To the Editor, We read the article by Acharya et al.[1] describing a case of high bifurcation of the brachial artery (HBBA) with interest. The brachial artery usually bifurcates into its terminal branches, the radial and ulnar arteries, slightly distal to the elbow joint. However, it is not uncommon for this bifurcation to occur proximally. The reported prevalence of HBBA is 12.3%.[2] HBBA is associated with a higher incidence of the failure of arteriovenous fistula creation.[3] The functional patency rate of arteriovenous fistulae at 12 months created in patients with HBBA is less (53.4%) than the normal brachial artery (74.5%).[3] Moreover, the superficial radial artery, which is associated with the HBBA, may pose a high risk for iatrogenic cannulation injuries, particularly in patients undergoing hemodialysis.[4] Even though the vascular mapping is recommended before the arteriovenous fistula creation, it is not uncommon to perform this procedure based on anatomical landmarks,[5] particularly in resource-poor settings. Thus, we intended to assess the prevalence of HBBA in Sri Lanka. This study was approved by the institutional ethics review committee. We randomly selected 20 cadavers (10 males and 10 females) with no history of trauma involving upper limbs, vascular instrumentation, or arteriovenous fistula creation. We dissected 20 upper limbs and measured the length of a line drawn perpendicularly from the intercondylar line to the brachial artery bifurcation using a Vernier caliper. We also measured the length of the brachial artery from the lower border of the teres major to its bifurcation using a measuring tape. The mean length of the brachial artery was 23.3 (range: 15.4–29.3, standard deviation [SD] = 3.7) cm. One cadaveric female left upper limb demonstrated HBBA 4.8 cm proximal to the level of the intercondylar line [Figure 1]. The mean distance from the intercondylar line to the bifurcation of the brachial artery was 3.7 cm (range: 4.8 cm proximal to the intercondylar line to 6.1 cm distal to the line, SD = 2.3). We did not observe previously reported other common anatomical variations of the brachial artery, such as the superficial brachial artery, accessory brachial artery, brachioradial artery, or brachioulnar artery.Figure 1: High bifurcation of the brachial artery in a female cadaver. The point of bifurcation is indicated by the blue arrow. The intercondylar line is shown by the dashed lineIn conclusion, we report that HBBA in our population is not uncommon. Since a significant proportion of the population may have an HBBA, vascular mapping is essential before arteriovenous access creation. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

The distal great saphenous vein is a popular site for venous access by means of percutaneous cannulation or venous cutdown in a hemodynamically unstable patient. The aim of this study was to precisely define the surface anatomy and dimensions of the distal part of the great saphenous vein to facilitate the aforementioned procedures. Cross-sectional anatomy of the distal saphenous vein was studied in 24 cadaveric ankles sectioned at a horizontal plane across the most prominent points of the medial and lateral malleoli. The curvilinear distance from the most prominent point of the medial malleolus to the center of the saphenous vein, its widest collapsed diameter and skin depth were obtained. The great saphenous vein was located at a mean distance of 24.4 ± 7.9 mm anterior to the medial malleolus. The mean widest collapsed diameter was 3.8 ± 1.5 mm. The mean distance from the skin surface to the vein was 4.1 ± 1.2 mm. These measurements could be used to locate the saphenous vein accurately, particularly in hemodynamically unstable patients with visually indiscernible veins.

We aimed to describe anatomical landmarks to accurately locate the five nerves that are infiltrated to accomplish anaesthesia of the foot in an ankle block. Twenty-four formaldehyde-fixed cadaveric ankles were studied. Photographs of cross sections of the frozen legs, cut at a horizontal plane across the most prominent points of the medial and lateral malleoli, were analysed. The curvilinear distance from the most prominent point of the closest malleolus to each of the five cutaneous nerves and their depth from the skin surface were measured. Sural, tibial, deep peroneal, saphenous and medial dorsal cutaneous nerves were located 5.2 ± 1.3, 9.2 ± 2.4, 7.4 ± 1.9, 2.8 ± 1.1, 2.1 ± 0.6 mm deep to the skin surface. The curvilinear distances from the medial malleolus to the tibial, deep peroneal and saphenous nerves were 32.5 ± 8.9, 62.8 ± 11.1 and 24.4 ± 7.9 mm, respectively. The curvilinear distances from the lateral malleolus to the sural and medial dorsal cutaneous branches of superficial peroneal nerves were 27.9 ± 6.3 and 52.7 ± 7.3 mm, respectively. The deep peroneal nerve was found between the tendons of the extensor hallucis longus and the extensor digitorum longus in the majority of specimens, while the medial dorsal cutaneous nerve was almost exclusively found on the extensor digitorum longus tendon. The sural and tibial nerves were located around halfway between the most prominent point of the relevant malleolus and the posterior border of the Achilles tendon. In conclusion, this study describes easily identifiable, palpable bony and soft tissue landmarks that could be used to locate the nerves around the ankle.

The morphology of human ejaculatory ducts has not been well established. The objective of this study was to describe macroscopic and microscopic anatomy of ejaculatory ducts. We conducted a systematic review using MEDLINE, Scopus, PubMed, and Cochrane databases. Search terms were: “ejaculatory ducts,” “seminal colliculus,” “prostatic utricle,” “anatomy,” “histology,” “radiology,” and “embryology.” We only included studies assessing adult (>18 years) humans published before November 1, 2019. We excluded studies describing pathological ducts and case reports. Independent authors extracted data using predefined criteria. Fourteen studies were included in the qualitative synthesis. Usually, the ejaculatory ducts entered the prostate by piercing the central part of its base. Most studies identified an anteromedial curve of the ducts at the outset within the prostate, their subsequent course being a straight path towards the seminal colliculus, their terminal parts diverging immediately before joining the prostatic urethra. However, the morphology of the terminal part of the ducts was inconsistent. The mean length of the ducts ranged from 1.4 to 2.2 cm. In conclusion, the luminal diameter gradually decreased as the ducts traveled towards the seminal colliculus. Ejaculatory ducts angulate anteromedially at their onset within the prostate and travel straight towards the seminal colliculus. Their terminal parts diverge immediately before joining the prostatic urethra. However, the reported dimensions of the ducts differ among studies.

Forehead aesthetics have a major contribution to the youthful appearance of the face. Restoration of the upper facial aesthetics is important to counteract the changes related to the ageing process. The interaction between the frontalis and its antagonists' muscles contributes to the overall aesthetic balance of the forehead. In this study, we evaluated the gross anatomy of the frontalis and classified the muscle according to the morphological appearance. 26 cadavers of Caucasian and South East Asian origin were dissected. The frontalis muscle was dissected without mobilisation, and the gross anatomy and variations were analysed on the backdrop of gender and ethnicity. Our dissection studies revealed three main variations of the muscle based on the extent of interdigitation between the two bellies in the midline. The average length of the muscle was 10.9 cm in males and 9.1 cm in females. The width of the muscle in females was 4 cm at the origin and 6.5 cm at the insertion and in males 4.4 cm at the origin and 5.8 cm at the insertion. In six specimens, the muscle attached only up to the medial two-thirds of the eyebrows. This was predominantly observed in the Caucasians cadavers and may contribute to the constitutional downward slanting eyebrows in some individuals. This study provides an in-depth analysis and classification of the frontalis muscle. Understanding the morphological variation of the muscle helps to amend clinical application and treatment protocols. Evaluation of the patterns of decussation of the frontalis muscle may assist with non-surgical interventions using botulinum toxin in the treatment of forehead rhytids. Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

The purpose of this study was to identify surface landmarks of digital nerves corresponding to the pigmented border of the toes.

IntroductionSpleen is an organ enriched in vascular and lymphoid tissue located in left hypochondrium. It has morphological variations which may be misinterpreted as a disease condition involving the spleen. Therefore, knowledge on such morphological differences in a population is vital to distinguish normal variations from the disease conditions. Objective of this study was to identify the morphological variations such as notches, fissures and lobulations in cadavers. MethodsTen-percent formalin fixed, selfdonated cadaveric human spleens (n=13) in the Department of Anatomy, Faculty of Medicine, University of Colombo were included in the present study. In the study population, male to female ratio was 10: 3 with age ranging from 26 to 95 years. The morphological features such as shape, notching of borders, fissures and lobulations were photographed, dissected and analyzed according to Michels NA classification. The morphological types of spleens were categorized by measuring hilar lengths. ResultsNotches were present in superior (n=8), inferior (n= 1) or intermediate (n=2) borders in ten spleens, while notches were absent in three. Five spleens had supernumerary notches. Six spleens contained fissures in both visceral and diaphragmatic surfaces. Four spleens had more than three lobules, while three had more than one hilum. The splenic types included compact, intermediate and distributed, which accounted for four, three and sixrespectively. ConclusionInconstant location of notches, presence of supernumerary notches, fissures and lobules were a common morphological variation observed.

Background: A primary objective in stroke rehabilitation is to restore functional balance, in order to reduce falls.Objectives: To identify the efficacy and safety of wobble board exercises when combined with conventional physiotherapy, in improving balance in hemiplegic patients following ischemic strokes.Methods: A block-randomized, controlled, observer blinded, superiority trial was conducted on ambulatory hemiplegic patients following ischemic strokes of middle cerebral artery territory. Subjects in the control group received a conventional physiotherapy regime. Subjects in the intervention group received training on a wobble board combined with conventional physiotherapy. Main Outcome measures were the improvement of Four-Square Step Test (FSST) and the Berg Balance Scale (BBS), both of which assess functional balance at the end of 6 weeks.Results: Thirty patients were randomly assigned for intervention (n = 15) and control (n = 15) groups. One patient dropped out from the study, leaving 29 eligible for the analysis. Intervention and control groups were comparable in sociodemographic characteristics and pre-test scores of balance. A repeated-measures MANOVA showed a significant difference in improvement of balance between the two study groups after 6 weeks [F(1,28) = 32.6,p = .000; Wilk's lambda = .46]. The improvement of mean score of balance in interventional group was greater than in the control group [BBS:9.5 (intervention group),5.5 (control group); FSST:3.9 (intervention group),1.7 (control group)]. There were no injuries in both groups.Conclusions: Wobble board exercises, when combined with the conventional physiotherapy, are safe and effective in restoring functional balance in patients with hemiplegia following ischemic strokes.

Observational studies in South Asian populations have suggested an association between vitamin B12 status and metabolic traits; however, the findings have been inconclusive. Hence, the aim of the present study was to use a genetic approach to explore the relationship between metabolic traits and vitamin B12 status in a Sri Lankan population and to investigate whether these relationships were modified by dietary intake. A total of 109 Sinhalese adults (61 men and 48 women aged 25–50 years) from Colombo City underwent anthropometric and biochemical measurements, dietary intake analysis, and genetic tests. Genetic risk scores (GRS) based on 10 metabolic single nucleotide polymorphisms (SNPs) (metabolic-GRS) and 10 vitamin B12 SNPs (B12-GRS) were constructed. The B12-GRS was significantly associated with serum vitamin B12 (p = 0.008) but not with metabolic traits (p > 0.05), whereas the metabolic-GRS had no effect on metabolic traits (p > 0.05) and vitamin B12 concentrations (p > 0.05). An interaction was observed between B12-GRS and protein energy intake (%) on waist circumference (p = 0.002). Interactions were also seen between the metabolic-GRS and carbohydrate energy intake (%) on waist-to-hip ratio (p = 0.015). Our findings suggest that a genetically lowered vitamin B12 concentration may have an impact on central obesity in the presence of a dietary influence; however, our study failed to provide evidence for an impact of metabolic-GRS on lowering B12 concentrations. Given that our study has a small sample size, further large studies are required to confirm our findings.

The purpose of this study was to identify surface anatomy of digital nerves in relation to the pigmented border of digits. Three-hundred and sixty digital nerves in 36 preserved adult cadaveric hands were dissected under magnification. The digital nerves were constantly located anterior to the pigmented border. The median curvilinear distance along the skin from the pigmented border to the digital nerves of the index, middle, ring and little fingers was 1.4 mm. In the thumb, this distance was 2.4 and 3.7 mm on the radial and ulnar sides, respectively. The digital nerve was located 2.4 mm deep to the skin in all fingers. The median angle to the nerve from the skin at the pigmented border was 30°. These dimensions differed in the thumb compared with the rest of the fingers. We conclude that the pigmented border of digits is a reliable anatomical landmark to locate digital nerves.

IntroductionWe intended to study the prevalence of occupational hazards in the anatomy laboratory and the safety measures taken by students. Methodology An audit was conducted among two batches of medical students, soon after the completion of the anatomy curriculum. Exposures, practices, health conditions of the students, their suggestions to improve safety measures and self-reported engagement in dissections in each session (in a ten-point Likert scale) were assessed using a validted self – administered questionnaire. ResultsOf 196 respondents, 50%(n=98) were males. Mean age was 21.8±1.1 years. During their first-year dissections, 1 5.8% (n = 31) had cut injuries, 86.7%(n=170) had skin contact with cadaver fluids while 5.6%(n=11) had eye splashes. Of those with skin contact, 43.5%(n=74) washed immediately. Of those who had eye splashes, only 18.2%(n=2) washed immediately for 20 minutes as recommended. Nine students reported new nail infections, seven developed allergies to cadaver fluids and 15 developed skin rashes during the period of dissections. Self-reported engagement in dissections positively correlated with the frequency of skin contact with cadaver fluids (r=.161, p=0.035), but not with the frequency of cut injuries (p>.05) or eye splashes (p>.05). Students suggested the following safety measures : 63.3%(n=72)-lab coats, 55.6%(n=109)- masks, 16.8% (n = 3 3) - goggles , 43.9% (n=86)-a lecture on lab safety, 44.4% (n = 87) – a workshop and 40.3% (n=79)-a formal safety protocol. ConclusionsStudents are exposed to numerous occupational hazards in the anatomy laboratory. Inadequate adherence to internationally recommended laboratory safety measures may increase the risk of occupational hazards.

The marginal mandibular branch of the facial nerve is vulnerable to iatrogenic injuries during surgeries involving the submandibular region. This leads to significant post-operative morbidity. Studies assessing accurate anatomical landmarks of the marginal mandibular branch are sparse in South Asian countries. Present study was conducted to assess the relationship between the marginal mandibular branch and the inferior border of the body of mandible.

Background Accurate anatomical landmarks to locate the thoracodorsal nerve are important in axillary clearance surgery. Methods Twenty axillary dissections were carried out on ten preserved Sri Lankan cadavers. Cadavers were positioned dorsal decubitus with upper limbs abducted to 90 0 . An incision was made in the upper part of the anterior axillary line. The lateral thoracic vein was identified and traced bi-directionally. The anatomical location of the thoracodorsal nerve was studied in relation to the lateral border of pectoralis minor and from a point along the lateral thoracic vein, 2 cm inferior to its confluence with the axillary vein. Results The lateral thoracic vein was invariably present in all the specimens. All the lateral thoracic veins passed lateral to the lateral border of pectoralis minor except in one specimen, where the lateral thoracic vein passed along its lateral border. The thoracodorsal nerve was consistently present posterolateral to the lateral thoracic vein. The mean distance to the lateral thoracic vein from the lateral border of pectoralis minor was 28.7 ± 12.6 mm. The mean horizontal distance, depth, and displacement, from a point along the lateral thoracic vein, 2 cm inferior to its confluence with the axillary vein to the thoracodorsal nerve were 14.5 ± 8.9 mm, 19.7 ± 7.3 mm and 25 ± 5 mm respectively. The thoracodorsal nerve was found in a posterolateral direction, at a 54 0 ± 12 0 angle to the horizontal plane, 95% of the time. Conclusions The lateral thoracic vein is an accurate guide to the thoracodorsal nerve. We recommend exploring for the thoracodorsal nerve from a point 2 cm from the confluence of the lateral thoracic vein and the axillary vein for a distance of 25 ± 5 mm in a posterolateral direction, at a 54 0 ± 12 0 angle to the horizontal plane.

Loss of ejaculation can follow transurethral resection of the prostate (TURP). Periverumontanal prostate tissue is preserved in ejaculation-preserving TURP (ep-TURP). Knowledge of ejaculatory duct anatomy in relation to the prostatic urethra can help in ep-TURP. This was evaluated in cross-sections of the prostate using a 3 D model to determine a safe zone for resecting the prostate in ep-TURP. A 3 D reconstruction of the ejaculatory ducts was developed on the basis of six prostate gland cross-sections. The measurements obtained from the 3 D model were standardized according to the maximum width of the prostate. Simple linear regressions were used to predict the relationships of the ejaculatory ducts. The maximum widths of the prostates ranged from 22.60 to 52.10 mm. The ejaculatory ducts entered the prostate with a concavity directed posterolaterally. They then proceeded toward the seminal colliculus in a fairly straight course, and from that point they angulated anteromedially. As they opened into the prostatic urethra they diverged. Significant regression models predicted the relationships of the ejaculatory ducts to the prostatic urethra based on the sizes of the prostates. The 3 D anatomy of ejaculatory ducts can be predicted on the basis of prostate width. The ejaculatory ducts can be preserved with 95% accuracy if a block of tissue 7.5 mm from the midline on either side of the seminal colliculus is preserved, up to 10 mm proximal to the level of the seminal colliculus, during TURP. Clin. Anat. 31:456-461, 2018. © 2017 Wiley Periodicals, Inc.

Introduction. Cadaveric dissections and prosections have traditionally been part of undergraduate medical teaching. Materials and Methods. Hundred and fifty-nine first-year students in the Faculty of Medicine, University of Colombo, were invited to participate in the above study. Students were randomly allocated to two age and gender matched groups. Both groups were exposed to identical series of lectures regarding anatomy of the abdomen and conventional cadaveric prosections of the abdomen. The test group (n = 77, 48.4%) was also exposed to cadaveric cross-sectional slices of the abdomen to which the control group (n = 82, 51.6%) was blinded. At the end of the teaching session both groups were assessed by using their performance in a timed multiple choice question paper as well as ability to identify structures in abdominal CT films. Results. Scores for spatial and radiological anatomy were significantly higher among the test group when compared with the control group (P < 0.05, CI 95%). Majority of the students in both control and test groups agreed that cadaveric cross section may be useful for them to understand spatial and radiological anatomy. Conclusion. Introduction of cadaveric cross-sectional prosections may help students to understand spatial and radiological anatomy better.

BACKGROUND:Carpal tunnel syndrome is a common presentation to surgical outpatient clinics. Treatment of carpal tunnel syndrome involves surgical division of the flexor retinaculum. Palmar and recurrent branches of the median nerve as well as the superficial palmar arch are at risk of damage.METHODOLOGY:Thirteen cadavers of Sri Lankan nationality were selected. Cadavers with deformed or damaged hands were excluded. All selected cadavers were preserved with the conventional arterial method using formalin as the main preservative. Both hands of the cadavers were placed in the anatomical position and dissected carefully. We took pre- determined measurements using a vernier caliper. We hypothesized that the structures at risk during carpal tunnel decompression such as recurrent branch of the median nerve and superficial palmar arch can be protected if simple anatomical landmarks are identified. We also hypothesized that an avascular area exists in the flexor retinaculum, identification of which facilitates safe dissection with minimal intra operative bleeding. Therefore we attempted to characterize the anatomical extent of such an avascular area as well as anatomical landmarks for a safer carpal tunnel decompression.Ethical clearance was obtained for the study.RESULTS:In a majority of specimens the recurrent branch was a single trunk (n =20, 76.9%). Similarly 84.6% (n = 22) were extra ligamentous in location. Mean distance from the distal border of the TCL to the recurrent branch was 7.75 mm. Mean distance from the distal border of TCL to the superficial palmar arch was 11.48 mm. Mean length of the flexor retinaculum, as measured along the incision, was 27.00 mm. Mean proximal and distal width of the avascular area on TCL was 11.10 mm and 7.09 mm respectively.CONCLUSION:We recommend incision along the radial border of the extended ring finger for carpal tunnel decompression. Extending the incision more than 8.16 mm proximally and 7.75 mm distally from the corresponding borders of the TCL should be avoided. Incision should be kept to a mean length of 27.0 mm, which corresponds to the length of TCL along the above axis. We also propose an avascular area along the TCL, identification of which minimizes blood loss.

Infection would seem to be an integral part of the pathogenesis of fistula in ano. The microbiology of acute anorectal sepsis is well documented, but the studies on chronic anal fistula have continuously raised doubts about the relevance of infection in fistula persistence. The present histological study complements the earlier work, which used microbiological methods alone where important organisms might have been overlooked.

BACKGROUND:A better understanding of volume distribution between the superficial (subcutaneous) and deep (subplatysmal) planes of the neck may be useful when deciding on the best course of management for patients presenting for cervical contouring.OBJECTIVES:The authors investigate the normal distribution of fat in the superficial and deep planes of the neck in a cadaver model, to determine the proportion of the submandibular gland that contributes to submental fullness.METHODS:Fat in the superficial and deep neck planes of 29 adult cadavers was dissected and weighed. The submandibular glands were also dissected and the cervical portion of each gland was shaved off, weighed, and compared to the weight of the whole gland.RESULTS:The mean weight of superficial fat collected from the specimens was 15.0 g in males (n = 14; range, 2.2-35.7 g) and 14.3 g in females (n = 15; range, 1.6-37.3 g); the mean weight of subplatysmal fat was 5.5 g in males (range, 1.3-15.2 g) and 3.7 g in females (range, 0.6-15.1 g). Mean weight was not statistically significantly different between the sexes, nor between the 2 racial/ethnic groups (Caucasian, n = 14; Southeast Asian, n = 15). Approximately 40% of the submandibular gland was found to lie inferior to the lower border of the mandible in the specimens examined. The authors found no anatomical evidence of submandibular gland ptosis, even in the oldest specimens.CONCLUSIONS:The study provides a comprehensive analysis of the distribution of adipose tissue in the superficial and deep planes of the neck, as well as the contribution of the submandibular glands to submental volume. This objective evaluation of neck volume may help guide clinicians in the surgical planning process and provide a foundation for designing new cervicofacial rejuvenation techniques.

Background Anatomically, it is difficult to give a systematic description of the superficial branch of the radial nerve (SBRN). Our aim was to describe the exact relationship of the SBRN to fixed bony points of radial styloid and Lister's tubercle, and to the cephalic vein. We also compared our data with other international studies. Methods The study was a descriptive anatomical study. Twenty-five forearms were dissected. Measurements were made from predefined fixed reference points. Results The mean distance to the point of emergence of the nerve from the radial styloid was 8.54 cm (SD = 1.32). The nerve branched at a mean distance of 5.57 cm (SD = 1.43) from the radial styloid. The mean distance to the point where the most medial and most lateral branches of the nerve crossing the wrist joint, measured from the Lister's tubercle were 2.51 cm (SD = 0.53) and 3.90 cm (SD = 0.64). In 17 specimens(68%) cephalic vein crossed the SBRN superficially once. Mean distance from the radial styloid to the most distal point where the vein crossed the nerve was 5.10 cm. Diffefrence between mean distance to the point of emergence and branching point, when compared with other international studies were not statistically significant. (P value > 0.05) Conclusions We recommend avoiding transverse incisions in the snuffbox region between 2.51 cm and 3.90 cm from the Listers tubercle. We also recommend avoiding cannulation of the cephalic vein in the distal forearm.