Upper Limb: The Region of the Wrist, Hand 1

Wrist o Going thru a split in flexor retinaculum

- Common site of injury o Surrounded by a synovial sheath

ANTERIOR ASPECT OF THE WRIST

Flexor Retinaculum
- A thickening of deep fascia that holds the long flexor
tendons in position at the wrist
- Stretches across the front of the wrist
- Converts the anterior surface of the hand into an
osteofascial tunnel → carpal tunnel
o For the passage of the
 median nerve
 the flexor tendons of the thumb
and fingers
- Is attached
o medially to the pisiform bone and the hook
of the hamate
o laterally to the tubercle of the scaphoid and
trapezium bones
- attachment to the trapezium:
o consists of
 superficial part
 deep par
o forms a synovial-lined tunnel for passage of
the tendon of the flexor carpi radialis
- upper border:
o corresponds to the distal transverse skin
crease in front of the wrist
o is continuous with the deep fascia of the
forearm
- lower border:
o attached to the palmar aponeurosis

Structures pass superficial to the flexor retinaculum (medial

to lateral)
- Flexor carpi ulnaris tendon
o Ending on the pisiform bone
o Does not actually cross the flexor
retinaculum but is included for the sake of
completeness
- Ulnar nerve
o Lies lateral to the pisiform bone
- Ulnar artery
o Lies lateral to the ulnar nerve
- Palmar cutaneous branch of the ulnar nerve
- Palmaris longus tendon
o If present, passing to its insertion into the
flexor retinaculum and palmar aponeurosis
- Palmar cutaneous branch of the median nerve

Structures pass beneath the flexor retinaculum (medial to

lateral)
- Flexor digitorum superficialis tendons & tendons of
flexor digitorum profundus
1
o Share a common synovial sheath
- Median nerve
- Flexor pollicis longus tendon
o Surrounded by a synovial sheath
- Flexor carpi radialis tendon
Gichelle Grace Billena Villaflor | Snell, R. (2006) Clinical Anatomy by Regions 8th edition & Gray’s Anatomy for students
 Upper Limb: The Region of the Wrist, Hand 2

(medial to lateral)
- Extensor carpi ulnaris tendon
o Grooves the posterior aspect of the head of
the ulna
- Extensor digiti minimi tendon
o Situated posterior to the distal radioulnar
joint
- Extensor digitorum & extensor indicis tendons
o Share a common synovial sheath
o Situated on the lateral part of the posterior
surface of the radius
- Extensor pollicis longus tendon
o Winds around the medial side of the dorsal
tubercle of the radius
- Extensor carpi radialis longus and brevis tendons
o Share a common synovial sheath
o Are situated on the lateral part of the
posterior surface of the radius
- Abductor pollicis longus and the extensor pollicis
brevis tendons
o Have separate synovial sheaths but share a
common compartment
POSTERIOR ASPECT OF THE WRIST
- Beneath the extensor retinaculum, fibrous septa
Extensor Retinaculum
pass to the underlying radius and ulna → form 6
- a thickening of deep fascia that stretches across the
compartments
back of the wrist
o Contain tendons of the extensor mm
- holds the long extensor tendons in position
o Each is provided with a synovial sheath,
- converts the grooves on the posterior surface of the
which extends above & below the
distal ends of the radius and ulna into 6 separate
retinaculum
tunnels for the passage of long extensor tendons
o each is lined with a synovial sheath, w/c
extends above and below the retinaculum
on the tendons
o they are separated from one another by
fibrous septa that pass from the deep
surface of the retinaculum to the bones
- is attached
o medially to the pisiform bone and the hook
of the hamate
o laterally: to the distal end of the humerus
- upper and lower borders:
o are continuous with the deep fascia of the
forearm and hand respectively

Structures pas superficial to the extensor retinaculum

(medial to lateral)
- Dorsal (posterior cutaneous branch of the ulnar
nerve
- Basilic vein
- Cephalic vein
- Superficial branch of the radial nerve
2

Structures pas beneath to the extensor retinaculum

Gichelle Grace Billena Villaflor | Snell, R. (2006) Clinical Anatomy by Regions 8th edition & Gray’s Anatomy for students
 Upper Limb: The Region of the Wrist, Hand 3

PALM OF THE HAND

- Skin
o Thick & hairless
o Bound down to the underlying deep fascia
by numerous fibrous bands
o Shows many flexure creases at the site of
skin movement, which are not necessarily
placed at the site of joints
o Sweat glands are present in large numbers
o Sensory nerve supply:
 Palmar cutaneous branch of
median nerve
 Crosses in front of the
flexor retinaculum
 Supplies the lateral part of
the palm
 Palmar cutaneous branch of the
ulnar nerve
 Also Crosses in front of
the flexor retinaculum
 Supplies the medial part
of the palm
 Lateral cutaneous nerve of the
forearm / superficial branch of the
radial nerve
 Supplies the skin over the
base of the thenar
eminence
3

Gichelle Grace Billena Villaflor | Snell, R. (2006) Clinical Anatomy by Regions 8th edition & Gray’s Anatomy for students

Gichelle Grace Billena Villaflor
Upper Limb: The Region of the Wrist, Hand 4
Palmaris brevis
- A small muscle that arises from the
o Flexor retinaculum
o Palmar aponeurosis
- Insertion: skin of the palm
- NS: superficial branch of ulnar nerve
- Fxn: corrugate the skin at the base of the
hypothenar eminence & so improve the grip of the
palm in holding a rounded object
Deep Fascia
- Is thickened to form
o Flexor retinaculum
o Palmar aponeurosis
PALMAR APONEUROSIS
- Triangular
- Occupies the central area of the palm
- Apex:
o Attached to the distal border of the flexor
retinaculum
o Receives the insertion of the Palmaris
longus tendon
- Base:
o Divides at the bases of the fingers into 4
slips
 Each is divided into 2 bands
 One passing superficially
to the skin
 The other passing deeply
to the root of the finger
↓
here each band divides
into 2 w/ diverge around
the flexor tendons 4
↓
finally fuse with the
fibrous flexor sheath and
the deep transverse
ligaments
| Snell, R. (2006) Clinical Anatomy by Regions 8th edition & Gray’s Anatomy for students
 Upper Limb: The Region of the Wrist, Hand 5

- Medial & lateral borders o all 8 tendons of FDS and FDP invaginate a
o Continuous with the thinner deep fascia common synovial sheath form the lateral
covering the hypothenar and thenar mm side
o From each of these borders, fibrous septa  allows the arterial supply to the
pass posteriorly into the palm and take part tendons enter them from the
the formation of the palmar fascial spaces lateral side
- Fxn: o tendon of flexor pollicis longus mm
o to give firm attachment to the overlying  runs through the lateral part of the
skin tunnel in its own synovial sheath
o improve the grip and protect the underlying o median nerve
tendons  passes beneath the flexor
retinaculum in a restricted space
bet the flexor digitorum
CARPAL TUNNEL superficialis and the flexor carpi
Carpus radialis mm
- is deeply concave on its anterior surface
- forms a bony gutter FIBROUS FLEXOR SHEATH
↓ - from the head of the metacarpal to the distal base of
Converted into a tunnel by the flexor retinaculum the phalanx
- a strong fibrous sheath that is attached to the side of
- where Long flexor tendons to the fingers & thumb the phalanges
pass & are accompanied by the median nerve - proximal end: open
o the 4 separate tendons of the flexor - distal end: closed & is attached to the base of the
digitorum superficialis mm are arranged in phalanx
anterior & posterior rows - this sheath & bones form a blind tunnel in which the
 those to the middle and ring flexor tendons of the finger lie
fingers lying in front of those to the
index and little fingers
o at the lower border of flexor retinaculum --- OSTEOFIBROUS TUNNEL
the 4 tendons diverge - in the thumb
↓ - contains the tendon of the flexor pollicis longus
Become arranged on the same plane - is occupied by the tendons of the flexor digitorum
superficialis and profundus
- the fibrous sheath is
o thick over the phalanges
o thin and lax over the joints

SYNOVIAL FLEXOR SHEATHS

o tendons of flexor digitorum profundus mm
 are on the same plane
 lie behind the superficialis tendons
Gichelle Grace Billena Villaflor | Snell, R. (2006) Clinical Anatomy by Regions 8th edition & Gray’s Anatomy for students
- the tendons of the flexor digitorum superficialis and
profundus mm invaginate a common synovial sheath
from the lateral side
- medial part:
o extends distally w/o interruption on the
tendons of the little finger
- lateral part:
o stops abruptly on the middle of the palm
o the distal ends of the long flexor tendons of
the index, the middle, and the ring fingers
acquire digital synovial sheaths as they
enter the fingers
- flexor pollicis longus
o has its own synovial sheath that passes into
the thumb
- fxn: allows the long tendons to move smoothly, with
5
a minimum friction, beneath the flexor retinaculum
& fibrous flexor sheaths
- radial bursa
o synovial sheath of the flexor pollicis longus
 Upper Limb: The Region of the Wrist, Hand 6

o communicates with the common synovial SMALL MUSCLES OF THE HAND

sheath of the superficialis and profundus Include:
tendons (ulnar bursa) at the level of the - 4 lumbrical mm
wrist in about 50% of subjects - 8 interossei mm
- vincula longa & brevia - Short mm of the thumb
o are small vascular folds of synovial o Abductor pollicis brevis
membrane that connect the tendons to the o Flexor pollicis brevis Thenar eminence
anterior surface of the phalanges o Opponens pollicis
o resemble a mesentery o Adductor pollicis
o covey blood vessels to the tendons - Short mm of the little finger
o abductor digiti minim
o flexor digiti minimi brevis Hypothenar
eminence
o opponens digiti minimi

INSERTION OF THE LONG FLEXOR TENDONS

Each tendon of the flexor digitorum superficialis

↓
Enters the fibrous flexor sheath
↓
Opposite the phalanx, it divides into 2 halves, which pass
around the profundus tendon
↓
Meet on its deep or posterior surface, where partial
decussation of the fibers take place

- the superficialis tendon, having united again, divides

almost at once into 2 further slips, which are
attached to the borders of the middle phalanx
- each tendon of the flexor digitorum profundus, 6
having passed through the division of the
superficialis tendon, continues downward, to be
inserted into the anterior surface of the base of the
distal phalanx

Gichelle Grace Billena Villaflor | Snell, R. (2006) Clinical Anatomy by Regions 8th edition & Gray’s Anatomy for students
 Upper Limb: The Region of the Wrist, Hand 7

SHORT MUSCLES OF THUMB

Muscle
Abductor pollicis brevis
Flexor pollics brevis
Opponens pollicis
Adductor pollicis
O I NS A
Schaphoid, trapezium, Base of proximal Median nerve Abduction of thumb
flexor retinaculum phalanx of thumb
Flexor retinaculum Base of proximal Median nerve Flexes
phalanx of thumb metacarpophalangeal
joint of thumb
Flexor retinaculum Shaft of metacarpal Median nerve Pulls thumb medially &
bone of thumb forward across palm
Oblique head - 2nd & 3rd Base of proximal Deep branch of ulnar Adduction of thumb
metacarpal bones phalanx of thumb nerve
rd
Transverse head - 3
metacarpal bone

SHORT MUSCLES OF LITTLE FINGER

Muscle
Adductor digiti minimi
Flexor digiti minimi
Opponens digiti minimi
O I
Pisiform bone Base of proximal
phalanx of little finger
Flexor retinaculum Base of proximal
phalanx of little finger
Flexor retinaculum Medial border of 5th
metacarpal bone
NS A
Deep branch of ulnar Abducts little finger
nerve
Deep branch of ulnar Flexes little finger
nerve
Deep branch of ulnar Pulls 5th metacarpal
nerve forward as in cupping
the palm

Gichelle Grace Billena Villaflor | Snell, R. (2006) Clinical Anatomy by Regions 8th edition & Gray’s Anatomy for students

ARTERIES OF THE PALM
Gichelle Grace Billena Villaflor
Upper Limb: The Region of the Wrist, Hand 8
Ulnar artery
- enters the hand
o anterior to the flexor retinaculum
o on the lateral side of the ulnar nerve & pisiform
bone
- gives off a deep branch then continues into the palm as
the superficial palmar branch
- branches:
o Superficial palmar arch
 A direct continuation of ulnar artery
 On entering the palm, it curves laterally behind
the palmar aponeurosis & in front of the long
flexor tendons
 Is completed on the lateral side by one of the
branches of the radial artery
 The curve of the arch lies across the palm, level
8
with the distal border of the fully extended
thumb
o Digital arteries
 Arise from the convexity of the arch & pass to
the fingers
o Deep branch of the ulnar artery
| Snell, R. (2006) Clinical Anatomy by Regions 8th edition & Gray’s Anatomy for students
 Upper Limb: The Region of the Wrist, Hand 9

 Arises in front of the flexor retinaculum NERVES OF THE PALM

 Passes between the abductor digiti minimi &
flexor digiti minimi
 Joins the radial artery to complete the deep
palmar arch

Radial artery
- Leaves the dorsum of the hand by turning forward
between the proximal ends of the 1st and 2nd metacarpal
bones & the 2 heads of the 1st dorsal interosseous mm
- On entering the palm, it cruves medially between the
oblique & transverse heads of the adductor pollicis &
continues as the deep palmar arch
o a direct continuation of radial artery
o curves medially beneath the long flexor tendons
and in front of the metacarpal bones and the
interosseous mm
o it is completed on the medial side by the deep
branch of the ulnar artery
o the curve of the arch lies at a level with the
proximal border of the extended thumb
o sends branches Median nerve
 superiorly: which take part in the anastomosis - enters the palm by:
around the wrist joint o passing behind the flexor retinaculum
 inferiorly: to jon the digital branches of the o through the carpal tunnel
superficial palmar arch - it immediately divides into:
- branches in the palm o lateral branches
o arteria radialis indicis o medial branches
 a branch of radial artery when it immediately - Branches:
enters the palm o Muscular branch
 Supplies the lateral side of the finger  takes a recurrent course around the lower
o arteria princeps pollicis border of flexor retinaculum
 divides into 2 and supplies the lateral and  lies about one fingerbreadth distal to the
medial sides of the thumb tubercle of the scaphoid
 supplies the muscles of:
VEINS OF THE PALM  thenar eminence
- superficial & deep palmar arterial arches  first lumbrical mm
→accompanied by superficial & deep palmar o Cutaneous branches
venous arches, receiving corresponding  supply:
tributaries
 palmar aspect of the lateral 3½fingers
 distal half of dorsal aspect of each finger
LYMPH DRAINAGE OF PALM
o Palmar cutaneous branch
 Lymph vessels of fingers
 given off in front of the forearm
– pass along their borders to reach the webs→ascend
 crosses anterior to the flexor retinaculum
onto dorsum of hand
 supplies skin over the lateral part of the palm
 Lymph vessels on palm
– form a plexus; drained by vessels that ascend in front
of forearm/pass around the medial&lateral borders to
join vessels on dorsum of hand
 Lymph from medial side of hand
– ascends in vessels that accompany basilica vein
– drain into supratrochlear nodes
– ascend to drain into lateral axillary nodes
 Lymph from lateral side of hand
9
– ascends in vessels that accompany cephalic vein
– drain into infraclavicular nodes
– some drain into lateral axillary nodes

Gichelle Grace Billena Villaflor | Snell, R. (2006) Clinical Anatomy by Regions 8th edition & Gray’s Anatomy for students
 Upper Limb: The Region of the Wrist, Hand 10

 cutaneous branches
o palmar aspect of the medial side of
the little finger
o adjacent sides of the little and ring
fingers
 supplies distal half of the dorsal aspect
of each finger
o deep terminal branch
 runs backward between the abductor digiti
minimi and the flexor digiti minimi
 pierces the opponens digiti minimi
↓
Winds around the lower border of the hook of
the hamate
↓
Passes laterally within the concavity of the deep
palmar branch

 lies behind the long flexor tendons and in front

of the metacarpal bones and interosseous mm
 branches:
 Muscular branches
o 3 mm of hypothenar eminence
 all palmar & dorsal interossei
 3rd & 4th lumbrical mm
 Both heads of the adductor pollicis mm
 Palmar cutaneous branch
o Given off in front of the forearm
o Crosses anterior to the flexor
retinaculum
o Supplies the skin over the medial
part of the palm

FASCIAL SPACES OF THE PALM

- are potential spaces filled with loose connective
tissue
- their boundaries are important clinically because
they may limit the spread of infection in the palm
Ulnar nerve - triangular palmar aponeurosis
- enters the palm anterior to the flexor retinaculum o fans out from the lower border of the flexor
alongside the lateral border of the pisiform bone retinaculum
- as it crosses the retinaculum, it divides into: o from its:
o superficial branch  medial border: a fibrous septum
 descends into the palm, lying in the passes backward & it is attached
subcutaneous tissue between the pisiform to the anterior border of the 5th
bone and the hook of the hamate metacarpal bone
 ulnar artery is on its lateral side  medial to this septum is a
 the ulnar nerve & artery may lie in a fibro- fascial compartment
osseous tunnel, the tunnel of Guylon covering the 3
 created by fibrous tissue derived from hypothenar mm
nd
the superficial part of the flexor  lateral border: a 2 fibrous septum
retinaculum passes obliquely backward to the 1
anterior border of the 3rd
 the nerve may be compressed at this 0
site giving rise to clinical signs and metacarpal bone
symptoms  usually the septum passes
 branches: between the long flexor
 muscular branch to Palmaris brevis
Gichelle Grace Billena Villaflor | Snell, R. (2006) Clinical Anatomy by Regions 8th edition & Gray’s Anatomy for students
 Upper Limb: The Region of the Wrist, Hand 11

tendons of the index and  divides into several dorsal digital

middle fingers nerves that supply the
 this septum divides the  thumb
palm into the thenar  index and middle fingers
space (lateral to the  lateral side of the ring
septum) & the finger
midpalmar space  variation --- the area of
(medial to the septum) skin on the back of the
 both are closed proximally hand and fingers
by the walls of carpal  frequently, a dorsal digital nerve,
tunnel a branch of the ulnar nerve, also
 distally the 2 spaces are supplies the lateral side of the
continuous with the finger
appropriate lumbrical
canals
1. fascial compartment covering the 3 hypothenar mm
o unimportant clinically
2. thenar space
nd
o lateral to the 2 fibrous septum
st
o contains the 1 lumbrical mm
o lies posterior to the long flexor tendons to
the index finger & in front of the adductor
pollicis mm
3. midpalmar space
o medial to the 2nd fibrous septum
o contains the 2nd, 3rd, & 4th lumbrical mm
o lies posterior to the long flexor tendons to
the middle, ring, and little fingers
o lies in front of the interossei & the 3rd, 4h,
and 5th metacarpal bones
4. lumbrical canal
o a potential space surrounding the tendon of
each lumbrical mm
o is normally filled with connective tissue
o proximally, it is continuous with one of the o posterior cutaneous branch of the ulnar
palmar spaces nerve
 winds around the ulna deep to the
flexor carpi ulnaris tendon
↓
Descends over the extensor
retinaculum
↓
THE DORSUM OF THE HAND Supplies the medial 3rd of the
Skin dorsum of the hand
- thin
- hairy  divides into several dorsal digital
- freely mobile on the underlying tendons and bones nerves that supply the medial side
- sensory nerve supply: of the ring and the sides of the
o superficial branch of the radial nerve little fingers
 winds around the radius deep to
the brachioradialis tendon
↓ DORSAL VENOUS ARCH (or NETWORK)
Descends over the extensor
1
retinaculum
1
↓
Supplies the lateral 2/3 of the
dorsum of the hand

Gichelle Grace Billena Villaflor | Snell, R. (2006) Clinical Anatomy by Regions 8th edition & Gray’s Anatomy for students
 Upper Limb: The Region of the Wrist, Hand 12

Figure 7.99 Dorsal interossei (palmar view).

Figure 7.100 Palmar interossei (palmar view).

Other images:

1
2

Gichelle Grace Billena Villaflor | Snell, R. (2006) Clinical Anatomy by Regions 8th edition & Gray’s Anatomy for students
 Upper Limb: The Region of the Wrist, Hand 13

Figure 7.103 Lumbrical muscles.

1
3

Gichelle Grace Billena Villaflor | Snell, R. (2006) Clinical Anatomy by Regions 8th edition & Gray’s Anatomy for students
 Upper Limb: The Region of the Wrist, Hand 14

CLINICAL CONSIDERATIONS o extension

DUPUYTREN’S CONTRACTURE
- a localized thickening and contracture of the palmar
aponeurosis
- commonly starts near the root of the ring finger &
draws the finger into the palm, flexing it at the
metacarpophalangeal joint
- later, the condition involves the little finger in the
same manner
- in long-standing cases, the pull on the fibrous
sheaths of these fingers results in flexion of the
proximal interphalangeal joints
- distal interphalangeal joints are not involved & are
actually extendned by the pressure of the fingers
against the palm

CARPAL TUNNEL SYNDROME

- formed by the concave anterior surface of the carpal
bones & closed by the flexor retinaculum
- is tightly packed with the long flexor tendons of the
fingers, with their surrounding synovial sheaths, and
median nerve
- characteristics
o buring pain or “pins & needles” along the
dist’n of the median nerve to the later 3
and half fingers → produced by
compression of median nerve within the
tunnel
TENOSYNOVITIS
- an infection of a synovial sheath
- most commonly results from the introduction of
bacteria into a sheath through a small penetrating
wound, such as that made by the point of a needle
or thorn
- rarely, the sheath may become infected by extension
of a pulp-space infection
- infection of a digital sheath results in distention of
the sheath with pus
- the finger is held semiflexed and is swollen
- any attempt to extend the finger is accompanied by
extereme pain because the distended sheath is
stretched
- as the inflammatory process continues, the pressure
within the sheath rises and may compress the blood
supply to the tendons that travel in the vincula longa
and brevia
- rupture or later severe scarring of the tendons may
follow
TRIGGER FINGER
- there is a palpable and even audible snapping when
the patient is asked to flex and extend the fingers
- cause:
o presence of localized swelling of one of the
1
long flexor tendon that catches on a 4
narrowing of the fibrous flexor sheath
anterior to the metacarpophalangeal joint
- may take place either in
o flexion
Gichelle Grace Billena Villaflor | Snell, R. (2006) Clinical Anatomy by Regions 8th edition & Gray’s Anatomy for students