Gross Anatomy of the Human Hand

2
Gabor Baksa, Peter Mandl, Szabolcs Benis, Lajos Patonay,
Geza P. Balint, and Peter Vince Balint

Layer-by-Layer Anatomy of the Hand

Skin, Subcutis and Nail

The first anatomical layer that both the rheumatologist and the ultrasonographer
encounter is the surface of the skin. Despite a lot of anatomical variants, there are
constant lines of the skin, which can serve as markers, e.g. for joint spaces. Several
sets of anatomical skin lines (e.g. Langer’s, Kreissl’s, Blaschko’s, etc.) have been
defined either in cadavers or live subjects. On the dorsal surface, the superficial
venous network of the hand feeds into the cephalic vein on the radial side and the
basilic vein on the ulnar side. The dorsal metacarpal veins run over the knuckles as
a venous arch. Skin creases over the proximal interphalangeal joints (PIP) and distal
interphalangeal joints (DIP) are also well visualized (Fig. 2.1). The surface of the
palm is broken by hills and valleys. Lumbrical muscles and neurovascular bundles
produce hills, while valleys contain flexor tendons. Distinction of creases on the

G. Baksa, MD (*) · L. Patonay, MD, DDS

Laboratory of Applied and Clinical Anatomy, Department of Anatomy, Histology and
Embryology, Semmelweis University, Budapest, Hungary
P. Mandl, MD, PhD
Division of Rheumatology, Department of Internal Medicine III, Medical University of
Vienna, Vienna, Austria
S. Benis, MD
Department of Orthopaedics and Traumatology, Ghent University Hospital, Ghent, Belgium
G. P. Balint, MD, FRCP, DSc
Ambulatory Care Clinic, National Institute of Rheumatology and Physiotherapy,
Budapest, Hungary
P. V. Balint, MD, PhD, FRCP
3rd Rheumatology Department, National Institute of Rheumatology and Physiotherapy,
Budapest, Hungary

© Springer International Publishing AG, part of Springer Nature 2018 15

P. V. Balint, P. Mandl (eds.), Ultrasonography of the Hand in Rheumatology,
https://doi.org/10.1007/978-3-319-74207-6_2
16 G. Baksa et al.

a b
N
DIPC
CDIP

CPIP PIPC

MO

DTC
IPC

CIP
PTC

ACV
ED LL CMF

DFC
Pi
U
STR PFC
PL
FCR

Fig. 2.1 Surface anatomy of the hand. (a) Dorsal surface; (b) palmar surface. ACV accessory
cephalic vein, CDIP crease over the distal interphalangeal joint, CIP crease over the interphalan-
geal joint, CMF crease of middle finger, CPIP crease over the proximal interphalangeal joint, DFC
distal flexure crease, DIPC distal interphalangeal crease, DTC distal transverse crease, ED exten-
sor digitorum tendons, FCR flexor carpi radialis tendon, IPC interphalangeal crease, K knuckle, LL
life line, MO monticuli, N nail, PFC proximal flexure crease, Pi pisiform, PIPC proximal interpha-
langeal crease, PL palmaris longus tendon, PTC proximal transverse crease, STR styloid process
of radius, U ulna

palmar hand are generally easy (Fig. 2.1). Friction ridges on the fingertips and the
palm are important not only for forensic medicine and identification (fingerprint)
but help with gripping function as well.
The palmar side of the hand is divided into the regions of the thenar, mesothenar
and hypothenar by the palmar aponeurosis and the medial and lateral intermuscular
septa. The intermuscular septae originate on both margins of the aponeurosis,
anchoring it to the second and fifth metacarpals. The palmar aponeurosis originates
either from the palmar ligament or in most cases is continuous with the tendon of
the palmaris longus muscle. However, it always inserts with longitudinal fibres on
the fibrous tendon sheets sheaths of the second to fifth fingers as well as sending
fibres into their subcutaneous tissue, respectively. At certain points proximally, it
adheres tightly to the palmar skin, while distally its fibres are looser. There are also
some transverse fibres traversing between the longitudinal fibres. These fibres form
three windows between the second and fifth fingers, where the common digital
arteries bifurcate into their proper digital branches. The nerves pass under the super-
ficial transverse metacarpal ligament, also called natatory ligament, more proxi-
mally, just under the transversal fibres. The nerves and vessels are covered only by
thick subcutaneous fat pads (monticuli), which are best visible when the palmar
skin is stretched by forced extension of the fingers (Fig. 2.2).
2 Gross Anatomy of the Human Hand 17

Fig. 2.2 First palmar layer

under the skin and
subcutaneous tissue. HTF
hypothenar fascia, MO
monticuli, PA palmar
aponeurosis, PB palmaris
brevis muscle, TF thenar
fascia

Palmaris brevis is a tiny muscle originating from the flexor retinaculum and the
palmar aponeurosis and inserting onto the skin of the hypothenar. It is the only hand
muscle innervated by the superficial branch of the ulnar nerve.
On the palmar side of the hand on the palm the skin is fixed to the palmar apo-
neurosis by perpendicular septae; similar septae fix the skin on the fingers at the
level of the metacarpophalangeal (MCP), PIP and DIP joints. At the fingers, digital
cutaneous ligaments called Cleland’s ligaments run dorsal to the digital nerves,
while on the volar aspect, we find Grayson’s ligament, superficial to the digital
nerves, attached to the skin fixing deep layers of fascia. A major advantage of this
type of tethering is that it limits the mobility of the skin during active movement,
and these structures also stabilize the digital neurovascular bundle.The distal dorsal
end of the finger is covered by a slightly convex nail. The nail plate has several
folds, namely two lateral (paronychium) and one proximal fold covered by the cuti-
cle at the eponychium. Altogether this is defined as the perionychium. The fourth
free margin is called the distal edge. On the opposite, proximal side we find the
lunula, which is the named after its resemblance to the shape and color of a waxing
or waning gibbous moon. The nail matrix (sterile (or hyponychium) and germinal)
lies deeply at the proximal folds. The proximal edge (or root) of the nail lies under
the skin and is called the occult margin. The nail bed has a very rich capillary net-
work and appears pink in healthy subjects. The nail itself has a hard keratin struc-
ture attached to the germinal and sterile matrix with two plates (dorsal and a ventral).
Not too far from the distal interphalangeal joint the ventral floor is attached firmly
to the periosteum next to the insertion of the extensor tendon.
18 G. Baksa et al.

Bones

Like the middle layer of a “sandwich”, bones divide the hand into the dorsal and
palmar aspect. Hand bones lay closer to the dorsal surface than to the palmar sur-
face, with the latter containing relatively more soft tissue and muscles. This leads to
the palmar part of the hand being thicker than the dorsal, which in turn results in
better acoustic resolution when examining the dorsal aspect of the hand. The hand
is joined to the two bones of the forearm (radius and ulna) and consists of the car-
pus, metacarpus and fingers. The distal ends of the radius and the ulna form a pivot
joint with the radial distal edge rotating in the ulnar notch. The proximal transverse
arch is formed by the two rows of carpal bones. Metacarpal heads form the distal
transverse palmar arch of the palm. The major longitudinal arch (third digital ray)
runs from the dorsal tubercle of the radius (Lister’s tubercle), through one of the
largest and strongest carpal bones, the capitate to the base of the third metacarpal.
Longitudinal hand arches fan out on both sides of the major longitudinal arch reach-
ing the second, fourth and fifth metacarpal bases, respectively. Along with the
thumb which opposes the other fingers, these arches form a ball-catcher’s hand. We
can also visualize four diagonal arches between the thumb and other fingers. All
these arches contribute to a semi-spherical basket hilt of the hand ideal for catching
and holding objects (Fig. 2.3).
The carpus is formed by four proximal and four distal carpal bones. The proxi-
mal row of the carpal bones (from radial to ulnar: scaphoid, lunate, triquetrum,
pisiform) forms the radiocarpal joint proximally with the radial bone and the mid-
carpal joint distally with the second row of carpal bones (from radial to ulnar:
trapezium, trapezoid, capitate and hamate) (Fig. 2.4). The most medially located

a b

Fig. 2.3 Hand arches. (a) Diagonal arches; (b) digital rays of the left hand and proximal and distal
transverse palmar arches of the right hand
2 Gross Anatomy of the Human Hand 19

a b

Fig. 2.4 Bones of the hand. (a) Palmar aspect; (b) dorsal aspect. C capitate, D distal phalanx, H
hamate, I–V first to fifth metacarpals, Lu lunate, M middle phalanx, P proximal phalanx, Pi pisi-
form, S scaphoid, Ta trapezium, To trapezoid, Tr triquetrum

pisiform and hamate bones and the laterally positioned scaphoid (with its tubercle)
and trapezium form the medial and lateral carpal eminences, respectively. The distal
end of the ulna and ulnar styloid process form a joint with the proximal carpal bones
and with the triangular fibrocartilage complex. The pisiform, a sesamoid bone on
which the flexor carpi ulnaris muscle inserts, is not an actual part of the radiocarpal
joint because it has a joint articulation surface only dorsally towards the
triquetrum.
The pisiform is the ulnar bony landmark of the proximal entry of the carpal tun-
nel. The tubercle of the scaphoid is the radial landmark of the proximal entry of the
carpal tunnel and also an identification point to localize the ulnar artery, situated
laterally from the pea-shaped bone. The distal bony pillars of the carpal tunnel are
the hook of the hamate (hamulus ossis hamatum) and the trapezium at the ulnar and
radial sides, respectively.
Sesamoid bones occur commonly on the palmar aspect of the hand and are con-
sidered normal variants. The numbers of carpal bones are frequently and variably
increased, with a large number of accessory ossicles described, the detailed review
of which is beyond the scope of this book.
The metacarpus consists of the five metacarpals, which can be divided into base,
shaft, neck and head. The head of the metacarpal bone is oblong and slightly elon-
gated in the dorso-palmar axis; although it may be irregular, the head has a smooth
convex area that is the intraarticular part. The extrasynovial areas of the head are
rough and contain a medial and lateral tubercle for the attachment of the collateral
ligaments, as well as an elevated ridge surrounding the intraarticular smooth area.
This ridge forms a dorsal depression which is smooth and well-­demarcated and has
20 G. Baksa et al.

reflective bone at its base. It occurs at the site of the fused growth plate and is a site
of entry for nutritional/feeding vessels. In an ultrasound study on cadavers, this
depression was visualized in 37% of examined MCP joints (highest frequency
found in the second MCP joint) and appeared as a well-defined bony groove on both
longitudinal and transverse ultrasound scans, with no cortical break [1].
The fingers are built up by the proximal, middle and distal phalanges, respec-
tively. The thumb has no middle phalanx. The distal phalanges have a so-called
tuberosity on their head portion.

Extrinsic and Intrinsic Ligament of the Wrists

Extrinsic ligaments connect the carpal bones proximally to the radius and ulna and
distally to the metacarpals. Intrinsic ligaments originate from and insert into differ-
ent carpal bones. Ligaments form a dorsal radiocarpal “V” ligament and proximal
and distal palmar “V” ligament complexes. For rheumatologists, perhaps the most
important ligaments are the scapholunate and the lunotriquetral ligament (Fig. 2.5).
Both ligaments have three parts: palmar, dorsal and intermediate. Both intrinsic

a b

Fig. 2.5 Coronal sections of hand joints. (a) Coronal section across the wrist, carpal and carpo-
metacarpal joints, (b) coronal section across the fourth metacarpal joint. AD articular disc, C capi-
tate, DA dorsal aponeurosis, DI dorsal interosseous, H hamate, II–IV second to fourth metacarpals,
LTL lunotriquetral ligament, Lu lunate, P proximal phalanx, R radius, S scaphoid, SCL scapholu-
nate ligament, TFC triangular fibrocartilage complex, To trapezoid, Tr triquetrum, U ulna, arrow-
heads metacarpal joint capsule and collateral ligament
2 Gross Anatomy of the Human Hand 21

interosseous and intrinsic capsular ligaments are important to maintain carpal

arches, mobility and stability; however ultrasound cannot depict interosseous liga-
ments. Scaphoid and lunate are the most mobile bones, and the second and third
metacarpal bases are the most fixed parts of the wrist.

Ligaments of the MCPs, PIPs, DIPs and IPs

Despite their different size and type of joint MCP joints are condyloid while the
others are hinge joints, ligaments are arranged similarly around MCPs, PIPs, DIPs
and interphalangeal joints (IPs) (Fig. 2.5). A major exception is the deep transverse
metacarpal ligament connecting the second, third, fourth and fifth metacarpal heads
and their respective palmar plates to avoid any unexpected separation of the meta-
carpals during the individual movement of the fingers. All joints have radial (more
horizontal) and ulnar (more oblique) collateral ligaments. Collateral ligaments have
two parts: the cord-like proper ligaments, which are located more dorsally, and fan-
shaped accessory ligaments, which are more palmar and at the proximal phalanx are
attached to the palmar plate and to the transverse metacarpal ligament. They act
differently based on their location of origin and insertion. Both stabilize the joint,
with the proper ligament tightening during flexion and relaxing during extension.
Accessory ligaments are tight during extension and relaxed during flexion. The
interosseous muscles pass dorsally to the transverse metacarpal ligament, while the
lumbrical muscles pass palmar to the same ligament and insert onto the collateral
ligaments, stabilizing the joints from lateral. Retinacular ligaments (both transverse
and oblique retinacular ligaments of Landsmeer) aid in flexion and extension of the
PIP and DIP joints. Oblique ligaments originate on the palmar part of the proximal
phalanx, cross the collateral ligament and insert more dorsally on the distal phalanx.
Transverse bands originating from the border of the flexor tendon sheath and insert
onto the lateral bands of the extensor hood.

Muscles in the Mid-layer

Lumbrical muscles originate from the deep flexor tendons and run towards and
insert onto the expansion of the extensor tendon functioning as flexors of the MCP
joints and extensors of the PIP joints. Interosseous muscles have two groups. The
palmar interossei originate on the side of the shaft of the second, fourth and fifth
metacarpal and insert onto the bases of the proximal phalanges of the second, fourth
and fifth fingers as well as onto the expansion of the extensor tendons (Fig. 2.6).
Their main action is adduction, but they also contribute to flexion and extension of
the fingers. The dorsal interossei also originate on the side of the shaft of the second
to fifth metacarpal and attach to the proximal phalanges of the second to fourth
fingers as well as onto the dorsal aponeurosis of the extensor tendons. Their main
action is abduction of the fingers.
22 G. Baksa et al.

Fig. 2.6 Deep layer of the

hand muscles. Note, the
first palmar interosseous
muscle is covered by the
adductor pollicis muscle.
ADP adductor pollicis
muscle (oblique and
transverse head), APB
abductor pollicis brevis
muscle, DPA deep palmar
arch, DUA deep branch of
ulnar artery, FPB flexor
pollicis brevis muscle, FR
flexor retinaculum, L
lumbricals, PI palmar
interosseous muscle, PMA
palmar metacarpal arteries,
UA ulnar artery

Vascular Arches, Blood Supply and Lymphatic Vessels

Due to their complexity and clinical importance, we provide a brief overview of

the arterial supply of the hand. The vessels originate from the two main branches
of the brachial artery: the radial and ulnar artery. The radial artery is located on
the dorsal side of the hand, where it runs above the wrist through the radial
foveola (“fossa tabatiere”), then cruises under the tendon of extensor pollicis
longus and perforates the first dorsal interosseous muscle. This perforator branch
is the main input of the deep palmar arch, which takes its other origin from the
deep branch of the ulnar artery. The latter enters the hypothenar between the
flexor digiti minimi brevis and abductor digiti minimi muscles. The deep arch
gives off the four palmar metacarpal arteries, which then supply the interosseous
muscles and partially also some carpal structures. Running then distally forward,
they usually anastomose with the common digital palmar arteries from the super-
ficial arch. The digital arteries originate from the superficial arch, and even small
arteries enter into the joint cavity and also supply tendons via the mesotenon.
Under the joint capsule, the central slip and the dorsal depression of the metacar-
pal head are rich in small vessels and capillaries (Figs. 2.7 and 2.8). Outside the
joints, muscles and especially nailbeds are characterized by rich capillary net-
works. Deoxygenated blood is collected first by the palmar digital veins, flowing
into the superficial and deep palmar arches before finally reaching the medial
antebrachial vein, ulnar vein and radial vein and ultimately the basilic and
cephalic veins into the upper arm. Lymphatic vessels follow the veins, and the
first major lymph nodes are located in the cubital region. No lymph node exists
in the hand and wrist.
2 Gross Anatomy of the Human Hand 23

a b

Fig. 2.7 (a) Anatomical snuff box with injected radial artery (tendon of extensor pollicis longus
muscle are cut). (b) Vascular corrosion cast of hand arteries. Arteries injected with blue-coloured
resin. CPA common palmar digital artery, DI first dorsal interosseous muscle, DMA dorsal meta-
carpal arteries, ECB extensor carpi radialis brevis tendon, ECL extensor carpi radialis longus ten-
don, ED extensor digitorum tendon, EI extensor indicis tendon, EPB extensor pollicis brevis
tendon, EPL extensor pollicis longus tendon, PPA proper palmar digital artery, RA radial artery,
SRA superficial branch of radial artery, UA ulnar artery

a b

Fig. 2.8 Arterial arches of the hand. (a) Superficial palmar arch; (b) deep palmar arch. ADP
adductor pollicis muscle, APB abductor pollicis brevis muscle, DI second dorsal interosseous
muscle, DPA deep palmar arch, DUA deep branch of the ulnar artery, FDM flexor digiti minimi
brevis, FDS flexor digitorum superficialis tendons, FPB flexor pollicis brevis muscle, FTS fibrous
tendon sheath, L lumbricals, MN median nerve, PCA common palmar digital arteries, PI palmar
interosseous muscle, PMA palmar metacarpal arteries, STS synovial tendon sheath, SUN superfi-
cial branch of ulnar nerve, UA ulnar artery, arrowheads superficial palmar arch, double arrow-
heads volar carpal artery

Neural Network

The median nerve divides into three main branches, the recurrent branch and the
digital cutaneous branches (separating further to common palmar digital and proper
palmar digital branches) before the nerve enters the carpal tunnel, but the branches
remain strictly together and diverge only after exiting the tunnel. The lateral
24 G. Baksa et al.

Fig. 2.9 Guyon’s canal

and carpal tunnel. Note,
the median nerve divided
in three branches and
the thenar motoric branch
exiting from the carpal
tunnel. FDS superficial
flexor digitorum tendons,
FR flexor retinaculum, MN
median nerve, UA ulnar
artery, UN deep and
superficial branches of the
ulnar nerve, arrowheads
motor branch to thenar
muscles

recurrent branch, also called “the million-dollar nerve”, perforates the lateral inter-
muscular septum and runs to the thumb and to the radial side of the index. Just after
exiting from the tunnel, it gives off a short branch to the thenar musculature. The
further two branches remain in the mesothenar running towards the second to fourth
fingers. A well-known variation is the so-called “bifid” median nerve, where the
nerve enters the carpal tunnel as two strong nerve stems. The prevalence of a bifid
median nerve is less than 10% with a high likelihood of a bilateral condition and is
sometimes but not always accompanied by a persistent median artery. The median
nerve provides sensory innervation for the skin of the palmar aspect of the thumb,
index and middle fingers and the palmar-radial side of the ring finger. The median
nerve also innervates the dorsal aspect of the first three fingertips. The ulnar
nerve enters Guyon’s canal (Fig. 2.9). During ramification, it gives off two branches
called the superficial and deep branches of the ulnar nerve. A number of anastomo-
ses between the median and ulnar nerve have been described, as anatomical varia-
tions [2]. The ulnar nerve provides sensory innervation to the palmar side of the fifth
digit as well as the palmar-ulnar aspect of the fourth digit. Radial nerve: the main
trunk of the nerve does not enter the hand. It divides into a deep branch, which
becomes the posterior interosseous nerve and a superficial branch, which goes on to
innervate the back of the hand. Branches of the radial nerve innervate the dorsal
surface of the lateral side of the palm as well as the lateral three and half digits.
Finally, common palmar digital nerves and proper palmar (digital) nerves run on
both sides of the fingers along the arteries until the finger tips. Motor innervation of
extrinsic and intrinsic hand muscles and their origin, insertion and function are
shown in Tables 2.1 and 2.2.
2 Gross Anatomy of the Human Hand 25

Table 2.1 Extrinsic hand muscles

Muscle Origin Insertion Function Innervation
Flexor carpi Medial Base of the second Elbow: Median nerve
radialis epicondyle, metacarpal bone flexion,
fascia antebrachii pronation
Wrist: radial
abduction,
palmar
flexion
Flexor carpi Medial Hamate, the tendon Elbow: Muscular
ulnaris epicondyle, also includes the flexion branches of the
medial part of the pisiform as a Wrist: ulnar ulnar nerve
olecranon sesamoid bone, abduction,
basis of the fifth palmar
metacarpal bone flexion
Palmaris longus Medial Palmar aponeurosis Ensure firm Median nerve
epicondyle hand grip
Flexor Medial Second to fifth Second to Median nerve
digitorum epicondyle, middle phalanx fifth fingers:
superficialis tendinous arc flexion
between coronoid
process of ulna
and radius
Flexor pollicis Palmar part of the Thumb distal Thumb Median nerve
longus radius phalanx flexion
Flexor Ulnar tuberosity Distal phalanx of Second to Median (second
digitorum and interosseous the second to fifth fifth fingers: and third
profundus membrane fingers flexion fingers) and
ulnar nerve
(fourth and fifth
fingers)
Pronator Medial part of the Lateral and palmar Lower arm Median nerve
quadratus distal ulna part of the distal pronation
radius
Brachioradialis Above the lateral Styloid process of Elbow: Radial nerve
epicondyle of the radius flexion
humerus Lower arm:
pronation
Joint
stabilizator
Extensor carpi Above the lateral Dorsal part of the Wrist: dorsal Radial nerve
radialis longus epicondyle of the base of the second flexion,
humerus metacarpal radial
abduction
Extensor carpi Lateral Dorsal part of the Wrist: dorsal Radial nerve
radialis brevis epicondyle of the base of the third flexion
humerus metacarpal
(continued)
26 G. Baksa et al.

Table 2.1 (continued)

Muscle Origin Insertion Function Innervation
Extensor Lateral Second to fifth Finger Radial nerve
digitorum epicondyle of the middle and distal extensor
humerus and phalanx
dorsal forearm
fascia
Extensor Lateral Fifth extensor Fifth finger Radial nerve
digitorum epicondyle of the tendon extensor
minimi humerus
Extensor carpi Lateral Dorsal part of the Wrist: dorsal Radial nerve
ulnaris epicondyle of base of the fifth flexion,
humerus, metacarpal ulnar
superficial abduction
forearm fascia
Abductor Middle part of the Base of the first Abduction of Radial nerve
pollicis longus ulna, radius and metacarpal the thumb
interosseous
membrane
Extensor Ulna, Base of the Thumb Radial nerve
pollicis brevis interosseous proximal phalanx extensor and
membrane and of the thumb abductor
dorsal part of the
radius
Extensor Middle part of the Base of the distal Thumb Radial nerve
pollicis longus ulna and phalanx of the extensor and
interosseous thumb abductor
membrane
Extensor indicis Distal part of the Second extensor Second finger Radial nerve
ulna tendon extensor

Table 2.2 Intrinsic hand muscles

Muscle Origin Insertion Function Innervation
Palmaris Flexor Skin of the hypothenar Keeping skin Superficial
brevis retinaculum and stretched out, branch of the
from the palmar improving ulnar nerve
aponeurosis grip
Abductor Transverse carpal Lateral side of the base of Abduction of Recurrent
pollicis ligament/tubercle the proximal phalanx of the thumb branch of the
brevis of the scaphoid the thumb and the capsule and assists in median nerve
and tubercle of of the opposition
the trapezium metacarpophalangeal joint and extension
of the thumb
Opponens Transverse carpal Radial side of the first Opposition Median nerve
pollicis ligament and metacarpal bone of the thumb
trapezium and flexion
of the thumb
2 Gross Anatomy of the Human Hand 27

Table 2.2 (continued)

Muscle Origin Insertion Function Innervation
Flexor Flexor Proximal phalanx of the Flexion of Superficial
pollicis retinaculum, thumb the thumb head of the
brevis trapezium muscle:
recurrent
branch of the
median nerve
Deep head of
the muscle:
deep branch of
the ulnar nerve
Adductor Anterior part of Medial part of the Adductor of Deep branch
pollicis the third proximal phalanx of the thumb of the ulnar
metacarpal bone thumb and the ulnar nerve
(transverse head sesamoid
of the muscle)
Bases of the
second and the
third metacarpal
bones, trapezoid
and capitate
(oblique head of
the muscle)
Abductor Flexor Base of the proximal Abduction of Deep branch
digiti retinaculum, phalanx of the fifth finger fifth finger of the ulnar
minimi pisiform and nerve
pisohamate
ligament
Flexor Hamate The base of the proximal Flexor of the Deep branch
digiti phalanx of the fifth finger fifth finger of the ulnar
minimi nerve
Opponens Flexor Medial part of the fifth Opposition Deep branch
digiti retinaculum and metacarpal bone of fifth of the ulnar
minimi hook of the finger, fifth nerve
hamate finger rotator
Lumbricals Deep flexor Extensor expansion Flexion of Third and
digitorum tendon MCP joints fourth: deep
and extension branch of
of PIP joints the ulnar nerve
First and
second:
median nerve
Volar Side part of Bases of proximal Adduction, Deep branch
interossei second, fourth phalanges of the second, flexion and of the ulnar
and fifth fourth and fifth fingers extension of nerve
metacarpal shaft and extensor expansions fingers
Dorsal Side part of the Proximal phalanges of the Abduction of Deep branch
interossei second to fifth second to fourth fingers fingers of the ulnar
metacarpal shaft and extensor expansions nerve
28 G. Baksa et al.

Cross-Sectional Anatomy

In order to better understand the topography of the anatomical structures, the hand
can be examined from the three standard anatomical planes: coronal (Fig. 2.5),
transverse (Figs. 2.10 through 2.18) and sagittal (Figs. 2.19 and 2.20).

Fig. 2.10 Transverse section of wrist at the level of radius and ulna. Proximal view, left hand. APL
abductor pollicis longus tendon, BR brachioradialis tendon, ECB extensor carpi radialis brevis
tendon, ECL extensor carpi radialis longus tendon, ECU extensor carpi ulnaris tendon, ED&EI
extensor digitorum and extensor indicis tendons, EDM extensor digiti minimi tendon, EPB exten-
sor pollicis brevis tendon, EPL extensor pollicis longus tendon, FCR flexor carpi radialis tendon,
FCU flexor carpi ulnaris muscle and tendon, FDS&FDP flexor digitorum superficialis tendons and
flexor digitorum profundus tendons, FPL flexor pollicis longus tendon, LT Lister’s tubercle, MN
median nerve, PB palmaris brevis tendon, PL palmaris longus tendon, PQ pronator quadratus, R
radius, RA radial artery, U ulna, UA ulnar artery, UN ulnar nerve
2 Gross Anatomy of the Human Hand 29

Fig. 2.11 Transverse section across the proximal carpal bones. Proximal view, left hand. APL
abductor pollicis longus tendon, CV cephalic vein, ECB extensor carpi radialis brevis tendon, ECL
extensor carpi radialis longus tendon, ECU extensor carpi ulnaris tendon, ED extensor digitorum
tendons, EDM extensor digiti minimi tendon, EI extensor indicis tendon, EPB extensor pollicis
brevis tendon, EPL extensor pollicis longus tendon, FCR flexor carpi radialis tendon, FDP flexor
digitorum profundus tendons, FDS flexor digitorum superficialis tendons, FPL flexor pollicis lon-
gus tendon, Lu lunate, MN median nerve, Pi pisiform, RA radial artery, S scaphoid, Ta trapezium,
Tr triquetrum, UA ulnar artery, UN ulnar nerve

Fig. 2.12 Transverse section across the distal carpal bones. Proximal view, left hand. ADM
abductor digiti minimi muscle, APB abductor pollicis brevis muscle, APL abductor pollicis longus
tendon, C capitate, CV cephalic vein, ECB extensor carpi radialis brevis tendon, ECL extensor
carpi radialis longus tendon, ECU extensor carpi ulnaris tendon, ED extensor digitorum tendons,
EDM extensor digiti minimi tendon, EI extensor indicis tendon, EPB extensor pollicis brevis ten-
don, EPL extensor pollicis longus tendon, FCR flexor carpi radialis tendon, FDP flexor digitorum
profundus tendons, FDS flexor digitorum superficialis tendons, FPL flexor pollicis longus tendon,
H hamate, MN median nerve, RA radial artery, Ta trapezium, To trapezoid, UA ulnar artery, UN
ulnar nerve
30 G. Baksa et al.

Fig. 2.13 Transverse section across the metacarpal bases. Proximal view, left hand. ADM abduc-
tor digiti minimi muscle, APB abductor pollicis brevis muscle, APL abductor pollicis longus ten-
don, C capitate, CV cephalic vein, ECB extensor carpi radialis brevis tendon, ECL extensor carpi
radialis longus tendon, ED extensor digitorum tendons, EDM extensor digiti minimi tendon, EI
extensor indicis tendon, EPB extensor pollicis brevis tendon, EPL extensor pollicis longus tendon,
FDM flexor digiti minimi muscle, FR flexor retinaculum, H hamate, I–V first to fifth metacarpals,
ODM opponens digiti minimi muscle, PB palmaris brevis muscle, PL palmaris longus tendon, RA
radial artery, Ta trapezium, To trapezoid

Fig. 2.14 Transverse section across the metacarpal bones. Proximal view, left hand. ADM abduc-
tor digiti minimi muscle, ADP adductor pollicis muscle, APB abductor pollicis brevis muscle, DI
dorsal interosseous muscle, ED extensor digitorum tendons, EDM extensor digiti minimi tendon,
EI extensor indicis tendon, EPB extensor pollicis brevis tendon, EPL extensor pollicis longus
tendon, FDM flexor digiti minimi muscle, FDS flexor digitorum superficialis muscle, FPB flexor
pollicis brevis muscle, FPL flexor pollicis longus muscle, I–V first to fifth metacarpals, ODM
opponens digiti minimi muscle, OP opponens pollicis muscle
2 Gross Anatomy of the Human Hand 31

Fig. 2.15 Transverse section proximal to the metacarpal heads. Proximal view, left hand. ADM
abductor digiti minimi muscle, ADP adductor pollicis muscle, APB abductor pollicis brevis mus-
cle, CPA common palmar digital arteries, DA dorsal aponeurosis, DMA dorsal metacarpal artery,
EI extensor indicis tendon, FDM flexor digiti minimi muscle, FPB flexor pollicis brevis muscle,
FPL flexor pollicis longus muscle, FTS fibrous tendon sheath, I–V first to fifth metacarpals, PMA
palmar metacarpal arteries, PPA proper palmar digital arteries, RS radial sesamoid of pollex, US
ulnar sesamoid of the thumb

Fig. 2.16 Transverse

section of the second finger
(index) across the
metacarpal head. CPA
common palmar digital
artery, DI dorsal
interosseous tendon, ED
extensor digitorum tendon,
EI extensor indicis tendon,
II second metacarpal bone
(head), L lumbrical, PI
palmar interosseous
tendon, SI sesamoid bone
of index
32 G. Baksa et al.

a b

Fig. 2.17 Transverse section across the proximal phalanges at the level of crossing of the flexor
digitorum tendons. (a and b) Same section; different structures indicated. AL annular ligament, DA
dorsal aponeurosis, DI dorsal interosseous tendons, FDP flexor digitorum profundus tendons, FDS
flexor digitorum superficialis tendons, MO monticuli, P proximal phalanges, PI palmar interosse-
ous tendons, PPA proper palmar digital arteries

Fig. 2.18 Transverse

section across the distal
phalanx of the middle
finger. AL annular
ligament, D distal phalanx,
DA dorsal aponeurosis,
FDP flexor digitorum
profundus tendon, PPA
proper palmar digital artery

Fig. 2.19 Sagittal section across the second digital ray. ADP adductor pollicis muscle, APB abduc-
tor pollicis brevis muscle, D distal phalanx, DA dorsal aponeurosis, ECL extensor carpi radialis
longus tendon, ED extensor digitorum tendon, FDP flexor digitorum profundus tendon, FDS flexor
digitorum superficialis tendon, FPB flexor pollicis brevis muscle, FPL flexor pollicis longus tendon,
DI dorsal interosseous muscle, II second metacarpal, L lumbrical, M middle phalanx, OP opponens
pollicis muscle, P proximal phalanx, PQ pronator quadratus, R radius, S scaphoid, Ta trapezium
2 Gross Anatomy of the Human Hand 33

Fig. 2.20 Sagittal section across the third digital ray. ADP adductor pollicis brevis muscle, APB
abductor pollicis brevis muscle, C capitate, D distal phalanx, DA dorsal aponeurosis, ECB extensor
carpi radialis brevis tendon, ED extensor digitorum tendon, EPL extensor pollicis longus tendon,
ER extensor retinaculum, FDP flexor digitorum profundus tendon, FDS flexor digitorum superfi-
cialis tendon, FPB flexor pollicis brevis muscle, FR flexor retinaculum, III third metacarpal, L
lumbrical, L lunate, M middle phalanx, OP opponens pollicis muscle, P proximal phalanx, PI
palmar interosseous muscle, PQ pronator quadratus, R radius, arrowhead crossing of the flexor
digitorum tendons (chiasma)

Regional and Subregional Anatomy

Compartments, Canals, Channels, Cavities, Capsules

and Connections

The “six Cs”, namely, compartments, canals, channels, cavities, capsules and con-
nections, are very important structures for rheumatologists. Commonly affected by
pathological changes and lesions, they are essential landmarks for orientation for
any imaging method and are key sites for anatomical variants.

Compartments

Compartments have two, different meanings in medicine, namely, fascial compart-

ments and pharmacokinetic compartments. Examples of pharmacokinetic compart-
ments include blood plasma, interstitial fluid, fatty tissue, intracellular fluid and
transcellular fluid. Intraarticular joint fluid is a good example for what we call a
transcellular fluid compartment.
Fascial compartments are anatomical structures surrounded by fascicules (con-
nective tissue septa, intermuscular septa) that contain muscles, their blood supply
and nerves. Bones can serve as the basis of a compartment, but they are not part of
the compartment.
The hand is divided into five major fascial compartments: from radial to ulnar on
the palmar side thenar, mesothenar (or central compartment) and hypothenar and on
the dorsal side the interosseous compartments and the adductor compartment
between the thenar and interosseous compartments (Table 2.3).
34 G. Baksa et al.

Fig. 2.21 Compartments of the hand. Muscles of thenar and hypothenar. Structures of mesothe-
nar are covered by the palmar aponeurosis. ADM abductor digiti minimi muscle, ADP adductor
pollicis muscle, APB abductor pollicis brevis muscle, APL abductor pollicis longus tendon, DI
dorsal interosseous muscle, FDM flexor digiti minimi muscle, FPB flexor pollicis brevis muscle,
FPL flexor pollicis longus tendon, GC Guyon’s canal, L lumbricals, ODM opponens digiti minimi
muscle, PA palmar aponeurosis, Pi pisiform, black arrows deep transverse metacarpal ligament

Table 2.3 Muscle contents of the fascial compartments

1. Thenar compartment: abductor pollicis brevis, flexor pollicis brevis and opponens pollicis
muscles
2. Mesothenar (or central) compartment: lumbrical muscles and three palmar interossei (all
unipennate)
3. Hypothenar compartment: abductor digiti minimi, opponens digiti minimi and flexor digiti
minimi brevis muscles over the fascia of the palmaris brevis muscle (Fig. 2.21)
4. Interosseous compartment: four dorsal interossei (all of them bipennate)
5. Adductor compartment: adductor pollicis (caput obliquum and transversum)

Anatomical Snuffbox
Anatomical snuffbox (foveola radialis/fossa tabatiere) is not a compartment but a very
important subregion of the hand. The radial border of the anatomical snuffbox is formed
by the tendon sheath of the extensor pollicis brevis and the abductor pollicis longus
muscles, while on its ulnar side, we find the extensor pollicis longus muscle. This causes
the appearance of a radial and an ulnar cord-like eminence of the skin which is visible
especially when the thumb is abducted and extended. Between these cords, we find a pit
known as the snuffbox (where people put tobacco for snuffing). The radial artery runs
through the floor of the snuffbox, then passes under the tendon of extensor pollicis lon-
gus and perforates the first dorsal interosseous muscle (Figs 2.7 and 2.22).
2 Gross Anatomy of the Human Hand 35

Fig. 2.22 Anatomical snuff box. ADP adductor pollicis muscle, APL abductor pollicis longus ten-
don, DA dorsal aponeurosis, DI dorsal interosseous muscle, ECB extensor carpi radialis brevis ten-
don, ECL extensor carpi radialis longus tendon, EPB extensor pollicis brevis tendon, EPL extensor
pollicis longus tendon, ER extensor retinaculum, RFo anatomical snuff box (radial foveola)

Canals

The two most important canals of the hand are the carpal tunnel (canalis carpi) and
Guyon’s tunnel (canalis ulnaris). They are also called osteofibrous canals, which
highlights the fact that the bottom and the sides are often paved by fibrocartilage and
bony tissue easing the gliding of the sheathed flexor tendons in the canals.

Carpal Tunnel
This canal is situated on the palmar side of the wrist. Because it narrows from proximal
to distal, its spatial shape resembles that of a truncated gullet. The bottom of the tunnel
is formed by the carpal bones. The medial and lateral sides of the tunnel rest on four
pillars: we find the pisiform on the medial side proximally and distally the hook of the
hamate and laterally the tubercles of the scaphoid (proximally) and the trapezium (dis-
tally). The palmar side of the tunnel is covered by the slightly convex transverse carpal
ligament, which is attached medially to the scaphoid and laterally to the pisiform.
Outside of the tunnel, most laterally we find the tendon of the flexor carpi radialis mus-
cle in its sheath lying in the bony sulcus of the scaphoid and the trapezium. Within the
tunnel, in the most lateral position, we can identify the tendon of the flexor pollicis lon-
gus muscle which possesses its own tendon sheath. The median nerve is situated just
directly under the retinaculum over the second and third superficial flexor tendons.
Usually the median nerve is ellipsoid, but in some cases, it may be more rounded or
triangular. There is one more common tendon sheath in the tunnel, that of the superficial
and the deep common flexors of the fingers. The superficial tendons run superficial in
the tunnel and form two rows. In the first row, we find the third and fourth tendons, while
the second and the fifth tendons constitute the second row. At the entry of the carpal tun-
nel, the deep tendons envelop their respective superficial tendons (forming a U). Finally,
as we exit the tunnel, the superficial and the deep tendons rearrange themselves, forming
two rows, respectively, located in close proximity to the appropriate digits (Fig. 2.23).
36 G. Baksa et al.

Fig. 2.23 Guyon’s canal and carpal tunnel. Superficial and deep flexor digitorum tendons are cut.
ADP adductor pollicis muscle, DUN deep branch of ulnar nerve, FR flexor retinaculum, MN
median nerve, PI palmar interosseous muscle, SUN superficial branch of ulnar nerve, UA ulnar
artery, arrowheads carpal tunnel, doubled arrowheads Guyon’s canal

Guyon’s Tunnel
The triangular Guyon canal is situated medially and more superficially than the carpal
tunnel. A small ligament runs between the pisiform and the hamate (pisohamate liga-
ment) bridging over the ulnar nerve. The medial border of the tunnel is the pisiform,
the roof is the transverse carpal ligament, and the lateral border is formed by the hook
of the hamate. The ulnar artery is positioned lateral to the ulnar nerve (Fig. 2.23).
The sensory and motor branches are usually divided into three zones. Zone 1 is
situated before the ulnar nerve bifurcation (holding mixed motor and sensory
branches), Zone 2 includes the deep motor branch, and Zone 3 includes the superfi-
cial sensory branch of the ulnar nerve.

Channels

Channels contain tendons with tendon sheaths or paratenon or tendons which are
simply covered with loose connective tissue. The terms channels and compartments
are used interchangeably.

 xtensor Tendon Channels of the Wrist

E
The extensor tendons of the hand can be found under the extensor retinaculum on
the dorsal surface of the wrist. The extensor retinaculum attaches medially to the
distal part of the ulna and the medial carpal bones and laterally to distal part of the
radius and the lateral carpal bones. The foundation of the channels is formed by the
dorsal surface of the distal part of the radius and the ulna and the dorsal surface of
the carpal bones. The six extensor channels are separated by septae, which originate
from the extensor retinaculum. Starting radially, the first channel contains the ten-
dons of the abductor pollicis longus and extensor pollicis brevis muscles sharing a
single tendon sheath. In the second channel, we find the tendons of the extensor
2 Gross Anatomy of the Human Hand 37

Fig. 2.24 Extensor tendon channels. ADM abductor digiti minimi muscle, ECB extensor carpi
radialis brevis tendon, ECL extensor carpi radialis longus tendon, ECU extensor carpi ulnaris ten-
don, ED extensor digitorum tendons, EDM extensor digiti minimi tendon, EI extensor indicis
tendon, EPB extensor pollicis brevis tendon, EPL extensor pollicis longus tendon, II second meta-
carpal, RFo anatomical snuff box (radial foveola)

carpi radialis longus and brevis muscles, situated in their common tendon sheath,
while in the third channel, the tendon of the extensor pollicis longus muscle can be
found in its own sheath. In the fourth channel, the tendons of extensor digitorum and
of the indicis muscles run in a common tendon sheath. In the fifth channel, the ten-
don of the extensor digiti minimi muscle and in the sixth the tendon of the extensor
carpi ulnaris muscle are situated in their respective tendon sheaths (Fig. 2.24). It
helps to count the different tendons by starting medially (or radially) from the first
channel or by remembering that Lister’s tubercle separates the second from the third
channel. Also, a simple mnemonic (longus, brevis, longus, brevis) starting from
radial until the fourth channel may help in memorizing the muscles.

 inger Flexor Channels

F
The common tendon sheaths for the deep and superficial flexor tendons of the sec-
ond, third, and fourth fingers run in separate channels beginning from the middle of
the palm (Figs. 2.11, 2.12, and 2.13). Proximally of the carpal tunnel, the flexor
tendon sheath of the thumb and of the fifth finger is usually continuous with the
forearm. At the level of the proximal phalanx, the superficial flexor tendons split
into two parts, and between them the deep flexor tendon emerges to become super-
ficial (chiasma tendinum). The superficial flexor tendons insert onto the shaft of the
middle phalanx and the deep flexor tendons attach to the distal phalanx.
On the outside the sheaths are fibrous, while on the inside they are similar to the
synovial membrane of joints and also produce synovial fluid, partly ensuring smooth
movement of the tendons and partly contributing to the nutrition of the tendons via
the mesotenon (Fig. 2.25). The two parts of the tendon sheath may also be called
the visceral (close to the tendon) and parietal (far from the tendon separated from
the visceral layer by a layer of synovial fluid) part. Unlike the joint cavity or the
hyaline cartilage found on bone endings, tendons also get their blood supply from
the longitudinal artery on the dorsal surface of the tendon, which segmentally gives
38 G. Baksa et al.

Fig. 2.25 Crossing and

insertion of flexor
digitorum tendons. FDP
flexor digitorum profundus
tendon, FDS flexor
digitorum superficialis
tendon, FTS fibrous tendon
sheath, VT vinculum

branches to the tendon. Arising from the tendon sheath some small arteries also sup-
ply the tendon itself.

Connections

It is clear that on a microstructural level, all structures are connected to adjacent

structures. Here we use the term connection to implicate soft-tissue structures
whose main function is to connect (or surround) structures. Ligaments which con-
nect bones were covered previously in the chapter.

Extensor Retinaculum
The main function of the extensor retinaculum is to keep the extensor tendons in
place during the movement of the wrist and tendons and to ease the gliding of the
tendons during extension. The extensor retinaculum attaches to the lateral margin of
the radius and to the triquetrum and pisiform.

Connexus Intertendinei
Between the third and fourth and also between the fourth and fifth extensor digito-
rum tendons, connexus intertendinei can be seen proximally from the MCP joints.
These connexi help harmonize the movement of extensor digitorum tendons and
help to avoid the medial drift or slipping of the extensor tendon over the MCP joints
(Fig. 2.26).

Extensor Hood
The extensor hood, also known as dorsal aponeurosis extends over the dorsal sur-
face from the base of the proximal phalangeal bone until the distal phalangeal bone
and conveys the traction of the tendons of the lumbricals, the interossei and the
extensor digitorum and indicis tendons, thereby facilitating the extension of the PIP
and the DIP joint. The central slip component of the extensor hood acts primarily on
the PIPs, while the lateral bands act primarily on DIPs (Fig. 2.27).

Flexor Retinaculum
The flexor retinaculum forms the roof of the carpal tunnel as well as the floor of
Guyon’s tunnel. Located on the palmar side of the wrist, it attaches to the pisiform
bone and to the hook of the hamate and on the radial side to the tubercle of scaphoid
and to the trapezium. Palmaris longus and brevis are very superficial muscles lying
2 Gross Anatomy of the Human Hand 39

Fig. 2.26 Dorsal

tendinous structures of the
hand. CI connexus
intertendinei, DA dorsal
aponeurosis, DI dorsal
interossei, ECB extensor
carpi radialis brevis
tendon, ECL extensor carpi
radialis longus tendon, ED
extensor digitorum
tendons, EDM extensor
digiti minimi tendon, EI
extensor indicis tendon,
EPB extensor pollicis
brevis tendon, EPL
extensor pollicis longus
tendon

Fig. 2.27 Extensor hood of middle finger. CI connexus intertendinei, DA dorsal aponeurosis, DI
dorsal interosseous muscles, ED extensor digitorum tendons, I insertion of the extensor hood, LF
lateral fibres, MF medial fibres, asterisks insertion of dorsal interosseous muscle tendons

over this retinaculum. Many hand muscles originate from the flexor retinaculum and
the transverse carpal ligament (Tables 2.1 and 2.2).

Pulleys
The pulley is a cuff-like, fibrous structure embracing the tendon sheath of flexor
tendons. Annular pulleys are fixed to the palmar plates of the metacarpals (A1 pul-
ley) or to the palmar plate of proximal interphalangeal joints (A3 pulley). Between
them we find the A2 pulley located around the tendon over the proximal phalangeal
shaft. The A5 pulley is located over the DIP joint, while the A4 is located between
the A3 and the A5 pulleys over the midphalangeal shaft. Over other parts of the
tendon sheath, we find the cross-like structures of the cruciate pulleys (C1-3) which
are located between the annular pulleys (Fig. 2.28). When the finger is flexed, the
40 G. Baksa et al.

AP CP AP AP AP

FDP FDS

Fig. 2.28 Pulleys of the third finger. AP annular pulley, CP cruciate pulley, D distal phalanx, FDP
flexor digitorum profundus tendon, FDS flexor digitorum superficialis tendon

rigid annular pulleys move closer to each other, while the softer parts of the fibrous
sheath bunch up as we can see when flexing the finger. Annular pulleys prevent the
bowstringing of the flexor tendons while cruciate pulleys prevent the sheath from
collapsing and expanding during the movement of the fingers. The thumb also has
an oblique pulley between the A1 and A2 annular pulleys. The flexor tendon sheaths
contain both the deep and superficial flexor tendon.

Cavities and Capsules

 rist (Distal Radioulnar, Radiocarpal, Ulnocarpal and Midcarpal

W
Joint)
The wrist is a relatively loose, mobile, instable joint, with a system of strong stabi-
lizing ligaments. The joint cavities of the wrist are surrounded by the joint capsule,
that is strengthened by ligaments. The wrist consists of four different joints: the
distal radioulnar joint, the radiocarpal joint, the ulnocarpal joint – with the articular
disc located between the ulnar styloid and the lunate and triquetrum – and the mid-
carpal joint. These joint frequently communicate with each other and furthermore
may communicate with the pisiform-triquetral cavity, the common carpometacarpal
cavity, the first carpometacarpal cavity and with the intermetacarpal cavities as well.
In the distal radioulnar joint the main synovial recess is the sacciform recess. The
ulnocarpal joint has a recess known as the prestyloid recess which sometimes com-
municates with the pisotriquetral joint and its recess. The radiocarpal joint has a
palmar and a more relaxed dorsal joint recess and may communicate with the space
of Poirier, a central weak area of the wrist in the floor of the carpal tunnel. Between
the proximal and distal row of carpal bones, there lies the well-defined but nearly
fully immobile intercarpal joint, which communicates with the carpometacarpal
joints. Strong interosseal, palmar and dorsal ligaments are strengthening the carpus.
The carpometacarpal joints are also nearly immobile joints. There are strong liga-
ments between the carpal bones and the bases of the metacarpals both on the palmar
and dorsal side. The midcarpal joint has one dorsal recess over the capitate. Certain
terms are used specifically within the clinical context, for example, the triscaphe
joint which is a shared joint between the scaphoid, trapezium and trapezoid bones
in the wrist. This joint is also known as the scaphotrapeziotrapezoid (STT) joint.
2 Gross Anatomy of the Human Hand 41

Fig. 2.29 Sagittal section

of second
metacarpophalangeal joint.
II second metacarpal head,
P proximal phalanx, R
joint recesses, SI sesamoid
bone of index finger

The first carpometacarpal joint is a very mobile saddle joint between the trapezium
and the base of the first metacarpal bone. The capsule of this joint is ample; there are
no strengthening ligaments which results in a relatively free range of movement
required for gripping.
The second to fifth metacarpophalangeal joints are limited in their range of
motion. The spherical head of the metacarpal bones is flattened on both sides. The
joint capsules are ample, especially dorsally. Dorsal proximal, palmar proximal and
phalangeal base recesses are the most important joint cavity enlargements
(Fig. 2.29). The extensor tendon is fixed to the palmar plate by ligaments preventing
the dislocation of the tendon. The palmar plate is a fibrocartilaginous plate for fixa-
tion of the flexor tendon sheath. Each plate is connected to the neighbouring plates
by strong ligaments. This causes, for example, the passive flexion of the fourth digit
upon active flexion of the third digit. The MCP joint can be slightly hyperextended,
abducted and adducted; adjacent fingers can also be crossed. In the flexed position,
both abduction and adduction are impossible due to the tightening of the collateral
ligament. The interphalangeal joints are ginglymus joints allowing only flexion and
extension. The collateral ligaments of the interphalangeal joints are also very tight.

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