Superior Ulnar Collateral Artery Research Articles

VARIATIONS IN THE ORIGIN OF PROFUNDA BRACHII ARTERY FROM BRACHIAL ARERTY-SYSTEMATIC REVIEW

Objective: The profunda brachii artery (PBA) is a chief artery in anterior compartment of the arm for the nutritional source. Knowledge of variations in the origin and branching is helpful for the surgeon during catheterization and harvesting of lateral flaps. Methods: During the routine dissection for medical undergraduate students we found variations in the branching pattern of PBA in 72 arms from 36 cadavers in the Department of Anatomy, Viswabharathi Medical College, Penchikalapadu, and Kurnool, over 5 years. We preserved all the variations carefully. Results: We observed PBA in all the cadavers, patterns of origin, branches, and termination were recorded. In 96.9% of cadavers artery arises from the brachial artery (BA), in 1.4% from the axillary artery, and in 1.7% cadavers from a common stem with the superior ulnar collateral arteries. In 11.1% and 16.7% of the cadavers showed duplication and early branching. Conclusion: Humeral fractures and BA catheterization the incidence of duplication and early branching make it vulnerable to inadvertent injury and may complicate lateral arm flaps. Pre-operative angiographic evaluation is therefore recommended.

An unreported innervation of the coracobrachialis longus by the radial nerve: a potential pitfall for clinicians

PurposeThe aim of the presented case is to describe an unprecedented innervation of the coracobrachialis longus muscle by the radial nerve.MethodsAn 82-year-old body donor at death was subjected to a routine anatomical dissection for teaching and research purposes at the Department of Anatomical Dissection and Donation in Lodz, Poland.ResultsWe have found an additional branch of the radial nerve, which departed from it just below its beginning. Its initial section ran alongside the radial nerve in the axilla, then headed medially accompanying superior ulnar collateral artery. Then, it reaches the coracobrachialis longus muscle and is the only one to innervate it.ConclusionsThe brachial plexus (BP) is very variable and well understood. Nevertheless, we must remember that there may still be variations in its structure, which may involve problems at every stage of diagnosis and treatment of diseases associated with its structures. Their knowledge is extremely important.

Bilateral absence of the deep brachial artery.

The aim of the following study was to present and comprehensively describe a case of a bilateral absence of the deep brachial artery (DBA). Furthermore, its embryology and clinical significance will also be discussed. During routine dissection, a 71-year-old male cadaver with a bilateral abnormality in the DBA and its branches was found. The first branch of the brachial artery (BA) was found to be the radial collateral artery, which passed behind the radial nerve. Furthermore, the middle collateral artery originated distal to the radial collateral artery and gave off first a singular, minor muscular branch and then the superior ulnar collateral artery. Later, the preceding nutrient arteries of the humerus and the deltoid branch consecutively branched off from the middle collateral artery. Subsequently, the middle ulnar collateral artery, the inferior ulnar collateral artery, the deltoid artery, the radial artery, and the ulnar artery branched off from the BA, as adapted in the current knowledge regarding the anatomy of the upper extremity. Furthermore, detailed measurements of the distances between the mentioned arteries were carried out. In the present study, a bilateral absence of the DBA was demonstrated. Meta-analysis focusing on the anatomy of this artery has shown how variable its characteristics are. However, our case report is the first in the literature to present this extremely rare variation. Having adequate knowledge regarding the anatomy of the arteries of the proximal arm is of immense importance when performing orthopaedic and reconstructive surgeries in this area.

Anatomic feasibility study of osteocutaneous free flap from the proximal ulna

ObjectiveThe present anatomic study aimed to assess the feasibility of an osteocutaneous free flap harvested from the proximal ulna for reconstruction after complex hand trauma. MethodNineteen upper limb specimens free of scarring in the elbow region were injected in the brachial artery. After S-shaped incision centered on the medial epicondyle, a systematic approach to the epitrochlear-olecranal groove exposed the superior ulnar collateral artery and ulnar nerve. Bone and skin perforators were screened for during dissection and their emergence with respect to the medial epicondyle was assessed. Pedicle length was also assessed. The skin paddle was harvested in the distal part of the S incision and the operative site was closed by local skin plasticity. ResultsBone and skin perforators from the superior ulnar collateral artery were found in all 19 specimens. Mean pedicle length from the artery was greater than 9cm in all cases. The skin perforator emerged at a mean 19mm distally from the medial epicondyle, and the bone perforator at a mean 40mm. DiscussionAn osteocutaneous free flap can be harvested from the proximal ulna and medial side of the elbow. As bone and skin perforators were found in all 19 cases, this flap can be used routinely. Harvesting, however, systematically involves ulnar nerve release and anterior transposition. This osteocutaneous free flap harvested from the proximal ulna offers an alternative for osteocutaneous defects in the hand, with harvesting from the same limb. ConclusionIn this anatomic series, an osteocutaneous free flap could in all cases be harvested from the posterior ulnar recurrent artery via a medial elbow approach. Safety and efficacy remain to be demonstrated in in vivo reconstruction. Level of evidenceIII.

Cutaneous perforators of the arm and anatomical landmarks for defining the flap donor sites.

There are few studies searching for possible perforator flap donor sites on the arm. This study aimed to identify the locations of cutaneous perforators of the arm according to anatomical landmarks. Thirteen Thiel-fixed and latex-filled upper extremities of bodies donated to science were used. The distance between the acromion and medial or lateral epicondyle of the humerus was defined as the Y-axis, and the axis that cut the Y-axis perpendicularly through the epicondyles of the humerus was identified as the X-axis. The Y-axis was then divided into three parts Cutaneous arterial perforators were found using surgical dissection. The locations of the perforators were determined according to the defined lines and regions. On the lateral side, there were 6.00 ± 2.08 perforators per arm, of which 56.4% were septocutaneous and 43.6% muscular. In all extremities, with in the distal 1/3 of the lateral arm, there were 1-4 radial collateral artery-based perforators. The mean distance of these perforators to the Y-axis was 1.16 ± 0.53cm. On the medial side, there were 5.05 ± 1.44 perforators per arm, which were all septocutaneous perforators. In 85% of the extremities, within the middle 1/3 of the medial arms, there were 1-2 superior ulnar collateral artery-based perforators. The mean distance of these perforators to the Y-axis was 1.53 ± 0.61cm. There are always perforators from the radial collateral artery with in the distal third of the lateral arm. Within the middle third of the medial arm, it is usually possible to find a perforator from the superior ulnar collateral artery.

The ulnar nerve in the cubital tunnel: a foetal study.

The ulnar nerve (UN), a terminal branch of the medial cord of the brachial plexus, is located posteromedial to brachial artery coursing along medially in the arm from the anterior to the posterior compartment through the arcade of Struthers. It passes posterior to medial epicondyle of humerus and enters the cubital tunnel. Then, it exits through the distal part of the cubital fossa to enter the medial side of the forearm between the two heads of the flexor carpi ulnaris muscle underneath Osborne's ligament to enter the anterior compartment of the forearm. Entrapment of the UN at the cubital tunnel results in a pain and a tingling sensation on the medial side of the forearm and fourth and fifth digits. This foetal study documented the course of the UN within the cubital tunnel and its anatomical relations utilising bilateral microscopic dissection of 25 foetuses (gestational age: 19-36 weeks). The UN followed the standard anatomical course in 96% (48/50) of the specimens, however it was found to lie deep to the muscles of the cubital tunnel in 6% (3/50). The radial artery joined the UN distal to the cubital tunnel in 8% (4/50), while the superior ulnar collateral artery was posteriorly related to the UN in 32% (16/50) of specimens. The Osborne's ligament (crossed between the two heads of the flexor carpi ulnaris muscle, posterior to the medial epicondyle of the humerus) was present in all specimens 100% (50/50). It had a mean length of 6.32 ± 0.97 mm and 6.30 ± 1.10 mm on the left and right sides, respectively. The current study observed that the flexor pronator aponeurosis was present in 2% (1/50) of specimens. Knowledge of the normal and variable anatomical course of the UN in the cubital tunnel in this study may assist in the diagnosis and treatment of compressive neuropathy of the UN in the cubital tunnel.

Musculocutaneous flap of the medial head of the triceps brachii: pedicled flap to cover the posterior cubital region.

The medial head of the triceps brachii flap is already described as a local muscular or as a free flap. It allows coverage of defects of the posterior cubital region. The aim of this study was to describe the vascular anatomy of the musculocutaneous medial triceps brachii pedicled flap. Eleven fresh-frozen upper limbs (6 come from women and 5 from men) were proximally injected with Indian ink agar solution. The medial head of the triceps brachii muscle was dissected and the superior ulnar collateral artery (SUCA) was isolated with its collaterals. The collateral arteries were dissected to determine whether there were septocutaneous or musculocutaneous arteries for vascularization of the skin in front of the medial head. Lengths of those collaterals arteries were measured. The average number of collaterals arteries from the SUCA supplying the medial head of the triceps brachii is 4.5 (from 3 to 6 arteries). Among these collaterals' arteries, there are one average 1.5 (0.6-4.5) septocutaneous arteries and 3 (1-4.8) musculocutaneous arteries. A musculocutaneous flap with the medial head of the triceps brachii muscle can be described with the muscle. The SUCA gives perforator arteries musculocutaneous and septocutaneous for the vascularization of the triceps brachii medial head. The use of local pedicled flap with similar tissue maximizes healing with a minimal morbidity of the donor site. This study demonstrated the feasibility of the medial head triceps brachii musculocutaneous flap to cover defect of the posterior aspect of the elbow.

Angiosomes of the Ulnar Nerve at the Elbow: A Cadaver Trial Using Contrast-Enhanced Ultrasound.

Three major arteries supplying the ulnar nerve in the cubital tunnel are commonly known. However, their vascular territories (angiosomes) have not been described yet. Contrast-enhanced ultrasound was used to identify the angiosomes of posterior ulnar recurrent artery, inferior ulnar collateral artery and superior ulnar collateral artery in 20 fresh, non-frozen human body donors. The arteries were cannulated, and physiologic blood flow was simulated. Contrast agent was applied in each vessel in a randomized sequence, and the length of the contrast-enhancing ulnar nerve segment was measured by a radiologist blinded to the sequence. The angiosome of the posterior ulnar recurrent artery overlaps both other angiosomes. It fully covers the cubital tunnel in 63.6% of specimens. In addition, collateral flow via nerve and muscle branches of the arterial anastomotic network around the elbow (rete articulare cubiti) partly maintains the intra-neural blood flow in the absence of a vascular pedicle. The posterior ulnar recurrent artery is the dominant nutrient vessel of the ulnar nerve in the cubital tunnel. A potential watershed zone exists proximal to the Osborne ligament. Knowledge of these angiosomes may advance surgery of the ulnar nerve in the cubital tunnel.

Anatomy of the ulnar nerve in the posterior compartment of the upper arm: Relationships with the triceps brachii muscle

The aim of our descriptive anatomical study was to clarify the relationships between the ulnar nerve and the triceps brachii muscle in the posterior compartment of the upper arm. This study involved 30 fresh adult upper limbs. In all specimens, the ulnar nerve crossed from the anterior to posterior compartment in a space formed by the medial intermuscular septum and muscle fibers of the triceps' medial head. This transition zone was located an average of 126mm (115-135mm) proximal to the start of the ulnar groove. In the posterior compartment, the nerve descended vertically, and its anterior side was attached to the posterior side of the septum. Its posterior and lateral sides were covered by muscle fibers from the medial head. Its medial side was always free meaning that the nerve did not penetrate through the medial head. The other heads of the triceps muscle had no direct interactions with the ulnar nerve within this compartment. During its posterior course, the nerve was accompanied by the superior ulnar collateral artery. The ulnar nerve did not give off any branches in the upper arm.

Effect of skin soft tissue expansion on repair of large area of scars on extremities

Objective: To investigate the effect of skin soft tissue expansion on repair of large area of scars on extremities. Methods: Twenty-five patients with large area of scars on extremities were admitted to our department from June 2007 to October 2014. There were 14 males and 11 females, aged 4 to 36 years. Operations were performed under local infiltration anesthesia or general anesthesia. In the first stage, 1 to 5 cylindrical expanders with capacities of 250 to 600 mL were placed at left or right sides or at upper or lower parts of the scars. In the second stage, scars of 21 patients were repaired with expanded transverse propulsive and lateral flaps, and scars of 4 patients were repaired with expanded perforator flaps whose pedicles were perforators of brachial artery, superior ulnar collateral artery, or posterior interosseous artery according to areas and shapes of the scars. The secondary wound areas ranged from 13 cm×7 cm to 34 cm×18 cm after dissolution or excision of scars. The areas of flaps ranged from 13 cm×7 cm to 20 cm×12 cm. The donor sites were sutured directly. The flaps after operation and follow-up of patients were observed and recorded. Results: All expanded flaps survived after operation. And the superficial distal part of flap whose pedicle was perforator of posterior interosseous artery in one patient was with necrosis, and other flaps survived well. During follow-up of 3 to 15 months after operation of the second stage, color and texture of flaps were similar to surrounding skin, while extremities of donor sites were thinner and auxiliary incisional scars formed after expansion. Conclusions: Expanded flap is a good way to repair large area of scar on extremities. Bilateral skin of scar is the first choice of donor site of expanded flap. If there isn't enough skin for expanding on bilateral sides, expanded perforator flap designed at upper or lower part of the scar is another choice to repair the scar.

An unusual branching pattern of the axillary artery

Variations in the branching pattern of axillary artery are frequently found. Knowledge about the variations in the branching pattern of Axillary artery is important for surgeons to avoid intraoperative injuries in axilla. An unusual unilateral variation in branching pattern of axillary artery was found during routine undergraduate dissection in Medical College & Hospital, Kolkata. Variation consist of origin of a common arterial trunk from the 2nd part of axillary artery which was giving rise to 4 branches namely, Anterior & Posterior circumflex humeral artery, Arteria profunda brachii and superior ulnar collateral artery, rest of the branches were as usual.

Procurement of Extended Vascularized Skin Flaps from the Donor Enables Hand Transplantation in Severe Upper Extremity Burns: An Anatomical Study.

Hand transplantation in patients with severe upper extremity burns can be associated with an increased risk of exposure of vessels, tendons, and nerves because of extensive skin and soft-tissue deficit. This study evaluated how to reliably transfer additional extended skin flaps with a standard hand allograft. Twenty-five upper extremities were used. Sixteen were injected with latex to map the perforating branches of the brachial, superior ulnar collateral, radial, ulnar, and posterior interosseous arteries. Nine hand allografts were procured, injected with blue ink through the brachial artery to assess the perfusion of the skin flaps, and then mock transplanted. Sizable perforators from the brachial, superior ulnar collateral, radial, ulnar, and posterior interosseous arteries were used to augment the vascularization of the skin flaps. The average stained area of the medial arm flap was between 85.7 and 93.9 percent. The stained area of the volar forearm flap was the smallest when based on perforators within 6 cm from the wrist crease (51.22 percent). The dorsal forearm flap showed the least amount of staining (34.7 to 46.1 percent). The average time to repair tendons, nerves, and vessels was longer when a single volar forearm-arm flap was harvested (171.6 minutes). Harvest of the allograft associated with a distally based forearm flap and islanded arm flap was the fastest (181.6 ± 17.55 minutes). Extended skin flaps, based on perforators of the main axial vessels, can be reliably transplanted with a standard hand allograft based on the brachial or axillary vascular pedicle.

Clinical effect observation of vascularized anterior transposition of ulnar nerve for treatment of severe cubital tunnel syndrome

Objective To evaluate the clinical outcomes of a modified procedure of ulnar nerve anterior transposition in the treatment of severe cubital tunnel syndrome. Methods From September 2015 to May 2016, 25 patients with cubital tunnel syndrome underwent vascularized ulnar nerve anterior transposition were followed up after operation. All the patients had severe muscular atrophy and deformity of elbow joint before operation. According to Gu Yudong's classification of cubital tunnel syndrome, they were graded as severe. In this modified procedure, the sufficient neurolysis of ulnar nerve as well as the anterior transposition of ulnar nerve accompanied with superior ulnar collateral artery were conducted. Results All the 25 patients were follow-up from 12 to 21 months with an average of 15.3 months. All the patients achieved sensory recovery in different degrees without temporary worsening of clinical symptoms. Completely sensory recovery was observed in 20 patients (80%). 4 patients (16%) remained occasional sensory symptoms while only 1 patient (4%) remained persistently moderate sensory symptoms. The mean two-point discrimination of little finger pulp was improved from preoperative 6.08 mm to postoperative 2.93 mm. Obvious improvement of intrinsic muscular atrophy was observed in 17 patients (68%). According to the Gu Yudong's function evaluation standard of cubital tunnel syndrome, the results were excellent in 16 patients, good in 6 patients and fair in 3 patients with the excellent and good rate being 88%. Conclusion The modified technique of vascularized anterior transposition of unlar nerve appears to be an effective and safe procedure for the treatment of severe cubital tunnel syndrome. It might reduce the incidence of postoperative nerve symptoms caused by devascularization of ulnar nerve. Key words: Cubital tunnel syndrome; Ulnar nerve; Vascularized; Anterior transposition

Abstract: Hand Transplantation in Patients with Extensive Burns of the Upper Extremities: Anatomical Study on Feasibility

INTRODUCTION: Hand transplantation in patients with severe burns of the upper extremity presents unique challenges because of extensive skin and soft tissue deficit. In skin grafted recipient limbs there is an increased risk of exposure of vascular anastomosis, tendons and nerves. The aim of this anatomical study was to evaluate how to reliably transfer increased amounts of skin from the upper extremity based on the perforators of the main axial vessels to replace the scarred recipient skin. METHODS: 25 upper limbs were studied. Based on the vascular anatomy of the perforators, forearm based hand allografts were harvested with 3 different patterns: A) volar and dorsal forearm flaps based only on distal perforators of Radial (RA), Ulnar (UA) and Posterior Interosseous (PIA) arteries and islanded medial arm flap based on Brachial and/or Superior Ulnar Collateral (SUCA) arteries; B) volar and dorsal forearm flaps with preservation of proximal RA perforators with only distal UA perforators and the islanded medial arm flap C) dorsal forearm flap and extended medial arm-volar forearm skin flap. 16 samples were injected with latex to map the perforating branches of the BA, SUCA, RA, UA and PIA. 3 samples for each group were dissected and injected with blue ink from the proximal BA to assess the retained perfusion of the flaps. RESULTS: The medial arm flap was constantly supplied by perforators from the BA and the SUCA (respectively 4.35 ± 1.64, diameter 1.03 ± 0.34mm and 2.6 ± 0.76, diameter 0.90 ± 0.34mm) and adequately perfused when the perforators from the BA or SUCA were preserved (90.8% stained). Perforators from RA (9.3 ± 1.62) if preserved, proved to be adequate to supply the total volar forearm skin (87.6% stained). The harvesting of the PIA with its perforators (5.25 ± 0.95) provided vascularization to the proximal half of the posterior flap. CONCLUSION: The medial arm flap should be safely based on perforators from the BA and/or SUCA. The design of the specimens in group B proved higher vascularization reliability and versatility as they provided adequate vascularization to the skin flaps with minimal interference with the dissection and repair of vessels, tendons and nerves.

Vascular territories of the medial upper arm-an anatomic study of the vascular basis for individualized flap design.

Fasciocutaneous flaps supplied by discrete perforator arteries can be raised in numerous parts of the human body and are routinely used in plastic surgery. The aim of this anatomical investigation was to provide a description of the vascular supply of the medial upper arm, to localize and measure the perforator arteries and to define potential perforator flap dimensions in pendency of individual anatomical conditions. A total of 20 upper limbs from 11 fresh cadavers were examined. The brachial arteries were exposed and the medial perforator arteries selectively injected with methylene blue and india ink in an alternating sequence. The size of the angiosomes, the diameter and length of the perforators' pedicles and distances between the arteries and the medial epicondyle and apex of the axilla respectively were measured. On average, 4.55 ± 1.47 perforating arteries arose from the brachial artery and it's medial off branching arteries. Their mean diameter was 0.68 ± 0.27 mm and their pedicles had an average length of 3.62 ± 1.61 cm measured from suprafascial until arborisation. In 80% the first proximal perforator was present in an area of 4 cm radius at centre coordinates of (20/2). A constant distal perforator was found within a circle of 3 cm radius, of which the centre had the coordinates (8/1). The average size of the angiosomes was 121.1 ± 58.5 cm2 . Direct branches of the brachial artery feed circular shaped vascular territories, whereas superior ulnar collateral arteries (SUCAs) feed oblong shaped territories. This anatomical study provides valuable data of the medial arm flap in order to be applied clinically. © 2016 Wiley Periodicals, Inc.

Ultrasonic Observation and Clinical Application of Arcade of Struthers in the Mid-Arm

The mid-arm structure named arcade of Struthers has been shrouded in controversy since it was identified. Most specimens in previous studies were European. The occurrence, component, extent, and position of this structure in the xanthoderm are not clear. Moreover, research into the arcade of Struthers has been at the anatomic level and there has been no ultrasonic research. The aim of this study was to elucidate and measure this anatomy by both anatomic dissection and ultrasonic observation to provide clear and definite criteria to classify the arcade of Struthers, as well as operation guidelines for identifying the arcade of Struthers in ultrasonic imaging and surgical decompression. Sixty-four upper limb specimens of 32 adult cadavers were dissected. The tendinous arcade of Struthers (TAS) and muscular arcade of Struthers (MAS) were observed and measured, as well as the position at which the medial intermuscular septum was pierced by the ulnar nerve. The position at which the concomitant blood vessel began to accompany the ulnar nerve was also recorded. Twenty healthy adult participants were enrolled for ultrasonic research. The ulnar nerve was scanned from the cubital tunnel to the fossa axillaris for the anatomic structure crossing it. Once the arcade of Struthers was found, the distal and proximal limits were marked on the skin and it was then measured. Anatomic study showed TASs in 21 limbs, and MASs were found in 16 limbs. The total incidence of the arcade of Struthers was 57.8%. The length of TAS (2.12 ± 0.62 cm) and MAS (4.46 ± 1.96 cm) had a significant difference and the distance between its proximal limit and the medial humeral epicondyle were 8.93 ± 1.38 cm and 9.50 ± 1.69 cm, respectively. Ultrasonic study showed that the incidence of the arcade of Struthers was 50.0%. The distance between its proximal limit and the medial humeral epicondyle was 8.52 ± 1.88 cm and 9.45 ± 1.76 cm. The length was 1.85 ± 1.8 cm and 4.23 ± 1.93 cm, respectively. We believed that an arcade of Struthers described by multiple investigators did exist in Chinese people, and based on our study, it was classified into 2 types: TAS and MAS. Caution should be used to preserve the superior ulnar collateral artery when incising the arcade of Struthers. Ultrasonography can detect the existence ratio, dimension, and location of the arcade of Struthers.

Variations in the branching pattern of brachial, ulnar and radial arteries

AbstractDuring routine dissection of a cadaver alloted to the undergraduate students in the department of anatomy in SN Medical College, Bagalkot, the authors found multiple variations in the branching pattern of brachial, ulnar and radial arteries. There was high division of brachial artery into ulnar and radial arteries. The profunda brachii originated from brachial artery as usual while superior and inferior ulnar collateral arteries originated from ulnar artery. The radial artery gave origin to common interosseous artery which further divided into anterior and posterior interosseous arteries. All the three arteries i.e. brachial, ulnar and radial were considered as superficial arteries as they were superficial throughout the course. These observations of vascular anomalies are of clinical significance to vascular and plastic surgeons.

Applied anatomical study of the vascularized ulnar nerve and its blood supply for cubital tunnel syndrome at the elbow region.

Cubital tunnel syndrome is often accompanied by paresthesia in ulnar nerve sites and hand muscle atrophy. When muscle weakness occurs, or after failure of more conservative treatments, anterior transposition is used. In the present study, the ulnar nerve and its blood vessels were examined in the elbows of 18 adult cadavers, and the external diameter of the nutrient vessels of the ulnar nerve at the point of origin, the distances between the origin of the vessels and the medial epicondyle of the humerus, and the length of the vessels accompanying the ulnar nerve in the superior ulnar collateral artery, the inferior ulnar collateral artery, and the posterior ulnar recurrent artery were measured. Anterior transposition of the vascularized ulnar nerve was performed to treat cubital tunnel syndrome. The most appropriate distance that the vascularized ulnar nerve can be moved to the subcutaneous tissue under tension-free conditions was 1.8 ± 0.6 cm (1.1–2.5 cm), which can be used as a reference value during the treatment of cubital tunnel syndrome with anterior transposition of the vascularized ulnar nerve.

Treatment of cubital tunnel syndrome with ulnar nerve anterior submuscular transposition and medial epicondyle muscle group in situ reconstruction via a bone tunnel

Objective To investigate the clinical effectiveness of treating moderate to severe cubital tunnel syndrome with ulnar nerve decompression,anterior submuscular transposition and medial epicondyle muscle group in situ reconstruction via a bone tunnel.Methods The clinical data of 45 cases of moderate to severe cubital tunnel syndrome diagnosed between January 2005 and October 2012 were analyzed.The ulnar nerve was decompressed and its perfnsion by the superior ulnar collateral artery was observed under the surgical microscope intraoperatively.After ulnar nerve was transposed anteriorly,the detached medial epicondyle muscle group was reconstructed in situ through a bone tuunel under direct view.The size of the new ulnar nerve tunnel and mobility of the ulnar nerve were observed.Postoperative recovery was follow-up including pain,sensation,muscular atrophy recovery,claw hand,grip strength,wrist flexion and forearm pronation.Results All 45 cases were follow-up for 6 to 18 months.Intraoperative microscopic observation showed good ulnar nerve perfusion by the superior ulnar collateral artery.Reattachment of the medial epicondyle muscle group was secure.The newly formed cubital tunnel could allow an 8 mm dilator without tension in elbow full extension position.Ulnar nerve could glide freely upon elbow flexion and extension.According to the cubital tunnel syndrome function evaluation standard suggested by Gu Yudong,the results were graded as excellent in 20 cases,good in 17 cases,and fair in 8 cases.The overall excellent and good rate was 82.22％.Wrist flexion and forearm pronation force recovered to preoperative level in all the patients 3 months after the operation.Conclusion Including superior ulnar collateral artery in the anterior transposition of the ulnar nerve provides good blood supply to the nerve and benefits nerve recovery.In situ reconstruction of the medial epicondyle muscle group through a bone tunnel puts the ulnar nerve anderneath flexor carpi ulnaris and pronator teres.The new tunnel is big enough to avoid compression of the nerve.The surrounding tissues are loose so there will be neither ulnar nerve compression around the elbow nor nerve stretch upon elbow flexion.Muscle reattachment via a bone tunnel is secure.No postoperative elbow immobilization with a cast is needed.This allows early protected movement and early return to normal life and work. Key words: Cubital tunnel syndrome; Humerus; Anterior submuscular transposition; Bone tunnel; Reconstruction in situ

Unilateral Aberrant Branch to the Thoracic Region of the Brachial Artery

The brachial artery begins at the lower margin of the tendon of the teres major muscle, and, passing down the arm, ends about 1 cm. below the bend of the elbow, where it divides into the radial and ulnar arteries. Branches of the brachial artery are the profunda brachii artery (also known as the deep brachial artery), nutrient humeral artery, superior ulnar collateral artery, inferior ulnar collateral artery, radial artery (a terminal branch) and ulnar artery (a terminal branch). Superior thoracic artery (highest thoracic artery) is a small vessel normally arising from the first division of the axillary artery and the lateral thoracic artery (or external mammary artery) is a blood vessel that supply to the upper and lateral structures of the thorax and breast. The thoracodorsal artery is a branch of the subscapular artery. It travels inferiorly with the thoracodorsal nerve and also supplies the lateral wall of thorax. We found an aberrant branch of the left brachial artery in an adult, Caucasian, male cadaver during a routine dissection. This aberrant artery originated from brachial artery, 2 cm below of the profunda brachii artery, then course to the thoracic region on the left side. This aberrant branch was divided to superficial and deep branches over the pectoralis major muscle at the lower border of fifth costa. Variations of arterial system in the upper limb are well documented. According to human anatomy text books and available literature, this aberrant branch of the brachial artery is possible very rare and there is no existing text about it. This kind or arterial variations may cause complications during axillary, thoracic or abdominal surgical operations as well as during normal life time of these individuals.