Klin Chir 107:553–582, 1917.
6. Spinner M. Injuries to the major branches of peripheral nerves of
the forearm, 2nd ed. Philadelphia: WB Saunders, 1978.
7. Siegel DB, Gelberman RH. Median nerve: applied anatomy
and operative exposure. In: Gelberman RH, ed. Operative nerve
repair and reconstruction. Philadelphia: JB Lippincott, 1991:
365–378.
8. Warwick R, Williams PL, eds. Gray’s anatomy, 35th ed.
(British). Philadelphia: WB Saunders, 1973:1041–1043.
9. Kaplan EB. Functional and surgical anatomy of the hand, 2nd ed.
Philadelphia: JB Lippincott, 1965.
10. Kaplan EB, Spinner M. Normal and anomalous innervation
patterns in the upper extremity. In: Omer GE, Spinner M, eds.
Management of peripheral nerve problems. Philadelphia: WB
Saunders, 1980:75–99.
11. Clemente CD. Gray’s anatomy, 13th ed. Baltimore: Williams &
Wilkins, 1985.
12. Kerr AT. The brachial plexus of nerves in man, the variations in
its formation and branches. Am J Anat 23:285–288, 1918.
13. Hollingshead WJH. Anatomy for surgeons: the back and limbs,
vol 3. Philadelphia: JB Lippincott, 1982:341–529.
14. Mayfield FH. Compression syndromes of the shoulder girdle
and arms. In: Vinken PJ, Bruyn GW, eds. Handbook of clinical
neurology, vol 7: Diseases of nerves. New York: American Elsevier,
1970:441–444.
15. Kameda Y. An anomalous muscle (accessory scapularis-teres
latissimus) in the axilla penetrating the brachial plexus in man.
Acta Anat 96:513, 1976.
16. Miller R. Observations upon the arrangement of the axillary
artery and brachial plexus. Am J Anat 64:143, 1939.
17. Spinner M. Management of nerve compression lesions of the
upper extremity. In: Omer GE, Spinner M, eds. Management of
peripheral nerve problems. Philadelphia: WB Saunders, 1980:
569–587.
18. Struthers J. On some points in the abnormal anatomy of the
arm. Br Foreign Med Chir Rev 14:170–179, 1854.
19. Struthers J. Anatomical and physiological observations. Part 1.
Edinburgh: Sutherland and Knox, 1854.
20. Solieri S. Neuralgia del nervo mediano da processo sopraepitrocleare. Chir Organi Mov 4:171, 1929.
21. Mandruzzato F. Patologia e chiurgia del processo sopraepitrocleare dell’omero. Chir Organi Mov 24:123, 1938.
22. Barnard LB, McCoy SM. The supracondyloid process of the
humerus. J Bone Joint Surg 28:845, 1946.
23. Crotti FM, Manisasalli EP, Rampini P. Supracondyloid process
and anomalous insertion of pronator teres as sources of median
nerve neuralgia. J Neurosurg Sci 25:41, 1981.
24. Eversmann WW Jr. Entrapment and compression neuropathies.
In: Green DP, ed. Operative hand surgery, 2nd ed. New York:
Churchill-Livingstone, 1988:1424–1432.
25. Gardner E. The innervation of the elbow joint. Anat. Rec 102:
161–174, 1948.
26. Dellon AL, Mackinnon SE. Musculoaponeurotic variations
along the course of the median nerve in the proximal forearm.
J Hand Surg [Br] 12:359–363, 1987.
27. Dellon AL, Mackinnon SE, Seiler WA. Peripheral nerve diseases. In: Adams RJ, Swindle MM, eds. Experimental surgery
and physiology: induced animal models of human disease. Baltimore: Williams & Wilkins, 1988:278–283.
28. Bhadra N, Keith MW, Peckham H. Variations in the innervation of the flexor digitorum profundus muscle. J Hand Surg
[Am] 24:700–703, 1999.
29. Inglis AE. Surgical exposure of peripheral nerves. In: Omer GE,
Spinner M, eds. Management of peripheral nerve problems.
Philadelphia: WB Saunders, 1980:317–331.
30. Gelberman RH, Zakaib GS, Mubarak SJ, et al. Decompression
of forearm compartment syndromes. Clin Orthop 134:
225–229, 1978.
31. Hollingshead WH. Anatomy for surgeons: the back and limbs, vol
3. Philadelphia: JB Lippincott, 1982:341–529.
32. Sunderland S, Ran LJ. Metrical and non-metrical features of the
muscular branches of the median nerve. J Comp Neurol 85:
113–120, 1946.
33. Henry AK. Extensile exposure, 2nd ed. New York: ChurchillLivingstone, 1973:94–99.
34. Spinner M. The anterior interosseous nerve syndrome with special attention to its variations. J Bone Joint Surg Am 52:84–94,
1970.
35. Sunderland S. The intraneural topography of the radial,
median, and ulnar nerves. Brain 68:243–299, 1945.
36. Meals RA, Calkins ER. Anomalous innervation of the upper
extremity. In: Gelberman RH, ed. Operative nerve repair and
reconstruction. Philadelphia: JB Lippincott, 1991:197–211.
37. Taleisnik J. The palmar cutaneous branch of the median nerve
and the approach to the carpal tunnel. J Bone Joint Surg Am
55:1212–1217, 1973.
38. Eversmann WW. Proximal median nerve compression. Hand
Clin 8:307–315, 1992.
39. Mannerfelt L. Studies of anastomoses between the median and
ulnar nerves in the forearm. Acta Univ Lund II(6), 1964.
40. Murphey F, Kirklin JW, Finlayson AE. Anomalous innervation
of intrinsic muscles of the hand. Surg Gynecol Obstet 83:
15–23, 1946.
41. Rowntree T. Anomalous innervation of the hand muscles. J
Bone Joint Surg Br 31:505–510, 1949.
42. Highet WB. Innervation and function of the thenar muscles.
Lancet 1:227–230, 1943.
43. Schwarz M. Kann die Hauttextur als Wegweiser fur den Verlauf
und die Variation des N medianus dienen? Handchirurgie 20:
344–346, 1988.
44. Sunderland S. Nerves and nerve injuries, 2nd ed. New York:
Churchill-Livingstone, 1978.
45. Brooks HSJ. Variations in the nerve supply of the lumbrical
muscles in the hand and foot, with some observations on the
innervation of the perforating flexors. J Anat Physiol 212:
575–585, 1887.
46. Mannerfelt L. Studies on the hand in ulnar nerve paralysis. Acta
Orthop Scand Suppl 87:1–176, 1966.
47. Cliffton EE. Unusual innervation of the intrinsic muscles of the
hand by median and ulnar nerve. Surgery 23:12–31, 1948.
48. Shu HS, Chantelot C, Oberlin C, et al. Martin-Gruber communicating branch: anatomical and histological study. Surg
Radiol Anat 21:115–118, 1999.
49. Taams KO. Martin-Gruber connections in South Africa: an
anatomical study. J Hand Surg [Br] 22:328–330, 1997.
50. Curtis R. Recherches anatomiques sur l’anatomoses et du
median et du cubital a l’avantbras. Int Mschr Anat Physiol 3:
309–324, 1886 (cited by Hovelacque).
3 Nerve Anatomy 227
51. Gruber W. Ueber die Verbindung des Nervus medianus mit
dem Nervus ulnaris an Unterarme des Menschen und der
Saugethiere. Arch Anat Physiol 37:501–522, 1870.
52. Hirasawa K. Plexus brachialis und die nerven der oberen
extremitat. Anatomischen Institutes der Kaiserlichen Universitat.
Serie A, Heft 2, Kyoto, Japan, 1931.
53. Martin R. Tal om nervus allmanna egenskaper l mannsikans
kropp. Stockholm: Lars Salvius, 1763 (cited by Kaplan and
Spinner).
54. Thompson A. Third annual report on the Committee of Collective Investigation of the Anatomical Society of Great Britain
and Ireland for the year 1891–1892. J Anat Physiol 27:
183–194, 1893.
55. Buchthal F, Rosenfalck A, Trojaborg W. Electrophysiological
findings in entrapment of the median nerve at the wrist and
elbow. J Neurol Neurosurg Psychiatry 37:340–360, 1974.
56. Gutmann L. Median-ulnar nerve communications and carpal
tunnel syndrome. J Neurol Neurosurg Psychiatry 40:982–986,
1977.
57. Iyer V, Fenichel GMP. Normal median nerve proximal latency
in carpal tunnel syndrome: a clue to coexisting Martin-Gruber
anastomosis. J Neurol Neurosurg Psychiatry 39:449–452,
1976.
58. Marinacci AA, von Hagen KO. Misleading “all median hand.”
Arch Neurol 12:80–83, 1965.
59. Uncini A, Lange DJ, Lovelace RE. Anomalous intrinsic hand
muscle innervation in median and ulnar nerve lesions: an electrophysiological study. Ital J Neurol Sci 9:497–503, 1988.
60. Crutchfield CA, Gutmann L. Hereditary aspects of medianulnar nerve communications. J Neurol Neurosurg Psychiatry
43:53–55, 1980.
61. Hepburn D. The comparative anatomy of the muscles and
nerves of superior and inferior extremities of the anthropoid
apes. J Anat Physiol 26:149–186, 1892.
62. Brandsma JW, Birke JA, Sims DS. The Martin-Gruber innervated hand. J Hand Surg [Am] 11:536–539, 1986.
63. Sunderland S. The innervation of the flexor digitorum profundus and lumbrical muscles. Anat Rec 93:317–321, 1945.
64. Sunderland S. The innervation of the first dorsal interosseous
muscle of the hand. Anat Rec 95:7–10, 1946.
65. Beaton LE, Anson BJ. The relation of the median nerve to the
pronator teres muscle. Anat Rec 75:23–26, 1939.
66. Jamieson RW, Anson BJ. The relation of the median nerve to
the heads of origin of the pronator teres muscle. Q Bull Northwest Univ Med School 26:34–35, 1952.
67. Gantzer CFL. De musculorum varietates. Thesis. Berlioni: J.F.
Starchii, 1813.
68. Mangini U. Flexor pollicis longus muscle: its morphology and
clinical significance. J Bone Joint Surg Am 42:467–470, 1960.
69. Kaplan EB. Correction of a disabling flexion contraction of
thumb. Bull Hosp Joint Dis 3:51–54, 1942.
70. Amadio PC. Anatomic variation of the median nerve within the
carpal tunnel. Clin Anat 1:23–31, 1988.
71. Hartmann H. Etude de quelques anastomoses elliptiques des
nerfs du membre superiur. Bull Soc Anat Paris 63:151–164,
1888.
72. Winkelman NZ, Spinner M. A variant high sensory branch of
the median nerve to the third web space. Bull Hosp Joint Dis
34:161–166, 1973.
73. Hovelacque A. Anatomie des nerfs craniens et rachidiens et du systeme grand sympathique, vol. 1. Paris: Libraire Octave Doin,
1927.
74. Hovelacque A. Anatomie des nerfs craniens et rachidiens et du systeme grand sympathique, chez l’homme, vol 2. Paris: Libraire
Octave Doin, 1927.
75. Lejars F. L’innervation de l’eminence thenar. Bull Mem Soc
Anat Paris IV(5th Series):433–437, 1890.
76. Lipscomb PR. Historical perspective on nerve compression syndromes. In: Szabo RM, ed. Nerve compression syndromes: diagnosis and treatment. Thorofare, NJ: Slack, 1989:1–14.
77. Seyffarth HJ. Primary myoses in the M. pronator teres as cause
of lesion of the N. medianus (the pronator syndrome). Acta
Psychiatr Neurol Suppl 74:251, 1951.
78. Spinner M, Spinner RJ. Management of nerve compression
lesions of the upper extremity. In: Omer GE, Spinner M, Van
Beek AL. Management of peripheral nerve problems, 2nd ed.
Philadelphia: WB Saunders, 1998.
79. Goldner JL. Median nerve compression lesions: anatomical and
clinical analysis. Bull Hosp Joint Dis 44:199–223, 1984.
80. Wertsch JJ, Melvin J. Median nerve anatomy and entrapment
syndrome: a review. Arch Phys Med Rehabil 63:623, 1982.
81. Kojima T, Harase M, Ietsune T. Pronator syndrome: report of
six cases. Orthop Surg (Jpn) 19:1147–1148, 1968.
82. Morris HH, Peters BH. Pronator syndrome: clinical and electrophysiological features in seven cases. J Neurol Neurosurg
Psychiatry 39:461–464, 1976.
83. Bell GE Jr, Goldner JL. Compression neuropathy of the median
nerve. South Med J 49:966–972, 1956.
84. Solnitzky O. Pronator syndrome: compression neuropathy of
the median nerve at the level of the pronator teres muscle.
Georgetown Med Bull 13:232–238, 1960.
85. Fuss FK, Wurxel GH. Median nerve entrapment. pronator teres
syndrome: surgical anatomy and correlation with symptom patterns. Surg Radiol Anat 12:267–271, 1990.
86. Gressini L, Jandolo B, Pietranseli A, et al. The Seyffarth syndrome (round pronator syndrome): considerations on 19 cases.
Chir Organi Mov 66:481, 1980.
87. Hartz CR, Linschied RL, Gramse RR, et al. The pronator teres
syndrome: compressive neuropathy of the median nerve. J Bone
Joint Surg Am 63:885, 1981.
88. Johnson RK, Spinner M. Median nerve compression in the
forearm: the pronator tunnel syndrome. In: Szabo RM, ed.
Nerve compression syndromes: diagnosis and treatment. Thorofare,
NJ: Slack, 1989:137–151.
89. Tirrins S, Sommer J. Pronator teres syndrome: compression of
the median nerve in the proximal forearm. Useskr Laeser
28:142(18):1152, 1980.
90. Wissins CE. Pronator syndrome. South Med J 75:240, 1982.
91. Bayerl W, Fischer K. The pronator teres syndrome: clinical
aspects, pathogenesis and therapy of a non-traumatic median
nerve compression syndrome in the space of the elbow joint.
Handchirurgie 11:91, 1979.
92. Farrell HF. Pain and the pronator teres syndrome. Bull Hosp
Joint Dis 37:59–62, 1976.
93. Flory PJ, Berser A. The accessory brachial tendon: a cause of
pronator teres syndrome. Handchir Mikrochir Plast Chir 17:
270, 1985.
94. Martinelli P, Gabellini AS, Foppi M, et al. Pronator syndrome
due to thickened bicipital aponeurosis. J Neurol Neurosurg Psychiatry 45:131, 1982.
95. Chidgey LK, Szabo RM. Anterior interosseous nerve palsy. In:
Szabo RM, ed. Nerve compression syndromes: diagnosis and treatment. Thorofare, NJ: Slack, 1989:153–162.
96. Bouche P, Travers MA, Saillant G, et al. The anterior
interosseous nerve syndrome: a rare lesion of the median nerve
branch in the forearm—a case. Presse Med 14(1):31–33, 1985.
97. Bucher TPJ. Anterior interosseous nerve syndrome. J Bone
Joint Surg Br 54:55, 1972.
98. Fearn CBd’A, Goodfellow JW. Anterior interosseous nerve
palsy. J Bone Joint Surg Br 47:91–93, 1965.
228 Systems Anatomy
99. Gardner-Thorpe C. Anterior interosseous nerve palsy: spontaneous recovery in two patients. J Neurol Psychiatry 37:
1146–1150, 1974.
100. Huffman G, Leven BN. Interosseus Anterior-Syndrome:
Bericht uber 4 Eigene und 49 Falle aus der Literatur. J Neurol
213:317–326, 1976.
101. Krag C. Isolated paralysis of the flexor pollicis longus muscle: an
unusual variation of the anterior interosseous nerve syndrome:
case report. Scand J Plast Reconstr Surg 8:250–252, 1974.
102. Lake PA. Anterior interosseous nerve syndrome. J Neurosurg
41:306–309, 1974.
103. Luppino TT, Celli L, Montelone M. Paralisi dissocita del nerve
mediano all’avambraccio da compressione del nervo interosseo
anteriore. Chir Organi Mov 61:89–94, 1972.
104. Maeda K, Miura T, Komada T, et al. Anterior interosseous nerve
paralysis: report of 13 cases and review of Japanese literatures.
Hand 9:165–171, 1977.
105. Mills RH, Mukherjee K, Bassett IB. Anterior interosseous nerve
palsy. BMJ 2:555, 1969.
106. Nakano KK, Lundergan C, Okihiro MM. Anterior interosseous
nerve syndromes: diagnostic methods and alternative treatments. Arch Neurol 34:477–480, 1977.
107. Nakano KK. The entrapment neuropathies. Muscle Nerve 1:
264, 1978.
108. O’Brien MD, Upton ARM. Anterior interosseous nerve syndrome: a case report with neurophysiological investigation. J
Neurol Neurosurg Psychiatry 35:531–536, 1972.
109. Sharrard WIW. Anterior interosseous neuritis: report of a case.
J Bone Joint Surg Br 50:804–805, 1968.
110. Smith B, Herbst BA. Anterior interosseous nerve palsy. Arch
Neurol 30:330–331, 1974.
111. Woltman HW, Learmonth JR. Progressive paralysis of the
nervus interosseous dorsalis. Brain 57:25–31, 1934.
112. Hill NA, Howard FM, Huffer BR. The incomplete anterior
interosseous nerve syndrome. J Hand Surg [Am] 10:4–16, 1985.
113. Farber JS, Bryan RS. The anterior interosseous nerve syndrome.
J Bone Joint Surg Am 50:521–523, 1968.
114. Kiloh LG, Nevin S. Isolated neuritis of the anterior interosseous
nerve. BMJ 1:850–851, 1952.
115. Benini A, Tedeschi N. Die Schadigung des Nervus Interosseous
Anterior (Kiloh-Nevin Snydrom). Schweiz Med Wochenschr
104:1695–1697, 1974.
116. De Vecchis L. Su una rara sindrome dissociata del mediano
all’avambraccio (sindrome di Kiloh-Nevin). Riv Chir Mano 6:
110–115, 1968.
117. Passerini D, Vall G. Contributo alla conoscenza della sindrome
del nervo interosseo anteriore (Kiloh e Nevin). Riv Pat Nerv
Ment 89:1–11, 1968.
118. Stern MB, Rosner LJ, Blinderman EE. Kiloh-Nevin syndrome:
report of a case and review of the literature. Clin Orthop 53:
95–98, 1967.
119. Thomas DF. Kiloh-Nevin syndrome. J Bone Joint Surg Br 44:
962, 1962.
120. Assmus H, Homer J, Martin K. Das Nervus-InterosseusAnteriro-Syndrom. Nervenarzt 46:659, 661, 1975.
121. Schmidt H, Eiken O. The anterior interosseous nerve syndrome. Scand J Plast Reconstr Surg 5:53–56, 1971.
122. Warren JD. Anterior interosseous nerve palsy as a complication
of forearm fractures. J Bone Joint Surg Br 45:511–512, 1963.
123. Lipscomb PR, Burelson RJ. Vascular and neural complications
in supracondylar fractures in children. J Bone Joint Surg Am
37:487–492, 1955.
124. Spinner M, Schrieber SN. The anterior interosseous-nerve
paralysis as a complication of supracondylar fractures in children. J Bone Joint Surg Am 51:1584–1590, 1969.
125. Finelli PF. Anterior interosseous nerve syndrome following cutdown catheterization. Ann Neurol 1:205–206, 1977.
126. Page CM. An operation for the relief of flexion-contracture in
the forearm. J Bone Joint Surg 5:233–234, 1923.
127. Reimann AF, Daseler EH, Anson BJ, et al. The palmaris longus
muscle and tendon: a study of 1600 extremities. Anat Rec 89:
495–505, 1944.
128. Spinner M. Cryptogenic infraclavicular brachial plexus neuritis:
preliminary report. Bull Hosp Joint Dis 37:98–104, 1976.
129. Parsonage MJ, Turner JWA. Neuralgic amyotrophy: the shoulder-girdle syndrome. Lancet 1:973–978, 1948.
130. Carroll RE, Green DP. The significance of the palmar cutaneous
nerve at the wrist. Clin Orthop 83:24–28, 1972.
131. Stellbrink G. Compression of the palmar branch of the median
nerve by atypical palmaris longus muscle. Handchirurgie 4:
155–157, 1972.
132. Bennett JB, Crouch CC. Compression syndrome of the recurrent motor branch of the median nerve. J Hand Surg [Am] 7:
407–409, 1982.
133. Kozin SH. The anatomy of the recurrent branch of the median
nerve. J Hand Surg [Am] 23:852–858, 1998.
134. Mumford J, Morecraft R, Blair WF. Anatomy of the thenar
branch of the median nerve. J Hand Surg [Am] 12:361–365,
1987.
135. Amadio PC. Bifid median nerve with a double compartment
within the transverse carpal canal. J Hand Surg [Am] 12:
366–368, 1987.
136. Falconer D, Spinner M. Anatomic variations in the motor and
sensory supply of the thumb. Clin Orthop 195:83–96, 1985.
137. Johnson RK, Shrewsbruy MM. Anatomical course of the thenar
branch of the median nerve: usually in a separate tunnel
through the transverse carpal ligament. J Bone Joint Surg Am
52:269–273, 1970.
138. Lanz U. Anatomical variations of the median nerve in the carpal
tunnel. J Hand Surg [Am] 2:44–53, 1977.
139. Tountas CP, Bihrle DM, MacDonald CJ, et al. Variations of the
median nerve in the carpal canal. J Hand Surg [Am] 12:
708–712, 1987.
140. Brooks HSJ. Variations in the nerve supply of the flexor brevis
pollicis muscle. J Anat Physiol 20:641–644, 1886.
141. Eiken O, Carstan N, Eddeland A. Anomalous distal branching
of the median nerve. Scand J Plast Reconstr Surg 5:149–152,
1971.
142. Entin MA. Carpal tunnel syndrome and its variants. Surg Clin
North Am 48:1097–1112, 1968.
143. Graham WP III. Variations of the motor branch of the median
nerve at the wrist. Plast Reconstr Surg 51:90–92, 1973.
144. Hartmann H. Note sur l’anatomie des nerfs de la paume de la
main. Bull Soc Anat Paris 62:860–864, 1887.
145. Kessler I. Unusual distribution of the median nerve at the wrist:
a case report. Clin Orthop 67:124–126, 1969.
146. Lanz U. Variations of the median nerve at the carpal tunnel.
Handchirurgie 7:159–162, 1975.
147. Linburg RM, Albright JA. An anomalous branch of the median
nerve. J Bone Joint Surg Am 52:182–183, 1970.
148. Ogden JA. An unusual branch of the median nerve. J Bone
Joint Surg Am 54:1779–1781, 1972.
149. Papathanassiou BT. A variant of the motor branch of the median
nerve in the hand. J Bone Joint Surg Br 50:156–157, 1968.
150. Mannerfelt L, Hybbeinette CH. Important anomaly of the
thenar motor branch of the median nerve: a clinical and
anatomical report. Bull Hosp Joint Dis 33:15–21, 1972.
151. Cannieu JMA. Recherches sur une anastomose entre la branche
profunde du cubital et le median. Bull Soc Anat Physiol Bord
18:339–340, 1897 (cited by Hovelacque and Spinner).
3 Nerve Anatomy 229
152. Riche P. Le nerf cubitale et les muscle de l’eminence thenar. Bull
Soc Anat Paris 5:251–252, 1897.
153. Harness D, Sekeles E. The double anastomotic innervation of
the thenar muscles. J Anat 109:461–466, 1971.
154. Gehwolf S. Weitere Falle von Plexus bildung in der Hohlhand.
Anat Anz 54:435–440, 1921.
155. Foerster O. Spezielle Anatomie und Physiologie der peripheren
Nerven. In: Lewandowsky M, ed. Handbuch der Neurologie,
Etganzungsband. Berlin: Springer, 1929 (cited by Sunderland).
156. Foerster O. Die Symptomatologie der Schussverletzungen der
peripheren Nerven. In: Levandorosky M, ed. Handbuch der
Neurologie, Etganzungsband. Berlin: Springer, 1929.
157. Meals RA, Shaner M. Variations in digital sensory patterns: a
study of the ulnar nerve-median nerve palmar communicating
branch. J Hand Surg [Am] 8:411–414, 1983.
158. Berrettini P. Tabulae anatomicae. Rome: F Amidei, 1741.
159. Bonnel R, Vila RM. Anatomical study of the ulnar nerve in the
hand. J Hand Surg [Br] 10:165–168, 1985.
160. Von Schroeder H, Botte MJ. Carpal tunnel syndrome. Hand
Clin 12:643–655, 1996.
161. Botte MJ, von Schroeder HP, Abrams RA, et al. Recurrent
carpal tunnel syndrome. Hand Clin 12:731–743, 1996.
162. Benson YR, de Bisschop G, Lavaivre M, et al. Diagnostic and
therapeutic problems in atypical carpal tunnel syndrome. Electrodiagn Ther 18(2):37, 1981.
163. Cannon BW, Love JG. Tardy median palsy, median neuritis,
median thenar neuritis amenable to surgery. Surgery 20:210,
1946.
164. Cornwall MW, Nelson C. Median nerve F-wave conduction in
healthy subjects. Phys Ther 64:1679, 1984.
165. Crymble B. Brachial neuralgia and the carpal tunnel syndrome.
BMJ 3:470–471, 1968.
166. Dunn WA. Fractures and dislocations of the carpus. Surg Clin
North Am 52:1513, 1972.
167. Fissette J, Ondelinz A, Fandi N. Carpal and Guyon tunnel syndrome in burns at the wrist. J Hand Surg[Am] 6:13, 1981.
168. Frank DH, Robson MD. Unusual occurrence of chronic nerve
compression syndromes at the wrist of thermally injured
patients. Orthop Rev 8:180, 1979.
169. May JW Jr, Rosen H. Division of the sensory ramus communicans between the ulnar and median nerves: a complication following carpal tunnel release. J Bone Joint Surg Am 63:
836–838, 1981.
170. Morsan RF, Terranova W, Nichter LS, et al. Entrapment neuropathies of the upper extremity. Am Fam Physician 31:123,
1985.
171. Phalen GS. Reflections on 21 years experience with the carpaltunnel syndrome. JAMA 212:1365–1367, 1970.
172. Robbins H. Anatomical study of the median nerve in the carpal
tunnel and etiologies of the carpal tunnel syndrome. J Bone
Joint Surg Am 45:953–966, 1963.
173. Schultz RJ, Endler PM, Huddleston HD. Anomalous median
nerve and an anomalous muscle belly of the first lumbrical associated with carpal tunnel syndrome. J Bone Joint Surg Am 55:
1744–1746, 1973.
174. Silver MA, Gelberman RH, Gellman H, et al. Carpal tunnel
syndrome: associated abnormalities in ulnar nerve function and
the effect of carpal tunnel release on these abnormalities. J
Hand Surg [Am] 10:710, 1985.
175. Szabo RM. Carpal tunnel syndrome. In: Szabo RM, ed. Nerve
compression syndromes: diagnosis and treatment. Thorofare, NJ:
Slack, 1989:101–120.
176. Watson-Jones R. Carpal semilunar dislocations and other wrist
dislocations with associated nerve lesions. Proc R Soc Med 22:
1071, 1929.
177. Wood VE. Nerve compression following opponensplasty as a
result of wrist anomalies: report of a case. J Hand Surg[Am] 5:
279, 1980.
178. Case DB. A pseudotumor of the hand (an abnormal flexor digitorum sublimis). Postgrad Med J 42:574–575, 1966.
179. Furnas DW. Muscle tendon variation in the flexor compartment of the wrist. Plast Reconstr Surg 36:320–324, 1965.
180. Gardner RC. Confirmed case and diagnosis of pseudocarpaltunnel (sublimis) syndrome. N Engl J Med 282:858, 1970.
181. Graper L. Ein sehr seltene Varietat des M. Flexor Digitorum
Sublimis. Anat Anz 50:80–92, 1917.
182. Mainland D. An uncommon abnormality of the flexor digitorum sublimis muscle. J Anat 62:86–89, 1927.
183. Wesser DR, Calostypis F, Hoffman S. The evolutionary significance of an aberrant flexor superficialis muscle in the human
palm. J Bone Joint Surg Am 51:396–398, 1969.
184. Vichare NS. Anomalous muscle belly of the flexor digitorum
superficialis. J Bone Joint Surg Br 52:757–759, 1970.
185. Butler B, Bigley E. Aberrant index (first) lumbrical tendinous
origin associated with carpal tunnel syndrome: a case report. J
Bone Joint Surg Am 53:160–162, 1971.
186. Bugg EI Jr, Coonrad RW, Grim KB. Giant-cell arteritis: an
acute hand syndrome. J Bone Joint Surg Am 45:1269–1272,
1963.
187. Dubreuil-Chambardel L. Variations des arteres du membre
superieur. Paris: Masson, 1926.
188. Lilly CJ, Magnell TD. Severance of the thenar branch of the
median nerve as a complication of carpal tunnel release. J Hand
Surg[Am] 10:399–402, 1985.
189. Siegel DB, Gelberman RH. Ulnar nerve: applied anatomy and
operative exposure. In: Gelberman RH, ed. Operative nerve
repair and reconstruction. Philadelphia: JB Lippincott, 1991:
413–424.
190. Masear VR, Meyer RD, Pichora DR. Surgical anatomy of the
medial antebrachial cutaneous nerve. J Hand Surg[Am] 14:
267–271, 1989.
191. Grant JCB. An atlas of anatomy, 6th ed. Baltimore: Williams &
Wilkins, 1972:1–104.
192. Kane F, Kaplan EB, Spinner M. Observations of the course of
the ulnar nerve in the arm. Ann Chir 27:487–496, 1973.
193. Spinner M, Kaplan EB. The relationship of the ulnar nerve to
the medial intermuscular septum in the arm and its clinical significance. Hand 8:239–242, 1976.
194. Kaplan EB, Spinner M. Normal and anomalous innervation
patterns in the upper extremity. In: Omer GE, Spinner M, eds.
Management of peripheral nerve problems. Philadelphia: WB
Saunders, 1980:75–99.
195. Leffert RD. Anterior submuscular transposition of the ulnar
nerves by the Learmonth technique. J Hand Surg [Am] 7:
147–155, 1982.
196. Osborne G. Compression neuritis of the ulnar nerve at the
elbow. Hand 2:10–13, 1970.
197. Uriburu IJF, Morchio FJ, Marin JC. Compression syndrome of
the deep branch of the ulnar nerve (piso-hamate hiatus syndrome). J Bone Joint Surg Am 58:145–147, 1976.
198. Vanderpool DW, Chalmers J, Lanb DW, et al. Peripheral compression lesions of the ulnar nerve. J Bone Joint Surg Br 50:
792–802, 1968.
199. Botte MJ, Cohen MS, Lavernia CJ, et al. The dorsal branch of
the ulnar nerve: an anatomic study. J Hand Surg [Am] 15:
603–607, 1990.
200. Henle J. Handbuch der systematichen Anatomie des Menschen.
Braunschweig: Vieweg, 1868.
201. Balogh B, Valencak J, Vesely M, et al. The nerve of Henle: an
anatomical and immunohistochemical study. J Hand Surg [Am]
24:1103–1108, 1999.
202. McCabe SJ, Lleinert JM. The nerve of Henle. In: Proceedings of
230 Systems Anatomy
the American Society for Surgery of the Hand, 43rd annual meeting, Baltimore, September 1988.
203. Fischer L, Neidhardt JH, Comlet JJ. Preliminary note on the
topography of the dorsal cutaneous branch of the ulnar nerve:
its value in surgical approach of the inferior quarter of the ulna.
Lyon Med 224:897–899, 1970.
204. Fischer JL, Neidhardt JH, Comlet JJ, et al. Surgical anatomy of
the dorsal cutaneous branch of the ulnar nerve. C R Assoc Anat
147:226–270, 1970.
205. Linell EA. The distribution of nerves in the upper limb, with
reference to variabilities and their clinical significance. J Anat
55:79–112, 1921.
206. Poirier P, Charpy A. Traite d’anatomie humaine, vol 3. Paris:
Masson, 1901 [quoted by Spinner and Spinner (78)].
207. Kaplan EB. Variation of the ulnar nerve at the wrist. Bull Hosp
Joint Dis 24:85–88, 1963.
208. Learmonth JR. A variation of the radial branch of the musculospiral nerve. J Anat 53:371–372, 1919.
209. Panas J. Sur une cause peu connue de paralysie du nerf cubital.
Arch Gen Med 2:5 1878.
210. Childress HM. Recurrent ulnar-nerve dislocation at the elbow.
Clin Orthop 108:168–173, 1975.
211. Feindel W, Stratford J. The role of the cubital tunnel in tardy
ulnar palsy. Can J Surg 1:296, 1958.
212. Omer GE. The cubital tunnel syndrome. In: Szabo RM, ed.
Nerve compression syndromes: diagnosis and treatment. Thorofare,
NJ: Slack, 1989:163–175.
213. Osborne G. The surgical treatment of tardy ulnar neuritis. J
Bone Joint Surg Br 39:782, 1957.
214. Patel VV, Heidenreich FP Jr, Bindra RR, et al. Morphologic
changes in the ulnar nerve at the elbow with flexion and extension: a magnetic resonance imaging study with 3-dimensional
reconstruction. J Shoulder Elbow Surg 7:368–374, 1998.
215. Platt H. The pathogenesis and treatment of traumatic neuritis
of the ulnar nerve in the postcondylar groove. Br J Surg 13:409,
1926.
216. Rayan GH. Proximal ulnar nerve compression. Hand Clin
8:325–335, 1992.
217. Folfsen L. Snapping triceps tendon with ulnar neuritis. Acta
Orthop Scand 41:74–76, 1970.
218. Amadio PC. Anatomical basis for a technique of nerve transposition. Surg Radiol Anat 8:155–161, 1986.
219. Collinet P. Luxation congenital du nerf cubital. Bull Soc Anat
Paris 79:358, 1896.
220. Cobb F. Recurrent dislocation of the ulnar nerve. Ann Surg
21:652, 1903.
221. Momberg. Die luxation des nervus ulnaris. Arch Klin Chir
70:215, 1903.
222. Davidson AJ, Horwitz MT. Late or tardy ulnar nerve paralysis.
J Bone Joint Surg 17:224, 1911.
223. Adson AW. The surgical treatment of progressive ulnar paralysis. Minn Med 1:445, 1918.
224. Gay JR, Love JG. Diagnosis and treatment of tardy paralysis of
the ulnar nerve. J Bone Joint Surg 29:1087, 1947.
225. Barber KW Jr, Bianco AJ Jr, Soule EH, et al. Benign extraneural
soft tissue tumors of the extremities causing compression of
nerves. J Bone Joint Surg Am 44:98–104, 1962.
226. Gelberman RH, Yamaguchi K, Hollstien SB, et al. Changes in
interstitial pressure and cross-sectional area of the cubital tunnel
and of the ulnar nerve with flexion of the elbow: an experimental study. J Bone Joint Surg Am 80:492–501, 1998.
227. Apfelberg DB, Larson SJ. Dynamic anatomy of the ulnar nerve
at the elbow. Plast Reconstr Surg 51:76–81, 1973.
228. Guyon F. Note sur une disposition anatomique propre a la face
anterieure de la region du poignet et non encore de crite par le
docteur. Bull Soc Anat Paris 6:184, 1861.
229. Botte MJ, Gelberman RH. Ulnar nerve compression at the
wrist. In: Szabo RM, ed. Nerve compression syndromes: diagnosis
and treatment. Thorofare, NJ: Slack, 1989:121–136.
230. Gross MS, Gelberman RH. The anatomy of the distal ulnar
tunnel. Clin Orthop 196:238–247, 1985.
231. Jabaley M, Wallace W, Heckler F. Internal topography of major
nerves of the forearm and hand. J Hand Surg[Am] 5:1–18, 1980.
232. Bergfield TG, Aulicino PL. Variation of the deep motor branch
of the ulnar nerve at the wrist. J Hand Surg [Am] 13:368–369,
1982.
233. Day MH, Napier JR. The two heads of the flexor pollicis brevis. J Anat 95:123–130, 1961.
234. Turner W. Further examples of variation in the arrangement of
the nerves of the human body. J Anat Physiol 8:299, 1874.
235. Lanz U. Lahmung des Tiefen Hohlhandastes des Nervus
Ulnaris, bedingt durch eine anatomische Variante. Handchirurgie 6:83–86, 1974.
236. Lassa R, Shrewbury MM. A variation in the path of the deep
motor branch of the ulnar nerve at the wrist. J Bone Joint Surg
Am 57:990–991, 1975.
237. Denman EE. An unusual branch of the ulnar nerve in the hand.
Hand 9:92–93, 1977.
238. Denman EE. The anatomy of the space of Guyon. Hand 10:69,
1978.
239. Engber WD, Gmeiner JG. Palmar cutaneous branch of the
ulnar nerve. J Hand Surg [Am] 5:26–29, 1980.
240. Kopell HP, Thompson WA. Peripheral entrapment neuropathies.
Baltimore: Williams & Wilkins, 1963.
241. Nicolle FV, Woolhouse FM. Nerve compression syndromes of
the upper limb. J Trauma 5:313–318, 1965.
242. Torok G, Giora A. Ulnar nerve lesion in the palm: entrapment
neuropathy of the deep branch of the ulnar nerve. Isr Med J
23:121–128, 1964.
243. Bakke JL, Wolff HG. Occupational pressure neuritis of the
deep palmar branch of the ulnar nerve. Arch Neurol Psychiatry
60:549, 1948.
244. Bacorn RW, Kurtze JF. Colles’ fracture: a study of two thousand
cases from the New York State Workman’s Compensation
Board. J Bone Joint Surg Am 35:643, 1953.
245. Baird DB, Predenberg ZB. Delayed ulnar nerve palsy following
a fracture of the hamate. J Bone Joint Surg Am 50:570, 1968.
246. Dell PC. Compression of the ulnar nerve at the wrist secondary
to a rheumatoid synovial cyst: case report and review of the literature. J Hand Surg[Am] 4:468, 1979.
247. Dodds GA, Hale D, Jackson WT. Incidence of anatomic variants in Guyon’s canal. J Hand Surg [Am] 15:352–355, 1990.
248. Dupont C, Cloutier GE, Prevost Y, et al. Ulnar-tunnel syndrome at the wrist. J Bone Joint Surg Am 42:757, 1965.
249. Ebeling P, Gilliantt RW, Thomas DK. A clinical and electrical
study of ulnar nerve lesions in the hand. J Neurol Neurosurg
Psychiatry 23:1, 1960.
250. Eckman PB, Pertstein G, Altrocchi PH. Ulnar neuropathy in
bicycle riders. Arch Neurol 32:130, 1975.
251. Fahrer M. The proximal end of the palmar aponeurosis. Hand
12:33, 1980.
252. Gloobe H, Pecket P. An anomalous muscle in the canal of
Guyon. Anat Anz 133:477, 1973.
253. Harris W. Occupational pressure neuritis of the deep palmar
branch of the ulnar nerve. BMJ 1:98, 1921.
254. Hunt JR. Occupational neuritis of the deep palmar branch of
the ulnar nerve. J Nerv Ment Dis 35:676, 1908.
255. Kalisman M, Laborde K, Wolff TW. Ulnar nerve compression
secondary to ulnar artery false aneurysm at the Guyon’s canal. J
Hand Surg[Am] 7:137, 1982.
256. Leslie IJ. Compression of the deep branch of the ulnar nerve
due to edema of the hand. Hand 12:271, 1980.
3 Nerve Anatomy 231
257. McDowell CL, Henceroth WD. Compression of the ulnar
nerve in the hand by a ganglion. J Bone Joint Surg Am 59:980,
1970.
258. McFarland GB, Hoffer MM. Paralysis of the intrinsic muscles
of the hand secondary to lipoma in Guyon’s tunnel. J Bone
Joint Surg Am 53:375, 1971.
259. Moneim MS. Ulnar nerve compression at the wrist: ulnar tunnel syndrome. Hand Clin 8:337–344, 1992.
260. O’Hara JJ, Stone JH. Ulnar neuropathy at the wrist associated
with aberrant flexor carpi ulnaris insertion. J Hand Surg [Am]
13:370–371, 1988.
261. Russell WR, Whitty CWM. Traumatic neuritis of the deep palmar branch of the ulnar nerve. Lancet 1:828, 1947.
262. Salgebac S. Ulnar tunnel syndrome caused by anomalous muscles: a case report. Scand J Plast Reconstr Surg 11:255, 1977.
263. Tashima Y, Kimata Y. A case of ganglion causing paralysis of
intrinsic muscles innervated by the ulnar nerve. J Bone Joint
Surg Br 43:153, 1961.
264. Taylor AR. Ulnar nerve compression at the wrist in rheumatoid
arthritis. J Bone Joint Surg Br 56:142, 1974.
265. Vance RM, Gelberman RH. Acute ulnar neuropathy with fractures at the wrist. J Bone Joint Surg Am 60:692, 1978.
266. Worster-Drought C. Pressure neuritis of the deep palmar
branch of the ulnar nerve. BMJ 1:247, 1929.
267. Weeks PM, Young VL. Ulnar artery thrombosis and ulnar nerve
compression associated with anomalous hypothenar muscle.
Plast Reconstr Surg 69:130–131, 1982.
268. Brooks DM. Nerve compression by simple ganglia. J Bone Joint
Surg Br 34:391, 1952.
269. Mallet BL, Zilkha KJ. Compression of the ulnar nerve at the
wrist by a ganglion. Lancet 268:8901, 1955.
270. Milberg P, Kleinert HE. Giant cell tumor compression of the
deep branch of the ulnar nerve. Ann Plast Surg 4:426, 1980.
271. Richman DA. Carpal ganglion with ulnar nerve compression. J
Bone Joint Surg Br 45:513, 1963.
272. Seddon HJ. Carpal ganglion as a cause of paralysis of the deep
branch of the ulnar nerve. J Bone Joint Surg Br 34:386, 1952.
273. Shea JD, McClain EJ. Ulnar nerve compression syndromes at
and below the wrist. J Bone Joint Surg Am 51:1095, 1969.
274. Thomas CG. Clinical manifestation of an accessory palmaris
muscle. J Bone Joint Surg Am 40:929, 1958.
275. Spinner M, Freundlich BD. An important variation of the palmaris longus. Bull Hosp Joint Dis 28:126–130, 1967.
276. Wood J. On some varieties in human myologies. Proc R Soc
Lond 13:299–303, 1864.
277. Swanson AB, Biddulph SL, Baughman FA, et al. Ulnar nerve
compression due to an anomalous muscle in the canal of
Guyon. Clin Orthop 83:64, 1972.
278. Jeffery AK. Compression of the deep palmar branch of the ulnar
nerve by an anomalous muscle. J Bone Joint Surg Br 53:718,
1971.
279. Schjelderup H. Aberrant muscle in the hand causing ulnar
nerve compression. J Bone Joint Surg Br 46:361, 1964.
280. Turner MS, Caird DM. Anomalous muscles and ulnar nerve
compression at the wrist. Hand 9:140, 1977.
281. Hayes JR, Mulholland RC, O’Connnor BT. Compression of
the deep palmar branch of the ulnar nerve. J Bone Joint Surg Br
51:469, 1969.
282. Lipscomb PR. Duplication of hypothenar muscles simulating
soft tissue tumor of the hand: report of a case. J Bone Joint Surg
Am 42:1058, 1960.
283. Harrelson JM, Newman M. Hypertrophy of the flexor carpi
ulnaris as a cause of ulnar-nerve compression in the distal part
of the forearm: case report. J Bone Joint Surg Am 57:554–555,
1975.
284. Szabo RM, ed. Nerve compression syndromes: diagnosis and treatment. Thorofare, NJ: Slack, 1989:67–88.
285. Comtet MM, Quicot L, Moyey B. Compression of the deep
palmar branch of the ulnar nerve by the arch of the adductor
pollicis. Hand 10:176, 1978.
286. Fragiadakis EG, Lamb DW. An unusual cause of ulnar nerve
compression. Hand 2:14–15, 1970.
287. Howard FM. Ulnar nerve palsy in wrist fractures. J Bone Joint
Surg Am 43:1197, 1961.
288. Kleinert HE, Hayes JW. Ulnar tunnel syndrome. Plast Reconstr Surg 47:21, 1971.
289. Liveson JA, Ranschoff J, Goodgold J. Electromyographic studies in a case of foramen magnum meningioma. J Neurol Neurosurg Psychiatry 36:561–564, 1973.
290. Guse TR, Ostrum RF. The surgical anatomy of the radial nerve
around the humerus. Clin Orthop 320:149–153, 1995.
291. Siegal DB, Gelberman RH. Radial nerve: applied anatomy and
operative exposure. In: Gelberman RH, ed. Operative nerve
repair and reconstruction. Philadelphia: JB Lippincott, 1991:
393–407.
292. Whitson RO. Relation of the radial nerve to the shaft of the
humerus. J Bone Joint Surg Am 36:85–88, 1954.
293. Ip MC, Chang KSF. A study on the radial supply of the
brachialis muscle. Anat Rec 162:363–371, 1968.
294. Salsbury CR. The nerve to the extensor carpi radialis brevis. Br
J Surg 26:95–97, 1938.
295. Duthie HL. Radial nerve in osseous tunnel at humeral fracture
site diagnosed radiographically. J Bone Joint Surg Br 39:746,
1957.
296. Garcia A Jr, Maeck BH. Radial nerve injuries in fractures of the
shaft of the humerus. Am J Surg 99:625–627, 1960.
297. Holstein A, Lewis GB. Fractures of the humerus with radial
nerve paralysis. J Bone Joint Surg Am 45:1382–1388, 1963.
298. Mast JW, Spiegel PG, Harvey JP, et al. Fractures of the humeral
shaft. Clin Orthop 12:254–262, 1975.
299. Pollock FH, Drake D, Bovill EG, et al. Treatment of radial neuropathy associated with fractures of the humerus. J Bone Joint
Surg Am 63:239–243, 1981.
300. Ward EF, White J. Interlocked intramedullary nailing of the
humerus. Orthopedics 12:1167–1169, 1985.
301. Ward FE, Suvoie FH, Huges JL. Fractures of the diaphyseal
humerus. In: Browner BD, Jupiter JB, Levine AM, et al., eds.
Skeletal trauma: fractures, dislocations, ligamentous injuries.
Philadelphia: WB Saunders, 1992:1177–1200.
302. Lotem M, Fired A, Levy M, et al. Radial palsy following muscular effort: a nerve compression syndrome possibly related to a
fibrous arch of the lateral head of the triceps. J Bone Joint Surg
Br 53:500–506, 1971.
303. Manske PR. Compression of the radial nerve by the triceps
muscle. J Bone Joint Surg Am 59:835–836, 1977.
304. Brash JC. Neuro-vascular hila of limb muscles. Edinburgh: E and
S Livingstone, 1955.
305. Abrams RA, Brown RA, Botte MJ. The superficial branch of the
radial nerve: an anatomic study with surgical implications. J
Hand Surg[Am] 17:1037–1041, 1992.
306. Auerbach DM, Collins ED, Kunkle KL, et al. The radial sensory nerve: an anatomic study. Clin Orthop 241–249, 1994.
307. Abrams RA, Zeits RJ, Lieber RL, et al. Anatomy of the radial
nerve motor branches in the forearm. J Hand Surg [Am]
22:232–237, 1997.
308. Branovacki G, Hanson M, Cash R, et al. The innervation pattern of the radial nerve at the elbow and in the forearm. J Hand
Surg [Br] 23:167–169, 1998.
309. Albritten F Jr. The surgical repair of the deep branch of the
radial nerve. Surg Gynecol Obstet 82:305–310, 1946.
232 Systems Anatomy
310. Davies R, Laird M. The supinator muscle in the deep radial
(posterior interosseous) nerve. Anat Rec 101:243–250, 1948.
311. Packer JW, Foster RR, Garcia A, et al. The humeral fracture
with radial nerve palsy: is exploration warranted? Clin Orthop
88:34–38, 1972.
312. Shevkunenko VN. Atlas of the peripheral nervous and venous systems. Moscow: Medgiz, 1949.
313. Lazorthes G. Le systeme neuro-vasculaire. Paris: Masson, 1949.
314. Krause W. Handbuch der menschlichen Anatomie. Bd. III:
Anatomische Varietaten. Hanover: Hahn, 1880.
315. Von Luschka H. Die Anatomie des menschlichen Korpers. Tubingen: H. Laupp, 1862
316. Froment JBF. Traite d’anatomie humaine. Paris: MequignonMarvis, 1846:494.
317. Rauber A. Vater’sche Korper der Bander und Periostnerven. Inaug
Diss Munichb 1865 (cited by Lanz).
318. Rauber A. Ueber die Nerven der Knochenhaut, und Knochen des
Vorderaremes und Unterschenkeis. Munchen: C. Fritsch, 1868.
319. Bichat XAV. Traite d’anatomie descriptive, tome troisieme. Paris:
Brosson and Gabon, 1802:269.
320. Appleton AB. A case of abnormal distribution of the musculocutaneous nerve, with complete absence of the ramus coetaneous
nerve radialis. J Anat Physiol Third Ser 46:89–94, 1911–1912.
321. Roles NC, Maudsley RH. Radial tunnel syndrome: resistant
tennis elbow as a nerve entrapment. J Bone Joint Surg Br
54:499–508, 1972.
322. Lister GD, Belsole RB, Kleinert HE. The radial tunnel syndrome. J Hand Surg [Am] 4:52–59, 1979.
323. Campbell CS, Wulf RF. Lipoma producing a lesion of the deep
branch of the radial nerve. J Neurosurg 11:310–311, 1954.
324. Richmond DA. Lipoma causing a posterior interosseous nerve
lesion. J Bone Joint Surg Br 35:83, 1953.
325. Peimer CA, Wheeler DR. Radial tunnel syndrome/posterior
interosseous nerve compression. In: Szabo RM, ed. Nerve compression syndromes: diagnosis and treatment. Thorofare, NJ:
Slack, 1989:177–191.
326. Wu KT, Jordan FR, Eckert C. Lipoma, a cause of paralysis of
deep radial (posterior interosseous) nerve: report of a case and
review of the literature. Surgery 75:790–795, 1974.
327. Capener N. Posterior interosseous nerve lesions. Proceedings of
the Second Hand Club. J Bone Joint Surg Br 46:361, 1964.
328. Cartstam N. Operative treatment of fractures of the head and
neck of the radius. Acta Orthop Scand 19:502–526, 1950.
329. Crenshaw AH. Surgical techniques and approaches. In: Canale
ST, ed. Campbell’s operative orthopaedics, 9th ed. St. Louis:
Mosby, 1998:126–130.
330. Fuss FK, Wurzl GH. Radial nerve entrapment at the elbow: surgical anatomy. J Hand Surg [Am] 16:742–747, 1991.
331. Hotchkiss RN. Displaced fractures of the radial head: Internal
fixation or excision? J Am Acad Orthop Surg 5:1–10, 1997.
332. Jupiter JB, Mehne DK. Trauma to the adult elbow and fractures
of the distal humerus. In: Browner BD, Jupiter JB, Levine AM,
et al., eds. Skeletal trauma: fractures, dislocations, ligamentous
injuries, vol 1. Philadelphia: WB Saunders, 1992:1125–1176.
333. Kaplan EB. Surgical approach to the proximal end of the radius
and its use in fractures of the head and neck of the radius. J
Bone Joint Surg 23:86–92, 1941.
334. Low CK, Chew JT, Mitra AK. A surgical approach to the posterior interosseous branch of the radial nerve through the brachioradialis: a cadaveric study. Singapore Med J 35:394–396,
1994.
335. Mayer JH, Mayfield PH. Surgery of the posterior interosseous
branch of the radial nerve. Surg Gynecol Obstet 84:979–982,
1947.
336. Mekhail AO, Ebraheim NA, Jackson WT, et al. Vulnerability of
the posterior interosseous nerve during proximal radius exposures. Clin Orthop 315:199–208, 1995.
337. Mekhail AO, Ebraheim NA, Jackson WT, et al. Anatomic considerations for the anterior exposure of the proximal portion of
the radius. J Hand Surg [Am] 21:794–801, 1996.
338. Prasartritha T, Liupolvanish P, Rojanakit A. A study of the posterior interosseous nerve (PIN) and the radial tunnel in 30 Thai
cadavers. J Hand Surg [Am] 18:108–112, 1993.
339. Sanders RA, French HG. Open reduction and internal fixation
of comminuted radial head fractures. Am J Sports Med
14:130–135, 1986.
340. Spinner M, Freundlich BD, Teicher J. Posterior interosseous
nerve palsy as a complication of Monteggia fracture in children.
Clin Orthop 58:141–145, 1968.
341. Strachan JH, Ellis BW. Vulnerability of the posterior
interosseous nerve during radial head resection. J Bone Joint
Surg Br 53:320–323, 1971.
342. Wadsworth TG. The elbow. New York: Churchill Livingstone,
1982:24–27.
343. Young C, Hudson A, Richards R. Operative treatment of palsy
of the posterior interosseous nerve of the forearm. J Bone Joint
Surg Am 72:1215–1219, 1990.
344. Lichter R, Jacobsen T. Tardy palsy of the posterior interosseous
nerve with Monteggia fracture. J Bone Joint Surg Am
57:124–125, 1975.
345. Dilberti T, Botte MJ, Abrams RA. Anatomical considerations
regarding the posterior interosseous nerve during posterolateral
approaches to the proximal part of the radius. J Bone Joint Surg
Am 82:809–813, 2000.
346. Spinner M. The arcade of Frohse and its relationship to posterior interosseous nerve paralysis. J Bone Joint Surg Br
50:809–812, 1968.
347. Frohse F, Frankel M. Die Muskeln des menschlichen Armes. In:
Bardeleben’s Handbuch der Anatomie des Menschlichen. Jena:
Fisher, 1908:164.
348. Bryan FS, Miller LS, Panijaganond P. Spontaneous paralysis of
the posterior interosseous nerve: a case report and review of the
literature. Clin Orthop 80:9–12, 1971.
349. Capener N. The vulnerability of the posterior interosseous
nerve of the forearm: a case report and an anatomical study. J
Bone Joint Surg Br 48:770–773, 1966.
350. Goldman S, Honet JC, Soble R, et al. Posterior interosseous
nerve palsy in the absence of trauma. Arch Neurol 21:435–441,
1969.
351. Grigoresco D, Iordanesco G. Une cas rare de paralysie partielle
du nerf radial. Rev Neurol 2:102–104, 1937.
352. Guillain G, Courtellemont. L’action du muscle court supinator
dans la paralysie du nerf radial. Presse Med 13:50–52, 1905.
353. Kruse F Jr. Paralysis of the dorsal interosseous nerve not due to
direct trauma: a case showing spontaneous recovery. Neurology
8:307–308, 1958.
354. Mulholland RC. Non-traumatic progressive paralysis of the
posterior interosseous nerve. J Bone Joint Surg Br 48:781–785,
1966.
355. Nielsen HO. Posterior interosseous nerve paralysis caused by
fibrous band compression at the supinator muscle: a report of
four cases. Acta Orthop Scand 47:304–307, 1976.
356. Hobhouse N, Heald CB. A case of posterior interosseous paralysis. BMJ 1:841, 1936.
357. Otenasek FJ. Progressive paralysis of the nervus dorsalis: pathological findings in one case. Bull Johns Hopkins Hosp
81:163–167, 1947.
358. Sharrard WJW. Posterior interosseous neuritis. J Bone Joint
Surg Br 48:777–780, 1966.
359. Silverstein A. Progressive paralysis of the dorsal interosseous
3 Nerve Anatomy 233
nerve: report of a case. Arch Neurol Psychiatry 38:885–886,
1937.
360. Whitely WH, Alpers BJ. Posterior interosseous palsy with spontaneous neuroma formation. Arch Neurol 1:226–229, 1959.
361. Woltman HW, Kernohan JUW. Disease of peripheral nerves.
In: Baker AB, ed. Clinical Neurology. New York: HoeberHarper, 1955:1629.
362. Marie P, Meige H, Patridios L. Paralysie radiale dissociee simulant une griffe cubitale. Rev Neurol 24:123–124, 1917.
363. Dharapak C, Nimberg GA. Posterior interosseous nerve compression: report of a case caused by traumatic aneurysm. Clin
Orthop 101:225–228, 1974.
364. Vaughan-Jackson OJ. Rupture of the extensor tendons by attrition at the inferior radioulnar joint. J Bone Joint Surg Br
30:528–530, 1948.
365. Wartenberg R. Cheiralgia paresthetica (isolierte Neuritis des
Ramus Superficialis Nervi Radialis). Z Ges Neurol Psychiatr
141:145–155, 1932.
366. Turkof E, Puig S, Choe SS, et al. The radial sensory nerve
entrapped between the two slips of a split brachioradialis tendon: a rare aspect of Wartenberg’s syndrome. J Hand Surg [Am]
20:676–678, 1995.
367. Szabo RM. Superficial radial nerve compression syndrome. In:
Szabo RM, ed. Nerve compression syndromes: diagnosis and treatment. Thorofare, NJ: Slack, 1989:193–199.
368. Linscheid RL. Injuries to the radial nerve at the wrist. Arch Surg
91:942–946, 1965.
369. Latarjet M, Neidhart JH, Morrin A, et al. L’entrée du nerf musculo-cutan dans le muscle coraco-brachial. C R Assoc Anat
138:755–765, 1967.
370. Arnold F. Handbuch der Anatomie des Menschen, vol 2. Freiburg:
Emmerling und Herder, 1851.
371. Horiguchi M. The recurrent branch of the lateral cutaneous
nerve of the forearm. J Anat 132:243–247, 1981.
372. Moore KL. Clinically oriented anatomy, 2nd ed. Baltimore:
Williams & Wilkins, 1985.
373. Burkitt HG, Young B, Heath JW. Wheather’s functional histology: a text and color atlas. Edinburgh: Churchill Livingstone,
1993.
SUGGESTED READINGS
Agnew DH. Bursal tumor producing loss of power of forearm. Am J
Med Sci 46:404–405, 1863.
Alegado RB, Meals RA. An unusual complication following surgical
treatment of DeQuervain’s disease. J Hand Surg[Am] 4:185–186,
1979.
Baruch A, Hass A. Anomaly of the median nerve. J Hand Surg[Am]
2:331–332, 1977.
Bassett EH, Nunley JA. Compression of the musculocutaneous nerve
at the elbow. J Bone Joint Surg Am 64:1050, 1982.
Berger RA. Partial denervation of the wrist: a new approach. Tech
Hand Upper Extrem Surg 2:25–35, 1998.
Blunt MJ. The vascular anatomy of the median nerve in the forearm
and hand. J Anat 93:15–22, 1959.
Bowen TL, Stone KH. Posterior interosseous nerve paralysis caused by a
ganglion at the elbow. J Bone Joint Surg Br 48:774–776, 1966.
Boyd HB. Surgical exposure of the ulna and proximal third of the radius
through one incision. Surg Gynecol Obstet 71:86–88, 1940.
Braidwood AS. Superficial radial neuropathy. J Bone Joint Surg Br
57:380–383, 1975.
Carpenter N. The vulnerability of the posterior interosseous nerve of
the forearm. J Bone Joint Surg Br 48:770–773, 1966.
Cobb TK, Carmichael SW, Cooney WP. Guyon’s canal revisited: an
anatomic study of the carpal ulnar neurovascular space. J Hand
Surg [Am] 21:861–869, 1996.
Comtet JJ, Chambaud D. Parlysie “spontanee” du nerf inter-osseux
posterieur par lesion inhabituelle: deux observations. Rev Chir
Orthop 61:533–541, 1975.
Comtet JJ, Chambaud D, Genety J. La compression de la branche
posterieure du nerf radial: une etiologie meconnue de certaines
paralysies et de certaines epicondyhlalgies rebelles. Nouv Presse
Med 5:1111–1114, 1954.
Contreras MG, Warner MA, Charboneau WJ, et al. Anatomy of the
ulnar nerve at the elbow: potential relationships of the acute ulnar
neuropathy to gender differences. Clin Anat 11:372–378, 1998.
Costigan DG, Riley JM, Coy FE. Thrombofibrosis of the ulnar artery
in the palm. J Bone Joint Surg Am 41:702, 1959.
Craig WS, Clark JMP. Of peripheral nerve palsies in the newly born.
J Obstet Gynaecol Br Commonw 65:229–237, 1958.
Dawson GD, Scott JW. Recording of nerve action potentials through
skin in man. J Neurosurg Psychiatry 12:259, 1949.
Dellon AL, Mackinnon SE. Radial sensory nerve entrapment in the
forearm. J Hand Surg [Am] 11:199–205, 1986.
Eaton CJ, Lister GD. Radial nerve compression. Hand Clin 8:
345–357, 1992.
Ehrlich GE. Antecubital cysts in rheumatoid arthritis: a corollary to
popliteal (Baker’s) cysts. J Bone Joint Surg Am 54:164–169, 1972.
Fahrer M. Rare variations in a left radial nerve: case report. J Anat
103:208, 1968.
Fahrer M, Millroy PJ. Ulnar compression neuropathy due to an
anomalous abductor digiti minimi: clinical and anatomic study. J
Hand Surg[Am] 6:266, 1981.
Fennay JB. Deep ulnar nerve paralysis resulting from an anatomical
abnormality. J Bone Joint Surg Am 47:1381, 1965.
Fenning JB. Deep ulnar nerve paralysis resulting from an anatomic
abnormality. J Bone Joint Surg Am 47:1381–1382, 1965.
Freundlich BD, Spinner M. Nerve compression syndrome in
derangements of the proximal and distal radioulnar joints. Bull
Hosp Joint Dis 19:38–47, 1968.
Furusawa S, Hara T, Maehiro S, et al. Neuralgic amyotrophy. Orthop
Surg (Jpn) 20:1286–1296, 1969.
Gelberman RH. Operative nerve repair and reconstruction. Philadelphia: JB Lippincott, 1991.
Gore DR. Carpometacarpal dislocation producing compression of
the deep branch of the ulnar nerve. J Bone Joint Surg Am
53:1387–1390, 1971.
Gray DJ, Gardner E. The innervation of the joints of the wrist and
hand. Anat Rec 151:261–266, 1965.
Greene MH, Hadied AM. Bipartite hamulus with ulnar tunnel syndrome: case report and literature review. J Hand Surg[Am] 6:605,
1981.
Gunther SF, DiPasquale D, Martin F. The internal anatomy of the
median nerve in the region of the elbow. J Hand Surg [Am]
17:648–656, 1992.
Hall HC, Mackinnon SE, Gilbert RW. An approach to the posterior
interosseous nerve. Plast Reconstr Surg 74:435–438, 1984.
Harburger A. Anomalie de division de la branche posterieure du nerf
radial extenseur propre du medius. Bull Memb Soc Anat Paris
94:236–238, 1924.
Hassan DM, Johnston GH. Safety of the limited open technique of
bone-transfixing threaded-pin placement for external fixation of
distal radial fractures: a cadaver study. Can J Surg 42:363–365,
1999.
Haussmann P, Kendel K. Oligofascicular median nerve compression
syndrome. Handchirurgie 13:268, 1981.
Henry AK. Extensible exposure. Edinburgh: Churchill Livingstone,
1973.
Hoppenfeld S, deBoer P. Surgical exposures in orthopaedics: the
anatomic approach, 2nd ed. Philadelphia: JB Lippincott, 1994.
234 Systems Anatomy
Hunt JR. Thenar and hypothenar types of neural atrophy of the
hand. BMJ 2:642, 1930.
Hutton WK. Remarks on the innervation of the dorsum manus with
special reference to certain rare anomalies. J Anat Physiol 40:
326–331, 1906.
Inserra S, Spinner M. An anatomic factor significant in transposition
of the ulnar nerve. J Hand Surg [Am] 11:80–83, 1986.
Jackson JP. Traumatic thrombosis of the ulnar artery in the palm. J
Bone Joint Surg Br 36:718, 1971.
Jenkins SA. Osteoarthritis of the pisiform-triquetral joint. J Bone
Joint Surg Br 33:532, 1957.
Jumentie MJ. Fausse griffe cubitale par lesion dissocice du nerf radial.
Rev Neurol 37:756–758, 1921.
Kamineni S, Lavy CB. Percutaneous fixation of scaphoid fractures: an
anatomical study. J Hand Surg [Br] 24:85–88, 1999.
Kasai T. About the N. cutaneous brachii lateralis inferior. Am J Anat
112:305–309, 1963.
Khoo D, Carmichael SW, Spinner RJ. Ulnar nerve anatomy and
compression. Orthop Clin North Am 27:317–338, 1996.
Kimura I, Ayyar DR. The hand neural communication between the
ulnar and median nerves: electrophysiological detection. Electromyosurg Clin Neurophysiol 24:409, 1984.
Kimura I, Ayyar DR, Lippman SM. Electrophysiological verification
of the ulnar to median nerve communications in the hand and
forearm. Tohoku J Exp Med 141:269, 1983.
King TS, O’Rahilly RM. Palmaris accessorius and duplication of m.
palmaris longus. Acta Anat 10:327–331, 1950.
Kleinert JM, Mehta S. Radial nerve entrapment. Orthop Clin North
Am 27:305–315, 1996.
Kopell HP, Thompson WAL. Pronator syndrome. N Engl J Med
259:713–715, 1958.
Kozin SH, Porter S, Clark P, et al. The contribution of the intrinsic muscles to grip and pinch strength. J Hand Surg [Am] 24:64–72, 1999.
Kutz JE, Singer R, Lindsay M. Chronic exertional compartment syndrome of the forearm: a case report. J Hand Surg[Am] 10:302,
1985.
Lampe EW, Netter FH, Walton JH. Surgical anatomy of the hand.
Clin Symp 40:1–36, 1988.
Lauritzen RS, Szabo RM, Lauritzen DB. Innervation of the lumbrical muscles. J Hand Surg [Br] 21:57–58, 1996.
Learmonth JR. Technique for transplanting the ulnar nerve. Surg
Gynecol Obstet 75:792–793, 1942.
Leffert RD, Dorfman HD. Antecubital cyst in rheumatoid arthritis:
surgical findings. J Bone Joint Surg Am 54:1555–1557, 1972.
LeGeyt MT, Ghobadi F. Aberrant position of the ulnar nerve and
artery overlying the carpal canal. Am J Orthop 27:449–450,
1998.
Lieberman JS, Taylor RG. Electrodiagnosis in upper extremity nerve
compression. J Hand Surg [Am] 19:241–245, 1994.
Mackinnon SE, Dellon AL. The overlap pattern of the lateral antebrachial cutaneous nerve and the superficial branch of the radial
nerve. J Hand Surg[Am]10:522–526, 1985.
Mackinnon SE, Dellon AL. Anatomic investigations of nerves at the
wrist: I. orientation of the motor fascicle of the median nerve in
the carpal tunnel. Ann Plast Surg 21:32–35, 1988.
MacKinnon SE, Dellon AL. Surgery of the peripheral nerve. New York:
Thieme, 1988.
Mannerfelt L. Median nerve entrapment after dislocation of the
elbow. J Bone Joint Surg Br 50:152–155, 1968.
Marble HC, Hamlin E Jr, Watkins AL. Regeneration in the ulnar,
median and radial nerves. Am J Surg 55:274–294, 1942.
Marmor L, Lawrence JF, Dubois E. Posterior interosseous nerve paralysis due to rheumatoid arthritis. J Bone Joint Surg Am 49:
381–383, 1967.
Marshall SC, Murray WR. Deep radial nerve palsy associated with
rheumatoid arthritis. Clin Orthop 103:157–162, 1974.
Martini K. Abnormal distribution of the median nerve at the wrist
and forearm. Plast Reconstr Surg 71:711, 1983.
Matsuzaki A, Kobgayashi M, Mitsuyasu M, et al. Neuralgic amyotrophy with the feature of palsy of the anterior interosseous nerve.
Orthop Surg (Jpn) 20:916–923, 1969.
Mazurek MT, Shin AY. Upper extremity peripheral nerve anatomy:
current concepts and applications. Clin Orthop 383:7–20, 2001.
McCarthy RE, Nalebuff EA. Anomalous volar branch of the dorsal
cutaneous ulnar nerve: a case report. J Hand Surg [Am] 5:19–20,
1980.
McFarlane RM, Mayer JR. Digital nerve grafts with the lateral antebrachial cutaneous nerve. J Hand Surg [Am] 1:169–173, 1976.
McFarlane RM, Mayer JR, Hugill JV. Further observations on the
anatomy of the ulnar nerve at the wrist. Hand 8:115, 1976.
McFarlane RM. Observation on the functional anatomy of the intrinsic muscles of the thumb. J Bone Joint Surg Am 44:1376–1386,
1962.
Mekhail AO, Checroun AJ, Ebraheim NA, et al. Extensile approach
to the anterolateral surface of the humerus and the radial nerve. J
Shoulder Elbow Surg 8:112–118, 1999.
Millender LH, Nalebuff EA, Holdsworth DE. Posterior interosseous
nerve syndrome secondary to rheumatoid synovitis. J Bone Joint
Surg Am 55:753–757, 1973.
Millender LH, Nalebuff E, Kasdon E. Aneurysms and thromboses of
the ulnar artery in the hand. Arch Surg 105:686, 1972.
Miller MR, Ralston HJ III, Kasahara M. The pattern of cutaneous
innervation of the human hand. Am J Anat 102:183–217, 1958.
Millesi HG, Meissl G, Berger A. Further experience with interfascicular grafting of the median, ulnar and radial nerves. J Bone Joint
Surg Am 58:209–218, 1976.
Mills WJ, Hanel DP, Smith DG. Lateral approach to the humeral
shaft: an alternative approach for fracture treatment. J Orthop
Trauma 10:81–86, 1996.
Morris AH. Irreducible Monteggia lesion with radial-nerve entrapment. J Bone Joint Surg Am 56:1744–1746, 1974.
Mowell JW. Posterior interosseous nerve injury. Int Clin 2:188–189,
1921.
Muller LH. Anatomical abnormalities at the wrist joint causing neurological symptoms in the hand. J Bone Joint Surg Br 45:431, 1963.
Nisenfield FG, Neviaser RJ. Fracture of the hook of the hamate: a
diagnosis easily missed. J Trauma 14:612, 1974.
Nunley JA, Howson P. Lateral antebrachial nerve compression. In:
Szabo RM, ed. Nerve compression syndromes: diagnosis and treatment. Thorofare, NJ: Slack, 1989:201–208.
O’Rahilly R, Gardner E. The timing and sequence of events in the
development of the limbs in the human embryo. Anat Embryol
148:1–23, 1975.
Olson IA. The origin of the lateral cutaneous nerve of forearm and its
anaesthesia for modified brachial plexus block. J Anat 105:
381–382, 1968.
Omer GE, Spinner M, Van Beek AL. Management of peripheral nerve
problems, 2nd ed. Philadelphia: WB Saunders, 1998.
Packer NP, Fisk GR. Compression of the distal ulnar nerve with clawing of the index finger. Hand 14:38-40, 1982.
Perela-Cruz MA. Surgical exposures of the peripheral nerves in the
extremities. In: Omer GE, Spinner M, Van Beek AL, eds. Management of peripheral nerve problems, 2nd ed. Philadelphia: WB
Saunders, 1998:175–209.
Phalan GS, Kiendrick JI, Rodriguez JM. Lipomas of the upper
extremity. Am J Surg 121:P298–P306, 1971.
Poisel S. Ursprung und Verlauf des R muscularis des Nervus digitalis
palmaris communis I (N medianus). Chir Prazis 18:471–474,
1974 (cited by Lanz).
Popelka S, Vainio K. Entrapment of the posterior interosseous branch
of the radial nerve in rheumatoid arthritis. Acta Orthop Scand
45:370–372, 1974.
3 Nerve Anatomy 235
Portilla Molina AE, Bour C, Oberlin C, et al. The posterior interosseous nerve and the radial tunnel syndrome: an anatomical
study. Int Orthop 22:102–106, 1998.
Rath AM, Perez M, Mainguene C, et al. Anatomic basis of the physiopathology of the epicondylalgias: a study of the deep branch of
the radial nerve. Surg Radiol Anat 15:15–19, 1993.
Riordan DC. Radial nerve paralysis. Orthop Clin North Am
5:283–287, 1974.
Ritter MA, Marshall JL, Straub LR. Extra-abdominal desmoid of the
hand: a case report. J Bone Joint Surg Am 51:1641, 1969.
Roberts WH. Anomalous course of the median nerve medial to the
trochlea and anterior to the medial epicondyle of the humerus.
Ann Anat 174:309–311, 1992.
Rogers MR, Bergfield TG, Aulicino PL. A neural loop of the deep
motor branch of the ulnar nerve: an anatomic study. J Hand Surg
[Am] 16:269–271, 1991.
Rollins J, Meals RA. Recognition of acutely lacerated ulnar
nerve–median nerve palmar communicating branch. Clin Orthop
201:91–93, 1985.
Rosenfeld N, Dolich BH. Use of the articular branch of the ulnar
nerve to the wrist for a local nerve graft. Plast Reconstr Surg 60:
466–467, 1977.
Roussy G, Branche J. Deux cas de paralyies dissociees de la branche
posterieure du radial a type de pseudo-griffe cubitale. Rev Neurol
24:312–314, 1917.
Schuind FA, Goldlschmidt D, Bastin C, et al. A biomechanical study of
the ulnar nerve at the elbow. J Hand Surg [Br] 20:623–627, 1995.
Sponseller PD, Engber WD. Double entrapment of radial tunnel syndrome. J Hand Surg [Am] 8:420–423, 1983.
Stahl S, Kaufman T, Ben-David B. Neuroma of the superficial branch
of the radial nerve after intravenous cannulation. Anesth Analg
83:180–182, 1996.
Stancic MF, Eskinja N, Stosic A. Anatomic variations of the median
nerve in the carpal tunnel. Int Orthop 19:30–34, 1995.
Starke W, Rathay B, Hulsmann P. Anatomische Variante als seltene
Urasche einer distalen Ulnariskompression. Handchirurgie 20:
347–348, 1988.
Stein F, Grabias SL, Deffer PA. Nerve injuries complicating Monteggia lesions. J Bone Joint Surg Am 53:1432–1436, 1971.
Stilwell DL Jr. The innervation of deep structures of the hand. Am J
Anat 101:75–99, 1957.
Strauch RJ, Rosenwasser MP, Glazer PA. Surgical exposure of the
dorsal proximal third of the radius: how vulnerable is the posterior interosseous nerve? J Shoulder Elbow Surg 5:342–346,
1996.
Sunderland S. Traumatic injuries of peripheral nerves: I. simple compression injuries of the radial nerve. Brain 68:56–72, 1945.
Teece LG. Thrombosis of the ulnar artery. Aust N Z J Surg 19:156,
1949.
Thomsen PB. Compression neuritis of the ulnar nerve treated with
simple decompression. Acta Orthop Scand 48:164, 1977.
Tinel J. Nerve wounds. New York: William Wood, 1918:183–185.
Torres J. The clinical significance of the processur supratrochlearis.
Handchirurgie 3:15, 1971.
Uhl RL, Larosa JM, Sibeni T, et al. Posterior approaches to the
humerus: when should you worry about the radial nerve? J
Orthop Trauma 10:338–340, 1996.
Vichare NA. Spontaneous paralysis of the anterior interosseous nerve.
J Bone Joint Surg Br 50:806–808, 1968.
Voiculescu V, Popescuj F. Non-traumatic progressive paralysis of the
deep branch of the radial nerve. Neurologia (Bucur) 14:111–115,
1969.
Wadsworth TG. The external compression syndrome of the ulnar
nerve at the cubital tunnel. Clin Orthop 124:189–204, 1977.
Wallace WA, Coupland RE. Variation in the nerves of the thumb and
index finger. J Bone Joint Surg Br 57:491–494, 1975.
Watchmaker GP, Jabaley ME. Pertinent internal topography of
peripheral nerves. In: Omer GE, Spinner M, Van Beek AL, eds.
Management of peripheral nerve problems, 2nd ed. Philadelphia:
WB Saunders, 1998.
Weinberger LM. Non-traumatic paralysis of the dorsal interosseous
nerve. Surg Gynecol Obstet 69:358–363, 1939.
White NB. Neurilemomas of the extremities. J Bone Joint Surg Am
49:1605, 1967.
Wood VE, Frykman GK. Unusual branching of the median nerve at
the wrist: a case report. J Bone Joint Surg Am 60:267–268, 1978.
Zoega H. Fracture of the lower end of the radius with ulnar nerve
palsy. J Bone Joint Surg Br 48:514, 1966.
236 Systems Anatomy
4
VASCULAR SYSTEMS
MICHAEL J. BOTTE
This chapter discusses vascular systems of the upper extremity. Included are separate sections on the major arteries,
veins, lymphatics, and lymph nodes. Similar to the other
systems chapters (Chapters 1 to 3), this chapter is provided
as a reference for specific vascular structures. The discussion
of each vascular structure contains a gross anatomic description, followed by a description of the associated branches
and the area or structures supplied. The intraosseous vascular supply to the skeletal structures is covered in the chapter
on Skeletal Anatomy (Chapter 1). The vascular contributions to specific muscles are listed under each separate muscle in the chapter on Muscle Anatomy (Chapter 2). Discussions of variations and clinical correlations of the described
anatomy follow each section.
ARTERIAL ANATOMY
AXILLARY ARTERY
Gross Anatomic Description: Axillary
Artery
The axillary artery begins at the distal edge of the first rib
and ends at the distal edge of the teres major tendon (Figs.
4.1 and 4.2). It is formed as the continuation of the subclavian artery. The subclavian artery crosses deep to the clavicle and superior to the first rib to become the axillary artery
(1–10). Some authors consider the axillary artery to begin
at the distal edge of the clavicle (11,12). The axillary artery
is the central structure of the axilla and continues across the
axilla to the distal edge of the teres major tendon. At that
point, where it leaves the axilla, the axillary artery becomes
the brachial artery (1–12). From its beginning at the first
rib, the axillary artery continues in a distal and inferior
direction (when the arm is at the side) to reach the inferior
aspect of the proximal arm. The artery initially lies deep in
the axilla, inferior to the anterior border of the deltoid and
covered in part by the pectoralis minor and more distally by
the pectoralis major. As it crosses anterior to the teres major,
it becomes superficial and palpable in the axilla, just before
it becomes the brachial artery. In its most distal part, the
axillary artery is covered only by skin and fascia (1,2,3,6).
The axillary vein lies parallel to the axillary artery and is
positioned anterior or inferior to the artery along the
artery’s course through the axilla.
The axillary artery is conventionally divided into three
parts, based on its relationship to the pectoralis minor
(Table 4.1; see Fig. 4.2). The first part of the axillary artery,
also called the proximal part, is proximal to the pectoralis
minor. The second or posterior part is posterior to the muscle. The third part, also called the distal part, is distal to the
pectoralis minor (3,4,11).
The First (Proximal) Part of the Axillary Artery
The first (proximal) part of the axillary artery is approximately 2.5 cm long and extends from the lateral border of
the first rib to the medial border of the pectoralis minor
(7,8,11). It is bordered superiorly by the anterior deltoid
muscle and covered anteriorly by the skin, superficial fascia, platysma, supraclavicular nerves, deep fascia, a portion of the clavicular part of the pectoralis major, and the
clavipectoral fascia. Anterior to the first part of the artery
lie the lateral pectoral nerve, the loop of communication
between the lateral pectoral nerve and the medial pectoral
nerve, and the thoracoacromial and cephalic veins. Posterior to the first part of the artery are the first intercostal
space, the corresponding external intercostal muscle, the
first and second digitations of the serratus anterior, the
long thoracic and medial pectoral nerves, and the medial
cord of the brachial plexus. Lateral to the first part of the
artery are the posterior and lateral cords of the brachial
plexus, separated from the artery by the areolar tissue.
Medial to the first part of the artery lie the axillary vein
and a portion of the medial cord of the brachial plexus.
The first part of the axillary artery is enclosed with the
axillary vein and brachial plexus in a fibrous axillary
sheath that is continuous with the prevertebral layer of the
deep cervical fascia (1–4,8,12). The first part of the axillary artery gives off the superior (supreme) thoracic artery
(see under Main Branches: Axillary Artery, later) (11)
(Table 4.2).
238 Systems Anatomy
FIGURE 4.1. The main arterial trunks of the upper extremity.
The Second (Posterior) Part of the Axillary
Artery
The second (posterior) part of the axillary artery is approximately 3 cm long and consists of the portion of the artery
that lies deep to the pectoralis minor (7,8,11). This part
courses anterior to the subscapularis muscle and is surrounded by the cords of the brachial plexus. Anterior to the
artery lie the skin, superficial and deep fascia, the pectoralis
major muscle, and, immediately anterior to the artery, the
4 Vascular Systems 239
FIGURE 4.2. The axillary artery and its six associated branches. From proximal to distal, these
include the superior (supreme) thoracic artery arising from the first part of the axillary artery; the
thoracoacromial and lateral thoracic arteries arising from the second part of the axillary artery;
and the subscapular artery and the anterior and posterior humeral circumflex arteries arising
from the third part of the axillary artery.
pectoralis minor. Posterior to the second part of the artery
are the posterior cord of the brachial plexus and the areolar
tissue that separates the posterior cord from the deeperlying subscapularis. Lateral to the second part of the artery
are the lateral cord of the brachial plexus and the coracobrachialis. Medial to the second part of the artery are the
axillary vein, the medial cord of the brachial plexus, and the
medial pectoral nerve. The cords of the brachial plexus
therefore surround the second part of the axillary artery on
three sides (posterior, lateral, and medial), with the relative
positions implied by their names, and separate the artery
from the axillary vein and adjacent muscles (1–4,8,12). The
second part of the axillary artery gives off the thoracoacromial and lateral thoracic arteries (see later, under Main
Branches: Axillary Artery) (11) (see Table 4.1).
The Third (Distal) Part of the Axillary Artery
The third (distal) part of the axillary artery is approximately
7.5 cm long and extends from the lateral border of the pectoralis minor to the distal border of the tendon of the teres
major (7,8,11). Anterior to the proximal portion of this
third part is the pectoralis major muscle. Anterior to the
distal portion of the third part, the artery is covered only by
skin and superficial fascia. It is palpable in this subcutaneous location. Posterior to the third part of the artery are
the inferior part of the subscapularis muscle and the tendons of the latissimus dorsi and teres major. Lateral to the
third part of the artery is the coracobrachialis muscle.
Medial to the third part of the artery is the axillary vein.
The branches of the brachial plexus have the following relationships to the third part of the axillary artery: On the lateral aspect are the lateral root and trunk of the median
nerve, and, for a short distance, the musculocutaneous
nerve. On the medial aspect (between the axillary vein and
artery) lie the ulnar nerve and (to the medial aspect of the
vein) the medial brachial cutaneous nerve. Anterior to the
third part of the artery are the medial root of the median
nerve and the medial antebrachial cutaneous nerve. Posterior to the third part of the axillary artery are the radial and
axillary nerves. The axillary nerve extends only as far as the
distal border of the subscapularis (1,2). The third part of
the axillary artery gives off the subscapular artery and the
anterior and posterior humeral circumflex arteries (see later,
under Main Branches: Axillary Artery) (11) (see Table 4.1).
The direction and shape of the axillary artery varies with
the position of the arm (3,4). When the arm is at the side,
the axillary artery becomes convex superiorly. In this position, the third part of the artery is “clasped” by the two
heads of the median nerve (11). When the arm is raised
above the head, the axillary artery becomes concave superiorly. When the arm is abducted 90 degrees, the artery is
basically straight, and the two roots of the median nerve lie
loosely around the third part (3,4,11).
Main Branches: Axillary Artery
The first part of the axillary artery gives off the superior
(supreme) thoracic artery. The second part gives off the thoracoacromial and lateral thoracic arteries. The third part
gives off the subscapular artery and the anterior humeral
and posterior humeral circumflex arteries (see Table 4.1 and
Figs. 4.1 and 4.2).
Superior Thoracic Artery
The superior (supreme) thoracic artery arises from the proximal part of the first part of the axillary artery (see Figs. 4.1
and 4.2). It is a small branch that usually originates just distal to the clavicle, but variations include its origin from the
thoracoacromial artery or its complete absence (1–4,11).
The artery extends downward or medially, usually posterior
to the axillary vein, and continues along the chest wall in
the first and possibly second intercostal spaces (see Fig. 4.1).
The superior thoracic artery pierces the clavipectoral fascia
and courses between the pectoralis minor and pectoralis
major, supplying both muscles. It continues along the chest
wall and anastomoses with the internal thoracic and upper
one or two intercostal arteries. It also reaches and supplies
the sternoclavicular joint (8). Besides supplying the pectoralis major and minor, the superior thoracic artery supplies the associated intercostal muscles and the upper portion of the serratus anterior (7).
Thoracoacromial Artery
The thoracoacromial artery, arising from the second part of
the axillary artery, is a short arterial trunk with several
240 Systems Anatomy
TABLE 4.1. BRANCHES OF THE THREE PARTS THE
AXILLARY ARTERY
First (proximal) part of the axillary artery
Superior thoracic artery
Second (posterior) part of the axillary artery
Thoracoacromial artery
Clavicular branch
Pectoral branch
Deltoid branch
Acromial branch
Acromial rete
Lateral thoracic artery
Lateral (external) mammary branches
Third (distal) part of the axillary artery
Subscapular artery
Circumflex scapular artery
Thoracodorsal artery
Posterior humeral circumflex artery
Acromial rete (anastomosis)
Anterior humeral circumflex artery
Bicipital branch
Pectoral branch
branches of its own (3,4) (see Figs. 4.1 and 4.2). It originates deep to or just proximal to the proximal edge of the
pectoralis minor. Near the artery’s origin, it branches into
four terminal branches: the clavicular, humeral, acromial,
and pectoral branches. The artery or its separate branches
pierce the clavipectoral fascia and the branches radiate away
from each other to reach their respective destinations. The
thoracoacromial artery may initially divide into two short
trunks, one of which descends inferiorly and medially to
form the clavicular and pectoral branches, the other of
which ascends superiorly and laterally to form the acromial
and humeral branches.
The Clavicular Branch
The clavicular branch of the thoracoacromial artery usually
is relatively small and ascends or descends medially in a retrograde direction between the clavicular part of the pectoralis major and the clavipectoral fascia. The branch supplies the sternoclavicular joint, the subclavius muscle, and a
part of the thoracic wall (1,2,8). It may send a nutrient vessel to the clavicle (7).
The Pectoral Branch
The pectoral branch of the thoracoacromial artery is the
largest branch of the thoracoacromial artery. It descends
with the lateral pectoral nerve between the pectoralis minor
and pectoralis major muscles. It supplies both muscles, as
well as the breast. The pectoral branch then forms anastomoses with the intercostal branches of the internal thoracic
and lateral thoracic arteries (2). It may send a deep branch
posterior to the pectoralis minor that may supply the adjacent part of the thoracic wall (7).
The Deltoid Branch
The deltoid branch of the thoracoacromial artery also is a
relatively large branch, and often arises with the acromial
branch. It crosses anterior to the pectoralis minor but deep
to the clavicular head of the pectoralis major as it ascends
toward the lateral aspect of the shoulder. The branch continues along with the cephalic vein between the pectoralis
major and deltoid. It may give branches that pass through
the interval between the pectoralis major and deltoid to
become superficial to both muscles. The deltoid branch
supplies both the pectoralis major and the deltoid as it continues along the deltopectoral groove (3,4,8).
The Acromial Branch
The acromial branch of the thoracoacromial artery is a relatively small branch that often arises with the deltoid
branch. It ascends toward the superior aspect of the shoulder. The branch crosses over in the vicinity of the coracoid
process deep to the deltoid muscle. It either perforates the
deltoid or crosses through the interval between the deltoid
and the clavicular head of the pectoralis major. The acromial branch supplies the deltoid and continues superiorly
toward the acromion. At the acromion, the artery forms
anastomoses with the branches of the suprascapular artery,
the deltoid branches of the thoracoacromial artery, and the
posterior humeral circumflex arteries. The anastomosis over
the acromion is called the acromial rete (from the Latin rete,
which means “net”) (8).
Lateral Thoracic Artery
The lateral thoracic artery arises most commonly from the
second part of the axillary artery, but may have several common variations (see Figs. 4.1 and 4.2). It originates from the
second part of the axillary artery in approximately 50% of
individuals, from the subscapular artery in approximately
30%, from the first part of the axillary artery in approximately 11%, and from the thoracoacromial artery in 7%
(7). It passes deep to the pectoralis minor and descends
along the lateral border of the muscle to reach the thoracic
wall, passing anterior to the lateral cutaneous branches of
the thoracic segmental nerves. It continues downward along
the superficial aspect of the serratus anterior. It usually has
a branch that extends laterally across the axilla to reach the
anterior surface of the subscapularis and the axillary lymph
nodes. The lateral thoracic artery forms anastomoses with
the internal thoracic, subscapular, and intercostal arteries
and the pectoral branch of the thoracoacromial artery. The
artery supplies the pectoralis minor and major, the serratus
anterior, the subscapularis, the second to fifth intercostal
spaces, and the axillary lymph nodes. In women, the lateral
thoracic artery is large and also forms the lateral mammary
branches (sometimes referred to as the external mammary
branches). These branches can be of considerable size, and
curve around the free lateral border of the pectoralis major
to supply the breast (1–4).
Subscapular Artery
The subscapular artery usually is the largest branch of the
axillary artery (see Figs. 4.1 and 4.2). It arises from the third
part of the axillary artery at the distal border of the subscapularis muscle. It descends along the anterior surface of
the subscapularis muscle, deep to the latissimus dorsi. It
usually lies adjacent to the lower subscapular and thoracodorsal nerves. The subscapular artery usually is accompanied by several veins, which unite and communicate with
the circumflex scapular vein and continue to either the axillary vein or the medial brachial vein. At approximately 2.5
to 4 cm from its origin point from the axillary artery, the
subscapular artery divides into the circumflex scapular and
thoracodorsal arteries (3,4).
The Circumflex Scapular Artery
The circumflex scapular artery usually is larger than the
thoracodorsal artery, and courses posteriorly and then
medially. It curves around the lateral border of the scapula
4 Vascular Systems 241
to pass through the triangular space (bordered by the teres
minor and subscapularis superiorly, the teres major inferiorly, and the long head of the triceps laterally) (3,4). The
circumflex scapular artery then enters the infraspinous fossa
between the teres minor and the scapula, and remains close
to the posterior surface of the scapula. The artery then
forms anastomoses with the several intercostal arteries and
with the deep branch of the transverse cervical artery or
with the descending branch of the descending scapular
artery. The posterior portion of circumflex scapular artery
supplies the infraspinatus muscle. As the artery passes
through the triangular space, it usually gives a branch to the
subscapularis muscle. The circumflex scapular artery usually
also has another large branch that continues along the lateral border of the scapula between the teres major and teres
minor. This branch may form anastomoses with the deep
branch of the transverse cervical artery (or descending
branch of the descending scapular at the inferior angle of
the scapula). The vessel supplies the teres major and minor
muscles as well as the long head of the triceps and the deltoid (1,3,4). There also may be additional anastomoses with
other arteries in the shoulder region, and branches originating from the suprascapular artery may contribute to vascularity of the rotator cuff (13) (Table 4.1 and Fig. 4.2).
The Thoracodorsal Artery
The thoracodorsal artery is the continuation of the scapular
artery and courses inferiorly across the axilla along the anterior border of the latissimus dorsi muscle. The artery lies adjacent to the thoracodorsal nerve. The thoracodorsal artery
forms anastomoses with the circumflex scapular artery and
with the deep branch of the transverse cervical artery (or
descending branch of the descending scapular artery). The
thoracodorsal artery supplies the subscapularis as well as providing the principal vascular supply to the latissimus dorsi.
One or two large branches cross the axilla to supply the serratus anterior and intercostal muscles. These branches may
form anastomoses with the intercostal, lateral thoracic, and
thoracoacromial arteries. When the lateral thoracic artery is
small or absent, a branch of the thoracodorsal may supply the
associated muscles (1,3,4) (Table 4.1 and Fig. 4.2)
Additional subscapular branches may arise from the second or third part of the axillary artery and descend to supply the subscapularis. One branch that usually is consistent
accompanies the upper subscapular nerve (7).
Anterior Humeral Circumflex Artery
The anterior humeral circumflex artery, along with the posterior humeral circumflex artery, are the most distal arterial
branches from the axillary artery (see Table 4.1 and Figs. 4.1
and 4.2). It is much smaller than the posterior humeral circumflex artery and originates from the third part of the axillary artery near the inferior border of the subscapularis muscle. The posterior humeral circumflex artery also originates at
the same level on the axillary artery. The anterior humeral circumflex artery may arise from a common trunk with the posterior humeral circumflex or consist of several small branches.
The anterior humeral circumflex artery leaves the axillary
artery along the superior or lateral margin of the arterial
trunk and ascends upward or laterally deep to the coracobrachialis muscle and short head of the biceps brachii. It
curves anterior to the neck of the humerus. As it reaches the
intertubercular sulcus of the humerus, the anterior humeral
circumflex artery gives off a branch, the bicipital branch of
the anterior humeral circumflex, that ascends in the sulcus to
supply the tendon of the long head of the biceps, the head of
the humerus, and the shoulder joint. A pectoral branch of the
anterior humeral circumflex artery may descend along the
tendon of insertion of the pectoralis major. This branch contributes to the vascular supply of the pectoralis major tendon.
The main branch of the artery continues laterally, in close
proximity to the humerus, deep to the long head of the
biceps brachii and the deltoid. It forms an anastomosis with
the posterior humeral circumflex artery (3,4).
Posterior Humeral Circumflex Artery
The posterior humeral circumflex artery, along with the anterior humeral circumflex artery, are the most distal arterial
branches from the axillary artery (see Table 4.1 and Figs. 4.1
and 4.2). It originates from the third part of the axillary
artery near the inferior border of the subscapularis muscle,
and is much larger than the anterior humeral circumflex
artery. The posterior humeral circumflex artery courses deep
and posteriorly, to pass through the quadrangular space (bordered by the teres minor and subscapularis superiorly, the
long head of the triceps brachii medially, the teres major inferiorly, and the surgical neck of the humerus laterally). The
artery curves around the surgical neck of the humerus and
forms anastomoses with the anterior humeral circumflex
artery, the deltoid branch of the profunda brachii artery, and
the acromial branches of the suprascapular and thoracoacromial arteries. The posterior humeral circumflex artery provides branches to the deltoid, the teres major and minor, the
long and lateral heads of the triceps brachii, the greater
tuberosity of the humerus, and the shoulder joint. The posterior humeral circumflex may have anastomoses with the
acromial rete (3,4).
Anomalies and Variations: Axillary Artery
The axillary artery has considerable variations in its branch
patterns (14–18). The branches described previously may
arise together, or their subsequent smaller branches may be
given off directly by the main axillary artery. Instead of 6
branches, the axillary artery may have a total of 5 to 11 (8).
The axillary artery has been noted to pass posterior to the
medial cord of the brachial plexus (19).
Bilateral double axillary arteries have been noted (20).
242 Systems Anatomy
A thoracoepigastric artery is a rare variation of a branch
that arises from the axillary artery (14). The branch leaves
the axillary artery and passes as a common trunk between
the roots of the median nerve, and divides into two
branches. The lateral one gives rise to muscular branches
that supply the shoulder and fasciae, whereas the medial
one descends on the anterior aspect of the axillary fossa,
reaching the hypogastric region. The artery forms an anastomosis with the superficial epigastric artery, which is a
branch of the femoral artery (14).
An alar thoracic artery is a branch, usually from the second part of the axillary artery, that specifically supplies the
fat and lymph nodes in the axilla (3).
The vascular supply to the serratus anterior muscle usually originates from the thoracodorsal artery and vein.
Goldberg et al. noted that the artery to the serratus anterior
could originate directly from the subscapular artery (21).
The thoracodorsal pedicle arose directly from the axillary
artery and separately from the subscapular vascular pedicle
in 3% of cases. This has implications for dissection and
transfer of the serratus anterior (21).
The lateral thoracic artery arises most commonly from
the second part of the axillary artery and is conventionally
illustrated as such in anatomy textbooks. This, however, is
observed only in approximately 50% of individuals. Its origin is variable, and includes the subscapular artery in
approximately 30%, from the first part of the axillary artery
in approximately 11%, and from the thoracoacromial
artery in 7% (7). The lateral thoracic artery has been noted
to originate proximal to the origin of the superior thoracic
artery (instead of its usual more distal origin point) (15).
The subscapular artery usually arises from the third part
of the axillary artery. Variations include point of origin from
the second part of the axillary in approximately 15%, or
from a common trunk with the posterior humeral circumflex artery in approximately 15% (7).
The subscapular, anterior and posterior humeral circumflex
arteries, and the profunda brachii artery may arise from a
common branch. The branches of the brachial plexus can
surround this anomalous artery instead of the axillary artery
(3,4,7). The posterior humeral circumflex and the subscapular arteries may share a common trunk in approximately 15%
(7). The posterior humeral circumflex artery may originate
from the profunda brachii artery, passing inferior to the teres
major instead of through the quadrangular space (3,4).
The axillary artery may give rise directly to the radial and
ulnar arteries in the axilla, sometimes referred to as the high
division axillary anomaly (22–34). The high origin of the
radial artery is among the most common of all vascular variations in the upper extremity (23,24). Celik and colleagues
noted this anomaly in 7 of 81 (8.6%) of arteriograms, and it
represented 86% of all variations noted in their series (24).
The radial artery can be connected to the axillary artery (or
occasionally to the brachial artery) through a long, slender
anastomotic artery, referred to as the vasa aberrantia (25).
High division of the ulnar artery from the axillary is rare
compared with the anomaly in the radial artery (24,26).
This has been observed in only approximately 1% to 2% of
cases (22,24,29), originating from the second part of the
axillary artery. High division of the ulnar artery can occur
concomitantly with a high division of the radial artery (22).
The high division involving the ulnar artery has been
referred to as a superficial ulnar artery (27–34). The superficial ulnar artery has been noted to cross ventral to the medial
root of the median nerve before continuing toward the
medial part of the arm (27,33,34). The superficial ulnar
artery may cross superficial to the median nerve and brachial
artery. In general, the anomalous ulnar artery is smaller than
the radial artery or interosseous arteries. When the ulnar
artery originates directly from the axillary artery, it has been
noted that the common interosseous artery (which usually
originates from the ulnar artery) originates from the radial
artery (30). These anomalies of the radial and ulnar arteries
may be bilateral (23,27,31).
The axillary artery also may give rise directly to an anterior
interosseous artery. Similarly, the axillary artery may divide in
the axilla into two main branches. The branches continue into
the arm, where one usually runs more superficially and may
represent the radial or ulnar arteries; the deeper branch usually
corresponds to the brachial artery proper (8).
Clinical Correlations: Axillary Artery
The axillary artery is easily palpable in its third (distal) part,
as it crosses anterior to the teres major and is covered on the
lateral axillary surface only by skin and fascia. This is a useful landmark for the administration of local anesthesia for
the placement of an axillary block regional anesthetic
(35–38). The more proximal portions of the artery can be
mapped out, when the arm is raised, by a line drawn from
the point of artery palpation (distal part) to the mid-clavicle (area of the proximal part). Although it is used as a landmark to identify the brachial plexus, pseudoaneurysm or
obliteration of the axillary artery can occur from injury to
the artery from axillary block (39,40).
In anatomic and operative dissections of the axilla, the
coracoid process and pectoralis minor are key landmarks for
identification of the axillary artery and surrounding
brachial plexus. The second part of the axillary artery lies
deep to the pectoralis minor. From this second part of the
axillary artery, the specific designation of the cords of the
brachial plexus has been made [the lateral cord lies lateral to
the axillary artery (second part), the medial cord lies medially, and the posterior cord lies posteriorly] (1–4,11). Thus,
the pectoralis minor can help with identification of the second part of the axillary, and this also corresponds to the
level of the brachial plexus that contains the cords.
The second part of the axillary artery lies inferior to the
coracoid process, deep to the pectoralis minor. Risk of
injury to the artery may be lessened if the arm is adducted
4 Vascular Systems 243
while performing operative procedures involving the coracoid process (6,8).
An appreciation of the relatively high incidence (8.6%) of
the anomalous radial artery or, less commonly, the ulnar
artery originating high in the axilla directly from the axillary
artery, is important during the operative exposure of the axilla
or forearm or in the interpretation of arteriograms (23,24).
These variations also may be relevant in the dissection for
pedicle and free flaps that are based on the forearm arteries.
The axillary artery is vulnerable to injury from a variety
of well documented trauma events. These include proximal
humeral fractures or dislocations, which can cause thrombosis (from torn intima), pseudoaneurysm, or rupture
(41–52). Clavicle fractures are a less common cause of axillary artery injury (48). Penetration of the artery by the
proximal locking screws of humeral intramedullary nails
has been reported (50). In addition, chronic, incorrect use
of crutches has been associated with axillary artery stenosis,
aneurysm formation, and secondary axillobrachial thromboembolic disease (51,52).
Of all upper extremity emboli, up to 20% arise from an
arterial, not a cardiac source (51). Axillary artery thromboses contribute to a substantial number of these cases.
Sports-related trauma, especially that involving professional baseball pitchers, is well known to cause injury to the
axillary artery (53–57). Arterial aneurysm, thrombosis, or
occlusion can lead to hand ischemia from insufficiency or
emboli (57,58).
Several muscles or related structures can compress the
axillary artery. Thrombosis of the axillary artery has
occurred from compression by the pectoralis minor or from
an anomalous muscle in the axillary fossa (58–60).
Quadrilateral Space Syndrome
Quadrilateral space syndrome consists of compression of
the posterior humeral circumflex artery and the axillary
nerve by fibrotic bands as the artery and the nerve traverse
the quadrilateral space (61). Symptoms often are secondary
to compression of the axillary artery, not the posterior
humeral circumflex artery. Because of the vague, often nonspecific clinical presentation of patients with quadrilateral
space syndrome, diagnosis is challenging and requires a
high index of suspicion. Subclavian arteriography confirms
the diagnosis. Conservative treatment has been successful;
operative management is reserved for selected, refractory
patients (61).
BRACHIAL ARTERY
Gross Anatomic Description: Brachial
Artery
The brachial artery, which is a continuation of the axillary
artery, begins at the distal margin of the teres major and
continues approximately 1 cm distal to the elbow, where it
ends to form the radial and ulnar arteries (7,11) (Fig. 4.3;
see Figs. 4.1 and 4.2). It passes down the medial aspect of
the arm and becomes more anteriorly located as it descends
so that it is along the anteromedial aspect of the elbow
joint. It is superficial and palpable along its course, covered
only by skin and superficial and deep fascia. The artery
passes deep to the bicipital aponeurosis. In the proximal
part of the arm, the median nerve lies anterior to the
brachial artery. The median nerve crosses the brachial artery
in the mid-portion of the arm so that the nerve lies medial
to the artery at the elbow. The ulnar nerve lies immediately
medial to the brachial artery in the proximal part of the
arm. The brachial artery then curves anteriorly away from
the ulnar nerve so that the two structures are separated from
each other at the elbow.
In the proximal arm, located posterior to the brachial
artery, is the radial nerve and the profunda brachii artery,
and the long head of the triceps. The brachial artery then
passes along the medial head of the triceps, along the insertion of the coracobrachialis, and then continues along the
brachialis. In the proximal arm, lateral to the brachial
artery, is the median nerve and coracobrachialis. More distally, the biceps brachii lies lateral to the artery. On the
medial aspect of the artery, in the proximal arm, are the
medial antebrachial cutaneous nerve and ulnar nerves.
More distally, the median nerve is located medially after it
crosses the artery. The basilic vein also lies along the medial
aspect of the brachial artery, but is separated from the artery
in the distal part of the arm by fascia. The brachial artery
usually is accompanied by two venae comitantes, which lie
in close contact to the artery and are interconnected at
intervals by short transverse branches (1–6,11).
At the elbow, the brachial artery courses anteriorly to
cross the mid-portion of the cubital fossa. It is covered anteriorly by skin, superficial fascia, and the median cubital
vein. At the level of the radial neck, the brachial artery
divides into the radial and ulnar arteries. In the cubital
fossa, the brachialis lies posterior and lateral to the brachial
artery. The median nerve lies medial to the artery as it
divides into the radial and ulnar arteries (3).
244 Systems Anatomy
TABLE 4.2. BRANCHES OF THE BRACHIAL ARTERY
Profunda brachii (deep brachial artery)
Deltoid (ascending) branch
Radial collateral artery
Middle collateral artery
Nutrient (accessory) branch to the humerus
Principal nutrient artery of the humerus
Superior ulnar collateral artery
Inferior ulnar collateral artery
Posterior branch
Anterior branch
Muscular branches
Main Branches: Brachial Artery
The brachial artery gives off the profunda brachii artery, the
superior and inferior ulnar collateral arteries, as well as a
principal nutrient artery of the humerus and several muscular branches (3) (see Figs. 4.2 and 4.3 and Table 4.2).
Profunda Brachii Artery
The profunda brachii artery (deep brachial artery) is the
largest and most proximal branch of the brachial artery (see
Figs. 4.2 and 4.3). It arises from the posteromedial aspect of
the brachial artery just distal to the distal border of the teres
major. The profunda brachii artery initially spirals backwards into the posterior compartment of the arm between
the long and lateral heads of the triceps brachii. Proximally,
the profunda brachii gives off the deltoid ascending branch.
The profunda brachii artery then continues distally along
with the radial nerve in the spiral groove of the humerus
between the lateral and medial heads of the triceps. The
nerve and artery continue posterior to the humerus. The
profunda brachii artery divides into the radial collateral and
the middle collateral arteries. The profunda brachii also
gives off a nutrient branch to the humerus (3).
4 Vascular Systems 245
FIGURE 4.3. The brachial artery and major branches,
including the collateral circulation of the elbow.
The Deltoid Ascending Branch
The deltoid ascending branch of the profunda brachii is a
small artery that leaves the profunda brachii artery proximally and ascends between the long and lateral heads of the
triceps brachii. It anastomoses with a descending branch of
the posterior humeral circumflex artery (arising from the
axillary artery). In 7%, the anastomosis to the posterior
humeral circumflex artery may be the major or sole source
of the profunda brachii. In addition, this anastomosis may
be the major or sole source of the posterior humeral circumflex from the profunda brachii in 16% (7). The deltoid
ascending branch helps supply the brachialis and deltoid
muscles (1,3,7) (Table 4.2).
The Radial Collateral Artery
The radial collateral artery of the profunda brachii is one
of the terminal distal divisions of the profunda brachii
artery. [The middle collateral artery of the profunda is the
other terminal division (see later).] The radial collateral
artery, frequently described as the terminal portion of the
profunda brachii, continues along with the radial nerve,
along the humerus and on the surface of the lateral head of
the triceps brachii. It continues distal to the elbow to enter
the forearm, still in association with the radial nerve. The
artery lies deep to the lateral head of the triceps to the level
of the lateral supracondylar ridge of the humerus. Here it
courses anteriorly to cross through the lateral intermuscular septum into the flexor compartment of the arm, and
continues distally between the brachioradialis and the
brachialis muscles to the palmar aspect of the lateral epicondyle. The radial collateral artery terminates as it anastomoses with the radial recurrent artery. Other branches
may follow the posterior antebrachial cutaneous nerve and
continue with the nerve to reach the skin. Before the radial
collateral artery pierces the intermuscular septum, it may
give a branch that continues distally to the posterior aspect
of the lateral epicondyle and contributes to the anastomoses around the elbow. The radial collateral artery usually
contributes to the intraosseous circulation of the capitellum and the lateral aspect of the trochlea as well (62)
(Table 4.2 and Fig. 4.3).
The Middle Collateral Artery
The middle collateral artery of the profunda brachii usually
is larger than the radial collateral artery. Along with the
radial collateral, the middle collateral artery is the terminal
division of the profunda brachii artery. The middle collateral artery passes through the long and medial heads of the
triceps muscle and continues distally posterior to the
humeral diaphysis and lateral epicondyle. At the distal
humerus, the middle collateral artery forms an anastomosis
with the interosseous recurrent artery and contributes to the
anastomoses around the elbow (3,4). This anastomosis has
been referred to as the olecranon articula rete (7) (Table 4.2
and Fig. 4.3).
An Accessory Nutrient Artery
An accessory nutrient artery of the profunda brachii usually
is given off of the profunda brachii artery, which supports
the principal nutrient artery from the brachial artery. This
accessory nutrient artery usually enters the humerus
through a nutrient canal located posterior to the deltoid
tuberosity. This branch may be absent (3,4) (Table 4.2).
Principal Nutrient Artery of the Humerus
The humerus has one main or principal nutrient artery.
This artery arises directly from the brachial artery in the
mid-portion of the arm, often near the origin of the superior ulnar collateral artery or, less frequently, from the superior ulnar collateral artery itself (7). The nutrient artery
enters the humerus through a nutrient canal located near
the insertion of the coracobrachialis, near or distal to the
middle of the humerus but anterior to the proximal end of
the medial supracondylar ridge (3,4,7) (Table 4.2).
Superior Ulnar Collateral Artery
The superior ulnar collateral artery arises from the brachial
artery at a level just distal to the mid-portion of the arm (see
Table 4.2 and Figs. 4.2 and 4.3). It also may originate from
the proximal part of the profunda brachii in up to 22% (7).
It is a long, slender vessel that pierces the medial intermuscular septum to reach the posterior compartment of the
arm. The artery joins the ulnar nerve and both structures
continue distally along the medial head of the triceps
brachii. The artery and nerve course posteriorly behind the
medial epicondyle in the interval between the epicondyle
and the olecranon. The vessel continues deep to the flexor
carpi ulnaris. Traditional textbooks usually show or discuss
an anastomosis of the superior ulnar collateral artery with
the posterior ulnar recurrent artery (1–4); however, recent
studies demonstrated no identifiable direct anastomosis
between these arteries in 20 of 22 specimens (62). There
usually is a more proximal anastomosis with the inferior
ulnar collateral artery just proximal to the medial epicondyle (Fig. 4.2). The superior ulnar collateral artery also
may anastomose with the anterior ulnar recurrent artery
and may provide a branch to the medial epicondyle (1,2).
The superior ulnar collateral artery (along with the inferior
ulnar collateral and the posterior ulnar recurrent arteries)
provides a segmental extraneural and intraneural vascular
supply to the ulnar nerve (62–64).
Inferior Ulnar Collateral Artery
The inferior ulnar collateral artery originates from the
medial side of the brachial artery approximately 5 cm proximal to the medial epicondyle (see Table 4.2 and Figs. 4.2
and 4.3). It continues medially on the surface of the
brachialis and divides into anterior and posterior branches.
246 Systems Anatomy
The posterior branch crosses through the medial intermuscular septum to the posterior compartment of the arm. This
branch passes laterally on the dorsal aspect of the distal
humerus, deep to the triceps brachii to reach the lateral
aspect of the posterior humerus. This branch anastomoses
with the middle collateral branch of the profunda brachii at
the lateral margin of the humerus. By this junction with the
middle collateral branch, the inferior ulnar collateral artery
forms an arterial arch just proximal to the olecranon fossa.
At the medial margin of the humerus, the posterior branch
also may provide a branch that communicates with the superior ulnar collateral and the posterior ulnar recurrent arteries
(posterior to the medial epicondyle). The anterior branch of
the inferior ulnar collateral artery, which leaves the trunk at
the medial aspect of the humerus, continues distally and
passes anterior to the distal humerus and medial epicondyle
to communicate with the anterior ulnar recurrent artery.
The inferior ulnar collateral also contributes to the vascular
supply to the medial aspect of the trochlea through a circumferential vascular ring that originates from the inferior
ulnar collateral artery at the level of the elbow (62).
Recent studies have shown that the inferior ulnar collateral artery (along with the superior ulnar collateral and the
posterior ulnar recurrent arteries) provides a segmental
extraneural and intraneural vascular supply to the ulnar
nerve (63). The inferior ulnar collateral artery provides the
only direct vascularization to the nerve in the region just
proximal to the cubital tunnel (62–64).
Muscular Branches
There are usually three or four muscular branches that originate from the brachial artery to supply the coracobrachialis,
biceps brachii, and the brachialis muscles (Table 4.2).
Anastomoses of the Brachial Artery
The branches of the brachial artery form an anastomotic
network posterior and anterior to the elbow, with interconnections to branches from the radial and ulnar arteries (see
Fig. 4.3). These have been described individually previously. For descriptive purposes and to summarize, these
have been divided by Clemente into those that pass anterior
and those that pass posterior to the medial and lateral epicondyles of the humerus (3).
The branches that anastomose anterior to the medial epicondyle include the anterior branch of the inferior ulnar collateral, the anterior ulnar recurrent, and (possibly) an anterior branch of the superior ulnar collateral. The branches
that anastomose posterior to the medial epicondyle include
the inferior ulnar collateral, the posterior ulnar recurrent,
and the posterior branch of the superior ulnar collateral.
The branches that anastomose anterior to the lateral epicondyle include the radial recurrent and the radial collateral
branch of the profunda brachii artery.
The branches that anastomose posterior to the lateral
epicondyle include the middle collateral branch of the profunda brachii, the interosseous recurrent artery, and the terminal portion of the inferior ulnar collateral artery as it
reaches the lateral aspect of the humerus.
A transverse arch is formed on the posterior aspect of the
humerus proximal to the olecranon fossa. This arch is
formed by the anastomoses of the inferior ulnar collateral,
posterior ulnar recurrent, the middle collateral branch of
the profunda brachii, and the interosseous recurrent arteries (1).
Yamaguchi and colleagues have divided the extraosseous
vascular patterns of the elbow into three vascular arcades:
medial, lateral, and posterior. The medial arcade is formed
by the superior and inferior ulnar collateral arteries and the
posterior ulnar recurrent artery. The lateral arcade is formed
by the radial and middle collateral, radial recurrent, and the
interosseous recurrent arteries. The posterior arcade is
formed by the medial and lateral arcades and the middle
collateral artery (62).
Anomalies and Variations: Brachial
Artery
High (proximal) divisions of the brachial artery: Several
anomalous branches or variations of branches of the
brachial artery have been described (22,33,65–85). Most
common are the more proximal divisions of the brachial
artery, occurring in 12% to 15% (7,83). These are often
referred to as high divisions. (See also earlier discussion of
high division of the axillary artery, which includes several
analogous branches from the axillary artery.) The superficial
brachial artery is an anomalous artery that originates from
a high division of the brachial artery (1,7,73–75,78), usually proximal in the arm, and has been observed to occur in
as low as 1% and as high as 17% of individuals (66–69,
72,83). It can continue into the forearm as the superficial
antebrachial artery or may rejoin the brachial artery distally
(66,69). In addition, a high division of the brachial artery
can form the radial, ulnar, and common interosseous arteries more proximally, at the level of the arm. Considered to
be among the most frequent of the high divisions, the radial
artery can branch high in the arm, occurring in up to 7%
to 15% (7,22,65,70,76,78,79,81). When the radial artery
arises high from the brachial artery, the other limb of the
bifurcation consists of the ulnar and common interosseous
arteries. In some cases, the ulnar artery can arise more proximally than normal, and the radial and common
interosseous form the other limb of the bifurcation (33,
80,81,86,87). The incidence of the high division of the
ulnar artery is much less than that of the radial artery,
occurring only in approximately 2% (7). Occasionally the
common interosseous arises at a more proximal level (1), or
may be absent in the presence of a high radial artery division (77).
4 Vascular Systems 247
A distal division of the radial and ulnar arteries has been
noted to occur 8 cm distal to the antecubital fossa (82).
This distal division has implications in preparing the radial
forearm flap.
Absent brachial artery and branches: Agenesis of the
brachial artery, profunda brachii artery, and superior and
inferior ulnar collateral arteries has been noted. The axillary
artery supplies collateral circulation to the forearm (88).
Vasa aberrantia: The vasa aberrantia is an anomalous
series of long slender vessels that anastomose with the
brachial or axillary artery and radial or ulnar arteries (or one
of their branches). Interconnections with the radial artery
are more common (1–4).
If there is a supracondylar process present with the commonly associated ligament of Struthers, the brachial artery
(with the median nerve) often passes deep to the ligament
(the ligament often is a proximal extension of the pronator
teres). The brachial artery, along with the median nerve,
takes a medial course along the border of the biceps toward
the medial supracondylar area. The structures then pass
deep to the pronator teres to reach the elbow region. [Note:
In the presence of the ligament of Struthers, the median
nerve may pass deep to the ligament, accompanied by the
inferior ulnar collateral artery (with the brachial artery
assuming its usual course) (1–4,7,89)].
The profunda brachii has considerable variation in its
origin. It exists as the classic artery as described earlier only
in approximately 55%, in which it arises as a single trunk
from the posteromedial aspect of the brachial artery. The
site of origin is at or slightly distal to the level of the teres
major (1,2,7). Variations include the vessel originating as a
common trunk with the superior ulnar collateral artery in
22%, from the axillary artery in 16%, or as a branch of the
posterior humeral circumflex artery in 7% (7).
Clinical Correlations: Brachial Artery
Collateral Circulation
As described previously, there is a well established series of
anastomoses around the elbow and shoulder. This provides
a substantial collateral circulation. If there is laceration or
mechanical block (e.g., from a ligature) of the brachial
artery in the proximal third of the arm (proximal to the origin of the profunda brachii), blood can possibly flow
through branches from the anterior and posterior humeral
circumflex and subscapular arteries to communicate with
the ascending branches of the profunda brachii artery. If the
main trunk of the brachial artery is blocked distal to the
level of the profunda brachii and the superior ulnar collateral arterial origins, circulation may possibly be maintained
by branches through these vessels, which anastomose with
the inferior ulnar collateral, posterior ulnar recurrent, the
radial recurrent, and the interosseous recurrent arteries (3).
Brachial Artery, Supracondylar Process, and
the Ligament of Struthers
In the presence of a supracondylar process and associated
ligament of Struthers, the median nerve and brachial artery
often pass deep to the ligament. Although median nerve
compression under the ligament is discussed more commonly, potential arterial compromise also is possible (89).
The brachial artery usually takes a more medial course
along the medial aspect of the biceps if it passes deep to the
ligament of Struthers. It then passes deep to the pronator
teres at the level of the elbow.
ULNAR ARTERY
Gross Anatomic Description: Ulnar Artery
The ulnar artery is formed as one of the two main terminating branches of the brachial artery (Fig. 4.4; see Fig.
4.3). The brachial artery bifurcates approximately 1 cm distal to the elbow joint into the ulnar and radial arteries. The
ulnar artery usually is the larger of the two, originating on
the ulnar side of the brachial artery at the level of the radial
neck and distal base of the coronoid process. From its point
of origin it courses distally and medially, and reaches the
ulnar margin of the forearm approximately midway
between the elbow and wrist joints. The ulnar nerve joins
the ulnar artery in the proximal quarter of the forearm, with
the nerve located ulnar to the artery. The nerve accompanies the ulnar artery through the forearm to the wrist. From
the mid-forearm distally, the artery continues along the
ulnar margin of the distal half of the forearm. The artery
and nerve cross the wrist superficial to the flexor retinaculum, with both structures on the radial side of the pisiform.
The artery supplies a portion of the flexor retinaculum as it
continues distally (90). The artery and nerve pass through
the ulnar tunnel (Guyon’s canal), and the distal part of the
ulnar artery forms the superficial palmar arch (1–4,7,11).
In the proximal half of the forearm, the ulnar artery is
located deep to the pronator teres, flexor carpi radialis, palmaris longus, and flexor digitorum superficialis muscles. It
lies superficial to the brachialis for a short distance, and
continues distally throughout the forearm superficial to the
flexor digitorum profundus muscles. Proximally, the
median nerve is located medial to the artery for a short distance. At approximately 2 to 3 cm distal to the origin point
of the ulnar artery, the median nerve crosses superficial to
the ulnar artery (separated from the artery by the ulnar half
of the pronator teres). The median nerve then continues on
the lateral side of the artery (1–4,11).
In the distal half of the forearm, the ulnar artery lies
superficial to the flexor digitorum profundus, between the
flexor digitorum superficialis (located radially) and the
flexor carpi ulnaris (located ulnarly). The ulnar nerve
248 Systems Anatomy
remains ulnar to the artery throughout the distal forearm
and gives off the palmar cutaneous branch of the ulnar
nerve, which continues distally along the distal ulnar artery
to reach the palm. The ulnar artery has a superficial course
in the distal forearm, covered anterior by the deep and
superficial fascia, and skin. The ulnar artery usually has two
adjacent venae comitantes (1–4,11). Proximal to the wrist,
the ulnar artery forms anastomoses with the anterior
interosseous artery, and both provide vascularity to the distal ulna and associated soft tissues (91,92).
4 Vascular Systems 249
FIGURE 4.4. The main arteries of the
palmar forearm and hand.
At the level of the wrist, the ulnar artery crosses superficial to the flexor retinaculum, with the ulnar nerve continuing on the dorsoulnar aspect of the artery. Both structures
pass radial to the pisiform.
The ulnar artery and nerve enter the ulnar tunnel
(Guyon’s canal), covered anteriorly by fascia, skin, and the
palmaris brevis muscle (1–4).
Main Branches: Ulnar Artery
The main branches of the ulnar artery can be divided into
three groups: those in the forearm, wrist, and palm (Table
4.3). The forearm branches include the anterior ulnar recurrent artery, the posterior ulnar recurrent artery, the common
interosseous artery (which divides in the anterior and posterior interosseous arteries), and several muscular branches.
The wrist branches include the palmar carpal and dorsal
carpal arteries. The branches in the hand include the deep
palmar arch and the superficial arch (which give rise to the
common palmar digital arteries).
Anterior Ulnar Recurrent Artery
The anterior ulnar recurrent is the most proximal branch of
the ulnar artery, arising from the medial aspect of the ulnar
artery just distal to the ulnar artery origin from the brachial
artery (see Figs. 4.3 and 4.4). The artery passes anteriorly
and proximally between the brachialis and the pronator
teres. It continues anterior to the medial epicondyle to anastomose with the interior ulnar collateral artery. The anterior
ulnar recurrent artery supplies the brachialis and pronator
teres muscles.
Posterior Ulnar Recurrent Artery
The posterior ulnar recurrent usually is the second main
branch of the ulnar artery (see Figs. 4.3 and 4.4). The posterior ulnar recurrent artery usually is larger than the anterior ulnar recurrent artery and arises more distally from the
medial aspect of the ulnar artery. The posterior ulnar recurrent artery passes posteriorly and proximally between the
flexor digitorum superficialis and flexor digitorum profundus, and continues in a proximal direction posterior to the
medial epicondyle. As the artery ascends, it passes through
the interval between the medial epicondyle and the olecranon, with the artery passing adjacent to the ulnar nerve in
this region. The artery continues either deep to or between
the heads of the flexor carpi ulnaris. The posterior ulnar
recurrent artery continues proximally to anastomose with
the superior and inferior ulnar collateral and the
interosseous recurrent arteries. The posterior ulnar recurrent artery supplies the flexor digitorum superficialis, flexor
digitorum profundus, flexor carpi ulnaris, and elbow joint,
as well as extending to several of the other neighboring
muscles (1–4). The artery also contributes to the vascular
supply to the olecranon (along with vessels from the
interosseous recurrent artery) from vessels given off that
course along the medial and lateral aspect of the distal end
of the humerus (62). In addition, the posterior ulnar recurrent artery (with the superior and inferior ulnar collateral
arteries) provides a segmental extraneural and intraneural
vascular supply to the ulnar nerve (62–64).
Common Interosseous Artery
The common interosseous usually is the third main branch
from the ulnar artery (see Figs. 4.3 and 4.4). It is a short, thick
vessel, only approximately 1 cm long (93–96). The common
interosseous artery arises from the posterolateral aspect of the
ulnar artery from a point approximately 1 cm distal to the
branch point of the posterior ulnar recurrent artery. Its branch
point corresponds to the level of the radial tuberosity. A rare
high division of the common interosseous artery has been
noted, arising from the brachial artery in the proximal or distal third of the arm (77,96) (see later, under Anomalies and
Variations: Ulnar Artery and Its Branches). The artery divides
250 Systems Anatomy
TABLE 4.3. BRANCHES OF THE ULNAR ARTERY
Branches in the forearm
Anterior ulnar recurrent artery
Posterior ulnar recurrent artery
Common interosseous artery
Anterior interosseous artery
Median artery
Muscular branches to forearm
Nutrient vessels to radius and ulna
Palmar carpal branch
Palmar radiocarpal arch
Palmar intercarpal arch
Palmar carpal network
Dorsal carpal network
Dorsal carpal branch
Dorsal radiocarpal arch
Dorsal intercarpal arch
Basal metacarpal arch
Posterior interosseous artery
Interosseous recurrent artery
Dorsal carpal network
Muscular branches
Branches at the wrist
Palmar carpal artery
Transverse arches at the carpus
Palmar radiocarpal arch
Palmar intercarpal arch
Dorsal carpal artery
Branches in the hand
Deep palmar artery
Superficial palmar arch
Common palmar digital arteries
Proper palmar digital arteries
Dorsal branches (to the dorsal digital arteries)
Vinculum longum superficialis
Vinculum brevis superficialis
Vinculum longum profundus
Vinculum brevis profundus
into two main branches, the anterior and posterior
interosseous arteries. Both of these arteries have received
attention in anatomic studies because of their relevance in
pedicle or free tissue flaps or grafts of the forearm (97–127).
The Anterior Interosseous Artery (Proximal Part)
The anterior interosseous artery arises a few centimeters
distal to the level of the radial tuberosity (see Fig. 4.4).
The diameter of the artery at its origin varies from 0.9 to
1.5 mm (101). It passes through the deep flexor compartment of the forearm along the anterior interior
interosseous ligament. The anterior interosseous artery is
accompanied by the anterior interosseous nerve. Along its
course in the forearm, the artery passes deep to or through
the flexor digitorum profundus and flexor pollicis longus,
and gives off a small, inconsistent vessel of variable size,
the median artery, as well as several muscular branches
(3,4,7,8) (Table 4.3). The anterior interosseous artery
appears to be the main periosteal and endosteal supply of
the ulna, with its branches supplying the distal one-fourth
of both the ulnar and radius (91,92,128,129). [Other
contributing arteries that supply the ulna include the
ulnar artery proper, the ulnar recurrent artery, and the
recurrent interosseous artery (128).] The anterior
interosseous artery also gives off five to seven cutaneous
branches that reach the overlying skin in the posterior
aspect of the distal two-thirds of the forearm (101).
At the proximal border of the pronator quadratus,
branches separate from the anterior interosseous artery to
supply a portion of the triangular fibrocartilage and the distal radioulnar joint (100,130). These branches arborize in a
fanlike fashion around the distal radioulnar joint. Small vessels are given off that penetrate and supply the capsule and
the triangular fibrocartilage from the palmar, dorsal, and
medial sides (130,131). These terminal branches of the anterior interosseous artery are joined by the posterior
interosseous artery (101). The terminal branches of the anterior interosseous artery usually also are joined by a small
branch of the ulnar artery to give the direct peridiscal vessels
that supply the palmar, medial, and dorsal margins of the triangular fibrocartilage. These small vessels arborize and anastomose with each other and form a terminal capillary network that ends at the peripheral segments of the triangular
fibrocartilage. The small arteries are arranged radially in a
series of terminal capillary loops. The outer 15% to 20% of
the triangular fibrocartilage is vascularized, leaving the central
segments of the fibrocartilage devoid of vessels (130,131).
The dorsal branch of the anterior interosseous artery gives off
a terminal branch that forms an anastomosis with the posterior interosseous artery at the distal part of the forearm, and
both continue to contribute to the vascular supply of the dorsal capsule of the distal radioulnar joint (100,130).
At its distal end, the anterior interosseous artery divides
into palmar and dorsal branches that continue distally to
supply the palmar and dorsal aspects of the carpus, respectively. The palmar branch continues deep to the pronator
quadratus and bifurcates 5 to 8 mm proximal to the radiocarpal arch (discussed later, under Radial Artery). The palmar branch of the anterior interosseous artery usually contributes at least one branch to the palmar radiocarpal arch
to supply the ulnar aspects of the lunate and triquetrum
(132–136). The palmar branch then terminates by anastomosing with the recurrent vessels from the deep arch
(132,133) (Table 4.3 and Fig. 4.6).
The dorsal branch of the anterior interosseous artery
continues distally on the interosseous membrane to reach
the carpus, where it contributes to the dorsal radiocarpal
arch in 89% of studied specimens (discussed later, under
Radial Artery) (132). Small branches extend radially to supply the lunate and anastomose with several branches from
the radial artery that supply the dorsal ridge of the scaphoid
(137–140). The dorsal branch of the anterior interosseous
artery bifurcates at the intercarpal level, with each branch
contributing to the intercarpal arch (in 83% of specimens)
(132,133). The dorsal branch of the anterior interosseous
artery terminates by forming an anastomosis with the recurrent vessels from the basal metacarpal arch at the third and
fourth interosseous spaces (in 70% of specimens) (132)
(Table 4.3 and Fig. 4.5).
The Median Artery
The median artery is a long, thin vessel that usually arises in
the proximal part of the anterior interosseous artery and
passes anteriorly to reach the median nerve (141–172)
(Table 4.3). It is variable in size and occurrence, with a diameter ranging from 0.7 to 2.7 mm (167). The incidence of a
substantial median artery has been suggested to be approximately 8% to 10% (7); however, reported incidences have
varied from 2% to 23% (158,161,167). It often is visible as
a small vessel in continuity with or adjacent to the median
nerve in the forearm or extending into the carpal canal.
Although it usually arises from the anterior interosseous
artery, it also can arise from the common interosseous trunk
directly from the ulnar artery (2%) (141,142,150). The
median artery continues along with the median nerve and
supplies the nerve in their course through the forearm. In
2%, the median artery has been noted to penetrate or split
the median nerve (141). The median artery is of variable
size, sometimes barely visible along the nerve or, conversely,
greatly enlarged and continuing through the carpal tunnel
into the palm to anastomose with the superficial palmar arch
(149). When enlarged or thrombosed, the median artery can
contribute to the formation of carpal tunnel syndrome or
can penetrate the median nerve in the forearm and produce
pronator syndrome (151–172). The median artery occasionally contributes to the carpal arches, especially if the superficial and deep arches are absent or poorly developed (7,145).
The incidence appears higher in neonatal cadavers compared
with those of adults. It has been proposed that the median
artery may undergo regression even after birth (142).
4 Vascular Systems 251
The Anterior Interosseous Artery (Distal Part)
The anterior interosseous artery continues distally along the
anterior surface of the interosseous ligament to reach the
proximal edge of the pronator quadratus. At this point, the
anterior interosseous artery gives off a small vessel, the palmar carpal branch of the anterior interosseous artery, that
continues deep to the pronator quadratus to help form the
palmar carpal network. The palmar carpal network is a collection of anastomosing vessels on the anterior surface of
the wrist (on the deep surface of the carpal canal) that
receives interconnections from the palmar carpal branches
of the anterior interosseous artery, ulnar artery, and radial
artery, and a retrograde branch from the deep palmar arch.
The anterior interosseous artery, after giving off the palmar
carpal branch, passes through a small foramen in the anterior interosseous ligament to reach the extensor compartment of the forearm. The anterior interosseous artery continues for a short distance along the posterior aspect of the
anterior interosseous ligament to form an anastomosis with
the radial artery and the posterior interosseous artery, and
contributes to the formation of the dorsal carpal network
(Fig. 4.5). These anastomosing branches between the anterior and posterior interosseous arteries and ulnar artery contribute to the vascular supply of the distal ulnar and dorsal
capsule of the distal radioulnar joint (91,92,130). Anastomoses with the anterior and posterior interosseous arteries
and the radial artery help supply vascularity to the distal
radius. These anastomoses form vessels used for the harvest
of distal radius vascularized bone grafts (91,92) (see later
discussion of vascularized bone grafts, under Clinical Correlations: Radial Artery).
The terminal part of the anterior interosseous artery
continues distally on the posterior aspect of the anterior
interosseous ligament along with the terminal portion of
the posterior interosseous nerve to reach the dorsum of the
wrist and contribute to the dorsal carpal network (Fig. 4.5).
The Posterior Interosseous Artery
The posterior interosseous artery arises as the other terminal branch of the common interosseous artery (along with
the anterior interosseous artery), and is formed at the level
of the radial tuberosity (Fig. 4.5; see Fig. 4.4). The posterior interosseous artery usually is smaller than the anterior
interosseous artery, and passes dorsally between the
oblique cord and the proximal border of the interosseous
ligament to reach the posterior compartment of the forearm. The posterior interosseous artery passes between the
adjacent borders of the supinator and the abductor pollicis longus. It then passes distally in the posterior compartment of the forearm between the superficial and deep layers of the extensor muscles, and provides branches to both
groups of muscles. The posterior interosseous artery continues along the dorsal surface of the abductor pollicis
longus and the extensor pollicis brevis, and is accompanied by the posterior interosseous nerve. In the distal forearm, the posterior interosseous artery forms an anastomosis with the terminal branches of the anterior interosseous
artery, the radial and ulnar artery, and the dorsal carpal
network. These anastomosing branches between the anterior and posterior interosseous arteries and ulnar artery
contribute to the vascular supply of the distal ulnar and
dorsal capsule of the distal radioulnar joint (91,92,130).
Anastomoses with the radial artery and anterior
interosseous artery help supply the vascularity of the distal radius. These anastomoses form vessels used for the
harvest of distal radius vascularized bone grafts (91,92)
(see later discussion of vascularized bone grafts, under
Clinical Correlations: Radial Artery).
The Interosseous Recurrent Artery
The interosseous recurrent artery is one of the few main
branches of the posterior interosseous artery (see Table 4.3
and Figs. 4.3 and 4.5). It arises proximally from the posterior interosseous artery, near its origin from the common
interosseous artery. At times, the interosseous recurrent
artery may arise directly from the common interosseous
artery. The interosseous recurrent artery passes on or
through the supinator muscle, then posteriorly between the
radius and ulna, and continues proximally in a retrograde
fashion posterior to the radial head to reach the interval
between the lateral epicondyle and the olecranon. Its course
is deep to the anconeus muscle. In the distal posterior compartment of the arm, the interosseous recurrent artery
forms an anastomosis with the middle collateral branch of
the profunda brachii artery, and the posterior ulnar recurrent and the inferior ulnar collateral arteries (1) (Fig. 4.3).
Besides muscular branches to neighboring muscles, the
interosseous recurrent artery usually contributes to the
intraosseous circulation to the radial head, capitellum, and
the lateral aspect of the trochlea through posterior perforating vessels (62). The vessels that supply the radial head penetrate the elbow capsular insertion at the neck of the radius.
(Note: The radial head has a dual blood supply through
both the interosseous recurrent artery and the radial recurrent artery.) The interosseous recurrent artery also contributes to the vascularity of the olecranon (along with vessels from the posterior ulnar recurrent artery) from vessels
that course along the lateral and medial aspect of the
humerus (62) (Fig. 4.3).
Muscular Branches of the Ulnar Artery in the
Forearm
The ulnar artery supplies many of the muscles of the flexor
forearm, giving off multiple muscular branches as the artery
descends distally. These branches supply most of the ulnar
muscles of the flexor forearm, including the pronator teres,
flexor carpi radialis, flexor digitorum superficialis, flexor digitorum profundus, flexor carpi ulnaris, and brachialis (173).
252 Systems Anatomy
4 Vascular Systems 253
FIGURE 4.5. The main arteries of the
dorsal forearm and hand.
Palmar Carpal Branch of the Ulnar Artery
The palmar carpal branch of the ulnar artery is a small
branch that arises from the radial aspect of the ulnar artery
at the level of the wrist or near the distal border of the
pronator quadratus, just proximal to the carpal tunnel. It
courses radially toward the midline, deep to the flexor digitorum profundus on the palmar aspect of the proximal
wrist. It forms an anastomosis with the corresponding palmar carpal branch of the radial artery (see Fig 4.4) (1). This
branch may correspond to the palmar radiocarpal arch,
described by Gelberman and colleagues in their classic
descriptions of the extraosseous vascular patterns of the carpus (see later) (132) (Fig. 4.6).
Palmar Radiocarpal Arch
The palmar radiocarpal arch is one of three vascular transverse arches that provide vascularity to the carpus (132)
(Fig. 4.6). The other two arches include the palmar intercarpal arch and the deep palmar arch. The palmar radiocarpal arch spans the radiocarpal joint, arising on the ulnar
side from the radial aspect of the ulnar artery, and on the
radial side from the ulnar aspect of the radial artery. It usually receives a central contribution from the distal end of
the anterior interosseous artery. The palmar radiocarpal
arch is the most proximal of the transverse arches, and it
extends 5 to 8 mm proximal to the radiocarpal joint at the
level of the distal metaphysis of the radius and the ulna. The
artery lies in the wrist capsule. It usually has an anastomosis with the palmar intercarpal arch through a longitudinal
interconnection branch. The palmar radiocarpal arch was
found to be consistently present by Gelberman and colleagues, formed by branches from the ulnar, radial, and
interosseous arteries in 87% of specimens, and by the ulnar
and radial arteries alone in 13% (132). The palmar radiocarpal arch supplies the palmar surface of the lunate and triquetrum.
Palmar Intercarpal Arch
The palmar intercarpal arch is one of three vascular transverse arches that provide vascularity to the carpus (132)
(see Fig. 4.6). The other two include the palmar radiocarpal arch (more proximally; see earlier) and the deep
palmar arch (located distally; see later, under Radial
Artery). The palmar intercarpal arch is located between
the proximal and distal carpal rows, and arises from the
radial aspect of the ulnar artery and from the ulnar aspect
of the superficial palmar branch of the radial artery. It usually receives a contribution from the distal end of the anterior interosseous artery. It is variable in occurrence. Gelberman and associates found it to be present in 53% of
specimens, formed by branches of the ulnar, radial, and
anterior interosseous arteries in 75%, and formed by the
ulnar and radial arteries alone in 25%. The arch is small,
and is not considered a major contributor of nutrient vessels to the carpus (132,133).
Dorsal Carpal Branch of the Ulnar Artery
The dorsal carpal branch of the ulnar artery arises proximal
to the pisiform, between 1.6 and 4.4 cm proximal to the
ulnar styloid, and curves medially and dorsally to wind
around the wrist, crossing deep to the flexor carpi ulnaris
tendon (174) (see Fig. 4.4). The artery passes to the ulnar,
then dorsal aspect of the wrist and continues toward the
midline of the dorsal wrist, deep to the extensor tendons. It
forms an anastomosis with the corresponding dorsal carpal
branch of the radial artery (and dorsal radiocarpal arch,
Figs. 4.5 and 4.6). The dorsal carpal branch of the ulnar
artery supplies an area of skin overlying the ulnar
metacarpals and the ulnar hypothenar region (174). Just
distal to its origin, the dorsal carpal branch also gives a small
branch that courses along the ulnar aspect of the fifth
metacarpal to supply the ulnar aspect of the dorsal surface
of the small finger (1–4).
Deep Palmar Branch of the Ulnar Artery
The deep palmar branch of the ulnar artery is a small branch
that arises from the ulnar aspect of the distal ulnar artery at
the level of the carpal canal. It courses ulnarly a short distance on the anterior surface of the flexor retinaculum and
anterior to the ulnar nerve to reach the hypothenar muscles.
The arterial branch then continues between the abductor
digiti minimi and flexor digiti minimi brevis and through
the origin of the opponens digiti minimi. The vessel curves
laterally into the palm, along with the deep branch of the
radial nerve. The deep palmar branch of the ulnar artery
then forms an anastomosis with the radial artery to complete
the deep palmar arch (1) (Fig. 4.1). In 14% of cases, the
deep palmar branch of the ulnar artery gives rise to the perforating branch of the fourth interspace (175).
Superficial Palmar Arch
The superficial palmar branch is formed mainly by the terminal portion of the ulnar artery, and often is completed
with contributions from the superficial branch of the radial
artery or, less frequently, from a branch of the princeps pollicis or by the radialis indicis; rarely, it is completed with
contributions from the median artery (11) (see Figs. 4.4
and 4.6). Several variations exist in the formation of the
superficial palmar arterial arch (176–201). The ulnar artery
enters the palm through Guyon’s canal with the ulnar nerve,
usually on the lateral aspect of the pisiform and superficial
to the flexor retinaculum. Initially, the artery usually is
located radial and deep to the ulnar nerve, although
several
variations exist (176–183,202–212). The structures pass
through the ulnar tunnel (Guyon’s canal), deep to the pal254 Systems Anatomy
maris brevis, and continue medial to the hook of the
hamate. The artery remains superficial to the base of the
flexor digiti minimi brevis and opponens digiti minimi.
The artery then curves laterally, convex distally to cross the
palm deep to the palmar fascia. This corresponds to the
level of the metacarpal diaphysis, roughly at the level
slightly proximal to the distal transverse palmar crease
(2,4,41). As the superficial palmar arch crosses the palm
transversely, it usually is located at a level distal to the deep
palmar arch; however, it passes at a level proximal to the
level of deep arch in 14% (175). Its mean lumen diameter
is 1.8 mm (range, 1 to 3 mm) (191) (Table 4.4). As the
superficial palmar arch continues across the palm in a radial
direction, it remains superficial to the tendons of the flexor
digitorum superficialis and flexor digitorum profundus, the
lumbrical muscles, and the branches of the median and
ulnar nerves. The superficial palmar arch, along with its
common palmar digital arteries, supplies the superficial
4 Vascular Systems 255
FIGURE 4.6. The arteries of the palmar wrist. Note the transverse carpal arches: the palmar
radiocarpal arch, palmar intercarpal arch, and deep palmar arch.
flexor tendons, flexor retinaculum, median and ulnar
nerves, flexor pollicis longus tendon, lumbrical muscles,
palmar aponeurosis, and the skin of the palm of the hand
(204–206,208,209). A terminal branch of the superficial
palmar arch helps supply the thumb as well, although most
of the thumb’s supply comes from the princeps pollicis
artery with contributions from the first dorsal metacarpal
artery (usually originating from the radial artery; see later,
under Radial Artery) (189,203,204,207). Erbil and colleagues noted in five cases that the first web space of the
hand and the associated portion of the thumb received
arteries only from the superficial palmar arch. None of the
branches was large enough to be considered a “princeps pollicis artery” (207).
Vascular contributions to the superficial (and deep) arch
are variable, and have been the subject of several investigations (145,146,184–200) (see earlier discussion of the
median artery, under Common Interosseous Artery). Several authors have indicated that the superficial palmar arch
usually communicates with (or is completed by) the superficial palmar branch of the radial artery (6,8,11,12).
Williams notes that in approximately one-third, the superficial arch is formed by the ulnar artery alone; in an additional third, it is formed by the ulnar artery with significant
contributions from the superficial palmar branch of the
radial artery, and in the final third, the superficial arch is
formed by the ulnar artery with contributions from a
branch of the princeps pollicis or the radialis indicis, or,
more rarely, from the median artery (4). Tountas and
Bergman describe the contributions to the superficial arch
as those formed by the ulnar artery and completed by the
radial artery in 30%, completed by the union with the deep
palmar arch through the princeps pollicis artery in 42%,
and completed by a median artery in 8% (7).
Wilgis and Kaplan have presented an extensive classification of the arterial patterns of the superficial palmar arch
(185). Three general patterns (or variants) are noted, each
with several subtypes.
In the first variant, the ulnar artery is responsible for the
formation of the superficial palmar arch, and this occurs in
approximately 66%. Seven subtypes of the first variant are
noted:
Type I: The ulnar artery is responsible for the formation
of all the digital arteries.
Type II: The ulnar artery ends as the radial collateral of
the index finger; the two collaterals of the thumb are
formed by the first palmar metacarpal artery of the radial
artery.
Type III: In this, the most frequent variation, the ulnar
artery ends in the second intermetacarpal space; the two
palmar collaterals of the thumb and the collateral radial of
the index are furnished by the radial artery.
Type IV: The ulnar artery runs vertically from the pisiform bone to the third intermetacarpal space. It supplies the
five collateral arteries to the fingers; the other five collateral
arteries are furnished by the first and the second palmar
metacarpal branches of the radial artery.
Type V: The ulnar artery runs vertically and reaches the
fourth intermetacarpal space, furnishing only three collateral arteries for the fingers; the other seven are supplied by
the metacarpal branches of the radial artery.
Type VI: The ulnar artery, reduced in size, supplies only
the ulnar collateral to the fifth finger.
Type VII: The ulnar artery gives only insignificant
branches to the digital arteries, and the main supply is from
the radial artery.
In the second variant of the superficial arch, the superficial palmar radial artery participates in the formation of
the arch, and this occurs in approximately 30%. This second variant has five subtypes:
Type I: In this type, which occurs very frequently, it is
noted that before the anastomosis with the ulnar artery, one
or two collaterals for the thumb are furnished by the radial
artery.
Type II: In addition to the collateral of the thumb, there
are one or two collaterals from the radial artery to supply
the index finger.
Type III: In this, the most frequent type, there are regular anastomoses between the superficial radial palmar artery
and the ulnar artery.
Type IV: The superficial palmar radial artery supplies the
thumb, the index finger, and the radial side of the long finger, terminating directly in the radial branch of the long finger. It supplies the five digital branches (two to the thumb,
two to the index finger, and one to the long finger). The
ulnar artery supplies the remaining five digital arteries (two
to the small, two to the ring, and one to the long finger). It
ends as the ulnar branch to the long finger.
Type V: The ulnar artery either supplies only the ulnar
two digits, or none at all. If the ulnar artery does not supply the small or ring finger, the superficial branch of the
radial artery supplies all the fingers, and the ulnar artery
supplies mostly the hypothenar muscles.
256 Systems Anatomy
TABLE 4.4. VESSEL LUMEN DIAMETERS OF
ARTERIES OF THE WRIST AND HAND
Vessel Diameter (Range)
Radial artery 2.6 mm (2.3–5 mm)
Ulnar artery 2.5 mm (1.4–4.5 mm)
Superficial palmar arch 1.8 mm (1–3 mm)
Deep palmar arch 1.5 mm (1–2.3 mm)
Common palmar digital arteries 1.6 mm (1–2 mm)
(of superficial palmar arch)
Common metacarpal arteries 1.2 mm (1–2 mm)
(of deep palmar arch)
From Gellman H, Botte MJ, Shankwiler J, et al. Arterial patterns of
the deep and superficial palmar arches. Clin Orthop 383:41–46,
2001, with permission.
In the third variant of the superficial arch, the median
artery contributes to the formation of the arch, and this was
seen in only 4%. In this variant, types similar to those previously described can occur, in which arteries participate in
the formation of the arch. Very infrequently, an additional
subcutaneous transverse anastomosis with the subcutaneous
branch of the superficial branch of the ulnar artery is found.
If present, it is located superficial to the palmar arch, and
may be mistaken for the superficial palmar arch if its position is not properly assessed (185).
Coleman and Anson, in their classic study evaluating
650 limbs, noted the superficial arch to be complete in 80%
and incomplete in 20% (184). In the complete arch group,
five patterns (or types) were described.
Type I indicated an arch formed by the superficial palmar branch of the radial artery and the (larger) ulnar artery.
This was found in 34.5%.
Type II (37%) indicated an arch formed entirely by the
ulnar artery.
Type III (4%) indicated an arch formed by an enlarged
median artery.
Type IV (1.2%) indicated an arch formed by the radial
artery, median artery, and the ulnar artery.
Type V indicated an arch formed by the ulnar artery
joined by a large vessel from the deep palmar arch joining the
superficial arch at the base of the thenar eminence (184). The
incomplete arch was divided into four patterns or (types).
Koman et al. have noted that the superficial palmar arch
is completed by branches from the deep palmar arch (39%),
the radial artery (34.5%), or the median artery (5%) (212).
Overall, the ulnar arch had communications with these arterial contributions, and the superficial arch was considered to
have adequate collateral flow in a total of 78.5% of patients.
In the remaining 21.5%, the arch was “incomplete,” and collateral flow was thought to be inadequate (212).
Gellman and colleagues also classified the superficial arch
as complete or incomplete in a study of 45 cadavers (191).
Complete superficial palmar arches were seen in 84.4% of
specimens. The complete arch was subdivided into five subtypes (types A through E), and the incomplete arches were
subdivided into two subtypes (types F and G). In the complete arches, the type A pattern was the most common, seen
in 35.5% of specimens, and consisted of a superficial arch
formed by anastomosis between the continuation of the ulnar
artery and the superficial palmar branch of the radial artery.
This is the variant most commonly described in anatomic
textbooks (1–4). In type B, the superficial arch was formed by
a continuation of the ulnar artery with formation of common
digital vessels to the thumb and index web space. It was considered a complete arch because it reached all the digits; however, it was formed entirely by the ulnar artery. This pattern
was seen in 31.1% of the specimens. In type C, the arch was
complete but formed by the continuation of the ulnar artery
with a contribution from the median artery. This pattern was
seen in 13.3% of the specimens. The type D pattern consisted
of a complete arch formed from contributions from all three
arteries (ulnar, radial, and median). This pattern was seen in
only 2.2% of the specimens. The last complete arch pattern,
type E, consisted of an arch formed largely by the continuation of the ulnar artery, with a communication with the deep
palmar arch (instead of the more common anastomosis with
the superficial palmar branch of the radial artery). This variation was seen in 2.2% of the specimens. Gellman et al. also
noted two patterns designated as incomplete arches (types F
and G), where the ulnar artery failed to reach the thumb and
first web space, and there was a lack of anastomosis of the
radial or median artery with the ulnar artery. In type F, the
ulnar artery comprised most of the arch but did not reach or
contribute to the arterial supply to the thumb and index fingers. This was the most commonly encountered type of
incomplete arch, seen in 11.1% of specimens. In type G, the
other type of incomplete arch, the ulnar artery supplied the
ulnar digits and the superficial palmar branch of the radial
nerve supplied the radial digits and thumb, and there were no
anastomoses between the two arteries. This type was seen in
4.4% of the specimens (191).
In 80 cadaver hands, Ozkus and colleagues (145) demonstrated a superficial palmar arch formed by anastomosis of
both the ulnar and radial arteries in 80%, and a superficial
arch formed by the ulnar artery alone in 17%. In two specimens, the arches were supplied by a median artery (145).
In Lippert’s study, a complete arch with contributions from
both the radial and ulnar arteries was found in 42%. In 58%,
there was no connection between the two arteries (213).
Further variation in the arches was demonstrated by
Ruengsakulrach and colleagues (146). In a study of 50
cadaver limbs, a superficial palmar arch was found to be
continuous with the radial artery in 34%, although every
hand had at least one major branch connecting the radial
and ulnar arteries.
Ikeda and colleagues conducted an investigation using
stereoscopic arteriographs of 220 cadaver hands (189). The
authors grouped the superficial palmar arch into complete
(96.4%) and incomplete (3.6%) types (189). Using the
Doppler flowmeter, Al-Turk and Metcalf showed the superficial arch to be complete in 84% and incomplete in 14%
of cases (192). Similarly, using ultrasound techniques,
Doscher and colleagues noted the arch to be incomplete in
11% of 200 normal hands (193).
The lumens of the superficial arch and associated
branches are listed in Table 4.4 (191).
Branches of the Superficial Palmar Arch:
Common Palmar Digital Arteries and Proper
Digital Artery to the Ulnar Small Finger
Three common palmar digital arteries and the proper digital artery to the ulnar aspect of the small finger are usually
4 Vascular Systems 257
given off by the superficial palmar arch as it crosses the
palm from medial to lateral (1–4,11,191) (Fig. 4.6).
The first branch usually is the proper palmar digital
artery for the ulnar aspect of the small finger, which arises
as far proximal as the level of and deep to the palmaris brevis. This palmar digital artery continues superficial to and
in line with the fibers of the hypothenar muscles. It courses
in a fairly straight line to reach the ulnar aspect of the base
of the small finger. Proximal to the level of the metacarpal
neck, the artery usually is superficial to the associated digital nerve. As the artery continues distally, it becomes deep
to the proper digital nerve (usually at approximately the
level of the metacarpal neck). The artery continues in this
relationship dorsal to the nerve through the digit. In the
digits, the artery passes deep to Grayson’s ligaments and
superficial to Cleland’s ligaments (214–217).
After giving off the proper palmar digital artery for the
ulnar aspect of the small finger, the superficial palmar arch
gives rise to three common palmar digital arteries (see Figs.
4.4 and 4.6). These vessels leave the arch on its converse
side, cross superficial to the lumbricals, and continue distally toward the fourth, third, and second web spaces. Each
vessel receives a contribution from the corresponding palmar metacarpal artery from the deep palmar arch. Proximal
to the level of the metacarpal neck, the common palmar
digital artery usually is superficial to the associated common digital nerve. As the artery continues distally, it
becomes deep to the proper digital nerve (usually at
approximately the level of the metacarpal neck). This relationship is maintained, with the artery remaining dorsal to
the nerve through the digit. Although the vascular supply
to the radial aspect of the index finger usually is not
described as being supplied by the branches of the superficial palmar arch (1–4,7,8,11), Gellman et al. noted that the
superficial arch actually did supply the radial border of the
index finger and radial aspect of the thumb as a common
pattern, occurring in 83% of specimens (191). The common palmar digital arteries, along with direct branches
from the superficial palmar arch, supply the superficial
flexor tendons, flexor retinaculum, median and ulnar
nerves, flexor pollicis longus tendon, lumbrical muscles,
palmar aponeurosis, and the skin of the palm of the hand
(204). The lumen size of the common palmar digital arteries varies from 1 to 2 mm, with an average of 1.6 mm (191)
(see Table 4.4).
Each common palmar digital artery then divides into
two proper palmar digital arteries (see Figs. 4.4 and 4.8). In
the fourth web space, the common digital artery divides to
provide proper palmar digital arteries to the radial side of
the small finger and the ulnar side of the ring finger. In the
third web space, the common palmar digital artery divides
to provide proper palmar digital arteries to the radial side of
the ring finger and the ulnar side of the long finger. In the
second web space, the common digital artery divides to provide proper palmar digital arteries to the radial side of the
long finger and the ulnar side of the index finger. [Note:
The proper digital artery to the radial side of the index finger is usually a continuation of the radial index artery (arteria radialis indicis), a branch from the radial artery, and the
palmar digital arteries to the thumb are supplied by the
princeps pollicis artery (arteria princeps pollicis), also
derived from the radial artery (1–4,218–232)].
The proper palmar digital arteries continue to the distal
aspect of each respective digit. The artery remains dorsal to
the corresponding proper digital nerve in the digit. The
artery also passes deep to Grayson’s ligament and superficial
to Cleland’s ligament. The digital arteries send several small
vessels throughout the digit to supply the soft tissues and
osseous structures, including the digital nerves and flexor
tendons (218) (discussed later and in Chapter 2). Vascularization of the digital nerves is supplied by numerous anastomotic vessels connecting the digital arteries, epineurial
vessels, and the periarterial network (venae comitantes and
vasa vasorum) (218–232).
The proper palmar digital arteries give rise to the vincular system, which provides the segmental vascular supply of the extrinsic tendons in the flexor sheath
(233–249). The vincular system consists of long and short
vincular connections. The vincula, which attach directly
to the dorsal surface of the flexor tendons in the sheath,
are vessels in a mesentery that is flexible to allow movement of the tendons. The vincula comprise the vinculum
brevis superficialis, the vinculum brevis profundus, the
vinculum longum superficialis, and the vinculum longum
profundus.
The vinculum longum superficialis arises as small branches
from the proper palmar digital arteries at the level of the
base of the proximal phalanx. The branches course anterior
toward the midline, deep to the tendons. The branches then
interconnect anterior to the phalanx, still deep (dorsal) to
the tendons. From these branches the vinculum longum
superficialis arises at the floor of the digital sheath. The vinculum longum superficialis passes anteriorly, then splits to
allow passage of the flexor digitorum profundus. The vinculum then passes anteriorly to attach directly to the dorsal
surface of the flexor digitorum superficialis (233–249).
The vinculum brevis superficialis is a small, triangular
mesentery that arises near the insertion of the flexor digitorum superficialis. The vinculum brevis superficialis arises
from the proper palmar digital artery, at the level of the
neck of the proximal phalanx. It supplies the flexor digitorum superficialis tendon near its insertion into the middle
phalanx. A portion of the vinculum brevis superficialis continues anteriorly, at the level of the proximal interphalangeal joint, toward the flexor digitorum profundus to
form the vinculum longum profundus. The vinculum
longum profundus also may arise as a separate vessel. The
vinculum longum profundus attaches to and supplies the
flexor digitorum profundus in the region of the middle phalanx (233–249).
258 Systems Anatomy
The vinculum brevis profundus also is a small mesentery
that arises from interconnecting branches that arise from
the proper palmar digital arteries at the level of the middle
phalanx. The branches interconnect dorsal to the flexor digitorum profundus, form a mesentery, and attach to the dorsal surface of the tendon near its insertion into the distal
phalanx (249).
Because the vincula enter the tendon on the dorsal surface, the vascularity of the dorsal half of the tendon in the
digits is richer than the palmar half. The vincula often are
variable in presence and configuration (249). In addition to
the vascular supply, the tendons in the synovial sheath
receive nutrition through synovial fluid diffusion.
The proper palmar digital arteries continue along the
palmar aspects of the radial and ulnar borders of each digit.
The diameters of the digital arteries have been evaluated
with arteriograms, clinical measurements, and high-frequency ultrasound (219–220). The index and long fingers
have been shown usually to have a larger digital artery on
the ulnar border, whereas the ring and small fingers usually
have a larger digital artery on the radial border (220). Each
proper digital artery also usually gives off two dorsal cutaneous branches that form anastomoses with the dorsal digital arteries (derived from the dorsal metacarpal arteries; see
later, under Radial Artery) (221). These branches contribute to the vascular supply of the soft tissues on the dorsum of the middle and distal phalanges, including the proximal and distal interphalangeal joints (222).
The proximal interphalangeal joint is supplied chiefly by
small vessels that leave the proper digital artery on the
artery’s dorsal surface, although additional vascularity is
supplied by smaller vessels that leave the proper digital
artery on its palmar surface, or from vessels derived from
the dorsal digital arteries. The vessels that leave that proper
digital artery on its dorsal surface arise 1.5 to 2.5 cm proximal to the proximal interphalangeal joint and divide into
branches to the dorsal skin, branches to the proximal phalanx, those continuing to the vincular system, and those
supplying the lateral surface of the joint and the palmar
plate. Other branches arise distal to the proximal interphalangeal joint and provide branches to the palmar aspect of
the distal interphalangeal joint and to the vincular system
(223).
The proper digital arteries arborize in the distal phalanx
region to supply the matrix of the fingernail, and form the
complex anastomosis of the subcutaneous pulp of the digital tip (224).
Anomalies and Variations: Ulnar Artery
and Its Branches
The ulnar artery may arise more proximally than the standard bifurcation of the brachial artery in the proximal forearm (3,24,25,29–34,68,76,80,81,250–259). This may
occur in the arm from a high division of the brachial artery,
or in the axilla from a high division of the axillary artery
(see earlier, under Anomalies and Variations for both the
brachial and the axillary arteries). The incidence of high
division of the ulnar artery is much less than that of the
radial artery, occurring in only approximately 2% (7). With
a high division of the ulnar artery, the artery may take a
more superficial course, and has been referred to as a superficial ulnar artery (27–34). The superficial ulnar artery has
been noted to cross ventral to the medial root of the median
nerve before continuing toward the medial part of the arm
(27,33,34). The superficial ulnar artery may cross superficial to the median nerve and brachial artery. The anomalous
ulnar artery usually is smaller than the radial artery or
interosseous arteries. When the ulnar artery originates
directly from the axillary artery, the common interosseous
artery (which usually originates from the ulnar artery) has
been noted to originate from the radial artery (30). These
anomalies of the radial and ulnar arteries may be bilateral
(23,27,31).
A distal division of the radial and ulnar arteries has been
noted to occur 8 cm distal to the antecubital fossa (82).
This distal division has implications in preparing the radial
forearm flap.
Variations of the superficial palmar arch: The superficial
palmar arch shows several patterns and variations. These are
so common and numerous that they are described previously in the discussion of the anatomy of the superficial palmar arch.
Although the radial index artery (radialis indicis arteria)
usually arises from the deep palmar arch, it may originate
independently from the superficial palmar arch in approximately 13% and in combination with the deep arch in
42%. When it arises in combination with the deep arch, the
superficial component is usually the larger of the two. The
princeps pollicis artery also may arise from the superficial
arch (7).
The common interosseous artery can arise more proximal than its normal origin from the ulnar artery. A high
division has been noted where the common interosseous
artery originated from the brachial artery, either in the
proximal third of the arm (96) or at the level of the humeral
intercondylar line (95). When arising from the proximal
arm, the common interosseous artery continued distally
and followed the brachial artery. It supplied muscular
branches, then formed the ulnar recurrent arteries, and in
the distal part of the cubital fossa it divided into anterior
and posterior interosseous arteries. The brachial artery
passed medially to the median nerve, gave off superior and
inferior ulnar collateral arteries, and, proximal to the superior border of the pronator teres muscle, the artery divided
into the ulnar and radial arteries (96).
The common palmar digital arteries usually arise separately from the superficial palmar arch (1–4,11,213). There
usually are three common palmar digital arteries, given off
to the fourth, third, and second web spaces. The first and
4 Vascular Systems 259
second common palmar digital arteries may arise as a common trunk from the superficial palmar arch (210).
Clinical Correlations: Ulnar Artery and Its
Branches
Thrombosis of the Ulnar Artery
The ulnar artery is among the most common upper extremity
arteries involved with occlusion or thrombosis (260–284).
The more common site for thrombosis is in the hypothenar
eminence, either in or just distal to the ulnar tunnel, although
thrombosis has been noted in several sites from the mid-forearm to the digits (266). Associated factors include blunt
trauma (260,275,278) and anomalous muscles (267,270,
283), but it may occur spontaneously (274). Cases associated
with carpal tunnel syndrome (277) as well as bilateral symmetric thrombosis have been reported (276). The venae comitantes to the ulnar artery also may be involved with thrombosis (285). A variation of thrombosis of the ulnar artery is the
hypothenar hammer syndrome (212,286–338). This syndrome involves a posttraumatic aneurysmal dilatation with
associated thrombosis, and subsequent vascular insufficiency
or emboli to the ulnar digits. It is associated with repetitive
blunt trauma to the hypothenar eminence. Symptoms,
including pain, cold intolerance, numbness, and weakness,
develop secondary to thrombosis or occlusion. The etiology
responsible is repetitive trauma with disruption of the internal
elastic lamina, producing dilatation with mural thrombi,
complete occlusion, or distal emboli (212). The arterial dilatation may take on a corkscrew configuration, seen by angiography or at operative exposure.
True and False Aneurysm of the Ulnar Artery
Along with thrombosis, the ulnar artery is afflicted relatively
frequently with aneurysm (339–373). A true or false
aneurysm may result. A true aneurysm usually is the result of
repetitive trauma that leads to intimal damage to the media,
disruption of the internal elastic lamina, exposure of
endothelial collagen, and aneurysmal dilatation or thrombosis (212). The wall of the vessel thus dilates to produce the
pulsatile mass that contains a true endothelium and the normal layers of an arterial wall. A true aneurysm usually is fairly
uniform in shape. A false aneurysm usually occurs after penetrating trauma, in which local hemorrhage and extravasation
cause the surrounding soft tissues to organize, undergo fibrosis, and recanalize. The lumen of a false aneurysm is in continuity with a true vessel, but it lacks a true endothelial layer
(in contrast to the true aneurysm, which contains an
endothelial layer). The false aneurysm may not be uniform in
shape. There appears to be a similar incidence of true and
false aneurysms involving the ulnar artery (339).
Allen Test
The Allen test is a clinical test used to evaluate the patency
of the radial and ulnar arteries in the forearm and wrist
(374–386). The test consists of compressing both the radial
and ulnar arteries at the distal forearm or wrist, and then
emptying the hand of blood by the patient’s active flexion
and extension of the digits. The pressure is then removed
from the radial artery, and the hand is allowed to fill
(demonstrating flow from the radial artery). The test is
repeated by releasing the pressure to the ulnar artery, and
again the hand is allowed to fill (now showing flow from the
ulnar artery). If one of the two arteries is occluded or if one
of the palmar aches is incomplete, the compromised circulation becomes evident. Gelberman and Blasingame have
evaluated a timed Allen test in 800 hands (378). The
authors found that the average ulnar artery fill time was 2.3
± 1.0 seconds, and the average radial artery fill time was 2.4
± 1.2 seconds. Seven percent of ulnar arteries and 2% of
radial arteries did not fill completely within 6 seconds.
Ninety-one percent of the hands tested were considered
complete, with uniform brisk refill (378). The Allen test is
valuable in the routine evaluation of the vasculature of the
hand, but is particularly valuable in preoperative assessment
before procedures that involve the vasculature or those performed in the vicinity of these structures. It also is helpful
in posttraumatic vascular evaluation. The Allen test is difficult to perform in the setting of acute fracture or trauma.
Arterial Dominance
Arterial dominance in the hand has been the subject of several anatomic studies (387–393). Authors continue to disagree as to which artery, the ulnar or radial, is the major or
“dominant” artery of the hand, although most studies support the radial artery. In a study evaluating dynamic values
of vessel diameter, blood velocity, and flow rate in vivo,
Trager and colleagues found variability between individuals
in artery dominance, noting 11 with the ulnar artery dominant, 7 with the radial dominant, and 2 with equal values
(388). With radionucleotide flow studies and anatomic dissections, Tonks and colleagues found no difference in the
anatomic dimensions of the vessels, but that the radial
artery appeared to be the dominant vessel compared with
the ulnar (389). Using arterial pressure measured simultaneously in the thumb and in the contralateral arm by straingauge plethysmography in 100 healthy subjects, Husum
and Palm showed radial artery dominance in 110 hands
(55%), ulnar artery dominance in 24 (12%), and neither
artery dominant in 66 (33%) (390). Patsalis et al. found a
ratio of radial artery dominance to ulnar artery dominance
of 13:4 by studying 164 hands in vivo using digital pulse
electronic oscillography and the Allen test (391). Kleinert
and associates studied 200 hands using pulse-volume
plethysmography amplitudes during radial or ulnar artery
260 Systems Anatomy
compression. In their study, only 5% were found to have
ulnar artery dominance (i.e., pulse-volume plethysmography amplitude larger during radial artery compression) in
all digits, and 28% were found to have complete radial
artery dominance. Ulnar artery dominance in three or more
digits was seen in 22%, compared with 57% with radial
artery dominance. Overall, 87% of thumbs and 71% of
index, 60% of long, 52% of ring, and 52% of small fingers
were found to be radial artery dominant (393). From lumen
diameters alone, the radial artery is slightly larger at the
wrist (mean, 2.6 mm; range, 2.3 to 5 mm) compared with
the ulnar (mean, 2.5 mm; range, 1.4 to 4.5 mm) (191) (see
Table 4.4).
Ulnar Artery Repair
In an evaluation of repair of injuries to the ulnar or the
radial artery, or both, it was shown that the overall success
rate for all repairs was 54%. It appears that, besides operative technique, back pressure in the distal arterial stump and
the extent of original ischemia of the hand relative to its
normal blood supply (a function of the completeness of the
palmar arches) are important factors influencing vessel
patency after repair (132).
Forearm Flaps and the Ulnar Artery
For soft tissue coverage and hand reconstructive procedures,
several forearm flaps are available, usually vascularized from
a distally based inflow from either the radial or ulnar artery
(252–254,266,386–404). The forearm flap also may be elevated as a free flap, based on a proximal radial artery inflow
(402,403). For harvest of distally or proximally based radial
artery forearm flaps, an intact ulnar artery and a superficial
palmar arch that provides a strong contribution to the vascularity of all the digits are prerequisite. Conversely, for harvest of a distally based ulnar artery forearm flap, an intact
radial artery to provide circulation to the hand is prerequisite. Clinical examination with the Allen test, Doppler
examination, or an arteriogram helps confirm these data.
Because several variations and anomalies of the ulnar and
radial arteries exist (as noted earlier, under Anomalies and
Variations), these have potential implications in the harvest
of the forearm flaps.
Persistent Median Artery and Carpal Tunnel
Syndrome or Pronator Syndrome
A persistent and enlarged median artery that extends into
the carpal canal is a known cause of median nerve compression, especially if associated with thrombosis,
aneurysm, or calcification (151–170). The incidence of a
persistent median artery is approximately 2.2% to 4.4%,
with an overall incidence of related carpal tunnel syndrome
of 1.1% to 1.8% (161). A median artery also has been associated with pronator syndrome (171), and has been noted
to pass through the substance of the median nerve in the
forearm just proximal to the origin of the anterior
interosseous nerve (172). The persistent median artery in
the forearm can give rise to a vascular leash to the flexor
muscles that can compress the median nerve (171).
Other Anomalies and Variations
Similar to the ulnar artery in Guyon’s canal and in the
hypothenar region, the superficial palmar artery is vulnerable to several lesions. Besides trauma (sometimes associated
with carpal tunnel release), reports have noted aneurysm,
occlusion, or thrombosis (405–412). Its anatomic position
and vulnerability has become of greater interest with the
advent of endoscopic carpal tunnel release (410).
Compared with the ulnar artery in the palm, aneurysm
of the common and proper digital arteries is rare. True and
false aneurysms have been reported, usually as isolated cases
(413–434).
For soft tissue coverage in a digit, several local flaps have
been described, many based on a distal digital artery
(reverse digital artery flap) (435–442).
Spinner and colleagues have described a patient with
neurovascular symptoms due to penetration of a proper digital nerve by a common digital artery. The authors consider
this an underrecognized but possibly relatively common
anatomic variation (443).
Relationships Between the Digital Arteries
and Digital Nerves
In the region of the metacarpal shaft, the common digital
arteries are positioned palmar to the associated common
digital nerves. At approximately the level of the metacarpal
necks, this relationship is reversed, so that the digital
artery in the digit is located dorsal to the associated digital nerve.
RADIAL ARTERY
Gross Anatomic Description: Radial
Artery
The brachial artery bifurcates into the radial and ulnar
arteries at approximately the level of the neck of the radius,
usually approximately 1 cm distal to the elbow joint (see
Figs. 4.3 and 4.4). The radial artery appears to be a continuing extension of the brachial artery because of its slightly
lateral direction. The radial artery may be slightly smaller
in diameter than the ulnar artery. The radial artery continues along the radial aspect of the forearm to the wrist to
reach the dorsum of the wrist, deep to the tendons of the
4 Vascular Systems 261
abductor pollicis longus and the extensor pollicis longus
and extensor pollicis brevis. The radial artery continues distally and dorsally to the space between the dorsal bases of
the thumb and index metacarpals. The artery then passes
between the two heads of the first dorsal interosseous muscle into the palm of the hand, joining the deep palmar
branch of the ulnar artery to form the deep palmar arch.
The radial artery has been divided into three parts for
descriptive purposes. These include the radial artery in the
forearm, in the wrist, and in the hand (3) (Table 4.5).
The radial artery in the forearm extends from the neck
of the radius to the anterior aspect of the styloid process. It
passes along the medial aspect of the radius in the proximal
forearm, and passes anterior to the radius in the middle and
distal portions (1–4,444). It is deep to the brachioradialis
proximally, then exits the deep surface of the muscle along
the medial border of the muscle. The radial artery then
becomes superficial, covered anteriorly by skin and superficial and deep fascia. Along its course in the forearm, the
artery passes superficial to the biceps tendon, the supinator
muscle, the pronator teres muscle, the radial origin of the
flexor digitorum superficialis muscle, the flexor pollicis
longus, the pronator quadratus muscle, and the distal end
of the radius. In the proximal third of its course, the artery
lies between the brachioradialis and the pronator teres muscles. In the distal third of its course, it lies between the brachioradialis and flexor carpi radialis muscles or associated
tendons. The superficial branch of the radial nerve joins the
radial artery in the proximal third of the forearm and
remains adjacent and lateral to the artery in the middle
third of the forearm. Small branches of the lateral antebrachial cutaneous nerve may run along the distal part of
the artery as it winds around the wrist. The radial artery is
accompanied by a pair of venae comitantes through its
course. In the distal forearm, the radial artery lies on the
distal anterior aspect of the radius and is positioned superficially, covered only by skin and antebrachial fascia. The
flexor carpi radialis is located medial to the artery at the distal forearm (3).
In the proximal forearm, the radial artery gives off the
radial recurrent artery. Throughout its course, it gives off
several small muscular branches. In the distal forearm, a
small palmar carpal branch arises. The radial artery forms
anastomoses with the anterior and posterior interosseous
arteries (which in turn form anastomoses with the ulnar
artery) in the distal forearm, which contribute to the vascularity of the distal radius (91,92,129). Branches of these
anastomoses are used for harvest of distal radius–vascularized bone grafts (91,92) (see discussion of vascularized
bone grafts, under Clinical Correlations: Ulnar Artery and
Its Branches, earlier). Just proximal to the wrist, the radial
artery gives off a branch that contributes to the palmar
radiocarpal arch, which contributes to the vascularity of
the carpus (132) (Figs. 4.6 and 4.8). A relatively small
branch, the superficial palmar branch (of the radial
artery), also is given off just distal to the carpus. This
branch continues into the palmar aspect of the wrist and
usually helps form the radial aspect of the superficial palmar arch. The superficial branch of the radial artery also
contributes to form the palmar intercarpal arch (along
with contributions from the anterior interosseous artery
and the ulnar artery). The palmar intercarpal arch contributes to the vascularity of the carpus. These branches
are discussed separately later (3) (see Tables 4.5 and 4.6).
At the wrist, the radial artery curves dorsally and distally to wind around the lateral aspect of the wrist to reach
the dorsal surface. It passes between the capsule of the
wrist and deep the tendons of the abductor pollicis longus
and extensor pollicis brevis. This interval, referred to as
the anatomic snuff-box, lies just distal to the extensor retinaculum, between the extensor pollicis longus and extensor pollicis brevis. The radial artery crosses the snuff-box
superficial to the scaphoid and trapezium and deep to
both the extensor tendons. It also remains deep to the distal branches of the superficial radial nerve as the nerve
branches continue distally to the thumb and index finger.
The radial artery exits the distal edge of the extensor pollicis longus and continues distally toward the first dorsal
web space (1,2,445). The artery then dives abruptly
through the interval between the two heads of the first
dorsal interosseous muscle (3).
In the hand, the radial artery passes between the heads of
the first dorsal interosseous to reach the deep palmar surface
262 Systems Anatomy
TABLE 4.5. BRANCHES OF THE RADIAL ARTERY
Branches in the forearm
Radial recurrent artery
Muscular branches
Superficial palmar branch
Palmar carpal branch
Palmar radiocarpal arch
Branches at the wrist
Palmar intercarpal arch
Dorsal carpal branch
Dorsal radiocarpal arch
Artery to the dorsal ridge of the scaphoid
Dorsal intercarpal arch
Basal metacarpal arch
Dorsal metacarpal branches
Branches in the hand
Dorsal metacarpal branches (from the basal metacarpal arch)
First dorsal metacarpal artery
Princeps pollicis
Radial index artery
First palmar metacarpal artery
Deep palmar arch
Palmar metacarpal arteries
Perforating branches
Radial recurrent artery of the deep palmar arch
Ulnar recurrent artery of the deep palmar arch
Accessory ulnar recurrent artery of the deep palmar arch
(variable)
of the hand. The artery crosses the deep palm transversely
between the oblique and transverse heads of the adductor
pollicis muscle. The continuing artery pierces the transverse
head and reaches the base of the small finger metacarpal,
where it forms a variable anastomosis with the deep palmar
branch of the ulnar artery, completing the deep palmar arch
(446–451) (Figs. 4.4, 4.6, and 4.8).
Main Branches: Radial Artery
The branches of the radial artery can be roughly divided
into three groups for descriptive purposes (3). These groups
are the radial artery branches in the forearm, wrist, and
hand, although many of the arteries span more than one
region (see Table 4.5).
Radial Recurrent Artery
The radial recurrent artery is the first major branch of the
radial artery. It arises just distal to the radiocapitellar joint or
in the region of the neck of the radius (see Fig. 4.3). It originates from the lateral aspect of the artery and ascends proximally between the branches of the radial nerve. It passes
superficial to the supinator and continues between the brachioradialis and brachialis muscles. The artery supplies these
adjacent muscles and the elbow joint, including vessels to the
radial head, capitellum, and the lateral aspect of the trochlea
(supplied by posterior perforating vessels arising from the
radial recurrent artery) (62,444). The artery continues proximally, anterior to the elbow joint, to form an anastomosis
with the radial collateral artery branch of the profunda
brachii artery. Other branches may follow the posterior antebrachial cutaneous nerve and continue with the nerve to
reach the skin. Before the radial collateral artery pierces the
intermuscular septum, it may give a branch that continues
distally to the posterior aspect of the lateral epicondyle and
contributes to the anastomoses around the elbow. The radial
collateral artery usually also assists the radial recurrent artery
in supplying the intraosseous circulation to the capitellum
and the lateral aspect of the trochlea (62).
Muscular Branches of the Radial Artery
The radial artery provides several small muscular branches
to the brachioradialis and pronator teres muscles, and to a
portion of the superficial and deep flexor pronator muscles
located on the radial aspect of the forearm.
Superficial Palmar Branch (Artery) of the
Radial Artery
The superficial palmar branch arises in the distal forearm
from the radial artery proximal to the wrist (see Figs. 4.4,
4.6 and 4.8). It leaves the radial artery 5 to 8 mm proximal
to the radial styloid, usually from the medial or anterior
aspect of the radial artery (132,133). Because of its direction, it occasionally may appear as a small continuation of
the radial artery (as the main trunk of the radial artery continues distally, curving dorsally and laterally). The superficial palmar branch passes between the flexor carpi radialis
and the brachioradialis, and curves anteriorly and slightly
medially to pass superficial to the radial aspect of the transverse carpal ligament. It reaches the base of the thenar muscles. It then crosses the radial aspect of the carpus and forms
communications with the palmar intercarpal arch, which in
turn supplies the tubercle of the scaphoid and the radiopalmar surface of the trapezium. The superficial palmar branch
usually passes through the thenar muscles, but occasionally
may continue superficial to these muscles. It supplies the
thenar muscles and then, to a variable degree, forms an
anastomosis with the terminal portion of the ulnar artery,
completing the superficial palmar arch (see Superficial Palmar Arch, under Main Branches: Ulnar Artery, earlier). The
superficial palmar branch of the radial artery is variable in
size and configuration. When small, it may not complete
the anastomosis with the superficial palmar arch, and can
terminate at the level of the thenar muscles. Conversely, it
may remain large and appear as a palmar continuation of
the radial artery (3).
Palmar Carpal Branch of the Radial Artery and
Palmar Radiocarpal Arch
The palmar carpal branch of the radial artery arises in the
distal part of the forearm, usually near the distal border of
the pronator quadratus and approximately 5 mm distal to
the point where the superficial palmar branch is given off.
The palmar carpal branch is a small artery and passes across
the palmar aspect of the wrist toward the ulna. It forms an
anastomosis with the palmar carpal branch of the ulnar
artery. The palmar carpal branches of the radial and ulnar
arteries are joined by the anterior interosseous artery, to
form the palmar radiocarpal arch (see earlier under Ulnar
Artery; see Fig. 4.6). The palmar radiocarpal arch is the
most proximal of three transverse vascular arches that provide vascularity to the carpus (132,133,452–458). The
other two arches include the palmar intercarpal arch and
the deep palmar arch (Fig. 4.6 and see later). The palmar
radiocarpal arch crosses the anterior aspect of the proximal
wrist at the level of the distal metaphysis of the radius and
the ulna. It lies in the wrist capsule and usually has an anastomosis with the palmar intercarpal arch through a longitudinal interconnection. The palmar radiocarpal arch was
found to be consistently present by Gelberman and colleagues, formed by branches from the radial, ulnar, and
interosseous arteries in 87% of specimens, and by the radial
and ulnar arteries alone in 13% (132). The palmar radiocarpal arch (along with the palmar intercarpal arch and the
ulnar recurrent branch of the deep arch) contributes to the
4 Vascular Systems 263
palmar vascular supply of the lunate (452). It also supplies
the palmar surface of the triquetrum (132).
Palmar Intercarpal Arch of the Radial Artery
The palmar intercarpal arch is a small branch that usually
arises from the superficial palmar branch of the radial artery
(or anastomoses with it), usually at the level of the scaphotrapezial joint (see Fig. 4.6). It spans the palmar carpus
between the proximal and distal carpal rows. It is the most
variably occurring of the palmar carpal arches, and is found
in 53% of specimens studied (132). It is formed by
branches of the radial, ulnar, and anterior interosseous
arteries in 75%, and by the radial and ulnar arteries alone
in 25%. The arch is small and is not thought to be a major
contributor of vascularity to the carpus, although it does
contribute to the vascular supply to the lunate, capitate, and
triquetrum (132,133).
Dorsal Carpal Branch of the Radial Artery and
the Dorsal Radiocarpal Arch
The dorsal carpal branch of the radial artery usually originates at the level of the radiocarpal joint and runs dorsally
and ulnarly, penetrating the radiocarpal ligament deep to
the extensor tendons. It commonly forms an anastomosis
with the ulnar artery on the dorsum of the wrist. It contributes to a dorsal carpal network of several small vessels
or vascular arches (see later) that supply the dorsal carpus.
It crosses the carpus transversely and supplies or forms the
dorsal radiocarpal arch, which also receives contributions
from the ulnar artery and from the dorsal branch of the
anterior interosseous artery (see earlier, under Ulnar
Artery; Fig. 4.7). The dorsal radiocarpal arch, studied in
detail by Gelberman and associates, was found to be present in 80% of specimens, and is the most proximal of the
three dorsal carpal arches (the other two arches, the dorsal
intercarpal arch and the basal metacarpal arch, are
described later) (132). The dorsal radiocarpal arch is
located at the level of the radiocarpal joint, and lies deep to
the extensor tendons. The dorsal radiocarpal arch provides
the main vascular supply to the lunate and the triquetrum
(132). Although the dorsal radiocarpal arch usually is
formed by anastomosing branches of the radial and ulnar
arteries and the dorsal branch of the anterior interosseous
artery, it occasionally is formed by the radial and ulnar
arteries alone or by the radial and anterior interosseous
arteries (132,133).
Artery to the Dorsal Ridge of the Scaphoid
The artery to the dorsal ridge of the scaphoid is a direct
branch of the radial artery in 75% of specimens or originates
as a branch from the radiocarpal or intercarpal arch in 25%
of specimens (132) (Fig. 4.7). It arises at or near the level of
the scaphoid waist or distal scaphoid, usually at a level
between the dorsal radiocarpal arch (discussed previously)
and the dorsal intercarpal arch (discussed later), and takes an
ulnar retrograde course to reach the dorsal surface of the
scaphoid. In 70% of specimens studied, the dorsal ridge vessel arose directly from the radial artery. In 23%, the dorsal
ridge vessels had their origin from the common stem of the
intercarpal artery. In 7%, the dorsal ridge vessels originated
from both the intercarpal artery and the radial artery. There
are consistent, well developed anastomoses between the dorsal ridge vessels of the scaphoid (from the radial artery) and
the dorsal branch of the anterior interosseous artery. On the
dorsum of the scaphoid, an oblique ridge lies between the
articular surfaces of the radius and of the trapezium and
trapezoid. The major dorsal vessels to the scaphoid are
attached to the scaphoid by a soft tissue leash. The vessels
enter the bone through small foramina located on this dorsal ridge, usually at the level of the scaphoid waist (although
occasionally vessels enter slightly proximal or distal to the
waist) (132,133,138,139). The artery to the dorsal ridge of
the scaphoid supplies 70% to 80% of the scaphoid in the
proximal and central portions. The remaining 20% to 30%
in the distal portion is supplied by several palmar vessels
from the radial artery that enter the scaphoid through the
region of the tubercle. These are the palmar scaphoid
branches, discussed in the following section (138,139).
Palmar Scaphoid Branches
The palmar scaphoid branches are small arteries that arise
directly from the radial artery (or, less commonly, from the
superficial palmar branch of the radial artery). These vessels
supply the distal palmar aspect of the scaphoid in the tubercle region. When the branches arise directly from the radial
artery, the origin is just distal to that of the superficial palmar branch of the radial artery. The palmar scaphoid
branches consist of several small branches that course
obliquely and distally over the palmar aspect of the
scaphoid to enter the bone through the region of the tubercle (138,139) (Fig. 4.6). The small arteries further branch
into several smaller branches just before penetrating the
scaphoid. In 75% of specimens studied, these arteries arose
directly from the radial artery (138). In the remaining 25%,
they arose from the superficial palmar branch of the radial
artery. Consistent anastomoses exist between the palmar
division of the anterior interosseous artery and the palmar
scaphoid branch of the radial artery, when the latter arises
from the superficial palmar branch of the radial artery.
There are no apparent communicating branches between
the ulnar artery and the palmar branches of the radial artery
that supply the scaphoid. The palmar scaphoid branches
enter the palmar aspect of the tubercle and divide into several smaller branches to supply the distal 20% to 30% of
264 Systems Anatomy
the scaphoid. There are no apparent anastomoses between
the palmar and dorsal vessels (132).
Dorsal Intercarpal Arch
The dorsal intercarpal arch is the largest of the dorsal transverses, and is consistently present (see Fig. 4.7). It arises
from the radial artery approximately 5 mm distal to the
branch point of the artery to the dorsal ridge of the
scaphoid (132), usually at the level of the distal carpal row
or between the proximal and distal carpal rows. It runs
transversely across the dorsal carpus either between the
proximal and the distal carpal rows, or across the trapezoid
and capitate. The dorsal intercarpal arch supplies the distal
carpal row and forms an anastomosis with the radiocarpal
arch to supply the lunate and triquetrum. Branches also
contribute to the vascular supply of the trapezoid, capitate,
and hamate. Like the radiocarpal arch, the dorsal intercarpal arch usually is formed by various contributions from
the radial, ulnar, and anterior interosseous arteries. It
receives contributions from all three arteries (radial, ulnar,
and anterior interosseous) in 53% of cadavers studied
(132). Alternatively, it may be formed by the radial and
ulnar arteries alone in 20%, by the radial and anterior
interosseous arteries in 20%, and by the ulnar and anterior
interosseous arteries in 7% (see also under Ulnar Artery,
earlier) (132).
4 Vascular Systems 265
FIGURE 4.7. The arteries of the dorsal wrist. Note the transverse carpal arches: the dorsal radiocarpal arch, dorsal intercarpal arch, and basal metacarpal arch.
Basal Metacarpal Arch
The basal metacarpal arch is the most distal of the dorsal
transverse arches and is located at the base of the
metacarpals, just distal to the carpometacarpal joints (see
Fig. 4.7). It is the smallest and most variable of the dorsal
transverse arches and actually is considered a series of vascular retia. It is complete in 27% of specimens, and present
in its radial aspect alone in 46% (132). It is formed by interconnecting branches of the radial and ulnar arteries, from
perforating arteries from the second, third, and fourth
intraosseous spaces, as well as from anastomoses with the
dorsal intercarpal arch. It contributes to the vascularity of
the distal carpal row through anastomoses with the intercarpal arch (132,133).
Dorsal Metacarpal Branches
The dorsal metacarpal branches (with the exception of the
first dorsal metacarpal artery) arise from the dorsal carpal
network or from contributions from the basal metacarpal
arch (see Fig. 4.7). (Note: The first dorsal metacarpal arises
directly from the radial artery and is described later.) Three
thin dorsal metacarpal arteries usually are present but variable, and run distally on the second, third, and fourth dorsal interosseous muscles (3,459–464). At the level of the
second, third, and fourth digital web spaces, the dorsal
metacarpal arteries bifurcate into dorsal digital branches,
supplying adjacent dorsal sides of the index, middle, ring,
and small fingers. Each dorsal metacarpal artery has four to
eight cutaneous branches (459). The dorsal digital branch
vessels form anastomoses with the proper palmar digital
branches of the superficial arch. The dorsal metacarpal
branches also form anastomoses with the deep palmar
branch through the (proximal) perforating branches,
located proximally at the bases of the metacarpal. Further
anastomoses are formed with the dorsal metacarpal
branches near their points of bifurcation, where communications are formed with the common palmar digital vessels
of the superficial palmar arch by the (distal) perforating
arteries (3,4) (Figs. 4.5 and 4.7).
First Dorsal Metacarpal Artery
The first dorsal metacarpal artery arises separately at the
base of the thumb and index metacarpal just before the
radial artery passes anteriorly between the two heads of the
first dorsal interosseous muscle. The artery then forms two
branches, one of which continues along the index
metacarpal to supply the dorsoradial aspect of the index finger. The other branch continues distally along the dorsoradial aspect of the thumb to approximately the level of the
thumb metacarpal head. It then further divides into two
branches, one directed radially and one ulnarly to supply
the dorsal aspect of the thumb. The radial aspect of the dorsal thumb may receive a separate branch that arises directly
from the radial artery (3,4,189,459,462) (Fig. 4.7).
Princeps Pollicis Artery
The princeps pollicis artery arises from the radial artery or
from the most radial part of the deep palmar arch (Fig. 4.8).
As the radial artery passes between the heads of the first dorsal interosseous to enter the deep palm, it then turns medially to form the deep palmar arch. The princeps pollicis
forms from the anterolateral aspect of the radial artery (or
deep arch), and then continues distally toward the thumb
along the ulnar aspect of the thumb metacarpal (465). It
passes between the first dorsal interosseous muscle and the
oblique head of the adductor pollicis, crossing deep to the
tendon of the flexor pollicis longus. The princeps pollicis
then divides into the two proper palmar digital arteries of
the thumb. These branches continue distally toward the
thumb, with the ulnar proper digital artery passing to the
ulnar side of the insertion of the adductor pollicis and the
radial proper digital artery passing to the radial aspect of the
muscle. The proper palmar digital arteries continue to reach
the pulp of the thumb, supplying branches to the soft tissues and interphalangeal joint (202,203,466). Similar to
the digits, complex anastomoses occur between the two digital arteries at the level of the distal phalanx (3). The princeps pollicis is one of the principal arteries to supply the
thumb; however, variations are common (189,192,207,
210,467). The vascular supply to the thumb also may come
from the superficial branch of the radial artery (8%), the
first palmar metacarpal artery (18%), and the dorsal
metacarpal artery (8%) (467).
Radial Index Artery (Arteria Radialis Indicis)
The radial index artery usually is the second branch from
the radial artery as the radial artery enters the deep palm.
The radial index artery arises just ulnar and in close proximity to the princeps pollicis artery, usually originating
between the first dorsal interosseous muscle and the transverse head of the adductor pollicis muscle. The radial index
artery continues distally along the radial aspect of the index
finger to reach the level of the distal phalanx. The radial
index artery then forms a complex anastomosis with the
ulnar-sided proper palmar digital artery. Although the
radial index artery usually arises directly from the radial
artery (or deep arch), variations are common, and it also
may originate from a common trunk shared by the proximal portion of the princeps pollicis artery (3,4,192,202,
203,210). This trunk is then called the first palmar metacarpal artery (3,4,202,203,468).
266 Systems Anatomy
Deep Palmar Arch
The deep palmar arch is the terminal part of the radial artery,
which crosses transversely across the deep palm (11) (see Figs.
4.4, 4.6 and 4.8). It is located at the level of the metacarpal
bases, 5 to 10 mm distal to the palmar carpometacarpal
joints. The deep palmar arch is located proximal to the superficial palmar arch in 83%, but is distal to the superficial arch
in 15% (201). The lumen diameter of the deep palmar arch
varies between 1 and 2.3 mm, with an average of 1.5 mm
(191) (see Table 4.4). It is nearly consistently present and
usually forms an anastomosis with the deep palmar branch of
the ulnar artery, although variations in vascular patterns are
not uncommon. The most frequent variations are with the
complete or incomplete formation of the deep arch, with or
without anastomoses of the radial artery with the deep
branches of the ulnar artery (see later under Anomalies and
Variations: Radial Artery) (3,4,7,198,201,208,209,213,446,
448,450). The deep palmar arch is deeply situated in the
palm, superficial to the interosseous muscles, but deep to the
extrinsic flexor tendons, lumbricals, and the oblique head of
the adductor pollicis (8). In approximately two-thirds of
cases, the deep palmar arch lies deep to the ulnar nerve; in
one-third, the deep arch lies superficial to the nerve (to the
palmar side) (3). The deep palmar arch rarely may be doubled, and encircle the ulnar nerve. The deep palmar arch
crosses the palm in a radial-to-ulnar direction. It gives off
three (or four) palmar metacarpal arteries, several perforating
branches, and two recurrent branches (Fig. 4.8).
4 Vascular Systems 267
FIGURE 4.8. The arteries of the palmar hand. S, superficial palmar arch;
D, deep palmar arch.
The three or four palmar metacarpal arteries arise from
the distal convex edge of the deep palmar arch. These vessels course distally, usually toward the intermetacarpal
spaces of the index and long, the long and ring, and the ring
and small fingers. The palmar metacarpal arteries, like the
deep arch, are deeply situated, superficial to the interosseous muscle but deep to the extrinsic flexor tendons and
associated lumbrical muscles. The palmar metacarpal arteries reach the web spaces of the digits and form an anastomosis with the common palmar digital arteries (which are
derived from the superficial palmar arch) (3).
The deep palmar arch gives rise to the perforating
branches. Three perforating branches pass directly from the
deep palmar arch in a dorsal direction, through the second,
third, and fourth interosseous muscle spaces. The perforating branches form an anastomosis with the dorsal metacarpal arteries.
The deep palmar arch also gives rise to the radial and
ulnar recurrent branches (arteries). These branches originate
from the proximal concave aspect of the deep arch, and continue in a proximal direction along the anterior aspect of the
wrist. These vessels supply the carpal bones (mainly distal
carpal row), intercarpal articulations, and end in the palmar
carpal network. The radial recurrent branch contributes to
the vascular supply of the trapezoid and trapezium (132).
The ulnar recurrent branch contributes to the vascular supply of the capitate, hamate, and lunate (132). Theses
branches also send perforating branches to the dorsal basal
metacarpal arch and the palmar metacarpal arteries (3,132).
In 27% of specimens studied, an accessory ulnar recurrent
artery was present. It originates from the deep arch 5 to 10
mm medial to the ulnar recurrent artery and supplies the
medial aspect of the hook of the hamate. When this vessel is
not present, the medial aspect of the hamate is supplied by
direct branches from the ulnar artery (132) (Fig. 4.8).
Anomalies and Variations: Radial Artery
The radial artery may arise more proximal than usual, either
proximal to the elbow, or from various locations directly
from the brachial or axillary artery (23,79,95,469–471).
This may occur in as much as 12% of specimens (3), can be
associated with a high origin of the common interosseous
artery in the same extremity (95), and has been noted to be
bilateral (79). In the forearm, variations of the radial artery
are less frequent than those of the ulnar artery.
Various anomalies in the configuration of the radial
artery in the forearm have been noted, including tortuous
configurations (5.2%), hypoplasia (1.7%), and a radioulnar
loop (0.9%) (472).
In the region of the anatomic snuff-box, the radial artery
has been noted to pass superficial to the extensor tendons of
the thumb (instead of deep to these structures) (3,473–475).
The anomaly has occurred bilaterally (474). The superficial
radial artery at the wrist has been referred to as the arteria
antebrachialis superficialis dorsalis (476) or the arteria radialis
superficialis (473).
Absence of the Radial Artery
In its absence, a normal ulnar artery or an enlarged anterior
interosseous or median artery can replace the radial artery.
The anterior interosseous and median artery can contribute
directly to the formation of the palmar arches (3,477–480).
Absence of the radial artery also is observed in radial preaxial hemimelia, and in specific genetic and chromosomal disorders (Fanconi’s anemia, Holt-Oram syndrome) (480).
Anomalous Course of the Superficial Branch
Anomalous course of the superficial branch of the radial
artery: An abnormal course of the superficial branch of the
radial artery passing through the carpal tunnel was noted in
2 of 70 (2.85%) cadaver extremities studied (481). This
anomaly can potentially cause or contribute to carpal tunnel syndrome (481).
Accessory Radial Artery
In the arm and forearm, an accessory radial artery has been
noted that had a high division, passed lateral to the brachial
artery and lateral to the radial artery, and ultimately formed
an anastomosis with the princeps pollicis artery in the hand
(482).
The radial artery has been noted to pass along the forearm superficial to the deep fascia, as opposed to the normal
position deep to the antebrachial fascia (3).
The radial artery has been noted to pass superficial to the
brachioradialis instead of deep to its medial border (3).
Variations of the Deep Palmar Arch
Although consistent data indicate that the deep palmar arch
is less variable than the superficial arch, several variations
have been described. The incidence of a complete arch
(with contributions from both the radial artery and the
deep branch or branches of the ulnar artery) varies from
79% to 100% (175,213,448–450). Wilgis and Kaplan note
the most frequent pattern is the deep palmar arch existing
as an anastomosis between the radial artery and the deep
branch of the ulnar artery (185). The anterior interosseous
artery may participate in the formation of the deep palmar
arch with the radial artery alone or with the ulnar artery
alone (185). Mezzogiorno and associates noted the deep
arch formed from contributions from both the radial and
ulnar arteries in 89%, with formation by the radial artery
alone in 8% and by the ulnar artery alone in 3% (448).
Gellman and associates found less variability in the deep
palmar arch than in the superficial palmar arch; however, in
their study, the deep arch was complete and anastomosed
268 Systems Anatomy
with the ulnar artery in all specimens (191). Three general
patterns were noted in the communication of the radial
artery with the ulnar artery, with the radial artery communicating with the inferior deep branch of the ulnar artery in
44%, with the superior deep branch of the ulnar artery in
33%, or with both deep branches of the ulnar artery in
20% (191).
Olave and Prates noted in a study of 60 cadaver hands
that although the radial artery usually passed through the
first interosseous space to form the deep arch (85% of specimens), an anomalous route of the radial artery passing
through the second interosseous space was noted in as
much as 13% of specimens (449).
Absence of the Princeps Pollicis
In the absence of the princeps pollicis (noted in 2.4% of
220 cadavers), the vascular supply for the thumb was provided by the terminal branches of the superficial palmar
arch or the first dorsal metacarpal artery, both of which
originate from the radial artery (189).
Clinical Correlations: Radial Artery
Soft Tissue Forearm Flaps and the Radial
Artery
For soft tissue coverage and hand reconstructive procedures,
several forearm flaps are available, usually vascularized from
a distally based inflow from either the radial or ulnar arteries, or associated branch arteries (483–502). The forearm
flap also may be elevated as a free flap, based on a proximal
radial artery inflow (117,402,403). For harvest of a distally
or proximally based radial artery forearm flap, an intact
ulnar artery and superficial palmar arch that provides a
strong contribution to the vascularity of all the digits are
prerequisite. Conversely, for harvest of a distally based ulnar
artery forearm flap, an intact radial artery to provide circulation to the hand is prerequisite. Recent investigations have
led to the development of forearm flaps that do not sacrifice
a major forearm artery (483,487). Clinical examination
with the Allen test, Doppler examination, or an arteriogram
helps confirm these data. Several variations and anomalies
of the ulnar and radial arteries exist (as noted in the previous section) and have potential implications for the harvest
of forearm flaps.
Vascularized Bone Grafts and the Radial
Artery
The use of pedicled vascularized bone grafts for reconstruction of carpal nonunions or dysvascular conditions has
become more popular and feasible, especially in the last two
decades (503–524). These usually are based on the ulnar,
radial, or anterior or posterior interosseous arteries, or their
branches. Roy-Camille described the transfer of the
scaphoid tubercle with attached abductor pollicis brevis
muscle to assist healing of a scaphoid fracture (91,92,522).
Beck transferred a decorticated pisiform on a vascular pedicle in the revascularization of the lunate in a patient with
Kienböck’s disease (91,92,523,524). Braun used a distal
radius bone graft based on the pronator quadratus muscle
and anterior interosseous artery pedicle to successfully treat
five established scaphoid nonunions (504). Detailed and
concise descriptions of several reverse-flow, pedicled, vascularized bone grafts from the dorsal distal radius have now
been applied to difficult scaphoid fractures, nonunions, or
avascular necrosis of carpal bones. These and related techniques have shown significant potential. Shin and Bishop
have summarized the harvest of several of these distal radius
vascularized bone grafts based on anastomosing vessels
between the radial artery, the anterior and posterior
interosseous arteries, and carpal arch vessels. The radial
artery and posterior division of the interosseous artery usually are the primary sources. When harvested with retrograde anastomosing vessels, a vascularized graft of greater
reach is provided (91,92). These have been used for
scaphoid nonunion and Kienböck’s disease.
Radial Artery and Aneurysm, Thrombosis, and
Emboli
Although not as common as in the ulnar artery, aneurysm
(true and false), thrombosis, and embolization of the radial
artery are well reported (523–534). These have been noted
at the level of the forearm or wrist (525,528,530) or at the
anatomic snuff-box (534). The most common cause of true
aneurysm is blunt trauma (526). Other reported causes of
true and false aneurysm have been idiopathic, iatrogenic
(528,529), and penetrating trauma (530). In the region of
the anatomic snuff-box, the radial artery passes deep to the
extensor pollicis longus tendon. Compression of the artery
against the proximal epiphysis of the first metacarpal was
thought to be the etiology of emboli that resulted in
ischemic changes of the thumb and index finger (534).
Approximately 25% of those with true aneurysms of the
extremity have shown secondary problems with thromboembolism (526).
Metacarpal Arteries and Soft Tissue or Bone
Tissue Transfers
Anatomic studies have evaluated the dorsal metacarpal
arteries and anastomosing branches with regard to soft tissue and bone transfer procedures. The first or second dorsal
metacarpal artery can be used for an axial or retrograde
nutrient supply to vascularize a pedicled soft tissue flap for
hand reconstruction (221,222,440, 460,463,464). The second metacarpal has been described as a vascularized graft
for thumb reconstruction (461,513).
4 Vascular Systems 269
VENOUS ANATOMY
The veins of the upper extremity are divided into two
groups, superficial and deep (535–547). The superficial
veins are subcutaneous in the superficial fascia. Both
groups exhibit substantial variability, and disagreement
exists in the described patterns and names of veins. Many
of the superficial veins remain unnamed. The deep veins
accompany the arteries, including the palmar arches and
the dorsal arterial arch, and pass deep to the deep fascia
to continue between the muscles. The deep veins include
the venae comitantes. The deep veins often are doubled,
and the larger veins often are named after their corresponding artery, but usually are slightly smaller in caliber
than the artery. The deep veins not only run parallel with
the arteries, but often cross the arteries at various angles
(185). Both the superficial and deep veins have extensive
interconnections, and often form several parallel channels
of drainage from any single region. Both groups have
valves, but valves are more numerous in the deep veins
(4,185).
For descriptive purposes, the superficial veins are
described first, followed by the deep veins. The veins are
discussed from distal to proximal, in the direction of
blood flow. Because variations of the venous system are so
common, only the few well established variations are discussed.
SUPERFICIAL VEINS
Gross Anatomic Description: Superficial
Veins
The superficial veins include the venous network on the
dorsum of the hand, the superficial venous palmar arch, the
cephalic and accessory cephalic vein, the basilic vein, the
median antebrachial and cubital vein, and their associated
branches (Table 4.6).
Venous Network of the Dorsal Hand
The venous network of the dorsal hand forms initially from
venules of the distal digits and dorsal digital venous arches
that coalesce to form the dorsal digital veins (535,537,541)
(Fig. 4.9). The dorsal digital veins pass along the sides of the
digits and are joined to one another by additional oblique
communicating branches. There are frequent communications between the superficial and deep venous arches, and
between the palmar and lateral vessels (541). The digital
veins from the adjacent sides of the digits coalesce and also
receive interconnections from the palmar digital veins
through the intercapitular veins located in the digital web
space (see Fig. 4.10) (537). The dorsal digital veins and
intercapitular veins coalesce to form three dorsal metacarpal
veins, which end in the venous network on the dorsum of
the hand (3,4,537). The radial part of the network is joined
by the dorsal digital vein from the radial side of the index
finger and by the dorsal digital veins of the thumb. These
eventually coalesce to form the distal aspect of the cephalic
vein (which arises on the radial aspect of the hand. The
ulnar part of the network receives the dorsal digital vein of
the ulnar side of the small finger and hand to contribute to
the formation of the basilic vein. An additional venous
interconnection often forms with either the cephalic or
basilic vein in the forearm (3,537).
These digital veins have valves that prevent the flow of
blood from the dorsum to the palmar aspect, from proximal
to distal, and from the ulnar to radial digits in the proximal
venous arches (537).
270 Systems Anatomy
TABLE 4.6. VEINS OF THE UPPER EXTREMITY
Superficial veins
Venous network of the dorsal hand
Dorsal digital veins
Intercapitular veins
Dorsal metacarpal veins
Superficial venous palmar arch
Palmar digital veins
Intercapitular veins
Transverse anastomoses
Cephalic vein
Accessory cephalic vein
Basilic vein
Median antebrachial vein
Median cubital vein
Deep veins
Deep veins of the hand
Common palmar digital veins
Palmar metacarpal veins
Dorsal metacarpal veins
Superficial palmar venous arch
Deep palmar venous arch
Deep veins of the forearm
Venae comitantes of the radial artery
Venae comitantes of the ulnar artery
Venae comitantes of the posterior interosseous artery
Venae comitantes of the anterior interosseous artery
Brachial veins
Axillary veins
Brachial vein
Basilic vein
Posterior humeral circumflex vein
Circumflex scapular vein
Long thoracic vein
Subscapular vein
Thoracodorsal vein
Thoracoepigastric vein
Lateral thoracic vein
Superior thoracic vein
Cephalic vein
Superficial Venous Palmar Arch
The superficial venous palmar arch is a more delicate network than the venous network of the dorsal hand. It is initially formed by the palmar digital veins that drain into
venous networks located over the palmar digits and thenar
and hypothenar eminences (Fig. 4.10). The palmar digital
veins interconnect with the dorsal digital veins and dorsal
metacarpal veins through the intercapitular veins located
in the digital web spaces (see Fig. 4.9). There are transverse anastomoses between the intercapitular veins at the
base of the digits on the palmar side. The palmar digital
vessels with their interconnections in turn drain proximally over the palmar surface of the wrist and contribute
to the median antebrachial vein (centrally in the palmar
forearm) and the cephalic vein (on the radial aspect) and
the basilic vein (on the ulnar aspect) (3,4) (see Figs. 4.10
and 4.11).
Cephalic Vein
The cephalic vein is formed on the radial aspect of the wrist,
often in the region of the anatomic snuff-box. It arises from
the lateral contributions of the dorsal venous networks and
the superficial venous palmar arch (Figs. 4.9 through 4.11). It
courses proximally and winds along the radial aspect of the
forearm, receiving contributions from both the palmar and
dorsal surfaces of the hand and forearm (548–550). In the
palmar forearm, the cephalic veins communicate with the
median antebrachial vein (median cubital vein) and subsequently with the basilic vein. The main trunk of the cephalic
vein continues proximally along the radial side of the antecubital fossa in the groove between the brachioradialis and the
biceps brachii muscles (Fig. 4.12) . Here it crosses superficial
to the lateral antebrachial cutaneous branch of the musculocutaneous nerve. The cephalic vein enters the arm and continues proximally in the groove along the lateral border of the
4 Vascular Systems 271
FIGURE 4.9. The veins of the dorsal hand
and digits.
biceps brachii. In the proximal third of the arm, the cephalic
vein passes between the pectoralis major and deltoid muscles,
where it lies adjacent to the thoracoacromial artery (Fig.
4.13). From the interval between the pectoralis major and deltoid muscles and the clavicle (the deltopectoral triangle), the
cephalic vein passes deep to the clavicular head of the pectoralis major muscle to pierce the clavipectoral fascia. It
crosses anterior to the axillary artery, coursing in a medial
direction to reach the axillary vein. It connects with the axillary vein just inferior to the clavicle. The cephalic vein usually
has a valve near its junction with the axillary vein. The
cephalic vein may communicate with the external jugular vein
by a connection that ascends anteriorly to the clavicle (3,4).
Accessory Cephalic Vein
The accessory cephalic vein is located on the radiopalmar
forearm (see Fig. 4.11). It arises from the small vessels on
the dorsum of the forearm or from the ulnar side of the dorsal venous network in the hand. The accessory cephalic vein
continues proximally, remaining on the radial aspect of the
cephalic vein, and joins the cephalic vein in the proximal
forearm just distal to the elbow. The accessory cephalic vein
may arise form the cephalic vein, proximal to the wrist, and
then join it again in the proximal forearm. A large oblique
anastomosis often connects the cephalic and basilic veins on
the dorsum of the forearm (3,4).
Basilic Vein
The basilic vein arises on the dorsoulnar aspect of the hand,
initially formed from contributions of the dorsal venous network (see Figs. 4.9 and 4.10). The basilic vein continues proximally on the dorsal surface of the ulnar side of the forearm. It
curves toward the medial aspect of the forearm in the middle
third of the forearm to reach the anterior medial forearm just
272 Systems Anatomy
FIGURE 4.10. The veins of the palmar hand and digits.
4 Vascular Systems 273
FIGURE 4.11. The veins of the palmar forearm. Variation exists as to the venous patterns.
proximal to the elbow (551–561) (Fig. 4.11). Here the basilic
vein receives the median antebrachial vein. The basilic vein
then continues obliquely in a proximal direction in the groove
between the biceps brachii and the pronator teres. The vein
crosses the brachial artery, separated by the bicipital aponeurosis. Small nerve branches of the medial antebrachial cutaneous
nerve pass both anteriorly and posteriorly to the basilic vein in
this area. The basilic vein continues proximally in the anteromedial arm, along the medial aspect of the biceps brachii (Fig.
4.12). The vein perforates the deep fascia in the middle third
of the arm, usually slightly distal to the mid-portion. The vein
then continues proximally on the medial side of the brachial
artery to the distal border of the teres major. It joins the
brachial vein to help form the axillary vein (3,4) (Fig. 4.13).
Median Antebrachial and Median Cubital
Veins
The median antebrachial vein drains the central part of
the venous plexus on the palmar surface of the hand (see
Fig. 4.11). It continues proximally toward the ulnar side
of the anterior forearm. The median antebrachial vein
reaches the proximal forearm and either empties into the
basilic vein or forms the median cubital vein. It may
divide into two vessels, one of which joins the basilic vein
and the other joining the cephalic vein distal to the antecubital fossa (545–547). The median antebrachial vein
also has interconnections with the deep veins of the forearm (3).
274 Systems Anatomy
FIGURE 4.12. The veins of the anterior elbow.
DEEP VEINS
Gross Anatomic Description: Deep Veins
The deep veins of the upper extremity consist of the deep
veins of the hand and forearm, the brachial veins, and the
axillary vein (see Table 4.6). In general, the deep veins follow the associated arteries as the venae comitantes. These
veins often are arranged in pairs along both sides of the
artery. There usually are several short transverse or diagonal
intercommunicating branches between the veins.
Deep Veins of the Hand
The superficial palmar arch and the deep palmar arch of the
hand usually are accompanied by a pair of venae comitantes
that form the superficial and deep palmar venous arches.
These venous arches receive the veins corresponding to the
branches of the arterial arches.
Interestingly, the proper palmar digital arteries usually
are not accompanied by double venae comitantes (185).
The proper digital artery may be accompanied by a single
palmar digital vein, but this is not consistent. Frequently,
small veins unrelated to the palmar digital arteries are found
in the subcutaneous layers of a digit. These drain either into
the superficial system or into the deep veins of the palmar
arches. The superficial system, which is more abundant,
collects into lateral veins over the dorsum of the digits and
is then directed toward the interdigital spaces to form the
venous network over the dorsum of the hand (see earlier,
under Superficial Veins).
The common palmar digital veins drain into the superficial venous arch and the palmar metacarpal veins flow into
the deep palmar venous arch. The dorsal metacarpal veins
receive perforating branches from the palmar metacarpal
veins and end in the radial veins and the superficial veins on
the dorsum of the wrist (3,4).
Deep Veins of the Forearm
The deep veins of the forearm consist of the venae comitantes of the radial and ulnar arteries. The deep veins of the
palm, including the superficial and deep palmar venous
4 Vascular Systems 275
FIGURE 4.13. The veins of the axilla, including the brachial, cephalic, and axillary veins.
arches, drain into these veins. The deep palmar venous arch
drains principally into the radial veins. The superficial palmar arch drains into the ulnar veins. The radial and ulnar
venae comitantes coalesce at the level of the elbow to form
the brachial veins. The radial veins usually are smaller than
the ulnar veins, and usually receive the dorsal metacarpal
veins. The ulnar veins receive small connections from the
deep palmar venous arch and communicate with the superficial veins at the wrist. At the level of the elbow, the ulnar
veins receive the anterior and posterior interosseous veins.
There also usually is a communicating branch to the
median cubital vein.
Brachial Veins
There usually are two brachial veins, located on the medial
and lateral aspects of the brachial artery (see Figs. 4.12 and
4.13). The brachial veins usually are formed by the union
of the radial and ulnar venae comitantes near the level of the
elbow. These brachial veins receive branches that correspond to the branches given off by the artery. Near the distal margin of the subscapularis muscle, these veins join the
axillary vein. The medial brachial vein often flows into the
basilic vein. The basilic vein may take the place of the
medial brachial accompanying vein. These deep veins have
numerous anastomoses (with each other and with the
superficial veins); there are frequent variations, and the
nomenclature of the veins is not consistent among textbooks or studies (1–11).
Axillary Vein
The axillary vein begins at the union of the basilic and
brachial veins, usually located at the distal border of the
teres major muscle (see Fig. 4.13). The axillary vein terminates to become the subclavian vein at the distal outer border of the first rib. The branches of the axillary vein are variable, but roughly correspond to the associated branches of
the axillary artery. These branches include the circumflex
scapular vein, long thoracic vein, subscapular vein, thoracodorsal vein, thoracoepigastric vein, and superior thoracic
vein (see Table 4.6 and Fig. 4.13). In addition, the cephalic
vein joins the axillary vein proximal in the axilla, near the
first rib. The axillary vein is located on the medial aspect of
the axillary artery. In the proximal axilla, between the axillary vein and the axillary artery, are the medial cord of the
plexus and the medial pectoral nerve. More distally in the
axilla, between the axillary vein and artery, are the median
and ulnar nerves and the medial cutaneous nerve of the
forearm. The medial cutaneous nerve of the arm is located
medial to the vein. The lateral group of the axillary lymph
nodes is located posteromedial to the axillary vein. The axillary vein has a pair of valves near its distal end, at the border of the subscapularis muscle. Valves also are located near
the ends of the subscapular veins. As with the brachial
veins, there are frequent variations in the descriptions of the
axillary vein, and the nomenclature, branching, and patterns depicted between the veins are not consistent among
reports or textbooks (1–11).
Anomalies and Variations: Superficial
and Deep Veins
Absence of the Cephalic or Basilic Veins
Because of the substantial variation of the superficial veins
of the forearm, there often is a reciprocal relationship in the
size of the cephalic and basilic veins. Either one may predominate or be lacking. Absence of the cephalic vein has
been observed in 3% of men and 1% of women in a study
of 170 men and 96 women (546). With absence of the
cephalic vein, the median antebrachial vein usually is
enlarged to drain the area of the cephalic vein (3,4).
Absence of communication between the cephalic and
basilic veins has been noted in 9% of men and 7% of
women (546)
Absence of the Median Antebrachial Vein
The median antebrachial vein may be absent (1,2).
Median Cephalic Vein and Median Basilic Vein
The median cubital vein may be split into a distinct “Y”
pattern, with one arm of the Y draining into the cephalic
and the other into the basilic vein. In this case, one branch
is called the median cephalic vein and the other the median
basilic vein (3,4).
Clinical Correlations: Superficial and
Deep Veins
In the elbow region, the basilic vein passes in the groove
between the biceps brachii and the pronator teres. In this
area, small nerve branches of the medial antebrachial cutaneous nerve pass both anteriorly and posteriorly to the
basilic vein, and are vulnerable to injury if the vein is mobilized, explored, or harvested for venous graft.
The cephalic, basilic, and median cubital veins are clinically important from the standpoint of venipuncture, formation of arteriovenous fistulas for vascular access, the use
of pedicled flaps on the upper extremity, and the pathologic
formation of hemangiomas or aneurysms (551–571). The
median cubital vein is commonly used for venipuncture.
Because it has substantial anastomosing branches with the
deep veins, it is “anchored down,” and this helps facilitate
placement of a needle by preventing the vein from slipping
or rolling away.
276 Systems Anatomy
LYMPHATIC VESSELS AND
NODES
The lymphatic system is a widely dispersed network of thinwalled lymphatic vessels, larger lymph vessels, and associated nodes. The system drains fluid formed in the interstitial spaces and the tissue spaces of most organs. The lymph
fluid is then returned to the venous system for recirculation.
Peripherally, the lymphatic vessels do not communicate
with the blood vessels, but the lymph eventually empties in
to the venous system at the junction of the jugular and subclavian veins at both sides of the neck. The endothelium at
this point is continuous with that of the lymphatic vessels
(3,4).
Lymph fluid consists of an ultrafiltrate of blood that
contains plasma proteins. On its way to the venous system,
the lymph fluid is circulated through lymphatic tissue and
lymph nodes. The lymph nodes contain phagocytes that
function to remove foreign matter. Lymphocytes also enter
the lymphatic fluid at the nodes, as well as immunoglobulins or antibodies, playing a role in immunologic protection
(3,4,8).
In the upper extremity, lymphatic drainage is directed
along the routes of the major vascular channels. The lymphatic vessels are divided into superficial and deep lymphatic vessels. The superficial lymph vessels are present in
greater numbers than the deep (572). The lymph nodes are
similarly divided into superficial and deep lymph nodes.
The superficial lymphatics generally follow the veins,
whereas the deep lymphatics usually follow the arteries.
Most of the lymph from the upper limbs drains to the axillary nodes; in addition, two groups of superficial lymph
nodes, the supratrochlear node(s) located proximal to the
medial elbow and the deltopectoral node(s) located at the
deltopectoral grove, assist with lymph drainage. In general,
the hand, forearm, and arm have very few lymph nodes,
and those present are very small (3,4,572,573).
SUPERFICIAL AND DEEP LYMPHATIC
VESSELS
Gross Anatomic Description: Superficial
Lymphatic Vessels
The superficial lymphatic vessels include the digital
plexuses, the palmar plexus, and the radial, median, and
ulnar channels (3,4,572,573) (Table 4.7). The superficial
vessels arise in a complex lymphatic plexus that courses
throughout the skin of the entire limb (Figs. 4.14 and
4.15). Commencing in the each digit, vessels arise distally
and course in a proximal direction along the sides of each
finger to form a digital plexus. The meshes of vessels are
denser on the palmar aspect of the digit, but head in a
slightly dorsal direction to reach the dorsum of the hand.
In addition, fine but dense meshes of plexuses form in the
palm to form the palmar plexus. The lymph in the palmar
plexus courses in different directions, proximally toward
the wrist, distally to join the digital vessels, medially to
join the vessels on the ulnar border of the hand, and laterally to the vessels of the thumb (3). In addition, a palmar trunk is formed from several vessels that arise in the
central part of the palmar plexus and unite to pass around
the metacarpal of the index finger to join the vessels on
the back of the index finger and thumb. Continuing in a
proximal direction, lymphatic vessels at the wrist form
three roughly parallel channels, the radial, median, and
ulnar lymphatic vessels. These vessels course, respectively,
along the cephalic, median, and basilic veins in the forearm. Some of the ulnar lymph vessels end or pass through
the small supratrochlear node(s), located on the medial
elbow, proximal to the joint level (see Fig. 4.15). Some of
the radial lymph vessels continue proximally to form a
trunk that ascends with the cephalic vein to reach the deltopectoral nodes. [Some of these vessels may continue
with the cephalic vein to penetrate the clavipectoral fascia
to enter the apical group of the axillary nodes in the infraclavicular region, or may ascend as far as the lower deep
cervical nodes proximal to the clavicle (3,572,573).] Most
of the superficial lymph vessels of the upper extremity,
however, continue proximally to reach the lateral group of
axillary nodes (see Figs. 4.15 and 4.16).
4 Vascular Systems 277
TABLE 4.7. LYMPHATIC VESSELS AND LYMPH
NODES OF THE UPPER EXTREMITY
Superficial lymphatic vessels
Digital plexus
Palmar plexus
Radial vessels
(Some to deltopectoral nodes)
Median lymph vessels
Ulnar lymph vessels
(Some to supratrochlear nodes)
Deep lymphatic vessels
Deep radial lymphatic vessels
Deep ulnar lymphatic vessels
Deep anterior interosseous lymphatic vessels
Deep posterior interosseous lymphatic vessels
Deep brachial lymphatic vessels
Superficial lymph nodes
Supratrochlear lymph nodes
Deltopectoral lymph nodes
Deep lymph nodes
Axillary lymph nodes
Lateral group
Pectoral (anterior) group
Subscapular (posterior) group
Central group
Apical (subclavicular) group
Gross Anatomic Description: Deep
Lymphatic Vessels
The deep lymphatic vessels include the deep radial, deep
ulnar, deep anterior and posterior interosseous, and deep
brachial lymphatic vessels (see Table 4.7). The deep lymphatic vessels accompany the deep blood vessels. In the
forearm, there are four sets, which correspond to and follow
the radial, ulnar, and anterior and posterior interosseous
arteries. These deep lymphatic vessels communicate at
intervals with the superficial lymphatic vessels, and some
may end in the associated nodes. In the arm, these deeper
lymphatic vessels follow the brachial artery. Some vessels
terminate in small nodes along the artery, but most continue proximally to reach the axillary nodes (3,4,574,575)
(see Figs. 4.15 and 4.16).
Gross Anatomic Description: Superficial
Lymph Nodes
Although most of the lymph nodes of the upper extremity
are grouped in the axillary nodes, several nodes exist along
the superficial vessels. These include the supratrochlear and
deltopectoral nodes (see Table 4.7).
The supratrochlear nodes consist of one to five small
nodes located on the medial distal arm, just proximal to the
medial epicondyle of the elbow (see Fig. 4.15). Located in
the superficial fascia, these nodes usually are medial to the
basilic vein. The supratrochlear nodes receive lymph flow,
usually through the (superficial) ulnar lymphatic vessels
that follow the basilic vein, to drain fluid from the middle,
ring, and small fingers, the medial portion of the hand, and
the superficial areas over the ulnar side of the forearm.
Because these vessels intercommunicate with the other
lymph vessels of the digits and fingers, it is conceivable that
the supratrochlear nodes can receive fluid from other parts
of the upper extremity as well.
The deltopectoral nodes consist of only a few nodes
located along the cephalic vein in the deltopectoral grove,
between the pectoralis major and deltoid muscles, just inferior to the clavicle (Fig. 4.16; see Fig. 4.15). The deltopectoral nodes can receive lymph flow from the (superficial)
radial lymph vessels, which follow the cephalic vein (3,4,8,
575).
278 Systems Anatomy
FIGURE 4.14. Schematic illustration of the fine superficial lymph vessels on the dorsum of the digits and
hand.
4 Vascular Systems 279
FIGURE 4.15. Schematic illustration of the fine superficial lymph vessels on the palmar hand and
forearm. The supratrochlear, deltopectoral, and axillary nodes are shown.
Gross Anatomic Description: Deep Lymph
Nodes
The deep lymph nodes are located and mainly comprise the
axillary lymph nodes. There are, however, sporadic, variable, isolated deep lymph nodes in the forearm along the
course of the radial, ulnar, and interosseous arteries, and in
the arm along the medial side of the brachial artery (3).
The axillary nodes are relatively large, and vary from 20
to 30 in number. These are divided into several groups,
including the lateral, pectoral (anterior), subscapular (posterior), central, and apical (subclavicular) nodes (3,4,575,576)
(see Table 4.7 and Fig. 4.16).
Lateral Group of the Axillary Lymph Nodes
The lateral group consists of four to six axillary nodes
located medial and posterior to the axillary vein (575,576)
(see Fig. 4.16). This group includes among the most distal
of the axillary nodes and receives lymph vessels from nearly
the entire upper limb (with the exception of those vessels
that accompany the cephalic vein, some of which drain into
the deltopectoral nodes). The lymph vessels also pass to the
central and apical group of the axillary nodes (located deep
and proximal to the lateral group) (3,4,8).
Pectoral (Anterior) Group of the Axillary
Lymph Nodes
The pectoral group of lymph nodes is located inferior to the
lateral group and consists of four or five nodes that lie along
the lateral border of the pectoralis minor muscle, close to
the lateral thoracic artery (see Fig. 4.16). The lymph vessels
that drain into the pectoral group arise in the skin and muscles of the anterior and lateral thoracic walls, and from the
central and lateral parts of the mammary gland. These vessels also connect to the central and apical groups of lymph
nodes (3,4,8).
Subscapular (Posterior) Group of the Axillary
Lymph Nodes
The subscapular lymph nodes are located along the lower
margin of the posterior wall of the axilla, close to the subscapular artery (576,577) (see Fig. 4.16). These usually are
280 Systems Anatomy
FIGURE 4.16. The several groups of lymph nodes comprising the axillary nodes.
inferior to the central and lateral groups of nodes. The subscapular group consists of six or seven axillary nodes. The
lymph vessels that drain into the subscapular group arise in
the skin and muscles of the posterior neck and the posterior
thoracic wall. The lymph vessels then continue to the central group of nodes (3,4,8).
Central Group of the Axillary Nodes
The central group of lymph nodes is located deep in the
axilla, in the adipose tissue (576,577) (see Fig. 4.16). The
central group consists of three or four nodes. Because of its
central location, this group does not drain a specific part of
the upper extremity directly, but does receive vessels from
the lateral, pectoral, and subscapular groups of nodes. Vessels that enter the central group may continue proximally
and superiorly to reach the apical nodes (3,4,8)
Apical (Subclavicular) Group of the Axillary
Nodes
The apical group of nodes is located superiorly and proximally in the axilla, and consists of 6 to 12 nodes (576)
(see Fig. 4.16). The nodes lie partly deep to the superior
part of the pectoralis minor and partly in the apex of the
axilla, medial and superior to the superior border of the
muscle. The lymph vessels that drain into the apical
nodes follow the cephalic vein. The apical lymph nodes
usually receive a few vessels from those draining the superior part of the mammary gland. The apical nodes also
receive communicating vessels from the other axillary
nodes. The vessels from the apical nodes unite to form
the subclavian trunk, which continues either directly into
the junction of the internal jugular and subclavian veins
or into the jugular lymphatic trunk. On the left side, the
subclavian trunk may end in the thoracic duct. A few vessels from the apical nodes also may pass to the inferior
deep cervical nodes (3,4,8).
Anomalies and Variations: Lymphatic
Vessels and Nodes
Because of the normal variations in the lymphatic system,
these are described in the sections on normal anatomy of
the vessels and nodes (see the Gross Anatomic Description
sections for the superficial and deep lymph vessels and
nodes, earlier).
Clinical Correlations: Lymphatic Vessels
and Nodes
Unilateral upper extremity lymphedema is a well recognized
potential occurrence after operative axillary node dissection
(i.e., performed with mastectomy for breast carcinoma)
(573,577,578).
Palpable enlargement and possible tenderness of the axillary or supratrochlear nodes can follow infection or
metastatic disease, an important finding in the clinical evaluation of these problems.
REFERENCES
1. Grant JCB. An atlas of anatomy, 6th ed. Baltimore: Williams &
Wilkins, 1972:1–104.
2. Agur AMR, Lee MJ. Grant’s atlas of anatomy. Philadelphia: Lippincott Williams & Wilkins, 1999:413–517.
3. Clemente CD. Gray’s anatomy, 13th American ed. Baltimore:
Williams & Wilkins, 1985:709–728.
4. Williams PW. Gray’s anatomy: the anatomical basis of medicine
and surgery, 38th ed. New York: Churchill Livingstone,
1995:1537–1544, 1589–1591, 1613–1615.
5. Gray H, Mayo C. Anatomy of the human body. Philadelphia: Lea
and Febiger, 1973:610–624, 700–704, 747–750.
6. Netter FH, Colacino S. Atlas of human anatomy. Summit, NJ:
Ciba-Geigy Corporation, 1990:395–456.
7. Tountas CP, Bergman RA. Anatomic variations of the upper
extremity. New York: Churchill Livingstone, 1993:187–210.
8. Rosse C, Gaddum-Rosse P. Hollinshead’s textbook of anatomy.
Philadelphia: Lippincott-Raven, 1997:193–306.
9. Hollinshead HH. Anatomy for surgeons: the back and limbs.
Philadelphia: Harper and Row, 1982:203–562.
10. Henry AK. Extensile exposure. Edinburgh: Churchill Livingstone, 1973:15–124.
11. Last RJ. Anatomy: regional and applied, 5th ed. Baltimore:
Williams & Wilkins, 1972:95–192.
12. Clemente CD. Anatomy: a regional atlas of the human body.
Philadelphia: Lea and Febiger, 1975:1–96.
13. De la Garza O, Lierse W, Steiner D. Anatomical study of the
blood supply in the human shoulder region. Acta Anat (Basel)
145:412–415, 1992.
14. Kogan I, Lewinson D. Variation in the branching of the axillary
artery: a description of a rare case. Acta Anat (Basel) 162:
238–240, 1998.
15. Yuksel M, Yuksel E. Anomalous branching order of the superior
and lateral thoracic arteries. Clin Anat 10:394–396, 1997.
16. Yucel AH. Unilateral variation of the arterial pattern of the
human upper extremity with a muscle variation of the hand.
Acta Med Okayama 53(2):61–65, 1999.
17. Cavdar S, Zeybek A, Bayramicli M. Rare variation of the axillary artery. Clin Anat 13:66–68, 2000.
18. Pick TP, Howden R. Anatomy, descriptive and surgical. Philadelphia: Running Press, 1974.
19. Nakatani T, Tanaka S, Mizukami S. Case report: bilateral location of the axillary artery posterior to the medial cord of the
brachial plexus. J Anat 189:457–459, 1996.
20. Jurjus AR, Correa-de-Aruaujo R, Bonh RC. Bilateral double
axillary artery: embryological basis and clinical implications.
Clin Anat 12:135–140, 1999.
21. Goldberg JA, Lineaweaver WC, Buncke HJ. An aberrant independent origin of the serratus anterior pedicle. Ann Plast Surg
25:487, 1990.
22. Uglietta JP, Kadir S. Arteriographic study of variant arterial
anatomy of the upper extremities. Cardiovasc Intervent Radiol
12:145–148, 1989.
23. Gonzalez-Compta X. Origin of the radial artery from the axillary artery and associated hand vascular anomalies. J Hand Surg
[Am] 16:293–296, 1991.
24. Celik HH, Gormus G, Aldur MM, et al. Origin of the radial
4 Vascular Systems 281
and ulnar arteries: variations in 81 arteriograms. Morphologie
85:25–27, 2001.
25. Uzun A, Seelig LL Jr. The anastomotic artery connecting the
axillary or brachial artery to one of the forearm arteries. Folia
Morphol (Warsz) 59:217–220, 2000.
26. Yildirim M, Kopuz C, Yildiz Z. Report of a rare human variation: the superficial ulnar artery arising from the axillary artery.
Okajimas Folia Anat Jpn 76:187–191, 1999.
27. Jacquemin G, Lemaire V, Medot M, et al. Bilateral case of
superficial ulnar artery originating from axillary artery. Surg
Radiol Anat 23:139–143, 2001.
28. Ozan H, Simsek C, Onderoglu S, et al. High division of the
axillary artery: a rare case of superficial ulnar artery. Acta Anat
(Basel) 151:68–70, 1994.
29. Fadel RA, Amonoo-Kuofi HS. The superficial ulnar artery:
development and surgical significance. Clin Anat 9:128–132,
1996.
30. Anil A, Turgut HB, Peker TV. A variant of superficial ulnar
artery. Surg Radiol Anat 18:237–240, 1996.
31. Yazar F, Kirici Y, Ozan H, et al. An unusual variation of the
superficial ulnar artery. Surg Radiol Anat 21:155–157.
32. Gormus G, Ozcelik M, Hamdi Celik H, et al. Variant origin of
the ulnar artery. Clin Anat 11:62–64, 1998.
33. Aharinejad S, Nourani F, Hollensteiner H. Rare case of high
origin of the ulnar artery from the brachial artery. Clin Anat
10:253–258, 1997.
34. Nakatani T, Tanaka S, Mizukami S, et al. The superficial ulnar
artery originating from the axillary artery. Anat Anz
178:277–279, 1996.
35. Coleman MM, Peng P. Localization of the axillary artery in
brachial plexus block. Reg Anesth Pain Med 24:192–193, 1999.
36. Scott DB. Techniques of regional anaesthesia. Norwalk, CT:
Appleton and Lange/Mediglobe, 1989:100–104.
37. Moore DC. Regional block: a handbook for use in the clinical
practice of medicine and surgery, 4th ed. Springfield, IL: Charles
C Thomas, 1965:243–256.
38. Brown DL. Regional anesthesia and analgesia. Philadelphia: WB
Saunders, 1996:254–278.
39. Groh GI, Gainor BJ, Jeffries JT, et al. Pseudoaneurysm of the
axillary artery with median-nerve deficit after axillary block
anesthesia: a case report. J Bone Joint Surg Am 72:1407–1408,
1990.
40. Ott B, Neuberger L, Frey HP. Obliteration of the axillary artery
after axillary block. Anesthesia 44:773–774, 1989.
41. Hoppenfeld S, deBoer P. Surgical exposures in orthopaedics: the
anatomic approach, 2nd ed. Philadelphia: JB Lippincott,
1994:2–214.
42. Seitz J, Valdes F, Kramer A. Acute ischemia of the upper extremity caused by axillary contused trauma: report of 3 cases. Rev
Med Chil 119:567–571, 1991.
43. Jensen BV, Jacobsen J, Andreasen H. Late appearance of arterial injury caused by fracture of the neck of the humerus. J
Trauma 27:1368–1369, 1987.
44. Sathyarup D, Huilgol AK, Iyer KM. Axillary artery thrombosis
following a fracture of the neck of the humerus. Injury 19:
45–47, 1988.
45. Zieren J, Kasper A, Landwehr P, et al. Traumatic pseudoaneurysm of the axillary artery after shoulder dislocation.
Chirurg 65:1058–1060, 1994.
46. Johnson SF, Johnson SB, Strodel WE, et al. Brachial plexus
injury: association with subclavian and axillary vascular trauma.
J Trauma 31:1546–1550, 1991.
47. Emadian SM, Lee WW. Axillary artery pseudoaneurysm and
axillary nerve palsy: delayed sequelae of anterior shoulder dislocation. Am J Emerg Med 14:108–109, 1996.
48. Byrd RG, Byrd RP Jr, Roy TM. Axillary artery injuries after
proximal fracture of the humerus. Am J Emerg Med
16:154–156, 1998.
49. Manak P, Klein J. Axillary artery injury in closed fracture of the
humeral neck. Acta Univ Palacki Olomujc Fac Med 140:87–88,
1996.
50. Riemer BL, D’Ambrosia R. The risk of injury to the axillary
nerve, artery, and vein from proximal locking screws of humeral
intramedullary nails. Orthopedics 15:697–699, 1992.
51. Tiesenhausen K, Amann W, Koch G, et al. Arterial complications caused by using an axillary crutch. Z Orthop Ihre Grenzgeb 138:544–546, 2000.
52. Feldman DR, Vujic I, McKay D, et al. Crutch-induced axillary
artery injury. Cardiovasc Intervent Radiol 18:296–299, 1995.
53. Baker CL Jr, Liu SH. Neurovascular injuries to the shoulder. J
Orthop Sports Phys Ther 18:360–364, 1993.
54. McCarthy WJ, Yao JS, Schafer MF, et al. Upper extremity arterial injury in athletes. J Vasc Surg 9:317–327, 1989.
55. Nuber GW, McCarthy WJ, Yao JS, et al. Arterial abnormalities
of the shoulder in athletes. Am J Sports Med 18:514–519,
1990.
56. Schneider K, Kasparyan NG, Altchek DW, et al. An aneurysm
involving the axillary artery and its branch vessels in a major
league baseball pitcher: a case report and review of the literature.
Am J Sports Med 27:370–375, 1999.
57. Ishitobi K, Moteki K, Nara S, et al. Extra-anatomic bypass graft
for management of axillary artery occlusion in pitchers. J Vasc
Surg 33:797–801, 2001.
58. Finkelstein JA, Johnston KW. Thrombosis of the axillary artery
secondary to compression by the pectoralis minor muscle. Ann
Vasc Surg 7:287–290, 1993.
59. Kee ST, Dake MD, Wolfe-Johnson B, et al. Ischemia of the
throwing hand in major league baseball pitchers: embolic occlusion from aneurysms of axillary artery branches. J Vasc Interv
Radiol 6:979–982, 1995.
60. Karacagil S, Eriksson I. Entrapment of the axillary artery by
anomalous muscle: case report. Acta Chir Scand 153:633–634,
1987.
61. Lester B, Jeong GK, Weiland AJ, et al. Quadrilateral space syndrome: diagnosis, pathology, and treatment. Am J Orthop
28:718–725, 1999.
62. Yamaguchi K, Sweet FA, Bindra R, et al. The extraosseous and
intraosseous arterial anatomy of the adult elbow. J Bone Joint
Surg Am 79:1653–1662, 1997.
63. Yamaguchi K, Sweet FA, Bindra R, et al. The extraneural and
intraneural arterial anatomy of the ulnar nerve at the elbow. J
Shoulder Elbow Surg 8:17–21, 1999.
64. Lim BH, Toh CL, Wong HP, et al. Cadaveric study on the vascular anatomy of the ulnar nerve at the elbow: a basis for anterior transposition? Ann Acad Med Singapore 21:689–693,
1992.
65. Jurjus A, Sfier R, Bezirdjian R. Unusual variation of the arterial
pattern of human upper limb. Anat Rec 215:82–83, 1986.
66. Inoue Y, Taylor GI. The angiosomes of the forearm: anatomic
study and clinical implications. Plast Reconstr Surg 98:
195–210, 1996.
67. Fuss FK, Matula CW, Tschabitscher M. The superficial brachial
artery. Anat Anz 160:285–294, 1985.
68. Fuss FK. A superficial ulnar artery with high origin and atypical location. Gegenbaurs Morphol Jahrb 134:215–220, 1988.
69. Inoue K, Masuko S, Isobe Y. A case of a double superficial
brachial artery and a case of a superficial antebrachial artery.
Kaibogaku Zasshi 56:13–18, 1981.
70. Keller FS, Rosch J, Dotter CT, et al. Proximal origin of radial
artery: potential pitfall in hand angiography. AJR Am J
Roentgenol 134:169–170, 1980.
71. Rodriguez-Niedenfuhr M, Burton GJ, Deu J, et al. Develop282 Systems Anatomy
ment of the arterial pattern in the upper limb of staged human
embryos: normal development and anatomic variations. J Anat
199:407–417, 2001.
72. Rodriguez-Niedenfuhr M, Sanudo JR, Vasquez T, et al. Anastomosis at the level of the elbow joint connecting the deep, or
normal, brachial artery with major arterial variations of the
upper limb. J Anat 187:473–479, 2000.
73. Sarikcioglu L, Coskun N, Ozkan O. A case with multiple
anomalies in the upper limb. Surg Radiol Anat 23:65–68, 2001.
74. Nakatani T, Tanaka S, Miszukami S. Anomalous triad of a leftsided inferior vena cava, a retroesophageal right subclavian
artery, and bilateral superficial brachial arteries in one individual. Clin Anat 11:112–117, 1998.
75. Nakatani T, Tanaka S, Mizukami S. Superficial brachial artery
continuing as the common interosseous artery. J Anat 191:
155–157, 1997.
76. Celik HH, Sargbon MF, Konan A, et al. High brachial artery
bifurcation: a report of two cases. Bull Assoc Anat 80:13–14,
1996.
77. Sargon MF, Tanyeli E, Surucu HS, et al. A complicated variation of the upper extremity vascularization. Kaibogaku Zasshi
71:211–214, 1996.
78. Omori O, Umetani T, Sugioka K, et al. A case of the bilateral
superficial brachial arteries which continued to the radial arteries in the forearms. Kobe J Med Sci 42:105–109, 1996.
79. Icten N, Sullu Y, Tuncer I. Variant high-origin radial artery: a
bilateral case. Surg Radiol Anat 18:63–66, 1996.
80. Tohno S, Tohno Y, Yamaoka J, et al. Anomaly of the ulnar
artery arising from the brachial artery. Kaibogaku Zasshi 70:
31–34, 1995.
81. Golan J, Kaus M, Szwarc P. High origin of the ulnar and radial
arteries in humans. Folia Morphol (Warsz) 53:37–48, 1994.
82. Small JO, Miller R. The radial artery forearm flap: an anomaly
of the radial artery. Br J Plast Surg 38:394, 1985.
83. Weathersby HT. Anomalies of brachial and antebrachial arteries
of surgical significance. South Med J 49:46, 1956.
84. Quain R. The anatomy of the arteries of the human body. London: Taylor and Walton, 1844:273.
85. Cox GW, Griswold JA. High bifurcation of the brachial artery.
Injury 222:119–120, 1991.
86. Hazlett WB. The superficial ulnar artery with reference to accidental intra-arterial injection. CMAJ 61:289, 1949.
87. Fatah MF, Nancarrow JD, Murray DS. Raising the radial forearm
flap: the superficial ulnar artery trap. Br J Plast Surg 38:394, 1985.
88. Ciervo A, Kahn M, Pangilinan AJ, et al. Absence of the brachial
artery: report of a rare human variation and review of upper
extremity arterial anomalies. J Vasc Surg 33:191–194, 2001.
89. Talha H, Enon B, Chevalier JM, et al. Brachial artery entrapment: compression by the supracondylar process. Ann Vasc
Surg 1:479–482, 1987.
90. Zbrodowski A, Gajisin S. The blood supply of the flexor retinaculum. J Hand Surg [Br] 13:35–39, 1988.
91. Shin AY, Bishop AT. Vascular anatomy of the distal radius. Clin
Orthop 383:60–73, 2001.
92. Shin AY, Bishop AT, Berger RA. Vascularized pedicled bone
grafts for disorders of the carpus. Tech Hand Upper Extremity
Surg 2:94–109, 1998.
93. Pahl S, Schmidt HM. Clinical anatomy of the interosseous
arteries of the forearm. Handchir Mikrochir Plast Chir
26:246–250, 1994.
94. Illuminati G, Calio FG, Bertangi A, et al. Infectious aneurysm
of the interosseous artery at the forearm: case report. J Cardiovasc Surg (Torino) 37:589–591, 1996.
95. Sargon M, Celik HH. Proximal origins of radial and common
interosseous arteries. Kaibogaku Zasshi 69:406–409, 1994.
96. Wozniak W, Bruska M, Markowski M. A case of high origin of
the common interosseous artery. Folia Morphol (Warsz)
57:389–391, 1998.
97. Martin K, Rivet K, Boileau R, et al. The posterior radial epiphysis free flap: a new donor site. Br J Plast Surg 42:499–506,
1989.
98. Rath S, Hung LK, Leung PC. Vascular anatomy of the pronator quadratus muscle-bone flap: a justification for its use with a
distally based blood supply. J Hand Surg [Am] 15:630–636,
1990.
99. Pagliei A, Brunelli F, Gilbert A. Anterior interosseous artery:
anatomic bases of pedicled bone-grafts. Surg Radiol Anat
13:152–154, 1991.
100. Shibata M, Ogishyo N. Free flaps based on the anterior
interosseous artery. Plast Reconstr Surg 97:746–755, 1996.
101. Hu W, Martin K, Foucher G, et al. Anterior interosseous flap.
Ann Chir Plast Esthet 39:290–300, 1994.
102. Enzler M, Jaeck W, Berger M, et al. Bypass to the anterior
interosseous artery of the arm: follow-up of three years. Vasa
27:250–252, 1998.
103. Fritsche E, Hort C, Trachslin N, et al. Soft tissue reconstruction
of the finger with free, posterior ramus of the anterior
interosseous artery-based septo-cutaneous flap: anatomy–technique–case examples. Handchir Mikrochir Plast Chir 31:
27–34, 1999.
104. Penteado CV, Masquelet AC, Chevrel JP. The anatomic basis of
the fascio-cutaneous flap of the posterior interosseous artery.
Surg Radiol Anat 8:209–215, 1986.
105. Masquelet AC, Penteado CV. The posterior interosseous flap.
Ann Chir Main 6:131–139, 1987.
106. Costa H, Soutar DS. The distally based island posterior
interosseous flap. Br J Plast Surg 41:221–227, 1988.
107. Zancolli EA, Angrigiani C. Posterior interosseous island forearm flap. J Hand Surg [Br] 13:130–135, 1988.
108. Bayon P, Pho RW. Anatomical basis of dorsal forearm flap:
based on posterior interosseous vessels. J Hand Surg [Br] 13:
435–439, 1988.
109. Luo YX, Cao DC, Wu YG, et al. Clinical application of the
forearm island skin and fascia flap with posterior interosseous
artery pedicle: report of 15 cases. J Tongji Med Univ 9:
107–110, 1989.
110. Tonkin MA, Stern H. The posterior interosseous artery free
flap. J Hand Surg [Br] 14:215–217, 1989.
111. Qian YL. Reversed forearm island flap with dorsal interosseous
artery for reconstruction of postburn deformities of the hand:
report of six cases. Zhonghua Zheng Xing Shao Shang Wai De
Za Zhi 6:81–82, 1990.
112. Qian YL. Clinical application of expanded forearm reverse dorsal interosseous artery island flap. Zhonghua Zheng Xing Shao
Shang Wai De Za Zhi 7:182–183, 238, 1991.
113. Kuhlmann JN, Ninoun M, Guerin-Surville H, et al. The posterior interosseous artery: descriptive anatomy. Possibilities of
clinical and orthopedic applications. Bull Assoc Anat (Nancy)
76:13–18, 1992.
114. Angrigiani C, Grilli D, Dominikow D, et al. Posterior
interosseous reverse forearm flap: experience with eighty consecutive cases. Plast Reconstr Surg 92:285–293, 1993.
115. Yu MS, Luo YX. Applied anatomic study of the posterior
interosseous artery in forearm. Zhonghua Zheng Xing Shao
Shang Wai De Za Zhi 9:383–384, 399, 1993.
116. Arnez ZM, Lister GD. The posterior interosseous arterial graft.
Plast Reconstr Surg 94:202–206, 1994.
117. Song J, Feng YL, Zhang G. Repair of soft tissue defect on the
hand using antebrachial posterior interosseous artery retrograde
island flap. Zhonghua Zheng Xing Shao Shang Wai De Za Zhi
11:26–28, 1995.
118. Chmiel Z. Use of a fascia-cutaneous island flap based on the
4 Vascular Systems 283
posterior interosseous artery of the forearm: a case report. Chir
Narzadow Ruchu Ortop Pol 61:17–21, 1996.
119. Gupta A, Wang A, Baylis W, et al. Anterior transposition of the
posterior interosseous artery flap through the interosseous
membrane. J Hand Surg [Br] 22:32–33, 1997.
120. Park JJ, Kim JS, Chung JI. Posterior interosseous free flap: various types. Plast Reconstr Surg 100:1186–1197, discussion
1198–1199, 1997.
121. Sungpet A, Patradul A. The new flap based on the longitudinal
fascial branches of the posterior interosseous artery. J Med Assoc
Thai 81:458–461, 1998.
122. Chang MH, Chen HC, Santamaria E, et al. Preoperative ultrasound Doppler study and clinical correlation of free posterior
interosseous flap. Changgeng Yi Xue Za Zhi 20:258–264, 1997.
123. Roux JL, Leandris M, Allieu Y. Anatomical study of interosseous
flaps and the concept of postero-anterior interosseous flap: preliminary report. Ann Chir Plast Esthet 42:260–271, discussion
272–273, 1997.
124. Giunta R, Lukas B. Impossible harvest of the posterior
interosseous artery flap: a report of an individualized salvage
procedure. Br J Plast Surg 51:642–645, 1998.
125. O’Ferrell DA, Cannon DP, Nunley JA. Digital ischemia associated with a thrombosed aneurysm of the dorsal interosseous
artery: a case report. J Bone Joint Surg Am 79:441–443,
1997.
126. Holevich-Madjarova B, Paneva-Holevich E. Fasciocutaneous
island flap from the dorsal forearm. Handchir Mikrochir Plast
Chir 23:23–27, 1991.
127. Ding YC. Micro-anatomy of nutrient vessels of skin of dorsal
surface of forearm and its clinical applications. Zhonghua
Zheng Xing Shao Shang Wai Ke Za Ahi 5:36–39, 77–78, 1989.
128. Menck J, Schreiber HW, Hertz T, et al. Angioarchitecture of the
ulna and radius and their practical relevance. Langenbecks Arch
Chir 379:70–75, 1994.
129. Giebel GD, Meyer C, Koebke J, et al. Arterial supply of forearm bones and its importance for the operative treatment of
fractures. Surg Radiol Anat 19:149–153, 1997.
130. Mikic Z. The blood supply of the human distal radioulnar joint
and the microvasculature of its articular disk. Clin Orthop
275:19–28, 1992.
131. Thiru RG, Ferlic DC, Clayton ML, et al. Arterial anatomy of
the triangular fibrocartilage of the wrist and its surgical significance. J Hand Surg [Am] 11:258–263, 1986.
132. Gelberman RH, Panagis JS, Taleisnik J, et al. The arterial
anatomy of the human carpus. Part I: the extraosseous vascularity. J Hand Surg[Am] 8:367–375, 1983.
133. Gelberman RH, Botte MJ. Vascularity of the carpus. In: Lichtman DM, Alexander AH, eds. The wrist and its disorders, 2nd
ed. Philadelphia: WB Saunders, 1997:34–47.
134. Freedman DM, Botte MJ, Gelberman RH. Vascularity of the
carpus. Clin Orthop 383:47–59, 2001.
135. Panagis JS, Gelberman RH, Taleisnik J, et al. The arterial
anatomy of the human carpus. Part II: the intraosseous vascularity. J Hand Surg[Am] 8:375–382, 1983.
136. Gelberman RH, Bauman RD, Menon J. The vascularity of the
lunate bone and Kienbock’s disease. J Hand Surg[Am]
5:272–278, 1980.
137. Barber H. The intraosseous arterial anatomy of the adult human
carpus. Orthopedics 5:1–19, 1972.
138. Gelberman RH, Menon J. The vascularity of the scaphoid
bone. J Hand Surg[Am] 5:508–513, 1980.
139. Grettve S. Arterial anatomy of the carpal bones. Acta Anat
25:331–345, 1955.
140. Taleisnik J, Kelly PJ. Extraosseous and intraosseous blood supply of the scaphoid bone. J Bone Joint Surg Am 48:1125–1137,
1977.
141. Srivastava SK, Pande BS. Anomalous pattern of median artery
in the forearm of Indians. Acta Anat (Basel) 138:193–194,
1990.
142. Kopuz C, Gulman B, Baris S. Persistent median artery: an
anatomical study in neonatal and adult cadavers. Kaibogaku
Zasshi 70:577–580, 1995.
143. Kopuz C, Baris S, Gulman B. A further morphological study of
the persistent median artery in neonatal cadavers. Surg Radiol
Anat 19:403–406, 1997.
144. Inoue G, Minura T. Arteriographic findings in radial and ulnar
deficiencies. J Hand Surg [Br] 16:409–412, 1991.
145. Ozkus K, Pestelmaci T, Soyluoglu AI, et al. Variations of the
superficial palmar arch. Folia Morphol (Warsz) 57:251–255,
1998.
146. Ruengsakulrach P, Eizenberg N, Fahrer C, et al. Surgical implications of variations in hand collateral circulation: anatomy
revisited. J Thorac Cardiovasc Surg 122:682–686, 2001.
147. Lippert H. Variability of hand and foot arteries. Handchir
Mikrochir Plast Chir 16:254–258, 1984.
148. Krishnamoorthy L, Murison MS, Sydes PJ. Arteriovenous malformation of the forearm as a result of a persistent median
artery. J Hand Surg [Br] 23:820–821, 1998.
149. Sanudo JR, Chikwe J, Evans SE. Anomalous median nerve associated with persistent median artery. J Anat 185:447–451,
1994.
150. Rodriguez-Niedenfuhr M, Sanudo JRE, Vasquez T, et al.
Median artery revisited. J Anat 195:57–63, 1999.
151. Zeiss J, Guilliam-Haidet L. MR demonstration of a persistent
median artery in carpal tunnel syndrome. J Comput Assist
Tomogr 17:482–484, 1993.
152. Jackson IT, Campbell JC. An unusual cause of carpal tunnel
syndrome: a case of thrombosis of the median artery. J Bone
Joint Surg Br 52:330–333, 1970.
153. Maxwell JA, Kepes JJ, Detchum LD. Acute carpal tunnel syndrome secondary to thrombosis of a persistent median artery:
case report. J Neurosurg 38:774–777, 1973.
154. Barfred T, Hojlund AP, Bertheussen K. Median artery in carpal
tunnel syndrome. J Hand Surg [Am] 10:864–867, 1985.
155. Krajcinovic J. Carpal tunnel syndrome caused by median artery
thrombosis. Med Pregl 38:257–258, 1985.
156. Galassi E, Benfenati A, Tognetti F, et al. Persistence of the
median artery: possible cause of the carpal tunnel syndrome.
Riv Neurol 50:159–166, 1980.
157. Nather A, Chacha PB, Lim P. Acute carpal tunnel syndrome
secondary to thrombosis of a persistent median artery (with
high division of the median nerve): a case report. Ann Acad
Med Singapore 9:118–121, 1980.
158. Levy M, Pauker M. Carpal tunnel syndrome due to thrombosed
persisting median artery: a case report. Hand 10:65–68, 1978.
159. Mauersberger W, Meese W. Carpal tunnel syndrome caused by
the persistence of the median artery. Neurochirurgia (Stuttg)
18:15–19, 1975.
160. Wright C, MacFarlane I. Aneurysm of the median artery causing carpal tunnel syndrome. Aust N Z J Surg 64:66–67, 1994.
161. Luyendijk W. The carpal tunnel syndrome: the role of a persistent median artery. Acta Neurochir (Wien) 79:52–57, 1986.
162. Dickinson JC, Kleinert JM. Acute carpal-tunnel syndrome
caused by a calcified median artery: a case report. J Bone Joint
Surg Am 73:610–611, 1991.
163. De Graad M, Rodseth DJ. Median artery thrombosis as a cause
of carpal tunnel syndrome. S Afr Med J 76:78–79, 1989.
164. Rayan GM. Persistent median artery and compression neuropathy. Orthop Rev 15:241–244, 1986.
165. Toranto IR. Aneurysm of the median artery causing recurrent
carpal tunnel syndrome and anatomic review. Plast Reconstr
Surg 84:510–512, 1989.
284 Systems Anatomy
166. Balakrishnan C, Smith MF, Puri P. Acute carpal tunnel syndrome from thrombosed persistent median artery. J Emerg Med
17:437–439, 1999.
167. Olave E, Prates JC, Gabrielli C, et al. Median artery and superficial palmar branch of the radial artery in the carpal tunnel.
Scand J Plast Reconstr Surg Hand Surg 31:13–16, 1997.
168. Feldkamp MM, Gentili F, Hudson AR, et al. A persistent
median artery causing carpal tunnel syndrome in a patient with
chronic renal failure: case report. Neurosurgery 37:140–143,
1995.
169. Rose RE. Acute carpal tunnel syndrome secondary to thrombosis
of a persistent median artery. West Indian Med J 44:32–33, 1995.
170. Lisanti M, Rosati M, Pardi A. Persistent median artery in carpal
tunnel syndrome. Acta Orthop Belg 61:315–318, 1995.
171. Jones NF, Ming NL. Persistent median artery as a cause of
pronator syndrome. J Hand Surg [Am] 13:728, 1988.
172. Gainor BJ, Jeffries JT. Pronator syndrome associated with a persistent median artery. J Bone Joint Surg Am 69:303, 1987.
173. Revol MP, Lantieri L, Loy S, et al. Vascular anatomy of the forearm muscles: a study of 50 dissections. Plast Reconstr Surg
88:1026–1033, 1991.
174. Oppikofer C, Buchler U, Schmid E. The surgical anatomy of
the dorsal carpal branch of the ulnar artery: basis for a neurovascular dorso-ulnar pedicled flap. Surg Radiol Anat
14:97–101, 1992.
175. Olave E, Prates JC, Gabrielli C, et al. Perforating branches:
important contribution to the formation of the dorsal
metacarpal arteries. Scand J Plast Reconstr Surg Hand Surg
32:221–227, 1998.
176. Konig PS, Hage JJ, Bloem JJ, et al. Variations of the ulnar nerve
and ulnar artery in Guyon’s canal: a cadaveric study. J Hand
Surg[Am] 19:617–622, 1994.
177. Richards RS, Dowdy P, Roth JH. Ulnar artery palmar to palmaris brevis: cadaveric study and three case reports. J Hand
Surg [Am] 18:888–892, 1993.
178. LeGeyt MT, Ghobadi F. Aberrant position of the ulnar nerve
and artery overlying the carpal canal. Am J Orthop
27:449–450, 1998.
179. Netscher D, Polsen C, Thornby J, et al. Anatomic delineation
of the ulnar nerve and ulnar artery in relation to the carpal tunnel by axial magnetic resonance imaging scanning. J Hand Surg
[Am] 21:273–276, 1996.
180. Lindsey JT, Watumull D. Anatomic study of the ulnar nerve
and related vascular anatomy at Guyon’s canal: a practical classification system. J Hand Surg [Am] 21:626–633, 1996.
181. Olave E, Del Sol M, Gabirelli C, et al. The ulnar tunnel: a rare
disposition of its contents. J Anat 191:615–616, 1997.
182. Dodds GA III, Hale D, Jackson WT. Incidence of anatomic variants in Guyon’s canal. J Hand Surg [Am] 15:352–355, 1990.
183. Cobb TK, Carmichael SW, Cooney WP. Guyon’s canal revisited: an anatomic study of the carpal ulnar neurovascular space.
J Hand Surg [Am] 21:861–869, 1996.
184. Coleman SS, Anson BJ. Arterial patterns in the hand based
upon a study of 650 specimens. Surg Gynecol Obstet 113:
409–424, 1961.
185. Wilgis EFS, Kaplan EB. The blood supply of the hand. In:
Spinner M, ed. Kaplans’s functional and surgical anatomy of the
hand, 3rd ed. Philadelphia: JB Lippincott, 1984:203–221.
186. Backhouse KM. The blood supply of the arm and hand. In:
Tubiana R, ed. The hand, vol I. Philadelphia: WB Saunders,
1981:297–309.
187. Edwards EA. The anatomy of collateral circulation. Surg
Gynecol Obstet 107:183–194, 1958.
188. Edwards EA. Organization of the small arteries of the hand and
digits. Am J Surg 99:837–846, 1960.
189. Ikeda A, Ugawa A, Kazihara Y, et al. Arterial patterns in the
hand based on a three-dimensional analysis of 220 cadaver
hands. J Hand Surg [Am] 13:501–509, 1988.
190. Lawrence HW. The collateral circulation in the hand: after cutting the radial and ulnar arteries at the wrist. Ind Med
6:410–411, 1937.
191. Gellman H, Botte MJ, Shankwiler J, et al. Arterial patterns of
the deep and superficial palmar arches. Clin Orthop 383:
41–46, 2001.
192. Al-Turk M, Metcalf WK. A study of the superficial palmar
arteries using the Doppler ultrasonic flowmeter. J Anat 138:
27–32, 1984.
193. Doscher W, Viswanathan B, Stein T, et al. Hemodynamic
assessment of the circulation in 200 normal hands. Ann Surg
198:776–779, 1983.
194. Gould JS. Microsurgical reconstruction of the hand. Microsurgery 10:1747–1753, 1987.
195. Jaschtschinski SN. Morphologie und topographie des arcus
volaris sublimis und profundus. Anat Hefte 7:163–188, 1897.
196. Karlsson S, Niechajev IA. Arterial anatomy of the upper
extremity. Acta Radiol Diagn 23:115–121, 1982.
197. Little JM, Zylstra PL, West J, et al. Circulatory patterns in the
normal hand. Br J Surg 60:652–655, 1973.
198. Tandler J. Zur anatomie der arterien der hand. Anat Hefte
7:263–282, 1897.
199. Mercier FJ, Basdevant C, De Tovar G, et al. Doppler preoperative evaluation of the prevalence of functional abnormalities of
palmar arches in children. Ann Fr Anesth Reanim 13:785–788,
1994.
200. Mestdagh H. Anatomy of the arcus volaris profundus of man.
Anat Anz 147:180–187, 1980.
201. Olave E, Gabrielli C, Del Sol N, et al. A biometric study on the
relationships between the deep palmar arch and the superficial
palmar arch, the distal wrist and palmar creases. Folia Morphol
(Warsz) 57:383–388, 1998.
202. Bianchi H. Anatomy of the radial branches of the palmar arch:
variations and surgical importance. Hand Clin 17:139–146,
vii–viii, 2001.
203. Bianchi HF, Leiro R. The arterial trunk of the thumb-index digital collaterals. Surg Radiol Anat 9:63–67, 1987.
204. Gajisin S, Zbrodowski A. Local vascular contribution of the
superficial palmar arch. Acta Anat (Basel) 147:248–251, 1993.
205. Koncilia H, Kuzbari R, Worseg A, et al. The lumbrical muscle
flap: anatomic study and clinical application. J Hand Surg [Am]
23:111–119, 1998.
206. Poisel S, Gaber O. Macroscopic blood supply of the tendons of
the superficial and deep flexor muscles of the fingers in the
palm. Handchir Mikrochir Plast Chir 17:314–319, 1985.
207. Erbil M, Aktekin M, Denk CC, et al. Arteries of the thumb
originating from the superficial palmar arch: five cases. Surg
Radiol Anat 21:217–220, 1999.
208. Weinzweig N, Starker I, Sharzer LA, et al. Revisitation of the
vascular anatomy of the lumbrical and interosseous muscles.
Plast Reconstr Surg 99:785–790, 1999.
209. Zbrodowski A, Mariethoz E, Bednarkiewicz M, et al. The blood
supply of the lumbrical muscles. J Hand Surg [Br] 23:384–388,
1998.
210. Onderoglu S, Basar R, Erbil KM, et al. Complex variation of
the superficial palmar arch: case report. Surg Radiol Anat
19:123–125, 1997.
211. Doscher W, Viswanathan B, Stein T, et al. Physiologic anatomy
of the palmar circulation in 200 hands. J Cardiovasc Surg
(Torino) 26:171–174, 1985.
212. Koman LA, Ruch DS, Smith BP, et al. Vascular disorders. In:
Green DP, Hotchkiss RN, Pederson WC, eds. Green’s operative
hand surgery, 4th ed. New York: Churchill Livingstone,
1999:2254–2302.
4 Vascular Systems 285
213. Lippert H. Variability of hand and foot arteries. Handchir
Mikrochir Plast Chir 16:254–258, 1984.
214. Cleland, J. On the cutaneous ligaments of the phalanges. J Anat
Physiol 12:526, 1878.
215. Grayson J. The cutaneous ligaments of the digits. J Anat
75:164, 1941.
216. Gosset J. Dupuytren’s disease and the anatomy of the palmodigital aponeurosis. In: Hueston JT, Tubiana R, eds. Dupuytren’s
disease, 2nd English ed. Edinburgh: Churchill Livingstone,
1985:13–26.
217. McGrouther DA. Dupuytren’s contracture. In: Green DP,
Hotchkiss RN, Pederson WC, eds. Green’s operative hand
surgery, 4th ed. New York: Churchill Livingstone, 1999:
563–591.
218. Dautel G, Merle M. The blood supply of digital nerves: a
microanatomical study of superficial and deep palmar venous
networks. J Hand Surg [Am] 17:632–637, 1992.
219. Singh S, de Trafford JC, Goss DE, et al. Ultrasound imaging of
digital arteries. Clin Phys Physiol Meas 11:313–317, 1990.
220. Leslie BM, Ruby LK, Madell SJ, et al. Digital artery diameters:
an anatomic and clinical study. J Hand Surg [Am] 12:740–743,
1987.
221. Endo T, Kojima T, Hirase Y. Vascular anatomy of the finger dorsum and a new idea for coverage of the finger pulp defect that
restores sensation. J Hand Surg [Am] 17:927–932, 1992.
222. Yang M, Yan Y, Li S. Applied anatomy of the vessels in the dorsum of the finger. Zhonghua Zheng Xing Shao Shang Wai Ke
Za Zhi 13:282–284, 1997.
223. Yousif NJ, Cunningham MW, Sanger JR, et al. The vascular
supply to the proximal interphalangeal joint. J Hand Surg [Am]
10:852–861, 1985.
224. Smith DO, Oura C, Kimura C, et al. Artery anatomy and tortuosity in the distal finger. J Hand Surg [Am] 16:297–302,
1991.
225. Chase R. Anatomy of the thumb. In: Streickland JW, ed. The
hand and upper limb, vol II: The thumb. Edinburgh: Churchill
Livingstone, 1994:15–29.
226. Murakami T, Takaya K, Outi H. The origin, course, and distribution of arteries to the thumb, with special reference to the socalled A. princeps pollicis. Okajimas Folia Anat Jpn 46:
123–137, 1969.
227. Parks BJ, Arbelaez J, Horner RL. Medical and surgical importance of the arterial blood supply of the thumb. J Hand Surg
[Am] 3:383–385, 1978.
228. Earley MJ. The arterial supply of the thumb, first web and
index finger and its surgical application. J Hand Surg [Br]
11:163, 1986.
229. Conrad MC. The circulation to the skin. In: Functional
anatomy of the circulation to the lower extremities. Chicago: Year
Book, 1971:64–95.
230. Conrad MC, Green HD. Blood-to-skin heat transfer in peripheral vascular disease. Circulation 28:705–706, 1963(abstr).
231. Glicenstein J, Dardour JC. The pulp: anatomy and physiology.
In: Tubiana R, ed. The hand, vol I. Philadelphia: WB Saunders,
1981:116–121.
232. Voche P, Merle M. Vascular supply of the palmar subcutaneous
tissue of fingers. Br J Plast Surg 49:315–318, 1996.
233. Armenta E, Fisher J. Anatomy of the flexor pollicis longus vinculum system. J Hand Surg [Am] 9:210–212, 1984.
234. Ochiai N, Matsui T, Miyaji N, et al. Vascular anatomy of flexor
tendons: I. vincular system and blood supply of the profundus
tendon in the digital sheath. J Hand Surg[Am] 4:321–330,
1979.
235. Armenta E, Lehrman A. The vincula of the flexor tendons of
the hand. J Hand Surg[Am] 5:127–134, 1980.
236. Brokis JG. The blood supply of the flexor and extensor tendons
of the fingers in man. J Bone Joint Surg [Br] 35:313–338, 1953.
237. Caplan HS, Hunter JM, Merklin RJ. Intrinsic vascularization of
the flexor tendon. In: AAOS symposium on tendon surgery of the
hand. St. Louis: CV Mosby, 1975:48–58.
238. Caplan HS, Hunter JM, Merklin RJ. The intrinsic vascularization of flexor tendons in the human. J Bone Joint Surg [Am]
57:726, 1975(abstr).
239. Chaplan DM. The vascular anatomy within normal tendons,
divided tendons, free tendon grafts, and pedicle tendon grafts in
rabbits. J Bone Joint Surg [Br] 55:369–389, 1973.
240. Edwards D. The blood supply and lymphatic drainage of tendons. J Anat 80:147–154, 1946.
241. Edwards EA. Organization of the small arteries of the hand and
digits. Am J Surg 99:837–846, 1960.
242. Gambier R, Asvazadurian A, Venturini G. Recherchez sur la
vascularisation des tendons. Rev Chir Orthop 48:225, 1962.
243. Hergenroeder PT, Gelberman RH, Akeson WH. The vascularity of the flexor pollicis longus tendon. Clin Orthop
162:298–303, 1982.
244. Lundborg G, Myrhage R. The vascularization and structure of
the human digital tendon sheath as related to flexor tendon
function: an angiographic and histological study. Scand Plast
Reconstr Surg 11:195–203, 1977.
245. Lundborg G, Myrhage R, Rydevik B. The vascularization of
human flexor tendons within the digital synovial sheath region:
structural and functional aspects. J Hand Surg[Am] 2:417–427,
1977.
246. Lundborg G. The vascularization of the human flexor pollicis
longus tendon. Hand 2:28, 1979.
247. Manske PR, Lesker PA. Flexor tendon nutrition. Hand Clin
1:13–24, 1985.
248. Matsui T, Miyagi N, Merklin RJ, et al. Vascular anatomy of
flexor tendons: II. normal blood vessel arrangement of tendons
and the effects of injuries to tendons and vincula on distribution of tendon blood vessels. J Jpn Orthop Assoc 53:301, 1979.
249. Strickland JW. Flexor tendons: acute injuries. In: Green DP,
Hotchkiss RN, Pederson WC, eds. Green’s operative hand
surgery, 4th ed. New York: Churchill Livingstone, 1999:
1851–1897.
250. Yuksel M, Yuksel E, Weinfeld AB, et al. Superficial ulnar artery:
embryology, case report, and clinical significance in reconstructive microsurgery. J Reconstr Microsurg 15:415–420, 1999.
251. Sanudo JR, Mirapeix RM, Garcia R, et al. A superficial ulnar
artery anastomosing with a larger anterior interosseous artery to
supply the wrist and hand. J Anat 192:439–441, 1998.
252. Thoma A, Young JE. The superficial ulnar artery “trap” and the
free forearm flap. Ann Plast Surg 28:370–372, 1992.
253. Devansh. Superficial ulnar artery flap. Plast Reconstr Surg 97:
420–426, 1996.
254. Madaree A, McGibbon IC. Anatomic variation in the blood
supply of the radial forearm flap. J Reconstr Microsurg 9:
277–279, 1993.
255. Rodriguez-Baeza A, Nebot J, Ferreira B, et al. An anatomical
study and ontogenetic explanation of 23 cases with variations in
the main pattern of the human brachio-antebrachial arteries. J
Anat 187:473–479, 1995.
256. McWilliams RG, Shdha I. Doppler ultrasound diagnosis of a
superficial ulnar artery. Eur J Ultrasound 2000;12:155–157.
257. Canter HI, Erdem A, Denk CC. Superior and inferior ulnar
collateral arteries originating as a common trunk in the arm.
Ann Plast Surg 45:103–104, 2000.
258. Isakovic E, Delic J. Anomalies in the location of the ulnar
artery. Med Arh 54:185–186, 2000.
259. Murphy RX Jr, Korngold JM, Jaffe JW, et al. Bilateral radial
286 Systems Anatomy
artery pseudoaneurysms associated with bilateral ulnar artery
atresia: a case report. J Hand Surg [Am] 25:565–570, 2000.
260. Zweig J, Lie KK, Posch JL, et al. Thrombosis of the ulnar artery
following blunt trauma to the hand. J Bone Joint Surg [Am]
51:1191–1198, 1969.
261. Herndon WA, Hershey SL, Lambdin CS. Thrombosis of the
ulnar artery in the hand. J Bone Joint Surg [Am] 57:994–995,
1975.
262. Given KS, Puckett CL, Kleinert HE. Ulnar artery thrombosis.
Plast Reconstr Surg 61:405–411, 1978.
263. Koman LA, Urbaniak JR. Ulnar artery insufficiency: a guide to
treatment. J Hand Surg [Am] 6:16–24, 1981.
264. Mathews RE, Gould JS. Thrombosis of the ulnar artery: resection and microvascular vein graft. Hand 15:85–90, 1983.
265. Mehlhoff TL, Wood MB. Ulnar artery thrombosis and the role
of interposition vein grafting: patency with microsurgical technique. J Hand Surg[Am] 16:274–278, 1991.
266. Thoma A, Ginty M. Spontaneous thrombosis of the ulnar
artery from midforearm to common digital arteries: a case
report. J Hand Surg [Am] 17:211–213, 1992.
267. Pribyl CR, Moneim MS. Anomalous hand muscle found in the
Guyon’s canal at exploration for ulnar artery thrombosis: a case
report. Clin Orthop 306:120–123, 1994.
268. Toby EB, Alvine GF. Partial ulnar artery thrombosis with
emboli. Orthopedics 20:352–354, 1997.
269. Porubsky GL, Brown SI, Urbaniak JR. Ulnar artery thrombosis: a sports-related injury. Am J Sports Med 14:170–175, 1986.
270. Weeks PM, Young VL. Ulnar artery thrombosis and ulnar nerve
compression associated with an anomalous hypothenar muscle.
Plast Reconstr Surg 69:130–131, 1982.
271. Lawrence RR, Wilson JN. Ulnar artery thrombosis in the palm:
case reports. Plast Reconstr Surg 36:604–608, 1965.
272. Paaby H, Stadil F. Thrombosis of the ulnar artery. Acta Orthop
Scand 39:336–345, 1968.
273. Haberhauer G, Feyertag J, Hanusch-Enserer U, et al. Joint
hypermobility syndrome and bilateral total occlusion of the
ulnar arteries presenting as Raynaud’s phenomenon. Clin Exp
Rheumatol 18:270–271, 2000.
274. Jones NF, Baker JM. Ulcerated plaque in the ulnar artery causing distal seeding of microemboli: a possible early stage of ulnar
artery thrombosis. J Hand Surg [Am] 24:1056–1060, 1999.
275. Klein W, Rieger H, Grunert J, et al. Traumatically-induced
thrombosis of the distal ulnar artery: case report and review of
the literature. Handchir Mikrochir Plast Chir 23:39–45, 1991.
276. Calberg G. Bilateral and symmetric thrombosis of the ulnar
artery: apropos of a case. Acta Orthop Belg 42:272–276, 1976.
277. Tallian A, Krakovits G. Thrombosis of the ulnar artery in carpal
tunnel syndrome. Orv Hetil 118:1173–1174, 1977.
278. Luning P. A patient with thrombosis of the ulnar artery in the
hand caused by blunt trauma. Ned Tijdschr Geneeskd
115:1997–1998, 1971.
279. Reumert T, Jeremiassen HP. Ulnar artery thrombosis: a field for
microsurgical treatment. Ugeskr Laeger 144:1215–1217, 1982.
280. Hirai M. Ulnar artery occlusion and digital ischemia. Vasa
8:298–302, 1979.
281. Barriere H, Visset J, Welin J. Recurrent digital pulp necrosis
caused by anomalies of the ulnar artery: report of two cases.
Ann Dermatol Venereol 105:641–642, 1978.
282. Cho KO. Entrapment occlusion of the ulnar artery in the hand:
a case report. J Bone Joint Surg Am 60:841–843, 1978.
283. Carneirio RS, Mann RJ. Occlusion of the ulnar artery associated with an anomalous muscle: a case report. J Hand Surg
[Am] 4:412–414, 1979.
284. Feldmeier C, Hauer G, Wilhelm K. Compression of the ulnar
nerve at the wrist. Med Klin 71:1910–1912, 1976.
285. Gonzalez MH, Hall RF Jr. Thrombosis of the vena comitantes
of the ulnar artery. J Hand Surg[Am] 15:773–776, 1990.
286. Koman LA, Urbaniak JR. Ulnar artery thrombosis. In: Brunelli
S, ed. Textbook of surgery. Milan: Masson, 1988:75–83.
287. Koman LA, Ruch DS, Smith TL, et al. Arterial reconstruction
in the ischemic hand and wrist: effect on microvascular physiology. Adv Vasc Imaging Photoplethysmogr 221:71–75, 1995.
288. Koman LA, Urbaniak JR. Ulnar artery thrombosis. Hand Clin
1:311–325, 1985.
289. Kleinert HE, Volianitis GJ. Thrombosis of the palmar arterial
arch and its tributaries: etiology and new concepts in treatment.
J Trauma 5:447–457, 1965.
290. Hammond DC, Matloub HS, Yousif NJ, et al. The corkscrew
sign in hypothenar hammer syndrome. J Hand Surg [Br] 18:
767–769, 1993.
291. Kreitner KF, Duber C, Muller LP, et al. Hypothenar hammer syndrome caused by recreational sports activities and muscle anomaly
in the wrist. Cardiovasc Intervent Radiol 19:356–359, 1996.
292. Muller LP, Kreitner KF, Seidl C, et al. Traumatic thrombosis of
the distal ulnar artery (hypothenar hammer syndrome) in a golf
player with an accessory muscle loop around Guyon’s canal: case
report. Handchir Mikrochir Plast Chir 29:183–186, 1997.
293. Wong GB, Whetzel TP. Hypothenar hammer syndrome: review
and case report. Vasc Surg 35:163–166, 2001.
294. Brodmann M, Stark G, Aschauer M, et al. Hypothenar hammer
syndrome caused by posttraumatic aneurysm of the ulnar artery.
Wien Klin Wochenschr 113:698–700, 2001.
295. Tsapatsaris NP, Jewell ER, Kasparyan NG, et al. Images in vascular medicine: hypothenar hammer syndrome. Vasc Med
6:121–122, 2001.
296. Velling TE, Brennan FJ, Hall LD, et al. Sonographic diagnosis
of ulnar artery aneurysm in hypothenar hammer syndrome:
report of 2 cases. J Ultrasound Med 20:921–924, 2001.
297. Higgins JP, Orlando GS, Chang P, et al. Hypothenar hammer
syndrome after radial forearm flap harvest: a case report. J Hand
Surg[Am] 26:772–775, 2001.
298. Murric GA, Tenholt M, Voss EU. Hypothenar-hammer syndrome. Vasa 30:132–134, 2001.
299. Lambert M, Hatron PY, Hachulla E, et al. Hypothenar hammer
syndrome followed by systemic sclerosis. J Rheumatol 27:
2516–2517, 2000.
300. Mueller LP, Mueller LA, Degreif J, et al. Hypothenar hammer
syndrome in a golf player: a case report. Am J Sports Med 28:
741–745, 2000.
301. Noel B, Hayoz D. A tennis player with hand claudication. Vasa
29:151–153, 2000.
302. Bakhach J, Chahidi N, Conde A. Hypothenar hammer syndrome: management of distal embolization by intra-arterial fibrinolytics. Chir Main 1998;17:215–220.
303. Jagenburg A, Goyen M, Hirchelmann R, et al. Hypothenar
hammer syndrome: causes, sequelae and diagnostic aspects.
Rofo Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr
172:295–300, 2000.
304. Liskutin J, Dorffner R, Resinger M, et al. Hypothenar hammer
syndrome. Eur Radiol 10:542, 2000.
305. DeMonaco K, Fritsche E, Rigoni G, et al. Hypothenar hammer
syndrome. Retrospective study of nine cases. J Hand Surg [Br]
24:731–734, 1999.
306. Dean Okereke C, Knight S, McGowan A, et al. Hypothenar
hammer syndrome diagnosed by ultrasound. Injury 30:
448–449, 1999.
307. Ferris BL, Taylor LM Jr, Oyama K, et al. Hypothenar hammer
syndrome: proposed etiology. J Vasc Surg 31:104–113, 2000.
308. Houshian S, Mahdi BH. Hypothenar hammer syndrome.
Ugeskr Laeger 161:4643–4644, 1999.
4 Vascular Systems 287
309. Schneider W, Reinbold WD. Regional fibrinolysis with rt-PA in
hypothenar hammer syndrome. Radiologie 39:320–322, 1999.
310. Haferkamp H. Ulnar nerve compression in the area of the wrist.
Langenbecks Arch Chir Suppl Kongressbd 115:635–640, 1998.
311. Neill-Cage DJ, Rechnic M, Braun RM. Bilateral thenar hammer syndrome as a result of cumulative trauma: a case report. J
Hand Sur[Am] 22:1081–1083, 1997.
312. Taute BM, Behrmann C, Cappeller WA, et al. Ultrasound
image of the hypothenar hammer syndrome Ultraschall Med
19:220–224, 1998.
313. Van de Walle PM, Moll FL, DeSinet AA. The hypothenar hammer syndrome: updated and literature review. Acta Chir Belg
98:116–119, 1998.
314. Kroger K, Hinrichs A, Rudofsky G. Diagnosis and therapy of
hypothenar hammer syndrome. Chirurgie 69:102–104, 1998.
315. Avva R, McFarland DR, Eidt JF. Radiological case of the
month: hypothenar hammer syndrome. J Ark Med Soc 93:
303–304, 1996.
316. Duncan WC. Hypothenar hammer syndrome: an uncommon
cause of digital ischemia. J Am Acad Dermatol 34:880–883,
1996.
317. Muller LP, Rudig L, Dreitner KF, et al. Hypothenar hammer
syndrome in sports. Knee Surg Sports Traumatol Arthrosc 4:
167–170, 1996.
318. Kaji H, Honma H, Usiu M, et al. Hypothenar hammer syndrome in workers occupationally exposed to vibrating tools. J
Hand Surg[Br] 18:761–766, 1993.
319. Koga Y, Scki T, Caro LD. Hypothenar hammer syndrome in a
young female badminton player: a case report. Am J Sports Med
21:890–892, 1993.
320. Wernick R, Smith DL. Bilateral hypothenar hammer syndrome:
an unusual and preventable cause of digital ischemia. Am J
Emerg Med 7:302–306, 1989.
321. DiBenedetto MR, Nappi JF, Ruff ME, et al. Doppler mapping
in hypothenar syndrome: an alternative to angiography. J Hand
Surg [Am] 14:568–569, 1988.
322. Mosquera D, Goldman M. An unusual variant of the
hypothenar hammer syndrome. Br J Ind Med 45:568–569,
1988.
323. Savader SJ, Savader BL, Drewry GR. Hypothenar hemmer syndrome with embolic occlusion of digital arteries. Clin Radiol
39:324–325, 1988.
324. Debure C. The hypothenar hammer syndrome. Ann Dermatol
Venereol 115:1293–1296, 1988.
325. Spencer-Green G, Morgan GJ, Brown L, et al. Hypothenar
hammer syndrome: an occupational cause of Raynaud’s phenomenon. J Rheumatol 14:1048–1051, 1987.
326. Vayssairat M, Debure C, Cormier JM, et al. Hypothenar hammer syndrome: seventeen cases with long-term follow-up. J Vasc
Surg 5:838–843, 1987.
327. Barre PS, Keith MW, Sobel M, et al. Vascular insufficiency in
Okihiro’s syndrome secondary to hypothenar hammer syndrome. J Hand Surg [Am] 12:401–405, 1987.
328. Williams WV, Hohnson A, Wilson D. Hypothenar hammer
syndrome presenting as bilateral Raynaud’s phenomenon.
Arthritis Rheum 30:234–235, 1987.
329. Pineda CJ, Weisman MH, Bookstein JJ, et al. Hypothenar
hammer syndrome: form of reversible Raynaud’s phenomenon.
Am J Med 79:561–570, 1985.
330. Baker GL. The hypothenar hammer syndrome. J Rheumatol
12:1016–1017, 1985.
331. Foster DR, Cameron DC. Hypothenar hammer syndrome. Br
J Radiol 54:995–996, 1981.
332. Ettien JT, Allen JT, Vargas C. Hypothenar hammer syndrome.
South Med J 74:491–493, 1981.
333. Gaylis H, Kushlick AR. The hypothenar hammer syndrome. S
Afr Med J 50:125–127, 1976.
334. Pinkerton JA Jr, Helling T, Dixon D. Digital ischemia:
hypothenar hammer syndrome. J Kans Med Soc 76:125–128,
1975.
335. Benedict KT, Chang W, McCready FJ. The hypothenar hammer syndrome. Radiology 111:57–60, 1974.
336. Little JM, Ferguson DA. The incidence of the hypothenar hammer syndrome. Arch Surg 105:684–685, 1972.
337. Conn J Jr, Bergan JJ, Bell JL. Hypothenar hammer syndrome:
posttraumatic digital ischemia. Surgery 68:1122–1128, 1970.
338. Conn J Jr, Bergan JJ, Bell JL. Hand ischemia: hypothenar hammer syndrome. Proc Inst Med Chicago 28:83, 1970.
339. Ho PK, Wieland AJ, McClinton MA, et al. Aneurysms of the
upper extremity. J Hand Surg [Am] 12:39–46, 1987.
340. Kleinert HE, Burget GC, Morgan JA, et al. Aneurysms of the
hand. Arch Surg 106:554–557, 1973.
341. Latshaw RF, Weidner WA. Ulnar artery aneurysms: angiographic considerations in two cases. AJR Am J Roentgenol
1978;131:1093–1095.
342. Mays ET. Traumatic aneurysm of the hand. Am Surg 36:
552–557, 1970.
343. Smith JW. True aneurysm of traumatic origin in the palm. Am
J Surg 104:7–13, 1962.
344. Yoshii S, Ikeda K, Muradami H. Ulnar nerve compression secondary to ulnar artery true aneurysm at Guyon’s canal. J Neurosurg Sci 43:295–297, 1999.
345. Baba Y, Miyazono N, Kanetsuki I, et al. Combined arteriovenous malformation and aneurysm of the ulnar artery: successful
arterial embolization by using absolute ethanol. Cardiovasc
Intervent Radiol 22:266–267, 1999.
346. Torre J. Ulnar artery aneurysm with digital ischemia. Vasc Med
4:143–145, 1999.
347. Erdoes LS, Brown WC. Ruptured ulnar artery pseudoaneurysm. Ann Vasc Surg 9:394–396, 1995.
348. Axe MJ, McClain EJ. Complete involvement of the ulnar nerve
secondary to an ulnar artery aneurysm: a case report. Am J
Sports Med 14:178–180, 1986.
349. Martini G, Martinoli S, Merenda C. Aneurysms of the ulnar
artery of the hand: a rare occupational disease. Z Unfallchir Versicherungsmed Berufskr 80:145–149, 1987.
350. Lawhorne TW Jr, Sanders RA. Ulnar artery aneurysm complicated by distal embolization: management with regional thrombolysis and resection. J Vasc Surg 3:663–665, 1986.
351. Bacourt F, Bornet P, Fourcade R, et al. Aneurysm of the ulnar
artery in Streptococcus bovis septicemia: first case. Presse Med
16:450, 1987.
352. Kay PR, Abraham JS, Davies DR, et al. Ulnar artery aneurysms
after injury mimicking acute infection in the hand. Injury
19:402–404, 1988.
353. Harris EJ Jr, Taylor LM Jr, Edwards JM, et al. Surgical treatment of distal ulnar artery aneurysm. Am J Surg 159:527–530,
1990.
354. Vayssairat M. Traumatic aneurysm of the cubital artery. J Radiol
72:473–475, 1991.
355. May JW Jr, Grossman JA, Costas B. Cyanotic painful index and
long fingers associated with an asymptomatic ulnar artery
aneurysm: case report. J Hand Surg [Am] 7:622–625, 1982.
356. Carlson CS Jr, Clark GL. False aneurysm of ulnar artery in
Guyon’s canal. J Hand Surg [Am] 8:223–224, 1983.
357. Bayle E, Tran K, Benslamia H, et al. Ulnar artery aneurysm of
the hand. Int Surg 68:215–217, 1983.
358. Martin RD, Manktelow RT. Management of ulnar artery
aneurysm in the hand: a case report. Can J Surg 25:97–99,
1982.
288 Systems Anatomy
359. Vracevic D. Aneurysm of the ulnar artery in the hypothenar
region. Acta Chir Iugosl 23:329–334, 1976.
360. Jeshrani MK. Bilateral ulnar artery aneurysm in the palm: a case
report. East Afr Med J 53:13–18, 1976.
361. Milling MA, Kinmonth MH. False aneurysm of the ulnar
artery. Hand 9:57–59, 1977.
362. Mukerjea SK. Occupational true aneurysm of the ulnar artery
in the palm. Br J Surg 58:934, 1971.
363. Thio RT. False aneurysm of the ulnar artery after surgery
employing a tourniquet. Am J Surg 123:604–605, 1972.
364. Ee B, Doshi M, Cheah JS. Mycotic aneurysm of the ulnar
artery. Med J Aust 1:462–463, 1979.
365. Von Kuster L, Abt AB. Traumatic aneurysm of the ulnar artery.
Arch Pathol Lab Med 104:75–78, 1980.
366. Gaylis H, Kushlick AR. Ulnar artery aneurysms of the hand.
Surgery 73:478–480, 1973.
367. Gaylis H. Occupational trauma to the ulnar artery. S Afr Med
J 59:746–748, 1981.
368. Shapira Z, Rubinstein ZJ, Jacob ET. Traumatic aneurysm of the
ulnar artery in the palm. Harefuah 95:263–264, 1978.
369. Kaplan EB, Zeide MS. Aneurysm of the ulnar artery: a case
report. Bull Hosp Joint Dis 33:197–199, 1972.
370. Erdos G. Ulnar artery aneurysm on the hand. Magy Traumatol
Orthop Helyreallito 21:135–137, 1978.
371. Millender LH, Nalebuff EA, Dasdon E. Aneurysms and thromboses of the ulnar artery in the hand. Arch Surg 105:686–690,
1972.
372. Hankey GJ. Median nerve compression in the palm of the hand
by an anomalously enlarged ulnar artery. Aust N Z J Surg
58:511–513, 1988.
373. Suszko B. Traumatic aneurysm of the ulnar artery. Wiad Lek
27:1899–1901, 1974.
374. Allen EV. Thromboangiitis obliterans: methods of diagnosis of
chronic occlusive arterial lesions distal to the wrist with illustrative cases. Am J Med Sci 178:237–244, 1929.
375. Koman LA. Diagnostic study of vascular lesions. Hand Clin
1:217–231, 1985.
376. Wilgis EFS. Special diagnostic studies. In: Omer GE, Spinner
M, Van Beek AL, eds. Management of peripheral nerve problems,
2nd ed. Philadelphia: WB Saunders, 1998:77–81.
377. Gelberman RH, Menon J, Fronek A. The peripheral pulse following arterial injury. J Trauma 20:948–951, 1980.
378. Gelberman RH, Blasingame JP. The timed Allen test. J Trauma
21:477–479, 1981.
379. Scavenius M, Fauner M, Walther-Larsen S, et al. A quantitative
Allen’s test. Hand 13:318–320, 1981.
380. Cable DG, Mullany CJ, Schaff HV. The Allen test. Ann Thorac Surg 67:876–877, 1999.
381. Fuhrman TM, Reilley TE, Pippin WD. Comparison of digital
blood pressure, plethysmography, and the modified Allen’s test
as means of evaluating the collateral circulation of the hand.
Anaesthesia 47:959–961, 1992.
382. McConnell EA. Performing Allen’s test. Nursing 27(11):26,
1997.
383. Thompson CE, Stroud SD. Allen’s test: a tool for diagnosing
ulnar artery trauma. Nurse Pract 9(12):13, 16–17, 1984.
384. Jarvis MA, Jarvis CL, Jones PR, et al. Reliability of Allen’s test
in selection of patients for radial artery harvest. Ann Thorac
Surg 70:1362–1365, 2000.
385. Hosokawa K, Hata Y, Yano K, et al. Results of the Allen test on
2940 arms. Ann Plast Surg 24:149–151, 1990.
386. Hirai M, Kawai S. False positive and negative results in Allen
test. J Cardiovasc Surg 21:353–360, 1980.
387. Fuhrman TM, Pippin WD, Talmage LA, et al. Evaluation of
collateral circulation of the hand. J Clin Monit 8:28–32, 1992.
388. Trager S, Pignataro M, Anderson J, et al. Color flow Doppler:
imaging the upper extremity. J Hand Surg[Am] 18:621–625,
1993.
389. Tonks AM, Lawrence J, Lovie MJ. Comparison of ulnar and
radial arterial blood-flow at the wrist. J Hand Surg [Br] 20:
240–242, 1995.
390. Husum B, Palm T. Arterial dominance in the hand. Br J
Anaesth 50:913–916, 1978.
391. Patsalis T, Hoffmeister HE, Seboldy H. Arterial dominance of
the hand. Handchir Mikrochir Plast Chir 29:247–250, 1997.
392. Usmanov NU, Sultanov DD. Blood flow measurement in palmar arterial arch of the hand and digital arteries. Khirurgiia
(Mosk) 5:57–59, 1998.
393. Kleinert JM, Fleming SG, Abel CS, et al. Radial and ulnar
artery dominance in normal digits. J Hand Surg [Am] 14:
504–508, 1989.
394. Gelberman RH, Nunley JA, Koman LA, et al. The results of
radial and ulnar arterial repair in the forearm: experience in three
medical centers. J Bone Joint Surg [Am] 64:383–387, 1982.
395. Gelberman RH, Blasingame JP, Fronek A, et al. Forearm arterial injuries. J Hand Surg 4:401–408, 1979.
396. Cavanagh S, Pho RW. The reverse radial forearm flap in the
severely injured hand: an anatomical and clinical study. J Hand
Surg [Br] 17:501–503, 1992.
397. Grobbelaar AO, Harrison DH. The distally based ulnar artery
island flap in hand reconstruction. J Hand Surg [Br] 22:
204–211, 1997.
398. Axalai I, Menesi L. Reverse ulnar artery flap in the repair of an
electric burn injury. Magy Traumatol Orthop Helyreallito Seb
34:121–124, 1991.
399. Lovie MJ, Duncan GM, Glasson DW. The ulnar artery forearm
free flap. Br J Plast Surg 37:486–492, 1984.
400. Karacalar A, Ozcan M. The distally based ulnar artery forearm
flap supplied by the dorsal carpal arch. Ann Plast Surg 41:
304–306, 1998.
401. Foucher G, Van Genecheten M, Merle M, et al. Single stage
thumb reconstruction by a composite forearm island flap. J
Hand Surg [Br] 9:245–248, 1984.
402. Wood MB. Atlas of reconstructive microsurgery. Rockville, MD:
Aspen, 1990:39–62.
403. Song RY, Gao YZ, Song YG, et al. The forearm flap. Clin Plast
Surg 9:21–26, 1982.
404. Heden P, Gylbert L. Anomaly of the radial artery encountered
during elevation of the radial forearm flap. J Reconstr Microsurg 6:139, 1990.
405. Iossifidis A, As’ad S, Sutaria PD. Aneurysm of the superficial
palmar arch: a case report. Int Orthop 19:403–404, 1995.
406. Balogh B, Piza-Katzer H, Kosak D. A rare combination of true
and false aneurysm of the palm of the hand. Handchir
Mikrochir Plast Chir 21:287–290, 1989.
407. Greenberg BM, Cuadros CL, Jupiter JB. Interpositional vein
grafts to restore the superficial palmar arch in severe devascularizing injuries of the hand. J Hand Surg[Am] 13:753–757,
1988.
408. MacDonald RI, Lichtman DM, Hanlon JJ, et al. Complications of surgical release for carpal tunnel syndrome. J Hand
Surg [Am] 3:70–76, 1978.
409. Murphy RX Jr, Jennings JF, Wukich DK. Major neurovascular
complications of endoscopic carpal tunnel release. J Hand Surg
[Am] 19:114–118, 1994.
410. Kunou M. An anatomical study of the carpal tunnel for endoscopic carpal tunnel release. Nippon Seideigeka Gakkai Zasshi
68:878–884, 1994.
411. Sterett WI. Pseudoaneurysm of the superficial palmar arch. J
Bone Joint Surg Am 78:1089–1091, 1996.
4 Vascular Systems 289
412. Tountas CP, Jones T, Van Dyke D. Occlusion of the superficial
palmar arch: diagnosis and treatment. Minn Med 61:697–700,
1978.
413. Lucas GL. Bilateral digital artery thrombosis: a case report. J
Microsurg 1:472–474, 1980.
414. Abouzahr MK, Coppa LM, Boxt LM. Aneurysm of the digital
arteries: a case report and literature review. J Hand Surg [Am]
22:311–314, 1997.
415. Yoshii S, Ikeda K, Murakami H. True aneurysm of the digital
artery: case report and review. Scand J Plast Reconstr Surg
Hand Surg 34:279–281, 2000.
416. Halla RF Jr, Watt DH. Osseous changes due to a false aneurysm
of the proper digital artery: a case report. J Hand Surg [Am]
11:440–442, 1986.
417. Freiberg A, Fish J. Aneurysm of a common digital artery: case
report and literature review. Can J Surg 31:254–255, 1988.
418. Tyler G, Stein A. Aneurysm of a common digital artery: resection and vein graft. J Hand Surg [Am] 13:348–349, 1988.
419. Montoya I, Trias I, Rodriguez JE. False aneurysm of a digital
artery: a case report. Int Orthop 15:283–284, 1991.
420. Garcia Mas R, Aramburo Hostench F. Pseudoaneurysm of the
common digital artery. Ann Chir Main Memb Super
11:166–169, 1992.
421. Shidayama R, Kaji S, Kobayashi K, et al. Traumatic false
aneurysm of finger tip: case report. Scand J Plast Reconstr Surg
Hand Surg 26:113–114, 1992.
422. Trabulsy P, Leitner DW. A true aneurysm of a collateral branch
of a proper digital artery. Ann Plast Surg 29:161–163, 1992.
423. Lanzetta M, Fox U. Aneurysms of the palmar arch and a proper
digital artery: case report and literature review. J Reconstr
Microsurg 8:371–374, 1992.
424. Peterson T, Neudeck FE, Schmidt G. Traumatic aneurysm of
the hand: a rare complication of a stab injury. Handchir
Mikrochir Plast Chir 24:250–252, 1992.
425. Adant JP, Grattagliano B, Fissette J. True aneurysm of digital
artery in hemophilia: a case report. Ann Chir Main Memb
Super 13:278–281, 1992.
426. Yajima H, Tamai S, Ono H. Aneurysm of the digital artery: a
review and report of three cases. Microsurgery 16:566–570,
1995.
427. Yasuda T, Takeda R. False aneurysm of a digital artery in a softball catcher evaluated by sonography: a case report. J Trauma
41:153–155, 1996.
428. Suzuki K, Takahashi S, Nakagawa T. False aneurysm in a digital
artery. J Hand Surg [Am] 5:402–403, 1980.
429. Layman CD, Ogden LL, Lister GD. True aneurysm of digital
artery. J Hand Surg [Am] 7:617–618, 1982.
430. Sanchez A, Archer S, Levine NS, et al. Traumatic aneurysm of
a common digital artery: a case report. J Hand Surg [Am] 7:
619–621, 1982.
431. Dangles CJ. True aneurysm of a thumb digital artery. J Hand
Surg [Am] 9:444–445, 1984.
432. Baruch A. False aneurysm of the digital artery. Hand 9:
195–197, 1977.
433. Hueston JT. Traumatic aneurysm of the digital artery; a complication of fasciotomy. Hand 5:232–234, 1973.
434. Turner S, Howard CB, Dallimore NS. A case report of a true
aneurysm of a digital artery. J Hand Surg [Br] 9:205–206,
1984.
435. Wang T, Gu Y. Clinical application of the reversed digital artery
island flap containing palmar digital vein. Zhongguo Xiu Fu
Chong Jian Wai De Za Zhi 12:342–344, 1998.
436. Lai CS, Lin SD, Yang CC. The reverse digital artery flap for fingertip reconstruction. Ann Plast Surg 22:495–500, 1989.
437. Lai CS, Lin SD, Tsai CC, et al. Reverse digital artery neurovascular cross-finger flap. J Hand Surg [Am] 20:397–402, 1995.
438. Cormack G. Reverse digital artery flaps: a note of caution
regarding cold intolerance. Br J Plast Surg 46:86–88, 1993.
439. Moiemen NS, Elliot D. A modification of the Zancolli reverse
digital artery flap. J Hand Surg [Br] 19:142–146, 1994.
440. Yang D, Morris SF. Reversed dorsal digital and metacarpal
island flaps supplied by the dorsal cutaneous branches of the
palmar digital artery. Ann Plast Surg 46:444–449, 2001.
441. Yang D, Morris SF. Vascular basis of dorsal digital and
metacarpal skin flaps. J Hand Surg [Am] 26:142–146, 2001.
442. Karacalar A, Ozcan M. A new approach to the reverse dorsal
metacarpal artery flap. J Hand Surg [Am] 22:307–310, 1997.
443. Spinner RJ, Varela CD, Urbaniak JR. Digital nerve penetration
by a digital artery in a patient with neurovascular symptoms: a
case report. J Hand Surg[Am] 21:1101–1103, 1996.
444. Girard JY, Rogez JM, Robert R, et al. Vascularisation of the
head of the radius in the adult. Surg Radiol Anat 17:41–45,
1995.
445. Steinberg BD, Plancher KD, Idler RS. Percutaneous Kirschner
wire fixation through the snuff bow: an anatomic study. J Hand
Surg[Am] 20:57–62, 1995.
446. Kuhlmann JN, Guerin-Surville H. The deep arterial system of
the wrist. Bull Assoc Anat (Nancy) 64:501–508, 1980.
447. Kuhlmann JN, Guerin-Surville H, Boabighi A. Vascularization
of the carpus, a systematic study. Surg Radiol Anat 10:21–28,
1988.
448. Mezzogiorno A, Passiatore C, Mezzogiorno V. Anatomic variations of the deep palmar arteries in man. Acta Anat (Basel)
149:221–224, 1994.
449. Olave E, Prates JC. Deep palmar arch patterns in Brazilian individuals. Surg Radiol Anat 21:267–271, 1999.
450. Hammer H, Ebner I. The end of the deep palmar arch on its
ulnar face. Anat Anz 167:213–218, 1988.
451. Oberlin C, Salon A, Pigeau I, et al. Three-dimensional reconstruction of the carpus and its vasculature: an anatomic study. J
Hand Surg [Am] 17:767–772, 1992.
452. Gelberman RH, Gross MS. The vascularity of the wrist: identifying arterial patterns at risk. Clin Orthop 202:40–49, 1986.
453. Lawrence HW. The collateral circulation in the hand. Ind Med
6:410–411, 1937.
454. Travaglini E. Arterial circulation of the carpal bones. Bull Hosp
Joint Dis Orthop Inst 20:19–35, 1959.
455. Mestdagh H, Bailleu JP, Chambou JP, et al. The dorsal arterial
network of the wrist with reference to the blood supply of the
carpal bones. Acta Morphol Neerl Scand 17:73–80, 1979.
456. Williams CS, Gelberman RH. Vascularity of the lunate:
anatomic studies and implications for the development of
osteonecrosis. Hand Clin 9:391–398, 1993.
457. Failla JM. Hook of hamate vascularity: vulnerability to
osteonecrosis and nonunion. J Hand Surg [Am] 18:1075–1079,
1993.
458. Minne J, Depreux R, Mestdagh H, et al. Les pedicules arteriels
du massif carpien. Lille Med 18:1174–1185, 1973.
459. Zhao H, Zhou X, Wu X. Anatomic observation of the dorsal
metacarpal arteries. Zhonghua Zheng Xing Shao Shang Wai Ke
Za Zhi 12:415–418, 1996.
460. Jing H, Liu XY, Ge BF, et al. The second dorsal metacarpal flap
with vascular pedicle composed of the second dorsal metacarpal
artery and the dorsal carpal branch of the radial artery. Plast
Reconstr Surg 92:501–506, 1993.
461. Pierer G, Steffen J, Hoflehner H. The vascular blood supply of
the second metacarpal bone: anatomic basis for a new vascularized bone graft in hand surgery: an anatomical study in cadavers. Surg Radiol Anat 14:103–112, 1992.
462. Sherif MM. First dorsal metacarpal artery flap in hand reconstruction: anatomical study. J Hand Surg[Am] 91:26–31, 1994.
463. El-Khatib HA. Clinical experiences with the extended first dor290 Systems Anatomy
sal metacarpal artery island flap for thumb reconstruction. J
Hand Surg[Am] 23:647–652, 1998.
464. Wang S, Cheng Y, Liu W. Microsurgical anatomy and clinical
application of the second metacarpal dorsal artery island flap.
Zhonghua Zheng Xing Shao Shang Wai Ke Za Zhi 10:46–48,
1994.
465. Moschella R, Cordova A, Pirrello R, et al. Anatomic basis for
the dorsal radial flap of the thumb: clinical applications. Surg
Radiol Anat 18:179–181, 1996.
466. Azar CA, Culver JE, Fleegler EJ. Blood supply of the flexor pollicis longus tendon. J Hand Surg[Am] 8:471–475, 1983.
467. Ames EL, Bissonnette M, Acland R, et al. Arterial anatomy of
the thumb. J Hand Surg[Br] 18:427–436, 1993.
468. Prowans P, Brzezinski W, Deskur Z. The use of radial artery for
the revascularization of the amputated thumb. Chir Narzadow
Ruchu Orthop Pol 63:217–220, 1998.
469. Drizenko A, Maynou C, Mestdagh H, et al. Variations of the
radial artery in man. Surg Radiol Anat 22:299–303, 2000.
470. Sahin B, Seelig LL. Arterial, neural and muscular variations in
the upper limbs of a single cadaver. Surg Radiol Anat
22:305–308, 2000.
471. Keller FS, Rosch J, Dotter CT, et al. Proximal origin of radial
artery: potential pitfall in hand angiography. AJR Am J
Roentgenol 134:169–170, 1980.
472. Yokoyama N, Takeshita S, Ochiai M, et al. Anatomic variations
of the radial artery in patients undergoing transradial coronary
intervention. Catheter Cardiovasc Interv 49:357–362, 2000.
473. Sachs M. The arteria radialis superficialis: an unusual variation
of the arteria radialis of man and its phylogenetic significance.
Acta Anat (Basel) 128:110–123, 1987.
474. Diaz JC, Ares X, Tarrazo AM, et al. Acta Anaesthesiol Scand
42:1020, 1998.
475. Wood SJ, Abrahams PH, Sanudo JR, et al. Bilateral superficial
radial artery at the wrist associated with a radial origin of a unilateral median artery. J Anat 189:691–693, 1996.
476. Brown MJ, Edstrom LE, Zienowicz RJ. A symptomatic radial
artery anomaly and its surgical treatment. J Hand Surg [Am]
24:178–181, 1999.
477. Odero A, Chierichetti F, Canidio E, et al. Aplasia of the radial
artery. Cardiovasc Surg 1:270–272, 1993.
478. Suzuki T, Dodo YH, Mitsuhashi K. A case study of radial artery
absence. Okajimas Folia Anat Jpn 62:53–65, 1985.
479. Poteat WL. Report of a rare human variation: absence of the
radial artery. Anat Rec 214:89–95, 1986.
480. Prues-Latour V, Papaloizos M. Absence of the radial artery: case
report and review of the literature. Rev Chir Orthop Reparatrice Appar Mot 86:741–745, 2000.
481. Olave E, Prates JC, Gabrielli C, et al. Abnormal course of the
superficial palmar branch of the radial artery. Surg Radiol Anat
18:151–153, 1996.
482. Czerwinski F, Michalska G, Mierzwa A, et al. Rare case of the
accessory radial artery. Folia Morphol (Warsz) 56:183–186, 1997.
483. Safak T, Akyurek M. Free transfer of the radial forearm flap with
preservation of the radial artery. Ann Plast Surg 45:97–99,
2000.
484. Sasaki K, Nozaki M, Aiba H, et al. A rare variant of the radial
artery: clinical considerations in rising a radial forearm flap. Br
J Plast Surg 53:445–447, 2000.
485. Demirkan F, Wei FC, Lutz BS, et al. Reliability of the venae
comitantes in venous drainage of the free radial forearm flaps.
Plast Reconstr Surg 102:1544–1548, 1998.
486. Coessens BC, Hamdi M. The distally planned lateral arm flap
in hand reconstruction. Chir Main 17:133–134, 1998.
487. Chang SM, Hou CL. The development of the distally based
radial forearm flap in hand reconstruction with preservation of
the radial artery. Plast Reconstr Surg 106:955–957, 2000.
488. Hovius SE, Sluimers JE, Van Adrichem LN, et al. The radial
forearm flap. Neth J Surg 40:69–75, 1988.
489. Timmons MJ. The vascular basis of the radial forearm flap.
Plast Reconstr Surg 77:80–92, 1986.
490. Tan BK, Lim BH. The lateral forearm flap as a modification of
the lateral arm flap: vascular anatomy and clinical implications.
Plast Reconstr Surg 105:2400–2404, 2000.
491. Meirer R, Schrank C, Putz R. Posterior radial collateral artery as
the basis of the lateral forearm flap. J Reconstr Microsurg
16:21–24, discussion 24–25, 2000.
492. Meland NB, Core GB, Hoverman VR. The radial forearm flap
donor site: should we vein graft the artery? A comparative study.
Plast Reconstr Surg 91:865–870, 1993.
493. Szekeres P, Kubatov M, Nyarady J, et al. Use of a distally pedicled radial artery as an island flap for covering traumatic skin
losses. Magy Traumatol Ortop Kezseb Plasztikai Seb 36:31–35,
1993.
494. Goffin D, Brunelli F, Galbiatti A, et al. A new flap based on the
distal branches of the radial artery. Ann Chir Main Memb
Super 11:217–225, 1992.
495. Iwasawa M, Furuta S, Hayasi M, et al. Use of a monitor muscle
flap in buried free forearm flap transfer. Ann Plast Surg
37:364–366, 1996.
496. Valentino J, Funk GF, Hoffman HT, et al. The communicating
vein and its use in the radial forearm free flap. Laryngoscope
106:648–651, 1996.
497. Suominen S, Ahovuo J, Asko-Seljavaara S. Donor site morbidity of radial forearm flaps: a clinical and ultrasonographic evaluation. Scand J Plast Reconstr Surg Hand Surg 30:57–61,
1996.
498. Funk GF, Valentino J, McCulloch TM, et al. Anomalies of forearm vascular anatomy encountered during elevation of the
radial forearm flap. Head Neck 17:284–292, 1995.
499. Bauer TR, Schoeller T, Wechselberger G, et al. The radial artery
perforator free flap. Plast Reconstr Surg 104:885, 1999.
500. Mordick TG. Vascular variation of the radial forearm flap: a case
report. J Reconstr Microsurg 11:345–346, 1995.
501. Shima H, Ohno K, Michi K, et al. An anatomical study on the
forearm vascular system. J Craniomaxillofac Surg 24:293–299,
1996.
502. Otsuka T, Terauchi M. An anomaly of the radial artery: relevance for the forearm flap. Br J Plast Surg 44:390–391, 1991.
503. Bishop AT. Vascularized bone grafting. In: Green DP, Hotchkiss
RN, Pederson WC, eds. Green’s operative hand surgery, 4th ed.
New York: Churchill Livingstone, 1999:1221–1250.
504. Braun RM. Viable pedicle bone grafting in the wrist. In: Urbaniak JR, ed. Microsurgery for major limb reconstruction. St.
Louis: CV Mosby, 1987:220–229.
505. Brunelli F, Mathoulin C, Saffar P. Description of a vascularized
bone graft taken from the head of the second metacarpal bone.
Ann Chir Main Memb Super 11:40–45, 1992.
506. Chacha PB. Vascularized pedicular bone grafts. Int Orthop
8:117–138, 1984.
507. Guimberteau JC, Panconi B. Recalcitrant non-union of the
scaphoid treated with a vascularized bone graft based on the
ulnar artery. J Bone Joint Surg Am 72:88–97, 1990.
508. Heymans R, Adelmann E, Koebke J. Anatomical bases of the
pediculated pisiform transplant and the intercarpal fusion by
Graner in Kienbock’s disease. Surg Radiol Anat 14:195–201,
1992.
509. Heymans R. Koebke J. The pedicled pisiform transposition in
Kienbock’s disease: an anatomical and function analysis. Handchir Mikrochir Plast Chir 25:199–203, 1993.
510. Kawai H, Yamamoto K. Pronator quadratus pedicled bone graft
for old scaphoid fractures. J Bone Joint Surg Br 70:829–831,
1988.
4 Vascular Systems 291
511. Kuhlmann JN, Minoun M, Boabighi A, et al. Vascularized bone
graft pedicled on the volar carpal artery for non-union of the
scaphoid. J Hand Surg [Br] 12:203–210, 1987.
512. Leung PC, Hung LK. Use of pronator quadratus bone flap in
bony reconstruction around the wrist. J Hand Surg [Am]
15:637–640, 1990.
513. Pierer G, Steffen J, Hoflehner H. The vascular blood supply of
the second metacarpal bone: anatomic basis for a new vascularized bone graft in hand surgery: an anatomical study in cadavers. Surg Radiol Anat 14:103–112, 1992.
514. Rath S, Hung LK, Leung PC. Vascular anatomy of the pronator quadratus muscle-bone flap: a justification for its use with a
distally based blood supply. J Hand Surg [Am] 15:630–636,
1990.
515. Saffar P. Remplacement du semi-lunaire par le pisiforme:
description dune nouvelle technique pour le traitement de la
maladie de Kienbock. Ann Chir Main 1:276–279, 1982.
516. Zaidemberg C, Siebert JW, Angrigiani C. A new vascularized
bone graft for scaphoid nonunion. J Hand Surg [Am] 16:
474–478, 1991.
517. Barth H. Histologische untersuchungen uber knock-entransplantation. Beitr Pathol Anat Allg Pathol 17:65–142, 1895.
518. Shaffar PJW, Field GA, Wilber RG, et al. Experimental vascularized bone grafts: histopathologic correlations with postoperative bone scan: the risk of false positive results. J Orthop Res 5:
311–319, 1987.
519. Bishop AT. Vascularized pedicle grafts from the dorsal distal
radius: design and application for carpal pathology. In: Saffar P,
Amadio PC, Foucher G, eds. Current practice in hand surgery.
London: Martin Dunitz, 1997:307–313.
520. Sheetz KK, Bishop AT, Berger RA. The arterial blood supply of
the distal radius and its potential use in vascularized pedicled
bone grafts. J Hand Surg [Am] 20:902–914, 1995.
521. Shin AY, Bishop AT. Treatment of Kienbock’s disease with dorsal distal radius pedicled vascularized bone grafts. Atlas Hand
Clin 4:91–118, 1999.
522. Roy-Camille R. Fractures et pseudarthrosis du scaphoide
moyen: utilisation d’un graffo pedicule. Actual Chir Orthop R
Poincare 4:197–214, 1965.
523. Beck E. Die Verpflanzung des Os Pisiforme am Gafasstiel zur
Behandlung der Lunatummalazie. Handchirurgie 3:64–67,
1971.
524. Beck E. Der Os Pisiforme-transfer. Orthopade 15:131–134,
1986.
525. Lee BY, Kim KK, Maddeen JL. True aneurysm of the radial
artery: report of a case with long-term follow-up. J Am Geriatr
Soc 25:376–378, 1997.
526. Gray RJ, Stone WM, Fowl RJ, et al. Management of true
aneurysm distal to the axillary artery. J Vasc Surg 28:606–610,
1998.
527. Turner WH, Turnbull AR. True radial artery aneurysm. Br J
Surg 75:233, 1988.
528. Kerr CD, Duffey TP. Traumatic false aneurysm of the radial
artery. J Trauma 28:1603–1604, 1988.
529. Holm-Knudsen RJ, Nygard E, Ravn JB, et al. Cannulation of
the radial artery: risks, effective examination methods and monitoring of the circulation in the hand during the procedure.
Ugeskr Laeger 152:1278–1281, 1990.
530. Gerard F, Obert L, Garbuio P, et al. An unusual complication of
reimplantation of the hand: a false aneurysm of the radial artery
anastomosis. Apropos of a treated case. Chir Main 18:149–152,
1999.
531. Ruch DS, Aldridge M, Holden M, et al. Arterial reconstruction
for radial artery occlusion. J Hand Surg [Am] 25:282–290,
2000.
532. Tomaino MM. Arterial reconstruction for radial artery occlusion. J Hand Surg [Am] 25:982–984, 2000.
533. McNamara MG, Butler TE, Sanders WE, et al. Ischaemia of the
index finger and thumb secondary to thrombosis of the radial
artery in the anatomical snuffbox. J Hand Surg [Br] 23:28–32,
1998.
534. Longo GM, Friedman AC, Hollins RR, et al. Distal radial
artery lesion as a source of digital emboli. J Vasc Surg 28:
710–714, 1998.
535. Chaudakshetrin P, Kumar VP, Satku K, et al. The arteriovenous
pattern of the distal digital segment. J Hand Surg [Br] 13:
164–166, 1988.
536. Lucas GL. The pattern of venous drainage of the digits. J Hand
Surg[Am] 9:448–450, 1984.
537. Moss SH, Schwartz KS, von Drasek-Ascher G, et al. Digital
venous anatomy. J Hand Surg [Am] 10:473–482, 1985.
538. Gorgas K, Bock P, Tischendorf F, et al. The fine structure of
human digital arterio-venous anastomoses (Hoyer-Grosser’s
organs). Anat Embryol (Berl) 150:269–289, 1977.
539. Elliot D, Meyer M. The use of the veins of the thenar eminence
in digital revascularization and replantation. J Hand Surg [Br]
18:163–164, 1993.
540. Hao YBP. Re-evaluation of vascular anatomy of dorsal lateral
digital island flap and its clinical significance. Zhonghua Zheng
Xing Shao Shang Wai Ke Za Zhi 7:113–115, 1991.
541. Nystrom A, von Drasek-Ascher G, Friden J, et al. The palmar
digital venous anatomy. Scand J Plast Reconstr Surg Hand Surg
24:113–119, 1990.
542. Elsner T, Schramm U, Schrader M. Analysis of the vascular
anatomy of the palm and its clinical relevance in morbus
Dupuytren. Ann Anat 183:379–382, 2001.
543. Handley RC, Pooley J. The venous anatomy of the scaphoid. J
Anat 178:115–118, 1991.
544. Wang S, Luo S, Hao X. The superficial vein, cutaneous nerve
and its nutrient vessels in the forearm: anatomic study and the
clinical implication. Zhonghua Zheng Xing Shao Shang Wai Ke
Za Zhi 16:212–215, 2000.
545. Wasfi FA, Dabbagh AW, AlAthari FM, et al. Biostatistical study
on the arrangement of the superficial veins of the cubital fossa
in Iraqis. Acta Anat (Basel) 126:183–186, 1986.
546. Dharap AS, Shaharuddin MY. Patterns of superficial veins of
the cubital fossa in Malays. Med J Malaysia 49:239–241, 1994.
547. Singh JD. Patterns of superficial veins of the cubital fossa in
Nigerian subjects. Acta Anat (Basel) 112:217–219, 1982.
548. Au FC. The anatomy of the cephalic vein. Am Surg 55:
638–639, 1989.
549. Seeger JM, Schmidt JH, Flynn TC. Preoperative saphenous and
cephalic vein mapping as an adjunct to reconstructive arterial
surgery. Ann Surg 205:733–739, 1987.
550. Robie G, Sterba R. Accessory cephalic vein: intravenous infusions in infants. Am J Dis Child 133:97–98, 1979.
551. Lindner J. Transposition of the basilic vein in the arm for vascular access in hemodialysis. Rozhl Chir 76:126–128, 1997.
552. Patrick W, May J. Basilic vein transposition. Am J Surg 143:
254, 1982.
553. Lindstedt E, Lindergard B. Transposition of the basilic vein in
the forearm for the construction of haemodialysis arteriovenous
fistula. Scand J Urol Nephrol 14:207–209, 1980.
554. Dagher F, Gelber R, Rasmos E, et al. The use of basilic vein and
brachial artery as an A-V fistula for long term hemodialysis. J
Surg Res 20:373–376, 1976.
555. Dagher FJ, Gelber R, Reed W. Basilic vein to brachial artery,
arteriovenous fistula for long-term hemodialysis: a five year follow-up. Proc Clin Dial Transplant Forum 10:126–129, 1980.
556. Zincke H, Aguilo JJ. Basilic vein swing-over for creation of arte292 Systems Anatomy
riovenous fistula of forearm for hemodialysis. Urology 7:
319–320, 1976.
557. Mazzitelli R, Cozzupoli P, Biagini M, et al. Superficialization of
the basilic vein in dialyzed patients with exhausted vascular
access. Minerva Nefrol 26:191–194, 1979.
558. Landmann J, Brunner F, Muller HR, et al. Basilic vein fistula of
the upper arm: a neglected vascular access for chronic hemodialysis. Helv Chir Acta 51:97–100, 1984.
559. Barnett SM, Waters WC III, Lowance DC, et al. The basilic
vein fistula for vascular access. Trans Am Soc Artif Intern
Organs 25:344–346, 1979.
560. LoGerfo FW, Menzoian JO, Kumaki DJ, et al. Transposed
basilic vein-brachial arteriovenous fistula: a reliable secondaryaccess procedure. Arch Surg 113:1008–1010, 1978.
561. Geis WP, Giacchino JL, Iwatsuki S, et al. The reverse fistulas for
vascular access. Surg Gynecol Obstet 145:901–904, 1977.
562. Goto Y, Sakurada T, Nanjo H, et al. Venous aneurysm of the
cephalic vein: report of a case. Surg Today 28:964–966, 1998.
563. Nishi G. Venous flaps for covering skin defects of the hand. J
Reconstr Microsurg 10:313–319, 1994.
564. Ekim H, Gelen T, Darpuzoglu G. Multiple aneurysms of the
cephalic vein: a case report. Angiology 46:265–267, 1995.
565. Wang ED, Li Z, Goldstein RY, et al. Venous aneurysm of the
wrist. J Hand Surg [Am] 26:951–955, 2001.
566. Le Saout J, Vallee B, Person H, et al. Anatomical basis for the surgical use of the cephalic vein (V. Cephalica): 74 anatomical dissections. 189 surgical dissections. J Chir (Paris) 120:131–134, 1983.
567. Chitkara N, Garg P, Tehlan RN. Cephalic vein cutdown: a new
approach. Trop Doct 27:192, 1997.
568. Vialle R, Pietin-Vialle C, Cronier P, et al. Anatomic relations
between the cephalic vein and the sensory branches of the radial
nerve: how can nerve lesions during vein puncture be prevented. Anesth Analg 93:1058–1061, 2001.
569. Birkinshaw K. Finding the cephalic vein. Anaesthesia 31:959,
1976.
570. Jarrett F. Cavernous hemangiomas of the cephalic vein. Cardiovasc Surg 1:386–388, 1993.
571. Ascher E, Hingoran A, Gunduz Y, et al. The value and limitations of the arm cephalic and basilic vein for arteriovenous
access. Ann Vasc Surg 15:89–97, 2001.
572. Hidden G. Some recent, or claiming to be recent, data on the
superficial lymphatic circulation of the limbs. J Mal Vasc
15:149–151, 1990.
573. Ding ZH, Cao XT. Anatomical study of lymph vessels accompanying the cephalic vein. Zhonghua Wai Ke Za Zhi 26:48–49,
1988.
574. Chepelenko GV. Lymphatic vessels of the upper extremity and
their relation to nodes in the axillary area in healthy subjects
and lymph flow blockade. Arkh Anat Gistol Embriol 89:74–81,
1985.
575. Misnik VP. Anatomy of lymph nodes situated adjacent to the
axilla in adult humans. Arkh Anat Gistol Embriol 77:34–39,
1979.
576. Misnik VP. The anatomy and topography of the human axillary
lymph nodes. Arkh Anat Gistol Embriol 69:40–45, 1975.
577. Mellor RH, Stanton AW, Azarbod P, et al. Enhanced cutaneous
lymphatic network in the forearms of women with postmastectomy oedema. J Vasc Res 37:501–512, 2000.
578. Milanov NO, Abalmasov KG, Lein AP. Changes in the lymphatic vessels of the upper extremity following a radical mastectomy (based on lymphographic data). Vopr Onkol 32(2):
23–28, 1986.
4 Vascular Systems 293
6
ARM
JAMES R. DOYLE
Compared with the anatomic and functional complexities
of the shoulder region, forearm, wrist, and hand, the arm is
remarkably less complex. The arm in large part is presented
exclusive of the shoulder and the elbow, which are discussed
elsewhere. This arbitrary division is meant to facilitate the
presentation of the necessary information for the region and
should not be taken as a failure to recognize the important
interactions among all parts of the upper extremity. As with
all such divisions, there may be omissions or additions
made for the sake of clarity and the descriptive process.
DESCRIPTIVE ANATOMY
Contents
Bone: The humerus.
Blood Vessels: The cephalic and basilic veins and the
brachial artery and its branches.
Nerves: The median, musculocutaneous, ulnar, radial,
and superficial cutaneous nerves.
Muscles and Septa: The biceps, brachialis, coracobrachialis, and triceps muscles and medial and lateral intermuscular septa.
External Landmarks
Lateral Arm
Useful lateral landmarks include the prominent deltoid
muscle covering the proximal half of the arm, the lateral
biceps groove that contains the cephalic vein, the lateral and
long heads of the triceps, and the lateral epicondyle and
olecranon (Fig. 6.1).
Posterior Arm
Posteriorly, the long and lateral heads of the triceps that
cover the deep medial head form a bulky muscle mass over
the shaft of the humerus. The olecranon process of the ulna
is a prominent bony landmark, as is the posterior aspect of
the acromion process and the medial and lateral humeral
condyles (Fig. 6.2).
Anteromedial Arm
Useful anteromedial landmarks include the coracoid
process of the scapula inferior to the outer aspect of the
clavicle, the long head of the biceps tendon, and the greater
tuberosity of the humerus palpable just lateral and superior
to the biceps tendon (Fig. 6.3). The deltopectoral groove is
marked by the cephalic vein. The biceps is the prominent
and relatively mobile muscle mass on the front of the arm
that overlies the brachialis. The medial biceps groove, which
contains the basilic vein, marks the medial margin of the
biceps and defines the interval between the anterior and
posterior compartments of the arm.
Skeletal Anatomy
Humerus
The humerus is the longest and largest bone in the upper
extremity, with expanded proximal and distal articular ends
joined by a long shaft.
Humeral Shaft
The humeral shaft is almost round in its proximal aspect
and becomes triangular (apex anterior) in its distal aspect.
Proximal and Anterior Surface of the Humerus
The proximal and anterior surface demonstrates two
prominent ridges or crests flanking the bicipital or intertubercular groove that are distal continuations of the greater
and lesser tuberosities (Fig. 6.4A). The crest from the
greater tuberosity, which is lateral, provides an insertion for
the pectoralis major, and the crest of the lesser tubercle,
which is medial, receives the insertion of the teres major.
The intertubercular groove contains the tendon of the long
316
FIGURE 6.1. A: Lateral arm. B: external landmarks and
muscles.
A
head of the biceps and also provides a point of attachment
for the latissimus dorsi.
The deltoid tuberosity is a laterally situated prominence at
approximately the mid-portion of the shaft that is the insertion point of the deltoid muscle. Just distal to the deltoid
tuberosity and beginning posteriorly and spiraling distally
and laterally is a groove for the radial nerve. At approximately
the level of the deltoid tuberosity, the cross-sectional shape of
the humerus begins to change from circular to triangular,
with the apex of the triangle being anterior. As this triangular configuration continues distally, it begins to narrow in the
anteroposterior plane while simultaneously widening in the
medial and lateral aspects to form the medial and lateral
supracondylar ridges. The anteriorly situated ridge of the triangular configuration courses between the coronoid and
radial fossae to end between the trochlea and capitellum.
Hueter’s line, also known as the interepicondylar line, is a
straight line drawn from the tips of the humeral epicondyles
in the coronal plane (1). It is a useful landmark for locating
the possible site of division of the radial nerve into motor and
sensory components at the elbow (see discussion of distal
radial nerve division, later).
6 Arm 317
FIGURE 6.2. A: Posterior arm. B: external landmarks and muscles.
A B
Posterior Surface of the Humerus
The posterior aspect of the humerus is relatively flat from the
region of the deltoid tuberosity to the distal articulation (see
Fig. 6.4B). Posteriorly, a prominent oblique ridge begins
medially just distal to the surgical neck and runs laterally to
end near the deltoid tuberosity. This ridge represents the
point of origin of the lateral head of the triceps (2).
Humeral Torsion
When the humerus is viewed along its longitudinal axis
from proximal to distal, the proximal and distal articular
axes are divergent by approximately 15 degrees (see Fig.
6.4C). The articular axis of the proximal humerus looks
posteriorly by 15 degrees in relationship to the distal intercondylar axis, which is in the coronal plane (2).
318 Regional Anatomy
FIGURE 6.3. A: Anteromedial arm. B: external landmarks and muscles.
A
B
6 Arm 319
FIGURE 6.4. A: Anterior view of humerus
with external landmarks and cross-sectional
anatomy. Observe the changes in the
medullary canal, external shape, and cortical
thickness from proximal to distal. B: Posterior
humerus, external landmarks. C: Humeral torsion. The proximal and distal axes of the
humerus are divergent by approximately 15
degrees. The articular axis of the proximal
humerus looks posteriorly by 15 degrees in
relationship to the distal intercondylar axis,
which is in the coronal plane.
ANATOMIC RELATIONSHIPS
Veins of the Arm
Two major veins are present in the arm: the cephalic and
the basilic, which run in the biceps groove on each side of
the arm (Fig. 6.5). The cephalic continues proximally to
the deltopectoral groove, where it acts as a useful landmark for identification of the interval between the deltoid
and pectoralis muscles (3). At the deltopectoral triangle
(the infraclavicular fossa) just inferior to the clavicle, the
cephalic vein perforates the clavipectoral fascia and empties into the axillary vein. The cephalic vein in the deltopectoral groove is accompanied by the deltoid branch
of the thoracoacromial artery, which exits from the deltopectoral triangle and gives muscular branches to the
deltoid and clavicular head of the pectoralis major. In
contrast to the more superficial course of the cephalic
vein, the basilic vein pierces the brachial fascia at approximately the mid-aspect of the arm, where it ascends
medial to the brachial artery in the neurovascular bundle
to the lower margin of the teres major, where it becomes
the axillary vein (2).
320 Regional Anatomy
FIGURE 6.5. Veins of the arm and forearm, anterior view. The cephalic and basilic veins mark the
division between the flexor and extensor compartments of the arm and the location of the medial
and lateral intermuscular septa. The cephalic vein
continues proximally to the deltopectoral groove,
where it may act as a useful landmark to identify
the interval between the deltoid and the pectoralis
muscles. In the forearm, the cephalic and basilic
veins flank the median antebrachial vein in the
forearm. Note the median cubital vein in the region
of the antecubital fossa.
Cutaneous Nerves of the Upper Extremity
Lateral Antebrachial Cutaneous Nerve
The musculocutaneous nerve from the lateral cord of the
brachial plexus pierces the coracobrachialis, which it innervates, and descends laterally between the biceps and
brachialis, which it also innervates, to exit from the lateral
margin of the biceps, where it becomes the lateral antebrachial cutaneous nerve (LACN) of the forearm (Fig. 6.6).
The LACN is discussed in detail in Chapter 8.
Medial Antebrachial Cutaneous Nerve
The counterpart of the LACN on the medial aspect of the
arm, the medial antebrachial cutaneous nerve (MACN),
was studied by Masear et al. in 50 cadavers (4) (Fig. 6.7).
They found that the MACN arises in the axilla from the
medial cord in 78% and from the lower trunk in 22%. In
54%, the MACN and medial brachial cutaneous nerve
(MBCN) had a common origin from either the medial cord
or the lower trunk. When a common origin was present,
the MBCN divided from the MACN an average of 6 cm
(range, 1 to 20 cm) distal to the origin from the medial cord
or lower trunk. Twenty-six percent (13 of 50) had a second
MBCN branch off the MACN. In 8 of these 13, the highest medial brachial branch arose from the plexus separate
from the origin of the MACN. Four percent had three
MBCN branches of the MACN in the proximal two-thirds
of the arm. One specimen had no MBCN, and a thoracic
nerve sent cutaneous branches to the posteromedial arm
into the distribution ordinarily supplied by the MBCN. In
two specimens, the MBCN, MACN, and medial pectoral
nerve had a common trunk off the medial cord. The
MACN communicated with the medial brachial nerve in
4% and with the ulnar nerve in 6%. No communication
was found with the palmar cutaneous branch of the ulnar
nerve in the distal forearm. This nerve is adjacent to the
basilic vein as it descends along the medial side of the
brachial artery and then pierces the brachial fascia to
become superficial at the middle or distal arm. The relationship of the nerve to the basilic vein is variable because
half of the nerves cross deep and the other half superficial
to the median cubital vein at the elbow. In the distal arm,
the MACN divides into anterior and posterior branches at
an average of 14.5 cm (range, 1 to 31 cm) proximal to the
medial humeral epicondyle, with most (92%) branching
between 7 and 22 cm proximal to the medial epicondyle.
The anterior branch traverses the elbow between the medial
epicondyle and the biceps tendon, usually lying 2 to 3 cm
anterolateral to the epicondyle but sometimes crossing
directly over it. The anterior branch gives off variable cutaneous branches (two to five) to the antecubital fossa and the
proximal and distal anterior arm. Most of these branches
arose 6 cm proximal and 5 cm distal to the elbow. The main
anterior branch then continues distally superficial to the
flexor carpi ulnaris (FCU) and is traceable to an average of
5.6 cm from the wrist flexion crease. The posterior branches
(one to four) were found to course posteriorly from 6 cm
proximal to 4 cm distal to the epicondyle. Most (90%)
crossed at or proximal to the epicondyle. Anteromedial
articular branches were found in 34% (17 of 50), with 6
from the anterior and 11 from the posterior branches (3,4).
Clinical Significance
The MACN is a useful nerve graft for brachial plexus reconstruction (4). The MACN is a long nerve, similar in diameter to the sural, and is readily accessible in the surgical exposure of the plexus. If the length of only one sural nerve is
needed, the MACN usually suffices, and surgical time may
be shortened. In the 50 dissected specimens of Masear et al.,
the average graft length was 18.7 cm (range, 10 to 26 cm)
(4). Graft diameter proximally averaged 3.15 mm with 10.2
groups of fascicles, and in the mid-brachium near the bifurcation, the average diameter was 2 mm with 7 fascicular
groups. If the MACN is selected as a graft for a digital or
cutaneous nerve of the hand or wrist, a good size match is
obtained by using the anterior branch just proximal to the
elbow. Graft diameter may be increased or decreased by
moving proximally or distally as needed (4). Masear et al.
advise against taking the posterior branch because this
results in numbness over the olecranon, and the resulting
neuroma is in an area subjected to trauma (4). Cheney has
noted the MACN is a branching nerve of appropriate length
and diameter that matches the surgical requirements for cranial nerve reconstruction in head and neck surgery (5). He
noted that the MACN closely resembles the distal facial
nerve in terms of diameter and branching (5).
Medial Brachial Cutaneous Nerve
The other major medial cutaneous nerve of the arm is the
MBCN. It arises from the medial cord of the brachial
plexus and passes medial and posterior to the ulnar nerve as
it courses distally. Two to 3 cm proximal to the medial epicondyle, the nerve arborizes into two to five branches that
terminate over the medial epicondyle in 80% of specimens;
in the remaining 20%, the branches end in the mid-portion
of the medial arm (6).
Clinical Significance
Both the MACN and the MBCN send multiple branches
to the medial side of the elbow, which is the location of the
standard incision for ulnar nerve transposition. Race and
Saldana noted that 100% of the terminal branches of the
posterior arborization of the MACN and 80% of the
MBCN are in the fascia directly over the medial epicondyle
and the flexor pronator mass (7). The authors note that
unless these three to seven branches are carefully dissected,
any incision placed over the medial cubital tunnel will transect these nerves and result in anesthesia over the medial
6 Arm 321
322 Regional Anatomy
FIGURE 6.6. Palmar (A) and Dorsal (B) views of the cutaneous nerves of the arm and forearm.
All but one (the axillary) of the five terminal branches of the brachial plexus contribute branches
to the hand. The musculocutaneous nerve ends in the lateral antebrachial cutaneous nerve
(LACN); the median nerve ends as a major component of sensibility to the palmar and radial
aspect of the hand; the ulnar nerve ends as its medial counterpart; and the radial nerve ends by
sharing innervation of the dorsum of the hand with the median and ulnar nerves. The cutaneous
branch of the axillary nerve is the upper lateral brachial cutaneous nerve, which innervates the
skin over the outer and inferior aspect of the deltoid and upper aspect of the arm.
6 Arm 323
FIGURE 6.6. (continued) The posterior cord of the plexus is represented by five cutaneous
nerves, including the axillary nerve branch already mentioned. The remaining four are the posterior brachial cutaneous, the lower lateral brachial cutaneous, the posterior antebrachial cutaneous, and the superficial branch of the radial nerve. The LACN and medial antebrachial cutaneous (MACN), as well as the medial brachial cutaneous (MBCN), are the most significant nerves
on the anterior and medial aspects of the arm. The LACN, the distal sensory continuation of the
musculocutaneous nerve, innervates the skin on the flexor and radial one-half of the forearm.
The LACN is useful as a digital nerve graft and the MACN as a nerve graft for brachial plexus
reconstruction. Both the MACN and the MBCN send multiple branches to the medial side of the
elbow that may be at risk during surgery in this region (see text).
324 Regional Anatomy
FIGURE 6.7. A: Origin and distribution of
medial antebrachial cutaneous nerve
(MACN). This nerve arises most often from
the medial cord of the brachial plexus in the
axilla and descends adjacent to the basilic
vein to become superficial at the middle or
distal arm, where it divides into anterior and
posterior branches. The anterior branch traverses the elbow between the medial epicondyle and the biceps tendon, usually lying
1 to 3 cm anterolateral to the epicondyle,
where it gives off branches to the antecubital
fossa and proximal forearm. It then continues distally to innervate the flexor and ulnar
one-half of the forearm. The posterior
branch continues distally to innervate the
skin over the ulnar and dorsal aspect of the
forearm.
epicondyle and olecranon (7). Review of the authors’
patients with the standard incision for ulnar nerve transposition revealed a number with dense anesthesia over the olecranon and posteromedial aspect of the forearm. Painful
neuromas were not encountered, but this problem has been
reported by others (8). Because of their anatomic studies
and the findings on their patients who had undergone ulnar
nerve transposition, the authors now use a posterior
approach that affords better protection to the branches of
the MACN and MBCN (7).
Intercostobrachial Cutaneous Nerve
The intercostobrachial cutaneous nerve from the lateral
cutaneous branch of the second thoracic nerve is joined by
the MBCN from the medial cord of the brachial plexus to
innervate the skin on the proximal posteromedial aspect of
the arm. The intercostobrachial cutaneous nerve may be
sacrificed as part of the axillary portion of a modified radical mastectomy.
Muscles and Intermuscular Septa of the
Arm
Biceps Brachii
The biceps brachii is a fusiform muscle that derives its name
from its two proximal parts or heads: a long head that arises
by means of a tendon from the supraglenoid tubercle of the
scapula, and a short head that arises from the apex of the
coracoid process of the scapula (2,9) (Fig. 6.8). The long
head starts in the shoulder joint capsule as a long, round
tendon and arches over the humeral head to descend in the
intertubercular groove, where it is retained by the transverse
humeral ligament and a fibrous expansion of the pectoralis
major tendon. The tendon is surrounded by a synovial
sheath in the groove. The two heads lead into the muscle
bellies that, although closely applied, may be separated to
within 7 cm of the elbow joint (2). The muscle ends in a
flattened tendon that attaches to the rough posterior aspect
of the radial tuberosity. The bicipitoradial bursa separates
the tendon from the smooth portion of the radial tuberosity. As it approaches its insertion, the biceps tendon spirals
or twists, with its anterior surface becoming lateral. The
biceps is covered proximally by the pectoralis major and the
deltoid. Its medial margin touches the coracobrachialis and
it covers the brachial artery and median nerve. The lateral
border is adjacent to the deltoid proximally and the brachioradialis distally. The biceps is the main supinator of the
forearm and an elbow flexor, and it may play a role in preventing proximal migration of the humerus with contraction of the deltoid during abduction.
Brachialis
This muscle arises from the anterior and distal half of the
humerus, beginning in a “U”-shaped fashion from around
6 Arm 325
FIGURE 6.7. (continued) B: Fresh cadaver dissection of the MACN in the right arm. Note the
size and distribution of this cutaneous nerve.
B
the deltoid insertion (Fig. 6.9). It also arises from the intermuscular septa, more from the medial than the lateral
because it is separated from the lateral septum by the brachioradialis and the extensor carpi radialis longus. Although
it begins under cover of the biceps in its mid-portion, it is
uncovered anterolaterally. Its insertion is by a broad tendon
to the ulnar tuberosity on the anterior aspect of the coronoid process. The brachialis is a flexor of the elbow.
Coracobrachialis
This muscle arises from the coracoid process of the scapula,
which it shares as a point of origin with the short head of
the biceps (see Fig. 6.9). The muscle also arises from the
proximal 10 cm of the short head of the biceps. Insertion is
into an impression, 3 to 5 cm in length, on the medial
aspect of the mid-portion of the humerus between the triceps and brachialis (2). The coracobrachialis flexes the arm
forward and medially, and in abduction it acts with the
anterior deltoid (2).
Triceps
This muscle, like the biceps, takes its name from the number of heads of origin: the long, lateral, and medial (9). The
long and lateral heads are superficial and cover the deep
medial head; thus, the triceps may be considered to have
two layers (Fig. 6.10).
326 Regional Anatomy
FIGURE 6.8. Anterior arm muscles, the biceps. Note
the relationship of the biceps to the brachialis, the
coracobrachialis, and the medial intermuscular septum.
Long Head
The long head arises by a flat tendon from the infraglenoid
tubercle of the scapula (see Fig. 6.10A). Its muscle fibers
descend medial to the lateral head and superficial to the
medial or deep head to join them to form a large, common
posterior tendon.
Lateral Head
The lateral head arises from a long, narrow ridge that begins
medially and distal to the surgical neck and continues distally and laterally to end posterior to the deltoid tuberosity
(see Fig. 6.10A).
Medial Head
The medial head, which is covered in large part by the long
and lateral heads, arises from the proximal and posterior
shaft of the humerus just distal to the teres major and follows the medial margin of the radial groove to continue its
broad origin on the remainder of the posterior humeral
shaft down to the region of the elbow joint capsule (see Fig.
6.10B). It also arises from the medial intermuscular septum
and from the distal part of the lateral intermuscular septum.
The tendon of the triceps begins near the middle of the
muscle and has two layers, one superficial in the distal half
of the muscle and one deep in the substance of the muscle.
However, after receiving all the muscle fibers distally, the
two layers become one and insert on the olecranon. The triceps is the major extensor of the forearm. The medial head
is active in all forms of extension, whereas the lateral and
long heads are minimally active except in extension against
resistance.
Intermuscular Septa
The distal half of the arm is divided into anterior and posterior compartments by the lateral and medial intermuscular septa (Fig. 6.11). The lateral intermuscular septum arises
from the lateral epicondyle and epicondylar ridge of the
humerus and ends at the insertion of the deltoid. The
medial intermuscular septum, located in the distal twothirds of the arm, begins at the medial epicondyle and epicondylar ridge and blends proximally with the fascia of the
coracobrachialis near its insertion, to end at the medial lip
of the intertubercular sulcus distal to the teres major. The
radial and ulnar nerves pierce the lateral and medial septa,
respectively, as they change compartments in the middle
third of the arm.
Neurovascular Structures
Brachial Artery/Neurovascular Bundle
The brachial artery, a continuation of the axillary, which by
definition begins at the lower border of the teres major
muscle, continues distally to the neck of the radius, where
it bifurcates into the radial and ulnar arteries (3) (Fig. 6.12).
In the proximal arm, the artery is deep and medial and
gradually migrates to an anterior and central position as it
reaches the antecubital fossa. At this level, in the proximal
arm, the neurovascular bundle contains the brachial artery
and the median, ulnar, radial, medial antebrachial cutaneous, and medial brachial cutaneous nerves, as well as the
basilic vein. Spatial orientation at this level places the
median nerve anterior to the artery, the ulnar nerve medial,
and the radial nerve posterior. The median nerve gradually
crosses over the brachial artery as it descends so that it lies
medial to it in the antecubital fossa. The brachial artery is
flanked by brachial veins on either side. The anterior
6 Arm 327
FIGURE 6.9. Anterior arm muscles, brachialis and coracobrachialis. Note the relationship of the coracobrachialis and the
brachialis.
branches of the brachial artery are depicted in Figure 6.12B.
The brachial artery gives off numerous muscular branches
in the arm, mainly from its lateral side, and its major
branch is the deep brachial artery (its largest branch), from
the posteromedial aspect and arising distal to the teres
major (see Fig. 6.12C). This artery accompanies the radial
nerve through the spiral groove. On the posterior aspect of
the humerus, an ascending deltoid branch is given off that
communicates proximally with the posterior humeral circumflex artery. The deep brachial divides into the radial and
the middle collateral arteries. The middle collateral
descends in the substance of the medial head of the triceps
and participates in an anastomosis posteriorly in the supracondylar region between the laterally placed radial collateral
and a branch from the medially placed inferior ulnar collateral artery, and then continues distally to anastomose with
the interosseous recurrent artery posteriorly in the proximal
forearm. The radial collateral artery continues distally
between the brachialis and brachioradialis anterior to the
lateral epicondyle to anastomose with the radial recurrent
artery. The superior ulnar collateral arises from the medial
side of the brachial artery in the mid-humeral region and
accompanies the ulnar nerve, piercing the medial intermuscular septum with that nerve to descend between the medial
328 Regional Anatomy
FIGURE 6.10. A, B: Triceps. This muscle, like the biceps, derives its name from the number of
heads of origin; the long, lateral, and the medial. Note that the medial or deep head is covered
by the long and lateral heads.
6 Arm 329
FIGURE 6.11. A: Intermuscular septa. The distal aspect of the arm is divided into anterior and
posterior compartments by the medial and lateral intermuscular septa. The lateral septum arises
from the lateral epicondyle and epicondylar ridge of the humerus and ends at the deltoid insertion. The medial septum is located in the distal two-thirds of the arm and has similar but medial
epicondylar origins; it ends proximally by blending with the fascia of the coracobrachialis near its
insertion. B: Cross-section of the arm through the medial and lateral intermuscular septa. Note
the division of the distal arm into anterior and posterior compartments by the septa, and the
relationships of the various neurovascular structures to the septa.
FIGURE 6.12. A: The axilla and medial aspect of the arm. Note the brachial artery and its relationship to the nerves in the axilla and medial aspect of the arm (see text). (continued on next page)
A
330 Regional Anatomy
FIGURE 6.12. (continued) B: Anterior
branches of the brachial artery. Note the
course and branching of the brachial artery
and its subsequent division into the radial
and ulnar arteries in the forearm.
6 Arm 331
FIGURE 6.12. (continued) C: Posterior
branches of the brachial artery. Note the relationship of the posterior branches of the
brachial artery to the deltoid and triceps muscles.
epicondyle and the olecranon and ending deep to the FCU
by anastomosing with the posterior ulnar recurrent and
inferior ulnar collateral arteries. The inferior ulnar collateral
artery arises 3 to 4 cm proximal to Hueter’s line, passes
medially over the median nerve, and soon divides into a
posterior and a descending branch. The posterior branch
penetrates the medial intermuscular septum and anastomoses with the middle collateral artery posteriorly. The
descending branch anastomoses with the anterior ulnar
recurrent artery.
Intraosseous Arterial Supply of the Humerus
The following information is based on an injection study of
30 adult humeri performed by Laing (10) (Fig. 6.13). The
discussion of the intraosseous blood supply of the humerus
excludes the rich blood supply from the periosteum and the
muscular and ligamentous attachments, and the practical
relationship between these two sources is discussed later
under the section on Clinical Significance.
Arteries of the Humeral Head
A constant anterolateral artery from the ascending branch
of the anterior humeral circumflex enters the proximal
humerus either at the upper end of the bicipital groove or
by branches entering the greater and lesser tuberosities.
After entering the bone, this vessel (which may be multiple)
curves posteromedially just below the obliterated epiphyseal
line of the humeral head, and has been called the arcuate
artery. Additional contributions to the blood supply of the
humeral head were noted from the posterior humeral circumflex as posteromedial arteries. Inconsistent arteries also
were noted to enter the head posteriorly and anteriorly from
the attachment of the rotator cuff.
Arteries of the Humeral Shaft
Main Nutrient Artery
The main nutrient artery of the humeral shaft usually
arose directly from the brachial artery, and in this series
of 30 humeri was single in 28 and double in 2 instances.
In two-thirds of the specimens, this artery entered the
humerus anteromedially, medially in six cases, anteriorly
in five, and posteromedially in one case. The point of
entry of the main nutrient artery was at the junction of
the middle and distal thirds or in the lower part of the
middle third of the humerus in 24 cases, approximately
the mid-portion in 4 cases, and at the junction of the
third and fourth quarters in 2 bones. In all cases, the
course of the artery through the cortex was distalward,
and the length of the intracortical canal varied from 0.25
to 2 inches. When the nutrient artery was single it
divided into ascending and descending branches either in
the intracortical canal or in the medullary canal. In two
cases, the division took place outside the bone, and each
branch had its own canal and nutrient foramen. The
superior branch became the ascending artery of the shaft
and the inferior branch, the descending artery. The
ascending branch courses up the medullary canal and
anastomoses with any accessory nutrient arteries that may
be present. In some specimens this intramedullary artery
anastomosed with the periosteal arteries by small
transcortical vessels. The descending branch usually was
smaller than the ascending branch, and usually immediately divided into many fine arteries and continued distally in the intramedullary canal to reach the supracondylar and epicondylar regions.
Accessory Nutrient Arteries of the Humeral Shaft
One to four accessory nutrient arteries of the shaft were
found in almost all specimens, but were never as large as the
main nutrient artery.
Accessory Arteries from the Profunda Brachii. In seven
specimens, one or several arteries from the profunda brachii
artery entered the posterior surface of the humerus in the
spiral groove. These vessels were all small and no nutrient
foramen was visible on the surface.
Accessory Arteries from the Humeral Circumflex. In nine
specimens, an accessory nutrient vessel from the descending
branch of the anterior humeral circumflex artery entered
the upper end of the shaft anterolaterally. In one specimen,
a branch from the posterior humeral circumflex entered the
proximal humerus posteromedially. Only one specimen
demonstrated a sizable accessory nutrient vessel laterally.
Thus, most of the accessory nutrient arteries entered the
upper third of the humeral shaft anteriorly or anteromedially. Also, no true accessory nutrient vessels were seen
between the site of the main nutrient artery and the epicondylar region.
Arteries of the Distal Humerus
In addition to the descending branch of the main humeral
nutrient artery that reached the epicondylar region, on each
side there were arteries that entered the epicondyles medially, laterally, and posteriorly. Arterial branches were noted
to enter the trochlea, capitellum, and olecranon fossa, but
no vessels were noted anteriorly.
Clinical Significance of the Blood Supply to the
Humerus
Fractures of the Shaft. Although the periosteum represents
a rich source of blood supply to the humerus, the intraosseous supply also is important and both sources of blood
332 Regional Anatomy
6 Arm 333
FIGURE 6.13. Interosseous arterial supply to the humerus.
Note the arterial supply to the humeral head from the
humeral circumflex arteries, and the main nutrient artery
from the brachial artery entering the humerus anteromedially at the junction of the middle and distal thirds and dividing into ascending and descending branches and medial and
lateral branches to the epicondyles (see text).
supply must be respected and preserved. Fractures of the
shaft at the junction of the middle and distal thirds most
likely will destroy the main nutrient artery, and the upper
margin of the distal component of the humerus then
depends on vessels from the periosteum and those intramedullary vessels ascending from the epicondyles. Extensive stripping of the periosteum of the distal fragment in
open reductions in this region should be avoided to preserve the remaining components of the blood supply. This
concept is illustrated by the potential for compromise of the
blood supply of the shaft of the humerus by insertion of an
intramedullary device in conjunction with an open reduction of the fracture. The intramedullary device has the
potential to compromise the intramedullary blood supply,
and in combination with extensive periosteal stripping at
the fracture site, may diminish the blood supply to the fracture site.
Fractures of the Humeral Head/Metastatic Deposits.
The upper half of the humerus has an excellent blood
supply from the ascending branch of the main nutrient
artery and the accessory arteries, which may explain the
predilection of metastatic deposits for this part of the
humerus. Fractures of the surgical neck of the humerus
occur below the main blood supply of the humeral head
and above the main blood supply to the proximal shaft,
and thus both sides of the fracture interface have an excellent blood supply. This may account for the rapid union
of these fractures. When operating in this region, it is
appropriate to remember that the main blood supply of
the humeral head enters it through the upper end of the
bicipital groove or from the adjacent parts of the greater
and lesser tuberosities.
Fractures of the Distal Humerus. The importance of preserving the muscular and ligamentous attachments when
operating on the lower end of the humerus is well known.
Excessive stripping of soft tissues should be avoided to preserve the periosteal blood supply to the distal humerus and
associated fracture fragments.
Nerves
Radial Nerve
The radial nerve arises from the posterior cord and is the
largest branch of the brachial plexus. The radial nerve leaves
the medial side of the arm accompanied by the deep
brachial artery and passes laterally between the long and
medial heads of the triceps to a shallow groove beneath the
lateral head. The radial nerve comes in contact with the
humerus in the spiral groove approximately 3 cm proximal
to the deltoid tuberosity. It continues in this groove laterally
and distally to pierce the lateral intermuscular septum and
enters the anterior compartment at approximately the junction of the middle and distal thirds of the humerus. It then
continues to descend toward the forearm in a groove
between the brachialis and brachioradialis. It is between
these two muscles that it enters the forearm.
Radial Nerve Division and Branches
Medial Branches. Muscular branches from the radial are
given off in medial, posterior and lateral locations. Medial
branches (Fig. 6.14A) include a branch to the long head of
the triceps and a branch to the medial half of the medial or
deep head of the triceps. The branch to the medial head is
a long, slender nerve that arises in the axilla and enters the
medial head two handbreadths distal to the acromion. It lies
close to the ulnar nerve as far as the distal third of the arm,
and is called the ulnar collateral nerve because of this proximity (9).
Posterior Branches. Two posterior branches may be
found; the most proximal leaves the posterolateral aspect of
the radial nerve in a more transverse course than its parent
and enters the lateral head of the triceps (see Fig. 6.14A and
B). The second and more distal branch leaves the radial
nerve posteriorly to enter the lateral half of the medial or
deep head of the triceps. This nerve also may send a branch
to the lateral head. This branch to the medial head continues distally through the substance of the lateral half of the
medial head to end in the anconeus.
Clinical Significance. The fact that two parallel and sufficiently separated radial nerve branches (the medially situated ulnar collateral and the laterally placed posterior
branch) innervate the medial or deep head of the triceps
results in a useful gap between the two nerves that allows
the surgeon to split the medial head to expose the posterior
aspect of the humerus without denervating the muscle (9).
Lateral Branches. These arise anterior to the lateral intermuscular septum and supply the lateral one-third or less of
the brachialis and all of the brachioradialis and extensor
carpi radialis longus (see Fig. 6.14C).
Distal Radial Nerve Division. At the elbow, the radial
nerve may divide into its motor and sensory branch at any
level within a 5.5-cm segment, from 2.5 cm above to 3 cm
below Hueter’s line (a line drawn through the tips of the
epicondyles of the humerus) (1) (see Fig. 6.14C).
Ulnar Nerve
The ulnar nerve arises from the medial cord, and after leaving the axilla continues distally medial to the brachial artery
until it reaches the midarm, where it pierces the medial inter334 Regional Anatomy
6 Arm 335
FIGURE 6.14. A: Medial and posterior branches of the radial nerve.
Note the medial and posterior
branches to the triceps. The main
stem of the radial nerve penetrates
the lateral intermuscular septum to
enter the anterior aspect of the
arm at approximately the junction
of the middle and distal thirds of
the arm. (continued on next pag
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