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Doppler ultrasound diagnosis of a superficial ulnar artery
European Journal of Ultrasound 12 (2000) 155 – 157 www.elsevier.com/locate/ejultrasou
Clinical Science: Case Report
Doppler ultrasound diagnosis of a superficial ulnar artery Richard G. McWilliams *, Illa Sodha Department of Radiology, Royal Li6erpool Uni6ersity Hospital, Prescot Street, Li6erpool L7 8XP, UK Received 3 May 2000; received in revised form 7 July 2000; accepted 10 July 2000
Abstract The ulnar artery may lie in a superficial position in the forearm as a normal anatomical variant. We report a case where this variant was clinically mistaken for phlebitis but was diagnosed correctly with Doppler ultrasound. In this report, we discuss the anatomy and clinical relevance of the superficial ulnar artery. © 2000 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Ultrasound; Ulnar artery; Diagnosis
1. Case report A 38-year-old man was referred to our hospital with a suspicion of superficial phlebitis in his right forearm. He had noticed a swelling in his forearm 3 weeks earlier while drying himself. He was reviewed by his family doctor who suspected phlebitis although it was recorded that the lump was not painful. The patient reported two episodes of shooting pains in the right arm but no other symptoms. There was no history of trauma and no relevant past medical history. Clinical examination revealed a superficial arterial pulse on the ulnar * Corresponding author. Tel.: + 44-151-7062744; fax: +44151-7065799. E-mail address: [email protected] (R.G. McWilliams).
aspect of the forearm. Colour Doppler ultrasound was requested to define the vascular anatomy and exclude an aneurysm. Doppler ultrasound demonstrated a superficial artery on the ulnar aspect of the antecubital fossa. This was the lump that the patient complained of. There was no associated haematoma or aneurysm. The artery could be followed proximally where it was seen to join the brachial artery just above the elbow skin crease. When followed distally this vessel coursed along the ulnar aspect of the forearm to the wrist. Spectral Doppler showed a normal arterial waveform and a diagnosis of a superficial ulnar artery was made (Fig. 1). There was no evidence of similar anatomical variation in the left arm. The patient was discharged from hospital after the ultrasound examination. Three months after discharge both the patient and his family doctor
0929-8266/00/$ - see front matter © 2000 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 9 2 9 - 8 2 6 6 ( 0 0 ) 0 0 1 0 6 - 3
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R.G. McWilliams, I. Sodha / European Journal of Ultrasound 12 (2000) 155–157
were contacted by telephone. There had been no further problem and the patient was still aware of the pulsatile lump, which had not changed. The patient was instructed to inform doctors and phlebotomists of the superficial artery that is vulnerable during venepuncture.
2. Discussion Anatomical variation of the arterial anatomy of the arm is well described. Anomalies of the brachial, radial and ulnar arteries are recorded and the commonest anomaly is high takeoff of the radial artery from the brachial artery in the arm (Funk et al., 1995). In one study of 408 upper extremities, a superficial ulnar artery was found in 2.5% of specimens (Funk et al., 1995).
The brachial artery normally divides into radial and ulnar arteries in the antecubital fossa. The ulnar artery normally disappears from the antecubital fossa by passing deep to the pronator teres muscle and beneath the fibrous arch of the flexor digitorum superficialis (Last, 1984). Below this the normal ulnar artery is sandwiched between the flexor muscles for most of its course, Fig. 2 (Fatah et al., 1985). A superficial ulnar artery is usually associated with high takeoff from the brachial artery in the arm (Funk et al., 1995). Origin of the superficial ulnar artery from the axillary artery has been reported (Yazar et al., 1999). In our case, however, the ulnar artery was seen to join the brachial artery just above the elbow skin crease. The superficial ulnar artery passes superficial to the pronator teres and flexor muscles of the forearm and courses along the medial border of the fore-
Fig. 1. Ultrasound image with a spectral trace showing a normal arterial waveform from a superficial ulnar artery (curved white arrow) which lies on the surface of the flexor muscles of the forearm.
R.G. McWilliams, I. Sodha / European Journal of Ultrasound 12 (2000) 155–157
Fig. 2. Drawing of the normal anatomy of the forearm arteries with the radial and ulnar arteries both lying deep to the superficial muscles of the forearm.
157
arm to the wrist (Fig. 3). The superficial ulnar artery lies superficial to the forearm muscles and may lie either beneath or more rarely above the deep fascia (Fatah et al., 1985). Knowledge of forearm arterial anomalies is especially important to plastic surgeons intending to harvest a radial flap of muscle and bone along with the radial artery. After such a procedure, the patient is reliant on their ulnar artery for blood supply to the hand. It is possible for a superficial ulnar artery to be at risk of ligation during such a procedure as the skin is harvested (Fatah et al., 1985). The superficial ulnar artery may be diagnosed clinically by careful palpation of the antecubital fossa and forearm (Funk et al., 1995). We are not aware of any previous cases of ultrasound diagnosis of this anomaly, which in our case had led to some clinical confusion. Doppler ultrasound allowed a confident diagnosis of a normal anatomical variant, excluded any complication and led to prompt discharge from hospital. It is important to inform the patient of this variant as the superficial ulnar artery is vulnerable to accidental venepuncture (Funk et al., 1995).
.
Acknowledgements Thanks to Gill Rycroft in the medical illustration department of the Royal Liverpool University Hospital for drawing figures 2 and 3.
References
Fig. 3. Drawing of the position of the superficial ulnar artery (arrow) which lies superficial to the flexor muscles of the forearm.
Funk GF, Valentino J, McCulloch TM, Graham SM, Hoffman HT. Anomalies of forearm vascular anatomy encountered during elevation of the radial forearm flap. Head Neck 1995;17:284 – 92. Fatah MF, Nancarrow JD, Murray DS. Raising the radial artery forearm flap: the superficial ulnar artery trap. Br J Plast Surg 1985;38:394 – 5. Last RJ, editor. Anatomy, Regional and Applied. London: Churchill Livingstone, 1984:83. Yazar F, Kirici Y, Ozan H, Aldur MM. An unusual variation of the superficial ulnar artery. Surg Radiol Anat 1999;21:155 – 7.
Clinical Science: Case Report
Doppler ultrasound diagnosis of a superficial ulnar artery Richard G. McWilliams *, Illa Sodha Department of Radiology, Royal Li6erpool Uni6ersity Hospital, Prescot Street, Li6erpool L7 8XP, UK Received 3 May 2000; received in revised form 7 July 2000; accepted 10 July 2000
Abstract The ulnar artery may lie in a superficial position in the forearm as a normal anatomical variant. We report a case where this variant was clinically mistaken for phlebitis but was diagnosed correctly with Doppler ultrasound. In this report, we discuss the anatomy and clinical relevance of the superficial ulnar artery. © 2000 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Ultrasound; Ulnar artery; Diagnosis
1. Case report A 38-year-old man was referred to our hospital with a suspicion of superficial phlebitis in his right forearm. He had noticed a swelling in his forearm 3 weeks earlier while drying himself. He was reviewed by his family doctor who suspected phlebitis although it was recorded that the lump was not painful. The patient reported two episodes of shooting pains in the right arm but no other symptoms. There was no history of trauma and no relevant past medical history. Clinical examination revealed a superficial arterial pulse on the ulnar * Corresponding author. Tel.: + 44-151-7062744; fax: +44151-7065799. E-mail address: [email protected] (R.G. McWilliams).
aspect of the forearm. Colour Doppler ultrasound was requested to define the vascular anatomy and exclude an aneurysm. Doppler ultrasound demonstrated a superficial artery on the ulnar aspect of the antecubital fossa. This was the lump that the patient complained of. There was no associated haematoma or aneurysm. The artery could be followed proximally where it was seen to join the brachial artery just above the elbow skin crease. When followed distally this vessel coursed along the ulnar aspect of the forearm to the wrist. Spectral Doppler showed a normal arterial waveform and a diagnosis of a superficial ulnar artery was made (Fig. 1). There was no evidence of similar anatomical variation in the left arm. The patient was discharged from hospital after the ultrasound examination. Three months after discharge both the patient and his family doctor
0929-8266/00/$ - see front matter © 2000 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 9 2 9 - 8 2 6 6 ( 0 0 ) 0 0 1 0 6 - 3
156
R.G. McWilliams, I. Sodha / European Journal of Ultrasound 12 (2000) 155–157
were contacted by telephone. There had been no further problem and the patient was still aware of the pulsatile lump, which had not changed. The patient was instructed to inform doctors and phlebotomists of the superficial artery that is vulnerable during venepuncture.
2. Discussion Anatomical variation of the arterial anatomy of the arm is well described. Anomalies of the brachial, radial and ulnar arteries are recorded and the commonest anomaly is high takeoff of the radial artery from the brachial artery in the arm (Funk et al., 1995). In one study of 408 upper extremities, a superficial ulnar artery was found in 2.5% of specimens (Funk et al., 1995).
The brachial artery normally divides into radial and ulnar arteries in the antecubital fossa. The ulnar artery normally disappears from the antecubital fossa by passing deep to the pronator teres muscle and beneath the fibrous arch of the flexor digitorum superficialis (Last, 1984). Below this the normal ulnar artery is sandwiched between the flexor muscles for most of its course, Fig. 2 (Fatah et al., 1985). A superficial ulnar artery is usually associated with high takeoff from the brachial artery in the arm (Funk et al., 1995). Origin of the superficial ulnar artery from the axillary artery has been reported (Yazar et al., 1999). In our case, however, the ulnar artery was seen to join the brachial artery just above the elbow skin crease. The superficial ulnar artery passes superficial to the pronator teres and flexor muscles of the forearm and courses along the medial border of the fore-
Fig. 1. Ultrasound image with a spectral trace showing a normal arterial waveform from a superficial ulnar artery (curved white arrow) which lies on the surface of the flexor muscles of the forearm.
R.G. McWilliams, I. Sodha / European Journal of Ultrasound 12 (2000) 155–157
Fig. 2. Drawing of the normal anatomy of the forearm arteries with the radial and ulnar arteries both lying deep to the superficial muscles of the forearm.
157
arm to the wrist (Fig. 3). The superficial ulnar artery lies superficial to the forearm muscles and may lie either beneath or more rarely above the deep fascia (Fatah et al., 1985). Knowledge of forearm arterial anomalies is especially important to plastic surgeons intending to harvest a radial flap of muscle and bone along with the radial artery. After such a procedure, the patient is reliant on their ulnar artery for blood supply to the hand. It is possible for a superficial ulnar artery to be at risk of ligation during such a procedure as the skin is harvested (Fatah et al., 1985). The superficial ulnar artery may be diagnosed clinically by careful palpation of the antecubital fossa and forearm (Funk et al., 1995). We are not aware of any previous cases of ultrasound diagnosis of this anomaly, which in our case had led to some clinical confusion. Doppler ultrasound allowed a confident diagnosis of a normal anatomical variant, excluded any complication and led to prompt discharge from hospital. It is important to inform the patient of this variant as the superficial ulnar artery is vulnerable to accidental venepuncture (Funk et al., 1995).
.
Acknowledgements Thanks to Gill Rycroft in the medical illustration department of the Royal Liverpool University Hospital for drawing figures 2 and 3.
References
Fig. 3. Drawing of the position of the superficial ulnar artery (arrow) which lies superficial to the flexor muscles of the forearm.
Funk GF, Valentino J, McCulloch TM, Graham SM, Hoffman HT. Anomalies of forearm vascular anatomy encountered during elevation of the radial forearm flap. Head Neck 1995;17:284 – 92. Fatah MF, Nancarrow JD, Murray DS. Raising the radial artery forearm flap: the superficial ulnar artery trap. Br J Plast Surg 1985;38:394 – 5. Last RJ, editor. Anatomy, Regional and Applied. London: Churchill Livingstone, 1984:83. Yazar F, Kirici Y, Ozan H, Aldur MM. An unusual variation of the superficial ulnar artery. Surg Radiol Anat 1999;21:155 – 7.