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A novel method to release the carpal tunnel is presented. It combines the advantages of endoscopic and open techniques while utilizing standard instruments. A lighted Killian nasal speculum is introduced between the palmar fascia and the transverse carpal ligament. The ligament is incised under direct vision. The procedure was performed in 28 cadaver hands and followed by inspection utilizing the open method through an interthenar incision. The transverse carpal ligament was completely divided in all hands without nerve or tendon injury. The superficial palmar arch was injured in one hand (3.6 percent). The advantages, disadvantages, pitfalls, and results are discussed. The technique is simple and effective, employs inexpensive instruments, and has a low complication rate.

Introduction: Ischaemic injury of the hand following radial artery cannulation although rarely reported is a severe complication. One mechanism of injury is radial artery thrombosis in the absence of adequate ulnar collateral circulation. Allen test is usually performed before a radial artery cannulation. Recently, some authors have proposed the registration of a finger pulse oximetric signal after compression of the radial artery to assess the collateral circulation in the handl. The aim of our study is to compare Allen modified test (AT)* and pulse oxymetry (PO)3 to Doppler ultrasound (DU) considered as the reference method. Patients and Nethods: After approval of our Ethical Commitee, fifty consecutive ASA II-IV patients undergoing CABG or major vascular surgery (34 males / 16 females, age ranged from 26 to 76, mean = 59.2 yrs) gave their informed consent and were tested preoperatively by three investigators. Each investigator performed always the same test and was not aware of the other investigators findings. The first hand tested (right or left) was randomly assigned. A directional 8 MGHZ DU flow probe (DUH 800) was used to assess the functionality of the superficial palmar arch: the collateral circulation was classified in: good (DU+), poor or absent (DU-). Results of AT were classified according to the time of full palmar blush (FPB) after release of the ulnar compression: < 7 set, 7s FPB< 15 set, FPB 5 15 sec. Finger probe of a pulse oxymeter (Nellcor 200) was placed on the thumb and the pulse oximetric signal was registered; after compression of radial artery at the wrist the presence (PO+) or absence (PO-) of signal was recorded. Results: The superficial palmar arch was functional in 89/100 hands at the DU. When AT was compared to DU (Tab.l), AT showed a sensibility of 0.86 and a specificity of 0.54 (PPV = 0.93, NPV = 0.33) when the time accepted to observe a FPB was limited to < 7 sec. When this time increased to < 15 sec., sensibility of AT became 0.99 and specificity 0.27 (PPV = 0.91, NPV = 0.75); consequently, the risk of considering normal collateral circulation according to AT when it was absent, according to DU, increased from 0.46 to 0.73 when time of PBF was increased. When PO was compared to DU (Tab 2), PO showed a sensibility of 0.89 and a specificity of 0.45 (PPV = 0.93, NPV = 0.38). The probability to have a PO+ with a DUwas 0.55. Conclusion: AT and PO do not seem to be accurate in assessing collateral circulation in the hand in patients undergoing major cardiovascular surgery.

The characteristic angiographic appearances found in the superficial palmar arch are described in five cases of the hypothenar hammer syndrome. The symptoms depend on the anatomical peculiarities of the arteries in the hand, the extent of the causative lesion and the condition of the peripheral digital arteries. The condition is probably more common than is thought. It can be differentiated from other vascular abnormalities of the hand by angiography.

Fractures of the hook of the hamate frequently fail to unite. In symptomatic nonunion, surgical excision of the hook has provided relief of pain in the few reported cases. In a survey of surgeons, 133 cases of excision of the hook to treat nonunion were reviewed retrospectively. The complication rate associated with excision is three percent. These complications, such as injury to the ulnar nerve or the superficial palmar arch and median nerve paresthesias secondary to retraction are due more to the surgical exposure than the actual excision.

Three patients were treated for severe atherosclerotic obstructive disease in the upper extremity. In all three, vein bypass grafts were placed from the forearm to the superficial palmar arch. The grafts have remained patent for the period of follow-up between 8 and 18 months, and significant palliation was achieved.

True palmar aneurysms are rare tumors of the hand. They occur most commonly in the hypothenar region and are the result of nonpenetrating blunt trauma. This trauma may be repetitive or a single episode. The absence of palmar fascia, the proximity to the hook of hamate, and the superficial location of the distal ulnar artery and superficial palmar arch are predisposing factors.

A case of unilateral absence of the radial artery is reported. The arterial system of the specimen was developmentally primitive with the anterior interosseous artery the chief blood supply to the forearm and hand. A "superficial ulnar artery" of small caliber supplemented the supply of the hand. Three large branches of the anterior interosseous artery supplied the hand with the lateral terminal branch replacing the radial artery distal to the wrist. The superficial palmar arch was formed by an anastomosis of the media and lateral terminal branches of the anterior interosseous artery. No deep palmar arch was present, but three palmar metacarpal arteries arose from a perforating artery which branched from a large dorsal branch of the anterior interosseous artery. The median artery was of small caliber and could not be traced beyond the midforearm. Based on this specimen and a review of other forearm and hand arterial variations, it is postulated that the ulnar artery may developmentally precede the median artery.

Three-dimensional analysis of 220 cadaveric hands to the submacroscopic level was done with clear stereoscopic arteriographs. The superficial palmar arch could be grouped into complete (96.4%) and incomplete (3.6%) arches. The complete arch was divided into four types on the basis of the terminal formation of the deep palmar arch. In the deep palmar arch, the complete arch was seen in 76.9% of the hands. This rate was smaller than that in other reports. The second dorsal metacarpal artery was seen in 92%. With regard to formation of the deep palmar arch, half of all the cases exhibited collateral pathways for the palmar side from the dorsum, sometimes the main arterial source of the deep palmar arch. The blood supply of the thumb comes mainly from the princeps pollicis artery, the terminal branch of the superficial palmar arch, and the first dorsal metacarpal artery, which originates from the radial artery or from different combinations of these arteries. The arteries of the thumb are classified by their anatomic course. The princeps pollicis artery (first palmar metacarpal artery) was absent in 2.4%.

The use of an interpositional vein graft to restore inflow to the digits by recreating the superficial palmar arch is presented. This technique is best reserved for severe, devascuiarizing injuries to the hand, significant damage to the palmar vessels, and when there may a paucity of donor vein available.

A case is reported of an unusual double injury, in which a lower limb salvage procedure employed a free radial forearm flap from an amputated upper limb. The use of amputated parts for salvage procedures is well documented but none has previously involved a free forearm flap. This clinical case shows that the entire forearm and hand skin can be adequately perfused on the radial artery along with the superficial palmar arch.

This article describes a subcutaneous endoscopic operative procedure for carpal tunnel syndrome and analyzes its effectiveness using electrophysiological data. Subcutaneous transverse carpal ligament release under universal subcutaneous endoscope (USE) was performed using local anesthesia without pneumotourniquet in 54 hands of 45 patients since June 1986. The mean follow-up period was 13.8 months. Sensory disturbances began to subside immediately after the operation and disappeared within 2 months in all cases. After the disappearance of sensory disturbances, we performed postoperative electrophysiological studies in 27 patients (33 hands). Postoperative electrophysiological data were significantly improved in all cases. Patients did not suffer from any serious complications such as motor branch injuries of the median nerve, hypesthesia of the palm, or injuries of the superficial palmar arch. From these results, we conclude that the transverse carpal ligament can be safely incised by this procedure

This is a study of the origin of the palmar collateral arteries of the thumb and radial side of the index finger. The different patterns of the main trunk, the first palmar interosseous artery, in the commissure are discussed, together with the relations of its branches with those of the superficial palmar arch and its relations with the accessory fasciculi of the adductor pollicis and first dorsal interosseous muscles.

A case is described of aneurysm of the bifurcation of the ulnar artery, occurring in a haemophiliac as a result of blunt trauma, and causing thrombosis of the superficial palmar arch and ischaemia of the fingers and thumb. The anatomical, physiological, and pathological aspects are discussed. The ulnar artery is shown to play a greater part in the blood-supply of the digits than is generally realized, and a diagnosis of thrombosis to be tenable even in a haemophiliac. The features of ulnar artery aneurysm are described and the literature reviewed.

Purpose The aim of this study was the examination of the superficial anatomy of palmar creases and their relation to deeper neuro-vascular structures. Methods Four creases: distal wrist flexion crease, thenar crease, proximal palmar crease and distal palmar crease were evaluated with reference to the following structures: palmar cutaneous branch of median nerve, palmar cutaneous branch of ulnar nerve, the nerve of Henle, transverse palmar branches from ulnar nerve, recurrent motor branch of median nerve, radial proper palmar digital nerve to the index and the ulnar proper palmar digital nerve to the thumb, Berrettini’s communicating branch, ulnar nerve and artery, superficial palmar arch. We performed dissections of 20 cadaveric upper limbs derived from a homogenous Caucasian group. In our study we measured the location of surgically important structures with reference to palmar skin creases. Results Among the other observations we noticed that the palmar cutaneous branches of the median and ulnar nerves were located at least 0.5 cm away from the thenar crease. The superficial palmar arch was found between the thenar and proximal palmar crease and never crossed the proximal or distal palmar creases. Conclusions These anatomical dissections will provide reference material for further ultrasound studies on the arrangements of neuro-vascular structures in reference to superficial palmar creases.

Raynaud's phenomenon is a prominent manifestation of systemic sclerosis (scleroderma) affecting the hand. The resulting digital ischaemia may progress to digital tip ulceration or gangrene. Four patients with scleroderma, presenting with severe unremitting unilateral pain in the hand, were evaluated by arteriography and plethysmography. In addition to the usual changes of narrowing and occlusion of the digital arteries themselves, arteriography revealed more proximal occlusion of the radial and ulnar arteries at the wrist and the superficial palmar arch. Plethysmography confirmed virtual absence of pulsatile digital blood flow. Two patients underwent microsurgical reconstruction of the radial and ulnar arterial inflow into the hand and the superficial palmar arch using reversed interposition vein grafts, with immediate subjective resolution of their severe pain and rapid healing of the digital ulcers. Both remain pain free 1 year post-operatively, and pulse-volume recordings have confirmed objectively the restoration of pulsatile blood flow to the fingers.

The frequent use of arterial puncture, cannulation, and A-V shunting has demonstrated a greater degree of safety than could be predicted from previous anatomic and angiographic studies. Using a noninvasive technique, the status of the superficial palmar arch (SPA) and relative contributions of radial and ulnar arteries were determined in 100 volunteers with no history of vascular disease. Although there was no significant difference in the diameter of the vessels at the wrist, the flows showed statistically significant ulnar dominance, suggesting that the difference is a factor of a lower distal resistance on the ulnar side. The lower resistance across the ulnar bed probably is responsible for the clinically observed ease of sacrifice of the radial artery contribution to palmar flow. The SPA was found to be incomplete in 11.0% of the hands.

Review of a series of 186 operative cases of carpal tunnel release revealed 34 complications in 22 patients, for an incidence of 12%. Complications were grouped into seven categories: (1) inadequate section of the transverse carpal ligament (associated with both transverse and curved incisions), (2) symptoms related to damage to the palmar cutaneous branch of the median nerve, (3) reflex sympathetic dystrophy, (4) unsightly hypertrophic scar due to inappropriate incision, (5) damage to the superficial palmar arch following blind sectioning of the transverse carpal ligament, (6) bowstringing of the flexor tendons after excision of the transverse carpal ligament, and (7) adherence of the flexor tendons following excision of the mesotenon. Except for four of the complications, two each of bowstringing and reflex sympathetic dystrophy which occurred in our own practice, all of the complications were seen in patients referred for care. Most complications can be prevented by proper operative technique.

The organs of the circulation (angiologia) include the bloodvascular system and the lymphatic system. The bloodvascular system (systema cardiovasculare) consists of the heart, its central organ, and the blood vessels among which we differentiate the arteries, running centrifugally from the heart, and the veins which are directed towards the heart. The arterial and venous networks are connected by the capillaries. The blood circulating within these vessels, the organs of blood formation (haematopoiesis) and the organs responsible for the breakdown of the blood cells are also part of the bloodvascular system.

Entrapment neuropathies are nerve injuries that occur in predictable areas; they are evaluated in similar fashion and probably have a common pathophysiology. Ionic, mechan­ ical, and vascular lesions are involved in the pathophysiologic mechanism of entrapment neuropathies. I The initiating mechanism in the neurologic disturbance of a compression neuropathy is often uncertain in any particular patient; in one patient the ionic lesion may be most prominent as the initiat­ ing factor, while in another a vascular or mechanical lesion may produce the initial symptoms. The vascular lesions seem to be most understandable from the standpoint of pathophys­ iologic mechanisms. 2 Study of the vascular anatomy of nerves over the last 300 years has revealed a segmental vascu­ lar supply to the nerve trunk that is carried in a mesoneurium, permitting motion and allowing changes of position and ten­ sion of the nerve with motion of the joints of the extremity. 3 The arcades of the mesoneurium vary with location. The me­ dian nerve at the wrist is supplied by a mesoneurium from the anterior medial side of the nerve proximal to the transverse carpal ligament as well as by a series of vessels from the superficial palmar arch distal to the transverse carpal liga­ ment.:1• 4 The smaller vessels enter the epineurium of the nerve and immediately divide into ascending and descending epineural branches. The epineurial network of vessels, after forming an anastomotic network in the subepineurium of the nerve, further subdivides to a vascular plexus at the perineurium. The capillary bed within the nerve itself is con­ tained within the fascicles of the nerve so that from the perineurial level of vascular plexus, small end arteries and capillary beds form the remainder of the vascular network within the nerve trunk. 3

Y-shaped vein grafts that have been specifically selected from the venous anatomy on the dorsum of the foot have been used to bridge the arterial defects in multiple digit replantations. In this technique, the two outflow limbs of the Y-shaped vein graft are anastomosed to the distal digital arteries of two adjacent fingers before osteosynthesis. The inflow stem of the Y-shaped graft is then anastomosed to a common digital artery or to the superficial palmar arch to provide rapid and reliable restoration of arterial inflow simultaneously into two adjacent digits.

Our objective was to describe the imaging features of hypothenar hammer syndrome using minimally invasive contrast-enhanced MR angiography in comparison with oscillography study. In five patients with hypothenar hammer syndrome Gd-BOPTA-enhanced elliptically reordered 3D pulse sequence MR was compared with oscillography findings and clinical symptoms focusing on angiographic appearance of vessel injury, distribution pattern of hand vasculature and joining branches between the radial and ulnar artery supply. All patients showed segmental occlusion at the site of trauma impact with varying involvement of the superficial palmar arch, common volar digital arteries. Embolic disease was present in 50% of patients and could be clearly identified with MRA. Good correspondence was found between angiographic appearance including the presence of collaterals, clinical symptoms and oscillography. Bilateral comparison was helpful in distinguishing between vessel variants and pathology. Bilateral Gd-BOPTA-enhanced MR angiography is a minimally invasive method to depict clearly the localization and extent of vessel injury in hypothenar hammer syndrome providing valuable information about distribution pattern of hand vasculature and presence of collaterals; however, no flow data can be obtained.

The use of vein grafts has increased the successful survival rate of replanted fingers or hands."? Utilizing vein grafts in replantation allows a reduction in tension between the anastomosed vessels. However, the disadvantage of this method is that, especially in the case of multiple arterial injuries such as amputation in the palm, it requires more operating time to establish multiple vessel anastomoses. In these cases a metatarsal venous arch graft obtained from the dorsum of the foot is an excellent alternative. The indication for this technique is replantation at the metacarpal level of the hand in which the superficial palmar arch is lost, and cannot be repaired without vein grafts (Fig. 1). After suturing the transected tendons, a dorsal venous arch of the right foot is obtained as a vein graft, with several communicating branches of the cutaneous veins (Fig. 2). The vein graft is then transferred to the arterial defects in the metacarpal region, and the distal end of the graft is anastomosed to the proximal end of the superficial palmar arch. The branches on the proximal portion of the vein graft are joined to the ends of the palmar metacarpal or digital arteries (Figs. 3 and 4). It is generally accepted that vein grafts from the forearm or the lower leg are essential for the successful reconstruction of long or short arterial defects in amputated hands or the fingers."? However, in the case of wide crush amputation especially at the metacarpal level it is very time-consuming to reconstruct the several

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Variations in formation of the superficial palmar arch are common. A classic superficial palmar arch is defined as direct continuity between the superficial branch of the ulnar artery and superficial palmar branch of the radial artery. During routine dissection classes to undergraduate medical students we have observed formation of superficial palmar arch solely by superficial branch of ulnar artery without any contribution from the radial artery or median artery. Knowledge of the anatomical variations of the arterial pattern of the hand is crucial for safe and successful hand surgery.