Arterial system of the fingers The arterial system in 141 fresh human cadavers was studied under the operating microscope using magnifications of 8 to 25 times. The vascular system was injected with latex material alone for identification of the vessels during dissection, and with latex and lead for x-ray contrast studies. An overall repetitive pattern in size, location, and distribution of the vessels was noted. The dorsal branches of the paired digital vessels in each phalanx were generally 4 and demonstrated a regular, repetitive distribution corresponding to: a, condylar vessel; b, metaphyseal vessel; c, dorsal skin vessel; and d, tranverse palmar arch. Proximal and middle transverse palmar arches were found always in relation to the cruciate ligaments. The distal transverse palmar arch lay just distal to the insertion of the profundus. (J HAND SURG 1990j15A:148.54.)
Berish Strauch, MD, and Wilson de Moura, MD, Bronx, N.Y.
Numerous articles dealing with the arterial anatomy of the digits have limited themselves to localized anatomic areas of the fingers. I - 16 The availability of large quantities of fresh cadaver material, combined with incidental arterial findings associated with another anatomic study,17 afforded us the opportunity to investigate the arterial system of the fingers in its entirety.
Materials and methods The arterial system in 141 fresh human cadaver digits was studied, using the operating microscope with magnifications between 8 and 25 times. The vascular system was injected with latex material alone for identification of the vessels during dissection, and latex and lead for x-ray contrast studies. The vessels of fresh specimens were prepared at the humeral level by initial irrigations with warm soapy water. Neoprene latex 671 (Dupont, Delaware) was mixed in 100 ml aliquots with 10 ml of blue oil color pigment to obtain the proper concentrations and color of the latex. Sixty milliliters were injected into the
From the Department of Plastic and Reconstructive Surgery, Montefiore Medical Center and the Albert Einstein College of Medicine, Bronx, N.Y. Received for publication Ocl. 25, 1988; accepted in revised form Feb. 6, 1989. No benefits in any fonn have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Berish Strauch, MD, 3331 Bainbridge Ave., Bronx, NY 10467. 3/1/12188
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humeral artery. If the material was to be injected into the subclavian artery, I 10 ml was used. Greater amounts in either case were avoided, as rupture of the smaller vessels would occur. Specimens were dried for 48 hours. Hot water immersion accelerated the hardening process.
Findings This article documents the results of our findings in the fingers. Of the two digital vessels in the thumb, index, and long fingers, the ulnar vessel is almost always larger (Fig. I, A and B). The radial vessel is almost always larger in the ring and small fingers. The common digital vessel to the third web space divides into branches that are large on both sides of the web space. The radial digital artery at the base of the proximal phalanx of the index finger is 1.4 mm ± 0.10. The ulnar artery measures 1. 8 mm ± 0.15. At the base of the distal phalanx, the radial artery measures 0.76 mm ± 0.15 and the ulnar artery measures 0.86 mm ± 0.10. The ring and small fingers measure as follows. The radial digital vessel at the level of the metacarpophalangeal (MP) joint averages 1.75 mm ± 0.15, and at the level just proximal to the distal transverse palmar arch, 0.95 ± 0.15. Comparable ulnar vessels are 1.35 mm ± 0.2 and 0.85 ± O.l. There are three major palmar arches (Fig. 2). The proximal and middle transverse arches are Gothic (pointed); the distal transverse palmar arch (DTPA) is Romanesque (rounded). The middle transverse arch is about 1.5 times larger than the proximal transverse palmar arch. The DTPA is about the same size as the middle arch. The locations of the arches are constant.
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Fig. 1. A, The ulnar vessel is almost always larger in the thumb, index, and long fingers, and the radial vessels are almost always larger in the ring and small fingers. The common digital vessel to the third web space divides into branches that are large on both sides of the web space. B, X-ray film demunstrating these findings.
Fig. 2. There are three major palmar arches, Le., the proximal, middle, and distal transverse palmar arches. The locations of the arches are constant. The proximal and middle arches arc always in association with the limbs of the proximal and distal cruciate ligaments (CI and C3 in Doylc's classification). The DTPA lies just distal to the insertion of the profundus tendon.
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Fig. 3. The dorsal branches of the paired digital vessels in each phalanx arc more consistently 4, and show a regular repetitive distribution: a, condylar vessel; b, metaphyseal vessel; c, dorsal skin vessel; d, transverse palmar arch.
The proximal and middle arches are always in association with the limbs of the proximal and distal cruciate ligaments described in our last communication. 17 The DTPA lies just distal to the insertion of the profundus tendon. The palmar branches of the digital arteries average 4 from each side at the level of the proximal and middle phalanges (Fig. 3). However, there were as many as 7 branches in one specimen. When there were more than 4 branches, they generally arose from the dominant vessel. The dorsal branches of the paired digital vessels in each phalanx were more consistently 4 in number and demonstrated a regular repetitive distribution corresponding to: a, Condylar vessel, b, Metaphyseal vessel, c, Dorsal skin vessel, and d, Transverse palmar arch. The first dorsal branch is the condylar vessel to the head of the metacarpal (Figs. 3 and 4). This is a recurrent branch and may arise from the common digital vessel. This vessel is present as a single entity in 60% of the dissections. Its size varies between 0.1 and 0.5 mm. It may occasionally arise in common origin with b, the metaphyseal vessel. This vessel measures between 0.1 and 0.2 mm; c, the dorsal skin vessel, is in the midportion of the proximal phalanx and is a large branch that supplies the overlying dorsal skin of the proximal phalanx. This vessel varies between 0.4 and
0.5 mm in external diameter. This branch was absent on one side in 5% of the digits. In these cases, the dorsal skin was supplied by a large branch of the dorsal interosseus artery. The proximal transverse palmar arch is d. It is always constant in relation to the proximal cruciate ligament and measures between 0.3 and 0.6 mm. The major portion of the vessel goes transversely, meeting the vessel coming from the opposite side, and then sends out the following smaller branches. In the midportion of the peaked arch, it sends branches to the vinculum longus and brevis to the profundus and superficiali!'> tendons, a branch to the dorsal skin proximal to the proximal interphalangeal (PIP) joint, and a branch to the distal metaphysis of the proximal phalanx. In almost all digits, a branch arises from the midportion of the arch that crosses the joint to the proximal metaphysis of the middle phalanx. In the middle phalanx (Fig. 3), the first branch, n, sends a branch to the condylar area of the proximal phalanx and the major portion of the vessel ascends dorsally to supply the skin over the P[P joint. The condylar vessel was constant in 80% of the dissections. [n 20%, the condylar circulation came from the metaphyseal vessel origin and rarely did it come from a branch of the PTPA. The a vessel averaged 0.2 mm ± 0.05 in external diameter.
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Fig. 4. Vessels of the proximal phalanx. Round pinhead at MP joint demonstrating from left to right superiorly, the condylar vessel, metaphyseal vessel, dorsal skin vessel, and transverse palmar arch.
Fig. S. Longitudinal vessels arising from the DTPA on the palmar aspect of the finger travel to the tip of the pulp, and tum dorsally to communicate with the distal matrix arch.
The next significant branch, b, goes to the proximal metaphysis of the middle phalanx. This was a constant vessel. It was the largest of the three proximal metaphyseal vessels. It averaged 0.25 mm ± 0.05 in size. At the midportion of the middle phalanx arises the c vessel that is a relatively large dorsal skin branch that supplies most of the dorsal skin over the middle phalanx. It is present in all dissected digits and measures between 0.3 to 0.6 mm, with an average size of 0.45 mm ± 0.1.
The next major branch, d, is the middle transverse palmar arch that, in 90% of the dissections, was 1.5 times the size of the PTPA. It too is a peaked arch. It was present in all fingers, always in relationship to the distal cruciate ligament, CD. The size of this vessel varied between 0.6 and 1.0 mm, with an average of 0.85 mm ± 0.2. The folIowing branches arise from this arch: the distal vinculum vessel to the profundus tendon, a branch to the distal metaphysis of the middle phalanx, and a
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Fig. 6. At the arrow, the vessel going dorsally to become the distal matrix arches, travels through a defect in the fibrous tissue. This defect is constant in all fingers. The vessel that forms the proximal matrix arch does not have a similar defect as it travels dorsally.
branch that goes dorsally to supply the skin over the distal interphalangeal (DIP) joint, as well as continuing on to join the proximal matrix arch dorsally at the level of the proximal growth plate of the nail, and finally, small branches that go across the DIP joint to nourish the proximal metaphyseal area of the distal phalanx. The distal phalanx is based in general on a similar a, b, c, d (Fig. 3) zone pattern. However, it is more complicated, because of the circulation of the distal tuft, as well as the subungual circulation. The first vessel, a, arises from the digital vessel to supply the condylar area of the distal end of the middle phalanx. It measures 0.14 mm ± 0.05. This vessel may arise as a common vessel with b, the proximal metaphyseal vessel of the distal phalanx, in 20% of the specimens. The proximal metaphyseal vessel was present in all cases. This vessel averages 0.14 mm ± 0.0 l. Vessel c arises from the digital vessel just prior to the beginning of the distal transverse palmar arch and goes dorsally to join with its mate coming from the opposite side, to form the proximal matrix arch at the level of the proximal growth plate of the nail. The measurements for this vessel varied between 0.2 and 0.4 mm. Joining the proximal matrix arch are the two vessels that originally arose from the middle palmar arch and traveled dorsally and distally. These vessels averaged 0.25 mm ± 0.05 in diameter. They now join on the dorsal surface with the proximal matrix arch. The digital vessels then tum ccntraIIy to join each
other, forming the distal transverse palmar arch. It forms a rounded arch and crosses at the distal end of the profundus insertion. This would be the d vessel of the distal phalanx. Its size is 0.85 mOl ± 0.1. Extending from this arch in a longitudinal manner are 3 or more relatively large vessels, averaging 0.58 mm ± 0.10, that travel to the tip of the pulp and tum dorsally to communicate with the distal matrix arch (Fig. 5). Arising from either the two lateral longitudinal vessels on either side, or more commonly (60% of the specimens) from two more centrally situated longitudinal vessels, is a branch that goes dorsally on either side. Its size varies between 0.4 and 0.6 mOl, with an average of 0.48 mOl ± 0.1. As it approaches the dorsal surface, it divides and joins its mate on the opposite side, forming the middle matrix arch at the level of the lunula and the distal matrix arch that lies at the level of the distal third of the nail matrix under the nail hed. The arches averaged 0.29 mm ± 0.05. The longitudinal vessels coming around the end of the finger join the distal matrix. arch without going through a capillary bed. The vessel going dorsally to become the middle and distal matrix arches travels through a defect (Fig. 6) in the fibrous tissue from the lateral tendon expansion at a point distal to its insertion. This defect, allowing the vessel to go dorsally, is constant in all fingers studied. The vessel that forms the proximal matrix arch does not have a similar defect as it travels dorsally.
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Fig. 7. The dorsal branches of the paired digital vessels in each phalanx are generally 4 and demonstrate a regular, repetitive distribution corresponding to: a, condylar vessel; b, metaphyseal vessel; c, dorsal skin vessel at the rnidphalangeallevel; and d, transverse palmar arch vessel (TPA).
Discussion Although the arterial circulation of the digits has generally been thought to be highly variable, our present study demonstrates an orderliness and consistency of distribution and location not previously described. The relationship of the major transverse palmar arches to known anatomic landmarks is quite constant. Recent reexaminations of the digital annular ligaments/s, 19 have now placed the proximal and distal cruciate ligaments (el and C3, according to Doyle's classification) in the identical locations as CP and CD in the terminology advocated by our previous communication. l ? The importance of this synchronization is the constant relationship of the proximal and middle transverse palmar arches to these structures. The present description of the anatomy of the vessels of the distal phalanx is similar to Flint's6,? description, but differs with respect to the site of the origin of the vessel arising in the middle phalanx, the site of the origin of the common vessel that eventually forms the middle and distal matrix arches, and the relationship of the distal transverse palmar arch. Our findings were, in general, consistent with the findings of Yousif et al. 14 in the areas of the PIP joint. We appear to be at variance with Hunter's8, 9 description of the location and number of the major transverse palmar arches, but do not disagree with his description of the intrinsic blood supply of the tendons. The clinical implications of our findings include the
following. The location and operative identification of major vascular structures are more assured. In digital amputations of the thumb, index, and long fingers, look for the ulnar vessel first, as it will be the larger of the two. The reverse is true for the ring and small fingers. The middle and distal transverse arches are consistently large (almost I mm) and may be used for arterial vessel repairs either proximally or distally, depending on the length and direction needed. Anatomic location of the transverse arches, in relation to the cruciate ligaments and the distal profundus insertion, allows for rapid clinical identification. The dorsal skin in each phalanx can be thought of as an arterialized flap potential, based on the c vessels. This would allow the surgeon greater freedom in constructing and transferring a skin flap from this location. An island dorsal skin flap based on the c vessel and perhaps a dorsal vein can be conceived. Surgery to the skin and soft tissues just proximal to the nail should take account of the arterial branch traveling from the middle transverse palmar arch up to meet the proximal matrix arch, in order to better preserve the vascularity of the skin. The large caliber of the distal vessels from the middle transverse palmar arch out distally, the size disparity of the paired digital vessels, as well as the regularity of the vessels in relation to other known anatomic structures (Fig. 7), have considerable import for hand surgeons in general, but are especially vital to those hand
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surgeons routinely involved in replantation surgery of the fingers. 9. The anatomic studies were undertaken at the Laboratoire D' Anatomie de UER Biomedicale, Universite Rene Descartes, Paris, France. We thank Professor J. Hureau for his kindness.
REFERENCES 1. Bonnel F, Teissier J, Allieu Y, Rabischong P, Mansat M. Arterial supply of ligaments of the metacarpophalangeal joints. J HAND SURG 1982;7:445. 2. Braun J. Les arteres de la main. [Dissertation] University of Nancy, Faculties of Medicine, 1977. 3. Braun JB, Werner JE, Borrelly J, Foucher G, et al. Quelques notions d'anatomie artericlle de la main et leurs applications chirurgicales. Ann Chir 1979;33:701. 4. Coleman SS, Anson BJ. Arterial patterns in the hand based upon a study of 650 specimens. Surg Gynecol Obstet 1961;113:409. 5. Edwards EA. Organization of the small arteries of the hand and digits. Am J Surg 1960;99:837. 6. Flint MH. Some observations on the vascular supply of the nail bed and terminal segments of the finger. Br J Plast Surg 1955-56;8:186. 7. Flint MH, Harrison SH. A local neurovascular flap to repair loss of the digital pulp. Br J Plast Surg 1965;18:156. 8. Hunter JM. Anatomy of flexor tendons-pulley, vincular, synovia, and vascular structures: The retinacular and sheath systems. In Kaplan EB. Functional and sur-
10. 11. 12.
13. 14.
15.
16.
17. 18. 19.
gical anatomy of the hand. 2nd ed. Philadelphia: Lippincott, 1975:65-92. Hunter JM, Cook JF, Ochiai N, Konikoff J, Merklin RJ, Mackin EA. The pulley system. Proceedings of the American Society for Surgery of the Hand. Orthop Trans 1980;4:4. Kaplan EB. Functional and surgical anatomy of the hand. 2nd ed. Philadelphia: Lippincott, 1975:196. Leffert DR, Weiss C, Athanasoulis CA. The vincula. J Bone Joint Surg 1974;56A:1191. Ochiai N, Matsui T, Miyaji N, et a!. Vascular anatomy of flexor tendons. I: vincular system and blood supply of the profundus tendon in the digital sheath. J HAND SURG 1979;4:321. Poitevin LA. Structure et vascularisation de la pulpe des doigts. Bull Soc Anat Paris 1983;8:67. Yousif NJ,Cunningham W, Sanger JR, Gingrass RP, Matloub HS. The vascular supply to the proximal interphalangeal joint. J HAND SURG 1985;lOA:852. Warren RA, Kay NRM, Norris SH. The microvascular anatomy of the distal digital extensor tendon. J HAND SURG 1988;13B:161. Chaudakshetrin P, Kumar VP, Satku K, Pho RWH. The arteriovenous pattern of the distal digital segment. J HAND SURG 1988;13B:I64. Strauch B, de Moura W. Digital flexor tendon sheath: an anatomic study. J HAND SURG 1985;10A:785. Idler RS. Anatomy and biomechanics of the digital flexor tendons. Hand Clinics 1985;1:3. Doyle JR. Anatomy of the finger flexor tendon sheath and pulley system. J HAND SURO 1988;13A:473.
Berish Strauch, MD, and Wilson de Moura, MD, Bronx, N.Y.
Numerous articles dealing with the arterial anatomy of the digits have limited themselves to localized anatomic areas of the fingers. I - 16 The availability of large quantities of fresh cadaver material, combined with incidental arterial findings associated with another anatomic study,17 afforded us the opportunity to investigate the arterial system of the fingers in its entirety.
Materials and methods The arterial system in 141 fresh human cadaver digits was studied, using the operating microscope with magnifications between 8 and 25 times. The vascular system was injected with latex material alone for identification of the vessels during dissection, and latex and lead for x-ray contrast studies. The vessels of fresh specimens were prepared at the humeral level by initial irrigations with warm soapy water. Neoprene latex 671 (Dupont, Delaware) was mixed in 100 ml aliquots with 10 ml of blue oil color pigment to obtain the proper concentrations and color of the latex. Sixty milliliters were injected into the
From the Department of Plastic and Reconstructive Surgery, Montefiore Medical Center and the Albert Einstein College of Medicine, Bronx, N.Y. Received for publication Ocl. 25, 1988; accepted in revised form Feb. 6, 1989. No benefits in any fonn have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Berish Strauch, MD, 3331 Bainbridge Ave., Bronx, NY 10467. 3/1/12188
148
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humeral artery. If the material was to be injected into the subclavian artery, I 10 ml was used. Greater amounts in either case were avoided, as rupture of the smaller vessels would occur. Specimens were dried for 48 hours. Hot water immersion accelerated the hardening process.
Findings This article documents the results of our findings in the fingers. Of the two digital vessels in the thumb, index, and long fingers, the ulnar vessel is almost always larger (Fig. I, A and B). The radial vessel is almost always larger in the ring and small fingers. The common digital vessel to the third web space divides into branches that are large on both sides of the web space. The radial digital artery at the base of the proximal phalanx of the index finger is 1.4 mm ± 0.10. The ulnar artery measures 1. 8 mm ± 0.15. At the base of the distal phalanx, the radial artery measures 0.76 mm ± 0.15 and the ulnar artery measures 0.86 mm ± 0.10. The ring and small fingers measure as follows. The radial digital vessel at the level of the metacarpophalangeal (MP) joint averages 1.75 mm ± 0.15, and at the level just proximal to the distal transverse palmar arch, 0.95 ± 0.15. Comparable ulnar vessels are 1.35 mm ± 0.2 and 0.85 ± O.l. There are three major palmar arches (Fig. 2). The proximal and middle transverse arches are Gothic (pointed); the distal transverse palmar arch (DTPA) is Romanesque (rounded). The middle transverse arch is about 1.5 times larger than the proximal transverse palmar arch. The DTPA is about the same size as the middle arch. The locations of the arches are constant.
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Arterial system of the jin!(ers
Fig. 1. A, The ulnar vessel is almost always larger in the thumb, index, and long fingers, and the radial vessels are almost always larger in the ring and small fingers. The common digital vessel to the third web space divides into branches that are large on both sides of the web space. B, X-ray film demunstrating these findings.
Fig. 2. There are three major palmar arches, Le., the proximal, middle, and distal transverse palmar arches. The locations of the arches are constant. The proximal and middle arches arc always in association with the limbs of the proximal and distal cruciate ligaments (CI and C3 in Doylc's classification). The DTPA lies just distal to the insertion of the profundus tendon.
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Fig. 3. The dorsal branches of the paired digital vessels in each phalanx arc more consistently 4, and show a regular repetitive distribution: a, condylar vessel; b, metaphyseal vessel; c, dorsal skin vessel; d, transverse palmar arch.
The proximal and middle arches are always in association with the limbs of the proximal and distal cruciate ligaments described in our last communication. 17 The DTPA lies just distal to the insertion of the profundus tendon. The palmar branches of the digital arteries average 4 from each side at the level of the proximal and middle phalanges (Fig. 3). However, there were as many as 7 branches in one specimen. When there were more than 4 branches, they generally arose from the dominant vessel. The dorsal branches of the paired digital vessels in each phalanx were more consistently 4 in number and demonstrated a regular repetitive distribution corresponding to: a, Condylar vessel, b, Metaphyseal vessel, c, Dorsal skin vessel, and d, Transverse palmar arch. The first dorsal branch is the condylar vessel to the head of the metacarpal (Figs. 3 and 4). This is a recurrent branch and may arise from the common digital vessel. This vessel is present as a single entity in 60% of the dissections. Its size varies between 0.1 and 0.5 mm. It may occasionally arise in common origin with b, the metaphyseal vessel. This vessel measures between 0.1 and 0.2 mm; c, the dorsal skin vessel, is in the midportion of the proximal phalanx and is a large branch that supplies the overlying dorsal skin of the proximal phalanx. This vessel varies between 0.4 and
0.5 mm in external diameter. This branch was absent on one side in 5% of the digits. In these cases, the dorsal skin was supplied by a large branch of the dorsal interosseus artery. The proximal transverse palmar arch is d. It is always constant in relation to the proximal cruciate ligament and measures between 0.3 and 0.6 mm. The major portion of the vessel goes transversely, meeting the vessel coming from the opposite side, and then sends out the following smaller branches. In the midportion of the peaked arch, it sends branches to the vinculum longus and brevis to the profundus and superficiali!'> tendons, a branch to the dorsal skin proximal to the proximal interphalangeal (PIP) joint, and a branch to the distal metaphysis of the proximal phalanx. In almost all digits, a branch arises from the midportion of the arch that crosses the joint to the proximal metaphysis of the middle phalanx. In the middle phalanx (Fig. 3), the first branch, n, sends a branch to the condylar area of the proximal phalanx and the major portion of the vessel ascends dorsally to supply the skin over the P[P joint. The condylar vessel was constant in 80% of the dissections. [n 20%, the condylar circulation came from the metaphyseal vessel origin and rarely did it come from a branch of the PTPA. The a vessel averaged 0.2 mm ± 0.05 in external diameter.
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Fig. 4. Vessels of the proximal phalanx. Round pinhead at MP joint demonstrating from left to right superiorly, the condylar vessel, metaphyseal vessel, dorsal skin vessel, and transverse palmar arch.
Fig. S. Longitudinal vessels arising from the DTPA on the palmar aspect of the finger travel to the tip of the pulp, and tum dorsally to communicate with the distal matrix arch.
The next significant branch, b, goes to the proximal metaphysis of the middle phalanx. This was a constant vessel. It was the largest of the three proximal metaphyseal vessels. It averaged 0.25 mm ± 0.05 in size. At the midportion of the middle phalanx arises the c vessel that is a relatively large dorsal skin branch that supplies most of the dorsal skin over the middle phalanx. It is present in all dissected digits and measures between 0.3 to 0.6 mm, with an average size of 0.45 mm ± 0.1.
The next major branch, d, is the middle transverse palmar arch that, in 90% of the dissections, was 1.5 times the size of the PTPA. It too is a peaked arch. It was present in all fingers, always in relationship to the distal cruciate ligament, CD. The size of this vessel varied between 0.6 and 1.0 mm, with an average of 0.85 mm ± 0.2. The folIowing branches arise from this arch: the distal vinculum vessel to the profundus tendon, a branch to the distal metaphysis of the middle phalanx, and a
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Fig. 6. At the arrow, the vessel going dorsally to become the distal matrix arches, travels through a defect in the fibrous tissue. This defect is constant in all fingers. The vessel that forms the proximal matrix arch does not have a similar defect as it travels dorsally.
branch that goes dorsally to supply the skin over the distal interphalangeal (DIP) joint, as well as continuing on to join the proximal matrix arch dorsally at the level of the proximal growth plate of the nail, and finally, small branches that go across the DIP joint to nourish the proximal metaphyseal area of the distal phalanx. The distal phalanx is based in general on a similar a, b, c, d (Fig. 3) zone pattern. However, it is more complicated, because of the circulation of the distal tuft, as well as the subungual circulation. The first vessel, a, arises from the digital vessel to supply the condylar area of the distal end of the middle phalanx. It measures 0.14 mm ± 0.05. This vessel may arise as a common vessel with b, the proximal metaphyseal vessel of the distal phalanx, in 20% of the specimens. The proximal metaphyseal vessel was present in all cases. This vessel averages 0.14 mm ± 0.0 l. Vessel c arises from the digital vessel just prior to the beginning of the distal transverse palmar arch and goes dorsally to join with its mate coming from the opposite side, to form the proximal matrix arch at the level of the proximal growth plate of the nail. The measurements for this vessel varied between 0.2 and 0.4 mm. Joining the proximal matrix arch are the two vessels that originally arose from the middle palmar arch and traveled dorsally and distally. These vessels averaged 0.25 mm ± 0.05 in diameter. They now join on the dorsal surface with the proximal matrix arch. The digital vessels then tum ccntraIIy to join each
other, forming the distal transverse palmar arch. It forms a rounded arch and crosses at the distal end of the profundus insertion. This would be the d vessel of the distal phalanx. Its size is 0.85 mOl ± 0.1. Extending from this arch in a longitudinal manner are 3 or more relatively large vessels, averaging 0.58 mm ± 0.10, that travel to the tip of the pulp and tum dorsally to communicate with the distal matrix arch (Fig. 5). Arising from either the two lateral longitudinal vessels on either side, or more commonly (60% of the specimens) from two more centrally situated longitudinal vessels, is a branch that goes dorsally on either side. Its size varies between 0.4 and 0.6 mOl, with an average of 0.48 mOl ± 0.1. As it approaches the dorsal surface, it divides and joins its mate on the opposite side, forming the middle matrix arch at the level of the lunula and the distal matrix arch that lies at the level of the distal third of the nail matrix under the nail hed. The arches averaged 0.29 mm ± 0.05. The longitudinal vessels coming around the end of the finger join the distal matrix. arch without going through a capillary bed. The vessel going dorsally to become the middle and distal matrix arches travels through a defect (Fig. 6) in the fibrous tissue from the lateral tendon expansion at a point distal to its insertion. This defect, allowing the vessel to go dorsally, is constant in all fingers studied. The vessel that forms the proximal matrix arch does not have a similar defect as it travels dorsally.
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Fig. 7. The dorsal branches of the paired digital vessels in each phalanx are generally 4 and demonstrate a regular, repetitive distribution corresponding to: a, condylar vessel; b, metaphyseal vessel; c, dorsal skin vessel at the rnidphalangeallevel; and d, transverse palmar arch vessel (TPA).
Discussion Although the arterial circulation of the digits has generally been thought to be highly variable, our present study demonstrates an orderliness and consistency of distribution and location not previously described. The relationship of the major transverse palmar arches to known anatomic landmarks is quite constant. Recent reexaminations of the digital annular ligaments/s, 19 have now placed the proximal and distal cruciate ligaments (el and C3, according to Doyle's classification) in the identical locations as CP and CD in the terminology advocated by our previous communication. l ? The importance of this synchronization is the constant relationship of the proximal and middle transverse palmar arches to these structures. The present description of the anatomy of the vessels of the distal phalanx is similar to Flint's6,? description, but differs with respect to the site of the origin of the vessel arising in the middle phalanx, the site of the origin of the common vessel that eventually forms the middle and distal matrix arches, and the relationship of the distal transverse palmar arch. Our findings were, in general, consistent with the findings of Yousif et al. 14 in the areas of the PIP joint. We appear to be at variance with Hunter's8, 9 description of the location and number of the major transverse palmar arches, but do not disagree with his description of the intrinsic blood supply of the tendons. The clinical implications of our findings include the
following. The location and operative identification of major vascular structures are more assured. In digital amputations of the thumb, index, and long fingers, look for the ulnar vessel first, as it will be the larger of the two. The reverse is true for the ring and small fingers. The middle and distal transverse arches are consistently large (almost I mm) and may be used for arterial vessel repairs either proximally or distally, depending on the length and direction needed. Anatomic location of the transverse arches, in relation to the cruciate ligaments and the distal profundus insertion, allows for rapid clinical identification. The dorsal skin in each phalanx can be thought of as an arterialized flap potential, based on the c vessels. This would allow the surgeon greater freedom in constructing and transferring a skin flap from this location. An island dorsal skin flap based on the c vessel and perhaps a dorsal vein can be conceived. Surgery to the skin and soft tissues just proximal to the nail should take account of the arterial branch traveling from the middle transverse palmar arch up to meet the proximal matrix arch, in order to better preserve the vascularity of the skin. The large caliber of the distal vessels from the middle transverse palmar arch out distally, the size disparity of the paired digital vessels, as well as the regularity of the vessels in relation to other known anatomic structures (Fig. 7), have considerable import for hand surgeons in general, but are especially vital to those hand
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surgeons routinely involved in replantation surgery of the fingers. 9. The anatomic studies were undertaken at the Laboratoire D' Anatomie de UER Biomedicale, Universite Rene Descartes, Paris, France. We thank Professor J. Hureau for his kindness.
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