disection of palm and sole.pptx

PALMER ASPECT OF
WRIST AND HAND
Features
The human hand is designed:
i. For grasping
ii. For precise movements, and
iii. For serving as a tactile organ.
There is a big area in the motor cortex of brain for
muscles of hand.

The skin of the palm is:
■ . Thick for protection of underlying tissues.
■ lmmobile because of its firm attachment to the
underlying palmar aponeurosis.
■ Creased. All of these characters increase the
efficiency of the grip.
The skin is supplied by spinal nerves C6-C8 through
the median and ulnar nerves.

■ The superficial fascia of the palm is made up of dense fibrous bands
which bind the skin to the deep fascia (palmar aponeurosis) and divide the sub-
cutaneous fat into small tight compartments which serve as water-cushions
during firm gripping.
■ The fascia contains a subcutaneous muscle, the palmaris brevis, which helps in
improving the grip by steadying the skin on the ulnar side of the hand.
■ The superficial metacarpal ligament which stretches across the roots of the
fingers over the digital vessels and nerves, is a part of this fascia.
■ The deep fascia is specialised to form:
■ i. The flexor retinaculum at the wrist.
■ Ii. The palmar aponeurosis in the palm.
■ Iii. The fibrous flexor sheaths in the fingers.
All three form a continuous structure which holds the tendons in position and thus
increase the efficiency of the grip.

Flexor retinaculum
■ Flexor retinaculum (Latin to hold back) is a strong fibrous band which bridges the anterior concavity
of the carpus and converts it into a tunnel, the carpal tunnel.
■ .Attachments
■ Medially, to:
■ 1 The pisiform bone, and
■ 2 The hook of the hamate
■ .Laterally, to:
■ 1 The tubercle of the scaphoid, and
■ 2 The crest of the trapezium.
■ On either side, the retinaculum has a slip:
■ 1 The lateral deep slip is attached to the medial lip of the groove on the trapezium which is thus
converted into a tunnel for the tendon of the flexor carpi radialis.
■ 2 The medial superficial slip (volar carpal ligament) is also attached to the pisiform bone. The ulnar
vessels and nerves pass deep to this slip .

■ Relations
■ The structures passing superficial to the flexor retinaculum are:
■ i. The palmar cutaneous branch of the median nerve (Fig. 9.16).
■ Ii. The tendon of the palmaris longus.
■ Iii. The palmar cutaneous branch of the ulnar nerve. Iv. The ulnar vessels.
■ V. The ulnar nerve.
■ The thenar and hypothenar muscles arise from the retinaculum.
■ The structures passing deep to the flexor retinaculum are:
■ i. The median nerve.
■ Ii. Four tendons of the flexor digitorum superficialis.
■ Iii. Four tendons of the flexor digitorum profundus.
■ Iv. The tendon of the flexor pollicis longus.
■ V. The ulnar bursa.
■ Vi. The radial bursa.
■ Vii. The tendon of the flexor carpi radialis lies between the retinaculum and its deep slip, in the
groove on the trapezium.

Palmar aponeurosis
■ This term is often used for the entire deep fascia of the palm.
■ However, it is better to restrict this term to the central part of the deep fascia of
the palm which covers the superficial palmar arch, the long flexor tendons, the
terminal part of the median nerve, and the superficial branch of the ulnar nerve .
■ Features
■ Palmar aponeurosis is triangular in shape. The apex which is proximal, blends with
the flexor retinaculumand is continuous with the tendon of the palmaris longus.
■ The base is directed distally. It divides into superficial and deep strata, superficial is
attached to dermis.
■ Deep strata divides into four slips opposite the heads of the metacarpals of the
medial four digits.
■ Each slip divides into two parts which are continuous with the fibrous flexor
sheaths. Extensions pass to the deep transverse metacarpal ligament, the capsule
of the metacarpophalangeal joints and the sides of the base of the proximal
phalanx.

■ The digital vessels and nerves, and
the tendons of the lumbricals emerge
through the intervals between the
slips.
■ From the lateral and medial margins
of the palmar aponeurosis, the
lateral and medial palmar septa pass
backwards and divide the palm into
compartments.
■ Functions
■
■ Palmar aponeurosis fixes the skin of
the palm and thus improves the grip.
It also protects the underlying
tendons, vessels and nerves.

Fibrous Flexor Sheaths of the Fingers
■ The fibrous flexor sheaths are made up of the deep fascia of the
fingers. The fascia is thick and arched. It is attached to the sides
of the phalanges and across the base of the distal phalanx.
Proximally, it is continuous with a slip of the palmar aponeurosis.
■ In this way, a blind osseofascial tunnel is formed which contains
the long flexor tendons enclosed in the digital synovial sheath.
The fibrous sheath is thick opposite the phalanges and thin
opposite the joints to permit flexion.
■ The sheath holds the tendons in position during flexion of the
digits.

CLINICAL ANATOMY
■ Dupuytren’s contracture: This
condition is due to inflammation
involving the ulnar side of the palmar
aponeurosis. There is thickening and
contraction of the aponeurosis. As a
result, the proximal phalanx and later the
middle phalanx become flexed and
cannot be straightened. The terminal
phalanx remains unaffected. The ring
finger is most commonly involved .

INTRINSIC MUSCLES OF HAND
There are 20 muscles in the hand. These are:
1 a. Three muscles of thenar eminenence
i . Abductor pollicis brevis
ii. Flexor pollicis brevis
iii. Opponens pollicis
b. One adductor of thumb: Adductor pollicis.
2 Four hypothenar muscles
i. Palmaris brevis
ii. Abductor digiti minimi
iii. Flexor digiti minimi
iv. Opponens digiti minimi Muscles
(ii) to (iv) are muscles of hypothenar eminence
3 Four lumbricals
4 Four palmar interossei
5 Four dorsal interossei

The origin and insertion of the thenar and hypothenar muscles

Attachments of small muscles of the
hand
Muscles of thenar eminenence
Name Origin Insertion
Abductor pollicis brevis Tubercle of scaphoid, crest of
trapezium, flexor retinaculum
Base of proximal phalanx of
thumb
Flexor pollicis brevis Flexor retinaculum, crest of
trapezium and capitate
bones
Base of proximal phalanx of
thumb
Opponens pollicis Flexor retinaculum crest of
trapezium
Lateral half of palmar
surface of the shaft of

Name Nerve supply Actions
Abductor pollicis brevis Median nerve Abduction of thumb
Flexor pollicis brevis Median nerve Flexes
metacarpophalangeal
joint of thumb
Opponens pollicis Median nerve Pulls thumb medially
and forward across palm

Muscles of hypothenar eminence
Abductor digiti minimi Pisiform bone Base of proximal
phalanx of little finger
Flexor digiti minimi Flexor retinaculum Base of proximal
phalanx of little finger
Opponens digiti minimi Flexor retinaculum Medial border of fifth
metacarpal bone

Muscles Nerve supply Action
Abductor digiti minimi Deep branch of ulnar
nerve
Abducts little finger
Flexor digiti minimi Deep branch of ulnar
nerve
Flexes little finger
Opponens digiti minimi Deep branch of ulnar
nerve
Pulls fifth metacarpal
forward as in cuppin
palm

Adductor of thumb
Adductor pollicis Oblique head: Bases of
2nd-3rd metacarpals:
transverse head: Shaft
of 3rd metacarpal
Base of proximal
phalanx of thumb on its
medial aspect
Adductor pollicis Deep branch of ulnar
nerve which ends in this
muscle
Adduction of thumb

Muscle of medial side of palm
Palmaris brevis Flexor retinaculum Skin of palm on medial
side
Name Nerve supply Action
Palmaris brevis Superficial branch of
ulnar nerve
Wrinkles skin to improve
grip of palm

Lumbricals
Lumbricals (4) 1st Lateral side of
tendon
digitorum profundus of
2nd digit
2nd Lateral side of same
tendon of 3rd digit
3rd Adjacent side of
same tendons of 3rd
and 4th digits
4th Adjacent sides of
same tendons of 4th
and 5th digits
Via extensor expansion
into dorsum of bases of
distal phalanges

Lumbricals (4) First and second, i.e.
Lateral two by median
nerve; third and fourth
by deep branch of ulnar
nerve
Flex metacarpop-
halangeal joints, extend
interphalangeal joints of
2nd-5th digits

The origin of the lumbrical muscles from tendons of flexor digitorum
profundus

Palmer (4) 1st Medial side of base
of 1st
metacarpal
2nd Medial side of shaft
of 2nd metacarpal
3rd Lateral side of shaft
of 4th metacarpal
4th Lateral side of shaft
of 5th metacarpal
Medial side of base of
proximal phalanx of
thumb or 1st digit Via
extensor expansion into
dorsum of bases of
distal phalanges of 2nd
4th and 5th digits
Name Nerve supply Action
Palmer (4) Deep branch of ulnar
nerve
Palmar interossei adduct
fingers towards centre of
third digit or middle

Dorsal interossel
Dorsal 1st Adjacent sides of shafts
of 1st and 2nd MC
2nd Adjacent sides of shafts
of 2nd and 3rd MC
3rd Adjacent sides of shafts
of 3rd and 4th MC
4th Adjacent sides of shafts
of 4th and 5th MC
Via extensor expansion
into dorsum of bases of
distal phalanges of 2nd,
3rd, 3rd and 4th digits
Dorsal Deep branch of ulnar
nerve
Dorsal interossei abduct
fingers from centre of third
digit.

(a) The dorsal interossei muscles. (b) palmar interossei muscles,
and (c) dorsal and palmar interosse

ARTERIES OF HAND
• Ulnar Artery
• Radial Artery
Arteries of the hand are the terminal parts of the ulnar and radial
arteries. Branches of these arteries unite and form anastomotic
channels called the superficial and deep palmar arches.
•Features :

•ULNAR ARTERY:
• It enters the palm by passing superficial to the flexor retinaculum but deep
to volar carpal ligament.
• It ends by dividing into the superficial palmar branch, which is the main
continuation of the artery, and the deep palmar branch.
• These branches take part in the formation of the superficial palmar arch
and deep palmar arch, respectively.
Superficial Palmar Arch:
• The arch represents an important anastomosis between the ulnar and
radial arteries.
• The convexity of the arch is directed towards the fingers, and its most
distal point is situated at the level of the distal border of the fully
extended thumb.

Formation:
The superficial palmar arch is formed as the direct continuation of the ulnar
artery beyond the flexor retinaculum, i.e. By the superficial palmar branch.
On the lateral side, the arch is completed by superficial palmar branch of
radial artery.
Branches:
Superficial palmar arch gives off three common digital and one proper digital
branches which supply the medial 3½ digits. The lateral three common digital
branches are joined by the corresponding palmar metacarpal arteries from the
deep palmar arch.
The deep branch of the ulnar artery arises in front of the flexor retinaculum
immediately beyond the pisiform bone. Soon it passes between the flexor and
abductor digiti minimi to join and complete the deep palmar arch.

•RADIAL ARTERY:
In this part of its course, the radial artery runs obliquely downwards, and backwards
deep to the tendons of the abductor pollicis longus, the extensor pollicis brevis, and
the extensor pollicis longus, and superficial to the lateral ligament of the wrist joint
(Fig. 9.52a). Thus it passes through the anatomical snuffbox to reach the proximal
end of the first interosseous space. Further, it passes between the two heads of the
first dorsal interosseous muscle and between the two heads of adductor pollicis to
form the deep palmar arch in the palm.
Course:
Radial artery runs obliquely from the site of ‘radial pulse’ to reach the
anatomical snuffbox. From there, it passes forwards to reach first
interosseous space and then into the palm.

Anatomical snuffbox:
The anatomical snuffbox is a triangular
depression on the posterolateral side
of wrist. It is seen best when the
thumb is extended.
Contents:
The radial artery is deep while the
superficial branch of radial nerve and
cephalic vein are superficial.

Branches:
Dorsum of hand: On the dorsum of the hand, the radial artery gives off:
1 A branch to the lateral side of the dorsum of the thumb 2 The first dorsal
metacarpal artery. This artery arises just before the radial artery passes into the
interval between the two heads of the first dorsal interosseous muscle. It at once
divides into two branches for the adjacent sides of the thumb and the index finger.
Palm: In the palm (deep to the oblique head of the adductor pollicis),
the radial artery gives off:
1. The princeps pollicis artery which divides at the base of the proximal
phalanx into two branches for the palmar surface of the thumb .
2 The radialis indicis artery descends between the first dorsal
interosseous muscle and the transverse head of the adductor pollicis to
supply the lateral side of the index finger.

Deep Palmar Arch:
Deep palmar arch provides a second channel connecting the radial and ulnar
arteries in the palm (the first one being the superficial palmar arch already
considered). It is situated deep to the long flexor tendons.
Formation:
The deep palmar arch is formed mainly by the terminal part of the
radial artery, and is completed medially at the base of the fifth
metacarpal bone by the deep palmar branch of the ulnar artery.
Relations:
The arch lies on the proximal parts of the shafts of the metacarpals, and on
the interossei; under the cover of the oblique head of the adductor pollicis, the
flexor tendons of the fingers, and the lumbricals.
The deep branch of the ulnar nerve lies within the concavity of the arch.

1. From its convexity,i.e. from its distal side, the arch gives off three palmar
metacarpal arteries, which run distally in the 2nd, 3rd and 4th spaces, supply the
medial four metacarpals, and terminate at the finger clefts by joining the
common digital branches of the superficial palmar arch.
Branches:
2. Dorsally, the arch gives off three (proximal) perforating digital arteries which
pass through the medial three interosseous spaces to anastomose with the
dorsal metacarpal arteries.
The digital perforating arteries connect the palmar digital branches of the
superficial palmar arch with the dorsal metacarpal arteries.
3. Recurrent branch arises from the concavity of the arch and passes
proximally to supply the carpal bones and joints, and ends in the palmar carpal
arch.

CLINICAL ANATOMY:
The radial artery is used for feeling the (arterial) pulse at the wrist. The
pulsations can be felt well in this situation because of the presence of
the flat radius with pronator quadratus muscle behind the artery.

• ULNAR
NERVE
Ulnar nerve is the main nerve of the hand ( like the
lateral plantar nerve in the foot).
Course
Ulnar nerve lies superficial to flexor retinaculum,
covered only by the superficial slip of the retinaculum.
It terminates by dividing into a superficial and a deep
branch.

Branches
1. From Superficial Terminal Branch:-
– Muscular branch: To palmaris brevis.
– Cutaneous branches: Two palmar digital nerves supply the medical 1
1
2
fingers with their nail beds.
– The media branch supplies the medial side of the little finger.
– The lateral branch is a common palmer digital nerve.
– It divides into two proper palmar digital nerves for the adjoining sides of the ring and little fingers.

Branches
2. From Deep Terminal Branch:-
1. Muscular branches:-
■ Three muscles of hypothenar eminence.
■ As the nerve crosses the palm, it supplies the medial two lumbricals and eight
interossei.
■ The deep branch terminates by supplying the adductor pollicis, and occasionally the
deep head of the flexor pollicis brevis.
2. An articular branch supplies the wrist joint.

■ Clinical Anatomy:-
1. Ulnar nerve is known as ‘musician’s nerve’ because it controls fine movement
of fingers.
■ Injury at Elbow:-
1. Flexor carpi ulnaris & medial half of flexor digitorum profunds are paralysed.
2. An attempt to produce flexion at wrist result in abduction of hand.
3. Flexion of the terminal phalanges of ring & little finger is lost.

■ Ulnar clawhand is characterised by the following signs:-
1. Clawhand deformity is more obvious in wrist lesions as the profundus muscle is
spared: This causes marked flexion of the terminal phalanges.
2. Sensory loss is confined to the medial one-third of the palm and the medial 1
1
2
fingers including their nail beds. Medial half of dorsum of hand also shows
sensory loss.
3. Vasomotor changes: The skin areas with sensory loss is warmer due to
arteriolar dilatation; it is also drier due to absence of sweating because of loss
of sympathetic supply.
4. Trophic changes: Long-standing cases of paralysis lead to dry and scaly skin.
The nails crack easily with atrophy of the pulp of fingers.
5. The patient is unable to spread out the fingers due to paralysis of the dorsal
interossei.

MEDIAN NERVE
• It is branch of Brachial plexus which is made by
branches of lateral & medial cord.
• Root value : ventral rami of C5-C8, T1 segments
Of spinal cord.
• Important nerve of hand cause it’s controlling
movements of thumb.

Course & Branches
■ Median nerve lies deep to flexor retinaculum in carpal tunnel and
enters the palm. Soon it terminates by dividing into lateral & medial
division.
■ The lateral division gives off a muscular branch to the thenar
muscles, and three digital branches for the lateral 1.5 digits
including the thumb.
■ Out of the three digital branches two supply the thumb and one the
lateral side of the index finger. The digital branch to the index finger
also supplies first lumbrical.
■ The medial division divides into two common digital branches for the
second and third interdigital clefts supplying the adjoining sides of
the index, middle and ring fingers.

Clinical Anatomy
• The median nerve controls coarse movements of the hand, It is called the
labourers nerve. It is also called “eye of the hand ”as it is sensory to most of the
hand.
• Injury of Median nerve due to fracture at
elbow joint. ️
1.Paralysis of flexor pollicis longus & lateral
half of flexor digitorum profundus.
Patient is unable to bend terminal phalanx of
thumb, index finger & middle finger.

2.Paralysis Of pronators.
The forearm is kept in supine position.
3.Paralysis of long flexors of digits.
Flexion at interphalangeal joint of index
& middle finger is lost.
It is called pointed index finger.

4.Paralysis Of thenar muscles.
Ape or monkey thumb deformity.
5.Paralysis Of flexor carpi radialis.
Hand is adducted, flexion of wrist is
weak.
6.Vasomotor & trophic changes
Skin on lateral 3.5 digits is warm, dry
and scaly. Nails get cracked.
Sensory loss to its distribution in hand.

• Carpal Tunnel syndrome (CTS)
By compression of the median nerve in the carpal tunnel.
- Hypoesthesia to light touch on the palmer aspect of lateral 3.5
digits. However the skin over the fascia is not affected as the
branch of median nerve supplying it arise in forearm.
Froment’s sign/(book holding test) :
The patient is unable to hold the book
with thumbs & other fingers.
Paper holding test: The patient is unable
to hold paper between thumb and
fingers.
Both these tests are positive because of
paralysis of thenar muscles.

Motor Changes
Ape/monkey like thumb deformity, loss of
opposition of thumb. Index & middle
fingers lag behind while making the the fist
due to paralysis of 1st & 2nd lumbrical
muscles.
Sensory changes
Loss of sensation on lateral 3.5 digits
including the nails beds and distal
phalanges on dorsum of hand.

Vasomotor changes
The skin areas with sensory loss is warmer due to
arteriolar dilatation , it is also drier due to absence of
sweating due to absence of sweating due to loss of
sympathetic supply.
Trophic changes
Long-standing cases of paralysis lead to
dry and scaly skin. The nails crack easily
with atrophy of the pulp of fingers.

• Pain due to median nerve may be
referred proximally to the forearm & arm.
It is more common because of excessive
working on the computer. Phalen’s test is
attempted for CTS.
• Complete claw hand
If both median & ulnar nerves are
paralysed, the result is complete claw
hand.

RADIAL NERVE
• It is largest branch of posterior cord of brachial
Plexus.
• Root value : ventral rami C5-C8, T1 segments
of spinal cord.

Course & Branches
▪️ The part of the radial nerve seen in the hand is a continuation of the
superficial terminal branch.
▪️ It reaches the dorsum of the hand and divides into 4 dorsal digital
branches.
1 – Lateral side of thumb
2 – Medial side of thumb
3 – Lateral side of index
4 – Continuation sides of index & middle fingers.

Clinical Anatomy
•Injury of Radial nerve.
1.Sleeping in an armchair with the limb
hanging by the side of the chair or even the
pressure of the crutch (crutch paralysis).
2.Fractures of the shaft of the humerus. And
sensory loss over a narrow strip on the back of
forearm and on the lateral side of the dorsum.

• wrist drop is quite disabling, because
the patient cannot grip any object firmly
in the hand without the synergistic action
of the extensors.

DORSUM OF HANDS
1. Skin :-It is loose on the dorsum of hand. It can be
pinched off from the underlying structures.
2. Superficial fascia :-The fascia contains dorsal
venous plexus, cutaneous nerves, and dorsal carpal arch.

A. Dorsal Venous Plexus :-
■ The digital veins from adjacent sides of index, middle, ring and little fingers
form 3 dorsal metacarpal veins.
■ These join with each other on dorsum of hand. * The lateral end of this arch is
joined by one digital vein from index finger and two digital veins from thumb to
form cephalic vein.
■ It runs proximally in the anatomical snuff box, curves, round the lateral border
of wrist to come to front of forearm.
■ In a similar manner,
■ The medial end of the arch joins with one digital vein only from medial side of
little finger to form basilic vein. It also curves round the medial side of wrist to
reach front of forearm.
■ So, These metacarpal veins may unite in different ways to form a dorsal
venous plexus.

B.Cutaneous Nerves :- These are superficial branch of
radial nerve and dorsal branch of ulnar nerve.
The nail beds and skin of distal phalanges of 3½ lateral nails is
supplied by median nerve and 1½ medial nails by ulnar nerve.
The superficial branch of radial nerve supplies lateral half of
dorsum of hand with two digital branches to thumb and one to
lateral side of index and another common digital branch to adjacent
sides of index and middle fingers .
Dorsal branch of ulnar supplies medial half of dorsum of hand with
proper digital branches to medial side of little finger; two common
digital branches for adjacent sides of little and ring fingers and
adjacent sides of ring and middle fingers.
C. Dorsal Carpal Arch :-
■ It is formed by dorsal carpal branches of radial and ulnar
arteries and lies close to the wrist joint.
■ The arch gives three dorsal metacarpal arteries which supply
adjacent sides of index, middle, ring and little fingers.
■ One digital artery goes to medial side of little finger.

3. Spaces On Dorsum Of Hand:-
•There are two spaces on the dorsum of hand: -
A. Dorsal subcutaneous space, lying just subjacent to skin. Skin of dorsum of
hand is loose can be pinched and lifted off.
B. Dorsal subtendinous space lies deep to the
extensor tendons, between the tendons and the metacarpal bones.
4. Deep fascia:-
The deep fascia is modified at the back of hand to form extensor retinaculum.

• Extensor Retinaculum :-
• The deep fascia on the back of the wrist is thickened to
form the extensor retinaculum which holds the extensor
tendons in place.
• It is an oblique band, directed downwards and
medially. It is about 2 cm broad vertically.
• Compartments:-
• The retinaculum sends down septa which are
attached to the longitudinal ridges on the posterior surface
of the lower end of radius. In this way, 6 osseofascial
compartments are formed on the back of the wrist.
• The structures passing through each compartment,
from lateral to the medial side, are listed in,

•Anatomical Snuff Box: -
• The anatomical snuff box is a triangular depression
on the lateral side of the wrist.
• It is seen best when the thumb is extended.
• Boundaries:-
• It is bounded anteriorly by tendons of the abductor
pollicis longus and extensor pollicis brevis, and posteriorly
by the tendon of the extensor pollicis longus.
• It is limited above by the styloid process of the
radius.
• The floor of the snuff box is formed by the scaphoid
and the trapezium.
• The roof is formed by skin and superficial branch of
Radial nerve and Cephalic vein.

Clinical Anatomy
• De quervain’s syndrome is a painful condition
where The tendons forming one side of the ‘
anotomical shufbox ’ at the wrist on the thumb side
are inflamed.
• Cephalic used for intervenous injection because
large bore cannula easily placed.
• Radial artery is important clinically dur to its
location at the wrist,as it can be felt as a pulse and
can be used to determine the heart rate.

Sole is similar to palm.
The Skin, superficial fascia, deep fascia,
muscle, vessels and nerves.
Foot is an organ for Support and
locomotion.
The arches of foot help as elastic springs
for efficient walking, running, jumping
and support the body weight.

The skin of the sole, like that of the
palm is:
1. Thick for protection
2. Firmly adherent to the underlying plantar
aponeurosis and
3. Creased.
These features increase the efficiency of the
grip of the sole on the ground.

The skin of the sole, like that of the palm is:
The skin is mainly supplied by three cutaneous nerves
The nerves are:
a) Medial calcanean branches of the tibial nerve, to the
posterior and medial portions.
b) Branches from the medial plantar nerve to the
larger, anteromedial portion including the medial 3½
digits.
c) Branches from the lateral plantar nerve to the
smaller anterolateral portion including the lateral 1½
digits.d. Small areas on medial and lateral sides are
innervated by saphenous and sural nerves

The superficial fascia of the sole is fibrous and
dense.
Fibrous bands bind the skin to the deep fascia or
plantar aponeurosis, and divide the
subcutaneous fat into small tight compartments
which serve as water-cushions and reinforce the
spring-effect of the arches of the foot during
walking, running and jumping.
The fascia is very thick and dense over the
weight-bearing points. It contains cutaneous
nerves and vessels

1. Plantar Aponeurosis in the sole.
2. Deep transverse metatarsal ligament between
Metatarsophalangeal joints.
3. The fibrous flexor sheaths in the toe.

Thickened central band of the deep fascia in the
sole of the foot.
The aponeurosis is triangular in shape. The apex is
proximal.
It is attached to the medial tubercle of the
calcaneum, proximal to the attachment of the flexor
digitorum brevis.
The base is distal. It divides into five processes
near the heads of the metatarsal bones. The digital
nerves and vessels pass through the intervals
between the processes

Thickened central band of the deep fascia in the
sole of the foot.
Function
1. It fixes the skin of sole.
2. It protects deeper structure.
3. It help to maintaining longitudinal arches of foot.
4. It gives origin to muscles of the first layer of sole.

The muscle of the sole is
arranged in Four (4) Layers.
1. FIRST LAYER (SUPERFICIAL)
a) FLEXOR DIGITORUM BRVIS
b) ABDUCTOR HALLUCIS
c) ABDUCTOR DIGITI MINIMI

Origin : Medial Tubercle of calcaneum and plantar aponeurosis.
Insertion : Middle phalanges of digits 2-5
Nerve supply : Medial planter nerve
Action : Flexion on proximal interpharangeal and MTP joint.

Origin : Medial tubercle of calcaneum, flexor retinaculum, medial
intermuscular septum.
Insertion : Medial Plantar portion of proximal phalanx of great toe.
Nerve supply : Medial Plantar Nerve
Actions : Abducts great toe at MTP joint and flexes great toe at MTP
joint.

Origin : Medial and lateral processes of posterior calcaneal tuberosity
Insertion : Lateral side of base of proximal phalanx of 5th toe and 5th
metatarsal
Nerve supply : Lateral plantar (S2,3)
Action : Flexes and abducts 5th toe. Supports lateral
longitudinal arch.

1. FLEXOR DIGITORUM LONGUS
2. FLEXOR DIGITORUM ACCESSERIOUS (QUADRATUS PLANTAE)
3. FLEXOR HALLUCIS LONGUS
4. LUMBRICALS

Origin: From upper two thirds of the medial part of the posterior
surface below the soleal line.
Insertion: The muscle divides into four tendons. Each is inserted into
the lateral side of the tendon of the flexor digitorum longus.
Nerve Supply: Tibial nerve (S2, S3)
Action : Plantar flexion of lateral four toes and of ankle. Maintains
medial longitudinal arch.

Origin : It arises by two heads:
a. Medial head is large and fleshy; it arises from the medial
concave surface of the calcaneum
b. Lateral head is smaller and tendinous; it arises from the
calcaneum in front of the lateral tubercle.The two heads unite
at an acute angle.
Insertion : The muscle fibres are inserted into the lateral side of
the flexor digitorum longus.
Nerve supply : Main trunk of lateral plantar nerve.
Action : Straightens the pull of the long flexor muscles.
Flexes the toes through the long tendons.

Origin: Lower three-fourths of the posterior surface of fibula
except lowest 2.5 cm and adjoining interosseous
membrane.
Insertion: plantar surface of the base of distal phalanx of the
great toe.
Nerve Supply: Tibial nerve
Function: Plantar flexor of the big toe, plantar flexor of
ankle joint, maintains medial longitudinal arch.

Origin: They arise from the tendons of theflexor digitorum
longus.
The first lumbrical is unipennate, and theothers are
bipennate First lumbrical arises from medial side of 1st tendon
of flexor digitorum longus.
Second lumbrical arises from adjacent sides of 1st and 2nd
tendons of flexor digitorum longus.
Third lumbrical arises from adjacent sides of 2nd and 3rd
Fourth lumbrical arises from adjacent sides of 3rd and 4th

Insertion : Their tendons pass forwards on the medial sides of
the metatarsophalangeal joints of the lateral four toes, and
then dorsally for insertion into the extensor expansion.
Nerve supply : The first muscle by the medial plantar nerve;
and the other three by the deep branch of lateral plantar
nerve
Action : They maintain extension of the digits at the inter-
phalangeal joints so that in walking and running the toes
do not buckle under

Origin:
It arises by a Y-shaped tendon:a. The lateral limb, from the
medial part of the plantar surface of the cuboid bone, behind the
groove for the peroneus longus and from the adjacent side of the
lateral cuneiform boneb. The medial limb is a direct continuation
of the tendon of tibialis posterior into the foot.
Insertion : The muscle splits into medial and lateral parts, each of which
ends in a tendon. Each tendon is inserted into the corresponding
side of the base of the proximal phalanx of the great toe.
Nerve supply : Medial Plantar Nerve
Actions : Flexes the proximal phalanx at the metatarsophalangeal joint
of the great toe.

Origin : It arises by two heads: a. The oblique head is large, and arises from
the bases of the second, third, and fourth metatarsals, from the sheath
of the tendon of the peroneus longusb. The transverse head is small, and
arises from the deep metatarsal ligament, and the plantar ligaments of
the metatarsophalangeal joints of the third, fourth and fifth toes
(transverse head has no bony origin)
Insertion : On the lateral side of the base of the proximal phalanx of the big
toe, in common with the lateral tendon of the flexor hallucis brevis.
Nerve supply : Deep Branch of lateral plantar nerve, which terminates in
this muscle.
Actions : Adductor of great toe towards second toe.
Maintains transverse arches of foot.

Origin : a. Base of the fifth metatarsal bone
b. Sheath of the tendon of the peroneus longus
Insertion : Into the lateral side of the base of the proximal
phalanx of the little toe.
Nerve supply : Superficial branch of lateral plantar nerve
Action : Flexes the proximal phalanx at the
metatarsophalangeal joint of the little toe

Origin : Bases and medial sides of third, fourth and fifth metatarsals.
Insertion : Medial sides of bases of proximal phalanges and dorsal
digital/extensor expansions of 3rd, 4th and5th toes
Nerve supply : First and second by lateral plantar (deep branch). Third
by lateral plantar (superficial branch)
Function : Adductors of third, fourth and fifth toes toward the axis.
Flexor of metatarsophalangeal and extensor of inter-
phalangeal joints of third, fourth and fifth toes

Origin : Adjacent sides of metatarsal bones
Insertion : Bases of proximal phalanges and dorsal digital expansion of
toes; first on medial side of 2nd toe; second on lateral side of 2nd
toe; third on lateral side of 3rd toe and fourth on lateral side of 4th
toe.
Nerve supply : First, second, third by lateral plantar (deep branch),
fourth dorsal interosseous by superficial branch of lateral
plantar.
Function : Abductors of toes from axis of second toe. First and second
cause medial and lateral abduction of second toe. Third and fourth
for abduction of 3rd and 4th toes

Origin : Posterior surfaces of leg bones
Insertion : Tuberosity of navicular
Nerve supply : Tibial Nerve
Function : Plantar Flexion of ankle

Origin: Upper part of lateral surface of fibula
Insertion : Base of 1st metatarsal
Nerve Supply : Superficial peroneal nerve
Function : Evertor of foot

 origin and course :.
Largest terminal branch of Tibial nerve. It passes
forwards between Abductor hallucis and flexor
digitorum brevis and divides into its branches.
Root Value : L4, L5, S1
 Branches:
The Muscular branches supply the Four muscle.
1. Abductor hallucis
2. Flexor digitorum brevis
3. Flexor hallucis brevis
4. First lumbrical muscle

 Branches
Its muscular branches supply four muscles as follows.
1. The abductor hallucis.
2. The flexor digitorum brevis.
3. The flexor hallucis brevis receives a branch from the first
digital nerve.
4. The first lumbrical muscle receives a branch from the
second digital nerve.

 Branches
Cutaneous branches supply the skin of the medial part of the sole, and
of the medial 3½ toes through four digital branches.
The first digital nerve supplies the medial side of the great toe.
The second nerve supplies the adjacent sides of the first and second
toes.
The third nerve supplies the adjacent sides of the second and third
toes.
The fourth nerve supplies the adjacent sides of the third and fourth
toes.
Each digital nerve gives off a dorsal branch which supplies structures
around the nail of the digit concerned.
 Articular branches supply joints of the tarsus and metatarsus.

Origin:
Small terminal branch of Tibial nerve.
Passes laterally and forwards till base of fifth Metatarsal,
where it divides Superficial and Deep branches.
Its Root value is Ventral Primary Rami of S2,S3, its supply 14
muscles of the sole.

Branches :
The main trunk supplies two muscles-the flexor
digitorum accessorius and the abductor digiti minimi, and
the skin of the sole.
The main trunk ends by dividing into superficial and deep
branches.
The superficial branch divides into two branches- lateral
and medial.
The lateral branch supplies three muscles-flexor digiti
minimi brevis, the third plantar and fourth dorsal
interossei, and the skin on the lateral side of the little toe.

Branches :
The medial branch communicates with the medial
plantar nerve, and supplies the skin lining the fourth
interdigital cleft.
The deep branch supplies nine muscles, including the
second, third and fourth lumbricals; first, second and third
dorsal interossei; first and second plantar interossei and
adductor hallucis.

Beginning, Course and Termination :
Medial plantar artery is a smaller terminal branch of the posterior tibial
artery. It lies along the medial border of foot and divides into branches.

Branches
It gives off cutaneous, muscular branches to the overlying skin and to
the adjoining muscles, and three small superficial digital branches that
end by joining the first, second and third plantar metatarsal arteries
which are branches of the plantar arch

Lateral plantar artery is the larger terminal
branch of the posterior tibial artery. At the
base of the fifth metatarsal bone, it gives a
superficial branch and then continues as
the plantar arch

Branches :
Muscular branches supply the adjoining muscles. Cutaneous branches
supply the skin and fasciae of the lateral part of the sole. Anastomotic
branches reach the lateral border of the foot and anastomose with
arteries on the dorsum of the foot. A calcanean branch is occasionally
given off to the skin of the heel.

Plantar arch is formed by the direct continuation of the lateral plantar
artery after it has given off the superficial branch and is completed
medially by the dorsalis pedis artery. It extends from the base of the fifth
metatarsal bone to the proximal part of the first intermetatarsal space,
and lies between the third and fourth layers of the sole. It is
accompanied by venae comitantes. The deep branch of the lateral
plantar nerve lies in the concavity of the plantar arch

Branches of the Plantar Arch :
1. Four plantar metatarsal arteries run distally, one in each
intermetatarsal space. Each artery ends by dividing into two plantar
digital branches for adjacent sides of two digits.
The first artery also gives off a branch to the medial side of the great
toe. The lateral side of the little toe gets a direct branch from the
lateral plantar artery.

2. The plantar arch gives off three proximal perforating arteries that pass
through the second, third and fourth intermetatarsal spaces and
communicate with the dorsal metatarsal arteries which are the
branches of the arcuate artery.
The distal end of each plantar metatarsal artery gives off a distal
perforating artery which joins the distal part of the corresponding
dorsal metatarsal artery

Plantar fasciitis occurs in policemen due to stretching of
the plantar aponeurosis. This results in pain in the heel
region, especially during standing.

A neuroma may be formed on the branch of medial plantar nerve
between 3rd and 4th metatarsal bones. It is called Morton's neuroma
This causes pain between third and
fourth metatarsals. It may be also due
to pressure on digital nerve between
3rd and 4th metatarsals. Any of the
digital nerves, especially the one in the
third interdigital cleft may develop
neuroma. This is a painful condition

Fracture of shaft of 2nd/3rd/4th/metatarsal bones is called 'march
fracture. It is seen in army personnel, policemen as they have to
march a lot. It occurs due to decalcification and vascular necrosis.
Toes may be spread out
or splayed.
Longitudinal arches are
exaggerated leading to
pes cavus

Normal architecture of foot is subjected to insults due to 'high heels'.
Females apparently look taller, smarter but may suffer from sprains
and dislocations of the ankle joint

If foot is dorsiflexed, person walks on the hee lcondition is called
'talipes calcaneus' .
If foot is plantar flexed, person walks on toes. The condition is
called 'talipes equinus' .
If medial border of foot is raised, person walks on lateral border of
foot. The condition is called 'talipes varus'
If lateral border of foot is raised, person walks on medial border of
foot. The condition is called 'talipes valgus' .
Most common is talipes equinovarus in which theheel is medial,
the foot is plantar flexed and invertedwith high medial longitudinal
arch

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