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Romanian Journal of Morphology and Embryology 2009, 50(1):129135

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)

Department of Anatomy, Melaka Manipal Medical College


(Manipal Campus), Manipal, Karnataka, India
2)

Department of Anatomy, Kasturba Medical College,


Manipal, Karnataka, India

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

variations of the SPA are the superficial palmar branch


of the radial artery passing deep to the flexor
retinaculum to form the SPA [12], absence of the SPA
[13], incomplete development of the SPA [14], doubled
SPA [15] and princeps pollicis and radialis indicis
arteries arising from SPA [16].
The classical description of attachments of the
biceps brachii muscle include the short head arising
from the tip of the coracoid process of the scapula, and
the long head arising from the supraglenoid tubercle of
the scapula and from the glenoidal labrum, distally the
two bellies unite to form a common tendon, which is
inserted into the posterior rough part of the radial
tuberosity and through the bicipital aponeurosis to the
subcutaneous posterior border of ulna. It is one of the
most variable muscles in the human body in terms of the
number and morphology of its heads [15, 1719].
This muscle frequently has more than two heads arising
from the humerus at the insertion of the coracobrachialis
or the neck of the humerus. There are reports describing
supernumerary bicipital heads ranging from three to
seven. Among them, the three-headed variant represents
the most common type that has been reported with a
prevalence ranging from 7.518.3% [18, 2023].
The presence of accessory muscles in the forearm
was reported way back in 1813 by Gantzer, and from
then onwards these muscles have been reported with
variable attachments [2433]. The accessory heads of
the deep flexors of the forearm (Gantzers muscles)
have been described as small bellies inserting either

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Venkata Ramana Vollala et al.

into flexor pollicis longus (FPL) or flexor digitorum


profundus (FDP).
The musculocutaneous nerve is a mixed peripheral
nerve that originates from the lateral cord of the brachial
plexus in the axilla. It usually supplies the
coracobrachialis, biceps brachii and the brachialis
muscles in the anterior compartment of the arm and then
continues as the lateral cutaneous nerve of the forearm.
The musculocutaneous nerve has frequent variations
and these were discussed in detail in earlier articles.
It may be doubled, unusually short, or even absent.
The musculocutaneous nerve arises from the lateral cord
(90.5%), from the lateral and posterior cord (4%), from
the median nerve (2%), as two separate bundles from
the medial and lateral cords (1.4%) or from the posterior
cords (1.4%). The median nerve typically does not
innervate muscles in the upper arm. However, a branch
to the pronator teres muscle can occasionally be
observed. Some fibers of the median nerve may run in
the musculocutaneous nerve, leaving it to join their
proper trunk. Less frequently the reverse occurs, the
median nerve sending a branch to the musculocutaneous
nerve. A single puncture wound, therefore, could
theoretically impair the muscles innervated by both the
musculocutaneous and the median nerves if there were
complete or partial fusion of these nerves. Nerves
following an anomalous course are more susceptible to
accidental injury [34].
 Material and Methods
The present study involved the upper limb
dissections of a 45-year-old male cadaver in the
department of Anatomy, Melaka Manipal Medical
College, Manipal University, Manipal. The dissections
of both upper extremities (right and left) of the body
were carried out according to the instructions by
Cunninghams Manual of Practical Anatomy [35].
The dissections were carried out during 20062007.
The body was preserved by the injection of a formalinbased preservative (10% formalin) and stored at -40C.
Before taking photographs, the dissected region was
rinsed with water.
 Results
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, a branch from
lateral root of median nerve supplying coracobrachialis,
absence of musculocutaneous nerve and anomalous
branching of median nerve in arm and fore arm were
found in the right upper limb. However, the left upper
limb showed no abnormalities.
The brachial artery had a normal course in the arm
but at elbow level, it divided into the radial and
common interosseous arteries. The superficial ulnar
artery (Figure 1) was of a smaller caliber than both the
radial and common interosseous arteries. The branching
and course of radial artery in the cubital fossa was
normal. The common interosseous artery gave branches,
which replaced normal anterior and posterior ulnar

recurrent arteries. It also gave origin to median artery


before terminating into anterior interosseous and
posterior interosseous arteries (Figure 2).
The superficial ulnar artery is a well-known but very
rarely encountered abnormality. In the present case, the
artery arose from the brachial artery in the proximal part
of the arm. It then descended along the arm superficial
and lateral to the median nerve (Figure 1).
At the elbow level, the artery ran superficial to the
bicipital aponeurosis, coursed obliquely downwards and
medially, superficial to the forearm flexor muscles over
the antebrachial fascia and under the superficial venous
system to reach the distal third of the forearm, where it
was seen on the lateral side of flexor carpi ulnaris close
to the ulnar nerve.
The artery then passed anterior to the flexor
retinaculum where it divided into two terminal
branches. The superficial branch anastomosed with the
persistent median artery to form the superficial palmar
arch and the deep branch anastomosed with the radial
artery to form the deep palmar arch.
In the present report, the median artery, which is
palmar type, arose from the common interosseous artery
and descended to the wrist on the superficial aspect of
FDP and deep to flexor digitorum superficialis (FDS),
passed through carpal tunnel and terminated by forming
superficial palmar arch with superficial branch of ulnar
artery (Figures 2 and 3).
The variant superficial palmar arch in the present
case provided five branches, four common palmar
digital and one proper palmar digital artery to supply the
digits (Figure 3).
The superficial palmar branch of the radial artery
terminated in the thenar muscles without any
contribution to the superficial palmar arch. The first
common palmar digital artery divided into radialis
indicis and princeps pollicis arteries to supply the radial
side of the index finger and both sides of thumb, there
were no branches from the deep palmar arch to supply
the index finger and thumb. The second, third and
fourth common palmar digital arteries divided into
digital branches to supply the second, third and fourth
inter digital spaces. The proper palmar digital artery
supplied ulnar side of the little finger.
The accessory head of the biceps brachii muscle
arose from deltoid muscle (Figure 4). Some of the
deltoid muscle fibers from the acromion process
continued down as third head of biceps and converged
with both long and short heads to form a common
tendon, which inserted normally as the bicipital
aponeurosis and into the radial tuberosity.
In the present case, an additional belly for flexor
pollicis longus muscle was seen. The muscle fibers took
origin from the undersurface of the flexor digitorum
superficialis formed a narrow belly and its tendon was
inserting onto the medial aspect of the flexor pollicis
longus (Figure 5).
We also observed an anomalous pectoralis major
muscle in the present cadaver (Figure 6). The origin of
the muscle was normal but at the insertion the clavicular
fibers merged with the deltoid muscle and sternal fibers
inserted onto the lateral lip of intertubercular sulcus.

Multiple arterial, neural and muscular variations in upper limb of a single cadaver

131

Figure 1 B brachial artery; SUA


superficial ulnar artery.

Figure 2 B brachial artery; R radial artery;


CIA common interosseous artery; AIA
anterior interosseous artery; PIA posterior
interosseous artery; PMA persistent median
artery; MN median nerve.

Figure 3 PMA persistent median artery; SUA


superficial ulnar artery; SPA superficial palmar
arch; 1, 2, 3, 4 common palmar digital arteries;
5 palmar digital artery for little finger; 6
princeps pollicis artery; 7 radialis indicis artery;
MN median nerve; *** lateral branch; ****
medial branch.

Figure 4 D deltoid; Bb biceps brachii;


Thb third head of biceps brachii; tBb tendon
of biceps brachii; Bc brachialis.

Figure 5 AbFPL additional belly of flexor pollicis


longus; FPL flexor pollicis longus; FDS flexor
digitorum superficialis.

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Venkata Ramana Vollala et al.

Figure 6 Pmj pectoralis major; ## tendon


merging with the deltoid; $$ tendon inserting
onto the lateral lip of intertubercular sulcus; Bb
biceps brachii; Thb third head of biceps brachii;
D deltoid.

Figure 7 Lr lateral root; br a branch


supplying coracobrachialis; Mr medial root;
MN median nerve; Labcn lateral
antebrachial cutaneous nerve; **** a
branch replacing musculocutaneous nerve;
Bb biceps brachii.

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

consecutive intersegmental branches of the dorsal


aortae. Very early in development, the seventh cervical
intersegmental branch enlarges and becomes
consolidated as the main artery (axis artery) to the
developing upper limb bud. This axis artery gives rise to
the subclavian, axillary, brachial, and anterior
interosseous arteries and to the deep palmar arch. Other
arteries of the upper limb develop as sprouts of the axis
artery [4346]. The developmental reason for the
superficial ulnar artery in the present case may be due to
the ulnar artery establishing a connection with the axis
artery in the arm and the ventral muscle mass
developing dorsal to the ulnar artery. The bifurcation of
brachial artery into radial artery and common
interosseous artery may be due to the origin of posterior
interosseous artery from the axis artery just distal to the
connection of radial artery with the axis artery in the
cubital fossa region, and the continuation of the axis
artery between radial and posterior interosseous arteries
becomes the common interosseous artery.
Vascular anomalies occurring in common surgical
sites tend to increase the likelihood of their damage
during surgery. Owing to its unusual origin in the arm
and its subcutaneous course, the superficial ulnar artery
would be particularly vulnerable in surgical procedures
within the arm and forearm. In the present subject, the
ulnar artery was immediately subjacent to the median

Multiple arterial, neural and muscular variations in upper limb of a single cadaver

cubital vein. This would predispose the vessel to


inadvertent penetration during attempts at venipuncture
of the median cubital vein.
Although accidental intra-arterial injection of drugs
is rare, if it occurs, amputation of the forearm or fingers
is unfortunately sometimes necessary. Since the free
forearm flap on the radial artery is often used in
reconstructive surgery, the presence of a superficial
ulnar artery renders risk that it may be ligated or cut
instead of the superficial vein causing disorder of
circulation in the hand [36, 47]. On the other hand, the
presence of a superficial ulnar artery can be
advantageous, since it can be used to supply blood to
the forearm flap [48]. Radiographically, the superficial
ulnar artery can lead to misinterpretation of incomplete
angiographic pictures [47]. Therefore, it is important to
know if a patient has a superficial ulnar artery in the
forearm.
Anatomical variations in the formation of superficial
palmar arch are not uncommon. However, the present
case is interesting since the first common palmar
digital artery arising from the superficial palmar arch
was the sole source of arterial supply to the thumb.
McCormack LJ et al. [37] in their comprehensive study
on the arterial pattern of 750 hands did not find the
origin of the princeps pollicis and radialis indicis
arteries from the superficial palmar arch. According to
Ikeda A et al. [49], the artery arising from the
superficial palmar arch to supply the first web space
can be called as the first common palmar digital artery.
During surgical procedures of thumb in the cases
similar to ours, ligation of radial artery may not be
sufficient to stop the profuse bleeding since major blood
supply was coming from the superficial palmar arch.
Several techniques are used to identify and locate any
unusual vessel in the upper limb, including Doppler
ultrasound, the modified Allen test, pulse oximetry and
arterial angiography.
In this report, we also describe a rare case of a third
head of the biceps brachii that arose from the deltoid
muscle, a variant found in only one of 546 arms in the
study by Kosugi K et al. [17]. There was a similar
report [50] in which the third head was supplied by
musculocutaneous nerve, but in the present case the
third head was supplied by median nerve. The muscle
fibers arising from the acromion process contributed to
both deltoid and biceps brachii muscles in the present
case. These muscle fibers theoretically should have
action on three joints; on shoulder joint as abductors,
flexors of the elbow, and supinators of radioulnar joints.
Although, the third head of biceps brachii is a
common occurrence in mammals [5153], previous
studies in human beings show that the third head of
biceps brachii is seen in about 8% of Chinese [15], 10%
of white Europeans [15, 54], 12% in black Africans
[15], 18% of Japanese [15], 20.5% of South African
blacks; 8.3% of South African whites [20], 20% of
Brazilian whites; 9% of Brazilian blacks [18], 15% of
Turkish [21], and merely 2% in Indian population [55].
Therefore, the occurrence of third head of biceps brachii
in Indian population is rare. According to RodrguezNiedenfhr M et al. [22], the accessory bicipital head in

133

the present case corresponds to the inferolateral type.


The presence of the third head may cause unusual
bone displacement, subsequent to fracture. Such
variations have relevance in surgical procedures.
Clinically, this anatomic variation would be of
relevance especially to orthopedic surgeons who might
be unaware of it and discover it during routine elevation
of the deltoid insertion as part of humeral fracture
fixation or shoulder arthroplasty.
The anomalous pectoralis major muscle in the
present cadaver had normal origin but at the insertion
the clavicular fibers merged with the deltoid muscle and
sternal fibers inserted onto the lateral lip of
intertubercular sulcus. There are similar reports in the
literature [15, 56].
The accessory heads of the flexor muscles have been
described in primates and other mammals (pigs, foxes
and marmots) as a muscle belly that connects the medial
epicondyle origin of the FDS with the more or less
differentiated deep flexor muscles [57].
The flexor muscles of the forearm develop from the
flexor mass which subsequently divides into two layers,
superficial and deep. The deep layer gives rise to the
FDS, FDP and FPL [58]. The existence of accessory
muscles, which connect the flexor muscles, could be
explained by the incomplete cleavage of the flexor mass
during development.
Accessory muscles in the arm and forearm may lead
to confusion during surgical procedures or cause
compression of neurovascular structures or lead to
variation of the normal actions. To avoid clinical
complications, during radiodiagnostic procedures (CT,
MRI) or surgical approach of these regions, awareness
of such variations must be born in mind. These types of
variations are interesting not only to anatomists, but also
to orthopedic surgeons, physiotherapists and
radiologists.
In the present case, there was absence of
musculocutaneous nerve. A branch of the lateral root of
the median nerve innervated the coracobrachialis
muscle. There are two more articles closely related
to our case. During gross anatomy dissections of
60 embalmed cadavers by Gmalan Y et al. [59] the
coracobrachialis muscle was found to be innervated by a
nerve branch arising from the lateral root of the median
nerve (as in our case), but not from the musculocutaneous nerve nor from the lateral cord of the brachial
plexus. Dissection of 55-year-old male cadaver by
Tatar I et al. [60] showed coracobrachialis muscle
innervated by lateral root of median nerve.
The absence of the musculocutaneous nerve and
innervation of the coracobrachialis by the median
nerve is an unusual variation of the brachial plexus
[19, 34, 61]. Anatomical variants of the brachial plexus
may be significant in the context of axillary trauma.
Theoretically, in a person with an anomaly of the
brachial plexus that we have described, injury to the
lateral root of median nerve could result in functional
deficiency of the coracobrachialis.
Knowledge of the anatomical variations of the
peripheral nervous system is important in interpreting
unusual clinical presentations. This study will assist

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clinicians and surgeons by pointing out anatomical


anomalies associated with the musculocutaneous nerve,
the median nerve and their branches to the anterior
compartment muscles of the upper arm. Consideration
of possible anatomical variations of the brachial plexus
is important during surgical approaches of upper
extremity.
The median nerve is often involved in pathological
states such as the carpal tunnel syndrome or various
injuries of the palm and forearm. Cases of a split
median nerve are observed mostly during surgical
interventions or anatomical dissection, more rarely
during preoperative sonographic or MR imaging, and
appear with a frequency range of 13%. The division
occurs on different levels but most typically on the
distal third of the forearm [62]. Both the branches pass
centrally through the carpal tunnel with the flexor
tendons, making it more susceptible to compression and
injury as in the present case. The coexistence of the split
median nerve with other anomalies, such as an
abnormal insertion of a muscle or persistent median
artery, appears to be quite frequent [63].
Variations of median nerve have, as some authors
claim [6466], significant clinical implications. Carpal
tunnel syndrome is more likely to appear and presents
more treatment problems. When a bifid median nerve is
encountered during surgical release, both branches
should be decompressed [66]. In some cases, a split
median nerve has forced surgeons to convert endoscopic
to open release [64]. The persistent median artery,
because of prolonged compression in the carpal tunnel,
is more susceptible to thrombotic changes [67] and may
complicate treatment.
 Conclusions
Emphasis should be put on knowledge of the
arterial, muscular and neural variations of upper limb in
order to avoid accidental injuries and also to increase
the effectiveness of surgical approaches.
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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

Received: May 9th, 2008


Accepted: January 15th, 2009

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