The Regio Carpi.

The Hand. The Finger.

 The Regio Carpi
The borders of the regio carpi are the follow:
1) proximally is an imaginary line on finger breadth
proximally the processus styloidei radia and ulna
2) distally is a circumpherential line drawn just above
the os pisiforme.
 Layers of the Regio Carpi
The layers of the wrist are the
follow:
1) skin is thin and motionless;
2) superficial fascia and
subcutaneous fat contain the
origins of the v.cephalica and
branches of the r.superficialis
n.radialis laterally, v.basilica and r.
dorsalis n.ulnaris medially,
terminal branch of the n.cutaneus
antebrachii posterior are between
them in the posterior surface of
the wrist. Anteriorly are the
beginnings of the same veins and
v. intermedia antebrachii (if it
presents), terminal fibers of the
nn.cutanei antebrachii medialis
and lateralis and palmar branches
of the nn.medianus and ulnaris.
 Layers of the Regio Carpi

3) Deep fascia is well expressed

and strengthened by the fibers
from underlying tendons.
Because of this thickening the
deep fascia of the wrist is said
the lig.carpi palmare. In the
posterior aspect of the wrist the
deep fascia is said the lig.carpi
dorsale. These ligaments hold
back the muscular tendons,
nerves and vessels during
movements of the wrist.
Distally the lig.carpi palmare
growths together with the
retinaculum flexorum.
 Layers of the Regio Carpi
4) muscular tendons:
•superficial muscular tendons. In the
1st row are the tendons of the
mm.brachioradialis, flexor carpi radialis
(which passes through the canalis carpi
radialis), palmaris longus (which
converts distally into the aponeurosis
palmaris), flexor carpi ulnaris;
•tendons of the m.flexor digitorum
superficialis;
•tendons of the mm.flexor digitorum
profundus and flexor pollicis longus.
All these tendons together with
tendons of the m.flexor digitorum
superficialis and n.medianus follow to
the hand through the canalis carpi;
•m.pronator quadratus (proximally
only).
 Layers of the Regio Carpi: Nerves and Vessels
5) Nerves and vessels of the wrist run
between these tendons.
•Vasa radialia runs between the
mm.brachioradialis and flexor carpi
radialis. A.radialis runs behind the
mm.abductor pollicis longus and
extensor pollicis brevis to the dorsum
manus. R.palmaris superficialis
a.radialis runs above the thenar
muscles or through them to form the
arcus palmaris superficialis together
with the a.ulnaris.
•N.medianus passes laterally from the
tendons of the digital flexors and
enters the canalis carpi.
•Vasa ulnaria and n.ulnaris pass
between the mm.flexor carpi ulnaris
and flexor digitorum superficialis
through the canalis carpi ulnaris to
the hand.
 Canals of the Wrist
•Three tunnels for muscular
tendons, nerves and vessels are
in the regio carpi anterior:
canalis carpi radialis, canalis
carpi ulnaris and canalis carpalis.
•The beginning of the canalis
carpi radialis is formed by the
division of the lig. carpi palmare;
more distally superficial and
deep planes of the retinaculum
flexorum and the crest of the
trapezium take part in formation
of this canal. Tendon of the
m.flexor carpi radialis passes
through this tunnel to insert to
the bases of the 2d and 3d
metacarpal bones.
 Canals of the Wrist
•Canalis carpi ulnaris is formed by
the carpi palmare ligament
anteriorly, retinaculum flexorum
posteriorly, the os pisiforme is
medially. This tunnel is known as the
Guyon`s channel. Through this
tunnel the ulnar neurovascular
bundle runs to the hand.
•Canalis carpi is formed by the
division of the retinaculum flexorum.
The carpal canal is wider over the
ulnar side and narrower over the
radial side. The structures that pass
through the carpal canal are the
median nerve and 9 flexor tendons
of the fingers (m. flexor digitorum
superficialis, m. flexor digitorum
profundus and m. flexor pollicis
longus).
 Regio manus (the hand).

• The borders of the hand are

the follow:
• 1)proximal border is a
circular line drawn through
the os pisiforme
• 2) distal border is a crease
between the palm of the
hand and fingers is anteriorly
and heads of the metacarpal
bones are posteriorly.
 Surface Anatomy
• The hand can be divided into several parts. Medial eminence is
hypothenar, lateral eminence is said thenar, at the base of the II – V
fingers are monticuli, at the center of the hand between these
elevations is a palmar depression.
• There are three creases on the hand, they are distal, middle and
proximal creases.
 Layers of the Hand: the Skin
Skin is thick and motionless in the
center of the palm and thinner to the
radial side. It has well developed layers,
particularly the epidermis, which
contains many cell lines and is
keratinized. Thus skin is well recovered
in trauma. There are many sweat glands
and there are no hair follicles and
sebaceous glands in the palmar surface
of the hand and fingers, thus furuncles
are excluded in these regions.
Nerve supply of the skin from medial
to lateral side of the palm is provided
through the n.ulnaris (V and ½ IV
fingers)-3, and n.medianus (½ IV, III, II,I)-
2. The dorsum of the hand is supplied
from the radial nerve (I, II, 1/2 III) -1 and
the ulnar nerve (½ III, IV, V). Thus the
rule of the nerve supply of the hand
from its medial palmar surface to the
dorsal one is the follow: UMRU.
 Subcutaneus Fat
Very thin layer of cellular fat is
observed in the midpalmar region
with fibrous strands uniting the skin
to the underlying aponeurotic sheet.
Thus the subcutaneous fat is
separated into many small fatty
compartments. The creases of the
palm skin appear to be joined even
more firmly than the rest of the
palmar skin. Thin layer of
subcutaneous fat becomes much
thicker toward the thenar and
hypothenar eminences, forming thick
fat pads over each eminence. The
pad over the hypothenar may be
especially thick and contains fibers of
the palmaris brevis muscle. The pads
of both eminences play their role as
protectors of the nerves, vessels and
muscles.
 Fascias of the Hand
Muscles of the thenar and
hypothenar eminences show a thin
fascial cover that turns around the
radial side of the hand for the
thenar area and around the ulnar
side of the hand for the hypothenar
area and continues directly with the
fascia that covers the interosseus
muscles over the dorsum of the
hand. The thenar and hypothenar
fascias are joined in the center of
the palm by the dense, fibrillar,
shiny central connective tissue
fibers named the aponeurosis
palmaris. Thus, the fascias of the
volar aspect of the hand are
described as the thenar,
hypothenar fascias and the
aponeurosis palmaris or midpalmar
fasciae.
 The Aponeurosis Palmaris
The aponeurosis palmaris is a continuation of
the m.palmaris longus fibers and its bands
extend from the retinaculum flexorum to the
metacarpophalangeal joints of the II – IV
fingers. Aponeurosis palmaris is triangular in
shape, with the wide distal base oriented
toward the fingers and narrow proximal base.
Distal part of this aponeurosis is very dense
and shows a system of longitudinal and
transverse fibers. The longitudinal fibers run
exactly parallel with and anterior to the flexor
tendons of the III and IV fingers, forming
distinct (pretendinous) bands. The longitudinal
bands continue distally and adhere firmly to
the fibrous sheaths of the flexor tendons of
the four fingers.
 The Foramina Comissuralia
The pretendinous bands on each side and
the transversal bands contribute to the
formation of three windows (foramina
comissuralia, web spaces) between the
index and the middle intermetacarpeal
area, between the middle and ring fingers
and between the ring and little fingers.
These foramina comissuralia are closed by
three large fat pads. They stand out as the
intermetacarpeal elevations when the
pretendinous bands are tense and depress
the palmar skin over the metacarpal
heads on hyperextension of the fingers.
When removed, they exposed the digital
nerves and arteries in their course from
the palm of the hand to the fingers. The
fat pads covering the windows are in
direct connection with the tissue found
under the aponeurosis palmaris and
communicate to each other behind the
longitudinal bands.
 Muscular Compartments of the Hand
There are two septa beginning
from the medial and lateral borders of the
aponeurosis palmaris.
Septum intermusculare mediale
connects the midpalmar aponeurosis with
the fifth metacarpal bone, and septum
intermusculare laterale passes backwards
to the third metacarpal bone and the
deep palmar fascia. These septa divide
the palm of the hand into three
compartments for muscular tendons,
nerves and vessels. The most lateral of
these, the thenar compartment, contains
short muscles of the thumb, the most
medial, the hypothenar, contains short
muscles of the little finger, and the
intermediate compartment contains the
flexor tendons, surrounded by the thin
and relatively loose connective tissue,
vessels and the median nerve.
 The Thenar Compartment
It is bounded by the thenar fascia
anteriorly and laterally, and septum
intermusculare laterale from ulnar
side, the first interosseus muscle
from the back. It contains short
muscles of the thumb, m.flexor
pollicis longus in its synovial sheath,
the main muscular branch and the
palmar digital (sensory) branches of
the median nerve and radial artery
branches.
Short muscles of the thumb
are behind the proper fascia. They
are the m. flexor pollicis brevis,
m.abductor pollicis brevis,
m.adductor pollicis brevis, and
m.opponens pollicis.
 The N.Medianus Branches
•The main muscular branch
(recurrent branch) of the median
nerve arises near the distal border
of the retinaculum flexorum and
curves laterally and proximally into
the thenar muscles. The
arrangement of this motor branch
of the median nerve is limited by
two fingers distally from the distal
crease of the wrist and two fingers
laterally to the medial vertical palm
crease. No incisions in this
prohibitive area which was
described by Kanavel!
 The N.Medianus Branches
•The palmar digital branches of the
n.medianus are sensitive and pass
deep to the aponeurosis palmaris and
the superficial palmar arch in
subaponeurotic space. Frequently
there is one proper palmar digital
nerve to the radial side of index finger
and three common palmar digital
nerves (i) to both sides of the thumb,
(ii) to the adjacent sides of the index
and middle fingers, (iii) to the to the
adjacent sides of the middle and ring
fingers. The last of this receives a
communication from the common
palmar digital branch of the ulnar
nerve.
 Hypothenar Compartment
Hypothenar compartment is
bounded by the hypothenar fascia anteriorly
and medially, septum intermusculare mediale
from the radial side and the fifth metacarpal
bone and the third m. Interosseus from the
back.
It contains short muscles of the little
finger, the ulnar nerve branches and the ulnar
artery branches. The superficial branch of the
ulnar nerve divides into two. Medially, there is
a proper palmar digital nerve which passes
distally on the flexor digiti minimi brevis and
the middle aspect of the little finger, supplying
its palmar surface. Laterally there is a common
palmar digital nerve, which passes to the ring
and little fingers. It divides into two proper
palmar digital nerves, which pass to adjacent
sides, palmar surface, nail beds of these
fingers.
The short muscles of the little finger
are m. flexor digiti minimi, m.abductor digiti
minimi, m.opponens digiti minimi, and m.
palmaris brevis (in subcutaneous fat).
 Central Compartment
•is limited by the aponeurosis palmaris anteriorly, the
medial and septum intermusculare laterale, and the
layer of the deep fascia posteriorly. It contains the flexor
tendons, three mm.lumbricales, arcus palmaris
superficialis, the median and ulnar nerves branches.
•The arcus palmaris superficialis is formed by the ulnar
artery and the superficial branch of the radial artery.
Four arteries arise from the convexity of the arch,
arteriae digitales palmares communes and the proper
palmar digital artery to the ulnar border of the little
finger. Each of common digital arteries divides into two
arteriae digitales palmares propriae, which supply the
contiguous sides of the related fingers. On the sides of
the fingers they run behind corresponding digital
nerves, and give off dorsal branches which anastomose
with the dorsal digital arteries. Each common palmar
artery is joined, just before it divides, by a palmar
metacarpal artery from the deep palm arch and a distal
perforating branch from a dorsal metacarpal artery.
 Synovial Sheaths of the Flexor Tendons
•There are two synovial sheaths
to flexor tendons, they are the
radial and ulnar bursas. Both
bursas begin approximately 2 - 3
cm proximal to the styloid
process of the radia and ulna.
Each sheath has a visceral layer
which surrounds and is attached
to the tendon, and a parietal
layer, which lines the
surrounding fibrous or
osteofibrous compartment
through which the tendon runs.
•The bursa synovialis radialis
which surrounds the flexor
pollicis longus, terminates at the
insertion of this muscle in the
base of the distal phalanx.
 Synovial Sheaths of the Flexor Tendons
•The bursa synovialis ulnaris, which is
the largest, surrounds the tendons of
both flexor digitorum profundus and
flexor digitorum superficialis. Distally,
the common flexor synovial bursa
terminates at the middle of the palm
for the II, III, IV fingers and extends to
the base of the distal phalanx of the V
finger.
•In about 10% of people there is a
communication between the bursa
ulnaris and bursa radialis in the hand.
•In the proximal part of the hand and in
the wrist both sheaths pass through
the canalis carpi and they are
extending to the lower third of the
forearm to Pirogoff-Parona’s space.
 Deep Structures of the Hand
•Behind the deep fascia are the
interossei palmares, the deep
branch of the ulnar nerve and the
deep palmar arch.
•Deep motor branch of the ulnar
nerve supplies the short muscles of
the little finger, mm.interossei, the 3
and 4 lumbrical muscles, adductor
pollicis together with caput
profundus m.flexor pollicis brevis.
• N.medianus provides nerve supply
of the thenar muscles and
mm.lumbricales. Thus some
muscles have double nerve supply
(caput profundus m.flexor pollicis
brevis, mm. lumbricales the III, IV
and rarer II).
 Fat Spaces of the Hand
•The deepest muscular plane of the
palm is the adductor compartment
containing the adductor pollicis.
•The most important spaces of the
palm of the hand are the thenar
space and the midpalmar space.
The last one is the deep space
behind the deep fascia.
•The anatomic location of the
thenar space is underneath the
fascia palmaris and it is bounded
dorsally by the caput transversum
of the m.adductor pollicis and
extends from the radial bursa to the
third metacarpal bone. On its ulnar
side a fibrous septum
intermusculare laterale divides it
from the midpalmar space.
 Fat Spaces of the Central Compartment
•The central osteofibrous compartment is
bounded by the aponeurosis palmaris
anteriorly, septum intermusculare mediale
and laterale, and the layer of the deep fascia
posteriorly. It contains two parts – the
superficial space and the deep one.
•The superficial subaponeurotic space is
between the aponeurosis palmaris and the
flexor tendons. It contains the arcus palmaris
superficialis and the median and ulnar nerves
branches. This space communicates with the
intermetacarpeal elevations along the vessels
and nerves.
•The deep part is said the subtendons space,
which lies between the flexor tendons and
their sheaths and the deep fascia. Distally,
prolongations of loose connective tissue
round the tendons of the lumbrical muscles
allow tracking fluid or pus into the web space
of fingers and the subaponeurotic space.
Proximally subtendons space communicates
with a similar potential space in front of
pronator quadratus (Pirogoff - Parona’s
space).
 Fat Spaces of the Central Compartment
•Behind the deep fascia and
the metacarpals there is one
last deep midpalmar space
with the arcus palmaris
profundus, its branches
(aa.metacarpeae palmares)
and mm.interossei.
•Pus can track along the
metacarpal arteries to web
spaces and dorsal aspect of
the hand.
•The midpalmar space is
continuous with the anterior
compartment of the forearm
via the carpal tunnel.
 The Finger.
• The proximal borders of the fingers are the
finger-palmar creases of the hand anteriorly
and the heads of the metacarpals on the
dorsum of the hand.
 Skin of the Finger

•The skin has well developed

layers anteriorly, particularly the
epidermis, which consists of many
cell lines (approximately 100 lines
in the nail phalanx) and is
keratinized. Thus the skin is well
recovered in trauma. There are
many sweat glands in the skin, and
there are no hair follicles and
sebaceous glands in the palmar
surfaces of the palm and fingers,
thus furuncles are excluded in
these regions. Skin on the dorsal
surface of the finger contains hair
follicles, so furuncles and
carbuncles can be present here.
 Superficial Fat
•The subcutaneous fat is loose and thin and
contains a little fat on the back of the hand
and fingers. In the palm surface is embodies
tough strong strands of connective tissue
which enclose the fat in loculi and connect the
skin firmly to the periosteum or the deep
fascia (the fibrous sheaths of the flexors
tendons). For this reason pus on the hand and
fingers tracks not superficially, but into the
depth.
•A very important pad occurs in the palmar
surfaces of the distal phalanges where the skin
is tacked down to the distal two-thirds of each
phalanx by strong fibrous strands between
which are the loculi containing fat. In this way
the chief tactile exploratory instrument of the
body are provided with a resilient and strong
backing. A sheet of fibrous tissue runs from
the distal flexor crease to the periosteum, and
so separated the pulp space from the rest of
the finger. There is a little room for swelling, so
that infection causes a throbbing pain early.
 Blood and Nerve Supply of the Fingers
•On the lateral side of every digit the
aa.digitales palmares propriae (from the
superficial palmar arch) run anteriorly and
aa.digitales dorsales propriae are posteriorly
(from arcus dorsalis arise aa.metacarpeae
dorsales which divides into dorsal digital
arteries). There are no aa.digitales dorsales
propriae on the distal phalanx. Both palmar
digital arteries divide into smaller branches to
form arterial plexus. These small arteries run
in separate fatty loculi and provide blood
supply of the distal phalanx. Thus
compression of these loculi because of pus
collection can result in necrosis of the bone.
•Nerve supply of the fingers is provided by
the median, ulnar and radial nerves. There
are two nerves on the lateral side of each
finger. Nn.digitales palmares propriae are
antero-laterally, and nn.digitales dorsales
propriae pass postero-laterally. There are no
nn.digitales dorsales propriae in the distal
phalanx too.
 Osteofibrous Sheaths of the Digits
•The deep fascia of the digits and the
periosteum are connected to the bones and
formed the digital sheaths (6).
•The fibrous digital sheaths are attached to
the raised lateral and medial edges of the
palmar surface of the proximal and middle
phalanges and to the palmar surface of the
distal phalanx. Between these attachments
the fibrous tissue composing each sheath
arches from one side of the finger to the
other, so completing an osteofibrous tunnel
in which the flexor tendons run, surrounded
their synovial sheaths. This tunnel is closed
distally by the attachment of the sheath to
the distal phalanx, but is open proximally,
deep to the palmar aponeurosis.
•The sheathes are strengthened by the
ligaments (pars annularis vaginae fibrosae- 9
and pars cruciformis vaginae fibrosae - 8),
which hold the tendons closely applied to
the bones and prevents herniation of the
sheaths during flexion and extension of the
digits.
 Synovial Sheaths to the Flexor Tendons
•Each fibrous digital sheath is lined by a
synovial sheath which envelops the tendons
of mm.flexores digitales superficialis and
profundus. Under the slightest pressure, the
synovial sheaths distend in places where they
are not compressed and become bulbous.
These synovial sheaths for II, III and IV fingers
extend from the head of the metacarpal
proximally to the base of the distal phalanx.
•There is a special synovial sheath to the
thumb (bursa synovialis radialis) which
contained m.flexor pollicis longus and extends
from 2-3 cm above processus styloideus radia
to the base of the distal phalanx of the
thumb. Another common synovial sheath
(bursa synovialis ulnaris) contains the flexor
tendons of the fifth finger and terminates in
the base of the distal phalanx of the little
finger and at the middle of the palm for II, III
and IV fingers.
 The Vincula Tendinea
•Every synovial sheath consists of two
layers – parietal is adjacent to the fibrous
sheath, and visceral which is covering
muscles tendons. Inside the digital sheaths,
the tendons are not attached by a
continuous mesotenon to the synovial wall;
instead, there are separate synovial bands,
the vincula tendinea longa and brevia. The
vincula carry blood vessels and nerves,
reach the tendons posteriorly, and attach
them to the bone.
•The vincula brevia are the small triangular
bands of connective tissue attached to the
front of the interphalangeal joint and the
distal part of the proximal phalanx. They
occupy the interval between the tendon
and the digit close to the insertion. The
vincula longa are variable, narrow bands
extending from the back of the tendon to
the proximal part of the palmar surface of
the proximal phalanx.
 Flexor Tendons
•In the palm the m.flexor digitorum superficialis
tendon in company with the corresponding
tendon of the m. flexor digitorum profundus
enters the synovial flexor sheath of its own digit.
•At the level of metacarpophalangeal joint, each
tendon of m.flexor digitorum superficialis
divides into two. The two halves pass
posteriorly, with a spiral twist, round the sides of
the tendon of flexor digitorum profundus, into
the margins of the palmar surface of the middle
phalanx. Some of tendinous fibers decussate
posterior to the tendon of the profundus,
forming for it a tunnel which can not be
obliterated by tension.
•The tendons of flexor superficialis are also
attached to the bones of the fingers by vincula
tendineum which convey to them the small
blood vessels necessary for their nutrition.
• The tendon of m. flexor digitorum profundus
enters the fibrous sheath of its digit behind the
tendon of flexor digitorum superficialis, and
pierces this tendon opposite the proximal
phalanx. It inserts into the anterior surface of
the base of the distal phalanx.
 Lymph Vessels
•The superficial digital lymph vessels form two or
three collateral channels that follow the
corresponding collateral digital artery. These
channels are directed dorsally in the interdigital
spaces and along the medial and lateral borders
of the hand.
•The subcutaneous lymphatic network is very
dense over the volar surface of the hand and less
dense over the dorsal surface.
•The superficial lymph vessels collect in the
forearm with dorsal and palmar aspects and
continue into the arm.
•The deep lymph vessels accompany the deep
arteries and veins and follow the deep channels
that are the satellites of the arteries and veins of
the forearm.
•The lymph vessels from the 2 and 3 fingers
terminate in the lymphonodes infraclaviculares or
the lymphonodes supraclaviculares.
•The lymph vessels from the 4 and 5 fingers are
connected with the cubital and axillary lymph
nodes.