- Email: [email protected]
The deep lymphatic anatomy of the hand
Accepted Manuscript Title: The deep lymphatic anatomy of the hand Authors: Chuan-Xiang Ma, Wei-Ren Pan, Zhi-An Liu, Fan-Qiang Zeng, Zhi-Qiang Qiu PII: DOI: Reference:
S0940-9602(18)30032-3 https://doi.org/10.1016/j.aanat.2018.03.001 AANAT 51241
To appear in: Received date: Accepted date:
28-11-2017 12-3-2018
Please cite this article as: Ma, Chuan-Xiang, Pan, Wei-Ren, Liu, Zhi-An, Zeng, FanQiang, Qiu, Zhi-Qiang, The deep lymphatic anatomy of the hand.Annals of Anatomy https://doi.org/10.1016/j.aanat.2018.03.001 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Original Article
The deep lymphatic anatomy of the hand
IP T
Running head: Deep lymphatics of the hand
SC R
Authors: Chuan-Xiang Ma, BBSci, MS. 1
U
Wei-Ren Pan, MD, PhD.1
N
Zhi-An Liu, MD, MS.1
ED
1
M
Zhi-Qiang Qiu, MD.2
A
Fan-Qiang Zeng, MDip, MD. 1
Department of Anatomy, College of Biomedical Sciences, Xuzhou Medical
Department of Radiology, Xuzhou Oriental People’s Hospital, Xuzhou Medical
CC E
2
PT
University, Xuzhou, Jiangsu, P.R.China.
University, Xuzhou, Jiangsu, P.R.China.
A
Corresponding Author Contact Information: Professor Wei-Ren Pan, MD, PhD Department of Anatomy, College of Biomedical Sciences,
Xuzhou Medical University, 209 Tongshan Road, Xuzhou, Jiangsu, P.R.China. 221004
IP T
Telephone number: (+86516) 83262040
SC R
E-mail: [email protected]; [email protected]
Abstract
U
Background: the deep lymphatic anatomy of the hand still remains the least
N
described in medical literature.
A
Methods: eight hands were harvested from four nonembalmed human cadavers
M
amputated above the wrist. A small amount of 6% hydrogen peroxide was employed
ED
to detect the lymphatic vessels around the superficial and deep palmar vascular arches, in webs from the index to little fingers, the thenar and hypothenar areas. A 30-gauge
PT
needle was inserted into the vessels and injected with a barium sulphate compound.
CC E
Each specimen was dissected, photographed and radiographed to demonstrate deep lymphatic distribution of the hand. Results:
five groups of deep collecting lymph vessels were found in the hand:
A
superficial palmar arch lymph vessel (SPALV); deep palmar arch lymph vessel (DPALV); thenar lymph vessel (TLV); hypothenar lymph vessel (HTLV); deep finger web lymph vessel (DFWLV). Each group of vessels drained in different directions first, then all turned and ran towards the wrist in different layers.
Conclusion: the deep lymphatic drainage of the was been presented. The results will provide an anatomical basis for clinical management, educational reference and scientific research. Key words: hand; deep lymphatic vessels; superficial palmar arch; deep palmar arch;
IP T
finger web.
SC R
Introduction
The hand is the most important part of the body in our daily lives, and is involved
U
in a variety of disorders, ranging from congenital dysplasia to inflammation, trauma,
N
tumor and dynamic processes of secondary lymphedema, etc. (Beasley, 2003;
A
Maschke, 2005). Clinical management requires accurate and detailed anatomical
M
understanding. Although the knowledge of the superficial lymphatic anatomy in the
ED
upper limb has been updated during the last decade (Pan, 2015; Pan, 2017), further studies should be carried out, especially regarding the deep lymphatic pathways, to
PT
renew our knowledge of the human lymphatic system.
CC E
In this study, details of the deep lymphatic distribution and the communicating lymph vessels in the hand are described and demonstrated by radiographs and photographs.
A
Materials and Methods The investigation was performed with appropriate institutional ethics approval. For this study, a total of eight hands were collected from four nonembalmed human cadavers, disarticulated 7cm above the wrist. Two males and two females aged from
70 to 80 years (average age 74 years old) were used. Using a 1ml syringe, a small amount of 6% hydrogen peroxide (Zhonglian Chemical Co., Ltd, Suzhou, China) was injected into the tissue around the superficial palmar arch (SPA), deep palmar arch (DPA) the web between fingers, thenar and
IP T
hypothenar. Under a surgical microscope (Leica Microsystems Ltd, Heerbrugg, Switzerland) the distended lymphatic vessels were identified in the area. Each vessel
SC R
was inserted by a 30 gauge needle (Zhejiang KDL Medical Equipment Group Ltd., Wenzhou, China; Precision glide needle: Becton Dickinson & Co, Franklin Lakes,
U
N.J., USA) and injected with a radio-opaque mixture (Barium sulphate 15g: Shanghai
N
Silian Indusry Co. Ltd., China; Milk powder 5g: Heinz Ltd., Qingdao, China;
A
Concentrated poster color - dark green 3g: Liaoyuan arts and stationery Ltd., Hunang,
M
China; Water 20 ml). In one specimen, both barium sulphate and lead oxide (Lead
ED
oxide 15g: Wenzhou reagent chemical laboratory, Zhijiang, China; Milk powder 5g: milk powder 5g: Heinz Ltd., Qingdao, China; Water 20 ml) mixtures were used for
PT
determining the relationship between the superficial and deep lymph vessels of the
CC E
hand. Lymphatic vessels were then traced, photographed and radiographed (Digital X-ray Dignostic System - Multix Select DR: Siemens Healthcare Diagnostic Co. Ltd., Erlangen, Germany) to demonstrate their distribution. The final results were
A
transferred to a computer (Dell Vostro 200: Dell Computer Inc. Chinese Division, P.R. China) for image analysis using Photoshop software (Adobe Photoshop CS5 V12, Adobe Systems Software Co., Ltd, Beijing, China). Results
Five groups of deep collecting lymph vessels have been found in the hand (Figs. 1 and 2). Each group of vessels drained in different directions first and then all turned and ran towards the wrist in different layers. Superficial palmar arch lymph vessel (SPALV)
IP T
Beneath the palmar aponeurosis, one or two collecting lymph vessels arose beside the superficial palmar arch (SPA) and ran horizontally towards the thumb (Figs
SC R
1 to 4). In the web space between the thumb and index fingers, they received one or two collecting lymph vessels that arose from the surface of the adductor pollicis
U
before turning to the dorsum of the hand, where they joined with the superficial
N
lymphatic group (Fig. 3 right).
A
The average diameter of the vessel was 0.5 mm (ranging from 0.3 to 0.8 mm) in
M
the web area.
ED
Deep palmar arch lymph vessel (DPALV)
One or two collecting lymph vessels arose beside the deep palmar arch and ran
PT
horizontally towards the thumb (Figs. 1 and 2). Penetrating the adductor pollicis and
CC E
the 1st dorsal interosseous muscles, the lymph vessel passed through the space between the 1st and 2nd metacarpal bones and ran with DPA vessels (Fig. 1 left). It crossed the floor of the anatomical snuff box, and then curved medially around the
A
scaphoid and trapezium. At the bifurcation of the radial artery in the wrist, it received a lymph vessel (TLV – see below) arising aside of the superficial palmar arch in the thenar and then ran with the radial artery and vein in the forearm (Fig 4 center and right).
In three cases the DPALV and TLV ran separately in the wrist section, the former curved around the EPL tendon after passing through the space between the 1st and 2nd metacarpal bones and then ran with/under the tributary of the cephalic vein, while the latter ran with the radial artery and vein (Figs. 1 and 2 ).
IP T
In one case, a communicating lymph vessel was found between the SPALV and DPALV. It ran from the DPALV to SPALV (Fig. 4 left).
SC R
The average diameter of the vessel was 0.4 mm (ranging from 0.3 to 0.6 mm); measurements were taken from the point before the vessel penetrated muscles
U
between the 1st and 2nd metacarpal bones.
N
Thenar lymph vessel (TLV)
A
One collecting lymph vessel was found arising next to the superficial palmar
M
arch in the thenar muscles and ran towards the wrist (Figs. 2 and 4). At the bifurcation
ED
of the radial artery on the wrist, it converged with DPALV and then ran along the radial vessels. In three cases, the PDPALV and TLV ran separately in the wrist section,
PT
the former ran with/under the tributary of the cephalic vein while the latter ran with
CC E
the radial artery and vein (Figs. 1 and 2). The average diameter of the vessel was 0.3 mm (ranging from 0.2 to 0.4 mm);
measurements were taken from the point near the bifurcation of the radial artery on
A
the wrist.
Hypothenar lymph vessel (HTLV) One collecting lymph vessel was found and ran proximally in the ulnar side of the 3rd common palmar digital artery (CPDA) and then along with the superficial
palmar arch (Figs. 1, 2 and 5). It went through the Palmaris brevis, passed by the pisiform and then ran with the ulnar vessels. In one specimen, an additional lymph vessel was found next to the common palmar digital nerve (CPDN) in the hypothenar (Fig. 5) and then ran parallel to the
IP T
lymph vessel (described in the previous paragraph) in the same pathway. They converged together in the forearm (Figs. 1 to 3).
SC R
The average diameter of the vessel was 0.3 mm (ranging from 0.2 to 0.5 mm), measuring from the point near to the pisiform.
U
Deep finger web lymph vessel (DFWLV)
N
In three web spaces from the index to little fingers, each had one collecting
A
lymph vessel arising around the bifurcation of the CPDA (Fig. 6). All of them ran a
M
very short distance in webs, turned towards the opisthenar, and then ran
ED
subcutaneously (Figs. 1, 2 left and right).
With an average diameter of 0.4 mm (ranging from 0.2 to 6 mm) measuring
CC E
Discussion
PT
between the finger webs.
Clinical management of disorders of the hand requires accurate and detailed
anatomical understanding (Beasley, 2003; Maschke, et al., 2005). The anatomical
A
structures of the hand have been well documented in textbooks (Schmidt and Lanz, 2003; Standring et al., 2015), apart from the lymphatics. Although the superficial lymphatic anatomy of the hand has been updated during the last decade (Suami, 2007; Pan, 2014 and 2017), the deep lymphatics of the hand still remain the least described
in medical literature. In this study, we have presented five groups of the deep lymph vessel of the hand. The characteristics of the drainage pattern are described as follows: 1. They arose from the different areas and layers of the palm;
IP T
2. Each group of vessels drained in different directions first and then all turned and ran towards the wrist in different layers;
SC R
3. SPALV and HTLV ran in the subcutaneous of the opisthenar after turning in the finger webs.
U
4. DPALV travelled either with the dorsoradial DPA (deep layer) or with the
N
tributary of the cephalic vein (superficial layer) after passing through the
A
space between the 1st and 2nd metacarpal bones.
M
5. Occasionally, there is a CLV to connect SPALV and DPALV.
ED
We believe that our results have provided additional information for enriching
Conclusion
PT
knowledge of the lymphatic anatomy in the hand.
CC E
The deep lymphatic drainage of the hand was described. The results will provide an anatomical basis for clinical management, educational reference and scientific
A
research.
Author Disclosure Statement No competing financial interests exist.
Acknowledgement The authors would like to pay tribute to body donors who contributed their bodies for this study and thank their families for assistance. Many thanks to the National Natural Science Foundation of China (No: 31671253), Xuzhou Medical University
IP T
President special fund (No: 53051116) and the foreign experts special fund of the Department of International Cooperation and Exchange (No: 537101) for supporting
A
CC E
PT
ED
M
A
N
U
SC R
this study.
References Beasley, R.W., 2003. Bealsley’s surgery of the hand. Thieme, New York. Maschke, S.D., Graham, T.J., Evans, P.J., 2005. The hand, third edition. Wolters Kluwer, New York.
IP T
Pan, W.R., 2015. Changing concepts in lymphatic pathways. In: Neligan PC, et al (Ed). Lymphedema: Complete medical and surgical management, Ch. 5. CRC Press:
SC R
Taylor and Francis Group, New York, pp. 61-96.
Pan, W.R., 2017. Atlas of lymphatic anatomy in the head, neck, chest and limbs.
U
People’s Medical Publishing House, Beijing; Springer, Singapore.
N
Schmidt, H., Lanz, U., 2003. Surgical anatomy of the hand. Thieme, New York.
A
Standring, S., et al, 2015. Gray’s anatomy, 41th edition. Elsevier, London.
M
Suami, H; Taylor, G.I., Pan, W.R., 2007. The lymphatic territories of the upper limb:
A
CC E
PT
ED
anatomical study and clinical implications. Plast Reconstr Surg. 119(6), 1813-1822.
Legends
A
CC E
PT
ED
M
A
N
U
SC R
IP T
Figure 1. Distribution of the deep lymphatics in the right hand (radiograph, AP view).
Figure 2. Radiographs (left) and photographs (center and right) of a specimen. Five groups of deep collecting lymph vessels in the hand have been highlighted in different colors (left). Note SPALV and DFWLV groups turn their courses in the finger webs, from the palm to the dorsum of the hand and then run in the subcutaneous tissue
IP T
(right). Red arrows indicate the direction of lymph drainage within lymphatic vessels. V = Deep palmar arch vein; A = Deep palmar arch artery; T = Extensor pollicis longus
A
CC E
PT
ED
M
A
N
U
SC R
tendon.
Figure 3. In one specimen (left and center), photographs show SPALV group turning their courses in webs, between the thumb and index finger of the right hand, from the palm to the dorsum and then run in the subcutaneous layer of the hand. In the other specimen (right), a SPALV (vessel filled by Lead Oxide mixture - Red) runs with the
IP T
superficial lymphatic vessels (vessels filled by Barium sulphate mixture – green) in the subcutaneous layer of the hand. Red arrows indicate the course of lymphatic
SC R
vessels. FPLT = Flexor pollicis longus tendon; PDN = Palmar digital nerve; V = the
A
CC E
PT
ED
M
A
N
U
tributary of the cephalic vein.
Figure 4. In different layers (left), SPALV group runs with the superficial palmar arch (has been cut) and DPALV with the deep palmar arch (DPA, partially cut). They are connected by a communicating lymph vessel (CLV). TLV converges with DPALV near the bifurcation of the radial artery (center and right). Red arrows indicate the
IP T
course of lymphatic vessels. A = DPA in the anatomical snuff box; V = the tributary of
A
CC E
PT
ED
M
A
N
U
longus tendon; EPBT = Extensor pollicis brevis tendon.
SC R
the cephalic vein; LVs = SPALV in the dorsum of the hand; EPLT = Extensor pollicis
Figure 5. HTLV in the hypothenar side of the right hand. Red arrows indicate the course of lymphatic vessels. HT = hypothenar muscles; CPDN = Common palmar
A
CC E
PT
ED
M
A
N
U
SC R
IP T
digital nerve.
Figure 6. DWLV in finger webs of the right hand (palmar view). CPDA = Common
A
CC E
PT
ED
M
A
N
U
SC R
IP T
palmar digital arteries; CPDN = Common palmar digital nerve.
S0940-9602(18)30032-3 https://doi.org/10.1016/j.aanat.2018.03.001 AANAT 51241
To appear in: Received date: Accepted date:
28-11-2017 12-3-2018
Please cite this article as: Ma, Chuan-Xiang, Pan, Wei-Ren, Liu, Zhi-An, Zeng, FanQiang, Qiu, Zhi-Qiang, The deep lymphatic anatomy of the hand.Annals of Anatomy https://doi.org/10.1016/j.aanat.2018.03.001 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Original Article
The deep lymphatic anatomy of the hand
IP T
Running head: Deep lymphatics of the hand
SC R
Authors: Chuan-Xiang Ma, BBSci, MS. 1
U
Wei-Ren Pan, MD, PhD.1
N
Zhi-An Liu, MD, MS.1
ED
1
M
Zhi-Qiang Qiu, MD.2
A
Fan-Qiang Zeng, MDip, MD. 1
Department of Anatomy, College of Biomedical Sciences, Xuzhou Medical
Department of Radiology, Xuzhou Oriental People’s Hospital, Xuzhou Medical
CC E
2
PT
University, Xuzhou, Jiangsu, P.R.China.
University, Xuzhou, Jiangsu, P.R.China.
A
Corresponding Author Contact Information: Professor Wei-Ren Pan, MD, PhD Department of Anatomy, College of Biomedical Sciences,
Xuzhou Medical University, 209 Tongshan Road, Xuzhou, Jiangsu, P.R.China. 221004
IP T
Telephone number: (+86516) 83262040
SC R
E-mail: [email protected]; [email protected]
Abstract
U
Background: the deep lymphatic anatomy of the hand still remains the least
N
described in medical literature.
A
Methods: eight hands were harvested from four nonembalmed human cadavers
M
amputated above the wrist. A small amount of 6% hydrogen peroxide was employed
ED
to detect the lymphatic vessels around the superficial and deep palmar vascular arches, in webs from the index to little fingers, the thenar and hypothenar areas. A 30-gauge
PT
needle was inserted into the vessels and injected with a barium sulphate compound.
CC E
Each specimen was dissected, photographed and radiographed to demonstrate deep lymphatic distribution of the hand. Results:
five groups of deep collecting lymph vessels were found in the hand:
A
superficial palmar arch lymph vessel (SPALV); deep palmar arch lymph vessel (DPALV); thenar lymph vessel (TLV); hypothenar lymph vessel (HTLV); deep finger web lymph vessel (DFWLV). Each group of vessels drained in different directions first, then all turned and ran towards the wrist in different layers.
Conclusion: the deep lymphatic drainage of the was been presented. The results will provide an anatomical basis for clinical management, educational reference and scientific research. Key words: hand; deep lymphatic vessels; superficial palmar arch; deep palmar arch;
IP T
finger web.
SC R
Introduction
The hand is the most important part of the body in our daily lives, and is involved
U
in a variety of disorders, ranging from congenital dysplasia to inflammation, trauma,
N
tumor and dynamic processes of secondary lymphedema, etc. (Beasley, 2003;
A
Maschke, 2005). Clinical management requires accurate and detailed anatomical
M
understanding. Although the knowledge of the superficial lymphatic anatomy in the
ED
upper limb has been updated during the last decade (Pan, 2015; Pan, 2017), further studies should be carried out, especially regarding the deep lymphatic pathways, to
PT
renew our knowledge of the human lymphatic system.
CC E
In this study, details of the deep lymphatic distribution and the communicating lymph vessels in the hand are described and demonstrated by radiographs and photographs.
A
Materials and Methods The investigation was performed with appropriate institutional ethics approval. For this study, a total of eight hands were collected from four nonembalmed human cadavers, disarticulated 7cm above the wrist. Two males and two females aged from
70 to 80 years (average age 74 years old) were used. Using a 1ml syringe, a small amount of 6% hydrogen peroxide (Zhonglian Chemical Co., Ltd, Suzhou, China) was injected into the tissue around the superficial palmar arch (SPA), deep palmar arch (DPA) the web between fingers, thenar and
IP T
hypothenar. Under a surgical microscope (Leica Microsystems Ltd, Heerbrugg, Switzerland) the distended lymphatic vessels were identified in the area. Each vessel
SC R
was inserted by a 30 gauge needle (Zhejiang KDL Medical Equipment Group Ltd., Wenzhou, China; Precision glide needle: Becton Dickinson & Co, Franklin Lakes,
U
N.J., USA) and injected with a radio-opaque mixture (Barium sulphate 15g: Shanghai
N
Silian Indusry Co. Ltd., China; Milk powder 5g: Heinz Ltd., Qingdao, China;
A
Concentrated poster color - dark green 3g: Liaoyuan arts and stationery Ltd., Hunang,
M
China; Water 20 ml). In one specimen, both barium sulphate and lead oxide (Lead
ED
oxide 15g: Wenzhou reagent chemical laboratory, Zhijiang, China; Milk powder 5g: milk powder 5g: Heinz Ltd., Qingdao, China; Water 20 ml) mixtures were used for
PT
determining the relationship between the superficial and deep lymph vessels of the
CC E
hand. Lymphatic vessels were then traced, photographed and radiographed (Digital X-ray Dignostic System - Multix Select DR: Siemens Healthcare Diagnostic Co. Ltd., Erlangen, Germany) to demonstrate their distribution. The final results were
A
transferred to a computer (Dell Vostro 200: Dell Computer Inc. Chinese Division, P.R. China) for image analysis using Photoshop software (Adobe Photoshop CS5 V12, Adobe Systems Software Co., Ltd, Beijing, China). Results
Five groups of deep collecting lymph vessels have been found in the hand (Figs. 1 and 2). Each group of vessels drained in different directions first and then all turned and ran towards the wrist in different layers. Superficial palmar arch lymph vessel (SPALV)
IP T
Beneath the palmar aponeurosis, one or two collecting lymph vessels arose beside the superficial palmar arch (SPA) and ran horizontally towards the thumb (Figs
SC R
1 to 4). In the web space between the thumb and index fingers, they received one or two collecting lymph vessels that arose from the surface of the adductor pollicis
U
before turning to the dorsum of the hand, where they joined with the superficial
N
lymphatic group (Fig. 3 right).
A
The average diameter of the vessel was 0.5 mm (ranging from 0.3 to 0.8 mm) in
M
the web area.
ED
Deep palmar arch lymph vessel (DPALV)
One or two collecting lymph vessels arose beside the deep palmar arch and ran
PT
horizontally towards the thumb (Figs. 1 and 2). Penetrating the adductor pollicis and
CC E
the 1st dorsal interosseous muscles, the lymph vessel passed through the space between the 1st and 2nd metacarpal bones and ran with DPA vessels (Fig. 1 left). It crossed the floor of the anatomical snuff box, and then curved medially around the
A
scaphoid and trapezium. At the bifurcation of the radial artery in the wrist, it received a lymph vessel (TLV – see below) arising aside of the superficial palmar arch in the thenar and then ran with the radial artery and vein in the forearm (Fig 4 center and right).
In three cases the DPALV and TLV ran separately in the wrist section, the former curved around the EPL tendon after passing through the space between the 1st and 2nd metacarpal bones and then ran with/under the tributary of the cephalic vein, while the latter ran with the radial artery and vein (Figs. 1 and 2 ).
IP T
In one case, a communicating lymph vessel was found between the SPALV and DPALV. It ran from the DPALV to SPALV (Fig. 4 left).
SC R
The average diameter of the vessel was 0.4 mm (ranging from 0.3 to 0.6 mm); measurements were taken from the point before the vessel penetrated muscles
U
between the 1st and 2nd metacarpal bones.
N
Thenar lymph vessel (TLV)
A
One collecting lymph vessel was found arising next to the superficial palmar
M
arch in the thenar muscles and ran towards the wrist (Figs. 2 and 4). At the bifurcation
ED
of the radial artery on the wrist, it converged with DPALV and then ran along the radial vessels. In three cases, the PDPALV and TLV ran separately in the wrist section,
PT
the former ran with/under the tributary of the cephalic vein while the latter ran with
CC E
the radial artery and vein (Figs. 1 and 2). The average diameter of the vessel was 0.3 mm (ranging from 0.2 to 0.4 mm);
measurements were taken from the point near the bifurcation of the radial artery on
A
the wrist.
Hypothenar lymph vessel (HTLV) One collecting lymph vessel was found and ran proximally in the ulnar side of the 3rd common palmar digital artery (CPDA) and then along with the superficial
palmar arch (Figs. 1, 2 and 5). It went through the Palmaris brevis, passed by the pisiform and then ran with the ulnar vessels. In one specimen, an additional lymph vessel was found next to the common palmar digital nerve (CPDN) in the hypothenar (Fig. 5) and then ran parallel to the
IP T
lymph vessel (described in the previous paragraph) in the same pathway. They converged together in the forearm (Figs. 1 to 3).
SC R
The average diameter of the vessel was 0.3 mm (ranging from 0.2 to 0.5 mm), measuring from the point near to the pisiform.
U
Deep finger web lymph vessel (DFWLV)
N
In three web spaces from the index to little fingers, each had one collecting
A
lymph vessel arising around the bifurcation of the CPDA (Fig. 6). All of them ran a
M
very short distance in webs, turned towards the opisthenar, and then ran
ED
subcutaneously (Figs. 1, 2 left and right).
With an average diameter of 0.4 mm (ranging from 0.2 to 6 mm) measuring
CC E
Discussion
PT
between the finger webs.
Clinical management of disorders of the hand requires accurate and detailed
anatomical understanding (Beasley, 2003; Maschke, et al., 2005). The anatomical
A
structures of the hand have been well documented in textbooks (Schmidt and Lanz, 2003; Standring et al., 2015), apart from the lymphatics. Although the superficial lymphatic anatomy of the hand has been updated during the last decade (Suami, 2007; Pan, 2014 and 2017), the deep lymphatics of the hand still remain the least described
in medical literature. In this study, we have presented five groups of the deep lymph vessel of the hand. The characteristics of the drainage pattern are described as follows: 1. They arose from the different areas and layers of the palm;
IP T
2. Each group of vessels drained in different directions first and then all turned and ran towards the wrist in different layers;
SC R
3. SPALV and HTLV ran in the subcutaneous of the opisthenar after turning in the finger webs.
U
4. DPALV travelled either with the dorsoradial DPA (deep layer) or with the
N
tributary of the cephalic vein (superficial layer) after passing through the
A
space between the 1st and 2nd metacarpal bones.
M
5. Occasionally, there is a CLV to connect SPALV and DPALV.
ED
We believe that our results have provided additional information for enriching
Conclusion
PT
knowledge of the lymphatic anatomy in the hand.
CC E
The deep lymphatic drainage of the hand was described. The results will provide an anatomical basis for clinical management, educational reference and scientific
A
research.
Author Disclosure Statement No competing financial interests exist.
Acknowledgement The authors would like to pay tribute to body donors who contributed their bodies for this study and thank their families for assistance. Many thanks to the National Natural Science Foundation of China (No: 31671253), Xuzhou Medical University
IP T
President special fund (No: 53051116) and the foreign experts special fund of the Department of International Cooperation and Exchange (No: 537101) for supporting
A
CC E
PT
ED
M
A
N
U
SC R
this study.
References Beasley, R.W., 2003. Bealsley’s surgery of the hand. Thieme, New York. Maschke, S.D., Graham, T.J., Evans, P.J., 2005. The hand, third edition. Wolters Kluwer, New York.
IP T
Pan, W.R., 2015. Changing concepts in lymphatic pathways. In: Neligan PC, et al (Ed). Lymphedema: Complete medical and surgical management, Ch. 5. CRC Press:
SC R
Taylor and Francis Group, New York, pp. 61-96.
Pan, W.R., 2017. Atlas of lymphatic anatomy in the head, neck, chest and limbs.
U
People’s Medical Publishing House, Beijing; Springer, Singapore.
N
Schmidt, H., Lanz, U., 2003. Surgical anatomy of the hand. Thieme, New York.
A
Standring, S., et al, 2015. Gray’s anatomy, 41th edition. Elsevier, London.
M
Suami, H; Taylor, G.I., Pan, W.R., 2007. The lymphatic territories of the upper limb:
A
CC E
PT
ED
anatomical study and clinical implications. Plast Reconstr Surg. 119(6), 1813-1822.
Legends
A
CC E
PT
ED
M
A
N
U
SC R
IP T
Figure 1. Distribution of the deep lymphatics in the right hand (radiograph, AP view).
Figure 2. Radiographs (left) and photographs (center and right) of a specimen. Five groups of deep collecting lymph vessels in the hand have been highlighted in different colors (left). Note SPALV and DFWLV groups turn their courses in the finger webs, from the palm to the dorsum of the hand and then run in the subcutaneous tissue
IP T
(right). Red arrows indicate the direction of lymph drainage within lymphatic vessels. V = Deep palmar arch vein; A = Deep palmar arch artery; T = Extensor pollicis longus
A
CC E
PT
ED
M
A
N
U
SC R
tendon.
Figure 3. In one specimen (left and center), photographs show SPALV group turning their courses in webs, between the thumb and index finger of the right hand, from the palm to the dorsum and then run in the subcutaneous layer of the hand. In the other specimen (right), a SPALV (vessel filled by Lead Oxide mixture - Red) runs with the
IP T
superficial lymphatic vessels (vessels filled by Barium sulphate mixture – green) in the subcutaneous layer of the hand. Red arrows indicate the course of lymphatic
SC R
vessels. FPLT = Flexor pollicis longus tendon; PDN = Palmar digital nerve; V = the
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tributary of the cephalic vein.
Figure 4. In different layers (left), SPALV group runs with the superficial palmar arch (has been cut) and DPALV with the deep palmar arch (DPA, partially cut). They are connected by a communicating lymph vessel (CLV). TLV converges with DPALV near the bifurcation of the radial artery (center and right). Red arrows indicate the
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course of lymphatic vessels. A = DPA in the anatomical snuff box; V = the tributary of
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longus tendon; EPBT = Extensor pollicis brevis tendon.
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the cephalic vein; LVs = SPALV in the dorsum of the hand; EPLT = Extensor pollicis
Figure 5. HTLV in the hypothenar side of the right hand. Red arrows indicate the course of lymphatic vessels. HT = hypothenar muscles; CPDN = Common palmar
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digital nerve.
Figure 6. DWLV in finger webs of the right hand (palmar view). CPDA = Common
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palmar digital arteries; CPDN = Common palmar digital nerve.