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Report of a rare human variationAbsence of the radial artery.

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THE ANATOMICAL RECORD 214239-95 (1986)
Report of a Rare Human Variation: Absence of the
Radial Artery
WILLIAM L. POTEAT
Department ofdnatomy, School of Medicine, University of South Carolina,
Columbia, S C 29208
ABSTRACT
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.
Variations and anomalies of the arterial pattern of the
upper extremity of man are fairly common. McCormack
et al. (1953) and Coleman and Anson (1961) have published detailed descriptions of the major and minor variations of the arteries of the upper limb and hand.
However, a variation that is quite rare is the complete
absence of the radial artery in the forearm. Such cases
have been reported by Charles (1894) and Kadanoff and
Balkansky (1966).A third has now been observed which
differs significantly from the other two cases, may be
the most primitive pattern ever reported, and has potential embryologic and surgical significance. The pattern
to be described has not been previously reported and
does not appear t o fit the description of the embryologic
development of these arteries (Woollard, 1922; Singer,
1933).
MATERIALS AND METHODS
The specimen was from a Caucasian female. The axilla, arm, and part of the forearm had been dissected
and several of the smaller branches had been sacrificed
by the time the students brought the variation to the
attention of the author. When the potential significance
of the variation was recognized, the author completed
the dissection of the forearm and hand. The variation
was present on the left side and the right side exhibited
an unremarkable pattern of arterial distribution. No
scars or surgical incisions were observed in the skin.
The nomenclature to be used will be the English version
of the Paris Nomina Anatomica and is consistent with
that of the 38th British edition of Gray’s Anatomy.
RESULTS
The branching pattern of the subclavian artery was
not unusual, but the branches of the axillary artery
exhibited some variability. The subscapular artery was
0 1986 ALAN R. LISS, INC.
of large caliber, for it was the origin of the lateral thoracic and posterior humeral circumflex arteries. The
anterior humeral circumflex artery appeared normal.
The profunda brachii artery arose from the brachial
artery 5.0 cm distal to the origin of the subscapular
artery. Three centimeters distal t o the origin of the
profunda brachii artery, a “superficial ulnar” artery
arose and coursed distally on the medial surface of the
brachialis muscle. This artery supplied the brachialis
muscle via several small branches and passed anterior
to the origin of the flexor muscles from the medial epicondyle (Fig. 1).In the middle of the forearm the superficial ulnar joined the ulnar nerve and continued distally
with it just lateral to the tendon of the flexor carpi
ulnaris muscle.
The brachial artery continued distally with the median nerve to the cubital fossa where it could then be
named the common interosseus artery as there was no
bifurcation into radial and ulnar arteries. In the cubital
fossa a radial recurrent artery arose and coursed superiorly adjacent to the radial nerve (Fig. 1).The posterior
ulnar recurrent artery arose from the common interosseous 2.0 cm distal to the origin of the radial recurrent
artery (Fig. 1).This vessel crossed the brachialis tendon,
passed deep to the humeral head of the flexor digitorum
superficialis muscle, and joined the ulnar nerve deep to
the flexor carpi ulnaris muscle. A superior ulnar collateral artery was identified as it arose from the brachial
artery between the profunda brachii artery and the superficial ulnar artery. It could be traced distally to a
point very close to the posterior ulnar recurrent vessel.
Neither an inferior ulnar collateral artery nor an ante-
Received April 30, 1985; accepted July 1, 1985
90
W.L. POTEAT
Fig. 1. Anterior view of left forearm. The pin at the left marks the
position of the elbow joint. a, brachial artery; b, anterior interosseous
a.; c, “superficial ulnar a,,”; d, medial terminal branch of anterior
interosseous; e, flexor pollicis longus tendon; f, pronator teres muscle
(reflected medially);g, median a,;h, lateral terminal branch of anterior
interosseous; i, accessory muscle described i n text; J, posterior ulnar
recurrent a.; k,radial recurrent a.
Fig. 2. Anterior view of distal forearm and wrist. a, anterior interosseous a,; b, lateral
terminal branch; c, medial terminal branch; d, lateral cut edge of‘ pronator quadratus muscle;
e, approximate position of radiocarpal joint; f, radius: g, long flexor tendons of the digits
reflected medially; h, tendon of flexor pollicis longus.
rior ulnar recurrent artery were identified with certainty.
The common interosseous artery continued distally
from the cubital fossa, passing first deep to the pronator
teres muscle, then deep to the flexor digitorum profundus muscle, and continued distally on the anterior surface of the interosseous membrane as the anterior
interosseous artery (Fig. 1).The posterior interosseous
artery arose from the common interosseous artery 3 cm
distal to the origin of the posterior ulnar recurrent and
deep to the pronator teres muscIe and was distributed
normally. The anterior interosseous artery was of approximately the same caliber as the brachial artery and
the common interosseous artery (Fig. 1).From the anterior interosseous artery a small branch arose that
coursed distally in company with the median nerve and
was presumed to be the median artery. It was small and
could be traced only to the distal third of the forearm
P i g . 1).
No vessel was observed arising from the brachial artery in the cubital fossa that coursed distally with any
resemblance of a radial artery, nor was any vessel ob-
ABSENCE OF RADIAL ARTERY
91
Fig. 3. Anterior view of distal forearm and hand. a, medial terminal branch of anterior
interosseous artery anastomosing with “superficial ulnar a,”; b, “superficial ulnar a.”; c,
superficial palmar arch; d, lateral terminal branch of anterior interosseous a.
served arising from the axillary or brachial that would
have been a “superficial radial artery.” The muscles of
the forearm were supplied by the superficial ulnar artery, the common interosseous artery, and the very large
anterior interosseous artery.
The anterior interosseous artery passed deep to the
pronator quadratus muscle and divided into two terminal branches of equal caliber at the distal border of the
muscle (Fig. 2). The medial terminal branch continued
medially deep to the long flexor tendons, turned anteriorly between the long flexor tendons of the fifth digit
and the flexor carpi ulnaris tendon, and joined the superficial ulnar 4 cm proximal to the pisiform bone by a
direct anastomosis (Fig. 3). The medial terminal branch
of the anterior interosseous artery was approximately
four times the caliber of the superficial ulnar. After the
two vessels anastomosed, the resulting single vessel continued into the hand lateral to the pisiform bone and
anterior to the transverse carpal ligament. A fairly typical superficial palmar arch was formed by the anastomosis of the lateral and medial terminal branches of the
anterior interosseous artery (Fig. 3). No deep ulnar
branch was identified.
The lateral terminal branch of the anterior interosseous artery continued distally for 1 cm and turned
laterally across the distal end of the radius (Fig. 2.) At
this point it was deep to the flexor pollicis longus tendon
and the tendon of an anomalous muscle t o be described
subsequently. The artery continued distally through the
floor of the “anatomical snuff box” with relations identical to a normal radial artery. On the dorsum of the
hand the lateral terminal branch pierced the first dorsal
interosseous muscle and came t o lie between it and the
adductor pollicis muscle. This artery was in contact with
the first metacarpal bone after piercing the first dorsal
interosseous muscle. It continued distally to the meta-
carpophalangeal joint where the princeps pollicis artery
arose. The lateral terminal branch then pierced the adductor pollicis muscle t o complete the superficial palmar
arch with the medial terminal branch of the anterior
interosseous artery. The vessel did not have any
branches resembling a deep palmar arterial arch. A
typical deep arch was not observed in this specimen but
was replaced by an artery to be described. On the dorsum of the hand the lateral terminal branch was the
origin of a small dorsal carpal branch and a typical first
dorsal metacarpal branch.
A third large branch arose 0.5 cm proximal to the
termination of the anterior interosseous artery and deep
to the pronator quadratus muscle (Fig. 5). This artery
pierced the interosseous membrane and continued distally across the dorsal aspect of the radiocarpal joint to
the proximal end of the third intermetacarpal space
(Fig. 4).At this point the vessel continued distally as a
dorsal metacarpal artery and was the origin of a very
large proximal perforating artery which passed between
the two heads of the third dorsal interosseous muscle
and entered the palm where it was deep to the transverse head of the adductor pollicis muscle. The proximal
perforating artery divided into three terminal branches
which continued distally to the digits (Fig. 5). The lateral of these three branches continued distally deep to
the transverse head of the adductor pollicis muscle until
it reached the radial side of the index finger where it
was distributed as a typical radialis indicis artery. A
short branch of the superficial palmar arch anastomosed
with this radialis indicis artery just proximal to the
second MP joint. The medial branch of the large proximal perforating artery coursed medially between the
muscles of the hypothenar eminence and the two long
flexor tendons to the fifth digit where it was distributed
as a typical proper palmar digital artery. This vessel
92
W.L. POTEAT
Flg. 4. View of dorsal aspect of distal forearm, wrist, and hand. a , dorsal terminal branch of
anterior interosseous artery; b, dorsal metacarpal a,: c, proximal perforating a.: d, distal end of
ulnar.
had no anastomotic connections with the superficial palmar arch. The third branch of the proximal perforating
artery coursed distally resembling a palmar metacarpal
artery. This artery passed deep to the flexor tendons to
the fourth digit and joined the common palmar digital
artery to the fourth and fifth digits just proximal to its
division into proper palmar digital arteries. The medial
side of the second digit, the entire third digit, and the
lateral side of the fourth digit were supplied by the first
and second common palmar digital arteries with no anastomotic connection with the deep vessels arising from
the proximal perforating artery (Fig. 5).
After the origin of the proximal perforating artery, the
large dorsal metacarpal vessel continued distally and
joined the second common palmar digital artery just
proximal to its bifurcation. This anastomosis completed
the major anastomotic connections in the hand of this
specimen. Other than the anastomosis of the superficial
ulnar artery with the medial terminal branch of the
anterior interosseous, it should be emphasized that all
other anastomoses were of branches of the anterior interosseous artery, making it essentially the sole blood
supply to the hand (Fig. 5).
Two muscle variations were also observed in this specimen. The flexor carpi radialis muscle inserted on the
trapezium where it blended with the origin of the abductor pollicis brevis muscle. The other variation was a n
extra muscle which arose from the radius distal to the
origin of the flexor pollicis longus muscle. Its tendon
passed deep to the origins of the thenar musculature
and inserted at the base of the second metacarpal bone.
The muscle would have acted as a n accessory flexor of
the wrist. Another observed variation was the Dosterior
interosseous nerve terminating on the dorsum of the
second and third digits rather than at the wrist.
DISCUSSION
The arterial pattern of this specimen may be the most
primitive ever reported in man because 1) the anterior
interosseous artery was the dominant supply of the
hand, 2) the median artery was very small, 3) the ulnar
artery was represented by a “superficial ulnar artery,”
4)no deep palmar arch was present, and 5 ) no “superficial brachial” or “superficial radial” arteries were present. The anterior interosseous artery is the distal part
of the axial vessel in the developing human forearm, as
well as being phylogenetically the oldest of the limb
vessels (Woollard, 1922; Singer, 1933). The arterial pattern described above differs significantly from other
cases of absence of the radial artery reported by Charles
(1894) and Kadanoff and Balkansky (1966). The chief
difference is in the termination of the anterior interosseous artery. In the present case, the anterior interosseous terminated by bifurcating into medial and lateral
terminal branches, whereas in the others it terminated
as the lateral terminal branch only. In all three cases
the lateral terminal branch entered the palm similar to
a normal radial artery. However, in the Kadanoff and
Balkansky case, the lateral terminal branch formed the
deep palmar arch, instead of forming the superficial
arch as it does in this case. Charles (1894) did not describe the distribution of the anterior interosseous arterv in the hand. The Dresence of the “suDerficia1 ulnar
artkry” makes this case more primitive, fbr in the other
two the brachial artery terminated by bifurcating in the
cubital fossa, whereas in this case it simply continued
ABSENCE OF RADIAL ARTERY
Fig. 5. Diagrammatic representation of the arteries of the hand.
Solid lines represent arteries on the palmar aspect of the hand. Dashed
lines represent arteries on the dorsum. a, anterior interosseous a.; b,
“superficial ulnar a,”;c, dorsal branch of anterior interosseous artery;
d, medial terminal branch of anterior interosseous a,; e, proximal
perforating a,; f, palmar metacarpal a,; g, common palmar digital aa.;
h, dorsal metacarpal a,; i, radialis indicis a,; j, princeps pollicis a.; k,
anastomotic connection of superficial palmar arch with radialis indicis
a.; 1, lateral terminal branch of anterior interosseous artery.
as the anterior interosseous artery. McCormack et al.
(1953) reported a “superficial ulnar artery” in 2.26% of
their series, but none anastomosed with a branch of the
anterior interosseous artery as in the present case. A
further difference is that in the Kadanoff-Balkansky
case there was a large dorsal terminal branch of the
anterior interosseous artery which they reported formed
the dorsal carpal rete, instead of terminating as in this
case. Fontana and Ghilardi (1973) reported a case of a
small radial artery with large ulnar artery and anterior
93
interosseous artery, but in their case the ulnar artery
supplied most of the hand. Therefore, the present case is
quite different from other reported arterial variations of
the upper extremity. The anterior interosseous artery in
this case was almost the sole blood supply to the hand,
being reinforced only by the small anastomotic connection from the superficial ulnar artery.
Based on the embryologic development of these arteries (Keibel and Mall, 1910; Singer, 1933;Mrazkova, 1973)
and reported adult anomalies, the sequence of arterial
development may differ from the classical descriptions.
Since a reasonable assumption is that the present case
represents developmental arrest at one of the early
stages, then stages 2 and 3 of the classical description
may be reversed (Fig. 6). Instead of the median artery
being the first vessel t o develop after the axial system,
it may be that the ulnar artery develops prior to the
median, making it the more primitive vessel and the
second dominant vessel t o the hand after the anterior
interosseous. In one of Muller’s (1903) illustrations of a
human embryo the ulnar artery is depicted as being
further developed than the median artery. Since 1)the
arterial pattern in the present report is so primitive, 2)
a superficial ulnar artery does reach the hand where it
anastomoses with the anterior interosseous artery, and
3) a very small median artery is present in the proximal
forearm, one is then led to the conclusion that the development of the arteries of the upper limb may follow the
proposed arrangement shown in Figure 6. In this arrangement it would be postulated that the ulnar system
was the second to develop and that it developed like the
superficial brachial-radial system. A “superficial ulnar
artery” would first develop and later an anastomotic
connection would develop in the cubital fossa between
the brachial and the superficial ulnar, after which the
proximal part of the superficial ulnar would degenerate
or atrophy. The distal part of the ulnar would be derived
from the medial terminal branch of the anterior interosseous artery. It would follow that the median artery
network would develop next and join the hand plexus,
at which time the anterior interosseous artery would
regress in size. Stages 4 and 5 of Singer’s description
would then occur as described. The above postulate is,
of course, based on the assumption that the present case
represents developmental arrest. One is left with the
conclusion that either the classical description cannot
be used to explain the variation or that it occurred as a
result of some chance variation in the hemodynamic
factors causing the median artery to regress in size
rather than, or prior to, the regression of the anterior
interosseous artery. The anastomosis of the medial terminal branch of the anterior interosseous artery with
the superficial ulnar artery resembles the described development of the superficial brachial and radial arteries,
so that the ulnar system may developjust like the radial
system (Senior, 1926; Manners-Smith, 1910).This would
indicate that the lateral terminal branch of the anterior
interosseous artery forms the distal part of the radial
artery system and that the superficial brachial forms
the proximal part and later joins the lateral terminal
branch of the anterior interosseous artery. It is also
possible that the medial and lateral terminal branches
of the anterior interosseous artery regress in size and
remain as the palmar carpal rete of a normal specimen.
W.L. POTEAT
94
PRESENT
CASE
STAGE 2
STAGE I
STAGE
3
U
PROPOSED
STAGE
I
DESCRIPTION
2
STAGE
STAGE
3
S T A G E 4,5
m
CLASSICAL
DESCRIPTION
Fig. 6. Diagrams of the proposed and classical descriptions of the sequence of arterial
development of the human upper limb. The diagram of the classic description is modified after
Singer (1933). a, axillary a,;ai, anterior interosseous a,; b, brachial a,; c, anastomotic connection; m, median a,; r, radial a,; sb, superficial brachial a.; su, superficial ulnar a.; u, ulnar a.
Another point supporting the proposed development is
that when the median artery persists as a major vessel
to the hand, the ulnar artery and radial artery are
always present in some size, but when the anterior interosseous artery persists as a major vessel only the
ulnar artery is present in the hand. Manners-Smith
(1910) cites several examples in lower primates of the
anterior interosseous artery terminating in a cross connection between the radial artery and ulnar artery and
points to the major dorsal continuation of the anterior
interosseous artery in lower primates, which is similar
to the present report. The author is aware of no reported
cases of the anterior interosseous artery and median
artery being the only ones represented in the anastomosis and plexus of the hand. If' Singer's (1955) description is correct, one would predict such cases.
In the extensive series of cases reported by Coleman
and Anson (1961) on the arterial pattern in the hand,
none resembled the pattern exhibited by this specimen.
This may indicate that the superficial palmar arch is
the more primitive of the two arches and that the deep
palmar arch develops later on either by forming an
anastomotic connection with the deep palmar branch of
the ulnar or by subsequent anastomosis of the perforating vessels of the dorsal metacarpal arteries as is seen
in this specimen. Besides the developmental implica-
ABSENCE OF RADIAL ARTERY
tions, the clinical significance of potential vascular problems in this sort of specimen such as in operations for
carpal tunnel syndrome must be noted. Other clinical
points would be a n absence of a radial pulse available
a t the normal site, although there would have been a
possibility of taking the pulse in the “anatomical snuff
box.” Also in this case there would undoubtedly have
been a strong pulse over the dorsal aspect of the wrist
joint, due to the large dorsal terminal branch of the
anterior interosseous artery. Such arteries may also
present a hazard to venipuncture, as do anomalous arteries in the cubital fossa (Hazlett, 1949).It is of further
interest to note variations of the muscles and nerves
that occurred in conjunction with the major arterial
variation, reinforcing the concept that variations within
one system of the limb frequently occur with those of
other systems (Van Allen et al., 1982). The question of
the interrelationships of these systems in limb development is beyond the scope of this report. Van Allen et al.
(1982) reported the morphology of the radial artery in
cases of radial aplasia in fetuses with many other profound anatomical defects. In some of their cases the
radial artery was absent and they related this absence
to other limb defects such as absence of the radius itself.
Furthermore, these authors point out these variations
of the radial artery are not known to occur in adults.
Such a comment clearly indicates the rarity of a specimen such as the one described in the present report.
Very abnormal vasculature has been related to other
morphologic defects in the limb (Van Allen et al., 1982;
Pettersen et al., 1979).The vasculogenesis of the limb is
also thought to be a significant factor for mesenchyme
differentiation into muscle and bone (Caplan and Koutroupas, 1973; Caplan, 1978). It is interesting to note
that two muscular anomalies were also present in this
specimen.
ACKNOWLEDGMENTS
The aid of Dr. Miller J. Sullivan and Dr. Marcia G.
Welsh in preparation of the manuscript is gratefully
acknowledged.
95
LITERATURE CITED
Caplan, A.I. (1978) The molecular basis for limb morphogenesis. In:
Birth Defects. Proc. Fifth Int. Conference. J.W. Littlefield and J.
DeBrouchy, eds. Excerpta Medica, Amsterdam.
Caplan, A.I., and S. Koutroupas (1973) The control of muscle and
cartilage development in t h e chick limb: The role of differential
vascularization. J. Embryol. Exp. Morphol., 29t571-583.
Charles, J.J. (1894) A case of absence of the radial artery. J. Anat.
Physiol. 28~449-450.
Coleman, S.S., and B.J. Anson (1961) Arterial patterns in the hand
based upon a study of 650 specimens. Surg. Gynecol. Ohstet.,
113:409-424.
Fontana, A.M., and F. Ghilardi (1973) Preliminary findings in the
angiogaphic study of some malformations of the extremities. Min.
Chir., 26t1445-1453.
Hazlett, J.W. (1949) Superficial ulnar artery with reference to accidental intra-arterial injection. Can. Med. Assoc. J., 61:289-293.
Kadanoff, D., and G. Balkansky (1966) Two cases with rare variations
of arteries of t h e upper extremities. Anat. Anz., 118:259-296.
Keibel, F., and F.P. Mall (1910) Manual of Human Embryology, Philadelphia, J.B. Lippincott and Co., pp. 659-667.
Manners-Smith, T. (1910) The limb arteries of primates. J. Anat. P h y s ~
iol., 4523-64.
McCormack, L.J., M.D. Cauldwell, and B.J. Anson (1953) Brachial and
antebrachial arterial patterns. Surg. Gynecol. Obstet., 96:43-54.
Mrazkova, 0. (1973) Ontogenesis of arterial trunks in the human
forearm. Folia Morphol., 21:193-196.
Muller, E. (1903) Bertrage zur morphologie des Gefass-system. I. Die
Armarterien des Menschen. Anat. Hcfte., 22379-547.
Pettersen, J.C., E.T. Bersu, and S.C. Calacino (1979) Anatomical phenotypes in human aneuploid. In: Advances in Human Genetics. H.
Harris and K. Hirschhorn, eds. New York, Plcnuni Puhlishing
Corp., pp. 132-157.
Singer, E. (1933) Embryological pattern persisting in the arteries of
the arm. Anat. Rec., 55t403-409.
Senior, H.D. (1926) A note on the development of t h e radial artery.
Anat. Rec., 32:220-221.
Van Allen, M.I., H.E. Hoyme, and K.L. Jones (1982) Vascular pathogenesis of limb defects. I. Radial artery anatomy in radial aplasia.
J. Pediatr., 10lt832-838.
Woollard, H.H. (1922) The development of the principal arterial stems
in the forelimb of the pig. Carnegie Contrib. Embryol., 22t139-154.
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