Dr. Ahmed Fathalla Ibrahim

THE SKIN

1. Flexure creases (lines of palm)

2. Papillary ridges (fingerprints): improve grip & increase surface area

3. Abundant sweat gland

SUPERFICIAL FASCIA

1. Contains: cutaneous nerves & vessels

2. Contains: Palmaris brevis

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 FASCIA

Flexor 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 FASCIA

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

SEGMENTS THROUGH SEGMENTS THROUGH MEDIAN & ULNAR NERVESMEDIAN & ULNAR NERVES

INTRINSIC MUSCLES

THENAR MUSCLESTHENAR MUSCLES

THENAR MUSCLESTHENAR MUSCLES1. Abductor pollicis brevis2. Flexor pollicis brevis3. Opponens pollicis4. Adductor pollicisN.B.:• Muscles # 1, 2, 4 are inserted into the

proximal phalanx of thumbproximal phalanx of thumb: act on MP & CM joints of thumb

• Muscle # 3 is inserted into 11stst metacarpal metacarpal bonebone: opposition of CM joint of thumb (abduction + flexion + medial rotation)

HYPOTHENAR MUSCLESHYPOTHENAR MUSCLES

HYPOTHENAR MUSCLESHYPOTHENAR MUSCLES• Abductor digiti minimi• Flexor digiti minimi• Opponens digiti minimiN.B.:• Muscles # 1, 2 are inserted into the

proximal phalanx of little fingerproximal phalanx of little finger: act on MP joint of little finger

• Muscle # 3 is inserted into 55thth metacarpal metacarpal bonebone: rotates 5th metacarpal bone

LUMBRICALSLUMBRICALS

1.1. Origin:Origin: tendons of FDP

2.2. Insertion:Insertion: tendons of ED

3.3. Action:Action: Writing positionWriting position (flexion of MP & extension of IP joints of medial 4 fingers

INTEROSSEIINTEROSSEI• PALMAR INTEROSSEIPALMAR INTEROSSEI

1.Origin: metacarpal bone

2.Insertion: proximal phalanx

3.Action: Adduction of fingers (PAD)(PAD)• DORSAL INTEROSSEIDORSAL INTEROSSEI

1.Origin: adjoining sides of 2 metacarpal bone

2.Insertion: proximal phalanx

3.Action: Abduction of fingers (DAB)(DAB)

PALMARIS BREVIS

1.1. Origin:Origin: Palmar aponeurosis

2.2. Insertion:Insertion: skin of medial border of hand

3.3. Action:Action: deepening the hollow of palm to get a firmer grip

ARTERIAL ARCHES IN HAND

• SUPERFICIAL PALMAR ARCH

• DEEP PALMAR ARCH

1. Formation

2. Site

3. Surface anatomy

4. Branches

SUPERFICIAL PALMAR ARCH

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

tendons• SURFACE ANATOMY:SURFACE ANATOMY: level with the distal border

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

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

the lateral one & half fingers:1.1. Radialis indicis:Radialis indicis: supplies lateral side of index2.2. Princeps pollicis:Princeps pollicis: supplies both sides of thumb

DEEP PALMAR ARCH

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

metacarpal bones• SURFACE ANATOMY:SURFACE ANATOMY: lies one inch

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

wrist joint2. Articular & muscular branches

ULNAR NERVE IN THE HANDULNAR NERVE IN THE HAND

• MUSCULAR BRANCHES:MUSCULAR BRANCHES: 1. Palmaris brevis2. Adductor pollicis3. Hypothenar muscles4. Interossei5. Medial two lumbricals• CUTANEOUS BRANCHES: CUTANEOUS BRANCHES:

Palmar digital to medial 1 ½ fingers

MEDIAN NERVE IN THE HANDMEDIAN NERVE IN THE HAND

• MUSCULAR BRANCHES:MUSCULAR BRANCHES:

1. Abductor pollicis brevis

2. Flexor pollicis brevis

3. Opponens pollicis

4. Lateral two lumbricals

• CUTANEOUS BRANCHES: CUTANEOUS BRANCHES:

Palmar digital to lateral 3 ½ fingers