Int J.

Morphol,
30 (4): 1577-1584, 2012.

Multiple Muscle and Neurovascular variations in the Upper Limb. Case

Presentation
Mltiples Variaciones Musculares y Neurovasculares
en los Miembros Superiores. Presentacin de Caso.
* Luis Ernesto Ballesteros; Ivn Daro Quintero ** & *** Pedro Luis Forero
* MD, MSc. Professor Universidad Industrial de Santander, Bucaramanga, Colombia.
** Student Medical School. Industrial University of Santander, Bucaramanga, Colombia.
*** MD, Eng. Patol. Assistant Professor Industrial University of Santander, Bucaramanga, Colombia.

SUMMARY: It is presented a rare case of multiple variations in the upper limbs of a 45 years old
male cadaver specimen, ownership of the morphology laboratory of the Universidad Industrial de
Santander (Bucaramanga, Colombia). Muscle variations were observed (presence of both additional
heads of the biceps brachii and the flexor pollicis longus, agenesis of right palmaris longus), nervous
variations (anastomosis between median and musculocutaneous nerve and between ulnar and
median at superficial palmar level). Additionally it presented the radial artery origin from upper left
segment of the brachial artery. These various morphological expressions determine relevant clinical
implications and should be taken into account in the various surgical approaches to the upper limbs.
KEY WORDS: Anatomical variation; Biceps brachii muscle; Flexor pollicis longus muscle;
Palmaris longus muscle; Median nerve; Musculocutaneous nerve; Ulnar nerve; Radial artery.

RESUMEN: Se presenta un raro caso de mltiples variaciones en los miembros superiores de un

espcimen cadavrico de 45 aos de gnero masculino, del laboratorio de morfologa de la
Universidad Industrial de Santander (Bucaramanga-Colombia). Se observ variaciones musculares
(presencia bilateral de cabezas adicionales del bceps braquial y del musculo flexor largo del pulgar,
agenesia del palmar largo derecho), nerviosas (anastomosis entre mediano y nervio musculo
cutneo, y entre ulnar y mediano al nivel palmar superficial). Adicionalmente, present el origen de
la arteria radial izquierda desde el segmento superior de la braquial. Estas diversas expresiones
morfolgicas determinan relevantes implicaciones clnicas y deben tenerse en cuenta en los
diferentes abordajes quirrgicos de los miembros superiores.
PALABRAS CLAVE: Variaciones anatmicas; Msculo bceps braquial; Msculo flexor largo
del pulgar; Msculo palmar largo; Nervio musculocutneo; Nervio mediano; Nervio ulnar;
Arteria radial.

INTRODUCTION
The muscular and neurovascular variations in the upper limbs are relatively frequent. Within muscle
variations include the presence of additional heads or aplasia of these structures; has been reported
the presence of an additional head of biceps brachii (CABB) in the range of 20% 3,7 (Ashvath et al,
1993;. Santo Neto et al, 1998; Kopuz et al, 1999; Rai et al, 2007; Poudel & Bhattarai, 2009;

Ilayperuma et al, 2011).; additional head of flexor pollicis longus (CAFLP) with an incidence of 4667% (Hemmady et al., 1993, Al-Qattan, 1996; Shirali et al, 1998;. Pai et al, 2008;.'s Domiaty et al,
2008) and agenesis of palmaris longus (APL) in the range of 4.4 to 37% (Ballesteros & Saldarriaga.,
2002, Sebastin & Lim, 2006; Kayode et al, 2008;. Mbaka & Ejiwunmi, 2009; Eric et al, 2009;. Alves
et al, 2011;. Kigera & Mukwaya, 2011).
Described anastomosis of the musculocutaneous nerve (NMC) to medium (NM) nerve in different
population groups with an incidence of 16 to 63.5% (Chianapattanakon et al, 1998;. Kaus &
Wotowicz., 1995, Maeda et al, 2009; Aqueelah & Loukas, 2005); also, can occur anastomosis
between the ulnar nerve (UN) and the superficial palmar level NM (AUMPS) which is reported by
most authors in a range of 80 to 96.4% (Meals & Shaner, 1983; Ferrari & Gilbert, 1991; Stancic et
al, 1999;. Bas & Kleinert, 1999; Don Griot et al, 2000;. Olave et al, 2001;. Loukas et al, 2007)..
Within the vascular changes in the upper limbs, the high radial artery origin (braquiradial artery) has
been reported with a frequency of 2.3 to 13.8% (Keen, 1961; Uglietta & Kadir, 1989, RodrguezNiedenfhr et al, 2001;. Pelin et al., 2006; Yang et al, 2008).. This artery arises from the axillary or
upper half of the brachial or segments.
Existing information on the various muscular and neurovascular variations of the upper limbs is
enriched by studies on a particular variation; multiple variations observed in a specimen, are
reported as cases.
The clinical significance of these variants is based on expressions that good knowledge of these
allows otherwise reduce iatrogenic injuries of these structures during surgical approaches to the
upper limb. Moreover, lesions of NMC, NM and NU in patients presenting anastomotic branches,
can substantially modify the biomechanical pattern expected for this type of trauma (Loukas &
Aqueelah; Badawoud, 2003).
CASE REPORT
Corpse 45 male sex, fixed with formaldehyde solution 10% belonging to the lab morphology of the
Industrial University of Santander. The approach of the upper limbs was performed using a midline
incision from the middle third of the clavicle to the proximal digital crease of the third finger, with
separation of the medial and lateral fasciocutaneous flaps; then dissected by planes nervous,
muscular and vascular structures contained in the arm, forearm and hand. The following anatomical
variations were found.
Muscle. CABB was observed bilaterally. Additional heads originated on both sides, in the
inferomedial humeral segment, with an average thickness of 18 mm (right 21.2; left 14.8 mm). The
average length of the additional heads was 111.3 mm (115.3 right, left 107.2 mm). The innervation
of pro assignor to NMC originated distally detached bouquets bouquets for the short and long heads
of the biceps brachii muscle. The right engine CABB point was located 99.5 mm from the biepicondilia line, while the left side was located at 118.9 mm ( Fig. 1 A, B ).
The right and left forearms CAFLP presented. Right originated in the coronoid process of the ulna,
while the left was made in the medial epicondyle of the humerus; sources on both sides is
performed via superficial flexor digitorum. Bilaterally insertion is presented via a short, thin tendon
on the medial surface of the upper third of the flexor pollicis longus
(Fig. 2 A, B ). Length
accounted for 86.3 mm head right and 91.6 mm for the left. The average diameter of the muscle
bellies was 10.2 mm (10.5 mm right, left 9.9 mm). The muscle bellies presented voluminous sorting
according to the Domiaty et al. Bilaterally above posterolateral interosseous nerve was compared to
CAFLP. On his left forearm agenesis of palmaris longus was observed.

Nerve. Anastomosis NMC-NM in the left arm. The anastomotic branch extended oblique trajectory
from the NMC to NM, a distal piercing coracobrachialis. ( Fig. 3 ) The distances to the acromion of
the proximal and distal communicating branch points were 103.2 mm and 200.6 mm
respectively. The length of the anastomotic branch was 92.9 mm. With an arm length, measured
from the lateral margin of the acromion to the elbow biepicondlea line of 298 mm, the anastomotic
branch was located in the middle third.
AUMPS in the right hand ( Fig. 4 ) oblique trajectory was found between the fourth common digital
nerve of the ulnar nerve and the third common digital nerve; presented a length of 19.2 mm. The
distance from the top margin of the flexor retinaculum at the proximal and distal communicating
branch points were 19.5 and 30.5 mm, respectively. While the distance of the communicating
branch to the lower margin of the flexor retinaculum, the level of the axis of the third finger was 5.4
mm.
Vascular. The origin of the left radial artery at the upper segment of the brachial artery (47 mm from
the lateral margin of the latissimus dorsi muscle (observed FIG. 5 ). Adopted a downward course,
ahead of the medial intermuscular septum of arm and medially to the CABB. Supplied the branch to
the biceps brachii muscle at 45 mm from its origin. At the elbow crossed in front of the tendon of the
biceps brachii and forearm provided an habitual course.

Fig.1. Additional
head
of
biceps
brachii
muscle. (A)
.ARM
left.
(B)
right
.ARM. *. Armpit; CB. Coracobrachialis;BBCC. Additional head of biceps brachii; BB. Brachial
biceps muscle; TBB. Tendon of biceps brachii; MB. Brachial muscle; MS: medial
epicondyle; D. Deltoid muscle.

Fig. 2.Cabeza additional flexor longus. (A). Left forearm. (B). Right forearm, PT. Pronator
teres muscle; NM.Median nerve; FSD. Superficial flexor digitorum; FDP. Deep flexor muscle
of the fingers; MB. Brachioradialis muscle; FLP. Flexor pollicis longus; *. Additional Head of
flexor pollicis longus; Date: anterior interosseous nerve.

Fig.3. Anastomosis between the median nerve and musculocutaneous nerve in left
arm. *. Armpit; DMsculo deltoid NMC. Musculo-cutaneous nerve; NM. Median nerve,
BB. Brachial biceps muscle; CAB. Additional head of biceps brachii; AB. Brachial
artery; Arrow. Anastomotic branch.

FIG. 4 medium-ulnar anastomosis in superficial palmar region. Hand derecha.NU. Ulnar

nerve; AU. Ulnar artery;ACP. Abductor pollicis brevis muscle; FCP. Short flexor muscle of
the thumb; APS. Superficial palmar arch; ADM.Abductor muscle of little toe; RF. Flexor
retinaculum; *
.Cuarto
Common
digital
nerve; **. Third
common
digital
nerve; Arrow. Anastomotic branch.

FIG. 5 radial artery originated from the superior segment of the left brachial artery
.ARM. AB. Brachial
artery; AR.Radial
artery; CB. Coracobrachialis; Deltoid
muscle; BB. Brachial biceps muscle; Additional head of biceps brachii muscle.

DISCUSSION
The presence of CABB is a rare variation. Most studies (Rodrguez-Niedenfhr et al, 2003;. Poudel
& Bhattarai;. Santo et al .; Kopuz Neto et al .; Rai et al) the reported in the range of 7-15%. Some
authors have reported frequencies of 20% (Ashvath et al.) And 25% (Rincn et al., 2002) in a small
sample of Colombian specimens.Ilayperuma et al. and Cheema & Singla (2011) in Indian population
reported the lowest incidence (2.3-3.4%). In our case bilateral presence of CABB was observed,
however, the unilateral presence is reported by several authors as the most frequent (RodrguezNiedenfhr et al, 2003;. Poudel & Bhattarai,. Ilayperuma et al), while Ashvath et al., reported
prevalence of bilateral expression. As noted in our specimen, the inferior-medial surface of the
humerus has been reported in the literature as the most common site of origin of the CABB.
The presence of CABB has functional and clinical implications; She can help increase the capacity
of the flexor and forearm supinator and presence of fractures of the distal humerus contributes to or
increases bone displacement. Additionally, during surgical procedures elbow this variant structure
may generate difficulty operator and precipitate iatrogenic (Poudel & Bhattarai, Rincn et al .;
Cheema & Singla).
The presence of CAFLP is reported by most studies in a range of 52-67% (Mangini; Hemmady et al
.; al-Qattan,. Shirali et al .; The Domiaty et al .; Mahakkanukrauh et al, 2004; Oh et al, 2000;. Jones
et al, 1997;. Uyaruglu et al, 2006).. Lower frequencies are reported by Kara et al. (2012)
(34.5%); Pai et al. (2008b) (46%) and Sharma et al. (2008) (40%). The predominance of bilateral
presentation of this anatomical variation and right over the left is also stated, (Mahakkanukrauh et al
.; Oh et al .; Jones et al .; Uyaruglu et al ; Sharma et al.).
There is obvious controversy surrounding the origin of CAFLP. Some reports (. Hemmady et al .;
Mangini Mahakkanukrauh .; et al .; Sharma et al) identified the medial epicondyle of the humerus as
the primary site of origin in a range of 41-74%; Other studies (Oh et al .; Uyaruglu et al.) describe
the coronoid process as the point of origin in the majority of cases. Also described in some papers,
as in this case, a predominant source, on the proximal surface of the superficial flexor tendon
digitorum, with high frequency of 40-80% (Kara et al .; The Domiaty et al .; Jones et
al.). Additionally, simultaneous origin have been described in the medial epicondyle and the
coronoid process with a range of 5-30% (Hemmady et al .; The Domiaty et al .; Mangini, Sharma et
al.). This wide range of variability observed in the literature is probably due to various possibilities of
biological expression of this structure and the diversity of criteria on record the findings.
The length and diameter of the muscle belly CAFLP observed in our specimen (89 and 10.2 mm
respectively) are slightly higher than the averages reported in previous studies. The work of Kara et
al. Jones et al. Uyaroglu et al. Pai et al. and The Domiaty et al. noted CAFLP length in a range of
75-82 mm and a thickness of 7 mm. The voluminous body of muscle observed in the present report,
has been described as rare in the range of 15-30% (The Domiaty et al .; Jones et al., Pai et al.). The
presence of CAFLP constitutes an anatomical component of the anterior interosseous nerve
syndrome, which can be compressed by the muscle belly that lies ahead, giving rise to disturbances
in the innervation of the muscles of the anterior compartment of the deep plane of forearm,
especially pronator quadratus (Oh et al .; Shirali et al .; al-Qattan).
The APL has a wide range of variability: low incidence (4.4 to 12%) are reported by Ndou et
al. (2010), Mbaka & Ejiwunmi, Sebastin & Lim, Kigera & Mukwaya; Pai et al, 2008a.; mids (17-26%)
have been reported by Kose et al.(2009), Kapoor et al. (2008), Alves et al., Ballesteros &
Saldarriaga, Thompson et al. (2001), while the highest incidence of absence of this muscle structure
has been reported in a range of 28-37% (Eric et al, Kayode et al, Sankar et al, 2011;... Sater et al,
2010. ). Considering the condition of unilateral or bilateral agenesis, most authors have reported
with unilateral predominance, and the left side (Sankar et al .; Sater et al .; Eric et al .; Mbaka &
Ejiwunmi; Alves et al .; Ballesteros & Saldarriaga); Kose et al. and Sebastin & Lim reported similar

incidence in both sides while Sater et al., Kose et al. and Kayode et al. reported a greater number of
cases with bilateral nature of this morphological expression. The long palmar muscle tightens
palmar aponeurosis and secondarily attached to the wrist; additionally, has underlined the role of
stabilizing the joint during flexion (Salgado et al., 2012). Those with APL, to make slight flex the wrist
or hand wide (Ballesteros & Saldarriaga) medial deviation.
Most reports indicate an incidence of NMC-NM anastomosis in the range of 20-35%
(Chianapattanakon et al .; Choi et al, 2002;. Laburthe-Tolra, 1995; Badawoud). To highlight the high
incidence reported by Loukas & Aqueelah 63.5% and Maeda et al. 41.5%. Also numerous reports
are consistent in pointing out the predominance of unilateral presentation on the bilateral (Olave et
al, 2000;. Loukas & Aqueelah; Kosugi et al., 1992).Furthermore, Olave et al. (2000) and Malukar &
Rathva (2011) report this morphological expression predominantly on the left side.
The distances to the acromion of the emergency and end of the communicating branch obtained in
this case (103 and 200.6 mm) and its location in the middle third of the arm are consistent with
reports Olave et al. (2000) and Loukas & Aqueelah. In this case we look at the anastomotic branch
NMC-NM associated with the simultaneous presence of the additional head of biceps brachii, a
feature that is also qualified in other studies (Maeda et al .; Ferner, 1938).
The presence of NMC-NM anastomosis with communicating branch originated after piercing
coracobrachialis by the NMC was observed in our material. This anastomotic type is reported as the
most frequent (Guerri-Guttenberg & Ingolotti., 2009 Maeda et al .; Olave et al, 2000). It clarifies that
work Beheiry (2004); Loukas & Aqueelah, Uzun & Seelig (2001); Choi et al. Ferner and only
referenced the direction of the communicating branch of the NMC NM while Olave et al. (2000),
Kosugi et al. and Chianapattanakon et al. reported in the range 10-28% during the connection from
the NM to the NMC.
The NMC-NM connections must be considered in the clinical examination of nerve injuries of axilla
and arm as well as the surgical approach in these regions; MCL injuries or proximal sites located in
NM or communicating branches distal to determine beneficial or catastrophic changes as
appropriate, the biomechanical pattern of upper limb (Loukas & Aqueelah; Badawoud).
The CB oblique path between the fourth and third common digital nerve, observed in our case, is the
most frequently described in the literature (Don Griot et al .; Meals & Shaner, Ferrari & Gilbert; Tagil
et al., 2007; Bas & Kleinert) with range of 60-80%.
AUMPS length Griot reported by Don et al. Loukas et al. is similar to that found in this case (19.2
mm). Similarly, other morphometric aspects, such as the distances of the proximal and distal to the
upper margin of the flexor retinaculum (19.5 and 30.5 mm respectively) points are slightly lower than
those indicated in previous studies (Don Griot et al .; Olave et al, 2001;. Viera et al, 2002)..
The palm of the hand area prone to traumatic injuries and surgical approach zone is a territory
vulnerable to complications as the AUMPS injuries, which can develop complex regional pain
syndromes by the formation of neuromas (Kawashima et al. 2004).
The braquiradial artery has been reported in various studies with a relatively low incidence: Yang et
al. 2.3%;Rodrguez-Baeza et al. (1995) 4%; Keen 5.9%; Uglieta et al. 9% Rodrguez-Niedenfhr et
al. (2001) 13.8%.Regarding the presentation side, the different reports match point and right
unilateral predominance, although no statistically significant differences (Niedfrfur Rodriguez et al,
2001;. Pelin et al .; Uglieta et al.). Similarly, there is agreement that the most frequent site of origin
of this vascular variant is the top third of the brachial artery, as observed in our case, with a
frequency of 50 to 65.4% (Rodriguez-Baeza et al .; Rodriguez-Niedenfhr et al, 2001;. Uglieta et
al.). Knowledge of this anatomical variation is crucial for radiodiagnosis and surgical procedures,

especially in cases of trauma. Additionally, it should be noted that for the surface current in the
proximal segment, the risk of trauma injure even under the medial aspect of the arm is increased.
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