Hand Anatomy

Saba Motakef, MD
Catherine A. Walsh, MD
Outline
Questions
Skin, subcutaneous tissue, and fascia
Blood supply
Nerves
Muscles and tendons
Bones and joints
This space lies between the pronator quadratus
and digital flexor tendons

A. Thenar space
B. Midvolar space
C. Interdigital space 0% 0% 0% 0% 0%

D. Paronas space

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E. Hypothenar space
This structure provides lateral stabilization of the
extensor tendon over the MCP joint

A. Lateral band
B. Transverse retinacular ligament
C. Oblique retinacular ligament 0% 0% 0% 0% 0%

D. Sagittal band

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E. Wrist radial/ulnar deviation -10 to
+/-10
You are repairing a complete FPL division from a
knife wound over the proximal phalanx. Which of
the following statements is correct?

A. This represents a zone III injury

B. The proximal tendon is unlikely to
have retracted proximally
C. Preservation of the oblique pulley 0% 0% 0% 0% 0%
is most important

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D. The thumb has both annular and

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cruciate pulleys
E. The neurovascular bundles are
more protected than in the fingers
Which one of the following is innervated by a
branch of the median nerve?

A. FDP to RF
B. Dorsal interossei
C. ADM 0% 0% 0% 0% 0%

D. Deep branch of FPB

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E. APB
Which one of the following statements is correct
regarding the arterial supply to the hand?
A. The princeps pollicis artery arises
consistently from the superficial palmar
arch
B. The ulnar artery lies ulnar to the ulnar
nerve at the wrist
C. In the fingers, the digital vessels lie volar
to the digital nerves 0% 0% 0% 0% 0%

D. The deep volar arch arises from the

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larger terminal branch of the ulnar artery
E. Kaplans cardinal line is a useful marker
of the superficial palmar arch
Dorsal skin
Dorsal skin thin, pliable, anchored by loose areolar tissue
More mobile
Majority of venous drainage and lymphatics are dorsal
Edema often first evident dorsally
Volar skin
Palmar skin characterized by thick dermal layer and stratum
corneum, anchored by diffusely distributed vertical fibers
(fibrous septa)
Thicker, less mobile, has papillary ridges for grasping
Fingertips have specialized nerve endings (Meissners
corpuscles)
Kaplans Cardinal Line
Littlers Diamonds

Mark joint axes and the intersection of PIP/DIP joint crease. A midaxial line through the
three joint axes does not change in length with flexion/extension
Incisions on the palm
1. Bruners
2. Littlers
3. Diagonal lateral
4. Mixed diagonal
5. Diagonal for
thumb
Palmar Fascia
Anchors volar skin to bone for grasping, in contrast to loose skin
on dorsum
Triangular-shaped fascia attached proximally to palmaris longus
tendon
Composed of longitudinal, vertical, transverse fibers
Palmar fascia
Intermediate septum
Midpalmar oblique septum
from palmar fascia to 3rd
metacarpal
Divides thenar space from
midpalmar space
Deep to flexor tendons,
superficial to metacarpals
Deep fascial spaces of the palm
Potential spaces for infection
Midpalmar space
Thenar space
Hypothenar space
Interdigital webspace
Location of collar button abscess
Paronas space
Infections can spread to this space from radial
or ulnar bursahorseshoe abscess
Grayson and Clelands Ligaments
Fibrous bands from phalangeal
periosteum to dermis
Graysons ligament is volar to
neurovascular bundle
Clelands ligament is dorsal to
neurovascular bundle
Graysons ground, Clelands ceiling
Vascular supply
Brachial artery gives rise to
radial and ulnar artery
Ulnar artery artery gives rise to
anterior and posterior
interosseous arteries
Radial artery
Runs between BR/FCR at wrist
Splits into large dorsal branch
that courses through anatomic
snuffbox, under first extensor
compartment to supply deep
palmar arch between IF and
thumb metacarpals
Smaller volar branch joins
superficial palmar arch
Over FCR tendon, through or
between thenar muscles
Ulnar artery
Lies radial to ulnar nerve at wrist
adjacent to FCU, through
Guyons canal
Bordered by pisiform (ulnar) and
hook of hamate (radial)
Floor is transverse carpal ligament
Roof is volar carpal ligament
Splits into large volar branch that
forms superficial palmar arch,
smaller branch joins deep palmar
arch
Superficial volar arch gives rise to
common digital arteries
Superficial arch
Arises from ulnar artery, small contribution from radial
artery
Blood to SF, RF, LF, and ulnar side of IF
Gives rise to common digital arteries, which branch into digital
arteries distally
Ulnar side of SF has no CDA: PDA comes directly from
superficial arch
Superficial arch
CDA lie volar to common digital nerves in the palm, then
bifurcate proximal to the webspace into radial and ulnar proper
digital arteries which lie dorsal to nerves in fingers
PAN: palm artery nerve
FNA: finger nerve artery
At IP joints, digital arteries give off branches that pass under
flexor tendons and anastomose with branches from the other
side to form vincular blood supply
 Study of the relationship of the distal edge of TCL to fat pad,
superficial palmar arch, recurrent branch
18 fresh-frozen cadaver hands; proximal aspect of palmar fat pad,
distal edge of TCL, superficial palmar arch, and motor branch of the
median nerve identified
Distances measured between structures along axis of radial border of RF
8 hands radiographically imaged with fingers flexed/extended (wrist neutral)
to determine if this influenced measurements
 Proximal aspect of palmar fat pad average 2.0 mm proximal to distal edge of TCL; distal end of TCL is
12.7 mm from most proximal aspect of palmar arch and 6.5 mm from nearest aspect of motor branch
Flexing fingers decreases distance between distal end of TCL and fat pad
Did not markedly affecting distance between TCL and palmar arch or motor branch
Conclusion: When dividing the TCL, visualization of proximal aspect of fat pad indicates that distal edge
of the TCL is within ~ 2 mm
Deep palmar arch
One centimeter proximal to superficial arch, deep to flexor
tendons
Blood to thumb and radial side of index finger
Princeps pollicis artery
Divides into proper digital arteries of thumb
Proper digital artery of radial side of IF
May come directly off deep palmar arch or off princeps pollicis
Gives off palmar metacarpal arteries which run distally along
IOs and join CDAs before bifurcation into PDAs
Superficial and deep palmar arches
 Palmar arches of 48 cadavers identified through dissection; most distal points of
palmar arches measured in relation to Kaplans cardinal line, distal wrist crease,
and CMCJ of each RF
The superficial palmar arch (SPA) and deep palmar arch DPA) were average 15.3
+/- 8.60 mm and 6.70 +/- 4.82 mm distal to Kaplans cardinal line, respectively
SPA ave 51.8 +/- 7.56 mm, DPA ave 40.17 +/- .92 mm distal to distal wrist crease
SPA ave 32.2 +/- 6.33 mm, DPA ave 18.3 +/- 4.64 mm proximal to CMCJ of RF
Dorsal carpal arch
Anastomosis of dorsal branches of radial and
ulnar arteries at the wrist
Branches into dorsal metacarpal arteries
which divide into dorsal digital arteries
FDMA arises directly from radial artery between 1st
and 2nd metacarpals not from dorsal carpal arch
Dorsal digital arteries to mid P2
Proper (volar) digital arteries send dorsal branches
to distal finger
Dorsal carpal arch
Dorsal digital artery
 Cadaveric study of 30 fresh right hands from male and female
cadavers using a vascular injection technique with methyl
methacrylate
Origins, course, and characteristics of the arteries of the thumb
described
Arteries of the thumb
Princeps pollicis artery (PPA) was present in all of the hands and was
the origin of the radial and ulnar digital arteries in 73.3%; in the other
26.7% of cases it ended as one of the two digital arteries
Radial and ulnar digital arteries originated from PPA or branches of
palmar metacarpal artery in 53.3% and 83.3% of dissections,
respectively
Dorsally, the dorsal ulnar artery was present in 100% of hands and
originated mainly from PPA (73.3%)
Dorsal radial artery was present in 66.7% of dissections as a direct
branch of the radial artery
Several anastomoses were observed between radial and ulnar digital
arteries and between dorsal and palmar systems
PPA arising from radial artery below first dorsal IO Most common pattern of origin of Digital arteries originating from first palmar MCA
ulnar digital artery from first palmar
MCA and PPA
Arrows indicate the origins of the dorsal arteries of the thumb. UCA, ulnar digital artery; DUA, dorsal ulnar artery; DRA, dorsal radial
artery; RA, radial artery; PPA, princeps pollicis artery.
Nerves
Radial Nerve
Supination, extension of the wrist, fingers,
and thumb
Enters forearm between 2 heads of
supinator
Innervates brachioradialis, ECRL/ECRB
Divides into superficial sensory branch
(SSB) and motor branch (PIN) at elbow
PIN innervates supinator and remaining
extensors of wrist, finger, thumb (ECU,
EDC, EDM, APL, EPL, EPB, EIP)
Radial nerve
SSB passes beneath brachioradialis at musculotendinous junction in
forearm and pierces fascia in distal forearm between brachioradialis
and ECRL where 1st and 2nd compartments intersect
Sensation to dorsoradial hand, dorsum of thumb, IF, LF
Radial nerve
Median Nerve
Precise manipulation
Enters forearm deep to PT or between two heads of PT
Lies between FDS and FDP in forearm
Median Nerve
Motor innervation
AIN (arises in forearm): supplies FPL, IF and sometimes LF FDP, PQ
Proper median nerve innervates PT, FCR, FDS, PL and sometimes LF FDP
Recurrent motor branch off central or radial aspect of median nerve in carpal
tunnel innervates OP, APB, FPB (superficial portion)the OAF muscles
May pass through TCL
Small motor branches from common digital nerves innervate lumbricals to IF
and LF (the L in LOAF)
The median nerve innervates LOAF muscles: lateral (radial) two
lumbricals, opponens pollicis, abductor pollicis, FPB (superficial
head). All other intrinsics ulnar nerve innervated
Median Nerve
Sensory innervation
Volar cutaneous branch 5-6 cm proximal to wrist crease; sensation to
thenar eminence
Proper median nerve enters carpal tunnel then divides into common
and then proper digital nerves, innervate thumb, IF, LF, RF (radial side)
 Meta-analysis of
prevalence of median nerve
variations in the carpal
tunnel and variations in its
thenar motor branch
31 studies (n = 3918
hands) included
Results
Pooled prevalence rates:
Extraligamentous 75.2%
Ulnar side of branching found in 2.1% of hands
Subligamentous 13.5%
Transligamentous courses 11.3%
Ulnar Nerve
Power grasp
Passes through cubital tunnel at elbow
Enters forearm between heads of FCU
Lies under FCU in forearm, passes through Guyons canal
Ulnar nerve proper ulnar to UA, radial to FCU, at wrist
Motor innervation
Forearm: FCU, FDP to RF and SF
Hand: deep motor branch (arises within Guyons canal), passes around
hook of hamate innervates hypothenar muscles (ADM, ODM, FDM),
lumbricals to RF and SF, all interossei, deep head of FPB, ADP
Ulnar Nerve
Sensory innervation
Dorsal sensory branch originates 5-7 cm proximal to ulnar styloid
process and innervates dorsoulnar aspect of hand
Smaller palmar sensory nerve gives sensation to hypothenar area
Distal to Guyons canal, the main nerve divides into common and
proper digital nerves that innervate SF and ulnar side of RF
Muscles
Extrinsic extensors
Originate in forearm
Extrinsic flexors
Originate in forearm
Intrinsics
Originate in hand
Extensor tendons
Extensor retinaculum
2 cm band on dorsum of wrist
Divides extensor tendons into 6 compartments
Muscles of the dorsal wrist
compartments
APL inserts on base of thumb metacarpal, extensor of first metacarpal, thumb abductor
EBP inserts on base of thumb proximal phalanx, extensor of thumb at MCPJ
ECRL inserts on 2nd MC, primary radial deviation of wrist, secondarily wrist extension
ECRB inserts on 3rd MC, prime wrist extensor
EPL travels obliquely around Listers tubercle (45o), extends thumb IPJ
EDC extends MPJ, with extrinsic muscles, extends IPJs; connected by juncturae tendinae
EIP extends IF (lies ulnar to EDC)
EDM prime extensor of SF MPJ (lies ulnar to EDC)
ECU inserts on base of 5th MC, primarily ulnar deviation of wrist, secondarily wrist extension

All innervated by radial nerve main nerve innervates brachioradialis, ECRL, ECRB; PIN
innervates the rest
Extensor tendon zones
Eight zones
Odd numbers over joints, starting
with Zone I over DIP
Even numbers between joints
Thumb TI - TV
Extensor mechanism
Involves intermingling of
extrinsic and intrinsic
mechanisms
EDC tendons insert onto
extensor aponeurosis over MP
joint
Continue distally and trifurcate
at mid P1 into central slip and
two lateral bands
Extensor mechanism
Sagittal bands arise from volar plate of
MP joint, stabilize extensor tendon over
MP joint
Transverse fibers wrap around MCP
Attaches to the conjoined tendons of volar
and dorsal interossei
Attaches to volar plate/intermetacarpal
ligaments
Extensor mechanism

Central slip inserts on base of middle

phalanx, contributes to PIP joint
extension with intrinsics
Two lateral slips arise from central
slip; join IOs and lumbricals to
become conjoined lateral bands
Insert on base of distal phalanx as
terminal tendon
Retaining ligaments of the finger
Transverse retinacular
ligament
Lateral side of PIP joint,
superficial to collateral ligament
Prevents dorsomedial
displacement of lateral bands
Oblique retinacular ligament
(ligament of Landsmeer)
Originates on volar aspect of
middle phalanx, inserts on dorsal
aspect of distal phalanx
Extensor mechanism
Flexors
Superficial muscles
Pronator teres pronates forearm,
wrist, hand
FCR prime wrist flexor
PL ancillary wrist flexor
FCU primarily ulnar deviator of wrist
Flexors
Intermediate muscles
FDS flexes PIPJ
Deep muscles
FDP flexes DIPJs, fingers
FPL flexes thumb IPJ
Ulnar nerve innervates FCU and ulnar
half of FDP. Rest innervated by Median
Flexors (cont.)
Superficial muscles
originate from medial
epicondyle of humerus
Intermediate muscles
(FDS) originate from
three separate heads:
humeral, ulnar, and
radial
Deep muscles
originate from ulna
Carpal Tunnel
9 flexor tendons and median nerve within carpal tunnel
4 FDS, 4 FDP, and FPL
Ulnar border hook of hamate, triquetrum, pisiform
Radial border - Scaphoid, trapezium
Roof - TCL
FDS tendons separated by two layers, 34 over 25
FDP deepest, median nerve radial to FDS/FDP, FPL radial to median nerve
Flexors
FDS inserts on base of P2, causing PIP joint flexion, is median
innervated
Divides into 2 slips, allowing FDP to pass through (Campers Chiasm)
FDP inserts on base of P3, causing DIPJ flexion. IF/LF are median
innervated, RF/SF are ulnar innervated
FPL inserts on base of thumb P2, causing thumb IPJ flexion, median
innervated
PL inserts on volar fascia (unilateral absence in 15%, bilateral absence in
8%), median innervated
FCR inserts on 2nd and 3rd MC, causing wrist flexion, median innervated
FCU inserts on 5th MC, causing wrist flexion/ulnar deviation, ulnar
innervated
Pulleys
Flexor tendons enter fibroosseous tunnel at MCP joint (flexor
tendon sheath)
Thickened at critical points to create 5 annular pulleys
Less important cruciate pulleys (3) are between annular pulley
Expand and compress like accordions during flexion/extension
Thumb: A1 and A2 pulleys over MPJ and IPJ
Oblique pulley lies between A1 and A2 and is most important
to prevent bowstringing
Flexor tendon sheath
Flexor Tendon Zones
Intrinsic muscles
Three groups
Thenar muscles
Hypothenar muscles
Interossei, lumbricals, and adductor pollicis
All thenar and hypothenar muscles originate from TCL
Except abductor digiti minimi, originates from pisiform / triquetrum
All thenar and hypothenar muscles insert distal to MCPJ
Except opponens muscles (OP and ODM) which insert along MC edge
Hypothenar and thenar muscles
Thenar
APB palmar abduction, slight metacarpophalangeal flexion and IP
extension (median)
OP rotates thumb pinch with SF (median)
FPB (superficial) flexes and stabilizes MPJ (median)
FPB (deep portion) flexes MPJ (ulnar)
Hypothenar
ODM rolls 5th MCP toward thumb, flexes 4th, 5th MCPJ for opposition
FDM flexes MPJ
ADM abducts SF, flexes 5th MPJ, extends IPJ when MPJ stabilized
PB Pulls skin to help cup palm; rudimentary muscle
Thenar Muscles
Interossei
Volar interossei adduct fingers, dorsal interossei abduct fingers
4 bipennate dorsal interossei, 3 unipennate volar interossei
Ulnar nerve innervated
DAB, PAD
Adductor pollicis similar to interosseus
Originates from 3rd metacarpal
Inserts on base of proximal phalanx and on extensor apparatus of
thumb
Adducts thumb, flexes MPJ
Interossei
Lumbricals
Along with interossei, flex MP joints
and extend finger IP joints
Arise from radial side of FDP, ulnar
two have contribution from adjacent
FDP
Ulnar two are ulnar innervated,
radial two are median nerve
innervated
Pass volar to intermetacarpal
ligament
Bones and joints
Eight carpal bones
Five metacarpals
Three phalanges for each finger, two for thumb
Bones
IP joints
Tight fitting joints
Collateral ligaments provide lateral
stability throughout range of motion
Unlike volar plate at MPJ, PIPJ volar
plates have strong proximal and
distal attachments, and prevent
hyperextension
Metacarpophalangeal joints

Loose fitting joints

Collateral ligaments pass obliquely in dorsal to volar direction,
from metacarpal head to proximal phalanx
Collateral ligaments are tightest and provide greatest stability
when MP joint is flexed, allow lateral movement when MP joint
is extended
Volar plates are fibrocartilaginous part of capsule
Provide additional stability
Strong distal attachment, loose proximal attachment allowing MP joint
hyperextension
Joints and ligaments
Checkrein ligaments
Carpometacarpal joints
Thumb CMC joint is a saddle joint, has maximal mobility
Stabilized by a complex of ligaments, including volar beak ligament
IF and LF CMC joints have little mobility
RF and SF CMC joints have 20-30 degrees of flexion/extension
(important for power grip)

Because RF/SF CMCJ and thumb CMCJ have so much mobility,

these metacarpals can tolerate greater degrees of angulation
with minimal loss of function
Wrist
Two rows: proximal and distal carpal rows
Proximal row: scaphoid, lunate, triquetrum
Distal: trapezium, trapezoid, capitate, hamate
Pisiform is a sesamoid bone; lies within substance of FCU
Scaphoid joins proximal and distal rows
Most commonly fractured carpal bone
Wrist
Wrist biomechanics
Movements are complex interactions between carpal bones and
radius
Main movements are flexion-extension and radioulnar deviation
with axis through capitate
Scaphoid is primary rotational element during radial deviation,
triquetrum is primary rotational element during ulnar deviation
Wrist joint
Composed of radiocarpal joint and midcarpal joint
Radius/ulna articulate with the proximal carpal row at
radiocarpal joint
Proximal and distal carpal rows articulate with each other at
midcarpal joint
Gilulas Lines
First arc running along the proximal
convexity of the scaphoid, lunate and
triquetrum
Second arc running along the distal
concavities of the scaphoid, lunate and
triquetrum
Third arc running along the proximal
curvatures of the capitate and hamate

The presence of abnormalities in these arcs

may be an indication of carpal pathology
Wrist ligaments
Extrinsic and intrinsic ligaments
Extrinsic ligaments connect carpal
bones to radius and ulna
Intrinsic ligaments connect carpal
bones to each other
Extrinsic ligaments are divided
into dorsal and volar
Volar extrinsic ligaments are more
important for wrist stability
Scapholunate is the most
commonly injured wrist ligament
DRUJ
Forearm joint (as opposed to wrist)
Articulation of ulnar head with sigmoid notch of radius
Allows radius to rotate around fixed unit of ulna
Allows forearm rotation (supination/pronation) along with sister
joint at elbow (proximal radioulnar joint or PRU joint)
TFCC
TFCC is primary stabilizer of DRUJ
Articular disk, distal radioulnar ligaments, ulnocarpal ligaments, ECU
tendon subsheath
Originates from radius, attaches to fovea and base of ulnar styloid
Transmits 20% of load across wrist
Central 80% of TFCC is avascular; poor healing potential
DRUJ
Nail complex
Nail plate
5-7 mm proximal to eponychium
Nail folds
Eponychium, hyponychium
Nail bed
Sterile matrix, germinal matrix
Lunula
References
1. Greens Operative Hand Surgery, 6th Edition: Chapters 1 and 2.
2. Essentials of Plastic Surgery, 3rd Edition: Chapter 49.
3. McLean KM, Sacks JM, Kuo YR, Wollstein R, Rubin JP, Lee WP. Anatomical landmarks to the
superficial and deep palmar arches. Plast Reconstr Surg. 2008 Jan;121(1):181-5.
4. Ramrez AR, Gonzalez SM. Arteries of the thumb: description of anatomical variations and
review of the literature. Plast Reconstr Surg. 2012 Mar;129(3):468e-476e.
5. Henry BM, Zwinczewska H, Roy J, Vikse J, Ramakrishnan PK, Walocha JA, Tomaszewski KA.
The Prevalence of Anatomical Variations of the Median Nerve in the Carpal Tunnel: A Systematic
Review and Meta-Analysis. PLoS One. 2015 Aug 25;10(8).
6. Madhav TJ, To P, Stern PJ. The palmar fat pad is a reliable intraoperative landmark during carpal
tunnel release. Hand Surg Am. 2009 Sep;34(7):1204-9.