CASE REPORT
Multiple arterial, neural and muscular
variations in upper limb
of a single cadaver
VENKATA RAMANA VOLLALA1), SOMAYAJI NAGABHOOSHANA1),
SEETHARAMA MANJUNATHA BHAT1), BHAGATH KUMAR POTU2),
V. RODRIGUES1), N. PAMIDI1)
1)
Abstract
During routine dissection classes to undergraduate medical students, we have observed some important anatomic variations in the right
upper limb of a 45-year-old cadaver. The anomalies were superficial ulnar artery, persistent median artery, variant superficial palmar arch,
third head for biceps brachii, accessory head for flexor pollicis longus, variant insertion of pectoralis major, absence of musculocutaneous
nerve, coracobrachialis muscle supplied by lateral root of median nerve and anomalous branching of median nerve in arm and forearm.
Although there are individual reports about these variations, the combination of these variations in one cadaver has not previously been
described in the literature consulted. Awareness of these variations is necessary to avoid complications during radiodiagnostic procedures
or surgeries in the upper limb.
Keywords: superficial ulnar artery, superficial palmar arch, persistent median artery, biceps brachii, flexor pollicis longus,
median nerve.
Introduction
The term superficial ulnar artery is applied to an
artery that arises from the axillary, brachial or
superficial brachial arteries and courses over the origins
of the superficial forearm muscles to join with the ulnar
artery at the midlevel of the forearm, sometimes
replacing it [13]. Its incidence ranges from 0.7% [4] to
3.3% [5]. The superficial ulnar artery has been reported
with different terminologies; arteria antebrachialis
superficialis ulnaris [46], high origin of the ulnar
artery [78], and superficial ulnar artery with a high
origin [9].
Persistent median arteries vary in their mode of
origin and have been described as arising from the
ulnar, common or anterior interosseous, radial or
brachial arteries [10]. The median artery may persist in
adult life in two different patterns, palmar and
antebrachial, based on their vascular territory.
The palmar type, which represents the embryologic
pattern, is large, long and reaches the palm.
The antebrachial type, which represents a partial
regression of the embryonic artery is slender, short, and
terminates before reaching wrist [11].
The major source of blood supply to the hand and
fingers is from the superficial palmar arch (SPA).
SPA is normally formed by the superficial branch of
ulnar artery and completed on the lateral side by either
the superficial palmar branch of radial artery; princeps
pollicis artery or radialis indicis artery. The reported
130
Multiple arterial, neural and muscular variations in upper limb of a single cadaver
131
132
There was no musculocutaneous nerve; coracobrachialis muscle was supplied by lateral root of median
nerve and the median nerve supplied biceps brachii and
brachialis muscles and one of the muscular branches
continued down as lateral cutaneous nerve of fore arm
(Figure 7). In the distal part of forearm the median
nerve terminated by dividing into medial and lateral
branches. Both the branches passed through the carpal
tunnel to reach the palm. The distribution of median
nerve in the palm was normal.
Discussion
The superficial course of the ulnar artery over the
forearm flexors has been described in two ways: under
the antebrachial fascia [7, 3638] or, more infrequently,
as in our case, over the antebrachial fascia in a
subcutaneous position [36, 39]. The artery has been
described as gaining the lateral border of flexor carpi
ulnaris at midforearm level [37] or after passing deep to
the palmaris longus [36, 37, 40, 41]. However, in our
case this relationship was gained at the distal third of the
forearm, close to the wrist joint. There are reports
stating presence of superficial ulnar artery along with
persistent median artery [7, 40, 42] as in our case.
Developmentally, the upper limb bud is initially
supplied by a vascular plexus derived from four or five
Multiple arterial, neural and muscular variations in upper limb of a single cadaver
133
134
Multiple arterial, neural and muscular variations in upper limb of a single cadaver
[31] KIDA M., The morphology of the Gantzers muscle
with specific reference to the morphogenesis of the
flexor digitorum superficialis, Kaibogaku Zasshi, 1988,
63:539546.
[32] TOUNTAS C. H. P., BERGMAN R. A., Anatomic variations of
the upper extremity, Churchill Livingstone, New York, 1993,
147156.
[33] JONES M., ABRAHAMS P. H., SAUDO J. R., Case report:
accessory head of the deep forearm flexors, J Anat, 1997,
191(Pt 2):313314.
[34] GMSBURUN E., ADIGZEL E., A variation of the brachial
plexus characterized by the absence of the musculocutaneous nerve: a case report, Surg Radiol Anat, 2000,
22(1):6365.
[35] ROMANES G. J., Cunninghams Manual of Practical
th
Anatomy. Vol. 1. Upper and lower limbs, 15 edition, Oxford
University Press, 2004, 2889.
[36] HAZLETT J. W., The superficial ulnar artery with reference
to accidental intra-arterial injection, Can Med Assoc J,
1949, 61(3):289293.
[37] MCCORMACK L. J., CAULDWELL E. W., ANSON B. J.,
Brachial and antebrachial arterial patterns; a study of
750 extremities, Surg Gynecol Obstet, 1953, 96(1):4354.
[38] ANIL A., TURGUT H. B., PEKER T. V., A variant of superficial
ulnar artery, Surg Radiol Anat, 1996, 18(3):237240.
[39] QUAIN R., The anatomy of the arteries of the human body,
Taylor and Walton, London, 1844, 326337.
[40] SCHWYZER A. G., DE GARIS C. F., Three diverse patterns of
the arteria brachialis superficialis in man, Anat Rec, 1935,
63:405416.
[41] WEATHERSBY H. T., Anomalies of brachial and antebrachial
arteries of surgical significance, South Med J, 1956,
49(1):4649.
[42] PABST R., LIPPERT H., Beiderseitiges Vorkommen von
A. brachialis superficialis, A. ulnaris superficialis und
A. mediana, Anat Anz, 1968, 123(2):223226.
[43] AREY L. B., Arteries of the limbs. In: AREY L. B. (ed),
st
Developmental Anatomy, 1 edition, W. B. Saunders,
Philadelphia, 1966, 358359.
[44] PATTEN B. M., Arteries of the extremities. In: PATTEN B. M.
rd
edition, McGrawHill,
(ed), Human Embryology, 3
New York, 1968, 518521.
[45] ALLAN F. D., Arteries of the extremities. In: ALLAN F. D. (ed),
nd
edition, Oxford
Essentials of Human Embryology, 2
University Press, London, 1969, 97.
[46] HAMILTON W. J., MOSSMAN H. W., Arteries of the limb buds.
In: HAMILTON W. J., BOYD J. D., MOSSMAN H. W. (ed),
Hamilton, Boyd and Mossmans Human Embryology,
th
4 edition, W. Heffer and Sons Ltd., Cambridge, 1972,
208209, 271.
[47] POTEAT W. L., Report of a rare human variation: absence of
the radial artery, Anat Rec, 1986, 214(1):8995.
[48] DEVANSH M. S., Superficial ulnar artery flap, Plast Reconstr
Surg, 1996, 97(2):420426.
[49] IKEDA A., UGAWA A., KAZIHARA Y., HAMADA N., Arterial
patterns in the hand based on a three-dimensional analysis
of 220 cadaver hands, J Hand Surg [Am], 1988,
13(4):501509.
135
Corresponding author
Venkata Ramana Vollala, Lecturer, Department of Anatomy, Melaka Manipal Medical College (Manipal Campus),
Manipal University, Manipal576104, Karnataka State, India; Phone 918202922642, Fax 918202571905,
e-mail: ramana.anat@gmail.com