The arteries supplying the upperlimb exhibit lots of variations. The present study was
conducted on 102 upper limbs of 51 Nepalese bodies ( 30 males and 21 females). The
objective was to find out the variations, if any in prevailing branching pattern of arteries in upper limb of Nepalese population. Arterial variation at axillary, arm, forearm and palmar level had been noted. Various types of variation and their clinical implications are discussed.
Variations in the origin, branching and course of the principal arteries of the upper
extremities have long received the attention of anatomists, surgeons, cardiologists and particularly vascular specialists. The arterial pattern of the human upper limbs shown in text books is rarely encountered with major and minor variations being well documented. Often the arterial system of upper limb found in cadaver is very confusing to student because of the great variability from the descriptions and illustrations in text books and atlases. Analysis of series of dissections have been recorded but without uniformity of results. Normality in anatomy consist of range of morphologies that are most typical and others less frequent, which are called variations and not considered abnormal.1 The normal arterial system in upper limb is that subclavian artery continues as axillary artery from outer surface of first rib. The axillary artery gives off superior thoracic artery from its first part, thoracoacromial and lateral thoracic from its second part and subscapular, anterior and posterior circumflex humeral from third part. Then it becomes the brachial artery when it crosses the lower border of teres major muscle. Brachial artery gives off profunda brachii and radial and ulnar collateral arteries in the upper arm. The brachial artery ends in the cubital fossa dividing into radial and ulnar arteries. Radial artery gives off radial recurrent artery and ulnar artery gives off common interosseous and ulnar recurrent arteries in the cubital fossa. Ulnar artery forms the superficial palmar arch of the hand with superficial palmar branch of radial artery whereas the radial artery forms the deep palmar arch with the deep branch of ulnar artery.2 Many authors have published different series of reports about arterial anomalies of the upper extremities. This article is based on analyses of series of studies of anatomic variations of arterial system of upper limb that was carried out on 102 upper limbs.
Materials and methods
One hundreds and two dissected upper limbs belonging to 51 cadavers (30 males;21
females) were studied in Anatomy department of Manipal College of Medical Sciences
and BP Koirala Institute of Health Sciences. Observations were made and detail findings on arterial systems, either normal pattern or variations, were noted down. The observations were made at four levels:
A. At Axillary level
B. Arm level
C. Fore arm level
D. Palmar level
The types of variations and their frequency in percentage following the observation of
102 upper limbs:
The study result showed that superior thoracic artery was absent in 63.7% of total cases. Superior thoracic artery arose from thoracoacromial artery in 3.9% cases. Common trunk arising from second part of axillary artery and giving of lateral thoracic artery, subscapular artery and posterior circumflex humeral artery in 18.7% cases. Posterior circumflex humeral artery arose from subscapular artery in 1.8% cases. Lateral thoracic artery was found from thoracoacromial artery in 0.9% cases. Subscapular artery from second part of axillary artery was seen in 0.9% cases. Lateral thoracic artery from subscapular artery was found in 0.9% cases. At arm level high division of brachial artery into radial and ulnar artery was found in 4.9% cases. Absence of collateral arteries and profunda brachii continued as muscular branch was seen in 0.9% cases. At forearm level communication between radial and ulnar arteries was existed in 0.9% cases. In 12.7% cases there were common interroseous artery arising from radial artery. Superficial ulnar artery was observed in 1.8% cases. Presence of median artery was seen in 0.9% cases. At palmar level superficial palmar arch was found by ulnar artery alone in 31.3% cases. In 0.9% cases deep palmar arch got no contribution from ulnar artery.
Variations in the arterial anatomy of the upper extremities are quite common.3-6
Muhammad Saeed et.al.observed in 3.8% cases a bilateral common subscapularcircumflex
humeral trunk emerging from the 3rd part of the axillary artery and branching
into the circumflex humeral and thoracodorsal arteries and in 1.9% cases a bilateral
thoracohumeral trunk arising from the 2nd part of the axillary artery and branching into the lateral thoracic,circumflex humeral,subscapular and thoracodorsal arteries.7 Durgun et.al also observed,on right side,the subscapular artery gave rise to a large posterior circumflex humeral artery in addition to the thoracodorsal and circumflex scapular arteries.8 In the study of Mildred Trotter on 384 arms it was found that supreme thoracic (superior thoracic) and the thoracoacromial originated from the axillary in all but five arms; in four of these which were right arms (two white males, one negro male and one negro female), the supreme thoracic originated from the thoracoacromial and lateral thoracic arose from subscapular in 5 white-male axillae (6 percent), in 10 negro- male axillae (11percent ), in two white-female axillae (2 percent), and seven negro- female axillae (8 percent), lateral thoracic arose from the thoracoacromial in 3 white- male axillae (3 percent), in one negro-male axillae (1 percent), and in one negro- female axilla (1 percent). When the posterior circumflex came from the subscapular (in fifty-one axillae), the lateral thoracic arose from the subscapular also in four white- male axillae (8 percent), in five negro-male axillae (10 percent), and in three negro-female axillae (6 percent); and from the thoraco-acromial in three white-male axillae (6 percent), in three negro-male axillae (6 percent), and in one negro-female axilla (2 percent).9 Bergman et.al.also found the axillary artery giving rise to a common trunk for the subscapular,anterior,and posterior humeral circumflex,profunda brachii and ulnar arterial collateral arteries.10 BJ Anson reported origin of superior thoracic artery from thoracoacromial artery and also observed the origin of subscapular artery from second part of axillary artery.11 Gardner E, Gray DJ, O Rahilly R observed origin of thoracoacromial artery from either first or second part of axillary artery.12 Origin of lateral thoracic artery from thoracoacromial or subscapular arteries is also reported in text book of anatomy written by Hollinshead WH and Rosse C.13 Patnaik, Kalsey, Singla Rajan K, in their study of 50 upperlimbs of 25 cadavers, reported the absence of superior thoracic artery in 10% cases.14 De Garis et. al found from their study of arterial variations of upperlimb that circumflex arteries arose by a common trunk in 8% cases, lateral thoracic from subscapular artery in 6% cases. Superior thoracic from thoracoacromial in 0.01% cases and absence of thoracoacromial and various branches arose directly from axillary artery in 0.01% cases.15 The present study showed that superior thoracic artery was absent in 63.7% of total cases, superior thoracic artery arose from thoracoacromial artery in 3.9% cases, common trunk arising from second part of axillary artery and giving of lateral thoracic artery, subscapular artery and posterior circumflex humeral artery in 18.7% cases. Posterior circumflex humeral artery arose from subscapular artery in 1.8% cases. Lateral thoracic artery was found from thoracoacromial artery in 0.9% cases. Subscapular artery from second part of axillary artery was seen in 0.9% cases. Lateral thoracic artery from subscapular artery was found in 0.9% cases.
B.Durgun et.al also found that radial and ulnar arteries arose from the brachial artery at the level of arm and also observed the arciform anastomosis between the radial and ulnar arteries.8 Jurjus et.al.,in a case report,found no collateral arteries and profunda artery terminated as muscular branches.16 M.R.Kumar reported a large median artery arising from the main trunk of ulnar artery proximal to the origin of the common interosseous artery.17 Karlsson and Niechajev observed high origin of radial artery in 3.47% patients and in 0.43% patients ulnar artery had a high origin from the brachial artery.18 In the present study, high division of brachial artery into radial and ulnar artery at arm level was found in 4.9% cases, absence of collateral arteries and profunda brachii continued as muscular branch was seen in 0.9% cases and communication between radial and ulnar arteries was existed in 0.9% cases. Ajay Udayavar reported common interosseous artery arising from radial artey.19 In present study we also reported the radial artery giving common interosseous artery in 12.7% cases. Fadel RA et.al,Yazar F et.al and Yildrim M et.al reported the Superficial ulnar artery.20-22 In present study it was observed in 1.8% cases. Colman and Anson studied the pattern of arterial arches of hand and found the incomplete superficial palmar arches in 21.5%cases and in 3%cases there was incomplete deep palmar arches. The deep palmar arch was found to be comparatively less variable than superficial palmar arch.23 In the present study superficial palmar arch was found by ulnar artery alone in 31.3% cases and in 0.9% cases deep palmar arch formed by radial artery only. This study also showed that superficial palmar arch more variable than deep palmar arch in line with Colman and Anson.
A thorough knowledge of the vasculature of the axilla and upper limb is of crucial clinical importance. The upper limb is frequently the site of trauma and other pathology like frequent abscess formation in axilla, space infection of palmar spaces, and various joint disease in joints of upper limb which all require interventions that demand of proper anatomical knowledge, especially of its regional blood vessels and lymphatics as well as their possible variations. Axillary lymph node dissections is an important part of many cancer operations, particularly those involving removal of breast.24 Surgeons should make every effort to preserve and protect, among other structures, the axillary artery and vein. Anomalous origin and distribution of the arteries in upper limb make them more vulnerable to trauma during surgery. Such aberrations may cause difficulty for cardiologists in catheterization of the artery25,26 for radiologists in making radiological diagnosis, surgeons especially during raising the myocutaneous flap for surgical reconstruction and orthopaedic surgeons while dealing with trauma and disease of joints and bones of upper limb. Therefore both the normal and variant anatomy of the region should be well known for accurate diagnosis, better treatment and avoidance of iatrogenic injuries during interventional vascular procedures.
1. Willian PL, Humpherson JR. Concept of variation and normality in morphology: important issues at risk of neglect in modern undergraduate medical courses. Clin Anat 1999; 12:185-190.
2. Hollinshead WH. Anatomy for surgeons. 3rd ed. Vol.3. Philadelphia: Harper and Row 1982; 285-93 : 359-60.
3. Poynter CWM. Congenital anomalies of the arteries and veins of the human body with bibliography. University Studies, University of Nebraska 1920; 22:1-106.
4. McCormack LJ, Cauldwell EW, Anson BJ. Brachial and antebrachial arterial patterns: A study of 750 extremities. Surg Gyncecol Obstet 1953; 96: 43-54.
5. Huelke DF. Variation in the origins of the branches of the axillary artery. Anat Rec 1959; 35: 33-41.
6. Ozan H, Simsek C, Onderoglu S, Kirici Y, Basar R. High division of the axillary artery: A rare case of superficial ulnar artery. Acta Anat (Basel) 1994; 151: 68-70.
7. Saeed M, Rufai Amin A, Elsayed Salah E, Sadiq Muhammad S. Variations in the subclavian-axillary arterial system. Saudi Med J 2002; 23(2): 206-12.
8. Durgun B, Yucel AH, Kizilkant ED, Dere F. Multiple arterial variation of the human upper limb. Surg Radiol Anat 2002; 24: 125-28.
9. Trotter M, Henderson JL, Gass H et al. The origins of branches of the axillary artery in whites and in American negroes. Anat Record 1930; 46:133-37.
10. Bergman RA, Thompson SA, Afifi AK, Saadeh FA. Compendium of human anatomic variation. Munich: Urban and Schwarzenberg 1988; 72-73.
11. Anson BJ. Morris Human Anatomy, 12th ed. Berkeley: McGraw-Hill Inc. 1966; 708-24.
12. Gardner E, Gray DJ, O Rahilly R. Anatomy: A Regional study of Human structure, 5th ed. Philadelphia: W.B. Saunders Company 1986; 107-8.
13. Hollinshead WH, Rosse C. Text book of Anatomy. 4th ed. Philadelphia: Harper and Row publishers Inc.1985; 187-9.
14. Patnaik VVG, Kalsey G, Singla Rajan K. Branching pattern of axillary artery – A morphological study. J Anat Soc India 2000; 49(2) 127-32.
15. DeGaris CF and Swartley WB. The axillary artery in white and negro stocks. Am J Anat 1928; 41:353.
16. Jurjus AR, Sfeir RE, Bezirdjian R. Unusual variation of the arterial pattern of the human upper limb. Anat Rec 1986; 215: 82-3.
17. Kumar MR. Multiple arterial variations in the upper limb of a south Indian female cadaver. Clin Anat 2004; 17: 233-35.
18. Karlsson S, Niechajev IA. Arterial anatomy of the upper extremity. Acta Radiol 1982; 23:115-21.
19. Udayavar A. Anomalous termination of the brachial artery. J Anat Soc India 2004; 53:41.
20. Fadel RA, Amonoo-Kuofi HS. The superficial ulnar artery: development and surgical
significance.Clin Anat1996; 9:128-32.
21. Yazar F, Kirci Y, Ozan H, Aldur MM. An unusual variation of the superficial ulnar artery. Surg Radiol Anat1999; 21:155-57.
22. Yildrim M, Kopuz C, Yildiz Z. Report of a rare human variation:the superficial ulnar artery arising from the axillary artery. Okajimas Folia Anat Jpn 1999; 76:187-91.
23. Coleman S, Anson J. Arterial pattern in hand based upon a study of 650 specimens. Surg Gynaecol Obstet
24. Anson BJ, Wright RR, Wolfer JA. Blood supply of the mammary gland. Surg Gynecol Obstet 1939; 69:468 - 73.
25. Eascott HHG. Arterial Surgery. 3rded. Edinburg: Churchill Livingstone 1992; 342-97.
26. Magee A, Sim E, Benson LN, Williams WG, Trusler Freedom RM. Augmentation of pulmonary blood with an axillary arteriovenous fistula after a cavopulmonary shunt. J Thoracic Cardiovasc Surg 1996; 111: 176-80
Source(s) of Funding
This article has been downloaded from WebmedCentral. With our unique author driven post publication peer
review, contents posted on this web portal do not undergo any prepublication peer or editorial review. It is
completely the responsibility of the authors to ensure not only scientific and ethical standards of the manuscript
but also its grammatical accuracy. Authors must ensure that they obtain all the necessary permissions before
submitting any information that requires obtaining a consent or approval from a third party. Authors should also
ensure not to submit any information which they do not have the copyright of or of which they have transferred
the copyrights to a third party.
Contents on WebmedCentral are purely for biomedical researchers and scientists. They are not meant to cater to
the needs of an individual patient. The web portal or any content(s) therein is neither designed to support, nor
replace, the relationship that exists between a patient/site visitor and his/her physician. Your use of the
WebmedCentral site and its contents is entirely at your own risk. We do not take any responsibility for any harm
that you may suffer or inflict on a third person by following the contents of this website.