Atlas Phẫu Thuật Vi Phẫu Mạch Máu (Atlas of Microvascular Surgery)

POSTERIOR INTEROSSEOUS FLAP (POSTERIOR FOREARM FLAP)
79
Approach to the PIA (Fig. 2–41)
Tracing these septocutaneous perforators, the inter-
muscular septum between the extensor carpi ulnaris
and extensor digiti m inim i (2) is identified. After
ligating the muscular branches, the PIA (1) is exposed
by retracting the extensor digitorum minimi (2) radi-
ally. With further dissection, the anastom otic branch
from the AIA can be identi ed from underneath the
tendon of the extensor indicis (7), joining the PIA 3 cm
proximal to the distal radioulnar joint.
Figure 2–41
Approach to the PIA.
1. PIA and its perforators
2. Extensor digiti minimi m.
4. Anastomotic branch of AIA
6. Posterior interosseous n.
7. Tendon of extensor indicis

80
I.2 UPPER EXTREMITY: FOREARM REGION
Elevation of the Ulnar Portion of
the Flap (Fig. 2–42)
The ulnar border of the ap is carefully incised to pre-
serve the dorsal branch of the ulnar nerve (5). While
visualizing the PIA and its perforators (1), the anasto-
m otic branch from the AIA is ligated, and the ap is
gradually elevated from distal to proximal.
Figure 2–42
Elevation of the ulnar portion of the ap.
1. PIA and its perforators
5. Dorsal branch of ulnar n.
2. Extensor digiti minimi m.
6. Posterior interosseous n.
3. Extensor carpi ulnaris m.
7. Tendon of extensor indicis
4. Anastomotic branch of AIA

POSTERIOR INTEROSSEOUS FLAP (POSTERIOR FOREARM FLAP)
81
Pedicle Dissection (Fig. 2–43)
The PIA (1) is dissected between the extensor carpi
ulnaris (3) and extensor digiti m inim i (2); the poste-
rior interosseous nerve (6) lies radial to the artery.
During the dissection, the nerve should be protected,
especially near the distal border of the supinator
(9) where its motor branch to the extensor carpi ulnaris
(3) m ay cross over the PIA.
After ligating the interosseous recurrent artery, the
posterior interosseous vascular pedicle (1) can be
dissected proximally beneath the supinator m uscle.
Figure 2–43
Pedicle dissection.
1. PIA
2. Extensor digiti minimi m.
3. Extensor carpi ulnaris m.
6. Posterior interosseous n.
9. Supinator m.

82
I.2 UPPER EXTREMITY: FOREARM REGION
REVERSED POSTERIOR
INTEROSSEOUS FLAP
Flap Design (Fig. 2–44)
According to the location and size of the defect on the
hand or wrist, the ap is designed mainly on the m iddle
third of the line from the lateral epicondyle of the
humerus to the head of the ulna. A rotation pivot point
is situated 3 cm proximal to the distal radioulnar joint.
The distance between the pivot and the proximal edge
of the defect should match the distance between the
pivot and the distal border of the ap as the length of
the reversed vascular pedicle. The proxim al border of
the ap is allowed to exceed only 2 to 3 cm over the
point between the proximal and middle thirds of the
line. Usually, a reversed posterior interosseous ap may
not cover a defect distal to the MP joint of the ngers.
Figure 2–44
Flap design.
1. PIA
5. Middle septocutaneous perforator
2. Extensor digiti minimi m.
6. Anastomotic branch of AIA
3. Extensor carpi ulnaris m.
7. Supinator m.
4. Proximal septocutaneous perforator
N

REVERSED POSTERIOR INTEROSSEOUS FLAP
83
Elevation of Radial Portion and
Approach to PIA (Fig. 2–45)
The radial border of the ap is incised and raised with
the deep fascia toward the intermuscular septum. The
septocutaneous perforators are identi ed and evalu-
ated. Usually, the most proximal septocutaneous perfo-
rator (4) is larger. The dissection proceeds in the
septum to expose the posterior interosseous vessels (1)
and nerve. The relationship between the most proximal
septocutaneous perforator and the motor nerve branch
to the extensor carpi ulnaris (3) is assessed.
During the dissection around the point between the
middle and distal thirds of the line, that is, the middle
portion of the PIA (1), attention should be paid to iden-
tify the middle septocutaneous perforator (5), which
contains one of the communicating veins between the
super cial and deep venous system in the forearm. It
should be included in the ap to improve venous
drainage. This vessel should be sought out while
dissecting the distal portion of the pedicle if it is not
available during elevation of the radial portion and
approach to the PIA.
Figure 2–45
Elevation of radial portion and approach to PIA.
1. PIA
2. Extensor digiti minimi m.
3. Extensor carpi ulnaris m.
4. Proximal septocutaneous perforator
5. Middle septocutaneous perforator

84
I.2 UPPER EXTREMITY: FOREARM REGION
Dissection of the Distal Portion of the
Pedicle (Fig. 2–46)
A skin incision is extended distally along the line, and
the intermuscular septum between the extensor carpi
ulnaris (3) and extensor digiti minim i (2) is identi ed.
In case the middle cutaneous perforator was not avail-
able in the prior step, it should now be identi ed and
preserved intact between the vascular pedicle (1) and a
portion of the deep fascia with the super cial vein.
Tracing the septocutaneous perforators and retracting
these two m uscles or tendons, the posterior in-
terosseous vessels (1) are exposed. A careful dissection
is performed distally to nd and evaluate the anasto-
motic branch from the AIA, which comes from beneath
the extensor indicis proprius. During the dissection,
attention should be paid to preserving all branches that
go distally to join the dorsal carpal arch.
Figure 2–46
Dissection of the distal portion of the pedicle.
1. PIA
2. Extensor digiti minimi m.
3. Extensor carpi ulnaris m.
6. Anastomotic branch of AIA

REVERSED POSTERIOR INTEROSSEOUS FLAP
85
Complete Raising of the Flap
(Fig. 2–47)
The ulnar half of the ap is raised, and the posterior
interosseous vessels are dissected to the distal edge of
the supinator (7). It is imperative, after clamping the vas-
cular pedicle at its proximal end and releasing the
tourniquet, that blood perfusion in the ap be evaluated
before ligating the vascular pedicle at the proximal end.
A subcutaneous tunnel on the dorsum of the wrist
is created by a blunt dissection.
Figure 2–47
Complete raising of the ap.
1. PIA
2. Extensor digiti minimi m.
3. Extensor carpi ulnaris m.
6. Anastomotic branch of the AIA
7. Supinator m.

86
I.2 UPPER EXTREMITY: FOREARM REGION
Flap Transfer to the Hand (Fig. 2–48)
The vascular pedicle is ligated, and the reversed poste-
rior interosseous ap is turned distally through the
subcutaneous tunnel to cover the defect on the hand.
In cases where the m otor nerve branch to the
extensor carpi ulnaris (3) crosses the vascular pedicle
super cially and there is no adjacent septocutaneous
perforator with an adequate diameter (Fig. 2–38C, p. 75),
the nerve branch would be sectioned and repaired
again.
Figure 2–48
Flap transfer to the hand.
1. PIA
2. Extensor digiti minimi m.
3. Extensor carpi ulnaris m.
6. Anastomotic branch of the AIA

REVERSED POSTERIOR INTEROSSEOUS OSTEOCUTANEOUS FLAP
87
REVERSED POSTERIOR
INTEROSSEOUS OSTEOCUTANEOUS
FLAP
For cases of skin defect with metacarpal bone loss on the
dorsum of the hand, this ap provides both components,
with no sacri ce of a major arterial supply to the hand.
Bony Segment Proposed (Fig. 2–49)
The ap design is in accordance with the description
given for the reverse posterior interosseous ap. The
size of the ap can be up to 12 cm in length and 8 cm in
width. According to the defect of the metacarpal in the
hand, the ulna bone is proposed for harvesting up to
7 cm in length on its radial side, and the width cannot
exceed one third of the diameter of the ulna to avoid
postoperative fracture.
Figure 2–49
Bony segment proposed.
1. PIA
6. Abductor pollicis longus m.
2. Extensor digiti minimi m.
7. Extensor pollicis longus m.
3. Extensor carpi ulnaris m.
8. Ulna
4. Supinator m.
9. Interosseous membrane
5. Posterior interosseous n.
N

88
I.2 UPPER EXTREMITY: FOREARM REGION
Flap Elevation and Pedicle Approach
(Fig. 2–50)
Flap elevation and exposure of the vascular pedicle fol-
low the description given for the reversed posterior in-
terosseous ap. The dissection is perform ed on the
vascular pedicle of the posterior interosseous vessels
(1) from its distal and m iddle thirds, where they are
more super cial. Attention should be paid to include
the m iddle cutaneous perforator in the ap or its
vascular pedicle to improve venous drainage.
Dissection proceeds proxim ally to expose the distal
edge of the supinator (4), where the posterior in-
terosseous vessels (1) em erge into the posterior inter-
m uscular septum . After the posterior interosseous
nerve (5) and its branches are identi ed and protected,
the posterior interosseous vessels are ligated at their
em ergence. During the dissection for the proxim al
portion, the muscular branches to the abductor pollicis
longus (6) and extensor pollicis longus (7) m uscles
should be kept intact at their attachments on the ulna,
in addition to the proximal cutaneous perforator for the
ap.
Figure 2–50
Flap elevation and pedicle approach.
1. PIA
5. Posterior interosseous n.
2. Extensor digiti minimi m.
6. Abductor pollicis longus m.
3. Extensor carpi ulnaris m.
7. Extensor pollicis longus m.
4. Supinator m.

REVERSED POSTERIOR INTEROSSEOUS OSTEOCUTANEOUS FLAP
89
Exposure of Interosseous Membrane
(Figs. 2–51A, 2–51B)
The abductor pollicis longus (6) and extensor pollicis
longus muscles (7) are incised along the radial side of
the posterior interosseous vessels to expose the in-
terosseous membrane (9), leaving a muscle cuff with
attachment to the ulna.
Figure 2–51A
Exposure of interosseous membrane.
1. PIA
5. Posterior interosseous n.
2. Extensor digiti minimi m.
6. Abductor pollicis longus m.
3. Extensor carpi ulnaris m.
7. Extensor pollicis longus m.
4. Supinator m.
9. Interosseous membrane

90
I.2 UPPER EXTREMITY: FOREARM REGION
Bony Exposure (Fig. 2–51B)
The ulnar portion of the ap is ipped to show the
extensor carpi ulnaris (3) muscle. According to the pro-
posed line for bony harvest, the extensor carpi ulnaris
m uscle is divided and the periosteum on the ulna is
incised and slightly elevated along the proposed line.
Figure 2–51B
Bony exposure.
1. PIA
2. Extensor digiti minimi m.
3. Extensor carpi ulnaris m.
7. Extensor pollicis longus m.
8. Ulna

REVERSED POSTERIOR INTEROSSEOUS OSTEOCUTANEOUS FLAP
91
Osteotomy on the Ulna (Fig. 2–52)
The interosseous m em brane is incised to reach the
deep exor compartment of the forearm. With protec-
tion of the anterior structures, the ulna bone segment is
divided with a saw. The reverse posterior interosseous os-
teocutaneous ap is raised with its vascular pedicle and
turned to the dorsum of the hand for defect coverage.
Figure 2–52
Osteotomy on the ulna.
1. PIA
6. Abductor pollicis longus m.
2. Extensor digiti minimi m.
7. Extensor pollicis longus m.
3. Extensor carpi ulnaris m.
8. Ulna
4. Supinator m.
9. Interosseous membrane
5. Posterior interosseous n.

92
I.2 UPPER EXTREMITY: FOREARM REGION
Dorsal Approach and Identi cation of
the Vascular Pedicle (Fig. 2–54)
The proximal extended incision is rst made and the
deep fascia is divided. After the extensor digitorum
tendons (1) and extensor indicis m uscle (2) are re-
tracted ulnarly, and the extensor pollicis longus muscle
(3) is retracted radially, the interosseous membrane (4)
is reached. Usually, the posterior branch of the AIA (5),
which penetrates the interosseous membrane at 3 cm
proximal to the distal radioulnar joint, can be identi-
ed. Imm ediately after its penetration, it is dissected to
identify its branches, including the branch that commu-
nicates with the PIA (6). Among these branches, the dor-
sal cutaneous branch is identi ed running distodorsally
onto the extensor retinaculum.
Figure 2–54
Dorsal approach and identi cation of the vascular
pedicle.
1. Tendons of extensor digitorum m.
2. Extensor indicis m.
3. Extensor pollicis longus m.
4. Interosseous membrane
5. AIA and its branch
6. PIA
ANTERIOR INTEROSSEOUS FLAP
(DORSAL WRIST FLAP)
Flap Design (Fig. 2–53)
A line is drawn along the dorsal crease of the wrist as an
axis for the ap design; ap size can be up to 3
5 cm.
From the midpoint of the proximal border of the ap,
an additional line is extended proximally for 4 cm for
exposure of the vascular pedicle.
Figure 2–53
Flap design.
1. Tendons of extensor digitorum m.
2. Extensor indicis m.
3. Extensor pollicis longus m.
4. Interosseous membrane
5. AIA and its branch
6. PIA
N

ANTERIOR INTEROSSEOUS FLAP
93
Flap Elevation and Further Dissection
of the Pedicle (Fig. 2–55)
After the dorsal cutaneous branch is carefully dissected,
the skin ap is elevated from the dorsum of the wrist.
Dissection proceeds to ligate the com m unicating
branch with the PIA (6) and to isolate the AIA (5) at the
point where it penetrates the interosseous membrane.
At this point, the pedicle of the ap can be 3 to 4 cm
long with an arterial diameter of 1.5 m m. In case a
longer pedicle is needed, the interosseous membrane
can be divided to reach the exor compartment, and
the AIA is dissected immediately under the membrane.
Figure 2–55
Flap elevation and further
dissection of the pedicle.
1. Extensor digitorum m.
2. Extensor indicis m.
3. Extensor pollicis longus m.
4. Interosseous membrane
5. AIA and its branch
6. PIA

94
I.2 UPPER EXTREMITY: FOREARM REGION
RECIPIENT SITE EXPOSURES
Exposure of Bifurcation of the Radial
and Ulnar Arteries
Incision (Fig. 2–56)
An S-shaped incision is made from the medial bicipital
groove, via the exion crease, to the m edial border of
the brachioradialis muscle.
Figure 2–56
Incision.
1. Brachial a. and v.
2. Median n.
3. Biceps m.
4. Brachioradialis m.
5. Pronator teres m.
6. Brachialis m.
7. Triceps m.
8. Bicipital aponeurosis
9. Tendon of biceps m.
10. Supinator m.
11. Ulnar a. and v.
12. Radial a. and v.
13. Recurrent radial a.
N

RECIPIENT SITE EXPOSURES
95
Approach to the Brachial Artery
(Fig. 2–57)
The super cial veins, including the median cubital vein,
are ligated. The deep fascia and bicipital aponeurosis
(8) are divided vertically along the medial side of the
biceps muscle (3) and tendon, and the biceps tendon is
retracted laterally to display the contents of the fossa
where the brachial artery lies between the biceps
tendon and the median nerve (2).
Figure 2–57
Approach to the brachial artery.
1. Brachial a. and v.
2. Median n.
3. Biceps m.
4. Brachioradialis m.
5. Pronator teres m.
6. Brachialis m.
7. Triceps m.
8. Bicipital aponeurosis

96
I.2 UPPER EXTREMITY: FOREARM REGION
Tracing to the Bifurcation (Fig. 2–58)
The brachioradialis (4) is retracted laterally. Tracing the
brachial artery, the bifurcation is identi ed, and the ra-
dial artery (12) can be dissected further along the lat-
eral border of the pronator teres (5). Using care to
protect the m edian nerve (2), the pronator teres is
retracted to expose the ulnar artery (11). The radial
recurrent artery (13) arises from the radial artery near its
origin. The ulnar artery gives off anterior and posterior
ulnar recurrent arteries and the common interosseous
artery, after its origination.
Figure 2–58
Tracing to the bifurcation.
1. Brachiall a. and v.
2. Median n.
3. Biceps m.
4. Brachioradialis m.
5. Pronator teres m.
6. Brachialis m.
7. Triceps m.
8. Bicipital aponeurosis
9. Tendon of biceps m.
10. Supinator m.
11. Ulnar a. and v.
12. Radial a. and v.
13. Radial recurrent a.

RECIPIENT SITE EXPOSURES
97
Exposure of Radial Artery in
the Forearm
Incisions (Fig. 2–59)
A line is drawn from the antecubital fossa to the tuber-
cle of the scaphoid. A skin incision can be made on the
line at its proxim al, middle, or distal portion, depending
on the level of recipient artery required.
Figure 2–59
Incisions.
1. Radial a. and v.
6. Pronator teres m.
2. Super cial branch of radial n.
7. Supinator m.
3. Recurrent radial a.
8. Bicipital aponeurosis
4. Brachioradialis m.
9. Flexor pollicis longus m.
5. Flexor carpi radialis m.

98
I.2 UPPER EXTREMITY: FOREARM REGION
Exposure of Proximal
Portion (Fig. 2–60)
If the proximal portion of the radial artery (1) is required,
the incision is deepened to identify and enter the inter-
muscular septum between the brachioradialis (4) and the
exor carpi radialis (5) muscles. Retracting the brachiora-
dialis m uscle (4) laterally, the radial artery (1) can be
exposed and dissected out.
Figure 2–60
Exposure of the proximal
portion.
1. Radial a. and v.
2. Super cial branch of radial n.
3. Recurrent radial a.
4. Brachioradialis m.
5. Flexor carpi radialis m.
6. Pronator teres m.
7. Supinator m.
8. Bicipital aponeurosis

RECIPIENT SITE EXPOSURES
99
Exposure of the Distal
Portion (Fig. 2–61)
If the distal portion of the radial artery (1) is required,
the deep fascia is divided and the radial artery can be
easily isolated between the tendons of the brachioradi-
alis (4) and exor carpi radialis (5). The cephalic vein is
available near the incision, lying in the super cial fascia
at the radial side of the wrist.
Figure 2–61
Exposure of the distal portion.
1. Radial a. and v.
2. Super cial branch of radial n.
4. Brachioradialis m.
5. Flexor carpi radialis m.
9. Flexor pollicis longus m.

100
I.2 UPPER EXTREMITY: FOREARM REGION
Exposure of Ulnar Artery
in the Forearm
Incisions (Fig. 2–62)
A line is drawn from the m edial epicondyle of the
humerus to the lateral edge of the pisiform bone. The
incision can be made on the middle or distal third of
the line.
Figure 2–62
Incisions.
1. Ulnar a. and v.
2. Ulnar n.
3. Flexor carpi ulnaris m.
4. Flexor digitorum super cialis m.
5. Flexor digitorum profundus m.
6. Dorsal cutaneous branch of ulnar n.
7. Pronator quadratus m.

RECIPIENT SITE EXPOSURES
101
Exposure of the Middle Third of the
Artery (Fig. 2–63)
In the middle third, by deepening the incision and divid-
ing the deep fascia, the interm uscular septum between
the exor carpi ulnaris (3) and the exor digitorum su-
per cialis (4) m uscles is identi ed and entered. Re-
tracting the exor carpi ulnaris m uscle m edially and
the exor digitorum super cialis m uscle laterally, the
ulnar artery (1) is located on the radial side of the ulnar
nerve (2) and then isolated.
Figure 2–63
Exposure of the middle
third of the artery.
1. Ulnar a. and v.
2. Ulnar n.
3. Flexor carpi ulnaris m.
4. Flexor digitorum super cialis m.
5. Flexor digitorum profundus m.

102
I.2 UPPER EXTREMITY: FOREARM REGION
Exposure of the Distal Third
of the Artery (Fig. 2–64)
In the distal third, the deep fascia is incised. While
retracting the exor carpi ulnaris tendon (3), care
should be taken to protect the dorsal cutaneous branch
of the ulnar nerve (6) that is given off 8 cm above the
wrist and then passes under the exor carpi ulnaris ten-
don via the ulnar side of the wrist to reach the back of
the hand. The ulnar artery (1) can be identi ed and
isolated between the tendons of the exor carpi ulnaris
(3) and exor digitorum (4) on the radial side of the
ulnar nerve (2).
Figure 2–64
Exposure of the distal third of the artery.
1. Ulnar a. and v.
2. Ulnar n.
3. Flexor carpi ulnaris m.
4. Flexor digitorum super cialis m.
6. Dorsal cutaneous branch of ulnar n.
7. Pronator quadratus m.

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103
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I.2 UPPER EXTREMITY: FOREARM REGION

ANATOMY OF THE RADIAL
ARTERY—DEEP PALMAR ARCH
SYSTEM (FIG. 3–1)
The radial artery (1) turns to the dorsal aspect
of the carpus between the lateral ligament of
the wrist and the tendons of the abductor
pollicis longus and extensor pollicis brevis at
the wrist. It then runs on the scaphoid and
trapezium bones in the “snuff box,” where it
is crossed by the origin of the cephalic vein
and super cial branch of the radial nerve.
Having passed through the proxim al end of
the rst interosseous space between the
heads of the rst dorsal interosseous, the ar-
tery goes between the oblique and transverse
head of the adductor pollicis (12,13) and runs
transversely across the palm.
3
Hand and Wrist
Figure 3–1
Anatomic diagram of the
arterial system of the hand.
1. Radial a.
2. Ulnar a.
3. Deep palmar arch
4. Super cial palmar arch
5. Super cial palmar branch
6. Deep palmar branch
7. Princeps pollicis a.
8. Radialis indicis a.
9. Palmar metacarpal a.
10. Common palmar digital a.
11. Ulnar palmar digital a. of little nger
12. Transverse head of adductor pollicis m.
13. Oblique head of adductor pollicis m.

110
I.3 UPPER EXTREMITY: HAND AND WRIST
At the base of the fth metacarpal, it anastomoses
with the deep palmar branch of the ulnar artery (6) to
form the deep palm ar arch (3), which lies on the bases
of the metacarpal bones and the interossei and is cov-
ered by the oblique head of the adductor pollicis, the
exor tendons of the ngers, and the lumbricals.
The princeps pollicis artery (7) is given off from the
radial artery just as it curves medially into the palm. It
runs under the oblique head of the adductor pollicis
and lateral to the rst palmar interosseous muscle. At
the base of the proximal phalanx of the thumb, it lies
deep to the exor pollicis longus tendon and divides
into a pair of digital arteries running along the radial
and ulnar sides of the tendon.
The radialis indicis artery (8) usually springs from
the proxim al part of the princeps pollicis artery (7),
passing between the rst dorsal interosseous and
transverse head of the adductor pollicis (12) and run-
ning along the radial side of the index.
The three palmar metacarpal arteries (9) arise from
the deep palmar arch and join the common digital arteries
of the super cial palmar arch at the web of the nger.
ANATOMY OF THE ULNAR ARTERY—
SUPERFICIAL PALMAR ARCH SYSTEM
(FIG. 3–1)
The ulnar artery (2) goes into the hand with the ulnar
nerve super cial to the exor retinaculum and lateral to
the pisiform bone. It then runs medial to the hook of
the hamate and curves in the palm at the level of the
palm ar m idpoint to form the super cial palm ar arch
(4), anastomosing with the super cial palmar branch of
the radial artery (5). The super cial palm ar arch lies
deep to the palm ar fascia and in front of the exor
tendons and digital branches of the medial nerve.
Three common palmar digital arteries (10) are given
off from the convexity of the super cial palmar arch (4)
and travel distally on the second, third, and fourth lum-
bricals. Each merges with the palmar metacarpal artery
(9) from the deep palm ar arch (3) and then divides into
two proper palmar digital arteries, 1 cm proximal to
the web.
Each proper palmar digital artery travels along the
side of the exor tendon, dorsal to the digital nerve and
deep to Cleland’s ligament, which is a thin brous sheet
attaching from the lateral side of the phalanx to the
derm is of the palm ar skin in the nger. The palmar dig-
ital artery on the ulnar side of the little nger arises
from the arch under the palmaris brevis.
Measurements
Diameter (average, mm)
Radial a. (at anatomic snuff box)
1.8 – 2.0
Deep palmar arch
1.4
Princeps pollicis a.
1.3
Palmar metacarpal aa.
1.1
Ulnar a. (in front of exor aponeurosis)
2.0 – 2.4
Super cial palmar arch
1.8
Common palmar digital a.
1.5 – 1.7
Proper palmar digital a.
At web space
0.8 – 1.2
At distal interphalangeal joint
0.4 – 0.6

ANATOMY OF THE ULNAR ARTERY—SUPERFICIAL PALMAR ARCH SYSTEM
111
Variations of the Super cial Palmar
Arch (Fig. 3–2)
A. Typical radioulnar com m unication of super cial
palmar arch (35% of cases)
B. Super cial palmar arch formed only by ulnar artery
(39% of cases)
C. Super cial palm ar arch com pleted by ulnar and
m edian artery; the latter, replacing the radial artery,
accompanies the m edian nerve (4% of cases)
D. Three arteries (ulnar, median, and super cial branch of
radial artery) join together to form the arch (1% of cases).
E. In this incomplete arch, the proper palmar arteries
are derived from the radial and ulnar arteries, with-
out com m unication across the m iddle line of the
hand at the super cial level (16% of cases).
F. Three arteries (ulnar, median, and super cial branch
of radial artery) separately contribute to the digital
vessels, without anastom osing with each other at
the super cial level (5% of cases).
Figure 3–2
Variations of the
super cial palmar arch (see text for
details).

112
I.3 UPPER EXTREMITY: HAND AND WRIST
Variations of the Deep Palmar Arch
(Fig. 3–3)
A. Typical radioulnar com munication of deep palmar
arch (35% of cases)
B. The deep palmar arch is complete, and it also sup-
plies the ulnar side of the hand (13% of cases).
C. The deep palm ar branch of the ulnar artery does
not join the deep palmar arch, but the radioulnar
communication is still complete, with connections
between the palm ar m etacarpal arteries and the
common palmar digital arteries (49% of cases).
D. The radial and ulnar arteries supply each side in the
deep system; there may be poor communication if
the super cial palm ar arch is incom plete (3% of
cases).
Figure 3–3
Variations of the deep palmar arch
(see text for details).

RECIPIENT SITE EXPOSURES
113
Identi cation of the Super cial Structures
(Fig. 3–5)
The cephalic vein (1) and super cial branch of the
radial nerve (2) are identi ed in the subcutaneous
tissue and retracted dorsally.
Figure 3–4
Incision.
1. Cephalic v.
2. Super cial branch of radial n.
3. Extensor pollicis longus
tendon
4. Extensor pollicis brevis
tendon
5. Radial a. and v.
Figure 3–5
Identi cation of the
super cial structures.
1. Cephalic v.
2. Super cial branch of radial n.
3. Extensor pollicis longus tendon
4. Extensor pollicis brevis tendon
RECIPIENT SITE EXPOSURES
Radial Artery in the Anatomic
Snuff Box
Incision (Fig. 3–4)
A curvilinear incision is made from the styloid process
of the radius to a point between the bases of the rst
and second metacarpals.

114
I.3 UPPER EXTREMITY: HAND AND WRIST
Figure 3–6
Exposure of the radial artery.
1. Cephalic v.
2. Super cial branch of radial n.
3. Extensor pollicis longus tendon
4. Extensor pollicis brevis tendon
5. Radial a. and v.
Exposure of the Radial Artery (Fig. 3–6)
The deep fascia is divided longitudinally between the
tendons of the extensors pollicis longus and brevis
(3,4), which are then retracted dorsally and palm arly.
The radial artery (5), accom panied by two venae com i-
tantes, is identi ed and exposed as it em erges under
the tendons of the abductor pollicis longus and exor
pollicis brevis, running distally to the interspace of the
rst and second m etacarpals.
Ulnar Artery at the Wrist
Incision (Fig. 3–7)
A skin incision is made along the hypothenar crease. At
the exion crease of the wrist, it curves medially and
then turns upward for a short distance along the radial
side of the exor carpi ulnaris tendon.
Figure 3–7
Incision.
1. Flexor carpi ulnaris m.
2. Flexor digitorum
super cialis tendons
3. Pisiform
4. Super cial part of the
exor retinaculum
5. Palmaris brevis m.
6. Palmar fascia
7. Hypothenar m.
8. Ulnar a.
9. Ulnar n.
10. Deep branch of the ulnar
n.
11. Ulnar palmar digital a. of
little nger

RECIPIENT SITE EXPOSURES
115
Identi cation of the Super cial Structures
(Fig. 3–8)
The palmar deep fascia are incised along the line with a
skin incision to identify the pisiform bone (3), the exor
carpi ulnaris tendon (1), and the palmaris brevis (5). The
latter runs transversely from the exor retinaculum (4)
and the palmar faascia (6) to the dermis on the ulnar
side of the hand.
Figure 3–8
Identi cation of the
super cial structures.
1. Flexor carpi ulnaris m.
2. Flexor digitorum super cialis tendons
3. Pisiform
4. Super cial part of the exor
retinaculum
5. Palmaris brevis m.
6. Palmar fascia
7. Hypothenar m.

116
I.3 UPPER EXTREMITY: HAND AND WRIST
Exploration of the Ulnar Artery (Fig. 3–9)
The palmaris brevis m uscle (5) and the super cial part
of the exor retinaculum (4) are divided lateral to the
pisiform bone (3). Then, the ulnar artery (8) can be
identi ed lateral to the ulnar nerve (9) between the
pisiform bone and the exor retinaculum . Retracting
the exor carpi ulnaris tendon (1) medially, the dissec-
tion proceeds proximally to expose the ulnar artery and
nerve. Although the ulnar nerve needs to be m obilized,
care should be taken not to injure the deep branch of
the nerve (10), which plunges between the exor and
abductor digiti minimi to reach the deeper layer of the
palm.
Figure 3–9
Exploration of the ulnar artery.
1. Flexor carpi ulnaris m.
2. Flexor digitorum super cialis tendons
3. Pisiform
4. Super cial part of the exor retinaculum
5. Palmaris brevis m.
6. Palmar faascia
7. Hypothenar m.
8. Ulnar a.
9. Ulnar n.
10. Deep branch of the ulnar n.
11. Ulnar palmar digital a. of little nger

RECIPIENT SITE EXPOSURES
117
Princeps Pollicis Artery and the Origin
of the Deep Palmar Arch
This artery is a dominant blood supply to the thumb,
and it is located deeply under the thenar m uscle.
Both palm ar and dorsal approaches to the artery are
possible.
Palmar Approach
Incision (Fig. 3–10)
A curved incision is m ade from the ulnar side of the
base of the thum b at the rst web, along the thenar
crease to the wrist between the thenar and hypothenar
em inences.
Figure 3–10
Incision.
1. Median n.
2. Flexor retinaculum divided
3. Flexor pollicis longus tendon
4. Transverse and oblique heads of adductor pollicis m.
5. Thenar m.
6. Recurrent branch of median n.
7. Palmar fascia
8. Flexor digitorum super cialis tendon
9. Lumbrical m.
10. First dorsal interosseous m.
11. Princeps pollicis a.
12. Radial indicis a.
13. Deep palmar arch

118
I.3 UPPER EXTREMITY: HAND AND WRIST
Protection of the Motor Branch of the
Median Nerve (Fig. 3–11)
The palm ar fascia (7) and exor retinaculum (2) are
divided, and the motor branch (sometimes called the
recurrent branch) and sensory branches to the thumb
and index of the median nerve (1) are then identi ed
and carefully protected.
Figure 3–11
Protection of the
motor branch of the median nerve.
1. Median n.
2. Flexor retinaculum divided
3. Flexor pollicis longus tendon
4. Transverse and oblique heads of
adductor pollicis m.
5. Thenar m.
6. Recurrent branch of median n.
7. Palmar fascia
8. Flexor digitorum super cialis
tendon
9. Lumbrical m.

RECIPIENT SITE EXPOSURES
119
Exposure of the Princeps Pollicis Artery
(Fig. 3–12)
Retracting the thenar muscles (5) with the motor and
sensory branches of the thumb radially, and the exor
pollicis longus tendon (3) and oblique head of the
adductor pollicis (4) ulnarly, the princeps pollicis artery
(11) is identi ed on the palm ar aspect of the rst
metacarpal bone, under the oblique head of the adduc-
tor pollicis (4). If a wider exposure is required, the lateral
insertion of the oblique head of the adductor pollicis can
be divided, and the radialis indicis artery (12) and origin
of the deep palmar arch (13) can be exposed.
Figure 3–12
Exposure of the princeps pollicis artery.
1. Median n.
7. Palmar fascia
2. Flexor retinaculum divided
8. Flexor digitorum super cialis tendons
3. Flexor pollicis longus tendon
10. First dorsal interosseous m.
4. Transverse and oblique heads
11. Princeps pollicis a.
of adductor pollicis m.
12. Radialis indicis a.
5. Thenar m.
13. Deep palmar arch
6. Recurrent branch of median n.

120
I.3 UPPER EXTREMITY: HAND AND WRIST
Dorsal Approach
Incision (Fig. 3–13)
An incision is made from the ulnar side of the metacar-
pophalangeal joint of the thum b to the anatom ic
snuff box.
Figure 3–13
Incision.
1. Adductor pollicis m.
2. Extensor pollicis longus tendon
3. First dorsal interosseous m.
4. First metacarpal
5. Radial a.
6. Princeps pollicis a.
7. Radialis indicis a.
8. Deep palmar arch
Figure 3–14
Identi cation of the radial artery.
1. Adductor pollicis m.
2. Extensor pollicis longus tendon
3. First dorsal interosseous m.
4. First metacarpal
5. Radial a.
Identi cation of the Radial Artery (Fig. 3–14)
The extensor pollicis longus tendon (2) is isolated and
retracted radially. The radial artery (5) is identi ed over
the junction of the bases of the rst and second
metacarpal bones.

RECIPIENT SITE EXPOSURES
121
Exposure of the Princeps Pollicis Artery
(Fig. 3–15)
Tracing the radial artery (5) distally, the rst dorsal
interosseous muscle (3) is divided, and the origins of
the princeps pollicis and radialis indicis arteries (6,7),
as well as the origin of the deep palmar arch (8), are
then identi ed. Along the palm ar aspect of the rst
metacarpal bone (4), the dissection proceeds to isolate
the princeps pollicis artery (6). If greater exposure is
needed, the insertion of the transverse head of the
adductor pollicis (1) can be detached.
Figure 3–15
Exposure of the princeps
pollicis artery.
1. Adductor pollicis m.
2. Extensor pollicis longus tendon
3. First dorsal interosseous m.
4. First metacarpal
5. Radial a.
6. Princeps pollicis a.
7. Radialis indicis a.
8. Deep palmar arch

122
I.3 UPPER EXTREMITY: HAND AND WRIST
Super cial Palmar Arch
Incision (Fig. 3–16)
A skin incision is made along the proximal palm ar and
hypothenar creases, ending at the wrist between the
thenar and hypothenar eminences.
Figure 3–16
Incision.
1. Ulnar a. and n.
2. Flexor tendon
3. Common palmar digital a.
4. Flexor retinaculum
5. Median n.
6. Thenar m.
7. Palmar fascia
8. Common digital n.
9. Super cial palmar arch

RECIPIENT SITE EXPOSURES
123
Exposure of the Super cial Palmar Arch
(Fig. 3–17)
Deepening the skin incision, the palm ar fascia (7) is
divided and the dissection is then performed under the
fascia. The skin ap, together with the palmar fascia, is
mobilized and turned over to the radial side. The super-
cial palm ar arch (9) is exposed super cial to and
crossing the exor tendons (2) and the common digital
nerve of the medial nerve (8). At that point, it gives off
three com m on palm ar digital arteries (3) and then
anastomoses with the super cial palm ar branch of the
radial artery.
At the proximal portion of the incision, dividing the
palmaris brevis facilitates the exposure of the origin of
the super cial palm ar arch, that is, the distal continua-
tion of the ulnar artery (1).
Figure 3–17
Exposure of the super cial
palmar arch.
1. Ulnar a. and n.
2. Flexor tendon
3. Common palmar digital a.
4. Flexor retinaculum
5. Median n.
6. Thenar m.
7. Palmar fascia
8. Common digital n.
9. Super cial palmar arch

124
I.3 UPPER EXTREMITY: HAND AND WRIST
Digital Artery and Nerve
Incision (Fig. 3–18)
A longitudinal skin incision is made on the line of the
junction of the palmar and dorsal skin of the nger.
Exposure of the Digital Artery (Fig. 3–19)
Cleland’s ligament (6) is divided longitudinally, and the
neurovascular bundle (1,2) is then exposed. Generally, the
digital nerve (2) may be identi ed rst; the digital artery
(1) is located dorsal and lateral to the nerve.
Figure 3–18
Incision.
1. Digital a.
5. Phalanx
2. Digital n.
6. Cleland’s ligament
3. Flexor tendons
7. Extensor tendon
4. Articular capsule and lateral ligament of
proximal interphalangeal joint
Figure 3–19
Exposure of the digital
artery.
1. Digital a.
2. Digital n.
3. Flexor tendons
4. Articular capsule and lateral ligament
of proximal interphalangeal joint
6. Cleland’s ligament
Note. The proper palmar digital arteries on
the ulnar side of the index and middle
ngers and thumb usually are somewhat
larger than on the radial side; those on the
radial side of the ring and little ngers are
larger than on the ulnar side.

RECIPIENT SITE EXPOSURES
125
Cross-Sectional Diagram for the Approach
(Fig. 3–20)
Approach to the digital artery and nerve in cross
section.
Figure 3–20
Cross-sectional diagram
for the approach.
1. Digital a.
2. Digital n.
3. Flexor tendons
5. Phalanx
6. Cleland’s ligament
7. Extensor tendon

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Part II
Lower Extremity