Proper Branches Research Articles

ANATOMICAL VARIATIONS IN ARTERIAL SUPPLY OF THUMB AND INDEX FINGER IN CADAVERIC HANDS

Human hand is highly evolved in terms of complexity and variations. In this modern medical era, vascular anatomy of the human hand has clinical importance in medical, surgical and radiological sciences. The intention of the current study is to determine the variations which occur as the radial artery branches thus making a contribution to the arterial supply of the index finger and the thumb. The study design was descriptive case series, carried out in the Department of Anatomy in King Edward Medical University from December 2018 to May 2019 on 30 cadaveric limbs. Vivisection of the cadaveric hands was performed following Cunningham’s Manual of practical anatomy. The origin and the course of RA, UA and MA were dissected and identified with further exploration of the blood supply of the index finger and the thumb. All details were entered in a predesigned proforma, and the dissected limbs were photographed. Data was analyzed to find the frequencies of superficial palmar arch as well as the arterial supply of thumb and index finger were also expressed in frequencies. Great variation was observed in the arterial supply to palmar aspect of index finger and thumb. Main contributing artery being radial artery in majority of cases through its common palmar or proper palmar branches arising from SPA or SPBRA. Ulnar artery and median artery were also observed to be supplying these areas in 6.6% and 3.3% cases respectively. The median artery when present was replacing the radial artery on palmar aspect of hand. The dorsum, however, was supplied by the princeps pollicis and the radialis indicis branches of radial artery in all the cases. We concluded that in about 1/3rd (11/30 are incomplete SPA) of our studied sample, arterial supply of the index finger and the thumb is highly dependent on radial artery and should any damage occur to it, vitality of these useful structures will be compromised.

Unexplored parameters of ulnar nerve in the palm and its clinical implications; A cadaveric study

ObjectivesSeveral studies have been conducted on the variations and branching pattern of the ulnar nerve in the hand. There are few studies conducted on defining the distance of ulnar nerve from bony landmarks in the palm. Ulnar nerve is closely related to the pisiform and hook of hamate which act as important landmarks. MethodsThe study was conducted on 30 formalin fixed adult hand specimens in the department of Anatomy. Various measurements related to the ulnar nerve in the palm were taken using a divider and Vernier Calipers and the values were tabulated after obtaining the mean and standard deviation. ResultsThe average distance seen in the hand specimens [n = 30] from pisiform to the division of ulnar nerve into superficial and deep branch was 0.89 ± 0.25cm and the distance between pisiform bone up to the division of superficial branch of ulnar nerve into proper and common digital branches was 1.36 ± 0.59 cm. The average distance from the origin of proper digital branch of ulnar nerve to the head of fifth metacarpal bone was 5.25 ± 0.59 cm. The length of common digital branch of ulnar nerve from its origin to division into 2 sensory branches was 4.31 ± 1.09 cm. ConclusionThis study provides the metric parameters of the ulnar nerve in the hand from its significant bony landmarks which should be kept in mind during surgical procedures to minimize the incidence of injury to its branches. It would assist the orthopedic surgeon in the treatment of ulnar nerve compression in the Guyon's canal.

Hyperbaric oxygen therapy and fluorescence angiography in arterial insufficiency secondary to injection of crushed hydromorphone

Introduction: Foreign body emboli can lead to acute arterial insufficiency. We present a case report of upper extremity arterial insufficiency in an intravenous (IV) drug user secondary to intra-arterial injection of crushed tablet particles successfully treated with hyperbaric oxygen (HBO2) therapy. Case: A 37-year-old right-hand-dominant male developed pain and swelling of the left hand after attempting to inject crushed hydromorphone tablets into his venous circulation. Angiography revealed incomplete distal filling of the proper digital arteries, princeps pollicis, and radialis indicis branches of the left hand. The patient was treated with HBO2 for acute arterial insufficiency, secondary to these findings. Fluorescence angiography was performed prior to, during and after completion of HBO2, which showed improved perfusion of the hand upon completion of serial imaging. The patient underwent subsequent partial amputation of the left second digit and removal of the thenar and third finger pads. Discussion: Much of the literature on treatment of arterial insufficiency with HBO2 are in relation to chronic problem wounds. However, there is limited data on adjunctive treatment with HBO2 for foreign body embolism. Fluorescence angiography and clinical exam were used to track tissue perfusion and progression throughout course of therapy with HBO2. Conclusion: Acute arterial insufficiency induced by foreign body embolism was successfully treated with HBO2 and provided increased tissue salvage of the patient’s hand. The use of fluorescence angiography as a secondary measure of perfusion can provide additional insight regarding qualitative tissue oxygenation and may be a viable tool to track patient progress during HBO2 treatment.

Comparison principles for viscosity solutions of elliptic branches of fully nonlinear equations independent of the gradient

The validity of the comparison principle in variable coefficient fully nonlinear gradient free potential theory is examined and then used to prove the comparison principle for fully nonlinear partial differential equations which determine a suitable potential theory. The approach combines the notions of proper elliptic branches inspired by Krylov ^{[<span class="xref"><a href="#b18" ref-type="bibr">18</a></span>]} with the <i>monotonicity-duality method</i> initiated by Harvey and Lawson ^{[<span class="xref"><a href="#b12" ref-type="bibr">12</a></span>]}. In the variable coefficient nonlinear potential theory, a special role is played by the <i>Hausdorff continuity of the proper elliptic map</i> Θ which defines the potential theory. In the applications to nonlinear equations defined by an operator <i>F</i>, structural conditions on <i>F</i> will be determined for which there is a correspondence principle between Θ-<i>subharmonics/superharmonics</i> and <i>admissible viscosity sub and supersolutions</i> of the nonlinear equation and for which comparison for the equation follows from the associated compatible potential theory. General results and explicit models of interest in differential geometry will be examined. Examples of improvements with respect to existing results on comparison principles will be given.

MORPHOLOGICAL TRANSFORMATIONS OF TUBULAR STRUCTURES OF THE FETUSES HEPATODUODENAL LIGAMENT

The components of the hepatoduodenal ligament play an important role in the process of digestion. Calculi in the common bile duct are found in 10-15% of individuals suffering from chronic calculous cholecystitis, and obstruction of bile ducts is found in 59,1-67,4% of cases. The objective of the study was to investigate peculiarities of component morphogenesis of the hepatoduodenal ligament during the perinatal period of human ontogenesis, individual and age anatomical variability, spatial-temporal transformations, and anatomical-histological peculiarities of its structures. To achieve the stated purposes the following complex of methods was used: macroscopic – for visual detection of the state of the hepatoduodenal ligament components, vascular injection – to study peculiarities and variants of angioarchitectonics of the arterial components of the hepatoduodenal ligament, statistical – to determine peculiarities of morphological transformations of the components and adjacent structures of the hepatoduodenal ligament at different periods of prenatal and postnatal periods of human ontogenesis. According to the results of the study several accessory triangles of the hepatoduodenal ligament were found and described. The common bile duct, the common hepatic duct, cystic duct, left and right hepatic ducts, hepatic portal vein, common hepatic artery, right gastric artery, hepatic artery proper, right, left and accessory branches of the hepatic artery proper are permanent components of the ligament forming a number of combinations-crossings between themselves. Meanwhile, we have determined certain regularities of the formed pattern including minimum 5 permanent triangles to be distinguished: Calot’s triangle or "superior lateral triangle", "superior medial triangle", "inferior medial triangle", "inferior lateral triangle", "central space of the hepatoduodenal ligament".

Brachial plexitis or neuritis? MRI features of lesion distribution in Parsonage-Turner syndrome.

This study seeks to characterize lesion distribution in Parsonage-Turner Syndrome (PTS) using high-resolution MRI. MRIs of 27 patients with clinically confirmed PTS were reviewed. Two radiologists independently evaluated the brachial plexus proper, side and terminal plexus branches, and more distal, upper extremity nerves. All patients had at least 1 clinically involved nerve. MRI revealed that the plexus appeared normal in 24 of 27 patients; in 3 other patients, signal hyperintensity was seen immediately proximal to the take-off of abnormal side or terminal branch nerves. Focal intrinsic constrictions were detected in 32 of 38 nerves. MRI interobserver agreement was high (Cohen's κ = 0.839). MRI findings, corroborated by electrodiagnostic testing, localized abnormalities to plexus branches and peripheral nerves, suggesting that PTS is characterized by 1 or more mononeuropathies rather than changes involving a portion of or the complete plexus proper. These results may improve diagnosis, prognostication, and management. Muscle Nerve 58: 359-366, 2018.

Reverse dorsal digital island flap with cutaneous branches of proper digital nerve for repair of soft tissue defects of the same fingertip

Objective To explore the clinical outcomes of reverse dorsal digital island flap with cutaneous branches of proper digital nerve for repair of soft tissue defects of the same fingertip. Methods From March 2014 and June 2016, 25 patients (30 fingers) of fingertip soft tissue defects were treated using reverse dorsal digital island flap with cutaneous branches of proper digital nerve. The proper digital cutaneous branches of the flap were sutured with the digital nerve of the wound. The fingertip defect area ranged from 1.4 cm×1.6 cm to 2.0 cm×3.5 cm (average, 2.1 cm×2.5 cm). The flap area was enlarged by 10%. The donor sites were covered with autologous full-thickness skin. Results All the flaps survived. All the donor and recipient wounds achieved primary healing. Venous crisis occurred in one case which healed after the removal of some sutures. Postoperative follow-up period ranged from 6 to 18 months. The shape of the flaps was plump and the texture was soft. Partial superficial sensation of the flaps recovered without donor site pain and interphalangeal joint dysfunction. The two-point discrimination ranged from 5 to 8 mm, with the average being 5.7 mm. According to the functional evaluation standards issued by Hand Surgery Society of the Chinese Medical Association, the results were excellent in 17 cases, good in 8 cases. Conclusion The application of reverse dorsal digital island flap with cutaneous branches of proper digital nerve for repair of soft tissue defects of the same fingertip can achieve good sensory recovery. Key words: Finger injuries; Surgical flaps; Treatment outcome; Sensory reconstruction

A study on variations of branching patterns of median nerve in the carpal tunnel

Abstract Background &amp; aims: The carpal tunnel, located on the palmar surface of the wrist, is a common site of median nerve compression. The median nerve, on passing through the carpal tunnel, divides into lateral and medial branches. The lateral branch then gives off proper palmar digital branches to the thumb and the radial aspect of the index finger, and a recurrent muscular branch to the thenar muscles. The recurrent muscular branch shows different types of variations of the median nerve. Also, there are other variations of the median nerve in the carpal tunnel. These variations greatly influence the symptoms, as well as the treatment of the carpal tunnel syndrome. So, the present work is carried out to study the variations of branching patterns of median nerve in the carpal tunnel. Materials and methods: 40 wrists [20 right and 20 left] from 20 formaldehyde fixed human perinatal fetuses of 34 - 38 weeks of gestation were dissected in the Department of Anatomy, Gauhati Medical College and Hospital, Guwahati. Due ethical clearance was obtained from the Institutional Ethical Committee, Gauhati Medical College and Hospital, Guwahati. Results: In the present study, 24 [66.7%] hands [11 right and 13 left] showed extraligamentous and 12 [33.3%] hands [8 right and 4 left] showed transligamentous variety of thenar branch of median nerve. Also, 4 [10%] hands showed accessory thenar branch of median nerve, all of which took origin within the flexor retinaculum. The comparisons of numbers of variations of thenar branch of median nerve between right and left hands were found to be statistically non significant [P &gt; 0.05]. Conclusion: A detailed knowledge of the median nerve variations in the carpal tunnel is required for successful diagnosis and treatment of the carpal tunnel syndrome and its complications.

A rare variation of cutaneous innervation of dorsum of hand by posterior interosseous nerve

AbstractAnatomical knowledge of variation of cutaneous supply of hand is required to the anesthetist to give local anesthesia and to the surgeon for various operations around wrist. The present case was reportedto enlighten the knowledge of anatomists as well as to the clinicians. During routine dissection of 70 year old male cadaver a rare variation of distribution of posterior interosseous nerve on dorsum of hand of right side was observed. The adjacent sides of index and middle fingers supplied by posterior interosseous nerve. Cutaneous nerve supply of thumb and lateral side of index finger was by three proper digital branches from superficial division of radial nerve and rest was supplied by ulnar nerve. Anatomical knowledge of this variation willbe useful to anaesthetists and surgeons during various operations.

Topographical mapping of α- and β-keratins on developing chicken skin integuments: Functional interaction and evolutionary perspectives

Avian integumentary organs include feathers, scales, claws, and beaks. They cover the body surface and play various functions to help adapt birds to diverse environments. These keratinized structures are mainly composed of corneous materials made of α-keratins, which exist in all vertebrates, and β-keratins, which only exist in birds and reptiles. Here, members of the keratin gene families were used to study how gene family evolution contributes to novelty and adaptation, focusing on tissue morphogenesis. Using chicken as a model, we applied RNA-seq and in situ hybridization to map α- and β-keratin genes in various skin appendages at embryonic developmental stages. The data demonstrate that temporal and spatial α- and β-keratin expression is involved in establishing the diversity of skin appendage phenotypes. Embryonic feathers express a higher proportion of β-keratin genes than other skin regions. In feather filament morphogenesis, β-keratins show intricate complexity in diverse substructures of feather branches. To explore functional interactions, we used a retrovirus transgenic system to ectopically express mutant α- or antisense β-keratin forms. α- and β-keratins show mutual dependence and mutations in either keratin type results in disrupted keratin networks and failure to form proper feather branches. Our data suggest that combinations of α- and β-keratin genes contribute to the morphological and structural diversity of different avian skin appendages, with feather-β-keratins conferring more possible composites in building intrafeather architecture complexity, setting up a platform of morphological evolution of functional forms in feathers.

Angiographic identification of extrahepatic perfusion after hepatic arterial pump placement: implications for surgical prevention

BackgroundHepatic arterial infusion (HAI) chemotherapy is an effective treatment for patients with liver malignancy. Extrahepatic perfusion (EHP) after HAI pump placement requires correction prior to starting chemotherapy. The aim of this study was to define the origin of arterial branches causing EHP in order to determine if alterations in surgical technique during pump placement might prevent EHP. MethodsA prospectively maintained, single-centre HAI database was reviewed for all patients (2008–2011) with EHP. The origin of arterial branches causing EHP was classified anatomically and patient outcomes were analysed. ResultsOf the 327 patients with pumps implanted, 24 evidenced EHP. The arterial branch responsible for EHP perfused the duodenum, pancreas and/or stomach. The branch responsible for EHP arose from the proper hepatic artery (PHA), 1st, 2nd, or 3rd order hepatic artery branches in 7, 10, 5 and 2 patients, respectively. The majority of branches beyond the PHA causing EHP (13/17) originated from the right hepatic artery. In 18 patients, aberrant branches were successfully treated with embolization. ConclusionThese findings provide the anatomic basis for prevention of up to one-third of the cases of EHP intra-operatively, decreasing the number of patients who will require additional procedures for correction of EHP post-operatively.

Antidromic sensory nerve conduction study of the digital branches of the medial plantar nerve: A novel method to detect early diabetic sensory axonal polyneuropathy

Distal sensory neuropathy is the most common form of diabetic neuropathy. We developed a novel antidromic technique for assessment of distal nerve function for early diagnosis of diabetic neuropathy. Diabetic and control groups underwent standard and more distal sensory nerve conduction studies (NCS); sensory nerve action potentials (SNAPs) of the proper digital branches of the medial plantar nerve were recorded with our method after stimulation at the sole and recording from digits I and II. Comparison between controls and diabetics showed a statistically significant difference in mean SNAP amplitudes for all nerves tested. A higher percentage of abnormal SNAPs was obtained with our technique than with either conventional or more distal NCS in all patients. As compared with clinical evaluation and other NCS, our antidromic stimulation was the most sensitive method to detect abnormal sensory nerve conduction in symptomatic and asymptomatic diabetic patients.

A rare anatomical variation of the Berrettini anastomosis and third common palmar digital branch of the median nerve

Variations in the origin and distribution of Berrettini anastomosis between the digital branches of the ulnar and median nerves exist and are well described in the literature. During regular dissections by medical students, we encountered a rare variation in the left hand of an approximately 50-year-old male cadaver. Berrettini anastomosis connecting the third common palmar digital branch of the median nerve with the fourth common palmar and proper palmar digital branches of the ulnar nerve presented a plexiform nature. This communicating branch and the third common palmar digital branch of the median nerve were perforated by the superficial palmar arch. Further, the superficial palmar arch was incomplete, and it was solely formed by the superficial branch of the ulnar artery. The unusual relationship of Berrettini anastomosis with the superficial palmar arch is very rare, and knowledge about such a variation is important when performing carpal tunnel release, flexor tendon surgery, and Dupuytren's fasciectomy and when dealing with arterial repairs and vascular graft applications in the hand.

Innervated Reverse Island Flap Based on the End Dorsal Branch of the Digital Artery: Surgical Technique

Fingertip or pulp loss of the fingers is observed frequently in unskilled workers. To reconstruct a sensate fingertip or pulp we designed the innervated reverse island flap based on the end dorsal branch of the digital artery, which was harvested from the dorsum of the middle phalanx. The sensation of the fingertip or pulp was re-established through coaptation of the proper branches of the digital dorsal nerves to the digital nerves. Three fingertip or pulp defects were reconstructed with this technique. All patients achieved satisfactory functional and cosmetic results. The mean follow-up time was 7.7 months. The average size of the flaps was 1.6 x 1.8 cm. The average static 2-point discrimination and moving 2-point discrimination of the flaps were 4.6 mm and 3.0 mm, respectively. The technique we applied seems to be an excellent option for 1-stage reconstruction of fingertip or pulp defects.

Innervated reverse island flap based on the dorsal cutaneous branch at distal interphalangeal joint of the digital artery

目的 介绍用指动脉远侧指间关节背侧皮支逆行岛状皮瓣修复指端及指腹缺损,并同时重建感觉的一种新的术式. 方法根据指背皮肤血供及神经支配的特点,应用指动脉远侧指间关节背侧皮支为血管蒂的中节指背皮瓣,逆行转移修复指端及指腹缺损,同时应用指背部神经的分支重建指端及指腹感觉3例. 结果术后皮瓣全部存活,随访3～6个月,外形满意,质地柔软,耐磨,无触痛,耐寒冷,动态及静态两点辨别觉分别为2～4 mm及4～6 mm,指间关节活动范围减少在10°以内. 结论该术式不需牺牲主要血管及神经,采用中节指背非功能面的皮肤为供区,并能重建良好的感觉,不需2次手术,是修复指端及指腹缺损可选用的皮瓣之一。

Chemoembolization for Hepatocellular Carcinoma via the Inferior Pancreaticoduodenal Artery in Patients with Celiac Artery Stenosis

Twenty-one patients with hepatocellular carcinoma (HCC) accompanied by extensive celiac artery stenosis or obstruction were treated by chemoembolization via the inferior pancreaticoduodenal artery (IPDA). The tip of the catheter was placed in the arteries in front of the confluence with the proper hepatic artery in 12 patients (group A: the proximal portion of the IPDA in 10, and common hepatic artery in 2), and in the proper hepatic artery or branches of it (group B) in 9 using a coaxial catheter system. Transient hyperamylasemia was observed in 10 of the 12 patients in group A and in 3 of the 9 patients in group B after chemoembolization. Splenic infarction developed in 8 patients in group A and in none in group B. Intrapancreatic fluid collection was present in 2 patients in group A following chemoembolization. No fatal complications were encountered. The 1-, 2-, and 3-year survival rates of the 10 patients in group A treated by only chemoembolization were 90, 57, and 23%, respectively (mean survival 780 days). The 1- and 2-year survival rates of 9 patients in group B were 85.8 and 85.8% (mean 879 days), respectively. Considering the severity of complications and the survival rates in groups A and B, chemoembolization by superselective catheterization into the hepatic artery via the IPDA is the treatment of choice. However, chemoembolization from the arteries in front of the confluence with the proper hepatic artery seems to be acceptable in cases of hypervascular HCC which fail to be superselectively catheterized.

Evaluation of Hankel functions with complex argument and complex order

The use of F.W.J. Olver's (1974) uniform asymptotic expansions to compute Hankel functions (of interest in EM scattering) of complex argument z and complex order v is examined. Emphasis is placed on how to choose the proper branches in evaluation of the complex functions in the asymptotic representations. Comparison is made with the nonuniform formulas of Debye and Watson. The Debye formulas are valid when z and v are far apart, and the Watson formulas are valid when z and v are close together. The fact that the Olver formulas are uniform is important from a numerical viewpoint, because a satisfactory criterion for deciding when to switch between the Debye and Watson (1958) formulas is not available. Validation by comparison with two nonasymptotic methods verifies that the Olver formulas are considerably more accurate than the Debye or Watson formulas. >

An anatomic basis for recurrence after Morton's neuroma excision.

Dissections of the common digital nerve and its branches were performed in the second and third web spaces in five fresh-frozen cadaveric feet. Plantarly directed nerve tetherings, which were histologically demonstrated to be nerve branches, were consistently present along the course of each common digital nerve. These plantarly directed nerve branches were found in highest concentration in the distal aspect of the common digital nerve proximal to the bifurcation into the proper digital branches. The presence of these nerve branches may contribute to the high incidence of Morton's neuroma recurrence either due to traumatic neuroma formation in the branches or to failure of proximal retraction of the more distally resected nerve stump.