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Abstract Background This case report documents a rare variation of a persistent median artery. Normally a transient vessel present during embryologic development of the limbs, the median artery typically regresses by the eighth week of life as the radial and ulnar arteries predominate the distal vascular supply of the hand. In a subset of the adult population, this artery remains as a persistent median artery which most often ends in the carpal tunnel or hand without significant vascular dependence. Case presentation An 84-year-old female cadaver was found bilaterally to have an artery that penetrated the median nerve in the forearm, continued through the carpal tunnel, then joined the superficial arch, giving rise to the common digital artery to the second webspace. It also gave rise to the radialis indicis, the princeps pollicis, and an anastomotic branch to the radial artery. Conclusions This anatomic variant of a persistent median artery piercing the median nerve, traversing the carpal tunnel, and providing aberrant primary blood supply to a large area of the hand are details clinically relevant to those who treat hand disorders and injuries.

Purpose: This report describes a bilateral persistent median artery (PMA) originating from the ulnar artery and terminating at different levels of the upper limb. The PMA coexisted with a bilateral bifid median nerve (MN) and two bilateral interconnections (ICs characterized with the symbol -) of the MN with the ulnar nerve (UN) (MN-UN) and a unilateral reverse IC (UN-MN). Emphasis was given to the artery's developmental background. Methods: The PMA was identified in an 80-year-old formalin-embalmed donated male cadaver. Results: The right-sided PMA terminated at the wrist, posterior to the palmar aponeurosis. Two neural ICs were identified: the UN joined the MN deep branch (UN-MN), at the forearm's upper third, and the MN deep stem joined the UN palmar branch (MN-UN), at the lower third (9.7 cm distally to the 1st IC). The left-sided PMA ended in the palm giving off the 3rd and 4th proper palmar digital arteries. An incomplete superficial palmar arch was identified by the contribution of the PMA, radial, and ulnar arteries. After the MN bifurcation into superficial and deep branches, the deep branches formed a loop, that was penetrated by the PMA. The MN deep branch communicated with the UN palmar branch (MN-UN). Conclusions: The PMA should be evaluated as a causative factor of carpal tunnel syndrome. The modified Allen's test and the Doppler ultrasound may detect the arterial flow and the angiography may depict the vessel thrombosis in complex cases. PMA could also be a "salvage" vessel for the hand supply, in radial and ulnar artery trauma. [ABSTRACT FROM AUTHOR]

Introduction: Cadaveric studies suggest an increasing prevalence of the persistent median artery (PMA) over a prolonged timeframe. The aim of this retrospective cross‐sectional study was to evaluate the PMA prevalence in haemodialysis patients who had computed tomographic fistulograms (CTFs), and if present, their calibres and origins. Methods: All consecutive adult patients referred for an upper limb CTFs for assessment of arteriovenous fistula (AVF) dysfunction from 2006 to 2021 were included. Patients whose CTF did not include the forearm were excluded. PMA was identified as an artery running alongside the median nerve between flexor digitorum superficialis and flexor digitorum profundus. Patient demographics, presence of PMA including size and origin were recorded. Results: A PMA was found in 91/170 (53.5%) CTFs (7:3 male‐to‐female ratio, mean age 71‐years). When stratified by age, prevalence increased with decreasing age; 51% in >70‐year‐olds, 54% in 50–70‐year‐olds and 67% in <50‐year‐olds. The average PMA diameter was 2.2 mm proximally and 1.8 mm distally. No stenosis was observed in the PMAs. Conclusion: The PMA prevalence appears to increase with decreasing age and is a frequently encountered anatomical variant. Radiologists assessing forearm vasculature need to be aware of this anatomical variant and potentially include it in their future reports. Further research into the PMA may make its potential use as arterial conduits for AVF, potential donor grafts for coronary artery bypass surgery or additional vascular access options possible. Whether the reducing prevalence with age reflects an overall increasing prevalence is yet to be determined. [ABSTRACT FROM AUTHOR]

Median artery is usually a transient vessel during the embryonic period and may persist in adult life as the persistent median artery (PMA) in the upper limbs. It remains asymptomatic in most people; however, thrombosis leading to features of carpal tunnel syndrome is one of the known complications. We report a case of pseudoaneurysm of PMA following a trivial injury. This case report highlights the importance of being aware of this anatomical variation, to avoid complications during hand surgeries.

Background: This case report documents a rare variation of a persistent median artery. Normally a transient vessel present during embryologic development of the limbs, the median artery typically regresses by the eighth week of life as the radial and ulnar arteries predominate the distal vascular supply of the hand. In a subset of the adult population, this artery remains as a persistent median artery which most often ends in the carpal tunnel or hand without significant vascular dependence. Case presentation: An 84-year-old female cadaver was found bilaterally to have an artery that penetrated the median nerve in the forearm, continued through the carpal tunnel, then joined the superficial arch, giving rise to the common digital artery to the second webspace. It also gave rise to the radialis indicis, the princeps pollicis, and an anastomotic branch to the radial artery. Conclusions: This anatomic variant of a persistent median artery piercing the median nerve, traversing the carpal tunnel, and providing aberrant primary blood supply to a large area of the hand are details clinically relevant to those who treat hand disorders and injuries. [ABSTRACT FROM AUTHOR]

Carpal tunnel syndrome (CTS) is an upper extremity median nerve entrapment disorder that is rare in children and adolescents. Anatomical variations of the wrist, such as anomalous muscles, persistent median artery (PMA), and bifid median nerves (BMN), are rare etiology of CTS. Coexistence of all three variants combined with CTS in adolescents has been rarely reported. Case description: A 16-year-old right-hand dominant male presented to our clinic with several years of bilateral thenar muscle atrophy and weakness but no paresthesia or pain in his both hands. Ultrasonography showed that the right median nerve become significantly thinner, and the left median nerve was split into two branches by PMA. Magnetic resonance imaging (MRI) revealed that anomalous muscles in the bilateral wrist extending to the carpal tunnel, causing compression of the median nerve. Considering the possibility of CTS clinically, the patient underwent bilateral open carpal tunnel release without resection of anomalous muscles and PMA. The patient has no discomfort after 2 years. This suggests that anatomical variations of the carpal tunnel may contribute to CTS, which can be confirmed by preoperative ultrasonography and MRI, and the possibility of carpal tunnel anatomical variations should be considered when CTS occurs in adolescents. Open carpal tunnel release is an effective treatment for juvenile CTS without the need to resect abnormal muscle and PMA during the operation.

Being aware of the variants of upper extremity anatomy is of utmost importance to a surgeon. This case report describes a patient who presented with two separate wrist masses. Operative exploration was planned, and both the structures were investigated. The distal mass was identified as a volar wrist ganglion, and the more proximal mass was identified as the muscle belly of a reversed palmaris longus muscle. Incidentally, it was noted that the patient had a patent, persistent median artery. Although many variants of the palmaris longus have been described, as have been cases of a persistent median artery, both have not been previously documented in a single patient. Although this is rare, having knowledge of possible anatomic variations is valuable for any surgeon operating on the upper extremity.

Purpose: The purpose of this study is to characterize the division of the median nerve by the persistent median artery (PMA) and highlight the associated clinical implications. Penetration of the median nerve by the PMA is believed to cause compression of the median nerve and affect nerve conduction velocity. This paper explored whether the origin and the pattern of PMA dictate its ability to divide the median nerve. Methods: Origin, and relationship of the PMA to the median nerve were documented in 60 cadavers donated to the Human Anatomy Program at UT Health San Antonio. Entire path of this artery was followed in the forearm and the hand. Results: Twenty-five cases of a persistent median artery (PMA) were found in the upper limbs (20.83%; 25/120) of these donated cadavers. Most of the persistent median arteries originated from the ulnar artery (48%; 12/25) and the others originated either from the anterior interosseous artery (36%; 9/25) or from the common interosseous artery (16%; 4/25). Sixty percent (15/25) of the persistent median arteries penetrated and divided the median nerve in the forearm. Interestingly, all the persistent median arteries that originated from the ulnar artery (100%; 12/12) divided the median nerve in the forearm and a palmar type of PMA was found to be more likely to divide the median nerve. Conclusion: Clinicians performing surgeries in the forearm and hand need to be aware of this anomaly and should screen patients for the presence of this artery prior to surgical intervention. [ABSTRACT FROM AUTHOR]

Carpal tunnel syndrome is a common peripheral nerve entrapment neuropathy caused due to compression of the median nerve at the level of the wrist joint. Bifid median nerve associated with a persistent median artery is a rare entity and in itself asymptomatic anatomical variant. However, distension of the persistent median artery due to a thrombus can be symptomatic due to compression on the median nerve and can compromise the blood flow to the palm. We report a case of persistent median artery thrombosis in a young female patient who presented with symptoms of carpal tunnel syndrome diagnosed on the ultrasonography and confirmed on the MRI with subsequent improvement post anticoagulation therapy.

Background A rare case of carpal tunnel syndrome caused by a thrombosed persistent median artery is presented here. Case The diagnosis was delayed due to the overlapping cervical radiculopathy. Acute severe pain and nocturnal paresthesia were chief complaints. Ultrasonography, magnetic resonance imaging, and computed tomography angiography revealed that the median nerve was compressed by the occluded median artery. Instead of surgery, conservative therapy was tried. It worked well for six months. Conclusions The importance of using modalities for decision making of diagnosis and treatment is emphasized in this report.

Numerous vascular variations were observed in the upper limbs of a 109-year-old female donor to the Gift Body Program of Saint Louis University School of Medicine. Variations in the right upper limb included the presence of a brachioradial artery (BRA), persistent median artery (PMA), and an ulnar-dominant incomplete type B superficial palmar arch (SPA). In the left upper limb, the brachial artery bifurcated normally into the ulnar artery (UA) and radial artery (RA). However, a more developed palmar type of PMA was observed, replacing much of the palmar circulation typically supplied by the superficial palmar branch of the RA, which existed only as a small branch anastomosing with the PMA to form a rare arcus medianoradialis-type SPA. Both PMAs arose from their respective UAs distal to the origin of the common interosseous arteries. The left PMA pierced the median nerve (MN) as it descended the forearm. The extent of these variations together presents a unique case of vascularity in the upper limbs. Knowledge of these variations is pertinent to MN compression pathologies as well as procedures involving the upper limb., Competing Interests: Human subjects: All authors have confirmed that this study did not involve human participants or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Lee et al.)

Background: It is vital to know the anatomical variations of the wrist to avoid iatrogenic injuries during carpal tunnel (CT) surgery. Purpose: To determine the anatomical variations of the median nerve (MN) and the prevalence of persistent median artery (PMA) on wrist magnetic resonance imaging (MRI). Material and Methods: A total of 300 wrists evaluated by MRI during 2013–2015 were retrospectively identified. While branching of the MN distal to the CT is accepted as the normal anatomy, proximal to the tunnel and within the tunnel were considered as variations. The prevalence of PMA was also evaluated. The patients were assigned to groups according to age, gender, and wrist side and compared to determine whether there was any significant difference in terms of these variations. All evaluations were assessed with the shared decision of a musculoskeletal radiologist and a radiology resident. Results: Of the 300 wrists, 38 (12.7%) and 34 (11.3%) had a bifid MN proximal to the CT and within the CT, respectively. Only one nerve trifurcation was seen within the CT. The MN exhibited branching distal to the CT in 227 (76%) patients. PMA was observed in 44 (14.7%) patients. Of the 44 PMA cases, 28 (63.6%) also had a coexisting MN variation. There was no significant difference in the prevalence of MN variations and PMA in the subgroups (P > 0.05). Conclusion: Nearly one in four patients (24.4%) have MN variations and 14.8% had PMA. Preoperative evaluation of these common anatomical variations with MRI will be protective against postoperative complications of CT surgery. [ABSTRACT FROM AUTHOR]

Objective: To study the morphological variations of median nerve observed in patients during carpal tunnel release surgery . Study Design: Cross Sectional study. Setting: Qazi Hussain Ahmad Medical Complex, Nowshera. Period: One year (November, 2019 till October, 2020). Material & Methods: This Cross-sectional study was conducted after obtaining ethical approval from the Institutional Ethical Review Board (IERB), NMC in which people were tracked with mild to severe carpal tunnel symptoms for a year. Less than 24 hours after their arrival, the Patients were operated on under local anesthesia in Qazi Hussain Ahmad Medical Complex, Nowshera, Pakistan. Each surgical method viewed the nerve. Branches around the carpal tunnel were seen and documented on a Microsoft Excel spreadsheet. 150 were planned. The statistics were in percentages. Results: In 150 instances, 102 (68%) were female and 48 (32%) were male. 138 (92%) individuals showed normal median nerve morphology, whereas 12 (8%) had aberrant branching. The transverse carpel ligament had significant splitting. There was a persistent median artery in three of the 12 instances. Conclusion: The top division of the median nerve showed altered branching morphology. As with the persistent median artery, recurring median artery raises the chance of median nerve dysfunction. [ABSTRACT FROM AUTHOR]

Persistent median artery (PMA) is an anatomical variation of the hand vascularity arising from brachial artery in early embryonic life. The presence and thrombosis of PMA may result in several complications such as carpal tunnel syndrome. Early diagnosis and treatment of acute thrombosis of PMA is important because many complications and the need for surgery can be prevented with early anticoagulation therapy. In this report, we present the findings of a thrombosed PMA causing wrist pain in a 37-year-old male. Early anticoagulant therapy provided a complete resolution of the symptoms.

Background: Carpal tunnel syndrome is a common condition in adults with an estimated prevalence of up to 5% in the general population. The presence of a persistent median artery is an important consideration for plastic and orthopedic surgeons who frequently perform carpal tunnel release. This artery may persist into adulthood and constitute a significant supply of blood to the hand, sometimes compressing the median nerve. Purpose: In this case series, we describe the prevalence of the persistent median artery identified intraoperatively in Polish subjects undergoing surgical open carpal tunnel release. Methods: The data regarding the prevalence of persistent median artery were retroactively collected postoperatively from the standard surgical protocols. Results: Persistent median artery was identified in 36 out of 1285 operated hands (2.8%). The observed PMAs were identified in 15 (2.0%) cases out of 750 right upper limbs and in 21 (3.9%) cases out of the 535 left upper limbs. Conclusions: Persistent median artery can be present in the operating field of any surgeon that performs carpal tunnel release and any other surgical procedures in the wrist region. Therefore awareness of its presence is crucial to minimize intraoperative complications such as bleeding or digital ischemia.

Objective This study aims to investigate the utility of handheld, Bluetooth-capable ultrasound in identifying millimeter-sized vasculature in both living and cadaveric subjects. Methods Using handheld, linear ultrasound probes, the carpal tunnel of 87 living individuals (174 forearms) was assessed for the presence of a persistent median artery (PMA). Radial, ulnar, and persistent median arterial diameters were measured, along with forearm circumference. Using the same probes, 46 cadaveric forearms were assessed for the presence of a "potential" PMA. Those same forearms were subsequently dissected to confirm the presence of the artery.  Results A PMA was identified in 3.4% of individuals (1.7% of forearms). Radial, ulnar, and persistent median arterial diameters were 2.12 ± 0.40 mm, 1.89 ± 0.41 mm, and 0.82 ± 0.33 mm, respectively. The radial artery was significantly larger than the ulnar artery (p < 0.0001). In cadaveric subjects, four "potential" PMAs were identified by pre-dissection ultrasound. Upon dissection, only one of the "potential" PMAs was confirmed, and three previously unidentified PMAs were identified.  Conclusions The prevalence of PMA in living subjects was lower than previously reported. Additionally, handheld ultrasound had low accuracy in identifying PMAs in cadavers prior to dissection. This could be an indication that current handheld ultrasound lacks the sensitivity to identify millimeter-sized vasculature, such as a PMA. In both populations of subjects, key, non-anomalous anatomy was readily seen, indicating the utility of handheld ultrasound in the proper context., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Liberty University Institutional Review Board issued approval IRB-FY22-23-863. We are pleased to inform you that your study has been approved by the Liberty University Institutional Review Board (IRB). This approval is extended to you for one year from the following date: April 7, 2023. If you need to make changes to the methodology as it pertains to human subjects, you must submit a modification to the IRB. Modifications can be completed through your Cayuse IRB account. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Thibault et al.)

An 89-year-old Caucasian male cadaver with prostate cancer demonstrated bilateral persistence of the median artery and bifid median nerve (BMN) during upper limb dissection. The persistent median artery (PMA) originated from the common interosseous artery and coursed alongside the median nerve. Proximal to the carpal tunnel, the median nerve bifurcated into medial and lateral branches. To our knowledge, this is the first documented case of a bilateral PMA and BMN. While the majority of existing literature focuses on a unilateral PMA or unilateral BMN, bilateral occurrences of either variation are rare. This report presents a novel finding by documenting the simultaneous presence of a bilateral PMA and BMN., Competing Interests: Human subjects: All authors have confirmed that this study did not involve human participants or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Aribindi et al.)

Carpal tunnel syndrome (CTS) is the most common neuropathy of the upper extremity.1 We report a case in which a twenty-eight-year-old manual labourer presented with acute thrombosis in a persistent median artery which triggered acute carpal tunnel symptoms. A bifid median nerve was found upon carpal tunnel release. The knowledge of the existence of this anatomic variation is important in order to prevent inadvertent injury. We further discuss the possible aetiologies for CTS as well as neurovascular anomalies which may lead to median nerve compression at the wrist.

Background and objective. In our daily practice we find anatomical variations that will have a diagnostic and therapeutic repercussion. With this article we emphasize the importance of vascular anatomical variations presenting an anatomical case of a persistent median artery which alters the vascularization of the fingers, and that is frequently associated with the presence of a bifid median nerve. Following this finding, a literature review and a clinical study were conducted to highlight the association of this malformation with carpal tunnel syndrome (STC) Methods. Our study is divided into two parts: anatomical and clinical. The anatomical study of a forearm showed us as a persistent median palmar artery which is responsible for vascularization of the 1st and 2nd fingers, associated with a bifid median nerve. Then, we conducted a literature review and a prospective study in order to know the percentage of medium arteries found in the STC surgery, chosen in a random way based on their incorporation to the waiting list of our hospital for a 4 months period. Results. A total of 128 STC patients were operated, finding a persistent median artery in 3 patients, which corresponds to 2.34% of the total valued. Discussion. The percentage of presentation of persistent medium artery in our study is coincident with the various studies reviewed in adult patients. We agree on the importance of the knowledge of anatomical variations by themselves and their implication in the symptomatology of STC. It is also important to keep in mind the existence of these anatomical variations when faced with a traumatic injury or when we dissect a flap. [ABSTRACT FROM AUTHOR]

Le syndrome du canal carpien est une neuropathie périphérique fréquente, le plus souvent idiopathique ou post-traumatique. Il entraîne des douleurs neuropathiques dans le territoire du nerf médian. L'artère persistante du nerf médian est une variation anatomique rare à l'âge adulte, qui peut se compliquer de thrombose, et entraîner un syndrome du canal carpien de survenue brutale, avec sensation de froid ou d'œdème. Ces caractéristiques inhabituelles doivent faire évoquer une cause vasculaire au syndrome du canal carpien, et conduire à la réalisation d'un écho-Doppler couleur, qui permet de confirmer le diagnostic. Le scanner avec injection de produit de contraste et l'angio-IRM peut également aider au diagnostic. Nous décrivons ici 2 cas de syndrome du canal carpien par thrombose de l'artère persistante du nerf médian, dont une observation originale secondaire à une thromboangéite oblitérante. Ces thromboses peuvent également être d'origine post-traumatique. La prise en charge thérapeutique ne fait pas l'objet de recommandations spécifiques, mais peut reposer sur le traitement anti-agrégant plaquettaire, les statines, l'anticoagulation curative, ou encore une prise en charge chirurgicale. Carpal tunnel syndrome is a common peripheral neuropathy, usually idiopathic or post-traumatic due to the compression of the median nerve. Numbness and paresthesias in the median nerve distribution are the most common symptoms associated with this condition. Persistent median artery is a rare anatomic variation, thrombosis of this additional artery can be responsible for an acute carpal tunnel syndrome, and patients frequently complain about coldness and acute hand swelling. These unusual features must lead clinicians to think of a vascular cause. The diagnosis can be easily confirmed by using ultrasound doppler, but CT-scan and MRI are sometimes helpful. We describe 2 cases of acute carpal tunnel syndrome due to thrombosed persistent median artery, including a case of thromboangiitis obliterans. These thrombosis might also be due to traumatic causes. No guidelines are currently available to help physicians for the management of carpal tunnel syndrome from thrombosed persistent median artery. Antiplatelet therapy, statin, anticoagulant might be helpful, and surgery has sometimes be reported as effective. [ABSTRACT FROM AUTHOR]

Carpal tunnel syndrome (CTS) is a common complication in acromegaly and is often associated with enlargement of the median nerve. Morphological changes in the median nerve and surrounding tissues can be visualized easily by ultrasound (US) scanning in suspected patients. Ultrasonography also offers priceless contributions to visualization of anatomical variations and pathological conditions that may potentially be associated with CTS. We present the presence of bifid median nerve and persistent median artery, which are both unusual findings, during the US screening for CTS in a 36‐year‐old male patient with acromegaly. [ABSTRACT FROM AUTHOR]

Objective This pilot project aimed to assess the prevalence and variations of the median artery (MA) on a small scale in preparation for a large-scale study investigating MA in Lithuanian cadavers. Methods Eight formalin-fixed adult female cadavers were used in this study. Dissection was performed to allow for the observation of MA presence, type, origin, termination, and relations with other structures. The gathered data was analyzed, and a literature search was performed to compare the findings. Results MA was found in 10 of the 16 upper limbs examined; therefore, the incidence of MA in the present study was 62.5%. Of the 10 MAs found, six (60%) were of the antebrachial type (a-MA), and four (40%) were palmar (p-MA). Thus, the prevalence of a-MA and p-MA in the upper limbs examined was 37.5% (N = 6/16) and 25% (N = 4/16), respectively. Among the six cadavers that were found to possess MA, it was identified bilaterally in four (66.7%) and unilaterally in two (33.3%). The associations between the antimere and the presence of MA or MA-type were not statistically significant. MA most commonly originated from the common interosseous artery (50%, N = 5/10), followed by the ulnar artery (UA) (40%, N = 4/10), and the anterior interosseous artery (10%, N = 1/10). Two (33.3%) of the six a-MAs terminated in the mid-forearm, while four (66.7%) a-MAs ended in the distal forearm. Meanwhile, three (75%) of the four p-MAs terminated by joining the UA, while one (25%) terminated as the first common palmar digital artery. In the forearm, nine (90%) of the 10 MAs traveled anteriorly to the anterior interosseous nerve (AIN), and only one (10%) traveled posteriorly to the AIN. Additionally, one (10%) of the 10 MAs was found to pierce the median nerve. Conclusions Our findings confirm the variability in MA characteristics reported by previous studies. The high incidence of MA discovered in our sample calls attention to the importance of being aware of MA in a clinical setting, as this would allow for a timely and accurate response to a potential pathology associated with this structure., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, Berškys et al.)

Here, we present a 37-year-old right-handed female patient who presented with increasing paresthesia, tingling, and numbness in the radial palm and lateral three fingers of her right hand for six months. Because of the intense wrist discomfort and unilateral involvement, ultrasonography was used to evaluate the patient in addition to a nerve conduction study to exclude secondary causes of carpal tunnel syndrome., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, Yildizgoren et al.)

During a routine cadaveric dissection of a 93-year-old male donor, unique arterial variations were observed in the right upper extremity. This rare arterial branching pattern began at the third part of the axillary artery (AA), where it gave off a large superficial brachial artery (SBA) before bifurcating into the subscapular artery and a common stem. The common stem then gave off a division for the anterior and posterior circumflex humeral arteries, before continuing as a small brachial artery (BA). The BA terminated as a muscular branch to the brachialis muscle. The SBA bifurcated into a large radial artery (RA) and small ulnar artery (UA) in the cubital fossa. The UA branching pattern was atypical, giving off only muscular branches in the forearm and a deep UA before contributing to the superficial palmar arch (SPA). The RA provided the radial recurrent artery and a common trunk (CT) proximally before continuing its course to the hand. The CT from the RA gave off a branch that divided into anterior and posterior ulnar recurrent arteries, as well as muscular branches, before it bifurcated into the persistent median artery (PMA) and the common interosseous artery. The PMA anastomosed with the UA before entering the carpal tunnel and contributed to the SPA. This case presents a unique combination of arterial variations in the upper extremity and is clinically and pathologically relevant.

We report a case of bilateral carpal tunnel syndrome (CTS) with bilateral bifid median nerve (BMN) without a persistent median artery diagnosed by clinical examination, NCV and Ultrasonography. Bilateral BMN to produce bilateral CTS is extremely rare and is contrary to the popular classifications which state that BMN without persistent median artery or its anomalies will not produce CTS. Ultrasonogram is of additional help to identify such aberrations in the median nerve to prevent iatrogenic injuries during carpal tunnel decompression. [ABSTRACT FROM AUTHOR]

Background: Awareness of anatomical variations of the median nerve at wrist is important in repair of traumatic injuries and treatments of compression syndrome because in these situations precise dissection of the nerve is mandatory and such variations are not infrequent. Materials and Methods: In this study, 52 hands of 52 fresh cadavers were dissected and median nerve anatomy along with the presence of persistent median artery (PMA) was noted. Results: A total of 26 hands (50%) had the deviation from the standard text book anatomy of the median nerve. There was early division of the median nerve into the medial and lateral branches in 11.53% hands. There was early branching of the 2 nd common digital nerve in 9.6% hands. The transligamentous motor branch to the thenar muscle was most prevalent (42.3% hands). The single motor branch to the thenar muscles was found in the majority of hands (84.6%). The PMA was present in 11.53% hands and it was associated with variations in the median nerve anatomy in all cases. Conclusions: This study shows a high percentage of deviation from standard anatomy as well as a high percentage of transligamentous thenar muscle motor branch. The presence of PMA was associated with variations in the median nerve anatomy in all cases. Therefore if PMA is present there are very high chances of associated median nerve anomalies.

Among the numerous causes of carpal tunnel syndrome, thrombosed persistent median artery with bifid median nerve is extremely rare. Our presentation shows that an unusual case and surgical outcome of thrombosed persistent median artery with bifid median nerve causing acute carpal tunnel syndrome. Care has to be taken that identification of abnormal anatomy in the carpal tunnel is essential, especially in abruptly occurred carpal tunnel syndrome. We suggest that Doppler ultrasound examination is very useful in an outpatient clinic-based for identification of abnormal structure, which makes more quickly and accurate diagnosis than magnetic resonance image. [ABSTRACT FROM AUTHOR]

The pre-ligamentous variant of the thenar motor branch (TMB) of the median nerve is extremely rare. In all previously reported cases, the branch arose from the radial or antero-radial aspect of the median nerve in the distal forearm and then pierced the antebrachial fascia to reach the thenar muscles. We report on a case in which the pre-ligamentous TMB not only arose from the ulnar side of the median nerve but it also remained deep to both the antebrachial fascia and the transverse carpal ligament until it reached the thenar muscles. The course of this variant puts the TMB at significant risk of injury during both open and endoscopic carpal tunnel release. Level of Evidence: Level V, risk study. [ABSTRACT FROM AUTHOR]

• Possible anatomical variations of the vascular supply for the hand. • Screen patients for the presence of persistent median artery. The superficial palmar arch (SPA) is a major source of blood supply to much of the hand and is conventionally formed by the anastomosis of the ulnar artery with the superficial branch of the radial artery. The SPA has been classified into complete or incomplete based on the presence or absence of anastomosis between the arteries contributing to the formation of this palmar arch. Reported here is a unilateral presentation of incomplete superficial palmar arch. The ulnar artery (UA) gave off one proper palmar digital artery, which supplied the ulnar side of the little finger, and two common palmar digital arteries, which supplied the little, ring, and the middle finger. The superficial palmar branch of the radial artery gave off a proper palmar digital artery to the thumb, and two common palmar digital arteries, which supplied the thumb, index, and middle fingers. Apart from the presence of the incomplete SPA, persistent median arteries were also observed bilaterally in this cadaver. The prevalence of incomplete SPA has been reported to vary between 3.6–54.76%. To the best of our knowledge, this is the first case report describing an incomplete palmar arch and bilateral persistent median artery in a cadaver. Patients should be screened for the presence of complete or incomplete SPA before harvesting the radial artery either for myocardial revascularization or for radial artery forearm flap to prevent ischemic complications in the hand. [ABSTRACT FROM AUTHOR]

A persistent median artery is a rare anomaly. It accompanies the median nerve along its course in the forearm and is of variable origin. It is associated with other local anatomical variations and may contribute significantly towards formation of the superficial palmar arch. In embryos, it is responsible mainly for the blood supply to the hand. The objective of this study was to research the frequency, type (forearm or palmar) and origin of the median artery in fetuses, correlating its presence with sex and body side. Red-colored latex was injected into 32 brachial arteries of human fetuses until its arrival in the hand could be seen. Twenty-four hours after the injection, the median arteries were dissected without the aid of optical instruments. Among the 32 forearms dissected, the median artery was present in 81.25 % (26) of the cases, and it was found more frequently in females and on the left side. Regarding origin, most of the median arteries originated in the common interosseous artery (38.5 %) and anterior interosseous artery (34.6 %). The mean length of the median arteries was 21.1 mm for the palmar type and 19.8 mm for the forearm type. The median artery has a high rate of persistence. It is important to be aware of this anatomical variation, since its presence may give rise to difficulties during routine surgical procedures on the wrist. Its presence may cause serious functional complications in the carpal tunnel, anterior interosseous nerve, round pronator syndromes, and ischemia of the hand. [ABSTRACT FROM AUTHOR]

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Purpose: This study investigated the frequency of persistent median artery (PMA) in patients with carpal tunnel syndrome (CTS) and controls. Methods: A total of 84 CTS patient wrists, and 136 wrists of control subjects without CTS, were examined on ultrasonography (US) and color Doppler US (CDUS), and by electrophysiological evaluations. The frequency of PMA in CTS was evaluated. Results: Of 84 CTS patient wrists, 2 (2.4 %) had a PMA (both on the right side). Of 136 control wrists, 12 (9 %) had a PMA, which was unilateral in eight (three right and five left), and bilateral in two, cases. There was no significant difference between the CTS patient and control groups with respect to the frequency of PMA ( P > 0.05). Conclusions: There was no significant difference between the CTS patient and control groups in the frequency of PMA. We suggest that an ipsilateral PMA does not increase the risk of CTS. [ABSTRACT FROM AUTHOR]

The median artery is a transient embryological structure that normally disappears with the development of the radial and ulnar arteries. In rare instances, though, it persists as the persistent median artery (PMA). The superficial and deep palmar arches are formed through the anastomoses of the radial and ulnar arteries, giving hand and digits their main blood supply. This complex network of vessels and their anastomoses are prone to anatomical variations based on how the anastomosis occurs and which arteries contribute to this anastomosis. While it normally forms through the anastomosis of the radial and ulnar arteries, the superficial palmar arch (SPA) may also form differently, as in our case here, where the median artery persisted and branched off the radial artery, anastomosing with the ulnar artery to give rise to the SPA. This may also interfere with the normal compartmental architecture within the hand, possibly contributing to various clinical pathologies like carpal tunnel syndrome (CTS). Notably, in addition to the persistent median artery, our findings revealed a reversed palmaris longus and a bifid median nerve. These two additional variations can potentially exacerbate the risk of CTS. Alone, the coexistence of the PMA and the reversed palmaris longus is deemed a rare anomaly, only reported once in the literature. The addition of a third variation to the existing ones, like the bifid median nerve, is first reported by us and calls for more investigation for a possible genetic mutation. In this case, we report a persistent median artery, reversed palmaris longus muscle, and bifid median nerve in the forearm of a male cadaver found during a routine anatomy teaching session., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Elhossiny et al.)

The median artery is the axis artery of forearm till the 8th week of gestation and thereafter normally regresses, only its proximal part remaining patent as the companion artery of the median nerve in adults. A large, well developed persistent median artery extended to the palm and contributed to its vascular supply in 6 out of 100 upper limbs dissected. Dissection was used to demonstrate the persistent median arteries from their origin to termination. The persistent median artery originated from the ulnar artery in the cubital fossa. It pierced the median nerve, descended anterior to the nerve in a common sheath and passed deep to the flexor retinaculum. An accessory head of flexor pollicis longus, which is a usual finding associated with the persistent median artery, was seen in one forearm. The superficial palmar arch was not seen in any specimen with persistent median artery. In all the specimens with persistent median artery, the lateral half of the palm and lateral 2½ digits were supplied by it, whereas the medial half of palm and the medial 2 ½ digits were supplied by the ulnar artery. The persistent median artery may contribute to median nerve compression neuropathy. The variations in the vascular supply of hand have clinical implications. [ABSTRACT FROM AUTHOR]

Variants of the median nerve, extra forearm flexor muscles heads are relationships of the persistent median artery (PMA) that have been extensively reported. We report the findings of a PMA (diam. 3.25 mm), a pierced median nerve, and accessory heads of the flexor digitorum profundus (FDP) and flexor policis longus (FPL) muscles coexisting with a brachioradial artery (BRA) (diam.1.8mm) in the left upper limb of a 65 year-old male cadaver. The median nerve provided a ring for the passage of the PMA about the junction of the proximal and middle thirds of the forearm. Both accessory muscles were placed anterior to the ulnar artery, with the brachioradial artery coursing superficially in the brachium and antebrachium. The notable diameter of the PMA may be etiological in the causation of a carpal tunnel syndrome, while the hypoplastic BRA may pose some challenges in its selection as good conduit for catheterization and other surgical interventions like CABG in the upper limb. Additional clinical interest include the possible reduction in blood supply to the hand from the compressive effect of the 2 accessory muscles on the ulnar artery and possible inadvertent drug injection due to the superficial placement of the brachioradial artery close to veins. [ABSTRACT FROM AUTHOR]

The persistent median artery can be a rare cause of carpal tunnel syndrome. We present an anatomic variant of this artery. A 47-year-old female patient with bilateral carpal tunnel syndrome was found to have bilateral patent, functional persistent median arteries (PMA) upon operative exploration. Unlike previous reports, the PMAs were not located dorsal to the flexor retinaculum (FR). Rather, the PMAs were interposed between the palmar aponeurosis and the FR. Accompanied by two venae comitantes, the aberrant arteries were positioned directly in line with our carpal tunnel incisions on both hands. Although rare, it is important for the surgeon to be aware of this anatomic variant to prevent inadvertent injury to what may be an important vascular supply to the distal median nerve. [ABSTRACT FROM AUTHOR]

We report a rare combination of variations in the upper limb of a human cadaver. Accessory flexor carpi ulnaris with absent palmaris longus was observed in the left forearm during routine dissection of a male cadaver. Variant vascular pattern was observed bilaterally. Brachial artery bifurcated at a higher level. Ulnar artery gave rise to persistent median artery (PMA) which pierced the median nerve and accompanied it deep into flexor retinaculum to terminate as two common palmar digital arteries. Superficial palmar arch was not formed as the PMA did not anastomose with either the radial or ulnar artery. Radial artery was small and deep palmar arch was mainly contributed by the deep branch of ulnar artery. Awareness of these coexistent variations in the forearm and hand is anatomically as well as clinically important in reconstructive hand surgeries. [ABSTRACT FROM AUTHOR]

Objective: Magnetic resonance imaging for the diagnosis of musculoskeletal diseases can reveal different anatomical variants. A rare variant is the presence of a persistent median artery with the bifid median nerve. We aimed to visualize these anatomical variants and emphasize their clinical aspect. Methods: Informed consent was obtained from the patients, and ethics committee approval is not required as it is a retrospective case study. Magnetic resonance imaging of the right wrist of a 25-year-old female patient, the right wrist of a 29-year-old male patient, and the left wrist of a 57-year-old female patient taken at the Selçuk University Faculty of Medicine hospital were examined. Results: In these patients, ganglion cyst, lipoma, and tenosynovitis were detected in different localizations, respectively. The bifid median nerve and persistent median artery were found incidentally, which did not cause carpal tunnel syndrome symptoms. Conclusion: Pathological conditions in the persistent median artery and the bifid median nerve could be considered an anatomical risk factor for carpal tunnel syndrome. In the presence of a persistent median artery, surgeons must be aware of the possibility of additional median nerve anomalies. In hand trauma cases or carpal tunnel release patients, these anatomical variations should be considered. Radiological imaging methods such as color Doppler ultrasonography or magnetic resonance imaging are important for diagnosis. [ABSTRACT FROM AUTHOR]

Background: Awareness of anatomical variations of the median nerve at wrist is important in repair of traumatic injuries and treatments of compression syndrome because in these situations precise dissection of the nerve is mandatory and such variations are not infrequent. Materials and Methods: In this study, 52 hands of 52 fresh cadavers were dissected and median nerve anatomy along with the presence of persistent median artery (PMA) was noted. Results: A total of 26 hands (50%) had the deviation from the standard text book anatomy of the median nerve. There was early division of the median nerve into the medial and lateral branches in 11.53% hands. There was early branching of the 2nd common digital nerve in 9.6% hands. The transligamentous motor branch to the thenar muscle was most prevalent (42.3% hands). The single motor branch to the thenar muscles was found in the majority of hands (84.6%). The PMA was present in 11.53% hands and it was associated with variations in the median nerve anatomy in all cases. Conclusions: This study shows a high percentage of deviation from standard anatomy as well as a high percentage of transligamentous thenar muscle motor branch. The presence of PMA was associated with variations in the median nerve anatomy in all cases. Therefore if PMA is present there are very high chances of associated median nerve anomalies. [ABSTRACT FROM AUTHOR]

Carpal tunnel syndrome (CTS) is a common peripheral entrapment neuropathy that is caused by increased pressure within the carpal tunnel resulting in a chronic process of median nerve ischemia and segmental demyelination. We report on a patient with bilateral patent persistent median artery (PMA) affected by typical symptomatic CTS who was treated by bilateral mini-open decompression with complete improvement. For PMA-associated CTS, standard decompression is considered the treatment of choice, whereas resection should be reserved for pathological PMA. Mini-open decompression can be an alternative, as we have verified in this first description. [ABSTRACT FROM AUTHOR]

The presence of both a superficial ulnar artery (SUA) and persistent median artery (PMA) of antebrachial type is of both clinical and surgical significance. In an 84-year-old female cadaver received through the Gift Body Program at Saint Louis University School of Medicine, the right brachial artery was seen divided into an SUA and radial artery (RA) slightly below the interepicondylar line of the humerus. At the level of the radial neck, the RA sent out the common interosseous artery that then gave off the radial recurrent artery before bifurcating into anterior interosseous artery (AIA) and posterior interosseous artery. The AIA continued to appear to branch into the anterior ulnar recurrent artery and posterior ulnar recurrent artery, as well as a PMA of the antebrachial type. In the hand, the SUA and RA contributed to the complete superficial palmar arch seemingly equally, and the RA was the dominant contribution to the deep palmar arch. Ninety-one other arms were assessed for this variation, and none were observed. Knowledge of an anatomical variation such as this may lead to decreased complications in the planning of surgical bypass grafting., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Herstam et al.)

Bifid median nerve and persistent median arteries are natural anatomic variants that exist in a small percentage of the population. This case describes a young woman who was referred for electrodiagnostic (EDX) testing of her right upper extremity because of a one-year history of numbness, tingling, and discomfort in her right upper extremity consistent with carpal tunnel syndrome. Careful sonographic scanning (gray scale and power Doppler) and dynamic investigation revealed a bifid median nerve and associated persistent median artery (PMA). The awareness of a bifid median nerve and PMA is important when evaluating patients sonographically for diagnosis of upper extremity pathology, including enlargement due to carpal tunnel syndrome. Furthermore, as musculoskeletal sonography increases in clinical practice, it is important to raise awareness of this dual anatomic variant to ensure that appropriate evaluation and treatment are provided. The sonographic presentation of anatomic variations in this case along with a review of these anomalies is provided for translational clinical use. [ABSTRACT FROM PUBLISHER]

Persistent median artery (PMA) in present cadaver originated from the brachial artery and anastomosed with the superficial palmar arch (SPA). As the PMA may be the cause of carpal tunnel syndrome and SPA is the main source of arterial supply, knowledge of which are important for the hand surgical interventions. [ABSTRACT FROM PUBLISHER]

Purpose: Carpal tunnel syndrome is the most common compression neuropathy and carpal tunnel surgery is the most frequently performed hand surgery. Anatomic anomalies may predispose the median nerve to compression. The aim of the current study was to search for anatomic anomalies in open carpal tunnel surgeries through a cross-sectional study. Methods: During a cross-sectional study in a one-year period, 436 consecutive patients (307 females and 129 males) with the average age of 50.3 ± 2.4 years underwent 467 classic open carpal tunnel surgeries. Thirty-one patients had bilateral surgeries. A thorough inspection of the incisions was conducted to search for vascular, neural, tendon and muscular anomalies. Results: Forty-two (8.9%) hands (14 males and 28 females) had anomalies. The average age of the patients with discovered anomalies was 48.6 ± 7.6 years. Ten anomalies were seen on the left hands and 32 anomalies were seen on the right hands. Among the 42 anomalies, there were 16 persistent median arteries, 14 anomalies of the median nerve, 7 intratunnel intrusion of the flexor and lumbrical muscle bellies and 5 anomalies of the origin of the thenar muscles. There was no correlation between the discovered anomalies and the age, gender or hand sides. Conclusion: Anatomical anomalies are not uncommon in carpal tunnel surgeries. However, the frequencies of the reported anomalies vary among different studies. Familiarity with these anomalies increases the safety of the operation. [ABSTRACT FROM AUTHOR]

Two variations of the median nerve described in the Lanz study as type 3 anomalies were found during dissection. In the first case the median nerve splits in the cubital fossa and descends through the carpal tunnel to the palm of the hand. In the second of the reported cases the median nerve splits 45 mm before entering the carpal tunnel and is accompanied by a persistent median artery. Surgeons should take such variations into consideration in order to plan surgical approaches judiciously. [ABSTRACT FROM AUTHOR]