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Background: The Guatemalan Foundation for Children with Kidney Diseases collaborated with Bridge of Life, a not-for-profit charitable organization, to establish a vascular access program. We reviewed our experience with graded surgical responsibility and structured didactic training, creating arteriovenous fistulas (AVF) for Guatemalan children. Methods: Pediatric vascular access missions were completed from 2015 to 2023 and analyzed retrospectively. Follow-up was completed by the Guatemalan pediatric surgeons, nephrologists, and nursing staff. AVF patency and patient survival were evaluated by Kaplan–Meier life-table analysis with univariate and multivariable association between patient demographic variables by Cox proportional hazards models. Results: Among a total of 153 vascular access operations, there were 139 new patient procedures, forming the study group for this review. The mean age was 13.6 years, 42.6% were female, and the mean BMI was 17.3. Radial or ulnar artery-based direct AVFs were established in 100 patients (71.9%) and ten of the 25 transposition procedures. Brachial artery inflow was required in 29 direct AVFs (20.9%). Two patients underwent femoral vein transpositions. Access-related distal ischemia was not encountered. Seven of the AVF patients later required access banding for arm edema; all had previous dialysis catheters (mean = 9, range 4–12). Primary and cumulative patency rates were 84% and 86% at 12 months and 64% and 81% at 24 months, respectively. The median follow-up was 12 months. Overall patient survival was 84% and 67% at 12 and 24 months, respectively. There were no deaths related to AVF access. Conclusions: Safe and functional AVFs were established in a teaching environment within a Guatemalan comprehensive pediatric nephrology center. [ABSTRACT FROM AUTHOR]

Background and Aims: To evaluate the flow at the cannulation site in the radial artery, the resistive indices (RIs) before cannula insertion and 6 h after decannulation were measured (primary outcome). The secondary outcomes were measurement of the artery size by anteroposterior (AP) diameter at the insertion site, RI and AP diameter at a point 4 cm proximal and in the ipsilateral ulnar artery before insertion and 6 h after cannula removal. Methods: In 96 patients requiring an arterial line during surgery, peak systolic velocity (PSV) and end-diastolic velocity (EDV) were measured to derive RI using a linear ultrasound transducer. The RI was measured at R1 (insertion point), R2, 4 cm proximal to R1, and U1 on the ipsilateral ulnar artery. The AP diameter of the arteries at baseline R10, R20 and U10 was measured and repeated 6 h after removal of the cannula, R16, R26 and U16. Results: RI or AP diameter in R1 or R2 did not differ pre- and post-cannulation. Mean R10 1.143 [standard deviation (SD: 0.239)] versus R16 1.181 (SD: 0.260) m/sec [mean difference (MD): -0.0372 (95% confidence interval (CI): -0.098, 0.023), P = 0.230]. Mean AP diameter at baseline versus 6 h decannulation 0.177 (SD: 0.042) versus 0.172 (SD: 0.045) cm [MD: 0.005 (95% CI: 0.003, 0.013), P = 0.222] was also similar. The mean PSV in U10 versus U16 was higher: 0.480 (SD: 0.178) versus 0.528 (SD: 0.316) m/sec [MD: 0.120 (95% CI: -0.185, -0.054), P = 0.002] and AP diameter was also higher than baseline (P = 0.001). Conclusion: The flow in the radial artery did not change following cannulation. The PSV and AP diameter in the ulnar artery increased after decannulation, suggesting a compensatory increase in flow.

Objectives: This study aimed to evaluate patient‐reported quality of life and incidence of decision regret in patients undergoing radial (RFFF) and ulnar forearm‐free flaps (UFFF) reconstruction. Materials and Methods: Patients undergoing either RFFF or UFFF were assessed with the University of Washington Quality of Life (UW‐QOL) and Oral Health Impact Profile (OHIP‐14) questionnaires, and the Decision Regret Scale (DRS), both before and at least 12 months post‐reconstruction. Results: In total, 40 RFFF and 40 UFFF were included. Harvesting time was longer in RFFF (p = 0.043), and the donor‐site defect was significantly larger in RFFF than in UFFF (p = 0.044). Patients with UFFF scored better UW‐QOL in the appearance, pain, activity, mood, and social functioning domains (p < 0.05). However, the RFFF group excelled in swallowing and chewing domains. The DRS score revealed a significant difference between RFFF and UFFF, with scores of 36.26 versus 27.36, respectively. Moreover, the mean DRS score reduced at 12 months compared with 6 months, significantly superior for UFFF. Conclusion: Oral cancer patients reconstructed with UFFF exhibited a better appearance, social domain, and mild decision regret compared with RFFF, indicating that the UFFF may contribute to improving postoperative quality of life in oral cancer patients. [ABSTRACT FROM AUTHOR]

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Background: The superficial palmar arch is a crucial blood supply to the palm. However, it exhibits significant variations, posing challenges in surgical procedures. Gaining a comprehensive understanding of the relationship between different types, physiological indices, and the clinical significance of the superficial palmar arch will enhance the accuracy of diagnosing and treating patients. Materials and methods: In this study, we dissected a total of 72 specimens, comprising 39 males and 33 females. We observed the type, length, and diameter of the superficial palmar arch and analysed its correlation with the disease. Additionally, we conducted Doppler ultrasound measurements on 20 healthy volunteers (10 males and 10 females) and 18 patients with superficial palmar arch injury (10 males and 8 females) to assess the classification, diameter, intimal thickness, and blood flow velocity of the superficial palmar arch. We collected information on 9 male patients with finger fractures and observed the classification of the superficial palmar arch, fracture healing time, and basic function recovery time. Lastly, we analysed rare variant specimens encountered during the anatomy process. Results: In the exploration of human anatomy, there were 4 types of superficial palmar arch: ulnar artery arch type in 17 cases (23.61%), radial ulnar artery type in 46 cases (63.89%), ulnar artery without arch type in 6 cases (8.33%), and 3 cases (4.17%) of double arch type of radial and ulnar artery. One case of nonarched type was found in an imaging examination (5%). In one elderly male specimen, the hand's superficial palmar arch artery was tortuous and dilated. In addition, there was a positive correlation between the diameter and length of the superficial palmar arch (except the second common palmar digital artery in women), among which the ulnar artery and the third common palmar digital artery had the strongest correlation. Compared to healthy volunteers, patients with ulnar injury in the radial-ulnar artery type exhibited a decrease in the diameter and blood flow velocity of the ulnar artery, as well as the second and third common palmar digital arteries. No such change was observed in patients with radial injury. Additionally, patients with ulnar injury in other types of radial-ulnar artery also experienced a decrease in the diameter and blood flow velocity of the ulnar artery. Finger fracture patients with ulnar artery with arch and ulnar artery without arch had shorter fracture healing time and basic function recovery time compared to those with radial-ulnar artery type. Conclusions: This study investigated the relationship between the classification, physiological index, and clinical significance of the superficial palmar arch at all levels. The results demonstrated that when the superficial palmar arch is damaged, it is important to consider both the classification and the site of damage, because this potentially results in improved therapeutic outcomes. These findings provide a basis for future clinical research. [ABSTRACT FROM AUTHOR]

Background and Aims: To evaluate the flow at the cannulation site in the radial artery, the resistive indices (RIs) before cannula insertion and 6 h after decannulation were measured (primary outcome). The secondary outcomes were measurement of the artery size by anteroposterior (AP) diameter at the insertion site, RI and AP diameter at a point 4 cm proximal and in the ipsilateral ulnar artery before insertion and 6 h after cannula removal. Methods: In 96 patients requiring an arterial line during surgery, peak systolic velocity (PSV) and end-diastolic velocity (EDV) were measured to derive RI using a linear ultrasound transducer. The RI was measured at R1 (insertion point), R2, 4 cm proximal to R1, and U1 on the ipsilateral ulnar artery. The AP diameter of the arteries at baseline R10, R20 and U10 was measured and repeated 6 h after removal of the cannula, R16, R26 and U16. Results: RI or AP diameter in R1 or R2 did not differ pre- and post-cannulation. Mean R10 1.143 [standard deviation (SD: 0.239)] versus R16 1.181 (SD: 0.260) m/sec [mean difference (MD): -0.0372 (95% confidence interval (CI): -0.098, 0.023), P = 0.230]. Mean AP diameter at baseline versus 6 h decannulation 0.177 (SD: 0.042) versus 0.172 (SD: 0.045) cm [MD: 0.005 (95% CI: 0.003, 0.013), P = 0.222] was also similar. The mean PSV in U10 versus U16 was higher: 0.480 (SD: 0.178) versus 0.528 (SD: 0.316) m/sec [MD: 0.120 (95% CI: -0.185, -0.054), P = 0.002] and AP diameter was also higher than baseline (P = 0.001). Conclusion: The flow in the radial artery did not change following cannulation. The PSV and AP diameter in the ulnar artery increased after decannulation, suggesting a compensatory increase in flow. [ABSTRACT FROM AUTHOR]

Elbow defects have a number of etiologies and present a difficult task for the reconstructive surgeon. A number of reconstructive options have been previously reported. We describe a case of a 54-year-old woman with a recurrent elbow defect secondary to prior trauma, surgical fixation, and infection. This was successfully managed with a novel chimeric flexor capri ulnaris and ulnar artery flap for coverage of the defect, which has not been previously described. This may serve as a useful guide for surgeons moving forward. [ABSTRACT FROM AUTHOR]

Introduction: Ulnar artery aneurysms are rare with less than 250 previously reported in the literature. Most ulnar artery aneurysms occur distally near the palmar arch (hypothenar hammer syndrome). There are five previous reports of true ulnar artery aneurysms in the forearm; however, there are no reported cases of ulnar artery aneurysms proximal to the cubital fossa. Case presentation: An 87-year-old man presented with pain and a rapidly progressive median nerve palsy with a pulsatile mass in the arm. Duplex ultrasound showed an aneurysm of what was thought to be the brachial artery. CT angiography shows a high bifurcating brachial artery and true aneurysm of the ulnar artery proximal to the cubital fossa. The artery was explored and the decision was made to excise the aneurysm and ligate the artery. The patient's symptoms improved and full function was regained. Conclusion: This is a rare case of such a diagnosis in the absence of a history of arterial puncture or trauma. This case demonstrates the value in obtaining detailed imaging in the work-up to aid operative decision making. We highlight the thought processes on the table in our approach to this aneurysm and report a favourable post-operative outcome at follow up. [ABSTRACT FROM AUTHOR]

Palmaris longus is a highly variable muscle of the forearm. Knowledge of its variability is of importance to plastic surgeons, hand surgeons and radiologists. During our routine dissection classes for undergraduate medical students, a peculiar palmaris longus muscle was noted in the left upper limb of an adult male cadaver. The muscle had a fleshy belly in the middle and two tendons: a proximal and distal. The distal tendon of palmaris longus gave origin to a variant fleshy slip of muscle which was inserted partly to the pisiform bone and partly merged with the hypothenar muscles. The ulnar nerve and artery passed deep to this variant fleshy slip. The ulnar artery was tortuous both proximal and distal to this slip. The distal loop of the ulnar artery was very superficial and was in the median position. Both the palmaris longus and the variant fleshy slip were innervated by median nerve. [ABSTRACT FROM AUTHOR]

Background: Use of radial and ulnar access has increased due to its perceived benefits over femoral access. Ulnar artery catheterization can place patients at risk of significant complications, including pseudoaneurysm, expanding hematoma, compartment syndrome, ulnar nerve injury, and critical hand ischemia. The purpose of this study was to describe complications specific to ulnar artery catheterization. Methods: After obtaining institutional review board approval, a retrospective review was performed on all patients who underwent ulnar artery catheterization at our institution between 2019 and 2021. Complications were assessed, and complication rates were compared with previously published studies on ulnar artery catheterization for coronary angiography (percutaneous coronary intervention). Results: A total of 41 patients were available for review with a mean age of 59 years. Of these, 17 patients (41%) sustained complications in the immediate postprocedural period. These complications included hematoma (12 patients, 29%), pseudoaneurysm (1 patient, 2%), ulnar artery thrombosis (1 patient, 2%), ulnar neuropathy (3 patients, 7%), arterial damage requiring repair (2 patients, 5%), transient ischemia (3 patients, 7%), and compartment syndrome (2 patients, 5%). Three of these patients (7%) required operative intervention, and several were admitted to the hospital for an additional period of observation. Conclusions: This series highlights the significant risks associated with ulnar artery catheterization for percutaneous procedures. Complications include pseudoaneurysm, expanding hematoma, compartment syndrome, ulnar nerve damage, and critical hand ischemia. Several of these patients required urgent or emergent surgical intervention, with some patients experiencing ongoing ulnar nerve symptoms. [ABSTRACT FROM AUTHOR]

Variability in the topography of the arteries of the upper extremity is associated with fetal development. Determination of individual anatomical variants of the upper extremity blood supply at different stages of ontogeny, especially in human fetuses, is of great practical importance in vascular surgery. Aim of the study. To study the individual anatomical variability of the ulnar and radial arteries in human fetuses of different ages. Material and methods. The study of variants of the topography of the branches of the radial and ulnar arteries, the peculiarities of the formation of the superficial palmar arterial arch was carried out on 46 preparations of the upper extremities of 23 human fetuses 81. 0-375, 0 mm parieto-coccygeal length using macromicroscopic dissection, vascular injection and morphometry without external signs of anatomical abnormalities or congenital malformations of skeletal, fascial-muscular and vascular-nerve structures of the upper extremities. Results and discussion. Our study demonstrated fetal anatomical variability and bilateral asymmetry of the right and left upper extremity arteries in human fetuses. Thus, in a fetus with a PCL of 210.0 mm, the right brachiocephalic artery was found to originate from the right axillary artery. It should be noted that the initial portion of the right brachiocephalic artery passed anteriorly, not posteriorly, to the median nerve, and at the level of the middle third of the anterior shoulder region, the artery occupied a superficial position relative to the median nerve, which is located in the lateral bicuspid groove of the shoulder. The brachiocephalic artery was then directed in an oblique lateral direction to the lateral surface of the forearm. In this fetus, a high origin of the right ulnar artery was found, which originated from the trunk of the brachiocephalic artery in the upper third of the right anterior shoulder region. At the border of the middle and lower thirds of the anterior shoulder region, the ulnar artery crossed the ulnar nerve anteriorly and passed with it in the median biceps groove of the shoulder. 3.0 mm below the beginning of the ulnar artery, the superior circumflex ulnar artery bifurcated from the brachiocephalic artery, and in the lower third of the anterior shoulder region, a common trunk bifurcated from the brachiocephalic artery and bifurcated into the middle and inferior circumflex ulnar arteries. We found arterial anastomoses between the latter and branches of the ulnar artery. The immediate continuation of the right brachiocephalic artery in the palm was the brachiocephalic artery of the thumb. At the level of the base of the proximal phalanx of the thumb, the brachiocephalic artery branched into three palmar finger arteries, which were directed to both edges of the palmar surface of the first finger and the radial edge of the palmar surface of the second finger. The superficial palmar arch was formed by the superficial palmar branch of the brachial radial artery, the terminal ulnar artery, and the anterior interosseous artery. Four common palmar arteries originated from the superficial palmar arch and were directed to the ulnar edge of the palmar surface of the second finger and the palmar surfaces of the adjacent edges of the third through fifth fingers. The left superficial palmar arch had an atypical structure located under the palmar aponeurosis at the level of the middle of the metacarpals and formed by the terminal parts of the ulnar and anterior interosseous arteries. Because the radial artery in this fetus was traced to the distal part of the forearm (to the scaphoid bone), we did not find branches of this artery in the palm area, especially the superficial palmar branch of the radial artery. The ulnar artery was directed caudally to the palmar region, curving slightly in an arc to the radial side of the hand. From the terminal portion of the ulnar artery, three common palmar finger arteries bifurcated, which in turn bifurcated into five palmar finger arteries of their own. The latter supplied the ulnar edge of the third finger and the palmar areas of the fourth and fifth fingers. The radial edge of the third finger and the palmar areas of the II-I fingers were supplied by five separate palmar arteries originating from the terminal portion of the anterior interosseous artery. Anastomoses were found between the palmar arteries, mainly in the middle and terminal phalanges. In the area of the palm, numerous muscular branches bifurcated from the anterior interosseous and ulnar arteries, providing blood supply to the palm muscles. Conclusions. In the majority of the studied fetuses (82.61 %) the superficial palmar arch was closed, in 17.39 % of the observations it was not closed. In 10.5 % of cases, the superficial palmar arch was formed by the trunk of the ulnar artery and the median forearm artery, and in 5.2 % - with the participation of the ulnar and anterior interosseous arteries. The ulnar artery is predominantly involved in the formation of the superficial palmar arch. In a fetus with a PCL of 210.0 mm, the right brachiocephalic artery was found, as well as a high origin of the right ulnar artery from it and an atypical branching of other branches. In particular, the superficial palmar arch was formed by the superficial palmar branch of the brachial radial artery, the terminal ulnar artery, and the anterior interosseous artery, while the left superficial palmar arch was formed by the terminal ulnar and anterior interosseous arteries. [ABSTRACT FROM AUTHOR]

The superficial layer of the anterior compartment of the forearm is characterized by different morphological variations. During standard anatomical dissection, two morphological variations in the superficial compartment of the forearm were observed. The first one was the palmaris profundus, which originated from the radius and distally fused with the tendon to 3rd digit (from the flexor digitorum superficialis muscle) inserted on the medial phalanx of the third digit. The second variation was a distinct superficial flexor of the 4th digit represented by one muscle belly with originated from a common mass from the medial humeral epicondyle, passes through the carpal tunnel, and is inserted into the medial phalanx of the fourth digit. The flexor digitorum superficialis muscle was located deeply to it and it was divided only into three tendons (to 2nd, 3rd, and 5th digits). Tendons connected to the 2nd and 3rd digits were crossed with each other at the level of carpal tunnel. From the humeroulnar head of the flexor digitorum superficialis muscle, an additional muscle belly was arising and its tendon was fused with the superficial flexor of the fourth digit. Knowledge about morphological variations in this region is clinically important because of the direct correlation with the median nerve, and the possibility to cause carpal tunnel syndrome. [ABSTRACT FROM AUTHOR]

A 40-year-old man with a long-standing history of congenital arteriovenous malformation in his right forearm was seen with a large, pulsatile tumour in the hypothenar region extending with multiple tortuous vessels on the volar side of the forearm to the elbow crease. Preoperative Allen test and normal preoperative finger pressure measurement showed revascularization of the hand via radial artery. Ultrasonography, MRI and angiography described an arteriovenous malformation (AVM) type 4 Yakes, suggesting high risk for embolization. Surgical intervention with meticulous dissection and ulnar nerve release was performed in order to prevent important blood loss, distal ischemia and to preserve upper limb functionality. Surgical resection resulted in full recovery.

The largest branch of the terminal division of the brachial artery is the ulnar artery, which arises after the cubital fossa. This artery usually has a deep path in the muscles of the anterior forearm and is responsible for vascularization of the superficial and deep musculature on the ulnar side of the forearm and hypothenar area of the hand. We report an anatomical variant diagnosed by Doppler ultrasound in which the ulnar artery had a superficial position in the forearm. Occurrence of a superficial ulnar artery is rare, but it is an important fact for clinicians, surgeons, and nursing professionals. [ABSTRACT FROM AUTHOR]

Ulnar artery aneurysms are extremely rare and are mainly associated with hypothenar hammer syndrome, an ischemic disorder of the hand resulting from mechanical and repetitive trauma to the hypothenar region. The ulnar artery is hit against the hook of the hamate bone, causing damage to the vessel wall and leading to occlusion or formation of an aneurysm. We describe the case of a truck driver who underwent resection of an ulnar artery aneurysm in the right hand and reconstruction using end-to-end anastomosis with no complications or recurrence. [ABSTRACT FROM AUTHOR]

Acute limb ischemia (ALI) due to arterial thromboembolic occlusion is a critical emergency in vascular medicine, requiring attention for rapid diagnosis and intervention, to prevent limb loss and major amputation, which is associated with patient disability in the long term. Traditionally, surgical embolectomy has been used for the treatment of ALI. Endovascular treatment of ALI traditionally involved catheter-directed thrombolysis. This option, however, poses some limitations, including an increased risk for access site and systemic bleeding complications, especially in patients with high bleeding risk. Therefore, in the last decades, several devices have been developed and tested for the mechanical endovascular treatment of ALI. Such devices involve either rotational thrombectomy or continuous thrombus aspiration. While rotational thrombectomy is limited in rather large arteries due to the risk of dissection and perforation in arteries <3 mm, continuous thrombus aspiration can be applied in smaller vessels and tortuous anatomies. In our case series we present a minimal-invasive endovascular approach for the treatment of two patients with ALI due to thrombotic occlusion of tortious and small diameter arteries. Minimal-invasive mechanical thrombectomy using the Penumbra Aspiration System emerged as a successful alternative to surgical embolectomy, enabling prompt treatment and with a short hospital stay for both patients. Our article therefore highlights the use of continuous thrombus aspiration in small diameter vessels and tortuous anatomies, which may represent a contraindication for the use of rotational thrombectomy. In addition, this technique may be applied even in patients with higher bleeding risk since additional lysis is not necessary in patients, where complete thrombus removal can be achieved by this device. [ABSTRACT FROM AUTHOR]

Traumatic injuries to the radial and/or ulnar arteries represent a subset of arterial injuries. In the absence of injury to both forearm arteries, treatment was historically ligation if perfusion was maintained to the hand via the uninjured vessels or adequate collateral vessels. We sought to determine management of traumatic forearm arterial injuries in 2019 and to identify risk factors for major upper extremity amputation. The American College of Surgeons Trauma Quality Improvement Program database was queried by International Classification of Diseases 10 code for patients with traumatic radial and/or ulnar artery injuries within the year 2019. Patient demographics, Injury Severity Score, time to operating room, type of repair, outcomes, and mortality were collected. Multivariable logistic regression was used to identify risk factors for major upper extremity amputation. A total of 4048 patients with traumatic radial and/or ulnar artery injuries were identified. A total of 1907 radial artery operations were performed including repair (59%), ligation (29%), and interposition bypass (12%). A total of 1637 ulnar artery operations were completed including repair (67%), ligation (21%), and interposition bypass (12%). Major upper extremity amputation occurred in 0.6%. Older age (adjusted odds ratio [AOR]: 1.014, 95% confidence interval [CI]: 1.004-1.024, P = 0.0048), blunt mechanism (AOR: 2.457, 95% CI: 1.730-3.497, P < 0.0.0001), and ipsilateral radial and ulnar artery injury (AOR: 2.148, 95% CI: 1.298-3.553, P = 0.0029) were associated with major amputation. Surgical revascularization, time to operating room, fasciotomy, and compartment syndrome were not associated with major amputation, but this may be secondary to Type II error. In the operating room, radial and ulnar artery injuries were managed more often with restoration of flow versus ligation. Older age, blunt mechanism, and ipsilateral radial and ulnar artery injury were associated with major amputation. Amputation rate was low at 3% overall and 0.6% for amputation of the hand or a more proximal level. Upper extremity fracture, upper extremity nerve injury, and ipsilateral radial and ulnar artery injury were associated with need for revision operation. [ABSTRACT FROM AUTHOR]

Objective: The proximal ulna has a complex and unique architectural anatomy, therefore, its fractures are difficult to manage. This paper aimed to evaluate proximal ulnar angulations that contribute to the fixation and restoration of proximal ulna fractures in the Turkish population. Materials and Methods: This study was performed on 107 Turkish adult ulnae (55 right, 52 left) whose age and sex were unknown. The ulnar length (UL), proximal distance of varus angulation (PDVA), and widths at the point of varus angulation were measured with a digital caliper. The proximal ulna torsion angle (PUTA), varus angulation (VA), proximal ulna dorsal angulation (PUDA), articular angle (AA), and olecranon-diaphysis angle (ODA) were measured with a goniometer. The statistical analysis was carried out at the SPSS 21.0 program (IBM Corporation, Armonk, NY, USA). Results: The median UL was 251.97 mm (minimum: 196.84 - maximum: 497.76 mm), median PDVA was 82.7 mm (minimum: 16.21 - maximum: 108.62 mm), mean total width was 15.04±1.84 mm, mean posterior-interosseous width was 13.72±2.37 mm and mean posterior-anterior width was 15.15±1.93 mm. The mean PUTA was 27.10°±9.04°, the median VA was 14° (minimum: 5° - maximum: 23°), the median PUDA was 8° (minimum: -3° - maximum: 20°), the median AA was 25° (minimum: 19° - maximum: 39°), and the mean ODA was 17.39°±5.33°. A moderate negative correlation was detected between the PUDA and ODA (rs= -0.50, p<0.001). Conclusion: The mean proximal ulnar angulations in this study can be beneficial during surgery for the fixation of proximal ulna fractures. This study revealed the correlation between proximal ulnar angulations in the Turkish population. [ABSTRACT FROM AUTHOR]

Background: Thrombotic storm is a series of acute to subacute thrombotic events that evolve over a few days to weeks and result in progressive thromboses at multiple sites. There is often a predisposing event to thromboses, such as trauma or infections. Prompt initiation of anti-coagulation can prove life-saving in such patients. Case report: We describe a previously healthy young male who developed thromboses of the right axillary, brachial, radial, and ulnar arteries while bowling in a cricket match. A few hours later, he developed a stroke involving the right anterior and middle cerebral arteries. His thrombophilia workup was significant for elevated homocysteine levels. Although he had a delayed presentation to our hospital, he was treated with anticoagulation and given a trial of thromboembolectomy, which failed and he had to ultimately undergo a right below-elbow guillotine amputation. Conclusion: Thrombotic storm should be recognized promptly in the Emergency Department and timely anticoagulation should be initiated. [ABSTRACT FROM AUTHOR]

A 67-year-old lady presented to the vascular clinic with (8 × 4) cm pulsatile swelling in her right medial forearm and had congenital high-flow AV fistula in the same arm ligated in the antecubital fossa 2 years earlier. MR angiogram failed to make a definitive diagnosis and conventional angiogram was also inconclusive. As she became more symptomatic consequently, underwent surgical procedures. The finding was a large proximal ulnar artery aneurysm. The aneurysm was excised and artery was ligated. Proximal ulnar artery aneurysms are rarely reported in the literature. Thus, this case presents a diagnostic challenge in persistent flow despite the large thrombus.

INTRODUCTION: Anatomical variation of high brachial artery bifurcation and these morphological variations of the brachial artery should be considered by surgeons when performing procedures in the brachial artery area. CASE: The left anterior arm and anterior forearm regions of a thirty-three-year-old cadaver was dissected. The origin, course, and terminal branches of the Brachial artery were traced. It was then observed that the Brachial artery bifurcation was in the upper third of the humerus instead of the cubital fossa. CONCLUSION: Brachial artery and its terminal branch variations are less common. However Brachial artery could be bifurcated and then reunite. In this case, the brachial artery presented bifurcation one laterally and another one medially with the median nerve running between them. Both branches don’t reunite but continue laterally and medially, respectively.

In this case, we present a condition where the extension of the hamate hook in the Guyon canal can damage the ulnar artery or its branches, leading to the development of an aneurysm or pseudoaneurysm. The patient, a 12-year-old female, presented to our clinic with a complaint of an uncontrolled palm lump that has been growing for several months and began to bleed in a pulsatile manner after trauma. She was an amateur volleyball player who trained twice weekly for two hours. Color Doppler ultrasound examination revealed a 1.1×0.8 cm pseudoaneurysm in a branch of the ulnar artery. Aneurysmectomy and primary repair were performed. Timely diagnosis and treatment planning are crucial for ulnar artery pseudoaneurysms or aneurysms to prevent ischemic events in a later period.

Penetrating injury can cause pseudoaneurysm which can then affect nerve compression. Although rare, penetrating injuries leading to ulnar artery pseudoaneurysm (UAP) are implicated slightly more frequently than other upper extremity arterial segments. Manual compression, thrombin injections, and surgical reconstruction are typically chosen to effect repair. Conversely, peripheral stent-graft implantation has rarely been reported as an option to exclude upper extremity pseudoaneurysm. We describe a case of a 25-year-old male who was stabbed, presented with signs of ulnar nerve compression, and in whom UAP was instead discovered and treated by stentgraft deployment. [ABSTRACT FROM AUTHOR]

Background: In vascular and orthopedic surgeries, thorough knowledge of the brachial artery and its branches is vital with its varied origin, course, and branching. The variability in the brachial artery can be due to regression failure in some paths of embryonic arterial trunks. Aim: The present study was done to assess the brachial artery and its variation with its ontogenic basis in cadavers. Materials and methods: The study assessed 112 upper limbs from different genders and age groups 18 females and 38 males. The identification was done for the brachial artery and its branching pattern. The relationship between the brachial plexus and brachial artery was observed in the arm along with the documentation of the absence or presence of variations. Results: In 112 upper limbs, 94.64% (n=106) limbs had the normal morphological patterns in the branchial artery, and tortuous brachial artery with trifurcation to the radial artery was seen in 1.78% (n=2) limbs, and superficial brachial artery in 5.35% (n=6) limbs. Also, the common interosseous artery and the ulnar artery were seen in 1.78% (n=2) limbs each. Conclusion: The present study, considering its limitations concludes that it is clinically vital to study the brachial artery, its course, variation, and branching pattern for orthopedic surgeons treating supracondylar fractures and during various vascular surgeries. It is also vital for radiologists to assess the angiography of the upper limb. [ABSTRACT FROM AUTHOR]

Background. Vascular calcification (VC) has been observed in patients with hemodial- ysis, whereas few studies have investigated calcification in the upper extremity vascula- ture. Both ultrasound and X-ray are used to investigate the calcification of arteries in patients. However, there is a lack of data on the consistency between these two methods. The aim of this study was to investigate the occurrence of VC in the radial and ulnar arteries of hemodialysis patients and investigate the detection consistency in VC between ultrasound and X-ray. Methods. Ultrasound and X-ray examinations were performed in the radial and ulnar arteries of both the left and right upper extremities of 40 patients on hemodialysis. The calcification status of arteries was evaluated by the calcification index from ultrasound and X-ray respectively. Clinical variables of patients were collected from all the involved patients. Results. Of the 40 patients, VC was detected in 31 patients by ultrasound, while X-ray detected VC in 22 patients. Compared to ultrasound assessment, X-ray assessment was 73.21% sensitive but only 66.35% specific with a positive predictive value of 53.95% for detecting calcifications in the radial or ulnar artery. The level of agreement between ultrasound and X-ray results was fair. In addition, our data showed that more ulnar arteries had VCs than the corresponding radial arteries. Conclusion. Ultrasound is more sensitive in detecting the presence of calcified atherosclerotic lesions. Ultrasound and X-ray exhibited fair consistency. Ultrasound screening for upper extremity radial and ulnar arteries in hemodialysis patients may deserve attention to explore its clinical significance. [ABSTRACT FROM AUTHOR]

Dialysis access steal syndrome (DASS) is a phenomenon known to occur following creation of an arteriovenous fistula or arteriovenous graft. The clinical presentation of DASS is characterized by symptoms of limb ischemia due to diversion of arterial flow from the distal extremity. Ischemic monomelic neuropathy (IMN) is a rare subtype of DASS classically described as an acute, isolated presentation of peripheral neuropathy following dialysis access creation. Although the underlying pathophysiology is not entirely understood, the clinical manifestation of IMN is often described as severe distal limb pain that progresses to motor and sensory defects. The onset of IMN may occur immediately following dialysis access creation or intervention. Here, we present a case of IMN following assisted maturation of an endovascular fistula. [ABSTRACT FROM AUTHOR]

Masson's tumor is a benign tumor consisting of reactive proliferation of endothelial cells. It was first described by the French doctor, Pierre Masson, in 1923. A higher incidence was observed among women (1.3:1), and the average age at which it occurs is 31 years. It appears as a firm mass, with the appearance of a nodule or papule, located subcutaneously. The adjacent integument is bluish or reddish. On palpation it can be sensitive or painless. We will present the case of an 81-year-old man with Masson's tumor located at the level of the volar side of the left forearm, at the level of the flexor ulnar muscle of the carpi, which affects the ulnar artery. [ABSTRACT FROM AUTHOR]

Antiphospholipid syndrome (APS) is known to cause critical limb ischemia leading to limb loss or death from arterial occlusion. We reported a 45-year-old woman with critical digital ischemia and was suspected secondary to APS. This woman presented to the Emergency Department (ED) for the third time because of recurrent pain and numbness in the fingertips of her left hand with bluish discoloration of the left little finger. Her ulnar artery became faint on palpation, and her left fifth finger was cool, cyanotic, with prolonged capillary refill time (CRT) and unrecognised signal in SpO2. Angiography and ultrasound showed proximal thrombosis of the ulnar artery. Thrombectomy was performed twice because graft thrombosis had occurred during the first operation. The rheumatology team treated her as APS and administered antiplatelet drugs. We hope this case report will raise awareness among emergency physicians for early recognition and provide optimal treatment. [ABSTRACT FROM AUTHOR]

Objective: The present study is to document and provide information about both normal and variable morphology of the deep palmar arch (DPA) in adult human cadavers by the dissection method. Materials and Methods: We examined 12 upper extremities (6 cadavers). After the classification of the vascular patterns of DPA and its branches, measurements of the vessel diameters were carried out using a digital compass. Results: Deep palmar arch was found as a completed arch (100%) in all cases. The anastomosis between the distal deep palmar branch of the ulnar artery (DPBUA) and the terminal branch of the radial artery (RA) was the most common type in our study. The incidence of the DPA was reported as a complete arch ranging from 54.9% to 100%. Palmar metacarpal arteries (MPAs) originating from the DPA were divided into four branches (25%) in three cases and three branches (75%) in nine cases. The mean diameter of the MPAs at the point of origin at the DPA was between 0.3 mm and 0.6 mm. Conclusion: A comprehensive understanding of the DPA branching diameters in the hand will facilitate surgical and radiological approaches and contribute to a constantly expanding knowledge base in literature. [ABSTRACT FROM AUTHOR]

The pronator quadratus (PQ) muscle is an important stabilizer of the distal radio-ulnar joint and its pain referral pattern can mimic median or ulnar neuropathy. Research on treatment safety and efficacy with dry needling is scarce. To determine if a solid filiform needle accurately and safely penetrates the PQ during simulated clinical application of dry needling. A cadaveric descriptive study was conducted. Needling insertion of PQ was performed in 10 cryopreserved forearms with a 30*0.32 mm solid filiform needle. With the forearm pronated, the needle was inserted 3 cm proximal to the ulnar styloid in an anterior direction toward the muscle. The needle was advanced into the PQ based upon clinician judgment. Safety was assessed by calculating the distance from the needle to the surrounding neurovascular bundles. Accurate needle penetration of the PQ was observed in 90% of the cadavers (needle penetration: 19.8 ± 4.0 mm, 95%CI 17.0 to 22.6 mm). No neurovascular bundle was pierced during needling in any specimen forearms. The distance from the tip of the needle was 15.1 ± 4.8 mm (95%CI 11.7 to 18.5 mm) to the ulnar nerve, 15.6 ± 7.6 mm (95%CI 10.0 to 21 mm) to the ulnar artery, 11.2 ± 3.3 mm (95%CI 8.8 to 13.6 mm) to the median nerve, and 4.9 ± 1.4 mm (95%CI 3.9 to 5.9 mm) to the anterior interosseous neurovascular bundle. The results from this cadaveric study support the assumption that needling of the PQ by the dorsal aspect of the forearm can be accurately and safely conducted by an experienced clinician. Studies investigating the clinical safety and effectiveness of this interventions are needed. [ABSTRACT FROM AUTHOR]

Digital skin defects resulting from trauma are often associated with dysfunction of the digital nerve and the extensor and flexor tendons in the affected fingers. The repair of these complex tissue defects requires a graft containing multiple tissues that can be used to reconstruct the tendons and nerves and restore the skin. Such procedures can cause multiple injuries and significant damage to the donor site. The current study used a novel technique to repair complex dorsal and palmar digital soft‐tissue defects. First, multiple tissues were cut and collected from the donor site. Then, part of the flexor carpi ulnaris tendon was transplanted to repair the tendon defect, and a medial antebrachial cutaneous nerve graft was used to repair the digital nerve defect. Finally, a skin flap was used to cover the skin defect. This paper reports on 31 cases of complex soft‐tissue digital defects, with defect areas of 2–18 cm2. One patient presented with a postoperative arterial crisis in the flap. All other patients recovered without experiencing a vascular crisis, flap necrosis, or wound infection. The postoperative flaps were similar in texture to the original digital skin. The sensation and the extension/flexion functions in the affected fingers recovered well. The effect on grip strength, wrist flexion, and forearm sensation was minor and the postoperative total active motion scores of the affected digits were good or excellent in 96.77% of the cases. The flap sensation recovery rate was also excellent in 83.87% of the cases. The present technique facilitates the repair of multiple dorsal and palmar digital soft‐tissue, tendon and nerve defects, reduces the damage to the donor site, and significantly improves the success of surgical repair. [ABSTRACT FROM AUTHOR]

Leprosy is a chronic infection in humans that mainly affects the peripheral nerves and skin. Paraffin filling has been previously used for muscle atrophy treatment. However, the formation of paraffin granulomas (paraffinomas) can occur over the long term. We encountered a patient with leprosy who had hypothenar muscle atrophy caused by ulnar neuropathy. The patient was treated with paraffin injection at the hypothenar site for cosmetic appearance 60 years ago. Consequently, the paraffin formed a paraffinoma and a recurrent infected skin ulcer. Thus, paraffinoma removal and transfer of ulnar artery perforator adiposal flap (140 × 20 mm) were performed. The ulnar artery perforator adiposal flap was used for infection control and filling the dead space after paraffin removal. The skin healed without complications. Ultrasound confirmed residual adipose tissue and blood flow at the last follow-up.

Background: Ulnar artery thrombosis (UAT) refers to occlusion of the ulnar artery due to a blood clot and is a subcategory of hypothenar hammer syndrome (HHS). We present a case of right ulnar artery thrombosis that was pharmacologically managed in the Emergency Department (ED) and inpatient ward. Case report: A 52-year-old male with a history of anemia and elevated ferritin presented to the ED with a 5-day history of skin discoloration, numbness, and tingling of his right 5th finger. CT angiogram showed a focal 1.5 cm-long thrombotic ulnar artery occlusion at the palmar bifurcation and embolic occlusion of the 5th digital arteries in the finger. Following consultation with vascular surgery, he was given intravenous heparin, transitioned to apixaban for lifelong anticoagulation therapy, and discharged following the placement of a ZioⓇ patch. Why should an emergency physician be aware of this?: The patient's career involving manual labor, elevated ferritin, and smoking history may have been risk factors for UAT development. Our case illustrates the value of interdisciplinary collaboration and conservative management in low-acuity cases of UAT.

Background: Ulnar collateral ligament (UCL) reconstruction has received a unique level of attention in the press and social media. There has also been an increasing use of the internet by patients to seek medical information. Concern exists regarding the quality and comprehensibility of online information when used for patient education. Purpose: To evaluate the quality and comprehensibility of the most-viewed YouTube videos related to the diagnosis and management of UCL injuries. Based on our new evidence-based scoring rubrics, we hypothesized that the quality and comprehensibility of these videos would be poor. Study Design: Cross-sectional study. Methods: The YouTube platform was searched on September 7, 2021, with the terms "UCL injury," "ulnar collateral ligament injury," "UCL surgery," "ulnar collateral ligament surgery," and "Tommy John surgery," and the 50 most-viewed videos from each search were compiled, yielding 250 videos. After removal of duplicates and application of exclusion criteria, the 100 most-viewed videos remained. Basic attributes, including duration of video and number of views, were recorded. Each video was then analyzed by 2 independent reviewers and evaluated for 4 key parameters (quality of diagnostic content [QAR-D], quality of treatment content [QAR-T], presence of inaccurate information, and comprehensibility) and graded on a novel scale from 1 to 4 (4 being the most appropriate for patient education). Results: The mean QAR-D was 4.83 ± 3.41 (fair quality), and the mean QAR-T was 2.76 ± 3.26 (poor quality). Physician-led educational videos had both the highest mean QAR-D (6.37) and the highest mean QAR-T (4.34). No correlation was observed between video quality and views/likes. A total of 12 videos included ≥1 inaccuracy. The mean comprehensibility score was 2.66 ± 1.12, with 39 videos falling below the acceptable comprehensibility threshold (score <3). Conclusion: The overall quality of UCL injury–related YouTube content was low. In addition, the absence of correlation between video quality and views/likes suggests that patients are not preferentially utilizing the limited high-quality content that does exist on the YouTube platform. In addition, inaccurate videos were prevalent (12%), and almost half of all videos were deemed inappropriate for patient education in terms of comprehensibility, as defined by our comprehensibility parameter. [ABSTRACT FROM AUTHOR]

Background: Forearm perforator flaps are fascio-cutaneous flaps that are widely used to cover defects of the hand and forearm. It is critical to include a perforator in these flaps while harvesting them; hence, an understanding of the anatomy is the key. This study aims to map the location of the cutaneous perforators that arise from the radial and ulnar arteries in the cadaveric forearm. Methods: Eleven fresh frozen healthy Caucasian cadaveric forearms purposed for medical research (8 left, 3 right) of mean age 57.1 were used. The radial and ulnar arteries were identified proximally, cannulated, and clamped. An Indian ink, gelatin, and purified water solution were instilled under hand pressure. Specimens were then dissected, and radial and ulnar arteries and their perforators were identified. The location of the perforators was measured relative to the radial and ulnar styloid. Results: A total of 95 perforators were identified (54 radial, 41 ulnar). The average number of radial and ulnar artery perforators is 5 ± 2 and 4 ± 2 respectively. The most distal radial and ulnar perforator arteries are located at 30 mm (13–56) and 25 mm (8–42) respectively. Conclusions: There are more cutaneous perforators arising from the radial than the ulnar arteries. It may be safe to harvest the flaps based on their distance from the distal radius/ulna without having to intra-operatively identify the perforators and avoid the risk of their injury. Level of evidence: Not ratable. [ABSTRACT FROM AUTHOR]

Objectives: Systemic sclerosis (SSc) is a disease characterized by diffuse sclerosis of skin and organs and small vessel vasculopathy. Despite it, large vessels can also be involved with ulnar artery vasculopathy, revealing as a more frequent feature of SSc. The aim of this paper is to assess the macrovascular involvement of SSc patients through an ultrasound (US) evaluation of radial and ulnar arteries. Methods: Radial and ulnar resistance indices (RIs) and peak systolic velocity (PV) (cm/s) together with clinical features of SSc patients were evaluated. Raynaud phenomenon (RP) and healthy control (HC) groups were used for comparison. Results: Forty-three SSc patients were evaluated. Twelve patients (28%) had ulnar artery occlusions (UAOs). In nine cases (75%), UAOs were bilateral. A high UAO prevalence (42%) was found in SSc patients with late nailfold-video-capillaroscopy (NVC) pattern (p = 0.0264). Patients with UAOs had digital ulcers (DUs) in 10 cases (83.3%). Radial and ulnar PVs were lower in SSc and RP patients than the HC group. Radial and ulnar RIs were higher in SSc and RP patients than the HC group. A decision tree analysis led to the classification of 70% of SSc patients with an ulnar RI > 0.82 and ulnar PV > 2.8 cm/s. The most influential variables on UAO development were interstitial lung disease (ILD) (p = 0.002) and NVC pattern (p = 0.002). A positive correlation was shown between modified Rodnan skin score (mRSS) and ILD (p = 0.283; r = 0.033), mRSS and DU (r = 0.344; p = 0.012) and DU and ILD (r = 0.303; p = 0.024). Male sex was associated with increased UAO frequency (p = 0.042). Conclusions: UAO is a peculiar feature of severe SSc present in 28% of the cases, particularly associated with the presence of ILD and late NVC pattern. In 75% of the cases, UAOs are bilateral. DUs are very frequent in patients with UAOs (83%). The RI evaluated by US could be useful to distinguish SSc from HC patients. US could be a useful tool for assessing high-risk DU development in patients. [ABSTRACT FROM AUTHOR]

Background: Ulnar-sided wrist pain is associated with the development of multiple wrist pathologies. But the anatomical etiologies have not been fully understood. Purpose: To determine the association of three anatomical factors with ulnar-sided wrist pain, including ulnar variance (UV), distal ulnar volar angle (DUVA), and pisiform-ulnar distance (PUD). Material and Methods: A total of 64 patients who had ulnar-sided wrist pain associated with training injuries were retrospectively studied. A control group included 64 healthy athletes from the same unit. The UV, DUVA, and PUD of each individual was measured on radiographs. Results: The average UV and DUVA of those in the ulnar-sided pain group were 0.84 mm and 174.65°, respectively; the control group values were 0.39 mm and 175.11°. The differences between the two groups had no statistical significance (P > 0.05). The average PUD of the ulnar-sided wrist pain group was shorter than that of the control group (2.37 cm vs. 2.65 cm); the difference had statistical significance (P < 0.05). PUD had a negative correlation with ulnar-sided pain; it was an anatomical protective factor (odds ratio = 0.01; P < 0.00; 95% confidence interval=0.00–0.05). Both UV and DUVA had no significant correlations with ulnar-sided wrist pain (P > 0.05). Conclusion: PUD has a significant correlation with ulnar-sided wrist pain. It is the anatomical protective factor. Both the UV and DUVA have no statistical association with ulnar-sided wrist pain, but we cannot ignore their potential pathogenic effects on wrists, and further studies are needed to confirm the results. [ABSTRACT FROM AUTHOR]

The ulnar artery is the larger terminal branch of the brachial artery. It originates in the cubital fossa and is covered by the flexor muscles of the forearm. We report an anatomic variant in which the ulnar artery was in a superficial position in the forearm. Since this variant was unknown, an attempted venous puncture injured the artery, causing formation of a pseudoaneurysm. [ABSTRACT FROM AUTHOR]