palmar aponeurosis & muscles.pptx

1. Hand

2. Hand • Composed of • Bones • Muscles • Ligaments • To allow a large amount of movements

3. Hand • Has 2 surfaces • Palmar • Dorsal

4. Palm – Features • Hollow • Eminence • Creases

5. Palm – Features • Palmar surface • Thick skin • Devoid of • Hairs & sebaceous glands • Connected with deep fascia by • Many fibrous septa • Helps grip by restricting mobility of skin • Has fat • Act as cushion • To withstand pressure

6. Palm - features • Has • Creases or lines • 3 types • Flexure lines • Papillary ridges • Langer lines

7. Creases - Flexure lines • Visible marking • Lies close to joints • On medial 4 fingers • 2 interphalangeal creases • Proximal crease only marks joint • Crease between palm & fingers • Do not represent the metacarpophalangeal joint • Joint lies 2 cm proximal to crease • Distal skin crease of wrist • Represents proximal border of flexor retinaculum • At the midpoint • Median nerve passes behind

8. Creases - Flexure lines • Wrist • Proximal • Distal • Palm • Longitudinal • Mid-palmar • Radial • Transverse • Proximal • Longitudinal • Applied anatomy – Simian’s crease • Phalanges • Proximal • Middle • Distal

9. Creases – Papillary ridges • Otherwise - Finger prints • Peculiar over the flexor surface of distal phalanges • Corresponds to • Pattern of underlying dermal papilla • Ducts of sweat gland opens • 3 types • Whorl, loop & arch • Helps in personal identity • Dermatoglyphics • Science of finger prints

10. Creases – Langer lines • Produced by • Bundles of collagen fibres of dermis • On dorsum • Transverse • On palm • Longitudinal

11. Hand - Dorsum • Dorsal surface • Thin skin • Presence of • Hair & sebaceous & sweat glands • Beneath skin • Dorsal digital nerves • Dorsal venous plexus • Drains not only • Dorsal surface but also palm • To avoid the pressure of grip

12. Superficial fascia • Subcutaneous tissue • Contains • Fat • Palmaris brevis • Lies across the base of hypothenar eminence • Superficial transverse ligament of palm • Across roots of medial 4 fingers

13. Palmaris brevis • Lies across the base of hypothenar eminence • Origin • Flexor retinaculum & central part of palmar aponeurosis • Insertion • Dermis of ulnar border of hand • Nerve supply • Superficial branch of ulnar nerve • Action • Improves the grip • Morphology • Remnant of Panniculus carnosus •

14. Superficial transverse ligament of Palm • Modification of superficial fascia • Stretches across • Free margin of the webs of medial four fingers • Structures passing deep to it • Digital vessels & nerves

15. Cutaneous nerves • Palmar cutaneous branch of median– in lower part of forearm – passes into hand above flexor retinaculum – supplying skin over thenar eminence & middle of palm • Palmar cutaneous of ulnar – near lower forearm –supplies skin of medial 1/3 of palm

16. Deep fascia • Thickened at 3 sites • Flexor retinaculum • Palmar aponeurosis • Fibrous flexor sheath

17. Palmar aponeurosis • Triangular in shape • Occupies the central area of the palm • Has • Apex • Base • Apex • Blends with distal border of flexor retinaculum • Continuous with palmaris longus tendon • Base • Lies at bases of medial four fingers • Divides into four digital slips • Further each digital slip divided into • Superficial & deep sets of fibres

18. Palmar aponeurosis – superficial & deep fibres • Superficial fibres • Joins with dermis • Blend with superficial transverse ligament of palm • Deep fibres • Divides into 2 bands • Attaches to • Deep transverse ligament of palm • Palmar ligament of metacarpophalangeal joint • Bases of proximal phalanges • Fibrous flexor sheaths

19. Palmar aponeurosis – space between the slips • Intervals between the four digital slips • Connected by transverse fibres • Structures passing • Digital vessels • Digital nerves • Lumbricals

20. Palmar aponeurosis – medial & lateral palmar septa • Medial septum • From medial margin • To palmar surface of shaft of 5th metacarpal • Lateral septum • From lateral margin • To 1st metacarpal bone • Septa subdivide the palm into fascial spaces

21. Palmar aponeurosis – functions • Powerful grip • By firm attachment of overlying skin • Prevents bow-stringing • Of flexor tendons • Protects • Vessels & nerves • Provides • Origin to palmaris brevis • Potential spaces • Septa from aponeurosis forms • Peculiarity from plantar aponeurosis • Absence of digital slip to thumb • Allows free movement of thumb • Plantar aponeurosis • Has 5 slips • Morphology • Degenerated part of palmaris longus tendon

22. Palmar aponeurosis • Thickened deep fascia of the hand • Triangular in shape • Occupies the central area of the palm • The apex is attached to the distal border of flexor retinaculum and receives the insertion of palmaris longus tendon. • Base divides at the bases of the fingers into four slips that pass into the fingers • Functions • Gives firm attachment to the overlying skin and improves the grip. • Protects the underlying tendons, vessels & nerves

23. Palmar aponeurosis (Central part) • Thickened deep fascia of the hand • Triangular in shape • Occupies the central area of the palm • Apex is attached to the distal border of flexor retinaculum and receives the insertion of palmaris longus tendon. • Base divides at the bases of the fingers into four slips that pass into the fingers • Functions: • Gives firm attachment to the overlying skin and improves the grip. • Protects the underlying tendons, vessels & nerves

24. Dupuytren’s contracture • Hypertrophy of palmar aponeurosis –progressive fibrosis (ulnar side) • Shortening & thickening of fibrous bands from aponeurosis to little and ring fingers

25. Intrinsic muscles of hand

26. Intrinsic muscles • Thenar • Hypothenar • Lumbricals • Interossei muscles

27. Intrinsic Muscles • Situated totally within the hand • Divided into 4 groups:- • Lateral group • Four thenar muscles • Medial group • Three hypothenar muscles • Palmaris brevis • Central group: • Four lumbricals • Four palmar interossei • Four dorsal interossei • All muscles are supplied by • C 8 & T 1 spinal segments • Through median & ulnar nerves

28. Lumbricals • Earth worm • 4 lumbricals • Numbered from lateral to medial • Arise from 4 tendons of FDP • Inserted into extensor expansion • Numbered from lateral to medial • First & second are • Unipennate • Supplied by Median nerve • Third & fourth are • Bipennate • Supplied by deep branch of ulnar • Left Hand

29. Lumbricals - origin • I lumbrical • From radial side of tendon for index finger • II lumbrical • From radial side of tendon of middle finger • III lumbrical • From adjacent sides of the tendons for middle & ring fingers • IV lumbrical • From adjacent sides of the tendons for ring & little fingers • Right Hand

30. Lumbricals • Insertion • All lumbricals pass backwards on radial side of • 2nd , 3rd , 4th & 5th metacarpo-phalangeal joints respectively • Insert on lateral angle of extensor expansion • Action • Flex the metacarpo-phalangeal joints • Extend the interphalangeal joints

31. Thenar muscles • Abductor pollicis brevis • Flexor pollicis brevis • Opponens pollicis • Adductor pollicis

32. Abductor pollicis brevis • Origin • Tubercle of Scaphoid • Crest of Trapezium • Flexor retinaculum • Insertion • Lateral aspect of proximal phalanx of thumb • Near base • Action • Abduction & medial rotation • At • Metacarpophalangeal joint • Carpometacarpal joint • Right angle to the thumb • Nerve supply • Recurrent branch of Median (C 8 & T1)

33. Flexor pollicis brevis • Origin • Superficial head • Crest of Trapezium • Flexor retinaculum • Deep head • Trapezoid • Capitate • Insertion • Lateral aspect of proximal phalanx of thumb • Near base • Action • Flexion of carpometacarpal & metacarpophalangeal joints • Nerve supply • Recurrent branch of Median (C 8 & T1)

34. Opponens pollicis • Origin • Tubercle of trapezium • Flexor retinaculum • Insertion • I metacarpal • Lateral margin & lateral palmar aspect • Action • Opposition • At carpo metacarpal joint • Rotating & flexing the metacarpal on trapezium

35. Thenar eminence • Raised region between wrist & base of thumb • Muscles • Abductor pollicis brevis(median) • Opponens pollicis(median) • Flexor pollicis brevis(median & ulnar) • Adductor pollicis(ulnar) Carpal tunnel syndrome

36. Adductor pollicis • Origin • Oblique head – capitate, trapezoid & bases of 2nd & 3rd metacarpal bones • Transverse head – distal 2/3rd of shaft of 3rd metacarpal bone • Insertion • Ulnar side of base of proximal phalanx of thumb • Action • Transverse head – adductor &flexor of thumb • Nerve supply – Ulnar nerve (deep) C8 &T1

37. Interossei • Deepest structure of hand • Between the metacarpal bones • 8 muscles present • Arranged in 2 groups • Palmar interossei (4) • Dorsal interossei (4)

38. Palmar interossei • Superficial than dorsal interossei • Smaller ones • Unipennate • Adduct the fingers towards middle finger • No adductors for middle finger • Origin • 1st & 2nd • Medial side of shafts of 1st & 2nd metacarpals • 3rd & 4th • From radial side of shafts of 4th & 5th metacarpals • Insertion • Base of proximal phalanx of corresponding digit on side of their origin • Dorsal digital expansion 2 3 4

39. Dorsal interossei • Deepest structure • Fill up intermetacarpal spaces • Bipennate • Abductors • Little & thumb have their own abductors • Middle finger require abduction on both sides

40. Dorsal interossei • Fills up all (4) intermetacarpal spaces • Origin • Contiguous sides of shafts of metacarpals • Leaves a gap in between their origin • Space between first dorsal interossei transmits • Radial artery • Gap between 2nd 3rd & 4th dorsal interossei transmits • Proximal perforating arteries

41. Dorsal interossei • Insertion • Proximal phalanges of 2nd, 3rd & 4th • Middle finger gets insertion on both sides • 1st & 2nd • Radial side of bases of proximal phalanges of index & middle • 3rd & 4th • Ulnar side of bases of proximal phalanges of middle & ring fingers • Nerve supply • Deep branch of ulnar

42. • Lateral & medial angles of dorsal digital expansion of • Index, middle & ring fingers receives • Interossei

43. Hypothenar muscles • Abductor digiti minimi • Flexor digiti minimi • Opponens digiti minimi

44. Abductor digiti minimi • Origin • Pisiform, tendon of flexor carpi ulnaris • Insertion • Ulnar side of base of proximal phalanx • Action • Abductor of little finger • Nerve supply • Ulnar (deep) C8 & T1

45. Flexor digiti minimi brevis • Origin • Hook of hamate • Flexor retinaculum • Insertion • Ulnar side of base of proximal phalanx of little finger • Action • Flexor of proximal phalanx of little finger • Nerve supply • Ulnar (deep) C8 & T1

46. Opponens digiti minimi • Origin • Hook of hamate • Flexor retinaculum • Insertion • Ulnar border of 5th metacarpal • Action • Flexes 5th metacarpal • Nerve supply • Ulnar (deep) C8 & T1

47. Deep branch of ulnar nerve • Course • Passes between abductor digiti minimi & flexor digiti minimi • Accompanied by deep branch of ulnar artery • Perforates opponens digiti minimi • Follow deep palmar arch

48. Branches • Muscular • Abductor digiti minimi • Flexor digiti minimi brevis • Opponens digiti minimi • 3rd & 4th lumbricals • Adductor pollicis • Flexor pollicis brevis • Interossei • Articular • Intercarpal, carpometacarpal joints • Blood vessels – ulnar & palmar arteries

49. Median nerve contd… • Muscular branches to Thenar muscles – Abductor pollicis brevis – Flexor pollicis brevis – Opponens pollicis • Branches from digital nerves supply – 1st & 2nd lumbricals

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