Applied anatomy of the upper limb

1. Fascial spaces in the upper limb
Dr. Mohammed Mahmoud Mosaed

2. Fascial Spaces of the Palm
• Normally, the fascial spaces of the palm
are potential spaces filled with loose
connective tissue. Their boundaries are
important clinically because they may
limit the spread of infection in the palm.

3. The Palmar Aponeurosis
• The palmar aponeurosis is triangular thickening of the deep fascia
in the central area of the palm of the hand.
• The apex of the palmar aponeurosis receives the insertion of the
palmaris longus tendon.
• The base of the aponeurosis divides at the bases of the fingers into
four slips. Each slip divides into two bands, one passing superficially
to the skin and the other passing deeply to fuse with the fibrous
flexor sheath and the deep transverse ligaments.
• From each of these borders, fibrous septa pass posteriorly into the
palm and take part in the formation of the palmar fascial spaces.
• The function of the palmar aponeurosis is to give firm attachment
to the overlying skin and so improve the grip and to protect the
underlying tendons.

5. Midpalmar, Thenar and hypothenar
spaces
 From the medial border of the palmar aponeurosis a fibrous
septum passes backward and is attached to the anterior
border of the 5th metacarpal bone.
 Medial to this septum is a fascial compartment containing
the three hypothenar muscles, this compartment is
unimportant clinically.
 From the lateral border of the palmar aponeurosis, a second
fibrous septum passes obliquely backward to the anterior
border of the 3rd metacarpal bone.
 Usually the septum passes between the long flexor tendons
of the index and the middle fingers.
 This second septum divides the palm into the thenar space
which lies lateral to the septum and the midpalmar space
which lies medial to the septum.

7. Boundaries and contents of the palmar
spaces
• Thenar space
• Boundaries
• Medially : lateral palmar septum
• Roof: the long flexor tendons to the index
finger
• Floor: the adductor pollicis muscle.
• Contents: the 3 thenar muscles and first
lumbrical muscle

8. Midpalmar space
• Boundaries
• Medially : the medial palmar septum
• Laterally the lateral palmar septum
• Roof: the long flexor tendons to the middle, ring
and little fingers
• Floor: the interossei and the 3rd , 4th and 5th
metacarpal bone
• Contents: the 2nd , 3rd , and 4th lumbrical muscles

10. Clinical Correlates
 Infection of the midpalmar space may result from
tenosynovitis of the middle and ring fingers or
from a web infection which has spread proximally
through the lumbrical canals.
 When this happens the normal concavity of the
palm is obliterated and the swelling extends to
the dorsum of the hand.
 The space can be drained by an incision in either
the 3rd or 4th web depending on where the pus
points.

11. The lumbrical canal
• The lumbrical canal is a
potential space
surrounding the tendon
of each lumbrical muscle
and is normally filled
with connective tissue.
Proximally, it is
continuous with one of
the palmar spaces

12. The Pulp space of the fingers
• The pulp spaces are on the palmar side of the tips of the fingers
and thumb
• The deep fascia of the pulp of each finger fuses with the
periosteum of the terminal phalanx just distal to the insertion of
the long flexor tendons and closes off a fascial compartment
known as the pulp space.
• The pulp space is limited proximally by the firm adherence of the
skin of the distal flexion crease to the underlying tissue; this
prevents pulp infection from spreading proximally along the finger.
• Each pulp space is subdivided by the presence of numerous septa,
which pass from the deep fascia to the periosteum.
• Through the pulp space, which is filled with fat, runs the terminal
branch of the digital artery that supplies the diaphysis of the
terminal phalanx. The epiphysis of the distal phalanx receives its
blood supply proximal to the pulp space.

14. Clinical Correlates:
 The infection of this space is known as
felon.
 If neglected a felon may lead to
necrosis of the distal 4/5th of the
terminal phalanx due to occlusion of
the vessels by tension. The proximal
1/5th escapes because its artery does
not traverse the fibrous septa.

16. Dorsal spaces
• Dorsal subcutaneous space:
• It lies immediately deep to the loose skin of the
dorsum of the hand.
• In subcutaneous infections, the pus points through
the skin and can be drained at the pointing site.
• Dorsal subtendinous space:
• This space lies between the metacarpal bones and
the extensor tendons which are united to one
another by a thin aponeurosis.
• In subtendinous infection, the pus points either at the
webs or at the borders of the hand and can be
drained accordingly.

18. Space of Parona
 Forearm space of parona is a rectangular space
situated deep in the lower part of the forearm just
above the wrist.
 It lies just in front of the pronator quadratus and
deep to the long flexor tendons.
 Superiorly the space extends upto the oblique origin
of the flexor digitorum superficialis.
 Inferiorly, it extends up to the flexor retinaculum and
communicates with the midpalmar space; and
possibly also with the thenar space.
 The forearm space may be infected through
infection in the related synovial sheaths especially of
the ulnar bursa.

20. ARTERIAL ANASTOMOSIS AROUND THE SHOULDER
JOINT
It is an important arterial anastomosis between the branches of the 1st part of the
subclavian artery and 3rd part of the axillary artery, ensuring that an adequate blood flow
takes place into the upper limb
Anastomosis around the scapula
Branches from the Subclavian Artery
The suprascapular artery, which is distributed to the supraspinous and infraspinous
fossae of the scapula
The superficial cervical artery, which gives off a deep branch that runs down the medial
border of the scapula
Branches from the Axillary Artery
The subscapular artery and its circumflex scapular branch supply the subscapular and
infraspinous fossae of the scapula, respectively.
Anastomosis aroud the surgical neck of the humerus
The anterior circumflex humeral artery
The posterior circumflex humeral artery

22. Anastomosis around the elbow
• Laterally:
• Anterior to the lateral epicondye
• there is anastomosis between the anterior
descending branch of brofunda brachii artery
and radial recurrent artery from the radial artery.
• Posterior to the lateral epicondyle
• the anastomosis between the posterior
descending branch of brofunda brachii artery
and the interosseous recurrent artery from the
posterior interosseous artery.

23. Anastomosis around the elbow
• Medially:
• Anterior to the medial epicondyle
• between the anterior branch of inferior ulnar
collateral artery and anterior ulnar recurrent
artery from the ulnar artery.
• Posterior to the medial epicondyle
• between the posterior branch of the inferior ulnar
collateral artery and the superior ulnar collateral
artery (from brofunda brachii artery) and the
posterior ulnar recurrent artery (from the ulnar
artery)

26. Arterial anastomosis of the
hand
• 1. palmar carpal arch
• 2. dorsal carpal arch
• 3. Superfacial palmar arch
• 4. deep palmar arch

27. The palmar carpal arch
• The palmar carpal arch is the anastomosis of
two arteries: the palmar carpal branch of
radial artery and the palmar carpal branch
of ulnar artery.
• This anastomosis is joined by a branch from
the anterior interosseous artery above, and
by recurrent branches from the deep
palmar arch below, thus forming a palmar
carpal network which supplies the
articulations of the wrist and carpus.

28. The dorsal carpal arch
• The dorsal carpal arch is the anastomosis between
dorsal carpal branch of the radial artery and the
dorsal carpal branch of the ulnar artery near the back
of the wrist. It also anastomoses with the anterior
interosseous artery and the posterior interosseous
artery.
• Branches
• Three dorsal metacarpal arteries which bifurcate into
the dorsal digital arteries. Near their origin, they
anastomose with the deep palmar arch by perforating
arteries. They also anastomose with common palmar
digital arteries (from the superficial palmar arch), also via
perforating arteries. The first dorsal metacarpal artery
arises directly from the radial artery.

29. The superficial palmar arch
• The superficial palmar arch is formed
predominantly by the ulnar artery, with a
contribution from the superficial palmar
branch of the radial artery.
• the superficial palmar arch would lie
approximately at the level of a line drawn from
the distal border of fully extend thumb across
the palm. The superficial palmar arch extends
more distally than the deep palmar arch

30. Branches of The superficial
palmar arch
• Palmar digital artery runs on the ulnar side of the
little finger
• Three common palmar digital arteries arise from
the arch. They each receive a contribution from a
palmar metacarpal artery (branches of deep palmar
arch). Near the level of the metacarpophalangeal
joints, each common palmar digital artery divides into
two proper palmar digital arteries.
• The digital branches arise from this palmar arch
supply the medial 3 1/2 fingers

33. The deep palmar arch
• It is usually formed mainly from the terminal part of the
radial artery, with deep palmar branch of the ulnar
artery.
• The deep palmar arch lies upon the bases of the
metacarpal bones and on the interossei of the hand.
• Branches
• 3 Palmar metacarpal arteries at the metacarpal heads,
they anastomose with the common palmar digital
branches of the superficial arch also anastomose with the
dorsal metacarpal arteries through perforating branches