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20
2 Anatomy oftheHand andFoot
Fig. 2.19 Distribution type of cutaneous nerve. (1) Supercial branch
of radial nerve. (2) Dorsal branch of ulnar nerve. (3) Posterior antebrachial cutaneous nerve. (4) Lateral antebrachial cutaneous nerve
Deep Structures
Extensor Retinaculum
It is formed by the thickened deep fascia of forearm in the
dorsum of wrist, also called as dorsal carpi ligament (Fig.2.20).
whose width is 2–3cm, transverse and oblique, attached to the
lateral margin of the lower radius and styloid process of radius
on the radial side, bypassing the styloid process of ulna and its
distal continued with and exor retinaculum on the ulnar side,
and attached to the pisiform bone and triquetral bone.
Dorsal Deep Facial ofHand
Doral deep fascia of hand can be divided into two layers:
supercial and deep. The supercial layer is a continuation
of the dorsal carpi ligament (extensor retinaculum), which
binds to extensor tendon to form aponeurosis dorsalis manus,
the second and fth metacarpal bone are attached to one side,
respectively. The deep layer covers the dorsal surface of the
metacarpal bones from the second to the fth and the interosseous dorsal muscles from the second to the fourth and is
Fig. 2.20 Dorsal deep facial of hand. (1) Extensor retinaculum. (2)
Digital extensor tendon. (3) Dorsal interosseous fascia. (4) Second dorsal metacarpal artery
called dorsal interosseous fascia. At the proximal end of the
metacarpal, it is continued with the dorsal fascia of hand by
a brous lattice, and the two layers of fascia at the distal end
of nger web are bonded to each other.
Ficial Space
Since dorsal fascia of hand binds to each other at the proximal
and distal end of the metacarpal bone, subcutaneous and subaponeurotic spaces are formed between supercial fascia, aponeurosis dorsalis manus, and dorsal interosseous fascia. The two
spaces connect with each other, and when dorsum of hand is
infected, the entire dorsum of hand will be swollen obviously.
Tendon ofExtenson Digitorum
Tendon of extenson digitorum can be divided into radial
group and ulnar group (Fig.2.21).
1. Radial group: This group includes extensor pollicis longus and extensor pollicis brevis, which travel towards the
thumb to form the radial and ulnar boundaries of anatomical snuffbox and meet at the metacarpophalangeal
joint of the thumb, associated with thumb movement.
2. Ulnar group: This group includes tendon of extenson
digitorum, extensor tendon of index nger, and extensor
tendon of liittle nger, associated with the movement of
second to fourth nger. Tendon of extenson digitorum has
2.2 Applied Anatomy oftheHand
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21
four thin and at tendons, which go to the second to fth
nger, respectively. At the point close to the metacarpal
head, the tendons are connected by 3 oblique tendon ber
bundles, which are called intertendinous connections.
Intertendinous connections have the function of enhancing the stability of nger extension movement and limiting the individual movement of each nger, especially
that of the middle, ring, and little nger is more obvious.
When a certain extensor tendon is ruptured at the proximal side of the intertendinous connections, there is no
obvious extensor dysfunction. Except for the middle nger and ring nger are one extensor tendon, the other ngers are two. Except for the two extensor tendons of the
thumb, the extensor tendons of the index nger and the
little nger were combined with the extensor tendons of
the two ngers, and there was no obvious difference in
the insertion point and formation structure.
The skin and subcutaneous tissue of dorsum of hand are
weak. The extensor tendon may be injured by cutting, twisting,
squeezing, or tearing of dorsum of hand, and the incidence of
wound pollution is more common than that of the palm.
Dorsal Metacarpal Artery
Located in the corresponding metacarpal space between tendon of extenson digitorum and the dorsal interosseous muscle,
Fig. 2.21 Tendon of extensor digitorum. (1) Extensor pollicis longus.
(2) Extensor pollicis brevis. (3) Tendon of extensor digitorum. (4)
Extensor tendon of index nger. (5) Extensor tendon of little nger. (6)
Intertendinous connections. (7) Radial artery
a c
b
a total of 4 (Fig.2.22). First dorsal metacarpal artery originates
from dorsal part of radial artery through the rst dorsal interosseous muscle and runs distal along the supercial surface of
the muscle. The dorsal metacarpal artery (second to fourth) is
Fig. 2.22 Origin, course, and distribution of dorsal metacarpal artery.
(a) First dorsal metacarpal artery. (b) 2nd–4th dorsal metacarpal artery.
(c) Anastomosis and branches at nger web. (1) First dorsal metacarpal
artery. (2) Second metacarpal artery. (3) Third dorsal metacarpal artery.
(4) Forth dorsal metacarpal artery. (5) Dorsal digital artery. (6)
Anastomotic branches. (7) Radial artery
22
2 Anatomy oftheHand andFoot
formed by anastomosis of the proximal perforator of deep
metacarpal arch and the trafc branch of the distal dorsal
venous rete of wrist. It runs to the distal side of the supercial
dorsal muscle between the corresponding bones and is divided
into two small dorsal digital arteries at the head of the metacarpal bone. There are branches of anastomosis with common
palmar digital artery in interwebbed space. Because of the
supercial position of the dorsal metacarpal artery and it is
constant, free aps designed with it as the vascular pedicle is
often used to repair the skin defect of the hand.
2.2.2 Palm ofHand
Palm of hand is a quadrilateral area between the wrist and
ngers.
Supercial Structures
The skin is thick and tough, lack of elasticity, without hair follicles and sebaceous glands but is rich in sweat glands. The
a
supercial fascia is relatively loose at thenar area, and the palmar part is very tight. There are many bers passing through
perpendicular to the palmar surface, connecting the supercial
surface to skin, attaching the deep surface to palmar aponeurosis, and dividing the supercial fascia into numerous compartments, in which supercial blood vessels, lymphatics, and
cutaneous nerves go through (Fig.2.23). Since ber bundle connects skin and palmar aponeurosis closely together, the mobility
of the skin is so little, which is concomitant to hold tool, and
facilitate labor. However, when there is inammation in the
supercial fascia, the pus is limited and difcult to spread in all
directions. When the pus is cut open and discharged, the ber
bundle must be cut off to make drainage unblocked. The surgical incision of the palm should be parallel to the palmar crease
to reduce scar contracture and ensure the function of the hand.
The main structures in the supercial fascia include:
Cutaneous Nerves
There are three main cutaneous nerves. (1) Palmar cutaneous branch of ulnar nerve: Descending along the anterior
b
Fig. 2.23 Supercial fascia and structure of palm. (a) Object specimen. (b) Cast specimen. (1) Palmar cutaneous branch of ulnar nerve. (2) Palmar
cutaneous branch of median nerve. (3) Supercial branch of radial nerve. (4) Palmaris brevis
2.2 Applied Anatomy oftheHand
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23
border of ulnar nerve to the palm, it penetrates into the deep
fascia and distributes the skin of hypothenar; (2) Palmar
cutaneous branch of the median nerve: At the margin of the
exor retinaculum, which diverts from the median nerve,
penetrates the surface of the exor retinaculum and distributes the skin of the middle of palm and thenar; (3)
Supercial branch of radial nerve: after crossing extensor
retinaculum, it is divided into four to ve dorsal digital
nerves, of which rst dorsal digital nerve innervates the lateral skin of thenar.
Palmaris Brevis
It is a degenerate cutaneous muscle, located in the supercial
fascia of the proximal part of hypothenar, which has a xed
effect on supercial fascia and can protect ulnar nerve and
ulnar vessels.
Deep Structures
Deep Fascia
Deep fascia can be divided into supercial and deep layers.
Supercial layer: It is a dense connective tissue membrane
a
that covers the supercial surface of thenar muscle, hypothenar muscle, and exor tendon of palm. Palmar aponeurosis is
an aponeurotic structure composed of longitudinal bers on
the supercial side and transverse bers on the deep side,
located in the central part of palm, which covers the supercial surface of supercial palmar arch and the exor digitorum supercialis, is thick and tough, slightly triangular that
points to the proximal side. On the supercial side of exor
retinaculum, it is connected with palmaris longus, and the
distal part is formed into four longitudinal bers running at
the distal phalanx of the second to fth nger. It is connected
with the brous sheath of each nger and the collateral ligament of metacarpophalangeal joints, and attachepalmar phalangeal joined to both sides of the base of phalanx (Fig.2.24).
At the head of the metacarpal bone, the transverse bers
in the deep layer of palmar aponeurosis and the four bundles
of longitudinal bers from the distal part of the aponeurosis
form three ber spaces, which are called web space, rich in
fat, as well as blood vessels and nerves from palm to ngers,
which are the communication channels of palm, dorsum of
hand and ngers (Fig.2.24). Dupuytren’s contracture may be
b
Fig. 2.24 Palmar aponeurosis and palmaris brevis. (a) Object speci-
men. (b) Schematic diagram. (1) Palmaris longus. (2) Palmar cutaneous
branch of median nerve. (3) Supercial cutaneous branch of ulnar
nerve. (4) Palmar aponeurosis. (5) Longitudinal fasciculus. (6)
Transverse fasciculus. (7) Supercial transverse metacarpal ligament.
(8) Hypothenar. (9) Palmaris brevis. (10) Thenar
24
2 Anatomy oftheHand andFoot
caused by proliferative brous degeneration of palmar aponeurosis, which should be treated by cutting or resecting the
aponeurosis. Infections of web spaces are more common in
stab wounds, secondary infections (such as blisters and
cracks), and spread of infection in palmar spaces. Since the
palmar skin is thicker than the dorsal and the supercial fascia is dense, the redness and swelling on dorsum of hand will
be more obvious when the web space is infected. Deep layer:
covering the surface of metacarpal, palmar interossei and
adductor pollicis, compared with supercial layer, it is
weaker and is divided into palmar interosseous fascia and
fascia of adductor pollicis. Palmar interosseous fascia covers
the surface of palmar interosseous muscle and metacarpal
bone and is located in the deep side of exor digitorum profundus. Fascia of adductor pollicis arises from palmar
interosseous fascia and extends on the radial side of third
metacarpal bone and covers the surface of adductor pollicis.
Osteofascial Sheath
A brous septum arises from the lateral margin of palmar
aponeurosis and is attached to the rst metacarpal bone
through thenar and exor tendon of the index nger, which is
called lateral intermuscular septum of palm. From the medial
margin of palmar aponeurosis, a brous tissue septum,
known as medial intermuscular septum of palm, extends
deep between the hypothenar and exor tendon of the little
nger, and is attached to the fth metacarpal bone. Thus
palm forms the lateral, middle, and medial osteofascial
sheath (Fig.2.25).
Fascial Spaces
Located deep in palmar intermediate septum there is loose
connective tissue, including lateral thenar space and midpalmar space. Palmar intermediate septum is a brous tissue
septum connected between palmar aponeurosis and palmar
interosseous fascia. After wrapping exor tendon of the
index nger and rst lumbrical muscle, the palmar intermediate septum is attached to third metacarpal bone and divides
palmar fascia space into midpalmar space and thenar space
(Fig.2.26).
1. Midpalmar space: Located in deep ulnar side of palmar
intermediate septum. The anterior boundary starts from
the radial side of is exor tendon of third to fth nger
and second to fourth lumbricals; The posterior boundary
is posterior part of palmar intermediate septum, the third
and fourth metacarpal bones, interosseous muscle, and
palmar interosseous fascia. The medial boundary is
medial septum and the lateral boundary is palmar intermediate septum. Midpalmar space is communicated with
the second to fourth web spaces along the second to
fourth lumbricals canal and then leads to dorsum of hand.
The proximal midpalmar space reaches the deep surface
of the common tendinous sheath of exor digitorum and
communicated with posterior space of antebrachial exor
through carpal canal. So when this space is infected, it
can spread through the above channels.
2. Thenar space: Located in deep radial side of palmar inter-
mediate septum. The anterior boundary is the anterior part
Fig. 2.25 Osteofascial sheath of hand
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a
25
b
Fig. 2.26 Fascial spaces and tendinous sheath. (a) Projection; (b) axial
section of fascial space: (1) palmar intermediate septum, (2) thenar
space, (3) midpalmar space, (4) common tendinous sheath of exor
of palmar intermediate septum, exor tendon of index nger, and rst lumbricals. The posterior boundary is fascia
of adductor pollicis. The lateral boundary is the lateral
muscle septum. The medial boundary is posterior part of to
the palmar septum to the palmar septum. The thenar space
extends distal through rst lumbricals canal dorsum of
index nger, and the proximal end is a blind end.
Synovial Sheath ofPalm
The tendon is wrapped in the synovial sheath as it passes
below the ligament or through the brous canal to reduce
friction and facilitate tendon movement. There are common
tendinous sheath of exor digitorum (also known as ulnar
synovial capsule) and tendinous sheath of exor pollicis longus (also known as radial synovial capsule) on the palm surface (Fig.2.27). Variations in the synovial capsule and exor
tendinous sheath are common (Fig.2.28).
Common tendinous sheath of exor digitorum: Wrap
exor digitorum supercialis and profundus, most in the carpal canal. The proximal end of the capsule reaches two hori-
digitorum, (5) tendinous sheath of exor pollicis longus, (6) lumbricals
canal, and (7) synovial sheath of nger
zontal ngers above exor retinaculum, and the distal end is
at the same plane as the ulnar margin of thumb when
abducted. The distal ulnar side is constantly communicated
with synovial sheath of the little nger (accounting for 80%–
90%). In section view, the capsule penetrates into the middle
of exor digitorum supercialis and profundus, connects the
ulnar margin, and separates the radial margin, like an E.The
ulnar nerve walks on the supercial ulnar surface of the capsule, which should be avoided when the capsule is cut open.
Tendinous sheath of exor pollicis longus: Wrap the
exor pollicis longus, with the proximal end reaching the
two horizontal ngers above exor retinaculum, and the distal end communicating with the synovial sheath of the thumb
constantly. Because the medial side is attached to the ulnar
capsule, when one capsule is suppurated, it is easy to puncture the other. So the thumb and little nger can infect each
other. Median nerve goes on the supercial surface between
the radial and ulnar capsule, and its reverse branch goes on
the anterior lateral side of the radial capsule, which should be
avoided injury when the capsules are cut open.
26
2 Anatomy oftheHand andFoot
Fig. 2.27 Synovial sheath of palm. (1) Common tendinous sheath of
exor digitorum. (2) Tendinous sheath of exor pollicis longus. (3)
Synovial sheath of nger. (4) First lumbricals
Synovial sheath of nger: Wrap exor tendons of each
nger and attach to both sides of the phalanx and are covered
by the brous sheath of the nger. The proximal end reaches
the distal palmar crease or metacarpophalangeal joint, and
the distal end ends at the base of distal phalanx of each nger. The vasculars and nerves of ngers go on both sides of
palmar surface of synovial sheath, so incision of that should
be carried out at both sides of phalanx.
Fig. 2.28 Variations in the synovial capsule and exor tendinous
sheath
Intrinisic Muscles ofHand
Intrinisic muscles of hand include the lateral group, the middle group, and the medial group (Fig.2.29). The lateral group
consists of adductor pollicis brevis, exor pollicis brevis,
opponens pollicis and adductor pollicis. The middle group
consists of lumbricals, palmar interossei, and dorsal interossei. The medial group consists of abductor digiti minimi,
Fig. 2.29 Intrinsic muscles of hand. (1) Adductor pollicis brevis. (2) Flexor
pollicis brevis. (3) Opponens pollicis. (4) Transverse head of adductor pollicis. (5) Abductor digiti minimi. (6) Flexor digiti minimi brevis. (7)
Opponens digiti minimi. (8) Lumbricals. (9) Median nerve. (10) Ulnar nerve
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Table 2.1 Intrinisic muscles of hand
Muscle
groups Name Start point Insertion Function Innervation
The
lateral
group
The
middle
group
The
median
group
Adductor pollicis
brevis
Flexor pollicis brevis Supercial head:
Opponens pollicis Transverse carpal
Adductor pollicis Oblique head:
First,
second
Third,
fourth
First Palmar
Second,
third
First,
second
Third,
fourth
Abductor digiti minimi Pisiform bone,
Flexor digiti minimi
brevis
Opponens digiti
minimi
Lumbricals Radial side of exor
interrossei
Dorsal
interrossei
Transverse carpal
ligament, scaphoid
nodules
Transverse carpal
ligament
Deep head:
Transverse carpal
ligament, Trapezoid
bone
ligament, Trapezium
bone
Capitate bone,
transverse carpal
ligament
Transverse head:
Anterior of third
metacarpal
digitorum profundus
of index and middle
nger
Opposite side of
exor digitorum
profundus of ring and
little nger
Ulnar side of second
metacarpal
Radial side of fourth
and fth metacarpal
Opposite side of rst
to fth metacarpal
pisohamate ligaments
Hamate bone,
transverst carpl
ligament
Sesamoid bone on lateral side
of base of proximal phalanx
of the thumb
Sesamoid bone on both sides
of proximal phalanx of the
thumb
Radial side of rst metacarpal Oppose thumb Median
Basement of proximal
phalanx of the thumb
Aponeurosis dorsalis digiti of
proximal phalanx of second
to fth nger
Crosses ulnar side of the
index nger and terminates in
aponeurosis dorsalis digiti of
the nger
Crosses radial side of the
fourth to fth nger and
terminates in aponeurosis
dorsalis digiti of the ngers
Crosses radial side of the
second to third nger and
terminates in aponeurosis
dorsalis digiti of the ngers
Crosses ulnarl side of the
third to fourth nger and
terminates in aponeurosis
dorsalis digiti of the ngers
Ulnar side basement of
proximal phalanx of little
nger
Ulnar side of fth metacarpal Oppose little nger
Abduce thumb Median
nerve (C6, 7)
Flex metacarpophalangeal joint of
thumb
Adduct and ex thumb Ulnar nerve
Flex metacarpophalangeal joints and
extense interphalangeal joints
Adduct second, fourth, fth ngers,
ex metacarpophalangeal joints, and
extense interphalangeal joints
Abduct second, fourth ngers, ex
metacarpophalangeal joints and
extense interphalangeal joints
Flex and abduct little nger Ulnar nerve
Flex joints of little nger
Median
nerve (C6, 7)
Ulnar nerve
(C8)
nerve (C6, 7)
(C8)
Median
nerve (C6, 7)
Ulnar nerve
(C8)
Ulnar nerve
(C8)
(C8)
27
exor digiti minimi brevis, and opponens digiti minimi. The
starting point, function, and innervation of each muscle
(Table2.1).
arm are involved in the formation of dorsal carpal arterial
rete. Some individuals have developed median artery which
distributes in proximal part of palmar or participates in the
formation of supercial palmar arch.
Vasculars
The blood supply of hand mainly comes directly from the
branches of radial and ulnar arteries, which anastomosis with
each other into supercial palmar arch and deep palmar arch.
The anterior and posterior interosseous arteries of the fore-
Supercial palmar arch: On the deep surface of palmar
aponeurosis and palmaris brevis, and on the supercial surface of the exor digiti minimi brevis, common palmar digital nerve, exor digitorum, and lumbricals, the convex side
of the arc points to nger side. The projection line of the
28
2 Anatomy oftheHand andFoot
a
b
Fig. 2.30 Position, composition, and branches of supercial palmar
arch. (a) Object specimen. (b) Cast specimen. (1) Terminal branch of
ulnar artery. (2) Supercial palmar branch of radial artery. (3) Supercial
body surface is roughly in the curve from the middle point of
middle palmar crease to the radial side of pisiform bone.
Supercial palmar arch is formed by anastomosis of the terminal branch of ulnar artery and supercial palmar branch of
radial artery (Fig.2.30). The outer diameter of middle part of
supercial palmar arch is 2.2 mm.
The supercial palmar arch can be divided into four
types according to the source of the artery anastomosis with
the terminal branch of ulnar artery: ulnar artery type
(51.72%) is composed of the terminal branch of ulnar artery,
while radial artery is not involved. Radial ulnar artery type
(37.31%) is composed of the terminal branch of ulnar artery
and the supercial branch of radial artery. Median ulnar
palmar arc. (4) Common palmar digital arteries. (5) Ulnar palmar artery
of quinary nger. (6) Common palmar digital nerve. (7) Lumbricals. (8)
Proper palmar digital artery
artery type (4.51%) is composed of the terminal branch of
ulnar artery and median artery. Median radial artery type
(0.96%) is composed of the terminal branch of ulnar artery
and the supercial branch of radial artery and median artery
(Fig.2.31).
The convex side of supercial palmar arch often gives off
three common palmar digital arteries and ulnar palmar artery
of quinary nger, and the concave side sends out several
small reverse branches to the wrist to participate in the formation of palmar carpal rete. The supercial palmar arch and
its branches are accompanied by eponymous veins.
Common palmar digital arteries: The occurrence rate is
almost 100%, and the initial outer diameter of each artery is
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a c
Fig. 2.31 Types of supercial palmar arc. (a) Ulnar artery type, (b) radial ulnar artery type, (c) median ulnar artery type. (Note: Median radial
artery remains 1.0%)
b
1.2–1.5mm. Common palmar digital arteries are accompanied by common palmar digital nerve, descend along the corresponding lumbrical surface of second to fourth metacarpal
space, receive palmar metacarpal arteries and the perforating
branch of dorsal metacarpal arteries near the metacarpophalangeal joint, and send out two proper palmar digital arteries
at 1.2cm from web edge.
Ulnar palmar artery of quinary nger: It originates
from ulnar margin of the convex side of supercial palmar
arch, descends along the surface of thenar and distributes in
the ulnar side of little nger.
Deep palmar arc: It is located among exor digitorum
supercialis, exor digitorum profundus, lumbricals, supercial head the exor pollicis brevis, and the exor digiti
minimi brevis and interosseous muscle, transverse from the
basement of rst metacarpal space to the basement of fth
metacarpal space. The surface projection of the arch corresponds to the line from the proximal end of rst metacarpal
space to hamate bone. Deep palmar arch and its branches are
accompanied by eponymous veins.
Deep palmar arch is mainly composed of terminal branch
of radial artery, outer diameter of middle part of which is
2.0mm. The arc can be divided into two types according to
whether the terminal branch of radial artery anastomoses
with other arteries (Fig.2.32). (1) Complete type: (accounts
for 95%), the arch formed by the anastomosis of terminal
branch of radial artery with ulnar palmar branch or other
branches accounts for 55%, that formed by the anastomosis
of terminal branch of the radial artery with the upper or lower
palmar branch of ulnar palmar artery accounts for 30%, and
that formed by the anastomosis of common palmar artery or
ulnar palmar artery of the third nger accounts for 10%. (2)
Incomplete type:(accounts for 5%), the terminal branch of
radial artery runs inwards and does not anastomose with
other branches. In fact, the terminal branch of radial artery
has extensive anastomosis with other peripheral branches,
which just are small. The terminal branch may become a perforating branch passing through the fourth metacarpal space
to form the fourth dorsal metacarpal artery, or it may terminate at the fourth metacarpal space. The convex side of the
deep arch gives off three palmar arteries, the concave side of
the arc sends out two to four reverse branches to participate
in the formation of palmar carpal rete, and the dorsal side of
the arc sends out 3 penetrating branches to dorsum of hand.
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