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Persistent Median Artery in a Pediatric Trauma Patient: Case Report
SCIENTIFIC ARTICLE
Persistent Median Artery in a Pediatric Trauma Patient: Case Report Timothy Muratore, MD, Kagan Ozer, MD A persistent median artery is a well-described variation in the vascular anatomy of the upper extremity and hand, with an incidence of 1% to 30% in the general population. We present a case of a persistent median artery in a pediatric trauma patient. The median artery helped maintain blood flow to the nearly amputated hand after complete transection of radial and ulnar arteries. (J Hand Surg 2011;36A:658–660. Copyright © 2011 by the American Society for Surgery of the Hand. All rights reserved.) Key words Median artery, near amputation, revascularization.
a median artery at the level of the wrist is an anatomic variation with an incidence of 1% and 30% in the adult and pediatric populations.1–5 Such variation perhaps is related to a number of factors including racial difference among populations or developmental difference between adults and neonates. Vascular supply to the upper limb begins with the development of the axial artery on day 28 of embryological development.1 This artery gradually progresses to become the subclavian artery between days 32 and 37 and the brachial artery on day 41. On day 44, the initial part of the radial artery is clearly defined along with the ulnar and median arteries. By day 47, distal parts of the vascular tree including palmar arches are clearly present. During the latter half of the second month of gestation, the median artery begins to regress. The radial and ulnar arteries then become the dominant arteries to the hand.1,2 The persistence of a median artery has been shown to be a contributing cause of a number of entrapment neuropathies including carpal tunnel syndrome, pronator teres syndrome, and anterior interosseous nerve syndrome.2,6 –9 We present a case of
T
HE PRESENCE OF
From the Department of Orthopaedics, Denver Health Medical Center, University of Colorado Denver, Denver, CO. Received for publication September 21, 2010; accepted in revised form January 19, 2011. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Kagan Ozer, MD, Department of Orthopaedics, Denver Health Medical Center, University of Colorado Denver, MC 188, 777 Bannock Street, Denver, CO 80204; e-mail: [email protected]. 0363-5023/11/36A04-0017$36.00/0 doi:10.1016/j.jhsa.2011.01.020
658 䉬 © ASSH 䉬 Published by Elsevier, Inc. All rights reserved.
a persistent median artery in a pediatric trauma patient that helped to preserve the viability of the hand after laceration of the radial and ulnar arteries. CASE REPORT An 18-month-old girl sustained a near complete amputation of her right hand that had been caught in a dog leash. On initial evaluation she was noted to have a circumferential laceration and a pulse in her palm measured with a Doppler ultrasound. Initial reduction of the wrist was attempted with 2 K-wires (Fig. 1A, B). Owing to the complexity of the case, she was transferred to our level 1 hospital for further treatment. Eight hours after the initial injury, the patient was taken to the operating room for exploration. During the procedure, she was noted to have a circumferential laceration around her wrist with only a 2-cm-wide skin bridge remaining intact on the ulnar and volar border of the wrist. As a result, she had an open wrist joint with all extensor tendons ruptured at the musculotendinous junctions and pulled distal to the extensor retinaculum. She also had complete rupture of the flexor carpi radialis, the flexor carpi ulnaris, the radial and ulnar arteries, and the ulnar nerve. The wrist capsule was disrupted circumferentially (Fig. 1C). After irrigation, we first reduced and pinned the wrist joint using 0.9-mm Kwires. After that, we sutured the dorsal wrist capsule and ligaments in a continuous fashion. In an attempt to further assess the damage on the volar side, we then released the transverse carpal ligament and noted an intact median artery (Fig. 1D) along with intact median nerve and all long digital flexors.
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FIGURE 1: A The radiograph taken before the surgery at the outside facility. B The mildly congested hand immediately before the surgery. Intraoperatively, patient was noted to have circumferential disruption of the wrist joint as seen in C. D The course of the median artery in the carpal canal traveling along the median nerve (approximate diameter of the artery, 0.7– 0.9 mm). Further exploration distally revealed the connection to the superficial palmar arch.
The flexor carpi radialis, flexor carpi ulnaris, ulnar and radial arteries, and ulnar nerve were ruptured. Next, we trimmed all irregular ends of tendons and muscle bellies. During the repair, we overlapped the muscle and the tendon at least 3 to 4 mm, leaving the muscle on the ventral side of the repair. The repair was performed using 4-0 synthetic absorbable suture and the figure-of-8 technique. During this time, the hand remained perfused via flow through the intact median artery. We then harvested a 4-cm vein graft from the volar aspect of the wrist and interposed it to recon-
struct the ulnar artery using the end-to-end technique and surgical microscope. This was followed by the primary repair of the ulnar nerve. Because of a mild degree of congestion on the dorsum of the hand, we anastomosed a dorsal vein using the end-to-end technique (Fig. 1B). At the end of the surgery, the patient’s upper extremity was placed in an above-elbow splint. At the last follow-up 14 months after the surgery, she was using both hands in handling objects and had equal temperatures on both sides. Doppler examination of the ulnar artery revealed an
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FIGURE 2: Appearance of both hands at 14 months. A Dorsal view. B Palmar view showing ulnar intrinsic muscle activity.
intact flow. She also had signs of ulnar nerve recovery, as evidenced by functioning hypothenar muscles (Fig. 2). DISCUSSION The incidence of a persistent median artery is reported to be 0.9% to 30% in the adult population and may be higher in the neonatal and pediatric population.1–5 There are 2 described types based on location and termination: (1) The antebrachial type represents incomplete regression and terminates before the wrist; and (2) the palmar type represents persistence of the embryologic pattern and terminates in the hand.2 There are also well-described variances in the artery’s contribution to the vascular supply of the hand. The median artery is most often found terminating in a digital artery supplying the thumb and index fingers It has also been found to contribute to the superficial palmar arch.2,3,5 It most commonly originates from the common interosseous or ulnar arteries, although it has been found to arise from the anterior interosseous artery and, rarely, the radial artery. Although we did not specifically explore the origin of the median artery in this case, we found that it terminated in the superficial palmar arch. There have been multiple anatomic studies on the size of median arteries in cadavers, measuring between 0.8 and 3.0 mm along its course. A study by Claassen et al5 found 4 median arteries in 54 arms. Three of these arteries terminated in the superficial palmar arch. It has previously been described that when the median artery contributes to the superficial palmar arch, the radial artery is atrophied and has little or no contribution to the superficial arch. In the Claassen et al study, the median arteries varied between 1.5 and 2 mm and all 4 cadavers
had normal-size radial arteries, ranging between 3 and 5.5 mm proximally, and 3 and 4 mm distally. Although these studies clearly show its size, it is not clear whether the artery is functionally sufficient to supply the hand itself in the absence of all other sources. In our case, the median artery was 0.7 to 0.9 mm in diameter. One can argue that a small perforating vessel through the 2-cmwide intact skin bridge could contribute the circulation of the hand. We believe that the presence of a Doppler signal in the palm implied the presence of a major artery supplying the hand. REFERENCES 1. Rodríguez-Niedenführ M, Burton GJ, Deu J, Sañudo JR. Development of the arterial pattern in the upper limb of staged human embryos: normal development and anatomic variations. J Anat 2001; 199:407– 417. 2. Rodriguez-Niedenfuhr M, Sanudo JR, Vasquez T, Nearn L, Logan B, Parkin I. Median artery revisited. J Anat 1999;195:57– 63. 3. Tsuruo Y, Ueyama T, Ito T, Nanjo S, Gyuobo H, Satoh K, et al. Persistent median artery in the hand: a report with a brief review of the literature. Anat Sci Int 2006;81:242–252. 4. Lindley SG, Kleinert JM. Prevalence of anatomic variations encountered in elective carpal tunnel release. J Hand Surg 2003;28A:849 – 855. 5. Claassen H, Schmitt O, Wree A. Large patent median arteries and their relation to the superficial palmar arch with respect to history, size consideration and clinic consequences. Surg Radiol Anat 2008;30:57– 63. 6. Proudman TW, Menz PJ. An anomaly of the median artery associated with the anterior interosseous nerve syndrome. J Hand Surg 1992; 17B:507–509. 7. Balakrishnan C, Emanuele JA, Smith FM. Asymptomatic persistent median artery in a trauma patient. Injury 1997;28:697– 698. 8. Tollan CJ, Sivarajan V. A persisting median artery in a patient with symbrachydactyly and carpal tunnel syndrome. J Plast Reconstr Aesthet Surg 2008;61:819 – 821. 9. Davidson JSD, Pichora DR. Median artery forearm flap. Ann Plast Surg 2009;62:627– 629.
JHS 䉬 Vol A, April
Persistent Median Artery in a Pediatric Trauma Patient: Case Report Timothy Muratore, MD, Kagan Ozer, MD A persistent median artery is a well-described variation in the vascular anatomy of the upper extremity and hand, with an incidence of 1% to 30% in the general population. We present a case of a persistent median artery in a pediatric trauma patient. The median artery helped maintain blood flow to the nearly amputated hand after complete transection of radial and ulnar arteries. (J Hand Surg 2011;36A:658–660. Copyright © 2011 by the American Society for Surgery of the Hand. All rights reserved.) Key words Median artery, near amputation, revascularization.
a median artery at the level of the wrist is an anatomic variation with an incidence of 1% and 30% in the adult and pediatric populations.1–5 Such variation perhaps is related to a number of factors including racial difference among populations or developmental difference between adults and neonates. Vascular supply to the upper limb begins with the development of the axial artery on day 28 of embryological development.1 This artery gradually progresses to become the subclavian artery between days 32 and 37 and the brachial artery on day 41. On day 44, the initial part of the radial artery is clearly defined along with the ulnar and median arteries. By day 47, distal parts of the vascular tree including palmar arches are clearly present. During the latter half of the second month of gestation, the median artery begins to regress. The radial and ulnar arteries then become the dominant arteries to the hand.1,2 The persistence of a median artery has been shown to be a contributing cause of a number of entrapment neuropathies including carpal tunnel syndrome, pronator teres syndrome, and anterior interosseous nerve syndrome.2,6 –9 We present a case of
T
HE PRESENCE OF
From the Department of Orthopaedics, Denver Health Medical Center, University of Colorado Denver, Denver, CO. Received for publication September 21, 2010; accepted in revised form January 19, 2011. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Kagan Ozer, MD, Department of Orthopaedics, Denver Health Medical Center, University of Colorado Denver, MC 188, 777 Bannock Street, Denver, CO 80204; e-mail: [email protected]. 0363-5023/11/36A04-0017$36.00/0 doi:10.1016/j.jhsa.2011.01.020
658 䉬 © ASSH 䉬 Published by Elsevier, Inc. All rights reserved.
a persistent median artery in a pediatric trauma patient that helped to preserve the viability of the hand after laceration of the radial and ulnar arteries. CASE REPORT An 18-month-old girl sustained a near complete amputation of her right hand that had been caught in a dog leash. On initial evaluation she was noted to have a circumferential laceration and a pulse in her palm measured with a Doppler ultrasound. Initial reduction of the wrist was attempted with 2 K-wires (Fig. 1A, B). Owing to the complexity of the case, she was transferred to our level 1 hospital for further treatment. Eight hours after the initial injury, the patient was taken to the operating room for exploration. During the procedure, she was noted to have a circumferential laceration around her wrist with only a 2-cm-wide skin bridge remaining intact on the ulnar and volar border of the wrist. As a result, she had an open wrist joint with all extensor tendons ruptured at the musculotendinous junctions and pulled distal to the extensor retinaculum. She also had complete rupture of the flexor carpi radialis, the flexor carpi ulnaris, the radial and ulnar arteries, and the ulnar nerve. The wrist capsule was disrupted circumferentially (Fig. 1C). After irrigation, we first reduced and pinned the wrist joint using 0.9-mm Kwires. After that, we sutured the dorsal wrist capsule and ligaments in a continuous fashion. In an attempt to further assess the damage on the volar side, we then released the transverse carpal ligament and noted an intact median artery (Fig. 1D) along with intact median nerve and all long digital flexors.
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659
FIGURE 1: A The radiograph taken before the surgery at the outside facility. B The mildly congested hand immediately before the surgery. Intraoperatively, patient was noted to have circumferential disruption of the wrist joint as seen in C. D The course of the median artery in the carpal canal traveling along the median nerve (approximate diameter of the artery, 0.7– 0.9 mm). Further exploration distally revealed the connection to the superficial palmar arch.
The flexor carpi radialis, flexor carpi ulnaris, ulnar and radial arteries, and ulnar nerve were ruptured. Next, we trimmed all irregular ends of tendons and muscle bellies. During the repair, we overlapped the muscle and the tendon at least 3 to 4 mm, leaving the muscle on the ventral side of the repair. The repair was performed using 4-0 synthetic absorbable suture and the figure-of-8 technique. During this time, the hand remained perfused via flow through the intact median artery. We then harvested a 4-cm vein graft from the volar aspect of the wrist and interposed it to recon-
struct the ulnar artery using the end-to-end technique and surgical microscope. This was followed by the primary repair of the ulnar nerve. Because of a mild degree of congestion on the dorsum of the hand, we anastomosed a dorsal vein using the end-to-end technique (Fig. 1B). At the end of the surgery, the patient’s upper extremity was placed in an above-elbow splint. At the last follow-up 14 months after the surgery, she was using both hands in handling objects and had equal temperatures on both sides. Doppler examination of the ulnar artery revealed an
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PEDIATRIC PERSISTENT MEDIAN ARTERY
FIGURE 2: Appearance of both hands at 14 months. A Dorsal view. B Palmar view showing ulnar intrinsic muscle activity.
intact flow. She also had signs of ulnar nerve recovery, as evidenced by functioning hypothenar muscles (Fig. 2). DISCUSSION The incidence of a persistent median artery is reported to be 0.9% to 30% in the adult population and may be higher in the neonatal and pediatric population.1–5 There are 2 described types based on location and termination: (1) The antebrachial type represents incomplete regression and terminates before the wrist; and (2) the palmar type represents persistence of the embryologic pattern and terminates in the hand.2 There are also well-described variances in the artery’s contribution to the vascular supply of the hand. The median artery is most often found terminating in a digital artery supplying the thumb and index fingers It has also been found to contribute to the superficial palmar arch.2,3,5 It most commonly originates from the common interosseous or ulnar arteries, although it has been found to arise from the anterior interosseous artery and, rarely, the radial artery. Although we did not specifically explore the origin of the median artery in this case, we found that it terminated in the superficial palmar arch. There have been multiple anatomic studies on the size of median arteries in cadavers, measuring between 0.8 and 3.0 mm along its course. A study by Claassen et al5 found 4 median arteries in 54 arms. Three of these arteries terminated in the superficial palmar arch. It has previously been described that when the median artery contributes to the superficial palmar arch, the radial artery is atrophied and has little or no contribution to the superficial arch. In the Claassen et al study, the median arteries varied between 1.5 and 2 mm and all 4 cadavers
had normal-size radial arteries, ranging between 3 and 5.5 mm proximally, and 3 and 4 mm distally. Although these studies clearly show its size, it is not clear whether the artery is functionally sufficient to supply the hand itself in the absence of all other sources. In our case, the median artery was 0.7 to 0.9 mm in diameter. One can argue that a small perforating vessel through the 2-cmwide intact skin bridge could contribute the circulation of the hand. We believe that the presence of a Doppler signal in the palm implied the presence of a major artery supplying the hand. REFERENCES 1. Rodríguez-Niedenführ M, Burton GJ, Deu J, Sañudo JR. Development of the arterial pattern in the upper limb of staged human embryos: normal development and anatomic variations. J Anat 2001; 199:407– 417. 2. Rodriguez-Niedenfuhr M, Sanudo JR, Vasquez T, Nearn L, Logan B, Parkin I. Median artery revisited. J Anat 1999;195:57– 63. 3. Tsuruo Y, Ueyama T, Ito T, Nanjo S, Gyuobo H, Satoh K, et al. Persistent median artery in the hand: a report with a brief review of the literature. Anat Sci Int 2006;81:242–252. 4. Lindley SG, Kleinert JM. Prevalence of anatomic variations encountered in elective carpal tunnel release. J Hand Surg 2003;28A:849 – 855. 5. Claassen H, Schmitt O, Wree A. Large patent median arteries and their relation to the superficial palmar arch with respect to history, size consideration and clinic consequences. Surg Radiol Anat 2008;30:57– 63. 6. Proudman TW, Menz PJ. An anomaly of the median artery associated with the anterior interosseous nerve syndrome. J Hand Surg 1992; 17B:507–509. 7. Balakrishnan C, Emanuele JA, Smith FM. Asymptomatic persistent median artery in a trauma patient. Injury 1997;28:697– 698. 8. Tollan CJ, Sivarajan V. A persisting median artery in a patient with symbrachydactyly and carpal tunnel syndrome. J Plast Reconstr Aesthet Surg 2008;61:819 – 821. 9. Davidson JSD, Pichora DR. Median artery forearm flap. Ann Plast Surg 2009;62:627– 629.
JHS 䉬 Vol A, April