Musculoskeletal System

Appendicular System: Upper Limb

Lecture 5: Front of forearm
& Palm of hand

Dr. Ashraf Ramzy

Professor of Anatomy & Embryology
ash-ramzy@hotmail.com
Dr Ashraf Ramzy
Dr Ashraf Ramzy
Dr Ashraf Ramzy
Dr Ashraf Ramzy
S = Scaphoid
L = Lunate
T = Triquetrum
Radius Ulna
P = Pisiform
Tm = Trapezium
Td = Trapezoid
C = Capitate
L T
H = Hamate
S P
H
Tm C
Td

1 5
Palmar aspect 2 3 4
Dr Ashraf Ramzy
 Fascial Compartment of Forearm
* The forearm is enclosed in a sheath of deep
fascia which is attached to the posterior border
of ulna.

Dr Ashraf Ramzy
 Fascial Compartment of Forearm
* This sheath, together with the interosseous
membrane and fibrous septa divide the forearm
into 2 fascial compartments; anterior and
posterior.
* Each compartment has its muscles, nerves and
blood supply.

Dr Ashraf Ramzy
 The Interosseous Membrane
- Thin but strong membrane uniting the radius and
ulna, attached to their interosseous
borders.
- Its fibers run obliquely
downwards and medially,
so that force applied to lower
end of radius transmitted to
ulna then to humerus and scapula.
Dr Ashraf Ramzy
The Interosseous Membrane (contd)

- Provides
attachment to
muscles.
- Pierced in its
lower part by
anterior
interosseous artery.
Dr Ashraf Ramzy
Muscles of front
of forearm

Dr Ashraf Ramzy
 CONTENTS OF ANTERIOR
FASCIAL COMPARTMENT:
1- Muscles: * Superficial group: 5 muscles.
* Deep group: 3 muscles.
2- Blood supply to muscles:
* Ulnar and radial arteries.
3- Nerve supply to muscles:
* Branches from median and ulnar nerves.
Dr Ashraf Ramzy
MUSCLES OF ANTERIOR COMPARTMENT OF FOREARM (8):
3 Groups:
* A. Superficial group: 4 in number:
1- Pronator teres. 2- Flexor carpi radialis.
3. Palmaris longus (may be absent).
4. Flexor carpi ulnaris.
B. Intermediate group: *Flexor digitorum superficialis (at a
deeper plane).
C. Deep group: 3 in number: 1- Flexor pollicis longus.
2- Flexor digitorum profundus.
3- Pronator quadratus. Dr Ashraf Ramzy
Dr Ashraf Ramzy
Dr Ashraf Ramzy
All the superficial group have the following
characters:
1- All of them take origin from front of medial
epicondyle (common flexor origin). Some have
additional origin.
2- All are inserted in the hand except pronator teres
(inserted in the radius).
3- All are supplied by median nerve except flexor
carpi ulnaris (by ulnar nerve).
4- All help in flexion of elbow.
5- All help in flexion of wrist (except pronator
teres).
Dr Ashraf Ramzy
 Muscle Origin Insertion Action

1- Pronator 1- Humeral head: Middle of

lower 1/3 of med. lateral surface
teres: supracondylar of radius.
ridge & common
flexor origin (front - Flexion of
of medial elbow
epicondyle). - Pronation of
2- ulnar head: med. forearm.
border of coronoid
process of ulna.
2- Flexor Front of medial Palmar surface Flexion &
epicondyle of bases of 2nd abduction of
carpi (common flexor & 3rd wrist.
radialis: origin). metacarpal
bones.

Dr Ashraf Ramzy
Pronator teres
Humeral head

Ulnar head

Dr Ashraf Ramzy
Dr Ashraf Ramzy
 Muscle Origin Insertion Action

3- Palmaris Front of medial Apex of

epicondyle palmar - Flexion of
longus: aponeurosis
(common flexor wrist.
origin). and flexor
retinaculum.
4- Flexor 1- humeral head: Pisiform bone - Flexion &
front of medial & 5th adduction of
carpi epicondyle metacarpal wrist.
ulnaris: (common flexor bone & hook
origin). of hamate.
2- Ulnar head:
med. Margin of
olecranon
process & post.
borderof ulna

Dr Ashraf Ramzy
Palmaris longus

Dr Ashraf Ramzy
Dr Ashraf Ramzy
 Muscle origin insertion action

5-Flexor 1-humeroulnar - By 4 - Flexion of

digitorum head: from tendons into wrist.
med. the middle - Flexion of
superficialis: epicondyle of phalanges of proximal &
humerus medial 4 middle
(common flexor fingers. phalanges of
origin) and medial 4
med. border of fingers.
coronoid
process of ulna.
2-radial head:
from ant.
oblique line of
radius.

Dr Ashraf Ramzy
Dr Ashraf Ramzy
Dr Ashraf Ramzy
Dr Ashraf Ramzy
 B- Deep muscles: (3 in number):
1- Flexor pollicis longus.
2- Flexor digitorum profundus.
3- Pronator quadratus.
* All the deep muscles have the following characters:
1- All take origin from radius or ulna only.
2- All inserted in hand except pronator quadratus
(inserted in radius).
3- All supplied by anterior interosseous nerve
(branch from median) except medial ½ of flexor
digitorum profundus (by ulnar nerve).

Dr Ashraf Ramzy
 Muscle Origin Insertion Action
1- Flexor Upper 2/3 of ant. Terminal - Flexion of
pollicis surface of radius + phalanx of wrist.
longus: interosseous thumb. - Flexion of all
membrane + med. joints of
border of coronoid thumb.
process of ulna.
2- Flexor Upper 2/3 of ant. & Terminal - Flexion of
digitorum med.surface of ulna phalanges of wrist.
profundus: + interosseous medial 4 - Flexion of all
membrane + post. fingers. joints of medial
border of ulna. 4 fingers.
3- Pronator From lower ¼ of Lower ¼ of Pronation of
quadratus: ant. surface of ulna ant. surface forearm.
of radius

Dr Ashraf Ramzy
 Flexor
pollicis
longus

Dr Ashraf Ramzy
 Flexor
digitorum
profundus
Dr Ashraf Ramzy
 Pronator
quadratus

Dr Ashraf Ramzy
Dr Ashraf Ramzy
Note
that
• The pisiform bone is considered as a
sesamoid bone within the tendon of flexor
carpi ulnaris .
• In the palm of the hand → the tendons of
flexor digitorum superficialis are pierced by
the corresponding tendons of the flexor
digitorum profundus muscle.
Dr Ashraf Ramzy
• The median nerve enters the forearm by
passing between the two heads of pronator
teres while ulnar nerve enters the forearm by
passing between two heads of flexor carpi
ulnaris .
• Palmaris longus: May be absent.

Dr Ashraf Ramzy
Palm of Hand

Dr Ashraf Ramzy
 Bones of Hand

* 8 carpal bones: arranged in 2 rows (4

proximal and 4 distal).

* 5 metacarpal bones numbered 1- 5

from lateral to medial.

* 3 phalanges / finger (but 2 in thumb).

Dr Ashraf Ramzy
S = Scaphoid
L = Lunate
4 3 2 1
T = Triquetrum
P = Pisiform
5
Tm = Trapezium
Td
Td = Trapezoid C Tm
H
C = Capitate
P
H = Hamate T L S

Ulna Radius
Palmar aspect

Dr Ashraf Ramzy
Dr Ashraf Ramzy
 Deep Fascia of Palm
Is modified
(thickened):
1- Over the wrist to form
the flexor retinaculum.

2- In the middle of the

palm to form the palmar
aponeurosis.

3- In the fingers to form

the fibrous flexor sheaths.
Dr Ashraf Ramzy
 Flexor
retinaculum
@ Definition: Thickening of
deep fascia bridging over the
front of carpus, thus
converting the carpal groove
to a carpal tunnel.
@ Attachments:
1- Med. --- pisiform & hook of
hamate.
2- Lat. --- Scaphoid &
Trapezium (where it splits into
2 laminae to form a special
compartment for flexor carpi
radialis). Dr Ashraf Ramzy
Structures superficial to
it: (from med. to lat.):
1- Ulnar Nerve.
2- Ulnar vessels.
3- Palmar cutaneous
branch of ulnar N.
4- Palmaris longus
tendon.
5- Palmar cutaneous
branch of median N.

Dr Ashraf Ramzy
* Structures deep to it (in carpal tunnel):

a- Median N.
b- Tendon of Flexor carpi radialis (& its
synovial sheath).
c- Tendon of Flexor pollicis longus (& its
synovial sheath called radial bursa).
d- 4 tendons of flexor digitorum
superficialis + 4 tendons of flexor
digitorum profundus (& its synovial
sheaths called ulnar bursa).

Dr Ashraf Ramzy
 Carpal tunnel syndrome
** Due to: Deposition of fat & fibrous tissue DEEP to
flexor retinaculum causing compression of Median
nerve.
** Results:
1- Weakness of muscles of the thenar eminence & the
lat. 2 lumbricals.
2- Tingling & sensory loss of the lat. 3½ fingers (but
the palm is spared since it is supplied by the palmar
branch of median N. which passes SUPERFICIAL to
the retinaculum).
** Treatment: Surgical division of the retinaculum.

Dr Ashraf Ramzy
Carpal tunnel syndrome

Dr Ashraf Ramzy
Attachments

Hamate Trapezium
Pisiform Scaphoid

1- Ulnar N.
2- Ulnar A. Special
3- Palmar branch compartment
of ulnar N. for FCR

4- Palmaris 123 4 5 6
longus
5- Palmar branch Tm
of median N. H

Dr Ashraf Ramzy
Structures deep to it

a
d b
e c

a- Median N.
b- Flexor carpi radialis (& its synovial sheath) in the special
compartment over trapezium.
c- Flexor pollicis longus (& its synovial sheath called radial bursa).
d- 4 tendons of flexor digitorum superficialis.
e- 4 tendons of flexor digitorum profundus.
(& synovial sheaths of d & e called ulnar bursa).
Dr Ashraf Ramzy
Dr Ashraf Ramzy
 Arrangement of FDS tendons

Dr Ashraf Ramzy
 Synovial Sheaths of Flexor Tendons

**Definition: These are tubular sacs which surround

the terminal parts of the tendons before its
insertion to provide a sort of lubrication for it.
** Each synovial flexor sheath is composed of 2 layers;
inner & outer layers separated by a thin film of fluid
to facilitate the movements of the tendons.
** There are 3 sheaths that surround the long flexors
of the different digits.
** All start 1- 1½ inches above flexor retinaculum.

Dr Ashraf Ramzy
Dr Ashraf Ramzy
**These synovial sheaths include:
1. Radial bursa: The synovial sheath that surrounds
the tendon of flexor pollicis longus. It continues
around the tendon till its insertion.
2. The sheath that surrounds the tendon of flexor
carpi radialis (extends till its insertion).
3. Ulnar bursa: This is a common synovial sheath
which surrounds the 8 tendons of flexor digitorum
superficialis & profundus. The sheath extends
distally on its medial side without interruption on
the tendons of the little finger as far as their
insertion (into the base of the distal phalanx).

Dr Ashraf Ramzy
 Palmar
aponeurosis

Shape:
Triangular with its apex
proximally & its base distally
Attachments:
1- Proximally: Flexor
retinaculum & palmaris
longus tendon.
2- Distally: It gives 4 slips to
the med. 4 fingers, (Each slip
divides into 2 processes).

Dr Ashraf Ramzy
N.B.: There is no 5th slip to the thumb to keep it
freely mobile.
3- Medially & laterally:
a. Continuous with the deep fascia covering
hypothenar & thenar eminences respectively.
b. Its margins send med. & lat. palmar septa
into the depth of the palm separating the
flexor tendons from hypothenar & thenar
eminences.

Dr Ashraf Ramzy
 Fibrous flexor sheath

2 Processes

Slip
BASE

Lateral &
Medial margins

Flexor retinaculum Apex

Palmaris longus tendon

Dr Ashraf Ramzy
Dr Ashraf Ramzy
Function:
1- It is firmly attached to the overlying skin, so it improves
the gripping of the objects.
2-Due to its toughness, it protects the underlying
structures such as:
a- Superficial palmar arch and its branches.
b- Tendons of long flexors & their synovial sheaths.
c- Terminal branches of the median and ulnar nerves.
3- The lateral and medial margins of the palmar
aponeurosis are continuous with the deep fascia
covering the muscles of the thenar and hypothenar
eminences respectively.
4-Each margin of the palmar aponeurosis sends a septum
into the depth of the palm known as lateral and medial
palmar septa, which are attached to the 1st & 5th
metacarpal bones respectively, separating the long flexor
tendons in the palm from the muscles of thenar and
hypothenar eminences. Dr Ashraf Ramzy
@ Function: Protection of underlying palmar VANs.

Dr Ashraf Ramzy
@ Clinical importance: Dupuytren’s contracture
A Progressive shortening of the medial part of the palmar
aponeurosis → Flexion deformity of the ring & little fingers.

Dr Ashraf Ramzy
 Fibrous flexor sheaths
** These are dense plates of fibrous tissue
which arch across the flexor tendons in
the fingers.
** They extend from the heads of the
metacarpal bones to the bases of the distal
phalanges just beyond the insertions of
the tendons.
** They are attached to the margins of the
phalanges. Each forms with the phalanges
an osteofibrous tunnel which is lined by a
synovial sheath lubricating the movement
of the tendon
Dr Ashraf Ramzy
 Fibrous flexor sheath

2 Processes

Slip
BASE

Lateral &
Medial margins

Flexor retinaculum Apex

Palmaris longus tendon

Dr Ashraf Ramzy
 Fascial Compartments of Palm
* The lateral and medial palmar septa divide the palm into 3
main fascial compartments;
1- Lateral compartment: contains the thenar muscles.
2- Medial compartment: contains the hypothenar muscles.

Dr Ashraf Ramzy
3- Intermediate compartment: lies deep to the palmar
aponeurosis & is divided by the intermediate palmar septum into:
a- Lateral part (thenar compartment): This contains:
1- Tendon of flexor pollicis longus.
2- Long flexor tendons of the index finger.
3- 1st lumbrical muscle.
4- Digital nerves and
vessels of the thumb
and radial side of the
index finger.

Dr Ashraf Ramzy
b- Mid-palmar compartment: This contains:
1- Long flexor tendons of the middle, ring and little fingers.
2- 2nd, 3rd and 4th lumbrical muscles.
3- Superficial palmar arch (& common palmar digital arteries).
4- Digital nerves and vessels of the little, ring, middle and the
medial side of the index fingers.
N.B.: The adductor pollicis muscle lies in a special compartment
(adductor compartment).

Dr Ashraf Ramzy
Dr Ashraf Ramzy
 Fascial Spaces of Palm

** There are potential spaces filled with

loose connective tissue. Their boundaries
may limit the spread of infection but deep
infections in the palm are usually not
confined to any particular space.
** Because the palmar fascia is strong &
thick, swellings from hand infections
usually appear on dorsum of hand, where
the fascia is thinner.

Dr Ashraf Ramzy
 Pulp space

* It is the space which lies over the palmar surface of

the distal ¾ of the terminal (distal) phalanx, just
distal to the insertion of the tendon of flexor
digitorum profundus.

** Boundaries:
1- Dorsally: the phalanx and its periosteum.
2- Ventrally: the deep fascia.
3- It is traversed by: strong fibrous septa which
divide it into separate loculi that contain
subcutaneous fat & by the terminal branch of the
digital artery to supply the distal phalanx.
Dr Ashraf Ramzy
** Clinical Significance:
1- Its infection leads to accumulation of
pus which causes thrombosis and
obstruction of the arteries inside the space
causing necrosis of the distal ¾ of the
terminal phalanx.
2- Its infection is very painful due to
accumulation of pus in narrow spaces
under tension.
3- To drain the pulp space, all loculi must
be opened by transverse incision.
Dr Ashraf Ramzy
Dr Ashraf Ramzy
Muscles of Hand

Dr Ashraf Ramzy
 Bones of Hand

* 8 carpal bones: arranged in 2 rows (4

proximal and 4 distal).

* 5 metacarpal bones numbered 1- 5

from lateral to medial.

* 3 phalanges / finger (but 2 in thumb).

Dr Ashraf Ramzy
S = Scaphoid
L = Lunate
4 3 2 1
T = Triquetrum
P = Pisiform
5
Tm = Trapezium
Td
Td = Trapezoid C Tm
H
C = Capitate
P
H = Hamate T L S

Ulna Radius
Palmar aspect

Dr Ashraf Ramzy
 Muscles of Hand
1. Short muscles of thumb:
a. Muscles of thenar eminence.
b. Adductor pollicis.
2. Short muscles of little finger:
a. Muscles of hypothenar eminence.
b. Palmaris brevis.
3. Small muscles of fingers:
a. 4 lumbrical muscles.
b. 4 Palmar interosseii.
c. 4 Dorsal interosseii.

Dr Ashraf Ramzy
 Muscles of Hand
3 Thenar muscles:
1- Externally: Abductor
pollicis brevis.
2- Internally: Flexor
pollicis brevis.
3- In between: Opponens
pollicis.
(N. supply: Median N.)
Dr Ashraf Ramzy
3 Hypothenar muscles:
1- Externally: Abductor
digiti minimi.
2- Internally: Flexor digiti
minimi.
3- In between: Opponens
digiti minimi.
(N. supply: Ulnar N.)
 Adductor
F pollicis
O O
Hypothenar A F A Thenar
eminence eminence

Dr Ashraf Ramzy
Thenar muscles

Hypothenar
muscles
Dr Ashraf Ramzy
Dr Ashraf Ramzy
Dr Ashraf Ramzy
 Palmaris brevis
**This is a thin sheet of
subcutaneous muscle which covers
the proximal part of the
hypothenar muscles.
** Origin: From the medial
margin of the palmar aponeurosis
and the flexor retinaculum.
** Insertion: Into the skin of the
medial (ulnar) border of the hand.
** Nerve supply: Superficial
terminal branch of ulnar nerve.
** Action: Deepening the hollow
of the palm to improve the grip of
the palm during holding a rounded
object.
Dr Ashraf Ramzy
 The lumbricals
Origin : Tendons of flexor
digitorum profundus
Insertion: Extensor expansion
of the medial 4 fingers
Action: Writing position 1 2 3 4
(flexion of MCPjs. &
extension of the IPjs.)
Shape & Nerve supply:
* L1 & L2: are unipennate
(median N.)
* L3 & L4: are bipennate (ulnar
N.)
Dr Ashraf Ramzy
 Tendon of flexor
digitorum profundus

2
4 1
3
Unipennate &
Bipennate &
supplied by
supplied by
median N.
ulnar N.
Dr Ashraf Ramzy
Dr Ashraf Ramzy
 1st & 2nd Ms are
unipennate & supplied
3rd & 4th ms. are by median N.
bipennate & supplied
by ulnar N.

Dr Ashraf Ramzy
 4 Palmar Interosseii Muscles
Shape: Unipennate.
Action: 1- Writing position.
2- Adduction (PAD) of fingers.
* Since the thumb has its own adductor
(adductor pollicis, the 1st palmar interosseous
muscle may be absent).
Nerve supply: Ulnar N.

Dr Ashraf Ramzy
Action:
3 or 4 Palmar
Adduction interosseii
(PAD)

3
4
2

±1
N. supply:
Ulnar N.

Dr Ashraf Ramzy
 3 or 4 Palmar
interosseii

N. supply:
Ulnar N.

Action:
Adduction (PAD)
Dr Ashraf Ramzy
Action:
Adduction (PAD)

N. supply:
Ulnar N.

Dr Ashraf Ramzy
 4 Dorsal Interosseii Muscles
Shape: bipennate.
Action: 1- Writing position.
2- Abduction (DAP).
Nerve supply: Ulnar N.

Dr Ashraf Ramzy
4 Dorsal interossei

Action:
Abduction (DAB)

N. supply: 2 3 4
Ulnar N. 1
Dr Ashraf Ramzy
 4 Dorsal interosseii

N. supply:
Ulnar N.

Action:
Abduction (DAB)
Dr Ashraf Ramzy
 Action:
Abduction (DAB)

N. supply:
Ulnar N.

Dr Ashraf Ramzy
Abductors Adductors

Dab Pad

Dr Ashraf Ramzy
 Nerve supply
** All Ms. are supplied by the Ulnar N.
except 5 (thenar eminence & 1st 2
lumbricals) which are supplied by Median
N.
** Thenar muscles include:
a. Thenar eminence (supplied by Median N.)
b. Adductor pollicis (supplied by Ulnar N.)

Dr Ashraf Ramzy