THE SKIN

• PALM: characteristics:
1. Flexure creases (lines of palm)
2. Papillary ridges (fingerprints):
improve grip & increase surface area
3. 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 & vessels
2. 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 longus
2. Base: directed distally, divided into 4 slips for the
medial 4 fingers
3. 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
dupuytren contracture.
 Flexor retinaculum
It is a strong fibrous band of deep fascia connecting proximal and distal
carpal of bones of medial and lateral side
 Flexor retinaculum
• Attachment
Medially
Pisiform Bone and hook of the
hamate
• Laterally
It splits into superficial and deep
layers
Superficial layer is attached to
tubercle of the scaphoid and
tubercle of the trapezium.
Deep layer is attached to the
trapezium posterior to the
groove for the flexor carpi radialis
Proximal- continuous with
antebrachial fascia and fasci
covering FDS
Distal-continuous with palmar
aponeurosis
Particulars Superficial Deep

A. Tendon a. Palmaris longus FDS – Flexor digitorum

superficialis-4 Relations
FDP – Flexor digitorum
profundus -4
FPL – Flexor pollicis
longus – 1
FCR – Flexor carpi
radialis
B. Arteries a. Ulnar artery
b. Superficial palmar ---------------
branch of radial artery
C. Nerve a. Ulnar nerve
b. Palmar cutaneous Median nerve
branch of ulnar
nerve
c. Palmar cutaneous
branch of median

D. Synovial ------------ For flexor tendons

sheath
E.Bursae ------------ a. Radial bursa
b. Ulnar bursa
 Importance
A. It gives origin to thenar and hypothenar muscles.
B. The tendon of palmaris longus is fused in the midline.
C. It keeps all the flexor tendons in position.
D. It converts bony gutter into tunnel.
 Applied anatomy

Carpal tunnel syndrome:

Compression of median nerve in the carpal
tunnel gives rise to loss of sensations and
weakness of the muscles of the thenar
eminence, which constitute the carpal tunnel
syndrome.
Aetiology: .
I. Causes due to the involvement of bones:
i. Arthritis,
ii. Dislocation of the lunate,
iii. Old fracture of wrist joint.
II. Soft tissue pathology
i. Tenosynovitis,
ii. Acromegaly.
iii.Myxaedema,
iv. Obesity and
 Carpal tunnel syndrome

Sex variation : carpal tunnel syndrome is common in

female.
Age group : Occurs between 40 to 70 years.
Clinical features:
Intermittent attacks of pain, which are more in the
night. It is referred to proximal part of forearm. It may be
relieved by dorsiflexion
.
 Carpal tunnel syndrome
Wasting of thenar muscles
I. Flexor pollicis brevis.
II. Opponens pollicis.
III. Abductor pollicis brevis.
Treatment :
a. Pain is relieved by splinting of the wrist in slight
dorsiflexion.
b. The division of flexor retinaculum is required in
severe cases.
 INTRINSIC MUSCLES
• LATERAL GROUP:
FOUR THENAR MUSCLES
• MEDIAL GROUP:
THREE HYPOTHENAR MUSCLES
PALMARIS BREVIS
• CENTRAL GROUP:
FOUR LUMBRICALS
FOUR PALMAR INTEROSSEI
FOUR DORSAL INTEROSSEI
• ALL MUSCLES ARE SUPPLIED BY C8 & T1 SPINAL
SEGMENTS THROUGH MEDIAN & ULNAR NERVES
 INTRINSIC MUSCLES
• THENAR MUSCLES:
1. Abductor pollicis brevis
2. Flexor pollicis brevis
3. Opponens pollicis
4. Adductor pollicis
• HYPOTHENAR MUSCLES:
1. Abductor digiti minimi
2. Flexor digiti minimi
3. Opponens digiti minimi
 INTRINSIC MUSCLES OF THE HAND
1. Thenar Muscles :---

These consist of three short muscles:

1)Abductor pollicis brevis,
2) Flexor pollicis brevis and
3)Opponenspollicis
last one lies under cover of the former two
muscles.
They form the thenar eminence and
arise together from the flexor retinaculum and
from the two lateral bony pillars of carpal tunnel.
• Abductor pollicis brevis
• Origin:Tubercle fo
scaphoid
• Crest of trapezium
• Flexor retinaculum
• Insertion:Lateral side of
base of proximal phalanx of
thumb
• Action:Abduction of thumb
• Flexor pollicis brevis
Origin:Superficial head
from distal border of
flexor retinaculum
Deep head from
trapezoid and capitate
bones
Insertion:Lateral side of
the base of proximal
phalanx of thumb
• Action:Flexion of thumb
• Opponens pollicis
• Origin:Flexor
retinaculum
• crest of trapezium
• Insertion:Lateral border
and adjoining lateral half
of the palmar surface of
the first metacarpal bone.
• Actions:Opposition of
thumb
• Deepens the hollow of
palm
• Adductor policis
• Origin:Transverse
head:on palmar
surface of3rd
metacarpal
• ObliqueHead: Bases
of 2nd,3rd metacarpal
adjoining capitate &
hamate bones
Inserstion:Medial side
of base of proximal
phalanx of thumb
• Action:Adduction of
thumb
Hypothenar
Muscles
 Muscles Origin Insertion Action

Abductor digiti • Pisiform bone Ulnar side of the Abduction of little

minimi base of the finger
• Tendon of flexor proximal phalanx
carpi ulnaris of little finger

Flexor digiti minimi • Flexor Ulnar side of base Flexion of little

retinaculum of proximal finger
phalanx of little
• Hook of hamate finger along with
tendon of
abductor digiti
minimi

Opponens digiti • Flexor Medial surface of • Opposition of tip

minimi retinaculum the shalf of 5th of little finger with
metacarpal bone the tip of thumb.
• Hook of hamate • Deepens the
hollow of palm
 Abductor digitiminimi
• Origin
Pisiform bone
Tendon of
flexorcarpi ulnaris
• Insertion Abductor digitiminimi
Ulnar side of the
base of the
proximal phalanx of
little finger
• Nerve Supply
Debranch of ulnarnerve
• Action
Abduction of little finger
 Flexor digiti minimi
• Origin
Flexor retinaculum
Hook of hamate
• Insertion
Ulnar side of base of
proximal phalanx of little
finger along with tendon of
abductor digiti minimi
• Nerve Supply
Debranch of ulnarnerve
• Action
Flexion of little finger
 Opponens digiti minimi
• Origin
Flexor retinaculum
Hook of hamate
• Insertion
Medial surface of the
shalf of 5th metacarpa
bone
• Nerve Supply
Debranch of ulnarnerve
• Action
Opposition of tip of little
finger with the tip of thumb.
Deepens the hollow o
palm
 INTRINSIC MUSCLES
• LUMBRICALS
1. Origin: tendons of FDP
2. Insertion: tendons of ED
• PALMAR INTEROSSEI
1. Origin: metacarpal bone
2. Insertion: proximal phalanx
• DORSAL INTEROSSEI
1. Origin: adjoining sides of 2 metacarpal bone
2. Insertion: proximal phalanx
• PALMARIS BREVIS
1. Origin: Palmar aponeurosis
2. Insertion: skin of medial border of hand
 LUMBRICAL MUSCLES

There are four lumbrical muscles

and numbered first, second, third and fourth
from lateral to medial side.
They are small slender muscles one
for each digit.
They are named lumbricals because
of their elongated worm-like shape (L.lumbrical
= earthworm).
 LUMBRICAL MUSCLES
Origin :---
1. Lumbricals 1 and 2: From lateral
side of lateral two tendons of flexor digitorum profundus.

2. Lumbricals 3 and 4: From

adjacent sides of medial three tendons of flexor digitorum
profundus.
 LUMBRICAL MUSCLES
• Insertion :---

•
The tendons cross the radial
side of metacarpophalangeal
(MP) joints to be inserted into
the lateral side of dorsal digital
expansion of the
corresponding digit from
second to fifth.
 LUMBRICAL MUSCLES
Nerve supply :---

 Frist and second lumbricals by median nerve.

Third and fourth lumbricals by deep branch of ulnar

nerve (C8, T1)

Actions :---

 Lumbricals flex the metacarpophalangeal (MP) joints

and extend the proximal and distal interphalangeal (PIP and DIP)
joints.
 SUPERFICIAL PALMAR
ARCH

• Gives digital arteries which supplies medial 3½

fingers on the palmar surface
 SUPERFICIAL PALMAR
Situation:
ARCH
In palm of hand infront of flexor tendons,lumbricals,palmar digital
branches of median nerve and behind skin and palmar
aponeurosis,palmaris brevis
Formation:
Superficial branch of the ulnar artery joined laterally by
a) Superficial branch of
radial artery or
b) Arteria radialis indicis or
c) Arteria Princeps pollicis
Branches:
a) Palmar digital artery to
medial side of little finger
b) Three common palmar
digital arteries
Each common palmar
Digital artery

Two proper digital arteries

Adjacent sides of index,middle
ring and little fingers except
Radial side of index finger and thumb
All the arteries freely anastomose at finger tips and at the

interphalengeal joints by their small branches

Two dorsal branches- soft tissue of middle and distal phalnx

including nail bed

Palmar digital arteries supply-phalanges,

metacarpophalengeal and interphalengeal joints

They supply mainly digits