Journal of Plastic, Reconstructive & Aesthetic Surgery (2018) 71, 1577–1592

Review

The surgical anatomy of the superficial and

deep palmar arches: A Meta-analysisR
Michał P. Zarzecki a,b, Patrick Popieluszko a,b,
Alexander Zayachkowski a,b, Przemysław A. Pe˛kala a,b,
Brandon M. Henry a,b, Krzysztof A. Tomaszewski a,b,∗
a
International Evidence-Based Anatomy Working Group, 12 Kopernika St., 31-034 Kraków, Poland
b
Department of Anatomy, Jagiellonian University Medical College, 12 Kopernika St., 31-034 Kraków,
Poland

Received 5 December 2017; accepted 18 August 2018

KEYWORDS Abstract Introduction: The following study aimed to find the pooled prevalence estimate of
Superficial palmar anatomical variations in the palmar vasculature, namely the superficial palmar arch (SPA) and
arch; the deep palmar arch (DPA). The importance of understanding the vasculature of the hand has
Deep palmar arch; become critical with the increasing use of hand microsurgery.
Anatomy; Methods: Major online medical databases (PubMed, EMBASE, ScienceDirect, and Web of Sci-
Meta-analysis ence) were extensively searched for terms pertaining to the SPA, the DPA, and their anatomy
and variations. Articles reporting data on the SPA and/or the DPA were collected and their data
extracted. Furthermore, a reference search was performed, allowing to pinpoint any articles
that were not previously found. The collected data were analyzed using MetaXL 5.3.
Results: The analysis included 36 studies (n = 4841 palmar arches). The SPA was found to be
complete in 81.3% of cases, with the radioulnar anastomosis being the most common variant
(72.0%). The incomplete SPA was present in 18.7% of cases, with the ulnar artery supplying the
third finger from both radial and ulnar side as the most prevalent in 34.8%. The DPA was found
to be complete in 95.2% of cases.
Conclusion: In this study, the SPA was predominantly complete, with the anastomosis between
the radial and the ulnar artery being most prevalent. Furthermore, the DPA was also complete
in the vast majority of cases. The palmar arches and their variations should be kept in mind

R Presented during the EURO Hand 2017: XXII Federation of European Societies for Surgery of the Hand Congress and XII European Federa-

tion of Societies for Hand Therapy Congress, Budapest, Hungary, 21–24 June 2017 (Poster Presentation).
∗ Corresponding author at: Department of Anatomy, Jagiellonian University Medical College, 12 Kopernika St., 31-034 Kraków, Poland.

E-mail address: krtomaszewski@gmail.com (K.A. Tomaszewski).

https://doi.org/10.1016/j.bjps.2018.08.014
1748-6815/© 2018 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
1578 M.P. Zarzecki et al.

when considering the use of palmar vasculature for cardiac catheterization and other medical
procedures, due to the risk of iatrogenic ischemic hand complications.
© 2018 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by El-
sevier Ltd. All rights reserved.

Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1578
Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1579
Search strategy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1579
Eligibility assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1579
Data extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1579
Quality assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1580
Statistical analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1580
Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1580
Study identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1580
Characteristics of the included studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1580
Superficial palmar arch variants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1580
Complete SPA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1580
Incomplete SPA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1582
Deep palmar arch variants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1584
Heterogeneity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1584
Quality assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1584
Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1584
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1590
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1590
Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1590
Ethical considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1590
Conflict of interest statement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1590
Supplementary materials. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1590
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1590

Introduction nel syndrome, in what would otherwise be a routine surgi-

cal procedure of the hand or the wrist.9 The presence of
The blood supply to the hand is predominantly built-up of this artery, not regressed during the fetal life, can lead to
anastomosing vascular networks known as the superficial unprecedented and excessive bleeding during wrist surgery
palmar arch (SPA) and the deep palmar arch (DPA), with and can potentially cause carpal tunnel syndrome once an
the DPA found proximal to the SPA.1 The SPA is commonly aneurysm, thrombus, or compression of the median nerve
formed by collateral circulation between the ulnar artery by the MA occurs.10
(UA) and the superficial branch of the radial artery (RA), The arteries of the forearm are heavily used as sites
with the UA dominating this blood supply.2 The RA then for cardiac catheterization and bypass grafting.7 These ves-
continues to anastomose with the deep branch of the UA sels also serve as important access points for hemodialy-
resulting in the DPA, with the RA dominating this supply.2 sis.7 Anatomical variation in the vascularization of the hand
Nonetheless, both arches demonstrate a high prevalence of can potentially complicate these procedures if the collat-
anatomical variation which stems from embryologic devel- eral circulation is not sufficient, i.e., a successful harvest-
opment.3,4 Arey5 suggests that deviation from normal vessel ing of the RA for bypass surgery requires a complete PA and
development in the hand may be due to the persistence of a fully patent UA.11
vessels which normally regress during the embryogenesis. Other surgical techniques, e.g., use of vascularized skin
The median artery (MA) predominates as the axis artery of flaps, may be complicated by variant vasculature of the
the upper limb and degenerates when the UA and RA are hand.12 Synovial flaps taken from the flexor digitorum su-
ready to supply the blood to the hand,6 but it might persist perficialis (FDS) tendon can assist in the surgical treatment
and consequently contribute to the vascular supply of the of recurrent carpal tunnel syndrome. These flaps are sup-
hand.7 plied from the radial and ulnar arteries in addition to the PAs
An in-depth knowledge of anatomical variations of the and their branches.13 With the additional blood provided by
palmar arches (PAs) is essential for improving surgical tech- the SPA, surgeons are able to use synovial flaps of increased
niques and identifying the pathophysiology underlying dis- size.12,13
eases of the hand.8 One of such deviations, leading to Identification of the most commonly found variants will
clinical complications can be a persistent MA, shown to in- help both in the improvement of diagnosis and surgical tech-
crease surgical accidents, i.e., hand ischemia or carpal tun- niques. Awareness of the many types of the PAs may also
The surgical anatomy of the superficial and deep palmar arches 1579

help to minimize the number of false positive and false neg-

ative results seen in tests commonly used to verify the col-
lateral circulation of the hand such as the Allen’s Test (AT).7
In previous studies, the completeness of the SPA ranged
from 31.8%14 to 100%,15,16 whereas the DPA was reported as
complete in the range from 54.9%7 to 100%.4 , 17–20
Because ischemic complications may occur even when
the PAs are complete, there seems to be a need for a sum-
mary of the current knowledge regarding the anatomy of the
PAs. To the best of the authors’ knowledge, a meta-analysis
on this subject has not been previously performed. More-
over, some less common variants might be well documented
in certain regions of the world, while remain unknown in
others. Because of the clinical significance of both the SPAs
and DPAs, this paper aims to provide an up-to-date meta-
analysis as an accurate representation of the pooled preva- Figure 1 An example of the complete SPA.
lence estimate of the anatomical variations and point out
future directions of research surrounding the PAs.

Methods

Search strategy

A thorough search was performed through the major elec-

tronic databases (PubMed, EMBASE, Web of Science, Sci-
enceDirect) up to the August 2017, for articles regarding the
SPA or the DPA that could potentially be used in this meta-
analysis. It was carried out as one search for both the SPA
and/or the DPA. The search strategy used in this study in-
cluded the following terms: “deep palmar arch” or “super-
ficial palmar arch” or “deep volar arch” or “superficial volar
arch.” Neither language, nor date ranges were used as the
exclusion criteria. Moreover, the references of the included
studies were checked, thus allowing to pinpoint any other
potentially eligible articles. The authors rigorously followed
the Preferred Reporting Items for Systematic Reviews and
Meta-analyses (PRISMA) guidelines21 in the following study
(Supplement 1).

Eligibility assessment

The authors assessed all the articles potentially meeting the

inclusion criteria for the meta-analysis. The studies con-
taining relevant and extractable data on the PAs were in-
cluded. Notwithstanding, the articles were excluded when
they were: (1) case reports and case series, letters to the
editor, review articles, and conference abstracts, (2) re-
porting incomplete or nonextractable data, (3) carried out
on patients with hand pathologies, such as congenital hand
anomalies, hypothenar hammer syndrome, atherosclerosis,
or Raynaud’s phenomenon, and (4) performed on animals.
Studies written in languages not spoken fluently by the au-
thors were translated by medical professionals who were
fluent in both English and the language of the publication.
The reviewers contacted the authors of the original studies
in order to clarify any inconsistencies encountered during
the selection process. When it was impossible to do so, the
matter was consulted with all the reviewers until a consen-
sus was reached.
Figure 2 An example of the complete SPA.
Data extraction
The reviewers extracted the data from the studies selected
to be included in the meta-analysis. The data were col-
lected as follows: study modality (i.e., cadaveric/US, etc.),
sample size, geographical location, and prevalence of var-
ious patterns of formation of the SPA and the DPA. In this
meta-analysis, we have identified the PAs as being either
complete or incomplete. The complete arch was defined as
such when there was a clear anastomosis between the ar-
teries forming it (examples can be found in Figures 1 and
2). Furthermore, we followed Coleman and Anson’s classifi-
cation, where formation of the arch solely by the UA (where
the UA reaches across the palm to the ulnar side of the
1580 M.P. Zarzecki et al.

thumb to anastomose with the DPA vessels in its vascular

network) was considered as complete.22 Notwithstanding,
there were authors16 , 23–27 who considered the ulnar only
arch as incomplete. The incomplete arch was regarded as
such when there was no anastomosis present between the
arteries forming the arch or the UA present by itself failed
to supply the ulnar side of thumb and radial side of the in-
dex finger. Any discrepancies in the data were settled by
contacting the authors of the original studies and asking for
additional information, whenever possible.

Quality assessment

The authors followed the AQUA tool28 while evaluating both

quality and accuracy of the studies that were included in
this meta-analysis. In summary, the AQUA tool was devel-
oped to assess the potential risk of bias found in the studies.
The assessment is done over five domains (1. Objective(s)
and Subject Characteristics, 2. Study Design, 3. Methodol-
ogy Characterization, 4. Descriptive Anatomy, and 5. Re-
porting of Results). The domains’ risk is appraised by ad-
judging it as either “Low,” “High,” or “Unclear” with the
help of the signaling questions with answers “Yes,” “No,” or
“Unclear” found within each of the domains. All the queries
answered “Yes” arbitrated the domain to be of “Low” risk of
bias, whereas any question with the answer “No” indicated
that the domain was possibly biased. Nonetheless, meagre
data that did not permit for a clear scrutiny made the au- Figure 3 The PRISMA flowchart.
thors consider the domain’s risk of bias as “Unclear.”

articles that could potentially meet the inclusion criteria

Statistical analysis
were identified during the search. Reference search of all
the articles included in this meta-analysis revealed 22 more
The authors carried out the statistical analysis using MetaXL
articles that were assessed against the aforementioned cri-
version 5.3 by EpiGear International Pty Ltd (Wilston,
teria. A full text analysis was carried out on 82 studies, and
Queensland, Australia), in order to calculate the prevalence
46 articles were marked as excluded due to being case stud-
estimates for the variant patterns of the PAs formation. For
ies, contained cases with pathologies, or were missing rele-
all of the analyses, the random effects model was used.
vant, extractable data. Finally, 36 articles were considered
The χ 2 test and the Higgins I2 statistic were used to as-
as meeting the inclusion criteria and were included in the
sess the heterogeneity between the studies included in the
meta-analysis.
meta-analysis. As an indicator of significant heterogeneity
among the studies, p value of < 0.10 for the χ 2 test was
chosen.29 In case of Higgins I2 values, the values between
0% and 40% were considered as “might not be important,” Characteristics of the included studies
30% and 60% “might indicate moderate heterogeneity,” 50%
and 90% “may indicate substantial heterogeneity,” and 75% Tables 1 and 2 represent the characteristics of the included
and 100% “may represent considerable heterogeneity.”29 studies for the SPA and the DPA, respectively. Thirty-six
While looking for potential sources of heterogeneity, a studies (n = 4841 PAs) were assessed in this meta-analysis.
subgroup analysis by study design, geographical distribu- The publishing dates ranged from 1961 to 2017, and the
tion, and sensitivity analysis inclusive of studies with a num- geographical distribution was worldwide. Cadaveric studies
ber of arches studied ≥ 100 was carried out. Statistically dominated, with only six studies reporting medical imaging
significant differences between two or more groups were in the form of US, CT, or angiography.
determined using confidence intervals (CI). The differences
not considered as statistically significant were regarded as
such in case of overlapping CI.29
Superficial palmar arch variants

Results Complete SPA

Study identification
Figure 3- the PRISMA flowchart21 represents the process of
study identification and selection. One hundred sixty-three
A total of 31 articles (n = 3748 PAs) reported the variations
in the SPA. The complete SPA was found in 81.3% (95%CI:
74.7–87.3; Figure 4), whereas the incomplete SPA had a
prevalence of 18.7% (95%CI: 12.8–25.5; Figure 5). The I2
value for the analysis of the SPA being complete or incom-
The surgical anatomy of the superficial and deep palmar arches 1581

Table 1 The characteristics of the included studies for the SPA.

Study Country Type of study n (number of palmar arches)
Al-Turk and Metcalf, 198443 USA Imaging (US) 50
Bataineh et al., 200944 Oman Cadaveric 30
Bilge et al., 200611 Turkey Cadaveric 50
Coleman and Anson, 196122 USA Cadaveric 650
Doscher et al., 198333 USA Imaging (Doppler US) 200
Fazan et al., 200423 Brazil Cadaveric 46
Feigl et al., 201224 Austria Cadaveric 702
Gellman et al., 200145 USA Cadaveric 45
Ikeda et al., 198846 Japan Cadaveric 220
Jelicic et al., 198847 Switzerland Cadaveric 50
Joshi, 20148 India Cadaveric 100
Kaplanoglu and Beton, 201739 Turkey Imaging (CT) 156
Karlsson and Niechajev, 198248 Sweden Cadaveric 139
Loukas et al., 200519 USA Cadaveric 200
Madhyastha et al., 201125 India Cadaveric 48
Mbaka et al., 201449 Nigeria Cadaveric 134
McLean et al., 20081 USA Cadaveric 48
Mozersky et al., 197350 USA Imaging (Doppler US) 140
Ottone et al., 201026 Argentina Cadaveric 86
Ozkus et al., 199851 Turkey Cadaveric 80
Patnaik et al., 200220 India Cadaveric 50
Quadros et al., 201552 India Cadaveric 50
Rauch et al., 199914 Germany Imaging (Angiography) 66
Ruengsakulrach et al., 200142 Australia Cadaveric 50
Sacks et al., 200753 USA Cadaveric 48
Sajey et al., 201754 India Cadaveric 30
Singh et al., 20174 South Africa Cadaveric 50
Suman and Jayanthi, 201116 India Cadaveric 60
Tağıl et al., 200755 Turkey Cadaveric 20
Tasom et al., 201427 Thailand Cadaveric 100
Umapathy et al., 201230 India Cadaveric 50

Table 2 The characteristics of the included studies for the DPA.

Study Country Type of study n (number of palmar arches)
Bilbo and Stern, 198617 USA Cadaveric 10
Coleman and Anson, 196122 USA Cadaveric 200
Gelberman et al., 198318 USA Cadaveric 25
Gokhroo et al., 20167 India Imaging (Arteriogram) 102
Ikeda et al., 198846 Japan Cadaveric 220
Loukas et al., 200519 USA Cadaveric 200
Mezzogiorno et al., 199456 Italy Cadaveric 60
Olave and Prates, 199957 Brazil Cadaveric 60
Patnaik et al., 200220 India Cadaveric 50
Rauch et al., 199914 Germany Imaging (Angiography) 66
Ruengsakulrach et al., 200142 Australia Cadaveric 50
Singh et al., 20174 South Africa Cadaveric 50

plete was 95.7% (95%CI: 94.8–96.5). The evaluation is shown
in Table 3.
Within the studies describing the complete SPA, we
have identified 25 studies (n = 2517 PAs) that described the
arches in greater detail; hence we were able to represent
the variations in seven distinct categories:
a) Anastomosis between the RA and UA - 72.0% (95%CI: 58.0–
80.5).
b) UA only (with the UA reaching to the ulnar side of thumb
and radial side of the index finger) - 20.7% (95%CI: 11.2–
30.8).
c) Anastomosis between the UA and DPA - 2.5% (95%CI: 0.0–
6.8).
d) Anastomosis between the UA and MA - 2.5% (95%CI: 0.0–
6.8).
e) Anastomosis between the RA, UA, and MA - 1.1% (95%CI:
0.0–4.3).
1582
Figure 4 The complete SPA forest plot.
f) Anastomosis between the RA and MA - 0.6% (95%CI: 0.0–
3.1).
g) Double SPA - 0.7% (95%CI: 0.0–3.3).
The I2 value for the complete SPA variant analysis was
97.1% (95%CI: 96.5–97.7). The analysis is presented in
Table 4, and the schematic representation of the aforemen-
tioned variants can be found in Figure 6.
The double SPA (proximal and distal arch) was reported
by Umapathy et al.30 and Patnaik et al.20 Only the former
author described in details the formation of the double SPA:
M.P. Zarzecki et al.
the proximal SPAs in both cases were the classical anasto-
mosis between the UA and RA.30 In one case, the distal SPA
was formed by the connection between the UA and second
common digital branch.30 In the second case, the connec-
tion between the second and third common digital branches
formed the distal SPA.30
Incomplete SPA
In case of the incomplete SPA, we have identified 19 studies
(n = 555 PAs) that described the arches in greater detail. In
The surgical anatomy of the superficial and deep palmar arches
Figure 5 The incomplete SPA forest plot.
this instance, we were able to classify them in five subcate-
gories:
a) UA supplies the third finger from both sides (radial and
ulnar) - 34.8% (95%CI: 9.7–51.3).
b) UA supplies the third finger from the ulnar side, the RA
supplies the third finger from the radial side - 27.0%
(95%CI: 5.5–44.0).
c) UA supplies the index finger from both sides, but does
not supply the thumb - 14.0% (95%CI: 0.4–30.6).
1583
d) UA and MA supply the palm, but do not anastomose -
11.9% (95%CI: 0.0–28.3).
e) UA other - 12.4% (95%CI: 0.0–26.0).
The I2 value for the incomplete SPA variant analysis was
95.4% (95%CI: 94.0–96.5). Table 5 shows the detailed anal-
ysis, and Figure 7 presents a schematic drawing of the said
variants.
The UA other category represents the variants that did
not fall into the previous categories, but due to being re-
ported by very few authors were not counted as separate
1584
Table 3 The complete/incomplete variants of the SPA.
Total Complete
31 articles, 3748 arches 81.3 (74.7–87.3)
Cadaveric (26 articles, 3136 arches) 83.2 (75.9–89.7)
Imaging (5 articles, 612 arches) 71.8 (52.6–87.8)
North America (8 articles, 1381 arches) 81.5 (75.6–87.3)
Asia (12 articles, 838 arches) 90.6 (83.9–95.6)
Europe (6 articles, 1163 arches) 65.5 (46.3–82.5)
South America (2 articles, 132 arches) 69.4 (24.3–100)
Africa (2 articles, 184 arches) 84.7 (63.2–98.4)
Sensitivity N > 100 (9 articles, 2541 arches) 75.7 (61.9–87.3)
categories. These include as follows: (1) UA with the super-
ficial branch of the RA supplying the palm, (2) RA, UA, and
MA supplying the palm, (3) UA anastomosing with the DPA
(thumb, index, and ulnar side of middle finger supplied by
the DPA), (4) UA supplying the palm up to the ulnar side
of the index finger, whereas the radial side was supplied by
the deep branch of the RA, and (5) UA supplying the palm
up to the ulnar side of the index finger; the RA supplying
the radial side of the index finger with no branch to the
thumb.
Deep palmar arch variants
The DPA was found less variant than the SPA in the 12 stud-
ies included in this meta-analysis (n = 1093 PAs). The com-
plete DPA was present in 95.2% (95%CI: 85.3–99.3; Figure 8),
whereas the incomplete DPA in 4.8% (95%CI: 0.2–13.0; Figure
9). The I2 value for the DPA was 95.2% (95%CI: 93.1–96.6).
The evaluation can be found in Table 6.
Heterogeneity
As a source for potential heterogeneity, the present study
looked at the geographical distribution and type of studies
included in the meta-analysis (medical imaging or cadav-
eric). No statistically significant differences were found ei-
ther in ethnicity or in modality of the studies. In the more
detailed analysis of the incomplete SPA, higher p values for
Africa (0.069) and North America (0.013), and in case of the
general analysis of the DPA (p = 0.036 for North America),
result from the fact that the number of studies performed
in said regions was limited (two, three, and four, respec-
tively). Their significance as a potential source of hetero-
geneity is minimal. Medical imaging techniques were used
in only five studies carried out on the SPAs and two per-
formed on the DPAs, whereas there were 26 studies of the
SPAs and 10 studies of the DPAs carried out on cadavers. The
pooled prevalence estimate was slightly higher in cadaveric
studies than in medical imaging studies in that the preva-
lence of the complete arches was higher - complete SPA
83.2% (95%CI: 75.9–89.7), complete DPA 97.1% (95%CI: 90.4–
100.0) and complete SPA 71.8% (95%CI: 52.6–87.8), com-
plete DPA 72.6% (95%CI: 37.8–97.6), respectively. Notwith-
standing, because the 95%CI overlap, the differences are
not statistically significant. They might be attributed to
the minute number of studies carried out as medical imag-
M.P. Zarzecki et al.
Incomplete I2 p value
18.7 (12.8–25.5) 95.7 (94.8–96.5) 0.000
16.8 (10.4–24.3) 96.0 (94.9–96.8) 0.000
28.2 (12.2–47.4) 95.5 (92.0–97.4) 0.000
18.5 (13.0–24.9) 84.0 (70.0–91.4) 0.000
9.4 (4.4–16.1) 87.1 (79.2–92.0) 0.000
34.5 (17.5–53.7) 96.7 (94.7–97.9) 0.000
30.6 (0.0–75.7) 95.6 (87.3–98.5) 0.000
15.3 (1.6–36.8) 87.9 (53.3–96.9) 0.004
24.3 (12.7–38.1) 98.1 (97.4–98.6) 0.000
ing, as compared to more popularly published cadaveric
works.
Quality assessment
In the vast majority of the works domain one (objective(s)
and subject characteristics) and domain three (method-
ology characterization) were found to be at high risk of
bias, mainly due to the lack of demographic data (i.e.,
age, sex, ethnicity, and health status) of the patients or
the information about the authors’ experience. Low risk
of bias was found in domain two (study design), domain
four (descriptive anatomy), and domain five (reporting of
results). Nonetheless, there were studies that contained
results which were not consistent throughout the text or
their number did not match the original number of sub-
jects studied (and no reasoning behind this discrepancy was
provided). The AQUA tool evaluation for the present meta-
analysis can be found in Table 7.
Discussion
The vascular anatomy of the hand has been of interest to
many scientists for over two and a half centuries, with a
mention of the SPA and DPA dating back as far as 1753.31 To-
day, it is of particular interest for microvascular surgeons,
replantation, and composite tissue transfer procedures.8
The aim of this study was to identify the variations in the
formation of the PAs. We have found that the SPA is pre-
dominantly complete (81.3%), and the most common variant
is the anastomosis between the RA and the UA (72.0%). In
case of the incomplete SPA (18.7%), the most prevalent vari-
ant was the UA supplying the third finger from both radial
and ulnar sides (34.8%). While analyzing the DPA, we have
found that the arch was predominantly complete (95.2%),
but because of the scarcity of studies reporting its specific
variations, it was impossible for us to carry out a detailed
meta-analysis on this trait.
Coleman and Anson22 in their study of 650 SPAs concluded
that the complete arch was present in 78.5% of the cases.
The dominant type for the complete SPA in Coleman and An-
son’s study was the arch formed by the UA only. It comprised
37.0% of their sample,22 whereas in our study, this type was
prevalent in 20.1%. For the incomplete SPA, the UA supply-
ing the palm through the third finger was the most common
variation found in their research, prevalent in 13.4% of all
 The surgical anatomy of the superficial and deep palmar arches
Table 4 The detailed variants of the complete SPA.
Total Radio–Ulnar Ulnar only Ulnar – DPA Ulnar – Median Radial–Ulnar– Radial– Median Double I2 p value
Type Type Type Type Median Type Type Arch
25 articles, 2517 72.0 (58.3–80.5) 20.7 (11.2–30.8) 2.5 (0.0–6.8) 2.5 (0.0– 6.8) 1.1 (0.0–4.3) 0.6 (0.0–3.1) 0.7 (0.0–3.3) 97.1 (96.5–97.7) 0.000
arches
North America 57.3 (33.4–77.6) 25.7 (8.0–47.1) 2.6 (0.0–12.0) 10.2 (0.0–25.3) 3.7 (0.0–14.2) 0.3 (0.0–5.3) 0.3 (0.0–5.3) 96.0 (92.5–97.9) 0.000
(4 articles, 770
arches)
Asia (12 articles, 756 71.7 (50.2–86.7) 22.1 (7.2–40.2) 2.5 (0.0–10.5) 0.8 (0.0–6.4) 0.9 (0.0–6.5) 0.8 (0.0–6.4) 1.1 (0.0–7.2) 96.4 (95.1–97.4) 0.000
arches)
Europe (5 articles, 82.6 (45.0–100) 7.6 (0.0–36.6) 4.5 (0.0–29.5) 4.0 (0.0–28.1) 0.5 (0.0–15.3) 0.4 (0.0–14.8) 0.3 (0.0–14.2) 98.7 (98.2–99.1) 0.000
738 arches)
Africa (2 articles, 145 74.0 (15.0–100) 23.3 (0.0–83.3) 0.4 (0.0–29.3) 0.4 (0.0–29.3) 1.2 (0.0–35.6) 0.4 (0.0–29.3) 0.4 (0.0–29.3) 97.6 (94.0–99.0) 0.000
arches)
Sensitivity N > 100 64.1 (37.6–83.0) 22.4 (5.0–44.0) 8.0 (0.0–22.4) 4.0 (0.0–15.4) 1.3 (0.0–9.1) 0.2 (0.0–4.9) 0.1 (0.0–4.6) 98.7 (98.1–99.1) 0.000
(5 articles, 1499
arches)

Table 5 The detailed variants of the incomplete SPA.

Total UA through the UA through half of UA through the Mediano–Ulnar Ulnar othere I2 p value
third fingera the third finger, second fingerc Typed
other half from RAb
19 articles, 555 arches 34.8 (9.7–51.3) 27.0 (5.5–44.0) 14.0 (0.4–30.6) 11.9 (0.0–28.3) 12.4 (0.0–26.0) 95.4 (94.0–96.5) 0.000
North America 63.9 (28.2–90.4) 5.4 (0.0–24.3) 5.4 (0.0–24.3) 8.4 (0.0–30.1) 16.9 (0.0–43.5) 77.0 (25.2–93.0) 0.013
(3 articles, 155 arches)
Asia (10 articles, 82 29.9 (4.0–56.0) 20.9 (0.6–46.8) 11.8 (0.0–31.7) 18.6 (0.0–44.3) 18.8 (0.0–41.0) 84.7 (73.5–91.1) 0.000
arches)
Europe (3 articles, 268 27.4 (0.0–100) 34.4 (0.0–100) 34.2 (0.0–100) 2.0 (0.0–49.3) 2.0 (0.0–49.3) 97.9 (0.0–49.3) 0.000
arches)
Africa (2 articles, 22.7 (0.0–68.7) 71.7 (31.3–100) 1.9 (0.0–25.9) 1.9 (0.0–25.9) 1.9 (0.0–25.9) 69.9 (0.0–93.2) 0.069
39 arches)
Sensitivity N > 100 29.3 (0.0–100) 13.1 (0.0–100) 33.1 (0.0–100) 11.7 (0.0–100) 12.8 (0.0–100) 99.7 (99.4–99.8) 0.000
(2 articles, 366 arches)
a The UA supplies the third finger from both sides (radial and ulnar).
b The UA supplies the third finger from the ulnar side; the RA supplies the third finger from the radial side.
c The UA supplies the index finger from both sides, but does not supply the thumb.
d The UA and the MA supply the palm but do not anastomose.

1585
e The UA and another vessel supply the palm without anastomosing.
1586
Figure 6 Schematic representation of the complete SPA variants.
the SPAs, which is in accordance with our findings.22 The
aforementioned authors also evaluated the DPA, and their
prevalence of complete and incomplete arches agrees with
our results.22
Although the results of our meta-analysis demonstrate
that the majority of the SPAs and DPAs are complete, this
does not mean that patients will be asymptomatic follow-
ing occlusion of either the RA or UA, as variant anatomy
can potentially lead to ischemia.32 Doscher et al.33 state
that the blood supplied by the dominant UA is the same in
case of the complete and the incomplete SPA, hence they
M.P. Zarzecki et al.
suggest that the type of the arch does not determine the
resistance in the UA and the RA. The completeness of the
SPA does not necessarily imply a sufficient collateral blood
flow to the hand; in an event of compromising the blood
supply by one of the aforementioned arteries and regard-
less of arch’s completeness, ischemia may occur.33 Loukas
et al.34 reported a case in which the entire blood supply to
the thumb originated from the UA only SPA type. Although
the aforementioned variant was considered as a complete
SPA in this study (20.7% of the complete SPAs analyzed), we
would like to acknowledge the concerns raised by Loukas
The surgical anatomy of the superficial and deep palmar arches 1587

Figure 7 Schematic representation of the incomplete SPA variants.

UA through the third finger – the UA supplies the third finger from both sides (radial and ulnar); UA through half of the third finger,
other half from RA – the UA supplies the third finger from the ulnar side, the RA supplies the third finger from the radial side; UA
through the second finger – the UA supplies the index finger from both sides, but does not supply the thumb; Mediano–Ulnar Type –
the UA and the MA supply the palm, but do not anastomose.

et al. that this variation poses a risk of complications if the
total thumb blood supply comes from this type of the SPA,
should an injury happen to the UA.34
A double superficial arch may be clinically significant
when bleeding from the interdigital branches of the UA is
seen during vascular repair of hand trauma cases, thus im-
peding hemostasis.20 In these situations, ligation will have
to be performed proximal to the origin of the double arch
to provide complete hemostasis, or to one branch of the
arch to provide hemostasis while maintaining hand circula-
tion. In the present meta-analysis, the double SPA was seen
in 0.7% of variants of the complete SPA. While the exten-
sive vascular network full of multiple anastomoses makes
a person more prone to severe bleeding upon injury, Lock-
hardt et al.35 further suggest that it also helps with faster
recovery.
Complications may also arise when there is a persis-
tent MA in the vasculature of the PAs.9 When this artery
is present, it is normally seen as either a palmar or ante-
brachial type.36 The palmar type mirrors the artery that
was present during the embryological development and is
present in the area of the palm, whereas the antebrachial
type results from incomplete regression of the MA and does
not extend past the wrist.36 When this artery persists as the
palmar type, it may fully replace the RA. Within this study,
the MA was found in 4.2% of cases of a complete SPA and
11.9% of cases of incomplete SPAs. This variation may have
clinical consequences, as the path of the MA to join the
SPA often travels with the median nerve, and this proximity
may result in carpal tunnel syndrome, anterior interosseous
nerve syndrome, round pronator syndrome, and increased
ischemia of the hand while encountering complications dur-
ing a surgery or as a result of an injury.12 Furthermore, a
persistent MA is more often present alongside the incom-
plete SPA, hence the patients with the MA ligated during
a surgery are possibly more prone to the ischemia of the
hand.37
In anatomical variants that are dominated either by the
UA or the RA, injury to the main vessel may have severe is-
chemic complications. The UA is more prone to a traumatic
injury than the RA due to its route around the hook of the
hammate.38 On the other hand, the RA is commonly used
for entrance to cardiac catheterization in coronary artery
bypass surgery as well as in hemodialysis.39 These proce-
1588 M.P. Zarzecki et al.

Figure 8 The complete DPA forest plot.

Figure 9 The incomplete DPA forest plot.

dures pose increased risk of ischemic injury to the hand in
cases such as an incomplete SPA, a radial dominant SPA, or
with other vascular abnormalities in the UA.7 Therefore, a
thorough assessment of the anatomy of the PAs is important
before conducting vascular procedures in the area of the
hand, particularly catheterization, to prevent iatrogenic is-
chemia.
Additionally, the circulation of the PAs is of clinical rel-
evance during other types of surgeries including vascular
grafts, arterial repairs, and free or pedicle flap harvesting,
e.g., ulnar skin flaps.16 Aktouf et al.12 reported blood being
supplied to the FDS synovial flaps from the SPA. Alongside
Kuhlmann et al.13 they suggest that due to the abundant
amount of vascular networks in the synovial sheaths of the
FDS tendons in these instances, it should be possible for a
surgeon to use a larger synovial FDS flap for palmar tissue
repair, pedicled on the PAs.12 Nonetheless, Varley et al.37
report on the incidence of hand ischemia following free fibu-
The surgical anatomy of the superficial and deep palmar arches 1589

Table 6 The complete/incomplete variants of the DPA.

Total Complete Incomplete I2 p value
12 articles, 1093 arches 95.2 (85.3–99.3) 4.8 (0.2–13.0) 95.2 (93.1–96.6) 0.000
Cadaveric (10 articles, 925 arches) 97.1 (90.4–100) 2.9 (0.0–7.8) 92.5 (88.2–95.2) 0.000
Imaging (2 articles, 168 arches) 72.6 (37.8–97.6) 27.4 (2.4–62.2) 94.3 (82.2–98.2) 0.000
North America (4 articles, 435 arches) 98.8 (96.1–100) 1.2 (0.0–3.9) 65.0 (0.0–88.1) 0.036
Asia (3 articles, 371 arches) 81.7 (54.3–100) 18.3 (0.0–45.7) 96.7 (93.2–98.4) 0.000
Europe (2 articles, 266 arches) 95.3 (72.3–100) 4.7 (0.0–27.7) 96.4 (90.0–98.7) 0.000
Sensitivity N > 100 (4 articles, 722 arches) 87.4 (64.5–100) 12.6 (0.0–35.5) 98.4 (97.3–99.0) 0.000

Table 7 The AQUA tool - tabular display.

Study Risk of bias
Objective(s) and study Study design Methodology Descriptive Reporting of
characteristics characterization anatomy results
Al-Turk and Metcalf, 1984 High Low High Low Low
Bataineh et al., 2009 High Low High Low Low
Bilbo and Stern, 1986 High Low High Low Low
Bilge et al., 2006 High Low High Low Low
Coleman and Anson, 1961 High Low High Low Low
Doscher et al., 1983 Low Low High Low Low
Fazan et al., 2004 High Low High Low Low
Feigl et al., 2012 High Low High Low Low
Gelberman et al., 1983 High Low High Low Low
Gellman et al., 2001 High Low High Low Low
Gokhroo et al., 2016 High Low Low High Low
Ikeda et al., 1988 High Low High Low Low
Jelicic et al., 1988 High Low High Low High
Joshi, 2014 High Low High Low Low
Kaplanoglu and Beton, 2017 Low Low Low High High
Karlsson and Niechajev, 1982 Low Low High High Low
Loukas et al., 2005 Low Low High Low Low
Madhyastha et al., 2011 High Low High Low Low
Mbaka et al., 2014 Low Low High Low Low
McLean et al., 2008 High Low High Low High
Mezzogiorno et al., 1994 High Low High Low Low
Mozersky et al., 1973 High Low High Low Low
Olave and Prates, 1999 High Low High Low Low
Ottone et al., 2010 High Low High Low Low
Ozkus et al., 1998 High Low High Low Low
Patnaik et al., 2002 High Low High Low Low
Quadros et al., 2015 High Low High Low High
Rauch et al., 1999 High Low High Low Low
Ruengsakulrach et al., 2001 High Low High Low Low
Sacks et al., 2007 High Low High Low Low
Sajey et al., 2017 High Low High Low Low
Singh et al., 2017 High Low High Low Low
Suman and Jayanthi, 2011 High Low High Low Low
Tağıl et al., 2007 High Low High Low Low
Tasom et al., 2014 High Low High Low Low
Umapathy2012 High Low High Low Low

lar and radial forearm flaps harvesting and conclude that it
could have happened due to the incompleteness of the SPA
found on the angiogram. Henceforth, more research should
be conducted regarding the involvement of the PAs during
various flap harvesting surgeries.
The current practice of assessing hand collateral circu-
lation involves the AT, described first in 1929,40 and is nec-
essary, e.g., prior to the RA harvesting for bypass grafting
or catheterization.41 Notwithstanding, variant anatomy sur-
rounding the PAs might lead to false negative AT results.
1590
Agrifoglio et al.41 found that in 5.3% of cases, the RA har-
vesting was not recommended despite normal AT results.
The misleading AT outcomes might be attributed to, e.g.
the MA completing the SPA (the ulnar-median complete SPA
type, found in 2.5% of cases in this study), which is not com-
pressed alongside the UA during the AT and might cause re-
turn of blood flow with release of the RA - a false nega-
tive result.42 Similarly, the superficial dorsal branch of the
RA may also produce misleading results, as it might not be
compressed during the AT.42 The DPA could be formed by
the aforementioned branch, hence any injury to this branch
might compromise the vascular hand supply during a proce-
dure on the RA.42 Agrifoglio et al.41 suggest the use of echo
color Doppler in assessing the collateral hand circulation in-
stead of the AT. Nonetheless, patent and uncompromised
DPA may be the reason behind a proper Doppler assessment
prior to the surgery.37 Therefore, we suggest a considerate
and careful use of both the AT and Doppler ultrasonography,
having in mind the possibility of existence of hand vascular
variations.
This meta-analysis aimed to present an up-to-date rep-
resentation of the prevalence of different variants of the
SPA and DPA in order to aid physicians and surgeons. The
analysis was limited by the differences between studies
and the ways in which they were conducted, including
uses of different classification systems. Moreover, the avail-
able morphometric data on the PAs were limited. Fazan et
al.23 encountered a similar limitation stating that little is
known about the diameter of the vessels of the SPA. We
were unable to carry out a meta-analysis neither on this
trait nor on the arterial peak flows due to the scarcity
of the studies reporting it. Such morphometric data could
help clinically in order to enhance the development of fu-
ture surgical techniques, especially when performing re-
constructive surgeries of the hand.23 Notwithstanding, ob-
taining this kind of data has been understandably difficult.
Doscher et al.33 made a good point, stating that cadav-
eric studies do not perfectly assess the vessel sizes due
to changes in vascular beds during fixation and injection,
whereas imaging studies with angiographic dye pose dif-
ficulties with measurements due to vasospasm or vasodi-
lation of the vessels caused by the dye. Furthermore, it
would be useful for medical professionals to be aware of
the relationships between the PAs and anatomical land-
marks in the hand (i.e. distance between either the SPA
or DPA and Kaplan’s line or distal wrist crease or other
structures), because it may lead to a lower rate of iatro-
genic surgical injury, benefit in treatment of vascular oc-
clusive disease, or facilitate understanding of abnormal an-
giograms.1
Future studies should attempt to find a way to increase
morphometric and superficial landmark data of specific vari-
ants of the PAs, perhaps by employing different imaging
techniques such as ultrasound. It would be useful to carry
out an investigation of the PAs structure in patients who
developed hand ischemia following a surgical procedure to
know for sure which variants were responsible for the clin-
ical problem. We believe that knowledge about anatomy of
hand vasculature is essential during surgery and helps both
young and experienced surgeons to find the best solution for
the patient.
M.P. Zarzecki et al.
Conclusion
To conclude, the anatomy of the palmar vascular networks
is of dire importance to the medical professionals carrying
out invasive procedures in the palmar region. Negligence of
ensuring that the hand’s circulation is not compromised be-
fore treatment can result in serious complications - most
notably hand ischemia. Our findings show that both the SPA
and the DPA were predominantly complete. The most com-
mon variant of the complete SPA was the RA-UA anastomo-
sis, whereas for the incomplete SPA the most prevalent type
was the UA supplying the third finger from both radial and
ulnar sides. The closeness of a persistent MA to the median
nerve (leading potentially to carpal tunnel syndrome) or a
double SPA (resulting in unwanted perfusion of the interdigi-
tal arteries and potential hemorrhage during surgery) is just
an example of the PAs variants that can cause unexpected
problems. However, some areas of knowledge regarding the
PAs require further research, especially when it comes to
morphometrics and specific location of the arches in the
palm. Henceforth, proper knowledge of the likely types of
the PAs can possibly ameliorate the outcomes of the surgical
procedures in the hand, namely microsurgery.
Acknowledgments
Krzysztof A. Tomaszewski was supported by the Polish Min-
istry of Science and Higher Education grant for young scien-
tists.
We would like to thank Hasina M. Aziz for the anatomical
drawings used in this manuscript.
Funding
Jagiellonian University statutory funds.
Ethical considerations
None.
Conflict of interest statement
The authors declare no conflicting interests.
Supplementary materials
Supplementary material associated with this article can be
found, in the online version, at doi:10.1016/j.bjps.2018.08.
014.
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