Persistent median artery in the carpal tunnel—color Doppler sonographic findings

Gassner, Eva; Peer, Siegfried; Schocke, Michael; Bodner, Gerd; Jaschke, Werner

doi:10.1016/s0301-5629(03)00677-x

Cited by 48 publications

(78 citation statements)

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“…Barfred et al (35) reported nine patients in whom a persistent median artery was noted within the carpal tunnel at the time of carpal tunnel release. Since this report, smaller case series (33) and case reports (36,37) have been published. A persistent median artery is generally asymptomatic and, in some cases, can contribute significantly to perfusion of the hand (38).…”

Section: Vascular Anatomical Variations Persistent Median Arterymentioning

confidence: 99%

Anatomical variations of the carpal tunnel structures

Mitchell¹,

Chesney²,

Seal³

et al. 2009

CAN J PLAST SURG

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Asurgeon's expert competency should include an appreciation of anatomical variations, particularly with respect to common surgical procedures. One such procedure where this is relevant to plastic surgeons is the carpal tunnel release. The carpal tunnel has been recognized as a site where multiple anatomical variations can occur. These variations can involve neural, vascular, tendinous and muscular structures. If these are unrecognized, there is a risk of iatrogenic injury to the involved structures leading to unfavourable surgical outcomes. The purpose of the present review is to highlight recognized anatomical variations within the carpal tunnel and, hopefully, to help practitioners perform safe surgery. The Carpal TunnelThe carpal tunnel is defined as the space deep to the transverse carpal ligament. The transverse carpal ligament extends ulnarly from the hook of hamate and the triquetrum to the scaphoid and the trapezium radially. The carpal tunnel is bordered posteriorly by the carpal bones. Within the carpal tunnel lie the median nerve and nine flexor tendons: the flexor digitorum profundus (FDP) and flexor digitorum superficialis (FDS) tendons to the index, middle, ring and small fingers, as well as the flexor pollicis longus (FPL) tendon. A review of the literature identified variations in the structure within and around the carpal tunnel (Table 1). VariaTion in nerVe anaTomyhigh bifurcation of the median nerve In most subjects, the median nerve courses through the carpal tunnel as a single nerve, dividing to form the digital nerves distal to the transverse carpal ligament. Bifurcation of the median nerve proximal to the transverse carpal ligament is a relatively common anatomical variation present in 1% to 3.3% of individuals undergoing carpal tunnel release surgery (Figure 1) (1-3). High bifurcation of the median nerve can be an isolated finding (7) or it can be associated with a persistent median artery (4) or an accessory muscle belly of the long finger flexor superficialis (1,5,6). A case of a bifid median nerve wherein the radial-sided branch was located in its own compartment within the carpal tunnel has been identified by the senior author (AT) (Figure 2). To our knowledge, this is the first report of this variation. This additional compartment was also released with satisfactory outcome. There are many anatomical variations in and around the carpal tunnel that affect the nerves, tendons and arteries in this area. Awareness of these variations is important both during the clinical examination and during carpal tunnel release. The purpose of the present review is to highlight recognized anatomical variations within the carpal tunnel including variation in nerve anatomy, tendon anatomical variants, vascular anatomical variations and muscle anatomical variations.

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Section: Vascular Anatomical Variations Persistent Median Arterymentioning

confidence: 99%

Anatomical variations of the carpal tunnel structures

Mitchell¹,

Chesney²,

Seal³

et al. 2009

CAN J PLAST SURG

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“…As the tunnel size and shape is uncommonly altered, increased pressure is assumed to result from a change in volume or material properties of the contents of the tunnel, 8,9 of which the most likely is the SSCT, which is known to be fibrotic in patients with CTS. 8,[10][11][12] Ultrasound imaging has been described to detect pathologies such as thickening of the flexor tendons 13 and transverse carpal ligament, 14 shape and echogenicity alterations, restricted median nerve sliding in the carpal tunnel, 15,16 synovial proliferation, soft-tissue infection and joint effusion, tissue calcification and tumors, 17 persistent median artery, 18 tendinous and ligamentous injuries and swelling of the median nerve in the proximal part of the carpal tunnel, and flattening of the median nerve in the distal part of the carpal tunnel. 6,14,[19][20][21] High-resolution ultrasonography with approximately 7 MHz transducers is suitable for assessment of dynamic changes in the tunnel.…”

Section: Introductionmentioning

confidence: 99%

High‐resolution ultrasound analysis of subsynovial connective tissue in human cadaver carpal tunnel

Ettema

Bělohlávek

Zhao

et al. 2006

Journal Orthopaedic Research

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The carpal tunnel contains the median nerve, nine flexor tendons, two synovial bursae, and peritendinous subsynovial connective tissue (SSCT). Fibrosis of the SSCT is the most consistent pathological finding in patients with carpal tunnel syndrome. We investigated the anatomy and gliding characteristics of the flexor digitorum superficialis tendon and its adjacent SSCT with high-resolution ultrasound (15 MHz). Our hypotheses were that tendon and SSCT are distinguishable by ultrasound and that their velocities during tendon excursion are different. Qualitative ultrasound analysis of a flexor tendon and its SSCT was performed on five cadaver wrists and correlated to respective findings after anatomical study of the same cadavers. Quantitative Doppler velocity analysis of eight cadaver wrists was done to assess the sliding movement of the tendon and its SSCT within the carpal tunnel. No significant difference was found between the thickness of SSCT measured by ultrasound and that measured directly after dissection. The SSCT moved slower than its flexor tendon. The SSCT velocities were statistically different from the tendon velocities (t-test, p > 0.001). High-resolution ultrasound is a very precise method to display the anatomy of the tendon and SSCT within the carpal tunnel, and their different velocities can be detected with Doppler. Noninvasive assessment of the thickness and velocity of the tenosynovium in carpal tunnel syndrome by high-resolution sonography might be a new diagnostic tool for disorders affecting the SSCT, especially carpal tunnel syndrome. ß

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“…In contrast, some authors recently reported that the bifid median nerve is not an independent risk factor for development of carpal tunnel syndrome 7,9 . Meanwhile, co-existence of the bifid median nerve and persistent median artery was suggested by several authors 2,9 . Embryologically, the upper limb develops at the end of four weeks to eight weeks gestation.…”

Section: Discussionmentioning

confidence: 99%

“…Moreover, several causative factors increase the carpal tunnel pressure, which include space-occupying mass, tenosynovitis, aberrant musculature, or congenital abnormal median nerve. A persistent median artery is a numerous reported anatomical variant, which is supposed to degenerate over time 2,3 . In addition, studies have shown its co-existence with bifid median nerve.…”

mentioning

confidence: 99%

Thrombosed Persistent Median Artery with Bifid Median Nerve Causing Acute Carpal Tunnel Syndrome: A Case Report

Kim

Park

Choi³

2017

Arch Hand Microsurg

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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.

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Persistent median artery in the carpal tunnel—color Doppler sonographic findings

Cited by 48 publications

References 0 publications

Anatomical variations of the carpal tunnel structures

Anatomical variations of the carpal tunnel structures

High‐resolution ultrasound analysis of subsynovial connective tissue in human cadaver carpal tunnel

Thrombosed Persistent Median Artery with Bifid Median Nerve Causing Acute Carpal Tunnel Syndrome: A Case Report

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