Hand

DESCRIPTIVE ANATOMY OF THE PALMAR HAND

Contents
Bone: The metacarpals and phalanges of the five rays.
Blood Vessels: The terminal branches of the radial and ulnar arteries.
Nerves: The terminal branches of the median and ulnar nerves.
Tendons: The extrinsic flexor tendons of the five rays.
Muscles and Fascia: The intrinsic muscles, the thenar and hypothenar muscles, and the
palmar fascia.
External Landmarks
Important superficial landmarks on the palmar surface of the hand include the pisiform
bone, the thenar and hypothenar eminences, and the thenar, proximal palmar, distal
palmar, digital, and distal wrist flexion creases . fig 10.1
Pisiform Bone
The pisiform bone, located on the ulnar and palmar aspect of the base of the hand,
provides a visible and palpable landmark, which aids in the identification and location of
the flexor carpi ulnaris (FCU) tendon, the underlying ulnar neurovascular bundle, and the
hook process of the hamate.
Thenar and Hypothenar Eminences
The thenar eminence is formed by the abductor pollicis brevis (APB) and flexor pollicis
brevis (FPB), which overlie the opponens pollicis (OP). The less prominent hypothenar
eminence on the ulnar side of the hand is formed by the corresponding muscles of the
small finger.
Flexion Creases
The wrist, thenar, palmar, and digital flexion creases are skin flexion lines seen in the
vicinity of synovial joints, where the skin is attached to the underlying fascia. These
creases have been recognized as useful anatomic landmarks because of their relationship
to underlying structures. Digital creases facilitate movement of the digits without
impingement by providing folding points in the skin similar to the creases in a folded
road map, and because of strong attachments to the underlying fascia, they also provide
the stability to the skin required for forceful grasping. These creases may begin as
flexional skin folding of the hand during fetal development. Dual creases are present at
the proximal interphalangeal (PIP) joints, The proximal crease at the PIP joint is the most
prominent and is the crease used in measurements to determine the location of the
underlying joint. The approximate orientation of the creases is at right angles to the
longitudinal axis of the corresponding digit and parallel to the flexion-extension joint
axis. Thus, the pronounced obliquity of the thenar crease is readily apparent, as is the
lesser obliquity of the proximal and distal palmar creases.
Digital Skin Creases
The distal digital skin creases are located consistently proximal to their corresponding
DIP joints, lying at mean distances of 7 to 7.8 mm proximal to the joint. Middle digital

flexion creases also are located consistently proximal to their corresponding PIP joints,
with mean distances ranging from 1.6 to 2.6 mm. Proximal digital skin creases are
consistently located distal to their corresponding MCP joints, with mean values ranging
from 14.4 to 19.6 mm distal to the joint. In the thumb, the interphalangeal joint flexion
crease is located proximal to the interphalangeal joint by a mean distance of 2.2 mm,
whereas the MCP flexion crease is found to pass obliquely and directly over the MCP
joint
Palmar Skin Creases
The palmar skin creases, along with the proximal digital creases, are related to the MCP
joints. Although these creases demonstrate a variable course in the palm, the distal palmar
crease, originating on the ulnar side of the palm, is on average 7.9 mm proximal to the
small finger MCP joint, 10.3 mm proximal to the ring finger MCP joint, and 6.9 mm
proximal to the long finger MCP joint. The proximal palmar crease, originating on the
radial side of the hand, is on average 9.1 mm proximal to the index finger MCP joint, 18
mm proximal to the long finger MCP joint, and 22.1 mm proximal to the ring finger MCP
joint. A straight line drawn joining the lateral border of the proximal palmar
P.534
crease and the medial aspect of the distal palmar crease accurately identifies the location
of the metacarpal necks in most hands.
Thenar Crease
The thenar crease usually intersects the lateral side of the proximal palmar crease and
curves obliquely across the palm to intersect the distal wrist crease near the wrist center.
In the mid-portion of the palm, the thenar crease is located directly over the long finger
metacarpal over half the time. In the proximal palm, the thenar crease crosses the capitate
nearly half the time and the trapezoid approximately one-third of the time. Mean distance
from the thenar crease to the center of the trapeziometacarpal joint is 22.6 mm. The
thenar crease passes 18.7 mm from the hamate hook on the medial side of the carpus
Fig10.2
Distal Wrist Crease
Although there usually are three wrist flexion creases, only the distal crease is of
sufficient consistency to be used as a reliable landmark. The distal wrist crease is located
over the proximal carpal row and passes over the scaphoid waist in almost all instances
and over the pisiform 80% of the time. The lunate is consistently proximal to the distal
wrist crease, with its center being an average of 9.2 mm from the crease. The radiocarpal
joint is 13.5 mm proximal to the distal wrist crease, and the center point of the distal
radioulnar joint is 21.1 mm proximal to the wrist crease. On the lateral side of the wrist,
the distal wrist crease is within 1 mm of the center of the scaphoid waist. The mid-portion
of the trapeziometacarpal joint averages 19.4 mm distal to the distal wrist crease. On the
ulnar side of the wrist, the pisiform is directly under or slightly distal to the crease. The
base of the ulnar styloid is on average 11.7 mm proximal to the distal wrist crease
Relationship of Deeper Structures to Superficial Landmarks

Kaplan described a unique system of lines drawn on the palmar side of the hand that
coincided with important deeper structures (6). These lines may facilitate the recall and
identification of important deeper structures in the hand. These lines and corresponding
underlying structures are depicted in Figure 10.3.
Skeletal Anatomy
The Five Rays of the Hand
Thumb
The thumb is a continuation of the lateral column of the carpus formed by the scaphoid
and trapezium. The trapezium and scaphoid longitudinal axis is at a 45-degree angle to
the index metacarpal and the carpus, which accounts for the functional separation
between the first and second rays. This position and the sellar configuration of the
trapeziometacarpal joint allows the thumb to oppose the tips of the digits for pinch.
Thumb Metacarpal.
The thumb metacarpal is short and thick. Its dorsal or extensor surface is transversely
convex and the palmar or medial surface is longitudinally concave.
Fingers
Each of the four fingers is of different length. In flexion, the centrally positioned long
finger flexes in a line parallel with the long axis of the hand, whereas the index, ring, and
small fingers converge toward the central digit. This may be confirmed by comparing
finger motion in one's own hand and by noting the transverse orientation of the proximal
digital flexion crease of the long finger compared with the progressively oblique
orientation of the index, ring, and small fingers. Each of the MCP flexion creases are at
approximate right angles to the longitudinal arc of motion and thus confirm the fact that
the longitudinal arcs of motion of the index, ring, and small fingers are convergent. The
obliquity of the proximal and distal palmar creases (which converge in flexion) roughly
parallels the oblique transverse palmar axis, which forms an angle of 75 degrees with the
longitudinal axis of the long finger ray.
Index Metacarpal.
The index metacarpal is the longest of the metacarpals and has the largest base. The shaft
is triangular and longitudinally concave toward the palm. The distal dorsal surface is
broad but proximally narrows to a ridge.
Long Finger Metacarpal.
The shaft of this metacarpal resembles the index metacarpal. A short proximal styloid
process is present dorsally and laterally. The extensor carpi radialis brevis (ECRB)
attaches distal to this styloid process.
Ring Finger Metacarpal.
The ring finger metacarpal is shorter and thinner than the index and long fingers, but the
shaft is similar in configuration to the index finger.
Small Finger Metacarpal.
The small finger metacarpal differs on its medial surface, which is nonarticular and has a
tubercle for attachment of the extensor carpi ulnaris (ECU). The shaft has a triangular
dorsal area that almost reaches the base.

Longitudinal and Transverse Arches

The normal hand is cupped in both its long and transverse axes. The static aspects of
this transverse cupping are accounted for by the prominence of the thenar and hypothenar
eminences as well as by the transverse osseous arches at the distal carpal row and at the
neck of the metacarpals. Further dynamic cupping is achieved by convergent movement
of the thumb and small finger. The static aspects of the longitudinal cupping are due to
the proximal prominence of the thenar and hypothenar eminences and the natural palmar
concavity of the metacarpals and phalanges. The dynamic aspects of the longitudinal
cupping relate to the powerful intrinsic and extrinsic flexors, which maintain an attitude
of flexion in the fingers. Fig..
Phalanges of the Hand
There are 14 phalanges, 3 in each finger and 2 in the thumb. Each has a head, shaft, and
base. The shaft tapers distally and its dorsal surface is transversely convex (1). The
palmar surface is longitudinally concave. The bases of the proximal phalanges are
concave and transversely oval to accommodate the metacarpal head. The bases of the
middle phalanges have two concave facets arranged side by side and separated by a
vertical ridge to accommodate the dual articular condyles of the proximal phalanx. A
similar but less pronounced arrangement is present between the middle and distal
phalanges.
Stabilizing Ligaments of the Carpometacarpal Joint of the Thumb.
In the CMC joint of the thumb, ligaments provide joint stability during pinch and grasp .
Loss of ligamentous support is believed to be a primary cause of degenerative arthritis
five main ligaments as supporting structures of the thumb CMC joint. Three were found
to be intracapsular, and two extracapsular (anterior oblique and intermetacarpal) into 2
distinct ligaments, making a total of 7 stabilizing ligaments of the CMC joint of the
thumb
Superficial Anterior Oblique Ligament.
The superficial anterior oblique ligament (SAOL) is a thick, broad structure that is taut at
the extremes of rotation, especially pronation, and while the joint is extended .In addition,
the SAOL limits palmar subluxation in pronation, supination, or neutral. Except in
maximal extension, this ligament appears lax and redundant in all hands regardless of the
amount of articular thinning or frank eburnation of the joint. This may reflect the laxity
required to accommodate pronation during thumb opposition
Deep Anterior Oblique Ligament.
The deep anterior oblique ligament (DAOL), also known as the beak ligament, is deep to
the SAOL and can be easily separated from it when approached from within the CMC
joint. It is said to be an intraarticular ligament that lies in the concavity of the trapezium,
and is the closest ligament to the center of the joint. It serves as a pivot point for rotation,
specifically pronation; it becomes taut in wide abduction or extension.
Ulnar Collateral Ligament.

The ulnar collateral ligament (UCL) is an extracapsular ligament and is taut in extension,
abduction, and pronation. The UCL is slightly ulnar (medial) to the SAOL, which it
partially covers
Palmar Intermetacarpal Ligament.
The palmar component of the intermetacarpal ligament (IML) is extracapsular and is taut
in abduction, opposition, and supination. It stabilizes the thumb metacarpal during
radiopalmar translation of its base
Dorsal Intermetacarpal Ligament.
The dorsal component of the IML (DIML) is an extracapsular ligament, and like the
palmar component is transversely oriented between the base of the thumb and index
metacarpals. It becomes taut in pronation and with dorsal and radial translation of the
base of the thumb metacarpal, and appears primarily to restrain pronation of the thumb
metacarpal
Dorsoradial Ligament.
This capsular ligament is the widest and thickest of the stabilizing ligaments of the CMC
joint of the thumb. It is fan shaped and its origin on the trapezium is narrower that its
insertion on the metacarpal. The dorsoradial ligament (DRL) is taut with a dorsal or
dorsoradial subluxating force in all positions of the CMC joint except full extension. In
addition, the DRL tightens in supination regardless of joint position and tightens in
pronation when the CMC joint is concomitantly flexed
Small to Index Finger Carpometacarpal Joints
Small.
Examination of the CMC joints of the fingers reveals that the small and ring finger CMC
joints are hinge joints, with the hamate presenting two concavities for the convex bases of
the small and ring fingers .The lateral basal surface of the small finger metacarpal is
transversely concave and convex from palmar to dorsal, and articulates with a shallow
concavity in the hamate. The medial side is nonarticular and has a tubercle for attachment
of the ECU.
Ring.
The quadrangular articular surface of the ring finger metacarpal, which articulates with
the hamate, is convex palmarly and concave dorsally.
Middle.
The capitate has a comparatively plane base for the middle finger metacarpal. The middle
finger metacarpal has a short styloid process that projects proximally from the dorsal and
lateral surface and is proximal to the attachment of the ECRB.
Index.
The index metacarpal is mortised between the capitate and trapezium, and further
stability is added by an anteroposteriorly directed ridge on the trapezoid that fits like a

wedge into the base of the index metacarpal. The index metacarpal is the longest and has
the largest base.
Comparative Finger Carpometacarpal Joint Stability/Mobility.
The comparative stability of the index and especially middle finger metacarpal with the
more mobile ring and small finger metacarpals may be understood by noting the CMC
joint configurations of the fingers as just described. The middle finger metacarpal is like a
fixed keel or spine that supports the movement of the more mobile adjacent digits and
thumb.
Ligaments.
Dorsal.
Prominent dorsal ligaments connect the dorsal surfaces of the carpal and metacarpal
bones. The index metacarpal has two, one each from the trapezium and trapezoid. The
middle finger also has two, one from the trapezoid and one from the capitate. The ring
finger has two ligaments, one from the capitate and one from the hamate. The small
finger metacarpal has a single band from the hamate that is continuous with a single
palmar ligament
Palmar.
The palmar ligaments are similar except that the middle metacarpal has three ligaments, a
lateral from the trapezium, an intermediate from the capitate, and a medial from the
hamate.
Interosseous.
Interosseous ligaments are present between the distal aspect of the capitate and hamate
and the adjacent surfaces of the ring and small finger metacarpals.
Intermetacarpal Joints
The second to fifth metacarpal bases articulate with each other by small, cartilagecovered facets. These articulations are connected by dorsal, palmar, and interosseous
ligaments.
Thumb Metacarpophalangeal Joint
Joint Type.
The MCP joint of the thumb is classified as an ellipsoid joint, which is characterized by
an oval convex surface proximally that is opposed to an elliptical concavity distally
Joint Motion.
The primary arc of motion is flexion and extension, although limited abduction-adduction
and pronation-supination is present. The metacarpal heads of the thumb and the fingers
are not uniformly convex but are adapted to shallow concavities on the base of the
adjacent phalanges. The convex metacarpal head is partially divided on the palmar
surface and thus almost bicondylar . The distal articular surface of the thumb metacarpal,
when viewed from the dorsopalmar aspect, is only slightly curved, in contrast to the

finger metacarpals, which demonstrate a significant curvature. This shape coincides with
the limited abduction-adduction seen in the MCP joint of the thumb.
Shape of the Articular Head of the Thumb Metacarpal.
The shape of the distal articular aspect of the thumb metacarpal is different from the
finger metacarpals in that its dorsal side is slightly wider than the palmar side, and also in
that the articular surface is divided into two zones: one that articulates with the proximal
phalanx and another, more palmar, that articulates with the sesamoids in the palmar plate
(6) (Fig. 10.8). The radial condyle of the metacarpal head has greater dorsopalmar height
than the ulnar, which allows some pronation of the proximal and distal phalanges during
flexion. Range of flexion varies from thumb to thumb and is due to the variation in
curvature of the metacarpal head; more spherical heads are associated with greater
motion . There also is an increased incidence of soft tissue injury in joints with poor
range of flexion . fig..
Thumb Metacarpophalangeal Joint Stability.
The MCP joint of the thumb is stabilized by its capsule, ligaments, and surrounding
musculotendinous structures, and has little intrinsic stability from its shape
Joint Axes.
Many joints such as the wrist, CMC, and MCP joints have two axes of rotation that allow
greater freedom of movement . The flexion-extension axis is in the metacarpal passing
under the epicondyles, and the abduction-adduction axis passes between the sesamoids
just proximal to the beak of the proximal phalanx .
Ligaments.
Palmar Plate.
The palmar plate of the thumb MCP joint is a thick, fibrocartilaginous structure that is
firmly attached to the base of the proximal phalanx and forms the bottom of a two-sided
box. The sides of the box are made up of the collateral ligaments. The palmar plate
contains a radial and an ulnar sesamoid that articulate with the palmar surface of the
thumb metacarpal. These sesamoid bones are buried in the substance of the palmar plate,
and their exposed dorsal articular surfaces are flush with the inner surface of the palmar
plate, covered with hyaline cartilage, and articulate with the palmar facets on the adjacent
metacarpal head. The ulnar sesamoid is the largest and its exposed palmar surface, which
partially projects from the palmar plate, provides an insertion point for a portion of the
adductor pollicis. The smaller radial sesamoid, which is similarly arranged in the palmar
plate, provides an insertion point for the tendon of the superficial head of the FPB. In
contrast to the largest sesamoid in the body, the patella, which is imbedded in tendon
(quadriceps femoris), the hand sesamoid bones are imbedded in palmar plates, and in the
thumb provide attachments for tendons. The palmar plate sesamoids in the thumb appear
to provide a stronger point of tendon attachment than the fibrocartilaginous palmar plate.
The sesamoids also may react more favorably than the fibrocartilaginous palmar plate to
compression or other forces during joint movement.
Collateral Ligaments.

The collateral ligaments of the MCP joint of the thumb and fingers as well as the PIP and
DIP joints are divided into proper and accessory collateral ligaments (17). The proper
collateral ligaments are composed of strong, substantial cords that flank the joints, arise
from the posterior tubercle and adjacent pit on the side of the metacarpal head, and insert
on the palmar aspect of the adjacent phalanx. The accessory collateral ligaments span
between the cordlike proper collateral ligaments and the palmar plate. The proper
collateral ligaments become taut in flexion because of the camlike arrangement of the
metacarpal head, as seen in the sagittal plane in both the thumb and fingers because the
palmar surface of the metacarpal is wider than the dorsal surface. In contrast, the
accessory collateral ligaments are slack in full flexion. Fig
Finger Metacarpophalangeal Joint
Joint Type.
The finger MCP joints are structurally similar to the thumb MCP joint. However, there is
increased range of abduction-adduction in the fingers compared with the MCP joint of the
thumb. The finger MCP joints are ellipsoid joints characterized by an oval convex surface
that is apposed to an elliptical but shallow concavity. The metacarpal condyle, which has
a larger anteroposterior axis (resulting in a so-called cam effect), articulates with the base
of the proximal phalanx, which is smaller and concave and has a larger transverse axis.
This configuration permits a significant arc of flexion-extension as well as abductionadduction.
Joint Axes.
Primary motion is about two orthogonal axes (e.g., flexion-extension and abductionadduction), which may be combined as circumduction. When the MCP joints are flexed,
neither abduction nor adduction is possible because the articular surface of the metacarpal
is relatively flat on the palmar surface and the collateral ligaments are tight in flexion
because of their eccentric attachments to the heads of the metacarpals and the resultant
camlike effect of this arrangement . In addition, the palmar surface of the finger
metacarpal heads is wider than the dorsal side, which also accounts for increased tension
in the proper collateral ligaments when the joint is flexed. In contrast, the accessory
collateral ligaments are slack in full flexion.
Ligaments.
Palmar Plate.
The finger MCP palmar plates are thick, dense fibrocartilaginous structures attached
firmly to the palmar base of the proximal phalanx and the neck of the metacarpals. The
attachment to the metacarpals is by (a) the vertical fibers of the accessory collateral
ligaments, which span between the lateral and medial margins of the palmar plate and
attach to the palmar side of the proper collateral ligaments and the site of origin of the
proper collateral ligament; (b) the deep transverse IMLs, which are contiguous with the
palmar plate on each side; and (c) obliquely oriented fibers that arise from the proximal
corners of the palmar plate and attach to the interosseous fascia. The arrangement of the
vertically oriented accessory collateral ligaments may be compared with the vertical
element of a pendulum, which allows the counterweight or pendulum to swing to and fro
in a constrained arc. A somewhat similar arrangement is present between the sagittal

bands that course between the extensor tendon and the sides of the palmar plate. Side or
lateral stability is provided by the attachments of the transverse metacarpal ligaments,
and proximal restraint by the corner ligaments (Fig. 10.10). This arrangement, along with
the compressibility of the MCP palmar plate, allows flexion of the MCP joint without
impingement of the palmar plate. The comparative morphology and internal structure of
the palmar plates of the MCP and PIP joints is of significance, and Watson and Dhillon
have stated that the MCP palmar plate, because of its fiber arrangement, is compressible
by as much as one-third of its length, whereas the PIP palmar plate is more rigid (19).
This concept, as well as differences between the palmar plates of the MCP and PIP joints,
was studied by Gagnon and associates, who noted (a) the mean MCP palmar plate length
was twice the length of the PIP joint palmar plate (11.2 1.62 mm vs. 5.6 1.35 mm);
(b) the mean thickness of the MCP palmar plate was 0.3 mm thinner than the PIP palmar
plate; and (c) the MCP palmar plate shortened 33.8% compared with 26.6% for the PIP
palmar plate during 90 degrees of flexion. Light and electron microscopic examination of
the MCP palmar plate revealed loose connective tissue arranged in disorganized strands,
compared with the PIP joint palmar plate, which consisted of more dense, homogeneous
connective tissue. Both palmar plates were relatively avascular and there was no
significant difference in cellularity either as to size or numbers. Plate migration revealed
that the MCP plate migrated a mean of 7.85 mm or 79% of its length, whereas the PIP
plate migrated a mean distance of 6.39 mm or 139% of its initial length with 90 degrees
of flexion. The fact that the PIP palmar plate is less compressible probably accounts for
its greater proximal migration . The anatomic differences in the MCP and PIP palmar
plates, along with the presence of the more rigidly attached check-rein ligaments at the
PIP joint, may explain the greater tendency of the PIP joint to develop palmar plate
contracture. Fig.
Proximal Interphalangeal Joint
Joint Type.
The PIP joints are uniaxial hinge joints. In contrast to the finger MCP joints, the PIP
joints are stable in all positions because of strong and symmetric proper collateral
ligaments, the palmar plate, and the osseous architecture in the form of side-by-side
concentric condyles that articulate with matching glenoid concavities, forming a dual
shallow tongue-and-groove arrangement.
Ligaments.
Palmar Plate/Check-Rein Ligaments.
The palmar plate of the PIP joint is a thick, short fibrocartilaginous structure that is firmly
attached both to the base of the middle phalanx and the neck of the proximal phalanx
(Fig. 10.12). The attachments to the base of the middle phalanx are most dense at the
lateral margins, where the attachment is confluent with the insertion of the collateral
ligaments. The palmar tubercle at the base of the middle phalanx, which is prominent on
a lateral radiograph, is devoid of significant insertion by the palmar plate. In its central
80%, the palmar plate attaches by blending with the palmar periosteum of the middle
phalanx. The attachments to the proximal phalanx (the check-rein ligaments) arise from
bone and begin just inside the distal edge of the second annular (A2) pulley. The origins
of the first cruciform (C1) pulley are on the outside of the A2 pulley. The swallowtail

configuration of these proximal attachments of the palmar plate provides a tensionrelieving access route under the flexor sheath for the branches of the digital vessels to
reach the axial vincula. Bowers et al. view the palmar plate as a static restraint limiting
PIP joint extension . Sequential sectioning of the various components of the complex
suggested that the major static resistance to hyperextension is offered by the confluent
distal lateral insertion of the palmar plate-collateral ligament complex, where it cups the
lateral flared margin of the phalangeal condyle. Based on biomechanical studies, Bowers
et al. suggested that the site and nature of injury to this complex depended on the rate of
application of the deforming force: Rapid rates produce rupture at the distal attachment
and slow rates attenuate the proximal check-rein ligaments. Instability sufficient to permit
dorsal dislocation occurred only if there was interruption of the main collateral and
accessory collateral ligament complex in addition to disruption of the lateral attachments
of the palmar plate from the base of the middle phalanx fig.
Collateral Ligament.
The collateral ligaments of the PIP joints are divided into proper and accessory collateral
ligaments . The proper collateral ligaments are composed of strong cords that flank the
joints and arise from a concave fossa on the lateral aspect of each condyle and then pass
obliquely to insert on the palmar side of the middle phalanx and distal-lateral margin of
the palmar plate. The accessory collateral ligaments span between the cordlike proper
collateral ligaments and the palmar plate. The cordlike components of the collateral
ligaments demonstrate equal tension in flexion and extension, in contrast to the proper
collateral ligaments of the finger MCP joints. The key to PIP joint stability is the strong
conjoined attachment of the collateral ligaments and the palmar plate. This ligament-box
configuration results in three-dimensional strength that resists PIP joint displacement. For
displacement to occur, the ligament-box arrangement must be disrupted in at least two
planes
Clinical Significance.
In contrast to the finger MCP joints, which should be immobilized in flexion to avoid
contracture of the proper collateral ligaments, the PIP joints are immobilized in full
extension to avoid irreversible contracture. The proper collateral ligaments at the PIP
joints are under relatively uniform tension in flexion and extension and therefore are not a
factor in irreversible contracture. However, the check-rein ligaments at the proximal end
of the palmar plate at the PIP joint may hypertrophy and contract, resulting in a fixed
flexion contracture.
Distal Interphalangeal Joint
The DIP joints are uniaxial hinge joints. The DIP joint is structurally similar to the PIP
joint, but demonstrates hyperextension during pulp contact, as in pinch, or during forceful
pressure on the distal aspect of the finger.
ANATOMIC RELATIONSHIPS
Arterial Supply of the Hand
Most of the arterial supply of the hand comes through two main arteries, the radial and
the ulnar. Other sources include the median artery, which enters into formation of the

superficial palmar arch in approximately 10% of specimens, and the interosseous arteries,
mainly the anterior, which arise in the proximal forearm from the common interosseous
branch of the ulnar artery. The interosseous arteries usually are unimportant under normal
circumstances but may become significant if either the radial or ulnar artery is injured.
The typical or usual arrangement of the arteries is presented in this section, along with
anatomic variations.
Radial Artery
The radial artery, near the radial styloid, lies to the radial side of the flexor carpi radialis
(FCR) and at approximately this level gives off the palmar carpal branch, which usually
joins a companion vessel from the ulnar artery and the anterior interosseous artery to
form the palmar carpal arch . At this level, the radial artery gives off the superficial
palmar branch, which passes through and occasionally over the thenar muscles, which it
supplies, and in approximately one-third of individuals it joins the ulnar artery to aid in
the formation of the superficial palmar arch. The main component of the radial artery
passes dorsally beneath the abductor pollicis longus and extensor pollicis brevis (EPB)
tendons to enter the anatomic snuff-box. After entering the snuff-box, the radial artery
gives off the dorsal carpal branch to form part of the dorsal carpal arch. It then runs
distally beneath the EPL, passes between the bases of the thumb and index metacarpals,
through the first dorsal interosseous (DI) muscle and into the palm, to end as a
contributor to the deep palmar arterial arch. The deep arch lies on the proximal ends of
the metacarpals and interossei, beneath the finger flexors and the adductor pollicis.
Dorsal Carpal Arch
This dorsal plexus, which supplies the carpal bones, is formed variously by radial, ulnar,
or interosseous artery branches.
Dorsal Metacarpal Arteries (Five in Number)
At the distal aspect of the dorsal carpal arch, three dorsal metacarpal arteries (the second,
third, and fourth) are given off and course distally in the second, third, and fourth
intermetacarpal spaces
Branches of the Deep Palmar Arch
Proximal.
These are the recurrent carpal vessels, two or three in number, which course proximally
to end in the palmar carpal rete or join with the palmar carpal branches of the palmar
interosseous artery
Distal.
These include the so-called princeps pollicis, the artery to the radial side of the index
finger, which may arise in common with the princeps pollicis and the three PMAs
Palmar Metacarpal Arteries
that a palmar metacarpal vessel is one that arises from the deep arch and extends at least
as far distal as the MCP joint; (b) that the large artery to the thumb is considered to be the
first PMA, the large vessel that courses along the palmar aspect of the second metacarpal
bone is the second PMA, and these vessels may arise from a common trunk; and (c) the

remainder of the vessels are best considered on the basis of type and numberthe
smallest number of vessels found was three and the largest was six.
Dorsal Metacarpal Arteries
These are perforating branches, three in number, from the region of the second, third, and
fourth interspaces, that pass to the dorsum of the hand to join their respective dorsal
metacarpal arteries.
Ulnar Artery
The ulnar artery approaches the wrist just beneath and radial to the FCU tendon It is
radial to the ulnar nerve and is in the interval between the FCU and the flexor digitorum
superficialis (FDS) to the ring and small fingers. It enters the hand accompanied by the
ulnar nerve on top of the transverse carpal ligament (TCL) and radial to the pisiform
bone.
Guyon's canal begins at the proximal edge of the palmar carpal ligament and extends to
the fibrous arch of the hypothenar muscles. Beginning from proximal to distal, the roof of
the canal is formed by the palmar carpal ligament and the palmaris brevis muscle. The
floor is formed by the TCL, the pisohamate and pisometacarpal ligaments, and the
opponens digiti minimi (ODM). The ulnar wall is composed of the FCU, the pisiform,
and the abductor digiti minimi (ADM). The radial wall is formed by the tendons of the
extrinsic flexors, the TCL, and the hook of the hamate. The average length of Guyon's
canal is 27 mm (range, 20 to 34 mm) . The ulnar nerve and artery branches in this region
are covered by the palmaris brevis muscle and surrounded by a thick fat pad.
The deep branch of the ulnar artery most often enters the depths of the hand between the
flexor tendon sheath of the small finger and the FDM, to a position deep to the
interosseous fascia, where it joins the main stem of the radial artery to form the deep
palmar arch. The palmar digital artery to the ulnar side of the small finger arises a few
millimeters distal to the origin of the deep branch. main stem of the ulnar artery turns
radially to cross the palm as the superficial palmar arch, it gives rise to three common
palmar digital arteries that go to the three digital web spaces, where they divide into
proper digital arteries. In their study of this region fig
Superficial Palmar Arch
This arch lies just beneath the palmar fascia and on top of the superficialis tendons, and
may be complete or incomplete
Persistent Median Artery
A persistent median artery may descend into the palm and take part in the formation of
the superficial palmar arch.
Arterial Supply of the Fingers
There are three arterial sources to each finger: (a) the common palmar digital, (b) the
palmar metacarpal, and (c) the dorsal metacarpal. Two proper digital arteries are formed,
each of which supplies the adjacent sides of the fingers. In most instances, the common

palmar digital arteries are the source of these digital arteries, but it is not uncommon for a
PMA to supplant a common palmar digital artery. In rare instances, principally in the first
and second interspaces, the main supply may come from the dorsal metacarpal vessels.
The dorsal metacarpal arteries, joined by perforating branches from the deep palmar arch
or PMAs that pass through and supply the interosseous muscles, pass distally adjacent to
the MCP joints to become the dorsal digital arteries. When these vessels terminate near
the neck of the proximal phalanges, the terminal supply is taken over by the proper
palmar digital arteries
First Interspace
The arterial supply to the first interspace usually is derived from the deep arch, either
from the first PMA alone or from both the first and second PMAs.
Second Interspace
This is derived approximately equally from the second PMA or the second common
palmar digital artery, thus being shared almost equally by the superficial and deep arches.
Third and Fourth Interspaces
These spaces are primarily supplied by the common palmar digital branches of the
superficial arch.
Digital Arterial Branches and Arches
Palmar Digital Arteries
The palmar branches of the digital arteries average 4 from each side at the level of the
proximal and middle phalanges, but there were as many as 7 in one specimen
Dorsal Digital Arteries
The dorsal branches of the digital arteries are of four types: (a) condylar vessels, (b)
metaphyseal vessels, (c) dorsal skin vessels, and (d) transverse palmar arches.
The Superficial Arch
The superficial or main stem branch of the ulnar artery may give rise to a common digital
artery to each web space
The Superficial Palmar Branch of the Radial Artery
The SPBR can vary from supplying only small branches to the carpal ligament
and thenar muscles to providing the main blood to the thumb and radial side of
the index finger
The First Palmar Metacarpal Artery
first branch of the radial artery on its return to the palm
Branches of the First Palmar Metacarpal Artery
The thumb palmar digital arteries

Branches at the level of the neck of the thumb metacarpal. These were constant, with
vessels curving around the neck to supply dorsal structures and the MCP joint.
Muscle branches to the adjacent thenar muscles.
Terminal communicating branches
Surgical Applications Based on the Earley Study
Interruption of the ulnar artery at the wrist may result in loss of blood flow in the
second through fourth interdigital cleft vessels and possibly lead to ischemia in
the fingers. Thumb viability would not be affected because both sides of the
thumb never are supplied only by the superficial palmar artery.
Interruption of the radial artery at the wrist could be a different matter, especially
in those hands with a large contribution from the SPBR (30% of hands in Earley's
study), because the common digital as well as palmar metacarpal arterial supply
would be lost. However, ischemia leading to necrosis might not occur if sufficient
interconnections were present from other arterial systems.
Landmarks for the arteries of the thumb are the FPL at the metacarpal level, the
sesamoid bones, and the oblique pulley of the flexor sheath. The distal part of the
oblique pulley marks the level of the digitopalmar arch. When looking for the
ulnopalmar thumb digital artery, it is helpful to remember the preadductor or
postadductor course of the artery and the possibility of its origin from the dorsal
vessels. In 90% of cases, the ulnopalmar artery is the largest of the two thumb
arteries and should be considered as the first choice for anastomosis in
replantation. If the ulnopalmar artery is not suitable for anastomosis, the A1
pulley area and the ulnar side of the radial sesamoid should be examined to locate
the radiopalmar digital artery. By this means, the deep variety (seen in 50%) can
be identified before it courses deep to the flexor sheath.
Nerves of the Hand
Cutaneous Innervation of the Palm
Four nerves were identified, one from the median [the palmar cutaneous branch of the
median nerve (PCBMN)] and three from the ulnar [the palmar cutaneous branch of the
ulnar nerve (PCBUN), the nerve of Henle, and transverse palmar branches from the ulnar
nerve in Guyon's canal]
Ulnar Nerve Branches
Palmar Cutaneous Branch of the Ulnar Nerve.
Nerve of Henle.
This nerve, the nervi vasorum of the ulnar artery, gave innervation to the forearm or palm
Nerve.
Multiple cutaneous nerves to the palm were noted from the ulnar nerve, the ulnar motor
branch to the hypothenar muscles, and the common digital ulnar sensory nerve as they
coursed through Guyon's canal. distal (range, 1.8 cm proximal to 1.7 cm distal) to the
center of the pisiform and was variable with respect to the ulnar nerve branch of origin.
In two specimens, these nerves traveled with the ulnar artery for less than 1 cm before
becoming cutaneous. Many of these nerves exited perpendicularly from the longitudinal

direction of the ulnar nerve, thus prompting a description of them as transverse. These
nerves pierced the palmar carpal ligament to innervate the skin and subcutaneous tissue
of the hypothenar eminence and midpalm, usually distal to that area innervated by either
the nerve of Henle or the PCBUN. The radial extent of these nerves was very variable,
but they routinely extended farther radial than the site of the carpal tunnel release incision
in the axis of the ring finger.
Clinical Significance
Based on this study, there is no internervous plane in this region of the palm. Injury to
these nerves may explain the lower rate of painful incisions after endoscopic carpal
tunnel release compared with open release.
Palmar Cutaneous Branch of the Median Nerve.
Clinical Significance
The most common pattern of median nerve branching to the thumb and radial side of the
index finger as described by Jolley et al. is at variance with the classic descriptions of
branching. Surgeons should be aware that the most common median nerve branching in
the first web space is that of a PDN branch to the radial side of the thumb and a common
digital nerve that divides to innervate the ulnar side of the thumb and the radial side of
the index finger.
Digital Nerves
In general, the PDNs course distally in intervals adjacent to the lumbrical muscles and
flexor tendon sheaths. They are deep to the superficial palmar arterial arch and its arterial
branches and remain deep to these vessels until they (the nerves) exit from beneath the
transverse fibers of the palmar fascia into a fat pad at the distal aspect of the palm. The
PDNs enter the digits beneath the natatory ligament, palmar to the transverse metacarpal
ligament, and adjacent to the longitudinal fibers of the palmar fascia; in the digits, the
nerves are palmar to the arteries. In the fingers, the PDN lies adjacent to the flexor sheath
and level with the palmar aspect of the phalanges. Each PDN gives off several branches
to the sides and palmar aspect of the finger, as well as branches to the adjacent joints.
These nerves supply the flexor tendon sheaths, the digital arteries, and sweat glands
Index Finger Digital Nerves
In the most common pattern of index finger innervation . the nerves pass through the
palm deep to the digital artery.
Thumb Digital Nerves
These nerves pass distally on the radial and ulnar side of the thumb palmar to the digital
artery, and at the level of the interphalangeal crease divide into three or four branches to
supply the pulp and nail bed
Ulnar Nerve
Classic Course and Configuration

The ulnar nerve, accompanied by the ulnar artery on its radial side, enters the hand on the
radial side of the pisiform bone through Guyon's canal
Ulnar Motor Branches
The motor component of the nerve at the level of the pisiform is ulnar and dorsal. The
motor branch gives off one to three (usually two) branches to the hypothenar muscles
before it enters the depths of the palm. Its course into the palm has been variously
described as passing between the origin of the FDM and ODM or beneath the proximal
origin of the FDM . It then courses around the ulnar and distal aspect of the base of the
hook process of the hamate. The proximal edge of the FDM demonstrates a fibrous
arcade where the motor branch may become entrapped . It then traverses the hand to
innervate the ring and small finger lumbricals, the palmar and dorsal interossei, the
adductor pollicis, and the deep head of the FPB.
Ulnar Sensory Branches
After division into a sensory trunk and motor branch in Guyon's canal, the sensory
component divides into the sensory branch to the ulnar side of the small finger (the
proper palmar digital) and the common sensory nerve, which courses to the fourth web
and divides there to become the PDN of the radial side of the small finger and the ulnar
side of the ring finger. The motor branch to the palmaris brevis usually arises from the
sensory branch to the small finger . The communicating branch from the common
sensory (ulnar) courses distally to join the common median sensory to the third web
space.
Anatomy of Guyon's Canal
Guyon's canal, or the ulnar tunnel, is the space that the ulnar nerve and artery traverse to
gain entrance to the hand from the forearm. Guyon's canal begins at the proximal edge of
the palmar carpal ligament and ends at or beyond the fibrous arch of the hypothenar
muscles (formed mainly by the FDM). Beginning from proximal to distal, the roof of the
canal is formed by the palmar carpal ligament, portions of the palmar aponeurosis, and
the palmaris brevis muscle. The floor is formed by the TCL, the pisohamate and
pisometacarpal ligaments, and the FDM. The ulnar wall is composed of the FCU, the
pisiform, and the ADM. The radial wall is formed by the tendons of the extrinsic flexors,
the TCL, and the hook process of the hamate , the average length of Guyon's canal is 27
mm (range, 20 to 34 mm), ., it is approximately 40 mm in length (27,57). The ulnar nerve
and artery branches in this region are covered by the palmaris brevis muscle and
surrounded by a thick fat pad. the distal aspect of Guyon's canal has both a superficial
and a deep exit The superficial exit conducts the superficial sensory nerve and main
trunk of the ulnar artery over the ADM and FDM distally, whereas the deep or motor
branch is conducted through a deep exit beneath the fibrous proximal edge of the FDM
and thus into the mid-palmar aspect of the hand .
Gross and Gelberman divided Guyon's canal into three zones. Zone 1 was from the
proximal edge of the proximal commissural ligament (PCL) to the bifurcation of the
ulnar nerve. Zones 2 and 3 were parallel zones that began at the bifurcation of the nerve
and, according to these authors, ended at the region just beyond the fibrous tissue arch of
the hypothenar muscles. Zone 2 contained the motor branch of the ulnar nerve, and zone

3 contained the sensory branch of the nerve. Zones 2 and 3 are comparable with the deep
and superficial exits
Muscles of the Hand.
The muscles of the hand may be divided into three groups based on their relative and
geographic location: (a) thenar, (b) hypothenar, and (c) intrinsic.
Thenar Muscles
The thenar muscles are the APB, the OP, the FPB, and the adductor pollicis
Abductor Pollicis Brevis
The APB, the most superficial of the thenar group, arises mainly from the TCL, although
a few fibers may arise from the tubercles of the scaphoid and trapezium. It inserts into the
radial side of the base of the proximal phalanx of the thumb and into the dorsal expansion
of the thumb. Although its main function is to abduct the thumb, it also may act to extend
the interphalangeal joint of the thumb because of its insertion into the dorsal expansion.
Opponens Pollicis
Immediately beneath the APB is the OP, which arises from the TCL and the tubercle of
the scaphoid to insert on a large portion of the palmar (radial) surface of the thumb
metacarpal. The OP acts as a flexor and abductor of the thumb.
Flexor Pollicis Brevis
The FPB has a superficial and deep portion. The superficial portion arises from the distal
aspect of the TCL and the distal part of the tubercle of the trapezium and inserts on the
radial side of the base of the proximal phalanx of the thumb. The deep portion arises from
the trapezoid and capitate bones and from the palmar ligaments of the distal carpal row
and inserts on the ulnar side of the base of the proximal phalanx of the thumb. The FPL
tendon passes between the two heads of the FPB. The FPB flexes the MCP joint of the
thumb.
Adductor Pollicis
The adductor pollicis has transverse, oblique, and accessory heads (66). The triangular (or
perhaps trapezoid) transverse head arises from the palmar surface of the distal two-thirds
of middle finger metacarpal and inserts into the ulnar base of the proximal phalanx of the
thumb by a short tendon of insertion. The similarly shaped oblique head arises from the
capitate bone and the palmar bases of the index and middle finger metacarpals, the
palmar ligaments of the carpus, and the sheath of the FCR tendon. It inserts into the ulnar
sesamoid bone in the palmar plate at the MCP joint of the thumb. The accessory head
arises dorsal and radial to the oblique head from the base of the index metacarpal and
inserts into the ulnar aspect of the dorsal thumb expansion adjacent to the MCP joint.
Hypothenar Muscles
The hypothenar muscles are the palmaris brevis, the ADM, the FDM, and the ODM
Palmaris Brevis

The palmaris brevis is a thin, quadrilateral muscle on the proximal aspect of the
hypothenar eminence. Its origin is from the TCL and the ulnar border of the palmar
fascia, and it is attached to the skin on the ulnar border of the hand. It is superficial to the
ulnar artery and nerve. Its action is to assist in cupping the hand.
Abductor Digiti Minimi
The ADM arises from the pisiform bone, the tendon of the FCU, and the pisohamate
ligament. It attaches to the ulnar side of the proximal phalanx of the small finger and
forms the ulnar lateral band of the small finger, which ends in the dorsal digital
expansion. As its name implies, it acts as an abductor of the small finger and also has an
intrinsic function through its attachment to the hood. Structurally and functionally, it is
similar to a deep head of the dorsal interosseous.
Flexor Digiti Minimi
The FDM lies to the radial side of the ADM and arises from the convex surface of the
hook process of the hamate and the adjacent TCL. It inserts into the ulnar side of the base
of the proximal phalanx of the small finger. The FDM acts as a flexor of the small finger
MCP joint.
Opponens Digiti Minimi
The ODM, a narrow triangular muscle, lies under cover of the ADM and FDM in its
middle and distal thirds and arises from the convexity of the hook process of the hamate
and the adjacent portion of the TCL. It inserts along the ulnar and palmar aspect of the
small finger metacarpal. The ODM flexes the small finger metacarpal and to some extent
rotates (supinates) the small finger metacarpal into the position of opposition.
Intrinsic Muscles
Interosseous Muscles
The interosseous muscles are located between the metacarpal shafts and are either dorsal
or palmar. Some anatomists have concluded that there are three palmar interosseous
muscles, whereas others have described the presence of four palmar interosseous
muscles. The controversy involves the presence or absence of a palmar interosseous in
the first web space. The convention adopted in this text is that there are three palmar and
four dorsal interosseous muscles. The DI are divided into superficial and deep
components. In general, the superficial components of the DI insert into bone; the deep
components (along with the palmar interosseous), except for the first DI, insert into the
extensor hood. The details of comparative insertion percentages into bone or extensor
hood are discussed later
Dorsal Interosseous.
The DI muscles are represented by four bipennate muscles that arise from the opposing
sides of two metacarpal bones, beginning in the thumb-index finger web space and
ending in the ring-small finger intermetacarpal space
Superficial Head.

In general, the superficial heads (the most dorsal of the two components) of the first and
second DI insert by means of a tendon into the radial base of the proximal phalanx of the
index and middle fingers, respectively, whereas the third and fourth insert into the ulnar
base of the middle and ring fingers. The first DI inserts almost exclusively into bone and
may have a small and variable deep belly component. The third DI is the least likely to
have a bony insertion
Deep Head.
In general, the deep heads of the DI each form a lateral band at the level of the MCP
joint, and over the middle of the proximal phalanx send fibers that join similar fibers
from the lateral band on the opposite side of the finger. The palmar component of each DI
is phylogenetically a palmar interosseous, is invariably fused to its dorsal component, and
may be partially fused to the palmar interossei. The deep component of the DI is roughly
fusiform and often multipennate. In the index finger, the tendon of the variably present
deep component of the first DI may fuse with the superficial component to attach to the
proximal phalanx, or the deep component may be a distinct muscle with insertion into the
hood. it, along with the lumbrical, forms the radial component of the hood that joins the
ulnar counterpart (lateral band) of the first palmar interosseous to form the extensor
expansion. In the middle finger, the radial lateral band is formed by the deep portion of
the second DI, and the ulnar lateral band from superficial and deep components of the
third DI. In the ring finger, the radial lateral band is from the second palmar interosseous,
and the ulnar lateral band from the deep head of the fourth DI. In the small finger, the
radial lateral band from the third palmar interosseous joins the lateral band extension of
the ADM to form the extensor expansion. The first and largest DI muscle is sometimes
called the abductor indicis. In the distal third of the proximal phalanx, oblique fibers
(spiral fibers) from the lateral bands continue distally to insert onto the lateral tubercles at
the base of the middle phalanx and act to extend the middle phalanx.
Function of Dorsal Interosseous.
Superficial Heads.
The superficial heads of the DI abduct the fingers from an imaginary line through the
central axis of the middle finger and weakly flex the proximal phalanx of the index,
middle, and ring fingers. Because the DI has no bony insertion on the small finger,
abduction in this digit is performed by the ADM and flexion by the FDM.
Deep Heads.
The deep heads flex and abduct the proximal phalanx and through the spiral or oblique
fibers of the lateral bands extend the middle phalanx. Extension of the distal phalanx is
from the distal extension of the lateral bands (the conjoined tendon).
Palmar Interosseous.
The palmar interosseous muscles are unipennate muscles (Fig. 10.40). Based on the
chosen convention of three, rather than four, palmar interosseous muscles, the first
palmar interosseous arises from the ulnar side of the index metacarpal and is inserted into
the extensor expansion on the same side of the index finger, forming the ulnar lateral
band of the index finger. Transverse fibers arch over the dorsum of the proximal phalanx

to join similar fibers from the opposite lateral band. The second palmar interosseous
arises from the radial side of the ring finger metacarpal and inserts into the extensor
expansion on the same side of the ring finger. It forms the radial lateral band of the ring
finger and also sends transverse fibers over the proximal phalanx of the ring finger. The
third palmar interosseous arises from the radial side of the small finger metacarpal and
inserts almost exclusively into the extensor expansion on the radial side of the small
finger, forming the radial lateral band of the small finger and sending fibers dorsally to
join the opposite lateral band. The third is the only palmar interosseous that has any
significant insertion into bone. Except for the third, none of the palmar interosseous
muscles insert into bone in the proximal phalanx, but all three of the palmar interossei
send oblique or spiral fibers to insert on the lateral tubercle of the middle phalanx. In
general, the three palmar interosseous muscles face the middle finger metacarpal. The
ulnar lateral band of the small finger is formed by the tendinous continuation of the
ADM.
Function of Palmar Interosseous.
Based on their anatomic position and insertions, it is easy to recognize that these muscles
act as adductors of their respective fingers toward the middle finger (the central axis),
flex the proximal phalanx, and extend the middle phalanx through their distal
continuation. Because the deep portions of the distal and the palmar interossei most often
are inserted into the hood mechanism, their action depends to some extent on the position
of the MCP joint and thus of the hood. When the MCP joint is in extension, the hood is
adjacent to the MCP joint, and the interossei are under tension and extend the middle and
distal phalanges. When the MCP joint is in flexion, the hood is more distal and acts as a
sling about the dorsal and proximal aspect of the proximal phalanx; when the interossei
contract, they act as flexors of the MCP joint. When the MCP joint is flexed, the
interossei cannot extend the middle and distal phalanges
Lumbrical Muscles
The lumbrical muscles are comparatively small intrinsics that arise from the flexor
digitorum profundus (FDP) tendons. The first and second lumbricals arise from the radial
and palmar surfaces of the index and long finger FDP tendons, the third from the adjacent
sides of the long and ring finger FDP, and the fourth from the adjacent sides of the ring
and small finger FDP tendons. The first and second lumbricals are unipennate and the
third and fourth bipennate. The tendon of each lumbrical passes palmar to the transverse
metacarpal ligament and, in general, joins the radial lateral band of each finger.
Insertion of the Lumbricals.
The usual pattern of insertion of the lumbricals is into the radial side of the extensor
hood, as demonstrated by the second lumbrical. Exceptions in the remaining lumbricals
noted by Eyler and Markee included: first lumbrical, small bony insertions into the index;
third lumbrical, insertion into the ulnar side of the long finger, bifid insertion (radial side
of ring finger and ulnar side of long finger), bony insertion; fourth lumbrical, ulnar side
of ring finger, bifid insertion (radial side of small finger, ulnar side of ring finger), and
part into bone and part into expansion
Function of the Lumbricals.

Various functions have been ascribed to the lumbricals, including the initiation of flexion
of the MCP joints, extension of the interphalangeal joints, flexion of the MCP joint, radial
deviation of the fingers, and pulling the FDP distally to allow the interphalangeal joints to
be more easily extended (64). Pulling distally on the FDP when this muscle is at rest
permits a reduction in the viscoelastic resistance of the FDP and indirectly facilitates the
action of the common extensor on the middle and distal phalanges . In contrast to the
interossei, the lumbricals may extend the middle and distal phalanges with the MCP joint
in flexion. In a low ulnar nerve lesion, the lumbricals acting alone may stabilize the MCP
joints and extend the interphalangeal joints of the index and middle fingers. When the
lumbrical contracts, it pulls the FDP distally and the lateral band proximally, resulting in
decreased force in the FDP, which allows more effective extension of the PIP and DIP
joints by the lumbrical. When the lumbrical and FDP contract together, interphalangeal
joint flexion may be limited. As the tips of the fingers close in a grasp, lumbrical tension
increases, and when grasp is almost complete, the lumbricals contribute most to flexion.
An important function of the lumbricals is to stabilize the MCP joint and to contribute to
the force of the final phase of grasp . Perhaps their most important function is
interphalangeal extension, after which they may act as MCP flexors
Extrinsic Extensors and Dorsal Aponeurosis
The extensor digitorum communis (EDC) and the index and small finger proprius
tendons join the extensor expansion at the MCP joint . These tendons are maintained over
the apex of the MCP joint by a substantial dorsal sling of transverse fibers, the sagittal
band, which invest the tendon dorsally and pass palmarward on each side of the MCP
joint to attach to the palmar plate and the transverse metacarpal ligament. The extensor
mechanism at the level of the proximal aspect of the finger is composed of a layered
criss-cross fiber pattern, which changes its geometric arrangement as the finger flexes
and extends. This arrangement allows the lateral bands to be displaced volarly in flexion
and to return to the dorsum of the finger in extension. The sagittal band acts as a static
tether to prevent radial or ulnar displacement of the extensor mechanism and also acts as
a dynamic tether that allows proximal and distal gliding of the extensor tendons during
finger flexion and extension. The sagittal bands are positioned between the tendons of
insertion of the superficial and deep components of the DI musculotendinous unit. This
arrangement allows freedom of movement to the sagittal band in the plane between the
two components of the DI and avoids impingement between the sagittal band and the
lateral band formed by the deep component of the DI or the palmar interosseous.
Function of the Extrinsic Extensors
Contraction of the extensors results in extension of the proximal phalanx by the proximal
phalangeal attachments of the sagittal bands. Hyperextension is avoided by the tethering
effect of the palmar plate and the intrinsic muscles, which insert into the extensor
expansion.
Distal Anatomy of the Extrinsic Extensors
Distal to the MCP joint, the extensor tendon divides into three components: the central
slip, which inserts into the dorsal base of the middle phalanx, and two lateral slips that
join the lateral bands at the distal aspect of the proximal phalanx. Smith has appropriately

called this union of the intrinsic muscle lateral bands and the lateral slips from the
extensor tendon the conjoined lateral bands (67). The lateral bands, at approximately the
middle portion of the middle phalanx, send slips to the central tendon. However, this
exchange of slips between the central portion of the extensor tendon and the lateral bands
(and vice versa) is best appreciated in special anatomic preparations, and may not always
be readily apparent in the operating room. The conjoined lateral bands fuse over the
middle phalanx to form the terminal tendon, which inserts into the dorsal base of the
distal phalanx. The transverse retinacular ligament, which spans between the lateral bands
and the flexor canal at the PIP joint, prevents dorsal migration of the lateral bands . The
triangular ligament maintains the conjoined lateral bands dorsally over the proximal
aspect of the middle phalanx.
Patterns of Deformity and Functional Loss Due to Intrinsic Muscle Weakness or Absence
Low Ulnar Nerve Palsy.
This pattern refers to denervation of the ulnar-innervated intrinsic muscles in the hand.
Thus, in general, the thenar muscles are spared along with the radial lumbrical muscles.
The resultant deformity is characterized by clawing of only the ring and small fingers.
Clawing of the index and middle fingers would not occur because of the median nerve
innervation of the radial two lumbricals. In addition to the clawing of the ring and small
fingers, there is loss of grip strength and abduction and adduction of the fingers. Attempts
to extend the ring and small fingers are associated with hyperextension of the MCP joints
because of the unopposed action of the EDC.
High Ulnar Nerve Palsy.
At this level, the innervation of the FCU and FDP to the ring and small fingers is lost, in
addition to the intrinsics. The resultant effect on the fingers is similar to the low ulnar
nerve lesion, except that the clawing is less severe, but the grip loss is more significant
Low Ulnar and Median Nerve Palsy.
In this lesion, the function of all intrinsic, thenar, and hypothenar muscles is lost. There is
significant loss of grip strength, clawing of all fingers, loss of abduction and adduction of
the fingers, and loss of opposition of the thumb. The loss of intrinsic flexion at the MCP
joint allows the unopposed long extensors to hyperextend the MCP joints during attempts
at finger extension. Extension of the middle and distal joints is lost, and the unopposed
action of the FDS and FDP accentuates the claw deformity.
High Ulnar and Median Nerve Palsy.
In this lesion, there is loss of all intrinsic muscle function as well as the extrinsic flexors.
Only the EDC is functional, and no claw deformity is present. When the EDC contracts,
the MCP joints hyperextend, along with extension of the interphalangeal joints. If the
median and ulnar nerves are successfully repaired, clawing may develop as the FDS and
FDP are reinnervated

Palmar Fascia
The palmar fascia is defined as the specialized fascial structure in the central portion of
the palm with longitudinal, transverse, and vertical fibers . It is distinguished from the
fascial covering of the thenar and hypothenar eminences by its triangular shape and
thickness. The longitudinal fibers represent the distal continuation of the palmaris longus
(when present). These fibers, which begin as a conjoined apex at the base of the palm,
form bundles in the middle and distal palm that course to the corresponding four fingers
and in some instances to the thumb. The longitudinal fibers are more or less parallel to
the deeper flexor tendons, and because of this arrangement sometimes are called
pretendinous bands. The four bundles of longitudinally oriented fibers overlay transverse
fibers in the palm that are located at the junction of the middle and distal thirds of the
palm and over the MCP joints. McGrouther has noted that these longitudinal fibers divide
into three layers in the distal palm (2). Layer one, the most superficial, inserts into the
skin of the distal palm and onto the proximal aspect of the flexor sheath. Layer two splits
and passes on each side of the flexor sheath, where it continues distally as the spiral band
of Gosset beneath the neurovascular bundle and natatory ligaments to insert on the
lateral digital sheet. Layer three passes on each side of the flexor sheath to the region of
the MCP joint (85). The transverse fibers of the palmar fascia course beneath the
longitudinal cords from the ulnar side of the small finger to the radial side of the index
finger. In the thumb-index finger web space, the proximal commissural ligament (PCL) is
the radial continuation of these transverse fibers. The more distal counterpart of the PCL
is the distal commissural ligament (DCL), which is more longitudinally oriented and
spans the space between the MCP joint of the thumb and index finger. Both the PCL and
DCL course toward the thumb MCP joint, where they send attachments to the
undersurface of the skin in the region of the MCP joint; the deep portion of the DCL
sends fibers to attach on both sides of the FPL sheath . The more longitudinal orientation
of the DCL may be a factor in its more likely involvement in Dupuytren's contracture,
although both the DCL and PCL may be involved in Dupuytren's contracture .
The PCL and DCL usually are thinner and less noticeable than the transverse fibers
between the fingers. Both the longitudinal and transverse fibers course through the
vertical septa to reach the transverse metacarpal ligament. The third component of the
palmar fascia consists of the nine vertical (sagittal) septa (the fibers of Legueu and
Juvara) located deep to the transverse fibers, which form the sides of eight canals: four of
which contain the underlying finger flexor tendons, and four adjacent canals that contain
the lumbrical muscles and neurovascular bundles. These paratendinous septa, along with
the transverse fibers of the palmar aponeurosis, form a fibrous tunnel system that has
been described as the palmar aponeurosis pulley. These nine vertical septa are anchored
to the transverse metacarpal ligament, palmar interosseous, and adductor fascia. BojsenMoller and Schmidt noted that these vertical septa divided the distal portion of the central
palmar space into eight canals . Although these vertical septa are not classically
considered as part of the palmar aponeurosis, the authors consider them to be an integral
component of the palmar fascia, and they therefore are included here.
.
Natatory Ligaments

These ligaments, located in the web spaces between the fingers, also are called the
superficial transverse metacarpal ligament . They are the superficial counterpart to the
more proximal deep transverse metacarpal ligament, which spans between the palmar
plates of the four finger metacarpals.
Clinical Significance of the Palmar Retinacular System
Compression Loading/Shock Absorbing Any discussion of the role of the palmar
retinacular structures must note that these structures are only a part of a complex tissue
consortium designed to meet a variety of functional demands. This complex threedimensional network may be considered as a fibrous skeleton or framework designed to
assist in the hand's mechanical functions. Compression loading is a common force
applied to the hand and requires a system of shock absorption. In the hand, one method of
shock absorption is to contain somewhat compliant tissues such as fat or muscle in
compartments that can change shape but not volume. This is amply demonstrated in the
palm, with its various layers of multidirectional fascia that contain and compartmentalize
fat and muscle while at the same time conforming to the shape or contour of the object
being grasped or manipulated.
Skin Anchorage
Skin is retained by fascial elements that allow the hand to flex while maintaining the skin
in position. The skin folds at prominent creases that are minimally anchored, in contrast
to the skin on the adjacent sides of the crease, which possess multiple strong anchor
points. This allows the relatively unanchored skin to fold while the anchored skin is held
in place. These fascial anchors may be vertical, horizontal, or oblique, depending on the
specific need of the skin envelope. A good example is the horizontal attachments of the
superficial fibers of the pretendinous bands, which attach to the dermis of the distal palm.
This arrangement resists horizontal shearing force in gripping actions such as holding a
hammer or golf club. The palmar aponeurosis, which includes the nine vertical septa
anchored to the deep transverse metacarpal ligament, is tensed with power grip and thus
anchors the skin to the skeleton of the hand
Skeletal Stability
Although not a part of the palmar fascia, the previously mentioned transverse metacarpal
ligament that attaches to the palmar plates of the MCP joints plays a role in maintaining
the transverse metacarpal arch, as do the transverse fibers of the palmar fascia and the
natatory ligaments
Joint Stability
The fascial ligaments in the web space of the finger and thumb may play a role in
limiting abduction and thus may indirectly limit the impact of potentially destabilizing
forces that might be applied to the digits.
Pulley Function
The transverse fibers of the palmar fascia, supported by the vertical septa, form what is
called the palmar aponeurosis pulley, and is discussed later in the section on the Pulley
System.

Radial Bursa
The radial bursa is the FPL synovial sheath that extends from the region of the
interphalangeal joint of the thumb to 2.5 cm proximal to the wrist flexion crease
The ulnar bursa is the synovial sheath that surrounds the FDS and FDP tendons in the
palm and wrist. It begins proximally at approximately the same level as the radial bursa
and continues distally to the region of the midpalm.
Wrist Space
The central compartment of the palm narrows proximally toward the carpal canal and is
connected through this canal to a space in the palmar aspect of the wrist (88). The name
Parona has been associated most often with this non-synoviallined space on the flexor
side of the wrist, which is located between the flexor tendons and the pronator quadratus
muscle and bounded radially by the FCR and ulnarly by the FCU and antebrachial fascia
Tendons
Nine extrinsic flexor tendons enter the hand through the carpal tunnel, the FDS and the
FDP to the four fingers, and the FPL to the thumb . The synovial sheaths and retinacular
constraints of these nine tendons have been presented in the preceding section.
Vascular Supply of the Flexor Tendons in Their Sheath
Terminology
The following terminology must be introduced at this time: a vinculum (singular) is a
specialized form of vascularized mesotenon adapted to function in the confines of the
flexor tendon synovial sheath. The plural of vinculum is vincula. A vinculum may be long
and filamentous (thus the words longum for singular and longa for plural) or short and
mesentery-like (breve for singular and brevia for plural). Having explained this
terminology, which often is encountered in descriptions of this unique vascular system,
the authors of this text propose to adopt and occasionally use the following conventions
when addressing these specialized forms of mesotenon. Both singular and plural forms
may be abbreviated along with the tendon they enter; thus, the notation VBP could
represent the singular or plural form. It may be interpreted as vinculum breve profundus
or vincula brevia profundus, but means a short, specialized form of mesotenon that
enters the profundus tendon. These abbreviations may be used occasionally, and it is
hoped that the adoption of this convention will aid the reader in his or her understanding
of this system.
Sources of Vascular Supply
In general, the vascular supply to the flexor tendons in the synovial sheath is from (a)
intrinsic longitudinal vessels in continuation from the palm region; (b) synovial
attachments to the enclosed flexor tendons in the proximal sheath; and (c) specialized
forms of mesotenon, the vincula, located inside the sheath.
SURGICAL EXPOSURES
General Principles
Elective Incisions in the Palm and Digits

Improperly placed incisions in the hand, especially in the palm and flexor aspect of the
fingers and thumb, have a great potential not only for being cosmetically unacceptable
but also for producing thick, heavy scars that may limit function. Incisions that cross
palmar or digital flexion creases at right angles uniformly result in a scar that limits
function. Incisions that parallel these creases or cross at oblique angles are less likely to
result in unfavorable scars. In general, skin incisions should be centered over the
operative site, but if moving the incision a few millimeters would improve the cosmetic
result, this should be considered. Skin incisions may be placed in skin creases as long as
invagination of the skin is avoided during closure. Skin flaps should be as thick as
possible, have broad bases, undermined only to the extent required, and handled gently,
especially at their tips.
Structures at Risk
structures are the proper sensory nerves to the radial side of the index finger and the
ulnar side of the small finger; the recurrent motor branch of the median nerve at the base
of the thenar eminence; and the radial digital nerve of the thumb adjacent to the A1
pulley. The index and small finger nerves are at risk with transverse incisions in the distal
aspect of the palm. The motor branch is at risk with any incision about the base of the
thenar eminence, and the radial sensory nerve of the thumb is at risk with trigger thumb
release.
Indications
Surgical incisions in the palm and digits may be required for the management of tumors,
aneurysms, Dupuytren's disease, flexor tendon or blood vessel lacerations, tendon grafts,
sheath infections, stenosing flexor tenosynovitis, harvesting of full-thickness skin grafts,
nerve injuries, and joint dislocations.
Landmarks
Useful landmarks include the thenar and hypothenar eminences, the thenar, proximal, and
distal palmar creases, and the proximal, middle, and distal digital flexion creases.
Patient Position
In general, the upper extremity is positioned on a well padded arm table with the forearm
in supination. The required position of the upper extremity usually is evident and is
presented as required.
Elective Incisions in the Palm, Fingers, and Thumb
Vertical
Although incisions in the palm often are transverse, they may be vertical if they do not
cross a flexion crease. Such vertical incisions are most useful in the distal palm for
stenosing tenosynovitis of the flexor tendons of the fingers.
The Zig-Zag
The zig-zag incision, initially designed for use in the flexor aspect of the finger, is a
useful incision in the palm. This incision allows crossing of the palmar creases at oblique

angles and can provide a comprehensive exposure when needed. Ideally, the points or tips
of the skin flaps should form an angle of 90 degrees or more.
Mid-Axial Incision
This incision was advocated by Bunnell and was used by him for primary tendon repair
and flexor tendon grafts. It was used extensively by Boyes and Stark for flexor tendon
grafts. The mid-axial incision centered over the respective joint also may be used to
expose the PIP and DIP joints.