Dr. Ahmed Fathalla Ibrahim

THE SKIN• PALM: characteristics:1. Flexure creases (lines of palm)2. Papillary ridges (fingerprints):

improve grip & increase surface area3. Fibrous bands connecting it to palmar

aponeurosis & dividing subcutaneous fat into small loculi (water-cushion withstanding considerable pressure)

4. Abundant sweat gland

SUPERFICIAL FASCIA• PALM: characteristics:1. Contains: cutaneous nerves & vessels2. Contains: Palmaris brevis (increases

the hollow of palm to get a firmer grip

DEEP FASCIA• PALM: thickened

at 3 sites:Palmar aponeurosis:• Definition• Description• Function• Clinical anatomy:

Dupuytren’s contracture

PALMAR APONEUROSIS• DEFINITION: It is a thickening of deep fascia in the

middle of the palm• DESCRIPTION: It is triangular in shape:1. Apex: directed proximally, continuous with tendon of

palmaris longus2. Base: directed distally, divided into 4 slips for the

medial 4 fingers3. Margins: send septa to metacarpal bones separating

the structures under the aponeurosis from thenar & hypothenar muscles

• FUNCTION: It protects the underlying tendons, vessels & nerves

• CLINICAL ANATOMY: DUPUYTREN’S CONTRACTURE: shortening of the medial part of aponeurosis resulting in flexion of the little & ring fingers

DEEP FASCIAFlexor retinaculum:• Definition• Attachments• Relations• Functions• Clinical anatomy:

Carpal tunnel syndrome

FLEXOR RETINACULUM• DEFINITION: It is a thickening of deep fascia

that lies over the front of the carpal bones converting the carpal groove (formed by carpal bones) into a tunnel

• ATTACHMENTS: 1. Lateral: by 2 laminae: superficial (to

tubercles of scaphoid & trapezium) & deep (to the medial lip of the groove on the trapezium)

2. Medial: to pisiform & hook of hamate

FLEXOR RETINACULUM• RELATIONS: • Superficial: from lateral to medial:1. Superficial palmar branch of radial artery2. Palmar cutaneous branch of median nerve3. Tendon of palmaris longus4. Palmar cutaneous branch of ulnar nerve5. Ulnar vessels6. Ulnar nerve• Deep: Structures passing through carpal tunnel1. Tendon of FPL & its synovial sheath (radial bursa)2. Tendons of FDS & FDP & their common synovial sheath (Ulnar

bursa)3. Tendon of FCR & its synovial sheath ( in a special compartment)4. Median nerve

FLEXOR RETINACULUM• FUNCTION: It keeps the flexor tendons

in position during movement of wrist joint

• CLINICAL ANATOMY (CARPAL TUNNEL SYNDROME): Compression of median nerve under the flexor retinaculum

DEEP FASCIAFibrous flexor sheaths• Definition• Attachments• Function

FIBROUS FLEXOR SHEATH• DEFINITION: It is a thickening of deep

fascia in front of the fingers• ATTACHMENTS: 1. Proximal: to the slips of palmar

aponeurosis2. Distal: to the base of distal phalanx3. On either side: to the side of phalanx• FUNCTION: It holds the long flexor

tendons during flexion of the fingers

INTRINSIC MUSCLES• LATERAL GROUP: FOUR THENAR MUSCLES• MEDIAL GROUP: THREE HYPOTHENAR MUSCLESPALMARIS BREVIS• CENTRAL GROUP: FOUR LUMBRICALSFOUR PALMAR INTEROSSEIFOUR DORSAL INTEROSSEI• ALL MUSCLES ARE SUPPLIED BY C8 & T1 SPINAL

SEGMENTS THROUGH MEDIAN & ULNAR NERVES

INTRINSIC MUSCLES• THENAR MUSCLES:THENAR MUSCLES:1. Abductor pollicis brevis2. Flexor pollicis brevis3. Opponens pollicis4. Adductor pollicis• HYPOTHENAR MUSCLES:HYPOTHENAR MUSCLES:1. Abductor digiti minimi2. Flexor digiti minimi3. Opponens digiti minimi

INTRINSIC MUSCLES

INTRINSIC MUSCLES• THENAR MUSCLES1. Have general origin (lateral side of flexor retinaculum

& lateral 2 carpal bones: scaphoid & trapezium) EXCEPT adductor pollicis (transverse head: 3rd metacarpal bone, oblique head: 2nd & 3rd metacarpal + 2nd & 3rd carpal bones: trapezoid & capitate)

2. Have general insertion (proximal phalanx of thumb) EXCEPT opponens pollicis (1st metacarpal)

• HYPOTHENAR MUSCLES1. Have general origin (medial side of flexor retinaculum

& medial 2 carpal bones: pisiform & hamate2. Have general insertion (proximal phalanx of little

finger) EXCEPT opponens digiti minimi (5th metacarpal bone)

INTRINSIC MUSCLES• LUMBRICALS1. Origin: tendons of FDP2. Insertion: tendons of ED• PALMAR INTEROSSEI1. Origin: metacarpal bone 2. Insertion: proximal phalanx• DORSAL INTEROSSEI1. Origin: adjoining sides of 2 metacarpal bone 2. Insertion: proximal phalanx• PALMARIS BREVIS1. Origin: Palmar aponeurosis 2. Insertion: skin of medial border of hand

ARTERIAL ARCHES IN HAND • SUPERFICIAL

PALMAR ARCH• DEEP PALMAR

ARCH1. Formation2. Site3. Surface anatomy4. Branches

SUPERFICIAL PALMAR ARCH• FORMATION:1. Direct continuation of ulnar artery (mainly)2. Superficial branch of radial artery• SITE: between palmar aponeurosis & long flexor

tendons• SURFACE ANATOMY: level with the distal border

of the fully extended thumb• BRANCHES: digital branches to the medial three &

half fingers• N.B.: Radial artery gives 2 branches that supplies

the lateral one & half fingers:1. Radialis indicis: supplies lateral side of index2. Princeps pollicis: supplies both sides of thumb

DEEP PALMAR ARCH• FORMATION:1. Direct continuation of radial artery (mainly)2. Deep branch of ulnar artery• SITE: between long flexor tendons &

metacarpal bones• SURFACE ANATOMY: lies one inch

proximal to superficial palmar arch• BRANCHES: 1. Branches sharing in anastomosis around

wrist joint2. Articular & muscular branches

NERVES IN HANDCutaneous innervation

NERVES IN HAND Muscular innervation

• ULNAR NERVE:• SUPERFICIAL BRANCH: 1. Palmaris brevis• DEEP BRANCH:1. Adductor pollicis2. Hypothenar muscles3. Interossei4. Medial two lumbricals

NERVES IN HAND Muscular innervation

• MEDIAN NERVE:1. Abductor pollicis brevis2. Flexor pollicis brevis3. Opponens pollicis4. Lateral two lumbricals