[Show abstract][Hide abstract] ABSTRACT: Purpose:
The anatomy of the radial recurrent artery (RRA) is important for different clinical procedures: interventional cardiology and microsurgery of the forearm; however, few studies have analysed its morphology: number, course, relations and distribution.
The RRA was analysed in 332 upper limbs divided into two groups: (1) normal pattern of the arterial axis of the upper limb (266 cases), (2) associated with major arterial variations (66 cases).
A second or accessory RRA existed in 31.2 % in group 1, and 30.3 % in group 2. In both groups, the second RRA originated from the brachial (100 %) and always (100 %) coursed behind the bicipital tendon. The accessory RRA supplied the brachioradialis, brachialis and biceps brachii muscles. The RRA in group 1, originated mostly from the radial artery (75 %), followed by radioulnar division and ulno-interosseous trunk. In group 2, the RRA arise from the brachioradial artery (65 %), or from the radial artery (in cases of ulnar or brachial artery variation). The course of the RRA behind the biceps brachii tendon was observed in 9.4 % of group 1 and in 6.1 % of group 2. The RRA supplied the brachioradialis, extensor carpi radialis longus and brevis, and supinator muscles. The RRA and accessory RRA anastomosed forming a ring around the biceps brachii tendon in 0.75 % in group 1 and in 13.6 % in group 2, the latter group having an important clinical interest.
The variability of the RRA may provide an advantage for microsurgical procedures of the elbow and disadvantage during transradial catheterism.
[Show abstract][Hide abstract] ABSTRACT: The aim of this work was to evaluate, to prove their reliability, the different surgical landmarks previously proposed as a mean to locate the recurrent laryngeal nerve (RLN).
The necks of 143 (68 male and 76 female) human adult embalmed cadavers were examined. RLN origin and length and its relationship to different landmarks were recorded and results compared with those previously reported. Statistical comparisons were performed using the chi-square test (significance, p ≤ .05).
Mostly, RLN is located anterior to the tracheoesophageal sulcus (41.6%), posterior to the inferior thyroid artery (35.8%), lateral to Berry's ligament (88.1%), below the inferior rim of the inferior constrictor muscle (90.4%), and entering the larynx before its terminal division (54.6%).
The position of the RLN in relation to those structures classically considered as landmarks is highly variable. The most reliable relationships are those with Berry's ligament or the inferior constrictor muscle.
Head & Neck 09/2012; 34(9):1240-6. DOI:10.1002/hed.21882 · 2.64 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The aim of this work is to analyse the variability of the obturator artery (oa), unify previous criteria and propose a simple classification for clinical use.
A sample of 119 adult human embalmed cadavers was used. Origin and course of the oa in relation with the external iliac artery, internal iliac artery and inferior epigastric artery were studied. Chi-squared and t test were used for statistical comparison, and p < 0.05 was considered significant.
Based on the number of roots of origin, three different situations were observed. The oa shows a single origin (96.55%). The oa presents a double origin (3.02%), or the oa arises from three roots (0.43%). The first situation was subclassified into six types according to the oa origin. Equal vascular pattern in both hemi-pelvises was observed in 58.93%.
Almost 31% of oa passes over the superior pubic ramus implying an increased risk during some procedures.
International Urogynecology Journal 06/2011; 22(10):1313-8. DOI:10.1007/s00192-011-1467-3 · 1.96 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Study and detailed description of the large connections between the normally recurrent inferior laryngeal nerve (RILN) and the sympathetic trunk (ST) because these may be mistaken for a nonrecurrent inferior laryngeal nerve (NRILN).
Morphologic study of adult human necks.
The necks of 144 human, adult, embalmed cadavers were examined (68 males, 76 females). They had been partially dissected by Cambridge preclinical medical students and then further dissected by the authors using magnification. The RILN, the ST, and their branches were identified and dissected. A total of 277 RILNs and STs (137 rights, 140 lefts) were observed.
A communicating branch (CB) with a similar diameter to the RILN occurred between the ST and the RILN in 48 of the 277 (17.3%) dissections, 24 from the 137 (17.5%) right dissections, and 24 from the 140 (17%) left dissections. In 12 cases, the CB was bilateral. The CB arose from the superior cervical sympathetic ganglion in 3 of the 48 (6.25%) cases, from the middle ganglion in 10 (21%) cases, from the stellate ganglion in 3 (6.25%) cases, and from the ST in 32 (66.6%) cases. One (0.36%) NRILN associated with a right retro-esophageal subclavian artery (arteria lusoria) was found.
1) The CB between the RILN and the ST may have a diameter and course similar to an NRILN and may be confused with it. 2) The occurrence of the CB is greater than the occurrence referred to in previous studies. 3) The occurrence of the CB is similar by side and sex. 4) The CB may arise at different levels from the cervical ST and ganglia and end in the thyroid area. 5) Other neural elements may also be confused with an RILN, such as the cardiac nerves and the collateral branches from an NRILN to the trachea and esophagus.
The Laryngoscope 02/2008; 118(1):56-60. DOI:10.1097/MLG.0b013e318156a04a · 2.14 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Fibularis tertius (FT) may be used during reconstructive surgery and muscle transposition with retention of function. The muscle was examined in both lower limbs of 41 cadavers. Measurements were made of muscle belly length and width, tendon length and width, and the size of the origin on the fibula. Tendon insertion, nerve and blood supplies were also examined. FT was absent in five (6.1%) lower limbs of three (7.3%) subjects. The size of its origin demonstrated inter- and intra-individual variation. FT arose from the distal fibula and on average occupied (28.4 +/- 9.1)% (mean +/- S. D.) of the total shaft length. In all cases the tendon inserted into the dorsal surface of the shafts of both the fourth and fifth metatarsals. A small nerve branch consistently arose from the deep fibular nerve near the origin of extensor digitorum longus. The nerve ran parallel to the length of this muscle, between it and extensor hallucis longus, before piercing FT. Anatomy textbooks describe FT as inserting into the fifth metatarsal only. This study, supported by data from previous reports, suggests that the "textbook" accounts of FT should be updated to record that most commonly its tendon reaches both the fourth and fifth metatarsals.
[Show abstract][Hide abstract] ABSTRACT: The insertion of the tendon of subscapularis is accepted as being on the lesser tubercle of the humerus. The transverse humeral ligament (THL) is described as a distinct entity in most textbooks, overlying the long tendon of biceps as it emerges from the capsule of the shoulder joint. In this study, we dissected 85 embalmed shoulders to clarify the anatomy of the THL and variation in the insertion of the tendon of subscapularis. In all specimens no distinct THL could be identified, but in every shoulder a fibrous expansion arose from the posterior lamina of the tendon of pectoralis major overlying the long tendon of biceps. In 86% of shoulders, fibres from the tendon of subscapularis passed over the long tendon of biceps within this fibrous expansion and inserted on to the greater tubercle of the humerus where one would expect to find the THL. In 33% of dissections, fibres from the tendon of subscapularis lay deep to the long tendon of biceps, inserting either into the bicipital groove or on to the greater tubercle. In only 8% of cases did the tendon of subscapularis insert exclusively on to the lesser tubercle. We conclude that the THL does not exist as a separate entity. We suggest that in the majority of cases, the structure overlying the long tendon of biceps as it emerges from the capsule of the shoulder joint consists of tendinous fibres from subscapularis, contained within a fibrous expansion derived from the posterior lamina of the tendon of pectoralis major. In the minority of shoulders, where the tendon of subscapularis inserts exclusively on to the lesser tubercle, we hypothesise that this fibrous expansion acts as a retinaculum preventing the long tendon of biceps from "bowstringing."
[Show abstract][Hide abstract] ABSTRACT: Compression of the femoral nerve in the iliac fossa has been reported as a consequence of several pathologies, but never as a result of muscular compression. Aberrant slips of iliacus, however, have occasionally been reported to cover or split the femoral nerve. This study aimed to assess such variations as potential factors in femoral nerve compression. A large and homogeneous sample of 121 embalmed cadavers (242 specimens) was studied. Statistical comparisons were made using the chi-squared test. Muscular slips from iliacus and psoas, piercing or covering the femoral nerve, were found in 19 specimens (7.9%). No significant differences by sex or side were found. The more frequent variation was piercing of the femoral nerve by a muscular slip (17 specimens, 7.0%). The nerve then entered the thigh as one or more branches. The less frequent variation found was a muscular slip or sheet covering the femoral nerve as it lay on iliacus (2 specimens, 0.8%). Each disposition may be a potential risk for nerve entrapment.
[Show abstract][Hide abstract] ABSTRACT: Knowledge of variations of the circumflex femoral arteries is important when undertaking clinical procedures within the femoral region and in hip joint replacement. Since the 19th century, many different patterns have been proposed to classify their origins. This work studied a statistically reliable sample, the lower limbs of 221 embalmed human cadavers (equal right-left and approximately equal sex distributions), and reviewed the previous literature to propose a unified and simple classification that will be useful to clinicians. Statistical comparisons were made using the chi(2) test. The medial and lateral circumflex femoral arteries have been classified into three different patterns based on the levels of their origin. Distribution related to sex and side was also studied. Pattern I: Both arteries arose from the deep femoral artery (346 cases, 78.8%). This pattern was more frequent in females, P = 0.01. There was no significant difference between sides. Type Ia, medial circumflex femoral artery origin was proximal to the lateral circumflex femoral artery origin (53.2%); Type Ib, lateral circumflex femoral artery origin was proximal to medial circumflex femoral artery origin (23.4%); Type Ic, both arteries arose from a common trunk (23.4%). Pattern II: One of the arteries arose from the femoral artery and the other from the deep femoral artery (90 cases, 20.5%). Type IIa, the medial circumflex femoral artery arose from the femoral artery (77.8%) and Type IIb, the lateral circumflex femoral artery arose from the femoral artery (22.2%). There were no significant differences between sexes or sides. Pattern III: Both arteries arose from the femoral artery (2 cases, 0.5%). In every disposition there was a significantly higher prevalence of unilateral rather than bilateral occurrence. In one dissection the medial circumflex femoral artery was absent. Awareness of these variations could avoid unexpected injuries.
[Show abstract][Hide abstract] ABSTRACT: This project was to study the different patterns of the anterior tibal and dorsalis pedis arteries in relation to the blood supply of the dorsum of the foot and ankle.
A reliable sample of 150 human embalmed cadavers was dissected.
Four different patterns were identified. The dorsalis pedis artery was most frequently (287 cases, 95.7%) found to be the continuation of the anterior tibial artery distal to the ankle, and lay between the tendon of extensor hallucis and the first tendon of extensor digitorum longus. The other 13 cases (4.3%) showed 3 variant patterns of the anterior tibial-dorsalis pedis vascular axis: the anterior tibial artery took a more lateral course, passing in front of the lateral malleolus (6 cases, 2%); the perforating branch of the peroneal artery assumed the expected course of the dorsalis pedis artery (4 cases, 1.3%); the anterior tibal artery gave a lateral branch that replaced the perforating branch of the peroneal artery to supply the lateral aspect of the ankle (3 cases, 1%). Conclusion: Arterial variations of the anterior tibial-dorsalis pedis axis occurred in almost 5% of cases.
An awareness of the existence of such variations is helpful during a preoperative assessment and could prevent injury during surgery.
Arthroscopy The Journal of Arthroscopic and Related Surgery 04/2006; 22(3):287-90. DOI:10.1016/j.arthro.2005.10.021 · 3.21 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: A rare case of a four-headed biceps brachii muscle associated with a double piercing of one of the supernumerary heads by the musculocutaneous nerve was observed in the right arm of an 87-year-old female cadaver. One of the supernumerary heads of the biceps brachii originated from the humerus, in the area between the lesser tubercle and the coracobrachialis and brachialis muscles and joined the long head at the level where the latter joined the short head. The second supernumerary head originated from the humerus at the point where the coracobrachialis muscle inserted and joined the biceps brachii tendon and its bicipital aponeurosis at the inferior third of the arm. The musculocutaneous nerve originated from the lateral cord of the brachial plexus and, after piercing the coracobrachialis muscle, coursed along one of the supernumerary heads of the biceps brachii muscle before piercing it from deep to superficial and then again from superficial to deep. It then adopted its normal position between the biceps brachii and brachialis muscles before exiting in the lateral aspect of the arm and continuing as the lateral cutaneous nerve of the forearm.
[Show abstract][Hide abstract] ABSTRACT: The arterial pattern of the upper limb is one of the systems that shows a large number of variations in the adult human body. However, embryological explanations for these variations have been subject to much debate. Recent studies have provided a new classification of the arterial variations in the upper limb, as well as a new model of arterial development based on the study of large anatomical and embryological samples. In the present article, we offer a review of the embryological and morphological data obtained in adults, contrasting them with those found in a new sample of adult material.
[Show abstract][Hide abstract] ABSTRACT: Supernumerary humeral heads of the biceps brachii muscle were found in 27 (15.4%) of 175 cadavers. They were bilateral in five cadavers and unilateral in 22 (8 left, 14 right), giving a total of 32 examples in 350 arms (9.1%). Depending on their origin and location, the supernumerary heads were classified as superior, infero-medial, and infero-lateral humeral heads. Previous studies were reviewed using this classification. The infero-medial humeral head was observed in 31 of 350 (9%) arms and was therefore the most common variation. The superior humeral head was observed in five (1.5%). The infero-lateral humeral head was the least common variation, observed only in one (0.3%) of 350 arms. A biceps brachii with three heads was observed in 27 of 350 (7.7%) arms and with four heads in five (1.4%) arms.
[Show abstract][Hide abstract] ABSTRACT: The extensor digitorum brevis manus (EDBM) is a supernumerary muscle in the dorsum of the hand frequently misdiagnosed as a dorsal wrist ganglion, exostosis, tendon sheath cyst or synovitis. Its presence in a living subject, confirmed by magnetic resonance imaging (MRI), is presented together with a review of the hitherto reported cases and the results of an anatomical study on 128 adult human cadavers (59 males and 69 females). The EDBM was found in three (2.3%) of the 128 cadavers. It occurred in two (3.4%) of the 59 male cadavers (one bilateral and one unilateral on the right side) and in one (1.5%) of the 69 female cadavers (unilateral on the left side). Consequently, the EDBM was found in four (1.6%) of the 256 upper limbs. It originated from the dorsal wrist capsule within the compartment deep to the extensor retinaculum for the extensor digitorum and inserted into the extensor hood of the index finger in one case and into that of the middle finger in three cases. In both hands of the living subject, the origin was similar but the insertion was into the index and middle fingers. In all cases, it was innervated by the posterior interosseous nerve and its blood supply was provided by the posterior interosseous artery.
[Show abstract][Hide abstract] ABSTRACT: Based on a study of 70 human cadavers (31 male, 39 female) and on cases described previously, we propose a new classification of the Martin-Gruber anastomosis, a neural connection between the median and ulnar nerves in the forearm. The anastomosis was found in 16 (22.9%) cadavers, being bilateral in three (18.7%) and unilateral in 13 (81.3%), five right and eight left. It occurred in eight (25.8%) of the 31 male cadavers and in eight (20.5%) of the 39 females. Therefore, the anastomosis was found in 19 (13.6%) of the 140 forearms. In Pattern I (89.5%) the anastomosis was made by only one branch, whereas in Pattern II (10.5%) it was made by two. The individual branches were classified as Types a, b, and c based on the nature of their origin from the median nerve. Type a (47.3%) arose from the branch to the superficial forearm flexor muscles, Type b (10.6%) from the common trunk, and Type c (31.6%) from the anterior interosseous nerve. Pattern II was a duplication of Type c (10.5%). The anastomotic branch took an oblique or arched course before joining the ulnar nerve, undivided in 15 cases, but divided into two branches in four cases. The anastomosis passed in front of the ulnar artery in four cases, behind it in six, and in nine cases it was related to the anterior ulnar recurrent artery.
[Show abstract][Hide abstract] ABSTRACT: The incidence and morphology of the intramuscular Martin-Gruber anastomosis are presented based on the study of 118 human cadavers (55 male, 63 female). The Martin-Gruber anastomosis was found in 25 (21.2%) of the 118 cadavers. It occurred in 11 (20%) of the 55 male cadavers (4 bilateral, 7 unilateral; 5 left and 2 right) and in 14 (22.2%) of the 63 female cadavers (2 bilateral, 12 unilateral; 8 left and 4 right). Therefore, the Martin-Gruber anastomosis was found in 31 (13.1%) of the 236 upper limbs. According to a recent classification (Rodríguez-Niedenführ et al., 2000), pattern I was found in 29 cases (93.5%), corresponding to Type A in 13 (41.9%), Type B in 3 (9.7%) and Type C in 13 (41.9%), whereas pattern II was found in 2 cases (6.5%), both being a duplication of Type IC. Intramuscular Martin-Gruber anastomosis was a single anastomosis that originated in all cases from the anterior interosseous nerve (pattern IC) and then passed through a muscle bundle of the flexor digitorum profundus and behind the ulnar artery to join the ulnar nerve as a single connecting branch. It did not send branches to the flexor digitorum profundus. This intramuscular course was observed in 3 of the 13 cases of Type C anastomosis (23.1%) or 3 cases out of 31 Martin-Gruber anastomoses (10%).
[Show abstract][Hide abstract] ABSTRACT: Variations in connections between the musculocutaneous and median nerves in the arm are not as uncommon as was once thought. This opinion led us to perform a study in 138 cadavers (66 male, 72 female). These variations were seen in 64 cadavers (46.4%), 9 bilaterally and 55 unilaterally (26 right and 29 left); in total, therefore, variations were observed in 73 out of 276 arms (26.4%), 42 male and 31 female. No statistically significant differences by gender and side were observed. We classify the variations in three main patterns: Pattern 1, fusion of both nerves (14 arms, 19.2%); Pattern 2, presence of one supplementary branch between both nerves (53 arms, 72.6%); and Pattern 3, two branches (5 arms, 6.8%). Pattern 2 was further subdivided into a sub-group 2a when a single root from the musculocutaneous nerve contributed to the connection (51 arms, 69.9%), and 2b when there were two roots from the musculocutaneous nerve (2 arms, 2.7%). A combination of Patterns 1 and 2a was observed in one case (1.4%). Further variations are described, published classification systems are reviewed and a meta-analysis of previous results is presented. An overall incidence of 33% of variant arms was observed. Of these variant arms, Pattern 1 represented 13.1%, Pattern 2 represented 75.4%, and Pattern 3, 8.5%, similar to our figures.
[Show abstract][Hide abstract] ABSTRACT: A total of 192 embalmed cadavers were examined in order to present a detailed study of arterial variations in the upper limb and a meta-analysis of them. The variable terminology previously used was unified into a homogenous and complete classification, with 12 categories covering all the previously reported variant patterns of the arm and forearm.
[Show abstract][Hide abstract] ABSTRACT: A separate supernumerary muscle in the lateral cubital fossa originating from the humerus or brachioradialis and inserting into the radius, pronator teres or supinator muscle has been considered as a variation of the brachioradialis muscle (Dawson, 1822; Meckel, 1823; Lauth, 1830; Halbertsma, 1864; Gruber, 1868b; Testut, 1884; LeDouble, 1897; Spinner & Spinner, 1996). However, a similar description was used to report additional heads of the brachialis or biceps brachii muscles (Gruber, 1848; Wood, 1864, 1868; Macalister, 1864–66, 1966–69, 1875; Gruber, 1868a; Wolff-Heidegger, 1937).The innervation of these variant muscles would be a good tool to assign each variation to its associated muscle. Consequently, innervation by the radial nerve would indicate that it is a derivative of the humero–radialis group of muscles, while innervation by the musculocutaneous nerve would support it as a derivative of the anterior musculature of the arm (Rolleston, 1887; Lewis, 1989). However, no references to the innervation were found in the available literature.Therefore this study set out to establish the phylogenetic origin of the brachioradialis accessorius muscle and, with the help of its innervation, to determine its incidence and unreported detailed morphology.
[Show abstract][Hide abstract] ABSTRACT: Major variations of the principal arteries of the upper limb have long received the attention of anatomists. These variations can be summarised as the presence of 2 main arteries traversing the cubital fossa, a deep (or normal) brachial artery in coexistence with a superficial brachial, radial or ulnar artery. Anastomosis between these arterial trunks at elbow level has been reported in 1–6% of cases as an incidental finding in studies on the major arterial variations of the upper limb (Quain, 1844; Müller, 1903; Poynter, 1922; Adachi, 1928; McCormack et al. 1953; Wankoff, 1962; Rodríguez-Baeza et al. 1995). Only a single report (Ljubomudroff, 1927) has dealt specifically with the anastomosis.
The anatomical pattern of the anastomosis has been classified into 2 or 3 types depending on different morphological details. Three types have been described, taking into account its length, calibre and form (Quain, 1844) or the positions of the origin and number of recurrent radial arteries (Ljubomudroff, 1927). Two types have been described on the basis of whether the anastomosis coursed anterior or posterior to the bicipital tendon (McCormack et al. 1953). The aim of this study was to revisit these specific morphological details in a statistically reliable sample in order to catalogue the variations of the anastomosis and to provide an embryological explanation.