This document provides an overview of the surgical anatomy of the hand. It describes the surface landmarks and structures of the palmar aspect of the hand such as the tubercles and bones that can be felt. It details the layers of the palm including the skin, superficial and deep fascia, muscles such as the palmaris brevis, nerves, blood vessels, and other structures. It also describes the dorsal aspect including fascia and extensor retinaculum. Key areas covered include the carpal tunnel, flexor retinaculum, fibrous flexor sheaths, intrinsic hand muscles, and fascial spaces of the palm.

1. SURGICAL ANATOMY OF HAND
DR INDUMATHI B

2. PALMAR ASPECT OF THE HAND
• SURFACE LANDMARS:
• Tubercle of scaphoid—can be felt at
the base of thenar eminence, just
lateral to the tendon of flexor carpi
radialis.
• Tubercle/crest of trapezium—can be
felt on deep palpation, distolateral to
the tubercle of scaphoid.
• Pisiform bone—can be felt at the
base of hypothenar eminence
medially.
• Hook of hamate—can be felt one
finger’s breadth distal to the pisiform
bone.

3. SKIN OF THE PALM
• 1. It is thick to withstand wear and tear
during work.
• 2. It is richly supplied by the sweat glands
• 3. It is immobile as it is firmly attached to
the underlying palmar aponeurosis.
• 4. It presents several longitudinal and
transverse creases where the skin is firmly
bound to the deep fascia.

4. SUPERFICIAL FASCIA OF THE PALM
• The superficial fascia of the palm is made up
of dense fibrous bands, which anchor the skin
to the deep fascia of the palm.
• It contains a subcutaneous muscle, the
palmaris brevis on the ulnar side of the palm.
• It thickens to form a superficial metacarpal
ligament, which stretches across the roots of
fingers over the digital nerve and vessels.

5. PALM OF THE HAND
• The palmaris brevis arises from the flexor
retinaculum and palmar aponeurosis
• It is inserted into the skin of the palm.
• It is supplied by the superficial branch of the
ulnar nerve.
• Its function is to corrugate the skin at the base
of the hypothenar eminence and so improve
the grip of the palm in holding a rounded
object.

7. PALM OF THE HAND
• The sensory nerve supply to the skin of the palm
is derived from the palmar cutaneous branch of
the median nerve, supplies the lateral part of the
palm.
• palmar cutaneous branch of the ulnar nerve;
the supplies the medial part of the palm.
• The skin over the base of the thenar eminence is
supplied by the lateral cutaneous nerve of the
forearm or the superficial branch of the radial
nerve

10. The Palmar Aponeurosis
• The palmar aponeurosis is triangular and occupies
the central area of the palm.
• The apex is attached to flexor retinaculum and the
palmaris longus tendon from which it is derived.
• 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 the root of the finger.
• Each deep band divides into two, which diverge
around the flexor tendons and finally fuse with the
fibrous flexor sheath and the deep transverse
ligaments.

12. Palmar aponeurosis

13. Palmar aponeurosis
• The medial and lateral borders of the palmar
aponeurosis are continuous with the thinner
deep fascia covering the hypothenar and
thenar muscles.
• 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.

14. Dupuytren’s Contracture
• Dupuytren’s contracture is a localized
thickening and contracture of the palmar
aponeurosis.
• It limits hand function and may eventually
disable the hand.
• It commonly starts near the root of the ring
finger.
• And draws that finger into the palm, flexing it
at the metacarpophalangeal joint.

15. Dupuytren’s Contracture
• In long-standing cases, the pull
on the fibrous sheaths of these
fingers results in flexion of the
proximal interphalangeal joints.
• Surgical division of the fibrous
bands followed by physiotherapy
to the hand is the usual form of
treatment.
• The alternative treatment of
injection of the enzyme
collagenase into the contracted
bands of fibrous tissue has been
shown to significantly reduce the
contractures and improve
mobility

16. Flexor Retinaculum
• It is a strong fibrous band which bridges the
anterior concavity of carpus and converts it
into an osseofibrous tunnel called carpal
tunnel for the passage of flexor tendons of the
digits.
• The flexor retinaculum is rectangular and is
formed due to thickening of the deep fascia in
front of carpal bones.

17. • Medially: It is
attached to the
pisiform and the
hook of hamate.
• Laterally: It is
attached to the
tubercle of
scaphoid and
the crest of
trapezium.

19. • The tendons of FDS and FDPare enclosed in a
synovial sheath called ulnar bursa.
• The tendon of flexor pollicis longus is on the
radial side and enclosed in a separate synovial
sheath called radial bursa.
• The tendon of flexor carpi radialis pass
through a separate canal in the lateral part of
the flexor retinaculum.

20. The Carpal Tunnel
• The bones of the hand and the flexor
retinaculum form the carpal tunnel.
• The long flexor tendons to the fingers and
thumb pass through the tunnel and are
accompanied by the median nerve.
• The median nerve passes beneath the flexor
retinaculum in a restricted space between the
flexor digitorum superficialis and the flexor
carpi radialis muscles.

22. Carpal Tunnel Syndrome
• It is produced by compression of the median
nerve within the tunnel.
• It consists of a burning pain or “pins and needles”
along the distribution of the median nerve to the
lateral three and a half fingers and weakness of
the thenar muscles.
• It may be due to thickening of the synovial
sheaths of the flexor tendons or arthritic changes
in the carpal bones .
• It is relieved by decompressing the tunnel by
making a longitudinal incision through the flexor
retinaculum

23. Fibrous Flexor Sheaths
• The anterior surface of each finger, from the head
of the metacarpal to the base of the distal
phalanx, is provided with a strong fibrous sheath
that is attached to the sides of the phalanges.
• The proximal end of the fibrous sheath is open,
whereas the distal end of the sheath is closed and
is attached to the base of the distal phalanx.
• The sheath and the bones form a blind tunnel in
which the flexor tendons of the finger lie.

25. • In the thumb, the osteofibrous tunnel
contains the tendon of the flexor pollicis
longus.
• In the case of the four medial fingers, the
tunnel is occupied by the tendons of the flexor
digitorum superficialis and profundus
• The fibrous sheath is thick over the phalanges
but thin and lax over the joints.

28. Synovial Flexor Sheaths
• In the hand, the tendons of the flexor digitorum
superficialis and profundus muscles invaginate a
common synovial sheath from the lateral side.
• The medial part of this common sheath extends
distally without interruption on the tendons of
the little finger.
• The lateral part of the sheath stops abruptly on
the middle of the palm,and the distal ends of the
long flexor tendons of the index, the middle, and
the ring fingers acquire digital synovial sheaths
as they enter the fingers

30. • The flexor pollicis longus tendon has its own
synovial sheath that passes into the thumb.
• The synovial sheath of the flexor pollicis
longus is referred to as the radial bursa.n
• It communicates with the common synovial
sheath of the superficialis and profundus
tendons referred to as the ulnar bursa.
• Function is to allow the long tendons of digits
to move freelywith minimum friction.

31. • The ulnar bursa extends
proximally into the forearm
about a finger breadth (5
cm) proximal to the flexor
retinaculum.
• Distally it extends in the
palm up to the middle of
the shafts of the metacarpal
bones.
• The distal medial end of
ulnar bursa is continuous
with the digital synovial
sheath of the little finger.

32. Vincula
• The fibrous flexor
sheaths, are connected
to the phalanges by the
thin bands of connective
tissue called vincula.
• The short ones are
called vincula brevia and
long ones vincula longa.

33. INTRINSIC MUSCLES OF THE HAND
• The intrinsic muscles of the hand are arranged
into the
• following five groups:
• 1. Thenar muscles.
• 2. Adductor of thumb.
• 3. Hypothenar muscles.
• 4. Lumbricals.
• 5. Interossei

34. Thenar Muscles
• Abductor pollicis brevis.
• Origin:Tubercle of
scaphoid
• Crest of trapezium
• Flexor retinaculum
• Inserted into Lateral side
of base of the proximal
phalanx of thumb
• Supplied by recurrent
branch of the median
nerve.

35. Thenar muscles
• Flexor pollicis brevis.
• Origin: Superficial
head from the distal
border of the flexor
retinaculum
• Deep head from
trapezoid and
capitate bones
• Inserted into Lateral
side of the base of
the proximal phalanx
of thumb.

36. • Opponens pollicis
• Origin :Flexor
retinaculum crest of
trapezium
• Insertion :Lateral
border and
adjoining lateral half
of the palmar
surface of the first
metacarpal bone.

37. Hypothenar muscles
• Abductor digiti
minimi
• Origin :Pisiform
bone, Tendon of
flexor carpi ulnaris
• Insertion:Ulnar
side of the base of
the proximal
phalanx of little
finger.

38. • Flexor digiti minimi
• Origin:Flexor retinaculum
,Hook of hamate
• Insertion:Ulnar side of
base of the proximal
phalanx of little finger
along with tendon of
abductor digiti minimi.
• Opponens digiti minimi
• Insertion:Medial surface
of the shaft of 5th
• metacarpal bone

39. • Adductor Pollicis Muscle
• Origin
• 1. Oblique head arises from anterior aspects of capitate
bone and bases of second and third metacarpal
bones— forming a crescentic shape.
• 2. Transverse head arises from ridge on distal two-third
of the anterior surface of the shaft of the third
metacarpal.
• Insertion
• Into the medial side of the base of proximal phalanx of
the thumb.

40. Adductor Pollicis Muscle

41. Lumbricals
• The lumbricals are slender,
worm-like muscles arising in the
palm from the radial side of the
four tendons of flexor digitorum
profundus.
• Each is attached distally to the
radial side of the extensor
expansion of its tendon.
• The two lateral lumbricals are
supplied by the median nerve,
the two medial by the ulnar
nerve.

43. Palmar interossei
• Origin:First arises from
base of 1st metacarpal;
remaining three from
anteriorsurface of shafts
of 2nd, 4th, and 5th
metacarpals.
• Proximal phalanges of
thumb and index, ring,
and little fingers and
dorsal extensor
expansion of each
finger.

44. Dorsal interossei
• Arises from the
Sides of shafts of
metacarpal bones.
• Inserted into
Proximal phalanges
of index, middle,
and ring fingers and
dorsal extensor
expansion.

45. Arteries of the Palm
• The superficial palmar
arch provides an
anastomosis between
the radial and ulnar
arteries in the hand.
• The superficial palmar
branch of the ulnar
artery passes laterally
deep to the palmar
aponeurosis to join the
terminal branch of the
radial artery superficial
to the long flexor
tendons.

46. • It provides four palmar
digital branches which,
bifurcates to supply
adjacent sides of the
fingers.
• The deep palmar arch, is
formed largely by the
radial artery and a
smaller branch from the
ulnar artery.
• It lies deep to the long
flexor tendons and
provides palmar
metacarpal arteries and
perforating arteries to
the dorsum of the hand.

47. nerves of the Palm

49. Fascial Spaces of the Palm
• Normally, the fascial spaces of the palm are
potential spaces filled with loose connective
tissue.
• There are midpalmar space, thenar space,
pulp space of digits.

50. Fascial Spaces of the Palm
• The midpalmar space
contains the 2nd, 3rd, and 4th
lumbrical muscles and lies
posterior to the long flexor
tendons to the middle, ring,
and little fingers.
• It lies in front of the
interossei and the third,
fourth, and fifth metacarpal
bones .
• The thenar space contains
the first lumbrical muscle and
lies posterior to the long
flexor tendons to the index
finger and in front of the
adductor pollicis muscle.

52. • The lumbrical canal is a potential space
surrounding the tendon of each lumbrical
muscle and is normally filled with connective
tissue.
• The pulp spaces of the digits are
subcutaneous spaces on the palmar side of
tips of the fingers and thumb.
• The pulp space is filled with subcutaneous
fatty tissue.

53. PULP SPACES OF THE DIGITS
• Superficially: Skin
and superficial
fascia.
• Deeply: Distal
two-third of
distal phalanx

55. Space of Parona
• It is merely a fascial
interval underneath the
flexor tendons on the front
of distal part of the
forearm.
• The forearm space
(Parona’s space) becomes
infected from infected
ulnar bursa.
• Pus collects behind the
long flexor tendons.

56. Surgical Incisions
• To drain abscess of the
thenar space, a vertical
incision at first web space
(A).
• To drain abscess from
midpalmar space, vertical
incision in the medial two
web spaces(B).
• To drain abscess from ulnar
bursa, incision should be
given along the radial margin
of hypothenar eminence (C).
• To drain abscess from radial
bursa, incision should be
given along the medial
margin of thenar eminence
(D).

57. • To drain pus from digital
synovial sheath, vertical
incisions should be given
along the side of proximal
and middle phalanges (E).
• To drain pus from pulp
space, vertical incision
should be along the sides of
pulp (F).
• To drain pus from space of
Parona, vertical incisions
should be given on the
distal part of forearm (G).

58. DORSUM OF THE HAND
• The skin on the dorsum of the hand is thin,
hairy, and freely mobile on the underlying
tendons and bones.
• Superficial Fascia:
• The superficial fascia on the dorsum of the
hand contains dorsal venous arch, cutaneous
branches of the radial nerve,and dorsal
cutaneous branch of the ulnar nerve.

59. DORSUM OF THE HAND

60. • The deep fascia on the
back of the wrist is
thickened to form an
oblique fibrous band
called extensor
retinaculum
• It is directed downwards
and laterally, and about 2
cm broad vertically.

61. • The space deep to the
extensor retinaculum
is divided into six
compartments by five
septa extending from
retinaculum to the
dorsal aspects of the
lower ends of radius
and ulna.
• The compartments are
numbered I to VI from
lateral to medial side.

62. Dorsal Venous Arch
• The dorsal venous arch lies in the
subcutaneous tissue proximal to the
metacarpophalangeal joints and
drains on the lateral side into the
cephalic vein and, on the medial
side, into the basilic vein
• The greater part of the blood from
the whole hand drains into the arch,
which receives digital veins and
freely communicates with the deep
veins of the palm through the
interosseous spaces.

63. EXTENSOR TENDONS ON THE
DORSUM OF THE HAND
• Tendons of the thumb:
• Tendon of abductor pollicis
longus (APL) is inserted on
the base of 1st metacarpal.
• Tendon of extensor pollicis
brevis (EPB) is inserted on
the base of proximal
phalanx.
• Tendon of extensor pollicis
longus (EPL) is inserted on
the base of distal phalanx.

64. EXTENSOR TENDONS ON THE
DORSUM OF THE HAND
• Tendons of extensor
digitorum
• four in number, which
diverge across the dorsum
of the hand.
• connected to one another
by three oblique fibrous
intertendinous bands.

65. ANATOMICAL SNUFF-BOX
• The anatomical
snuff-box is an
elongated
triangular
depression seen
on the lateral side
of the dorsum of
hand when the
thumb is
hyperextended.

66. ANATOMICAL SNUFF-BOX
Structures crossing the roof
deep to skin :
1. Cephalic vein, from
medial to lateral side.
2. Terminal branches of the
superficial radial nerve,
from lateral to medial side.

67. references
• 1.Bailey and love’s essential clinical anatomy
• 2.Clinical anatomy by regions,richard S.
Snell,9th edition.
• 3.lee McGregor’s synopsis of surgical anatomy.
• 4.netter’s surgical anatomy

68. •THANKYOU