SURGICAL ANATOMY OF THE

HAND AND UPPER EXTREMITY

 SURGICAL ANATOMY OF THE
HAND AND UPPER EXTREMITY

JAMES R. DOYLE, M.D.

Emeritus Professor of Surgery (Orthopaedics)
John A. Burns School of Medicine
University of Hawaii
Honolulu, Hawaii
Editor-in-Chief
The Journal of Techniques in Hand
and Upper Extremity Surgery

MICHAEL J. BOTTE, M.D.

Co-Director
Hand and Microsurgery Service
Division of Orthopaedic Surgery
Scripps Clinic
La Jolla, California
Orthopaedic Surgery Service
San Diego VA Health Care System
Clinical Professor
Department of Orthopaedic Surgery
University of California, San Diego
School of Medicine
San Diego, California

Illustrated by Elizabeth Roselius

with contributions by Christy Krames
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© 2003 by LIPPINCOTT WILLIAMS & WILKINS

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Library of Congress Cataloging-in-Publication Data

Doyle, James R.
Surgical anatomy of the hand and upper extremity / James R. Doyle and Michael J. Botte.
p. ; cm.
Includes bibliographical references and index.
ISBN 0-397-51725-4
1. Hand—Anatomy. 2. Arm—Anatomy. I. Botte, Michael J. II. Title.
[DNLM: 1. Arm—anatomy & histology. 2. Hand—anatomy & histology. WE 805
D754s 2003]
QM 548 .D69 2003
611′.97—dc21
2002030007

Care has been taken to confirm the accuracy of the information presented and to describe generally
accepted practices. However, the authors and publisher are not responsible for errors or omissions or for any
consequences from application of the information in this book and make no warranty, expressed or implied,
with respect to the currency, completeness, or accuracy of the contents of the publication. Application of
this information in a particular situation remains the professional responsibility of the practitioner.
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this text are in accordance with current recommendations and practice at the time of publication. However,
in view of ongoing research, changes in government regulations, and the constant flow of information
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10 9 8 7 6 5 4 3 2 1
To Julie Kaye Frances and Robert E. Carroll, M.D., friends and mentors.

J.R.D.

To my mother, Verona Louise Minning-Botte, M.D., and

my father, Joseph Michael Botte, M.D.
For their love, encouragement, and support
and for being the best teachers that I ever had.

M.J.B.
 CONTENTS

Contributing Authors ix SECTION II: REGIONAL ANATOMY 295

Foreword by David P. Green xi
Preface xiii 5 Brachial Plexus 297
Vincent R. Hentz and Y. Mark Hong
SECTION I: SYSTEMS ANATOMY 1 6 Arm 315
7 Elbow 365
1 Skeletal Anatomy 3
8 Forearm
2 Muscle Anatomy 92
Part 1: Flexor Forearm 407
Appendix 2.1. Muscles of the Hand and Forearm
and Arm: Origin, Insertion, Action, and Part 2: Extensor Forearm 461
Innervation 180
9 Wrist 486
Appendix 2.2. Muscle Compartments and Fascial Richard A. Berger, James R. Doyle, and Michael J. Botte
Spaces of the Upper Extremity 183
10 Hand
Appendix 2.3. Human Forearm Muscle Difference
Index Values: A Comparison of Architectural Part 1: Palmar Hand 532
Features of Selected Skeletal Muscles of the Upper Part 2: Dorsal Hand 642
Extremity 184
3 Nerve Anatomy 185
Appendix: Anatomic Signs, Syndromes, Tests, and
Appendix 3.1. Dermatomes of the Upper
Eponyms 667
Extremity 226
4 Vascular Systems 237 Subject Index 693
 CONTRIBUTING AUTHORS

Richard A. Berger, M.D., Ph.D. Professor, Departments of Anatomy and Orthopaedic

Surgery, Mayo Clinic, Rochester, Minnesota

Vincent R. Hentz, M.D. Chief, Hand Division, and Professor of Functional Restora-
tion (Hand), Department of Surgery, Stanford University School of Medicine, Palo
Alto, California

Y. Mark Hong, B.S. Department of Surgery, Stanford University School of Medicine,

Palo Alto, California
 FOREWORD
The best surgeons are those well versed in anatomy. A sur-
geon can never learn too much anatomy, but up until now,
he or she had to go to many sources to glean a broad base of
anatomical knowledge. My own career illustrates this point.
As a medical student, I began with Gray’s massive and dry
tome, learning anatomy for the sake of anatomy, with no
clinical relevance. Then, as a resident, I discovered
Hollinshead’s three-volume text that added functional impli-
cations. I also found, at that time, Henry’s classic book with
its quaint Irish-English prose and manual mnemonics. As a
young surgeon, I sought out books that would give me quick,
snapshot glimpses of anatomy that I could memorize and
carry in my head at least until the next day in the operating
room. Grant’s Atlas was the first of these, which was later
replaced on my shelf by McMinn and Hutchings’ magnifi-
cent atlas with its lifelike-quality color plates. Specialized texts
such as Sunderland and Spinner have described wonderfully
detailed and precise anatomy, but with a limited focus.
Now the hand and upper extremity surgeon has what all
of the above resources offered and more, packed into a sin-
gle volume. The thoroughness of Gray, the practical appli-
cations of Hollinshead, and the clarity of McMinn and
Hutchings have been blended into one unified source.
More than sixty crisp photographic prints depict
detailed cadaver anatomy with a precision and clarity that
rivals McMinn. Most of the drawings were created by Eliz-
abeth Roselius, a master among contemporary medical
illustrators. The exceptionally high quality of these illustra-
tions is complemented by a text that is not only thorough,
but also replete with clinical applications.
Another pleasant surprise in this text is the appendix of
anatomic signs, syndromes, tests, and eponyms, where even
the surgeon who has studied the history of surgery will find
new or more accurate information. Practical lessons in the
Greek and Latin derivations of words explain why similar-
sounding words that evolve from separate sources have dif-
ferent meanings.
One of the authors, James R. Doyle, was the first to
describe in detail the flexor pulley system in the fingers
(1975) and later in the thumb (1977). Jim Doyle has stud-
ied the anatomy of the hand throughout his entire profes-
sional career with the eye of an artist who can perceive
details better than most of us, with an inherent tenacity fired
even harder during a fellowship year with Robert E. Carroll,
and with an exquisite and careful attention to detail. This
book is the culmination of his life-long dedication.
Michael Botte, his co-author, brings to this project the
thoroughness and precision of a true scientist, and his input
is significant. The collaboration of Doyle and Botte has pro-
duced a remarkable piece of work that will benefit not only
the entire surgical community, but our patients as well.
Every serious hand surgeon will find a readily accessible
spot on his or her bookshelf for this text.
David P. Green, M.D.
Clinical Professor
Department of Orthopaedics
University of Texas Health
Science Center at San Antonio
San Antonio, Texas
 PREFACE
Our goal has been to assemble between two covers a com-
prehensive collection of anatomical material designed to aid
the hand and upper extremity surgeon in the evaluation and
treatment of patients. A comprehensive knowledge of
anatomy is a major prerequisite for safe and effective
surgery. Although written by hand surgeons for hand sur-
geons, the authors believe that this text will also be useful to
hand therapists, anatomists, neurologists, neurosurgeons,
sports medicine surgeons and physicians, physiatrists, and
bioengineers because it is a compendium of anatomic
knowledge. The science of anatomy and the art of surgical
technique are intertwined topics that are not easily sepa-
rated. Although this book is not designed as a text on oper-
ative surgery, overlap with surgical technique is inevitable,
appropriate, and complementary to the goal of the book.
Although another anatomy textbook may seem redun-
dant, we hope the reader will agree that this text represents
a unique and current collection of material, which may not
be conveniently found elsewhere. Much of the information
can be found in other resources such as texts and journals
but we hope the reader, who like us has had difficulty recall-
ing where we found a particular bit of information that we
now need to review or utilize in a timely fashion, will come
to value this comprehensive resource. Our primary goal in
this text is to provide a readily available source for this
information that is user friendly, easily portable, and clini-
cally relevant.
We hope that the arrangement, clarity, and brief yet
comprehensive presentations of these topics will be of suffi-
cient uniqueness to earn the designation of original, but we
readily admit that paraphrasing and adoption of others’
original concepts have been used (although we have done
our best to give credit where it was due). The words of Ana-
tole France (passed on to us by Adrian Flatt) bear repetition
here, “When a thing has been said and said well, have no
scruples, take it and copy it.”
The text is divided into sections on Systems Anatomy
and Regional Anatomy, followed by an Appendix on
Anatomic Eponyms, Signs, Syndromes and Tests. The sec-
tion on Regional Anatomy represents the practical compo-
nent of this text because it provides the reader with
anatomic landmarks, relationships, surgical approaches,
clinical correlations, and the anatomy of selected anatomic
variations found in that region. The student of anatomy
will also recognize the immense value of the systems
approach, found in the section on Systems Anatomy, in
providing a comprehensive and overall view of a given
anatomic structure or system.
The authors take great pride in the color photographs of
fresh cadavers used in this text. A quote by Emanuel
Kaplan, about color photographs, from his foreword to
Milford’s 1968 classic monograph on Retaining Ligaments of
the Digits of the Hand seems appropriate here as well, “The
natural color illustrations add precision and eliminate the
imaginary interpretive creativity leading to error.” We hope
that the quality of our color photography can approach that
of Milford and warrant the affirmation of Kaplan on the
value of natural color photographs. We hope these color
photographs, along with the excellent illustrations, will
serve to make the anatomy in this text as realistic as possi-
ble. We also believe that the combination of these two art
forms along with the descriptive text will provide the reader
with appropriate information, which will permit accurate
preoperative evaluation, diagnosis, and effective surgical
treatment.
Anatomy, as a surgeon must deal with it, is three dimen-
sional, but only two dimensions can be portrayed in a text.
This fact should immediately indicate to the reader that
there is no substitute for personal experience in the dissec-
tion room. In a two-dimension text, structures are often
portrayed as lying side by side when in reality they may be
vertically arrayed. A good example is the usual depiction of
the radial and ulnar arteries in the proximal forearm. The
ulnar artery is depicted as lying to the ulnar side of the
radial artery in the same anatomic plane whereas, in reality,
the ulnar artery is deep and ulnar to the radial artery and is
often difficult to find. The reader should also note that the
anatomic variations included are those that the authors per-
ceive to have some practical clinical relevance to the region
and that the list of variations is not encyclopedic.
Reported differences in anatomy may be due to
anatomic variations as well as inter-observer variability and
subsequent interpretation of the observation. It would seem
reasonable to assume that all observers of a particular region
or segment of anatomy would see or observe the same
things and interpret what they saw in a similar uniform
fashion. Such is not the case, and although many points of
anatomy are agreed upon there are many that are not. Two
xiv Preface
illustrative examples come readily to mind: (1) the arcade of
Struthers’ in the arm and (2) the location of the sesamoid
bones about the MP joint of the thumb. Some authors
describe in detail the arcade of Struthers’ 8 cm above the
medial humeral epicondyle and attach clinical significance
to it as a potential site of ulnar nerve compression in the
arm. Others claim that it does not exist or at least that they
have never seen it and thus it has no clinical relevance. The
location of the ulnar and radial sesamoid bones about the
MP joint of the thumb have been reported to be in the
adductor pollicis and flexor pollicis brevis tendons respec-
tively or in the palmar plate where they possess articular car-
tilage and articulate with the thumb metacarpal; two
entirely different pictures of the same structures. Inter-
observer variability may be illustrated by the imperfect, yet
humorous, analogy of six blind persons examining a camel.
Each of their descriptions are based upon their particular
location about the camel. Their significant inter-observer
variation results in a series of descriptions that would con-
found even a camel veterinarian. The authors include them-
selves in those observers who may be subject to imperfect
observation as well as faulty interpretation. Thus, there may
be a lively correspondence and commentary generated by
this text.
We believe that studies that have large numbers of spec-
imens in their data base have a greater potential for reflect-
ing what might be considered more common and thus
likely to be encountered in the day to day practice of
surgery. Studies with small numbers of specimens in which
several patterns or categories of anatomical arrangement are
noted tell us that significant variation exists. It may not tell
us the true incidence of a given pattern or arrangement in
spite of the authors’ conscientious reporting of one, two, or
three cases in their series which demonstrated a particular
pattern or arrangement. Such studies though, are still
important and tell us that significant variation exists in that
particular structure or region and that the surgeon must be
prepared to encounter such an arrangement or even a new
and unreported pattern or arrangement.
By now, the reader has begun to appreciate the fact that
anatomy is not a “fixed” science, but rather an evolving or
developing endeavor with many remaining challenges and
opportunities.
All authors have their own methods for placing thoughts
on paper. This quote from Wallace Stegner1, although
directed at the writer of autobiography or fiction, seems
appropriate, “You take something that is important to you,
something you have brooded about. You try to see it as
clearly as you can, and to fix it in a transferable equivalent.
All you want in the finished print is the clean statement of
the lens, which is yourself, on the subject that has been
absorbing your attention.”
The authors wish to recognize their debt to those sur-
geons and anatomists who have studied and described their
anatomic findings in the upper extremity and to our many
mentors and colleagues who have taught, encouraged, and
inspired us.
Finally, the authors wish to acknowledge their debt to
Robert Hurley and Keith Donnellan of the editorial staff at
Lippincott Williams & Wilkins who have patiently guided
and encouraged us throughout this process in such a com-
petent and professional manner. We also owe a great debt to
Elizabeth Roselius, medical artist, for her understanding of
complex anatomic concepts and her ability to convert those
concepts into clear and concise drawings.
James R. Doyle, M.D.
Michael J. Botte, M.D.
1
Stegner WE, Where the bluebird sings to the lemonade springs. New
York: Random House, 1992.
 S E C T I O N

SYSTEMS ANATOMY
 1

SKELETAL ANATOMY
MICHAEL J. BOTTE

The skeletal anatomy of the upper limb is divided into the Ossification Centers
shoulder girdle, the arm, elbow, forearm, carpus, and
The clavicle begins to ossify earlier than any other part of
hand. The scapula, clavicle, and sternum comprise the
the skeleton (4,5). It has three ossification centers, two pri-
skeletal shoulder girdle. The mid-portion of the humerus
mary centers for the shaft and one secondary center for the
comprises the skeletal arm. The distal humerus and prox-
medial end (Fig. 1.1). The primary centers for the shaft
imal ulna and radius form the skeletal elbow. The radius
consist of a medial and a lateral center, both of which
and ulna and associated soft tissues comprise the skeletal
appear during the fifth or sixth week of fetal life. The cen-
forearm. The carpus consists of the distal radius and ulna
ters fuse to each other approximately 1 week later. The sec-
along with the eight carpal bones: the scaphoid, lunate,
ondary ossification center is located at the sternal end of the
capitate, trapezium, trapezoid, triquetrum, hamate, and
clavicle and first appears approximately the eighteenth or
pisiform. The hand contains 19 bones: 5 metacarpals, 5
twentieth year, usually about 2 years earlier in women. The
proximal phalanges, 4 middle phalanges, and 5 distal pha-
secondary center unites with the remaining portion of the
langes.
clavicle at approximately the twenty-fifth year. An acromial
The skeleton of the upper limb is attached relatively
secondary center sometimes develops at 18 to 20 years of
loosely to the trunk. The clavicle provides the only direct
age, but it usually is small and fuses rapidly with the shaft
skeletal connection of the upper limb to the axial skeleton,
(2,6).
articulating through the sternoclavicular joint. The upper
The clavicle does not ossify in quite the normal manner
limb is substantially stabilized to the thorax by muscles of
of endochondral ossification, as occurs in most of the skele-
the soft tissue scapulothoracic articulation. This relatively
ton. Although the medial and lateral ends of the clavicle do
loose attachment maximizes upper limb mobility and flexi-
undergo endochondral ossification, the mid-portion is
bility, allowing rotation and translation of the scapula on
formed by a process that shares features of both endochon-
the thorax. The loose connection of the upper limb to the
dral and intramembranous ossification. The clavicle is pre-
trunk is in contrast to the lower extremity, where the major-
formed of cartilage in embryonic life, but does not proceed
ity of the stabilization is through the skeletal connection of
with endochondral ossification in the conventional manner.
the hip joint.
Instead, the cartilage model simply serves as a surface for the
In the following sections, each bone and associated
deposition of bone by connective tissues. Eventually, the car-
joint of the upper limb is discussed. The ossification cen-
tilage is resorbed and the clavicle becomes fully ossified
ters, descriptive osteology, articulations, muscle attach-
(7–10). [The process is shared by the mandible. The remain-
ments, and clinical implications are discussed. Osseous
ing long bones of the upper extremity are formed by con-
anomalies or variations, when significant, are described as
ventional endochondral ossification (7).]
well.

Osteology of the Clavicle

CLAVICLE
Derivation and Terminology
The clavicle derives its name from the Latin clavis, meaning
“key” (1–3). The plural of clavicle is claviculae (1,3). The
clavicle has been referred to alternatively as the clavicula.
Clavicular indicates “relating to the clavicle” (1,3).
The clavicle is a curved, roughly “S”-shaped long bone that
lies subcutaneously along the anterolateral base of the neck.
When viewed from its superior side, the clavicle shape
resembles the letter “F,” with the concavity of the medial
curve being directed posteriorly, and the concavity of the
lateral portion directed anteriorly (Figs. 1.2 and 1.3). It
4 Systems Anatomy
forms the most anterior portion of the shoulder girdle, and
is subcutaneous along its entire course. It is directed nearly
horizontally toward the acromion of the scapula, located
immediately superior to the first rib.
The clavicle consists of cancellous bone surrounded by
cortical bone (see Figs. 1.2 and 1.3). The cortical bone is
thicker in the intermediate or shaft portion, and relatively
thin at the acromial and sternal ends. The clavicle is unique
in that, unlike most other long bones, it usually has no
medullary cavity (5). This is related to its unique form of
ossification, which consists of both endochondral and
intramembranous ossification.
The clavicle has specific differences in men and women
and can be used to determine sex of a skeleton or specimen.
The clavicle in general is shorter, thinner, less curved, and
smoother in women than in men. Midshaft circumference
of the clavicle is a reliable single indicator of sex, especially
combined with the bone weight and length (11,12). In per-
sons who perform heavy manual labor, the clavicle becomes
thicker and more curved, and its ridges become more dis-
tinct for muscular attachment.
For its descriptive osteology, the clavicle is discussed here
from lateral to medial, beginning with the acromial portion
and moving to the lateral one-third, medial two-thirds, and
the sternal portion.
Acromial Portion of the Clavicle
The most laterally positioned part of the clavicle the acro-
mial portion, which contains the articulation for the
FIGURE 1.2. Right clavicle, superior surface, showing muscle origins (red) and insertions (blue).
FIGURE 1.1. Illustration of right clavicle show-
ing the three centers of ossification. There are
two primary centers (medial and lateral) for the
shaft and one secondary center for the medial
end.
acromion of the scapula and the associated attachments
of the acromial clavicular ligaments. The acromial por-
tion of the clavicle is somewhat flattened and is wider
compared with the mid-portions. The superior surface is
flat, with a rough ridge along the posterosuperior por-
tion. The anterior surface of the acromial portion is con-
cave and smooth, the posterior surface convex and
smooth, and the inferior somewhat convex and rough.
On the inferior surface, there are multiple small foramina
for nutrient vessels. The articular surface is oval and
directed obliquely and inferiorly. The rim of the articular
margin is rough, especially superiorly, for attachment of
the thick acromioclavicular ligaments. The acromial por-
tion of the clavicle projects slightly superiorly to the
acromion of the scapula. The acromioclavicular joint is
palpable approximately 3 cm medial to the lateral border
of the acromion.
Lateral Third of the Clavicle
The lateral third of the clavicle is wider and flatter than the
more medial portion. This portion has distinct superior,
inferior, anterior, and posterior surfaces. The superior and
inferior surfaces are flat. The posterior surface is rounded,
convex, and slightly thickened. The anterior surface is
mildly concave, and becomes wider and rough in the most
lateral portion as it approaches the acromion. The posterior
and anterior portions have roughened areas for the attach-
ment of the trapezius and deltoid muscles, respectively. On
its inferior surface in the lateral third, there is the conoid

FIGURE 1.3. Right clavicle, inferior surface, showing muscle origins (red) and insertions (blue).
tubercle for attachment of the conoid ligament (the medial
portion of the coracoclavicular ligament). Lateral to the
conoid tubercle is the trapezoid line, an oblique line on the
undersurface for attachment of the trapezoid ligament
(which is the lateral portion of the coracoclavicular liga-
ment).
Medial Two-Thirds of the Clavicle
The medial two-thirds of the clavicle is more rounded than
the sternal end or the lateral thirds, and becomes slightly
wider from lateral to medial. Anteriorly, the surface is
straight or curved with a mild convexity. Along this anterior
surface is the large origin of the clavicular head of the pec-
toralis major.
The posterior border of the clavicle in the medial two-
thirds is smooth and concave, and oriented toward the base
of the neck. The posterior border widens as it approaches the
sternum. Posteriorly and inferiorly, there is the small attach-
ment area for the origin of the sternohyoid muscle, which
extends into the sternal region. Also along the posterior bor-
der, on the superior margin, is the area of origin of the stern-
ocleidomastoid muscle. On the posterior border of the infe-
rior surface of the lateral two-thirds is a rough tubercle, the
conoid tubercle, for attachment of the conoid ligament.
From the conoid tubercle to the costal tuberosity (see later),
there is a large attachment area for the insertion of the sub-
clavius muscle. This surface also gives attachment to a layer
of cervical fascia, which envelops the omohyoid muscle.
In the medial portion of the medial two-thirds, the clav-
icle becomes slightly wider and thicker, especially when
viewed from above or below. In this medial portion, the
clavicle is rougher both anteriorly and posteriorly. On the
inferior surface of the medial clavicle extending into the
sternal portion is a delineated long roughened area, the
costal tuberosity, which is approximately 2 cm in length.
The costoclavicular ligament attaches in this area. The rest
of the area is occupied by a groove, which gives attachment
to the subclavius muscle. The clavipectoral fascia, which
1 Skeletal Anatomy 5
splits to enclose the subclavius muscle, is attached to the
margins of the groove.
The brachial plexus is located deep to the mid-portion of
the clavicle. The mid-portion of the clavicle is formed by
the intersection of two curves of the bone, anteriorly con-
vex on the lateral portion, and anteriorly concave in the
medial portion. At the junction of these two curves, the
clavicle overlies the divisions of the brachial plexus and the
subclavian vessels.
Sternal Portion of the Clavicle
At the sternal end, the clavicle becomes wider at the mid-
portion, but not in general as wide as the acromial end. The
relative widths of the bone can be used for easy determina-
tion between the sternal and acromial ends. As the sternal
end flares out, it becomes rough and more irregular. The
sternal end usually is easily palpable.
The sternal portion contains a sternal articular surface
for the manubrium of the sternum. The sternoclavicular
joint contains the articular disc. There is a triangular surface
for articulation with the cartilage of the first rib in this area
on the inferior surface of the clavicle. Surrounding the artic-
ular surfaces is a rim that is roughened for the attachments
of the sternoclavicular and costoclavicular ligaments. The
sternal end of the clavicle lies slightly above the level of the
manubrium and hence usually is palpable. This area is cov-
ered by the sternal end of the sternocleidomastoid muscle.
On the inferior surface of the sternal portion there is a
rough, raised ridge, the costal tuberosity, which extends into
the medial third of the clavicle (see earlier). The costoclav-
icular ligament attaches to the costal tuberosity.
Associated Joints
The clavicle articulates with the acromion of the scapula lat-
erally (acromioclavicular joint), and with the manubrium of
the sternum and cartilage of the first rib medially (stern-
oclavicular joint; Fig. 1.4).
6 Systems Anatomy
The acromioclavicular joint between the lateral end of
the clavicle and the acromion of the scapula is stabilized by
several structures: the acromioclavicular ligaments, coraco-
clavicular ligament, and joint capsule.
The acromioclavicular ligament crosses the acromioclav-
icular joint, most developed on the superior portion of the
joint. The ligament is oriented along the axis of the clavicle.
It attaches to the roughened areas on the adjacent ends of
the clavicle and acromion.
The coracoclavicular ligament stabilizes the acromioclav-
icular joint by anchoring the clavicle to the coracoid of the
scapula. It is more efficient in stabilizing the acromioclavic-
ular joint than the acromioclavicular ligaments, even
though it does not cross the joint. It consists of two parts:
the trapezoid ligament (located laterally) and the conoid lig-
ament (located medially).
The trapezoid ligament, as its name implies, is quadran-
gular or trapezoid in shape. It is broad and thin, and crosses
from the upper coracoid surface to the trapezoid line on the
inferior surface of the clavicle. It follows an oblique or
almost horizontal direction, ascending laterally as it crosses
from the coracoid process to the clavicle above.
The conoid ligament, located medial and slightly poste-
rior to the trapezoid ligament, attaches from the root of the
coracoid process in front of the scapular notch, and ascends
superiorly to attach to the conoid tubercle of the undersur-
face of the lateral clavicle. It is a dense ligament, roughly tri-
angular in shape.
At the sternal articulation, the sternoclavicular joint is
located at the superior portion of the manubrium. The
first costal cartilage is located inferior to the sternoclavic-
ular joint. The inferior surface of the medial end of the
clavicle articulates with a small portion of the first costal
cartilage.
FIGURE 1.4. Superior portion of ante-
rior manubrium showing medial clavi-
cles and sternoclavicular joints.
The sternoclavicular articulation involves the medial end
of the clavicle, which articulates with both the sternum (at
the sternoclavicular or clavicular notch) as well at the adja-
cent superior surface of the first costal cartilage. An articu-
lar disc composed of fibrocartilage lies between the end of
the clavicle and the sternum. The medial end of the clavicle
is convex vertically but slightly concave anteroposteriorly,
and therefore the shape often is described as “sellar” (per-
taining to a saddle, saddle-shaped) (1,3).
The articular disc of the sternoclavicular joint is flat and
generally circular, attached superiorly to the superoposterior
border of the clavicular articular surface (see Fig. 1.4.). The
disc is centrally interposed between the articulating surfaces
of the clavicle and sternum, and divides the joint into two
cavities, each of which is lined with synovial membrane.
The articular disc is thicker peripherally and in the supero-
posterior portion. The disc is attached inferiorly to the first
costal cartilage near its sternal junction. In the remaining
portion of the disc’s circumference, it is attached to the joint
capsule of the sternoclavicular joint. Most of the motion at
the sternoclavicular joint occurs between the articular disc
and the clavicle, with less movement occurring between the
articular disc and the sternum (5).
The ligaments and soft tissues that stabilize the stern-
oclavicular joint include the joint capsule, the anterior ster-
noclavicular ligament, the posterior sternoclavicular liga-
ment, the interclavicular ligament, and the costoclavicular
ligament (4,5) (see Fig. 1.4).
The joint capsule lies deep to the ligaments, and com-
pletely surrounds the articulation. The stability of the joint
is shared by the joint capsule and the associated ligaments.
The joint capsule varies in thickness and strength. The ante-
rior and posterior portions usually are thicker and stronger,
reinforced by the anterior and posterior sternoclavicular lig-

aments. The joint capsule is reinforced by the interclavicu-
lar ligament superiorly. The inferior portion of the stern-
oclavicular joint capsule is thin, and resembles areolar tissue
(4).
The anterior sternoclavicular ligament is broad and cov-
ers the anterior portion of the sternoclavicular joint (see Fig.
1.4). It is attached superiorly to the upper and anterior por-
tion of the medial end of the clavicle. The ligament passes
obliquely downward and medial from the clavicle to the
sternum. The ligament attaches to the superior part of the
manubrium. The sternocleidomastoid muscle passes over
the anterior sternoclavicular ligament. The joint capsule
and articular disc lie posterior to the anterior sternoclavicu-
lar ligament.
The posterior sternoclavicular ligament also is broad,
similar to the anterior sternoclavicular ligament. The liga-
ment spans the posterior portion of the sternoclavicular
joint, attached to the superior portion of the medial end of
the clavicle. It passes obliquely inferiorly and medially (sim-
ilar to the anterior sternoclavicular ligament), to attach infe-
riorly to the dorsal portion of the superior manubrium. The
articular disc and synovial membranes of the sternoclavicu-
lar joint lie anteriorly. The sternohyoid and the sternothy-
roid muscles lie posteriorly.
The interclavicular ligament connects the medial ends
of the two clavicles and is attached to the superior border of
the manubrium. The ligament spans from one clavicle
to the other, stretching along the superior border of the
manubrium. It is of variable size between individuals and
forms the floor of the jugular notch (see Fig. 1.4). Anterior
to the interclavicular ligament is the sternocleidomastoid
muscle. Dorsal to the ligament are the sternohyoids. The
interclavicular ligament adds considerable strength to the
superior portion of the sternoclavicular joint capsule.
The costoclavicular ligament is located at the inferior bor-
der of the medial end of the clavicle, outside of and just lateral
to the joint capsule (see Fig. 1.4). It helps stabilize the medial
end of the clavicle to the superior portion of the medial part
of the cartilage of the first rib. The ligament has an oblique
orientation, extending medially and inferiorly from the infer-
omedial clavicle to reach the superior portion of the costal car-
tilage. The clavicle has a slight ridge on its inferomedial end,
the costal tuberosity, to which the costoclavicular ligament
attaches. Anterior to the costoclavicular ligament lies the ten-
don of the origin of the subclavius muscle. Posterior to the
costoclavicular ligament is the subclavian vein.
Muscle Origins and Insertions
Muscle attachments to the clavicle include the trapezius,
pectoralis major, deltoid, sternocleidomastoid, subclavius,
and sternohyoid (see Figs. 1.2 and 1.3). The trapezius
inserts onto the superolateral shaft. The clavicular head of
the pectoralis major originates from the anteromedial por-
1 Skeletal Anatomy 7
tion of the shaft. The deltoid originates from the anterolat-
eral portion of the shaft. The sternocleidomastoid muscle
originates from the superomedial portion of the shaft. The
subclavius inserts onto the inferior surface of the middle
third of the shaft. The sternohyoid originates from the
inferomedial surface (2,4,5).
Clinical Correlations: Clavicle
Relationship to the Brachial Plexus
The mid-portion of the clavicle lies approximately over the
divisions of the brachial plexus. The clavicle is an important
bony landmark in planning incisions for supraclavicular or
infraclavicular brachial plexus exploration. It is a useful
landmark in the orientation and identification of structures
in brachial plexus. Although rare, neurovascular compres-
sion of the brachial plexus can occur with clavicular frac-
tures (13).
Clavicle Shaft Fractures
The clavicle is one of the most commonly fractured bones
(14). Fractures most often occur at the junction of the lat-
eral one-third and medial two-thirds, its weakest portion
(5,15,15a). The distal portion usually is displaced inferiorly,
in part because of the weight of the shoulder. The proximal
portion is displaced little. Nonunion is rare, but usually
occurs in the middle third (16). The clavicle commonly is
injured because of its subcutaneous location.
Neer Classification of Distal Clavicle Fractures
n Type 1: A nondisplaced, nonarticular fracture of the dis-
tal clavicle, with the acromioclavicular joint and liga-
ments intact.
n Type 2: A displaced fracture of the distal clavicle that is
interligamentous (fracture extends between the conoid
ligament medially and trapezoid ligament laterally). The
conoid ligament is torn, the trapezoid ligament remains
attached to the distal segment, and the medial segment is
displaced superiorly (due to loss of the conoid ligament).
The distal fragment remains aligned to the acromioclav-
icular joint (due to stabilization of intact trapezoid liga-
ment).
n Type 3: An intraarticular fracture of the distal clavicle
that is lateral to the coracoclavicular ligaments. There is
no displacement because the ligaments are intact
(17–19).
Acromioclavicular Separation
Injury at the acromioclavicular joint (AC separation) has
been classified by several descriptions. One of the most
8 Systems Anatomy
widely used classifications divides the injury into three
types. Type I is a partial tear of the ligaments, involves no
joint subluxation, and usually is treated symptomatically.
There is minimal widening (if any) of the acromioclavic-
ular joint space, which normally measures 0.3 to 0.8 cm.
Type II involves a more extensive but incomplete tear,
with partial subluxation seen radiographically. Widening
of the acromioclavicular joint or bone surfaces can be 1 to
1.5 cm. There usually is an associated increase in the cora-
coclavicular distance by 25% to 50%. Treatment also is
symptomatic, often with shoulder support with an immo-
bilizing device. Type III is a complete disruption of the
ligaments with dislocation of the clavicle from the
acromion. There is marked widening of the acromioclav-
icular joint, usually greater than 1.5 cm. It often is treated
surgically with internal fixation and repair or reconstruc-
tion of the ligaments (17). Recently, these injuries have
been classified into six types (20–22). Types I, II, and III
are similar to the traditional classification system. A type
IV injury is rare, and involves posterior dislocation of the
distal end of the clavicle. The clavicle is displaced into or
through the trapezius muscle. Shoulder motion therefore
usually is more painful than with the type III injury. The
type V injury is an exaggeration of type III in which the
distal end of the clavicle appears to be grossly displaced
superiorly toward the base of the neck. The apparent
upward displacement is the result of the downward dis-
placement of the upper extremity. There is more extensive
stripping of soft tissues of the clavicle and the patient usu-
ally has more pain than in the type III injury. The type VI
injury involves a subcoracoid dislocation of the distal clav-
icle. There is an inferior dislocation of the distal clavicle
(inferior to the coracoid process) and posterior to the
biceps and coracobrachialis tendons. Because of the
amount of trauma required to produce a subcoracoid dis-
location of the clavicle, there may be associated fractures
of the clavicle and upper ribs or injury to the upper roots
of the brachial plexus. Management of types IV, V, and VI
usually involves operative repair/reconstruction (20–22).
Type III injuries have been further divided into additional
variants, including those in children and adolescents
involving a Salter type I or II fracture through the physis
of the distal clavicle, or a complete separation of the
acromioclavicular articular surfaces combined with a frac-
ture of the coracoid process (22).
Sternoclavicular Separation
Sternoclavicular separation is rare compared with AC sepa-
ration. Posterior dislocations may cause pressure on the
great vessels or airway located posterior to the joint. Com-
puted axial tomography is helpful in determining the direc-
tion of subluxation/dislocation. Reduction of the posterior
dislocation is safest in the operating room in the presence of
a general or thoracic surgeon if damage has occurred or is
discovered involving the vessels or airway.
Posttraumatic Osteolysis of the Distal Clavicle
After injury to the shoulder, such as a type I injury to the
acromioclavicular joint, resorption of the distal end of the
clavicle occasionally may occur. The osteolytic process,
which is associated with mild to moderate pain, usually
begins within 2 months after the injury. Initial radiographs
show soft tissue swelling and periarticular osteoporosis. In
its late stage, resorption of the distal end of the clavicle
results in marked widening of the acromioclavicular joint
(17).
Cleidocranial Dysostosis
Cleidocranial dysostosis is a partial or complete absence of
the clavicle. It is associated with abnormal ossification of
the skull bones (23). Patients with congenital absence of the
clavicle have shown little or no limb dysfunction; however,
after clavicular excision (for trauma or tumor), noted find-
ings have included weakness, drooping of the shoulder, and
loss of motion (15,19,24).
Clavicular Dysostosis
Clavicular dysostosis is a result of incomplete union of the
two ossification centers of the clavicle (23).
SCAPULA
Derivation and Terminology
The scapula derives its name from the Greek for “spade”
(1,3). The plural of scapula is scapulae (1). Graves’ scapula
indicates a scapula in which the vertebral border is concave.
Scaphoid scapula indicates a scapula in which the vertebral
border is concave (same as Graves’ scapula). Winged scapula
indicates a scapula that is positioned with the vertebral bor-
der prominent (1).
Ossification Centers and Accessory Bones
The scapula has seven to eight ossification centers: one for
the body, two for the coracoid process, two for the
acromion, one for the medial (vertebral) border, and one for
the inferior angle (Fig. 1.5). Additional centers may be pre-
sent to help form the inferior and superior portions of the
glenoid cavity (4,5).
The body begins to ossify at approximately the second
month of fetal life, forming an irregular quadrilateral plate
of bone near the scapular neck, adjacent to the glenoid cav-
ity. The plate extends to form the major part of the scapula.

The spine extends up from the dorsal surface of this plate
approximately the third month of fetal life. At birth, the
major part of the scapula is osseous. The glenoid cavity,
coracoid process, the acromion, and the vertebral border
and inferior angle remain cartilaginous at birth. An ossifi-
cation center appears in the middle of the coracoid process
during the first year after birth. This ossification center
joins the rest of the scapula at approximately the fifteenth
year. Between the fourteenth and twentieth years, ossifica-
tion of the remaining parts of the scapula takes place in
quick succession. Ossification of these parts occurs in the
following order: the base of the coracoid process, the base of
the acromion, the ossification centers in the inferior angle
and adjacent part of the medial border, the tip or lateral
portion of the acromion, and the remainder of the medial
border (2,4,5).
The base of the acromion is formed from three or four
ossification centers. It is partially formed by an extension
from the spine of the scapula (from the ossification center
of the body), and partially from the two centers of the
acromion (which previously have united to each other). The
tip of the coracoid process may develop a separate ossifica-
1 Skeletal Anatomy 9
FIGURE 1.5. Illustration of right scapula showing sev-
eral centers of ossification. The scapula may have
seven to eight (or more) ossification centers: one for
the body, two for the coracoid process, two for the
acromion, one for the medial (vertebral) border, and
one for the inferior angle. Additional centers may be
present to help form the inferior and superior por-
tions of the glenoid cavity.
tion center. These various centers join the body by the
twenty-fifth year. Persistence of an ossification center of the
acromion that does not fuse with the others or with the
scapula can present as an accessory bone, the os acromiale.
An os acromiale usually is located at the lateral margin of
the acromion, is of variable size and shape, and usually is
bilateral (25). It also is possible for the os acromiale to exist
as a small accessory ossicle directly above the greater
tuberosity of the humerus. This ossicle is separated from the
acromion by approximately 1 cm, and usually is somewhat
circular in shape.
The superior third of the glenoid cavity may be ossified
from a separate center, or may ossify from an extension of
the center at the base of the coracoid. When ossification is
from a separate center, the center usually ossifies between
the tenth and eleventh years. This superior portion of the
glenoid then joins the rest of the scapula between the six-
teenth and eighteenth years. An epiphyseal plate or crescen-
tic epiphysis also may appear for the lower part of the gle-
noid cavity, which is thicker peripherally. This rim converts
the flat cavity into the gently concave fossa that is present in
the adult glenoid (2,4,5).
10 Systems Anatomy
Osteology of the Scapula
The scapula is a large, flat, triangular bone that spans the
dorsal aspect of the second through seventh ribs (Figs. 1.6
to 1.8). Its synovial articulations include those with the
humerus and the clavicle. In addition, the scapula is stabi-
lized to the dorsal surface of the thorax by muscle, forming
the scapulothoracic articulation.
The main processes (acromion, coracoid, and subchon-
dral portions of the glenoid) as well as the thicker portions
of the body contain trabecular bone (see Figs. 1.6 to 1.8).
The remaining portions generally consist of thin cortical
bone. The central portions of the supraspinous fossa and
most of the infraspinous fossa consist of thin cortical bone.
Occasionally the bone is so thin that it may appear translu-
FIGURE 1.6. Right scapula, anterior surface, showing muscle origins (red) and insertions (blue).
cent or may have areas that are incompletely ossified, being
filled with connective tissue.
Osteology measurements are given in Figure 1.9 and
Table 1.1. The mean length of the scapulae from the supe-
rior angle to the inferior angle is 15.5 cm. The width of the
scapula from the medial border to either the superior or
inferior rim of the glenoid is approximately 10.6 cm. The
scapula is significantly larger in men than women (26)
(Table 1.1).
For descriptive osteology, the scapula has two surfaces,
the costal (anterior) and the dorsal (posterior). It contains
the process of the acromion, the coracoid, and the spine. It
has three borders: superior, medial (or vertebral), and lateral
(or axillary). It has three angles: inferior, superior, and lat-
eral (26,27).

Surfaces of the Scapula
The costal surface forms the large subscapular fossa, a
slightly concave surface for the origin of the subscapularis
(see Fig. 1.6). The medial two-thirds of the subscapular
fossa is roughened, with ridges that course laterally and
superiorly. These ridges give origin to tendinous attach-
ments of the subscapularis. Along the medial border of the
costal surface is a long, thin rim that provides the insertion
of the serratus anterior.
The dorsal surface is slightly convex from superior to
inferior. It contains the two fossae for the supraspinatus and
infraspinatus, separated by the prominent spine of the
scapula. The supraspinatus fossa, which is much smaller
than the infraspinatus, is smooth, concave, and broader at
its medial aspect than its lateral border. It is bordered by the
spine inferiorly, the coracoid process laterally, and the supe-
rior and medial rim of the scapula superiorly and medially,
respectively. The supraspinatus muscle originates from the
medial two-thirds of the fossa (see Fig. 1.7).
The infraspinatus fossa is approximately three times
larger than the supraspinatus fossa. It has a slight concavity
1 Skeletal Anatomy 11
FIGURE 1.7. Right scapula, posterior sur-
face, showing muscle origins (red) and
insertions (blue).
superiorly to inferiorly, especially along the medial border.
There is a slight convexity throughout its central portion,
and a deep groove near the axillary border. The attachments
of the infraspinatus are located on the lateral third of the
fossa (see Fig. 1.7).
There is a slight bony ridge that runs along the lateral
border of the dorsal surface of the scapula. The ridge runs
from the lower part of the glenoid cavity, downward and
backward to the medial border, to an area approximately 2
to 3 cm superior to the tip of the inferior angle. This ridge
serves for the attachment of a fibrous septum that separates
the infraspinatus from the teres major and teres minor. The
surface between the ridge and the lateral border is narrow in
the superior two-thirds. In this area, the ridge is crossed
near its center by a groove that contains the circumflex
scapular vessels. This ridge provides attachment for the teres
minor superiorly and for the teres major inferiorly. The area
of origin of the teres major is broader and somewhat trian-
gular. The latissimus dorsi muscle glides over the lower
region, and frequently a few muscle fibers arise at the infe-
rior angle of the scapula. The teres muscles are separated
from each other by a fibrous septum that extends along an
12 Systems Anatomy
oblique line from the lateral border of the scapula to an ele-
vated ridge (2,4,5).
Processes of the Scapula
The scapula has three main processes: the acromion, the
coracoid process, and the spine of the scapula (see Figs. 1.6
to 1.9).
The acromion is a lateral extension of the spine. The
process becomes flattened as it extends laterally, overhang-
ing the glenoid, and forms the most superior portion or
“summit” of the scapula (see Fig. 1.9A–E). The shape is
variable, with a flat configuration in 23%, curved in 63%,
and hook-shaped in 14% (26). The mean length of the
acromion in the anteroposterior plane is 4.8 cm. The mean
width of the acromion in the mediolateral plane is 2.19 cm,
and the mean thickness is 9.4 mm. The narrowest portion
forms a neck, the diameter of which is 1.35 cm (26) (Table
1.1). The acromion is located an average distance of 16 mm
from the glenoid (26). The superior surface is rough and
FIGURE 1.8. Right scapula, lateral view,
showing glenoid cavity and profile of cora-
coid process, acromion, and body.
convex and provides attachment for the thick acromioclav-
icular ligaments and a portion of the deltoid muscle. The
remaining portions are subcutaneous and smooth. The
inferior surface of the acromion is smooth and concave. The
lateral border is thick and irregular and usually has three or
four tubercles for the tendinous origins of the deltoid mus-
cle. The medial border is shorter than the lateral and con-
cave. In this area, the acromion provides a portion of the
attachment of the trapezius muscle. On this medial border,
there is a small oval area of articular cartilage for articulation
with the acromial end of the clavicle. The apex of the
acromion is a small area where the medial and lateral bor-
ders intersect. In this area, the coracoacromial ligaments
form their attachment. Inferiorly, where the lateral border
of the acromion becomes continuous with the lower border
of the crest of the spine, the acromial angle is located. The
acromial angle can be palpated subcutaneously and used as
a landmark.
The coracoid process is a thick, curved projection of
bone that projects anteriorly, superiorly, and medially from
A B

C D
FIGURE 1.9. A: Anterior view of the right scapula showing the standard terminology of the
anatomic regions. B: Posterior view of the right scapula showing terminology and general mea-
surements. The measurements include [1] the maximum length of the scapula; [2] the width of the
scapula measured to the posterior rim of the glenoid; [3] the width of the scapula measured to the
anterior rim of the glenoid (also shown in Fig. 1-9C); [4] the inferior scapular angle; [5] the antero-
posterior thickness of the medial border of the scapula measured halfway along the medial edge
of the scapula and 1 cm from the edge; and [6] the distance from the superior rim of the glenoid
to the base of the suprascapular notch. The measurement values are shown in Table 1.1. C: The
right scapula (superior view as shown in the inset) showing the measurement of the spine. The
measurements include [7] the length of the scapular spine measured from the medial edge of the
scapula where it meets with the scapular spine to the lateral edge of the acromion; [8] the distance
from the medial edge of the scapula where it meets with the scapular spine to the edge of the spin-
oglenoid notch; [9] the anteroposterior width of the spine measured 1 cm from the medial edge
of the scapula; [10] the anteroposterior width of the spine measured 4 cm from the medial edge
of the scapula; [11] the anteroposterior width of the spine at the lateral edge (spinoglenoid notch);
and [12] the anteroposterior thickness of the acromial neck at its thinnest diameter. Also shown is
measurement [3], which is the width of the scapula measured on the anterior surface. The mea-
surement values are shown in Table 1.1. D: Scapular measurements of the length [13], width [14],
and thickness [15] of the acromion, and the coracoacromial distance [16], as seen from the superior
view of the right scapula. The measurement values are shown in Table 1.1.
(continued on next page)
 14 Systems Anatomy

E F

FIGURE 1.9. (continued) E: Lateral view of the right scapula, showing the
coracoacromial distance [16], the minimal distance between coracoid and
acromion [17], and the dimensions of the glenoid fossa [18–20]. The measure-
ment values are shown in Table 1.1. F: Measurements of the thickness of the
scapular head [21,22] and glenoid tilt angle [23] as seen from the inferior view
of the right scapula. The measurement values are shown in Table 1.1. G: Dimen-
sions of the coracoid process of the right scapula as seen from the anterior
view. Measurements include the length of the coracoid from the tip of the
coracoid to the point at which the coracoid angulates inferiorly [24]; the cora-
coid thickness measured in the superoinferior direction 1 cm from the tip of the
coracoid [25]; and the distance from the tip of the coracoid to the base of the
suprascapular notch [26]. The measurement values are shown in Table 1.1.
(From Von Schroeder HP, Kuiper SD, Botte MJ. Osseous anatomy of the scapula.
G
Clin Orthop 383:131–139, 2001.)
TABLE 1.1. MEASUREMENTS OF THE SCAPULA

All Female Male

Sex
Measurementa Figure Average SD Min Max Average SD Min Max Average SD Min Max Difference

General measurements
1 Length of scapula 1-9B 155.0 16.0 127 179 140.8 11.9 127 160 166.4 11.4 143 179 b

2 Post. glenoid–med. scapula distance 1-9B 106.0 8.5 92 122 99.0 3.4 92 103 112.3 5.7 101 122 b

3 Ant. glenoid–med. scapula distance 1-9B,C 106.9 9.7 89 126 98.9 4.5 89 106 113.4 7.8 99 126 b

4 Inferior angle (degrees) 1-9B 36.1 2.5 30 42 34.8 2.1 30 38 36.4 1.6 34 39 b

5 Thickness of medial edge 1-9B 3.8 0.7 3 5 3.6 0.7 3 5 3.9 0.7 3 5 NS
6 Superior glenoid to notch 1-9B 31.8 2.9 28 39 30.6 2.3 28 34 32.6 2.4 29 38 b

Scapular spine
7 Length of spine 1-9C 133.6 11.8 113 153 124.8 5.9 115 136 140.9 10.0 123 153 b

8 Length of base of spine 1-9C 85.5 8.7 71 101 78.5 5.4 71 88 91.1 6.6 78 101 b

9 Spine thickness at 1 cm 1-9C 7.3 1.2 6 10 7.3 1.4 6 10 7.2 1.3 6 10 NS

10 Spine thickness at 4 cm 1-9C 17.9 3.2 11 26 17.0 3.1 11 21 18.3 3.8 14 26 NS
11 Spine thickness laterally 1-9C 46.1 6.3 38 59 41.2 2.2 38 44 50.9 4.9 41 59 b

Acromion
12 Acromial neck diameter 1-9C 13.5 2.2 10 18 12.1 1.0 10 14 14.2 1.7 10 17 b

13 AP length of acromion 1-9D 48.0 5.1 38 57 43.6 3.6 38 51 50.9 3.5 44 57 b

14 ML width of acromion 1-9D 21.9 3.7 15 27 20.4 2.2 17 23 22.6 4.6 15 27 NS

15 Thickness of acromion 1-9D 9.4 1.1 8 12 8.7 0.8 8 10 9.8 0.9 8 11 b

16 Coracoacromial distance 1-9D,E 27.1 4.5 22 39 24.6 2.5 22 29 28.7 5.2 24 39 b

Glenoid and head of scapula

17 Superior glenoid-acromial distance 1-9E 15.5 1.8 13 19 14.9 1.8 13 19 16.1 1.5 14 19 NS
18 AP diameter of glenoid b
1-9E 28.6 3.3 25 34 25.8 0.9 25 27 30.9 3.1 25 34
19 Diameter of glenoid to notch 1-9E 26.0 2.9 22 32 23.6 0.9 22 25 27.8 3.0 23 32 b

20 SI length of glenoid 1-9E 36.4 3.6 30 43 33.6 1.7 30 36 38.0 3.3 32 42 b

21 Thickness of head at 1 cm 1-9F 22.0 3.5 17 30 19.4 2.2 17 24 24.7 2.8 21 30 b

22 Thickness of head at 2 cm 1-9F 12.9 3.0 8 18 11.0 1.8 8 14 14.5 3.2 8 18 b

23 Glenoid tilt angle (degrees) 1-9F 7.9 3.7 0 17 8.1 3.6 0 14 8.0 3.0 3 13 NS
Coracoid process
24 Length of coracoid 1-9G 45.3 4.7 35 54 42.3 3.0 36 47 48.3 3.4 41 53 b

25 Thickness of coracoid 1-9G 10.6 1.2 8 12 9.8 1.3 8 12 11.4 0.8 10 12 b

26 Distance from coracoid to notch 1-9G 50.7 4.8 40 58 47.7 3.0 40 52 54.0 3.6 48 58 b

aNumbers correspond to those used in figures; all measurements are in millimeters except 4 and 23, which are in degrees.

AP, anteroposterior; Max, maximum; Min, minimum; med, medial; ML, mediolateral; NS, not significant; Post, posterior; SI, superoinferior; SD, standard deviation.
bp < .05.

From von Schroeder HP, Kuiper SD, Botte MJ. Osseous anatomy of the scapula. Clin Orthop 383:131–139, 2001.
16 Systems Anatomy
the upper portion of the neck of the scapula (see Figs.
1.6–1.8, and 1.9A, D, E, G; Table 1.1). It is located approx-
imately 5.07 cm from the notch of the scapula (26). The
coracoid measures approximately 4.53 cm long and 1.06
cm thick. The base is broad and the anterior portion pro-
jects anteriorly. The coracoid process has a concave surface
that faces laterally. It is smooth to accommodate the gliding
of the subscapularis, which passes just inferior to it. The dis-
tal portion curves upward to angle more horizontally, and
its outer surface is rough and irregular for attachment of the
pectoralis minor. The pectoralis minor insertion is along the
anterior rim; the coracobrachialis and short head of the
biceps originate more laterally toward the tip. The clavipec-
toral fascia also attaches to the apex. The attachments of the
trapezoid and conoid ligaments are located just medial to
the pectoralis minor insertion. The coracoid is roughened
along this rim for the ligament and muscle attachments.
The coracoid process usually is palpable through the ante-
rior deltoid, and can be used as a valuable bony landmark
The spine of the scapula spans from the medial border
(at the junction of the upper and middle thirds of the
medial border) of the scapula to the acromion (see Figs. 1.6,
1.7, and 1.9A–C). The length of the spine from the medial
edge to the lateral edge of the acromion is approximately
13.3 cm, with the length of the base 8.5 cm. The antero-
posterior width of the spine at 1 and 4 cm from the medial
edge is 7 mm and 18 mm, respectively (26) (Table 1.1). The
upper and lower borders are rough to accommodate mus-
cular attachments. The dorsal border forms the crest of the
spine. The crest of the spine is subcutaneous and easily pal-
pable.
Borders of the Scapula
The scapula has three borders: superior, medial, and lateral
(see Figs. 1.6, 1.7, and 1.9A).
The superior border is the shortest and the bone here is
the thinnest. The edge can be somewhat sharp. The shape
of the border is concave, extending from the medial angle
to the base of the coracoid process. The scapular notch is a
semicircular groove in the rim of the superior border. It is
located at the lateral part of the superior border, with its
base approximately 3.2 cm from the superior rim of the gle-
noid (26). It is formed partly by the base of the coracoid
process. The superior rim of the suprascapular notch is
crossed by the superior transverse ligament. The ligament
may be ossified. The suprascapular notch has been shown to
exist as an osseous foramen in approximately 13% of spec-
imens (26). The suprascapular nerve passes through the
suprascapular notch, which is transformed into a foramen
by the ligament. This is a potential area of suprascapular
nerve entrapment. The suprascapular artery passes dorsal to
the ligament, and does not enter the notch (28). The por-
tion of the superior border adjacent to the notch also pro-
vides attachment for the omohyoid muscle.
The lateral border begins at or above the inferior margin
of the glenoid cavity (see Figs. 1.6, 1.7, and 1.9A). It
inclines obliquely downward and medially to the inferior
angle. Below the glenoid cavity, there is a roughed area, the
infraglenoid tubercle, which is approximately 2.5 cm long.
This area gives origin to the long head of the triceps brachii
muscle. The inferior third of the lateral border is thin and
sharp, and provides attachment of a portion of the teres
major posteriorly. The subscapularis originates anteriorly on
a portion of its anterior surface.
The medial (vertebral) border is the longest of the three
borders of the scapula (see Figs. 1.6, 1.7, and 1.9A). It
extends from the superior angle to the inferior angle. The
border is slightly arched with a posterior convexity. This
border is intermediate in thickness between the superior
and lateral borders, measuring approximately 4 mm thick at
1 cm from the edge (26). The portion superior to the spine
forms an obtuse angle of approximately 145 degrees with
the portion inferior to the spine. The border has an anterior
and posterior lip, with an intermediate narrow area. The
anterior lip provides attachment for the serratus anterior
muscle. The posterior lip provides attachment for the
supraspinatus muscle above the spine and the infraspinatus
below the spine. The narrow area between the two lips pro-
vides insertion for the levator scapulae muscle above the tri-
angular area, which marks the beginning of the spine. The
insertion of the levator scapulae may extend along the
major portion of the dorsal rim of the medial border supe-
rior to the spine (5,28). The rhomboid minor muscle
inserts on this edge inferior to the levator scapulae at the
level of the spine. The rhomboid major inserts on the rim
just inferior to the attachment of the rhomboid minor (and
inferior to the spine). The insertion of the rhomboid major
may extend along the major portion of the dorsal rim of the
medial border inferior to the spine (5,28). At the level of the
spine, the rhomboid minor also inserts into a fibrous arch
that attaches to the base of the spine.
Angles of the Scapula
The scapula has three angles: the superior, inferior, and lat-
eral angles (see Figs. 1.9A, 1.16, 1.17, 1.19A). The superior
angle is formed by the junction of the superior and medial
(vertebral) borders. This region is thin, smooth, and
rounded, and gives attachment for a portion of the levator
scapulae muscle. It measures approximately 80 degrees.
The inferior angle is formed by the junction of the
medial (vertebral) border and the lateral (axillary) borders.
It measures approximately 25 degrees. The inferior angle, in
contrast to the superior angle, is thick and rough. The dor-
sal surface provides attachment for the teres major and, in
some individuals, a few fibers of the latissimus dorsi (see
Fig. 1.17).
The lateral angle is the thickest part of the bone, and the
adjacent broadened portion of the bone sometimes is

referred to as the head of the scapula. It measures approxi-
mately 90 degrees. The broadened area is connected to the
rest of the scapula by a slightly constricted neck. This area
of the scapula forms part of the shoulder joint. The most
lateral portion becomes the glenoid, an oval, slightly con-
cave surface. The surface of the glenoid is relatively shallow.
The mean size of the glenoid is 2.9 cm in anteroposterior
width by 3.6 cm in superoinferior length (26) (Table 1.1).
It faces posteriorly by approximately 8 degrees (26). Its lat-
erally facing articular surface is deepened and broadened by
the glenoid labrum, which is a circumferential rim of fibro-
cartilage. The glenoid labrum plays an important role in
stabilizing the shoulder. Superior to the glenoid, near the
base of the coracoid process, there is a slight elevation, the
supraglenoid tubercle, which provides the origin of the long
head of the biceps brachii.
Associated Joints
The scapula articulates with the acromial end of the clavicle
at the acromioclavicular articulation (see earlier, under
Clavicle), and articulates with the proximal humerus at the
glenoid articulation. The scapula slides and rotates on the
thorax, stabilized by muscular attachments, and forms the
soft tissue scapulothoracic articulation.
Muscle Origins and Insertions
Muscle attachments include the trapezius, deltoid (del-
toideus), supraspinatus, infraspinatus, levator scapulae,
minor and major rhomboids (rhomboideus), serratus ante-
rior, teres major, teres minor, subscapularis, triceps, long
and short heads of the biceps, coracobrachialis, pectoralis
minor, and the omohyoid (see Figs. 1.6 and 1.7). The costal
(anterior) surface provides the origin for the subscapularis.
The dorsal (posterior) surface provides the origins for the
supraspinatus (from the supraspinatus fossa) and infra-
spinatus (from the infraspinatus fossa). The spine contains
part of the insertion of the trapezius as well as a portion of
the origin of the deltoid. The dorsal portion of the
acromion contains additional areas for the origin of the del-
toid. The coracoid process contains the origins of the cora-
cobrachialis and the short head of the biceps as well as the
insertion of the pectoralis minor. The dorsal rim of the
medial (vertebral) border receives the insertions of the leva-
tor scapulae and the minor and major rhomboid muscles.
The levator scapulae insertion is located superior to the
level of the spine, the rhomboideus minor insertion is
located at the level of the spine, and the superior rhom-
boideus major insertion is located inferior to the level of the
spine. The serratus anterior inserts along the anterior
(costal) surface of the medial border. The teres minor and
the teres major originate along the dorsal rim of the lateral
border. The teres minor origin lies superior to the teres
major. The origin of the long head of the triceps is located
1 Skeletal Anatomy 17
inferior to the glenoid. The long head of the biceps origi-
nates superior to the glenoid. The omohyoid inserts on the
upper rim of body, superior to the supraspinatus fossa.
Clinical Correlations: Scapula
Failure of Bony Union
Congenital failure of bony union between the acromion
and spine may occur. The junction may be stabilized by
fibrous tissue or may exist as a defect in the scapula. This
may be mistaken for a fracture of the acromion, when in
reality it represents a chronic fibrous union.
Os Acromiale
The base of the acromion is formed from three or four ossi-
fication centers. Persistence of one of the individual ossifi-
cation centers of the acromion that does not fuse with the
others or with the scapula can present as an accessory bone,
the os acromiale. The os acromiale can be mistaken for a
fracture of the acromion or humerus, or can resemble cal-
cific tendinitis of the supraspinatus tendon. The os acromi-
ale usually can be detected because it usually is located at
the lateral margin of the acromion; it is of variable size and
shape but usually is rounded and bilateral (25). It may exist
as a small accessory ossicle directly above the greater
tuberosity of the humerus, separated from the acromion by
approximately 1 cm, and usually is somewhat circular (25).
The Acromion as a Bony Landmark
The lateral border of the acromion usually is palpable. It
allows orientation for operative procedures in the vicinity of
the subdeltoid bursa or rotator cuff.
The Acromion’s Role in Impingement
Syndrome
Impingement of the rotator cuff usually involves thickening
of the acromion. The portion that usually is most thickened
or responsible for impingement is the anterior portion,
which often develops an exostosis or large osteophyte.
The Coracoid Process as a Bony Landmark
With the arm by the side, the tip of the coracoid process
is oriented anteriorly. It can be palpated by applying deep
pressure through the anterior portion of the deltoid mus-
cle approximately 2.5 cm below the lateral part of the
clavicle on the lateral side of the infraclavicular fossa.
Because muscles (pectoralis minor, short head biceps,
coracobrachialis) and ligaments (coracoclavicular and
coracoacromial ligaments) attach to the coracoid process,
and because of the close vicinity of the musculocutaneous
18 Systems Anatomy
nerve, the coracoid is a valuable palpable landmark for ori-
entation in terms of these structures. The coracoid process
also serves as a valuable landmark for operative approaches
to the glenohumeral joint and the brachial plexus. In addi-
tion, the base of the coracoid process forms a portion of
the suprascapular notch. It can be a potential aid in the
localization of the suprascapular nerve and suprascapular
notch.
Suprascapular Nerve Entrapment
The suprascapular notch is converted to a foramen by the
attachment of the superior transverse ligament, which
crosses across the upper open end of the notch (29,30). The
ligament may be ossified. [The suprascapular notch has
been shown to exist as an osseous foramen in approximately
13% of specimens (26).] The suprascapular nerve passes
through the notch, and is susceptible to nerve compression
in this area. This condition occasionally is seen in patients
with inflammatory conditions or in young, active athletes
and is characterized by localized pain or atrophy of the
supraspinatus and infraspinatus. Treatment includes conser-
vative management (antiinflammatory medications, possi-
ble cortisone injections, and activity modification). If it is
refractory to medical treatment or if localized atrophy is
present, operative nerve decompression usually is war-
ranted.
Winging of the Scapula
Winging of the scapula is a deformity in which the scapula
angles up from the thorax (scapula alta), usually due to
muscular imbalance. It often is caused by neuropathy of the
long thoracic nerve and weakness of the serratus anterior, or
by neuropathy of the spinal accessory nerve with weakness
of the trapezius muscle (30,31).
HUMERUS
Derivation and Terminology
Humerus is derived from the Latin humer, meaning “shoul-
der” (3). The plural of humerus is humeri.
Ossification Centers
The humerus has eight ossification centers: one each for the
body, the head, the greater tuberosity, the lesser tuberosity,
the capitulum, and the trochlea, and one for each epi-
condyle (Fig. 1.10). The ossification center for the body
appears near the central portion of the bone at approxi-
mately the eighth week of fetal life. Ossification soon
extends to either end of the bone, so that at birth the
humerus is nearly completely ossified, with only the ends
remaining cartilaginous.
In the proximal end of the humerus, ossification begins
in the head of the bone during the first year (or earlier in
some individuals). The center for the greater tuberosity
begins to ossify during the third year, and the center for the
lesser tuberosity begins to ossify during the fifth year. The
centers for the head and tuberosities usually join by the
sixth year, forming a single large epiphysis that fuses with
the body in approximately the twentieth year (see Fig.
1.10B).
In the distal end of the humerus, ossification begins in
the capitulum near the end of the second year and extends
medially to form the major part of the articular end of the
bone. The center for the medial part of the trochlea appears
at approximately 10 years of age. The medial epicondyle
begins to ossify at approximately the fifth year, and the lat-
eral epicondyle at approximately the twelfth or thirteenth
year. The lateral epicondyle and both portions of the artic-
ulating surface (having already joined together) unite with
the body. At approximately the eighteenth year, the medial
epicondyle is joined to the body of the humerus.
Osteology of the Humerus
The humerus is the largest bone in the upper extremity.
Each end of the humerus is composed of cancellous bone
covered by thin cortical bone. The diaphysis consists of
thick cortical bone throughout its length, with a well
defined medullary canal. The medullary canal extends the
entire length of the humerus. At the proximal and distal
metaphyses, the medullary canal changes to cancellous
bone, and the outer cortex becomes thinner (Figs 1.11 to
1.13).
For descriptive osteology, the humerus can be described
in terms of the proximal end, the shaft (diaphysis or body),
and the distal end (Fig. 1.14; see Figs 1.11 to 1.13). The
proximal end consists of the head, anatomic neck, surgical
neck, and the greater and lesser tuberosities. The distal end
includes the capitulum, trochlea, and medial and lateral
condyles and epicondyles.
Proximal End of the Humerus
The head of the humerus forms nearly half of a sphere (see
Figs. 1.11 to 1.13). With the arm at the side of the body,
the humeral head is directed medially, superiorly, and
slightly posteriorly, thus facing the glenohumeral joint. The
entire smooth area, covered by hyaline cartilage, articulates
with the glenoid of the scapula.
The anatomic neck of the humerus denotes an obliquely
oriented margin or circumference line that extends along
and inferior to the articular portion of the head (see Figs.
1.11 and 1.12). In this area there is a groove that encircles
the articular portion. The groove is well delineated along
the inferior half. In the superior portion, the groove nar-
rows to separate the head from the greater and lesser
 1 Skeletal Anatomy 19

FIGURE 1.10. A: Illustration of humerus showing centers of

ossification. There are eight ossification centers: one each
for the shaft, the head, the greater tuberosity, the lesser
tuberosity, the capitulum, and the trochlea, and one for
each epicondyle. B: Schematic illustration of proximal and
distal humerus in a young adult showing epiphyseal lines.
The dark lines indicate the attachment of the articular cap-
sule.

A B
20 Systems Anatomy

tuberosities. The circumference of the anatomic neck pro-

vides attachment for the articular capsule of the shoulder
joint. In this area, there are numerous foramina for nutrient
vessels (4).
The surgical neck is located distal to the anatomic neck
(see Figs. 1.11 and 1.12). It is the area of the junction of the
shaft with the proximal end of the humerus, just distal to
the head and tuberosities. As opposed to the anatomic neck,
there is no groove that delineates the surgical neck. Its name
derives from the common occurrence of fractures in this
area, many of which are managed by operative methods.
The greater tuberosity is located lateral to the head and
lateral to the lesser tuberosity (see Figs. 1.11 to 1.13). The
greater tuberosity often is referred to as the greater tubercle
in anatomy textbooks (4,5). The upper surface is rounded
and contains three flat impressions for muscle insertion.
The superiormost portion of the greater tuberosity provides
insertion for the supraspinatus. The middle impression is
for the infraspinatus, and the inferiormost impression for
the teres minor. The insertion site for the teres minor lies
approximately 2.5 cm distal to the insertion of the
supraspinatus, and a portion of the teres minor inserts onto
the shaft. The lateral surface of the greater tuberosity is
rough and convex. It merges distally into the lateral surface
of the shaft of the humerus.
The lesser tuberosity is smaller but more prominent than
the greater tuberosity (see Figs. 1.12 to 1.13). The lesser
tuberosity often is referred to as the lesser tubercle in
anatomy textbooks (4,5). It is located anteriorly, adjacent to
the anatomic neck. The anterior surfaced of the lesser
tuberosity provides the major points of insertion of the sub-
scapularis.
The greater and lesser tuberosities are separated from
each other by a deep groove, the bicipital groove (intertu-
bercular groove, intertubercular sulcus; see Figs. 1.12 and
1.13A). The tendon of the long head of the biceps brachii
muscle coursers along and within this groove, along with a
branch of the anterior humeral circumflex artery, which
travels superiorly to supply a portion of the shoulder joint.
The bicipital groove courses obliquely downward and ends
in the proximal third of the humeral shaft. The upper por-
tion of the bicipital groove is lined by a thin layer of carti-
lage and covered by an extension of the synovial membrane
of the shoulder. The lower portion of the groove becomes
progressively shallow and provides the insertion of the latis-
simus dorsi. On either side of the bicipital groove there is a
crest of bone. These are the crests of the greater and lesser
tuberosities, also known as the bicipital ridges. Distal to the
greater and lesser tuberosities, the circumference of the
bone narrows to where the shaft joins the proximal portion.
This is the surgical neck of the humerus. In the distal por-
FIGURE 1.11. Right humerus, posterior aspect.
tion of the bicipital groove, the latissimus dorsi inserts just
medial to the groove. The pectoralis major tendon inserts
just lateral to the groove, slightly distal to the insertion of
the latissimus dorsi.
 1 Skeletal Anatomy 21

FIGURE 1.12. Right humerus, anterior aspect.

22 Systems Anatomy

A B
FIGURE 1.13. A: Right humerus, anterior aspect, showing muscle origins and insertions. B: Right
humerus, posterior aspect, showing muscle origins (red) and insertions (blue).

Shaft of the Humerus
The shaft of the humerus, also anatomically referred to as
the body, spans the portion of the humerus from the surgi-
cal neck proximally and to the area just proximal to the por-
tion referred to as the distal extremity (see Figs. 1.11 to
1.13). (The distal extremity includes the condyles, capitu-
lum, and trochlea, as discussed later.) The shaft of the
humerus is cylindrical in the proximal portion, but
becomes progressively flatter and somewhat triangular dis-
tally. In the distal portion of the shaft, the bone actually has
three surfaces, but two borders (the medial and lateral bor-
ders).
The surfaces of the shaft of the humerus consist of an
anterolateral surface, an anteromedial surface, and a poste-
rior (or dorsal) surface. The anterior surface is divided into
the anterolateral and anteromedial surfaces by an oblique
ridge that starts proximally and laterally at the greater
tuberosity and extends distally to end near the medial epi-
condyle.
The anterolateral surface of the proximal humeral shaft
provides the elongated insertion area of the pectoralis major
muscle, which attaches along the distal part of the crest of
the greater tuberosity (see earlier, under The Proximal End
of the Humerus). Lateral and distal to the insertion of the
pectoralis major is an oblong area that provides the inser-
tion point of the deltoid muscle. This area, known as the
deltoid tuberosity, is located on the anterolateral surface of
the humerus and consists of a raised, slightly triangular ele-
vation. Distal and anterior to the deltoid tuberosity, extend-
ing along the anterolateral surface of the humeral shaft,
there is a relatively large, broad, slightly concave area that
provides the origin area for the brachialis. Also distal to the
deltoid tuberosity is the radial sulcus (radial groove), which
extends obliquely distally, spiraling along the lateral shaft,
and provides the path for the radial nerve and profunda
brachii artery (see Figs. 1.11 and 1.13B). The radial sulcus
is bordered on one side by the origin of the lateral head of
the triceps, the deltoid tuberosity, and the origin of the
brachialis (all located lateral and proximal to the groove).
On the other side of the radial sulcus is the origin of the
1 Skeletal Anatomy 23
FIGURE 1.14. Distal humerus, inferior surface, showing
articular surface and contours of trochlea and capitulum.
medial head of the triceps, located medial and distal to the
sulcus.
The anteromedial surface of the humeral shaft contains
a portion of the bicipital groove proximally. The tendon of
the latissimus dorsi inserts into or along the medial crest of
the intertubercular groove in the area just distal to that tra-
versed by the bicipital tendon. Distal and medial to this area
near the medial border, is the insertion area of the teres
major. In the midportion of the anteromedial shaft, near
the medial border of the humerus is the insertion area of the
coracobrachialis. In the distal portion of the anteromedial
surface of the humerus, the bone is flat and smooth, and
provides for the large origin of the brachialis muscle.
The dorsal surface of the humerus slightly rotates from
proximal to distal, so that the proximal portion is directed
slightly medially, and the distal portion is directed posteri-
orly and slightly laterally. The surface of the posterior sur-
face of the humerus is nearly completely covered by the lat-
eral and medial heads of the triceps brachii. The lateral head
arises from the proximal portion, on the lateral half of the
bone, just lateral to the radial sulcus. The origin of the
medial head of the triceps begins on the proximal third of
the posterior surface of the humerus, along the medial bor-
der of the bone and the medial distal border of the radial
sulcus. This large origin area extends the length of the pos-
terior humerus, covering the major portion of the posterior
half of the humerus. The triceps origin extends distally to
end as far as distal as the posterior portion of the lateral epi-
condyle, just proximal to the origin of the anconeus mus-
cle.
The medial and lateral borders run the entire length of
the humerus. The medial border of the humerus extends
from the lesser tuberosity to the medial epicondyle. The
proximal third of the medial border consists of a prominent
crest, the crest of the lesser tuberosity. The crest of the lesser
tuberosity provides the insertion area of the tendon of the
teres major. More distally, in the mid-portion of the shaft
and located on the medial border is a rough impression for
the insertion of the coracobrachialis. Distal to this area is
the entrance of the nutrient canal into the humerus. A sec-
ond nutrient canal may exist at the starting point of the
24 Systems Anatomy
radial sulcus. The anterior portion of the distal third pro-
vides the origin area for the brachialis muscle (see above
under shaft of the humerus). The posterior portion of the
distal third and medial border of the medial and distal
thirds of the shaft provide the wide origin area of the medial
head of the triceps. The distal third of the medial border is
raised into a ridge, the medial supracondylar ridge. This
ridge becomes more prominent distally. The medial supra-
condylar ridge provides an anterior lip for a portion of the
origin of the brachialis muscle. The ridge also provides a
posterior lip for a portion of the medial head of the triceps
brachii. The medial intermuscular septum attaches in an
intermediate portion of the medial supracondylar ridge.
The lateral border of the humerus extends from the dor-
sal part of the greater tuberosity to the lateral epicondyle.
The lateral border separates the anterolateral surface of the
humerus from the posterior surface. The proximal half of
the lateral border is rounded and indistinctly marked, serv-
ing for the attachment of part of the insertion of the teres
minor, and the origin of the lateral head of the triceps
brachii. The sulcus or groove for the radial nerve (see above)
crosses the central portion of the lateral border of the
humerus. The distal part of the lateral border forms a
rough, prominent margin, the lateral supracondylar ridge.
The lateral supracondylar ridge provides the attachment
area for several structures. Superiorly, there is an anterior lip
for the origin of the brachioradialis muscle. Distal to this
area, the lateral supracondylar ridge provides an area for the
origin for the extensor carpi radialis longus. Distally, there
is a posterior lip for a portion of the origin of the medial
head of the triceps brachii. The intermediate portion of the
lateral supracondylar ridge provides the attachment site for
the lateral intermuscular septum.
Distal Portion of the Humerus
The distal portion of the humerus is often referred anatom-
ically as the distal extremity of the humerus (see Figs. 1.11
to 1.14). The distal portion is flat, widened, and ends dis-
tally in a broad, articular surface. The distal portion con-
tains the two condyles, medial and lateral (see Fig. 1.14).
The lateral portion of the distal articular part consists of a
smooth, somewhat semi-spherical shaped capitulum of the
humerus. The capitulum is covered with articular cartilage
on its anterior surface and articulates with the fovea of the
head of the radius. Proximal to the capitulum, there is a
slight depression in the humerus, the radial fossa. The radial
fossa provides a space for the anterior border of the head of
the radius when the elbow is fully flexed. Just medial to the
capitulum is a slight shallow groove, in which the medial
margin of the head of the radius articulates. Just proximal
to the capitulum on the anterior surface of the humerus are
several small foramina for nutrient vessels.
The medial side of the articular surface of the distal
humerus is comprised of the spool-shaped trochlea (see
Fig. 1.14). The trochlea occupies the anterior, inferior,
and posterior surfaces of the condyle. The trochlea has a
deep groove between two well demarcated borders. The
lateral border is separated from the capitulum by the shal-
low groove. The medial border of the trochlea is thicker,
wider, and more prominent, and projects more distally
than the lateral border. The grooved portion of the articu-
lar surface of the trochlea is shaped well to fit the articu-
lar surface of the trochlear notch of the ulna. The trochlea
is wider and deeper on the dorsal surface than on the ante-
rior surface. Proximal to the anterior portion of the
trochlea is a small depression, the coronoid fossa. The
coronoid fossa provides a space for the coronoid process of
the ulna during flexion of the elbow. Proximal to the pos-
terior part of the trochlea is a deep, triangular depression,
the olecranon fossa. The olecranon fossa provides a space
to accept the most proximal portion of the olecranon
when the elbow is extended. The olecranon fossa and the
coronoid fossa are separated from each other by a thin,
sometimes translucent partition of bone. The partition
may be perforated to produce a supratrochlear foramen.
The fossae are lined by a synovial membrane that extends
from the elbow joint. The margins of the fossae provide
attachment for the anterior and posterior ligaments and
joint capsule of the elbow.
Above the medial and lateral condyles are the epi-
condyles. These projections provide the attachment for sev-
eral muscles. The medial epicondyle is larger and more
prominent than the lateral epicondyle. The medial epi-
condyle contains the origin of the extrinsic flexor pronator
muscles of the forearm and flexor muscles of the hand and
wrist. These include the pronator teres, flexor carpi radialis,
palmaris longus, flexor digitorum superficialis, flexor digi-
torum profundus, and flexor carpi ulnaris. The ulnar col-
lateral ligaments of the elbow joint also originate from the
medial epicondyle. On the posterior surface of the medial
epicondyle is a shallow groove in which the ulnar nerve tra-
verses.
The lateral epicondyle is smaller and less prominent than
the medial epicondyle. The lateral epicondyle contains the
origin of several muscles, including the wrist and digit
extrinsic extensor muscles and the supinator. Muscle attach-
ments to the lateral epicondyle include the supinator, exten-
sor carpi radialis longus, extensor carpi radialis brevis,
extensor digitorum communis, extensor carpi ulnaris, exten-
sor digiti minimi, and anconeus. The lateral epicondyle also
provides attachment for the radial collateral ligament of the
elbow joint
Associated Joints
The humerus articulates with the scapula at the gleno-
humeral joint, with the ulna at the ulnohumeral joint
(trochleoulnar joint), and with the radius at the radio-
capitellar joint.

Muscle Origins and Insertions
Muscle attachments include 24 muscles (see Figs. 1.13A–B).
The greater tuberosity provides the insertion of the
supraspinatus, the infraspinatus, and the teres minor. The
lesser tuberosity affords the insertion of the subscapularis.
The pectoralis major inserts to the anterior bicipital groove,
the teres major inserts to the posterior bicipital groove, and
the latissimus dorsi inserts to the central portion or crest of
the bicipital groove. The shaft of the humerus provides the
insertion of the deltoid and coracobrachialis, and the origins
of the brachialis and the triceps (medial and lateral heads).
The lateral shaft and epicondyle is the area of origin of the
brachioradialis; the medial epicondyle provides the origin of
the pronator teres, the flexor carpi radialis, the palmaris
longus, the flexor digitorum superficialis, the flexor digito-
rum profundus, the flexor carpi ulnaris, and the anconeus.
The lateral epicondyle provides origin for the extensor carpi
radialis longus and brevis, the extensor digitorum communis,
extensor digiti minimi, extensor carpi ulnaris, and anconeus.
Clinical Correlations: Humerus
The Surgical Neck
The surgical neck, located at the junction of the head (and
tuberosities) with the shaft, is an area of frequent fracture,
hence its name. Fractures of the surgical neck are much
more common than in the anatomic neck, and usually are
the result of a direct impact or a fall onto the elbow with the
arm abducted. Deformity of fractures of the surgical neck
usually include adduction or medial displacement of the
shaft due to the pull of the pectoralis major, teres major, and
latissimus dorsi. The proximal fragment may be abducted
by the pull of the supraspinatus muscle.
The Anatomic Neck
Fractures rarely occur along the anatomic neck. When frac-
tures do occur in this location, it usually is in an older
patient and often is the result of a fall onto the shoulder.
Because the shoulder capsule attaches to the bone distal to
the anatomic neck, fractures of the anatomic neck usually
are intracapsular.
Impingement Syndrome
Impingement syndrome of the shoulder refers to a condi-
tion in which the supraspinatus tendon and subacromial
bursa are chronically or repetitively entrapped between the
humeral head inferiorly and either the anterior acromion
itself, spurs of the anterior acromion or acromioclavicular
joint, or the coracoacromial ligament superiorly (17).
Osseous findings seen radiographically can include thicken-
ing or proliferation of the acromion, spurring at the
anteroinferior aspect of the acromion, degenerative changes
1 Skeletal Anatomy 25
of the humeral tuberosities at the insertion of the rotator
cuff, or a humeral head that is slightly superiorly located or
mildly superiorly subluxated. Magnetic resonance imaging
(MRI) can demonstrate soft tissue changes such as bursal
inflammation, thickening and effusion, and inflammatory
changes or partial tearing of the rotator cuff before osseous
changes seen by standard radiographs (17).
Neer Classification of Impingement Syndrome
(32)
n Stage I: Local edema or hemorrhage; reversible condi-
tion. Usual age group: young, active individuals involved
in sports requiring excessive overhead use of arm.
n Stage II: Fibrosis, thickening of subacromial soft tissue,
rotator cuff tendinitis, and possible partial tear of rotator
cuff; manifested by recurrent pain. Usual age group: 25
to 40 years.
n Stage III: Complete rupture of rotator cuff, progressive
disability. Usual age group: over 40 years.
Fractures of the Proximal Humerus
Neer has classified fractures of the proximal humerus as to
the number of segments (18):
n One-part fractures of the proximal humerus are fractures
with minimal or no displacement or angulation.
n Two-part fractures consist of two major displaced frag-
ments. This can include a displaced fracture of either the
greater or lesser tuberosity, fracture of the surgical neck,
or fracture of the anatomic neck.
n Three-part fractures consist of three major displaced
fragments. This can include fractures of both the greater
and lesser tuberosities, or a combination of fracture of
one of the tuberosities and fracture of the surgical neck.
n Four-part fractures consist of four displaced fragments,
such as those involving both tuberosities as well as the
surgical neck.
Anterior Dislocation of the Shoulder
In this injury, the humeral head dislocates anterior to the
glenoid; it accounts for 97% of shoulder dislocations. It
usually is diagnosed on anteroposterior radiographs. Defin-
itive radiographic diagnosis is by the transscapular (“Y”
view) or axillary view.
Hill-Sacks Lesion
This is a defect in the posterolateral aspect of the humeral
head resulting from anterior dislocation (often associated
with recurrent injuries). The lesion occurs when the dislo-
cated humeral head strikes the inferior margin of the gle-
noid, producing a “hatchet” compression fracture defect of
the humeral head. It usually is demonstrated on the antero-
26 Systems Anatomy
posterior view radiograph of the shoulder with the humerus
internally rotated. The presence of this lesion is virtually
diagnostic of previous anterior dislocation (17).
Bankart Lesion
Injury to the anterior-inferior cartilaginous labrum, which
is usually associated with an avulsion of the inferior gleno-
humeral ligament from the anterior-inferior glenoid rim.
Associated from anterior dislocation of the glenohumeral
joint. It may affect only fibrocartilaginous portion of the
glenoid, but is commonly noted in association with a frac-
ture of the anterior aspect of the inferior osseous rim of the
glenoid. The Bankart lesion is less commonly seen than the
Hill-Sacks lesion. The presence of this lesion is virtually
diagnostic of previous anterior dislocation (17).
Posterior Dislocation of the Shoulder
This accounts for 2% to 3% of shoulder dislocations. It can
occur from direct force or a blow to the anterior shoulder,
from indirect force applied to the arm combining adduction,
flexion, and internal rotation, or it can be associated with
severe muscle contraction from electric shock or convulsive
seizures. The humeral head is located posterior to the glenoid
fossa, and usually impacts on the posterior rim of the glenoid.
The shoulder usually is positioned or locked in adduction
and internal rotation. Standard radiographs may not demon-
strate the lesion (because the humeral head lies directly pos-
teriorly, and radiographs may appear unremarkable on stan-
dard anteroposterior views). Injury can be demonstrated by
either an axillary view (often difficult to obtain because of the
arm locked in adduction) or by a special anteroposterior view
with the patient rotated 40 degrees toward the affected side.
With this view, the normal clear space of the glenohumeral
joint is obliterated by the overlap of the humeral head located
posterior and slightly medial to the surface of the glenoid.
Fractures of the Shaft Proximal to the
Insertion of the Deltoid Muscle
If a fracture of the humeral shaft occurs just proximal to the
insertion of the deltoid, the proximal fragment of the
humerus usually is adducted or pulled medially by the pec-
toralis major, latissimus dorsi, and teres major. The distal
fragment usually is displaced or angulated laterally (apex
medially, or fracture in valgus) because of the deltoid.
Fractures of the Humeral Shaft Distal to the
Insertion of the Deltoid Muscle
If a fracture of the humeral shaft occurs just distal to the
insertion of the deltoid, the proximal fragment usually is
displaced laterally by the deltoid and supraspinatus muscle.
The distal fragment usually is pulled medially and upward
by the triceps, biceps, and the coracobrachialis muscles.
Fractures of the Humeral Shaft Associated
with Radial Nerve Palsy
Up to 18% of humeral shaft fractures have an associated
radial nerve injury (33–36). Most nerve injuries represent a
neurapraxia or axonotmesis, and 90% resolve in 3 to 4
months (37–39). This injury often is referred to as the Hol-
stein-Lewis fracture, which describes an oblique fracture of
the distal third of the humerus. However, radial nerve palsy
is associated most commonly with fractures of the middle
third of the humerus (34,38).
Supracondylar Fractures
The area of bone at the supracondylar level is relatively thin,
and fractures through this area are common, especially in
children. Structures at risk for injury in supracondylar frac-
tures include the brachial artery and median nerve anteri-
orly and the radial nerve laterally. Brachial artery injury
subsequently is associated with compartment syndrome of
the forearm.
Supracondylar Process
In approximately 1% of upper extremities, there is a down-
ward-curved, hook-shaped process of bone that emanates
from the medial cortex approximately 5 cm proximal to the
medial epicondyle. It can be associated with a connecting
fibrous band (ligament of Struthers), which can be a proxi-
mal extension of the pronator teres. The median nerve may
pass deep to the supracondylar process and ligament, and
may be subject to compression, resulting in median neu-
ropathy. The brachial artery also may pass deep to the liga-
ment (28,40–43).
Lateral Epicondylitis
Lateral epicondylitis commonly is referred to as tennis
elbow. It is thought to consist of either chronic inflamma-
tion, partial tear, or “overuse injury” of the common exten-
sor origin. Chronic or repetitive wrist or digital extension
often is associated with the onset of symptoms. The exten-
sor carpi radialis brevis often is implicated as the main mus-
cle involved. Although management usually is conservative
(activity modification, antiinflammatory medications,
splinting, cortisone injections), severe and refractory cases
can be managed with operative exploration and release,
debridement, or repair of the extensor carpi radialis brevis
origin or other involved muscle.
Medial Epicondylitis
Medial epicondylitis commonly is referred to as golfer’s
elbow. Similar to lateral epicondylitis, it is though to consist
of either chronic inflammation, partial tear, or overuse
injury of the common flexor pronator muscle origin.

Chronic or repetitive wrist or digital flexion often is associ-
ated with symptoms.
Osteochondrosis
Osteochondrosis (osteochondritis dissecans, osteonecrosis)
of the capitellum of the humerus is referred to as Panner’s
disease.
ULNA
Derivation and Terminology
The ulna derives its name from the Latin word meaning “the
arm” or “the elbow” (1,3). The plural of ulna is ulnae (1).
FIGURE 1.15. Illustration of ulna, showing the three centers of
ossification. There is one center in the shaft (body), one in the
proximal portion (proximal extremity), and one in the distal end
(distal extremity).
1 Skeletal Anatomy 27
Ossification Centers and Accessory Bones
The ulna has three ossification centers: one in the shaft
(body), one in the proximal portion (proximal extremity),
and one in the distal end (distal extremity). The mid-por-
tion of the shaft is the first ossification center to appear,
becoming visible at approximately the eighth week of fetal
life (Figs. 1.15 and 1.16). The ossification centers then
extend through the major part of the shaft. At birth, the
distal portions and the major part of the olecranon remain
cartilaginous. Between the fifth and sixth years, a center in
the central portion of the ulnar head appears and soon
extends into the styloid process. At approximately the
tenth year, a center appears in the olecranon near its outer
portion. Most of the ossification of the olecranon actually
develops from proximal extension from the center of the
shaft (2,4,5).
Several accessory bones can be associated with the distal
ulna. These accessory bones, if present, usually are the result
of secondary or additional ossification centers that do not
fuse with the distal ulnar or associated carpal bones. Acces-
sory bones associated with the distal ulna include the os tri-
angulare (os intermedium antebrachii, os triquetrum secun-
darium), the os ulnostyloideum, and the os pisiforme
secundarium (ulnare antebrachii, metapisoid) (see Fig.
1.27B) (44–46). The os triangulare is located distal to the
head of the ulna, between the ulnar head, lunate, and tri-
quetrum. The os ulnostyloideum is located in the vicinity
of the ulnar styloid. The os pisiforme secundarium is
located between the distal ulna and pisiform, close to the
proximal edge of the pisiform.
FIGURE 1.16. Illustration of proximal and distal ulna in a young
adult, showing epiphyseal lines.
28 Systems Anatomy

Accessory bones also can occur from other causes such as

trauma (46) or heterotopic ossification of synovial tags (47).
Therefore, anomalous, irregular ossicles or small, rounded
bones of abnormal size or shape may be encountered that
do not fit a specific described accessory bone or location.

Osteology of the Ulna

The ulna is located in the medial aspect of the forearm lying
parallel to the radius when the forearm is supinated. It is a
true long bone with a triangular cross-section proximally
that becomes rounded distally. The ulna consists of a shaft
with thick cortical bone and a long, narrow medullary canal
(Figs. 1.17 to 1.20). The cortex of the ulna is thickest along
the interosseous border and dorsal surface. In the proximal
and distal ends of the ulna, the cortical bone becomes thin-
ner, and the medullary canal is replaced with cancellous
bone. The cortical bone remains relatively thick along the
posterior portion of the olecranon.
The ulna is anatomically divided into three main por-
tions: the proximal end (proximal portion, proximal
extremity), the shaft (body), and the distal end (distal por-
tion, distal extremity) (Fig. 1.21; see Figs. 1.19 and 1.20).
The proximal end contains the hook-shaped olecranon and
the coronoid process to form the medial hinge-like portion
of the elbow. The shaft consists of the major portion of the
body between the proximal and distal portions. The distal
end consists of the head and styloid process. In general, the
ulna becomes progressively smaller and thinner from prox-
imal to distal.

Proximal Ulna
The proximal end of the ulna consists of the olecranon, the
coronoid process, the trochlear notch, and the radial notch
(see Fig. 1.21A–F).
The olecranon is the large, thick curved portion of the
proximal ulna. The most proximal portion of the olecranon
is angled slightly forward or distally to form a prominent lip
that passes into the olecranon fossa of the humerus when
the elbow is extended. The base of the olecranon is slightly
constricted where it joins the shaft of the ulna, forming the
narrowest part of the proximal ulna. The posterior surface
of the olecranon is triangular and smooth. This prominent
area, easily palpable through the skin, is covered by the ole- FIGURE 1.17. Right ulna and radius, anterior aspect, showing
cranon bursa. The superior (or most proximal) surface of muscle origins (red) and insertions (blue).
the olecranon is somewhat quadrilateral in shape and has a
rough surface for the insertion of the triceps tendon. The
anterior surface of the olecranon is concave and smooth, attachment for the oblique and posterior parts of the ulnar
and is lined with articular cartilage to form the proximal collateral ligament. The medial aspect of the olecranon also
portion of the trochlear notch. There usually is a nonartic- provides an area for the origin of a portion of the flexor
ular zone in the mid-portion of the articular surface (see carpi ulnaris muscle. The posteromedial portion also pro-
later discussion of trochlear notch). The elbow joint capsule vides a part of the origin of the flexor digitorum superfi-
attaches to the anterior aspect of the superior surface of the cialis. The lateral portion of the olecranon provides the
olecranon. The medial portion of the olecranon provides insertion of the anconeus muscle (see Fig. 1.18).

FIGURE 1.18. Right ulna and radius, posterior aspect, showing
muscle origins (red) and insertions (blue).
The coronoid process is a triangular eminence that pro-
jects from the anterior surface of the ulna, roughly at the
junction of the shaft with the proximal portion (see Fig.
1.19). Its base arises from the proximal and anterior part
of the shaft. The superior surface of the coronoid process
is smooth and concave, and forms the inferior portion of
the trochlear notch. Its inferior surface is concave and
1 Skeletal Anatomy 29
FIGURE 1.19. Right ulna and radius, anterior aspect.
rough. At the junction of the coronoid with the shaft of
the ulna is a thickened, rough eminence, the tuberosity of
the ulna. This tuberosity provides the attachment area for
the brachialis as well as the oblique cord of the radius. The
lateral surface of the coronoid contains the radial notch,
30 Systems Anatomy
which is a narrow, rounded, oblong depression lined with
articular cartilage. The radial notch articulates with the
rim of the radial head during forearm supination and
pronation. The medial surface of the coronoid process
provides the area of attachment of the anterior and
oblique portions of the ulnar collateral ligament. At the
anterior portion of the medial surface of the coronoid is a
small, rounded eminence for the origin of three humer-
FIGURE 1.20. Right ulna and radius, posterior aspect.
oulnar heads of the flexor digitorum superficialis. Poste-
rior to this eminence, a slight ridge extends from the
medial aspect of the coronoid distally. Along this ridge
arise the proximal portions of the insertions of the flexor
digitorum profundus, along with the ulnar head of the
pronator teres. In addition, a small ulnar head of the
flexor pollicis longus may arise from the distal part of the
coronoid process (see Fig. 1.17).
 1 Skeletal Anatomy 31

A B

C D
FIGURE 1.21. A: Proximal right ulna, lateral aspect. B: Right elbow, medial aspect, showing cap-
sular attachment and medial ligaments. C: Right elbow, lateral aspect, showing capsular attach-
ment and lateral ligaments. D: Right elbow, sagittal section. E: Proximal radioulnar joint, with
radial head removed, showing annular ligament.
(continued on next page)

The trochlear notch of the ulna is a large concave depres-
sion that is semilunar in shape and formed by the coronoid
process and the olecranon (see Figs. 1.19 and 1.21A,E, and
F). The trochlear notch, covered anteriorly by articular car-
tilage, provides the articular surface for the trochlea of the
humerus. The articular surface of the trochlear notch has an
area near its mid-portion that contains a central transverse
area that usually is deficient in articular cartilage. This area
subdivides the articular surface into a proximal portion (on
the anterior surface of the olecranon) and a distal portion
(on the anterosuperior surface of the coronoid). At this
mid-portion of the trochlear notch, the borders are slightly
indented near its middle, creating a narrow portion in the
proximal ulna.
The radial notch of the ulna is the articular depression
on the lateral aspect of the coronoid process (see Figs. 1.19,
 32 Systems Anatomy

E F

G H
FIGURE 1.21. (continued) E: Proximal radioulnar joint, with radial head removed, showing
annular ligament. F: Proximal ulna, with proximal radius removed to show annular ligament and
radial notch. G: Right elbow, anterior aspect, showing synovial membrane. The capsule has been
removed and the articular cavity distended. H: Right elbow, posterior aspect, showing synovial
membrane. The capsule has been removed and the articular cavity distended.

and 1.21A,E, and F). The notch is narrow, oblong, and
lined with articular cartilage. The notch articulates with the
circumferential rim of the radial head. The anterior and
posterior margins of the radial notch provide the attach-
ment areas for the annular ligament.
Shaft (Body) of the Ulna
The shaft (or body) of the ulna is triangular in cross-section
in the proximal two-thirds, but becomes round in the distal
third. Longitudinally, the proximal half of the shaft is
slightly convex dorsally and concave anteriorly. The distal
half (and sometimes central portion) becomes longitudi-
nally straight. The distal half of the shaft may be slightly
concave laterally and convex medially. In cross-section, the
triangular shape presents an anterior, posterior, and medial
surface, as well as an anterior border, posterior border, and
interosseous border (each of which is located at the apex of
the triangular cross-sectional shape). The interosseous liga-
ment is attached along the interosseous border apex of the
triangle, and there is no true lateral surface in this region of
the bone. More distally, the bone becomes progressively cir-
cular in cross-section. The shaft flares slightly distally as it
enlarges into the ulnar head.
The three borders of the ulnar shaft are the anterior,
posterior, and interosseous borders. The anterior border of
the ulna begins proximal at the prominent medial angle of
the coronoid process and extends distally along the
anteromedial aspect of the shaft to terminate anterior and
medial to the styloid process of the head of the ulna. The
anterior border is best defined in its proximal portion, and
becomes rounder, smoother, and less clearly defined in the
central distal portion as the shaft becomes progressively
circular in circumference distally. In this central portion of
the anterior border, the ulna provides a large surface ori-
gin for the flexor digitorum profundus muscle (see Fig.
1.17). The distal one-fourth of the anterior border is
referred to as the pronator ridge and provides origin for the
pronator quadratus (4).
The posterior border of the ulna begins proximally at the
apex of the triangular subcutaneous surface of the olecranon
(see Fig. 1.18). The posterior border extends distally along
the mid-posterior portion of the shaft, to terminate poste-
rior to the styloid process. The posterior border is well
defined along its proximal one-third to three-fourths; how-
ever, as the ulna becomes more circular in cross-section dis-
tally, the distal portion of the posterior border is more
rounded, smooth, and poorly defined. In the well defined
proximal portion, the posterior border of the ulna gives rise
to the attachments of an aponeurosis, which provides a
common origin for the flexor carpi ulnaris, the extensor
carpi ulnaris, and the flexor digitorum profundus (see Fig.
1.18). The posterior border separates the medial and poste-
rior surfaces of the ulna.
1 Skeletal Anatomy 33
The interosseous border of the ulna is well defined and
can be somewhat sharp in its central portion (see Figs 1.17
to 1.20). The interosseous border actually extends along the
lateral margin of the ulna, beginning at the radial notch and
curving slightly anteriorly as it extends distally. A proximal
portion of the interosseous border is referred to as the
supinator crest, providing a ridge for the attachment of a
portion of the supinator muscle. In the distal one-fourth of
the shaft, the interosseous border is less well defined. The
interosseous ligament attaches along the interosseous bor-
der and is thickest at its attachment in the central portion
of the interosseous border. The interosseous ligament pro-
vides a partition that separates the anterior and posterior
surfaces of the ulna.
There are three surfaces of the shaft of the ulna: the ante-
rior, posterior, and medial surfaces. The anterior surface of
the ulna lies between the interosseous border (located later-
ally) and the anterior border (located medially). The ante-
rior surface is wide in its proximal portion and slightly con-
cave along the proximal one-half or three-fourths of the
shaft. In this broad proximal portion, the surface is slightly
roughened and provides the large origin of the flexor digi-
torum profundus (see Fig. 1.17). The origin of the flexor
digitorum profundus extends to cover most of the anterior
surface, from the proximal third to the distal end of the
middle third. The distal fourth of the anterior surface is
covered by the pronator quadratus, which takes origin from
an oblique oval area (see Fig. 1.17). The nutrient canal
enters the ulna at the anterior surface at the junction of the
proximal and middle thirds. A branch of the anterior
interosseous artery enters at this site.
The posterior surface of the shaft of the ulna is the area
between the posterior border and the interosseous border
(see Figs. 1.18 and 1.20). This surface is somewhat laterally
located along the shaft and is broad proximally, where the
posterior edge is well defined. The middle portion of the
posterior surface is narrower, straight, and begins to loose
the definition of the posterior edge as the shaft becomes
progressively rounder in cross-section. In the distal third,
the posterior surface is round and flares slightly as the ulnar
head is formed. In the proximal portion, there is an
oblique line or ridge, which begins proximally at the dor-
sal end of the radial notch and continues distally (see Fig.
1.18). There is a triangular surface proximal to this ridge
that provides the insertion area for the anconeus muscle.
The proximal part of the ridge also provides a portion of
the origin area for the supinator. Along the mid-portion of
the posterior surface of the ulnar shaft, there is a central,
longitudinal ridge that is referred to as the perpendicular
line (4). This perpendicular line provides an attachment for
the extensor carpi ulnaris. The medial part is smooth, and
covered by the extensor carpi ulnaris. The lateral part is
wider and rougher, and provides the origin for the supina-
tor, the abductor pollicis longus, the extensor pollicis
34 Systems Anatomy
longus, and the extensor indicis proprius. Also attaching in
the vicinity of the perpendicular line is an aponeurosis that
provides a common attachment for the extensor carpi
ulnaris, flexor carpi ulnaris, and flexor digitorum profun-
dus (Fig. 1.18).
The medial surface of the shaft of the ulna is the area
between the posterior border and the medial border. The
medial surface is broad proximally and slightly concave in
its proximal two-thirds. As the shaft extends distally, the
medial surface becomes more narrow and round, and
slightly convex. The medial surface flares at the distal end to
form the head of the ulna. The proximal three-fourths of
the medial surface of the ulna provides a portion of the ori-
gin of the flexor digitorum profundus (Fig. 1.18).
Distal Ulna
The distal portion of the ulna consists of the head and sty-
loid process (Fig. 1.22; see Figs. 1.17 to 1.20). The head of
the ulna is a rounded, partially spherical eminence that
forms from the flare of the distal shaft. The head is covered
in its distal and lateral surfaces with articular cartilage. Dis-
tally, it articulates with the proximal surface of the triangu-
lar fibrocartilage complex and ulnocarpal ligaments. The
lateral, anterior, and medial surfaces of the ulnar head artic-
ulate with the ulnar notch of the distal radius to form the
distal radioulnar joint.
The styloid process is a narrow, nonarticular prominence
based posterior and slightly medial to the ulnar head. The
styloid process extends distally to become the most distal
portion of the ulna. It provides attachment for the triangu-
lar fibrocartilage complex and ulnocarpal ligaments.
The tendon of the extensor carpi ulnaris passes through
a shallow groove located between the head and styloid
process on the posterior surface of the distal ulna.
FIGURE 1.22. Axial view of right distal radius and ulna, showing configuration of distal radioul-
nar joint, the carpal articular surface, and distal end of ulnar head and styloid process.
Associated Joints
The ulna articulates by synovial joints with the humerus
and radius. The distal ulna also articulates with the carpus
through the ulnocarpal joint, a nonsynovial joint that is
capable of load transfer.
Proximally, the ulna articulates with the humerus
through the hinge-like ulnohumeral joint (see Fig.
1.21A–F). A proximal articulation also exists with the radial
head, the proximal radioulnar joint. The outer margin of
the radial head articulates with the radial notch of the ulna
(see Figs. 1.17 to 1.21).
Distally, the head of the ulna articulates with the radius
to form the distal radioulnar joint. This synovial joint nor-
mally does not communicate with the radial carpal joint.
Muscle Origins and Insertions
A variable number of muscles attach to the ulna, usually at
least 12 (see Figs. 1.17 and 1.18). The olecranon provides
attachment for the triceps insertion, anconeus insertion,
and origin of the ulnar head of the flexor carpi ulnaris
(medial aspect). The base of the coronoid process provides
the insertion area for the brachialis. The proximomedial
ulna also provides the attachment for a portion of the ori-
gin of the flexor digitorum superficialis and flexor digito-
rum profundus (whose origin extends into the shaft).
Medial to the insertion of the brachialis, the proximal shaft
or base of the coronoid process provides part of the origin
for the pronator teres. The proximolateral anterior ulna
provides the origin for the supinator. Occasionally, a small
portion of the origin of the flexor pollicis longus arises from
the proximal ulna (see Fig. 1.17). The dorsal shaft of the
ulna provides attachment for the common aponeurosis to
the extensor carpi ulnaris, flexor carpi ulnaris, and flexor

digitorum profundus, and the origin of the abductor polli-
cis longus, extensor pollicis longus, and extensor indices
(Fig. 1.18). On the anterior aspect of the shaft of the ulna,
the flexor digitorum profundus occupies a vast origin area,
covering the major portion of the anterior shaft. Distally,
the medial aspect of the anterior shaft provides the origin
for the pronator quadratus (Fig. 1.17).
Clinical Correlations: Ulna
Olecranon Osteotomy (Nonarticular Portion)
On the central portion of the articular surface of the proxi-
mal ulna, in the trochlear notch, there is an area in the joint
that is devoid of articular cartilage. In this area, the olecra-
non is slightly narrower. An olecranon osteotomy placed in
this area can avoid injury to the articular surface.
Fractures of the Olecranon
Several classification systems have been described for frac-
tures of the olecranon (17,47a). A modification of the Col-
son classification recently has been popularized (48):
n Type I: fracture of the olecranon that is nondisplaced
n Type II: fracture of the olecranon that is displaced but
without elbow instability
n Type III: fracture of the olecranon that is comminuted,
but without elbow instability
n Type IV: fracture of the olecranon that is comminuted,
unstable, and with elbow instability
Fractures of the Coronoid
Fractures of the coronoid has been classified into three types
(49):
n Type I: fracture of the coronoid involving only the tip
n Type II: fracture of the coronoid involving one-half or
less of the coronoid
n Type III: fracture of the coronoid involving more than
one-half (50)
Nightstick Fracture
This is a single-bone forearm fracture involving the shaft of
the ulna, often nondisplaced or minimally displaced (51). It
was originally described from nightstick injury, when the
forearm is placed above the shoulder to protect the face or
body from blow from nightstick.
Monteggia Fracture
This fracture of the proximal third of the ulna and a con-
comitant anterior dislocation of the radial epiphysis was
1 Skeletal Anatomy 35
described by Monteggia in 1814 (52). The classification has
been modified by Bado to include four subtypes (53):
n Type I: Anterior dislocation of the radial head with asso-
ciated anteriorly angulated fracture of the ulna shaft
n Type II: Fracture of the ulnar diaphysis with posterior
angulation at the fracture site and a posterolateral dislo-
cation of the radial head
n Type III: Fracture of the ulnar metaphysis with a lateral
or anterolateral dislocation of the radial head
n Type IV: Fracture of the proximal third of the radius and
ulna at the same level with an anterior dislocation of the
radial head
Fracture of the Ulnar Styloid and Implications
for Attached Ligaments
Because of the attachments of the triangular fibrocartilage
complex, fracture of the ulnar styloid may represent avul-
sion fracture or concomitant injury to the triangular carti-
lage complex.
Accessory Bones
Several accessory bones can be associated with the distal
ulna and may be mistaken for fractures. An accessory bone
usually represents the residual of a secondary ossification
center that does not fuse with the associated bone, but it
also may arise from trauma or from heterotopic ossification
of synovial tags (46,47). The accessory bones associated
with the distal ulna include the os triangulare (located dis-
tal to the distal end of the ulna, between the ulna, lunate
and triquetrum), the os ulnostyloideum (located in the
vicinity of the ulnar styloid), and the os pisiforme secun-
darium (located between the pisiform and distal ulna; see
Fig. 1.27B) (46) (see descriptions earlier, under Ossification
Centers and Accessory Bones). Disagreement exists as to the
origin of the os triangulare (25,46). It has been classified as
soft tissue calcification, an old avulsion fracture, or as aris-
ing from a secondary ossification center (from the ulna sty-
loid). It has been reported to be present bilaterally without
preexisting history of trauma, which supports its existence
as a true independent ossicle (25). Schultz (25) has empha-
sized that differentiation of an accessory bone from a recent
or nonunited fracture of the ulna styloid may be difficult.
Differentiation from a fracture of the ulnar styloid may be
assisted by noting the length and completeness of the ulna
styloid. If the styloid process is of normal contour and no
defects are present indicating the location of an avulsed
fragment, the area of ossification probably represents an
accessory bone. At times, the ulna styloid may arise from a
separate center of ossification, and failure of fusion of this
center leads to disruption of the normal contour of the sty-
loid. In a recent fracture, the fracture line is found dividing
36 Systems Anatomy

the ulna styloid without the presence of dense opposing sur-

faces. Comparative radiographs can assist in the diagnosis if
the condition is found to be bilateral.

Arthritis of the Distal Radioulnar Joint

Loss of congruity of the distal radioulnar joint can occur
from angulation or joint disruption in distal radius fractures
(Colles’ fracture), or from dislocation or subluxation from
Galeazzi-type fractures or fractures of the radial head with
concomitant injury to the interosseous ligament resulting
in proximal translation of the radius (Essex-Lopresti frac-
ture).

Positive Ulnar Variance

Positive ulnar variance can be associated with shortening of
the radius either from congenital or traumatic causes. Posi-
tive variance can lead to increased force transmission
through the ulnocarpal joint or to impingement of the
ulnar head on the lunate or triquetrum. Operative manage-
ment can consist of shortening of the ulna, distal ulna resec-
tion, or lengthening of the distal radius.

Negative Ulnar Variance

Negative ulnar variance is associated with Kienböck’s dis-
ease. In the absence of arthritic or degenerative changes,
management may consist of lengthening the ulna or short-
ening the radius to produce a neutral ulnar variance.

RADIUS
Derivation and Terminology
The radius derives its name from the Latin for spoke (i.e., of
a wheel) (1). The plural of radius is radii (1).
FIGURE 1.23. Schematic illustration of the radius, showing ossi-
fication centers. There are three centers: one for the proximal
portion, one for the body (shaft), and one for the distal portion.

Ossification Centers
The radius contains three ossification centers: one for the
proximal portion, one for the shaft (body), and one for the
distal portion (Figs. 1.23 and 1.24). The ossification center
for the shaft first becomes visible in the mid-portion of the
bone at approximately the eighth week of fetal life. Ossifi-
cation begins in the distal end during the second year of life.
Ossification of the proximal end becomes visible during the
fifth year. The proximal epiphysis fuses with the ossification
center of the shaft at 15 to 18 years of age. The distal epi-
physis fuses to the shaft between the seventeenth and twen-
tieth year. Occasionally, an additional center is visible in the
radial tuberosity, which appears at approximately the four-
teenth or fifteenth year.
Accessory bones can be associated with the distal
radius. These include the os radiostyloideum and the os
radiale externum (parascaphoid) (see Fig. 1.27B) (25,46).
The os radiostyloideum usually is located at the lateral
aspect of the distal radius, in the vicinity of the radial sty-
loid. The os radiale externum is located slightly distal to
the site of the os radiostyloideum, between the radial sty-
loid and the scaphoid. An accessory bone, if present, usu-
ally is the result of a secondary or additional ossification
center that does not fuse with the associated bone. That
associated with the distal radius usually is from a sec-
ondary or additional ossification center of the radial sty-
loid (46) (see Fig. 1.27B). Accessory bones also can occur
from other causes, such as trauma (46) or heterotopic ossi-
fication of synovial tags (47). Therefore, anomalous, irreg-
ular ossicles or ossicles of abnormal size or shape may be
encountered that do not fit a specific described accessory
bone or location.

Osteology of the Radius
The radius lies laterally in the forearm, has a long, narrow
shaft, and is widened proximally and distally to form the
head and styloid process, respectively. The radius consists of
three major parts: the proximal portion (proximal extrem-
ity), the shaft (body), and the distal portion (distal extrem-
ity). The radius lies parallel to and is slightly shorter than
the ulna (see Figs. 1.17 to 1.20). The proximal end is much
smaller than the distal portion. At the elbow, the radial head
articulates with the capitulum of the humerus and with the
radial notch of the proximal ulna. At the wrist, the distal
radius articulates with the scaphoid and lunate at the radio-
carpal joint, and with the head of the ulna at the distal
radioulnar joint. The proximal and distal articulations with
the ulna provide forearm pronation and supination. The
distal end articulation at the radiocarpal joint provides wrist
extension, flexion, and radial and ulnar deviation. The
radiocarpal joint usually transfers most of the force from the
wrist to the radius, and subsequently to the elbow.
The internal structure of the radius is that of a long bone
with a long, narrow medullary cavity (see Figs. 1.17 to
1.20). The medullary canal is enclosed by thick cortical
bone, which is strongest and thickest along the interosseous
border. The cortex becomes thinner at the proximal and
distal ends of the radius. At the proximal end, the shaft
flares out to form the head, with a central, cup-shaped area
of the head containing relatively thick subchondral bone.
The trabeculae of the proximal and distal radius are
arranged into a somewhat arched pattern. Proximally, the
trabeculae pass proximally from the cortical layer of the
shaft to the fovea of the head of the radius. These trabecu-
lae are crossed by transverse trabeculae that are oriented
parallel to the surface of the fovea. In a similar manner, the
1 Skeletal Anatomy 37
FIGURE 1.24. Proximal and distal radius in a young
adult, showing epiphyseal lines.
trabeculae of the distal radius are arranged so that they
extend longitudinally from the cortical bone and course to
the articular surface. Additional trabeculae cross parallel to
the surface of the joint.
Proximal Radius
The proximal end of the radius consists of the head, neck,
and the tuberosity (see Figs. 1.17 to 1.20). The head is
shaped somewhat like a thick disc or short cylinder. The
proximal surface forms a shallow cup, the central portion of
which is the fovea. The fovea of the radial head articulates
with the capitulum of the distal humerus. The articular
margin or periphery of the head is smooth and approxi-
mately 5 to 10 mm high. The radial head is thickest in the
medial portion where it articulates with the radial notch of
the ulna. The radial head is slightly shorter in the lateral
portions, where it is surrounded by the annular ligament.
The head is connected to the smooth, narrower radial neck.
The neck is cylindrical and has a thick cortex. The head
overhangs the neck, giving a slight mushroom-like appear-
ance. On the posterior aspect of the neck there is a slight
ridge or roughened surface for the insertion of a portion of
the proximal supinator. The anterior surface of the neck is
smooth. Along the anterior undersurface of the rim formed
by the junction of the radial head and radial neck there are
several small nutrient foramina. The tuberosity of the radius
lies on the anteromedial aspect of the proximal radius, dis-
tal to the neck. The tuberosity is rough on its most medial
and posterior aspects for the insertion of the biceps tendon.
On its most anterior aspect, the tuberosity is smooth, in
which a bursa is interposed between the tendon and the
radius.
38 Systems Anatomy
Shaft of the Radius
The shaft of the radius, often referred to in anatomic text-
books as the body, consists of the major portion of the bone
between the head and the distal end (2,4,5). In the proxi-
mal portion, the shaft is round or cylindrical where it joins
the radial neck. More distally, the shaft becomes triangular
in cross-section, with an apex directed toward the ulna
where the interosseous ligament attaches. The triangular
cross-sectional area of the shaft results in three surfaces
(anterior, posterior, and lateral) separated by three borders
(anterior, posterior, and interosseous). The interosseous
border along the medial aspect is sharp along its margin,
except proximally near the tuberosity. The shaft gradually
increases in size from proximal to distal. The shaft of the
radius is gently curved, convex dorsally and laterally. The
anterior (palmar, volar) surface is correspondingly gently
curved concave volarly. The interosseous border, on the
medial aspect, is gently curved concave ulnarly.
The anterior border is located on the anterolateral sur-
face of the shaft. It separates the anterior and lateral sur-
faces. It is well defined in its proximal and distal portions,
but poorly defined in its central or middle portion, where
the border is more rounded and less distinct. The anterior
border starts proximally from the distal portion of the
tuberosity and extends longitudinally to reach the anterior
part of the base of the styloid process. The proximal third
of the anterior border of the radius is elevated to form a
slight ridge known as the anterior oblique line of the radius.
The anterior oblique line is sharper and more defined in its
distal portion, forming a palpable crest along the lateral
margin of the anterior surface. The anterior oblique line
provides the area of origin of the flexor digitorum superfi-
cialis and flexor pollicis longus muscles. Proximal and lat-
eral to the anterior oblique line, the area on the radius pro-
vides a portion of the insertion of the supinator muscle. In
the distal part of the shaft of the radius, along the distal
one-fourth, the anterior border is more clearly defined than
the central portion. This part of the anterior border pro-
vides the insertion area of the pronator quadratus and
attachment of the dorsal carpal ligaments. The distal por-
tion of the anterior border continues distally and slightly
laterally, and terminates in a small tubercle on the antero-
lateral surface. This tubercle, located at the base of the sty-
loid process, provides the insertion attachment for the bra-
chioradialis muscle (Fig. 1.17).
The posterior border begins proximally at the posterior
aspect of the neck of the radius and extends distally to the
posterior aspect of the base of the styloid process. The pos-
terior border separates the posterior surface of the radius
from the lateral surface. The border actually is rounded and
not clearly defined, especially in the most proximal and dis-
tal aspects. It is best defined in its middle third, where it is
slightly roughened.
The interosseous border extends along the medial aspect
of the radius in proximity to the ulna. Proximally, the
interosseous border is poorly defined. Distal to the radial
tuberosity, the interosseous border changes from a rounded
contour to a sharp, somewhat rough, prominent edge. The
edge is the most prominent and thickest at the junction of
the proximal third and distal two-thirds. A the distal por-
tion of the interosseous border, approximately 5 cm from
the distal end of the radius, the interosseous border divides
into two ridges that continue to form the anterior and pos-
terior margins of the ulnar notch. This creates a triangular
surface between the ridges, known as the medial surface of
the distal radius (5). This triangular area serves as an inser-
tional area for a portion of the pronator quadratus. In this
distal area, the divided interosseous border separates the
anterior surface of the radius from the posterior surface.
Along its sharp distal three-fourths, the interosseous border
provides the attachment for the interosseous ligament, con-
necting the radius to the ulna.
The anterior surface of the shaft of the radius lies
between the anterior and interosseous borders. The surface
is concave in its proximal three-fourths, but becomes
slightly broader and flatter in its distal fourth. The large
concave proximal surface provides the origin for the flexor
pollicis longus. The muscle covers the major surface area of
the anterior surface. The flatter, broader distal portion of
the anterior surface is covered by the pronator quadratus.
Distal and radial to the attachment of the pronator quadra-
tus, in the palmar aspect of the radial styloid, there is a tri-
angular area separated from the shaft by a slight ridge. This
triangular area is roughened and provides attachment for
the radiocarpal ligaments. Several nutrient foramina are
present on the distal anterior surface of the radial metaph-
ysis. Near the midpoint or in the vicinity of the junction of
the proximal and middle thirds of the anterior surface, there
usually is a nutrient foramen and canal. The foramen
receives a branch from the anterior interosseous artery. The
nutrient vessel enters the radius with a somewhat proxi-
mally directed course.
The posterior surface of the radius lies between the pos-
terior and interosseous borders. It is flat, slightly convex, or
slightly rounded along most of its course. In the proximal
third, it is smooth and may be slightly concave, providing
for the attachment of the supinator, which covers the pos-
terolateral surface of the proximal radius. Just distal to the
attachment of the supinator is the oblique insertion area of
the pronator teres, which extends to the lateral surface. In
the middle third of the posterior surface, the surface is
broad and may become slightly concave, providing origin
for the abductor pollicis longus and extensor pollicis brevis.
In the distal third of the posterior surface of the radius, the
surface is broad, convex, irregular, and grooved, providing
the passage and routing of the dorsal extensor tendon com-
partments (see later, under Distal Radius) (Fig. 1.18).

The lateral surface of the radius is a gently convex sur-
face lying between the anterior and posterior borders. It
generally is smooth, rounded, and remains convex along its
entire surface. In the proximal portion, it provides a portion
of the attachment of the supinator muscle. In the central
portion there is a slightly roughened oval area for the inser-
tion of the tendon of the pronator teres. In the distal por-
tion of the lateral surface, the surface is smooth where the
tendons of the abductor pollicis longus and extensor polli-
cis brevis muscles cross.
Distal Radius
The distal portion of the radius includes the metaphyseal
and epiphyseal regions. This portion of the radius is quadri-
lateral in cross-section and encompasses the widest portion
of the radius. Anatomic features include the anterior, poste-
rior, medial, and lateral surfaces; the styloid process; the
dorsal (Lister’s) tubercle; the ulnar notch; and the radio-
carpal and distal radioulnar joint articular surfaces.
The lateral surface flares out gradually from the shaft,
extending further along the lateral margin to form the sty-
loid process. The styloid process is conical. A rough area at
the base of the styloid provides the attachment for the bra-
chioradialis. This lateral surface is slightly rough, and pro-
jects distally to terminate in the tip of the styloid. The dis-
tal area of the styloid provides attachment for the articular
capsule and the capsular thickening of the collateral liga-
ment. On the lateral surface of the radial styloid, there is a
flat groove for the passage the abductor pollicis longus and
extensor pollicis brevis tendons. The process is easily palpa-
ble and serves as a useful anatomic landmark to mark the
lateral margin of the radiocarpal joint.
The anterior surface of the distal radius is concave, pal-
marly directed, and widened or flared out from the contour
of the shaft. The surface is rough for the attachment of the
palmar radiocarpal ligaments, and multiple small foramina
are present to provide vascularity to this metaphyseal area of
the radius. The anterior surface has a thick, prominent
ridge, which is palpable approximately 2 cm proximal to
the thenar eminence. A portion of the anterior surface is
covered by the pronator quadratus, of which there are
attachments that extend distally to the area adjacent to the
area of the attachment of the wrist capsule and radiocarpal
ligaments.
The medial surface of the distal radius consists of the
ulnar notch and the articular surface for the ulnar head,
comprising the radial component of the distal radioulnar
joint. The ulnar notch is narrow, smooth, concave in the
anteroposterior plane, and roughly triangular, with the
widest portion distally. The margins of the articular surface
are bordered by a slight ridge, further defining the ulnar
notch. Small nutrient foramina are present just proximal to
the articular margin of the distal radioulnar joint.
1 Skeletal Anatomy 39
The posterior (dorsal) surface of the distal radius flares
out gradually from the shaft. It is irregular, rough, convex,
and contains multiple small vascular foramina for the distal
radial metaphysis. In the mid-portion of the posterior distal
radius is the prominent dorsal (Lister’s) tubercle. It lies from
5 to 10 mm from the distal joint surface. A portion of the
extensor retinaculum attaches to Lister’s tubercle. On the
medial aspect of the dorsal tubercle is a deep, smooth
groove for passage of the extensor pollicis longus tendon.
On the most lateral aspect of the posterior distal radius,
there are less defined grooves, from lateral to medial, for
passage of the abductor pollicis longus, extensor pollicis
brevis, extensor carpi radialis longus, and extensor carpi
radialis brevis, respectively. The groove that contains the
extensor carpi radialis longus and brevis is broad and shal-
low, and subdivided into two parts by a slight ridge to allow
passage of each of the two tendons, with the longus located
lateral to the brevis.
On the ulnar aspect of the posterior distal radius, ulnar
to Lister’s tubercle, are faint grooves for passage of the
extensor indicis and extensor digitorum communis. The
extensor indicis tends to pass slightly deeper than the exten-
sor digitorum communis. In this vicinity, along the dorsal
margin of the distal radius and adjacent to the cortex, the
posterior interosseous nerve courses.
The distal margin of the posterior surface of the distal
radius is rough to provide for the attachment of the dorsal
radiocarpal ligaments.
The carpal articular surface of the distal radius is roughly
triangular (apex lateral), smooth, concave, and curving and
extending distally along the lateral margin. The base of the
triangle intersects the articular surface of the distal radioul-
nar joint. On the carpal articular surface, there is a slight
division by a mild anteroposterior ridge. This divides the
articular surface into lateral and medial parts. The lateral
part is triangular and contains the scaphoid fossa. The
medial portion is more quadrangular and contains the
lunate fossa. The distal radiocarpal articular surface is con-
cave and slightly oval, elongated from anterior to posterior.
Between the distal radioulnar joint and the radiocarpal joint
there is a slight separation of the articular surfaces by a
prominent ridge. This ridge, located in the ulnar notch,
provides the radial attachment for the triangular fibrocarti-
lage.
Associated Joints
At the proximal end, the head of the radius articulates with
the capitulum of the humerus and with the radial notch of
the ulna (see Fig. 1.21B–F). At the distal end, the radius
articulates, through its ulnar notch, with the head of the
ulna to form the distal radioulnar articulation. Also at the
distal end, the radius articulates with the scaphoid and the
lunate at the radiocarpal joint. The scaphoid articulates
40 Systems Anatomy
with the scaphoid fossa of the distal radius. The specific
articulation with the scaphoid is referred to as the
radioscaphoid joint or, depending on the specific location in
the radioscaphoid joint, the articulation can be referred to
as the styloscaphoid joint [descriptive because of its signifi-
cance for arthritis and the scapholunate advanced collapse
(SLAC) wrist]. The specific articulation with the lunate is
referred to as the radiolunate joint. The lunate articulates
with the lunate fossa of the distal radius. The interosseous
ligament between the radius and the ulna can be considered
a nonsynovial articulation.
Muscle Origins and Insertions
There usually are nine muscles that attach to the radius (see
Figs. 1.17 and 1.18). The biceps insertion attaches to the
radial tuberosity. The supinator originates from the oblique
ridge of the proximal medial aspect. The flexor digitorum
superficialis originates along an oblique line on the anterior
proximal and central diaphysis. The flexor pollicis longus
origin covers the anterior shaft of the radius. The insertion
of the pronator quadratus attaches to the distal anterior dia-
physis and metaphysis. The midshaft on the radial aspect
provides the insertion of the pronator teres. The origins of
the abductor pollicis longus and extensor pollicis longus
attach to the posterior midshaft. The brachioradialis inserts
into the lateral aspect of the distal radius, just distal to the
styloid.
Clinical Correlations: Radius
The Oblong Shape of the Scaphoid Fossa
The oblong shape of the scaphoid fossa of the distal radius
influences radioscaphoid arthritis, as can be demonstrated
with the SLAC wrist from scapholunate instability. The
scaphoid fossa of the radius is somewhat oblong in shape,
and accepts the oblong articular surface of scaphoid. The
lunate fossa of the radius is more nearly spherical, and
accepts the more hemispherical articular surface of the
lunate. With scapholunate instability, mobility of the
scaphoid in the oblong fossa is not as well tolerated because
areas of stress concentration result if the scaphoid rotates
abnormally. The more spherical shape of the radiolunate
articulation can tolerate motion of the lunate more easily,
without stress concentration. Therefore, in long-standing
scapholunate instability, arthritic changes usually develop
first in the radioscaphoid joint (styloscaphoid joint),
whereas the radiolunate joint may be relatively well pre-
served until the latest stages (54–60).
Essex-Lopresti Lesion
Fracture of the radial head (which results in the loss of prox-
imal support of the radius) along with injury to the
interosseous ligament between the radius and ulna may
allow proximal migration of the radius. This injury was
described by Essex-Lopresti in 1951 (61,62). At the wrist,
the proximal migration of the radius results in relative
shortening of the radius, producing a relative positive ulnar
variance. Management in the acute setting includes recon-
struction or metallic prosthetic replacement of the radial
head (to regain proximal support), and, as needed, pinning
of the distal radius and ulna to hold the reduced distal
radioulnar joint accurately.
Galeazzi’s Fracture
Fracture of the distal radial shaft with an associated disloca-
tion or subluxation of the distal radioulnar joint was
described by Galeazzi in 1934 (63–65). The fracture usually
occurs at the junction of the middle and distal thirds of the
radius, and usually has a transverse or short oblique config-
uration. Open reduction with internal fixation (ORIF) usu-
ally is the preferred method of treatment (65).
Fracture Classification of the Radial Head
Fractures of the radial head have been described by Mason
in 1954 (65a), and recently modified by Hotchkiss. The
Hotchkiss classification is as follows (62):
n Type I: Nondisplaced or minimally displaced fracture of
the radial head or neck. Forearm rotation is limited only
by acute pain and swelling. Intraarticular displacement
of the fracture is less than 2 mm. Treatment usually is
sling immobilization and active motion as early as toler-
ated.
n Type II: Displaced (>2 mm) fracture of the head or neck,
motion may be mechanically limited or incongruous,
without severe comminution (repairable by ORIF), and
fracture involves more than a marginal lip of the radial
head. Treatment is variable, and includes either ORIF
(recently more popular), early motion without excision,
or excision.
n Type III: Severely comminuted fracture of the radial
head and neck, not reconstructible, and requires excision
for movement. Treatment usually is excision, with possi-
ble prosthetic replacement to improve valgus stability
and prevent proximal translation of the radius.
Colles’ Fracture
Colles described this fracture of the distal radius in 1814
(66). The fracture involves the distal metaphysis, which is
dorsally displaced and angulated, and usually occurs within
2 cm of the articular surface. The fracture may extend into
the distal radiocarpal joint. Classic features include dorsal
angulation (silver fork deformity), dorsal displacement,
radial angulation (loss of radial inclination), and radial
 1 Skeletal Anatomy 41

shortening. There often is accompanying fracture of the CARPUS

ulnar styloid, which may signify avulsion of the triangular
General Aspects
fibrocartilage complex (67).
The carpus consists of eight carpal bones, arranged in a
proximal and a distal row, each row containing four bones.
Barton’s Fracture
The proximal row includes (from lateral to medial) the
Barton described this fracture of the distal radius in 1838 scaphoid, lunate, triquetrum, and pisiform. The pisiform is
(68). The fracture is a fracture–dislocation in which the rim located palmar to the plane of the remaining three carpal
of the distal radius, dorsally or palmarly, is displaced with bones of the proximal row, and the pisotriquetral joint is
the hand and carpus (68,69). The fracture differs from the separated from the joining articulations. The distal row
Colles’ or Smith’s fracture in that the dislocation is the most includes (from lateral to medial) the trapezium, trapezoid,
clinically and radiographically obvious abnormality, with capitate, and hamate (Figs. 1.25 and 1.26).
the radial fracture noted secondarily. The volar Barton’s The proximal row is convex proximally and concave dis-
fracture is similar to the Smith’s type III fracture, where tally. The proximal row articulates proximally with the dis-
both involve palmar dislocation of the carpus associated tal radius and with the triangular fibrocartilage complex,
with an intraarticular distal radius component. forming the radiocarpal and ulnocarpal joint. The proximal
row articulates distally with the distal carpal row, forming
the midcarpal joint.
Smith’s Fracture
Smith described an additional fracture pattern of the dis-
tal radius in 1854. In this fracture, often called reverse
Colles’ fractures, the distal radial fragment is palmarly
angulated or displaced, producing a “garden spade” defor-
mity (69,70). The hand and wrist are displaced forward or
palmarly with respect to the forearm. The fracture may be
extraarticular, intraarticular, or part of a fracture–disloca-
tion (67,70,71). The classification modified by Thomas
includes type I, which is extraarticular; type II, which
crosses into the dorsal articular surface; and type III,
which is intraarticular and similar to the volar Barton’s
fracture–dislocation.

Chauffeur’s Fracture
This fracture of the radial styloid was described originally
because of the mechanism of injury, whereby the hand crank
of early automobiles would backspin to strike the wrist. The
fracture, if displaced, is treated with ORIF. If the fracture is
displaced more than 3 mm, there may be an associated
scapholunate dissociation, which may benefit from repair of
the ligament as well as ORIF of the styloid (67,72).

Accessory Bones
Accessory bones, the os radiostyloideum and the os radiale
externum, are located in the vicinity of the radial styloid
(25,46) (see Fig. 1.27B). The os radiale externum is located
slightly distal to the site of the os radiostyloideum. If pre-
sent, these accessory bones can be mistaken for a fracture.
An accessory bone usually represents the residual of a sec-
ondary ossification center that does not fuse with the asso-
ciated bone, but it also may arise from trauma or from het-
erotopic ossification of synovial tags (46,47) (see
description earlier, under Ossification Centers and Acces-
sory Bones). FIGURE 1.25. Skeletal hand and wrist, palmar aspect.
42 Systems Anatomy
FIGURE 1.26. Skeletal hand and wrist, dorsal aspect.
The four bones of the distal row articulate distally with
the five metacarpal bones and with each other. The bones of
the distal carpal row are straighter in alignment across the
wrist than the proximal row, especially at their distal articu-
lations with the metacarpal bones.
On the dorsal surface of the carpus, a gentle convex
arch is formed by the arrangement of the proximal and
distal rows. On the palmar surface, however, a deep con-
cavity if formed, designated the carpal groove. The carpal
groove is accentuated by the palmar projection of the pisi-
form and hook of the hamate medially, and by the projec-
tion of the scaphoid tuberosity and trapezial ridge later-
ally.
The midcarpal joint and the radiocarpal joint usually do
not communicate with each other; if communication does
occur, as seen through flow of dye from an arthrogram,
there is either a tear or incompetence of the scapholunate or
lunotriquetral ligaments.
The vascular supply to the carpus is through two main
systems, the dorsal carpal vascular system and the palmar
carpal vascular system (73) (see Fig. 1.29). The dorsal and
palmar systems consist of a series of dorsal and palmar
transverse arches that are connected by anastomoses formed
by the radial, ulnar, and anterior interosseous arteries. The
specific vascular patterns in each carpal bone (intraosseous
vascularity) are described in the section on osseous anatomy
(73).
The ossification of the carpus may be quite variable (5)
(see Fig. 1.26). The carpal bones usually are cartilaginous at
birth, with the exception of the capitate and the hamate,
where ossification already may be present. Each carpal bone
ossifies from one center; the capitate usually is first and the
pisiform usually last, but variability may exist in the order
of ossification of the other carpal bones (74–76) (Fig. 1.27).
The specifics of ossification of each carpal bone are dis-
cussed separately later.
The carpus can be associated with several accessory
ossicles (46) (see Fig. 1.27B; Table 1.2). In general, the
development of these accessory bones is from an addi-
tional or anomalous secondary ossification center, and
therefor the accessory bones are described later under sec-
tions on ossification. Accessory bones however, also can
occur from other causes such as trauma (46) or hetero-
topic ossification of synovial tags (47). Anomalous, irreg-
ular ossicles or ossicles of abnormal size or shape thus may
be encountered that do not fit a specific described acces-
sory bone or location.
In addition to accessory bones, congenital fusions (or
coalitions) have been noted to occur in most of the carpal
articulations (see Fig. 1.27C). Congenital coalitions are
thought to occur either by the fusion of two ossification
centers or by the nonseparation of two cartilage elements,
resulting in one bone (46,77).
SCAPHOID
Derivation and Terminology
The scaphoid (os scaphoideum, os naviculare manus, carpal
navicular) derives its name from the Greek skaphe, which
means “skiff ” or “light boat.” Scaphoid therefore denotes
“boat-shaped” (1). The word navicular is derived from the
Latin navicula, also indicating a boat.
Ossification Centers and Accessory Bones
The scaphoid usually has one ossification center (see Fig.
1.27A). It begins to ossify in the fourth year in girls, and the
fifth year in boys (74). Occasionally, an additional ossifica-
tion center fails to unite, forming an accessory ossicle, the
os centrale (centrale dorsale, episcaphoid). The os centrale
 FIGURE 1.27. A: Schematic illustrations showing
times of ossification of the carpus and hand. B:
Accessory ossicles of the wrist: schematic illustra-
tion of the carpus showing the various accessory
bones and approximate locations. C: Possible
sites for carpal coalitions. (B and C after O’Rahilly
R. Developmental deviations in the carpus and
A the tarsus. Clin Orthop 10:9–18, 1957.)

B C
44 Systems Anatomy
TABLE 1.2. ACCESSORY BONES OF THE WRIST
Os capitatum secundarium (carpometacarpale V)
Os centrale (centrale dorsale, episcaphoid)
Os epilunatum (centrale II)
Os epitrapezium
Os epitrapezoideum (trapezoideum dorsale)
Os epitriquetrum (epipyramis, centrale IV)
Os gruberi (carpometacarpale VI)
Os hamulare basale (carpometacarpale VII)
Os hamuli proprium
Os hypolunatum (centrale III)
Os hypotriquetrum
Os metastyloideum
Os parastyloideum (carpometacarpale III)
Os paratrapezium
Os pisiforme secundarium (ulnare antebrachii, metapisoid)
Os praetrapezium (carpometacarpale I)
Os radiale externum (parascaphoid)
Os radiostyloideum
Os styloideum (carpometacarpale IV)
Os subcapitatum
Os trapezium secundarium (multangulum majus secundarium,
carpometacarpale II)
Os trapezoideum secundarium (multangulum minus
secundarium)
Os triangulare (intermedium antebrachii, triquetrum
secundarium)
Os ulnare externum
Os ulnostyloideum
Os vesalianum manus (vesalii, carpometacarpale VIII)
From O’Rahilly (44–46).
occurs between the scaphoid, trapezoid, and capitate bones
(see Fig. 1.27B). During the second prenatal month, it is a
cartilaginous nodule usually fusing with the scaphoid.
Besides the os centrale, an additional ossification center
may give rise to two large portions of the scaphoid. If these
fail to fuse, the result is a bipartite scaphoid (25). Bipartite
scaphoids are rare, usually bilateral, and can be distin-
guished from a fracture by the smooth cortical edges, lack
of history of trauma, and absence of displacement or degen-
erative changes (25).
Several other accessory bones can be associated with
the scaphoid. These accessory bones, if present, usually
A B
FIGURE 1.28. Right scaphoid. A: Dorsal aspect. B: Palmar aspect.
are the result of secondary or additional ossification cen-
ters that do not fuse with the scaphoid. These include the
os centrale, the os radiale externum (os parascaphoid),
the os epitrapezium, os epilunatum (os centrale II), and
the os radiostyloideum (see Fig. 1.27B) (25,46). The os
centrale is located between the scaphoid, capitate, and
trapezoid. The os radiale externum is located at the distal
lateral margin of the scaphoid tubercle, adjacent to the
trapezium. The os epitrapezium is located just distal to
the site of the os radiale externum at the distal lateral
aspect of the scaphoid in close proximity to the trapez-
ium. The os epilunatum is located in the region between
the scaphoid and lunate, at the more distal aspect of the
scapholunate articulation. The os radiostyloideum is
located in the vicinity of the radial styloid, slightly prox-
imal to the lateral mid-portion of the scaphoid (46) (see
Fig. 1.27B).
Osteology of the Scaphoid
The scaphoid is the largest bone of the proximal carpal
row, located proximally and radially (Fig. 1.28; see Figs.
1.25, 1.26, 1.37, and 1.38). It consists internally of can-
cellous bone, surrounded by a cortical shell (see Fig. 1.28).
The cortex of the distal pole (tuberosity) is relatively
thick. The axis of the scaphoid is directed distally, laterally,
and palmarly. It rests in a plane at approximately 45
degrees to the longitudinal axis of the wrist (67). Articular
cartilage covers 80% of the surface (67). The major por-
tions include the tuberosity (located palmarly and dis-
tally), the body, and the proximal pole. The central narrow
portion of the body is the waist. The palpable scaphoid
tuberosity is located at the base of the thenar eminence
and usually is in line with the radial border of the long fin-
ger. The tuberosity extends palmarly, and is more readily
palpable with the dorsiflexed wrist in radial deviation
(which increases the palmar flexion of the scaphoid and
thus directs the tuberosity into the palm, where is
becomes easily palpable). When the wrist is ulnarly devi-
ated, the palmar flexion of the scaphoid decreases, and
thus the tuberosity is more difficult to palpate. The dorsal
surface is rough, grooved, and narrower than the palmar

surface. A dorsal groove courses the entire length of the
scaphoid, and provides for the attachment of ligaments
and vessels. The rough dorsal area in the region of the
waist contains small vascular foramina, more of which
usually are located slightly distally (78). These foramina
allow entrance of the vital dorsal ridge vessels, a leash of
vessels that supply vascularity to the body and, through
retrograde flow, to the proximal pole (73,79). The lateral
surface, directed proximally and radially, is convex and
covered with articular cartilage. The most medial surface,
which articulates with the lunate (lunate surface), is
located ulnarly, has a flat, semilunar shape, and contains a
relatively small surface area for lunate articulation. It is
covered with articular cartilage. The portion articulating
with the capitate is large, concave, and faces distomedially,
and is covered with articular cartilage. The most distal
portion articulates with the trapezium and trapezoid. This
distal portion is a continuous, slightly convex surface.
This distal articulation usually has two parts or “facets,”
separated by a small ridge. The presence and morphology
of the articular facets is variable; in approximately 25% of
specimens, there may be a palpable but not readily visually
identifiable separation of the facets, and the two facets
may not be distinguishable at all in approximately 19%
(see below, Anomalies and Variations). Two distinct facets
are present in at least 82% of specimens. The medial facet
articulates with the trapezoid, and the lateral facet articu-
lates with the trapezium. Each facet is covered with artic-
ular cartilage. The articular surfaces of the proximal por-
tion of the scaphoid (including those articulating with the
capitate, lunate, and distal radius) are all covered with
articular cartilage, and thus do not provide any soft tissue
attachments for vascularity. Hence, the vascular supply to
the proximal pole is from retrograde flow from the dorsal
ridge vessels located at the level of the waist.
Anomalies and Variations in Morphology
of the Scaphoid
There is anatomic variability in the morphology of the dis-
tal articular surface of the scaphoid that articulates with the
trapezium and trapezoid. The joint may or may not con-
tain two distinct facets. Viegas and coworkers have shown
that in 81.2% of scaphoids studied, there was a distinctly
separate facet for the trapezoid articulation and another
distinct facet for the trapezium, with an interfacet ridge
separating the two. The interfacet ridge was both visible
and palpable in 56.4% of wrists. In 24.8% of wrists, the
scaphoid was found to have a palpable, but not readily visu-
ally identifiable interfacet ridge. In the remaining 18.8% of
wrists, the scaphoid had a smooth distal articular surface
without a visually or palpably identifiable ridge between the
area of trapezial or trapezoidal articulation on the scaphoid
(80,81).
1 Skeletal Anatomy 45
Vascularity of the Scaphoid
The scaphoid receives its vascular supply mainly from the
radial artery. Vessels enter in the limited areas dorsally and
palmarly that are nonarticular areas of ligamentous attach-
ment (79,82–84) (Fig. 1.29).
The dorsal vascular supply to the scaphoid accounts for
70% to 80% of the internal vascularity of the bone, all in
the proximal region (79) (see Fig. 1.29A). On the dorsum
of the scaphoid, there is an oblique ridge that lies between
the articular surfaces of the radius and of the trapezium and
trapezoid. The major dorsal vessels to the scaphoid enter the
bone through small foramina located on this dorsal ridge
(79,82,84,85). The dorsal ridge is in the region of the
scaphoid waist. At the level of the intercarpal joint, the
radial artery gives off the intercarpal artery, which immedi-
ately divides into two branches. One branch runs transverse
to the dorsum of the wrist. The other branch runs vertically
and distally over the index metacarpal. Approximately 5
mm proximal to the origin of the intercarpal vessel at the
level of the styloid process of the radius, another vessel is
given off that runs over the radiocarpal ligament to enter
the scaphoid through its waist along the dorsal ridge. In
70% of specimens, the dorsal vessel arises directly from the
radial artery. In 23%, the dorsal branch has its origin from
the common stem of the intercarpal artery. In 7%, the
scaphoid receives its dorsal blood supply directly from the
branches of both the intercarpal artery and the radial artery.
There are consistent major communications between the
dorsal scaphoid branch of the radial artery and the dorsal
branch of the anterior interosseous artery. No vessels enter
the proximal dorsal region of the scaphoid through the dor-
sal scapholunate ligament, and no vessels enter through
dorsal cartilaginous areas.
The dorsal vessels usually enter the scaphoid through
foramina located on the dorsal ridge at the level of the
scaphoid waist. However, in a few of the studied specimens,
the vessels enter just proximal or distal to the waist. The
dorsal vessels usually divide into two or three branches soon
after entering the scaphoid. These branches run palmarly
and proximally, dividing into smaller branches to supply
the proximal pole as far as the subchondral region.
The palmar vascular supply accounts for 20% to 30% of
the internal vascularity, all in the region of the distal pole
(79,85) (see Fig. 1.29B). At the level of the radioscaphoid
joint, the radial artery gives off the superficial palmar
branch. Just distal to the origin of the superficial palmar
branch, several smaller branches course obliquely and dis-
tally over the palmar aspect of the scaphoid to enter
through the region of the tubercle (79,83). These branches,
the palmar scaphoid branches, divide into several smaller
branches just before penetrating the bone. In 75% of spec-
imens, these arteries arise directly from the radial artery
(79). In the remainder, they arise from the superficial pal-
mar branch of the radial artery. Consistent anastomoses
46 Systems Anatomy
A
FIGURE 1.29. A: Classic depiction of dorsal pericarpal arterial network.
exist between the palmar division of the anterior
interosseous artery and the palmar scaphoid branch of the
radial artery, when the latter arises from the superficial pal-
mar branch of the radial artery. There are no direct com-
municating branches between the ulnar artery and the pal-
mar branches of the radial artery that supply the scaphoid.
Vessels in the palmar scapholunate ligament do not pene-
trate the scaphoid. The palmar vessels enter the tubercle
and divide into several smaller branches to supply the distal
20% to 30% of the scaphoid. There are no apparent anas-
tomoses between the palmar and dorsal vessels (79).
Associated Joints
The scaphoid articulates with five bones: the radius proxi-
mally, the lunate medially, the capitate medially and distally,
and the trapezoid and trapezium distally (see Figs. 1.25,
1.26, 1.28, 1.37, and 1.38). The proximal lateral portion of
the scaphoid sits in the scaphoid fossa of the radius, forming
the radioscaphoid joint. In the distal portion of the
radioscaphoid joint, where the mid-lateral portion of
scaphoid articulates with the radial styloid, the specific por-
tion of the joint can be referred to as the styloscaphoid joint
(descriptive because of its significance for arthritis and SLAC
wrist). The articulation with the lunate, forming the
scapholunate joint, has a relatively small surface area, in part
because of the narrow crescent shape of the lunate, which
may contribute to the difficulty in performing arthrodesis of
this joint. The scaphocapitate articulation has a relatively
large surface area, usually allowing successful arthrodesis of
this joint. The distal articulation of the scaphoid with the
trapezoid and trapezium is referred to as the triscaphe joint.
 1 Skeletal Anatomy 47

B
FIGURE 1.29. (continued) B: Classic depiction of palmar pericarpal arterial network. (A and B
after Taleisnik J. The vascular anatomy of the wrist. In: Taleisnik J, ed. The wrist. New York:
Churchill Livingstone, 1985:51–78.) AIA, anterior interosseous artery; DMCA, dorsal metacarpal
artery; PF, perforating branches; PMA, palmar metacarpal artery; CPDA, common palmar digital
artery; PDA, proper palmar digital artery.
(continued on next page)
48 Systems Anatomy

FIGURE 1.29. (continued) C: Drawing of the arterial supply of the lateral aspect of the wrist.
D: Schematic drawing of the dorsum of the wrist, showing vascular contributions to the carpal
bones.

E 367, 1983.)
Muscle Origins and Insertions
A small portion of the abductor pollicis brevis may origi-
nate from the palmar surface of the scaphoid tuberosity.
(The major portion of origin of the abductor pollicis brevis
usually is from the proximal part of the palmar surface of
the trapezium.) A portion of the transverse carpal ligament
also attaches to the medial portion of the scaphoid tuberos-
ity (see Fig. 1.37).
Clinical Correlations: Scaphoid
The scaphoid is the most commonly fractured bone of the
carpus (86). It is susceptible to fractures at any level
[approximately 65% occur at the waist, 15% through the
proximal pole, 10% through the distal body, 8% through
the tuberosity, and 2% in the distal articular surface (67)].
Scaphoid fractures have a relatively high incidence of
nonunion (8% to 10%), frequent malunion, and late
sequelae of carpal instability and posttraumatic arthritis
(67).
The relatively small surface area of the scapholunate
joint (due in part to the narrow crescent shape of the
lunate) probably contributes to the difficulty in achieving
operative arthrodesis of this joint. While, the relatively large
surface area of the scaphocapitate joint facilitates successful
operative arthrodesis.
1 Skeletal Anatomy 49
FIGURE 1.29. (continued) E: Schematic
drawing of the palmar aspect of the wrist,
showing the vascular contributions to the
carpal bones. (C–E after Gelberman RH,
Panagis JS, Taleisnik J, et al. The arterial
anatomy of the human carpus: part I. the
extraosseous vascularity. J Hand Surg [Am] 8:
Arthrodesis of the triscaphe joint stabilizes or “anchors”
the distal portion of the scaphoid, and thus prevents col-
lapse into palmar flexion, as is seen when there is disruption
of the scapholunate ligaments. Therefore, triscaphe
arthrodesis has been described for treatment of scapholu-
nate instability.
The retrograde vascularity of the scaphoid enters the
dorsal waist through the dorsal ridge vessels (73,79), and
these vessels should be protected during dorsal exposure of
the scaphoid. Avascular necrosis of the proximal pole of the
scaphoid is due to disruption of the retrograde vessels that
supply the proximal pole. Preiser’s disease describes avascu-
lar necrosis of the scaphoid, usually occurring in the proxi-
mal pole (87,88).
Accessory Bones
Several accessory bones can be associated with the scaphoid
and may be mistaken for fractures. An accessory bone usu-
ally represents the residual of a secondary ossification cen-
ter that does not fuse with the associated bone, but it also
may arise from trauma or from heterotopic ossification of
synovial tags (46,47). The accessory bones associated with
the scaphoid include the os centrale (located between the
scaphoid, capitate, and trapezoid), the os radiale externum
(located at the distal radial border of the scaphoid tuberos-
ity), the os epitrapezium (located between the scaphoid and
50 Systems Anatomy
trapezium), os epilunatum (located between the scaphoid
and lunate), and the os radiostyloideum (located near the
radial styloid at the lateral border of the waist of the
scaphoid; see Fig. 1.27B) (25,46) (see descriptions earlier,
under Ossification Centers and Accessory Bones). The os
centrale exists as a free bone in lower primates (25).
The Bipartite Scaphoid
A bipartite scaphoid may be mistaken for a fracture. A
bipartite scaphoid arises from the failure of fusion of two
significant ossification centers. It often is bilateral. The
bipartite scaphoid may be distinguished from a fracture
from the lack of trauma history, bilaterality, and absence of
displacement or degenerative changes. It is possible to
injure the bipartite scaphoid, resulting in pain and a radi-
ographic appearance resembling a fracture. Symptoms from
injury to a bipartite scaphoid usually resolve with a course
of protection or immobilization.
LUNATE (OS LUNATUM, SEMILUNAR)
Derivation and Terminology
The lunate derives its name from the Latin luna, meaning
“moon” (1), and is so named because of its crescent or
moon shape (as visualized on the lateral projection). The
British literature may refer to the lunate as the semilunar,
derived from semi, meaning “half ” or “partly,” and lunar,
meaning “moon” (2).
Ossification Centers and Accessory Bones
The lunate is cartilaginous at birth. It usually has one ossi-
fication center that begins to ossify during the fourth year
(74) (see Fig. 1.27A). Variation in the ossification has been
noted, with ossification taking place at from 1.5 to 7 years
of age in boys, and between 1 and 6 years of age in girls
(89). Double ossification centers in the lunate also have
been noted (90,91).
Several accessory bones can be associated with the
lunate. Accessory bones, if present, usually are the result of
a secondary or additional ossification center that does not
fuse with the associated bone. Those associated with the
lunate include the os epilunatum (os centrale II), the os
hypolunatum (os centrale III), the os hypotriquetrum, the
os epitriquetrum (epipyramis, os centrale IV), and the os
triangulare (os intermedium antebrachii, os triquetrum
secundarium) (see Fig. 1.27B) (46). The os epilunatum is
located between the lunate, scaphoid, and capitate, along
the distal border of the scaphoid and lunate. The os hypol-
unatum is located between the lunate and the capitate, just
ulnar to the site of the os epilunatum. The os hypotri-
quetrum is located in the vicinity of the lunate, capitate,
proximal pole of the hamate, and the triquetrum. The os
epitriquetrum is located between the lunate, hamate, and
triquetrum, just ulnar to the site of the os hypotriquetrum.
The os triangulare is located between the lunate, tri-
quetrum, and the distal ulna (46) (see Fig. 1.27B).
Osteology of the Lunate
The lunate is crescentic, concave distally and convex proxi-
mally (Fig. 1.30; see Figs. 1.25, 1.26, 1.37, and 1.38). It
consists internally of cancellous bone, surrounded by a cor-
tical shell (see Fig. 1.30A,B). The dorsal and palmar sur-
faces are rough for the attachment of carpal ligaments. The
palmar surface is roughly triangular and is larger and wider
than the dorsal portion. The smooth, convex proximal
articular surface articulates with the lunate fossa of the dis-
tal radius and with a portion of the triangular fibrocartilage
on its proximoulnar aspect. The lateral surface is crescent
shaped, flat, and narrow, with a relatively narrow surface
area with which it contacts the scaphoid. The medial sur-
face is square or rectangular, fairly flat, and articulates with
the triquetrum. The distal surface is deeply concave and
articulates with the proximal portion of the capitate.
Anomalies and Variations in Morphology
of the Lunate
Differences in lunate morphology have been discussed by
Taleisnik, Zapico, Viegas, Shepherd, and others (85,92a–95).
The lunate has been divided into three types, based on
whether its proximal aspect is curved or angulated. The
lunate shape is evaluated by measurements of the angle
between the lateral scaphoid side and the proximal radial
side of the lunate. The type I lunate has an angle greater
than 130 degrees and is present in approximately 30% of
those studied. The type I lunate has been associated with an
ulnar minus wrist. The type II lunate has an angle of
approximately 100 degrees, and is present in approximately
50%. The type III lunate has two distinct facets on the
proximal surface, one that articulates with the radius and
another that articulates with the triangular fibrocartilage.
The type III lunate is the least common, present in approx-
imately 18% (85). The separate ulnar facet on the proximal
lunate, when present, has been noted to vary in size
between subjects (93).
Two types of lunate osseous morphology, based on the
presence or absence of a medial facet for hamate articula-
tion, have been noted and described by Viegas and cowork-
ers, Burgess, and Sagerman et al. (81,94–97). A type I
lunate is one in which there is no medial facet. Its reported
incidence is between 27% and 34.5% (81,94–96). A type II
lunate has a medial facet that articulates with the hamate.
The reported incidence is between 65.5% and 73%. The
size of the medial facet in the type II lunate ranges from a
shallow, 1-mm facet to a deep, 6-mm facet. In the type II
lunate with a large medial facet, there occasionally has been
 1 Skeletal Anatomy 51

A B

C
FIGURE 1.30. Right lunate. A: Proximolateral aspect. B: Distomedial aspect. C: Patterns of
intraosseous blood supply to the lunate (see text). (C after Gelberman RH, Bauman TD, Menon J,
et al. The vascularity of the lunate bone and Kienbock’s disease. J Hand Surg [Am] 5:272, 1980.)

associated ridging on the capitate and hamate (81,95).
When the facet is large, it is easily identifiable radiographi-
cally and can be distinguished easily from the type I lunate.
However, when the medial facet is small in the type II
lunate, it may be difficult to distinguish it from a type I
lunate (81,97). With the type II lunate, carpal kinetics and
kinematics are different than in wrists with the type I
lunate. The type II lunate has been shown to be associated
with an increased incidence of cartilage erosion on the prox-
imal pole of the adjacent, articulating hamate (see later,
under Clinical Implications).
Associated Joints
The lunate articulates with five bones: the radius, scaphoid,
capitate, hamate, and triquetrum (see Figs. 1.25, 1.26,
1.30, 1.37, and 1.38). The lunate articulates with the radius
on its proximal surface; it lies in the lunate fossa of the
radius, located on the ulnar aspect of the distal radius. The
lunate articulates with the scaphoid along the lunate’s radial
surface, with a relatively small, crescent-shaped articular
surface area. The lunate articulates with the capitate distally,
where the proximal pole of the capitate sits in the distal,
crescent-shaped articular surface of the lunate. The lunate
articulates with the triquetrum medially. In this area, the
articular surface of the lunate is rounded or oval. Between
the articular surfaces for the triquetrum and the capitate,
there usually is a narrow strip of articular surface for articu-
lation with the proximal portion of the hamate. A curved
ridge separates the articular surfaces for the hamate and cap-
itate. Contact with the hamate is maximized when the car-
pus is ulnarly deviated. Proximally, on the ulnar aspect of
the proximal articular surface of lunate, the lunate articu-
lates with a portion of the triangular fibrocartilage complex.
Muscle Origins and Insertions
There are no muscle origins or insertions on the lunate.
Vascularity of the Lunate
The lunate receives its blood supply from both palmar and
dorsal sources or from the palmar aspect alone (see Fig.
1.29A,B). In 80% of specimens, the lunate receives nutrient
vessels from both the palmar and dorsal surfaces. In 20% of
specimens, it receives nutrient vessels from the palmar sur-
face alone. Except for these relatively small dorsal and pal-
mar surfaces, the lunate is covered by articular cartilage, and
thus no other vessels enter the bone. The vessels entering the
dorsal surface are from branches of the dorsal radiocarpal
arch, the dorsal intercarpal arch, and occasionally from
smaller branches of the dorsal branch of the anterior
52 Systems Anatomy
interosseous artery (73,98,99) (Fig. 1.29A). On the palmar
aspect, the lunate nutrient vessels are supplied by the palmar
intercarpal arch, the palmar radiocarpal arch, and commu-
nicating branches from the anterior interosseous artery and
the ulnar recurrent artery (Fig.1.29B).
The vessels that enter dorsally are slightly smaller than
those entering palmarly. Major vessels branch proximally
and distally after entering the bone and terminate in the
subchondral bone. The dorsal and palmar vessels anasto-
mose intraosseously just distal to the mid-portion of the
lunate. The proximal pole has relatively less vascularity.
There are three major intraosseous patterns. These pat-
terns take the shape of the letters “Y,” “I,” or “X” (see Fig.
1.30C). The Y pattern is the most common, occurring in
59% of studied specimens. The stem of the “Y” is oriented
dorsally or palmarly with equal frequency. The I pattern
occurs in approximately 30% of specimens, and consists of
a single dorsal and a single palmar vessel. The single dorsal
and single palmar vessels anastomose in a straight line, thus
forming the “I”-shaped pattern. The X pattern occurs in
10% of specimens and consists of two dorsal and two pal-
mar vessels that anastomose in the center of the lunate, thus
forming an “X” (73,98,99).
In 20% of studied specimens, a single palmar supply was
noted. This pattern consists of a single large vessel that
enters on the palmar surface and branches in the lunate to
provide the sole blood supply.
Clinical Correlations: Lunate
The lunate and triquetrum usually begin to ossify in the
fourth and third years, respectively. Rarely, fusion of these
two ossification centers occurs, resulting in lunotriquetral
coalition. Of all of the carpal coalitions, lunotriquetral is
one of the most common (44,46,100–104).
Lunate ossification may be delayed in a variety of syn-
dromes, including epiphyseal dysplasias and possible homo-
cystinuria (81,105). Complete absence of the lunate also
has been reported (106).
The lunate has been divided into three types, based on
whether its proximal aspect is curved or angulated (see ear-
lier, under Anomalies and Variations). The lunate shape is
evaluated by measurements of the angle between the lateral
scaphoid side and the proximal radial side of the lunate.
The type I lunate has an angle greater than 130 degrees and
is present in approximately 30% of those studied. The type
I lunate has been associated with an ulnar minus wrist.
Two types of lunate morphology based on the presence
or absence of a medial facet have been described by Viegas
and coworkers (see earlier, under Osteology) (81,94,95,
107,108). The carpal kinetics and kinematics have been
shown to be different in wrists with the two types of lunate
(109). The type II lunate contains a medial facet for articu-
lation with the hamate. This has been associated with an
increased incidence of cartilage erosion with exposed bone
on the proximal pole of the hamate. These erosions usually
are not identifiable by radiography. The incidence of
hamate proximal pole erosions has been noted to be as high
as 44% with the type II lunate (containing the medial facet
articulating with the hamate). This is in contrast to the type
I lunate (which contains no medial facet), in which hamate
erosions or lesions were noted only in 0% to 2% (81,
95,107).
A triangular shape of the lunate on radiographs may
indicate a lunate dislocation, or tilting of the lunate in
either direction (dorsiflexion or palmar flexion). Disloca-
tion of the lunate (or perilunate dislocation) is the most
common type of carpal dislocation.
The relatively small contact surface area between the
lunate and scaphoid (due, in part, to the narrow crescent
shape of the lunate) probably contributes to the difficulty in
achieving operative arthrodesis of the scapholunate joint.
Although fractures through the central portion of the
lunate are rare, loss of vascularity (Kienböck’s disease) is
associated initially with increased radiodensity, followed by
flattening or osseous collapse with fragmentation/fracture
in the later stages (110–112).
The Stages of Kienböck’s Disease (110,111)
n Stage I: Normal appearance on radiographs, possible lin-
ear or compression fracture on tomogram. Avascular
changes visualized on MRI. Bone scan shows abnormal
uptake.
n Stage II: Bone density changes (sclerosis), slight collapse
of radial border.
n Stage III: Fragmentation, collapse, cystic degeneration,
loss of carpal height, capitate proximal migration,
scaphoid rotation (scapholunate dissociation).
n Stage IV: Advance collapse, scaphoid rotation, sclerosis,
osteophytes of the radiocarpal joint.
Accessory Bones
Several accessory bones may be associated with the lunate
and can be mistaken for fractures. An accessory bone usu-
ally represents the residual of a secondary ossification cen-
ter that does not fuse with the associated bone, but it also
may arise from trauma or from heterotopic ossification of
synovial tags (46,47). The accessory bones associated with
the lunate include the os epilunatum (located between the
lunate, scaphoid, and capitate), the os hypolunatum
(located between the lunate and capitate), the os hypotri-
quetrum (located between the lunate, capitate, proximal
pole of the hamate, and the triquetrum), os epitriquetrum
(located between the lunate, triquetrum, and proximal pole
of the hamate), and the os triangulare (located between the
lunate, triquetrum, and distal ulna; see Fig. 1.27B) (46) (see
descriptions earlier, under Ossification Centers and Acces-
sory Bones).

TRIQUETRUM (OS TRIQUETRUM,
TRIQUETRAL BONE, CUNEIFORM)
Derivation and Terminology
The name triquetrum is derived from the Latin for “three-
cornered” (1). The older British literature refers to the tri-
quetrum as the cuneiform, derived from the Latin cuneus,
meaning “wedge,” and forma, meaning “likeness” or “form”
(2).
Ossification Centers and Accessory Bones
The triquetrum is cartilaginous at birth. It has one ossifica-
tion center that begins to ossify during the third year (74)
(see Fig. 1.27A).
Several accessory bones can be associated with the tri-
quetrum. Accessory bones, if present, are usually the result
of an additional or secondary ossification center that does
not fuse with the associated bone. Those associated with the
triquetrum include the os hypotriquetrum, the os epitri-
quetrum (os epipyramis, os centrale IV), the os triangulare
(os intermedium antebrachii, os triquetrum secundarium),
and the os ulnare externum (46) (see Fig. 1.27B). The os
hypotriquetrum is located in the vicinity of the triquetrum,
lunate, capitate, and the proximal pole of the hamate. The
os epitriquetrum is located between the triquetrum, lunate,
and proximal hamate, just ulnar to the site of the os
hypotriquetrum. The os triangulare is located between the
triquetrum, lunate, and the distal ulna (46) (see Fig.
1.27B).
Osteology of the Triquetrum
The triquetrum is pyramid-shaped and located on the prox-
imoulnar aspect of the carpus (Fig. 1.31; see Figs. 1.25,
1.26, 1.37, and 1.38). Internally, the triquetrum consists of
cancellous bone, surrounded by a cortical shell (see Fig.
1.31). The triquetrum has several surfaces, including the
proximal, distal, lateral, dorsal, and palmar. The proximal
surface faces slightly medially, and contains both a rough,
nonarticular portion, and a lateral, slightly convex articular
portion that may “articulate” with the triangular fibrocarti-
lage complex. The distal surface is directed laterally and
contains both concave and convex surface portions. The
distal surface is curved and smooth for articulation with the
FIGURE 1.31. Right triquetrum. Distoradial aspect.
1 Skeletal Anatomy 53
medial surface of the hamate. The dorsal surface is rough
for the attachments of carpal ligaments. The palmar surface
contains two regions: medial and lateral. On the medial
region of the palmar surface is the articular surface for the
pisiform. This relatively small articular surface is round or
oval. The lateral portion of the palmar surface is rough and
nonarticular and provides attachments for carpal ligaments.
The lateral surface of the triquetrum forms the base of the
pyramid, which is flat and quadrilateral, for articulation
with the lunate. The medial and dorsal surfaces may be
somewhat confluent. The medial surface is the pointed
summit of the pyramid, and provides attachment for the
ulnar collateral ligament of the wrist.
Associated Joints
The triquetrum articulates with three bones: the lunate, the
pisiform, and the hamate (see Figs. 1.25, 1.26, 1.31, 1.37,
and 1.38). The articulation with the lunate on the radial
surface of the triquetrum is roughly square or rectangular,
or oval. The triquetrum articulates with the pisiform pal-
marly. The articular surface for the pisiform is round or oval
in shape. The articulation with the hamate is based distally
and slightly radially. The articular surface for the hamate is
smooth, curved, and slightly oval or triangular, extending
along the distoradial surface of the triquetrum.
Muscle Origins and Insertions
There are no muscle origins or insertions on the tri-
quetrum.
Vascularity of the Triquetrum
The triquetrum receives its blood supply from branches
from the ulnar artery, the dorsal intercarpal arch, and the
palmar intercarpal arch (see Fig. 1.29A,B). Nutrient vessels
enter from the intercarpal arches and pass through its two
nonarticular surfaces, on the dorsal and palmar aspects.
The dorsal surface of the triquetrum is rough for attach-
ments of associated carpal ligaments. This dorsal surface
contains a ridge that runs from the medial to the lateral
aspect. Two to four vessels enter this dorsal ridge and radi-
ate in multiple directions to supply the dorsal 60% of the
bone. This network is the predominant blood supply to the
triquetrum in 60% of specimens (73,99).
The palmar surface contains an oval facet that articulates
with the pisiform. One or two vessels enter proximal and
distal to the facet. The vessels have multiple anastomoses
with each other and supply the palmar 40% of the bone.
This palmar vascular network is predominant in 20% of
specimens (99).
Significant anastomoses between the dorsal and the pal-
mar vascular networks have been found in 86% of speci-
mens studied (99).
54 Systems Anatomy
Clinical Correlations: Triquetrum
The triquetrum and the lunate usually begin to ossify in the
third and fourth years, respectively. Rarely, fusion of these
two ossification centers occurs, resulting in lunotriquetral
coalition. Of all of the carpal coalitions, lunotriquetral is
one of the most common (44,46,100–104).
Fractures of the triquetrum result from a direct blow or
from an avulsion injury that may include ligament damage.
The most common fracture is probably the impingement
shear fracture of the ulnar styloid against the dorsal tri-
quetrum, occurring with the wrist in extension and ulnar
deviation, particularly when a long ulnar styloid is present
(97,113,114). An avulsion component also may be present.
A small bone fragment located dorsal to the triquetrum is
seen best on the lateral radiograph.
Accessory Bones
Several accessory bones may be associated with the tri-
quetrum and can be mistaken for fractures. An accessory
bone usually represents the residual of a secondary ossifica-
tion center that does not fuse with the associated bone, but it
also may arise from trauma or from heterotopic ossification
of synovial tags (46,47). The accessory bones associated with
the triquetrum include the os hypotriquetrum (located
between the triquetrum, lunate, capitate and the proximal
pole of the hamate), the os epitriquetrum (located between
the triquetrum, lunate, and proximal pole of the hamate, just
ulnar to the site of the os hypotriquetrum), the os triangulare
(located between the proximal triquetrum, lunate, and the
distal ulna), and the os ulnare externum (located at the distal
end of the triquetrum and adjacent to the ulnar border of the
distal hamate; see Fig. 1.27B) (46) (see descriptions earlier,
under Ossification Centers and Accessory Bones).
PISIFORM (OS PISIFORME)
Derivation and Terminology
The name pisiform is derived from the Latin pisum, mean-
ing “pea,” and forma, meaning “likeness,” “shape,” or
“form” (1). Pisiform thus denotes “pea shaped.”
Ossification Centers and Accessory Bones
The pisiform is cartilaginous at birth. It has one ossification
center that begins to ossify in the ninth or tenth year in
girls, and in the twelfth year in boys (74) (see Fig. 1.27A).
It usually is the last carpal bone to ossify (5).
There is an accessory bone that can be associated with
the pisiform. The os pisiforme secundarium, also known as
the os ulnare antebrachii or the os metapisoid, is located at
the proximal pole of the pisiform (46) (see Fig. 1.27B). The
os pisiforme secundarium, if present, usually is the result of
an additional, secondary ossification center that does not
fuse with the pisiform.
Osteology of the Pisiform
The pisiform is the smallest carpal bone. It is situated at the
base of the hypothenar eminence on the medial side of the
wrist (Fig. 1.32; see Figs. 1.25 and 1.37). It lies palmar to
the triquetrum, in a plane palmar to the other carpal bones.
The pisiform actually is a sesamoid bone in the tendon of
the flexor carpi ulnaris. It consists internally of cancellous
bone, surrounded by a cortical shell (see Fig. 1.32). It is
generally spherical, although there is a slight long axis in the
distolateral direction (4,5). The pisiform is flat on its dorsal
surface, where the only articular surface is located. It artic-
ulates only with the triquetrum. The pisotriquetral joint is
not a portion of the radiocarpal joint, and there usually is
not a communication between these joints. The palmar sur-
face of the pisiform is round and rough, and provides
attachments for the flexor carpi ulnaris (proximally) and the
abductor digiti minimi (distally). The lateral and medial
surfaces are rough. The lateral surface usually contains a
shallow groove that lies adjacent to the ulnar artery.
Associated Joints
The pisiform articulates with the triquetrum dorsally (see
Figs. 1.25, 1.32, and 1.37). This articular facet is flat and
oval, and is located slightly proximal on the dorsal surface.
Muscle Origins and Insertions
The flexor carpi ulnaris inserts onto the proximal palmar
edge of the pisiform, forming a crescent-shaped insertion
that is convex proximally and concave distally. The abduc-
tor digiti minimi (quinti) originates on the distal portion of
the pisiform, forming an oval origin area. The pisiform is
enclosed in these myotendinous structures (see Fig. 1.37).
There are no muscle origins or insertions on the dorsal
surface of the pisiform.
Vascularity of the Pisiform
The pisiform receives its blood supply through the proximal
and distal poles from branches of the ulnar artery (see Fig.
1.29A,B). The pisiform is a sesamoid bone in the tendon of
the flexor carpi ulnaris. The tendon attaches to the pisiform
proximally, and the proximal blood supply enters in this
area. One to three vessels penetrate inferior to the triquetral
FIGURE 1.32. Right pisiform. Dorsal aspect.

facet. These proximally entering vessels divide into multiple
branches. Two superior branches run parallel beneath the
articular surface of the facet, and one or two inferior
branches run along the palmar cortex and anastomose with
the superior branches (99).
The distal vascular supply includes one to three vessels
that enter inferior to the articular facets, divide into supe-
rior and inferior branches, and run parallel to the palmar
cortex. These distally entering vessels anastomose with the
proximal vessels. The superior vessels run deep to the artic-
ular facet and communicate with the proximal superior ves-
sels, forming an arterial ring deep to the facet. There are
multiple anastomoses between the proximal and the distal
vascular networks.
Clinical Correlations: Pisiform
Fracture of the pisiform can occur with a fall on the dorsi-
flexed, outstretched hand. Avulsion of its distal portion
with a vertical fracture can occur from a direct blow while
the pisiform is held firmly against the triquetrum under
tension from the flexor carpi ulnaris (67,113,115).
Accessory Bones
There is an accessory bone that can be associated with the
pisiform, the os pisiforme secundarium (Fig. 1.27B). It is
located at the proximal pole of the pisiform, and, if not
appreciated, it may be mistaken for a fracture. An accessory
bone usually represents the residual of a secondary ossifica-
tion center that does not fuse with the associated bone, but it
also may arise from trauma or heterotopic ossification of syn-
ovial tags (46,47).
HAMATE (OS HAMATUM, UNCIFORM)
Derivation and Terminology
Hamate is derived from the Latin hamulus, meaning
“hook,” and hamatum, meaning “hooked” (1). The hamate
also may be referred to as the unciform bone, derived from
the Latin uncus, also meaning “hook,” and forma, meaning
“likeness,” “shape,” or “form” (2).
A B
FIGURE 1.33. Right hamate. A: Medial aspect. B: Inferolateral aspect.
1 Skeletal Anatomy 55
Ossification Centers and Accessory Bones
The hamate is cartilaginous at birth. It has one ossification
center that begins to ossify at the end of the third month. Of
all the carpal bones, the hamate usually is the second to ossify
(after the capitate) and, on occasion, ossification already may
have started at birth (5,74–76) (see Fig. 1.27A).
Several accessory bones can be associated with the
hamate. Accessory bones, if present, usually are the result of
a secondary or additional ossification center that does not
fuse with the associated bone. Those associated with the
hamate include the os hamuli proprium, os hamulare basale
(carpometacarpale VII), os hypotriquetrum, os epitri-
quetrum (os epipyramis, os centrale IV), os ulnare exter-
num, os vesalianum manus (os vesalii, os carpometacarpale
VIII), os gruberi (os carpometacarpale VI), and os capita-
tum secundarium (carpometacarpale V) (see Fig. 1.27B)
(46). The os hamuli proprium is a secondary ossification
center in the hook of the hamate that does not fuse with the
body. It is located in the palmar aspect of the mid-body,
where the hook usually is located. The os hamulare basale is
located between the distal body of the hamate and the base
of the ring finger metacarpal. The os hypotriquetrum is
located proximal to the proximal pole of the hamate, adja-
cent to the lunate, capitate, and triquetrum. The os epitri-
quetrum is located proximal to the proximal pole of the
hamate, adjacent to the triquetrum and lunate, just ulnar to
the site of the os hypotriquetrum. The os ulnare externum
is located ulnar to the distal body of the hamate, distal to
the triquetrum. The os vesalianum manus is located proxi-
mal to the small finger metacarpal, near the styloid. The os
gruberi is located at the radiodistal margin of the body of
the hamate, between the hamate, capitate, and the base of
the ring and base of the long finger metacarpals. The os cap-
itatum secundarium is located just radial to the site of the
os gruberi, at the radiodistal margin of the hamate body and
between the capitate and bases of the ring and long finger
metacarpals (46) (see Fig. 1.27B).
Osteology of the Hamate
The hamate consists of a body, a proximal pole, and a hook
(hamulus; Fig. 1.33; see Figs 1.25, 1.26, 1.37, and 1.38). It
56 Systems Anatomy
consists internally of cancellous bone, surrounded by a cor-
tical shell (see Fig. 1.33). The hamate is an irregularly shaped
bone with an unciform hamulus (hook). The hook is located
on the distal portion of the palmar surface, slightly closer to
the medial aspect. The hook projects palmarly from the
rough palmar surface. The hook is slightly curved, with its
convexity medial and concavity lateral. The tip of the hook
has a slight lateral inclination and serves as a point of attach-
ment for a portion of the transverse carpal ligament. The
hook of the hamate and the pisiform contribute to the
medial wall of the carpal tunnel. The convex (medial) side of
the hook is rough. The concave (lateral) side is smooth
where the adjacent flexor tendons to the small finger pass. At
the base of the hook, on the medial side, there may be a
slight transverse groove in which the terminal deep branch
of the ulnar nerve may contact as it passes distally.
The body of the hamate is somewhat triangular or
cuneiform (wedge shaped), with a wide distal portion and a
narrowing into an apex proximolaterally. The dorsal and
palmar surfaces of the body are largely nonarticular, and are
rough for attachments of the carpal ligaments. The distal,
wide surface of the hamate consists of the articular surfaces
for the base of the small and ring finger metacarpals. The
articular surface thus has two facets, one for each
metacarpal, separated by a slight intraarticular ridge. The
facet for the ring finger metacarpal is smaller than that for
the small finger metacarpal. The proximal surface narrows
into a thin margin of the wedge-shaped body. At the tip of
the proximal surface there usually is a small, narrow facet
for articulation of the lunate. The hamate may be in con-
tact with the lunate only during ulnar deviation of the
wrist. The medial surface of the body of the hamate is broad
and somewhat rectangular. In contains the relatively large
articular surface for articulation with the triquetrum. The
surface is curved, with a convexity proximally that becomes
concave distally. At the distal aspect of the medial side of
the body, there is a narrow medial strip that is nonarticular.
On the lateral surface of the body of the hamate, the rela-
tively large surface is nearly completely articular, with the
exception of a small area on the distal palmar angle. The
proximal portion or the lateral aspect is convex, and the dis-
tal portion is slightly concave. The lateral aspect articulates
with the capitate.
Associated Joints
The hamate articulates with five bones: the triquetrum, the
capitate, the base of the ring and small finger metacarpals,
and the small articulation with the lunate (see Figs. 1.25,
1.26, 1.33, 1.37, and 1.38). The hamate articulation with
the triquetrum is along the proximal and medial aspects,
through a relatively large, oval-shaped articular surface area.
The hamate articulates with the capitate along its lateral
surface, also involving a relatively large, oval articular sur-
face area. The hamate articulates with the base of the
metacarpals through two facets, one to the small and one to
the ring finger. The articulation with the small finger
metacarpal usually involves a much larger articular facet. In
addition, the very most proximal portion articulates with
the lunate, especially when the wrist is ulnarly deviated.
Muscle Origins and Insertions
The opponens digiti minimi and flexor digiti minimi orig-
inate from the palmar ulnar surface of the hook of the
hamate (see Figs. 1.37 and 1.38). In addition, a small por-
tion of the flexor carpi ulnaris may insert into the palmar
aspect of the hamate (the major insertion of the flexor carpi
ulnaris is into the proximal portion of the palmar surface of
the pisiform) (2).
There are no muscle origins or insertions on the dorsal
surface of the hamate.
Vascularity of the Hamate
The vascularity of the hamate is supplied from three main
sources: the dorsal intercarpal arch, the ulnar recurrent
artery, and the ulnar artery (see Fig. 1.29A,B). The vessels
enter through the three nonarticular surfaces of the hamate,
which include the dorsal surface, the palmar surface, and
the medial surface through the hook of the hamate. These
nonarticular surfaces of the hamate are somewhat rough for
attachment of carpal ligaments.
The dorsal surface is triangular in shape and receives three
to five vessels. These branch in several directions to supply
the dorsal 30% to 40% of the bone (73,99). Small foramina
usually are easily visible on the dorsal surface.
The palmar surface also is triangular and usually receives
one large vessel that enters through the radial base of the
hook. It then branches and anastomoses with the dorsal ves-
sels in 50% of studied specimens (73,99).
The hook of the hamate receives one or two small vessels
that enter through the medial base and tip of the hook.
These vessels anastomose with each other but usually not
with the vessels to the body of the hamate.
Clinical Correlations: Hamate
Fracture of the hook of the hamate often occurs in sports-
related use of clubs, bats, or racquets (116). Direct force
exerted by these objects against the hypothenar eminence or
transverse carpal ligament has been implicated (67,116).
Fracture of the hook of the hamate often is not visible on
standard radiographs. It may be visualized with the carpal tun-
nel view. Alternatively, trispiral, computed tomography or
MRI may show difficult-to-visualize fractures.
Untreated displaced fractures of the hook of the hamate
may lead to attrition rupture of the flexor tendons to the
small finger because these tendons pass against the hook
and can be subject to wear from contact and friction against
 1 Skeletal Anatomy 57

a jagged fracture surface. A patient with a hook of the Ossification Centers and Accessory Bones
hamate fracture may perceive pain on the dorsum of the
The capitate usually is cartilaginous at birth. It has one ossi-
hamate and palpation over the hook on the palmar side
fication center that begins to ossify in the second month.
usually elicits tenderness.
Of all the carpal bones, the capitate (or hamate) usually is
The incidence and location of arthrosis and chondroma-
the first to ossify, and occasionally ossification already may
lacia (with cartilage erosions and exposed subchondral
have started at birth (5,74–76) (see Fig. 1.27A).
bone) is among the highest at the proximal pole of the
Several accessory bones can be associated with the capi-
hamate. Chondromalacia was found in 16.8%; arthrosis
tate. Accessory bones, if present, usually are the result of a
with exposed subchondral bone was found in 28.2% (94).
secondary or additional ossification center that does not
Arthrosis at the proximal pole of the hamate also is associ-
fuse with the associated bone. Those associated with the
ated with the presence of a mid-carpal plica. A mid-carpal
capitate include the os subcapitatum, os capitatum secun-
plica was identified in 1% of 393 wrists. All wrists that had
darium (carpometacarpale V), os gruberi (os car-
a mid-carpal plica also were found to have arthrosis at the
pometacarpale VI), os hypotriquetrum, os epitriquetrum
proximal pole of the hamate (94).
(epipyramis, os centrale IV), os hypolunatum (os centrale
III), os epilunatum (os centrale II), os centrale (os centrale
Accessory Bones dorsale, os episcaphoid), os metastyloideum, os parasty-
loideum (os carpometacarpale III), and os styloideum (car-
Several accessory bones may be associated with the hamate
pometacarpale IV) (see Fig. 1.27B) (25,46). The os subcap-
and can be mistaken for fractures (Fig. 1.27B). An accessory
itatum is located adjacent to the central portion of the body
bone usually represents the residual of a secondary ossifica-
of the capitate. The os capitatum secundarium is located at
tion center that does not fuse with the associated bone, but
the distoulnar corner of the capitate, adjacent to the distal
it also may arise from trauma or heterotopic ossification of
hamate, and the bases of the longer and ring finger
synovial tags (46,47). The accessory bones associated with
metacarpals. The os gruberi is located just ulnar to the site
the hamate include the os hamuli proprium (located in the
of the os capitatum secundarium, at the distoulnar corner
area of the hook), the os hamulare basale (located at the dis-
of the capitate and adjacent to the bases of the ring and long
tal margin of the hamate, in the vicinity of the bases of the
metacarpals. The os hypotriquetrum is located ulnar to the
long and ring finger metacarpals), the os hypotriquetrum
base of the capitate, proximal to the proximal pole of the
(located proximal to the proximal pole of the hamate, adja-
hamate, and adjacent to the triquetrum and lunate. The os
cent of the lunate, capitate, and triquetrum), the os epitri-
epitriquetrum is located just ulnar to the site of the os
quetrum (located proximal to the proximal pole of the
hypotriquetrum, proximal to the proximal pole of the
hamate, in the vicinity of the lunate, capitate, and tri-
hamate, and adjacent to the triquetrum and lunate. The os
quetrum, just ulnar to the site of the os hypotriquetrum),
hypolunatum is located just proximal to the proximal mar-
the os ulnare externum (located ulnar to the body of the
gin of the capitate, between the lunate and adjacent to the
hamate, just distal to the triquetrum), the os vesalianum
proximal pole of the scaphoid. The os epilunatum is located
manus (locate ulnar and slightly distal to the hamate, near
between the capitate, lunate, and scaphoid, just radial to the
the styloid process of the base of the small finger
site of the os hypolunatum. The os centrale is located
metacarpal), the os gruberi (located at the distoradial corner
between the capitate, scaphoid, and trapezoid. The os
of the hamate, adjacent to the capitate and bases of the long
metastyloideum is located at the distoradial aspect of the
and ring finger metacarpals), and os capitatum secundar-
capitate, between the trapezoid and base of the index finger
ium (located at the distoradial corner of the hamate, adja-
metacarpal. The os parastyloideum is located at the distora-
cent to the capitate and bases of the long and ring finger
dial aspect of the capitate, slightly distal to the site for the
metacarpals, just radial to the site of the os gruberi; see Fig.
os metastyloideum, between the capitate and base of the
1.27B) (46) (see descriptions earlier, under Ossification
index and long finger metacarpals. The os styloideum is
Centers and Accessory Bones).
located at the distal aspect of the capitate, just ulnar to the
site for the os parastyloideum, between the capitate and the
base of the index and long finger metacarpals (46) (see Fig.
CAPITATE (OS CAPITATUM, OS MAGNUM)
1.27B).
Derivation and Terminology
The name capitate is derived from the Latin caput, meaning
Osteology of the Capitate
“head.” Capitate denotes “head-shaped” (1). It also has been
suggested that the word capitate indicates the “head” of the The capitate is the largest and centrally located carpal bone,
wrist because it is the largest bone of the carpus. The older containing articulations with the lunate, scaphoid, trape-
British literature may refer to the capitate as the os magnum, zoid, the long, index, and ring finger metacarpals, the
derived from magnum, indicating “large” (2). hamate, and the triquetrum (Fig. 1.34; see Figs. 1.25, 1.26,
58 Systems Anatomy
A B
FIGURE 1.34. Right capitate. A: Medial aspect. B: Lateral aspect.
1.37, and 1.38). It consists internally of cancellous bone,
surrounded by a cortical shell (see Fig. 1.34). It is elongated
in the proximo distal direction, and thus contains a longi-
tudinal axis. There is a slight concavity to the dorsal, radial,
and ulnar surfaces, thereby producing a “waist” that is nar-
rowed and located slightly proximal to the transverse mid-
line. The dorsal surface is larger than the palmar surface.
Both are rough for attachment of carpal ligaments. The pal-
mar surface is flat or slightly convex. The proximal pole is
rounded. The distal end is flattened with slightly squared
corners on the medial and lateral aspects. The distal surface,
which is transverse to its axis, is triangular (apex located pal-
marly), with both a concave and a convex component. The
distal articulation is mainly with the base of the long finger
metacarpal. There are slight variations as to the specific
articulations distally (see later, under Anomalies and Varia-
tions). The medial and lateral borders are somewhat con-
cave. The lateral border usually has a narrow concave strip
for the medial side of the base of the index metacarpal. The
dorsal medial angle of the distal aspect usually (approxi-
mately 86% of wrists) has a facet for the articulation with
the base of the ring finger metacarpal. This small facet may
be absent in 14% (81,94,117). The relatively large head of
the capitate, consisting of the proximal rounded pole, pro-
jects into the concavity formed by the lunate and scaphoid.
The proximal surface articulates with the lunate and the
proximal portion of the lateral surface articulates with the
scaphoid. Along the distolateral surface, there is a separate
facet for the trapezoid. This facet may be separated from the
facet for the scaphoid by a rough interval. The medial sur-
face of the capitate has a relatively large, concave facet for
the hamate.
Anomalies and Variations in Morphology
of the Capitate
The distal aspect of the capitate articulates mainly with the
base of the long finger metacarpal. In 84% to 86% of
wrists, the capitate also has a small, narrow facet for articu-
lation with the base of the ring finger metacarpal
(94,117,118). The capitate–ring finger metacarpal articula-
tion, when present, usually is easily identifiable on standard
radiographs (118). A separate facet for articulation with the
ring finger metacarpal was found to be absent on the capi-
tate in 14% of wrists (81,94,117).
Associated Joints
The capitate articulates with seven bones, largely with the
lunate, scaphoid, trapezoid, the base of the long finger
metacarpal, and the hamate (see Figs. 1.25, 1.26, 1.34,
1.37, and 1.38). There are smaller articulations with the
base of the index and ring finger metacarpals, and, with
the wrist in certain positions (radial deviation), with the
triquetrum. The capitate articulates with the lunate prox-
imally, where the capitate’s proximal pole sits deep in the
crescent-shaped fossa of the lunate, forming a major por-
tion of the mid-carpal joint. The capitate also articulates
with the scaphoid proximally and radially; the articular
surface of the capitate is irregular and somewhat oval, and
encompasses the proximal portion of the lateral border of
the capitate. The capitate articulates with the trapezoid
on the distal portion of its lateral border through a rela-
tively small articular surface area. Distally, the capitate
articulates largely with the base of the long finger
metacarpal. On the distal radial corner of the capitate,
there is a smaller articulation with the ulnar proximal cor-
ner of the base of the index metacarpal. Along a small
strip of the distal ulnar corner of the capitate, there also
is a narrow articulation with the radial proximal corner of
the base of the ring finger metacarpal. (Thus, the capitate
articulates with three metacarpals: the index, long, and
ring fingers.) Along the entire concave ulnar border of the
capitate, there is a long, somewhat ovoid articulation
with the body and proximal pole of the hamate. At the
proximal ulnar border of the capitate there is a potential
small articulation with the triquetrum when the wrist is
radially deviated.

Muscle Origins and Insertions
Approximately half of the oblique head of the adductor pol-
licis (adductor pollicis obliquus) originates from the distal
radial part of the palmar surface of the capitate (see Figs.
1.37 and 1.38). The base of the long finger metacarpal
serves for the other, distal half of the origin of the oblique
head; the trapezoid also may contain a small portion of the
origin of the oblique head of the adductor pollicis.
There are no muscle origins or insertions on the dorsal
surface of the capitate.
Vascularity of the Capitate
The capitate receives its vascularity from both dorsal and
palmar sources. The main vascularity originates from vessels
from the dorsal intercarpal and dorsal basal metacarpal
arches, as well as from significant anastomoses between the
ulnar recurrent and palmar intercarpal arches (see Fig.
1.29A,B). The vessels that enter the capitate penetrate
through the two nonarticular surfaces on the dorsal and pal-
mar aspects of the bone.
The dorsal surface of the capitate is rough for attachments
of the dorsal carpal ligaments. The dorsal surface is broad, rel-
atively wide, and contains a deeply concave portion. Two to
four nutrient vessels enter the distal two-thirds of the dorsal
concavity. Smaller vessels occasionally enter more proximally,
near the neck. Multiple small foramina usually are visible in
this dorsal portion of the capitate. The entering dorsal vessels
course palmarly, proximally, and ulnarly within the capitate
in a retrograde fashion to supply the body and head. This
dorsal supply continues palmarly and proximally, eventually
reaching the vicinity of the convex rough palmar surface. Ter-
minal vessels reach the proximal palmar head and terminate
just deep to the articular surface (73,99).
The palmar vascular contribution is through one to three
vessels. These vessels enter the palmar surface on the distal
half of the capitate and course proximally in a retrograde
fashion. Small foramina may be visible in this palmar area
of the capitate. In 33% of studied specimens, the vascular-
ity to the capitate head originated entirely from the palmar
surface. There are notable anastomoses between the dorsal
and the palmar blood supplies in 30% of specimens studied
(73,99).
Clinical Correlations: Capitate
The capitate is rarely fractured because of its protected posi-
tion in the carpus.
The “naviculocapitate syndrome” consists of fracture of
the capitate and the scaphoid, with the proximal capitate
fragment rotated 90 to 180 degrees. The articular surface thus
is displaced anteriorly or faces the fracture surface of the cap-
itate neck (119). (Also known as scaphocapitate syndrome.)
1 Skeletal Anatomy 59
Accessory Bones
Several accessory bones may be associated with the capitate
and can be mistaken for fractures. An accessory bone usu-
ally represents the residual of a secondary ossification cen-
ter that does not fuse with the associated bone, but it also
may arise from trauma or from heterotopic ossification of
synovial tags (46,47). The accessory bones associated with
the capitate include the os subcapitatum (located adjacent
to the distal body), the os capitatum secundarium (located
between the capitate and bases of the long and ring finger
metacarpals), the os gruberi (located between the capitate
and bases of the ring and long finger metacarpals, just ulnar
to the site for the os capitatum secundarium), the os
hypotriquetrum (located between the capitate, proximal
pole of the hamate, triquetrum, and lunate), the os epitri-
quetrum (located between the capitate, proximal pole of the
hamate, triquetrum, and lunate, just ulnar to the site for the
os hypotriquetrum), the os hypolunatum (located between
the capitate, lunate, and scaphoid, just ulnar to the site of
the os epilunatum), the os epilunatum (located between the
capitate, lunate, and scaphoid), the os centrale (located
between the capitate, scaphoid, and trapezoid), the os
metastyloideum (located between the capitate, trapezoid,
and base of the index finger metacarpal), the os parasty-
loideum (located between the capitate and bases of the
index and long finger metacarpals), and the os styloideum
(located between the capitate and bases of the index and
long finger metacarpals, just ulnar to the site for the os
parastyloideum; see Fig. 1.27B) (46) (see descriptions ear-
lier, under Ossification Centers and Accessory Bones).
TRAPEZOID (OS TRAPEZOIDEUM,
OS MULTANGULUM MINUS, LESSER
MULTANGULAR)
Derivation and Terminology
The name is derived from the Latin trapezoides and the
Greek trapezoeides, both indicating “table-shaped.” This has
been extrapolated to denote a four-sided plane, with two
sides parallel and two diverging (1). The word multangular
pertains to “many-sided.”
Ossification Centers and Accessory Bones
The trapezoid is cartilaginous at birth. It has one ossifica-
tion center that begins to ossify during the fourth year in
girls and in the fifth year in boys (74) (see Fig. 1.27A).
Several accessory bones can be associated with the trape-
zoid. Accessory bones, if present, usually are the result of a
secondary or additional ossification center that does not
fuse with the associated bone. Those associated with the
trapezoid include the os trapezoideum secundarium (mul-
60 Systems Anatomy
tangulum minus secundarium), the os metastyloideum, the
os centrale (centrale dorsale, episcaphoid), and the os
trapezium secundarium (multangulum majus secundarium,
carpometacarpale II) (see Fig. 1.27B) (46). The os trape-
zoideum secundarium is located at the distal radial corner
of the trapezoid, between the trapezoid and the radial base
of the index finger metacarpal. The os metastyloideum is
located at the distal ulnar corner of the trapezoid, between
the trapezoid and the ulnar base of the index finger
metacarpal. The os centrale is located between the trape-
zoid, scaphoid, and capitate. The os trapezium secundarium
is located at the radial margin of the trapezoid, between the
trapezoid, trapezium, and base of the thumb and index
metacarpals (46) (see Fig. 1.27B).
Osteology of the Trapezoid
The trapezoid is a small, irregular carpal bone, with some-
what of a mushroom, wedge, or T-shape, larger dorsally
than palmarly (Fig. 1.35; see Figs. 1.25, 1.26, 1.37, and
1.38). It consists internally of cancellous bone, surrounded
by a cortical shell (see Fig. 1.35). The trapezoid is the small-
est bone in the distal carpal row. When viewed dorsally, the
dorsal surface is oval, elongated in the radioulnar direction.
Its dorsal surface is rough. The smaller palmar portion is a
projection from the wide dorsal portion, connecting to the
dorsal portion slightly laterally. When viewed palmarly, the
palmar portion is round or slightly squared. The distal sur-
face articulates with a groove in the base of the index
metacarpal. The distal surface is triangular, with the apex
palmar. This distal articular surface is convex, containing
two smaller concave facet-like surfaces located radially and
ulnarly. The medial surface articulates with the distal, radial
part of the capitate. The medial articular surface on the
trapezoid is narrow and concave from dorsal to palmar. The
narrow lateral surface of the trapezoid is convex and smooth
and articulates with the trapezium. The proximal portion
articulates with the scaphoid tuberosity articular surface,
forming the ulnar facet of the triscaphe joint.
Associated Joints
The trapezoid articulates with four bones: the base of the
index finger metacarpal, the capitate, the scaphoid, and the
trapezium (see Figs. 1.25, 1.26, 1.35, 1.37, and 1.38).
A B
FIGURE 1.35. Right trapezoid. A: Medial aspect. B: Inferolateral aspect.
Along its distal surface, the trapezoid articulates with base
of the index metacarpal, where the trapezoid sits in a groove
of the metacarpal. The trapezoid articulates along its ulnar
border with the capitate, where the trapezoid contains a
small rectangular facet on the ulnar aspect near the palmar
surface. The trapezoid articulates proximally with the
scaphoid, forming the ulnar component of the triscaphe
joint. The trapezoid also articulates radially with the trapez-
ium, where a convex surface of the lateral border of the
trapezoid sits in a concave articular surface of the trapez-
ium. The four articular surfaces of the trapezoid all connect
with each other, each separated by a relatively sharp edge.
Muscle Origins and Insertions
The trapezoid gives origin to one, and possibly two mus-
cles: the deep head of the flexor pollicis brevis, and, variably,
to a small portion of the origin of the adductor pollicis
(oblique head; see Figs. 1.37 and 1.38).
The deep head of the flexor pollicis brevis originates
from the palmar aspect of the trapezoid. (The superficial
head originates from the transverse carpal ligament and
from the palmar aspect of the trapezium.) The flexor polli-
cis brevis inserts into the radial sesamoid and into the radial
aspect of the base of the proximal thumb metacarpal.
A small portion of the origin of the adductor pollicis
oblique head (adductor pollicis obliquus) may originate
from the distal ulnar corner of the palmar surface of the
trapezoid. (The major origins of the adductor pollicis
obliquus are from the base of the long metacarpal and dis-
tal portion of the palmar surface of the capitate.)
There are no muscle origins or insertions on the dorsal
surface of the trapezoid.
Vascularity of the Trapezoid
The trapezoid is supplied by branches from the dorsal inter-
carpal and basal metacarpal arches and the radial recurrent
artery (see Fig. 1.29A,B). The nutrient vessels enter the
trapezoid through its two nonarticular surfaces on the dor-
sal and palmar surfaces.
The main blood supply of the trapezoid is from the dor-
sal supply. The dorsal surface is broad and flat, where the
nonarticular surface serves for attachment of carpal liga-
ments. Three or four small vessels enter the dorsal surface in

the central aspect of the rough surface. Multiple small
foramina usually are visible in this dorsal area. After pene-
trating the subchondral bone, the vessels branch to supply
the dorsal 70% of the bone. These dorsal vessels provide the
primary vascularity of the trapezoid (99).
The palmar blood supply provides vascularity to approxi-
mately 30% of the trapezoid. The palmar surface is narrow,
flat, and relatively small, and contains a small nonarticular
portion where ligaments attach. In this area, one or two small
vessels penetrate the central palmar portion. After entering
the palmar surface of the trapezoid, the vessels branch several
times to supply the palmar 30% of the bone. The palmar ves-
sels do not anastomose with the dorsal vessels (99).
Clinical Correlations: Trapezoid
Fractures of the trapezoid are rare because of its protected
position and its shape. Axial loading of the second metacarpal
can cause dorsal (or, more rarely, palmar) dislocation, with
associated rupture of the capsular ligaments (120).
Because of the wedge or mushroom shape of the trape-
zoid (with the wide portion dorsally), dislocations are much
more apt to occur dorsally than palmarly.
Oblique radiographs and tomography may be helpful to
visualize trapezoid fractures because the trapezoid is diffi-
cult to visualize on routine posteroanterior, anteroposterior,
or lateral views of the wrist.
Accessory Bones
Several accessory bones may be associated with the trape-
zoid and can be mistaken for fractures. An accessory bone
usually represents the residual of a secondary ossification
center that does not fuse with the associated bone, but it
also may arise from trauma or heterotopic ossification of
synovial tags (46,47). The accessory bones associated with
the trapezoid include the os trapezoideum secundarium
(located between the trapezoid, index finger metacarpal,
and trapezium), the os metastyloideum (located between
the trapezoid, base of the index finger metacarpal, and the
capitate), the os centrale (located between the trapezoid,
scaphoid, and capitate), and the os trapezium secundarium
(located between the trapezoid, trapezium, and the vicinity
of the bases of the index and thumb metacarpals; see Fig.
1.27B) (46) (see descriptions earlier, under Ossification
Centers and Accessory Bones).
TRAPEZIUM (OS TRAPEZIUM,
OS MULTANGULUM MAJUS,
GREATER MULTANGULAR)
Derivation and Terminology
The name is derived from the Latin and Greek trapezion,
indicating an irregular four-sided figure. The word multan-
gular denotes “many-sided.”
1 Skeletal Anatomy 61
Ossification Centers and Accessory Bones
The trapezium is cartilaginous at birth. It has one ossifica-
tion center that begins to ossify during the fourth year in
girls and the fifth year in boys (5,74) (see Fig. 1.27A).
Several accessory bones can be associated with the
trapezium. Accessory bones, if present, usually are the result
of a secondary or additional ossification center that does
not fuse with the associated bone. Those associated with the
trapezium include the os trapezium secundarium (multan-
gulum majus secundarium, carpometacarpale II), the os
praetrapezium (carpometacarpale I), the os paratrapezium,
the os epitrapezium, the os radiale externum (paras-
caphoid), and the os trapezoideum secundarium (multan-
gulum minus secundarium) (see Fig. 1.27B) (46). The os
trapezium secundarium is located between the trapezium
and the ulnar base of the thumb metacarpal. The os prae-
trapezium is located between the distal aspect of the trapez-
ium and the thumb metacarpal. The os paratrapezium is
located between the distoradial aspect of the trapezium and
the radial base of the thumb metacarpal. The os epitrapez-
ium is located at the proximal aspect of the trapezium,
between the trapezium and distoradial aspect of the
scaphoid. The radiale externum is located between the
trapezium and the distal scaphoid, proximal to the site of
the os epitrapezium (46) (see Fig. 1.27B).
Osteology of the Trapezium
The trapezium is the most radially located carpal bone,
assuming a functionally strategic position at the base of the
thumb metacarpal and positioned just distal to the scaphoid
(Fig. 1.36; see Figs. 1.25, 1.26, 1.37, 1.38, and 1.39). It
consists internally of cancellous bone, surrounded by a cor-
tical shell (see Fig. 1.36). The trapezium has an irregular
shape. The dorsal and palmar surfaces are rough. The dor-
sal surface is wide and may contain a slight indentation or
groove along which the radial artery passes. The palmar
surface is narrow and contains a deep groove on the pal-
mar ulnar surface. The groove forms the osseous portion
of the fibroosseous tunnel containing the flexor carpi radi-
alis tendon. Radial to the groove is a distinct longitudinal
ridge (trapezial ridge) running in the proximodistal direc-
tion. The trapezial ridge provides attachment for a portion
of the transverse carpal ligament (flexor retinaculum). The
trapezial ridge and palmar surface of the trapezium also
provide origins for the abductor pollicis brevis, opponens
pollicis, and flexor pollicis brevis muscles. The lateral sur-
face of the trapezium is broad and rough for attachment
of carpal ligaments. The trapezium contains four articular
surfaces for articulations with the scaphoid, trapezoid,
index finger metacarpal, and the thumb metacarpal. The
proximal articular surface is relatively small, and contains
the facet for the scaphoid. The distal articular surface is
relatively large and oval and saddle shaped. This distal
62 Systems Anatomy
A B
FIGURE 1.36. Right trapezium. A: Palmar aspect. B: Medial aspect.
articular surface articulates with the thumb metacarpal.
This large sellar (“saddle-shaped”) joint allows unique
mobility. The surface shape has been found to be funda-
mentally different in men and women. The surface area
also is significantly smaller in women (121). The ulnar
aspect of the trapezium is concave, and contains the artic-
ular surface for the trapezoid. A small area on the distal
ulnar aspect contains a narrow oval facet for articulation
with the radial base of the index finger metacarpal.
Associated Joints
The trapezium articulates with four bones: the scaphoid,
thumb metacarpal, trapezoid, and a small portion of the
index metacarpal (see Figs. 1.25, 1.26, and 1.36 to 1.38).
The trapezium articulates proximally with the scaphoid,
forming an important component of the triscaphe joint.
The articular surface on the trapezium for the scaphoid is
somewhat square or rectangular. Distally and radially, the
trapezium articulates with the thumb metacarpal through a
saddle-shaped articulation. The trapezium articulates with
the trapezoid along its medial border, where the articular
surface on the trapezium is somewhat square. Distally and
medially, there is a relatively small articulation of the trapez-
ium with the index metacarpal. This joint surface on the
trapezium is somewhat square or rectangular.
Muscle Origins and Insertions
The palmar surface of the trapezium contains origins of the
three thenar muscles: abductor pollicis brevis, flexor pollicis
brevis (superficial head), and opponens pollicis (see Figs.
1.37 and 1.38). These muscles attach to the palmar surface
or just lateral to the trapezial ridge. Although the flexor
carpi radialis does not actually insert into the trapezium, it
traverses through a fibroosseous tunnel along the ulnar
aspect of the trapezium.
There are no muscle origins or insertions on the dorsal
surface of the trapezium.
Vascularity of the Trapezium
The vascularity of the trapezium is from vessels from the
distal branches of the radial artery (see Fig. 1.29A,B).
Nutrient vessels enter the trapezium through its three
nonarticular surfaces. These surfaces are the dorsal and lat-
eral aspects, which are rough and serve as sites for ligamen-
tous attachment, and the prominent palmar tubercle from
which the thenar muscles arise. Dorsally, one to three ves-
sels enter and divide in the subchondral bone to supply the
entire dorsal aspect of the bone. Palmarly, one to three ves-
sels enter the mid-portion and divide and anastomose with
the vessels entering through the dorsal surface. Laterally,
three to six very fine vessels penetrate the lateral surface and
anastomose freely with the dorsal and palmar vessels. The
dorsal vascular supply usually supplies most of the vascular-
ity. There are frequent anastomoses among all three sys-
tems. The associated dorsal, palmar, and lateral surfaces of
the trapezium contain multiple foramina for the nutrient
vessels (83,99).
Clinical Correlations: Trapezium
Fracture of the articular surface of the trapezium is pro-
duced by the base of the thumb metacarpal being driven
into the articular surface of the trapezium by the adducted
thumb (67,122).
Avulsion fractures caused by capsular ligaments can
occur during forceful deviation, traction, or rotation (115).
Fracture of the trapezial ridge may occur from a direct
blow to the palmar arch or forceful distraction of the prox-
imal palmar arch to result in avulsion of the ridge of the
trapezium by the transverse carpal ligament (123,124). The
carpal tunnel view radiograph may be required to visualize
this fracture.
Accessory Bones
Several accessory bones may be associated with the trape-
zoid and can be mistaken for fractures. An accessory bone

usually represents the residual of a secondary ossification
center that does not fuse with the associated bone, but it
also may arise from trauma or heterotopic ossification of
synovial tags (46,47). The accessory bones associated
with the trapezium include the os trapezium secundarium
(located between the trapezium and the base of the
thumb metacarpal), the os praetrapezium (located
between the distal trapezium and central portion of the
base of the thumb metacarpal), the os paratrapezium
(located between the trapezium and the radial aspect of
the base of the thumb metacarpal), the os epitrapezium
(located between the trapezium and scaphoid), the os
radiale externum (located between the trapezium and
scaphoid, just proximal to the site for the os epitrapez-
ium), and the os trapezoideum secundarium (located
between the trapezium, trapezoid, and basses of the index
and thumb metacarpals; see Fig. 1.27B) (46) (see descrip-
tions earlier, under Ossification Centers and Accessory
Bones).
1 Skeletal Anatomy 63
METACARPALS (OSSA METACARPALIA)
Derivation and Terminology
The word metacarpal is derived from the Greek meta, which
indicates “beyond,” “after,” or “accompanying,” and karpos,
which means “wrist.” Therefore, metacarpal denotes
“beyond or after the wrist.”
General Features
The five metacarpals are named for their associated digit,
that is, thumb metacarpal, index finger metacarpal, long
finger metacarpal, ring finger metacarpal, and small finger
metacarpal. Although the metacarpals often are indicated
by number (thumb as the first metacarpal, small finger as
the fifth metacarpal), confusion has arisen as to which is the
first and which is the fifth. Therefore, identifying each by
associated digit is preferable.
Despite their small size, the metacarpals are true long
bones (4,5) (Figs. 1.37 to 1.39; see Figs. 1.25 to 1.27A).
FIGURE 1.37. Bones of right hand, palmar aspect,
showing muscle origins (red) and insertions (blue).
64 Systems Anatomy
A B
FIGURE 1.39. Right thumb metacarpal. A: Lateral (radial)
aspect. B: Medial (ulnar) aspect.
FIGURE 1.38. Bones of right hand, dorsal aspect,
showing muscle origins (red) and insertions (blue).
Each has an expanded proximal base, an elongated diaph-
ysis (shaft or body), and a distal head. The head and bases
consist internally of cancellous bone, similar to other long
bones. The shaft has a thickened cortex that gradually thins
at the diaphyseal–metaphyseal junction. A medullary canal
lies in the shaft.
Variation exists as to the relative lengths of the
metacarpals (125,126). The long finger metacarpal usually
appears as the longest, although the index finger metacarpal
often is the longest or of equal length to the long finger
metacarpal (125,126). The metacarpal of the ring finger
usually is shorter than that of the index finger. The small
finger metacarpal usually is the shortest. The metacarpal of
the ring and little finger may be unproportionately shorter
than those of the index and long fingers, resulting in an
asymmetry to the hand (125,126). With a clenched fist, the
metacarpal head of the long finger often appears to be the
most prominent. This is due in part to its greater length,

but also to the relatively “shorter” position of the index
metacarpal, which is recessed into the carpus slightly more
than the long finger metacarpal. This results in the long fin-
ger metacarpal appearing longer clinically. Posner and
Kaplan have described the relative length relationships in
terms of ratio of metacarpal size to the corresponding pha-
langes (125) (Table 1.3). The relative lengths of the proximal
phalanges compared with the corresponding metacarpals are
as follows: index, 1:1.6 to 2.4; long, 1:1.4; ring 1:1.3 to 1.5;
little, 1:1.7 (125,126).
The base of each metacarpal flares from the shaft into a
wide proximal end. The flared base is cuboidal, wider dor-
sally than palmarly.
The shafts of the metacarpals are curved longitudinally,
with a slight convexity dorsally and concavity palmarly. The
radial and ulnar aspects of the shafts also are curved in a
slight concavity, presenting a surface for attachment of the
interosseous muscles. On the palmar surface of the shaft is
a prominent ridge that separates the attachments of adja-
cent palmar interosseous muscles. The dorsal surface is flat-
tened and somewhat triangular, with the apex proximal.
The flattened dorsal surface allows easy gliding of the over-
lying extrinsic extensor tendons. The triangular outline
forms a ridge that runs along the dorsal aspect of the
metacarpal, separating two sloping surfaces that provide
attachments for the dorsal interosseous muscles.
The head of each metacarpal is slightly thicker in the
dorsopalmar direction. The articular surface of each head is
smooth, oblong, convex, and flattened from side to side.
On the radial and ulnar aspects of each head, at the level of
the dorsal surface, there is a tubercle that provides purchase
for a portion of the collateral ligaments. Between the tuber-
cles on the palmar side, there is a hollow fossa for the
attachment of a portion of the collateral ligament of the
metacarpophalangeal joint and for the joint capsule. The
dorsal surface of the head is broad and flat and accommo-
dates the overlying extrinsic extensor tendon. The palmar
aspect of the head contains a groove lying along the junc-
tion of the articular surface and the nonarticular portion of
the head. The extrinsic flexor tendons pass through the
groove, which helps form part of the fibroosseous tunnel of
the flexor sheath.
TABLE 1.3. RATIOS OF THE BONES OF THE
FINGERS
Distal Middle Proximal
Phalanx Phalanx Phalanx Metacarpal
Index 1 1.1–1.4 1.8–2.8 3.2–4.3
Middle 1 1.3–1.8 2.2–2.7 3.0–3.9
Ring 1 1.3–1.7 2.0–2.8 3.0–3.6
Small 1 1.0–1.2 1.6–2.2 2.7–3.9
From Posner MA, Kaplan EB. Osseous and ligamentous structures.
In: Spinner M, ed. Kaplan’s functional and surgical anatomy of the
hand, 3rd ed. Philadelphia: JB Lippincott, 1984:23–50.
1 Skeletal Anatomy 65
The articular surfaces are convex from dorsal to palmar
and from radial to ulnar, although there is less convexity
transversely. The metacarpal heads articulate with the proxi-
mal phalanges distally and the bases articulate with the distal
carpal row. The bases of the metacarpals also articulate with
each other (with the exception of the thumb metacarpal).
The metacarpals to the index, long, ring, and small finger
converge proximally. The thumb metacarpal, relative to the
other metacarpals, is positioned more anteriorly and rotated
medially on its axis through approximately 90 degrees, so
that its morphologic dorsal surface faces laterally and its mor-
phologic palmar surface faces medially. This rotation of the
thumb allows it to flex medially across the palm so that it can
be rotated into opposition with each finger. The motion of
opposition consists of flexion and medial rotation (prona-
tion) of the thumb across the palm, so that the pulp of the
thumb faces the pulp of the lesser digits.
The metacarpals can be associated with several sesamoid
bones. In general, a sesamoid is a bone that develops in a
tendon and occurs near a joint. By its location, the
sesamoid serves to increase the functional efficiency of the
joint by improving the angle of approach of the tendon into
its insertion (25). Sesamoids are variably present. They are
most common at the metacarpophalangeal joint of the
thumb, in the intrinsic tendons that flex the metacar-
pophalangeal joint. Sesamoids also often are present at the
metacarpophalangeal joint of the index and small finger,
and at the interphalangeal joint of the thumb. Occasionally,
one or two sesamoids may be present at any of the metacar-
pophalangeal joints of the hand (25). In addition to their
variable presence, a sesamoid may exist as a bipartite
sesamoid. They also may be fractured, resulting in two
small fragments with an irregular margin between them.
The metacarpals can be associated with several accessory
ossicles. In general, the development of these accessory
bones is from an additional or anomalous secondary ossifi-
cation center, and therefore the accessory bones are
described later under sections on ossification. Accessory
bones, however, also can occur from other causes such as
trauma (46) or heterotopic ossification of synovial tags (47).
Therefore, anomalous, irregular ossicles or ossicles of
abnormal size or shape may be encountered that do not fit
a specific described accessory bone or location. The acces-
sory bones located in the vicinity of the metacarpals, if pre-
sent, usually are near the base, between the metacarpal and
adjacent carpal bone. They usually form from a secondary
ossification center of the carpal bone (46).
THUMB METACARPAL
(OSSA METACARPALIA I)
Ossification Centers and Accessory Bones
The thumb metacarpal has two ossification centers, one pri-
mary center in the midshaft and one secondary center in
66 Systems Anatomy
the base (see Fig. 1.27A). This is in contrast to the remain-
ing metacarpals, which have one primary ossification center
in the shaft and one secondary center in the head. Ossifica-
tion in the midshaft begins in approximately the ninth
week of prenatal life. Ossification in the base begins late in
the second year in girls, and early in the third year in boys.
The ossification centers unite before the fifteenth year in
girls and before the seventeenth year in boys (127).
Several accessory bones can be associated with the
thumb metacarpal, usually located near or around the base
and in close proximity to the trapezium. These accessory
bones, if present, usually are the result of a secondary or
additional ossification center that does not fuse with the
associated bone. Those close to the thumb metacarpal usu-
ally are secondary ossification centers of the trapezium.
These accessory bones include the os trapezium secundar-
ium (multangulum majus secundarium, carpometacarpale
II), the os praetrapezium (carpometacarpale I), and the os
paratrapezium (46) (see Fig. 1.27B). The os trapezium
secundarium is located between the ulnar base of the thumb
metacarpal and the distal margin of the trapezium. The os
praetrapezium is located between the thumb metacarpal (in
the mid-portion of the base) and distal aspect of the trapez-
ium. The os paratrapezium is located between the radial
base of the thumb metacarpal and the distoradial aspect of
the trapezium (46) (see Fig. 1.27B).
Osteology of the Thumb Metacarpal
As emphasized by Williams [Gray’s Anatomy (5)], caution
needs to be exercised when describing the thumb
metacarpal because its position of rotation creates confu-
sion in describing the various surfaces. Morphologic terms
are used, but are supplemented in places by their topo-
graphic equivalents. For instance, the dorsal (lateral) surface
of the thumb can be considered to face laterally; its long axis
diverges in a distal lateral direction from the carpus.
The thumb metacarpal is short and thick, and differs in
shape and configuration from the metacarpals of the digits
(see Figs. 1.25, 1.26, and 1.37 to 1.39). It is more stout, its
shaft is thicker and broader, and it diverges to a greater
degree from the carpus than the other metacarpals.
The metacarpal contains the widened base, a narrow
shaft, and a rounded head. The head and the base of the
thumb metacarpal internally consist of cancellous bone sur-
rounded by a relatively thin cortical shell (see Fig. 1.39).
The shaft consists of thick cortical bone encircling the open
medullary canal. At the head and at the base, the medullary
canal rapidly changes to cancellous bone.
Base of the Thumb Metacarpal
The base of the thumb metacarpal differs greatly from all
the other metacarpals. The base flares into a wider trumpet-
shaped expansion, with a prominent palmar lip and thick-
ening on the radial and ulnar borders. The articular surface
at the base, which appears concave when viewed from the
medial lateral direction and convex when viewed from the
anteroposterior direction, is saddle shaped to accommodate
the saddle shape of the trapezial articular surface. The base
of the thumb metacarpal articulates only with the trapez-
ium. This complex joint surface configuration plays an
important role in the mechanism of opposition of the
thumb. It represents half of the saddle joint that it forms
with the corresponding surface of the trapezium (125). The
articular surface is demarcated from the shaft by a thick,
crestlike ridge that extends around the circumference,
clearly separating the articular surface from the shaft. On
the lateral (palmar) aspect of the base of the thumb
metacarpal lies the insertion area for the abductor pollicis
longus. There usually is a small tubercle at the lateral
metacarpal base for the insertion of this tendon. On the
ulnar aspect of the base lies the area of origin for the first
palmar interosseous muscle. This muscle origin may extend
distally to include a portion the ulnar aspect of the shaft.
There are no articular facets present on the sides of the
thumb metacarpal because this metacarpal does not articu-
late with any other metacarpal, in contrast to the remaining
metacarpals, each of which articulates at the base with its
adjacent metacarpal.
Shaft of the Thumb Metacarpal
The shaft of the thumb metacarpal is thick and broad. The
average thickness in the midshaft normally varies from 6 to
11 mm. The dorsal surface of the shaft is flat and wide, usu-
ally noticeably thicker and wider than the other
metacarpals. Its anteroposterior thickness is relatively less
pronounced, and in cross-section, the shaft is oval or some-
what triangular (apex palmar). It is mildly longitudinally
convex along its dorsal surface. It also is mildly longitudi-
nally concave palmarly, radially, and ulnarly. The palmar
(medial) surface of the shaft is divided by a blunt ridge into
a larger lateral (anterior) part, which gives rise to the oppo-
nens pollicis muscle, and a smaller medial (posterior) part,
which gives origin to the lateral head of the first dorsal
interosseous muscle (see Figs. 1.37 and 1.38).
Head of the Thumb Metacarpal
The head of the thumb metacarpal is rounded but less con-
vex than the other metacarpals. The head also is much less
spherical than the heads of the other metacarpals. It is thus
more suited for hingelike motion than it is for more uni-
versal joint motion (which is possible to a greater degree
with the other metacarpals). The articular surface is wide
and flat and has a quadrilateral appearance. The articular
surface extends much further palmarly than it does dorsally.
The head of the thumb metacarpal is thicker and broader
transversely. On the palmar aspect at the ulnar and radial

angles, there are two articular eminences or tubercles which
articulate the thumb sesamoid bones. The lateral articular
eminence is larger than the medial. The associated sesamoid
bones lie within the two heads of the flexor pollicis brevis.
Associated Joints
The head of the thumb metacarpal articulates with the base
of the proximal thumb phalanx (Fig. 1.40; see Figs. 1.25,
1.26, and 1.37 to 1.39). The base of the thumb metacarpal
articulates with the trapezium. Unlike the remaining
metacarpals, the thumb metacarpal does not articulate with
its adjacent (index) metacarpal.
Muscle Origins and Insertions
Four muscles usually attach to the thumb metacarpal:
abductor pollicis longus, opponens pollicis, first dorsal
interosseous and, inconsistently, a small portion of the ori-
gin of the flexor pollicis brevis (most of which originates
from the palmar trapezium) (4,5) (see Figs. 1.37 and 1.38).
In addition, the adductor pollicis and flexor pollicis brevis
muscles insert into the closely associated thumb sesamoid
bones, located palmar (medially) to the head of the thumb
metacarpal.
1 Skeletal Anatomy 67
The abductor pollicis longus inserts into a tubercle
located on the dorsal (lateral) aspect of the base of the
thumb metacarpal.
The opponens pollicis, which originates mainly from the
transverse carpal ligament as well as from the palmar trapez-
ium, inserts into a long, oval area along the radiopalmar
aspect of the shaft of the thumb metacarpal.
The first dorsal interosseous muscle is a bipennate muscle
with two heads of origin, one on the thumb metacarpal and
one on the index finger metacarpal. On the thumb
metacarpal, the muscle has its origin along the dorsomedial
aspect of the shaft of the thumb metacarpal. (On the index
metacarpal, the second head originates along the radial aspect
of the shaft.) The first dorsal interosseous inserts on the radial
base of the proximal phalanx of the index finger and acts to
abduct the index finger at the metacarpophalangeal joint.
There is disagreement over the attachment of a first
palmar interosseous muscle to the thumb. Although there are
three distinct palmar (volar) interossei, some accounts
describe four palmar interossei (128). When four are
described, the first palmar interosseous consists of a small
group of muscle fibers that takes origin from the ulnar side
of the thumb metacarpal and blends with the oblique head
of the adductor pollicis to insert with it on the ulnar side of
the thumb. The continuity of this slip with the origin of the
FIGURE 1.40. Frontal section through
articulations of the carpus.
68 Systems Anatomy
adductor pollicis from the bases of the index and long fin-
ger metacarpals, and its insertion with the adductor pollicis,
seem to be sufficient reason for calling it a part of the
adductor pollicis rather than a first palmar interosseous.
Some authors have called this same slip the deep head of the
flexor pollicis brevis. Functionally, the entire adductor pol-
licis is similar to a palmar interosseous (4,5,128).
The origin of the flexor pollicis brevis usually is from the
transverse carpal ligament, as well as from the trapezoid
(deep head) and trapezium (superficial head). However,
there may be a small slip of fibers that originates from the
base of the thumb metacarpal on the palmar, medial aspect.
These fibers join the superficial belly and continue to insert
on the radial sesamoid (4).
Clinical Correlations: Thumb Metacarpal
The thumb metacarpal ossifies somewhat like a phalanx.
For this reason, the thumb skeleton has been considered to
consist of three phalanges. However, others have considered
the distal phalanx of the thumb to represent fused middle
and distal phalanges, a condition occasionally seen in the
fifth toe (129). When the thumb has three phalanges, the
metacarpal usually has a distal and proximal epiphysis. It
occasionally bifurcates distally, the ulnar portion having no
distal epiphysis and bearing two phalanges, and the radial
bifurcation showing a distal epiphysis and three phalanges
(130). The existence of only a distal metacarpal epiphysis
may be associated with a greater range of movement at the
metacarpophalangeal joint. In the thumb, it is the car-
pometacarpal joint that has the wider range, and a basal epi-
physis in the first metacarpal may be attributable to this
(4,5). However, a distal epiphysis has been noted rarely in
the thumb metacarpal, and a proximal epiphysis has been
noted rarely in the index metacarpal (4,5).
In 1543, Vesalius originally suggested that the thumb
had three phalanges, considering the thumb metacarpal as
the proximal phalanx (4,5).
Sesamoid Bones
Sesamoid bones are common at the metacarpophalangeal
joints of the thumb and index and small fingers, and the
interphalangeal joint of the thumb. They may be mistaken
for fractures, and can themselves be fractured or develop as
bipartite sesamoids, further confusing the clinical impres-
sion. Schultz provides guidelines for distinguishing
sesamoids from fractures (25). Multipartite sesamoids usu-
ally are larger than a normal or fractured sesamoid. Multi-
partite sesamoids have smooth, more regular opposing sur-
faces with cortical margins, and may be bilateral. In an
acute fracture, the line of fracture is sharp, irregular,
assumes any shape, and may be displaced. At times, it may
be necessary to see fracture healing before the diagnosis can
be made (25,131–139).
Accessory Bones
Several accessory bones may be associated with the thumb
metacarpal and can be mistaken for fractures. An accessory
bone usually represents the residual of a secondary ossifica-
tion center that does not fuse with the associated bone, but
it also may arise from trauma or heterotopic ossification of
synovial tags (46,47). The accessory bones associated with
the thumb metacarpal are usually in the region of the base,
representing secondary centers associated with the trapez-
ium (see Fig. 1.27B). These accessory bones include the os
trapezium secundarium (located between the thumb
metacarpal and the distal ulnar corner of the trapezium),
the os praetrapezium (located between the central portion
of the base of the thumb metacarpal and the distal margin
of the trapezium), and the os paratrapezium (located
between the radial aspect of the base of the thumb
metacarpal and the distal radial corner of the trapezium
(46) (see Fig. 1.27B and descriptions earlier, under Ossifi-
cation Centers and Accessory Bones).
INDEX FINGER METACARPAL
(OSSA METACARPALIA II)
Ossification Centers and Accessory Bones
The index metacarpal (second metacarpal) has two ossifica-
tion centers, one primary center in the shaft and one sec-
ondary center in the head (see Fig. 1.27A). Ossification in
the midshaft begins in approximately the eighth or ninth
week of prenatal life. Ossification in the secondary head
center appears in the second year in girls, and between 1.5
to 2.5 years in boys. These secondary ossification centers
usually first appear in the index metacarpal, and sequen-
tially appear in the order of long finger, ring finger, and,
last, the small finger. The secondary ossification in the head
of the index metacarpal unites with the shafts at approxi-
mately the fifteenth or sixteenth year in women, and the
eighteenth, nineteenth, or twentieth year in men (127).
Several accessory bones can be associated with the index
finger metacarpal, usually located at the base between the
metacarpal and the trapezoid. These accessory bones, if pre-
sent, usually are the result of a secondary or additional ossi-
fication center that does not fuse with the associated bone.
Those associated with the index metacarpal usually are from
a secondary ossification center of the trapezoid. These
include the os trapezoideum secundarium (multangulum
minus secundarium), the os metastyloideum, and the os
parastyloideum (os carpometacarpale III) (see Fig. 1.27B)
(46). The os trapezoideum secundarium is located at the
radial base of the index metacarpal and the distal radial cor-
ner of the trapezoid. The os metastyloideum is located
between the ulnar base of the index finger metacarpal, the
distal ulnar corner of the trapezoid, and the distoradial cor-
ner of the capitate. The os parastyloideum is located

between the ulnar base of the index metacarpal, the dis-
toradial corner of the capitate, and the radial base of the
long finger metacarpal. It is located just radial to the site for
the os styloideum (which is associated with long finger
metacarpal; see Fig. 1.27B) (46).
Osteology of the Index Metacarpal
The index metacarpal often is the longest metacarpal and
usually has the largest base. It comprises a widened proxi-
mal base, a narrow curved shaft, and a rounded head (Fig.
1.41; see Figs. 1.25, 1.26, 1.37, and 1.38).
The head and base consist internally of cancellous bone
surrounded by a relatively thin cortical shell (see Fig. 1.41).
The shaft consists of thicker cortical bone that encircles the
open medullary canal. At the base and the neck, the
medullary canal rapidly changes to cancellous bone.
Base of the Index Finger Metacarpal
The base of the index metacarpal has a unique groove or
fork in the dorsopalmar direction. The fork is widened
proximally, slightly larger medially than laterally, and open
toward the carpus for articulation with the trapezoid. The
trapezoid thus is nestled securely by the base of the index
metacarpal. Medial to the groove in the base of the
metacarpal there is an extension of bone forming a ridge
that articulates with the capitate. On the lateral aspect of
the base, near the dorsal surface, is a quadrilateral facet for
articulation with the trapezium. Dorsal to the trapezial facet
A B
FIGURE 1.41. Right index finger metacarpal. A: Dorsolateral
aspect. B: Medial aspect.
1 Skeletal Anatomy 69
is a roughened area for the insertion of the extensor carpi
radialis longus. On the palmar surface of the base is a small
tubercle or ridge that provides attachment for the insertion
of the flexor carpi radialis. The medial side of the base of the
index metacarpal is thickened, forming the larger half of the
metacarpal base. This portion articulates with the base of
long finger metacarpal through a prominent thickening, the
styloid process of the base of the long metacarpal (125,
126). This articulation includes a long facet, narrow in its
central area. The base of the index metacarpal thus includes
a total of four articular facets. The ulnar side of the base of
the index metacarpal, which articulates with the styloid
process of the long metacarpal, has a small, roughened area
just distal to the articular facet for insertion of strong
interosseous ligaments. These ligaments hold the base of the
index and long finger metacarpals together. There is a slight
depression between the two halves of the base of the
metacarpal that usually contains several small foramina for
nutrient arteries that arise from the dorsal carpal arch. Sim-
ilar to the dorsal surface, the palmar surface of the
metacarpal has a roughened area with multiple foramina for
the palmar nutrient arteries entering the base (125).
Shaft of the Index Finger Metacarpal
The shaft of the index metacarpal is curved, convex dorsally
and concave palmarly. It has a flat, triangular dorsal surface
immediately proximal to the head. The shaft is oval or
slightly triangular in cross-section, flattened dorsally. The
dorsal surface is broad more distally, but proximally the
dorsal surface narrows to a ridge. The dorsal surface is lined
by lateral ridges that converge toward the dorsum, approx-
imately at the junction of the distal two-thirds with the
proximal third, to form a single ridge running proximally
and ending at the apex of the forked base. The palmar sur-
face of the shaft is smooth in the central area, but becomes
more irregular at the proximal and distal ends. The
metacarpal has converging borders that begin at the tuber-
cles, one on each side of the head for the attachment of col-
lateral ligaments. Along the shaft of the index metacarpal
three interosseous muscles originate, two dorsal
interosseous and one palmar interosseous. Proximally, the
lateral surface inclines dorsally for the ulnar head of the first
dorsal interosseous muscle. The medial surface inclines sim-
ilarly, and is divided by a faint ridge into two areas: a pal-
mar strip for origin of the first palmar interosseous and a
dorsal strip for the origin of the radial head of the second
dorsal interosseous muscle (2,4,5). At the junction of the
shaft and head, several small foramina usually are present
for the entrance of nutrient vessels.
Head of the Index Finger Metacarpal
The head of the index metacarpal is rounded and slightly
elongated in the dorsopalmar axis. Although the head may
70 Systems Anatomy
be irregular, it has a smooth convex area that extends fur-
ther in the palmar–distal direction than in the mediolateral
direction. The extraarticular areas of the head are rough-
ened and contain medial and lateral tubercles at the articu-
lar margins for attachment of the collateral ligaments and
joint capsule. The tubercles are located on the dorsal half of
the side of the metacarpal head. Along with the tubercles,
there is a slight elevated ridge that surrounds the articular
smooth area. The articular surface extends further over the
palmar aspect than over the dorsal aspect. There is a small
depression just proximal to the articular surface over the
mid-dorsal aspect of the head for the attachment of the cap-
sule of the metacarpophalangeal joint. On the medial and
lateral surface of the metacarpal head are longitudinal fur-
rows just proximal to the articular margin to assist the pas-
sage of the tendons of the interosseous muscles. At the mar-
gin of the articular surface, there are multiple small vascular
foramina in which vessels from the attaching soft tissues
enter the head.
Associated Joints
The base of the index metacarpal articulates largely with the
trapezoid, which lies in the groove at the metacarpal base
(see Figs. 1.25, 1.26, 1.37, 1.38, 1.40, and 1.41). In addi-
tion, the ulnar aspect of the base of the metacarpal contains
a small articular surface for articulation with the capitate,
and a more distal and ulnar articulation with the neighbor-
ing long finger metacarpal. On the radial aspect of the base
of the index metacarpal, there also is a small articular sur-
face for articulation with the trapezium. The index
metacarpal usually does not articulate with the thumb
metacarpal.
The head of the index metacarpal articulates with the
base of the proximal phalanx of the index finger.
Muscle Origins and Insertions
Six muscles attach to the index metacarpal: the flexor carpi
radialis, the extensor carpi radialis longus, the first and sec-
ond dorsal interosseous muscles, the first palmar
interosseous muscle, and, often, a relatively small portion of
the origin of the adductor pollicis oblique head (see Figs.
1.37 and 1.38).
The flexor carpi radialis inserts into the palmar aspect of
the base of the index metacarpal. The insertion point usu-
ally is wide, encompassing most of the width of the base of
the index metacarpal.
The extensor carpi radialis longus inserts into the dorsal
aspect of the base of the index metacarpal. The insertion
point usually is slightly radial to the longitudinal midline of
the metacarpal (4).
The first dorsal interosseous muscle (ulnar head) origi-
nates from the radial aspect of the shaft of the index
metacarpal. This muscle belly joins the belly originating
from the ulnar aspect of the thumb metacarpal (radial
head), thus forming a bipennate muscle with a common
insertion. The first dorsal interosseous muscle inserts into
the radial aspect of the base of the proximal phalanx of the
index finger. Considerable variations exist as to the bone
versus soft tissue insertion of the interosseous muscles (into
either the proximal phalanx or the extensor aponeurosis). In
the index metacarpal, most, if not all fibers insert into bone
(140), whereas the remaining dorsal and palmar
interosseous muscles show variation as to bone versus exten-
sor insertion. See discussions of individual muscles in
Chapter 2. Most of the bony insertion of the first dorsal
interosseous probably is functionally advantageous, whereas
the bony insertion of a strong first dorsal interosseous mus-
cle helps stabilize the index finger during pinch and grasp,
resisting the force exerted by the thumb by producing reci-
procal abduction of the proximal phalanx of the index fin-
ger.
The second dorsal interosseous muscle (radial head)
originates from the ulnar aspect of the shaft of the index
metacarpal. This muscle belly joins the belly originating
from the radial aspect of the shaft of the long finger
metacarpal (ulnar head), thus forming a bipennate muscle
with a common insertion. The second dorsal interosseous
then inserts into either the lateral base of the proximal pha-
lanx of the long finger, or the extensor aponeurosis (approx-
imately 60% bone, 40% extensor hood) (140).
The first palmar interosseous muscle originates from the
palmar aspect of the ulnar side of the index metacarpal
shaft. The first palmar interosseous muscle inserts into the
extensor aponeurosis or, to a variable degree, into the base
of the ulnar aspect of the proximal phalanx of the index fin-
ger. The palmar interosseous muscles function largely to
adduct and flex the proximal phalanx. Throughout the
extensor aponeurosis, the interosseous muscles also assist
with extension of the middle and distal phalanges.
A small portion of the adductor pollicis oblique head
may originate from the base of the index metacarpal. This
usually is in the proximal, ulnar corner of the metacarpal on
the palmar side. Most of the origin of the oblique head of
the adductor pollicis attaches to the capitate and to the base
of the long finger metacarpal.
Clinical Correlations: Index Finger
Metacarpal
The base of each metacarpal, including the index
metacarpal, is somewhat cuboid, wider dorsally than pal-
marly. This results in a slightly wedge-shaped bone, with
the apex palmar. With this configuration, subluxation or
dislocation of the base of the index metacarpal on the
trapezoid usually occurs in a dorsal direction. Palmar dis-
location of the base of the index metacarpal is under-
standably rare, usually prevented by the wide dorsal por-
tion of the base.

Sesamoid Bones
Sesamoid bones are common at the metacarpophalangeal
joints of the thumb and the index and small fingers, and
the interphalangeal joint of the thumb. They may be mis-
taken for fractures, and can themselves be fractured or
develop as bipartite sesamoids, further confusing the clin-
ical impression. Schultz provides guidelines for distin-
guishing sesamoids from fractures. Multipartite sesamoids
usually are larger than a normal or fractured sesamoid.
Multipartite sesamoids have smooth, more regular oppos-
ing surfaces with cortical margins, and may be bilateral. In
an acute fracture, the line of fracture is sharp, irregular,
assumes any shape, and may be displaced. At times, it may
be necessary to see fracture healing before the diagnosis
can be made (25).
Accessory Bones
Several accessory bones may be associated with the index
finger metacarpal and can be mistaken for fractures. An
accessory bone usually represents the residual of a secondary
ossification center that does not fuse with the associated
bone, but it also may arise from trauma or heterotopic ossi-
fication of synovial tags (46,47). The accessory bones asso-
ciated with the index metacarpal usually are in the region of
the base, representing secondary ossification centers associ-
ated with the trapezoid (see Fig. 1.27B). These accessory
bones include the os trapezoideum secundarium (located at
the radial base of the index metacarpal and the distal radial
corner of the trapezoid), the os metastyloideum (located
between the ulnar base of the index finger metacarpal, the
distal ulnar corner of the trapezoid, and the distoradial cor-
ner of the capitate), and the os parastyloideum (located
between the ulnar base of the index metacarpal, the dis-
toradial corner of the capitate, and the radial base of the
long finger metacarpal; see Fig. 1.27B) (46) (see descrip-
tions earlier, under Ossification Centers and Accessory
Bones).
LONG FINGER METACARPAL
(OSSA METACARPALIA III)
Ossification Centers and Accessory Bones
The long finger metacarpal (third metacarpal) has two
ossification centers, a primary ossification center in the
shaft and a secondary center in the head (see Fig. 1.27A).
Ossification in the midshaft begins in approximately the
ninth week of prenatal life. Ossification in the secondary
center in the head appears in the second year in girls, and
from 1.5 to 2.5 years in boys. These secondary ossification
centers usually appear first in the index metacarpal, and
sequentially appear in the order of long finger, ring finger,
and, last, the small finger. The secondary ossification in
1 Skeletal Anatomy 71
the head of the long finger metacarpal unites with the
shaft at approximately the fifteenth or sixteenth year in
women, and the eighteenth or nineteenth year in men
(127).
On the dorsal aspect of the long finger metacarpal there
is a raised, thickened protuberance of bone often referred to
as the styloid. This styloid process may have a separate ossi-
fication center, or form a separate ossicle (see later) (46,
127).
Several accessory bones can be associated with the long
finger metacarpal, usually located at the base between the
metacarpal and the trapezoid. These accessory bones, if pre-
sent, usually are the result of a secondary or additional ossi-
fication center that does not fuse with the associated bone.
Those associated with the long finger metacarpal usually are
from a secondary ossification center of the base of the
metacarpal (from the ossification center of the styloid) or
from a secondary center of the capitate. These include the
os styloideum (os carpometacarpale IV), the os parasty-
loideum (os carpometacarpale III), the os subcapitatum, the
os capitatum secundarium (os carpometacarpale V), and
the os gruberi (os carpometacarpale VI) (see Fig. 1.27B)
(46). The os styloideum is located at the radial corner of the
base of the long metacarpal, between the bases of the long
and index metacarpal and the distal radial corner of the cap-
itate. The os parastyloideum is located just radial to the site
of the os styloideum, at the radial corner of the base of the
long metacarpal, and between the base of the index
metacarpal and distal radial corner of the capitate. The os
subcapitatum is located proximal to the mid-portion of the
base of the long finger metacarpal, adjacent to the central
portion of the body of the capitate. The os capitatum
secundarium is located at the ulnar base of the long finger
metacarpal, between the metacarpal and the distoulnar cor-
ner of the capitate, and close to the hamate and base of the
ring finger metacarpal. The os gruberi is located just ulnar
to the site of the os capitatum secundarium, at the ulnar
corner of the base of the long finger metacarpal, between
the long and ring finger metacarpals, the distoulnar corner
of the capitate, and the distoradial corner of the body of the
hamate (46) (see Fig. 1.27B).
Osteology of the Long Finger Metacarpal
The long finger metacarpal usually is the second longest
metacarpal, second only to the index finger metacarpal (Fig.
1.42; see Figs. 1.25, 1.26, 1.37, and 1.38). Similar to the
other metacarpals, the long finger metacarpal consists of a
widened proximal base, a narrow curved shaft, and a
rounded head. The head and base are composed internally
of cancellous bone surrounded by a relatively thin cortical
shell (see Fig. 1.42). The shaft consists of thicker cortical
bone that encircles the open medullary canal. At the base
and at the neck, the medullary canal rapidly changes to can-
cellous bone.
72 Systems Anatomy
A B
Base of the Long Finger Metacarpal
The base of the long metacarpal is unique in that it contains
the styloid process, a short, consistent projection that
extends proximally from the radial side of the dorsal surface
(125). The base of the long finger metacarpal articulates
largely with the capitate by a facet that is convex anteriorly
and dorsally concave, where it extends to the styloid process
on the lateral aspect of its base (see Fig. 1.42). Through the
styloid process, there also is a narrow articulation for the
index metacarpal base comprising a narrow, striplike facet,
constricted centrally and somewhat hourglass-shaped.
There also may be a small articulation with the trapezoid on
the radial base of the styloid. The articular and size rela-
tionships of the bases of the index and long metacarpals are
variable. When the styloid process of the long finger
metacarpal is short, the ulnar part of the base of the index
metacarpal may articulate with a small portion of the capi-
tate. On the radial side of the base of the long metacarpal,
just distal to the articular surface for the index metacarpal
base, there is a rough area for insertion of the inter-
metacarpal interosseous ligament (125). The long finger
metacarpal base also has an articulation with the ring finger
metacarpal. It consists of two oval articular facets. The pal-
mar facet may be absent; however, less frequently the two
facets may be connected proximally by a narrow bridge
(4,5). This double facet articulates with a similar double
facet on the radial side of the base of the ring finger
metacarpal. There usually is a rough, raised area between
the two facets, just distal or palmar to the articular surface.
This rough area serves for the attachment of the associated
interosseous intermetacarpal ligament. On the palmar sur-
FIGURE 1.42. Right long finger metacarpal. A: Lateral aspect.
B: Medial aspect.
face of the base of the metacarpal, there may be a roughened
or raised area for a small portion of the insertion of the
flexor carpi radialis. (The major insertion point for the
flexor carpi radialis is at the palmar base of the index
metacarpal.) The dorsal surface of the base of the long fin-
ger metacarpal contains a roughened or slightly raised area
for insertion of the extensor carpi radialis brevis. The inser-
tion point is slightly radial to the midline of the shaft of the
metacarpal. On the widened, rough areas on the dorsal and
palmar surfaces of the base of the index metacarpal, there
usually are several small foramina for the nutrient arteries.
On the palmar surface of the base, there also is a portion of
a long longitudinal crest that extends to the shaft. This crest
serves for the origin of the adductor pollicis, and joins a
similar crest or roughened area on the capitate, which also
provides attachment for the adductor pollicis.
Shaft of the Long Finger Metacarpal
The shaft of the long finger metacarpal is curved, convex
dorsally and concave palmarly. To a large degree, the long
metacarpal resembles the index metacarpal. In cross-sec-
tion, the shaft of the long finger metacarpal is oval or trian-
gular, with the apex palmar. The dorsal surface of the shaft
is smooth to allow passage of the extrinsic extensor tendons.
The dorsal surface is somewhat flat, and is triangular with
the apex proximal. The dorsal surface widens slightly from
proximal to dorsal. There are two faint longitudinal lateral
ridges that form the edges of this dorsal triangle and con-
verge toward the proximal third of the dorsal surface. A sin-
gle ridge continues proximally toward the base. The exten-

sor digitorum communis crosses close to the triangular por-
tion of the dorsal surface. On its lateral surface, the ulnar
head of the second dorsal interosseous muscle originates.
This lateral surface is demarcated by the lateral ridges on
the dorsal surface. On the medial surface, the radial head of
the third dorsal interosseous muscle originates. At the junc-
tion of the shaft and head, several small foramina usually
are present for the entrance of nutrient vessels. There is no
consistent nutrient vessel in the shaft. The metacarpal
receives most of its vascularity from the base and from the
head and neck regions (125).
Head of the Long Finger Metacarpal
The head of the long finger metacarpal is similar to that of
the index metacarpal. It is rounded, and slightly elongated
in the dorsopalmar axis. In the anteroposterior plane, the
head is round, smooth, and convex, flatter on the medial
and lateral sides. The articular surface extends much more
palmarly than dorsally, thus providing for more flexion of
the proximal phalanx. The head is roughened medially and
laterally, with medial and lateral tubercles at the articular
margins for attachment of the collateral ligaments and joint
capsule. Palmar to the tubercles, on the medial and lateral
aspects of the head, there are grooves in which the tendons
of the interosseous muscles pass. On the palmar surface of
the head, just proximal to the articular margin, there are
two tubercles for the insertion of the palmar joint soft tis-
sues. Also in this region, at the margin of the articular sur-
face, the bone is rough, and there are multiple small vascu-
lar foramina for nutrient vessels.
Associated Joints
The base of the long finger metacarpal articulates largely
with the distal end of the capitate (see Figs. 1.25, 1.26, 1.37,
1.38, 1.40, and 1.42). In addition, on the lateral base of the
long finger metacarpal, there is a narrow, hourglass-shaped
articular surface for articulation with the base of the index
metacarpal. The styloid process may articulate with the
trapezoid. On the medial base of the long finger metacarpal,
there is a similar strip or pair of circular articular areas for
articulation with the base of the ring finger metacarpal.
Distally, the long finger metacarpal articulates with the
base of the proximal phalanx of the long finger.
Muscle Origins and Insertions
There are five major muscle attachments to the long finger
metacarpal. These include the extensor carpi radialis brevis,
the second and third dorsal interosseous muscles, the
oblique head of the adductor pollicis, and the transverse
head of the adductor pollicis (see Figs. 1.37 and 1.38). The
long finger metacarpal does not give origin to a palmar
interosseous muscle. (Because it lies in the midline of the
1 Skeletal Anatomy 73
hand, it does not need a muscle to adduct it into this posi-
tion.)
The long finger metacarpal also may receive attachments
from the insertion of the flexor carpi radialis (4,5). How-
ever, most of the insertion of the flexor carpi radialis is into
the base of the index finger metacarpal.
The extensor carpi radialis brevis tendon inserts into the
dorsal base of the long finger metacarpal. The point of
insertion usually is radial to the midline of the shaft of the
metacarpal (4).
The second dorsal interosseous muscle (ulnar head) orig-
inates along the shaft of the lateral border of the long finger
metacarpal. These fibers are joined by fibers of the second
interosseous that originate from the medial border of the
adjacent index finger metacarpal (radial head), thus form-
ing a bipennate muscle. The second dorsal interosseous
then inserts into either the lateral base of the proximal pha-
lanx of the long finger, or into the extensor aponeurosis
(approximately 60% bone, 40% extensor hood) (140).
The third dorsal interosseous muscle (radial head) orig-
inates along the shaft of the medial border of the long fin-
ger metacarpal. These fibers are joined by fibers of the
third dorsal interosseous that originate from the lateral
border of the ring finger metacarpal (ulnar head), thus
forming a bipennate muscle. The third dorsal interosseous
then inserts into either the medial base of the proximal
phalanx of the long finger, or into the extensor aponeuro-
sis (approximately 6% into bone, 94% into extensor
aponeurosis) (140,141)
The oblique head of the adductor pollicis originates
largely from the palmar aspect of the base of the long finger
metacarpal. The remaining fibers of the oblique head orig-
inate from the palmar capitate or trapezoid. The fibers of
the oblique head of the adductor pollicis join the fibers
from the transverse head, and collectively insert into the
ulnar sesamoid.
The transverse head of the adductor pollicis originates
from the palmar shaft of the long finger metacarpal. These
fibers join the fibers of the oblique head, and insert into the
ulnar sesamoid of the thumb metacarpal.
The flexor carpi radialis may insert partially into the
radial aspect of the base of the long finger metacarpal. Most
of the insertion of this muscle, however, is into the base of
the index metacarpal.
Clinical Correlations: Long Finger
Metacarpal
The base of the long finger metacarpal is somewhat cuboid,
wider dorsally than palmarly. This results in a slightly
wedge-shaped bone, with the apex palmar. The styloid
process at the base of the metacarpal adds to the width dor-
sally. With this configuration, subluxation or dislocation of
the base of the long finger metacarpal on the capitate usu-
ally occurs in a dorsal direction. Palmar dislocation of the
74 Systems Anatomy
base of the long finger metacarpal is understandably rare,
usually prevented by the wide dorsal portion of the base.
Accessory Bones
Several accessory bones may be associated with the long
finger metacarpal and can be mistaken for fractures. An
accessory bone usually represents the residual of a sec-
ondary ossification center that does not fuse with the asso-
ciated bone, but it also may arise from trauma or hetero-
topic ossification of synovial tags (46,47). The accessory
bones associated with the long finger metacarpal usually
are in the region of the base, representing secondary ossifi-
cation centers of the styloid of the metacarpal, or arise
from a secondary center of the capitate (see Fig. 1.27B).
These accessory bones include the os styloideum (located
at the radial corner of the base of the long metacarpal,
between the bases of the long and index metacarpal and the
distal radial corner of the capitate), the os parastyloideum
(located just radial to the site of the os styloideum, at the
radial corner of the base of the long metacarpal, and
between the base of the index metacarpal and distal radial
corner of the capitate), the os subcapitatum (located prox-
imal to the mid-portion of the base of the long finger
metacarpal, adjacent to the central portion of the body of
the capitate), the os capitatum secundarium (located at the
ulnar base of the long finger metacarpal, between the
metacarpal and the distoulnar corner of the capitate, and
close to the hamate and base of the ring finger metacarpal),
and the os gruberi (located just ulnar to the site of the os
capitatum secundarium, at the ulnar corner of the base of
the long finger metacarpal, between the long and ring fin-
ger metacarpals, the distoulnar corner of the capitate, and
the distoradial corner of the body of the hamate; see Fig.
1.27B) (46) (see descriptions earlier, under Ossification
Centers and Accessory Bones).
RING FINGER METACARPAL
(OSSA METACARPALIA IV)
Ossification Centers and Accessory Bones
The ring finger metacarpal (fourth metacarpal) has two
ossification centers, a primary ossification center in the
shaft and a secondary center in the head (see Fig. 1.27A).
Ossification in the midshaft begins in approximately the
ninth week of prenatal life. Ossification in the secondary
center of the head appears in the second year in girls, and
from 1.5 to 2.5 years in boys. These secondary ossification
centers usually first appear in the index metacarpal, and
sequentially appear in the order of long finger, ring finger,
and, last, the small finger. The secondary ossification in the
head of the ring finger metacarpal unites with the shaft at
approximately the fifteenth or sixteenth year in women, and
the eighteenth or nineteenth year in men (127).
Several accessory bones can be associated with the ring
finger metacarpal, usually located at the base between the
metacarpal and the hamate or capitate. These accessory
bones, if present, usually are the result of a secondary or
additional ossification center that does not fuse with the
associated bone. Those associated with the ring finger
metacarpal usually are from a secondary ossification center
of the neighboring hamate or capitate, or from a secondary
ossification center in the styloid of the base of the adjacent
long finger metacarpal. These accessory bones include the
os gruberi (carpometacarpale VI), the os capitatum secun-
darium (carpometacarpale V), and the os hamuli proprium.
The os gruberi is located at the radial corner of the base of
the ring finger metacarpal, between the base of the long
metacarpal and distoulnar corner of the capitate. The os
capitatum secundarium is located just radial to the site of
the os gruberi, between the radial corner of the base of the
ring finger metacarpal and the proximal ulnar corner of the
long finger metacarpal (between the distal margins of the
capitate and hamate). The os hamuli proprium is associated
more closely with the hamate, proximal to the base of the
ring finger metacarpal (46) (see Fig. 1.27B).
Osteology of the Ring Finger Metacarpal
The ring finger metacarpal is intermediate in size between
the long finger and small finger metacarpals, and noticeably
shorter and thinner than the index and long metacarpals
(Fig. 1.43; see Figs. 1.25, 1.26, 1.37, and 1.38). It is simi-
lar in overall shape to the other metacarpals, containing a
widened proximal base, a narrower curved shaft, and a
rounded head. It most resembles the long finger metacarpal,
especially in the head and shaft; however, the base shows
distinct differences (see later). Internally, it also is similar to
the remaining metacarpals. The head and base consist inter-
nally of cancellous bone surrounded by a relatively thin cor-
tical shell (see Fig. 1.43). The shaft consists of thicker cor-
tical bone that encircles the open medullary canal. At the
base and at the neck, the medullary canal rapidly changes to
cancellous bone (127).
Base of the Ring Finger Metacarpal
The base of the ring finger metacarpal is relatively small and
quadrilateral, usually containing two proximal articular
facets and articular surfaces on the radial and ulnar aspects
of the base for the adjacent metacarpals.
There is considerable variation in the shape of the base
of the ring finger metacarpal, and it has been described in
several ways (see Anomalies and Variations, later) (81,94,
108,117,118,142). The proximal articular surface is quad-
rangular, is directed somewhat medially, and is convex ante-
riorly and dorsally concave. There is a proximal elevation on
the dorsal surface that divides the articular surface into
radial and ulnar parts, or facets. The radial facet of the ring

A B
finger metacarpal articulates with the ulnar third of the dis-
tal articular surface of the capitate. The ulnar facet of the
metacarpal articulates with the radial facet of the hamate.
The metacarpal’s articular portion for the capitate usually
involves only a small oval or square facet. Also on the radial
aspect of the base of the ring finger metacarpal, there is a set
of two oval or round facets for articulation with the adja-
cent long finger metacarpal base. On the ulnar side of the
base of the ring finger metacarpal, there is an oval, or nar-
row, oblong facet, usually with a concave surface, for artic-
ulation with the adjacent base of the small finger
metacarpal. The roughened area between the two proximal
articular facets provides an area of attachment for the
interosseous intermetacarpal ligament. On the base of the
metacarpal, on the dorsal and palmar surfaces just distal to
the articular margin, there are multiple small foramina for
nutrient vessels (5,125).
Shaft of the Ring Finger Metacarpal
The shaft of the ring finger metacarpal is slender and
curved. It is convex dorsally and concave palmarly. To a
large degree, the ring finger metacarpal shaft resembles that
of the index and long finger metacarpals, although it is
noticeably shorter and thinner. The metacarpal may taper
proximally, so that the narrowest portion is at the junction
of the base and the shaft. In cross-section, the metacarpal is
round, oval, or slightly triangular (apex palmar). On the
medial aspect of the shaft is a slight concavity for the origin
of the radial head of the fourth dorsal interosseous muscles.
On the lateral aspect, there is a slight concavity for the ori-
gin of the ulnar head of the third dorsal interosseous mus-
cle. On the lateral surface of the shaft of the ring finger
metacarpal there is a faint ridge that separates the attach-
1 Skeletal Anatomy 75
FIGURE 1.43. Right ring finger metacarpal. A: Lateral aspect.
B: Medial aspect.
ments of the second palmar interosseous muscle from the
ulnar head of the third dorsal interosseous muscles. The
dorsal surface of the shaft is smooth and somewhat flat to
allow passage of the extrinsic extensor tendons. The trian-
gular flattened area present on the index and long
metacarpals also is present on the ring finger metacarpal.
The palmar surface, which is concave, is slightly flatter in
the proximal half. Along the distal half of the palmar sur-
face, the surface tends to form a slight longitudinal ridge
along the midline of the cortical surface. There is no con-
sistent nutrient vasculature in the shaft of the metacarpals.
The metacarpals receive most of their vascularity from the
base and the head and neck regions (125).
Head of the Ring Finger Metacarpal
The head of the ring finger metacarpal is similar to that of
the index and long metacarpals. It is round, but slightly
elongated in the dorsopalmar axis. The head is roughened
medially and laterally, with medial and lateral tubercles at
the articular margins for attachment of the collateral liga-
ments and joint capsule. At the margin of the articular sur-
face, there are multiple small vascular foramina through
which vessels from the attaching soft tissues enter the head.
Anomalies and Variations in Morphology
of the Ring Metacarpal
Recent studies on the carpometacarpal joints have shown
that the base of the ring finger metacarpal has considerable
variation in morphology (81,94,108,117,142–145). The
general shape of the base, noted to be relatively flat or con-
ical, usually is readily identifiable on standard radiographs
(117). With regard to articular morphology, the base of the
76 Systems Anatomy
ring finger metacarpal articulates with the hamate and, to a
variable degree, with the capitate (81,118,142,143,
146–148). The base of the ring finger metacarpal and the
associated articulations appear to exhibit more variation
than any of the other carpometacarpal joints (118). Five
different types of ring finger metacarpal base have been
described with regard to shape and articular configurations.
n Type I contains a broad base that articulates with the
hamate and has a single dorsal facet extension that artic-
ulates with the capitate. This type was present in approx-
imately 39% of wrists.
n Type II contains a broad base that articulates with the
hamate, and two facet extensions (one dorsal and one
palmar) that articulate with the capitate. Type II was pre-
sent in approximately 8% of wrists.
n Type III contains a relatively narrow base that articulates
only with the hamate. Type III was present in 9% of
specimens.
n Type IV contains a broad base that articulates with the
hamate and a separate, single dorsal facet that articulates
with the capitate. Type IV was present in approximately
34% of wrists.
n Type V contains a broad base that articulates with the
hamate and the capitate. Type V was present in approxi-
mately 9% of wrists (81,94,108,117).
Associated Joints
The base of the ring finger metacarpal articulates largely
with the distal end of the radial articular facet of the hamate
(see Figs. 1.25, 1.26, 1.37, 1.38, 1.40, and 1.43) (Also see
Anomalies above). In addition, on the medial base of the
ring finger metacarpal, there is a narrow, oval or hourglass-
shaped articular surface for articulation with the base of the
small finger metacarpal. On the lateral base of the long fin-
ger metacarpal, there is a similar strip or pair of circular
articular areas for articulation with the base of the long fin-
ger metacarpal. On the lateral base of the ring finger
metacarpal, between the articular facets for the hamate and
the long finger metacarpal, there is a small oval articular
area for the capitate.
Distally, the ring finger metacarpal articulates with the
base of the proximal phalanx of the ring finger.
Muscle Origins and Insertions
There are three major muscle attachments to the ring finger
metacarpal. These include the origins of the third dorsal
interosseous (ulnar head), the origin of the fourth dorsal
interosseous (radial head), and the origin of the second pal-
mar interosseous (see Figs. 1.37 and 1.38).
The third dorsal interosseous muscle (ulnar head) origi-
nates along the shaft of the lateral border of the ring finger
metacarpal. These fibers are joined by fibers of the third
dorsal interosseous that originate from the medial border of
the adjacent long finger metacarpal (radial head), thus
forming a bipennate muscle. The third dorsal interosseous
then inserts into the either the medial base of the proximal
phalanx of the long finger, or into the extensor aponeurosis
(approximately 6% bone, 96% extensor hood) (140).
The fourth dorsal interosseous muscle (radial head) orig-
inates along the shaft of the medial border of the ring finger
metacarpal. These fibers are joined by fibers of the fourth
dorsal interosseous that originate from the lateral border of
the small finger metacarpal (ulnar head), thus forming a
bipennate muscle. The fourth dorsal interosseous then
inserts into either the medial base of the proximal phalanx of
the ring finger, or into the extensor aponeurosis (approxi-
mately 40% bone, 60% extensor aponeurosis) (140,141).
The second palmar interosseous muscle originates from
the lateral palmar border of the shaft of the ring finger
metacarpal. The muscle inserts into the extensor aponeuro-
sis of the ring finger, or into the radial side of the base of the
proximal phalanx of the ring finger.
Clinical Correlations: Ring Finger
Metacarpal
The joint surfaces at the base of the ring and small finger
metacarpals are saddle-shaped or flat, respectively, and are
not confined by the borders of the adjacent metacarpal
bases or carpal bones (as with the index and long
metacarpals). This allows, in part, the greater motion at the
carpometacarpal joints of the small and ring finger, com-
pared with the relatively restricted motion of the car-
pometacarpal joints of the index and long fingers.
The base of each metacarpal, including that of the ring
finger, is somewhat cuboid, wider dorsally than palmarly.
This results in a slightly wedge-shaped bone, with the apex
palmar. With this configuration, subluxation or dislocation
of the base of the ring finger metacarpal on the hamate usu-
ally occurs in a dorsal direction. Palmar dislocation of the
base of the ring finger metacarpal is understandably rare,
usually prevented by the wide dorsal portion of the base.
Accessory Bones
Several accessory bones may be associated with the ring fin-
ger metacarpal and can be mistaken for fractures. An acces-
sory bone usually represents the residual of a secondary ossi-
fication center that does not fuse with the associated bone,
but it also may arise from trauma or heterotopic ossification
of synovial tags (46,47). The accessory bones associated
with the ring finger metacarpal usually are in the region of
the base, representing secondary ossification centers from
the capitate, hamate or a secondary center of the base of the
metacarpal (46) (see Fig. 1.27B). These accessory bones
include the os gruberi (located at the radial corner of the
base of the ring finger metacarpal, between the base of the
 1 Skeletal Anatomy 77

long finger metacarpal and distoradial corner of the hamate), A B

the os capitatum secundarium (located just radial to the site
of the os gruberi, between the radial corner of the base of
the ring finger metacarpal, the proximal ulnar corner of the
long finger metacarpal, and the distal margins of the capi-
tate and hamate), and the os hamuli proprium (which is
more closely associated with the hamate, located proximal
to the base of the ring finger metacarpal; see Fig. 1.27B)
(46) (see descriptions earlier, under Ossification Centers
and Accessory Bones).

SMALL FINGER METACARPAL

(OSSA METACARPALIA V)
Ossification Centers and Accessory Bones
The small finger metacarpal (fifth metacarpal) has two ossi-
fication centers, a primary ossification center in the shaft
and a secondary center in the head (see Fig. 1.27A). Ossifi-
cation in the midshaft begins in approximately the ninth
week of prenatal life. Ossification in the secondary center of
the head appears in the second year in girls, and from 1.5
to 2.5 years in boys. The secondary ossification centers usu-
ally appear last in the small finger metacarpal (usually
appearing first in the index metacarpal, and sequentially in
the long finger, ring finger, and, last, the small finger). The
secondary ossification in the head of the small finger
metacarpal unites with the shaft at approximately the fif-
teenth or sixteenth year in women, and the eighteenth or
nineteenth year in men (127).
An accessory bone can be associated with the small fin-
ger metacarpal, the os vesalianum manius (os vesalii, os car-
pometacarpale VIII). It usually is located at the ulnar base
of the metacarpal, distal to the ulnar aspect of the hamate.
An accessory bone, if present, usually is the result of a sec-
ondary or additional ossification center that does not fuse
with the associated bone. That associated with the small fin-
ger metacarpal may be from a secondary ossification center
of the base of the metacarpal or from a secondary center of
the hamate (46) (see Fig. 1.27B).
Osteology of the Small Finger Metacarpal
The small finger metacarpal usually is the thinnest and
smallest of the metacarpals, although the thumb
metacarpal, which is much thicker, may be shorter. The
overall shape of the small finger metacarpal is similar to that
of the other metacarpals, containing a widened proximal
base, a narrower curved shaft, and a rounded head (Fig.
1.44; see Figs. 1.25, 1.26, 1.37, and 1.38). It differs most in
the shape and characteristics of the base. Internally, the
small finger metacarpal is similar to the other metacarpals.
The head and base consist of cancellous bone surrounded
by a relatively thin cortical shell (see Fig. 1.44). The shaft
consists of thicker cortical bone that encircles the open
FIGURE 1.44. Right small finger metacarpal. A: Lateral aspect.
B: Medial aspect.
medullary canal. At the base and at the neck, the medullary
canal rapidly changes to cancellous bone (127).
Base of the Small Finger Metacarpal
The base of the small finger metacarpal is larger than that
of the ring finger, and slopes proximally and ulnarly. The
medial portion of the base is nonarticular and contains a
thickening of bone or a tubercle for insertion of the exten-
sor carpi ulnaris. The lateral base of the small finger
metacarpal articulates with the ulnar facet of the distal
hamate. The articular surface on the metacarpal is trans-
versely concave, and convex from palmar to dorsal. To some
degree, this articular surface, which is saddle-shaped, is not
unlike the articular surface of the base of the thumb
metacarpal. This configuration contributes to the relatively
greater motion at the hamate–small finger metacarpal joint
compared with the carpometacarpal joints of the index and
long finger rays. The overall area of the articular surface at
the base is oval or quadrangular and directed somewhat lat-
erally. On the lateral aspect of the base of the small finger
metacarpal, there is an oval or narrow facet for articulation
with the ring finger metacarpal base.
Shaft of the Small Finger Metacarpal
The shaft of the small finger metacarpal is slender and
curved. It is convex dorsally and concave palmarly. To a
large degree, the small finger metacarpal shaft resembles
that of the other metacarpals, although it is noticeably
shorter and thinner. On the dorsal portion of the lateral
aspect, there is a slight concavity for the origin of the ulnar
head of the fourth dorsal interosseous. On the palmar por-
tion of the lateral aspect, there is a slight concavity for the
78 Systems Anatomy
origin of the third palmar interosseous muscle. On the
medial surface of the shaft of the small metacarpal, there
is a concavity for attachment of the opponens digiti min-
imi. The dorsal surface of the shaft of the small metacarpal
is smooth to allow passage of the extrinsic extensor ten-
dons. The dorsal surface of the shaft may appear some-
what triangular, similar to the other metacarpal shafts.
The shaft of the small metacarpal may taper or become
somewhat constricted at the junction of the proximal shaft
with the base. This area may be the narrowest portion of
the metacarpal.
Head of the Small Metacarpal
The head of the small finger metacarpal is similar in shape
to that of the other metacarpals, although noticeably thin-
ner and smaller. It is rounded, and slightly elongated in the
dorsopalmar axis. The head is roughened medially and lat-
erally, with medial and lateral tubercles at the articular mar-
gins for attachment of the collateral ligaments and joint
capsule. At the margin of the articular surface, there are
multiple small vascular foramina through which vessels
from the attaching soft tissues enter the head.
Associated Joints
The base of the small finger metacarpal articulates largely
with the distal end of the hamate, through the ulnar distal
articular facet of the hamate. In addition, on the lateral base
of the small finger metacarpal, there is a narrow, oval or
hourglass-shaped articular surface for articulation with the
base of the ring finger metacarpal (see Figs. 1.25, 1.26,
1.37, 1.38, 1.40, and 1.44).
Distally, the small finger metacarpal articulates with the
base of the proximal phalanx of the small finger.
Muscle Origins and Insertions
There are three major muscle attachments to the small finger
metacarpal. These include the origins of the fourth dorsal
interosseous (ulnar head), and the insertion of the opponens
digiti minimi, and the origin of the third palmar interosseous
(see Figs. 1.37 and 1.38).
The fourth dorsal interosseous muscle (ulnar head) orig-
inates along the shaft of the lateral border of the small finger
metacarpal. These fibers are joined by fibers of the fourth
dorsal interosseous that originate from the medial border of
the ring finger metacarpal (radial head), thus forming a
bipennate muscle. The fourth dorsal interosseous then
inserts into either the medial base of the proximal phalanx of
the ring finger, or into the extensor aponeurosis (approxi-
mately 40% bone, 60% extensor aponeurosis) (140,141).
The third palmar interosseous muscle originates from
the lateral palmar border of the shaft of the small
metacarpal. The muscle inserts into the extensor aponeuro-
sis of the small finger, or into the radial side of the base of
the proximal phalanx of the small finger.
The extensor carpi ulnaris tendon inserts into the dorso-
medial base of the small finger metacarpal. There usually is
a thickening of bone or a small tubercle for insertion of the
tendon.
The opponens digiti minimi inserts into the medial bor-
der of the shaft of the small finger metacarpal.
Clinical Correlations: Small Finger
Metacarpal
The joint surfaces at the base of the small and ring finger
metacarpals are saddle-shaped and flat, respectively, and are
not confined by the borders of the adjacent metacarpal
bases or carpal bones (as are the index and long finger
metacarpals). This allows, in part, the greater motion at the
carpometacarpal joints of the small and ring finger, com-
pared with the relatively restricted motion of the car-
pometacarpal joints of the index and long fingers.
The base of each metacarpal, including that of the small
finger, is cuboid, wider dorsally than palmarly. This results
in a somewhat wedge-shaped bone, with the apex palmar.
With this configuration, subluxation or dislocation of the
base of the small finger metacarpal on the hamate usually
occurs in a dorsal direction. Palmar dislocation of the base
of the small finger metacarpal is understandably rare, usu-
ally prevented by the wide dorsal portion of the base.
Sesamoid Bones
Sesamoid bones are common at the metacarpophalangeal
joints of the thumb and index and small fingers, and the
interphalangeal joint of the thumb. They may be mistaken
for fractures, and can themselves be fractured or develop as
bipartite sesamoids, further confusing the clinical impres-
sion. Schultz provides guidelines for distinguishing
sesamoids from fractures. Multipartite sesamoids usually are
larger than a normal or fractured sesamoid. Multipartite
sesamoids have smooth, more regular opposing surfaces
with cortical margins, and may be bilateral. In an acute
fracture, the line of fracture is sharp, irregular, assumes any
shape, and may be displaced. At times, it may be necessary
to see fracture healing before the diagnosis can be made
(25).
Accessory Bones
The os vesalianum manus (os vesalii, os carpometacarpale
VIII) is an accessory bone that may be located at the ulnar
base of the small finger metacarpal, distal and ulnar to the
hamate. If present, it can be mistaken for a fracture. An
accessory bone usually represents the residual of a secondary
ossification center that does not fuse with the associated
bone, but it also may arise from trauma or heterotopic ossi-

fication of synovial tags (46,47) (see Fig. 1.27B and descrip-
tions earlier, under Ossification Centers and Accessory
Bones).
PHALANGES
Derivation and Terminology
The word phalanx is derived from the Greek word for a line
or array of soldiers (1).
General Features
Each digit has three phalanges: proximal, middle, and dis-
tal. The thumb has two phalanges: proximal and distal. The
proximal and middle digital phalanges all share a similar
internal structure, whereas the distal phalanges are
markedly different (see later). The phalanges are true long
bones with a well defined medullary canal (Fig. 1.45; see
Figs. 1.25, 1.26, 1.27A, 1.37, and 1.38), and contain, from
proximal to distal, a base, shaft (diaphysis), neck, and head.
Each head consists of two condyles. The distal phalanx does
not have a true head, but instead terminates in the distal
tuft. At either end, the bone becomes wider to form the
base and head, with the cortex becoming thinner and the
FIGURE 1.45. Illustration of digit showing metacarpopha-
langeal and interphalangeal joints, palmar aspect.
1 Skeletal Anatomy 79
internal portion being replaced with cancellous bone. In the
diaphysis, similar to other long bones, the cortex is thick,
and the medullary canal is open. The proximal phalanges
are the longest and largest, the distal the shortest and small-
est. Collectively, the three phalanges of the middle finger
(long finger) are the longest, resulting in the middle finger
usually having the greatest length. The ring finger usually is
second in length, and the small finger usually is the short-
est. The index finger usually is slightly shorter than the ring
finger, but may be equal to or longer than the ring finger
(125).
Each of the phalanges has two ossification centers (see
Fig. 1.27A). The primary center is located in the diaphysis
and the secondary center is in the proximal portion, in the
epiphysis. Ossification begins prenatally in the shafts at the
following periods: distal phalanges, eight or ninth week;
proximal phalanges, the tenth week; middle phalanges, the
eleventh week or later. The epiphyseal centers appear in the
proximal phalanges early in the second year in girls, and
later in the second year in boys. In the middle and distal
phalanges, the epiphyseal centers appear in the second year
in girls, and in the third or fourth year in boys. All of the
epiphyses unite approximately the fifteenth to sixteenth
year in women, and the seventeenth to eighteenth year in
men (5).
Because of the differences of the phalanges of the digits
and the thumb, their osteology is discussed separately from
that of the digital phalanges.
PROXIMAL PHALANX OF THE DIGITS
Ossification Centers
The proximal phalanx of each digit has two ossification
centers, one in the shaft and one in epiphysis at the base
(Table 1.4; see Fig. 1.27A). The primary ossification in the
shaft begins prenatally in approximately the tenth week.
The secondary ossification in the base appears early in the
second year in girls and later in the second year in boys.
The times of ossification of the secondary center of the
proximal phalanx vary slightly among the different digits, as
described in the following sections (149) (Table 1.4).
Ossification of Index Finger Proximal Phalanx
In the index finger proximal phalanx, the basal epiphysis
first appears in boys at 15 to 18 months of age and in girls
at the 9 to 13 months of age. The epiphysis fuses to the
shaft in boys between 16 and 17 years of age and in girls
between 14 and 15 years of age (149).
Ossification of Long Finger Proximal Phalanx
In the long finger proximal phalanx, the basal epiphysis first
appears in boys at 15 to 18 months of age and in girls at 9
TABLE 1.4. APPEARANCE OF OSSIFICATION CENTERS IN THEIR NORMAL SEQUENCE AND DATES OF
COMPLETE OSSIFICATION AND FUSION ACCORDING TO W. GREULICH AND S. I. PYLE

Sex First Appearance (mos.) Adult Status (yrs.)

Capitate Male Birth–3 17–18

Female Birth–3 15–16
Hamate Male 3 14–15
Female 3 12–13
Distal epiphysis of radius Male 12–15 18–19
Female 9–15 17–18
Basal epiphysis of proximal phalanx middle finger Male 15–18 15–17
Female 9–12 14–16
Basal epiphysis of proximal phalanx index finger Male 15–18 16–17
Female 9–13 14–15
Basal epiphysis of proximal phalanx ring finger Male 15–18 16–17
Female 9–12 14–15
Capital epiphysis metacarpal index finger Male 15–20 16–17
Female 9–13 15
Basal epiphysis of distal phalanx of thumb Male 15–18 15–151/2
Female 12–15 13–131/2
Capital epiphysis of middle metacarpal Male 15–20 16–17
Female 9–13 15
Capital epiphysis of ring metacarpal Male 15–20 16–17
Female 9–12 14–15
Basal epiphysis of proximal phalanx little finger Male 18–24 16–17
Female 15–18 14–15
Basal epiphysis of middle phalanx middle finger Male 18–24 16–17
Female 15–18 14–15
Basal epiphysis of middle phalanx ring finger Male 18–24 17
Female 15–18 15
Capital epiphysis of metacarpal little finger Male 24–30 16–17
Female 15–17 14–15
Basal epiphysis of middle phalanx index finger Male 24–32 16–17
Female 15–18 14–15
Triquetrum Male 24–36 15–16
Female 18–25 15–16
Basal epiphysis of distal phalanx middle finger Male 18–24
Female 18–24
Basal epiphysis of distal phalanx ring finger Male 18–24
Female 18–24
Basal epiphysis of first metacarpal Male 24–32
Female 18–22
Basal epiphysis of proximal phalanx of thumb Male 24–32
Female 18–22
Basal epiphysis of distal phalanx little finger Male 36–42
Female 18–24
Basal epiphysis of distal phalanx index finger Male 36–42
Female 24–30
Basal epiphysis of middle phalanx of little finger Male 42–48
Female 24–32
Lunate Male 32–42
Female 30–36
Lunate Male 32–42
Female 30–36
Trapezium Male 31/2–5 yrs.
Female 36–50
Trapezoid Male 5–6 yrs.
Female 31/2–4 yrs., 2 mo.
Scaphoid Male 5–6 yrs., 4 mo.
Female 31/2–4 yrs., 4 mo.
Distal epiphysis of ulna Male 5 yrs., 3 mo.–6-10 yrs.
Female 51/2–61/2 yrs.
Pisiform Male 17–18
Female 16–17
Sesamoid of abductor pollicis Male 12–13
Female 11

From, Greulich WW, Pyle SI. Radiographic atlas of skeletal development of the hand and wrist, 2nd
ed. Stanford, Stanford University Press, 1959, with permission.

to 12 months of age. The epiphysis fuses to the shaft in boys
between 15 and 17 years of age and in girls between 14 and
16 years of age.
Ossification of Ring Finger Proximal Phalanx
In the ring finger proximal phalanx, the basal epiphysis first
appears in boys at 15 to 18 months of age and in girls at 9
to 12 months of age. The epiphysis fuses to the shaft in boys
between 16 and 17 years and in girls between 14 and 15
years of age.
Ossification of Small Finger Proximal Phalanx
In the small finger proximal phalanx, the basal epiphysis
first appears in boys at 18 to 24 months of age and in girls
at 15 to 18 months of age. The epiphysis fuses to the shaft
in boys between 16 and 17 years of age and in girls between
14 and 15 years of age.
Osteology of the Proximal Phalanx
The proximal phalanx consists of a base, shaft, and head.
The proximal phalanx of each digit is similar. The proximal
phalanx of the long finger usually is the longest, followed,
in decreasing order of size, by the ring, index, and small fin-
ger proximal phalanges. The thumb proximal phalanx,
described separately later, usually is approximately the
length of the small finger proximal phalanx, although the
thumb proximal phalanx is much thicker and wider.
Base of the Proximal Phalanx
The base of each phalanx flares out from the shaft. There is
a slight convexity to the dorsal surface of the base. The pal-
mar base is concave, terminating in a thickened ridge or lip
that borders the palmar surface of the base at the joint. On
the palmar surface of the base of the proximal phalanges
there is a slight groove to accommodate passage of the flexor
tendons.
1 Skeletal Anatomy 81
Shaft of the Proximal Phalanx
The shaft of each phalanx is smooth, convex dorsally, and
concave palmarly, and narrows slightly medially and later-
ally from proximal to distal, terminating in the narrow
neck. This tapering is more pronounced in the middle pha-
lanx compared to the proximal phalanx. The shaft of the
proximal phalanx is oval in cross-section, with a slight
squaring on the volar aspect as the medial and lateral sur-
faces meet the palmar surface. The shaft of the phalanges
tapers from proximal to distal in both the frontal and sagit-
tal sections, resulting in a narrow distal portion of the shaft.
This narrow portion, located just proximal to the head,
often is referred to as the neck.
Head of the Proximal Phalanx
The neck of each proximal phalanx widens abruptly to
form the head of the phalanx. The head consists of two
condyles. The articular surface has a slight depression seen
in the anteroposterior plane, demarcating the two condyles.
The articular surface extends further palmarly than dorsally
to allow the greater amount of flexion (and relatively lim-
ited extension). The articular surface is rounded, as noted
on the lateral projection. The head does not have the
marked increase in thickness in the anteroposterior direc-
tion, as is present in the heads of the metacarpals.
Associated Joints
The proximal phalanx articulates with the head of the asso-
ciated metacarpal at each metacarpophalangeal joint, and
with the base of the associated middle phalanx at the prox-
imal interphalangeal joint (Fig. 1.46; see Fig. 1.45).
The metacarpophalangeal joint is a multiaxial joint that
allows movement in the medial and lateral directions, as
well as slight rotation, because of the more spherical shape
of the metacarpal head and the concavity of the base of the
proximal phalanx. The joint is stabilized by the collateral
ligaments, accessory collateral ligaments, volar plate, joint
capsule, and intrinsic and extrinsic overlying tendons.
FIGURE 1.46. Illustration of digit showing metacar-
pophalangeal and interphalangeal joints, lateral
aspect.
82 Systems Anatomy
The proximal interphalangeal joints are stabilized by the
collateral ligaments, accessory collateral ligaments, volar
plate, joint capsule, and overlying intrinsic and extrinsic
tendons. It is a hinge joint, unlike the multiaxial metacar-
pophalangeal joint. Thus, the proximal interphalangeal
joint does not produce the medial and lateral motions or
the slight rotation of which the metacarpophalangeal joint
is capable. The condyles of the proximal phalanx are sym-
metric, adding to the stability (and lack of motion) in the
medial and lateral planes.
Muscle Origins and Insertions
Several muscles insert into the base of the proximal pha-
langes. The palmar interosseous muscles insert into the ulnar
base of the index proximal phalanx, and the radial bases of
the ring and small finger proximal phalanges. The flexor dig-
iti minimi and abductor digiti minimi insert into the ulnar
base of the small finger proximal phalanx. The first dorsal
interosseous inserts, in part, to the radial base of the index
finger proximal phalanx. The second and third dorsal
interosseous muscles insert, in part, into the radial and ulnar
bases of the long finger proximal phalanx, respectively. The
fourth dorsal interosseous inserts, in part, into the ulnar base
of the ring finger proximal phalanx. The amount of inser-
tion into bone versus that into the extensor mechanism
tends to decrease consecutively from the index, long, and
ring fingers. This mechanism is complex, and is described in
detail in Chapter 2 (26,141) (Figs. 1.37 and 1.38).
MIDDLE PHALANX OF THE DIGITS
Ossification Centers
The middle phalanx of each digit has two ossification centers,
one in the shaft and one in epiphysis at the base (see Fig.
1.27A and Table 1.4). The primary ossification in the shaft
begins prenatally in approximately the eleventh week or later.
The secondary ossification in the base appears early in the
second year in girls and in the third or fourth year in boys.
The times of ossification in the secondary center of the
middle phalanx vary slightly among the different digits, and
are described in the following sections (149) (Table 1.4).
Ossification of Index Finger Middle Phalanx
In the index finger middle phalanx, the basal epiphysis first
appears in boys at 24 to 32 months of age and in girls at 15
to 18 months of age. The epiphysis fuses to the shaft in boys
between 16 and 17 years of age and in girls between 14 and
15 years of age.
Ossification of Long Finger Middle Phalanx
In the long finger middle phalanx, the basal epiphysis first
appears in boys at 18 to 24 months of age and in girls at 15
to 18 months of age. The epiphysis fuses to the shaft in boys
between 16 and 17 years of age and in girls between 14 and
15 years of age.
Ossification of Ring Finger Middle Phalanx
In the ring finger middle phalanx, the basal epiphysis first
appears in boys at 18 to 24 months of age and in girls at 15
to 18 months of age. The epiphysis fuses to the shaft in boys
at approximately 17 years of age and in girls at approxi-
mately 15 years of age.
Ossification of Small Finger Middle Phalanx
In the small finger middle phalanx, the basal epiphysis first
appears in boys at 42 to 48 months of age and in girls at 24
to 32 months of age. The epiphysis fuses to the shaft in boys
between 16 and 17 years of age and in girls between 14 and
15 years of age.
Osteology of the Middle Phalanx
The middle phalanges of the digits are similar to each other.
Overall, the middle phalanges are shorter than their associ-
ated proximal phalanges. The length ratio between the
proximal and middle phalanges varies, even in the same
individual and in the same hand. In general, the ratio of
length of the proximal phalanx to length of the middle pha-
lanx is between 2:1 and 1.3:1, regardless of finger (125)
(Table 1.3). The middle phalanx of the long finger usually
is the longest, the ring and index middle phalanges are sim-
ilar (although either may be the longer), and the small fin-
ger middle phalanx usually is the shortest. Each phalanx has
a base, shaft, and head.
Although the general appearance of the middle phalanges
is similar to that of the proximal phalanges, distinct differ-
ences exist. The palmar aspect of the middle phalanx shaft is
not as concave as is the palmar aspect of the proximal pha-
lanx. The lateral crests are thicker in the middle phalanx, and
tend to be wider and rougher, occupying the midpart of the
phalanx. The nutrient foramina may be more visible or more
numerous on the palmar aspect just proximal to the head. In
the middle phalanx, the dorsal aspect of the shaft is more nar-
row proximal to the head and widens to a steeper degree
toward the base. The dorsal aspect of the shaft is more con-
vex, smooth, and more nearly round than is the dorsal aspect
of the proximal phalanx. The heads of the middle and prox-
imal phalanx are similar in configuration (125).
Base of the Middle Phalanx
The base of each phalanx flares out from the shaft on the dor-
sal, medial, lateral, and palmar surfaces. On the dorsal aspect
of the base, there is a transverse ridge along the most proxi-
mal rim, separating the base from the articular surface. The
ridge is more accentuated in its mid-portion, forming a dor-

sal lip that extends proximally over the joint. This elevated
mid-portion forms a tubercle that provides insertion for the
central slip of the extensor mechanism. On the lateropalmar
aspect of the base, there is a prominent tubercle that termi-
nates in a ridge on the medial and lateral aspects of the base.
This tubercle provides insertion of the collateral ligaments.
Although the palmar base is concave or flat, it terminates in
a thickened ridge or lip on the midpoint that borders the pal-
mar surface of the base at the joint. This tubercle is just dis-
tal to the articular surface of the base. Just distal to this tuber-
cle are multiple small foramina for nutrient vessels. The
articular surface of the base is divided into facets, consisting
of two concave depressions for the two condyles of the head
of the proximal phalanx. The two articular facets are sepa-
rated by a dorsopalmar articular crest that corresponds to the
intercondylar depression of the head of the proximal phalanx.
This crest extends toward the dorsal tubercle of the base dor-
sally, and toward the palmar tubercle on the base volarly
(125). The palmar tubercle of the base of the middle phalanx
forms a palmar prominence in relation to the shafts of the
middle and proximal phalanges, and provides mechanical
advantages for the function of the flexor digitorum superfi-
cialis (125). The presence of the nutrient foramina in the pro-
tected areas under the tendon insertion is functionally advan-
tageous because this allows movement of the flexor tendons
without interfering with the entering vessels (125).
Shaft of the Middle Phalanx
The shaft of the middle phalanx is shorter than that of the
proximal phalanx (125) (Table 1.3). The middle phalanx
can be as much as half the length of the corresponding
proximal phalanx, with the ratio of length of the proximal
phalanx to length of the middle phalanx between 2:1 and
1.3:1 (125). The shaft of the middle phalanx is less convex
dorsally and less concave palmarly compared with the prox-
imal phalanx. The proximal half of the middle phalanx is
wider in proportion to the distal half, compared with the
proximal phalanx. The radial and ulnar borders of the shaft
are concave, and when viewed from dorsally, the shaft has a
slight hourglass shape, with the narrowest portion located
slightly distal to the mid-portion. There are prominent
crests on the proximal half of the shaft on both the radial
and ulnar aspects. On the palmar aspect of the middle pha-
lanx, along the radial and ulnar portions of the proximal
half, the cortex is rough for the insertion of the flexor digi-
torum superficialis. This rough area tends to blend with the
roughened proximal shaft and base, for attachment of the
volar plate and joint capsule. The narrow portion of the
shaft just proximal to the head of the middle phalanx often
is referred to as the neck.
Head of the Middle Phalanx
The head of the middle phalanx is similar to that of the
proximal phalanx, although much smaller. The head of
1 Skeletal Anatomy 83
each phalanx widens abruptly from the neck of the shaft.
The head consists of two condyles. The articular surface
has a slight depression seen in the anteroposterior plane,
demarcating the two condyles. The articular surface
extends further palmarly than dorsally to allow the greater
amount of flexion (and relatively limited extension). The
articular surface is rounded, as noted on the lateral pro-
jection. The head does not increase in thickness in the
anteroposterior direction, as do the heads of the
metacarpals.
DISTAL PHALANX OF THE DIGITS
Ossification Centers
The distal phalanx of each digit has two ossification centers,
one in the shaft and one in the epiphysis at the base (see Fig.
1.27A and Table 1.4). The primary ossification in the shaft
begins prenatally in the eight or ninth week. The secondary
ossification in the base appears early in the second year in
girls and in the third or fourth year in boys.
The times of ossification of the secondary center of the
distal phalanx vary slightly among the different digits, and
are described in the following sections (149) (Table 1.4).
Ossification of Index Finger Distal Phalanx
In the index finger distal phalanx, the basal epiphysis first
appears in boys at 36 to 42 months of age and in girls at 24
to 30 months of age. The epiphysis usually fuses to the shaft
in boys between 17 and 18 years of age and in girls between
15 and 16 years of age.
Ossification of Long Finger Distal Phalanx
In the long finger distal phalanx, the basal epiphysis first
appears in boys at 18 to 24 months of age and in girls at 18
to 24 months of age. The epiphysis usually fuses to the shaft
in boys between 17 and 18 years of age and in girls between
15 and 16 years of age.
Ossification of Ring Finger Distal Phalanx
In the ring finger distal phalanx, the basal epiphysis first
appears in both boys and girls at 18 to 24 months of age.
The epiphysis usually fuses to the shaft in boys at approxi-
mately 17 to 18 years of age and in girls at approximately
15 to 16 years of age.
Ossification of Small Finger Distal Phalanx
In the small finger distal phalanx, the basal epiphysis first
appears in boys at 36 to 42 months of age and in girls at 18
to 24 months of age. The epiphysis usually fuses to the shaft
in boys between 17 and 18 years of age and in girls between
15 and 16 years of age.
84 Systems Anatomy
Osteology of the Distal Phalanx
The distal phalanges differ in size, shape, and contour
from the proximal and middle phalanges. Each has a base,
a shaft, and distal tuft. Although the base and, to some
degree, the shaft share similarities to the proximal and
middle phalanges, the tuft is quite different in size and
configuration.
When compared with each other, the distal phalanges
of the long and ring finger tend to be similar in length,
followed by the slightly smaller index distal phalanx, fol-
lowed in turn by the shortest small finger distal phalanx.
In some individuals, the long finger distal phalanx may be
up to 2 mm longer than the others (125). All of the distal
phalanges are much shorter and thinner than the distal
phalanx of the thumb. The widths of all of the distal pha-
langes are similar, with the exception of the small finger,
which usually is thinner. In general, the shape and overall
outline of the base of the distal phalanges are similar to
those of the middle phalanges. The shaft of the distal pha-
langes differs slightly from those of the proximal and mid-
dle phalanges, with the distal phalanx containing a shaft
that is shorter, narrower, and straighter and lacking the
curved contours (convex dorsally) of the others. The dis-
tal phalanx terminates in the roughened distal tuft that is
wider than the shaft. The average length ratios of the mid-
dle phalanx to the distal phalanx (with the middle phalanx
used as a unit) are as follows: index, 1:0.6 to 1:0.9; long,
1:0.6 to 1:0.7; ring, 1.0.6 to 1:0.7; small 1:1 to 1:0.8
(125) (Table 1.3).
Base of the Distal Phalanx
The base of the distal phalanx usually has the same width
(or is slightly wider) than the adjacent head of the middle
phalanx. In general shape, it resembles the base of the mid-
dle phalanx, although much smaller. On the dorsal aspect,
the base flares out dorsally and centrally, creating a ridge
that separates the articular surface from the shaft. The dor-
sal base is roughened slightly and forms a raised area, the
dorsal tubercle. The dorsal tubercle provides the insertion
site of the extensor digitorum communis (and extensor
indicis proprius on the index distal phalanx). On the radial
and ulnar aspects of the base are bone prominences known
as the lateral tubercles. The lateral tubercles are roughened
and raised, and serve for the attachment of the collateral lig-
aments and joint capsule of the distal interphalangeal joint.
The lateral tubercles are most pronounced on the volar half
of the base. On the volar surface of the base, there is a pal-
mar lip or ridge along the joint margin, known as the volar
tubercle (125). The surface of the palmar aspect of the base
is, however, somewhat flatter and rougher, and irregular.
This area provides the insertion site for the flexor digitorum
profundus. In this area, multiple small foramina are present
for passage of the nutrient vessels.
Shaft of the Distal Phalanx
The shafts of the distal phalanges are short and thin com-
pared with the shafts of the middle and proximal phalanges.
The shafts also are much shorter and thinner than that of
distal phalanx of the thumb. The shaft is wide proximally
and becomes progressively thinner as the tuft is approached.
The narrowest portion of the shaft is just proximal to the
formation of the tuft. The dorsal surface of the shaft is
rounded and slightly convex, but much less so than that of
the middle and proximal phalanges. On the palmar surface,
the shaft is slightly concave, but to a lesser degree than in
the middle and proximal phalanges. The medial and lateral
surfaces are rounded, and the widest portion of the shaft is
slightly volar. On cross-section, the shaft of the distal pha-
lanx thus is oval or slightly triangular, with the base on the
volar half of the shaft.
Tuft of the Distal Phalanx
The distal phalanges terminate in a roughened, wide por-
tion known as the tuft. The tuft consists of a thicker ridge
of bone that is crescent-shaped and lines the distal portion
of the distal phalanx. The crest is symmetric when viewed
from the palmar or dorsal aspect. When viewed dorsally, the
tuft is a thicken margin along the distal aspect of the pha-
lanx, usually a few millimeters thick. When viewed from
the palmar surface, the margin of the tuft is thicker and
extends more proximally. The medial and lateral portions of
the tuft on the volar surface extend a few millimeters more
proximal into the shaft than the central volar portion. This
thickened area thus forms a horseshoe shape, opened prox-
imally. On the medial and lateral surfaces of the tuft, the
thickest portion extends obliquely, from proximal volar to
distal dorsal. Several small foramina are visible on the distal
tuft for entrance of nutrient vessels. These are most numer-
ous on the palmar surface. The tuft provides for the attach-
ment of the septa that help support, stabilize, and anchor
the pulp of the digit to the distal phalanx.
Associated Joints
The base of the distal phalanx articulates with the head of the
middle phalanx through the distal interphalangeal joint. The
distal interphalangeal joint is a hinge joint. The joint surface
of the base of the distal phalanx has two facets, medial and
lateral, which articulate with the corresponding medial and
lateral condyles of the head of the middle phalanx. The joint
is stabilized by the collateral ligaments, accessory collateral
ligaments, the volar plate, and extrinsic tendons of the flexor
digitorum profundus and extensor digitorum communis
(and extensor indicis proprius of the index finger).
Muscle Origins and Insertions
The flexor digitorum profundus inserts into the palmar sur-
face of the base of the distal phalanx. The extensor digito-

rum communis inserts into the dorsal surface of the base of
the distal phalanx. The extensor indicis proprius also inserts
into the dorsal surface of the base of the distal phalanx,
slightly ulnar to the extensor digitorum communis.
THUMB PROXIMAL PHALANX
Ossification Centers
The thumb proximal phalanx has two ossification centers: a
primary center in the shaft and a secondary center in the
epiphysis (at the base; see Fig. 1.27A and Table 1.4). Ossi-
fication begins prenatally in the shafts, usually in the tenth
week. Ossification in the epiphyseal center appears in the
mid-portion in the second year in girls (18 to 22 months of
age), and in the later months of the second year or in the
early months of the third in boys (24 to 32 months of age).
The epiphysis unites to the shaft at approximately the fif-
teenth to sixteenth year in girls and in the seventeenth to
eighteenth year in boys (5,149).
Osteology of the Thumb Proximal
Phalanx
The proximal phalanx of the thumb consists of a base,
shaft, and a head. Overall, the proximal phalanx resembles
the other proximal phalanges, but in general is shorter,
with a length approximately that of the proximal phalanx
of the small finger. It is thicker than that of the small fin-
ger.
Base of the Thumb Proximal Phalanx
The base of proximal phalanx of the thumb is similar to the
base of the proximal phalanges of the digits. The base flares
out from the shaft, more noticeably on the palmar surface
than dorsally. The dorsal surface of the base is flatter than
the palmar surface, and has a slight convexity. There also is
a slight crest or roughened area that separates the articular
surface from the shaft. This dorsal roughened area provides
the insertion site for the extensor pollicis brevis. The palmar
base is concave, terminating in a thickened ridge that bor-
ders the palmar surface of the base at the metacarpopha-
langeal joint. On the palmar surface of the base of the prox-
imal phalanges there is a slight groove to accommodate the
flexor tendons. This groove is better delineated in the prox-
imal phalanges of the digits compared with that of the
thumb. The articular surface at the base of the proximal
thumb phalanx differs slightly from those of the digital
proximal phalanges. In the thumb, the articular surface at
the base is flatter and less concave to accommodate the
articular surface of the head of the thumb metacarpal,
which tends to be flatter and less spherical than in the other
metacarpals.
1 Skeletal Anatomy 85
Shaft of the Thumb Proximal Phalanx
The shaft of the proximal phalanx of the thumb is approx-
imately the length of the proximal phalanx of the small fin-
ger (although it actually may be shorter). The shaft is rela-
tively thick, especially in its proximal portion, compared
with the other proximal phalanges. The shaft is rounded
and smooth, and in cross-section it is round or oval, slightly
flatted palmarly, and, to a lesser degree, flattened dorsally.
The shaft does not have the lateral crests seen on the prox-
imal phalanges of the digits. Very seldom can a small fora-
men for a nutrient vessel be identified on the shaft (125).
Head of the Thumb Proximal Phalanx
The head of the thumb proximal phalanx resembles the
head of the other proximal phalanges. The head is slightly
larger, with a wider articulating surface. The articular sur-
face extends more palmarly, and when viewed in the lateral
projection, the articular surface appears symmetrically
rounded. (There is no increase in thickness in the antero-
posterior direction, as is noted in the heads of the
metacarpals). It has a well defined margin separating the
articular surface from the palmar and dorsal surfaces of the
shaft. The head has two condyles, easily visualized in the
anteroposterior plane. The medial and lateral surfaces of the
head are flat and roughened to provide attachment for the
collateral ligaments and joint capsule. The flattened areas
laterally give the squared appearance of the head as seen on
the anteroposterior view. Several small foramina are located
just proximal to the articular surface, especially on the pal-
mar surface, providing access for nutrient vessels.
Associated Joints
The proximal phalanx of the thumb articulates proximally
with the head of the thumb metacarpal at the thumb
metacarpophalangeal joint. The proximal phalanx of the
thumb articulates distally with the base of the thumb distal
phalanx. The thumb metacarpophalangeal joint is similar to
that of the other metacarpophalangeal joints; however,
because of the shape of the adjoining joint surfaces, the
joint is more hingelike instead of multiaxial, as in the oth-
ers (125). The metacarpophalangeal joint of the thumb is
associated with two sesamoid bones located in the volar
plate or thenar tendons. The lateral sesamoid usually is
slightly larger than the medial sesamoid. The joint is stabi-
lized by collateral ligaments, accessory collateral ligaments,
and joint capsule, along with the intrinsic muscles (flexor
pollicis brevis, abductor pollicis brevis, extensor pollicis
brevis, and adductor pollicis) and the overlying extrinsic
tendons (flexor pollicis longus and extensor pollicis longus).
The interphalangeal joint of the thumb is a hinge joint,
larger than the interphalangeal joints of the digits. It is
stabilized by the collateral ligaments, accessory collateral
86 Systems Anatomy
ligaments, volar plate, and overlying extrinsic tendons
(flexor pollicis longus and extensor pollicis longus).
Muscle Origins and Insertions
Several muscles insert into the base of the thumb proximal
phalanx. The extensor pollicis brevis inserts into the dorsal
surface of the base. The abductor pollicis brevis inserts into
the radial aspect of the base. The flexor pollicis brevis inserts
into the palmar base. The adductor pollicis inserts into the
ulnar aspect of the base.
THUMB DISTAL PHALANX
Ossification Centers
The thumb distal phalanx has two ossification centers: a
primary center in the shaft and a secondary center in the
epiphysis (at the base; see Fig. 1.27A and Table 1.4). Ossi-
fication begins prenatally in the shaft, usually in the eighth
or ninth week. Ossification in the epiphyseal center appears
in the second year in girls (12 to 15 months of age), and in
the later months of the second year in boys (15 to 18
months of age). The epiphysis unites to the shaft at approx-
imately the thirteenth year in girls and in the fifteenth year
in boys (5,149).
Osteology of the Thumb Distal Phalanx
The distal phalanx of the thumb is markedly larger; it is
longer, thicker, and wider, than the distal phalanges of the
other digits. However, other than the size, the overall char-
acteristics and osteology are similar to those of the other
distal phalanges. The distal phalanx of the thumb consists
of a base, shaft, and a tuft. The tuft occasionally is incor-
rectly referred to as the head.
Base of the Thumb Distal Phalanx
The base of the thumb distal phalanx is wide and thick,
with pronounced flaring medially and laterally. There is a
ridge along the dorsal, medial, and lateral surfaces, outlin-
ing the articular surface. The dorsal base is roughened and
has a thick crest just distal to the articular surface. The crest
is more elevated in the central portion and provides the
attachment site of the extensor pollicis longus. On the
medial and lateral surfaces of the base, there is pronounced
flaring. Each side has small, irregular tubercles for attach-
ment of the collateral ligaments and joint capsule. These
tubercles are more accentuated in the thumb than in the
phalanges. The palmar surface of the base is flatter (or even
slightly concave) compared with the flared dorsal base.
With less flaring and a flatter surface, the palmar base joins
the shaft in a more gradual manner. The palmar surface is
rough for attachment of the flexor pollicis longus. The
articular surface at the base is divided by a slight midcrest
into two concave surfaces. These surfaces articulate with the
condyles of the head of the proximal phalanx. The base of
the thumb proximal phalanx has multiple small foramina
for nutrient vessels. These are most easily visualized on the
palmar surface.
Shaft of the Thumb Distal Phalanx
The shaft (and overall length) of the thumb distal phalanx
is longer and wider than those of the digits. The shaft is
rounded on the dorsal and lateral surfaces, and somewhat
flat or slightly convex on the palmar surface. On cross-sec-
tion, the shaft is oval or hemispherical in shape, and appears
much flatter than in the other digits. Specific foramina for
nutrient vessels usually are not visualized on the shaft.
Tuft of the Thumb Distal Phalanx
The distal tuft is a thickened, widened distal tip that
expands abruptly from the shaft. On the anteroposterior
projection, the tuft is oval, triangular, or somewhat dia-
mond-shaped. It contains a thickened rim along the distal,
medial, and lateral margins. The palmar surface of the tuft
is smoother and less pronounced, and blends with the shaft
in a gradual manner. The tuft is roughened to provide for
the attachments of the many septa that help support, stabi-
lize, and anchor the pulp of the distal portion of the thumb.
Associated Joints
The distal phalanx of the thumb articulates with the head
of the proximal phalanx through the interphalangeal joint
of the thumb. The articular surface of the base of the distal
phalanx is divided into two concave surfaces that articulate
with the two corresponding condyles of the head of the
proximal phalanx. The joint is a uniaxial hinge joint, stabi-
lized by two collateral ligaments, two accessory collateral
ligaments, a volar plate, and a joint capsule. The extrinsic
tendons of the extensor pollicis longus and flexor pollicis
longus move the joint, as well as adding stabilization.
Muscle Origins and Insertions
There are two muscle insertions on the thumb distal pha-
lanx. The extensor pollicis longus inserts into the base of the
phalanx on the dorsal surface. The flexor pollicis longus
inserts into the base of the phalanx on the palmar surface.
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 2
MUSCLE ANATOMY
MICHAEL J. BOTTE
The following sections describe the anatomic features of
skeletal muscles of the upper extremity. Each is provided as
a reference for a specific muscle, and is not intended for the
purpose of planning operative approaches. A summary of
muscle origin, insertion, innervation, vascular supply, and
action is listed initially, followed by a general description of
the gross anatomic features, actions and biomechanical
aspects, variations and anomalies, and clinical implications
of the anatomy (1–14). At the end of this chapter are sev-
eral appendices for further reference. Appendix 2.1 sum-
marizes the general features of each muscle for muscle
comparison. Appendix 2.2 lists the skeletal muscles as to
extremity compartments, from the standpoint of compart-
ment syndrome. Appendix 2.3 lists muscle difference index
values. These values are comparisons of the architectural
features of several muscles of the forearm. The architectural
difference index allows comparison of the relative differ-
ences (or similarities) of each skeletal muscle with regard to
design and function, based on architectural properties
(15).
DELTOID MUSCLE (DELTOIDEUS)
Derivation and Terminology. Deltoid is derived from the
Latin deltoides, which means “triangular in shape or form”
(1,2).
Origin. Lateral third of clavicle, acromion, and inferior
edge of spine of the scapula.
Insertion. Deltoid tuberosity of the lateral humerus.
Innervation. Axillary nerve (C5, C6). Occasionally, a
contribution from C4 also may be present in the axillary
nerve (3–8).
Vascular Supply. Acromial and deltoid branches of the
thoracoacromial artery; posterior and anterior circumflex
humeral arteries; subscapular artery, and deltoid branch of
the profunda brachii. The thoracoacromial, posterior and
anterior circumflex humeral arteries, and the subscapular
artery all arise from the axillary artery (3–11).
Principal Action. Abduction, forward flexion, and exten-
sion of the humerus.
Gross Anatomic Description: Deltoid
Muscle
The deltoid is a relatively thick, curved muscle in the shape
of an isosceles triangle, with the apex pointed inferiorly. It
occupies and comprises the deltoid muscle compartment of
the shoulder (Appendix 2.2). The deltoid surrounds the
humeral head and glenohumeral joint on all aspects except
medially and inferiorly, and, when viewed from above, the
muscle appears somewhat U-shaped, with the open portion
facing medially. The muscle has a broad origin, expanding
anteriorly from the lateral third of the anterior clavicle, lat-
erally from the superolateral aspect of the acromion, and
posteriorly along the inferior edge of the spine of the
scapula (Fig. 2.1). Based on the origin, the muscle has three
subdivisions: a clavicular, acromial, and a (scapular) spinous
part. The clavicular and spinous parts consist of long mus-
cle fiber bundles that coalesce laterally and inferiorly at the
insertion to help form a “V” or inverted triangle shape. At
the insertion, the fibers converge into a short, thick tendon
that attaches to the deltoid tuberosity of the lateral mid-dia-
physis of the humerus (Fig. 2.2). The tendon of the deltoid
also may give off an expansion into the brachial deep fascia
that may reach the forearm. The anterior and posterior por-
tions of the muscle converge directly into the insertion. The
mid-portion, from the acromion, however, is multipennate.
In this portion, four or five intramuscular septa or tendi-
nous expansions descend superiorly from the lateral aspect
of the acromion. Similarly, from the inferior insertional
area, three septa or tendinous expansions ascend from the
insertion site. The septa from the acromion above run
obliquely and insert or interdigitate with the separate septa
from the insertion site below (3,4,11–14). In addition,
there is interdigitation of the tendons from the clavicular
and spinous portions. The septa are interconnected with
short muscle fibers that provide powerful traction. The
muscle fasciculi are large, and produce a coarse longitudinal
striation. The deltoid is responsible for creating the
rounded profile of the shoulder (9–13).
The deltoid muscle is innervated by the axillary nerve
(C5, C6), which leaves the posterior cord of the brachial

plexus and courses posteriorly through the quadrangular
space to reach the deep surface of the deltoid muscle. The
nerve then crosses from posterior to lateral along the deep
surface of the muscle approximately 5 cm distal to the
acromion. The axillary nerve gives off motor branches along
its course, and courses anteriorly as far as the anterior edge
of the deltoid muscle. Although the axillary nerve com-
prises mostly fibers from C5 and C6, it may contain a con-
tribution from C4.
Actions and Biomechanics: Deltoid
Muscle
The deltoid is able to contract certain portions or parts
independently of others. Thus, parts of the muscle can act
A
FIGURE 2.1. Anterior (A) and posterior (B) views of the scapula, showing muscle origins (red)
and insertions (blue).
2 Muscle Anatomy 93
separately as well as together. When the entire muscle con-
tracts, the humerus can be abducted slightly beyond 90
degrees (3,4). (Additional humeral abduction actually is
produced in conjunction with scapular rotation.) The ante-
rior (clavicular) fibers contracting independently assist the
pectoralis major in producing forward flexion and internal
rotation of the humerus. The posterior fibers contracting
independently can assist the latissimus dorsi and teres major
in producing extension (to approximately 45 degrees) and
external rotation of the humerus. The clavicular and spin-
ous portions can contract simultaneously to assist with sta-
bilization of the humerus. The central portion of the mus-
cle is multipennate. This central (acromial) portion assists
with strong abduction of the humerus. Aided by the
supraspinatus, it can abduct the humerus until the joint
(continued on next page)
94 Systems Anatomy
B
FIGURE 2.1. (continued)
capsule is tense inferiorly. The trapezius also assists the del-
toid with humeral abduction. In general, the most effective
abduction takes place with the humerus in external rota-
tion. When the abduction takes place in the plane of the
body of the scapula, scapular rotation can be fully effective
in assisting with humeral abduction and raising the arm
above the head. During humeral abduction, the central
(acromial) fibers of the deltoid contract strongly, aided by
the anterior (clavicular) and posterior fibers, both of which
help prevent departure of the humerus from the plane of
motion. In the early stages of abduction, there is an upward
traction force on the humeral head produced by the deltoid.
The humeral head is prevented from translating upward by
the synergistic downward pull of the subscapularis, infra-
spinatus, and teres minor (3,4). Electromyography suggests
that deltoid contributes little to internal or external rota-
tion, but confirms that it does take part in most other
shoulder movements. When a weight or load produces a
downward drag on the upper extremity, the deltoid and the
supraspinatus contract to help resist the downward force.
Other common actions of the deltoid include assisting to
produce arm swinging during ambulation, and helping to
forward flex the arm to position the hand at various heights
during manual tasks (3,8,11,16).
Anomalies and Variations: Deltoid Muscle
Several variations of the muscle belly of the deltoid have
been noted (11). Each of the three parts may appear as a
separate muscle, so that there is a split in the muscle mass
or of the distal insertion tendon. A separate clavicular part
is the most common of these anomalies. The acromial and
spinous parts also may appear as a separate muscle.
The deep portion of the deltoid may be separated from
the major mass portion of the muscle, and this deep portion
may insert into the shoulder capsule or extend distally onto
the humerus (11).
Portions of the deltoid may be absent, especially those
originating from the clavicle or acromion.
Several accessory muscle or tendon slips may attach to
the deltoid. These muscle slips can connect to the fascia
covering the infraspinatus muscle or connect directly to the
trapezius muscle. Muscle slips also attach to the vertebral or
axillary borders of the scapula. An accessory tendon of
 2 Muscle Anatomy 95

A B
FIGURE 2.2. Anterior (A) and posterior (B) views of the humerus, showing muscle origins (red)
and insertions (blue).
96 Systems Anatomy
insertion has been noted to extend to the radial side of the
forearm.
The muscle belly of the deltoid may coalesce with adja-
cent muscles, and appear structurally joined to these mus-
cles. Coalescing muscles include the pectoralis major,
trapezius, infraspinatus, brachialis, and brachioradialis (11).
Clinical Correlations: Deltoid Muscle
Axillary palsy can produce severe deltoid atrophy. This, in
turn, results in prominence of the acromion, which can
simulate dislocation of the shoulder joint. The distance
between the acromion and humeral head is increased to
the extent that a fingertip may be inserted between them
(3,4).
Deltoid paralysis from axillary nerve injury is a well rec-
ognized complication of shoulder dislocation, especially
anterior and inferior (luxatio erecta) dislocations (17).
Central nervous disorders such as stroke can result in
deltoid paralysis. The paralysis can result in inferior sublux-
ation of the humeral head, which can secondarily result in
traction on the brachial plexus with associated pain or limb
paresthesias.
Thickening of the distal edge of the deltopectoral fascia
may produce compression of the median nerve (11,17,18).
CORACOBRACHIALIS MUSCLE
Derivation and Terminology. The coracobrachialis
derives its name from its origin from the coracoid process
and its insertion into the brachium. Coracoid is derived
from the Greek korakoeides, which means “crowlike” or
“like a crow’s beak” (korax = raven, and eidos = appearance),
and pertains to the coracoid process, which resembles a
bird’s beak. The word brachialis is derived from the Latin
and Greek brachialis and brachion, respectively, which des-
ignate or pertain to the arm (1,2). Note that brachi and
brachial pertain to arm, and should not be confused with
brachy (from Greek brachys), which refers to “short” (i.e.,
brachydactyly for short digits).
Origin. Apex of the coracoid process, along with the
conjoined tendon of the short head of the biceps. Muscle
fibers of the coracobrachialis also may originate from the
tendon of the short head of the biceps along the proximal
10 cm of the tendon.
Insertion. Medial humeral diaphysis, over a 3- to 5-cm
insertional impression on the cortex. The area of insertion
is roughly at the junction of the proximal and middle thirds
of the humerus, between the attachment of the triceps and
the brachialis.
Innervation. Musculocutaneous nerve (C5, C6, C7).
Vascular Supply. Muscular branches from the axillary
artery, the brachial artery, and the anterior circumflex
humeral artery (3,11).
Principal Action. Forward flexion and adduction of the
humerus.
Gross Anatomic Description:
Coracobrachialis
The coracobrachialis is a relatively long and slender muscle,
somewhat cylindrical in shape. Along with the biceps
brachii and brachialis, the coracobrachialis helps comprise
the anterior muscle compartment of the arm (Appendix
2.2). The coracobrachialis helps form the inconspicuous
rounded ridge on the upper medial side of the arm. The
pulse of the brachial artery often can be seen or palpated in
the depression posterior to the coracobrachialis. The muscle
fibers extend obliquely and in a parallel fashion. The mus-
cle usually contains an aponeurotic band that continues
from the deep surface of the muscle to the insertion. The
muscle originates from the apex of the coracoid process,
along with the conjoined tendon of the short head of the
biceps (see Fig. 2.1). Muscle fibers of the coracobrachialis
also may originate from the tendon of the short head of the
biceps along the proximal 10 cm of the tendon. The mus-
cle may be separated into two heads or parts, separated by
the musculocutaneous nerve, which passes in between.
When the superficial and deep parts are clearly defined, the
tendon of origin of the superficial part may be clearly sepa-
rated from that of the deep part and may be closely associ-
ated with the tendon of the short head of the biceps brachii
(3,4,8,11,19–25). The muscle extends from the coracoid
process in a distal direction toward the medial diaphysis of
the humerus. The muscle is cylindrical or fusiform in shape.
The muscle inserts into the medial humeral diaphysis over
a 3- to 5-cm insertional impression on the cortex (see Fig.
2.2A). The area of insertion is roughly at the junction of the
proximal and middle thirds of the humerus, between the
attachment of the triceps and the brachialis. At the inser-
tion point, there also may be two separate tendons from the
superficial and deep parts of the muscle (3,4,8,11).
The musculocutaneous nerve, derived mostly from C5,
C6, and C7, innervates the coracobrachialis. The nerve
exits the brachial plexus from the lateral cord near the level
of the acromion. The branch to the coracobrachialis usually
is the first (most proximal) motor branch from the muscu-
locutaneous nerve, followed by motor branches to the
biceps and then the brachialis. After exiting from the lateral
cord, the musculocutaneous branch to the coracobrachialis
enters the proximal third of the medial aspect of the muscle
and crosses through the muscle from medial to lateral near
its midline.
Flatow and colleagues (26) and Eglseder and Goldman
(27) have quantified the anatomic aspects of coraco-
brachialis innervation in relation to the coracoid process.
The distance from the coracoid process to the point where
the musculocutaneous nerve enters the coracobrachialis
muscle averages between 46 and 56 mm (range, 31 to

82 mm) (26,27). Small nerve twigs to the coracobrachialis
(proximal to the main nerve trunk) enter the muscle as
close as 17 mm distal to the coracoid process, with an aver-
age of 31 mm. The authors note that the frequently cited
range of 5 to 8 cm below the coracoid for the level of pen-
etration cannot be relied on to describe a “safe zone”
because 29% of the nerves entered the muscle proximal to
50 mm below the coracoid (74% if the proximal twigs are
considered) (26). The musculocutaneous nerve exits the
coracobrachialis muscle at a mean of 75.5 mm distal to the
coracoid process (27).
Actions and Biomechanics:
Coracobrachialis
The coracobrachialis functions mainly to assist with flexion
and adduction of the humerus. With the humerus in exten-
sion, the coracobrachialis assists in returning the humerus
to a neutral position. In abduction, the coracobrachialis acts
with the anterior fibers of the deltoid to stabilize the
humerus in the plane of motion. The coracobrachialis also
helps stabilize and maintain the head of the humerus in the
glenoid fossa. Theoretically, the coracobrachialis can help
rotate the scapula if the humerus is stabilized (3,8,11).
Anomalies and Variations:
Coracobrachialis
There are several variations of the insertion of the coraco-
brachialis, including those more proximal and those more
distal on the humerus. Those more proximal than the prox-
imal diaphysis include insertions into the surgical neck of
the humerus or capsule of the shoulder joint (28). The cora-
cobrachialis brevis (or coracobrachialis superior, coraco-
brachialis rotator humeri) is an anomalous muscle that
arises from the coracoid process and inserts proximally, into
the bicipital ridge of the humerus in the proximal diaphysis,
approximately 1 cm distal to the lesser tuberosity (3,11).
This muscle may represent a remnant of a separate portion
of the muscle formed embryologically. Those inserting
more distally may include attachment sites along the medial
margin of the humerus, or a separate insertion in the medial
distal humerus or medial epicondyle. The distal insertion
may consist of an elongated tendinous extension. The cora-
cobrachialis inferior or coracobrachialis longus denotes an
anomalous muscle that inserts much farther distally than
usual (3,11). These often insert into either the distal medial
aspect of the humerus, into the fibrous band of the medial
intermuscular septum, or into the ligament of Struthers.
The muscle also may extend distally into the medial supra-
condylar ridge, medial epicondyle, or an anomalous supra-
condylar process. The coracobrachialis inferior or coraco-
brachialis longus has been referred to as Wood’s muscle,
based on Wood’s descriptions of several muscle variations in
1870 (8,11,18).
2 Muscle Anatomy 97
Similar to the anomalous distal insertions, the coraco-
brachialis may have several accessory slips that attach to the
muscle distally. These include extensions to the medial epi-
condyle, the medial intermuscular septum, or the distal
medial aspect of the humerus (11,21).
Muscle or tendon slips have been noted to extend to var-
ious structures in the shoulder area, including the tendons
of the latissimus dorsi and teres major, or to the lesser
tuberosity of the humerus (22,23). Among these is the cora-
cobrachialis minor (le court coracobrachialis of Cruveil-
hier), an accessory muscle that arises from the coracoid
process and crosses the radial nerve in the axilla and inserts
into the tendinous part of the latissimus dorsi (11). Com-
plete absence of the coracobrachialis can also occur.
An anomalous muscle has been noted to arise from the
medial aspect of the distal half of the humerus, between the
coracobrachialis and brachialis, passing obliquely across the
front of the brachial artery and median nerve and attaching
with the common origin of the forearm flexor muscles
(22,23). It did not appear to be an additional head of the
coracobrachialis, biceps, or brachialis. The muscle appeared
to place the median nerve and brachial artery at risk for
compression; the authors suggest that the existence of this
muscle be kept in mind in a patient presenting with a high
median nerve palsy together with symptoms of brachial
artery compression (22,23).
Several variations in the musculocutaneous innervation
of the coracobrachialis have been noted, with most of the
differences involving the path of the nerve before muscle
innervation (11,21,26,27,29–33). Although the motor
branch from the musculocutaneous nerve usually pierces
the muscle and travels in its substance, the nerve may not
pierce the muscle in the proximal portion. Instead, the
nerve may continue along with or in the substance of the
median nerve, travel distally along the muscle, and then, as
a single trunk or as several branches, pass between the
biceps and brachialis, supplying these muscle as well as the
coracobrachialis from the more distal aspect. This variation
has been suggested to occur in approximately 20% of arms
(11). Alternatively, the motor nerve to the coracobrachialis
may split, with a branch entering and supplying the muscle,
and then a portion may rejoin the main musculocutaneous
nerve trunk. The nerve also may pass posterior to the cora-
cobrachialis or between it and the short head of the biceps
muscle before innervating the coracobrachialis. Rarely, the
lateral cord may enter as a nerve into the coracobrachialis
and then divide into the musculocutaneous nerve and the
lateral head of the median nerve.
Clinical Correlations: Coracobrachialis
Muscle
Several operative procedures involve mobilization or expo-
sure of the coracoid process. The musculocutaneous nerve
and motor branches to the coracobrachialis muscle are at
98 Systems Anatomy
risk for injury. The points of innervation of the musculocu-
taneous nerve to the coracobrachialis have wide variability,
with muscular branches entering the coracobrachialis from
31 to 82 mm distal to the coracoid process (26). In the past,
there has been a frequently cited “safe zone” of 5 to 8 cm
distal to the coracoid for the level of penetration of these
nerve branches. This safe zone cannot be relied on, how-
ever, because of the established variability of the nerve. This
variability should be kept in mind when exposing or mobi-
lizing the coracoid process, and the vicinity of the muscu-
locutaneous nerve and its branches should be appreciated.
The coracobrachialis, including the axillary vessels, can
be used as a local muscle flap for coverage of exposed infra-
clavicular or postmastectomy defects (34).
Isolated musculocutaneous nerve palsy has been noted to
occur. Atraumatic palsy (35) as well as palsies associated
with heavy exercise or violent extension of the elbow have
been reported (36–39). It can occur bilaterally (40). The
coracobrachialis, however, usually is spared weakness, and
the area of compression is thought to be possibly within the
muscle itself (39). The syndrome usually produces weakness
of the biceps brachii and brachioradialis, with sensory
abnormalities along the lateral forearm. It usually resolves
with rest, but may take weeks or months (see later, under
Clinical Correlations: Biceps Brachii).
The wide variation in the course of the musculocuta-
neous nerve before and inside the coracobrachialis, and the
high percentage of anomalies, emphasize the complexities
and irregularities of this anatomic region with regard to sur-
gical approaches (11,21,26,27,30–32).
BICEPS BRACHII MUSCLE
Derivation and Terminology. Biceps is derived from the
Latin and Greek bi, meaning “two,” and the Latin caput,
meaning “head.” Biceps thus refers to “two heads.”
Brachialis is derived from the Latin and Greek brachialis and
brachion, respectively, which designate or pertain to the arm
(1,2). Note that brachi and brachial pertain to the arm, and
should not be confused with brachy (from Greek brachys),
which refers to “short” (i.e., brachydactyly for short digits).
Origin. Short head: from the coracoid process, in the
conjoined tendon of the coracobrachialis. Long head: from
the supraglenoid tubercle of the scapula and from the pos-
terior part of the glenoid labrum by a long tendon of the
origin approximately 9 cm long.
Insertion. The bicipital tuberosity of the radius and into
the bicipital aponeurosis, which inserts into the deep fascia
on the ulnar aspect of the forearm.
Innervation. Musculocutaneous nerve (C5, C6).
Vascular Supply. The brachial artery and the anterior cir-
cumflex humeral artery. The short head may receive a
branch from the axillary artery (3,8,11,19).
Principal Action. Flexion and supination of the forearm.
Gross Anatomic Description: Biceps
Brachii
The biceps brachii is a relatively large, thick, and roughly
fusiform muscle comprising a major portion of the anterior
muscle compartment of the arm (Appendix 2.2). The mus-
cle has two heads, arising from two separate origins. The
muscle heads then partially coalesce into a single large mus-
cle belly, although it still grossly retains some features of two
separate heads (41).
The short head arises from the tip of the coracoid
process, originating as a thick, flat tendon that is conjoined
with the origin of the coracobrachialis muscle (see Fig. 2.1).
The short head then separates, and the muscle belly
becomes more defined. The muscle fibers of the short head
descend from the dorsomedial surface of the tendon, in a
vertical fashion, and join the fibers of the long head. The
fibers increase in number from proximal to distal as the
muscle approaches the insertion.
The long head arises from a rough or raised point just
superior to the rim of the glenoid fossa, known as the supra-
glenoid tubercle of the scapula. It is intracapsular at its origin.
From the origin, there is a well defined, long, stout tendon
that is approximately 9 cm long. The tendon runs from the
apex of the glenoid cavity enclosed in a double tubular
sheath that is an extension of the synovial membrane of the
joint capsule. The tendon is intracapsular as it crosses and
then arches over the head of the humerus. It emerges from
the joint posterior to the transverse humeral ligament. The
tendon then descends in the intertubercular sulcus of the
humerus, where it is held in place by the transverse humeral
ligament and a fibrous expansion from the tendon of the
pectoralis major. At the myotendinous junction, the muscle
belly of the long head joins the belly of the short head. The
muscle fibers extend distally and obliquely. The two bellies
appear joined together, and form a single elongated belly.
The two heads, however, can be separated from each other
to within approximately 7 cm of the elbow joint. The mus-
cle fibers then form a terminal tendon in the distal fourth
of the arm. The fibers coalesce and become tendinous, tak-
ing the shape of a flattened or oval tendon. As the tendon
approaches its insertion point, it spirals from proximal to
distal, so that the anterior surface turns to face laterally. The
tendon passes between the brachioradialis and the pronator
teres. It then inserts into a rough posterior attachment area
of the radial tuberosity (Fig. 2.3A). There is a bursa in the
vicinity of the tendon that separates the tendon from a
smooth anterior area of the tuberosity. Proximal to the
elbow joint, the tendon also has a broad medial fascial
expansion, the bicipital aponeurosis. This aponeurosis actu-
ally forms in the proximal part of the terminal tendon and
is first identifiable as a vertical septum between the two
heads of the biceps. More distally, it becomes a broadened
and flattened aponeurosis. Muscle fibers insert on the sides
of the septum and surfaces of the aponeurosis, the long
 2 Muscle Anatomy 99

A B
FIGURE 2.3. Anterior (A) and posterior (B) views of the radius and ulna, showing muscle origins
(red) and insertions (blue).

head chiefly on the deep surface, and the short head pri-
marily on the superficial surface. This fascial attachment
extends distally and medially superficial to the brachial
artery to coalesce with the deep fascia of the distal upper
arm and proximal forearm. This is in the vicinity of the ori-
gin of the flexor–pronator muscles of the forearm. The ten-
don often can be split as far distally as the radial tuberosity,
where the anterior and posterior layers can be traced back
to the separate bellies of the short and long head, respec-
tively (3,4,10–13,42).
The biceps muscle is innervated by the musculocuta-
neous nerve (C5, C6). Although each head receives its own
nerve branch, the two branches may extend together as a
small common nerve trunk. Several separate smaller
100 Systems Anatomy
branches may enter the muscle on the deep surface in the
proximal portion of the middle third. A distinct intramus-
cular fissure in each head has been noted where the nerve
enters the muscle (11,43).
The path and variations of the musculocutaneous nerve,
including the branch patterns to the biceps and brachialis
muscles, have been studied by Yang et al. (43) and Chiara-
pattanakom and colleagues (44). In microdissections of 24
fresh-frozen cadaver specimens, Yang et al. found that the
motor branch to the biceps exited from the musculocuta-
neous nerve 119 mm distal to the coracoid process. Varia-
tions were seen in the innervation of the two heads of the
biceps. A common primary motor branch that bifurcated to
supply the two heads was seen in 20 specimens (type I).
Two specimens had two separate primary branches origi-
nating from the main musculocutaneous nerve trunk to
individually supply each head of the biceps (type II). The
third variation (type III), also seen in two specimens, was
similar to type I, but with an additional distal motor branch
innervating the common belly of the biceps muscle. The
motor branch to the brachialis muscle exited from the mus-
culocutaneous nerve 170 mm distal to the coracoid process.
The motor branches to the biceps and brachialis muscles
may be dissected proximally from their points of exit from
the main trunk of the musculocutaneous nerve for mean
distances of 44 and 53 mm, respectively. These variations
have clinical application in the operative exposure of the
musculocutaneous nerve, especially in performing inter-
costal nerve to musculocutaneous motor branch transfer for
elbow flexion in patients with brachial plexus injuries (43).
In a subsequent study, Chiarapattanakom and colleagues
studied 112 musculocutaneous nerves from 56 cadavers
(44). There were three distinct types of branching patterns
for the biceps innervation: in 62%, there was one branch
only; in 33%, there were two branches; and in 5%, there
were three branches. The origin of the first branch averaged
130 mm from the acromion, regardless of branch type. The
maximum distance between the first and second branch was
53 mm. In 92%, there was only one branch to the brachialis
muscle (44).
Actions and Biomechanics: Biceps Brachii
The biceps is one of the primary flexors of the elbow. Flex-
ion of the elbow is most effective with the forearm in
supination. The biceps is also the strongest supinator of the
forearm, especially with rapid or resisted movements. The
short head, from its origin on the coracoid process, can
assist with adduction and forward flexion of the humerus.
The long head, from its origin just above the glenoid,
assists in stabilizing the humeral head in the glenoid cavity.
The long head can specifically help to prevent superior
migration of the humeral head during contraction of the
deltoid.
Based on cross-sectional analysis of the major elbow
muscle flexors, the biceps brachii appears to contribute
34% of flexion torque, with the brachialis contributing
47% and the brachioradialis 19% (20).
Anomalies and Variations: Biceps Brachii
Several variations of the biceps have been noted (11,22,23,
41,42). Most of these consist of accessory heads or inter-
connecting anomalous muscles bellies. Accessory heads are
often associated with variations in the musculocutaneous
innervation or with abnormal courses of the axillary and
brachial arteries (41). There may be an absence of one or
both heads of the biceps brachii or both heads may be sep-
arate along their complete course from origin to insertion.
Both heads may also be coalesced along most of their
course.
Supernumerary heads are common, occurring in over
10% of specimens (11,45,46). An accessory head may arise
from the coracoid process, capsule of the shoulder joint,
tendon of the pectoralis major, or the region of the deltoid
insertion (21,22,42).
A third or fourth (humeral) head has been found in
approximately 12% to 14% of arms (11,45,47,48). It usu-
ally arises from the proximal humerus in the region of the
greater tuberosity. Less commonly, two accessory heads may
arise together from the neck of the humerus or posterior to
the tendon of the pectoralis. These two anomalous heads
may be joined to the pectoralis tendon. The lateral of the
two accessory slips usually joins the long head of the biceps
and the medial head usually joins the short head.
A third head often arises from the superomedial part of
the brachialis and attaches to the bicipital aponeurosis and
medial side of the tendon of insertion (3). This head often
is located deep to the brachial artery. It also may consist of
two slips that extend distally, one slip superficial and one
deep to the brachial artery.
Muscle or tendon slips may extend from the lateral
aspect of the humerus or intertubercular sulcus to join the
main muscle belly of the biceps. The most common anom-
alous slip arises from the humerus near the insertion of the
coracobrachialis and extends distally between the coraco-
brachialis and brachialis. This anomalous slip usually joins
the short head, but most of the fibers pass into the part of
the tendon that forms the bicipital aponeurosis. This slip
also may be completely separated and terminate entirely in
the bicipital aponeurosis (11).
An accessory slip may arise from the deltoid.
Several variations have been noted at the distal end of the
muscle, including various muscular or tendinous slips that
extend from the biceps to the distal humerus, ulna, radius,
forearm fascia, or neighboring muscles (11,49,50). Super-
numerary heads may extend to or from the biceps to the
brachialis, brachioradialis, pronator teres, flexor carpi radi-

alis (FCR), flexor digitorum profundus (FDP), intermuscu-
lar septum, or medial epicondyle (11,49,50).
Muscle coalitions from the biceps have been noted where
the muscle “fuses” with the belly of neighboring muscles,
including the pectoralis major and minor, coracobrachialis,
and brachialis (11).
Attachments from a muscular or tendinous extension
from the distal biceps to the palmaris longus have been
noted (11). Attachments from a muscular or tendinous
extension from the distal biceps to the extensor carpi radi-
alis brevis (ECRB) have also been noted (51).
An anomalous muscle has been noted to arise from the
medial aspect of the distal half of the humerus, between
the coracobrachialis and brachialis, passing obliquely
across the front of the brachial artery and median nerve
and attaching with the common origin of the forearm
flexor muscles (22,23). The muscle did not appear to be an
additional head of the coracobrachialis, biceps, or
brachialis. The muscle, however, appeared to place the
median nerve and brachial artery at risk for compression.
The authors suggest that the existence of this muscle be
kept in mind in a patient presenting with a high median
nerve palsy together with symptoms of brachial artery
compression (22,23).
As noted previously in the descriptions of the coraco-
brachialis, several variations in the course and innervation of
the musculocutaneous nerve to the coracobrachialis, biceps,
and brachialis have been noted. Most variations involve the
path of the nerve before muscle innervation (11,26,27,
29–33,41). Although the motor branch from the musculo-
cutaneous nerve usually pierces the coracobrachialis and
travels in its substance, the nerve may not pierce the muscle.
Instead, the nerve may continue along with or in the sub-
stance of the median nerve, travel distally along the coraco-
brachialis, and then, as a single trunk or as several branches,
pass between the biceps and brachialis, supplying these mus-
cles as well as the coracobrachialis from the more distal
aspect. This variation has been suggested to occur in approx-
imately 20% of arms (11,21,26,27,29–33,41).
The musculocutaneous nerve may be absent. The biceps
(and brachialis) can receive its innervation directly from the
median nerve (32).
Clinical Correlations: Biceps Brachii
Rupture of the biceps tendon is among the most common
of closed tendon ruptures. These occur either proximally in
the tendon of the long head (or short head) (52–56), or dis-
tally, at or near the insertion (57–68).
Bicipital tendinitis occurs in the tendon of the long
head, usually along the anterior shoulder in the intertuber-
cular groove. Chronic tendinitis is associated with tendon
rupture, as well as a high incidence of associated related
shoulder problems, including impingement syndrome and
frozen shoulder (69–76).
2 Muscle Anatomy 101
The lacertus fibrosus is a structure known to cause or
contribute to median nerve compression in the forearm
(49,50).
Proximal paralysis of the brachial plexus involving the
C5 and C6 nerve roots (Erb-Duchenne palsy) results in
paralysis of the biceps. If C7 remains intact, the innervation
of the triceps remains intact. Functioning of the triceps in
conjunction with paralysis of the biceps results in the elbow
positioned in full extension. To restore elbow flexor power,
several operative flexorplasty procedures have been
described (77–80). These include proximal transfer of the
forearm flexor–pronator or wrist extensor mass (which
increases their moment arm across the elbow and enhances
their ability to act as secondary elbow flexors) (81–85),
transfer of part or all of the pectoralis major (with or with-
out transfer of the pectoralis minor) (86–89), transfer of the
latissimus dorsi (90–94), anterior transfer of the triceps ten-
don (95–97), and transfer of the sternocleidomastoid (98).
Proximal transfer of the flexor pronator muscle origin is
known as the Steindler flexorplasty (81–85), described in
1918 (81).
Weakness of the biceps brachii and brachialis muscle due
to isolated palsy of the musculocutaneous nerve has been
reported. It can follow heavy exercise (36–39) or occur
atraumatically (35). Bilateral palsy also has been noted (40).
Violent extension of the forearm may be a factor. The syn-
drome features painless weakness of the biceps and
brachialis, sensory loss in the distal lateral forearm, and a
history of recent vigorous upper extremity resistive exer-
cises. Loss of contour of the biceps has been noted (38).
The syndrome usually resolves with rest, but may take
weeks or months (37). The musculocutaneous nerve usually
is injured distal to the innervation of the coracobrachialis.
It has been postulated that nerve entrapment or stretching
occurs where the nerve passes through the coracobrachialis
(38). The condition should not be confused with C5 and
C6 radiculopathy, brachial plexopathy, or rupture of the
biceps brachii muscle belly or tendon.
With 6 weeks of heavy isometric strength training, the
strength of the elbow flexors can be increased by 14%, with
a mean increase in cross-sectional area of 5.4% (99). Male
and female percentage increases in strength and muscle size
are similar (no significant differences) (99).
The variations of the musculocutaneous innervation to
the biceps (described earlier under Gross Anatomic
Description: Biceps Brachii) should be appreciated when
planning intercostal to musculocutaneous nerve transfer to
restore elbow flexion in the patient with brachial plexus
palsy (43).
BRACHIALIS
Derivation and Terminology. Brachialis is derived from
the Latin and Greek brachialis and brachion, respectively,
102 Systems Anatomy
which designate or pertain to the arm (1,2). Note that
brachi and brachial pertain to “arm,” and should not be
confused with brachy (from Greek brachys), which refers to
“short” (i.e., brachydactyly for short digits).
Origin. Distal two-thirds of the anterior humerus,
medial and lateral intermuscular septa.
Insertion. Proximal ulna, base of the coronoid process,
anterior capsule of the elbow.
Innervation. Musculocutaneous nerve (C5, C6). Addi-
tional innervation is from small branches from the radial
and median nerves.
Vascular Supply. Muscular branches from the brachial
artery, ulnar artery, superior and inferior ulnar collateral
arteries, anterior ulnar recurrent artery, radial collateral
branch of the profunda brachii, and radial recurrent artery
(3,4,11).
Principal Action. Flexion of the forearm.
Gross Anatomic Description: Brachialis
The brachialis is a relatively large, wide muscle, and along
with the biceps brachii and coracobrachialis, the brachialis
comprises the anterior muscle compartment of the arm
(Appendix 2.2). The brachialis originates on the distal two-
thirds of the anterior humerus (see Fig. 2.2). The attach-
ment area of the origin is long and wide, commencing prox-
imally along the anterior and posterior margins of the
insertional tendon of the deltoid and extending distally
along the anterior humerus to end in an inverted “V” at the
level just proximal to the elbow capsule. The origin may
extend to within 2.5 cm of the articular surface of the
elbow, ending proximal to the radial and coronoid fossae
(3,4,11). At the level of the humerus below the midshaft,
the muscle envelops the distal humerus on the anterior, lat-
eral, and medial aspects to partially surround the shaft, cov-
ering approximately two-thirds of the bone circumference.
The muscle also arises from the medial intermuscular sep-
tum and from the lateral intermuscular septa proximal to
the origin of the brachioradialis and extensor carpi radialis
longus (ECRL), with more attachments from the medial
side. The muscle belly is somewhat flat, and is convex ante-
riorly and concave posteriorly as its extends distally. The
muscle fiber bundles descend in a specific pattern. The
middle bundles descend in a straight vertical direction. The
medial bundles descend in an oblique course, from medial
to lateral. The lateral bundles also descend in an oblique
course, from lateral to medial. In the distal fourth of the
muscle, the myotendinous junction begins. A portion of
the dorsal side of the lateral edge initially becomes tendi-
nous. This tendinous portion enlarges as the muscle extends
distally, and an additional tendinous portion joins the
myotendinous junction on the anterior surface of the mus-
cle proximal to the elbow joint. The tendon thickens and
converges as it extends distally. It passes along the anterior
capsule of the elbow joint and inserts onto a roughened area
on the anterior aspect of the base of the coronoid process
(see Fig. 2.3A). Cage and colleagues studied the anatomic
aspects of the brachialis in reference to the coronoid process
and associated fractures (100). The brachialis was found to
have a musculoaponeurotic insertion that included the
elbow capsule, coronoid, and proximal ulna. The bony
insertion averaged 26.3 mm in length, with its proximal
margin averaging 11 mm distal to the coronoid tip. The tip
of the coronoid process usually was not covered by capsule
or muscle attachments (in only 3 of 20 specimens did the
capsule actually insert onto the tip) (100). In general, it was
found that the brachialis insertion was more along the dis-
tal portion of the base of the coronoid, and only in Morrey
type III fractures (those through the base of the coronoid)
would the fracture fragment be large enough to include the
brachialis bony insertion (100).
The brachialis is innervated by the musculocutaneous
nerve (C5, C6). The nerve passes from medial to lateral
between the brachialis (located posterior to the nerve) and
the biceps (located anterior to the nerve). A motor branch
usually enters the brachialis on the anterior surface in the
proximal and medial portions of the muscle. The radial nerve
(C7) may supply a small branch to the distal lateral part of
the muscle (101). The median nerve also may supply a small
branch to the medial side of the brachioradialis (3,4,11).
As noted earlier in the discussion of the corocobrachialis
and biceps brachii, the path and variations of the musculo-
cutaneous nerve, including the branch patterns to both the
biceps and brachialis muscles, were studied in detail by Yang
and colleagues (43). In 24 fresh-frozen cadaver specimens,
the motor branch to the brachialis muscle exited from the
musculocutaneous nerve a mean of 170 mm distal to the
coracoid process. A single primary motor branch (type I)
was seen in most specimens, and the rare specimen (type II)
showed two separate primary motor branches innervating
the muscle. The motor branches to the biceps and brachialis
muscles may be dissected proximally from their points of
exit from the main trunk of the musculocutaneous nerve for
mean distances of 44 and 53 mm, respectively. These varia-
tions have clinical significance for the operative exposure of
the musculocutaneous nerve, especially in performing inter-
costal nerve to musculocutaneous motor branch transfer for
elbow flexion in patients with brachial plexus injuries (43).
In a subsequent study, Chiarapattanakom and colleagues
dissected 112 musculocutaneous nerves in 56 cadavers (44).
In 92% of specimens, there was one motor branch to the
brachialis muscle. It always emerged from the main trunk
distal to the nerve to the biceps and averaged 170 mm from
the acromion (44).
Actions and Biomechanics: Brachialis
The brachialis provides strong flexion to the forearm, in
both pronation and supination. Based on cross-sectional
analysis of the major elbow muscle flexors, the brachialis
appears to contribute 47% of flexion torque, with the
biceps brachii contributing 34% and the brachioradialis

19% (20). The brachialis also has a probable contribution
as a secondary stabilizer of the elbow joint (100).
Anomalies and Variations: Brachialis
The muscle belly of the brachialis may be divided into two
or more separate heads or bellies (11). When the brachialis
exists as two separate heads, each head commences on either
side of the deltoid tuberosity (one anterior and one poste-
rior to the deltoid insertion).
If two or more muscle bellies exist, the distal insertion
becomes more variable or irregular, to include several addi-
tional anomalous insertional sites. These insertion sites
include (besides portions of the coronoid process) the radius
on or below the bicipital tuberosity (radial tuberosity), both
the proximal radius and ulna, the radius with a tendinous
band joining it to the coronoid process of the ulna, fascia of
the forearm, or muscles of the forearm arising from the
medial epicondyle and from the flexor muscle origin (11).
The brachiofascialis muscle of Wood denotes an anom-
alous insertion portion of the brachialis into the forearm
fascia (11,18).
A slip from the brachialis may insert into the bicipital
aponeurosis. A slip of the brachialis may also insert into the
capsule of the elbow joint, and is known as the capsularis
brachialis muscle.
The brachialis may coalesce with several muscles, includ-
ing the brachioradialis, pronator teres, or biceps. The
brachialis may also be absent.
Variations in innervation may exist. The brachialis usu-
ally is innervated by the musculocutaneous nerve. The
radial nerve usually sends a small branch into the distal lat-
eral portion of the muscle. The median nerve also may
innervate a small portion of the brachialis, sending a small
branch into the medial side of the distal muscle near the
elbow joint (11).
The musculocutaneous nerve may be absent. The
brachialis can receive its innervation directly from the
median nerve (32).
Clinical Correlations: Brachialis
Although rupture of the proximal or distal tendons of the
biceps is a relatively common injury, isolated rupture of the
brachialis has been noted only rarely (102).
It is well established that the median nerve can be com-
pressed in the forearm by several structures, including the
lacertus fibrosus, pronator teres, and flexor digitorum
superficialis (FDS). In addition, an accessory slip of the
brachialis tendon distal in the forearm has been noted to
cause median nerve compression (49).
Weakness of the biceps brachii and brachialis due to iso-
lated palsy of the musculocutaneous has been reported. It
can follow heavy exercise (36–39) or can occur atraumati-
cally (35). Bilateral palsy also has been noted (40). Violent
extension of the forearm may be a factor. The syndrome fea-
2 Muscle Anatomy 103
tures painless weakness of the biceps and brachialis, sensory
loss in the distal lateral forearm, and a history of recent vig-
orous upper extremity resistive exercise. Loss of contour of
the biceps may be noted (38). The syndrome usually
resolves with rest, but may take weeks or months (37). The
musculocutaneous nerve is injured distal to the innervation
of the coracobrachialis. It has been postulated that nerve
entrapment or stretching occurs where the nerve passes
through the coracobrachialis (38). The condition should
not be confused with C5 to C6 radiculopathy, brachial
plexopathy, or rupture of the biceps brachii muscle belly or
tendon.
With 6 weeks of heavy isometric strength training, the
strength of the elbow flexors can be increased by 14%, with
a mean increase in cross-sectional area of 5.4% (99). Male
and female percentage increases in strength and muscle size
are similar (no significant differences) (99).
TRICEPS BRACHII
Derivation and Terminology. Triceps is derived from the
Latin and Greek tri meaning “three,” and the Latin caput,
meaning “head.” Triceps thus refers to “three heads.” Brachii
is derived from the Latin and Greek brachialis and brachion,
respectively, which designate or pertain to the arm (1,2).
Note that brachi and brachial pertain to “arm,” and should
not be confused with brachy (from Greek brachys), which
refers to “short” (i.e., brachydactyly for short digits) (1,2).
Origin. From three heads. Long head: from the infragle-
noid tubercle of the scapula. Lateral head: from a narrow,
linear or oblique ridge on the posterolateral surface of the
proximal humeral shaft and from the lateral intermuscular
septum. Medial head: from an extensive area including the
posterior surface of the humeral shaft, distal to the radial
groove from the insertion of the teres major to the distal
humerus (3,4,11).
Insertion. The olecranon process of the ulna.
Innervation. Radial nerve (C6, C7, C8), with separate
branches to each head.
Vascular Supply. The triceps is supplied by the axillary
artery through branches of the posterior humeral artery,
branches from the profunda brachial artery (including del-
toid and middle collateral branches), and from the superior
and inferior ulnar collateral arteries and interosseous recur-
rent artery (3,4,11,103).
Principal Action. Extension of the forearm. The long
head may assist with adduction of the abducted humerus,
or extension of the forward-flexed humerus.
Gross Anatomic Description: Triceps
Brachii
The triceps is a wide, powerful muscle that comprises the
entire posterior muscle compartment of the arm (Appendix
2.2). The muscle is complex, with three heads and an exten-
104 Systems Anatomy
sive, complex origin principally from the posterior humerus
(3,4,8,9,11,13).
The long head of the triceps originates from the infra-
glenoid tubercle of the scapula (see Fig. 2.1). It occasionally
may extend along the axillary border of the scapula to vary-
ing distances. The long head initially is a broad, flat tendon,
with attachments that blend with the inferior aspect of the
shoulder capsule (104). The long head extends distally and
somewhat laterally to join the lateral head. The long head
initially passes superficial to the medial head. In the mid-
portion of the humerus, the long head joins with the mus-
cle bellies of the lateral and medial head to from a large, sin-
gle muscle belly. To some degree, the fibers and course of
the long head can be traced from the insertion to the origin.
From the origin of the long head, the tendon splits into two
layers, one located inferiorly and one superficially (11). The
muscle fibers from the two layers extend distally in a paral-
lel fashion and then twist as they descend distally. At the
insertion level, the original anterior surface of the origin
becomes the dorsomedial portion of the tendon at the
insertion. The fibers of the long head of the muscle are
found on the medial side of the tendon, and terminate at
approximately the distal fourth of the arm as the myotendi-
nous junction is formed.
The long head of the triceps contributes to the forma-
tion of the well known quadrangular space and the triangu-
lar space of the axillary region. From its origin, the long
head extends distally anterior to the teres minor and poste-
rior to the teres major, dividing the wedge-shaped interval
between them into the triangular and quadrangular spaces
(3,4,11). The triangular space is bordered by the teres
minor (superiorly), the long head of the triceps (laterally),
and the teres major (inferiorly). Branches of the circumflex
scapular artery cross through the triangular space. The more
anatomically significant quadrangular space is bordered by
the teres minor and subscapularis (superiorly), the long
head of the triceps (medially), the teres major (inferiorly),
and the humeral neck (laterally). The axillary nerve and
posterior humeral circumflex artery pass through the quad-
rangular space (3,4,8,13,68).
The lateral head of the triceps originates as a flattened
tendon from a narrow, linear, oblique ridge on the poste-
rior surface of the proximal humeral shaft, just distal to the
neck (see Fig. 2.2B). The origin is medial to the insertion
of the teres minor, and is anterior and lateral to the proxi-
mal portion of the radial groove. The distal portion of the
origin of the lateral head is located just posterior to the
insertion of the deltoid. In addition, part of the lateral
head originates from the lateral intermuscular septum. The
fibers of the lateral head extend distally to coalesce with the
fibers of the long and medial heads. The superior fibers of
the lateral head pass vertically and the inferior fibers pass
obliquely to insert into the dorsal and ventral surfaces of
the proximal lateral margin of the common insertional ten-
don (3,4).
The lateral head of the triceps is visible as a prominence
in the posterolateral aspect of the proximal arm, most
apparent in athletic individuals. The prominence is parallel
and medial to the posterior border of the deltoid. The mus-
cle head becomes most prominent when the elbow is
actively extended. The mass that is located medial to the lat-
eral head is the long head (3,4).
The medial head of the triceps has an extensive origin
from the distal half of the posterior humeral shaft (see Fig.
2.2B). It is located posterior and medial to the radial groove
of the humerus. The origin extends from the vicinity of the
insertion of the teres major (proximal on the humerus) to
the distal portion of the humerus, to within 2.5 cm of the
trochlea. A portion of the medial head also originates from
the medial intermuscular septum and the lower part of the
lateral intermuscular septum. The medial head lies deep to
the long head, and when the muscles coalesce, the medial
fibers remain in the deeper parts of the muscle. Some of the
fibers attach directly to the olecranon, although most first
coalesce with the other heads to form the common tendon
of insertion (3,4,11).
Once the long, medial, and lateral heads have coalesced,
the fibers continue distally to converge into a thick, stout
tendon. The myotendinous junction is relatively large and
begins in the middle third of the muscle. Operative expo-
sure of the distal half of the muscle often exposes only a
large tendinous portion. The tendon has two layers, one
superficial and one deep. The layers unite to form the com-
mon tendon, which extends distally to attach to the olecra-
non (see Fig. 2.3B). Some of the muscle fibers or a portion
of the tendon on the lateral side form a band of fibers that
inserts into the articular capsule of the elbow or continues
distally over the anconeus to coalesce with the antebrachial
fascia. A part of muscle slip that inserts into the articular
capsule is referred to as the subanconeus muscle or articularis
cubiti (3,11).
The triceps muscle is innervated by the radial nerve (C6,
C7, C8). Each head receives a separate branch or branches.
The branch to the long head is the most proximal branch.
It arises in the axilla and enters the lateral margin of the
proximal muscle. The nerve may penetrate the muscle as
several small branches. The radial nerve continues distally
along the radial groove of the humerus, between the lateral
and medial heads. The radial head gives off two or three
small branches to supply the medial head, followed by sep-
arate branches to the lateral head.
Actions and Biomechanics: Triceps Brachii
The principal action of the triceps muscle is to extend the
forearm. The long head, which originates proximal to the
shoulder on the infraglenoid tubercle of the scapula, also
functions to assist with humeral adduction. When the
humerus is in a forward-flexed position, the long head can
assist with extending the humerus back to the neutral posi-

tion. The lateral head is the strongest and contributes most
to elbow extension. The long head has more effect on the
shoulder joint then at the elbow (104).
Electromyographic studies indicate that the medial head
is active in all forms of extension of the forearm. The long
and lateral heads, however, are minimally active except in
extension of the forearm against resistance (105). This
occurs as in pushing or supporting body weight on the
hands with the elbows in mid-flexion. The long head
appears to give support to the lower part of the shoulder
capsule, especially when the arm is raised (104).
The triceps has an important function in stabilization of
the elbow during forceful supination of the forearm with
the elbow flexed. In forceful forearm supination, there is
strong contraction of both the supinator and biceps brachii.
The triceps contracts synergistically to maintain the flexed
or semiflexed position of the elbow. Otherwise, without this
triceps cocontraction, it would be difficult forcefully to
supinate the forearm without simultaneously flexing the
elbow (3,4,11,68).
Anomalies and Variations: Triceps Brachii
The three heads of the triceps may coalesce with the neigh-
boring muscles (11). A fourth muscle head has been noted
to occur with the triceps (106). This head has been noted
to arise from the humerus, axillary margin of the scapula,
capsule of the shoulder joint, coracoid process, or tendon of
the latissimus dorsi (11,106).
The radial nerve is rarely noted to be absent. The triceps
is then innervated by the musculocutaneous or ulnar nerve
(11). The radial nerve rarely passes through the quadrangu-
lar space, along with the axillary nerve. The radial nerve still
innervates the three heads of the triceps (11).
The patella cubiti is a sesamoid bone in the triceps ten-
don, located near the insertion (107). It also is referred to as
the sesamum cubiti or elbow disc (11). Its presence has been
noted to be associated with a rupture of the distal triceps
tendon (see later) (107–116).
The latissimocondyloideus or dorsoepitrochlearis is an
anomalous muscle found in approximately 5% of individu-
als. The muscle extends from the tendon of the latissimus
dorsi to the brachial fascia, triceps brachii, shaft of the
humerus, lateral epicondyle, olecranon, or fascia of the fore-
arm (11). When absent (95% of individuals), the muscle
normally is represented by a fascial slip from the tendon of
the latissimus dorsi to the long head of the triceps of from
the brachial fascia. The muscle is innervated by the radial
nerve (11).
Clinical Correlations: Triceps Brachii
Ulnar neuropathy or neuritis at the elbow in conjunction
with an abnormal triceps muscle slip or an aberrant muscle
belly is well documented (117–125). This type of cubital
2 Muscle Anatomy 105
tunnel syndrome has been related to either a separate or
prominent medial head of the triceps (119,123), an unsta-
ble, dislocating medial triceps tendon (117,118,124,125),
or an abnormal insertion or subanconeus muscle (an auxil-
iary extension of the medial portion of the medial triceps
that inserts into the joint capsule, fascia, or medial epi-
condyle) (120,122).
Radial nerve entrapment by the lateral head of the tri-
ceps has also been noted (126).
Complete avulsion or incomplete rupture of the triceps
tendon is well documented (107–116). It usually involves
rupture at the distal tendon, but may occur at the muscu-
lotendinous junction (110). Rupture has been associated
with patients on hemodialysis (112,113,115) and with
those with secondary hyperparathyroidism (114), seizure
disorders (115), hypertension (110), or diabetes mellitus
(110). Spontaneous rupture also has been reported in asso-
ciation with a patella cubiti, a sesamoid bone in the triceps
tendon (107). In a rare case, it also has occurred in associa-
tion with radial neuropathy (111). Similar to rupture of the
biceps tendon, operative repair for complete rupture usually
is indicated (108–110,114,116). With incomplete rupture,
conservative management has been used successfully (112).
In arthrogryposis, the elbow is often in a fixed position
in varying degrees of extension. Triceps lengthening, in con-
junction with capsulotomy or tendon transfer, often is per-
formed to gain elbow motion (127,128).
ANCONEUS
Derivation and Terminology. The word anconeus is
derived from the Greek ankon, which means “elbow” (1,2).
Origin. The posterior surface of the distal aspect of the
lateral epicondyle.
Insertion. The lateral aspect of the olecranon and the
proximal fourth of the posterior surface of the shaft of the
ulna.
Innervation. Radial nerve (C6, C7, C8).
Vascular Supply. The interosseous recurrent artery, mid-
dle collateral (posterior descending) branch of the profunda
brachii (3,4,11).
Principal Action. Extension of the forearm. The
anconeus may have a secondary role in stabilizing the ulna,
especially during rotation of the forearm.
Gross Anatomic Description: Anconeus
The anconeus is a small, triangular or quadrangular muscle
of the posterolateral elbow. It is often partially blended with
the distal portion of the triceps, and is thought morpholog-
ically and physiologically to belong to the triceps. It has a
similar function of elbow extension and is supplied by the
same (radial) nerve. In some primates, the anconeus in not
distinguishable from the triceps (3).
106 Systems Anatomy
The anconeus originates from the distal aspect of the
posterior lateral epicondyle of the humerus (see Fig. 2.2B).
The origin consists of a short tendon, often covered with
muscle. The tendon extends on the deep surface and lateral
margin of the muscle. A portion of the muscle also origi-
nates from the adjacent portion of the posterior elbow joint
capsule. The fibers of the anconeus diverge medially toward
the ulna, with the more proximal fibers extending trans-
versely directly to the ulna, and the more distal and lateral
fibers extending more obliquely. The muscle covers the pos-
terior aspect of the annular ligament. The anconeus inserts
onto the lateral aspect of the olecranon and on the adjacent
lateral aspect of the proximal ulna (see Fig. 2.3B). The supe-
rior part of the muscle usually is continuous with the
medial head of the triceps brachii. The insertional area
extends distally to stretch along the proximal quarter of the
ulna.
The anconeus is innervated by the radial nerve (C6, C7,
C8). The motor branch arises from the radial nerve trunk
in the radial groove of the humerus. This motor branch
passes through the medial head of the triceps, supplying the
triceps and continuing distally to enter the proximal border
of the anconeus (3,4,11).
Actions and Biomechanics: Anconeus
The anconeus assists the triceps with extension of the
elbow. The major function of the anconeus may not be fully
recognized. The anconeus may have a secondary role in sta-
bilizing the ulna, especially during rotation of the forearm.
During pronation of the forearm, it has been postulated
that the anconeus moves the ulna laterally at the ulno-
humeral joint. In this way, the anconeus allows the forearm
to turn over the hand without translating it medially
(3,4,11,13).
Anomalies and Variations: Anconeus
The anconeus may be coalesced to the medial head of the
triceps to varying degrees. It also may blend with the exten-
sor carpi ulnaris (ECU) (11).
The subanconeus (articularis cubiti) is a small muscle
extension formed from fibers from the deep surface of the
distal part of the medial head of the triceps. It is a separate
muscle from the anconeus. The subanconeus crosses or cov-
ers a portion of the anconeus, attaching to the posterior
aspect of the elbow capsule or blending with the ante-
brachial fascia (3,11).
The epitrochleoolecranonis anconeus epitrochlearis
(epitrochleoanconeus, epitrochleocubital, or anconeus sex-
tus) is a muscle distinct from the anconeus and the triceps
(129). It extends from the medial epicondyle of the
humerus, arches across the groove for the ulnar nerve, and
inserts onto the olecranon process of the ulna. It is thought
to occur in 25% of individuals and takes the place of a
fibrous arch that usually passes between the epicondylar and
ulnar heads of the flexor carpi ulnaris (FCU) (11). The
anconeus may coalesce with the epitrochleoolecranonis.
Clinical Correlations: Anconeus
The anomalous muscles associated with the anconeus (the
epitrochleoolecranonis anconeus epitrochlearis, epitroch-
leoanconeus, epitrochleocubital, or anconeus sextus) may
be associated with cubital tunnel syndrome (120,121,130,
131). The muscles extend from the medial epicondyle and
cross superficial to the cubital tunnel to reach the olecra-
non. There is thus a potential compression of the ulnar
nerve.
BRACHIORADIALIS
Derivation and Terminology. Brachioradialis is derived
from the Latin and Greek brachialis and brachion, respec-
tively, which designate or pertain to the arm. Radialis is
from the Latin radii, which means “spoke” (used to describe
the radius of the forearm) (1,2). Note that brachi and
brachial pertain to “arm,” and should not be confused with
brachy (from Greek brachys), which refers to “short” (i.e.,
brachydactyly for short digits).
Origin. From the proximal two-thirds of the lateral ridge
of the humeral epicondyle and from the anterior surface of
the lateral intermuscular septum.
Insertion. The lateral aspect of the base of the styloid
process of the radius.
Innervation. Radial nerve (C5, C6).
Vascular Supply. The radial collateral branch of the pro-
funda brachii, the radial artery, and the radial recurrent
artery from the radial artery (3,4,132,133).
Principal Action. Flexion of the forearm. It may assist in
rotating the forearm to the neutral rotation position from a
position of full pronation or full supination.
Gross Anatomic Description:
Brachioradialis
The brachioradialis consists of muscle fibers in its proximal
half and a long, strong tendon in its distal half. Positioned
on the lateral aspect of the forearm, it forms the lateral mar-
gin of the cubital fossa. The brachioradialis, along with the
ECRL and ECRB, occupies the muscle compartment
known as the mobile wad compartment of the forearm
(Appendix 2.2) (12). The muscle originates mostly from the
proximal two-thirds of the lateral epicondylar ridge of the
humerus (see Fig. 2.2). Additional fibers originate from the
anterior aspect of the lateral intermuscular septum. The
muscle fibers extend distally and volarly to terminate in a
penniform manner on the tendon. The muscle belly twists
slightly as it extends from proximal to distal. At the origin,
 2 Muscle Anatomy 107

its broad surface faces laterally; in the forearm, the broad
surface faces anteriorly; and in the distal forearm, the tendon
twists so that it again faces laterally. The muscle may have
extensive fascial attachments or attachments to the bellies of
the neighboring muscles. The muscle fibers usually end
proximal to the mid-forearm level, and appear to form a
short, abrupt myotendinous junction. The tendon, however,
usually extends quite proximally on the deep surface of the
muscle. The brachioradialis tendon is oval or flat, and
extends distally along the radial margin of the radius to reach
the insertion point just proximal to the styloid. Along its
course, the tendon tapers and becomes narrower, and winds
around the radius from the volar to the lateral surface. It
widens proximal to the insertion point. Near the insertion
point of the tendon, the brachioradialis is crossed by the
abductor pollicis longus (APL) and extensor pollicis brevis
(EPB). The tendon inserts into the lateral aspect of the base
of the styloid process of the radius (see Fig. 2.3A).
Vascular studies have been performed on the brachiora-
dialis because of its potential use as a rotation musculocuta-
neous flap for local soft tissue reconstruction (132,133).
Sanger and colleagues found that the dominant perforator
to perfuse the muscle arose from the brachial artery in 27%,
from the radial recurrent artery in 33%, or from the radial
artery in 39% (132). Additional studies by Leversedge et al.
confirm the brachioradialis is perfused (partly) by the radial
recurrent artery [which perfuses an average of 41% (range,
20% to 60%) of the muscle length]. Injection studies of
combined radial artery and radial recurrent arteries show
that the two arteries combined account for perfusion of
80% (range, 59% to 100%) of the muscle length. This cor-
responds to 90% of the muscle volume (133).
Muscle function and design can be evaluated by the results
of tendon transfers from studies on muscle architecture
(15,134–142). Architectural features of a muscle include the
physiologic cross-sectional area of the muscle, the fiber bun-
dle length, muscle length, muscle mass, and pennation angle
(angle of the muscle fibers from the line representing the lon-
gitudinal vector of its tendon). Skeletal muscle architectural
studies by Lieber, Friden, and colleagues provide the data for
the brachioradialis (135–139) (Table 2.1 and Fig. 2.4). The
brachioradialis has relatively long fibers arranged at a small

TABLE 2.1. ARCHITECTURAL FEATURES OF SELECTED MUSCLES OF THE UPPER EXTREMITY

Muscle Muscle Fiber Pennation Cross-Sectional Fiber Length/

Mass Length Length Angle Area Muscle Length
Muscle (g) (mm) (mm) (Degrees) (cm2) Ratio

BR (n = 8) 17 ± 2.8 175 ± 8.3 121 ± 8.3 2 ± 0.6 1.33 ± 0.22 0.69 ± 0.062
PT (n = 8) 16 ± 1.7 130 ± 4.7 36 ± 1.3 10 ± 0.8 4.13 ± 0.52 0.28 ± 0.012
PQ (n = 8) 5 ± 1.0 39.3 ± 2.3 23 ± 2.0 10 ± 0.3 2.07 ± 0.33 0.58 ± 0.021
EDC I (n = 8) 3 ± .45 114 ± 3.4 57 ± 3.6 3 ± 0.5 0.52 ± 0.08 0.49 ± 0.024
EDC M (n = 5) 6 ± 1.2 112 ± 4.7 59 ± 3.5 3 ± 1.0 1.02 ± 0.20 0.50 ± 0.014
EDC R (n = 7) 5 ± .75 125 ± 10.7 51 ± 1.8 3 ± 0.5 0.86 ± 0.13 0.42 ± 0.023
EDC S (n = 6) 2 ± .32 121 ± 8.0 53 ± 5.2 2 ± 0.7 0.40 ± 0.06 0.43 ± 0.029
EDQ (n = 7) 4 ± .70 152 ± 9.2 55 ± 3.7 3 ± 0.6 0.64 ± 0.10 0.36 ± 0.012
EIP (n = 6) 3 ± .61 105 ± 6.6 48 ± 2.3 6 ± 0.8 0.56 ± 0.11 0.46 ± 0.023
EPL (n = 7) 5 ± .68 138 ± 7.2 44 ± 2.6 6 ± 1.3 0.98 ± 0.13 0.31 ± 0.020
PL (n = 6) 4 ± .82 134 ± 11.5 52 ± 3.1 4 ± 1.2 0.69 ± 0.17 0.40 ± 0.032
FDS I(P) (n = 6) 6 ± 1.1 93 ± 8.4 32 ± 3.0 5 ± 0.2 1.81 ± 0.83 0.34 ± 0.022
FDS I(D) (n = 9) 7 ± 0.8 119 ± 6.1 38 ± 3.0 7 ± 0.3 1.63 ± .22 0.32 ± 0.013
FDS I(C) (n = 6) 12 ± 2.1 207 ± 10.7 68 ± 2.8 6 ± 0.2 1.71 ± .28 0.33 ± 0.025
FDS M (n = 9) 16 ± 2.2 183 ± 11.5 61 ± 3.9 7 ± 0.7 2.53 ± .34 0.34 ± 0.014
FDS R (n = 9) 10 ± 1.1 155 ± 7.7 60 ± 2.7 4 ± 0.6 1.61 ± .18 0.39 ± 0.023
FDS S (n = 9) 2 ± 0.3 103 ± 6.3 42 ± 2.2 5 ± 0.7 0.40 ± .05 0.42 ± 0.014
FDP I (n = 9) 12 ± 1.2 149 ± 3.8 61 ± 2.4 7 ± 0.7 1.77 ± .16 0.41 ± 0.018
FDP M (n = 9) 16 ± 1.7 200 ± 8.2 68 ± 2.7 6 ± 0.3 2.23 ± .22 0.34 ± 0.011
FDP R (n = 9) 12 ± 1.4 194 ± 7.0 65 ± 2.6 7 ± 0.5 1.72 ± .18 0.33 ± 0.009
FDP S (n = 9) 14 ± 1.5 150 ± 4.7 61 ± 3.9 8 ± 0.9 2.20 ± .30 0.40 ± 0.015
FPL (n = 9) 10 ± 1.1 168 ± 10.0 45 ± 2.1 7 ± 0.2 2.08 ± .22 0.24 ± 0.010

BR, brachioradialis; PT, pronator teres; PQ, pronator quadratus; EDC I, extensor digitorum communis (index finger); EDC M, extensor digitorum
communis (middle finger); EDC R, extensor digitorum communis (ring finger); EDC S, extensor digitorum communis (small finger); EDQ,
extensor digiti quinti; EIP, extensor indicis proprius; EPL, extensor pollicis longus; PL, palmaris longus; FDS I (P), flexor digitorum superficialis of
index finger, proximal belly; FDS I (D), flexor digitorum superficialis of index finger, distal belly; FDS I (C), flexor digitorum superficialis of index
finger, combined properties of the proximal and distal bellies; FDS M, flexor digitorum superficialis (middle finger); FDS R, flexor digitorum
superficialis (ring finger); FDS S, flexor digitorum superficialis (small finger); FDP I, flexor digitorum profundus (index finger); FDP M, flexor
digitorum profundus (middle finger); FDP R, flexor digitorum profundus (ring finger); FDP S, flexor digitorum profundus (small finger); FPL,
flexor pollicis longus.
Reproduced from Lieber RL, Jacobson MD, Fazeli BM, et al. Architecture of selected muscles of the arm and forearm: anatomy and implications
for tendon transfer. J Hand Surg Am 17:787–798, 1992, with permission.
 108 Systems Anatomy
A logic cross-sectional area for the combined FDP
B digitorum superficialis (ring finger); FDS (S), flexor
C 1992, with permission.)
pennation angle, with a relatively small physiologic cross-
sectional area. This indicates that the brachioradialis is
designed more for excursion and velocity than for force gen-
eration (135). Its relative difference index values compare it
with other upper extremity muscles, based on architectural
features. These values are listed in Appendix 2.3.
The brachioradialis is innervated by the radial nerve
(C5, C6). This innervation is anatomically unusual because
the brachioradialis is a flexor of the elbow; the same radial
nerve also innervates the extensors (triceps) of the elbow.
The motor nerve branch to the brachioradialis exits from
FIGURE 2.4. Architectural features of selected
upper extremity muscles. A: Muscle fiber lengths
of selected upper extremity muscles: bar graph of
the fiber lengths from several studied muscles of
the upper extremity. Note that the flexors and
extensors are similar to one another and that the
brachioradialis differs significantly. B: Physiologic
cross-sectional areas of selected upper extremity
muscles: bar graph of the physiologic cross-sec-
tional areas from several studied muscles of the
upper extremity. Note that the flexors and exten-
sors are similar to one another and that the BR
and the PT differ significantly. C: Cross-sectional
area versus fiber length: scatterplot of fiber
lengths versus physiologic cross-sectional area of
selected upper extremity muscles. Fiber length
value (in millimeters) for the BR is listed in paren-
theses next to it on the chart because it would
actually place off the graph. Similarly, the physio-
and FDS muscles also is shown in parentheses.
Muscles that cluster together in this graph are
architecturally similar. Because fiber length is pro-
portional to muscle excursion (or velocity), and
physiologic cross-sectional area is proportional to
force generation, the location of each muscle indi-
cates its design characteristics and specialization.
(Muscles with higher fiber lengths are designed
more for excursion or velocity; muscles with
higher physiologic cross-sectional areas are
designed more for force generation.) Each bar
represents mean ± standard deviation (SEM). FCR,
flexor carpi radialis; FCU, flexor carpi ulnaris; PL,
palmaris longus; ECRB, extensor carpi radialis bre-
vis; ECRL, extensor carpi radialis longus; ECU,
extensor carpi ulnaris; FDS (I), flexor digitorum
superficialis (index finger); FDS (M), flexor digito-
rum superficialis (middle finger); FDS (R), flexor
digitorum superficialis (small finger); FDP (I),
flexor digitorum profundus (index finger); FDP
(M), flexor digitorum profundus (middle finger);
FDP (R), flexor digitorum profundus (ring finger);
FDP (S), flexor digitorum profundus (small finger);
FPL, flexor pollicis longus; EDC (I), extensor digito-
rum communis (index finger); EDC (M), extensor
digitorum communis (middle finger); EDC (R),
extensor digitorum communis (ring finger); EDC
(S), extensor digitorum communis (small finger);
EDQ, extensor digiti quinti; EIP, extensor indicis
proprius; EPL, extensor pollicis longus; PT, prona-
tor teres; PQ, pronator quadratus; BR, brachiora-
dialis. (A–C from Lieber RL, Jacobson MD, Fazeli
BM, et al. Architecture of selected muscles of the
arm and forearm: anatomy and implications for
tendon transfer. J Hand Surg [Am] 17:787–798,
the radial nerve trunk proximal to the level of the elbow, as
the radial nerve descends between the brachialis and bra-
chioradialis. The nerve branch continues distally and enters
the muscle in its proximal third.
Actions and Biomechanics:
Brachioradialis
The primary function of the brachioradialis is elbow flex-
ion. It has maximal mechanical advantage when the fore-
arm is in 0 degrees of pronation or supination, or in slight
 2 Muscle Anatomy 109

pronation. With the forearm in full pronation or full
supination, it may assist in bringing the forearm back to the
neutral position of 0 degrees of pronation or supination.
The brachioradialis can thus act as a supinator when the
forearm is extended and pronated (139). It can act as a fore-
arm pronator when the forearm is extended and supinated.
Based on electromyographic studies, the brachioradialis is
minimally active with slow flexion movements of the elbow
or with the forearm supine. It does, however, generate
increased activity when movements are rapid (105). The
brachioradialis also may function to help stabilize the elbow
during forearm rotation (3,4).
Based on cross-sectional analysis of the major elbow
muscle flexors, the biceps brachii appears to contribute
34% of flexion torque, with the brachialis contributing
47% and the brachioradialis 19% (20).
Anomalies and Variations: Brachioradialis
The muscle belly of the brachioradialis may be divided,
doubled, or multiple. The tendon may be doubled along its
course (11) (Fig. 2.5). An accessory brachioradialis may
exist, and may cause proximal radial nerve compression at
the level of the elbow (143).
In approximately 7% of individuals, the tendon of the
brachioradialis may divide into two or three separate slips
that insert into the radial styloid (11). A slip may insert into
the forearm fascia. A second belly may attach distally to the
radius near the radial tuberosity, or to the ulna (11). When
two slips of the brachioradialis tendon are present, the
radial sensory nerve may pass between them. The nerve is at
risk for compression if it penetrates between the slips
(144–146) (see Fig. 2.5).
The supinator longus accessories or brachioradialis bre-
vis is an accessory brachioradialis. It arises adjacent to the
brachioradialis and inserts onto the radial tuberosity or into
the supinator (see Fig. 2.5). It acts as a supinator of the fore-
arm. The brachioradialis brevis also may insert into the
pronator teres or into the ulna (11).
The brachioradialis may be coalesced or tethered with
other muscles, most commonly the brachialis (near the ori-
gin of the brachioradialis) as well as the ECRL, pronator

FIGURE 2.5. The normal brachioradialis (left) and some of its clinically relevant variations. The
split or duplicated muscle may cause confusion during harvest for tendon transfer. The split ten-
don may be responsible for neuropathy of the superficial branch of the radial nerve, if the nerve
passes through the split tendon. The brachioradialis brevis is an anomalous muscle that inserts
into the radial tuberosity or the biceps tendon. It can function as a supinator of the forearm, as
well as an elbow flexor (11).
110 Systems Anatomy
teres, and FCR (147). The brachioradialis may send slips to
the deltoid (see later), supinator, or APL (11).
The origin of the brachioradialis may extend proximally
as far as the mid-humerus, at the level of the deltoid inser-
tion (11). The insertion point may be located more proxi-
mally or more distally than the styloid. The brachioradialis
may insert as far proximal as the middle third of the radial
shaft. It may insert as far distally as the scaphoid, trapezium,
or base of the index metacarpal (11,148). The brachioradi-
alis muscle or tendon may be absent. If the tendon is
absent, the brachioradialis muscle may insert onto the
radius more proximally along the lateral diaphysis (11).
The brachioradialis usually is innervated by the radial
nerve. Anomalous innervation by the musculocutaneous
nerve has been reported as an unusual variation (149).
Clinical Implications: Brachioradialis
Sensory radial neuropathy may be caused by a split bra-
chioradialis tendon or muscle, resulting in compression of
the superficial branch of the radial nerve passing through
the split tendon.
Because the brachioradialis is relatively expendable, it is
used as a donor muscle for several reconstructive proce-
dures, including tendon transfer (134,139,150,151), as a
myocutaneous or rotation muscular flap for soft tissue
reconstruction (152,153), or for retinacular reconstruction
(154). Freehafer and associates studied the anatomy, prop-
erties, and value of the brachioradialis for tendon transfer in
the tetraplegic patient. The relatively large excursion and
adequate muscle force measurements of the brachioradialis
support its use as a donor for tendon transfer (134).
Friden et al. studied the architectural properties of the
brachioradialis and further emphasized the muscle’s value in
tendon transfers (139) (see Fig. 2.4). Its relatively high fiber
length indicates its design for excursion and velocity. The
brachioradialis does, however, have limitations as to excur-
sion secondary to extrinsic soft tissue constraints and inter-
connections, which may limit its potential true excursion
when used in reconstructive procedures. These constraints
include presence of an internal tendon, as well as substan-
tial fascial interconnections to the bellies of the neighboring
muscles and associated fascia (see earlier, under Anomalies
and Variations). Mobilization of the muscle and release of
these soft tissue constraints should increase the functional
range of excursion (135). When using the brachioradialis as
a donor for tendon transfer, it is optimal to mobilize and
free the muscle belly quite proximally in the forearm.
Awareness of the possible split muscle belly (and other
anomalies as described previously) avoids confusion if it is
encountered during harvest of the brachioradialis for ten-
don transfer (Fig. 2.5).
The brachioradialis may be a major participant in spas-
tic flexion of the elbow in patients with acquired spasticity.
Selective denervation or recession (proximal release) of the
brachioradialis in selected patients can help relieve the flex-
ion attitude of the elbow (155).
PRONATOR TERES
Derivation and Terminology. Pronator is derived from
the Latin pronus, meaning “inclined forward” (the Latin
pronatio denotes the act of assuming the prone position or
a state of being prone). Teres is derived from the Latin indi-
cating “long and round” (1,2).
Origin. Two heads exist. The humeral (principal) head
originates from the anterior surface of the medial epi-
condyle (common flexor origin) and from the intermuscu-
lar septum. The ulnar (deep) head originates from the
medial border of the coronoid process (3,4).
Insertion. The middle third of the lateral surface of the
radius.
Innervation. Median nerve (C6, C7).
Vascular Supply. The ulnar artery, by direct muscular
arterial branches (3,4).
Principal Action. Pronation of the forearm, through
rotation of the radius on the ulna.
Gross Anatomic Description: Pronator
Teres
The pronator teres is the most radial muscle of the superfi-
cial flexors of the forearm (which also include the FCR, pal-
maris longus, FDS, and FCU). The pronator teres lies in
the superficial volar muscle compartment of the forearm
(Appendix 2.2). As the name implies, the pronator teres is
a long, round, and somewhat cylindrical muscle. The
pronator consists of two heads: a larger, more superficial
humeral head (often designated as the principal or primary
head ) , and a smaller, deeper ulnar head (also referred to as
the accessory or deep head ). The humeral head has been
found to be consistently present. The ulnar head, however,
may be absent in approximately 22% of specimens
(156,157).
The humeral head arises from the common tendon of
the flexor–pronator muscles (see Fig. 2.2A). This tendon of
origin attaches to the medial epicondyle, arising from a
point of attachment on the proximal half of the anterior
surface of the epicondyle. The humeral head also arises
from the overlying antebrachial fascia, and from the inter-
muscular septum that separates the pronator teres from the
medial head of the triceps and the FCR.
The ulnar head is smaller, and positioned deeper. It arises
from an aponeurotic band attached to the medial border of
the coronoid process, located medial to the tendon of the
brachialis (see Fig. 2.3A). The origin is distal to the attach-
ment of the FDS. The ulnar head joins the humeral head at
an acute angle. The morphology of the ulnar head is vari-
able. In 11 of 60 limbs it was found to be muscular; in 6 of

60 it was predominantly tendinous, and in 30 of 60, it was
found to be mixed (156,157). A fibrous arch is formed by
the humeral and ulnar heads. The arch is located within 3
to 7.5 cm of the arch created by the origin of the FDS mus-
cle (158). In 83% of arms, the median nerve passes between
the pronator muscle heads. The median nerve is at risk for
compression as it passes through this arch (147,156–165).
The nerve is separated from the ulnar artery by the ulnar
head of the pronator (3,4,13).
The humeral and ulnar head join to form a common
muscle belly. The muscle passes obliquely across the proxi-
mal volar forearm in a medial-to-lateral direction. The mus-
cle fibers converge to end in a flat tendon that attaches to a
rough area on the lateral surface of the radial shaft (see Fig.
2.3B). The point of insertion is roughly at the junction of
the proximal third and distal two-thirds of the radius, at the
“summit” of the lateral curve of the radius (3,4). The lateral
border of the muscle forms the medial border of the cubital
fossa. At the point of insertion, the tendon of the pronator
teres becomes broader and winds around the anterior sur-
face of the radius, finally attaching to the cortex. Most of
the insertional tendon is continuous with muscle fibers
from the humeral head. The muscle fibers of the ulnar head
extend distally along the lateral border of the fibers from the
humeral head. Much of the ulnar head inserts or blends
into the radial side of the deep surface of the humeral head
(3,4,8,11).
Architectural features of the pronator teres include the
physiologic cross-sectional area of the muscle, the fiber bun-
dle length, muscle length, muscle mass, and pennation angle
(angle of the muscle fibers from the line representing the lon-
gitudinal vector of its tendon). Skeletal muscle architectural
studies by Lieber, Friden, and colleagues provide the data for
the pronator teres (135–139) (see Table 2.1 and Fig. 2.4).
The pronator teres has a relatively large physiologic cross-sec-
tional area, indicating that its design is more optimal for force
generation. It has a relatively short muscle fiber length, indi-
cating that it is not specifically designed for excursion or
velocity. Its relative difference index values compare it with
other upper extremity muscles, based on architectural fea-
tures. These values are listed in Appendix 2.3.
The pronator teres is innervated by a branch or branches
from the median nerve (C6, C7). Each head receives a sep-
arate branch. The branches usually exit the median nerve
trunk before the median nerve passes between the two
heads of the pronator. The nerve branch to the humeral
head enters the proximal part of the middle third of the
belly of the muscle, on its deep surface near the radial bor-
der. The branch to the ulnar head usually enters the muscle
proximal to the point where the two bellies join (11).
Actions and Biomechanics: Pronator Teres
The pronator teres pronates the forearm and acts with
cocontraction of the pronator quadratus. With full flexion
2 Muscle Anatomy 111
of the elbow, the fibers of the muscle are short and unable
to produce maximal force. The pronator teres also functions
as a weak elbow flexor (3,4,11).
Anomalies and Variations: Pronator Teres
A supracondylar process is a small, curved, hook-shaped
process of the distal humerus, several centimeters proximal
to the elbow, and usually located on the medial side. It often
is associated with a ligament (or muscle) slip that extends
distally to the medial epicondyle. The ligament, known as
the ligament of Struthers, is thought to be an extension of
the pronator teres. The median nerve may pass deep to the
ligament, and may thus be at risk for compression
(166–168). The brachial artery also may pass deep to a lig-
ament of Struthers, and brachial artery entrapment (pre-
senting as ischemia during extension of the elbow) may
occur (169).
Accessory slips may attach from the pronator teres to the
biceps brachii, brachialis, or to the median intermuscular
septum. Nebot-Cegarra et al. studied 60 upper extremities
and found slips to the biceps brachii in 3.3%, to the
brachialis in 5.0%, to the FDS muscle in 1.6%, and to
Gantzer’s muscle in 1.6%. In all cases, the accessory slips
were connected to the deep (humeral) head, and were in the
vicinity of the median nerve, possibly producing a risk for
nerve encroachment (156).
Clinical Correlations: Pronator Teres
The median nerve may become compressed as it passes
between the humeral and ulnar heads of the pronator teres,
referred to as pronator syndrome (147,156–165).
The median nerve (and brachial artery) may become
compressed if passing deep to the anomalous ligament of
Struthers. The ligament of Struthers, which is thought to be
an extension of the pronator teres, originates from a supra-
condylar process of the humerus and attaches to the medial
epicondyle (166–169).
FLEXOR CARPI RADIALIS
Derivation and Terminology. Flexor is derived from the
Latin flexus, indicating “bent” (and flexor, which indicates
“that which bends,” or “bending”). Carpi is from the Latin
carpalis and Greek karpos, both of which indicate “wrist”
(the carpus). Radialis is from the Latin radii, which means
“spoke” (used to describe the radius of the forearm) (1,2).
Origin. Medical epicondyle through the common flexor
origin.
Insertion. To the volar base of the index finger
metacarpal. An accessory slip may attach to the adjacent
volar base of the long finger metacarpal.
Innervation. Median nerve (C6, C7).
112 Systems Anatomy
Vascular Supply. The ulnar aspect by direct intramuscu-
lar branches; superior and inferior ulnar collateral arteries;
to a variable degree, contributions from the anterior and
posterior ulnar recurrent arteries; in the distal aspect, super-
ficial palmar branch of the radial artery; at the insertion, the
palmar metacarpal arteries and perforating branches from
the deep palmar arch. The anterior interosseous artery also
may supply the FCR (3,4,8,11).
Principal Action. Flexion of the wrist. Working with the
radial wrist extensor, the FCR can assist with wrist radial
deviation.
Gross Anatomic Description: Flexor Carpi
Radialis
The FCR comprises one of the more radially located mus-
cles of the superficial flexors of the forearm (along with the
A
FIGURE 2.6. Anterior (A) and posterior (B) views of the skeleton hand, showing muscle origins
(red) and insertions (blue).
pronator teres, palmaris longus, FDS, and FCU). The FCR
lies in the superficial volar muscle compartment of the fore-
arm (Appendix 2.2). The muscle is positioned between the
pronator teres (medially) and the palmaris longus (laterally)
(170). It originates from the common flexor origin of the
medial epicondyle (see Fig 2.2A). Additional sites of attach-
ment include the adjacent intermuscular septum and the
adjacent fascia of neighboring muscles. The muscle belly is
relatively large and fusiform, and usually extends to at least
the mid-portion of the forearm halfway to the wrist. The
muscle fibers from the epicondyle extend distally in a verti-
cal fashion to the anterior and sides of the tendon. The
fibers that originate from the intermuscular septa tend to
extend in an oblique fashion to the deep surface of the ten-
don. The mid-portion of the muscle belly lies in the central
portion of the proximal forearm. The myotendinous junc-
tion spans several centimeters and gives rise to a long ten-

don. Studies by Bishop et al. have shown the myotendinous
portion of the muscle begins an average of 15 cm (range, 12
to 17 cm) proximal to the radiocarpal joint. The muscular
fibers end an average of 8 cm (range, 6 to 9 cm) proximal
to the wrist (171). The tendon is initially flat, but becomes
rounder as it continues distally. The tendon passes across
the distal half of the forearm, coursing distally and radially
to the wrist. There is a torsional component of the tendon
as it passes distally (172). The radial artery usually is located
radial to the tendon of the FCR, situated between it and the
brachioradialis. The tendon passes radial to the carpal tun-
nel, and travels through its own fibroosseous tunnel formed
in part by a groove in the trapezium and overlying fibrous
arch. The tendon occupies 90% of the space in the
fibroosseous tunnel and is in direct contact with the slightly
roughened surface of the trapezium (171). The tendon does
not pass through the carpal tunnel. In this distal portion of
B
FIGURE 2.6. (continued)
2 Muscle Anatomy 113
its course, the tendon often has a synovial sheath. The ten-
don dives deep, deep to the oblique head of the adductor
pollicis, to reach the proximal aspect of the base of index
metacarpal (Fig. 2.6A). The tendon inserts into the proxi-
movolar aspect of the index metacarpal, and also commonly
sends a slip to the adjacent base of the long finger
metacarpal (173). A small slip often attaches to the trapezial
crest or tuberosity (171). The insertion tendon of the FCR
extends out from the muscle mass a distance equivalent to
approximately 75% of the muscle length.
Architectural features of the FCR include the physio-
logic cross-sectional area of the muscle, the fiber bundle
length, muscle length, muscle mass, and pennation angle
(angle of the muscle fibers from the line representing the
longitudinal vector of its tendon). Skeletal muscle architec-
tural studies by Lieber, Friden, and colleagues provide the
data for the FCR (135–139,174) (Table 2.2; see Fig. 2.4).
114 Systems Anatomy

TABLE 2.2. ARCHITECTURAL FEATURES OF WRIST EXTENSOR AND FLEXOR MUSCLES

One-Way
Measured Properties of Muscles and Tendonsa ANOVA
Significance
Parameter ECRB ECRL ECU FCR FCU Levelb

Muscle properties
Muscle length (mm) 186.4 ± 4.5 155.3 ± 6.9 209.9 ± 6.0 192.8 ± 4.8 220.6 ± 8.6 p < .01
Fiber length (mm) 70.8 ± 1.7 127.3 ± 5.6 58.8 ± 1.7 59.8 ± 1.5 41.9 ± 1.6 p < .0001
Physiological CSA (mm2) 240.1 ± 20.5 130.0 ± 11.1 210.0 ± 14.1 211.9 ± 15.4 363.6 ± 34.3 p < .0001
Predicted maximum tetanic 58.8 ± 5.0 31.9 ± 2.7 51.5 ± 3.4 51.9 ± 3.7 89.0 ± 8.4 p < .0001
tension (N)
Tendon properties
Aponeurosis length (mm) 101.3 ± 2.1 81.9 ± 15.2 153.7 ± 7.6 126.5 ± 5.8 160.6 ± 10.3 p < .0001
External tendon length (mm) 102.7 ± 4.6 182.1 ± 5.1 61.4 ± 8.7 103.8 ± 7.4 47.0 ± 4.7 p < .0001
Total tendon length (mm) 204.0 ± 4.4 264.1 ± 15.7 215.1 ± 4.9 230.3 ± 5.6 207.6 ± 9.1 p < .0001
Tendon length: fiber length 2.89 ± 0.11 2.10 ± 0.18 3.67 ± 0.13 3.86 ± 0.12 4.96 ± 0.18 p < .0001
ratio
Tendon CSA (mm2) 14.6 ± 0.7 14.2 ± 0.5 15.7 ± 1.4 17.7 ± 1.6 27.4 ± 3.6 p < .01
Tendon stress at P0 (MPa) 4.06 ± 0.29 2.30 ± 0.27 3.36 ± 0.25 3.06 ± 0.32 3.54 ± 0.66 p = .06
Tendon strain at P0 (%) 1.99 ± 0.20 1.78 ± 0.14 2.35 ± 0.30 2.48 ± 0.45 3.68 ± 0.31c p < .005
Modulus at P0 (MPa) 726.1 ± 73.5 438.1 ± 93.7 721.6 ± 167.3 595.4 ± 93.0 448.0 ± 95.7c p > .2
Ultimate stress (MPa) 71.3 ± 6.4 67.9 ± 4.4 70.8 ± 3.4 74.0 ± 13.5 51.6 ± 9.3c p > .4
Tangent modulus (MPa) 904.7 ± 161.2 604.1 ± 113.6 102.1 ± 131.9 857.5 ± 142.1 540.6 ± 152.6c p > .1
Safety factor (× P0) 18.0 ± 1.7 31.8 ± 4.4 21.4 ± 0.6 23.7 ± 2.7 16.8 ± 5.2c p < .05
Biochemical properties
Hydration (% dry mass) 77.0 ± 1.5 74.4 ± 2.9 80.3 ± 2.0 79.3 ± 1.8 83.6 ± 2.0 p = .06
Collagen (% dry mass) 77.0 ± 2.0 78.4 ± 2.1 79.6 ± 1.0 74.0 ± 5.1 69.4 ± 5.4 p > .3

ECRB, extensor carpi radialis brevis; ECRL, extensor carpi radialis longus; ECU, extensor carpi ulnaris; FCR, flexor carpi radialis; FCU, flexor carpi
ulnaris; CSA, cross-sectional area; P0, muscle maximum tetanic tension.
aValues shown are mean ± standard error of n = 5 independent measurements.
bSignificance level from one-way analysis of variance (ANOVA).
cSignifies n = 4.

Reproduced from Loren GJ, Lieber RL. Tendon biomechanical properties enhance human wrist muscle specialization. J Biomech 28:791–799,
1995, with permission.

The FCR has a moderate fiber length and physiologic cross-
sectional area, indicating that its design is moderate for
both excursion and force generation. Its relative difference
index values compare it with other upper extremity mus-
cles, based on architectural features. These values are listed
in Appendix 2.3. In comparing the architectural features of
the FCR with the FCU, the FCR muscle length is shorter
than the FCU, although the muscle fibers of the FCR are
longer (136,174). The relatively longer fiber length indi-
cates that the FCR is designed more for excursion and
velocity of contraction (because excursion and velocity are
proportional to fiber length) compared with the FCU. The
FCU, in contrast, has a higher pennation angle with a larger
physiologic cross-sectional area. This indicates that the
FCU is designed more for force production and less for
excursion and velocity compared with the FCR (because
cross-sectional area is proportional to force production)
(174,175) (see Table 2.2 and Fig. 2.4).
The FCR is innervated by the median nerve (C6, C7,
C8). It usually is supplied by a direct branch that divides
into smaller branches before entering the muscle. The nerve
branches usually enter the muscle near the junction of its
proximal and middle third, and enter on the deep surface
(3,4,176).
Actions and Biomechanics: Flexor Carpi
Radialis
The FCR functions mainly to flex the wrist. It works with
the FCU and the digital flexors during strong wrist flexion.
In addition, in working with the ECRL (and ECRB), the
FCR may assist with radial deviation of the wrist. The FCR
also can assist with elbow flexion, and can act as a relatively
weak pronator of the forearm.
As noted previously, from an architectural standpoint in
comparison with the FCU, the relatively longer fiber length
of the FCR indicates that it is designed more for excursion
and velocity than for force production (135,174).
Anomalies and Variations: Flexor Carpi
Radialis
The FCR may be absent (11,177). The FCR may exist as a
double or split muscle (11,178,179). Several accessory slips

of the FCR may exist in the proximal forearm, including
slips to or from the biceps tendon, brachialis, bicipital
aponeurosis, coronoid process, or radius. In the distal fore-
arm, the FCR may have slips that attach to the trapezium,
scaphoid, flexor retinaculum, or fourth metacarpal. Partial
or total insertion into the trapezium is the more common
insertional anomaly (11).
An FCR brevis has been described as a small muscle
arising from the radius and usually inserts into the fibrous
sheath of the tendon of the FCR. It was noted in 6 of 70
limbs by Wood, and in 1 of 400 limbs by Gruber (11), as
well as in a more recent case report by Effendy (180). An
additional, different FCR brevis muscle was described as
an anomalous muscle that originates from the anterior sur-
face of the radius and forms a tendon at the radiocarpal
joint. It enters the carpal tunnel and the tendon extends
between the bases of the index and long finger metacarpals
to interconnect with the tendon of the ECRB. The muscle
is innervated by the anterior interosseous nerve (181). In
addition, it was noted that the ECRB had split into two
tendons, one inserted normally into the radial part of the
base of the long finger metacarpal and the other connected
to the anomalous FCR brevis. It was postulated that this
anomaly may cause restricted wrist flexion or extension
(11).
Clinical Correlations: Flexor Carpi
Radialis
The FCR, innervated by the median nerve, is a common
muscle used for transfer to the extensor digitorum commu-
nis (EDC) to provide digital extension in patients with
radial nerve palsy (182–185). From an architectural stand-
point, its design for greater excursion makes it (architec-
turally) a better choice than the FCU, which is designed
more for force generation (see earlier, and Fig. 2.4C).
Attritional rupture of the FCR has been noted to occur
in association with scaphotrapezial osteoarthritis (186).
PALMARIS LONGUS
Derivation and Terminology. Palmaris is derived from
the Latin palma, which means “pertaining to the palm.”
Longus is the Latin for “long” (1,2).
Origin. Medical epicondyle through the common flexor
origin.
Insertion. The palmar fascia of the hand.
Innervation. Median nerve (C7, C8).
Vascular Supply. Muscle belly: the ulnar artery, brachial
artery, superior and inferior ulnar collateral arteries, ante-
rior interosseous artery, and variable contributions from the
anterior and posterior ulnar recurrent arteries. Distal ten-
don: rami from the ends of the superficial arch (3,4,8,11,
187,188).
2 Muscle Anatomy 115
Principal Action. Flexion of the wrist. It also contributes
to anchoring of the palmar fascia to resist horizontal shear-
ing forces moving distally in the hand. It can assist with
weak pronation of the forearm.
Gross Anatomic Description: Palmaris
Longus
The palmaris longus comprises one of the central muscles
of the superficial flexors of the forearm (along with the
pronator teres, FCR, FDS, and FCU). It lies in the super-
ficial volar muscle compartment of the forearm (Appendix
2.2). The palmaris longus is small but clinically important
(189–194). It also is well documented as one of the most
variable, in terms of presence (or absence) (195–206) as
well as muscle variations and anomalies (207–262). It is
clinically important because of its value as a free tendon
graft. Because absence is relatively common, this variation
is discussed here instead of under Variations and Anom-
alies. Its absence has been the subject of several anatomic
investigations (197–206). The incidence sometimes is
given in terms of patients (or cadavers), or in terms of
limbs. The frequency of absence in one or both limbs has
been noted from 6% (197) to as high as 31% to 64%
(187,194,198). Most studies indicate an absence in one or
both limbs in approximately 12% to 25% of patients (or
cadavers) (11,196,199), or 5% to 15% of individual limbs
(187,194,231).
In 2001, in a relatively large study, Thompson et al.
examined 300 caucasian subjects (150 male, 150 female)
and found unilateral absence of the palmaris longus in 49
subjects (16%), and bilateral absence in 26 (9%) (199).
The rate of absence of the tendon may be different in
different ethnicities. Reporting in the Indian Journal of
Medical Sciences, Ceyhan and Mavt in 1997 evaluated
7,000 students of the Graduate School at Gaziantep Uni-
versity for absence of the palmaris longus (198). Findings
included, in women, unilateral absence in 23% and bilat-
eral absence in 45.3%. In men, unilateral absence was
found in 19.5% and bilateral absence in 42.1%. The over-
all percentage of absence was 63.9%. This is among the
highest reported absence rates (198).
One of the lowest rates of absence was reported by
Troha and colleagues in 1990 (197). In 200 caucasian
patients (100 men, 100 women), the tendon was absent in
one extremity in only 3% of patients. Bilateral absence
was seen in 2.5%, for a 5.5% rate of total overall absence
(197). In addition, the frequency of absence has been as
low as 3.5% in the Japanese population and 2% in the
Chinese population (11).
There is disagreement as to the frequency of unilateral
versus bilateral absence. Several studies and authors have
noted a more common occurrence of bilateral absence
(11,198). However, studies do not consistently support this
(197,199). If a patient has a tendon absence on one side, it
116 Systems Anatomy
was shown that there is a 67% chance that the contralateral
tendon also will be absent (196).
Although some suggest that the palmaris longus is absent
more often in women, and more often on the left side (11),
Thompson et al., in a study of 300 caucasian subjects,
showed no statistical differences between the sexes or in
absence in the right versus the left extremity (199).
It has been suggested that there may a higher incidence
of Dupuytren’s disease in patients with a present palmaris
longus tendon (200). Additional investigations with larger
populations are needed to substantiate this association.
From an anatomic standpoint, the tendon arises with the
other superficial flexors (including the pronator, FCR,
FDS, and FCU) from the common flexor origin of the
medial epicondyle of the humerus (see Fig. 2.2A). It is slen-
der, usually fusiform or slightly triangular, and located ulnar
to the FCR and superficial and radial to the FDS. Besides
the medial epicondyle, the palmaris longus has proximal
attachments to the neighboring superficial muscle fascia as
well as from the intermuscular septa and deep antebrachial
fascia. The muscle fibers are aligned in a nearly parallel
course to the tendon. The muscle usually has a fairly abrupt
myotendinous junction located in the mid-portion of the
forearm, giving rise to a long, slender tendon. The tendon
extends distally, superficial to the flexor retinaculum. It
becomes broad and flat to form a sheet that connects or is
continuous with the palmar fascia (palmar aponeurosis) of
the hand. A few connections may interweave with the trans-
verse fibers of the retinaculum, although most of the fibers
are oriented longitudinally in a proximal-to-distal direction.
The radiating fiber bundles on the radial and ulnar aspects
extend distally to attach to the overlying fascia of the thenar
and hypothenar muscles. The more central bundles usually
are more developed and constitute the more substantial
portion of the palmar fascia (3,4,8).
Fahrer has shown that the proximal end of the palmar
fascia receives two important contingents of fibers from the
FCU. A superficial component blends with the fibers of the
palmaris longus; a deep component runs on the surface of
the pisohamate ligament and connects the flexor retinacu-
lum to the palmar fascia (193).
The tendon and palmar fascia continue distally to form
a diverging sheet that splits longitudinally to send thicken-
ings of the fascia to each of the four rays, with variable fiber
bundles extending toward the thumb (3,4). These diverging
fiber bundles form a triangular connective tissue sheet in
the midpalm with the apex proximal. The palmar fascia has
interconnections with the fibroosseous tendon sheaths,
with the skin, and in the fascia of the distal palm and digi-
tal webs.
Although the palmaris longus often is absent, absence of
the palmar fascia has not been noted (194). From gross and
microscopic observations, as well as staining properties, the
palmaris longus tendon and palmar fascia appear as tendon
and fascia, respectively. These observations support the idea
that the palmaris longus and palmar fascia are separate
anatomic structures that develop independently and are
associated only by anatomic proximity (194).
The morphology and biomechanical aspects of the pal-
maris longus tendon have been evaluated in terms of its use
as a tendon graft, and in comparison with other tendons
used as grafts (191). The palmaris longus mean tendon
length is 161 mm, its mean cross-sectional area 3.1 mm2,
and its mean volume 529 mm3. The tendon is among the
stiffest at 42.0 N/mm (191). The average width of the pal-
maris tendon is approximately 3 mm (189,191).
The arterial supply has been studied in detail by Wafae
and associates (187). Most muscles received one or two
arterial branches from the ulnar artery (86%), and less fre-
quently from the brachial artery (23%). The arterial
branches penetrate the muscle through the posterior sur-
face, 63% in the proximal third and 34% in the middle
third of the muscle. The most frequent patterns observed
included one or two branches of the ulnar artery penetrat-
ing the proximal third of the muscle (29%), and two
branches of the ulnar artery, one entering the proximal
third and one entering the middle third of the muscle belly
(187).
The architectural properties of the palmaris longus are
listed in Table 2.1 and shown in Fig. 2.4A and B.
The palmaris longus is innervated by the median nerve
(C7 and C8). The nerve branch usually is a common
branch from the median nerve that also supplies the FCR.
It often courses along with the branch supplying the proxi-
mal part of the FDS. The nerve to the palmaris longus usu-
ally enters in the middle third of the muscle (3,4,8,11).
Actions and Biomechanics: Palmaris
Longus
The palmaris longus is a weak flexor of the wrist. The
muscle also may assist with a relatively weak contribution
to forearm pronation. It may represent an evolutionary
remnant of a flexor of the metacarpophalangeal (MCP)
joints (188) because it appears that the palmar fascia
extends to that level. In addition, the palmaris longus
plays a role in the stabilization of the palmar fascia. A pur-
pose of the palmar fascia is to anchor the skin on the palm
to resist shearing forces (compared with the loose skin on
the dorsum of the hand, the palmar skin is relatively
immobile). This anchoring of the skin assists with grasp
functions, so that objects do not move or shift during
tight grasp. The palmaris longus, which has power to
apply force to the palmar fascia, contributes to this
anchoring of the palmar fascia to resist horizontal shearing
forces moving distally in the hand.
It has been postulated by Fahrer that, in congenital
absence of the palmaris, the FCU takes over as the longitu-
dinal tensor of the palmar fascia through interconnecting
fibers of the tendon and the palmar fascia (192,193).

Fahrer and Tubiana suggest that the palmaris longus con-
tribute to opposition and pronation of the thumb under
some circumstances (192). The palmaris longus, however, is
restricted in this motion because it is tethered by its ten-
don’s medial slip and terminal insertion that attaches to the
palmar fascia (192).
Kaplan and Smith also give credit to the palmaris longus
as a synergist in thumb opposition (195). The tendon
becomes tense when opposition of the thumb is attempted
or maintained. The contraction is thought to produce syn-
ergistic tension of the transverse carpal ligament to provide
better fixation at the origins of the thenar muscles (195). In
addition, the palmaris longus tendon often has a slip that
inserts into the abductor pollicis brevis (APB) and can
therefore act directly on the muscle during opposition. It
was concluded by Kaplan and Smith that the palmaris is an
unimportant flexor of the wrist but a strong synergist of
abduction and opposition of the thumb. In paralysis of the
other flexors of the wrist, the palmaris longus may become
a fairly important wrist flexor if it has a firm insertion into
the transverse carpal ligament or the carpal bones (195).
Anomalies and Variations: Palmaris
Longus
The palmaris longus is one of the most variable muscles in
the upper extremity (195). The presence (or absence) of the
palmaris longus is quite variable. In general, there is an
absence in one or both limbs in approximately 12% to 25%
of patients (or cadavers) (196,199), or absence in individual
limbs in 15% to 31% (187,194). Because absence is rela-
tively common, the incidences are discussed in more detail
earlier, under Gross Anatomic Description.
Several variations have been reported (207–262) (Fig.
2.7). These have clinical implications because of the value
of the palmaris as a free graft or transfer. An awareness of
the variability of the palmaris may help avoid difficulty or
confusion in the harvest of the free graft. In addition, many
of the anomalous muscles cause problems with nerve com-
pression, including the median nerve in the forearm
(207–210,224) and the carpal tunnel (229–231), the pal-
mar cutaneous branch of the median nerve (230–232), and
the ulnar nerve (225,233–235). The more common varia-
tions and anomalies are as follows:
Distal Belly (Reverse Belly, Palmaris Longus
Inversus)
The palmaris longus can have a distal or reverse muscle
belly (see Fig. 2.7). In the reversed form, the tendon is
proximal and the muscle is distal. Variations of this form
have been referred to as the palmaris longus inversus (11).
The distal muscle can cause median neuropathy in the
forearm (208,209,211). If the muscle reaches or enters the
carpal tunnel, carpal tunnel syndrome can result (212,
2 Muscle Anatomy 117
219). A reversed muscle also can lead to ulnar nerve com-
pression (234).
Digastric Head
The palmaris longus may have a digastric head (two heads,
one proximal and one distal, separated by an intercalary ten-
don) (see Fig. 2.7). The distal muscle belly may cause median
neuropathy in the forearm or, if it reaches or enters the carpal
tunnel, can result in carpal tunnel syndrome (227–232).
Split or Double Belly Tendon
The muscle may be split along its course, presenting as two
separate muscle bellies (see Fig. 2.7). When two bellies are
present, there may be several variations of the origin and
insertion attachments (198,237). The tendon itself may be
split or doubled (11,231). Dowdy and colleagues identified
2 specimens of 52 with a split palmaris longus tendon
(231). The palmar cutaneous branch of the median nerve
passed through the split at 1 to 1.5 cm proximal to the
insertion into the palmar fascia. In the presence of this
anomaly, the nerve is at risk for injury in the harvest of the
tendon. The authors recommend transecting the tendon
2 cm proximal to its insertion into the palmar fascia to
avoid possible nerve injury (231). In addition, this split
may place the nerve at risk for compression neuropathy.
Palmaris Longus Profundus
The palmaris profundus is an anomalous palmaris longus
that arises from the lateral edge of the radius, in its middle
third, external to the FDS and deep to the pronator teres.
The tendon passes deep to the flexor retinaculum (to the
radial side of the median nerve) and broadens in the palm
to insert into the deep side of the palmar aponeurosis
(11,215,221,228). It can be noted as an incidental opera-
tive finding without any clinical consequences. However, as
it enters the carpal canal, it can result in carpal tunnel syn-
drome (221). It has been reported to occur bilaterally
(215,221,228). The muscle also can cause ulnar nerve com-
pression at the wrist (261).
Palmaris Bitendinous
The palmaris bitendinous is an anomalous muscle that is
located deep to the palmaris longus and has a distal inser-
tion on the deep surface of the palmar aponeurosis, similar
to the palmaris profundus. It can result in median neuropa-
thy in the forearm and hand (210).
Continuous Muscle
The palmaris longus may have one continuous muscle
from origin to insertion. The distal muscle extension can
118
FIGURE 2.7. The normal palmaris longus and some of its clinically relevant variations. The pal-
maris longus with a distal muscle belly may be responsible for median or ulnar nerve compres-
sion. The median nerve can be compressed either in the distal forearm or in the carpal tunnel if
an anomalous portion or slips extend into the canal. The split or duplicated muscle belly of the
palmaris longus and the digastric variation (with a distal belly) may cause difficulty or confusion
during harvest for transfer or free graft if these possible variations are not appreciated or rec-
ognized. The digastric form also may contribute to median and ulnar nerve compression in the
forearm (11).

cause median neuropathy in the forearm or carpal tunnel
(195).
Central Belly
The muscle belly may be located centrally between two ten-
dons, so that the origin and insertion are both tendinous
(195,237).
Continuous Tendon
The palmaris longus may exist only as a tendon from origin
to insertion (11,195).
Triple Muscle Bellies
The muscle may exist as three distinct muscle bellies (195).
The tendon also may be split or triplicated (11).
Variable Origin
The site of origin is variable, and has been noted to include
attachments to the fascia of most of the muscles of the ulnar
side of the forearm (including the biceps, brachialis, and
FDS), from the medial intermuscular septum, from the
coronoid process of the ulna, and from the proximal radius
(11,195). With a double muscle belly, one can arise in a
normal fashion from the medial epicondyle, and the other
from the aforementioned muscles, fascia, intermuscular
septum, proximal ulna, or proximal radius (11,195).
Variable Insertion and Accessory Distal Slips
The site of insertion is equally as variable as the site of ori-
gin. It may have abnormal extensions, anomalous slips, an
abnormal split, and associated anomalous muscle bellies
(11,195,215,216,222–225,250). The palmaris longus may
insert into the tendon of the FCU, transverse carpal liga-
ment, antebrachial fascia, scaphoid, pisiform, or APB
(195). It commonly has fascial extensions to the fascia of
the base of the thenar and hypothenar muscles (and attach-
ments to these muscles are so common they may be con-
sidered part of the normal insertion). The tendon can insert
onto the deep surface of the palmar fascia (260). Several
accessory slips or anomalous muscle heads at the insertional
area have been identified. The accessory slips may attach to
various flexor tendons and extend distally as far as the MCP
joint (11). Median nerve compression in the forearm and
carpal tunnel has been associated with the accessory slips,
especially if the anomalous tendon or muscle enters the
carpal tunnel (215,216,222,224,250). An accessory muscle
inserting into the base of the hypothenar muscles has been
shown to cause carpal tunnel syndrome (213). An ulnar-
sided palmar accessory muscle was noted to cause ulnar
tunnel syndrome (234,236). An accessory slip has been
2 Muscle Anatomy 119
noted to split from the palmaris longus tendon and enter
the ulnar tunnel to cause ulnar tunnel syndrome (225,233).
The ulnar artery also may be compressed by an anomalous
palmaris longus slip that enters the ulnar tunnel (11).
Intrapalmar Muscle
An intrapalmar accessory head of the muscle has been iden-
tified in the carpal tunnel, causing carpal tunnel syndrome
(223).
Palmaris Longus and the Accessories Ad
Flexoram Digiti Minimi
The tendon of the palmaris longus may give origin to an
additional muscle, the accessories ad flexorum digiti min-
imi. This muscle usually inserts on the body and head of the
fifth metacarpal between the abductor digiti minimi and
flexor digiti minim brevis (11).
Palmaris Longus Substituting for Digital
Flexors
The palmaris longus can substitute for the ring finger FDS.
In the absence of the FDS, a palmaris longus was found to
extend to the middle phalanx of the ring finger and func-
tion as a digital flexor of the proximal interphalangeal joint
(PIP) (259).
Clinical Correlations: Palmaris Longus
The most important anatomic clinical considerations with
the palmaris longus include its variable presence and the
common anomalies. The specific anatomic forms are dis-
cussed in detail previously. The possible variations and
anomalies are important both from the standpoint of free
tendon harvest or transfer, as well as with regard to the
many associated nerve compression syndromes caused by
an anomalous palmaris longus tendon. Problems associ-
ated with anomalous muscles include median compression
in the forearm (208–210,212,224) and the carpal tunnel
(131–229), compression of the palmar cutaneous branch
of the median nerve (230–232), and compression of the
ulnar nerve in the forearm or ulnar tunnel (233–236,261)
(discussed in detail earlier, under Variations and Anom-
alies).
The possibility of absence is of clinical significance
because of the common use of the palmaris longus as a free
graft or tendon transfer (263–267). Its presence always
should be tested by having the patient place the pulp of the
thumb in opposition to the pulp of the small finger. When
the wrist is flexed, the tendon of the palmaris becomes
prominent. In general, there is an absence in one or both
limbs in approximately 12% to 25% of patients (or cadav-
ers) (11,196,199) and absence in individual limbs in 15%
120 Systems Anatomy
to 31% (187,199) (discussed in detail earlier, under Gross
Anatomic Description).
Magnetic resonance imaging or ultrasound (UTZ) have
been shown to be capable of detecting the absence of the
palmaris longus or the presence of anomalies (225,250).
Hypertrophy of a normal palmaris longus tendon can
result in median neuropathy simulating carpal tunnel syn-
drome (11,212,218).
For low median neuropathy, such as with severe, long-
standing carpal tunnel syndrome, the Camitz transfer is a
type of opponensplasty used to provide thumb palmar
abduction and opposition. It was popularized by Braun and
uses the palmaris longus, extended by a strip of palmar fas-
cia, to transfer to the thenar muscles (266–272).
FLEXOR DIGITORUM SUPERFICIALIS
(FLEXOR DIGITORUM SUBLIMIS)
Derivation and Terminology. Flexor is derived from the
Latin flexus, indicating “bent” (and flexor, which indicates
“that which bends,” or “bending”). Digitorum is from the
Latin digitus or digitorum, indicating the digits. Superficialis
denotes its superficial location in the forearm. The term
sublimis sometimes is used. This is derived from Latin sub-
limis, indicating “superficial” (1,2).
Origin. There are two heads with separate origins.
Humeroulnar head: from the medical epicondyle of the
humerus and from the proximal medial ulna. Radial head:
from a long, oblique, linear attachment from the volar
proximal radial shaft, along the proximal third of the dia-
physis.
Insertion. To the medial and lateral margins of the volar
shaft of the middle phalanges of the index, long, ring, and
small fingers.
Innervation. Median nerve (C7, C8, T1).
Vascular Supply. The ulnar artery, superior and inferior
ulnar collateral arteries, anterior and posterior ulnar recur-
rent arteries, superficial palmar arch, common and proper
palmar digital arteries (3,4,8).
Principal Action. Flexion of the PIPs of the index, long,
ring, and small fingers. It also contributes to flexion of the
digital MCP joints, and flexion of the wrist.
Gross Anatomic Description: Flexor
Digitorum Superficialis
The FDS is one of the central muscles of the superficial
flexors of the forearm (along with the pronator teres, FCR,
palmaris longus, and FCU). It lies in the superficial volar
muscle compartment of the forearm (Appendix 2.2). The
FDS is located medial and deep to the palmaris longus and
FCR. The FCU lies ulnar and superficial to the FDS. It is
an important flexor of the digits, and is one of the largest of
the superficial flexor muscles of the forearm (3,4,8,13).
The FDS has two main heads, the humeroulnar head and
the radial head. The humeroulnar head has several origin
sites. It arises, in part, from the medial epicondyle through
the common flexor origin (see Fig. 2.2A). The muscle has
additional origin attachments from the anterior band of the
ulnar collateral ligament, from adjacent intermuscular septa,
and from the medial side of the coronoid process proximal to
the ulnar origin of the pronator teres (Fig. 2.3A). Additional
origin attachments may connect to the fascia of the
brachialis. The radial head is a long, thin, flat muscular sheet.
It arises from the oblique line of the radius, which is a long,
linear, oblique attachment area from the volar radial shaft in
its proximal third (see Fig. 2.3A). The origin extends distally
from the anterior lateral border of the radius, just proximal to
the insertion of the pronator teres. The origin of the FDS
extends along the anterior diaphysis proximally and medially
to reach the medial side of the radial tuberosity. The two
heads form a muscular arch, through which the median nerve
and ulnar artery pass. The muscular arch formed by the FDS
is a well known site for potential median nerve compression,
especially in forearm compartment syndromes or ischemic
contracture (3,4,11,13,18,273–276).
The muscular fibers extend distally, with the fiber bun-
dles of the ulnar head and the upper part of the radial head
converging. The ulnar fiber bundles extend distally in a ver-
tical fashion. The fibers from the radial head extend distally
obliquely to form a common belly. The deep surface of the
FDS on the ulnar side usually is covered by a dense tendi-
nous or fibrous sheet (3,4).
The muscle belly of the FDS forms two separate submus-
cle bellies (273–284). These resemble planes or sheets of
muscle fibers (4), referred to as strata by Williams (3). There
is a deep and superficial plane of fibers. The superficial plane
of fibers further divides into two parts that end in the ten-
dons for the long and ring fingers. Similarly, the deep plane
of fibers further divides into two parts, which end in the ten-
dons for the index and small fingers (4). Of these muscles,
the FDS belly to the long finger may arise more indepen-
dently than the others (277). Before dividing, the deep plane
gives off a muscular slip to join the portion of the superficial
plane associated with the tendon of the ring finger. The
arrangement of deep and superficial muscle planes is retained
at the wrist level. As the four tendons continue distally in the
forearm and pass deep to the flexor retinaculum, they still are
arranged in pairs, the superficial and deep. The superficial
pair, located superficial and the central of the four tendons,
continues to the long and ring fingers. The deep pair, located
deep and at the radial and ulnar margins of the four tendons,
continues to the index and small fingers, respectively. (Note:
This arrangement of the tendons at the distal forearm and in
the carpal tunnel can be simulated on one’s own hand. If one
touches the index and small fingers behind the ring and long
fingers, the pattern of tendons is roughly simulated, with the
ring and long tendons located superficial and central, and the
index and small finger tendons located deep and to the radial

and ulnar margins, respectively.) The tendons diverge from
one another in the palm and extend distally deep to the
superficial palmar arterial arch and the digital branches of the
median and ulnar nerves. At the level of the base of the prox-
imal phalanges, each tendon divides into two slips. The diver-
gence of the two slips forms an interval through which the
associated tendon of the FDP passes. The two slips of the
FDS then rotate 90 to 180 degrees, flattened against the pro-
fundus tendon. The slips thus encircle the profundus tendon.
At the side of the profundus tendon, the spiraling, flat bands
of the FDS tendon have rotated such that the fibers that were
nearest to the midline in the undivided tendon become the
most volar at the sides of the middle phalanx. These anterior
fibers continue on the same side of the profundus tendon
attached to the proximal part of the ridge on the margin of
the middle phalanx. The posterior fibers sweep around the
profundus tendon to reunite dorsal to the profundus. The
two portions of the FDS reunite at Camper’s chiasma. In this
area, the FDS slips form a grooved channel for passage of the
profundus. At the level of Camper’s chiasma, the FDS slips
decussate in an “X” pattern (behind the profundus, on the
volar surface of the middle phalanx) and pass distally to
attach to the distal part of the ridge on the opposite margins
of the middle phalanx (282). Each slip of the tendon of the
FDS inserts into the medial and lateral aspects of the volar
shaft of the associated digit (see Fig. 2.6A). The chiasma can
be variable in terms of anatomy and morphology (3,4,284).
The vascular supply to the tendons comes from several
sources. These include the longitudinal vessels (some of
which may originate in the muscle belly) that enter in the
palm and extend down intratendinous channels; vessels that
enter at the level of the proximal synovial fold in the palm;
segmental branches from the paired digital arteries that
enter in the tendon sheaths by means of the long and short
vincula; and the vessels that enter the FDS and FDP ten-
dons at their osseous insertions (285–299). In the digital
sheath, the segmental vascular supply to the flexor tendons
is through long and short vincular connections. These
include the vinculum brevis superficialis, the vinculum bre-
vis profundus, the vinculum longum superficialis, and the
vinculum longum profundus. The vincula often are variable
in presence and configuration (299). In addition to the vas-
cular supply, the tendons in the synovial sheath receive
nutrition through synovial fluid diffusion.
The vinculum longum superficialis arises at the level of
the base of the proximal phalanx. Here, the digital arteries
give rise to branches on either side of the tendons that inter-
connect anterior to the phalanx, but deep (dorsal) to the
tendons. These branches form the vinculum longum super-
ficialis that connects to the FDS at the floor of the digital
sheath. The vinculum longum superficialis supplies the
FDS at the level of the proximal phalanx (285–299).
The vinculum brevis superficialis and the vinculum bre-
vis profundus consist of small triangular mesenteries near
the insertion of the FDS and FDP tendons, respectively.
2 Muscle Anatomy 121
The vinculum brevis superficialis arises from the digital
artery, at the level of the distal part of the proximal pha-
lanx. It supplies the FDS tendon near its insertion into the
middle phalanx. A portion of the vinculum brevis superfi-
cialis continues anteriorly, at the level of the PIP joint
toward the FDP to form the vinculum longum profundus
(285–299).
Because the vincula enter the tendon on the dorsal sur-
face, the vascularity of the dorsal half of the tendon in the
digits is richer than the palmar half.
Architectural features of the FDS include the physiologic
cross-sectional area of the muscle, the fiber bundle length,
muscle length, muscle mass, and pennation angle. Skeletal
muscle architectural studies by Lieber, Friden, and col-
leagues provide the data for the FDS to each digit
(135–139,174) (see Table 2.1 and Fig. 2.4). As can be seen
in the figures, the digital extrinsic flexor and extensor mus-
cles have similar architectural features (see Fig. 2.4A and B).
The relative difference index values compare the FDS with
other upper extremity muscles, based on architectural fea-
tures. These values are listed in Appendix 2.3.
The FDS is innervated by a branch from the median
nerve (C7, C8, T1). The nerve branch usually exits the
median nerve trunk proximal to the pronator teres and
accompanies the median nerve trunk through the two
heads of the pronator teres. The branch then divides into
multiple smaller motor branches that supply the radial head
of the muscle. The muscle portions that ultimately form the
tendons to the index and small fingers each may receive a
separate motor branch. On occasion, the motor branches
may exit the median nerve more distally, in the distal third
of the forearm, to supply the FDS (3,4,11,18).
Actions and Biomechanics: Flexor
Digitorum Superficialis
The FDS functions to flex the PIP joints of the index, long,
ring, and small fingers. It also contributes to flexion of the
digital MCP joints and flexion of the wrist. During flexion,
there is a slight adduction component as the FDS draws the
digits together, as in making a fist. The tendon of the small
finger has a minor rotatory (opposing) action at the car-
pometacarpal joint (11).
The FDS has independent muscle components to each
of the four digits. It therefore can flex each PIP indepen-
dently (unlike the FDP, which has a common muscle group
to the middle, ring, and small fingers). The ability of the
FDS to flex one PIP at a time is useful in assessing tendon
lacerations.
Anomalies and Variations: Flexor
Digitorum Superficialis
Among the many described muscle variations and anom-
alies of the FDS (300–333), the more common involve
122 Systems Anatomy
muscle slips that interconnect the FDS with the other fore-
arm flexors. These include slips to the flexor pollicis longus
(FPL), the palmaris longus, or the brachioradialis
(324,325). The variations seem to be more common in the
index and small fingers (11,311,313,319,326,332). As
much as 10% of 70 cadaver hands showed an anatomic
variation of the small finger that would preclude its inde-
pendent function (284). Some anomalies have been noted
to occur repeatedly in families or in different generations
(326), or to occur bilaterally (312,321,333).
A muscle slip, the radiopalmaris, may arise directly from
the radius deep to the FDS and attach to the palmar
aponeurosis or to the common sheath of the flexor tendons
(11,319).
Several variations of the radial head of the muscle have
been noted. These include complete absence of the radial
head (3,4), or absence of one or more of the distal divisions
(to form specific tendons) (300). The entire muscle may
originate from the radius (11). The muscle belly and tendon
to the small finger may be absent (301,326).
A rare anomaly is a digastric FDS, consisting of an addi-
tional distal muscle belly separated from the main muscle
belly by an intercalary tendon (11,302–304,329). The mus-
cle may occur as an accessory FDS, in the presence of a nor-
mal FDS (305,306).
An anomalous muscle, the palmar FDS accessories, may
arise from the palmar fascia and distal border of the trans-
verse carpal ligament and end in a tendon that joins the
flexor tendon of the index finger at the level of the MCP
(11,309,319). In a literature review by Elias and Schulter-
Ellis, the muscle was shown to be more common in women
than men in a 13:2 ratio, and involved the right hand in 12
of 13 cases (309). It was seen bilaterally in 4 of 13 cases.
The muscle involved the index finger in all cases; however,
a somewhat similar anomalous muscle involving the small
finger has been reported (312). This anomaly may present
as a painful palmar wrist mass (310,311,313). The muscle
usually can be identified with magnetic resonance imaging
(311,313). An additional variation of this anomaly includes
a palmar muscle belly that originates from the FDS to the
index finger by way of an accessory tendon (314). An
“accessory” FDS also has been noted, causing a volar soft
tissue wrist mass and ulnar neuropathy (307). The FDS
may be associated with Gantzer’s muscle (330).
Clinical Implications: Flexor Digitorum
Superficialis
The median nerve passes deep to the arch formed by the
heads of the FDS. This is a potential site of nerve compres-
sion, and should be considered in compartment syndrome
decompression or nerve exploration in ischemic contracture
(273,274).
Because the muscle bellies for each FDS tendon usually
are separate, it is possible independently to flex each of the
PIP joints. By holding the other three digits in extension,
the function of the remaining FDS can independently be
tested by having the patient attempt to flex the digit at the
PIP joint. Note that because the FDP muscle belly usually
consists of one belly supplying the four tendons (instead of
the four separate muscle bellies supplying the four tendons
of the FDS), holding the digits in extension helps to elimi-
nate function of the FDP. Thus, any flexion of the digit at
the PIP joint is performed by the FDS, and each digit can
be evaluated independently (3).
Carpal tunnel syndrome can be precipitated by anom-
alies and variations of the FDS. The anomalous muscles
bellies in the forearm can cause direct encroachment of the
median nerve. In addition, an anomalous muscle belly or a
belly from a normal muscle that extends abnormally distally
into the carpal tunnel can contribute to carpal tunnel syn-
drome (303,316–320,322,327,331). Holtzhausen and col-
leagues have shown the prevalence of the FDS and FDP
muscle bellies that extend into the carpal tunnel to be as
high as 46% in women and 7.8% in men (323). Intermus-
cular slips that pass between the FDS and the palmaris
longus can cause carpal tunnel symptoms (324). Bilateral
occurrence of carpal tunnel syndrome due to an anomalous
FDS has been reported (331).
Ulnar neuropathy has been reported by Robinson, due
to an accessory FDS that produced a palpable mass in the
volar forearm as well as ulnar nerve encroachment (307).
A painful mass in the palm along the tendon course to
the index finger may represent an anomalous muscle, the
palmar FDS accessories. This muscle may arise from the
palmar fascia and distal border of the transverse carpal liga-
ment and end in a tendon that joins the flexor tendon of
the index finger at the level of the MCP (309–313,319).
The mass usually can be identified as muscle by magnetic
resonance imaging (311,313). A fibroma in association
with an anomalous FDS tendon also has been the cause of
a painful palmar mass (315).
Agee and colleagues have studied the FDS, and note that
the muscle to the long finger may be anatomically the most
independent, arising separately. Therefore, this tendon may
be the most suitable for nonsynergistic tendon transfers
(277).
Progressive flexion contracture of the PIP (resembling
camptodactyly) of the right ring finger has been noted to
occur from an anomalous origin of the FDS. Operative
excision of the aberrant tendon restored normal range of
motion at the PIP joint (333).
In the absence of the FDS, a palmaris longus has been
found to extend to the middle phalanx of the ring finger
and function as a digital flexor of the PIP joint (259).
Because the vincula enter the tendon on the dorsal sur-
face, the vascularity of the dorsal half of the tendon in the
digits is richer than the palmar half. This has implications
for placement of sutures in the repair of lacerated tendons.
Sutures placed in the palmar half of the tendon should dis-

rupt the intratendinous vascularity to a lesser degree than
those in the dorsal half. The vincular system should be
appreciated and protected as much as possible in the explo-
ration or repair of the flexor tendons.
FLEXOR CARPI ULNARIS
Derivation and Terminology. Flexor is derived from the
Latin flexus, indicating “bent” (and flexor, which indicates
“that which bends,” or “bending”). Carpi is from the Latin
carpalis and the Greek karpos, both of which indicate
“wrist” (the carpus). Ulnaris is derived from Latin ulna,
indicating “arm” (1,2).
Origin. From two heads. Humeral head: from the med-
ical epicondyle through the common flexor origin. Ulnar
head: extensive origin from the medial margin of the ole-
cranon and proximal two-thirds of the posterior border of
the ulna by an aponeurosis shared with the ECU and FDP,
and from the adjacent intermuscular septum.
Insertion. To the pisiform; a few fibers may attach to the
flexor retinaculum.
Innervation. Ulnar nerve (C7, C8, T1).
Vascular Supply. The ulnar artery, superior and inferior
ulnar collateral arteries, anterior and posterior ulnar recur-
rent arteries, ulnar end of the superficial palmar arch
(3,4,334,335).
Principal Action. Flexion and ulnar deviation of the
wrist.
Gross Anatomic Description: Flexor Carpi
Ulnaris
The FCU is the most medial muscle of the superficial flex-
ors of the forearm (along with, from radial to ulnar, the
pronator teres, FCR, palmaris longus, and FDS)
(3,4,8,11,13). It lies in the superficial volar muscle com-
partment of the forearm (Appendix 2.2). The FCU is
located medial and superficial to the FDS. It has two heads
of origin (336). A smaller humeral head originates from the
distal part of the medial epicondyle through the common
flexor origin (see Fig. 2.2A). There also are fascial attach-
ments from the humeral head to the adjacent intermuscu-
lar septum and deep fascia of the forearm. The larger ulnar
head has a more extensive origin, arising from the medial
margin of the olecranon and proximal two-thirds of the
posterior border of the ulna by a fascial sheet or aponeuro-
sis (see Fig. 2.3B). It shares this aponeurotic origin with the
ECU and FDP. The FCU also has attachments to the
neighboring intermuscular septum between it and the FDS.
The two heads of the FCU create a muscular arch extend-
ing from the olecranon to the medial epicondyle. The ulnar
nerve and posterior ulnar recurrent artery pass through this
fibromuscular arch. The muscle belly from the humeral
head extends distally in a nearly longitudinal fashion. The
2 Muscle Anatomy 123
muscle fibers from the larger ulnar head, however, extend
distally obliquely and anteriorly. This muscle belly, which is
highly pennated, may continue nearly the entire length of
the muscle–tendon unit, almost to the insertion site. (This
is very different from the FCR, which has a fairly abrupt
myotendinous junction in the central portion of the fore-
arm, and a long solitary tendon that extends distally with-
out attaching muscle fibers.) The FCU has a long, thick
tendon that forms along the anterolateral border of the
muscle in its distal half. The tendon usually is more than 10
mm long (337). As the tendon extends distally, it usually
retains muscle fibers to the distal portion of the forearm
almost to the level of its insertion onto the pisiform (337).
Rarely, there is a discrete tendon without accompanying
muscle fibers (337). At the level of insertion, all the muscle
fibers insert in a penniform manner. The pisiform is a
sesamoid bone, and therefore is within a tendon (or liga-
ment). The FCU thus inserts primarily into the pisiform
(see Fig. 2.6A), but is also, to an extent, extended distally
through the pisiform to the hamate through the pisohamate
and pisometacarpal ligaments. In addition, a few fibers
attach to the flexor retinaculum and to the palmar aponeu-
rosis, and, possibly, to the base of the third, fourth, and fifth
metacarpals (338). As the muscle inserts into the pisiform,
the ulnar nerve and artery are located deep and radial to the
tendon.
Architectural features of the FCU include the physio-
logic cross-sectional area of the muscle, the fiber bundle
length, muscle length, muscle mass, and pennation angle
(angle of the muscle fibers from the line representing the
longitudinal vector of its tendon). Skeletal muscle architec-
tural studies by Lieber, Friden, and colleagues provide the
data for the FCU (135–139,174) (see Table 2.2 and Fig.
2.4). The FCU has a relatively small fiber length and rela-
tively large physiologic cross-sectional area. This indicates
that its design is more optimal for force generation (pro-
portional to cross-sectional area) than for excursion or
velocity (proportional to fiber length). Its relative difference
index values compare it with other upper extremity mus-
cles, based on architectural features. These values are listed
in Appendix 2.3. In comparing the architectural features of
the FCU with the FCR, the FCR muscle length is shorter
than the FCU, but the muscle fibers of the FCR are longer
(136,174). The relatively longer fiber length indicates that
the FCR is designed more for excursion and velocity of con-
traction (because excursion and velocity are proportional to
fiber length) compared with the FCU. The FCU, in con-
trast, has a higher pennation angle, with a larger physiologic
cross-sectional area. This indicates the FCU is designed
more for force production and less for excursion and veloc-
ity, compared with the FCR (because cross-sectional area is
proportional to force production) (174,175) (see Table 2.2
and Fig. 2.4).
The FCU is innervated by the ulnar nerve (C7, C8, T1).
The muscle usually receives two to three muscular branches
124 Systems Anatomy
in its proximal portion, although there may be up to six
separate branches (11,339). These branches usually leave
the ulnar nerve near the level of the elbow joint or in the
distal portion of the cubital tunnel. Rarely, a branch can
exit the ulnar nerve proximal to the elbow (339). The
motor branches often are visualized during cubital tunnel
decompression or ulnar nerve transposition. Each head of
the FCU receives a separate motor branch (336). There
occasionally is a single branch that leaves the ulnar nerve
trunk, enters the proximal FCU on the deep surface, and
then branches in the muscle to send long, slender motor
branches through the muscle to reach the middle third
(3,4,11,13,340).
Actions and Biomechanics: Flexor Carpi
Ulnaris
The FCU functions primarily to flex the wrist, and usually
works with the FCR. It also ulnarly deviates the wrist, espe-
cially working with the ECU. The FCU takes an important
role in stabilizing the wrist during strong power grip, as in
the tight grasp of a hammer. The wrist usually is held in
slight ulnar deviation during these functions because the
wrist is stabilized, in large part, by the FCU. The FCU also
helps stabilize the pisiform, and thus can assist the abductor
digiti minimi, which has its origin on the pisiform. The
FCU therefore can assist indirectly with abduction of the
small digit.
From its insertion on the medial epicondyle, and from
its course that positions the muscle directly over the medial
collateral ligament, it has been postulated that the FCU
(along with the FDS) functions to support or stabilize the
medial elbow joint (170).
As stated earlier, the FCU is architecturally designed
more for force generation than for excursion or velocity
compared with its radial counter part, the FCR. This is due
to the FCU having a larger physiologic cross-sectional area
(proportional to force generation), being highly pennated
(which helps increase the physiologic cross-sectional area),
and having a shorter fiber length (which is proportional to
excursion or velocity) (135–138,174,341,342).
Anomalies and Variations: Flexor Carpi
Ulnaris
The muscle and tendon arrangement of the FCU occurs in
three general types. The most common is a large muscle
belly that runs distally almost to the insertion on the pisi-
form. The next most common is a muscle belly that ends
more proximally, with some large muscle fibers that run
parallel to the tendon and almost reach the pisiform. Rarely,
the musculotendinous junction ends more proximally, with
only single muscle fibers that continue distally. These dif-
ferent muscle–tendon patterns should be kept in mind
when interpreting magnetic resonance images, during gen-
eral operative exploration for penetrating trauma, or when
performing muscle–tendon lengthening procedures
(135–138,174,341–344).
Among the most common variations of the FCU is an
accessory tendon or muscle slip that extends from the coro-
noid process and joins the muscle belly in the proximal
third of the muscle (3,11). An accessory muscle may extend
the entire length of the FCU and resemble a duplicated
muscle (345).
Distally, there are several possible variations of the inser-
tion of the tendon. It may send tendinous slips to the flexor
retinaculum. It may have extensions to the metacarpals of
the small, ring, or long fingers, or to the capsules of the car-
pometacarpal joints (3,4,11). A distal slip inserting into the
proximal phalanx of the ring finger has been described
(346). A distal anomalous muscle belly and a “reversed”
muscle belly located predominantly distally have been
noted and associated with ulnar nerve compression, either
in the forearm or in the ulnar tunnel (346–350). These
anomalous muscles entering the ulnar tunnel also have been
associated with ulnar artery thrombosis (351).
The insertional tendon may extend to the proximal por-
tion of the abductor digiti minimi.
The epitrochleoanconeus [epitrochleoolecranonis or
anconeus sextus of Gruber (11)] is a small anomalous mus-
cle closely associated with the FCU. It originates from the
posterior surface of the medial epicondyle of the humerus
and inserts into the olecranon process. It is superficial to the
ulnar nerve (from which it is innervated), and takes the
place of the fibrous arch of the deep fascia usually found in
the same location. The muscle has a frequency of approxi-
mately 25% in cadaver dissections (11). The muscle
restricts mobility of the ulnar nerve in the forearm, thereby
contributing to the development of neuropathy (especially
with trauma as a precipitating factor) (347).
A split FCU tendon has been noted, with the ulnar nerve
passing between the split. Ulnar nerve compression symp-
toms were produced with wrist hyperextension (352–354).
Clinical Implications: Flexor Carpi Ulnaris
Because the FCU is designed most optimally for force gen-
eration and less for excursion or velocity, it may be a less
optimal tendon transfer for use in radial nerve palsy. The
FCR, which is designed more for excursion, may be a more
appropriate transfer to achieve digital extension. (In radial
nerve transfers, great tendon motor power strength usually
is not as important as excursion because the antigravity
function of the transfer usually is sufficient to achieve good
functional results) (135–138,174,341–343).
The ulnar nerve and artery lie deep and radial to the
FCU tendon in the distal forearm (the artery is radial to the
nerve). This is a reasonable site for ulnar nerve local anes-
thetic block, by infiltration of the nerve deep to the palpa-
ble FCU tendon. For complete block of the ulnar portion

of the hand, the dorsal branch of the ulnar nerve, which
leaves the ulnar nerve trunk proximal to the wrist, should
be blocked as well. The dorsal branch of the ulnar nerve can
be blocked by a wheal of subcutaneous local anesthetic
injected circumferentially along the ulnar and dorsal bor-
ders of the wrist in the area just distal to the ulnar head.
As noted previously, variations and anomalies of the
FCU, either in the forearm with accessory slips, fibrous
bands, or muscles, or distally with extended muscle bellies
or anomalous bellies extending into the ulnar tunnel, can
result in ulnar neuropathy (346–350,355,356). In addition,
a split FCU tendon pierced by the ulnar nerve or one of its
branches can lead to neuropathy (352–354). An anomalous
muscle extending into the ulnar tunnel also has been asso-
ciated with ulnar artery thrombosis (351).
Sarcomere length of a muscle can be measured using
intraoperative laser diffraction techniques. With these tech-
niques, it is possible to show and measure the change of sar-
comere length after muscle transfer. When the FCU was
transferred to the EDC (to restore digital extension), the
absolute sarcomere length and sarcomere length operating
range of the FCU increased. It also was shown that despite
good clinical results, a more desirable result could be
obtained if the FCU sarcomere length was increased (by
approximately 5 µm) by further stretching of the muscle
during the transfer. The authors were able to quantify the
relationship between the passive tension chosen for transfer,
sarcomere length, and the estimated active tension that
could be generated by the muscle. These findings demon-
strate the feasibility of using intraoperative laser diffraction
techniques during tendon transfer as a guide for setting ten-
sion and the optimal placement and sarcomere length of the
transferred muscle (341–343).
FLEXOR DIGITORUM PROFUNDUS
Derivation and Terminology. Flexor is derived from the
Latin flexus, indicating “bent” (and flexor, which indicates
“that which bends,” or “bending”). Digitorum is from the
Latin digitus or digitorum, indicating the digits. Profundus is
from the Latin profundus, indicating “deep,” and refers to
the muscle’s location deep in the forearm (1,2).
Origin. From the median and anterior surface of the
ulna, interosseous membrane, and deep fascia of the fore-
arm.
Insertion. To the base of the distal phalanges.
Innervation. Anterior interosseous nerve (from the
median nerve) to the index and long finger; ulnar nerve to
the ring and small fingers.
Vascular Supply. Posterior ulnar recurrent artery, pos-
terior and anterior interosseous arteries, palmar carpal
arch, palmar metacarpal arteries, common and proper dig-
ital palmar arteries. In addition, the lateral portion is sup-
plied by the ulnar collaterals and the deep palmar arch,
2 Muscle Anatomy 125
and the medial part is supplied by the ulnar artery
(3,4,11,13,68).
Principal Action. Flexion of the distal and interpha-
langeal joints and flexion of the MCP joints. The FDP also
contributes to wrist flexion and functions as the origin for
the lumbrical muscles (3,4,11).
Gross Anatomic Description: Flexor
Digitorum Profundus
The FDP, with the FPL, is one of the deep flexors of the
forearm and lies in the deep volar muscle compartment of
the forearm (Appendix 2.2). The muscle is situated deep in
the forearm, lying against the ulnar portion of the
interosseous membrane. The FDP is covered anteriorly by
the FCU and the FDS. The median nerve courses between
the deep flexor muscle group and the superficial flexor
muscle group of the forearm. It is a strong, broad, some-
what flat muscle. The FDP arises deep to the superficial
flexors from an extensive origin (see Fig. 2.3). The origin
includes attachments to the proximal two-thirds of the
anterior and medial surface of the ulna. There also are
attachments of origin to a depression on the medial side of
the coronoid process. Some of its origin extends medially
and posteriorly around the ulna to reach the posterior sur-
face of the ulna, and there are connections through an
aponeurosis shared with the flexor carpi ulnaris and ECU.
In addition, the FDP has attachments from the ulnar half
of the anterior surface of the interosseous membrane.
There also may be an inconsistent origin from a small area
on the radius distal to the bicipital tuberosity. The exten-
sive origin then forms what resembles a single large muscle
belly, although the belly to the index finger usually is sep-
arate and may be discernible. The muscle then divides into
four parts that are more distinct. The myotendinous junc-
tion usually is in the central third of the forearm. At the
junction, the muscle attaches to the dorsal surface of the
tendon, so that more of the tendon is visible on the volar
aspect. The myotendinous junction gives rise to four sepa-
rate tendons usually aligned parallel to each other, from
radial to ulnar, to extend distally to the index, long, ring,
and small fingers, respectively. This is in contrast to the
FDS tendons, which, at the level of the wrist, have a
“stacked” pattern, with the FDS tendons to the long and
ring fingers located palmar and central to the FDS tendons
of the index and small fingers, which are located dorsal and
radial (for the index) or dorsal and ulnar (for the small fin-
ger) (3,4,11) (see earlier, under Gross Anatomic Descrip-
tion: Flexor Digitorum Superficialis). The muscle belly to
the long, ring, and small fingers remain interconnected to
some extent from the forearm to the palm through areolar
tissue and tendinous slips. The muscle and tendon to the
index finger usually remain separate and distinct through-
out their course from the muscle belly to the palm. In
some, the FDP tendon to the small finger may be more
126 Systems Anatomy
independent, and resemble that of the index finger. The
tendons to the long and ring finger are the least indepen-
dent and more often are connected by areolar tissue. The
tendons then extend distally, deep to the tendons of the
FDS, to cross through the carpal tunnel. At the distal
extent of the carpal tunnel, the tendons diverge to cross the
palm in the direction of each digit. Just proximal to the
MCP joints, the FDP tendons enter the A1 pulley of the
fibroosseous tunnel. In the digits, at the level of the proxi-
mal phalanx, the FDS tendons split and the associated
FDP tendon passes through the split. Each tendon contin-
ues distally to insert on the base of each of the distal pha-
langes (3,4,11,357) (see Fig. 2.6A).
At the level of the distal margin of the carpal tunnel, the
lumbricals arise from the radial aspect of each FDP tendon.
As discussed earlier (see under Gross Anatomic Descrip-
tion: Flexor Digitorum Superficialis), the vascular supply to
the FDP and FDS tendons comes from several sources.
These include the longitudinal vessels (some of which may
originate in the muscle belly) that enter in the palm and
extend down intratendinous channels. There also are vessels
that enter at the level of the proximal synovial fold in the
palm to supply the tendons. In addition, there is the vincu-
lar supply, supplied by segmental branches from the paired
digital arteries that enter into the tendon sheaths. The most
distal vascular supply to the flexor tendons includes vessels
that enter the FDS and FDP tendons at their osseous inser-
tions (285–299).
The vinculum longum superficialis arises at the level of
the base of the proximal phalanx. Here, the digital arteries
give rise to branches on either side of the tendons that inter-
connect anterior to the phalanx, but deep (dorsal) to the
tendons. These branches form the vinculum longum super-
ficialis that connects to the superficialis at the floor of the
digital sheath. The vinculum longum superficialis supplies
the FDS, at the level of the proximal phalanx.
In the digital sheath, the segmental vascular supply to
the flexor tendons is by means of long and short vincular
connections. These include the vinculum brevis superfi-
cialis, the vinculum brevis profundus, the vinculum
longum superficialis, and the vinculum longum profundus.
The vincula often are variable in presence and configuration
(285–299). In addition to vascular sources, the tendons in
the synovial sheath receive nutrition through synovial fluid
diffusion.
The vinculum brevis superficialis and the vinculum
brevis profundus consist of small, triangular mesenteries
near the insertion of the FDS and FDP tendons, respec-
tively. The vinculum brevis superficialis arises from the
digital artery, at the level of the distal part of the proximal
phalanx. It supplies the FDS tendon near its insertion into
the middle phalanx. A portion of the vinculum brevis
superficialis continues anteriorly, at the level of the PIP
joint, toward the FDP to form the vinculum longum pro-
fundus (299).
Because the vincula enter the tendon on the dorsal sur-
face, the vascularity of the dorsal half of the tendon in the
digits is richer than that of the palmar half.
Architectural features of the FDP include the physio-
logic cross-sectional area of the muscle, the fiber bundle
length, muscle length, muscle mass, and pennation angle.
Skeletal muscle architectural studies by Lieber, Friden, and
colleagues provide the data for the FDP to each digit
(135–139,174) (see Table 2.1 and Fig. 2.4). The digital
extrinsic flexor and extensor muscles have similar architec-
tural features. The relative difference index values compare
the FDP with other upper extremity muscles, based on
architectural features. These values are listed in Appendix
2.3.
The FDP is innervated by both the median nerve
(through the anterior interosseous nerve to supply the belly
of the index and long fingers) and by the ulnar nerve (to
supply the bellies of the ring and small fingers). The anterior
interosseous nerve usually exits the median nerve trunk
proximal to the nerve trunk entering the interval between
the heads of the pronator teres. The anterior interosseous
nerve branch usually accompanies the main median nerve
trunk through the interval between the humeral and ulnar
heads of the pronator teres, then through the interval created
by the fibromuscular arch of the origins of the FDS. The
anterior interosseous nerve then divides into several motor
branches to supply the muscle portions of the FDP to the
index and long fingers. The nerve branches enter the muscle
bellies on the radial border in the middle third of the mus-
cle. A branch of the anterior interosseous nerve continues
distally along the anterior surface of the interosseous liga-
ment to reach and enter the proximal border of the prona-
tor quadratus. The ulnar nerve innervation of the FDP is
from a motor branch that arises approximately the level of
the elbow joint. The nerve branch enters the anterior surface
of the muscle in the region of the junction of the proximal
and middle thirds. This branch supplies the part of the mus-
cle that provides tendons to the ring and small fingers. Con-
siderable variation exists as to the innervation of the muscle
bellies of the FDP. In only approximately 50% of extremities
do the median nerve and ulnar nerve specifically innervate
the index and long, and the ring and small finger muscle bel-
lies, respectively (3,4,11,358,359).
Actions and Biomechanics: Flexor
Digitorum Profundus
The FDP functions mainly to flex the digits. Through its
insertion onto the distal phalanx, it exerts powerful flexion
on the distal phalanx at the distal interphalangeal (DIP)
joint. However, by passing across the PIP and MCP joints,
the FDP tendons assist the FDS to flex the PIP joints, and
the FDP assists both the FDS and the interossei and lum-
bricals to flex the MCP joints. The FDP also assists with
flexion of the wrist. The FDP provides the origins for the

lumbricals muscles. When the FDP contracts and moves
proximally, there is a dynamic action on the lumbricals.
Anomalies and Variations: Flexor
Digitorum Profundus
There commonly are accessory muscles or tendinous slips
from the FDP to the radius, to the FDS, FPL, the medial
epicondyle, or to the coronoid process (3,4,11,360–365).
Flexor indicis profundus or flexor digitorum profundus
indicis. There may be more than four muscle bellies of the
FDP, and the separation between the tendons can occur to
varying degrees. The separation to the index finger usually
is the greatest, but also is variable. If the FDP to the index
exists as a separate muscle and tendon, it has been referred
to as the flexor indicis profundus or flexor digitorum profun-
dus indicis (11).
An anomalous accessory FDP tendon may exist as a sep-
arate muscle–tendon unit lying ulnar to the main flexor
digitorum profundus indicis. It has been noted then to join
the main tendon at the level of the distal palmar crease
(363).
Other rare described anomalies of the FDP include an
anomalous muscle in association with a fibroma of a tendon
sheath causing triggering of the wrist (364), and a rare con-
genital abnormality of the FDP causing a flexion deformity
of the long and ring fingers (365).
Clinical Implications: Flexor Digitorum
Profundus
Flexor tendon rupture can occur in the carpal tunnel from
several causes, including chronic abrasion against a hook of
the hamate fracture or nonunion, attrition against the radial
side of the pisiform affected by osteoarthritis of the pisotri-
quetral joint (366), and in the patient with rheumatoid
arthritis.
Avulsion of the FDP most commonly involves the ring
finger. This is due to its relatively greater length during
grasp. During grip, the ring fingertip becomes 5 mm more
prominent than any other digit in 90% of subjects, and it
absorbs more force than any other finger during pull-away
testing (367).
The anterior interosseous nerve syndrome involves pare-
sis or palsy of the FDP to the index and long (and occa-
sionally the ring) fingers, as well as paresis of the FPL and
pronator quadratus. The syndrome often is associated with
trauma, tight-fitting casts, neuritis, or anatomic structures
that impinge on the anterior interosseous nerve, including
fascial bands, adhesions, and muscle impingement (i.e.,
fibrous bands of the pronator teres) (368–376).
In 1979, Linburg and Comstock described an anom-
alous tendon slip from the FPL to the FDP to the index fin-
ger (360). It appears that the anomaly is present in at least
one extremity of 25% to 31% of individuals, and in both
2 Muscle Anatomy 127
extremities in 6% to 14%. If present it can be demonstrated
when a patient attempts to independently flex the inter-
phalangeal joint of the thumb, and there is coexisting flex-
ion at the DIP joint of the index finger (360,361), called
Linburg’s sign. This anomaly may be associated with chronic
tenosynovitis or carpal tunnel symptoms.
Because the vincula enter the tendon on the dorsal sur-
face, the vascularity of the dorsal half of the tendon in the
digits is richer than in the palmar half. This has implica-
tions for placement of sutures in the repair of lacerated ten-
dons. Sutures placed in the palmar half of the tendon
should disrupt the intratendinous vascularity to a lesser
degree than those in the dorsal half. The vincular system
should be appreciated and protected as much as possible in
the exploration or repair of the flexor tendons.
Tendon excursion of the FDP relative to the tendon
sheath has been shown to be greatest in zone II during PIP
joint rotation. This suggests that PIP joint motion may be
most effective in reducing adhesions after tendon repair in
zone II (377).
After laceration of the FDP distal to the superficialis
insertion, tendon advancement of the proximal cut end of
the tendon to the insertion has been used as a means of
repair. Anatomic studies suggest that 1 cm is approximately
the maximum amount that the tendon can be safely
advanced, without causing problematic shortening (378).
FLEXOR POLLICIS LONGUS
Derivation and Terminology. Flexor is derived from the
Latin flexus, indicating “bent” (and flexor, which indicates
“that which bends,” or “bending”). Pollicis is from the Latin
pollex, indicating “thumb.” Longus is the Latin for “long.” It
is the longest flexor of the thumb (1,2).
Origin. From the anterior surface of the middle third of
the radius, the anterior interosseous ligament.
Insertion. To the base of the distal phalanx of the thumb.
Innervation. Median nerve through anterior interosseous
branch (C6, C7, C8) (3,4).
Vascular Supply. From the radial artery through direct
muscular branches, anterior interosseous artery, princeps
pollicis artery, and palmar carpal arch. The tendon receives
vascularity, in part, through a vincular system, originating
from the digital arteries (3,4,11,379–384).
Principal Action. Flexion of the thumb interphalangeal
joint and MCP.
Gross Anatomic Description: Flexor
Pollicis Longus
The FPL, with the FDP, is one of the deep flexors of the
forearm and lies in the deep volar muscle compartment of
the forearm (Appendix 2.2). The FPL is located radial to
the FDP, roughly in the same deep plane. Like the FDP, it
128 Systems Anatomy
is a relatively large and flat muscle. It has a large area of
origin, arising from an obliquely oriented groove on the
anterior surface of the radius that extends from just below
the tuberosity to the proximal attachment of the pronator
quadratus (see Fig. 2.3A). The origin often extends as far
proximal as to within approximately 5 cm of the wrist
joint. The muscle belly thus attaches and covers the mid-
dle third of the anterior surface of the radial diaphysis. It
also has attachments from the adjacent interosseous liga-
ment, and there often is an attachment by a variable slip
from either the lateral or medial border of the coronoid
process. There also can be attachments from the medial
epicondyle of the humerus (385). The muscle fibers
extend distally and obliquely to attach in a penniform
manner on the tendon at the myotendinous junction. The
muscle has a relatively long and variable myotendinous
junction. At this junction, there usually is more tendon
that extends along the ulnar border of the muscle, on its
anterior surface. The muscle blends with its broad, flat
tendon, usually in the distal third of the forearm. The ten-
don extends distally, usually in the plane of the tendons of
the FDP. The adjacent anterior interosseous nerve also
continues distally, between the FPL and the FDP. The
FPL then enters the carpal tunnel. Some muscle fibers
may accompany the tendon to the level of the proximal
edge of the flexor retinaculum. As the tendon passes
through the carpal tunnel, it is located radial to the ten-
dons of the FDP and median nerve. It passes deep to the
superficial head of the flexor pollicis brevis (FPB). After
passing through the carpal canal, the tendon emerges deep
to the superficial palmar arch, between the opponens pol-
licis and the oblique head of the adductor pollicis. It con-
tinues between the thumb sesamoid bones, entering its
own synovial sheath. The tendon enters the fibroosseous
tunnel of the thumb through the A1 pulley at the level of
the MCP joint (386). The tendon continues distally to
insert onto the palmar surface of the base of the distal pha-
lanx of the thumb (see Fig. 2.6A).
Architectural features of the FPL include the physiologic
cross-sectional area of the muscle, the fiber bundle length,
muscle length, muscle mass, and pennation angle (angle of
the muscle fibers from the line representing the longitudi-
nal vector of its tendon). Skeletal muscle architectural stud-
ies by Lieber, Friden, and colleagues provide the data for the
FPL (135–139,174) (see Table 2.1 and Fig. 2.4). The digi-
tal extrinsic flexor and extensor muscles have similar archi-
tectural features. The relative difference index values com-
pare the FPL with other upper extremity muscles, based on
architectural features. These values are listed in Appendix
2.3 (15).
The FPL is innervated by the anterior interosseous nerve
from the median nerve (C6, C7, C8) (387–395). There
usually are at least two motor branches that enter the prox-
imal half of the muscle at its ulnar aspect.
Actions and Biomechanics: Flexor Pollicis
Longus
The FPL is the only muscle that flexes the thumb interpha-
langeal joint (396,397). It assists the thenar muscles with
flexion of the thumb at the MCP joint. In addition, the
FPL assists with flexion and adduction at the carpometa-
carpal joint.
If a load is applied to the FPL, the moment arm of the
tendon in the carpal tunnel can change as the tendon shifts
its position in the carpal tunnel (398).
Anomalies and Variations: Flexor Pollicis
Longus
Several anomalies of the FPL have been described
(399–427). The FPL can have interconnections of tendon
slips or muscle extensions with the FDS, the FDP, or the
pronator teres (360,361,399–401). The FPL actually may
coalesce and blend with the muscle belly of the FDP, FDS,
or pronator teres (402). The origin may extend proximally
to the medial epicondyle of the humerus. This anomalous
belly is the epitrochlear bundle of the FPL (11).
The best documented accessory head of the FPL is
Gantzer’s muscle. It has been noted in up to 52% to 66%
of limbs and is supplied by the anterior interosseous nerve
(403,404). It usually arises from either the medial humeral
epicondyle (in 85%) or from a dual origin from the epi-
condyle and coronoid process (15%). The muscle usually
inserts into the ulnar aspect of the FPL and its tendon.
Gantzer’s muscle usually is posterior to the median nerve
and either anterior or posterior to the anterior interosseous
nerves. Anatomic variations of Gantzer’s muscle have con-
tributed to median nerve compression in the forearm
(403–407).
Most commonly, there can be a tendon slip that con-
nects the tendons of the FPL to the FDP. Attempts at inde-
pendent flexion of the thumb interphalangeal produce con-
current flexion of the distal phalanx of the index finger.
This is referred to as Linburg’s sign, or the Linburg syndrome
(360,361) and may be associated with tendonitis or carpal
tunnel syndrome.
The original portion of the FPL that arises from the
interosseous ligament may be absent. The entire FPL may be
absent (11,408–417). Congenital absence of the FPL often
is associated with a hypoplastic thumb (408,416), and has
been noted bilaterally (413). The FPL may exist as a double
tendon or malpositioned tendon, or may have an accessory
tendon accompanying the normal tendon (420,421). This
has been associated with triggering of the thumb (422).
Various anomalous insertions of the FPL have been
noted and usually result in poor flexor power of the distal
phalanx (423–425). Of clinical significance, the FPL may
insert onto the proximal as well as the distal phalanx of the

thumb. This may appear to be congenital absence of the
FPL because of the lack of flexion on the distal phalanx
(423). This insertion can be bilateral. The FPL also may
insert into the soft tissue of the carpal tunnel, with the
muscle power diverted to flex the wrist. Inadequate flex-
ion power of the thumb will then be present (424). The
FPL may be conjoined to the extensor pollicis longus
(EPL) (425–427).
Clinical Implications: Flexor Pollicis
Longus
Neuropathy of the anterior interosseous nerve (anterior
interosseous nerve syndrome) results in paresis or palsy of
the FPL and the FDP to the index and long (and occasion-
ally the ring) fingers, as well as paresis of the pronator quad-
ratus. The syndrome may be caused by trauma, tight-fitting
casts, neuritis, or anatomic structures that impinge on the
anterior interosseous nerve, including fascial bands, adhe-
sions, or normal or anomalous muscle impingement (i.e.,
fibrous bands of the pronator teres, Gantzer’s muscle)
(368–377).
The anomalous tendon slip from the FPL to the FDP to
the index finger appears to be present in at least one extrem-
ity of 25% to 31% of individuals, and in both extremities
in 6% to 14% (360). It can be demonstrated when a patient
attempts independently to flex the interphalangeal joint of
the thumb, and there is coexisting flexion at the DIP joint
of the index finger (360,361), (Linburg’s sign). This anom-
aly may be associated with chronic tenosynovitis or carpal
tunnel symptoms.
PRONATOR QUADRATUS
Derivation and Terminology. Pronator is derived from
the Latin pronus, meaning “inclined forward” (the Latin
pronatio refers to the act of assuming the prone position or
the state of being prone). Quadratus is a Latin term indicat-
ing “squared” or “four sided” (based on the muscle’s shape)
(1,2).
Origin. There are two heads. The superficial head and
deep head originate from the anterior distal ulnar diaphysis.
Insertion. The superficial head inserts onto the anterior
distal radial diaphysis and anterior metaphysis. The deep
head inserts proximal to the ulnar notch of the distal radius.
Innervation. Anterior interosseous nerve of the median
nerve.
Vascular Supply. The radial artery, anterior interosseous
artery, anterior descending branch, recurrent branches of
the palmar carpal arch (3,4,11,13).
Principal Action. Pronation of the forearm. It usually
works with the pronator teres. The pronator quadratus may
be the principal pronator of the forearm; the pronator teres
2 Muscle Anatomy 129
appears to function more during rapid or forceful prona-
tion.
Gross Anatomic Description: Pronator
Quadratus
The pronator quadratus is a flat, quadrangular muscle
that covers the distal 25% of the palmar surface of the
radius and ulna. In textbooks, it usually is grouped with
or discussed under the section on deep flexors of the fore-
arm. The muscle more accurately belongs in its own sec-
tion. It is now considered to occupy a separate compart-
ment of the forearms, and should be addressed as such
with compartment syndromes (273,274,428–432)
(Appendix 2.2).
The origin of the pronator quadratus is along a relatively
narrow, oblique ridge on the anterior surface of the distal
ulnar diaphysis (see Fig. 2.3A). Some muscle fibers also
originate from the medial surface of the distal ulna and
from a thick aponeurosis that attaches to the medial third
of the muscle. The muscle fibers pass from medial to lateral,
and slightly distally, to reach the radius. The muscle fibers
are roughly transverse to the axis of the forearm. The mus-
cle inserts onto the palmar 20% of the distal radius, cover-
ing a portion of the distal diaphysis and a portion of the
metaphysis (see Fig. 2.3A). The deep (dorsal) fibers insert
into a triangular area proximal to the ulnar notch of the
radius. Both heads also have fibers that insert into the cap-
sule of the distal radioulnar joint (433).
The pronator teres appears to have two distinct heads: a
superficial oblique head and a deep head. The superficial
head originates from the ulna and passes transversely to an
insertion into the radius. It averages 5.1 cm in length, 4.5
cm in width, and 0.2 cm in thickness, and has a mean cross-
sectional area of 0.95 cm2. The superficial head has a con-
tractile volume of 2.6 cm3. The superficial head entirely
covers the deep head, whose muscle fibers are oblique from
their ulnar origin to the distal volar surface of the radius.
The deep head runs obliquely from a more proximal origin
on the ulna to a distal insertion on the radius. It has an aver-
age length of 4.0 cm, average width of 3.2 cm, and a thick-
ness of 0.4 cm. Its mean cross-sectional area is 1.64 cm2 and
its contractile volume is 2.5 cm3 (434). A group of fibers
occasionally has been noted deep to both heads, running at
right angles to them and paralleling the direction of the
fibers of the interosseous membrane (434).
The fibers of both heads are somewhat oblique to the
axis of rotation. From this orientation, both heads, by con-
tracting, develop a rotatory and a stabilizing force. The
superficial head is thought to provide the major force for
rotation in supination and pronation. The deep head func-
tions more to provide maintenance of transverse forces at
the distal radioulnar joint. The deep head coapts the joint
surfaces and stabilizes the joint (431,433,434).
130 Systems Anatomy
The pronator quadratus, located in the distal palmar
forearm, has been shown to occupy a functionally separate
fascial compartment (428–430,432). The muscle is
enclosed anteriorly by a well defined fascial sheath that
measures 0.4 to 0.5 mm in thickness. This sheath, along
with the relatively rigid posterior boundaries of the
interosseous ligament and distal radius and ulna, forms a
distinct fascial space. Experimentally injected dye into this
compartment does not communicate with the other fore-
arm compartments (430,432). Clinical correlations of
compartment syndrome involving the pronator quadratus
support the concept of the muscle occupying its own com-
partment (428–430,434).
The architectural features of the pronator quadratus,
including the fiber length and physiologic cross-sectional
area, are listed in Table 2.1 and depicted in Fig. 2.4.
The pronator quadratus is innervated by the anterior
interosseous nerve and receives its blood supply from the
anterior interosseous artery. The anterior interosseous nerve
extends distally along the anterior surface of the
interosseous ligament, passes dorsal (deep) to the middle of
the proximal margin of the muscle, and gives off several
branches to the muscle in its substance. The nerve fibers are
derived from C8 (mostly) and C7 (3,4,11,13).
Actions and Biomechanics: Pronator
Quadratus
The pronator quadratus appears to be the principal prona-
tor of the forearm. It usually works with the pronator teres.
The pronator teres appears to function more during rapid
or forceful pronation. The deeper fibers of the pronator sta-
bilize the distal ulna and radius by preventing or opposing
separation of their distal ends, especially during loading of
the carpus (3,4,434).
Anomalies and Variations: Pronator
Quadratus
The deep and superficial heads may exist as separate muscle
bellies (completely separated) (11). The pronator quadratus
may be absent (11). An anomalous head may extend prox-
imally, either to the radial shaft, pronator quadratus, or to
the FCR brevis (11). An anomalous head may extend distal
to the carpus, either to the radiocarpal or ulnocarpal cap-
sule, to the base of the thenar muscles, or to the adductor
pollicis (11).
Clinical Implications: Pronator Quadratus
The pronator quadratus, although situated in the volar fore-
arm, is considered to occupy a separate compartment.
Anatomic dye injection studies by Sotereanos and col-
leagues have demonstrated a distinct fascial space without
communications to the deep or superficial volar compart-
ment of the forearm (273,274,430–433). Decompression
of the volar compartment of the forearm without specifi-
cally addressing the pronator quadratus may not consis-
tently decompress the muscle (429,430).
The pronator quadratus is a potential pedicle flap, either
with or without a portion of attached, vascularized bone; it
also can serve as a free muscle flap (435–442).
From the standpoint of the use of the pronator as a mus-
cle–bone flap, the vascular anatomy has been studied in
detail (442). The anterior interosseous artery divides into a
muscular branch and a dorsal branch 1 to 3.5 cm from the
proximal margin of the pronator quadratus. There is a rich
periosteal plexus to which the anterior interosseous artery
also contributes. Both the anterior interosseous artery and
the dorsal branch can perfuse the muscle and the portion of
radial cortex used for the transfer. The dorsal branch, which
provides good perfusion of the distal radius, allows the
pedicle muscle flap to be mobilized a farther distance if the
dorsal branch is left intact (432). A muscle–bone pedicle
graft with a portion of the anteromedial cortex of the distal
radius that is mobilized with an intact anterior interosseous
artery can be mobilized less than 2 cm. After ligating and
dividing the anterior interosseous artery, blood supply to
the distal radius bone flap relies on flow through the dorsal
branch, and a bone flap can then be mobilized distally up
to 4 to 6 cm (442).
The pronator quadratus has been used successfully to
receive a relocated sensory nerve of the palm after resection
of a painful end-neuroma (443).
To test pronation strength of the pronator quadratus, the
elbow can be flexed past 90 degrees. Pronation strength is
then tested. This flexed elbow position helps isolate the
pronator strength of the pronator quadratus by eliminating
the contribution of the pronator teres (which is lax when
the elbow is passively flexed).
After stroke or brain injury, the forearm often is held in
spastic pronation by both the pronator teres and the prona-
tor quadratus. For correction, operative recession of the
pronator quadratus (along with the pronator teres) can be
performed by releasing the muscle off the insertion on the
distal anterior radius. This usually is performed in combi-
nation with digital and wrist flexor lengthening.
EXTENSOR CARPI RADIALIS LONGUS
Derivation and Terminology. The ECRL derives its
name from several sources. Extensor is from the Greek and
Latin ex, which indicates out of, and the Latin tendere, “to
stretch,” thus extension indicates a motion to stretch out,
and extensor usually is applied to a force or muscle that is
involved in the “stretching out or straightening out” of a
joint. Carpi is derived from the Latin carpalis or the Greek

karpos, both of which indicate “wrist” (the carpus). Radialis
is from the Latin radii, which means “spoke” (used to
describe the radius of the forearm). Longus is the Latin for
“long.” Therefore, extensor carpi radialis longus indicates a
long radial wrist extensor (1,2).
Origin. From the lateral epicondylar ridge, just proximal
to the lateral epicondyle. Additional areas of origin include
the lateral intermuscular septum, and the anterior fascia of
the muscles that arise from the common extensor origin at
the lateral epicondyle.
Insertion. To the dorsal base of the index metacarpal.
Innervation. Radial nerve (C6, C7).
Vascular Supply. The radial recurrent artery, interosseous
recurrent artery, posterior interosseous artery, and radial
collateral continuation of the profunda brachii artery
(3,4,11,13).
Principal Action. Extension and radial deviation of the
wrist. Assistance with weak flexion of the elbow. The ECRL
also helps stabilize the wrist (with cocontractions of the
wrist flexors) during powerful grasp functions.
Gross Anatomic Description: Extensor
Carpi Radialis Longus
The ECRL arises from the lateral epicondylar ridge, just
proximal to the lateral epicondyle (see Fig. 2.2A). It com-
prises part of the mobile wad muscle compartment, along
with the ECRB and the brachioradialis (Appendix 2.2)
(12). Its origin includes the distal third of the lateral
supracondylar ridge of the humerus, and the muscle is
partly overlapped by the brachioradialis. The ECRL also
has attachments of origin that include the common exten-
sor origin of the lateral epicondyle, the lateral intermus-
cular septum, and the anterior fascia of the ECRB and
EDC (both of which arise from the common extensor ori-
gin at the lateral epicondyle). The superficial surface of
the muscle at first faces radially in the proximal portion
near its origin. The muscle then twists slightly so that the
superficial surface faces dorsally. The muscle belly extends
approximately one-third to one-half the way down the
forearm to reach the myotendinous junction, usually
noted at the junction of the proximal third and distal two-
thirds. In this area, the tendinous portion first appears on
the lateral and deep surface of the muscle. It then forms a
stout, flat, thick tendon that usually is devoid of muscle
tissue the entire length. The tendon of the ECRL travels
along the lateral surface of the radius, located radial and
adjacent to the ECRB. The ECRL and ECRB pass deep to
the APL and EPB in the distal third of the forearm to
reach its own tunnel as a part of the extensor retinaculum.
The tendon lies in a groove on the dorsal surface of the
radius just proximal to the styloid process. The ECRL,
along with the ECRB, forms the second dorsal compart-
ment. [Editor’s note: The dorsal compartments of the wrist
2 Muscle Anatomy 131
are as follows: the APL and EPB comprise the first dorsal
compartment; the ECRL and ECRB form the second; the
EPL forms the third; the EDC and extensor indicis pro-
prius (EIP) form the fourth; the extensor digiti minimi
(EDM, also called extensor digiti quinti [EDQ]) forms
the fifth; and the ECU forms the sixth (6).] The tendon
of the ECRL continues distally deep to the tendon of the
EPL as the tendons exit the extensor retinaculum. The
tendon of the ECRL then inserts onto the base of the dor-
sal surface of the index metacarpal (see Fig. 2.6B). The
tendon is not centralized on the metacarpal, but rather
attaches off center on the radial aspect of the dorsal sur-
face of the metacarpal base. The insertion may have slips
that extend to the metacarpals of the thumb, index, or
long fingers, as well as possible slips to the intermetacarpal
ligaments (3,4,11,13).
Architectural features of the ECRL include the physio-
logic cross-sectional area of the muscle and the fiber bundle
length. Skeletal muscle architectural studies by Lieber and
colleagues provide the data for the ECRL (135–139,174)
(see Table 2.2 and Fig. 2.4). The relative difference index
values compare the ECRL with other upper extremity mus-
cles, based on architectural features. These values are listed
in Appendix 2.3 (15).
The ECRL is innervated by the radial nerve. The branch
leaves the radial nerve trunk proximal to the elbow joint.
There may be two nerve branches to the muscle. The motor
branches enter the muscle on the deep surface of the prox-
imal third of the muscle belly. The nerve fibers are derived
from C6 (mostly) and C7.
Actions and Biomechanics: Extensor Carpi
Radialis Longus
The ECRL functions mainly to provide extension of the
wrist. It works in conjunction with the ECRB and ECU.
The ECRL, by its insertion onto the radial aspect of the
hand, also provides radial deviation of the wrist. In addi-
tion, the ECRL gives assistance with weak flexion of the
elbow because the muscle’s origin is proximal to the elbow.
The ECRL (along with the ECRB and ECU) also helps sta-
bilize the wrist (with cocontractions of the wrist flexors)
during powerful grasp functions or heavy lifting (3,4,11,
13).
Anomalies and Variations: Extensor Carpi
Radialis Longus
The ECRL may coalesce with the ECRB, or have several
variations where muscle fibers are interconnected between
the two muscles. Muscle interconnections also may exist
between the APL or to the interosseous muscles (11,444).
The ECRL may have a split tendon or multiple tendons
that insert into the index metacarpal. There may be an anom-
 132 Systems Anatomy

alous insertion into the long finger metacarpal, or even to the
ring finger metacarpal or to the adjacent carpal bones.
The extensor carpi radialis intermedius is an anomalous
muscle situated between the ECRL and ECRB (Fig. 2.8). It
is a rare muscle that may arise independently from either
the lateral epicondyle of the humerus or more proximally
on the distal humeral diaphysis. It inserts into the index or
long finger metacarpal. The muscle also may present as a
muscle slip of variable size that arises from either the ECRL
or ECRB and inserts into the index or long finger
metacarpal, or both (445–447).
The extensor carpi radialis accessorius is an anomalous
muscle that arises from the humerus adjacent to the origin
of the ECRL. The muscle lies deep to the ECRL and
extends the length of the forearm. It usually inserts onto
either the base of the thumb metacarpal, the proximal pha-
lanx of the thumb, or into the tendon of the APB. It also
may originate as a muscle slip from the tendon of the ECRL
to insert as noted previously (11,446).
Clinical Implications: Extensor Carpi
Radialis Longus
Injury to the posterior interosseous nerve, including com-
pression at the arcade of Frohse (at the proximal edge of the
supinator muscle) does not effect the ECRL because the
motor nerve of the ECRL leaves the radial nerve trunk
proper, usually proximal to the elbow (and therefore proxi-

A B
FIGURE 2.8. The anomalous muscle, the extensor carpi radialis intermedius. It is situated
between the extensor carpi radialis longus and extensor carpi radialis brevis. It originates from
the lateral epicondylar region (A), or more proximally, on the lateral aspect of the distal humeral
diaphysis (B). The muscle inserts into the base of either the index or long finger metacarpal, or
both.

mal to the branching of the posterior interosseous nerve).
Complete laceration or dense neuropathy of the posterior
interosseous nerve usually presents clinically with loss of
digital and thumb extension, and weak wrist extension.
Residual wrist extension, produced by the intact ECRL, is
possible, but the wrist also deviates radially during exten-
sion because of the ECRL insertion into the index
metacarpal on the radial side of the hand. ECRB function
may be preserved because its motor branch usually exits the
radial nerve trunk or off of the posterior interosseous nerve
proximal to the arcade of Frohse (448–450).
Intersection syndrome is a condition of pain and
swelling in the region of the muscle bellies of the APL and
EPB. As noted by Wolfe, this area lies approximately 4 cm
proximal to the wrist joint, and may show increased
swelling of a normally prominent area (451). In severe
cases, redness and crepitus have been noted. The syndrome
originally was thought to be due to friction and inflamma-
tion between the APL and EPB muscle bellies and the mus-
cle bellies of the ECRL and ECRB (451–455). More
recently, Grundberg and Reagan have demonstrated that
the basic pathologic process appears to be tenosynovitis of
the ECRL and ECRB (455).
EXTENSOR CARPI RADIALIS BREVIS
Derivation and Terminology. The ECRB derives its
name from several sources. Extensor is from the Greek and
Latin ex, which indicates “out of,” and from the Latin ten-
dere, “to stretch”; thus, extension indicates a motion to
stretch out, and extensor usually is applied to a force or mus-
cle that is involved in the “stretching out or straightening
out” of a joint. Carpi is derived from the Latin carpalis and
the Greek karpos, both of which indicate “wrist” (the car-
pus). Radialis is from the Latin radii, which means “spoke”
(used to describe the radius of the forearm). Brevis is the
Latin for “short.” Therefore, extensor carpi radialis brevis
indicates a short radial wrist extensor (1,2).
Origin. From the lateral epicondyle of the humerus
through the common extensor origin (additional attach-
ments to the radial collateral ligament of the elbow, sur-
rounding intermuscular septum; see later).
Insertion. To the dorsal base of the long finger
metacarpal.
Innervation. Posterior interosseous nerve or directly
from the radial nerve (C7, C8).
Vascular Supply. The radial recurrent artery, interosseous
recurrent artery, posterior interosseous artery, radial collat-
eral continuation of the profunda brachii artery (3,4,11,
13).
Principal Action. Extension of the wrist. Assistance with
weak flexion of the elbow. The ECRB, along with the
ECRL and ECU, also helps stabilize the wrist (with cocon-
2 Muscle Anatomy 133
tractions of the wrist flexors) during powerful grasp func-
tions (3,4,11).
Gross Anatomic Description: Extensor
Carpi Radialis Brevis
The ECRB originates from the lateral epicondyle of the
humerus, as part of the common extensor origin (see Fig.
2.2A). It comprises part of the mobile wad muscle com-
partment of the forearm (12) (Appendix 2.2). The muscle
origin also includes attachments to the intermuscular sep-
tum, to the radial collateral ligament of the elbow joint,
and to a strong aponeurosis that covers the surface of the
muscle. The muscle is shorter than the ECRL and is in
part covered by it. The muscle belly, lying adjacent to that
of the ECRL, extends to the mid-portion of the forearm.
At the myotendinous junction, the tendinous portion is
seen first at the dorsolateral surface of the muscle. The
myotendinous junction also is in close proximity to that
of the ECRL. The tendon of the ECRL is a strong, flat
tendon, similar in size to that of the ECRL, and travels
with it to the wrist. The ECRB, along with the ECRL,
passes deep to the APL and EPB, and then enters the sec-
ond dorsal extensor compartment of the extensor retinac-
ulum. [Editor’s note: The dorsal compartments of the wrist
are as follows: the APL and EPB comprise the first dorsal
compartment; the ECRL and ECRB form the second; the
EPL forms the third; the EDC and EIP form the fourth;
the EDM forms the fifth; and the ECU forms the sixth
(6).] As the tendon extends through the second compart-
ment, it lies in a shallow groove on the dorsal surface of
the radius, medial to the tendon of the ECRL, and sepa-
rated from it by a low ridge. The tendon of the ECRB
continues distally to reach the base of the long finger
metacarpal (see Fig. 2.6B). Similar to the ECRL, the ten-
don does not insert centrally on the metacarpal, but rather
attaches off center on the radial aspect of the dorsal sur-
face of the metacarpal base. The insertion may have slips
that extend to the base of the adjacent index metacarpal
(3,4,11,13).
Architectural features of the ECRB include the physi-
ologic cross-sectional area of the muscle and the fiber
bundle length. Skeletal muscle architectural studies by
Lieber, Friden, and colleagues provide the data for the
ECRB (135–139,174) (see Table 2.2 and Fig. 2.4). The
relative difference index values compare the ECRB with
other upper extremity muscles, based on architectural
features. These values are listed in Appendix 2.3 (15,
456–458).
The ECRB is innervated by either the posterior
interosseous nerve or by branches directly from the radial
nerve. The muscle may receive several motor branches, sev-
eral of which enter the muscle at the medial margin of the
central third. The nerve fibers usually are derived from C6
(mostly), C7, and occasionally C5 (3,4,11,13).
134 Systems Anatomy
Actions and Biomechanics: Extensor Carpi
Radialis Brevis
The ECRB functions mainly to provide extension of the
wrist. It works in conjunction with the ECRL and ECU. It
may provide some radial deviation of the wrist, working
with the ECRL. In addition, the ECRB gives assistance
with weak flexion of the elbow because the muscle’s origin
is proximal to the elbow. The ECRB (along with the ECRL
and ECU) also helps stabilize the wrist (with cocontractions
of the wrist flexors) during powerful grasp functions or
heavy lifting (3,4,11,13,68).
Anomalies and Variations: Extensor Carpi
Radialis Brevis
The ECRB may coalesce with the ECRL, or have several
variations where muscle fibers are interconnected between
the two muscles (11).
The ECRB may have a split tendon or multiple tendons
that insert into the long finger metacarpal. There may be an
anomalous insertion into the adjacent metacarpal bases, or
to the adjacent carpal bones (11).
The extensor carpi radialis intermedius is an anomalous
muscle situated between the ECRL and ECRB (see Fig.
2.8). It is a rare muscle that may arise independently from
the lateral epicondyle of the humerus, and inserts into the
index or long finger metacarpal. The muscle also may pre-
sent as a muscle slip of variable size that arises from either
the ECRL or ECRB and inserts into the index or long fin-
ger metacarpal, or both (445).
The FCR brevis muscle is a rare anomalous muscle asso-
ciated with the ECRB. The FCR brevis originates from the
anterior surface of the radius and forms a tendon at the
radiocarpal joint. The muscle is innervated by the anterior
interosseous nerve (181). It enters the carpal tunnel and the
tendon extends between the bases of the index and long fin-
ger metacarpals to interconnect with the tendon of the
ECRB. The ECRB, in addition, splits into two tendons,
one that inserts normally into the radial part of the base of
the long finger metacarpal, and the other connected to the
anomalous FCR brevis. It has been postulated that this
anomaly causes restricted wrist flexion or extension (11).
Clinical Implications: Extensor Carpi
Radialis Brevis
Because of the central location of its insertion on the wrist
(between the ECRL and ECU), the ECRB often is used as
a recipient muscle for transfers to restore wrist extension
after nerve or spinal injury.
In lateral epicondylitis (tennis elbow), the ECRB is usu-
ally implicated as the principal muscle affected. Several
methods for operative management have been described,
including muscle release, lengthening or debridement of its
tendinous origin (459–463), or lengthening of the muscle
at the musculotendinous junction (462,463). Friden and
Lieber have studied the physiologic consequences of surgi-
cal lengthening of the ECRB at the tendon junction. The
authors found that the ECRB develops near-maximal iso-
metric force at full wrist extension. This decreases to 20%
maximum at full wrist flexion. Operative lengthening of the
tendon by 9.1 mm results in a mean 10% passive shorten-
ing of the fibers, and ECRB sarcomere shortening of 0.3
µm. This 0.3-µm sarcomere shortening, in turn, was pre-
dicted to have two primary biomechanical effects: (a) a
25% decrease in muscle passive tension that could lead to
reduced insertional tension and decrease pain; and (b) a
25% increase in active muscle force, which is in opposition
to the notion that tendon lengthening necessarily results in
muscle weakness (457,458).
Intersection syndrome is a condition of pain and
swelling in the region of the muscle bellies of the APL and
EPB. As noted by Wolfe, this area lies approximately 4 cm
proximal to the wrist joint, and may show increased
swelling of a normally prominent area (451). In severe
cases, redness and crepitus have been noted. The syndrome
originally was thought to be due to friction and inflamma-
tion between the APL and EPB muscle bellies and the mus-
cle bellies of the ECRL and ECRB (451–454). More
recently, Grundberg and Reagan have demonstrated that
the basic pathologic process appears to be tenosynovitis of
the ECRL and ECRB (455).
EXTENSOR DIGITORUM COMMUNIS
Derivation and Terminology. Extensor is from the Greek
and Latin ex, which indicates “out of,” and from the Latin
tendere, “to stretch”; thus, extension indicates a motion to
stretch out, and extensor usually is applied to a force or mus-
cle that is involved in the “stretching out or straightening
out” of a joint. Digitorum is from the Latin digitus or digi-
torum, indicating the digits. Communis is derived from the
Latin communis, meaning “common,” and is used to indi-
cate a structure serving or involving several branches or sec-
tions (1,2).
Origin. From the lateral epicondyle as part of the com-
mon extensor origin.
Insertion. To the base of the phalanges of the index,
long, ring, and small fingers.
Innervation. The posterior interosseous nerve, from the
radial nerve (C7, C8).
Vascular Supply. Posterior interosseous artery (which is a
branch of the common interosseous artery); interosseous
recurrent artery and the surrounding anastomoses; the dis-
tal continuation of the anterior interosseous artery after it
passes through the interosseous ligament to reach the dorsal
aspect of the forearm; the dorsal carpal arch; dorsal
metacarpal, digital, and perforating arteries (3,4,11,13).

Principal Action. Extension of the digits, primarily at the
MCP joints. The EDC also assists with extension of the PIP
and DIP joints, working with the interossei and lumbricals.
The tendons can assist with wrist extension.
Gross Anatomic Description: Extensor
Digitorum Communis
The EDC, with its associated extensor mechanism, junc-
turae, and anatomic variability, is a complex structure and
the subject of many investigations (464–498). It lies in the
dorsal muscle compartment of the forearm (Appendix 2.2).
It arises from the common extensor origin at the lateral epi-
condyle of the humerus (see Fig. 2.2A). The muscle also has
attachments that arise from the adjacent intermuscular
septa and from the fascia of the neighboring forearm mus-
cles (3,4,11,13). It is a relatively large muscle, and its mus-
cle belly is close to the muscle of the EDM. At the junction
of the proximal two-thirds and the distal one-third of the
forearm, the myotendinous junction arises and four sepa-
rate tendons are formed. The tendons may be partially
attached in the forearm, but more distally, at the level of the
extensor retinaculum, four discrete tendons are present.
The tendons pass deep to the extensor retinaculum in a tun-
nel with the EIP. The tendons of the EDC and EIP form
the fourth dorsal compartment. [Editor’s note: The dorsal
compartments of the wrist are as follows: the APL and EPB
comprise the first dorsal compartment; the ECRL and
ECRB form the second; the EPL forms the third; the EDC
and EIP form the fourth; the EDM forms the fifth, and the
ECU forms the sixth (6).] The tunnel also provides a syn-
ovial sheath. The tendons exit the retinaculum and diverge
on the dorsum of the hand, one or more tendon of the
EDC to each digit. The tendon of the EIP extends to the
index finger, along the ulnar margin of the EDC to the
index. Juncturae tendinum interconnect the tendons, with
fewer and thinner juncturae located on the radial aspect of
the hand. The ulnar tendons tend to have more, and thicker
juncturae (discussed later) (492–498). The tendons then
continue into the digits to form the extensor mechanism of
each digit. The EDC tendon, through the extensor mecha-
nism, inserts into the base of each distal phalanx (see Fig.
2.6B), the base of each middle phalanx (through the central
slip), and, to varying degrees, into the bases of the proximal
phalanges. Substantial tendon variability and multiplicity
exits with the extensor tendons (Table 2.3).
The extensor mechanism is complex, and is referred to as
the extensor aponeurosis, dorsal aponeurosis, or extensor expan-
sion (Fig. 2.9). Each of the four digits has a similar extensor
mechanism, and it intimately involves the intrinsic muscles
of the hand as well. Smith and von Schroeder and Botte
have described the mechanism in detail (484,494). Each
extrinsic extensor tendon enters the dorsal aponeurosis at
the level of the MCP joint. The tendon is joined by the
sagittal bands from the medial and lateral aspects. The
2 Muscle Anatomy 135
transverse lamina of the sagittal bands arise from the palmar
aspect of the MCP joint, attaching to the volar plate, to
intermetacarpal ligaments at the neck of the metacarpals,
and to a portion of the fibroosseous tunnel. The sagittal
bands extend over the medial and lateral aspects of the
MCP joint to envelop the EDC (and EIP) tendons. The
sagittal bands help stabilize and centralize the extrinsic
extensor tendons. (Injury to the sagittal bands may result in
extensor tendon subluxation.) The tendon continues dis-
tally, and in the fibrous expansion, the tendon divides into
a central slip and two lateral slips. The central slip inserts
into the base of the middle phalanx and provides extension
of the middle phalanx partially through the central slip. The
intrinsic tendons from the lumbricals and interosseous
muscles join the extensor mechanism at the level of the
proximal and mid-portion of the proximal phalanx. A por-
tion of the lateral band extends dorsally to join the central
slip. It is through this portion of the extensor tendon that
the intrinsic muscles contribute to PIP joint extension. A
portion of the lateral bands also continues distally to join
the terminal tendon, to insert onto the base of the distal
phalanx. The lateral slips join the tendons of the intrinsic
muscles to form the conjoined lateral bands, which con-
tinue distally to form the terminal tendon. The lumbricals
to the index and long fingers arise from the radial sides of
the associated profundus tendons (467,468). The lumbri-
cals to the ring and small finger arise from the adjacent sides
of the profundus tendons to the long, ring, and small fin-
gers. Variation of the lumbricals is common, and similar to
the extrinsic extensor tendons there is more variability on
the ulnar side of the hand. The lumbricals and interosseous
muscles are discussed in greater detail under their respective
muscle sections (464,465).
As mentioned previously, the extensor tendons are inter-
connected on the dorsum of the hand by the juncturae
tendinum and intertendinous fascia. These structures have
been studied in detail and classified by Wehbe and von
Schroeder et al. (489,493). The juncturae tendinum consist
of narrow connective tissue bands or slips that extend
between the EDC tendons as well as to the EDM. Very
rarely does the EIP have a connecting junctura (493). The
function of the junctura remains not entirely understood.
The juncturae may assist with spacing of the EDC tendons
or with force redistribution (486,487), or may help with
coordination of extension or stabilization of the MCP joints
(488). The junctura prevent independent extension of the
digits and are clinically important because they may bridge
and therefore mask tendon lacerations. Juncturae also may
cause snapping by subluxating across the metacarpal head.
The juncturae also may aid in the surgical identification of
the tendons of the hand and has been used in repair of the
dorsal aponeurosis. Complete transection of a juncturae
and the intertendinous fascia may lead to subluxation of the
EDC tendon over a flexed MCP joint (494). The juncturae
tendinum are variable, and become progressively thicker
136 Systems Anatomy
FIGURE 2.9. The extensor aponeurosis (see text).
from the radial to the ulnar side of the hand. Three distinct
type of juncturae tendinum have been identified (493) (Fig.
2.10). A thin filamentous junctura is defined as type 1, and
is found primarily between the EDC tendons to the index
and middle fingers and between the tendons to the middle
and ring fingers. Type 2 juncturae are thicker and well
defined and are present between extensor tendons to the
long and ring fingers and between the tendons to the ring
and small fingers. Type 3 juncturae consist of a thick, ten-
don-like slip between the extensor tendons to the middle
and ring fingers and between the tendons to the ring and
small fingers. Two subtypes of type 3 juncturae have been
identified, a “y” and an “r” type, based on the interconnec-
tions. The presence of certain juncturae appears to be asso-
ciated with the presence or absence of tendons. For
instance, the type of juncturae in the fourth intermetacarpal
space depends on the presence of an EDC tendon to the
small finger. Absence of the EDC small finger tendon has
been found to be associated with a double EDC ring finger
tendon and a thick type 3 junctura that substitutes for the
absent EDC small finger tendon (492,493). Although mul-
tiple EDC ring finger tendons usually are present, the ulnar
portion of the double EDC ring finger tendon and, as men-
tioned, the type 3 junctura may represent a developmental
remnant of the EDC small finger tendon. The presence of
juncturae between the extension tendons and adjacent ten-
 2 Muscle Anatomy 137

A B

C D
FIGURE 2.10. Juncturae tendinum of the extensor tendons. A: Type 1. The type 1 junctura is a
thin, filamentous connection between the extensor digitorum communis (EDC) of the long and
index fingers. It sometimes is present between the EDC of the ring and long fingers. B: Type 2.
The type 2 junctura has morphologic features between types 1 and 3. It typically is present
between the EDC tendons of the long and ring fingers and sometimes between the tendons of
the ring and small fingers. C: Type 3y. The type 3y junctura is a tendon slip most commonly pre-
sent between the EDC tendons of the small and ring fingers. D: Type 3r. The type 3r junctura is a
tendon slip most commonly present between the EDC of the ring finger and the extensor digiti
quinti. Its presence is associated with an absent EDC to the small finger. (Adapted from von
Schroeder HP, Botte MJ, Gellman H. Anatomy of the juncturae tendinum of the hand. J Hand Surg
[Am] 15:595–602, 1990, with permission.)
138 Systems Anatomy

dons should be appreciated when tendon transfer or har-
vesting is used (492,493).
Architectural features of the EDC include the physio-
logic cross-sectional area of the muscle, the fiber bundle
length, muscle length, muscle mass, and pennation angle
(angle of the muscle fibers from the line representing the
longitudinal vector of its tendon). Skeletal muscle architec-
tural studies by Lieber, Friden, and colleagues provide the
data for the EDC (135–139,174) (see Table 2.1 and Fig.
2.4). The digital extrinsic extensor and flexor muscles have
similar architectural features. In general, the EDC muscles
do have smaller physiologic cross-sectional areas compared
with the extrinsic flexors, indicating that the EDC is not
optimally designed for force generation. The relative differ-
ence index values compare the EDC with other upper
extremity muscles, based on architectural features. These
values are listed in Appendix 2.3 (15).
The EDC is innervated by the posterior interosseous
nerve, derived mostly from C7 as well as from C6 and C8.
The posterior interosseous nerve passes through the supina-
tor muscle, and branches into several motor branches that
enter the deep surface of the middle third of the muscle.
There is variation among the motor branches, and there
may be a common branch or branches that also innervate
the EDM or ECU. The EDC muscle may receive a variable
number of branches.
Actions and Biomechanics: Extensor
Digitorum Communis and the Associated
Extensor Mechanism
The EDC functions mainly to extend the digits, primarily
at the MCP joints (494). The EDC also assists with exten-
sion of the PIP and DIP joints, working with the interossei
and lumbricals. The tendons also can assist with wrist
extension.
Extension of the digits is a complex function, involv-
ing simultaneous actions of the intrinsic and extrinsic
extensor muscles (464,465,467,468,474,494). The
interossei and lumbricals extend the PIP and DIP joints
and flex the MCP joints. The extrinsic digital extensor

TABLE 2.3. EXTENSOR TENDON VARIATIONS AND MULTIPLICITY

Incidence as %

Tendons von Schroeder/ Mestdagh Leslie Ogura

Tendon or Slips Botte (492) Schenk et al. (479) (478) et al. (500)

EIP Absent 0 1 0
1 77 93 96
2 16 6 4
3 7
EIP to middle Present 5 3 2
EMP Present 12 5
EDC—index 1 98 95
2 2 5
EDC—long 1 51 61
2 28 39
3 16
4 5
EDC—ring 1 12 63
2 63 31
3 16 5
4 9
5
EDC—small Absent 54 56 91
1 19 44 9 97
2 26 3
3 2
EDQ 1 2 7 16 4
2 84 84 84 94
3 7 7 2
4 7 2
EDQ to ring Present 2 2
EDBM Present 0 0 3

EIP, extensor indicis proprius; EMP, extensor medii proprius; EDC, extensor digitorum communis; EDQ, extensor digiti quinti; EDBM, extensor
digitorum brevis manus.
Reprinted from von Schroeder HP, Botte MJ. Functional anatomy of the extensor tendons of the digits. Hand Clin 13:51–62, 1997, with
permission.

muscles, including the EDC, EIP, and EDM, function
primarily to extend the MCP joints, but do have extensor
function at the PIP and DIP joints. The flexor muscles
and respective tendons on the palmar aspect of the hand
are important in stabilizing and balancing the phalangeal
joints during extension. Despite all the separate tendons
involved in finger extension, complete independent
extension of each finger is not always possible. This is due
in part to the juncturae tendinum and intertendinous fas-
cia between the extrinsic tendons on the dorsum of the
hand (491–496).
As noted previously, the EDC muscles have smaller
physiologic cross-sectional areas than the extrinsic flexors,
indicating that the EDC is not optimally designed for force
generation (466) (see Table 2.1 and Fig. 2.4). Although the
EDC appears as a single muscle belly that forms four ten-
dons, each tendon usually can be traced back to a muscle
belly that can be separated from the remaining EDC mus-
cle. Each of these four muscle bellies are similar, however.
The EDCs to the long and ring fingers have a relatively
larger cross-sectional area than the EDCs to the index and
small fingers. The cross-sectional area of the EDC muscles
to the long and ring fingers also are larger that those of the
EIP or EDM.
At the level of the extensor retinaculum, the EDC usu-
ally exits as four tendons. Distal to the wrist, many of the
tendons divide into double or triple tendons. These
anatomic variations as well as their arrangement and inci-
dences have been recognized in clinical and anatomic stud-
ies (462,475,478,479,481) (Table 2.3). Because these vari-
ations are so common, it is difficult to label these as
anomalies; they perhaps are best considered as normal vari-
ations. In a study of 43 hands, the most common pattern
on the dorsum of the hand was a single EIP tendon (77%)
that inserted ulnar to the index finger EDC on the dorsal
aponeurosis of the index finger; a single index finger EDC
(98%); a single long finger EDC (51%); a double ring fin-
ger EDC tendon (63%) with a single insertion; an absent
small finger EDC (54%); and a double EDQ tendon (84%)
with a double insertion into the dorsal aponeurosis of the
small finger (492). The extensor tendons typically have lon-
gitudinal fissures or striae, but tendons that can be readily
divisible along fissures without sharp dissection are defined
as tendon slips (492).
Anomalies and Variations: Extensor
Digitorum Communis
The EDC tendons are extremely variable as to number and
presence (see Table 2.3). Double and triple tendons exist.
An EDC tendon may be absent (in 54% to 56% of
hands) (481,492). Absence of the EDC to the small finger
often is associated with a double EDM to the small finger
(492). There commonly are thick juncturae from the ring
finger EDC to the small finger (493).
2 Muscle Anatomy 139
The most common extensor tendon pattern is as follows:
a single EIP tendon (77%), a single index finger EDC
(98%), a single long finger EDC (51%), a double ring fin-
ger EDC (63%), an absent small finger EDC (54%), and a
double EDM (84%) (492).
Additional frequent variations include a double EIP
(16%), a double (28%) or triple (16%) long finger EDC, a
single (12%) or triple (16%) ring finger EDC, and a single
(19%) or double (26%) small finger EDC (492).
The juncturae tendinum of the EDC are variable, with
fewer and thinner juncturae on the radial side of the hand
compared with the ulnar (493). There is more tendon vari-
ability and multiplicity (along with more juncturae) toward
the ulnar side of the hand (492).
The muscle belly of the EDC may exist as a single or
double muscle, or as four separate bellies (11). The EDC
may have a tendon slip or a junctura that extends to the
extensor tendon of the thumb (11).
The extensor medii proprius (EMP), also known as the
extensor medii digiti or extensor medii communis, is a deeply
situated anomalous muscle that is analogous to the EIP but
inserts into the ulnar aspect of the dorsal aponeurosis of the
long finger (Fig. 2.11A). The EMP and EIP muscles usually
have a common origin on the distal ulna and adjacent
interosseous ligament. The EMP is encountered in 0.8% to
10.3% of hands (11,479,485,490), but is rarely described
or noted (478). The EMP is commonly found in Old
World monkeys, whereas the EMP is variably present in the
chimpanzee and gorilla, as it is in humans. Because of these
findings, von Schroeder and Botte speculate that the EMP
is an evolutionary remnant and not a variation of a normal
arrangement (494).
The extensor indicis et medii communis (EIMC) muscle is
an anomalous muscle similar to the EIP muscle, except that
it splits to insert into both the index and long fingers (see
Fig. 2.11B). It has been studied in detail by von Schroeder
and Botte, who observed an incidence of 3.4% (490). Sim-
ilar to the EMP, the EIMC commonly is found in Old
World monkeys, whereas the EIMC is variably present in
the chimpanzee and gorilla, as it is in humans. Because of
these findings, the EIMC (like the EMP) may be an evolu-
tionary remnant and not a variation of a normal arrange-
ment (494).
The extensor medii et annularis communis is an anom-
alous EIP muscle that splits to insert into both the long and
ring fingers (490).
The extensor digitorum brevis manus is an anomalous
muscle that originates from the distal radius, radiocarpal
ligament, or the distal ulna (Fig. 2.12). The tendon
inserts into the index finger or, less commonly, into the
long finger. It is innervated by a branch of the posterior
interosseous nerve. Most of the muscle belly is located on
the dorsum of the hand, and can cause local discomfort
or tendon dysfunction. It can be mistaken for a ganglion
or other tumor. The muscle may become symptomatic
140 Systems Anatomy

A B
FIGURE 2.11. Anomalous extensor tendons of the hand and forearm. A: Schematic illustration
of the extensor medii proprius (EMP). The EMP originates in the forearm and inserts into the dor-
sal aponeurosis of the long finger. The EMP is similar to the extensor indicis proprius (EIP); how-
ever, the EMP inserts into the aponeurosis of the long finger, not the index finger. The insertions
(cut) of the extensor digitorum communis (arrows) to the index and long fingers also are shown.
B: Schematic illustration of the extensor indicis et medii communis (EIMC). The EIMC consists of
one muscle belly and two tendons that insert into the index and long fingers. The EIP is absent.
The insertions (cut) of the extensor digitorum communis (arrows) to the index and long fingers
also are shown. (From von Schroeder HP, Botte MJ. The extensor medii proprius and anomalous
extensor tendons to the long finger. J Hand Surg [Am] 16:1141–1145, 1991, with permission.)

FIGURE 2.12. The extensor digitorum brevis

manus is an anomalous muscle that originates
from the distal radius, radiocarpal ligament, or
the distal ulna. It can resemble a dorsal wrist
ganglion.
 2 Muscle Anatomy 141

deep to the extensor retinaculum. Excision of this anom- Gross Anatomic Description: Extensor
alous muscle or decompression under the extensor reti- Indicis Proprius
naculum may be performed if symptoms warrant (494,
The EIP is a relatively small and short extensor located deep
499–504).
to the EDC, EDM, and ECU. It lies in the dorsal muscle
compartment of the forearm (Appendix 2.2). The EIP orig-
Clinical Implications: Extensor Digitorum inates from a diagonally oriented origin on the ulnar aspect
Communis of the distal forearm (see Fig. 2.3B). The muscle arises from
the dorsal surface of the distal ulna and from a portion of the
Their frequent multiplicity and variability and the possible
adjacent interosseous ligament. Additional attachments
presence of many anomalous extensor tendons should be
include the fascia or septum between the EIP and EPL. The
appreciated during extensor tendon exploration for trauma
muscle belly of the EIP lies next to and ulnar to the muscle
repair or tendon transfer.
belly of the EPL. The tendon of the EIP passes deep to the
The index finger has the greatest independent motion
EDM and EDC tendons in an oblique fashion as it extends
in extension. It has two independent tendons (index fin-
distally toward the index finger. It joins the tendons of the
ger EDC and EIP) that are the least variable of the exten-
EDC in the fourth dorsal compartment as it passes deep to
sor tendons. It also has the lowest frequency of intercon-
the extensor retinaculum. As the EIP enters the extensor
necting juncturae tendinum. These anatomic findings
retinaculum, it is located on the ulnar margin of the reti-
help explain its relatively independent extension capabili-
naculum, and positioned ulnar and deep to the EDC. In the
ties compared with the more ulnarly located digits (e.g.,
extensor retinaculum, the EIP tendon continues in a diago-
the ring finger).
nal course to cross deep to the EDC tendons, so that when
Occasionally, an anomalous junctura tendinum may
the EIP emerges from the extensor retinaculum, it is on the
cross between the EDC and the EPL tendons. This junctura
lateral aspect of the retinaculum. The tendon continues dis-
restricts digital motion, making it impossible actively to
tally and laterally toward the dorsal aspect of the index fin-
extend the digits fully while maintaining the interpha-
ger, and remains in close proximity and ulnar to the EDC to
langeal joint of the thumb in flexion (483).
the index finger. (This ulnar position of the tendon is impor-
The extensor digitorum brevis manus (see earlier) can be
tant in identification of the tendon for harvest for tendon
mistaken for a ganglion or other tumor. It may become
transfer during such procedures as opponensplasty.) At the
symptomatic deep to the extensor retinaculum. Excision of
level of the index metacarpal head and neck, the tendon of
this anomalous muscle or decompression under the exten-
the EIP joins the tendon of the index EDC to form a con-
sor retinaculum may be performed if symptoms warrant
tinuous extensor hood (3,4,11,13,68) (Fig. 2.6B).
(494,499–504) (see Fig. 2.12).
Architectural features, including the physiologic cross-
sectional area and the muscle fiber length of the EIP, are
listed in Table 2.1 and depicted in Fig. 2.4.
EXTENSOR INDICIS PROPRIUS
The EIP is innervated by the posterior interosseous nerve,
predominantly C7, as well as C8. Anatomic studies have
Derivation and Terminology. Extensor is derived from
shown that the branch to the EIP usually is the last or termi-
the Greek and Latin ex, which indicates “out of,” and from
nal motor branch of the posterior interosseous nerve (505).
the Latin tendere, “to stretch”; thus, extension indicates a
motion to stretch out, and extensor usually is applied to a
force or muscle that is involved in the “stretching out or Actions and Biomechanics: Extensor
straightening out” of a joint. Indicis is from the Latin to Indicis Proprius
indicate the index finger (1,2).
Origin. The dorsal surface of the distal ulna and adjacent The EIP assists with extension of the index finger. It also
interosseous ligament. assists with wrist extension. The separate muscle of the EIP
Insertion. The extensor hood of the index finger. provided to the index finger assists with the strong inde-
Innervation. Posterior interosseous nerve (C7, C8). pendent motion of the index finger. Principal action is on
Vascular Supply. The posterior interosseous artery, the MCP joint.
interosseous recurrent artery and its communicating vessels,
continuation of the anterior interosseous artery after it
Anomalies and Variations: Extensor
passes through the interosseous ligament; the dorsal carpal
Indicis Proprius
arch; dorsal metacarpal, digital and perforating arteries
(3,4,11,13). See also Anomalies and Variations: Extensor Digitorum
Principal Action. Extension of the index finger. As with Communis.
the index finger EDC, the principal action is on the MCP Despite the variability and multiplicity of the extensor
joint. tendons (see Table 2.3), the EIP usually exists as a single
142 Systems Anatomy
tendon. In a study of 43 hands, the most common pattern
on the dorsum of the hand was a single EIP tendon (77%)
that inserted ulnar to the index finger EDC on the dorsal
aponeurosis of the index finger, and a single index finger
EDC (98%) (492).
The EIP may be absent (11). The muscle or tendon of
the EIP may be doubled (11).
Muscle or tendon slips can pass to the thumb or adjacent
digits, including additional anomalous insertions into the
base of the long finger metacarpal or base of the long finger
proximal phalanx.
The extensor medii proprius (EMP) and the extensor
indicis et medii communis (EIMC) are anomalous muscles
similar to the EIP that attach to the index or long fingers,
and are seen in 2% to 6.5% of hands (478,490,506–508)
(see also under Anomalies and Variations: Extensor Digito-
rum Communis, and Fig. 2.10).
The EIP tendons usually insert ulnar to the index finger
EDC tendon (81% to 87% of specimens). However, they
may be located or insert directly palmar to the index finger
EDC in 10% to 11%, and radial to the index finger EDC
in 3% to 8% (11,479,490).
Clinical Implications: Extensor Indicis
Proprius
Their frequent multiplicity and variability, and the possible
presence of many anomalous extensor tendons should be
appreciated during extensor tendon exploration for trauma
or for tendon transfer (492,493,509).
The EIP usually is located along the ulnar aspect of the
index finger EDC tendon (3,4,11,13,492). This position-
ing helps identify the tendon for repair or for harvest for
transfer (i.e., for opponensplasty).
EXTENSOR DIGITI MINIMI (EXTENSOR
DIGITI QUINTI)
Derivation and Terminology. Extensor is from the Greek
and Latin ex, which indicates “out of,” and from Latin ten-
dere, “to stretch”; thus, extension indicates a motion to
stretch out, and extensor usually is applied to a force or mus-
cle that is involved in the “stretching out or straightening
out” of a joint. Digiti is the plural of the Latin digitus,
“digit.” Minimi is from the Latin minima, “the minimum,”
referring to the small finger (1,2).
Origin. From the lateral epicondyle through the com-
mon extensor origin, as well as from the adjacent intermus-
cular septum (between it and the ECU), and from the over-
lying fascia.
Insertion. To the extensor mechanism of the small finger.
Innervation. Posterior interosseous nerve (C7, C8).
Vascular Supply. The posterior interosseous artery;
interosseous recurrent artery and its communicating
branches; from the continuation of the anterior
interosseous artery after it passes through the interosseous
ligament; the dorsal carpal arch; dorsal metacarpal, digital,
and perforating arteries (3,4,11,13,68).
Principal Action. Extension of the MCP joint of the
small finger, extension of the PIP and DIP joints. The
EDM also assists with wrist extension.
Gross Anatomic Description: Extensor
Digiti Minimi
The EDM is a relatively small, slender muscle. It lies in the
dorsal muscle compartment of the forearm (Appendix 2.2).
It originates from the lateral epicondyle of the humerus as
part of the common extensor origin tendon (3,4,11,13)
(Fig. 2.2A). In addition, fibers arise from the adjacent inter-
muscular septum (between the EDM and the EDC) as well
as from the overlying deep antebrachial fascia. The narrow
muscle is formed and blends to some extent to that of the
EDC. The tendon forms in a manner similar to those of the
EDC in the distal third of the forearm. The tendon passes
deep to the extensor retinaculum, comprising the fifth dor-
sal compartment. [Editor’s note: The dorsal compartments
of the wrist are as follows: the APL and EPB comprise the
first dorsal compartment; the ECRL and ECRB form the
second; the EPL forms the third; the EDC and EIP form
the fourth; the EDM forms the fifth; and the ECU forms
the sixth (6).] The fifth dorsal compartment is located dor-
sal to the distal radioulnar joint. The tendon continues dis-
tally to reach the dorsal surface of the small finger
metacarpal. It remains on the ulnar side of the EDC tendon
to the small finger. The EDM inserts, in part, into the base
of the proximal phalanx of the small finger (Fig. 2.6B). The
tendon also is joined by the slip from the EDC to the small
finger. The tendon often is split or doubled, and exhibits
variability, as do the EDC tendons (492) (see Table 2.3).
The architectural features of the EDM are listed in Table
2.1 and depicted in Fig. 2.4.
The EDM is innervated by the posterior interosseous
nerve, mostly from C7 and C8. The nerve branch or
branches enter the muscle belly of the EDM in the middle
third of the muscle on the deep surface.
Actions and Biomechanics: Extensor
Digiti Minimi
The EDM provides extension of the MCP joint of the small
finger, as well as extension of the PIP and DIP joints. The
EDM also assists with wrist extension. It works with the
small finger EDC, and may be the only digital extensor of
the small finger if the small finger EDC tendon is absent
(3,4,11,13).
Anomalies and Variations: Extensor Digiti
Minimi
See also Anomalies and Variations: Extensor Digitorum
Communis.

The EDM exhibits variability similar to that of the EDC
tendons (see Table 2.3). The tendon may be absent, or exist
as a double or triple tendon. Its most common pattern is
that of a double tendon, seen in 84% (492,495,497,498).
The muscle belly may be doubled, or have an accessory
head. An accessory head may originate from the ulna (11).
The muscle belly may blend or coalesce with the EDC mus-
cle belly (11).
Several variations in the insertion can exist. A tendon
slip to the base of the ring finger proximal phalanx has been
noted in 6% to 10% (11,446). An ulnar slip has been noted
to insert onto the base of the small finger metacarpal (11).
Clinical Implications: Extensor Digiti
Minimi
The EDM may provide the principal digital extension for
the small finger in the absence of the EDC to the small fin-
ger. The most common pattern of the extensor tendons
actually is an absent small finger EDC, and a double ten-
don of the EDM (492,497,498) (Table 2.3).
EXTENSOR CARPI ULNARIS
Derivation and Terminology. Extensor is derived from
the Greek and Latin ex, which indicates “out of,” and from
the Latin tendere, “to stretch”; thus, extension indicates a
motion to stretch out, and extensor usually is applied to a
force or muscle that is involved in the “stretching out or
straightening out” of a joint. Carpi is from the Latin carpalis
or the Greek karpos, both of which indicate “wrist” (the car-
pus). Ulnaris is derived from the Latin ulna, “arm,” and
ulnaris, “pertaining to the arm” (1,2).
Origin. The lateral epicondyle of the humerus through
the common extensor origin. Additional attachments
include the posterior border of the ulna by an aponeurosis
that wraps around the ulna and is shared with the FCU and
FDP. The ECU also has attachments of origin from the
overlying fascia.
Insertion. Base of the small finger metacarpal, dorsal
aspect.
Innervation. Posterior interosseous nerve (C6, C7, C8).
Vascular Supply. The posterior interosseous artery;
interosseous recurrent artery (3,4,11,13).
Principal Action. Extension of the wrist. It contributes to
ulnar deviation of the wrist. The ECU also helps stabilize
the wrist during forceful grip or lifting, or production of a
clenched fist.
Gross Anatomic Description: Extensor
Carpi Ulnaris
The ECU originates mainly from the lateral epicondyle of the
humerus through the common extensor origin (see Fig. 2.2A).
It lies in the dorsal muscle compartment of the forearm
2 Muscle Anatomy 143
(Appendix 2.2). In addition, there may be several other sites
of origin (3,4,11,13). The ECU usually also has attachments
to the posterior border of the ulna that connect to an aponeu-
rosis that wraps around the ulna and is shared with both the
FCU and FDP (see Fig. 2.3B). The ECU also has attachments
of origin from the overlying fascia of the forearm muscles.
Two heads may be present. One head originates from the dis-
tal dorsal portion of the lateral epicondyle of the humerus and
from the investing fascia and septa between the ECU and
EDM, anconeus, and supinator. The other head originates
from the proximal dorsal border of the ulna. The muscle fibers
extend distally along the dorsal ulnar portion of the forearm
in an osteofascial compartment consisting of the dorsal surface
of the ulna, the fascia of the forearm, dense fascia lying on the
ulnar origin of the muscles of the thumb, and the origin of the
extensor indicis. The muscle usually extends the distal three-
fourths of the forearm to end in a thick tendon. The tendon
first appears on the dorsal surface of the muscle or deep in the
muscle on the radial border of the middle third of the poste-
rior surface of its belly (3,4,11). The tendon reaches the exten-
sor retinaculum to form the sixth dorsal compartment. [Edi-
tor’s note: The dorsal compartments of the wrist are as follows:
the APL and EPB comprise the first dorsal compartment; the
ECRL and ECRB form the second; the EPL forms the third;
the EDC and EIP form the fourth; the EDM forms the fifth;
and the ECU forms the sixth (6).] In the sixth compartment,
the tendon is stabilized by traversing a groove in the distal
ulna. The groove is located lateral to the styloid process of the
ulna, but medial to the head of the ulna. The dorsal retinacu-
lum holds the tendon in place. The tendon extends distally in
close proximity to the dorsomedial portion of the triangular
fibrocartilage (510,511). The tendon continues across the
ulnar carpus to reach the base of the fifth metacarpal (see Fig.
2.6B). It inserts onto a tubercle located on the medial aspect
of the dorsal base of the metacarpal (3,4,11,13) (Fig. 2.6B).
Architectural features of the ECU include the physio-
logic cross-sectional area of the muscle and the fiber length.
Skeletal muscle architectural studies by Lieber and col-
leagues provide the data for the ECU (135–139,174) (see
Table 2.2 and Fig. 2.4). The relative difference index values
compare the ECU with other upper extremity muscles,
based on architectural features. These values are listed in
Appendix 2.3 (15).
The ECU is innervated by the posterior interosseous
nerve, comprising contributions from the C6, C7, and C8
nerve roots. The branch to the ECU usually leaves the pos-
terior interosseous nerve just distal to the distal edge of the
supinator muscle. The nerve may branch into several
smaller branches that enter the middle third of the muscle
belly on its deep surface.
Actions and Biomechanics: Extensor Carpi
Ulnaris
The main function of the ECU is extension of the wrist. It
also contributes to ulnar deviation of the wrist. The ECU
144 Systems Anatomy
helps stabilize the wrist during forceful gripping or lifting,
or producing a clenched fist. It is a dynamic stabilizer of the
distal radioulnar joint and distal ulna. In stabilizing the dis-
tal radioulnar joint complex, the ECU works with the
interosseous ligament, the extensor retinaculum and com-
petence of the sigmoid notch of the distal radius, and the
dynamic forces of the pronator quadratus (510–515).
Anomalies and Variations: Extensor Carpi
Ulnaris
The ECU may consists of a double muscle belly, or termi-
nate in a double tendon (516,517). With a double tendon,
one slip may insert onto the base of the fourth metacarpal
(517).
The ulnaris digiti minimi (or ulnaris digiti quinti) is an
anomalous muscle closely associated with the ECU. It arises
distally in the forearm from the dorsal surface of the distal
ulna. This small muscle extends distally along the ulnar
wrist and hand to insert into the base of the distal phalanx
of the small finger. The ulnaris digiti minimi may represent
an extension or accessory belly of the ECU. It may be a sep-
arate tendon slip arising from the tendon of the ECU. The
ulnaris digiti minimi also may have insertions into the dor-
sal fascia of the fifth metacarpal, capsule of the MCP joint,
or proximal phalanx of the small finger (11).
The ECU may be absent (518). This is rare, occurring in
0.55% (11). Absence has been noted to be bilateral (518).
Clinical Implications: Extensor Carpi
Ulnaris
Duplication of the ECU tendon, or a double tendon that
extends to the base of the small finger distal phalanx, may
impair simultaneous extension of the wrist and the small
finger. Synovitis has been associated with this anomaly
(517).
Dislocation, subluxation, and stenosing tenosynovitis
are potential problems of the ECU tendon as it passes to
and through the dorsal retinaculum (519–522).
SUPINATOR
Derivation and Terminology. Supinator is derived from
the Latin supinatio, which denotes the act of assuming the
supine position, or the state of being supine. Applied to the
hand, it is the act of turning the palm forward (anteriorly)
or upward, performed by lateral rotation of the forearm
(1,2).
Origin. From the lateral epicondyle and the lateroposte-
rior ulna.
Insertion. To the proximal radius, along the lateral, pos-
terior, and anterior surface.
Innervation. Posterior interosseous nerve (C6, C7).
Vascular Supply. The radial artery; posterior interosseous
artery; radial recurrent artery; interosseous recurrent artery;
middle collateral artery (3,4,11,13).
Principal Action. Supination of the forearm (lateral rota-
tion of the forearm so that the palm faces anteriorly, or
superiorly if the elbow is flexed).
Gross Anatomic Description: Supinator
The supinator is a relatively broad and flat muscle of the
proximal deep forearm. It comprises one of the many mus-
cles of the dorsal muscle compartment of the forearm
(Appendix 2.2). It arises from two main areas: the lateral
epicondyle and the proximal lateral ulna (3,4,11,13) (see
Fig. 2.3). From the lateral epicondyle, it arises from the dor-
sal aspect from a tendinous band that joins the deep surface
of the tendons of origin of the ECRL, ECRB, and EDC. It
also has attachments to the radial collateral ligament of the
elbow joint. The other main area of origin is from the prox-
imal ulna, on its lateral aspect. Some fibers arise from a
depression distal to the radial notch and others from a crest
on the proximal ulna known as the supinator crest. The
fibers extend radially and slightly distally to the radius, to
insert onto the proximal radius (see Fig. 2.3). The insertion
area surrounds the proximal third of the radius, from the
radial tuberosity to the attachment of the pronator teres, or
to the upper part of the radius between the anterior and
posterior oblique lines. The muscle has two layers, a super-
ficial and a deep layer. These layers are separated by a con-
nective tissue septum through which the posterior
interosseous nerve courses. The two layers arise together,
the superficial by tendinous origin and the deep by muscu-
lar fibers from the lateral epicondyle of the humerus, from
the radial collateral ligament of the elbow joint and the
annular ligament of the superior radioulnar joint, from the
supinator crest of the ulna, and from the posterior aponeu-
rosis covering the muscle (523). The proximal portion of
the muscle contains an opening in the superficial layer, the
arcade of Frohse. The arcade of Frohse allows the passage of
the posterior interosseous nerve as it enters between the two
heads. There is variability of the anatomy pertaining to the
tendinous or membranous nature of the rim of the arcade
of Frohse (524–529). Thomas and colleagues noted that the
arcade of Frohse was lined by a tendinous rim in 32% and
a membranous rim in 68% (523). Conversely, Ozkan and
colleagues reported that the rim of the arcade was fibrous in
80% and membranous in 20% of specimens (524). In addi-
tion, Debouck and Rooze noted that the arcade was tendi-
nous in 64% (525) and Papadopoulos et al. noted a tendi-
nous arcade in 90% (528). The arcade of Frohse is a well
known area of possible nerve impingement resulting in pos-
terior interosseous neuropathy (526). It remains unclear if a
fibrous rim of the arcade predisposes the posterior
interosseous nerve to impingement (529). After the nerve
enters the supinator, it continues obliquely through the

muscle, with the direction of the nerve roughly perpendic-
ular to the fibers of the muscle. The nerve often branches
within the muscle, and several branches often are seen exit-
ing the distal edge of the muscle. The nerve also may be
compressed at the distal edge of the supinator (530).
The supinator is innervated by the branches of the pos-
terior interosseous nerve before the nerve passes through
the arcade of Frohse. Theses branches usually carry contri-
butions from C5, C6, and C7 (3,4,11,13,505,531).
Actions and Biomechanics: Supinator
The supinator functions mainly for supination of the fore-
arm (lateral rotation of the forearm so that the palm faces
anteriorly, or superiorly if the elbow is flexed). It works in
conjunction with the biceps for forearm supination, and is
thought to provide approximately half the power of the
biceps muscle for supination (11). It may act alone in slow,
unopposed supination and together with the biceps in fast
or forceful supination (3,4,11,13).
Anomalies and Variations: Supinator
The supinator may exist as only one muscle head, without
a superficial and deep layer (11).
Accessory slips of muscle or tendon may interconnect
the supinator with the biceps tendon, annular ligament of
the elbow, tuberosity of the radius, and neighboring areas
(11,532).
The tensor ligamenti anularis anterior muscle is an
anomalous muscle that connects the supinator to the annu-
lar ligament in 5% of individuals (11).
Clinical Implications: Supinator
The arcade of Frohse is the opening of the superficial layer
of the supinator. It often is lined by a fibrous rim, and pro-
vides the opening of the muscle through which the poste-
rior interosseous nerve passes. The arcade of Frohse is a well
known area of possible nerve impingement resulting in pos-
terior interosseous neuropathy (526).
ABDUCTOR POLLICIS LONGUS
Derivation and Terminology. Abductor is derived form
the Latin ab, meaning “away from,” and from ducere, which
means “to draw”; therefore, abductor is “that which draws
away from.” Pollicis is from the Latin pollex, indicating
“thumb.” Longus is derived from the Latin longus, indicat-
ing “long.” The APL is the longest abductor of the thumb
(1,2).
Origin. The mid-dorsal radial diaphysis and adjacent
portion of the interosseous ligament, and from the lateral
edge of the middle third of the ulnar diaphysis.
2 Muscle Anatomy 145
Insertion. The base of the thumb metacarpal, dorsal
aspect.
Innervation. Posterior interosseous nerve (C7, C8).
Vascular Supply. The posterior interosseous artery; per-
forating arteries and continuation of the anterior
interosseous artery; radial artery in the anatomic snuff-box;
first dorsal metacarpal artery; dorsal carpal arch (3,4,11,13).
Principal Action. Abduction of the thumb metacarpal
(abduction of the thumb in the radial direction in the plane
of the palm).
Gross Anatomic Description: Abductor
Pollicis Longus
The APL is located in the deep layer of the posterior fore-
arm. The muscle comprises one of the many muscles of the
dorsal muscle compartment of the forearm (Appendix 2.2).
It arises from the lateral edge of the dorsal radial diaphysis,
from a portion of the interosseous ligament, and from the
proximal part of the middle third of the ulna
(3,4,11,13,68). Its origin from the radius is distal and cen-
tral to the supinator, but proximal to the origins of the EPL
and EPB (see Fig. 2.3B). Additional areas of origin include
the septa between the APL and the supinator, the ECU, and
the EPL. The muscle fibers converge in a penniform man-
ner to join in a muscle belly that extends distally in an
oblique fashion, coursing radially in the direction of the
thumb. The muscle then forms the myotendinous junction
in the distal third of the forearm, joined by the tendon of
the EPB, which lies immediately ulnar to the APL. The ten-
don becomes more superficial in the distal third of the fore-
arm. The tendon of the APL is round and thick. At the level
of the extensor retinaculum, the APL and EPB enter their
own fibroosseous tunnel to comprise the first dorsal com-
partment (3,4,533). [Editor’s note: The dorsal compart-
ments of the wrist are as follows: the APL and EPB com-
prise the first dorsal compartment; the ECRL and ECRB
form the second; the EPL forms the third; the EDC and
EIP form the fourth; the EDM forms the fifth; and the
ECU forms the sixth (6).] The first dorsal compartment is
located on the dorsolateral surface of the distal radius, just
lateral to the tendons of the ECRL and ECRB of the sec-
ond dorsal compartment. The APL exits the first dorsal
compartment, remaining on the lateral side of the EPB, and
continues toward the base of the thumb to insert onto the
base of the thumb metacarpal on its radial surface (see Fig.
2.6A). The tendon often splits into two slips, one attaching
to the radial side of the thumb metacarpal base and the
other to the trapezium. Variations in the number and
course of the tendon are so numerous that the normal pat-
tern of a single APL and EPB occurs less than 20% of the
time (451,534). This variability has implications for the eti-
ology and treatment of de Quervain’s tenosynovitis
(534–553). The first dorsal compartment may have more
variations in tendon structure and organization than most
146 Systems Anatomy
other muscles in the upper extremity (451). This is dis-
cussed in detail later, under Anomalies and Variations:
Abductor Pollicis Longus.
The APL is innervated by the posterior interosseous
nerve, usually by one or more branches. The branches enter
the muscle just after the nerve exits the supinator muscle.
The branches then enter the proximal third of the muscle
belly, usually on the superficial surface. The motor branches
usually have contributions mainly from C7, but also from
C6 and C8 (3,4,11,13,68).
Actions and Biomechanics: Abductor
Pollicis Longus
The APL functions mainly to abduct the thumb metacarpal
from the hand in the radial direction and in the plane of the
palm. During maximal contraction, it also may contribute
to flexion of the wrist or radial deviation of the wrist. It is
considered an antagonist to the opponens pollicis (11). The
APL works in conjunction with the APB to abduct the
thumb; it works in conjunction with the EPL and EPB to
assist with extension at the thumb carpometacarpal joint.
Anomalies and Variations: Abductor
Pollicis Longus
The tendon of the APL often is doubled. It may have mul-
tiple tendons. With double tendons, both often still insert
to the base of the thumb metacarpal. In several studies, a
double tendon was more common that a single tendon,
with the single APL and EPL pattern occurring less than
20% of the time (451,534,537,538,540,542,544,546,549,
550,554,555). Failure to recognize these variations poten-
tially leads to persistence or recurrence of pain after opera-
tive decompression because of incomplete surgical release of
the tendon sheath (535,536,545).
The muscle belly may be split or doubled, or there may
be multiple bellies or slips (11).
Multiple accessory muscles or tendon slips have been
noted, including those that extend to the trapezium,
scaphoid, opponens pollicis, proximal phalanx of the
thumb, flexor retinaculum (volar carpal ligament), superfi-
cial muscles on the thenar eminence, other areas of the
thumb metacarpal, APB, or FPB (451,544,549,550).
The septum in the first dorsal compartment may have sev-
eral variations as well. In 24% to 34% of specimens in
anatomic studies, the first compartment was found to be sub-
divided by a longitudinal ridge and septum into two distinct
osteofibrous tunnels, an ulnar one for the EPB and a radial
one containing one or more slips of the APL (451,541–543).
The reported incidence of separate compartments at surgery
is higher than that seen in anatomic specimens in several
series (539,548,550–552,554), which, as noted by Wolfe,
raises the possibility that septationw increases the probability
that nonsurgical treatment will fail (451).
The abductor pollicis tertius (extensor atque abductor
pollicis accessorius) is a rare anomalous muscle that arises
from the dorsal aspect of the radius with the APL and
inserts, after coalescing with the APB, onto the thumb
metacarpal (11).
Clinical Implications: Abductor Pollicis
Longus
The APL and EPB often are afflicted with tendonitis,
resulting in the well known de Quervain’s tenosynovitis
(534–553). The disease often is referred to as stenosing ten-
ovaginitis of the first dorsal compartment. As noted earlier
under Anomalies and Variations, several studies have shown
a double tendon was more common that a single tendon,
with the single APL and EPL pattern occurring less than
20% of the time (451,534,537,538,540,542,544,546,549,
550,554,555). The number of variations in tendon struc-
ture and organization in the first dorsal compartment are
among the greatest of the upper extremity muscles. Failure
to recognize these variations potentially leads to persistence
or recurrence of pain after operative procedures because of
incomplete surgical release of the tendon sheath (535,536,
545).
The variability of the septa in the first dorsal compart-
ment may also be related to the incidence of stenosing
tenosynovitis. The reported incidence of separate compart-
ments at surgery is higher than that seen in anatomic spec-
imens in several series (539,548–552,554). Wolfe has noted
that this raises the possibility that septation of the EPB
increases the probability that nonsurgical treatment will
fail. Harvey et al. reported success with one or two steroid
injections in 80% of patients and found separate compart-
ments for the APL and EPB in 10 of 11 wrists that failed
injection and required surgical release (539). It also has
been noted that observations at surgical release suggest that
either one of both subdivisions of the first dorsal compart-
ment may be stenotic (544).
The radial nerve and, to a lesser extent, the radial artery
are at risk for injury during surgical release of the first dor-
sal compartment (451). The radial artery passes diagonally
across the anatomic snuffbox from the volar aspect of the
wrist to the dorsum of the web space deep to the APL,
EPB, and EPL. It is separated from the first dorsal com-
partment by areolar tissue, and usually is not at risk if the
floor of the compartment sheath is not perforated distal to
the radial styloid. The radial nerve, however, has two or
three terminal divisions that lie superficial to the first dor-
sal compartment and must be identified and protected
during the surgical procedure (451,534,547). Radial neu-
roma is a not uncommon complication, and can result in
failure of treatment.
Intersection syndrome is a condition of pain and
swelling in the region of the muscle bellies of the APL and
EPB. As noted by Wolfe, this area lies approximately 4 cm

proximal to the wrist joint, and may show increased
swelling of a normally prominent area (451). In severe
cases, redness and crepitus have been noted. The syndrome
originally was thought to be due to friction and inflamma-
tion between the APL and EPB muscle bellies and the mus-
cle bellies of the ECRL and ECRB (451–455). More
recently, Grundberg and Reagan have demonstrated that
the basic pathologic process appears to be tenosynovitis of
the ECRL and ECRB (455).
EXTENSOR POLLICIS BREVIS
Derivation and Terminology. Extensor is derived from
the Greek and Latin ex, which indicates “out of,” and the
Latin tendere, “to stretch”; thus, extension indicates a motion
to stretch out, and extensor is usually applied to a force or
muscle that is involved in the “stretching out or straighten-
ing out” of a joint. Pollicis is derived from the Latin pollex,
“thumb.” Brevis is the Latin for “short.” Therefore, extensor
pollicis brevis indicates a short thumb extensor (1,2).
Origin. The distal end of the middle third of the radius,
on the medial portion of the posterior surface of the radius
and adjacent interosseous ligament. This origin is distal to
the origins of the APL and EPL. The muscle also may have
origin attachments to the ulna.
Insertion. The base of the proximal phalanx of the
thumb.
Innervation. Posterior interosseous nerve (C7, C8).
Vascular Supply. The posterior interosseous artery, con-
tinuation and the perforating branches of the anterior
interosseous artery. The tendon receives vascularity from
the radial artery in the anatomic snuffbox from branches to
the radial side of the thumb, and from the first dorsal
metacarpal artery and dorsal carpal arch (3,4,11,13).
Principal Action. Extension of the proximal phalanx of
the thumb. It also assists with extension of the thumb
metacarpal.
Gross Anatomic Description: Extensor
Pollicis Brevis
The EPB lies close to the APL, and takes origin from the
radial diaphysis and adjacent interosseous ligament just dis-
tal to that of the APL (see Fig. 2.3B) (3,4,11,13,68). It
comprises one of the many muscles of the dorsal muscle
compartment of the forearm (Appendix 2.2). The area on
the radius includes a portion of the distal part of the mid-
dle third, along the medial border of the dorsal surface.
Approximately half of the origin is also from the adjacent
interosseous ligament. There may be rare attachments to
the adjacent ulna. The muscle fibers converge in a radial
direction toward the thumb, just distal to and adjacent to
the path of the APL. The EPB usually is thinner than the
APL. The EPB along with the APL crosses obliquely and
2 Muscle Anatomy 147
superficially to the ECRB and ECRL. In the distal forearm,
the EPB and APL are superficial to the most distal portion
of the brachioradialis. The myotendinous junction of the
EPB forms just proximal to the extensor retinaculum. The
EPL enters the extensor retinaculum with the APL to com-
prise the first dorsal compartment. [Editor’s note: The dor-
sal compartments of the wrist are as follows: the APL and
EPB comprise the first dorsal compartment; the ECRL and
ECRB form the second; the EPL forms the third; the EDC
and EIP form the fourth; the EDM forms the fifth; and the
ECU forms the sixth (6).] The tendon anatomy and pres-
ence of septa in the first dorsal compartment commonly
show anatomic variations and anomalies (see earlier, under
Abductor Pollicis Longus, Gross Anatomic Description and
Anomalies and Variations). In general, in approximately
24% to 34% of specimens in anatomic studies, the first
compartment has been found to be subdivided by a longi-
tudinal ridge and septum into two distinct osteofibrous
tunnels, the ulnar one for the EPB and the radial one con-
taining one or more slips of the APL (451,541–543). Mus-
cle fibers often extend to the proximal edge of the extensor
retinaculum. In the first dorsal compartment, the tendon is
located on the radial side of the radial metaphysis. The ten-
don is parallel with the ulnar border of the APL tendon,
and together the tendons pass through the fibroosseous
compartment. The EPL then crosses the dorsoradial carpus
to extend distally on the dorsal aspect of the thumb
metacarpal (see Fig. 2.6B). It remains radial to the EPL ten-
don. The EPB then inserts into the base of the proximal
phalanx of the thumb. It also may send slips to the capsule
of the MCP joint (3,4,11,13).
The EPB is innervated by the posterior interosseous
nerve, mostly from C7 with additional contributions from
C8. There usually is a single motor branch that supplies
the EPB. The nerve branch usually arises in common with
or near the nerve to the APL. The nerve may cross the APL
to reach the EPB. The motor nerve to the EPB enters the
muscle in the proximal third, usually along the radial bor-
der (11).
Actions and Biomechanics: Extensor
Pollicis Brevis
The EPB functions mainly to extend the proximal phalanx
of the thumb. Because it crosses the thumb car-
pometacarpal joint, the tendon also assists with extension of
the thumb metacarpal. In addition, at extremes of contrac-
tion, it assists with radial deviation of the wrist (3,4).
Anomalies and Variations: Extensor
Pollicis Brevis
Several variations of the septa and tendon slips in the first
dorsal compartment exist (see earlier, under Anomalies and
Variations: Abductor Pollicis Longus).
148 Systems Anatomy
The EPB is absent in 5% to 7% of individuals
(544,549,550). The EPB may have an anomalous tendon
slip that extends to the base of the thumb distal phalanx as
well the normal insertion into the base of the proximal pha-
lanx. Rarely, it inserts only onto the distal phalanx. The
muscle also may have a tendon slip to the thumb
metacarpal (11,556,557). The EPB may coalesce with the
APL, forming one muscle, and inserts into the thumb
metacarpal (11). The EPB may exist as a double tendon
(11). Rarely, the tendon coalesces with the EPL (3).
Clinical Implications: Extensor Pollicis
Brevis
See also Clinical Implications: Abductor Pollicis Longus.
The EPB and APL are the tendons involved with de
Quervain’s tenosynovitis (see earlier, under Clinical Impli-
cations: Abductor Pollicis Longus). Yuasa and Kiyoshige
have suggested that the EPB is the main tendon involved,
and have demonstrated successful resolution of symptoms
after decompression of the EPB alone (558).
Intersection syndrome is a condition of pain and
swelling in the region of the muscle bellies of the APL and
EPB. As noted by Wolfe, this area lies approximately 4 cm
proximal to the wrist joint, and may show increased
swelling of a normally prominent area (451). In severe
cases, redness and crepitus have been noted. The syndrome
originally was thought to be due to friction and inflamma-
tion between the APL and EPB muscle bellies and the mus-
cle bellies of the ECRL and ECRB (451–455). More
recently, Grundberg and Reagan have demonstrated that
the basic pathologic process appears to be tenosynovitis of
the ECRL and ECRB (455).
EXTENSOR POLLICIS LONGUS
Derivation and Terminology. Extensor derived is from
the Greek and Latin ex, which indicates “out of,” and the
Latin tendere, “to stretch”; thus, extension indicates a motion
to stretch out, and extensor usually is applied to a force or
muscle that is involved in the “stretching out or straighten-
ing out” of a joint. Pollicis is derived from the Latin pollex,
“thumb.” Longus is derived from the Latin longus, indicat-
ing “long.” Therefore, extensor pollicis longus indicates the
long extensor of the thumb (1,2).
Origin. The dorsal middle third of the ulna and adjacent
interosseous ligament.
Insertion. The base of the distal phalanx of the thumb.
Innervation. Posterior interosseous nerve (C7, C8).
Vascular Supply. The posterior interosseous artery,
continuation and the perforating branches of the ante-
rior interosseous artery. The tendon receives vascularity
from the radial artery in the anatomic snuffbox from
branches to the radial side of the thumb, and from the
first dorsal metacarpal artery and dorsal carpal arch (3,4,
11,13,559).
Principal Action. Extension of the distal phalanx of the
thumb. Also contributes to extension of the proximal pha-
lanx and the thumb metacarpal through the MCP and car-
pometacarpal joints, respectively.
Gross Anatomic Description: Extensor
Pollicis Longus
The EPL is a deep extensor of the dorsal forearm situated
between the EIP (ulnarly) and the EPB (radially) (3,4,11,14).
It is one of the many muscles that comprise the dorsal mus-
cle compartment of the forearm (Appendix 2.2). It is much
larger than the EPB. The EPL arises from the dorsal middle
third of the ulna, chiefly on its radial border (see Fig. 2.3B).
In addition, at least half of the muscle takes origin from the
adjacent interosseous ligament. Portions of the muscle also
arise from the septa between the EPL and the EIP and ECU.
The muscle courses obliquely in a radial direction as it
extends distally, in the direction of the thumb. The muscle
fibers converge in a bipenniform manner on the two sides of
a flattened tendon that first appears proximally on the dorsal
surface of the muscle. The EPL is initially deep to the EDC,
crossing obliquely toward the thumb to emerge from the
EDC and enter the extensor retinaculum just radial to the
EDC. The muscle belly usually is fusiform (7,8). The
myotendinous junction is located deep to the EDC, proximal
to the extensor retinaculum, and muscle fibers may continue
with the tendon as far distally as the extensor retinaculum.
The EPL then enters its own fibroosseous tunnel at the exten-
sor retinaculum to form the third dorsal compartment. [Edi-
tor’s note: The dorsal compartments of the wrist are as follows:
the APL and EPB comprise the first dorsal compartment; the
ECRL and ECRB form the second; the EPL forms the third;
the EDC and EIP form the fourth; the EDM forms the fifth;
and the ECU forms the sixth (6).] The path through the third
compartment continues in an oblique direction toward the
thumb. It is stabilized in part by a narrow groove in the distal
radius, and passes ulnar to Lister’s tubercle before taking a
more oblique direction. The tendon in this region appears to
have a slightly smaller cross-sectional area (560), and is rela-
tively poorly vascularized (561). This area also coincides with
an area commonly affected by closed rupture (see later, under
Clinical Implications: Extensor Pollicis Longus). The tendon
exits the third compartment over the distal radius or radio-
carpal joint. It passes across the dorsal surface of the carpus,
superficial to the tendon of the ECRL and ECRB, to the dor-
sum of the thumb metacarpal. It is located ulnar to the EPB,
and, in the region of the radial styloid and scaphoid, the EPL
and EPB form a triangular depression (when the thumb is in
full extension). This depression, referred to as the anatomic
snuffbox, lies over scaphoid, and point tenderness in this area
usually indicates injury to the scaphoid (or possibly the radial
styloid). The EPL remains ulnar to the EPB but becomes

adjacent to the EPB just proximal to the MCP joint. The EPL
tendon continues distally on the dorsal surface of the proxi-
mal phalanx and expands to insert onto the base of the distal
phalanx (see Fig. 2.6B). The tendon becomes an aponeurosis
as it is joined by the tendon of the APB laterally and the first
palmar interosseous and adductor pollicis medially. Together,
the EPL with the thumb intrinsic muscles form the aponeu-
rosis that comprises the extensor mechanism of the thumb
(3,4,11,562).
The EPL is innervated by the posterior interosseous
nerve, chiefly from C7, but also from C8 and C6. There
usually initially is one branch to the EPL that may divide
before entering the muscle belly. The motor branches usu-
ally enter the muscle in the proximal third, usually into the
radial border.
Actions and Biomechanics: Extensor
Pollicis Longus
The EPL functions mainly for extension of the distal pha-
lanx of the thumb. It also contributes to extension of the
proximal phalanx (working with the EPB) and to extension
of the thumb metacarpal (working with the APL) (563). In
extremes of contraction, it can contribute to radial devia-
tion of the wrist. When the thumb is in full extension, the
EPL also can contribute to adducting the thumb toward the
index metacarpal.
Anomalies and Variations: Extensor
Pollicis Longus
Most of the variations of the EPL involve variations in the
distal tendon. There may be an accessory slip to the base of
the carpal bones (especially the capitate), to the index fin-
ger (distal phalanx), to the EPB, or to the extensor retinac-
ulum (11,564–569). A double tendon or double muscle
belly may exist. An accessory EPL in the third dorsal com-
partment has caused dorsal wrist pain that resolved after
excision of the accessory EPL (570).
Extensor communis pollicis et indicis is an anomalous
muscle found in approximately 6% of dissected specimens.
It crosses between the EIP and the EPL. The muscle may
have two tendons that insert into the distal phalanges of the
thumb and the index finger. The muscle may replace the
EPL or EIP (11,564).
Clinical Implications: Extensor Pollicis
Longus
Closed rupture of the EPL is well documented (571–588),
and has been associated with tendon injury after fractures of
the distal radius (589–605), or inflammatory conditions
such as rheumatoid arthritis (590,606,607). Nonunion also
has been associated with EPL ruptures. Ruptures often
occur even after nondisplaced fractures, usually in the
2 Muscle Anatomy 149
region of the distal radius. Engkvist and Lundborg have
shown that in the common area of the rupture, there is a
relatively poorly vascularized portion of tendon (561). In
addition, Wilhelm and Qvick have shown that the cross-
sectional area of the tendon in this area is slightly smaller
(560). These factors may play a role in the closed or delayed
ruptures of the EPL (especially those associated with
nondisplaced fractures, where tendon injury or attrition
from uneven bone edges is unlikely).
In patients with rheumatoid arthritis, the EPL is at risk for
rupture at the level of Lister’s tubercle, due to either chronic
tenosynovitis (590) at the dorsal wrist or local attrition
against the friction point at the tubercle (especially if there is
bony irregularity from chronic arthritis). Closed rupture also
has occurred after use of anabolic steroids (608).
The EPL also is subject to subluxation or dislocation,
usually associated with rupture or damage to the radial side
of the extensor hood on the dorsum of the MCP joint of
the thumb. The EPL subluxates to the ulnar side (609,610).
Dislocation also can occur after fracture of the distal radius
(611,612).
The EPL can be affected by tenosynovitis, or triggering,
as it courses through the third dorsal compartment
(613–616).
ABDUCTOR POLLICIS BREVIS
Derivation and Terminology. Abductor is derived from
the Latin ab, meaning “away from,” and ducere, which
means “to draw”; therefore, abductor is “that which draws
away from.” Pollicis is derived from the Latin pollex,
“thumb.” Brevis is Latin for “short” (1,2). Therefore, abduc-
tor pollicis brevis indicates a short thumb abductor.
Origin. From the flexor retinaculum, scaphoid tubercle,
trapezial ridge or tubercle.
Insertion. To the base of the thumb proximal phalanx,
palmar surface.
Innervation. Recurrent branch of the median nerve (C8,
T1).
Vascular Supply. The radial artery and superficial palmar
arch.
Principal Action. Palmar abduction of the thumb (pulling
the thumb away from the palm) at right angles to the palm.
In addition, the APB contributes to flexion of the proximal
phalanx of the thumb. Through the superficial layer of the
APB that continues distally and dorsally to reach the EPL,
the APB contributes to extension of the thumb distal phalanx
as part of the extensor mechanism (3,4,68).
Gross Anatomic Description: Abductor
Pollicis Brevis
The APB, along with the opponens pollicis, FPB, and
adductor pollicis, comprises one of the thenar muscles (3,4,
150 Systems Anatomy

11,13,68). In terms of muscle compartments, it is one of
the three muscles that comprise the thenar muscle com-
partment of the hand. (The adductor pollicis has a separate
compartment, Appendix 2.2). The APB is located subcuta-
neously on the radial aspect of the thenar eminence, and
constitutes the shape and contour of the radial border of the
thenar eminence. The muscle is flat and broad, and covers
the opponens pollicis and approximately 30% of the FPB.
The ABP arises mostly from the flexor retinaculum (see Fig.
2.6A). Fibers also arise from the scaphoid tubercle, the
trapezial tubercle, and possibly from the terminal tendon or
tendon sheath of the APL, as the APL inserts onto the base
of the thumb metacarpal (496,617). The muscle courses
distally and radially toward the thumb, located as a superfi-
cial thenar muscle, in line with the thumb metacarpal. The
muscle fibers converge into a flat tendon. It joins the fibers
of the FPB. The muscle of the APB often consists of two
layers or bellies, a deep (or medial layer) and a superficial
(or lateral) layer. The deep layer inserts onto the radial
sesamoid and radial side of the base of the proximal phalanx
of the thumb (see Fig. 2.6A). The superficial layer contin-
ues radially and dorsally to join the aponeurosis of the EPL
as part of the extensor mechanism of the thumb.
The APB is innervated by the recurrent branch of the
median nerve. This usually is the first branch from the lat-
eral side of the median nerve in the hand. The nerve
receives contributions mostly from T1 and C8. The nerve
takes a recurrent course proximally and laterally superficial
to or through the superficial division of the FPB and enters
the deep surface of the APB in the middle third near its
ulnar border (11).
Actions and Biomechanics: Abductor
Pollicis Brevis
The APB functions mainly to provide palmar abduction of
the thumb (pulling the thumb away from the palm, at right
angles to the palm. The APB also contributes to flexion of
the proximal phalanx of the thumb. A superficial layer of
the distal tendon of the APB continues radially and dorsally
past the MCP joint of the thumb to reach and attach to the
tendon of the EPL. Through this aponeurosis, the APB
becomes part of the extensor mechanism of the thumb and
contributes to extension of the distal phalanx of the thumb.
Its extensor function of the distal phalanx is relatively weak
(496).
From architectural studies on the muscle’s physiologic
cross-sectional area, muscle length, muscle fiber length, and
muscle mass, it can be seen that the muscle architecture is
fairly close to that of the other thenar muscles (466). It there-
fore would have similar relative abilities for force generation,
velocity, and excursion (466) (Table 2.4 and Fig. 2.13).

TABLE 2.4. ARCHITECTURAL FEATURES OF INTRINSIC MUSCLES OF THE HAND

Muscle Muscle Mass Muscle Length Fiber Length Pennation Angle Cross-Sectional Area Fiber Length/
(n = 9) (g) (mm) (mm) (Degrees) (cm2) Muscle Length Ratio

ADM 3.32 ± 1.67 68.4 ± 6.5 46.2 ± 7.2 3.9 ± 1.3 0.89 ± 0.49 0.68 ± 0.10
APB 2.61 ± 1.19 60.4 ± 6.6 41.6 ± 5.6 4.6 ± 1.9 0.68 ± 0.28 0.69 ± 0.09
APL 9.96 ± 2.01 160.4 ± 15.0 58.1 ± 7.4 7.5 ± 2.0 1.93 ± 0.59 0.36 ± 0.05
AP 6.78 ± 1.84 54.6 ± 8.9 34.0 ± 7.5 17.3 ± 3.4 1.94 ± 0.39 0.63 ± 0.15
DI 1 4.67 ± 1.17 61.9 ± 2.5 31.7 ± 2.8 9.2 ± 2.6 1.50 ± 0.40 0.51 ± 0.05
DI 2 2.65 ± 1.01 62.8 ± 8.1 25.1 ± 6.3 8.2 ± 3.1 1.34 ± 0.77 0.41 ± 0.13
DI 3 2.01 ± 0.60 54.9 ± 4.6 25.8 ± 3.4 9.8 ± 2.8 0.95 ± 0.45 0.47 ± 0.07
DI 4 1.90 ± 0.62 50.1 ± 5.3 25.8 ± 3.4 9.4 ± 4.2 0.91 ± 0.38 0.52 ± 0.11
EPB 2.25 ± 1.36 105.6 ± 22.5 55.0 ± 7.5 7.2 ± 4.4 0.47 ± 0.32 0.54 ± 0.13
FDM 1.54 ± 0.44 59.2 ± 10.4 40.6 ± 13.7 3.6 ± 1.0 0.54 ± 0.36 0.67 ± 0.17
FPB 2.58 ± 0.56 57.2 ± 3.7 41.5 ± 5.2 6.2 ± 4.5 0.66 ± 0.20 0.73 ± 0.08
Lum 1 0.57 ± 0.19 64.9 ± 10.0 55.4 ± 10.2 1.2 ± 0.9 0.11 ± 0.03 0.85 ± 0.03
Lum 2 0.39 ± 0.22 61.2 ± 17.8 55.5 ± 17.7 1.6 ± 1.3 0.08 ± 0.04 0.90 ± 0.05
Lum 3 0.37 ± 0.16 64.3 ± 8.9 56.2 ± 10.7 1.1 ± 0.8 0.08 ± 0.04 0.87 ± 0.07
Lum 4 0.23 ± 0.11 53.8 ± 11.5 50.1 ± 8.4 0.7 ± 1.0 0.06 ± 0.03 0.90 ± 0.05
ODM 1.94 ± 0.98 47.2 ± 3.6 19.5 ± 4.1 7.7 ± 2.9 1.10 ± 0.43 0.41 ± 0.09
OP 3.51 ± 0.89 55.5 ± 5.0 35.5 ± 5.1 4.9 ± 2.5 1.02 ± 0.35 0.64 ± 0.07
PI 2 1.56 ± 0.22 55.1 ± 5.0 25.0 ± 5.0 6.3 ± 2.2 0.75 ± 0.25 0.45 ± 0.08
PI 3 1.28 ± 0.28 48.2 ± 2.9 26.0 ± 4.3 7.7 ± 3.9 0.65 ± 0.26 0.54 ± 0.08
PI 4 1.19 ± 0.33 45.3 ± 5.8 23.6 ± 2.6 8.2 ± 3.5 0.61 ± 0.23 0.52 ± 0.10

ADM, abductor digiti minimi; APB, abductor pollicis brevis; APL, abductor pollicis longus; AP, adductor pollicis; DI 1–4, dorsal interosseous
muscles; EPB, extensor pollicis brevis; FDM, flexor digiti minimi; FPB, flexor pollicis brevis; Lum 1–4, lumbrical muscles; ODM, opponens digiti
minimi; OP, opponens pollicis; PI 2–4, palmar interosseous muscles.
Values represent mean ± standard deviation.
Reproduced from Jacobson MD, Raab R, Fazeli BM, et al. Architectural design of the human intrinsic hand muscles. J Hand Surg [Am]
17:804–809, 1992, with permission.
 2 Muscle Anatomy 151

A B

C D

E
FIGURE 2.13. Architectural features of the intrinsic muscles of the hand. A: Intrinsic muscle
lengths. Note the short, uniform lengths. B: Intrinsic muscle fiber lengths. There is more dispar-
ity in fiber length than in muscle length. This illustrates the relatively large excursions of the rel-
atively short intrinsic muscles. C: Intrinsic muscle masses. The intrinsic muscles have low masses,
with the exception of the first dorsal interosseous (DI1) and the AddP. D: Intrinsic muscle cross-
sectional areas. The interossei have greater cross-sectional areas than the smaller lumbrical mus-
cles, and in general the lumbrical fibers are longer. This would indicate that the lumbricals are
designed more for excursion or velocity and less for force generation. E: Intrinsic muscle fiber
length/muscle length (FL/ML) ratios. Note the high FL/ML ratio of the intrinsic muscles, especially
the lumbricals, demonstrating their relative design for excursion and velocity. The lumbricals
have among the highest FL/ML ratios of all muscles studied (both extrinsic and intrinsic), and this
indicates their specialization for excursion (and velocity) and their relatively poor design for force
production. Bars represent mean ± standard deviation (SEM). AbDM, abductor digiti minimi;
AbPB, abductor pollicis brevis; AbPL, abductor pollicis longus; AddP, adductor pollicis; DI1–DI4,
dorsal interosseous muscles 1–4; EPB, extensor pollicis brevis; FDM, flexor digiti minimi; FPB,
flexor pollicis brevis; L1–L4, lumbrical muscles 1–4; ODM, opponens digiti minimi; OpP, opponens
pollicis; PI2–PI4, palmar interosseous muscles 2–4. (From Jacobson MD, Raab R, Fazeli BM, et al.
Architectural design of the human intrinsic hand muscles. J Hand Surg [Am] 17:804–809, 1992,
with permission.)
152 Systems Anatomy
Anomalies and Variations: Abductor
Pollicis Brevis
The APB may have two separate heads (besides the two dis-
tal layers, as discussed previously) (11). The APB may be
absent (11,618).
The muscle may have attachments to several other
neighboring structures. These include the scaphoid, the
radial styloid, the adductor pollicis, the EPL or EPB, oppo-
nens pollicis, palmaris longus, ECRL (accessory ECR), or
FPL (11,619,620). An entire third head may arise from the
opponens pollicis (11).
Clinical Implications: Abductor Pollicis
Brevis
Paralysis or laceration of the distal median nerve usually
results in thenar paralysis (as well as loss of sensibility on
the radiopalmar hand). Loss of thenar function results in
difficulty with attempted palmar abduction of the thumb
(bringing the thumb out of the palm). Therefore, despite
functioning of the adductor pollicis and FPL, thumb
opposition with the digits remains difficult. To restore
thumb opposition, several opponensplasty procedures
have been described. Muscles used for transfer for oppo-
nensplasty include the EIP, the FDS to the ring finger, the
abductor digiti minimi (Huber transfer), or the palmaris
longus elongated by a strip of the palmar fascia (Camitz or
Braun transfer, more commonly used with severe carpal
tunnel syndrome and thenar dysfunction) (266–272,
621–624).
FLEXOR POLLICIS BREVIS
Derivation and Terminology. Flexor is derived from the
Latin flexus, indicating “bent” (and flexor, which indicates
“that which bends,” or “bending”). Pollicis is derived from
the Latin pollex, “thumb.” Brevis is the Latin for “short.”
Therefore, flexor pollicis brevis indicates a short thumb
flexor (1,2).
Origin. From two heads, superficial and deep. Superfi-
cial head: from the trapezium, adjacent flexor retinaculum,
and the tendon sheath of the FCR. Deep head: from the
trapezoid and capitate, and from the palmar ligament from
the distal carpal row.
Insertion. Superficial head: to the radial side of the ante-
rior aspect of the proximal thumb phalanx. Deep head:
inserts into a tendon that connects with the superficial
head.
Innervation. Variable; classically, the recurrent branch of
the median nerve supplies the superficial head; the terminal
branch of the ulnar nerve supplies the deep head. Either
head may be supplied by either the recurrent branch of the
median nerve or by the ulnar nerve (see later).
Vascular Supply. The radial artery, superficial palmar
branch, branches from the opponens pollicis, and the radi-
alis indicis (3,4,11).
Principal Action. Flexion of the MCP joint of the
thumb.
Gross Anatomic Description: Flexor
Pollicis Brevis
The FPB lies medial and slightly deep to the APB (3,4,7,8).
It helps comprise the thenar muscle compartment of the
hand (Appendix 2.2). It has two heads, a superficial and a
deep (625). The superficial head arises from the distal bor-
der of the flexor retinaculum and the distal part of the
tubercle of the trapezium (see Fig. 2.6A). The superficial
head also may have origin attachments to the tendon sheath
of the FCR. The superficial head courses obliquely toward
the base of the thumb to reach the radial side of the base of
the proximal phalanx (Fig. 2.6A).
The deep head arises from the trapezoid and capitate and
from the palmar ligaments of the distal row of the carpus
(see Fig. 2.6A). The deep head passes deep to the tendon of
the FPL and joins the superficial head on the sesamoid bone
and base of the first phalanx.
An additional muscle head or fascicle has been described
by Tountas and Bergman (11). It arises from the ulnar side
of the base of the thumb metacarpal and the adjacent carpal
ligaments. It inserts onto the ulnar side of the base of the
proximal phalanx (see Fig. 2.6A). This fascicle sometimes is
considered to be the deep head of the FPB. It is closely
joined to the carpal head of the adductor pollicis, and the
two muscles share a common tendon. Some fibers of the
medial division of the tendon may be traced into the
aponeurosis of the extensor tendon. It has been suggested
that this portion of the muscle represents a first palmar
interosseous. This component of the FPB remains contro-
versial (11).
The architectural features of the muscle are listed in
Table 2.4.
The innervation of the FPB appears to be quite variable
(625). Classic descriptions suggest that the superficial head
usually is supplied by the lateral terminal branch of the
median nerve, and the deep head by the deep branch of the
ulnar nerve (3,4,68). More recently, the variable innerva-
tion has been described, and various combinations exist.
The muscle usually is supplied chiefly by branches that
originate from the recurrent branch of the median nerve.
The branch penetrates the muscle in the region of the
carpal tunnel. Additional branches derived from the ulnar
nerve also often are found, and usually supply the deep
portion. Contributions from both the median and ulnar
nerve were found in 19 of 29 cases. In 5 cases, the median
nerve alone supplied FPB, and in 5 the ulnar nerve alone
supplied the FPB muscles. In addition, when evaluating

innervation specifically of the deep head, the deep head
was supplied by the ulnar nerve in 16 of 24 cases, by the
median nerve in 3 of 24 cases, and by both nerves in 5 of
24 cases (11,625).
Actions and Biomechanics: Flexor Pollicis
Brevis
The FPB functions primarily to provide flexion of the MCP
joint of the thumb, as well as flexion of the carpometacarpal
joint of the thumb. It also contributes to rotation of the
thumb in the medial direction (in preparation for opposi-
tion). From its contributions into the extensor mechanism
of the thumb, the FPB contributes to extension of the dis-
tal phalanx of the thumb (3,4,68).
Anomalies and Variations: Flexor Pollicis
Brevis
A relatively common observation is the coalescing of the
superficial head with the opponens pollicis. The deep head
is variable in size and may be absent. The entire FPB may
be absent (11).
Clinical Implications: Flexor Pollicis
Brevis
Paralysis or laceration of the distal median nerve usually
results in thenar paralysis (as well as loss of sensibility on
the radiopalmar hand). Loss of thenar function results in
difficulty with attempted palmar abduction of the thumb
(bringing the thumb out of the palm). Therefore, despite
functioning of the adductor pollicis and FPL, thumb
opposition with the digits remains difficult. To restore
thumb opposition, several opponensplasty procedures have
been described. Muscles used for transfer for opponen-
splasty include the EIP, the FDS to the ring finger, the
abductor digiti minimi (Huber transfer), or the palmaris
longus elongated by a strip of the palmar fascia (Camitz or
Braun transfer, more commonly used with severe carpal
tunnel syndrome and thenar dysfunction) (266–272,
621–624).
OPPONENS POLLICIS
Derivation and Terminology. Opponens is the Latin indi-
cating the movement against or toward an opposing struc-
ture. Pollicis is derived from the Latin pollex, “thumb” (1,2).
Origin. From the tubercle of the trapezium and from the
flexor retinaculum.
Insertion. To the radial and palmar aspect of the thumb
metacarpal.
2 Muscle Anatomy 153
Innervation. Recurrent branch of the median nerve (T1
and C8). A branch from the deep branch of the ulnar nerve
also may contribute.
Vascular Supply. The radial artery, superficial palmar
branch, first palmar metacarpal artery, arteria princeps polli-
cis, arteria radialis indicis, deep palmar arch (3,4,11,13,14).
Principal Action. Flexion, adduction, and median rota-
tion of the thumb metacarpal (contributing to the motion
of opposition).
Gross Anatomic Description: Opponens
Pollicis
The opponens pollicis is a deep thenar muscle covered ante-
riorly by the APB (Appendix 2.2). It originates from the
tubercle of the trapezium and from the flexor retinaculum
(see Fig. 2.6A). It courses obliquely toward the thumb
metacarpal to insert onto the lateral and anterior aspects of
the diaphysis of the thumb metacarpal (see Fig. 2.6A). The
muscle usually covers the entire lateral part of the palmar
surface of the shaft (3,4).
The architectural features of the muscle are listed in
Table 2.4.
The opponens pollicis is innervated by the recurrent
branch of the median nerve. The branch takes a recurrent
course proximally and laterally, superficial to or through the
superficial divisions of the FPB near its origin. The nerve
provides one or two branches that enter the palmar surface
of the proximal third of the opponens pollicis near its ulnar
border (11). The nerve arises from C6, C7, and C8. As with
the FPB, the deep branch of the ulnar nerve can provide
various contributions. A double innervation of both the
recurrent branch of the median nerve and the deep branch
of the ulnar nerve was noted in 92 of 120 hands (625–627).
Because of the frequent duel innervation, it has been sug-
gested that double innervation with the median and ulnar
nerves be considered the normal (3).
Actions and Biomechanics: Opponens
Pollicis
The opponens pollicis functions mainly to provide flexion,
adduction, and medical rotation of the thumb metacarpal
(contributing to the motion of opposition) (3,4). Opposi-
tion occurs when the thumb is flexed, palmarly abducted,
and rotated medially so that the palmar surface of the
thumb opposes the palmar surface of the digits.
The opponens pollicis does not cross the MCP joint (as
does the APB and FPB), and therefore does not contribute
to flexion of the proximal phalanx of the thumb.
Anomalies and Variations: Opponens
Pollicis
The opponens pollicis may coalesce with the FPB (11). Two
heads of the opponens pollicis may be present (11). Com-
plete absence has been reported, but is rare (11).
154 Systems Anatomy
Clinical Implications: Opponens Pollicis
Paralysis or laceration of the distal median nerve usually
results in thenar paralysis (as well as loss of sensibility on the
radiopalmar hand). Loss of thenar function results in diffi-
culty with attempted palmar abduction of the thumb
(bringing the thumb out of the palm). Therefore, despite
functioning of the adductor pollicis and FPL, thumb oppo-
sition with the digits remains difficult. To restore thumb
opposition, several opponensplasty procedures have been
described. Muscles used for transfer for opponensplasty
include the EIP, the FDS to the ring finger, the abductor
digiti minimi (Huber transfer), or the palmaris longus elon-
gated by a strip of the palmar fascia (Camitz or Braun trans-
fer, more commonly used with severe carpal tunnel syn-
drome and thenar dysfunction) (266–272,621–624).
ADDUCTOR POLLICIS
Derivation and Terminology. Adductor is derived from
the Latin adducere, which means “to draw toward.” Pollicis
is derived from the Latin pollex, “thumb” (1,2).
Origin. Two heads. Oblique head: arises from the capi-
tate, bases of the second and third metacarpals, intercarpal
ligaments, and sheath of the FCR. Transverse head: arises
from the distal two-thirds of the palmar surface of the third
metacarpal.
Insertion. Oblique and transverse heads unite to insert
into ulnar side of the base of the proximal phalanx of the
thumb.
Innervation. Deep branch of the ulnar nerve (C8, T1).
Vascular Supply. Arteria princeps pollicis, arteria radialis
indicis, or combined artery as the first palmar metacarpal
artery, deep palmar arch (3,4,11).
Principal Action. Moves the thumb proximal phalanx
from an abducted position toward the palm of the hand. It
therefore adducts the thumb proximal phalanx. It also
assists with adduction of the thumb metacarpal.
Gross Anatomic Description: Adductor
Pollicis
The adductor pollicis lies deep to the extrinsic flexor ten-
dons and radial lumbricals. It occupies its own muscle com-
partment (Appendix 2.2). The muscle consists of two
heads, an oblique and a transverse. The oblique head (carpal
head) takes origin from several slips, including the palmar
capitate, the base of the second and third metacarpals, the
intercarpal ligaments, the sheath of the FCR, and possibly
from a slip from the flexor retinaculum (3,4,7,8,11,13,14)
(see Fig. 2.6A). From this origin, the muscle fibers converge
and pass distally and radially toward the base of the proxi-
mal phalanx of the thumb. The fibers converge into a com-
mon tendon (joined by the transverse head). The tendon
usually contains a sesamoid bone. The tendon inserts into
the ulnar side of the base of the proximal phalanx of the
thumb (see Fig. 2.6A). Additional fibers may pass more
obliquely deep to the tendon of the FPL to attach to the lat-
eral portion of the FPB and the APB (3,4).
The transverse head (deep head, metacarpal head) arises
from the long finger metacarpal. Its origin is a broad attach-
ment that includes the distal two-thirds of the palmar sur-
face of the long metacarpal along the palmar ridge. It also
may arise from the deep palmar fascia of the third inter-
space and, occasionally, from the deep fascia of the fourth
interspace and from the capsules of the second, third, and
fourth MCP joints. It is more deeply situated than the
thenar muscles. The transverse head is triangular and con-
verges in a radial direction toward the base of the proximal
phalanx of the thumb. Its distal border usually lies trans-
verse to the axis of the upper limb. The tendon continues
toward the proximal thumb phalanx to join the tendon of
the oblique head. The common tendon inserts onto the
ulnar side of the base of the proximal phalanx of the thumb
(3,4,7,8,11,13,14) (Fig. 2.6A). A sesamoid bone usually is
found in the tendon, just proximal to the MCP joint.
The architectural features of the muscle are listed in
Table 2.4.
The adductor pollicis is innervated by the deep branch
of the ulnar nerve, from T1 and C8. The deep branch of the
ulnar nerve, along with the deep palmar arterial arch, passes
through the interval created between the oblique and trans-
verse heads of the muscle (3,4).
Actions and Biomechanics: Adductor
Pollicis
The two heads usually work together. The muscle moves
the thumb proximal phalanx from an abducted position
toward the palm of the hand. It therefore adducts the
thumb proximal phalanx. It also assists with adduction of
the thumb metacarpal. The adductor pollicis works with
greatest advantage when the thumb is abducted (3,4,11).
Anomalies and Variations: Adductor
Pollicis
The two heads of the adductor pollicis vary in size. The two
heads can be coalesced to various degrees. The muscle also
can be split into additional bellies (11).
The transversus manum muscle is an anomalous muscle
closely related to the adductor pollicis. It arises from the
palmar MCP ligaments and connects to the base of the
thumb proximal phalanx, or in its vicinity (11).
Clinical Implications: Adductor Pollicis
The adductor pollicis may contribute to thumb-in-palm
deformity in patients with muscle spasticity (cerebral palsy,

traumatic brain injury, stroke). Release of the origin of the
adductor pollicis (muscle recession) often is incorporated in
muscles lengthened or released to help correct the defor-
mity. Care must be taken to protect the deep palmar arter-
ial arch and the deep branch of the ulnar nerve, both of
which pass through the interval created by the two heads of
the muscle.
PALMARIS BREVIS
Derivation and Terminology. Palmaris is derived from
the Latin palma, which means “pertaining to the palm.”
Brevis is the Latin for “short” (1,2).
Origin. From the flexor retinaculum and medial border
of the central part of the palmar fascia.
Insertion. Inserts into dermis on the ulnar border of the
hand.
Vascular Supply. The superficial palmar arch.
Principal Action. The palmaris brevis wrinkles the skin
on the ulnar side of the palm of the hand. It deepens the
hollow of the palm by accentuating the hypothenar emi-
nence.
Gross Anatomic Description: Palmaris
Brevis
The palmaris brevis is a small, thin muscle located in the
skin and subcutaneous tissue of the ulnar palm. It is quad-
rangular and arises from the flexor retinaculum and medial
border of the central part of the palmar aponeurosis. The
fibers are perpendicular to the axis of the upper extremity,
and insert into the dermis on the ulnar border of the hand.
This muscle is superficial to the ulnar artery and terminal
branches of the ulnar nerve (3,4,11).
The palmaris brevis is innervated by the superficial
branch of the ulnar nerve, from C8 and T1.
Actions and Biomechanics: Palmaris
Brevis
In wrinkling the skin on the ulnar side of the palm of the
hand and deepening the hollow of the palm, the palmaris
brevis may assist with cupping the hands for holding
water and may contribute to the security of the palmar
grip (3).
ABDUCTOR DIGITI MINIMI (ABDUCTOR
DIGITI QUINTI)
Derivation and Terminology. Abductor is derived form
the Latin ab, meaning “away from,” and ducere, which
means “to draw”; therefore, abductor is “that which draws
away from.” Digiti is the plural of the Latin digitus, “digit.”
2 Muscle Anatomy 155
Minimi is from the Latin minima or minimum, indicating
the smallest. Abductor digiti minimi therefore indicates the
abductor of the smallest digit(s). Quinti is from the Latin
quintus, indicating “fifth.” Therefore, the abductor digiti
quinti is the abductor of the fifth digit (1,2).
Origin. From the pisiform, terminal tendon of the FCU,
and the pisohamate ligament.
Insertion. Two slips: one slip to the ulnar side of the base
of the proximal phalanx of the small finger. The other slip
continues dorsally to the ulnar border of the dorsal digital
aponeurosis of the EDM.
Innervation. Deep branch of the ulnar nerve (C8, T1).
Vascular Supply. The ulnar artery, deep palmar branch,
ulnar end of the superficial palmar arch, palmar digital
artery (3,4,7,8,11,13,14).
Principal Action. Abduction of the small finger (proxi-
mal phalanx) from the ring finger (thus spreading the
fourth web space when the digits are extended). Through
its contribution to the extensor mechanism, the abductor
digiti minimi may contribute to extension of the middle
phalanx (and possibly of the distal phalanx) of the small
finger.
Gross Anatomic Description: Abductor
Digiti Minimi
The abductor digiti minimi is the most medial of the three
hypothenar muscles (which also include the flexor digiti
minimi and opponens digiti minimi; Appendix 2.2). The
abductor digiti minimi lies on the ulnar border of the
palm. The muscle arises from the pisiform, from the FCU
(at the FCU insertion), and from the pisohamate ligament
(496) (see Fig. 2.6A). The muscle extends distally along
the ulnar palm and splits into two slips. One slip inserts
into the ulnar side of the base of the proximal phalanx of
the small finger (see Fig. 2.6A). The other slip continues
distally and dorsally to join the ulnar border of the EDM
(in the dorsal digital aponeurosis) so that it contributes to
the extensor mechanism of the digits (3,4,7,8,11,13,14).
The architectural features of the muscle are listed in Table
2.4.
Actions and Biomechanics: Abductor
Digiti Minimi
The abductor digiti minimi functions mainly to provide
abduction of the small finger (proximal phalanx) from the
ring finger (thus spreading the fourth web space when the
digits are extended). It also provides some abduction when
the digits are tightly adducted in flexion and extension.
Through its connection to the extensor mechanism
(through the ulnar dorsal slip), the abductor digiti minimi
may contribute to extension of the middle phalanx (and
possibly of the distal phalanx) of the small finger (3,4,7,8,
11,13,14).
156 Systems Anatomy
Anomalies and Variations: Abductor
Digiti Minimi
Accessory slips may join the muscle from the tendon of the
FCU, the flexor retinaculum, the fascia of the distal fore-
arm, or the tendon of the palmaris longus (11). A part of
the muscle may insert onto the metacarpal of the small fin-
ger (11).
Clinical Implications: Abductor Digiti
Minimi
The abductor digiti minimi can be used to help restore
thumb opposition as a donor muscle for opponensplasty.
This transfer often is referred to as the Huber transfer,
described in 1921 (621–624).
FLEXOR DIGITI MINIMI (FLEXOR DIGITI
MINIMI BREVIS)
Derivation and Terminology. Flexor is derived from the
Latin flexus, indicating “bent” (and flexor, which indicates
“that which bends,” or “bending”). Digiti is the plural of
the Latin digitus, “digit.” Minimi is from the Latin minima
or minimum, indicating “the smallest.” Brevis is the Latin
for “short.” Flexor digiti minimi therefore indicates the short
flexor of the smallest digit(s) (1,2).
Origin. From the hook of the hamate and flexor retinac-
ulum.
Insertion. To the ulnar aspect of the base of the proximal
phalanx of the small finger.
Innervation. Deep branch of the ulnar nerve (T1, C8).
Vascular Supply. The ulnar artery, deep palmar branch,
ulnar end of the superficial palmar arch, palmar digital
artery (3,4,11).
Principal Action. Flexion of the proximal phalanx of the
small finger.
Gross Anatomic Description: Flexor Digiti
Minimi
The flexor digiti minimi, along with the abductor digiti
minimi and opponens digiti minimi, helps form the
hypothenar muscles (Appendix 2.2). The muscle lies deep
and adjacent to the abductor digiti minimi, along the radial
border of the abductor and coursing in the same direction.
The muscle takes origin from the convex surface of the
hook of the hamate and the palmar surface of the flexor
retinaculum (see Fig. 2.6A). The point of origin is slightly
more distal than that of the abductor digiti minimi. The
muscle extends distally in the same direction and plane as
the abductor digiti minimi to reach the insertion at the
ulnar side of the base of the proximal phalanx of the small
finger. The muscle inserts onto the lateral tubercle of the
proximal phalanx (see Fig. 2.6A). The insertion also is adja-
cent to that of the abductor digiti minimi, but located
slightly palmar. By this more palmar insertion point, the
muscle exerts a flexor force on the proximal phalanx. The
flexor digiti minimi is separated from the abductor digiti
minimi at its origin by the deep branches of the ulnar nerve
and ulnar artery (3,4,7,8,11,13,14). The architectural fea-
tures of the muscle are listed in Table 2.4.
Actions and Biomechanics: Flexor Digiti
Minimi
The flexor digiti minimi functions mainly to provide flex-
ion of the proximal phalanx at the MCP joint. It may assist
with lateral rotation of the proximal phalanx (3,4,11,13,
14). As noted earlier, because the flexor digit minimi inserts
onto the proximal phalanx at a point adjacent to but more
palmar than that of the abductor digiti minimi, the flexor
digiti minimi is able to exert a flexor force on the proximal
phalanx.
Anomalies and Variations: Flexor Digiti
Minimi
The flexor digiti minimi may be very small. If so, the
abductor digiti minimi usually is larger than normal (11).
The flexor digiti minimi may be absent (11). The flexor
digiti minimi may coalesce with the abductor digiti minimi
(11). The flexor digiti minimi may have a tendinous slip
that attaches to the metacarpal of the small finger (11).
OPPONENS DIGITI MINIMI
Derivation and Terminology. Opponens is the Latin term
indicating movement against or toward an opposing struc-
ture. Digiti is the plural of the Latin digitus, “digit.” Minimi
is from the Latin minima or minimum, indicating “the
smallest” (1,2).
Origin. The hook of the hamate and adjacent flexor reti-
naculum.
Insertion. The ulnar and anterior margin of the
metacarpal of the small finger.
Innervation. Deep branch of the ulnar nerve.
Vascular Supply. Ulnar artery, deep palmar branch,
medial end of the deep palmar arch (3,4).
Principal Action. Opposition of the small finger to the
thumb. This is a combination movement of abduction,
flexion, and lateral rotation of the metacarpal of the small
finger. It thereby brings the small finger in opposition to the
thumb.
Gross Anatomic Description: Opponens
Digiti Minimi
The opponens digiti minimi, along with the abductor dig-
iti minimi, and flexor digiti minimi, form the hypothenar

muscles (Appendix 2.2). The opponens digiti minimi lies
deep to the flexor digiti minimi and abductor digiti minimi
(3,4,7,8,11,13,14). It is triangular, broad at its base and
tapering to an apex distally. The muscle arises from the con-
vex surface of the hook of the hamate, the adjacent pisoha-
mate ligament, and the adjacent part of the palmar surface
of the flexor retinaculum (496) (see Fig. 2.6A). The muscle
becomes wider distally, to form a wide expansion for its
insertion. The muscle inserts along most of the ulnopalmar
surface of the diaphysis of the small finger metacarpal (see
Fig. 2.6A).
The architectural features of the muscle are listed in
Table 2.4.
The opponens digiti minimi is innervated by the deep
branch of the ulnar nerve, containing fibers from T1 and
from C8.
Actions and Biomechanics: Opponens
Digiti Minimi
The opponens digiti minimi permits opposition of the
small finger to the thumb. This is a combination movement
of abduction, flexion, and lateral rotation of the metacarpal
of the small finger. It thereby brings the small finger in
opposition to the thumb. This motion also is referred to as
supination of the small finger (496). Unlike the flexor digiti
minimi and abductor digiti minimi, the opponens digiti
minimi does not normally cross the MCP joint, and there-
fore does not act on the proximal phalanx of the small fin-
ger (3,4,7,8,11,13,14).
Anomalies and Variations: Opponens
Digiti Minimi
The opponens digiti minimi may be divided into two lay-
ers by the deep branches of the ulnar artery and ulnar nerve
(11). The opponens digiti minimi may coalesce with the
abductor digiti minimi or the flexor digiti minimi (11).
LUMBRICALS
Derivation and Terminology. Lumbrical is derived from
the Greek lumbricus, which means “earthworm.” The lum-
brical muscles resemble the earthworm in shape, size, and
color (1,2).
Origin. From the FDP tendon.
Insertion. To the tendinous expansion of the EDC (into
the extensor hood).
Innervation. The first and second lumbricals are inner-
vated by the median nerve (C8, T1). The third and fourth
are innervated by the deep branch of the ulnar nerve (C8,
T1). The third may receive variable innervation from the
median or ulnar nerve (3,4,628).
Vascular Supply. First and second lumbricals: first and
second dorsal metacarpal and dorsal digital arteries; arteria
2 Muscle Anatomy 157
radialis indicis, first common palmar digital artery. Third
and fourth lumbricals: second and third common palmar
digital arteries, third and fourth dorsal digital arteries and
their anastomoses with the palmar digital arteries (3,4).
Principal Action. Through the extensor mechanism, the
lumbricals function to provide extension at the PIP and
DIP joints. In addition, they provide assistance with flexion
of the MCP joint (629–634).
Gross Anatomic Description: Lumbricals
The lumbricals consist of four small, somewhat cylindrical
muscle bellies. They arise from the FDP tendons and insert
into the extensor hood. The muscles lie in the central pal-
mar compartment of the hand (Appendix 2.2; see Table
2.4). The first and second lumbricals take origin from the
radial sides and palmar surfaces of the FDP tendons of the
index and long finger, respectively (3,4,7,8,11,13,14). The
third lumbrical arises from the adjacent sides of the FDP
tendons of the long and ring fingers. The fourth lumbrical
arises from the adjacent sides of the FDP tendons of the
ring and small fingers. The muscles pass volar to the deep
transverse metacarpal ligament. Each lumbrical passes to
the radial side of the corresponding digit. At the level of the
MCP joint, the tendon of each lumbrical passes in a dorsal
direction to reach the radial lateral bands of the extensor
mechanism. The tendon of each muscle approaches the
digit at approximately a 40-degree angle before insertion
into the radial lateral band (484) (see Fig. 2.9).
The lumbricals are unique in that they originate from a
flexor tendon in the palm and insert into the dorsal aponeu-
rosis on the radial side of the four digits. These functions
have been studied and discussed in detail by von Schroeder
and Botte and Lieber and colleagues (466,496). Because the
lumbricals originate on the flexor side and insert into the
extensor side of the fingers, they provide unique proprio-
ceptive sensory information.
Each lumbrical muscle also is unique in that, by origi-
nating from the FDP tendon, it is the only muscle that is
able to relax the tendon of its own antagonist (484). Smith
has recommended that when considering lumbrical action,
it is best not to focus on its origin and insertion, but rather
on its two attachments—to the profundus tendon and to
the lateral band. Thus, if the profundus contracts and the
lumbrical relaxes, the interphalangeal joints of the fingers
flex. If the profundus is relaxed, contraction of the lumbri-
cal pulls the lateral band proximally and the profundus ten-
don distally. Thus, the flexion or tension of the profundus
is lessened, and the lumbrical is able to extend the proximal
and interphalangeal joints (484). Hence, the lumbrical has
relaxed its own antagonist. When both the profundus and
the lumbrical contract, the interphalangeal joints and MCP
flex simultaneously (484,617,631,632,635–637).
In addition, the lumbricals have a unique architectural
design. Their muscle fibers extend 85% to 90% of the
length of the muscle (466) and are designed for excursion
158 Systems Anatomy

(Table 2.4, Fig. 2.13). The actual length of the muscle fibers
is similar to that of the extrinsic extensors on the dorsum of
the forearm, but the lumbricals have a very small pennation
angle and cross-sectional area and are ideally suited for cre-
ating an even contractile force (466,496). The lumbricals of
the index and long fingers arise from their respective FDP
tendons, which allows a greater independent motion com-
pared with the lumbrical of the ring finger, which originates
from the adjacent sides of the two FDP tendons (long and
ring), or the lumbrical to the small finger, which originates
from the adjacent sides of the FDP tendons to the ring and
small fingers. Variation of the lumbricals is common (638)
and, as with the extensor tendons; more variability is
observed on the ulnar side of the hand (492,497,498). All
lumbricals insert into the lateral band on the radial side of
their respective fingers (Table 2.5). The architectural fea-
tures of the lumbricals are listed in Table 2.4 (466).
The innervation of the lumbricals is split. The median
nerve innervates the index and long finger lumbricals,
which corresponds to the innervation of the FDP to these
two fingers (496). The ring and small finger lumbricals are
innervated by the ulnar nerve, which also innervates the
FDP to the same fingers (496).
Actions and Biomechanics: Lumbricals
The function of the lumbricals is complex and has been dis-
cussed in detail by Smith and von Schroeder and Botte
(484,496). Roughly stated, the lumbricals provide exten-
sion of the proximal and interphalangeal joints and flexion
of the MCP joint. From origin to insertion, the lumbricals
pass volar to the deep transverse metacarpal ligaments. As
such, they are volar to the axis of rotation of the MCP joint
and therefore can act as MCP flexors (3,4,13,14,617).

TABLE 2.5. INTRINSIC MUSCLES OF THE HAND: ORIGIN, INSERTION, AND FUNCTION OF THE DEEP AND
SUPERFICIAL BELLIES OF THE DORSAL INTEROSSEI, THE VOLAR INTEROSSEI, AND THE LUMBRICALS

Muscle Group Origin Insertion Function

Interossei (7)a
Dorsal (4)
Deep belly (3) Index and long MC Lat tendon to lat band of DA, Abduct and flex MCP joint, extend IP
radial side of long finger joints long finger
Long and ring MC Lat tendon to lat band of DA, Abduct and flex MCP joint, extend IP
ulnar side of long finger joints long finger
Ring and small MC Lat tendon to lat band of DA, Abduct and flex MCP joint, extend IP
ulnar side of ring finger joints ring finger (abduction of small
finger by ADQ)
Superficial belly (3) Index MC Med tendon to lat tubercle of Abduct and weak flexion MCP joint,
prox phalanx, radial side of index index finger
finger
Index and long MC Med tendon to lat tubercle of Abduct and weak flexion MCP joint,
prox phalanx, radial side of long long finger
finger
Ring and small MC Med tendon to lat tubercle of Abduct and weak flexion MCP joint,
prox phalanx, ulnar side of ring ring finger
finger
Volar (3) Index MC Lat band of DA, ulnar side of Adduct and flex MCP joint, extend IP
index finger joints index finger
Ring MC Lat band of DA, radial side of Adduct and flex MCP joint, extend IP
ring finger joints ring finger
Small MC Lat band of DA, radial side of Adduct and flex MCP joint, extend IP
small finger joints small finger
Lumbricals (4) FDP index Lat band of DA, radial side of Extension IP joints, weak flexion MCP
index finger joint index finger
FDP long Lat band of DA, radial side of Extension IP joints, weak flexion MCP
long finger joint long finger
FDP long and ring Lat band of DA, radial side of Extension IP joints, weak flexion MCP
ring finger joint ring finger
FDP ring and small Lat band of DA, radial side of Extension IP joints, weak flexion MCP
small finger joint small finger
aNumbers in parentheses denote number of muscles.

ADQ, abductor digitorum quiti; DA, dorsal aponeurosis; FDP, flexor digitorum profundus tendon; IP, interphalangeal; lat, lateral; MC,
metacarpal bone; MCP, metacarpophalangeal; med, medial; prox, proximal.
Reprinted from von Schroeder HP, Botte MJ. The dorsal aponeurosis, intrinsic, hypothenar and thenar musculature of the hand. Clin Orthop
383:97–107, 2001, with permission.

However, as noted by several authors, the interossei and the
FDP and FDS tendons are primary flexors of the MCP
joints, whereas the lumbricals function primarily to extend
the interphalangeal joints through the dorsal aponeurosis
(496,629,630,633,638–642). The origins, insertions, and
functions of the lumbricals are summarized in Table 2.5
(496).
The role of the lumbricals in interphalangeal joint exten-
sion has been emphasized by Smith and others, who have
credited the lumbricals as the “workhorse of the extensor
apparatus” (484,633,634,640). Electromyography of the
lumbricals reveals high levels of activity whenever there is
active extension of the interphalangeal joints. In addition,
strong electrical stimulation of the lumbrical produces
interphalangeal joint extension followed by MCP joint flex-
ion. Low levels of electrical stimulation produce only inter-
phalangeal joint extension (629,630). Although the lum-
bricals are located on the radial side of the fingers, they
apparently do not function as abductors or adductors of the
MCP joints because of their relatively parallel paths along
the axis of the fingers (496). There is no radial deviation of
the digits when the lumbricals contract (484,631).
Although interphalangeal joint extension is an impor-
tant part of lumbrical function, the lumbrical contributes
relatively less or little to flexion of the proximal phalanx
(484). This may seem at first inherently somewhat odd
because the lumbrical tendon passes volar to the axis of the
MCP joint (and volar to the interossei). However, elec-
tromyographic studies performed by Long and Brown indi-
cated that under normal circumstances, the lumbrical con-
tributes little to MCP joint flexion (633). When the
interossei are paralyzed, however, the lumbrical can initiate
flexion at this joint. Flexion of the proximal phalanx also
may be achieved through contraction of the FDS and FDP.
When these muscle contract, they first flex the interpha-
langeal joints. After full interphalangeal joint flexion is
achieved, the long flexors flex the MCP joint until the digit
is completely flexed (484,642). If finger flexion were per-
formed solely by the FDP and FDS, MCP joint flexion
would occur only after interphalangeal joint flexion was
complete (643–654).
The fact that the lumbricals originate from the FDP ten-
dons but antagonize FDP flexion at the interphalangeal
joint is an interesting phenomenon. Although it seems to
contradict the respective functions of the muscle units, the
lumbricals can relax the FDP tendons and thereby enhance
their own function toward interphalangeal extension (496).
When the FDP and lumbricals contract simultaneously,
flexion of the interphalangeal and MCP joints occurs. This
cocontraction enhances stability and occurs in power grip.
The end result is simultaneous MCP and interphalangeal
joint flexion (496,633,635), compared with a sequential
contraction (DIP to PIP, then MCP contraction) that
occurs with FDP and FDS contraction (636). The interos-
sei also contribute to flexion of the MCP joints.
2 Muscle Anatomy 159
Anomalies and Variations: Lumbricals
Variations in sites of attachments of the lumbricals are rela-
tively common. Each muscle may originate by varying
amounts from the adjacent FDP tendons. The first lumbri-
cal may have attachments that extend to the FPL tendon.
Accessory tendon slips that attach to the adjacent FDS ten-
don may be present (11).
Clinical Correlations: Lumbricals
The lumbricals and interossei work together to provide flex-
ion of the MCP joints and simultaneous extension of the
PIP and DIP joints (see earlier, under Actions and Biome-
chanics: Lumbricals, and later, under Actions and Biome-
chanics: Dorsal Interossei, for specific differences and
nuances of function of these muscles). Both muscles often
are grouped together and referred to as the intrinsics or
intrinsic muscles of the hand. In a spastic deformity or
inflammatory condition with chronic spasm, with relative
overactivity of the intrinsic muscles, the hand assumes a
position dictated by these muscles—that is, flexion of the
MCP joints and extension of the PIP and DIP joints. This
position often is referred to as the intrinsic plus position,
indicating overactivity of these intrinsic muscles. In con-
trast, with paralysis of the intrinsics (due to ulnar nerve lac-
eration or neuropathy), the hand assumes a position oppo-
site to what the muscles would provide (secondary to
muscle imbalance of the functioning muscles). This results
in a position of extension of the MCP joints and flexion of
the PIP and DIP joints. This often is referred to as the
intrinsic minus position, indicating lack of intrinsic func-
tion. Intrinsic minus also can occur with relative overpull of
the extrinsic flexors and extensors, in conditions such as
ischemic contractures after severe compartment syndrome
(643– 654).
Although the thenar and hypothenar muscle are true
intrinsic muscles of the hand, the terms intrinsic plus and
intrinsic minus do not pertain to these muscles. Dysfunc-
tion of the thenar muscles is referred to simply as thenar
paralysis or (if present) thenar atrophy.
After amputation of the distal phalanx (or untreated dis-
tal FDP tendon laceration or rupture), the detached FDP
tendon may migrate proximally along with its lumbrical.
This initially may increase tension of the lumbrical on the
intrinsic extensor mechanism. If active flexion of the digit is
attempted, the detached FDP tendon migrates proximally
and pulls the lumbrical with it. Instead of digital flexion,
the tension of the lumbrical on the extensor apparatus
results in PIP joint extension. The hand is considered to
have a lumbrical plus digit. The undesired PIP extension
often is referred to as a paradoxical extension (because the
person actually is attempting to flex the digit). The lumbri-
cal plus digit does not occur consistently. If it does develop,
elective operative resection of the lumbrical eliminates the
160 Systems Anatomy
paradoxical extension and allows the FDS to assume flexion
control of the PIP joint (641).
DORSAL INTEROSSEI
Derivation and Terminology. Dorsal is derived from the
Latin dorsalis or dorsum, which indicates “the back.” Dorsal
usually is used to indicate the same side as the back, or the
“back side.” Interossei is derived from the Latin inter, which
indicates “between” or “among”; ossei is derived from ossis,
which means “bone.” The dorsal interossei are the muscles
between the bones, on the back side of the hand (1,2).
Origin. There are four dorsal interossei. The first arises
from adjacent sides of the thumb and index metacarpal, the
second from the adjacent sides of the index and long
metacarpal; the third from the adjacent sides of the long
and ring metacarpals, and the fourth from the adjacent
sides of the ring and small metacarpals (3,4,6,7,11,13).
Insertion. The first dorsal interosseous inserts into the
radial side of the base of the index proximal phalanx and
into the dorsal aponeurosis of the extensor hood of the
index finger. The second inserts into the radial side of the
base of the long finger proximal phalanx and into the dor-
sal aponeurosis of the extensor hood of the long finger. The
third inserts into the ulnar side of the base of the proximal
phalanx of the long finger and into the dorsal aponeurosis
of the extensor hood of the long finger. The fourth inserts
into the ulnar side of the base of the proximal phalanx of
the ring finger and into the dorsal aponeurosis of the exten-
sor hood of the ring finger. The relative amounts of inser-
tion into the associated proximal phalanx versus the
amount reaching the extensor are not the same for each
digit. The first dorsal interosseous inserts mainly into the
proximal phalanx, with a lesser component inserting into
the extensor hood. The second, third, and fourth have vari-
able insertions, but, in general, the second and fourth have
substantial contributions to both the associated proximal
phalanx and to the dorsal aponeurosis. The third dorsal
interosseous inserts mainly into the dorsal aponeurosis of
the long finger, with a minimal component inserting into
the base of the proximal phalanx (484,631,635) (for addi-
tional details, see later, under Gross Anatomic Description).
Innervation. Deep branch of the ulnar nerve (C8, T1).
Vascular Supply. Dorsal metacarpal arteries, second to
fourth palmar metacarpal arteries; small branches of the
radial artery; arteria princeps pollicis; arteria radialis indicis;
perforating branches from the deep palmar arch (proximal
perforating arteries); three distal perforating arteries; dorsal
digital arteries (3,4,6,7,11,13).
Principal Action. The dorsal interossei draw the index,
long, and ring finger proximal phalanges away from the
mid-axis of the long finger. The muscles also flex the MCP
joints. Through the extensor hood, the dorsal interossei
help to extend the PIP and DIP joints (475,484,496).
Because each dorsal interosseous muscle varies in the rela-
tive amounts of insertion into the proximal phalanx or into
the dorsal aponeurosis, the functions of the interossei vary
among the digits. The first dorsal interosseous inserts
mainly into the proximal phalanx of the index finger (usu-
ally nearly 100%); it tends to function more for abduction
of the proximal phalanx than it does for extension of the
PIP or DIP joints. Conversely, the third interosseous usu-
ally inserts more into the extensor hood (approximately
94%), and therefore functions more for interphalangeal
joint extension of the long finger. The second and forth
dorsal interosseous have variable but substantial insertions
into both the associated proximal phalanx and the dorsal
aponeurosis, and therefore the second and fourth dorsal
interossei contribute both to abduction of the associated
proximal phalanx and extension of the proximal and inter-
phalangeal joints. There also is a component of flexion of
the MCP joint provided by the dorsal interossei (see later,
under Actions and Biomechanics). The first dorsal
interosseous also adducts the thumb metacarpal toward the
index metacarpal during key pinch functions. This is com-
bined with simultaneous abduction of the index proximal
phalanx, which helps stabilize the MCP joint during force-
ful pinch. This provides simultaneous adduction of the
thumb (metacarpal) toward the index finger, and allows the
index finger (proximal phalanx) to oppose the force of the
thumb. Thus, a strong key pinch can be generated
(3,4,6,7,11,13,475,484,496,655).
Gross Anatomic Description: Dorsal
Interossei
There are four dorsal interossei and three palmar interossei.
The palmar interossei are described later in a separate sec-
tion. In general, the dorsal interossei are larger and have a
more complex anatomic arrangement than the palmar
interossei (484,496). The four dorsal interossei also com-
prise four separate dorsal interosseous muscle compart-
ments of the hand (Appendix 2.2). The dorsal interossei
originate from and lie between the metacarpals (see Fig.
2.6B). Cross-sections of the hand in this area show the mus-
cles occupying the space from the dorsal to palmar extent of
the metacarpal, although the space is shared by the palmar
interossei, which take origin more from the palmar portion
of the metacarpal shaft (656). Each dorsal interosseous
muscle is bipennate, with two muscle heads, each of which
arises from the adjacent metacarpal. The two bellies join in
a central longitudinal septum and the fibers course distally
toward the associated digit. Three of the four dorsal interos-
sei then form a deep muscle belly and three have a superfi-
cial muscle belly (484,496,655). The first and second dor-
sal interossei pass the radial side of the associated MCP
joints to reach their respective digits; the third and forth
dorsal interossei pass the ulnar side of the associated MCP
joints to reach their respective digits (496) (see Table 2.5).

The muscle bellies of the dorsal interosseous should not
be confused with the two heads of each muscle. Each mus-
cle head arises from the adjacent metacarpal and joins to its
associated partner head at the septum to form a bipennate
muscle. In contrast, the deep and superficial bellies are
more distally located divisions of the muscle. The superfi-
cial and deep head of each muscle usually form just proxi-
mal to the MCP joint and are the terminal divisions of each
muscle. The deep and superficial muscle bellies have differ-
ent final destinations for insertion, either into the associated
proximal phalanx (superficial belly) or into the associated
extensor hood (deep belly; see Fig. 2.9). The size, insertions,
and amount of muscle fibers of the deep and superficial bel-
lies ultimately determine the function of the specific dorsal
interosseous. The superficial and deep muscle bellies have
been studied and discussed in detail by Smith, Kaplan, von
Schroeder and Botte, Landsmeer, and others (475,484,496,
642,655–657). The origin, insertion, and function of the
deep and superficial bellies of the interossei and lumbricals
are summarized in Table 2.5 (496).
The deep belly of each dorsal interosseous muscle is the
portion of the muscle that continues to join the lateral
bands to reach dorsal aponeurosis and become part of the
extensor mechanism of the associated index, long, and ring
finger. Like the superficial belly, the deep belly arises as part
of the main dorsal interosseous muscle from the adjacent
surfaces of the midshafts of the adjacent metacarpals. Just
proximal to the MCP joint, the dorsal interosseous splits
into a deep and superficial belly. The deep belly continues
distally to form or terminate into the lateral tendon. This
lateral tendon of the deep belly is potentially larger than the
medial tendon (which is derived from the superficial belly).
The lateral tendon continues distally to pass superficial to
the sagittal bands. The lateral tendon passes the MCP joint
and continues distally and dorsally to become part of the
extensor aponeurosis. The lateral tendon of the deep belly
forms part of the transverse fibers of the dorsal aponeurosis
(of the intrinsic muscle apparatus; see Fig. 2.9). The lum-
brical tendon joins the extensor aponeurosis just distal to
the joining point of the lateral tendon of the dorsal
interosseous. The lumbricals help form the oblique fibers of
the extensor aponeurosis. Through the deep belly and its
insertion into the extensor apparatus, the dorsal
interosseous assists interphalangeal joint extension. This
muscle also provides flexion and assists with abduction of
the proximal phalanges. When the MCP joint is flexed to
approximately 90%, no significant abduction can be per-
formed by the deep belly (496). The deep and superficial
bellies of each dorsal interosseous muscle are of different
sizes; and, the relative insertion into the extensor mecha-
nism versus insertion into the proximal phalanx differs
among the interossei. These differences, in turn, influence
their respective functions of interphalangeal joint extension
versus proximal phalanx abduction. These issues are dis-
cussed later.
2 Muscle Anatomy 161
The superficial belly of each dorsal interosseous muscle
is the portion that inserts into the base of the associated
proximal phalanx and functions mostly for digital abduc-
tion. Although the superficial belly is a terminal division of
the dorsal interossei, the muscle belly arises from the adja-
cent surfaces of the midshafts of the contiguous metacarpals
as part of the main dorsal interosseous muscle. The fibers
form a bipennate muscle that continues distally to converge
into either a deep belly (described previously) or a superfi-
cial belly. The superficial belly splits from the main dorsal
interosseous muscle just proximal to the MCP joint. It then
forms or terminates into the medial tendon. The medial
tendon is a small tendon that continues distally and passes
deep to the sagittal bands of the MCP joint. The medial
tendon continues past the MCP joint to insert onto the lat-
eral tubercle at the base of the proximal phalanx. Through
this osseous insertion, the muscle belly functions primarily
as an abductor of the proximal phalanx. It also is a weak
flexor of the proximal phalanx (484). This weak flexion
component increases in power as the MCP joint is increas-
ingly flexed because the tendon passes volar to the axis of
rotation of the joint, and increasing flexion increases its
flexion moment arm. The superficial belly has no direct
effect on interphalangeal joint extension (655).
The first dorsal interosseous also is known as the abduc-
tor indicis, and is the largest of the dorsal interossei (3,4).
The first dorsal interosseous is triangular, thick, and flat. As
described earlier, there are two heads, each arising from the
adjacent metacarpal. The radial (lateral) head of the first
dorsal interosseous arises from the proximal half or three-
fourths of the ulnar border of the thumb metacarpal. The
ulnar (medial) head arises from the major portion of the
radial border of the second metacarpal. The origin from the
index metacarpal usually is slightly larger that that from the
thumb, but each covers approximately two-thirds to three-
fourths of the associated sides of the metacarpals (11). As a
bipennate muscle, there is a septum that separates the two
heads, in which the muscle fibers converge in an oblique
and distal direction. There also is a fibrous arch in the prox-
imal aspect of the first dorsal interosseous that forms an
interval through which the radial artery passes from the
dorsal aspect of the hand to form the deep palmar arterial
arch. The muscle fibers converge toward the septum, run-
ning centrally and longitudinally through the muscle. Just
proximal to the MCP joint, on the radial side of the joint,
the first dorsal interosseous muscle divides into the superfi-
cial and deep bellies, which in turn give rise to the medial
and lateral tendons, respectively (484,496). The first dorsal
interosseous is unique in that most of the muscle consists of
the superficial belly, which gives rise to a median tendon
that inserts into the base of the proximal phalanx. The deep
belly is small or inconsistent, and few, if any, fibers form
this deep belly to give rise to a lateral tendon to insert into
the dorsal aponeurosis (635). Therefore, the first dorsal
interosseous inserts almost entirely into the proximal pha-
162 Systems Anatomy
lanx of the index finger. The first dorsal interosseous thus
functions largely in abduction of the index finger proximal
phalanx. Through the proximal phalanx insertion, the first
dorsal interosseous also contributes to flexion of the MCP
joint. The first dorsal interosseous provides little, if any,
contribution toward PIP or DIP joint extension. The
abduction of the index proximal phalanx helps stabilize the
MCP joint, especially during key pinch function, where
index finger abduction action helps oppose the force of the
thumb.
The first dorsal interosseous also provides an important
function for the thumb metacarpal. The muscle adducts the
thumb metacarpal toward the index metacarpal. This func-
tion is used constantly during the pinch function, especially
in key pinch, where the thumb metacarpal is pulled toward
the index metacarpal in the plane of the palm. The simul-
taneous abduction of the index proximal phalanx helps sta-
bilize the index finger during the key pinch maneuver.
The second dorsal interosseous, like the other dorsal
interossei, has two heads. The radial (lateral) head arises
from the ulnar side of the index metacarpal. The ulnar
(medial) head arises from the radial side of the long
metacarpal. Each of these muscle origins covers approxi-
mately the proximal two-thirds to three-fourths of the sides
of the shafts of each associated metacarpal. The origin from
the long finger usually is slightly larger than that from the
index metacarpal (11). The fibers converge into a central
septum, with the fibers oriented obliquely distally and
toward the central septum, forming the bipennate muscle.
Proximal to the MCP joint, on the radial aspect of the
joint, the fibers of the second dorsal interosseous divide
into superficial and deep bellies (described previously).
Approximately 60% of the fibers insert into the proximal
phalanx of the radial aspect of the base of the long finger.
The remaining 40% of the fibers reach the extensor hood
(634). (Thus, functionally, the muscle’s contribution to
abduction of the long finger is approximately equal or
slightly greater compared with its function in extension of
the PIP and DIP joints.) Through the dorsal hood, the sec-
ond dorsal interosseous also contributes to flexion of the
MCP joint.
The third dorsal interosseous also has two heads. The
radial (lateral) head arises from the ulnar side of the long
metacarpal. The ulnar (medial) head arises from the radial
side of the ring metacarpal. As with the second dorsal
interosseous, the muscle origins of the third dorsal
interosseous attach to the proximal two-thirds to three-
fourths of the sides of the shafts of each associated
metacarpal. The origin from the long metacarpal usually is
slightly larger than that from the ring metacarpal (11). The
fibers converge into a central septum, with the fibers ori-
ented obliquely distally and toward the central septum,
forming the bipennate muscle. Proximal to the MCP joint,
on the ulnar aspect of the joint, the fibers of the third dor-
sal interosseous divide into superficial and deep bellies
(described previously). Approximately 6% of the fibers
insert into the proximal phalanx of the ulnar aspect of the
base of the long finger. The remaining 94% of the fibers
reach the extensor hood (635). (Thus, functionally, the
muscle’s contribution to abduction of the long finger is
minimal compared with its major function of extension of
the PIP and DIP joints.) Through the dorsal hood, the
third dorsal interosseous also contributes to flexion of the
MCP joint.
The fourth dorsal interosseous also has two heads. The
radial (lateral) head arises from the ulnar side of the ring
metacarpal. The ulnar (medial) head arises from the radial
side of the small finger metacarpal. As with the other dor-
sal interossei, the muscle origin covers the proximal two-
thirds to three-fourths of the sides of the shafts of each
associated metacarpal. The origin from the ring metacarpal
usually is slightly larger than that from the small finger
metacarpal (11). Similar to the other dorsal interossei, the
fibers of the fourth dorsal interosseous converge into a cen-
tral septum, with the fibers oriented obliquely distally and
toward the central septum, forming the bipennate muscle.
Proximal to the MCP joint, on the ulnar aspect of joint,
the fibers of the fourth dorsal interosseous divide into
superficial and deep bellies (described previously). Approx-
imately 40% of the fibers insert into the proximal phalanx
of the ulnar aspect of the base of the long finger. The
remaining 60% of the fibers reach the extensor hood
(635). (Thus, functionally, the muscle’s contribution to
abduction of the long finger is slightly less than its func-
tion in extension of the PIP and DIP joints.) Through the
dorsal hood, the fourth dorsal interosseous also contributes
to flexion of the MCP joint. It also may contribute to
adduction of the small finger metacarpal if the ring finger
metacarpal is fixed.
The dorsal interossei usually all are innervated by the
deep branch of the ulnar nerve. For each of the muscles, the
deep and superficial bellies are separately innervated by dis-
tinct small nerve branches (484). It therefore is possible to
contract the deep belly of a dorsal interosseous without con-
tracting the superficial belly, or vice versa (484).
Several variations in innervation are possible. The first
dorsal interosseous may be innervated by either the
median nerve, radial nerve, or musculocutaneous nerve.
Median nerve innervation is through the Martin-Gruber
or Riche-Cannieu anastomosis (see later, under Anomalies
and Variations).
Actions and Biomechanics: Dorsal
Interossei
In general, the dorsal interossei usually are credited with the
function of abduction of the associated digit (as well as flex-
ion of the MCP joint), along with and extension of the PIP
and DIP joints. The function of each dorsal interosseous is
different and depends on the relative amounts of insertion

into bone (the associated proximal phalanx), which provide
digital abduction, compared with the relative amounts of
insertion into the dorsal aponeurosis of the extensor hood,
which provide flexion of the MCP joint and extension of
the PIP and DIP joints (475,484). Studies have investigated
the relative insertions of each dorsal interosseous into the
proximal phalanx versus the extensor aponeurosis. Eyler
and Markee noted the following insertion ratios: first dor-
sal interosseous, 100% proximal phalanx, 0% extensor
aponeurosis; second dorsal interosseous, 60% proximal
phalanx, 40% extensor aponeurosis; third dorsal
interosseous, 6% proximal phalanx, 94% extensor aponeu-
rosis; forth dorsal interosseous, 40% proximal phalanx,
60% extensor aponeurosis (635). Given these relative
amounts of insertion into the proximal phalanx versus the
dorsal aponeurosis, the relative amounts of digital abduc-
tion versus interphalangeal joint extension provided by the
muscle can be extrapolated (475,484,496,655)
When the function of abduction of the digits is exam-
ined, it is understood that abduction refers to “a drawing
away from the midline.” In the digits, this refers to the mid-
line of the hand, and the mid-axis of the long finger usually
is used as the reference line. The first dorsal interosseous
functions to abduct the index finger, or draw it away from
the mid-axis of the long finger in the radial direction. The
second dorsal interosseous abducts the long finger, drawing
it away from the midline in a radial direction. The third
dorsal interosseous abduction component (although rela-
tively weak) abducts the long finger, drawing it away from
the midline in the ulnar direction. The fourth dorsal
interosseous abducts the ring finger, drawing it away from
the mid-axis of the long finger in the ulnar direction (496).
The long finger only abducts from the mid-axis, and there-
fore there are two abductors present on either side. There is
no such movement of adduction of the long finger when it
is in a normal resting position. It is, however, possible for
the long finger to adduct back to a normal position from a
position of abduction (radial or ulnar deviation). Returning
back to the normal position can, in a sense, be considered
as adduction of the long finger. Abduction of the small fin-
ger is performed by the abductor digiti minimi (quinti).
Abduction of the thumb is performed primarily by the APL
and APB (496). The first dorsal interosseous also functions
to adduct the thumb metacarpal toward the index
metacarpal in the plane of the palm.
Based on muscle architecture, the dorsal and palmar
interossei (and lumbricals as well) are all highly specialized
muscles with similar architectural features (see Table 2.4
and Fig. 2.13). These muscles, with their relatively long
fiber length and relatively small physiologic cross-sectional
areas, are designed more optimally for excursion (and veloc-
ity) than force generation.
The small finger has no dorsal interosseous muscle
inserting into it. Abduction of the small finger is performed
by the abductor digiti minimi.
2 Muscle Anatomy 163
Anomalies and Variations: Dorsal
Interossei
The deep branch of the ulnar nerve normally innervates all
of the dorsal interosseous muscles. Infrequently, the median
nerve may innervate the first dorsal interosseous (in 3% of
limbs) (11,484,628,639). This variation may be associated
with the Martin-Gruber anastomosis, which is the median-
to-ulnar nerve crossover in the forearm (658,659), or may
be associated with the Riche-Cannieu anastomosis, which is
the median-to-ulnar nerve crossover in the palm (475,660).
These anomalies are not uncommon, and their presence
explains continued function of the interosseous muscle(s) in
the presence of ulnar nerve laceration or severe neuropathy.
Rarely, the dorsal interosseous may be innervated by the
radial nerve or, more infrequently, there may be intercom-
munication between the musculocutaneous and median
nerves (628). The presence of these anomalies also explains
continued function of the interosseous muscle in the pres-
ence of ulnar nerve laceration or severe neuropathy.
The interossei may have additional muscle bellies or may
be completely absent in one or two of the interspaces (11).
Clinical Correlations: Dorsal Interossei
Because the first dorsal interosseous inserts mainly into the
proximal phalanx of the index finger, its principal function
is to abduct the proximal phalanx of the index finger (com-
pared with its contribution to extension of the PIP or DIP
joints). By abducting the index proximal phalanx away
from the long finger, the first dorsal interosseous is able to
help stabilize the index MCP joint by opposing the thumb
during key pinch. During key pinch, the first dorsal
interosseous can visibly be seen and felt contracting. The
second dorsal interosseous also has a substantial insertion
into the proximal phalanx (60%), and therefore this muscle
probably also contributes to opposing the force of the
thumb or stabilizing the long finger MCP joint. This is
functionally advantageous when the long finger participates
in pinch, such as in three-jaw chuck-type pinch (484,635).
As opposed to the first dorsal interosseous, most of the
fibers of the third dorsal interosseous continue to the dor-
sal aponeurosis to reach the extensor hood. Thus, func-
tionally, the third dorsal interosseous contributes much
more to extension of the PIP and DIP joint, compared
with its minimal contribution toward abduction of the
long finger. From a functional standpoint, this is advanta-
geous because abduction of the long finger (in the ulnar
direction) is relatively unimportant. However, extension of
the long finger PIP and DIP joints and flexion at the MCP
joint are useful and important movements provided by the
dorsal aponeurosis.
The interossei and lumbricals work together to provide
simultaneous extension of the PIP and DIP joints and flex-
ion of the MCP joints (475,484,496) (see earlier, under
164 Systems Anatomy
Actions and Biomechanics, for specific differences and
nuances of function of these muscles). This is known as
intrinsic function, and is a complex and important compo-
nent of hand movement required for everyday tasks. At the
initiation of a grasping maneuver, simultaneous extension
of the interphalangeal joints and flexion of the MCP joint
allows the digits to “wrap around” a relatively large object
such as a milk carton, doorknob, or orange-sized object.
Without the intrinsics providing the initial extension of the
interphalangeal joints, extrinsic tendon flexion function of
the digits results in flexion at the MCP, PIP, and DIP joints.
The flexion of the digits often starts at the DIP joint, fol-
lowed by the PIP and MCP. The digits flex and tend to “roll
up” onto themselves and into the palm, similar to the way
a party blower toy roles up on itself after it is blown out and
inflated into a straight position and allowed passively to roll
back up. When the fingers flex or “role up” into the palm,
grasping of large objects is impossible. The digits are unable
to wrap around the object (which requires interphalangeal
joint extension at the initiation of the maneuver). This is
demonstrated when the intrinsic minus hand (or claw
hand) attempts to grasp a large object, and is a major func-
tional problem of the intrinsic minus hand.
Function of an intrinsic minus hand can be roughly sim-
ulated in a cadaver. Flexion of the digits by the extrinsic
muscle in the absence of intrinsic muscle can be created in
a cadaver by grasping an extrinsic FDP tendon in the fore-
arm and pulling proximally. This produces extrinsic flexion
without intrinsic function. The digit flexes at the DIP, PIP,
and MCP joints, but tends to roll up onto itself, as
described previously. The difficulties of the intrinsic minus
hand in grasp can thus be demonstrated.
Both the interossei and lumbrical muscles often are
grouped together and referred to as the intrinsics or intrinsic
muscles of the hand (484,496,661). In a spastic deformity, or
an inflammatory condition with chronic spasm, with rela-
tive overactivity of the intrinsic muscles, the hand assumes a
position that the muscles normally produce or provide, that
is, flexion of the MCP joints and extension of the PIP and
DIP joints. This position often is referred to as the intrinsic
plus position, indicating overactivity of these intrinsic mus-
cles. In contrast, with paralysis of the intrinsics (due to ulnar
nerve laceration or neuropathy), the hand assumes a position
opposite to that which the muscles would provide (sec-
ondary to imbalance of the functioning muscles). This
results in a position of extension of the MCP joint and flex-
ion of the PIP and DIP joints. This often is referred to as the
intrinsic minus position, indicating lack of intrinsic function.
The intrinsic minus position also can be produced by rela-
tive overactivity or contracture of the extrinsic muscles. This
can be seen with ischemic contracture after compartment
syndrome of the forearm (662–664).
Although the thenar and hypothenar muscles are true
muscles intrinsic to the hand, the terms intrinsic plus and
intrinsic minus do not pertain to these muscles. Dysfunc-
tion of the thenar muscles is referred to simply as thenar
paralysis or (if present) thenar atrophy.
PALMAR INTEROSSEI
Derivation and Terminology. Palmar is derived from the
Latin palma, which means “palm,” or palmaris, which
means “pertaining to the palm.” Interossei is derived from
the Latin inter, which indicates “between” or “among”; ossei
is derived from ossis, which means “bone.” The palmar
interossei are the muscles between the bones, on the palm side
of the hand (1,2).
Origin. There are usually three palmar interossei
attached to the index, ring, and small fingers. Four palmar
interossei are sometimes described (see Anomalies and Vari-
ations, Palmar Interossei). The first arises from the ulnar
side of the index metacarpal. The second arises from the
radial side of the ring metacarpal. The third arises from the
radial side of the small finger metacarpal. The origins are
located palmar to the dorsal interossei, and both sets of
muscles share the metacarpals for their origins.
Insertion. The palmar interossei insert into the dorsal
aponeurosis of the associated digit. The first inserts into the
dorsal aponeurosis on the ulnar side of the index finger. The
second inserts into the dorsal aponeurosis on the radial side
of the ring finger. The third inserts into the dorsal aponeu-
rosis on the radial side of the small finger (3,4,484,496).
Innervation. From the deep branch of the ulnar nerve
(C8, T1).
Vascular Supply. Deep palmar arch, arteria princeps pol-
licis, arteria radialis indicis, palmar metacarpal arteries,
proximal and distal perforating arteries, common and
proper digital (palmar) arteries, common and proper pal-
mar digital arteries, dorsal digital arteries (3,4,6,7,11,13).
Principal Action. The first, second, and third palmar
interossei adduct the proximal phalanx of the index, ring,
and small finger, respectively.
Gross Anatomic Description: Palmar
Interossei
The three palmar interossei are smaller and more uniform
than the dorsal interossei, and occupy the palmar portion of
the intermetacarpal spaces, also shared with the dorsal
interossei.The three palmar interossei comprise three sepa-
rate palmar interosseous compartments of the hand
(Appendix 2.2). Each palmar interosseous arises form the
associated side of its metacarpal, covering the base to the
head and neck region of the bone (see Fig. 2.6A). The sec-
ond and third palmar interossei tend to arise from the entire
surface, whereas the first originates from and covers a
slightly smaller area (3,4,11,13). Each belly converges to a
tendon at the level of the MCP joint and passes the joint on
the adductor side (which corresponds to the ulnar side of

the joint for the first, and the radial side for the second and
third palmar interossei). In classic anatomy textbooks and
descriptions of the insertions of the palmar interossei, the
muscles have been described as inserting into both the lat-
eral bands of the extensor aponeurosis as well as into the
base of the proximal phalanx (3,4,13,14,662). From the
studies of Eyler and Markee, and as emphasized by Smith
and von Schroeder and Botte, it appears that the palmar
interossei have few, if any, significant insertions into the
proximal phalanx (484,496,635). Eyler and Markee studied
the relative insertions of each palmar interosseous into the
proximal phalanx versus into the extensor aponeurosis. The
relative ratios of muscle insertion for each palmar
interosseous were as follows: first palmar dorsal
interosseous, 0% proximal phalanx (of index finger), 100%
dorsal aponeurosis; second palmar interosseous, 0% proxi-
mal phalanx (of ring finger), 100% dorsal aponeurosis;
third palmar interosseous, 10% proximal phalanx (of small
finger), 90% dorsal aponeurosis (634). Smith has empha-
sized that the palmar interossei have no distinct deep and
superficial bellies (as do the dorsal interossei), and thus
none is inserted onto the proximal phalanx. Each of the pal-
mar interossei can still adduct and flex the proximal pha-
lanx and can extend the distal two phalanges of the finger.
But these functions are performed through insertions into
the lateral bands of the dorsal aponeurosis (and not through
bone insertions into the proximal phalanges) (484,496).
The origin, insertion, and function of the interossei and
lumbricals are summarized in Table 2.5 (496). Architectural
features are shown in Table 2.4 and Figure 2.13.
The first palmar interosseous arises from the ulnar side
of the second metacarpal diaphysis. The fibers converge
into its tendon at the level of the MCP joint, on its ulnar
aspect. The tendon then inserts into the lateral band of the
dorsal aponeurosis on the ulnar side of the proximal pha-
lanx of the index finger (3,4,484,496).
The second palmar interosseous arises from the radial
side of the ring metacarpal diaphysis. The fibers converge
into its tendon at the level of the MCP joint, on its radial
aspect. The tendon then inserts into the lateral band of the
dorsal aponeurosis on the radial side of the proximal pha-
lanx of the ring finger (3,4,484,496).
The third palmar interosseous arises from the radial side
of the small finger metacarpal diaphysis. The fibers con-
verge into its tendon at the level of the MCP joint, on its
radial aspect. The tendon then inserts into the lateral band
of the dorsal aponeurosis on the radial side of the proximal
phalanx of the small finger. According to Eyler and Markee,
a small amount, approximately 10% of the muscle, of the
third palmar interosseous also may insert into the base of
the proximal phalanx of the small finger (635).
Some authors describe four palmar interossei (3,13). In
usual descriptions, however, this muscle is considered as
part of the adductor pollicis (see later, under Anomalies and
Variations).
2 Muscle Anatomy 165
Actions and Biomechanics: Palmar
Interossei
Each palmar interosseous adducts and flexes the proximal
phalanx of the associated digit, and extends the middle and
distal phalanges (484). The first, second, and third palmar
interossei act on the proximal phalanx of the index, ring,
and small finger, respectively. Adduction of the digits refers
to drawing the digit toward the midline of the hand (toward
the mid-axis of the long finger). This movement is per-
formed by the muscles’ insertion into the dorsal aponeuro-
sis (3,4).
Anomalies and Variations: Palmar
Interossei
Variations of the palmar interosseous muscles are rare. A
muscle can be duplicated. Most of the variations are related
to innervation, such as with the median nerve (see earlier,
under Anomalies and Variations: Dorsal Interossei).
Although three palmar interossei usually are present,
occasionally a fourth palmar interosseous is present or
described (13). This may represent an alternative descrip-
tion of basically normal anatomy, or may be a variant of the
adductor pollicis. The authors who describe a fourth palmar
interosseous usually attach the term first palmar interosseous
to a muscle or fibers that passes from the base of the thumb
metacarpal to the base of the thumb proximal phalanx. This
muscle usually inserts with the adductor pollicis. In their
description, the remaining palmar interossei (as described
previously) become the second, third, and fourth palmar
interossei, respectively. Because the thumb has a large
adductor muscle of its own, these fibers have been consid-
ered as part of that muscle in most descriptions (3,13,14).
Clinical Correlations: Palmar Interossei
The thumb and the long finger do not have or need a pal-
mar interosseous muscle. The long finger lies in the midline
of the hand, and therefore does not need to be “adducted.”
If it is in a position of abduction in the ulnar or radial direc-
tion, it can be brought back to the midline (adducted, in a
sense) by the second or third dorsal interossei, respectively.
The thumb does not require a palmar interosseous because
it has the adductor pollicis (3,13,14).
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621. Huber E. Hilfsoperation bei median Uhlahmung. Dtsch Arch
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622. Littler JW, Cooley SGE. Opposition of the thumb and its
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627. Harness D, Sekeles E, Chaco J. The double motor innervation
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628. Cliffon EE. Unusual innervation of the intrinsic muscles of the
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629. Backhouse KM, Catton WT. Observations on the function of
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630. Backhouse KIM, Colton WTL. An experimental study of the
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631. Kaplan EB. Embryological development of the tendinous appa-
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2 Muscle Anatomy 179
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180 Systems Anatomy

APPENDIX 2.1. MUSCLES OF THE HAND AND FOREARM AND ARM: ORIGIN, INSERTION, ACTION,
INNERVATION

Muscle Origin Insertion Action Innervation (Nerve Roots)

Deltoid Lateral one-third Deltoid tuberosity of Abduction of humerus, Axillary n. (C5, C6)
clavicle, acromion, humerus forward flexion or
spine of scapula extension of humerus
Coracobrachialis Coracoid process of Medial humeral Forward flexion, adduction Musculocutaneous n. (C5, C6)
scapula diaphysis of humerus
Biceps brachii Short head from Radial tuberosity, Flexion, supination of Musculocutaneous n. (C5, C6)
coracoid process, lacertus fibrosis forearm
long head from
supraglenoid
tuberosity
Brachialis Distal two-thirds of Coronoid process of Flexion of forearm Musculocutaneous, (and
anterior humerus ulna occasionally radial) n. (C5,
C6, C7)
Triceps brachii Long head from Olecranon, deep fascia Extension of forearm, Radial n. (C6, C7)
infraglenoid of forearm adduction of arm
tuberosity of scapula, (long head)
lateral head from
posterolateral
humerus, medial
head from distal
posterior humerus
Anconeus Lateral epicondyle of Lateral side of Extension of forearm Radial n. (C7, C8)
humerus, posterior olecranon and
capsule of elbow posterior surface of
ulna
Brachioradialis Lateral supracondylar Lateral, distal radius, Flexion or forearm, Radial n. (C5, C6)
ridge of humerus, styloid process assistance of pronation
lateral intermuscular of forearm (when
septum forearm is supinated),
assistance of forearm
supination (when
forearm is pronated)
Pronator teres Humeral head from Central lateral radial Pronation of forearm, Median n. (C6, C7)
medial epicondylar diaphysis assistance of flexion
ridge of humerus, of forearm
ulnar head from
medial side of
coronoid process
of ulna
Flexor carpi Medial epicondyle of Base of metacarpals of Flexion, radial deviation Median n. (C6, C7)
radialis humerus (common index and long of wrist, assistance
flexor origin) fingers with flexion and
pronation of forearm
Palmaris longus Medial epicondyle of Palmar fascia Flexion of wrist, assists Median n. (C6, C7)
humerus (common (aponeurosis) flexion, pronation of
flexor origin) forearm
Flexor carpi Humeral head from Pisiform (possible Flexion, ulnar deviation Ulnar n. (C8, T1)
ulnaris medial epicondyle extensions to of wrist, assistance with
of humerus hamate and base flexion of forearm
(common flexor metacarpal of little
origin), ulnar head finger)
from proximal
dorsal ulna
Flexor digitorum Humeral head from Palmar middle Flexion of middle and Median n. (C7, C8)
superficialis medial epicondyle phalanges of digits proximal phalanges,
of humerus assistance with forearm
(common flexor and wrist flexion
origin), ulnar head
from coronoid
process of ulna,
radial head from
oblique line of
radial diaphysis
 2 Muscle Anatomy 181

APPENDIX 2.1. (continued)

Muscle Origin Insertion Action Innervation (Nerve Roots)

Flexor digitorum Medial anterior Palmar distal phalanges Flexion of distal (and Median n. to radial 2 digits,
profundus surface of ulna, middle and proximal) ulnar n. to ulnar 2 digits
interosseous phalanges, assistance (C7, C8)
membrane, deep with wrist flexion
fascia of forearm
Flexor pollicis Palmar surface of Base, palmar distal Flexion of distal (and Median n. (C8, T1)
longus radius, interosseous phalanx of thumb proximal) phalanx of
membrane, medial thumb
border of coronoid
process
Pronator Distal palmar ulna Distal palmar radius Pronation of forearm Median n. (C8, T1)
quadratus
Extensor carpi Lateral supracondylar Dorsal base of index Extension, radial Radial n. (C6, C7)
radialis longus ridge of humerus, metacarpal deviation of wrist
lateral intermuscular
septum
Extension carpi Common extensor Dorsal base of long Extension, radial Posterior interosseous
radialis brevis origin from lateral finger metacarpal deviation of wrist or radial n. (C6, C7)
epicondyle of
humerus, radial
collateral ligament
of elbow joint,
intermuscular
septum
Extensor Common extensor Dorsal bases of middle Extension of digits, Posterior interosseous of
digitorum origin from lateral and distal phalanges assistance with radial n. (C6, C7)
communis epicondyle of wrist extension
humerus,
intermuscular
septum
Extensor digiti Common extensor Dorsal base of distal Extension of little Posterior interosseous of
minimi origin from lateral phalanx of little finger radial n. (C7, C8)
epicondyle of finger
humerus,
intermuscular
septum
Extensor carpi Common extensor Dorsomedial base of Extension, ulnar Posterior interosseous of
ulnaris origin from lateral little finger deviation of wrist radial n. (C6, C7)
epicondyle of metacarpal
humerus, posterior
border of ulna
Supinator Lateral epicondyle of Radiopalmar surface Supination of forearm Radial n. (deep branch)
humerus, lateral of proximal radius (C6, C7)
capsule of elbow,
supinator crest and
fossa of ulna
Abductor Dorsal surface of Radial base of thumb Abduction of thumb, Posterior interosseous or
pollicis longus mid-diaphysis of metacarpal assistance of wrist radial n. (C6, C7)
radius and ulna, abduction
interosseous
membrane
Extensor pollicis Dorsal surface of Base, proximal Extension of proximal Posterior interosseous or
brevis radial diaphysis, phalanx of thumb phalanx (and radial n. (C6, C7)
interosseous metacarpal) of thumb
membrane
Extensor pollicis Dorsal surface of Dorsal base, distal Extension of distal Posterior interosseous or
longus ulnar diaphysis, phalanx of thumb phalanx of thumb, radial n. (C6, C7)
interosseous assists extension of
membrane proximal phalanx and
metacarpal of thumb
Extensor indicis Dorsal distal ulnar Dorsal proximal Extension of proximal Posterior interosseous or
proprius diaphysis, phalanx of index phalanx of index radial n. (C6, C7)
interosseous finger finger
membrane
182 Systems Anatomy

APPENDIX 2.1. (continued)

Muscle Origin Insertion Action Innervation (Nerve Roots)

Abductor Transverse carpal Radial side, base of Palmar abduction of Recurrent branch of median
pollicis brevis ligament, scaphoid proximal phalanx proximal phalanx of n. (C8, T1)
tubercle, palmar of thumb thumb
trapezium
Opponens Transverse carpal Radiopalmar surface Opposition of thumb to Recurrent branch of median
pollicis ligament, palmar of thumb digits (palmar n. (C8, T1)
trapezium abduction, pronation
metacarpal of thumb)
Flexor pollicis Transverse carpal Base proximal phalanx Flexion of proximal Recurrent branch median n.
brevis ligament, palmar of thumb phalanx of thumb (C8, T1)
trapezium
Adductor Oblique head from Ulnar side, base of Adduction of thumb, Deep branch of ulnar n.
pollicis palmar trapezium, proximal phalanx assistance with (C8, T1)
trapezoid, and of thumb opposition
capitate
Transverse head
from palmar
surface of long
finger metacarpal
Palmaris brevis Ulnar side of Skin on ulnar border Corrugation of skin on Superficial branch of ulnar n.
transverse carpal of palm ulnar palm (deepening (C8, T1)
ligament, palmar of palm)
aponeurosis
Adductor digiti Pisiform, tendon of Ulnar side, base of Abduction of little finger Deep branch of ulnar n.
minimi flexor carpi ulnaris proximal phalanx from palm (C8, T1)
of little finger,
aponeurosis of
extensor digiti
minimi
Flexor digiti Transverse carpal Ulnar side, base of Flexion of proximal Deep branch of ulnar n.
minimi ligament, hook of proximal phalanx of phalanx of little (C8, T1)
hamate little finger finger
Opponens Transverse carpal Ulnar side of metacarpal Opposition of little Deep branch of ulnar n.
digiti minimi ligament, hook of of little finger finger to thumb, (C8, T1)
hamate flexion of metacarpal
of little finger
anteriorly out of palm
Lumbricals Four lumbricals Join with interossei to Extension of the middle Median n. to radial two
arise from tendons form lateral bands phalanges, flexion of lumbricals, ulnar n. to
of flexor digitorum that become dorsal the proximal phalanges ulnar two lumbricals
profundus hood with the extensor (C8, T1)
digitorum communis
tendons; ultimate
insertions include base
of the middle phalanx
(central slip) and base
of distal phalanx
Dorsal interossei Four dorsal interossei First into radial side of Abduction of index, Deep branch ulnar
each from sides of proximal phalanx of long, ring fingers n. (C8, T1)
adjacent two index finger; second from midline of hand,
metacarpals into radial side of flexion of proximal
proximal phalanx of phalanges, extension
long finger; third into of middle phalanges
ulnar side of proximal
phalanx of long finger;
fourth into ulnar side
of proximal phalanx
of ring finger
All interossei also with
variable contributions
to lateral bands to
form part of the dorsal
hood
 2 Muscle Anatomy 183

APPENDIX 2.1. (continued)

Muscle Origin Insertion Action Innervation (Nerve Roots)

Palmar interossei Three palmar First into ulnar side of Adduction of digits Deep branch ulnar n. (C8, T1)
interossei: First proximal phalanx of
from ulnar side of index; second into
index metacarpal, radial side of proximal
second from radial phalanx of ring finger;
side of ring third into radial side
metacarpal, third of proximal phalanx
from radial side of of little finger
little finger
metacarpal

APPENDIX 2.2. MUSCLE COMPARTMENTS AND FASCIAL SPACES OF THE

UPPER EXTREMITY

Compartment Principal Muscles

Deltoid compartment Deltoids

Anterior compartment of the arm Coracobrachialis
Biceps brachii
Brachialis
Posterior compartment of the arm Triceps muscle (three heads)
Mobile wad compartment of the forearm Brachioradialis
Extensor carpi radialis longus
Extensor carpi radialis brevis
Superficial volar compartment of the forearm Pronator teres
Flexor carpi radialis
Palmaris longus
Flexor digitorum superficialis
Flexor carpi ulnaris
Deep volar compartment of the forearm Flexor digitorum profundus
Flexor pollicis longus
Pronator quadratus compartment Pronator quadratus
Dorsal compartment of the forearm Extensor digitorum communis
Extensor indicis proprius
Extensor carpi ulnaris
Extensor digiti quinti
Extensor pollicis longus
Supinator
Abductor pollicis longus
Extensor pollicis brevis
Carpal tunnela Extrinsic digital flexor tendons
Central palmar compartment of the hand Extrinsic flexor tendons
Lumbricals
Thenar compartment Abductor pollicis brevis
Flexor pollicis brevis
Opponens pollicis
Hypothenar compartment Abductor digiti minimi
Flexor digiti minimi
Opponens digiti minimi
Adductor compartment of the hand Adductor pollicis
Interosseous compartments of hand Dorsal interossei (four)
Palmar interossei (three)
a
Although not a true muscle compartment, the carpal tunnel is listed here because it can have the
physiologic properties of a closed compartment in the presence of compartment syndrome.
184
APPENDIX 2.3. HUMAN FOREARM MUSCLE DIFFERENCE INDEX VALUES: A COMPARISON OF ARCHITECTURAL FEATURES OF SELECTED
SKELETAL MUSCLES OF THE UPPER EXTREMITYA
FCR FCU PL ECRB ECRL ECU FDSI FDSM FDSR FDSS FDPI FDPM FDPR FDPS FPL EDCI EDCM EDCR EDCS EDQ EIP. EPL PT PQ BR

FCR 0.00
FCU 0.63 0.00
PL 0.63 1.23 0.00
ECRB 0.36 0.65 0.87 0.00
ECRL 0.94 1.40 0.94 0.86 0.00
ECU 0.27 0.39 0.90 0.33 1.06 0.00
FDSI 0.31 0.62 0.78 0.56 0.99 0.34 0.00
FDSM 0.42 0.46 1.02 0.38 1.00 0.23 0.37 0.00
FDSR 0.20 0.80 0.52 0.43 0.78 0.43 0.34 0.51 0.00
FDSS 0.84 1.44 0.25 1.03 1.03 1.10 1.01 1.23 0.73 0.00
FDPI 0.22 0.77 0.62 0.35 0.73 0.39 0.34 0.43 0.12 0.82 0.00
FDPM 0.46 0.51 1.02 0.49 1.02 0.31 0.30 0.14 0.52 1.25 0.45 0.00
FDPR 0.24 0.63 0.71 0.50 0.95 0.32 0.08 0.38 0.26 0.95 0.27 0.33 0.00
FDPS 0.27 0.66 0.79 0.23 0.78 0.29 0.37 0.28 0.29 0.99 0.18 0.34 0.32 0.00
FPL 0.15 0.61 0.65 0.44 1.07 0.30 0.39 0.50 0.32 0.84 0.36 0.54 0.32 0.40 0.00
EDCI 0.77 1.38 0.20 0.96 0.86 1.03 0.91 1.13 0.63 0.21 0.71 1.14 0.84 0.88 0.81 0.00
EDCM 0.59 1.21 0.28 0.73 0.68 0.84 0.74 0.92 0.43 0.40 0.49 0.93 0.67 0.65 0.65 0.25 0.00
EDCR 0.58 1.20 0.10 0.80 0.87 0.85 0.75 0.97 0.46 0.27 0.56 0.98 0.68 0.73 0.61 0.20 0.20 0.00
EDCS 0.78 1.39 0.16 1.01 0.98 1.05 0.92 1.17 0.66 0.15 0.76 1.17 0.86 0.93 0.80 0.13 0.34 0.21 0.00
EDQ 0.61 1.19 0.12 0.89 1.01 0.87 0.72 1.00 0.51 0.34 0.62 0.99 0.67 0.79 0.62 0.30 0.36 0.20 0.24 0.00
EIP 0.77 1.39 0.20 0.96 0.91 1.04 0.94 1.15 0.65 0.12 0.74 1.17 0.87 0.90 0.80 0.11 0.28 0.20 0.12 0.31 0.00
EPL 0.53 1.11 0.19 0.79 1.04 0.79 0.72 0.95 0.48 0.35 0.58 0.96 0.65 0.74 0.51 0.38 0.38 0.21 0.32 0.19 0.34 0.00
PT 0.71 0.57 1.26 0.45 1.24 0.54 0.87 0.58 0.84 1.41 0.77 0.72 0.83 0.63 0.72 1.36 1.15 1.19 1.39 1.27 1.34 1.15 0.00
PQ 0.92 1.42 0.75 0.87 0.86 1.10 1.18 1.20 0.86 0.69 0.87 1.28 1.11 0.95 0.95 0.70 0.62 0.68 0.76 0.86 0.64 0.77 1.14 0.00
BR 1.03 1.30 1.24 1.02 0.74 1.05 0.86 0.89 0.91 1.43 0.84 0.82 0.88 0.84 1.16 1.23 1.06 1.19 1.32 1.23 1.31 1.30 1.34 1.48 0.00

FCR, flexor carpi radialis; FCU, flexor carpi ulnaris; PL, palmaris longus; ECRB, extensor carpi radialis brevis; ECRL, extensor carpi radialis longus; ECU, extensor carpi ulnaris; FDSI, FDSM,
FDSR, FDSS, flexor digitorum superficialis to the index, middle, ring, and small fingers; FDPI, FDPM, FDPR, FDPS, flexor digitorum profundus to the index, middle, ring, and small fingers;
FPL, flexor pollicis longus; EDCI, EDCM, EDCR, EDCS, extensor digitorum communis to the index, middle, ring, and small fingers; EDQ, extensor digiti quinti; EIP, extensor indicis proprius;
EPL, extensor pollicis longus; PT, pronator teres; PQ, pronator quadratus; BR, brachioradialis.
a
Editors Note: Architectural features of a muscle include the physiologic cross-sectional area of the muscle, fiber bundle length, muscle length, muscle mass, and pennation angle (angle
of the muscle fibers from the line representing the longitudinal vector of its tendon.) This table lists each of the difference index values, which is a number that compares a pair of
muscles. The difference index is the amount that the two muscles differ from each other, and has been determined based on the architectural features (15). A lower number (index
value) indicates a lesser difference, a larger index value indicates a greater difference. The mean architectural difference index among the upper extremity muscles is 0.74.
Reproduced from Lieber RL, Brown CG. Quantitative method for comparison of skeletal muscle
architectural properties. J Biomech 25:557–560, 1992, with permission.
 3
NERVE ANATOMY
MICHAEL J. BOTTE
The gross anatomy of the upper extremity peripheral nerves
is described in the following sections. The physical course of
each nerve and its associated branches is outlined, followed
by descriptions of nerve anomalies or variations, and clini-
cal correlations. For descriptive purposes, each nerve dis-
cussion is divided into the regions of the arm, forearm, and
wrist and hand, if applicable. Sensory nerve organelles are
discussed at the end of the chapter. The dermatomes of the
upper extremity are depicted for reference in Appendix 3.1.
MEDIAN NERVE
Origin of the Median Nerve
The median nerve arises from the lateral and medial cords
of the brachial plexus, and comprises fibers from the ante-
rior rami of C5, C6, C7, C8, and T1 (Fig. 3.1). The median
nerve originates from two branches, one each from the lat-
eral and medial cords of the brachial plexus. The two
branches, referred to as the lateral and medial roots, unite
adjacent to and anterior or anterolateral to the third portion
of the axillary artery, in the vicinity of the medial border of
the coracobrachialis. This occurs approximately at the lon-
gitudinal level of the surgical neck of the humerus with the
shoulder abducted 90 degrees (1–5).
Median Nerve in the Axilla and Arm
The median nerve continues distally in the arm, posterior to
the pectoralis major, anterior to the coracobrachialis, lateral to
the brachial artery, and medial to the biceps brachii. In the
arm, and along most of its course, it lies anteromedial to the
brachialis muscle and posteromedial to the biceps brachii mus-
cle. The median nerve does not normally supply motor
branches to any muscle in the arm. In the mid-portion of the
arm, in the vicinity of the insertion of the coracobrachialis
muscle, the median nerve crosses anterior to the brachial artery
to lie on the medial side of the artery. The nerve continues to
the cubital fossa, remaining medial to the brachial artery. Both
the nerve and artery remain close to the biceps tendon just
proximal to the lacertus fibrosus. The mnemonic, MAT, helps
in remembering the relationship (from medial to lateral) of the
median nerve, brachial artery, and the biceps tendon in this
area (6). The nerve usually gives off several small vascular
branches, but does not provide innervation to muscles in the
arm (7,8) (Fig. 3.2). In the distal third of the arm, the brachial
artery gives off several muscular arteries, including the supra-
trochlear artery (inferior ulnar collateral arteries). These
branches cross anteriorly or posteriorly to the nerve, often in
close proximity. Adjacent to the brachial artery are venae comi-
tantes, two to three of which lie between the artery and the
median nerve (6). Throughout the course of the median nerve
in the arm, the ulnar nerve remains posterior and somewhat
parallel to the median nerve, diverging slightly from the
median nerve as the two nerves descend along the arm. The
ulnar nerve continues distally to reach the cubital fossa.
Anomalies and Variations: Median Nerve
in the Axilla and Arm
Although the median nerve usually is formed by the union
of the lateral and medial cords anterior or lateral to the axil-
lary artery, the nerve also has been noted rarely to be formed
by the branches of these cords uniting posterior to the axil-
lary artery (7).
The median nerve usually is formed at the level of the
third portion of the axillary artery. The nerve also can orig-
inate from the union of the lateral and medial cords more
distally, in the proximal third of the arm (7,9,10).
Fibers from C7 may leave the lateral root in the distal
part of the axilla and pass distomedially posterior to the
medial branch from the medial cord. The nerve usually
passes anterior to the axillary artery, to join the ulnar nerve.
These fibers are believed to be mainly motor fibers to the
flexor carpi ulnaris (3,11).
If the lateral cord is small, the musculocutaneous nerve
(C5, C6, and C7), which usually arises from the lateral
cord, can arise directly from the median nerve (1,3,11).
A branch from the musculocutaneous nerve occasionally
joins the median nerve after the musculocutaneous nerve
pierces the coracobrachialis muscle. This variation has been
reported in 8% to 36% of dissected specimens (12). The
fibers enter the musculocutaneous nerve from the lateral
cord rather than passing into the lateral root of the median
nerve. The communicating branch leaves the musculocuta-
neous nerve, descends from lateral to medial between the
brachialis and biceps muscles, and joins the median nerve
186 Systems Anatomy
in the mid-portion of the arm. When this anomaly occurs,
the branch (or branches) of the lateral cord that joins the
medial cord is smaller than normal.
Fibers may cross from the median to musculocutaneous
nerve. This anomaly is rare.
A nerve to the pronator teres muscle may leave the main
median nerve trunk in the arm as high as 7 cm proximal to
the epicondyles (7,13).
Clinical Correlations: Median Nerve in the
Axilla and Arm
The median nerve may be compressed at several points in
the upper extremity. These are well described by Siegal and
Gelberman (7), and include the following areas:
FIGURE 3.1. Schematic illustration
of the brachial plexus and associ-
ated major branches. A, nerve to
subclavius; B, lateral pectoral nerve;
C, subscapular nerves; D, thora-
codorsal nerve; E, medial ante-
brachial cutaneous nerve; F, medial
brachial cutaneous nerve; G, medial
pectoral nerve.
At the level of the coracoid process, the nerve (or lateral
cord) may be compressed by the pectoralis minor muscle.
The muscle lies on the anterior surface of the nerve, and can
cause nerve compression, especially when the arm is hyper-
abducted (7,14).
An anomalous muscle known as Langer’s muscle can
cause median nerve compression. This muscle arises from
the latissimus dorsi tendon, crosses the axillary neurovascu-
lar bundle, and inserts on the pectoralis major (7,15).
Median nerve compression can occur in the axilla and
arm from anomalous vascular arches, or perforations of the
nerve by anomalous vessels. The vascular anomalies may be
arterial or venous in origin. An 8% incidence of abnormal
relationships between the vascular and neural elements in
the axilla has been reported (7,16).
 3 Nerve Anatomy 187

FIGURE 3.2. Schematic illustration of the median nerve and the musculocutaneous nerve, with
associated branches and innervated muscles.
188 Systems Anatomy
The deltopectoral fascia, when thickened and fibrotic,
may occasionally compress the median nerve at its distal
edge. This has been noted after blunt trauma to the shoul-
der (7,17).
The supracondylar process and associated ligament of
Struthers may compress the median nerve in the distal arm
(7,18–23). The supracondylar process, a hook-shaped pro-
jection from the medial aspect of the distal humerus, usu-
ally is located 3 to 5 cm proximal to the medial epicondyle.
This anomalous protrusion provides attachment for an
anomalous ligament, the ligament of Struthers. The liga-
ment spans between the supracondylar process and medial
epicondyle, forming a fibroosseous tunnel, which is present
in 1% of limbs. It may represent an accessory origin of the
pronator teres muscle. The nerve passes through the tunnel
with either the ulnar or brachial artery and veins, medially
to the vessels. Nerve compression may be caused by either
the supracondylar process itself or by the ligament (7,24).
Just proximal to the elbow, in the area of the medial epi-
condyle, there is a constant relationship of the median nerve,
brachial artery, and the biceps tendon. The mnemonic, MAT,
describes this relationship (from medial to lateral) of the
median nerve, brachial artery, and biceps tendon (6).
Median Nerve in the Forearm
In the cubital fossa, the nerve dives deep to the lacertus
fibrosus, lying anterior to the brachialis muscle and medial
to the brachial artery. As the nerve crosses the level of the
elbow joint, one to two articular branches are given off to
supply the proximal radioulnar joint (25) (see Fig. 3.2).
The median nerve in the proximal third of the forearm
supplies the flexor pronator group of muscles that arise
from the medial epicondyle. These include the pronator
teres, the flexor carpi radialis, and the palmaris longus. The
proximal portion of the flexor superficialis, which arises
from the medial epicondyle and the thickened fascia
(raphe) in the proximal third of the forearm, obtains its
motor supply from the motor branches supplying the flexor
carpi radialis and the palmaris longus. The motor branches
supplying the medial portion of the flexor pronator mass
usually enter the muscles on their deep (posterior) surface
(6). When the anterior surface of the antecubital region is
exposed, these branches usually are not readily visible
because of their deep course. On deeper exposure and
inspection, three to four motor branches can be found tra-
versing deep to the muscles to innervate the pronator teres,
flexor carpi radialis, palmaris longus, and the humeral por-
tion of the flexor digitorum superficialis (see Fig. 3.2).
The nerve enters the forearm between the superficial
(humeral) and deep (ulnar) heads of the pronator teres mus-
cle. The nerve passes deep to the humeral head even when
there is a congenital absence of the ulnar head, as noted in
6% of cases (7,26). As the nerve passes through the muscle
bellies, it crosses the ulnar artery anteriorly, from medial to
lateral, separated from the artery by the deep head of the
pronator teres. Most commonly, the pronator teres motor
nerve has a common branch with nerve branches to the
superficial and deep heads (60% of specimens). Alterna-
tively, two separate nerve branches may be found, one going
to the superficial head and one going to the deep head of
the pronator teres (7,26,27).
After emerging from the pronator teres, the median
nerve passes deep to an arch created by the two heads of the
flexor digitorum superficialis. In the region of the superfi-
cialis arch, the median nerve usually provides three motor
branches to the flexor digitorum superficialis. These
branches are located on the deep surface of the muscle (6).
The nerve continues distally in the forearm between the
flexor digitorum superficialis and flexor digitorum profun-
dus (28). The nerve usually is in the fascia of the flexor dig-
itorum superficialis, or may occasionally lie in the substance
of the muscle (7,29). The nerve usually becomes superficial
approximately 5 cm proximal to the wrist, emerging
between the flexor digitorum superficialis and flexor carpi
radialis, dorsal and slightly radial to the tendon of the pal-
maris longus (7,30). In the proximal forearm, the median
nerve innervates the pronator teres, flexor carpi radialis, pal-
maris longus, and flexor digitorum superficialis (see Fig.
3.2). The branch to the pronator teres arises from 7 cm
above the medial epicondyle to 2.3 cm distal to the medial
epicondyle (31). In 45% of studied specimens, Sunderland
and Ran noted two branches to the pronator teres, in 30%
one branch, and in 25%, three or four branches (32). The
anterior interosseous nerve usually branches from the dor-
soradial surface of the median nerve trunk, usually arising
immediately distal to the flexor digitorum superficialis arch,
5 cm distal to the medial epicondyle (see later). Proximal to
the anterior interosseous nerve branch, the median nerve
supplies the flexor carpi radialis, palmaris longus, and flexor
digitorum superficialis. There usually is only a single nerve
to the flexor carpi radialis and only one to the palmaris
longus, but often from two to seven branches to the flexor
digitorum superficialis. The branch to the index finger por-
tion of the flexor digitorum superficialis arises in the mid-
portion of the forearm, up to 20 cm distal to the medial epi-
condyle. (7). The muscular branches of the median nerve
arise primarily from its medial surface (7,33).
The median nerve and its branches supply the sympa-
thetic fibers to the portions of the vascular structures of the
forearm and hand in a segmental fashion. At the elbow, the
median nerve provides a branch to the region of the bifur-
cation of the brachial artery. The nerve arborizes in the
proximal few centimeters of the radial and ulnar arteries.
The anterior interosseous nerve provides fibers to the ante-
rior interosseous artery (see later). The sympathetic
branches from the median nerve continue distally to pro-
vide sympathetic fibers into the palm to supply the superfi-
cial palmar arch, and, with the ulnar nerve, partially supply
the deep palmar arch of the hand (see later) (6).

Anterior Interosseous Nerve
The anterior interosseous nerve is the largest muscular branch
that originates from the median nerve. The anterior
interosseous nerve provides innervation to the flexor digito-
rum profundus to the index and long fingers (i.e., the radial
half of the muscle), the flexor pollicis longus, and the prona-
tor quadratus (34) (see Fig. 3.2). The terminal portion of the
nerve also provides sensory fibers to the carpal joints.
The nerve typically arises from the trunk of the
median nerve on the dorsoradial surface at a level of
approximately 5 to 8 cm distal to the medial epicondyle.
Sunderland has demonstrated that the interosseous nerve
actually becomes a separate group of fascicles at a point
approximately 2.5 cm proximal to its branching from the
median nerve trunk and at approximately 22 to 23 cm
proximal to the radial styloid process (35). After leaving
the median nerve, the anterior interosseous nerve initially
lies between the flexor digitorum superficialis and flexor
digitorum profundus. The nerve passes dorsally, in the
interval between the flexor pollicis longus and the flexor
digitorum profundus, providing two to six branches to
each of these muscles. The nerve reaches the anterior sur-
face of the interosseous ligament (interosseous mem-
brane) and continues distally, usually close to the anterior
interosseous artery. The nerve eventually reaches the
pronator quadratus, where it penetrates the muscle prox-
imally and passes deep to the belly to innervate the mus-
cle. The nerve continues distally to the wrist, containing
sensory afferent fibers for the intercarpal, radiocarpal,
and distal radioulnar joints (6).
The anterior interosseous nerve also supplies sympathetic
nerve fibers to the proximal forearm. The sympathetic nerve
fibers exit the anterior interosseous nerve and join with the
anterior interosseous artery to continue distally (6).
Palmar Cutaneous Branch of the Median
Nerve
The palmar cutaneous branch of the median nerve is the
last major branch of the median nerve in the forearm (see
Fig. 3.2). This nerve provides sensory fibers to the base of
the thenar eminence. It contains no motor fibers. The nerve
usually arises from the anteroradial aspect of the median
nerve trunk, 5 to 7 cm proximal to the wrist (6,36). This is
in the vicinity of the radial margin of the flexor digitorum
superficialis (37). The palmar cutaneous nerve usually con-
sists initially of only one nerve branch as it exits the main
median nerve trunk, and usually can be identified approxi-
mately 5.5 cm proximal to the radial styloid. Before branch-
ing, the nerve usually continues in or adjacent to the
epineurium of the median nerve trunk for 16 to 25 mm
before separating from the median nerve. The nerve courses
distally in the very distal forearm along the ulnar side of the
flexor carpi radialis tendon, adherent to the undersurface of
the antebrachial fascia. At the proximal edge of the trans-
3 Nerve Anatomy 189
verse carpal ligament, the nerve deviates ulnarly and enters
its own short fibrous tunnel in the ligament. The tunnel
through the transverse carpal ligament is usually 9 to 16
mm long (6,37). The nerve pierces the transverse carpal lig-
ament in line with the ring finger and enters the ligament,
dividing into ulnar and medial branches. These branches
supply the skin of the proximal two-fifths of the palm on
the radial side and the thenar eminence (7,24,38).
Anomalies and Variations: Median Nerve
in the Forearm
The most common nerve anomalies in the forearm are con-
nections between the median and ulnar nerves. A connection
often exists between the anterior interosseous and ulnar nerves
in the substance of the flexor digitorum profundus. This intra-
muscular communication leads to multiple variations in pat-
terns of innervation of the muscle. Dual innervation is most
common in the long finger flexor, but may occur in all the
digits. The median nerve, or rarely the ulnar nerve, may inner-
vate the entire flexor digitorum profundus (7,39). When the
median nerve supplies the entire flexor digitorum profundus,
it usually is through fibers from the anterior interosseous
nerve. (The anterior interosseous nerve normally supplies the
flexor digitorum profundus to the index and long finger, but
in the “all median nerve hand,” the anterior interosseous nerve
also supplies the flexor digitorum profundus to the ring and
small fingers.)
The complete median- and complete ulnar-innervated
hand: There are several described clinical situations where the
hand appears to be completely innervated by the median or
ulnar nerve. Within these described conditions, there are sev-
eral variations of reported findings. These variations probably
are due to gradations between median and ulnar innerva-
tions, representing individual differences in anatomic
arrangements. Fibers may pass between the ulnar and median
nerves in the forearm or hand. Their terminal branches may
send communicating fibers within the hand. The median
nerve sometimes innervates the interosseous muscles, partic-
ularly the first dorsal interosseous, either alone or jointly with
the ulnar nerve (40,41). In the extreme “all-median hand,”
the anterior interosseous nerve (from the median nerve) sup-
plies the flexor digitorum profundus to the ring and small
fingers (which normally are supplied by the ulnar nerve) (6).
The ulnar nerve more often provides dual or replacement
innervation to muscles usually innervated by the median
nerve (36,41–44). Less often, the median nerve innervates
muscles that usually are innervated by the ulnar nerve (44).
Each of the lumbrical muscles can have dual innervation
from both the median and ulnar nerves (45,46). Double
innervation of the flexor pollicis brevis is relatively common.
Several patterns with ulnar innervation of the thenar muscles
have been noted (43,45,47).
The Martin-Gruber anastomosis: The Martin-Gruber
anastomosis is an anomalous or variant communication that
190 Systems Anatomy
contains motor, sensory, or mixed fibers from the median or
anterior interosseous nerve to the ulnar nerve in the proximal
forearm (6,48,49). This anastomosis has been found in
approximately 15% (range, 10% to 44%) of dissected fore-
arms (39,50–52). Several variations of this anastomosis are
recognized, although most of the communications consist of
a communication branch that originates from either the
trunk of the median nerve or from the anterior interosseous
nerve and crosses ulnarly to reach the ulnar nerve in the prox-
imal, middle, or distal forearm. Approximately half of the
communications are recognized to arise from the anterior
interosseous nerve (6). Mannerfelt cites the earliest known
description of the anomaly by Martin in 1763 (46,53). Gru-
ber made similar findings in 1870 (51). The connections
usually pass distally and ulnarly, dorsal and adjacent to the
ulnar artery, in the plane between the flexor digitorum super-
ficialis and flexor digitorum profundus muscle bellies. In
addition, a variant of the Martin-Gruber anastomosis con-
sists of motor fibers from the motor branches of the flexor
digitorum profundus crossing over to the ulnar nerve in the
muscle of the flexor digitorum profundus. The Martin-Gru-
ber communication occasionally sends branches to the flexor
digitorum profundus or the flexor digitorum superficialis
(54). There may be a loop-shaped connection, with convex-
ity distally, that contains motor fibers. Straight connections
usually are sensory (7). Electrophysiologic and electrodiag-
nostic studies have supported these anatomic findings, where
investigators have identified Martin-Gruber communications
carrying median nerve fibers to the hand through the ulnar
nerve (55–59).
There is an increased incidence of the Martin-Gruber
communication in some families, and an autosomal domi-
nant inheritance pattern of median–ulnar connections has
been observed (60).
Comparative anatomy studies have shown that a com-
munication between the median and ulnar nerves exists in
the proximal forearm in all baboons, rhesus monkeys, and
certain (cynomolgus) monkeys (27,61).
The Martin-Gruber communication presents several dis-
tinctly different types of anomalous motor innervation of
the hand muscles. These have been studied and outlined by
Meals, Spinner, and others (6,34,36,41,62).
Of 226 ulnar or median nerve–injured patients, Rown-
tree found evidence of anomalous innervation of hands in
20% (41). These included cases where the median nerve
innervated the first dorsal interosseous muscle, and where
the ulnar nerve innervated the abductor pollicis brevis. He
also noted cases of the “complete median” or “complete
ulnar” innervation of the hand.
The so-called all-ulnar or all-median hand probably is
represented in situations where one or the other nerve is cut
without evident functional impairment of the hand
(36,41).
There is a pattern of variation that consists of motor
fibers that pass from the median to ulnar nerve, proceeding
to innervate muscles of the hand usually innervated directly
by median nerve branches (44,46,47). In this case, an addi-
tional crossover occurs in the palm for these fibers to reach
the thenar muscles.
There is a pattern of variation where fibers pass from the
median to ulnar nerve, eventually terminating in muscles
that usually are ulnar nerve innervated (6,34,46,47,58).
Here, the Martin-Gruber communication provides a path-
way for redirecting nerve fibers that were not completely
sorted in the brachial plexus.
There is a pattern of variation where ulnar nerve–derived
fibers targeted for muscles normally innervated by the ulnar
nerve sometimes cross over into the median nerve (ulnar to
median). This is a variation of the Martin-Gruber commu-
nication, and the fibers therefore must cross over again in
the palm to reach their targets (6,41).
Nerve anastomoses from the ulnar nerve to the median
nerve also are observed, but are much more infrequent than
from the median nerve to ulnar nerve. When present, the
connections usually are located in the distal forearm, pal-
mar to the flexor digitorum profundus (12).
Overlapping of territory in the innervation of the flexor
digitorum profundus by the median and ulnar nerves has
been noted in up to 50% of specimens. It is twice as com-
mon for the median nerve to encroach on the ulnar nerve
compared with ulnar encroachment on median-innervated
muscles (63,64). The portion of the flexor digitorum pro-
fundus to the index finger is the only part of that muscle
constantly supplied by one nerve, the median nerve
(63,64). In most specimens, the flexor digitorum profundus
and the lumbrical of a particular digit are innervated by the
same nerve. Encroachment of the median on the ulnar
nerve is less common for the lumbricals than for the flexor
digitorum profundus (63,64).
In 16% of specimens studied, the relation of the median
nerve to the two heads of the pronator teres varies from that
traditionally described (65,66). Some of these variations have
been found to be associated with congenital absence of the
ulnar head of the pronator teres. When the ulnar head is
absent, the nerve (which usually passes between the ulnar and
humeral heads) has been found to pass either deep to the
humeral head in 6% or through the humeral head in 2% (26).
Variations of the Anterior Interosseous Nerve
Several variations of the anterior interosseous nerve have
been described.
Anterior Interosseous Nerve Innervation to the Flexor
Digitorum Superficialis
Sunderland has noted that in 30% of 20 specimens studied,
the anterior interosseous nerve supplied a branch to the flexor
digitorum superficialis (35,63). The specimens also had sep-
arate nerve innervation from the main trunk of the median
nerve supplying the flexor digitorum superficialis. Thus, in a

dense anterior interosseous syndrome, there may be some
variable weakness of the flexor digitorum superficialis (6).
Anterior Interosseous Nerve Innervation to Gantzer’s
Muscle
Gantzer’s muscle is an accessory head to the flexor pollicis
longus (67–69). Its presence is variable, but it has been
noted in up to two-thirds of limbs. It is innervated by the
anterior interosseous nerve in most specimens (69).
Gantzer’s muscle is of clinical significance because it may be
a causative factor in anterior interosseous nerve syndrome
by muscle/fibrous entrapment; in addition, fibrosis of the
muscle with secondary contraction can produce a flexion
contracture of the thumb distal phalanx (69).
High Division of the Median Nerve and Bifid
Median Nerve in the Forearm
The median nerve may aberrantly divide into two compo-
nents at the level of the wrist or forearm. Subsequently, two
separate nerve “branches,” a medial and a lateral compo-
nent, extend down the forearm and enter the carpal tunnel.
The two branches can be of equal or unequal size. Early
descriptions of this anomaly, as noted by Sunderland, were
by Gruber, who described four cases in which the median
nerve branch to the third web space originated in the prox-
imal forearm (6,44). In addition, Amadio found high
branching of the median nerve in 3% of cases (70). Hart-
mann and Winkelman and Spinner also have reported a
similar high branching of the median nerve in the forearm
(71,72). In most of the cases studied by Amadio, the bifid
median nerve had two branches that remained independent
of one another. However, two of nine cases had a loop com-
munication in which one or the other median nerve branch
received a communicating branch from the other in or just
distal to the carpal canal (70). This communicating loop
was also noted in 3 of 29 cases reported in the literature at
the time of Amadio’s study (70). The variant branch of the
nerve may pass through the muscle mass or anterior to the
flexor digitorum superficialis (instead of its usual course
deep to the muscle) (6). At the level of the division, a small
or large ellipse or opening can occur, in which a tendon,
muscle, or vascular structure can pass (6,71). The high divi-
sion of the median nerve can be accompanied with multi-
ple other variants, including the Martin-Gruber anastomo-
sis, a communication between the ulnar and median nerves
distal to the flexor retinaculum, and two components to the
median nerve crossing the distal half of the forearm and
carpal canal (6). The high division of the median nerve is a
true division of the nerve into two separate components. It
therefore probably is incorrect to describe this variant as a
“duplication” of the median nerve, as it is sometime referred
to in the literature (see also later discussion of bifid median
nerve, under Anomalies and Variations: Median Nerve in
the Wrist and Hand).
3 Nerve Anatomy 191
Accessory Motor Supply to the Flexor
Digitorum Superficialis
Spinner has noted several variations to the flexor digitorum
superficialis (6). An accessory nerve to the flexor superficialis
can arise from the motor branches to the flexor carpi radialis
or palmaris longus. The accessory branch usually crosses
between the superficial and deep head of the pronator teres.
This branch then crosses deep to the flexor digitorum super-
ficialis arch to innervate a portion of the flexor digitorum
superficialis muscle. Similarly, the anterior interosseous
nerve, which supplies the flexor pollicis longus and flexor dig-
itorum profundus to the index and long fingers, also may at
times supply a portion of the flexor digitorum superficialis.
Variations of the Palmar Cutaneous Branch of
the Median Nerve
The palmar cutaneous branch of the median nerve usually
divides from the median nerve trunk approximately 5 to 7
cm proximal to the wrist (approximately 5.5 cm proximal
to the styloid) and traverses the transverse carpal ligament
through its own fibrous tunnel (6,17). Several variations of
the palmar cutaneous branch have been noted.
Two Separate Branches of the Palmar Cutaneous
Branch
Two separate nerves of the palmar cutaneous branch may
exist. One can arise at the usual location. The other can
arise more proximally, from 9 cm or more proximal from
the median nerve (44). In addition, two palmar cutaneous
nerves may exit the median nerve trunk at the normal loca-
tion, approximately 5.5 cm proximal to the styloid (73,74).
Distal Exit of the Palmar Cutaneous Branch of the
Median Nerve
The palmar cutaneous branch of the median nerve may exit
the median nerve trunk more distally than usual. It may con-
tinue with the median nerve trunk to the very distal forearm
flexor compartment before crossing the transverse carpal liga-
ment (70). It also has been observed to arise from the median
nerve at the radial styloid or in the proximal end of the carpal
tunnel. It penetrates the transverse flexor retinaculum and pal-
mar fascia to reach the skin at the base of the thenar muscles.
Absence of the Palmar Cutaneous Branch of the
Median Nerve
Complete absence of the palmar cutaneous branch of the
median nerve has been noted (6,44). In its absence, it has
been replaced with either an anterior division of the mus-
culocutaneous nerve, a branch of the superficial radial
nerve, a branch of the palmar cutaneous nerve from the
ulnar nerve, or a combination of these branches (75).
Palmar Cutaneous Nerve Deep to the Palmaris Longus
The palmar cutaneous branch of the median nerve may lie
deep to the tendon of the palmaris longus, especially if the
192 Systems Anatomy
palmaris longus is abnormal. At the level of the wrist crease,
the palmaris longus tendon may have a broad insertion into
the palmar fascia or a variant muscular attachment. In these
cases, the palmar cutaneous nerve has been noted to be deep
to or adjacent to the palmaris longus tendon (6).
Clinical Correlations: Median Nerve in the
Forearm
Martin-Gruber Anastomosis
The Martin-Gruber anastomosis consists of an anomalous
communication that carries motor fibers from the median
nerve to the ulnar nerve in the forearm (6,49) (see earlier,
under Anomalies and Variations: Median Nerve in the
Forearm). The motor fibers from the median nerve cross
from either the median nerve trunk or from the anterior
interosseous nerve, and travel to reach the ulnar nerve in the
proximal, middle, or distal forearm. The Martin-Gruber
communicating fibers from the median nerve often carry
the motor innervation of several of the intrinsic muscles of
the hand. These muscles include the first dorsal
interosseous, the adductor pollicis, the abductor digiti
quinti, and, less commonly, the second and third dorsal
interosseous muscles (46). Both anatomic and electrical
studies have noted these findings (6,46).
If a high ulnar nerve laceration (at or proximal to the
proximal forearm) is accompanied with preservation of
intrinsic muscle function, along with loss of function of the
flexor carpi ulnaris and flexor digitorum profundus to the
little finger, a Martin-Gruber communication should be
suspected distal to the area of nerve injury.
If a high median nerve laceration (at or proximal to the
proximal forearm) is accompanied with loss of some of the
intrinsic muscles (usually innervated by the ulnar nerve), a
Martin-Gruber communication should be suspected distal
to the area of nerve injury. Additional support for this
occurrence is provided if normal sensibility to the ring and
little fingers remains (innervated by the ulnar nerve).
Spinner has reported a patient with a complete ulnar
nerve laceration at the wrist that did not develop clawing.
That same patient did develop transient clawing only after
blocking the ulnar nerve at the elbow with local anesthetic
(6). A Martin-Gruber communication distally may have
been the pathway through which ulnar nerve–derived fibers
reached the intrinsic muscles (36).
Electrophysiologic Studies and the Martin-
Gruber Anastomosis
Electrophysiologic studies have been used to evaluate and
confirm the presence of Martin-Gruber connections
(55–59). When the Martin-Gruber connection carries
median nerve fibers to the hand through the ulnar nerve,
this can result in varying degrees of anomalous innervation
of the intrinsic muscles. This also effects or confuses the
findings from electrodiagnostic studies, when evaluation for
nerve compression is sought at specific sites. A patient with
carpal tunnel syndrome with median-to-ulnar nerve com-
munication may have normal latency from the elbow to the
thenar muscles, but prolonged latency across the wrist (36).
Because the incidence of the Martin-Gruber connection is
high (10% to 44%), it is not surprising that inconsistencies
occur between the clinical examination and electrodiagnos-
tic studies (39,50–52).
Compression of the Median Nerve in the
Forearm
The median nerve is at risk for compression at several sites
in the forearm. These include the lacertus fibrosus, the two
heads (humeral and ulnar heads) of the pronator teres mus-
cle, and the proximal origin or deep fascia of the flexor dig-
itorum superficialis (17,76–80).
Pronator Syndrome
The pronator syndrome is a result of median nerve compres-
sion in the proximal forearm, most often caused by or related
to the pronator teres muscle (6,77,81–84). The clinical syn-
drome includes several findings: pain in the proximal volar
forearm that is increased with pronation against resistance;
paresthesias or numbness in the palmar thumb, index, long,
and radial ring finger; negative Phalen’s test (wrist flexion
does not produce median nerve paresthesias); variable weak-
ness of the median-innervated intrinsic muscles (thenar mus-
cles and radial lumbricals); normal extrinsic function of mus-
cles innervated by the anterior interosseous nerve (flexor
pollicis longus, flexor digitorum profundus to the index and
long, and pronator quadratus); and electrodiagnostic studies
suggestive of localized sensory and motor conduction delay
in the proximal forearm (and absence of generalized polyneu-
ropathy). (Electrodiagnostic studies may be variable and
unreliable.) Although the pronator teres muscle most often is
the site of compression of the median nerve, compression at
two other adjacent sites also has been included in the prona-
tor syndrome (6). These include compression by the lacertus
fibrosus and by the fibrous arch of the flexor digitorum
superficialis. Reproduction of forearm pain with elbow flex-
ion and forearm supination against resistance suggests
involvement of the lacertus fibrosus. Forearm pain repro-
duced by flexion of the long finger proximal interphalangeal
joint (flexor digitorum superficialis) suggests a site of com-
pression at the arch of the flexor digitorum superficialis.
Causes of Pronator Syndrome
Anatomic abnormalities and related problems that have
been observed with the pronator syndrome include (6,66,
81,85–92):
n Hypertrophied pronator teres
n Fibrous bands in the pronator teres or associated tendons
(93)

n Median nerve passing posterior to both heads of the
pronator teres
n Thickened lacertus fibrosus (94)
n Hematoma deep to the lacertus fibrosus, resulting from
blood sample drawn from antecubital fossa with diffi-
culty in patient on renal dialysis or anticoagulant therapy
n Thickened flexor digitorum superficialis arch
n An accessory tendinous origin of the flexor carpi radialis
from the ulna
n Tightness of the lacertus fibrosus from serial casting to
correct elbow flexion contractures
Anterior Interosseous Nerve Syndrome
Compression or injury causing neuropathy of the anterior
interosseous nerve usually is associated with a classic clinical
presentation referred to as the anterior interosseous syndrome
(6,95–113). Because of Kiloh and Nevin’s early description
of neuritis of the anterior interosseous nerve (114), the syn-
drome also has been referred to as the Kiloh-Nevin syndrome,
especially in the international literature (115–119). The
clinical findings consist of paralysis or weakness of the flexor
pollicis longus, flexor digitorum profundus to the index and
long fingers, and pronator quadratus. An episode of pain in
the proximal forearm may precede the clinical paresis. When
the patient attempts to perform a thumb-to-index pulp
pinch or a three-jaw chuck pinch, the interphalangeal joint
of the thumb and the distal interphalangeal joints of the
index and long collapse into extension (owing to weakness
of the associated flexor muscles to the distal joints). Forearm
pronation may be weak because of involvement of the
pronator quadratus, although the pronator teres is intact and
still provides some pronation. There is no detectable sensi-
bility abnormality or involvement of other muscles supplied
by the median nerve. Variations in clinical presentation can
exist depending on the extent of the nerve lesion, whether
partial or complete, and the specific site of involvement
along the course of the nerve. In addition, specific anatomic
variations in a particular limb may contribute to variations
in clinical presentation. Spinner has noted that in the
extreme all-median hand, the anterior interosseous nerve
supplies all of the flexor profundus muscles. Thus, in this
variant, there would be weakness of flexion of the distal pha-
lanx of the ring and small fingers as well (6). Conversely, in
variations where the ulnar nerve innervates more of the pro-
fundi, the flexor digitorum profundus of the long finger may
be unaffected or only partially weakened by loss of function
of the anterior interosseous nerve (6). To test for insolated
function of the pronator quadratus in the presence of ante-
rior interosseous nerve syndrome, the pronation power of
the pronator teres must be eliminated. This can be accom-
plished by testing for forearm pronation strength with the
elbow fully flexed. In this position, most of the pronation
strength of the pronator teres is eliminated as the muscle is
shortened and slack. This can by corroborated by direct elec-
trodiagnostic studies.
3 Nerve Anatomy 193
Causes and Sites of Anterior Interosseous Nerve
Compression or Injury
Several causes of anterior interosseous nerve compression or
injury have been recognized, including injury by penetrat-
ing trauma, external compression, intrinsic compression by
either muscle/tendon structures or vascular structures, and
iatrogenic causes (6,120,121). Penetrating injuries of the
proximal forearm have included glass and metal lacerations,
stab wounds, injections by drug abusers, and gunshot
injuries. Fractures also have been known to result in ante-
rior interosseous syndrome (122), and usually consist of
either supracondylar fractures in children or forearm frac-
tures treated in either an open or closed fashion (6,123,
124). Iatrogenic injury also has been reported after cut-
down catheterization in the forearm (125) and from the
flexor pronator slide procedure (126). Causes of external
compression include tight-fitting casts, especially the prox-
imal rim of the short arm cast. Several causes of intrinsic
compression have been noted. Those involving compres-
sion by muscle or tendon structures include (6):
n A tendinous origin of the deep head of the pronator teres
(a tendinous loop encircling the median nerve at the level
of the origin of the anterior interosseous nerve) (6)
n A tendinous origin of the flexor superficialis to the long
finger
n An accessory head of the flexor pollicis longus (Gantzer’s
muscle)
n An accessory muscle and tendon from the flexor superfi-
cialis to the flexor pollicis longus
n A tendinous origin of anomalous muscles such as the pal-
maris profundus or the flexor carpi radialis brevis (127)
n An enlarged bicipital bursa encroaching on the median
nerve near the origin of the anterior interosseous nerve
n Vascular structures such as thrombosis or dilation of cross-
ing ulnar collateral vessels, and an aberrant radial artery
Anterior Interosseous Nerve and the Martin-Gruber
Anastomosis
The Martin-Gruber anastomosis (between the median and
ulnar nerves) occurs in 15% of limbs (54). In approximately
half of these anastomoses, the communication branch arises
from the anterior interosseous nerve. The communicating
branch from either the median nerve or anterior interosseous
nerve often carries fibers to various intrinsic muscles, includ-
ing the first dorsal interosseous, adductor pollicis, abductor
digiti minimi, and, less commonly, the second and third dor-
sal interosseous. Therefore, as noted by Spinner, in the pres-
ence of a Martin-Gruber communication, a patient with
dense anterior interosseous nerve syndrome also may show
some dysfunction of the intrinsic muscles of the hand (6).
Anterior Interosseous Nerve and the Flexor Digitorum
Superficialis
Sunderland has noted that in 30% of 20 specimens studied,
the anterior interosseous nerve supplied a branch to the
194 Systems Anatomy
flexor digitorum superficialis (35,63). The specimens also
had separate innervation from the main trunk of the median
nerve supplying the flexor digitorum superficialis. Spinner
thus has pointed out that in a complete anterior interosseous
nerve syndrome, there also may be some variable weakness
of the flexor digitorum superficialis muscles (6).
Differential Diagnosis in Anterior Interosseous Nerve
Syndrome
Several clinical conditions can produce loss of flexion of the
distal joints of the thumb, index, and long finger. These
include brachial plexus compression, traumatic lesions, or
neuritis (Parsonage-Turner syndrome; see later), compartment
syndrome or Volkmann’s contracture, attritional rupture of
the radial flexor tendons, and congenital absence of the flexor
tendons (128,129). Chronic inflammatory conditions such as
rheumatoid arthritis can produce carpal subluxation or ten-
don-damaging irregularities involving the scaphoid or lunate.
These can produce attritional ruptures of the radial digital
flexors of the hand. Congenital absence of the deep flexors of
the hand can involve the flexor pollicis longus and the flexor
digitorum profundus, thus resulting in a pinch similar to that
seen in anterior interosseous syndrome. A history of weakness
since birth, along with electrodiagnostic studies, helps con-
firm the diagnosis of the congenital condition (6).
Anterior Interosseous Nerve Palsy and the Neuritis of
Parsonage and Turner
In the patient presenting with weakness of flexion of the
interphalangeal joint of the thumb and the distal interpha-
langeal joints of the index and long fingers, the differential
diagnosis includes, besides the anterior interosseous syn-
drome, the neuritis described by Parsonage and Turner (129).
In the Parsonage-Turner syndrome, there often is weakness of
the distal phalanges of the thumb and index fingers. How-
ever, there usually is an associated variable weakness of the
scapular muscles, which distinguishes this form of brachial
plexopathy from anterior interosseous nerve palsy.
High Division of the Median Nerve (Bifid
Median Nerve)
High division of the median nerve can subject the nerve to
potential injury during forearm dissection, especially if one
of the two branches is not recognized. The variant branch
of the nerve may pass through the muscle mass or anterior
to the flexor digitorum superficialis (instead of its usual
course deep to the muscle) (6). If unrecognized, the anom-
alous nerve branch is at additional risk for injury during
operative procedures in the region.
High Division of the Median Nerve (Bifid
Median Nerve) and Forearm Lacerations
Laceration of the forearm associated with numbness of the
third web space and accompanying loss of sensibility in the
ulnar half of the long finger and radial half of the ring fin-
ger suggests the occurrence of a bifid median nerve with lac-
eration to the ulnar component (or perhaps a partial lacer-
ation of a normal median nerve) (6). Conversely, forearm
laceration with sparing of sensibility to the third web space
suggests either incomplete median nerve laceration (in a
normal nerve) or laceration to the radial component of a
bifid median nerve.
Injury to the Palmar Cutaneous Branch of the
Median Nerve
Surgery adjacent to or along the ulnar border of the flexor
carpi radialis must be performed with caution to avoid
injury to the palmar cutaneous branch of the median nerve.
The flexor carpi radialis and the radial styloid can be used
to help identify the palmar cutaneous branch of the median
nerve. The nerve usually exits the median nerve trunk as
one branch, approximately 5.5 cm proximal to the radial
styloid. The exit point is along the radial margin of the
flexor digitorum superficialis and continues along the ulnar
margin of the flexor carpi radialis longus tendon. If the
nerve is injured, the resulting loss of sensibility may be of
secondary concern compared with problems associated with
a painful neuroma (37,130). A painful neuroma can be dis-
abling. For this reason, if the palmar cutaneous branch of
the median nerve is inadvertently injured, or if the nerve is
found injured from penetrating trauma, nerve repair, if pos-
sible, usually is warranted (more from the standpoint of
neuroma prevention than from that of sensibility restora-
tion). If the nerve is not reparable, it can be transected
cleanly at its point of exit from the nerve trunk, or can be
placed in an area of protection deep to or inside a muscle
belly (37,130).
Isolated Compression of the Palmar
Cutaneous Branch of the Median Nerve
Entrapment of the palmar cutaneous nerve has been
reported, caused by or associated with an abnormal pal-
maris longus tendon. Associated symptoms included local-
ized pain, and numbness at the base of the thenar muscles.
Nerve decompression may be indicated (6,131).
Absence of the Palmar Cutaneous Branch of
the Median Nerve
With absence of the palmar cutaneous branch of the
median nerve, sensibility at the base of the thenar muscles
usually is provided by the anterior division of the musculo-
cutaneous nerve, a branch of the superficial branch of radial
nerve, a branch of the palmar cutaneous nerve from the
ulnar nerve, or a combination of these branches (75). In
these situations, lacerations of any of these nerves results in
anesthesia at the base of the thenar muscles.

Peripheral Block of the Palmar Cutaneous
Branch of the Median Nerve
To provide adequate local anesthesia for procedures in the
region of the palmar thenar muscles, block of the palmar
cutaneous branch must be included along with block of the
median nerve (unless the median nerve is blocked proximal
to the origin point of the palmar cutaneous nerve). Usually,
infiltration of anesthetic solution along the ulnar border of
the flexor carpi radialis anesthetizes the palmar cutaneous
branch of the median nerve.
Median Nerve in the Wrist and Hand
The median nerve becomes superficial in the distal forearm
approximately 5 cm proximal to the wrist, surfacing from the
radial border of the flexor digitorum superficialis. The nerve
continues distally, deep and slightly radial to the palmaris
longus (if present). The nerve is ulnar to the flexor carpi radi-
alis and anterior and ulnar to the flexor pollicis longus. In the
very distal forearm or at the level of the wrist, the median
nerve comes to lie palmar to the flexor digitorum superfi-
cialis, and continues into the carpal region by entering deep
to the transverse carpal ligament (flexor retinaculum). The
median nerve enters the carpal tunnel at a level that corre-
sponds to the volar flexion crease of the wrist. The carpal tun-
nel boundaries comprise the transverse carpal ligament on
the palmar aspect, the scaphoid and trapezium on the radial
aspect, the hook of the hamate and pisiform on the ulnar
aspect, and the palmar radiocarpal ligaments on the dorsal
aspect. The median nerve usually enters the carpal tunnel as
one nerve trunk. At this level, the internal topography of the
nerve is well organized and consistent. Within the
epineurium, the groups of fascicles are arranged linearly
according to their destination. The motor fibers are anterior.
The sensory fascicles for each of the web spaces and the radial
three and one-half digits are located from lateral to medial in
progressive sequence in the nerve (6,35,44).
Recurrent Motor Branch
After passing through the carpal tunnel, the recurrent
motor branch to the thenar muscle arises from the radial
surface of the median nerve (132–134). Variations of the
point of branching are well appreciated (see later, under
Anomalies and Variations: Median Nerve in the Wrist and
Hand). Most commonly, an extraligamentous recurrent
branch leaves the main nerve trunk at the distal margin of
the transverse carpal ligament. The nerve branch curves
proximally and radially to enter the thenar muscles. This
pattern has been noted in 46% of studied specimens. The
first muscle branch usually is to the flexor pollicis brevis,
followed by a branch to the abductor pollicis brevis. The
nerve then passes deeply to innervate the opponens pollicis
from the ulnar border of the muscle. The motor branch of
the median nerve rarely may supply innervation to the first
dorsal interosseous muscle (7).
3 Nerve Anatomy 195
The median nerve usually passes through the carpal tun-
nel as the most palmar structure (volar to the flexor ten-
dons), with the transverse carpal ligament lying immedi-
ately against the palmar surface of the nerve. The median
nerve then divides into three common palmar digital nerves
(discussed later). In general, the common digital nerves
divide at the junction of the middle and distal third of the
metacarpal shafts to form the proper digital nerves. This
branch point usually is approximately 1 cm distal to the
superficial palmar arch.
Common Palmar Digital Nerves
The first common palmar digital nerve divides into three
proper palmar digital nerves, two of which supply sensibility
to the palmar aspects of the thumb and one that continues
as the proper palmar digital nerve for the radial aspect of the
index finger (after supplying a small nerve branch to the first
lumbrical) (1,2,4,11). This branch to the first lumbrical
branches off just distal to the edge of the transverse carpal
ligament, in the proximal or middle palm (Fig. 3.2).
The second common palmar digital nerve supplies a small
nerve branch to the second lumbrical, and continues to the
web between the index and long fingers. The nerve splits into
proper digital nerves for the ulnar aspect of the index finger
and the radial aspect of the long finger (1–4,11) (Fig. 3.2).
The third common palmar digital nerve occasionally
gives a small branch to the third lumbrical (in which the
muscle receives double innervation from both the ulnar and
median nerves). The third common palmar digital nerve
also often communicates with a branch of the ulnar nerve,
and continues to the web space between the long and ring
fingers. The nerve then splits into proper digital nerves to
supply the ulnar aspect of the long finger and radial aspect
of the ring finger (Fig. 3.2).
Proper Digital Nerves
The proper digital nerves of the median nerve supply the
skin of the palmar surface and the dorsal surface of the dis-
tal phalanx of the respective digits. At the end of each digit,
the nerve terminates in two or three branches. One branch
usually innervates the pulp of the digit, another usually sup-
plies the tissue deep to the nail. These nerves often com-
municate with the dorsal digital branches of the superficial
radial nerve.
In the palm, the median nerve branches usually are
located deep to the associated arterial structures, but super-
ficial (palmar) to the flexor tendons. These branches pass
deep to the superficial palmar arch and usually cross deep to
the common digital arteries as the nerves and arteries course
distally. The division of the common digital nerves into
proper digital nerves usually occurs at the level of the
metacarpal necks. At this level, the proper digital nerves
course more palmarly, to come to lie palmar (superficial) to
the digital arteries. The nerves enter the digits between the
196 Systems Anatomy
deep and superficial transverse metacarpal ligaments,
maintaining their palmar relationship to the digital arter-
ies (7).
Anomalies and Variations: Median Nerve
in the Wrist and Hand
Because of its clinical relevance, the anatomy of the median
nerve has received substantial attention in anatomic studies.
As a result, several variations and anomalies have been
noted (36,44,134–139). In general, the anomalies usually
are one of the various patterns of the median nerve in the
carpal tunnel, or involve the median-to-ulnar or ulnar-to-
median nerve anastomosis in the palm.
Median Nerve Variations in the Carpal Tunnel
In the carpal tunnel, several variations of median nerve
anatomy have been described (6,41,71,72,137,138,
140–149) (Table 3.1). Lanz has described eight patterns
(138). These variations also have been classified by Spinner
(6) and by Amadio, based on evaluation of 275 carpal tun-
nel releases (70) (see Table 3.1). The variations described by
Lanz (138) include the following:
Among the most common patterns is the usual form and
course where the recurrent motor branch exits from the radial
aspect of the median nerve trunk just distal to the transverse
carpal ligament. This is a relatively safe pattern when per-
forming carpal tunnel release because the recurrent motor
branch courses distal to the area of ligament transection.
Although this is the most common pattern of the recurrent
branch of the median nerve, Amadio found an overall 19%
incidence of variations in a study of 275 patients undergoing
carpal tunnel release (70) (see Table 3.1).
TABLE 3.1. CLASSIFICATION OF MEDIAN NERVE
ANOMALIES IN THE CARPAL TUNNEL
High division
Open branching
Closed loop
Motor branch
Transretinacular
Multiple
Multiple and transretinacular
Palmar cutaneous branch
Transretinacular
Multiple
Multiple and transretinacular
Median–ulnar sensory ramus
(Arising on median nerve proximal to superficial arch)
Unclassified
From Amadio PC. Anatomic variation of the median nerve within
the carpal tunnel. Clin Anat 1:23–31, 1988.
A Transligamentous Passage of the Recurrent Motor
Branch
A transligamentous (transretinacular) passage of the recur-
rent motor branch is a pattern where the recurrent branch
penetrates the transverse carpal ligament, usually in the dis-
tal half. This pattern is the second most common type, and
is potentially problematic because the motor branch may
travel in the ligament and is at risk for injury when the lig-
ament is transected during carpal tunnel release (70,134,
135–139). The relatively high frequency of this transliga-
mentous course of the recurrent branch has been well doc-
umented by several authors (134,135–139). Spinner
describes a separate tunnel for the nerve in its transliga-
mentous course, where the nerve passes through the trans-
verse retinaculum 2 to 6 mm from the distal margin of the
ligament (6,137,149). The length of the transligamentous
tunnel is 15 to 30 mm (134,135–139). When the transliga-
mentous pattern is encountered during carpal tunnel
release, the nerve branch should be decompressed through-
out its tunnel through the ligament.
Subligamentous Origin of the Recurrent Motor Branch
Subligamentous origin of the recurrent motor branch is a
pattern where the recurrent motor branch leaves the median
nerve trunk more proximally, within the carpal tunnel, but
continues in a distal direction to the distal edge of the trans-
verse carpal ligament and curves back to the thenar muscles
in a retrograde fashion. The nerve branch does not pene-
trate the transverse carpal ligament.
Multiple Recurrent Motor Branches
Multiple recurrent motor branches is a pattern where the
nerves originate from the median nerve trunk in the more
common site just distal to the transverse carpal ligament,
but more than one branch is present (70,138,139,143,
146,147). This anomaly was found in 4% of patients
undergoing carpal tunnel release (70). When there are
multiple branches present, it is not uncommon for some
branches to pass through the ligament (70,143,147). The
nerve branches also may course either in their usual recur-
rent course or through different aberrant paths. On occa-
sion, an accessory motor branch can arise in the distal
forearm or proximal wrist. It can pass through the carpal
tunnel or through the flexor retinaculum (138,146–148).
In Amadio’s study, when multiple recurrent branches were
present, approximately half of the branches were found to
pass through the retinaculum (70). Mumford et al. found
2 branches in 1 of 10 dissections; one of the branches
passed through the retinaculum (134). An accessory
thenar nerve arising from the first common digital nerve
or the radial proper digital nerve was noted and reported
by Mumford et al. These findings were seen in 15 of 20
hands dissected (134). The accessory thenar nerve was the
only median nerve supply to the flexor pollicis brevis in
eight specimens.

Distal Branching of the Median Nerve
Distal branching of the median nerve is a pattern where the
recurrent motor branch leaves the median nerve more dis-
tally in the palm, distal to the carpal tunnel. The nerve
branch then loops back proximally to reach the thenar mus-
cles, extending in a retrograde fashion.
Recurrent Motor Branch Arising from the Ulnar
Aspect of the Median Nerve
The recurrent motor branch arises in or distal to the carpal
tunnel, but the branch point usually is on the ulnar aspect
of the median nerve trunk. In addition, the motor branch
can arise from the central, anterior surface of the median
nerve, then pass ulnarly and distally until it clears the trans-
verse carpal ligament, where it turns and passes radially and
somewhat retrograde over the ligament to reach the thenar
muscle mass (36,150). A variation of this anomaly was
reported by Papathanassiou, who noted one clinical case
and one dissection specimen in which the motor branch
arose from the ulnar, anterior aspect of the radial division of
the median nerve (149). This anomaly was found in 16 of
20 dissections by Mumford et al. (134). The anomaly also
was encountered once by Lanz (138,146).
Ulnar-sided Exit of the Recurrent Motor Branch with
Hypertrophy of the Flexor Pollicis Brevis or Palmaris
Brevis
An associated concomitant hypertrophy of the flexor polli-
cis brevis or palmaris brevis has been noted to occur com-
monly with the aberrant origin of the recurrent motor
branch arising from the ulnar side of the nerve rather than
from the radial aspect (150). The hypertrophied flexor pol-
licis brevis lies anterior to the flexor retinaculum. Spinner
emphasizes that when this muscle variant is found, it is safer
to identify the median nerve in the carpal tunnel, and locate
the motor branch by opening the carpal tunnel on the
medial side. The motor branch can then be traced distally
as it recurs through the superficial hypertrophied muscle
(6,150).
Recurrent Motor Branch Arising Anteriorly
Recurrent motor branch can arise anteriorly, then pass
over the surface of the transverse carpal ligament. The
recurrent motor branch arises in the carpal tunnel, more
proximally than normal, originating from the palmar
aspect of the nerve. The nerve extends distally, around the
distal edge of the transverse carpal ligament, and loops
back proximally to reach the thenar muscles in a retro-
grade fashion.
Recurrent Motor Branch and Median Nerve Passing
Anterior to the Transverse Carpal Ligament
A rare pattern noted by Sunderland involves the entire
median nerve passing superficial to the transverse carpal lig-
ament (44).
3 Nerve Anatomy 197
Absence of the Recurrent Motor Branch to the Thenar
Muscles
Complete absence of the recurrent motor branch to the
thenar muscles has been described (6,41,140). This is
observed in the all-ulnar hand, in which all of the thenar
muscles are innervated by the ulnar nerve through various
communicating branches (41,140).
High Division of the Median Nerve (Bifid Median
Nerve)
Branching of the median nerve proximal to the wrist is well
described, and often presents as a bifid median nerve
(135,141,144). The bifid median nerve can be discovered
in the carpal canal during carpal tunnel release or in the
forearm during operative exploration (138,141,144,146).
There usually is a larger, more radial component and a
smaller ulnar component that travels parallel to the larger
component.
This anomaly has been described by Gruber, who noted
four cases in which the median nerve branch to the third
web space originated in the proximal forearm. Amadio
found high branching of the median nerve in 3% of cases
(70). Hartmann and Winkelman and Spinner also have
reported high branching of the median nerve in the forearm
(71,72). In most of the cases studied by Amadio, the bifid
median nerve had two branches that remained independent
of one another. However, two of nine cases had a loop com-
munication in which one or the other median nerve branch
received a communicating branch from the other in or just
distal to the carpal canal (70). This communicating loop
also was noted in 3 of 29 cases reported in the literature at
the time of Amadio’s study (70).
A median artery also may be present with the bifid
median nerve. The median artery is an anomalous artery
that is a persistent extension of the anterior interosseous
artery. The median artery can result from persistence of an
embryonic artery known as the forearm axis artery.
Anomalous muscles such as aberrant flexor digitorum
superficialis or lumbricals also have been associated with a
high division of the median nerve.
Riche-Cannieu Anastomosis
Nerve communication between the median nerve recurrent
motor branch and the ulnar nerve deep branch is referred to
as a Riche-Cannieu communication or anastomosis. In 1897,
Riche and Cannieu independently described a connection
between these nerves occurring between the fibers of the
median nerve recurrent motor branch traveling to the super-
ficial head of the flexor pollicis brevis and the fibers of the
deep ulnar branch going to the deep head of the flexor polli-
cis brevis (151,152). Mannerfelt drew additional attention to
this important anastomosis (46,150). The communicating
fibers pass radially from the deep ulnar branch between the
heads of the adductor pollicis, then pass deep to the flexor
198 Systems Anatomy
pollicis longus tendon. The fibers continue proximally to
the radial side of the flexor pollicis longus tendon as they
approach the median nerve recurrent motor branch. This
communication was found in 77% of cadaver specimens
studied, and was found in virtually all fresh cadaver hands
(153). Riche described two other anatomic median–ulnar
nerve communications. In one, the communication
occurred between a thumb digital nerve (derived from the
median nerve) and fibers en route to the adductor pollicis
(derived from the deep ulnar nerve branch). The commu-
nicating fibers were found in the adductor muscle on the
medial side of the flexor pollicis longus tendon. In another
pattern, the communicating fibers passed through the first
lumbrical, which was innervated by the ulnar nerve
(36,152). It is now assumed that the Riche-Cannieu con-
nection usually carries motor fibers only (36,150,153),
although early investigators thought it carried sensory
fibers (154). Foerster, as a result of war-injury studies, and
Harness and Sekeles, as a result of anatomic dissections,
believed that the anastomosis was of the motor type
(153,155,156). Because Harness and Sekeles found that
most of the preserved specimens studied (77%) and virtu-
ally all of the fresh specimens contained the Riche-Cannieu
communication, they concluded that this nerve anastomo-
sis is common and normal, and may represent the more
usual innervation pattern of the thenar muscles (153).
Additional clinical and electromyographic studies have
supported this consideration (36,153). However, Manner-
felt has noted that the nature (sensory, motor, or mixed),
incidence, and direction of the fiber passage (i.e., median
to ulnar nerve, or ulnar to median nerve) remain unre-
solved (36,150). Either way, the communication provides
a potential pathway for double innervation of the intrinsic
muscles anywhere in the hand. A variation of the Riche-
Cannieu anastomosis has been noted by Harness and Seke-
les and by Hovelacque, in which a branch from the deep
ulnar nerve communicates with a thumb digital nerve.
This presents the possibility that median motor fibers des-
tined for the thenar muscles were traveling in the digital
nerve (36,157).
Basic Patterns of the Riche-Cannieu
Anastomosis
Spinner has summarized the basic patterns of the Riche-
Cannieu anastomosis (6):
n An anastomosis in the substance of the adductor pollicis
between the median and ulnar nerves
n A communicating branch from the motor branch of the
median nerve coursing anterior to the radial head of the
flexor pollicis brevis and the ulnar component passing
deep to the ulnar head of this muscle
n Anastomosis between the two motor nerves across the
first lumbrical
n Anastomosis between the branch of the deep ulnar nerve
to the adductor pollicis or flexor pollicis brevis and the
median nerve digital branch to the thumb or index fin-
ger
Palmar Ulnar–Median Communicating Branch
of Berrettini
As noted previously, the Riche-Cannieu anastomosis usu-
ally carries motor fibers and occurs in the region of the
adductor pollicis and thenar muscles. However, a distal
communicating branch between the ulnar and median
sensory nerves is not uncommon; in fact, the presence of
a communicating branch may be the most common (and
normal) nerve pattern. Classically, palmar sensation in the
fingers is described as divided between ulnar and median
nerves at the midline of the ring finger. Berrettini
described and illustrated this communicating branch in
1741 (158). More recently, Meals and Shaner found a
communicating branch between the ulnar and median
nerves in the palm in 40 of 50 dissected specimens. Sev-
eral studies have confirmed the common presence of this
communicating branch (44,46,52,159). The communi-
cating branch usually passes immediately deep to the
superficial palmar arch; however, in some specimens the
branch courses just distal to the transverse carpal ligament
(70,157).
Innervation of the Lumbricals and Associated
Flexor Digitorum Profundus
In general, the belly of the flexor digitorum profundus of
the index finger and the first lumbrical muscle nearly always
are supplied by branches of the median nerve. However,
innervation of the other flexor digitorum profundus muscle
bellies and their corresponding lumbricals is quite variable.
The lumbrical usually is supplied by the same major nerve
(median or ulnar) that supplies the corresponding belly of
the flexor digitorum profundus. However, in 50% of cases,
there are variations from the classic pattern of innervation
(in which the median nerve innervates the radial two bellies
and the ulnar nerve innervates the ulnar two bellies) (36).
The variation usually involves the median nerve encroach-
ing on the ulnar nerve distribution. However, the ulnar
nerve also can encroach laterally to innervate the long fin-
ger belly partially or exclusively (36).
Clinical Correlations: Median Nerve in the
Wrist and Hand
As the median nerve passes through the carpal tunnel, it is
the most palmarly located structure, with the transverse
carpal ligament adjacent to its palmar surface. The median
nerve is therefore at inherent risk for injury during carpal

tunnel release. Scarring or adhesions add to the risk of
injury if the median nerve is adherent to the ligament. This
risk is especially significant when repeat or revision carpal
tunnel release is performed (160,161).
Anatomic Aspects of Carpal Tunnel Syndrome
Several causes of carpal tunnel syndrome have been recog-
nized (6,142,160–177). Specific anatomic abnormalities
that can be factors in carpal tunnel syndrome include the
following:
n A palmaris profundus muscle. The palmaris profundus
is a muscle that originates from the radius, ulna, and
interosseous ligament in the forearm, and passes through
the carpal tunnel to insert onto the dorsal surface of the
palmar fascia. It can produce symptoms if its tendon is
large or if the musculotendinous junction extends into
the carpal tunnel (6,127)
n An anomalous flexor digitorum superficialis, especially
that with a muscle belly that extends distally into the
carpal tunnel (178–184)
n Anomalous lumbrical muscles that extend proximally
into the carpal tunnel (185)
n An enlarged, inflamed, thrombosed, or calcified median
artery in the carpal tunnel (186,187)
n A hypertrophied palmaris longus (160)
High Division of the Median Nerve (Bifid
Median Nerve)
The high division of the median nerve results in two
nerves entering the carpal tunnel. This variant can subject
the nerve to potential injury during carpal tunnel release,
especially if one of the two branches is not recognized. An
unrecognized branch is particularly vulnerable during
flexor tenosynovectomy or flexor tendon repair in the
carpal tunnel. Spinner notes that in carpal tunnel syn-
drome with atypical findings such as sensibility abnormal-
ities isolated only to the third web space or only to the
more lateral aspect of the hand (sparing the third web
space), the examiner should consider the bifid median
nerve as a potential finding (6). Similarly, laceration of the
forearm associated with numbness of the third web space
and its accompanying digital manifestation in the ulnar
half of the long finger and radial half of the ring finger
suggest the occurrence of a bifid median nerve (or perhaps
a partial laceration of a normal median nerve) (6). When
a bifid median nerve is encountered or a median nerve
found with high branches originating in the forearm, spe-
cial care is required during carpal tunnel release or median
nerve exploration, both for nerve protection and for ade-
quate decompression. Release of the median nerve
branches from separate fascial channels in the transverse
carpal ligament may be needed (36,135).
3 Nerve Anatomy 199
The Recurrent Motor Branch of the Median
Nerve
The most common pattern of the recurrent branch of the
median nerve is the course where the nerve exits the nerve
trunk distal to the transverse carpal ligament, then curves
back proximally in a retrograde fashion to reach the
thenar muscles. This common pattern also is relatively
safe because the nerve branch does not penetrate or lie
within the ligament that is transected. The presence of
variations in number and patterns of the recurrent branch
of the median nerve should be kept in mind during oper-
ative exploration of hand lacerations with loss of thenar
muscle function.
The Transretinacular Pattern
The transretinacular pattern of the recurrent motor branch,
in which the recurrent branch penetrates the transverse
carpal ligament, is the second most common pattern, and is
potentially problematic. The motor branch that travels in
the ligament is at risk for injury when the ligament is tran-
sected during carpal tunnel release. Injury to the nerve with
this pattern can be minimized by an appreciation of the
anatomy, as well as by transection of the transverse carpal
ligament carried out toward the ulnar side of the canal.
When the transligamentous pattern is encountered during
carpal tunnel release, the nerve branch should be decom-
pressed throughout its tunnel through the ligament. This
pattern has been thought to be potentially responsible for
carpal tunnel syndrome that presents with more motor or
even pure motor dysfunction, compared with sensory
abnormalities (6,188).
Palmar Ulnar–Median Communicating Branch
of Berrettini
The communicating sensory branch between the ulnar and
median nerves (palmar ulnar–median communicating
branch of Berrettini; see earlier) may course between the
nerves just distal to the transverse carpal ligament
(70,157). It is vulnerable to injury during carpal tunnel
release or palmar exploration for operative procedures such
as flexor tendon repair or partial palmar fasciectomy for
Dupuytren’s contracture, especially along the axis of ring
finger ray (36).
Common and Proper Digital Nerves and
Arteries
During nerve and artery exploration in the palm or digits,
an appreciation of the relationship between the common
and proper digital nerves and arteries is emphasized. In the
palm, the median nerve branches usually are located deep to
the associated arterial structures. These nerve branches pass
200 Systems Anatomy
deep to the superficial palmar arterial arch and usually pass
deep to the common digital arteries as the nerves and arter-
ies course distally. At the approximate level of the
metacarpal necks, the nerves course more palmarly, and
come to lie palmarly at the base and along the digits. In the
digits, the digital nerves are palmar to the digital arteries.
Thus, it is possible (and not uncommon) to encounter a
clinical situation where both digital nerves are lacerated in
the digit, but the digit remains vascularized. The deeper-
lying arteries are more protected, and can therefore more
often survive penetrating trauma.
All Ulnar Nerve–Innervated Hand
In the all ulnar nerve–innervated hand, there is absence
of a thenar branch from the median nerve. With a com-
plete median nerve laceration at the wrist, operative
exploration reveals only a small median nerve in the
carpal tunnel. The only deficit noted may be loss of sen-
sibility to the palmar aspect of the index finger. The ulnar
nerve provides the remaining motor and sensory fibers
(6).
ULNAR NERVE
Origin of the Ulnar Nerve
The ulnar nerve arises from the medial cord of the brachial
plexus, and is composed of fibers from the anterior rami of
C8, and T1 (1–4,11) (see Fig. 3.1).
TABLE 3.2. ORDER OF INNERVATION OF MUSCLES
SUPPLIED BY THE ULNAR NERVE
Muscle
Flexor carpi ulnaris
Flexor digitorum profundus
Abductor digiti minimi
Flexor digiti minimi
Opponens digiti minimi
Fourth web space interossei
Third web space interossei
Second web space interossei
Fourth lumbrical
Third lumbrical
Adductor pollicis (oblique head)
Adductor pollicis (transverse head)
First web space interosseous
From Sunderland S, Ran LJ. Metrical and non-metrical features of
the muscular branches of the median nerve. J Comp Neurol 85:191,
1946.
Ulnar Nerve in the Axilla and Arm
At the level of the pectoralis minor muscle, the medial
cord divides into two branches. One branch courses
slightly laterally to join a branch from the lateral cord to
form the median nerve. The other branch of the medial
cord continues distally to form the ulnar nerve (see Fig.
3.1). In the axilla and arm, the ulnar nerve remains the
most medially positioned major nerve. In the axilla, the
ulnar nerve is medial and adjacent to the axillary artery.
The axillary vein is located medial to the ulnar nerve. At
the inferior border of the subscapularis muscle, the ulnar
nerve may receive additional fibers of the C7 nerve root
through the “lateral root of the ulnar nerve” (189). This
supplemental nerve arises from either the lateral cord or
middle trunk (8). The ulnar nerve continues distally from
the medial cord deep (posterior) to the pectoralis minor
and pectoralis major and anterior to the subscapularis,
latissimus dorsi, and teres major. Along this course, it
remains medial or posteromedial to the axillary artery and
subsequent brachial artery. At the inferior border of the
pectoralis major, the ulnar nerve continues and diverges
medially from the brachial artery (as the artery courses
slightly anteriorly). The ulnar nerve pierces the medial
intermuscular septum approximately 8 cm proximal to the
medial epicondyle (13). As the nerve passes from the ante-
rior compartment to the posterior compartment through
the medial intermuscular septum, it passes deep to the
arcade of Struthers, if present (see later, under Anomalies
and Variations: Ulnar Nerve in the Axilla and Arm). In
this vicinity, the brachial artery gives off the superior ulnar
collateral artery, which also pierces the medial intermus-
cular septum and continues distally along with the nerve.
The nerve remains to the medial aspect of the superior
ulnar collateral artery. Both nerve and artery continue dis-
tally and medially on the anterior surface of the medial
head of the triceps muscle. The artery is then joined by a
branch of the inferior ulnar collateral artery at the medial
supracondylar ridge. These arteries continue in close prox-
imity to the nerve as the nerve enters the interval between
the medial epicondyle of the humerus and the olecranon.
The nerve passes into the ulnar groove on the dorsal
aspect of the medial epicondyle. The ulnar nerve does not
normally innervate any muscles of the arm, although a
muscular branch to the flexor carpi ulnaris may branch
from the ulnar nerve proper 1 cm proximal to the medial
epicondyle (189) (Table 3.2 and Fig. 3.3).
The Medial Antebrachial Cutaneous Nerve
The medial antebrachial cutaneous nerve (medial cuta-
neous nerve of the forearm) is a sensory nerve with several
branches that innervates the medial forearm (discussed in
detail later, under Medial Antebrachial Cutaneous Nerve;
Fig. 3.4). It is mentioned here because of its close anatomic
 3 Nerve Anatomy 201

FIGURE 3.3. Schematic illustration of the ulnar nerve and associated branches and innervated
muscles.
202 Systems Anatomy

A
FIGURE 3.4. Cutaneous nerves of the upper extremity. A: Anterior aspect.
 3 Nerve Anatomy 203

B
FIGURE 3.4 (continued). B: Posterior aspect.
204 Systems Anatomy
proximity to the ulnar nerve. The medial antebrachial cuta-
neous nerve originates from the lower trunk or medial cord
of the brachial plexus, just proximal to the actual origin of
the ulnar nerve (190). It contains fibers from C8 and T1. In
the axilla, the nerve runs with the ulnar nerve between the
axillary artery and vein. A small branch leaves the nerve to
supply the skin over the biceps muscle and the elbow flex-
ion crease (along with branches of the medial cutaneous
nerve of the arm, discussed in further detail later) (191).
The medial antebrachial cutaneous nerve descends along
the medial surface of the brachial artery. It pierces the ante-
brachial fascia in the middle third of the arm with the
basilic vein. The nerve divides into anterior and posterior
branches approximately 15 cm proximal to the medial epi-
condyle. The anterior branch passes anterior to the median
cubital vein between the medial epicondyle and biceps ten-
don, and innervates the mediopalmar skin of the forearm
(Fig. 3.4A-B). The terminal branches join the palmar cuta-
neous branches of the ulnar and median nerves in the hand.
The posterior branch of the medial cutaneous nerve of the
forearm often crosses the ulnar nerve from approximately 6
cm distal to the medial epicondyle. It descends along the
medial side of the basilic vein, supplying the dorsomedial
skin of the forearm. Distally, the nerve joins the dorsal cuta-
neous branch of the ulnar nerve (189,190) (Fig. 3.4A-B).
Anomalies and Variations: Ulnar Nerve in
the Axilla and Arm
The ulnar nerve normally originates from the medial cord
of the brachial plexus. It may, however, receive fibers from
several other sources, including the lateral cord, the middle
trunk, and the anterior division of the middle trunk. These
neural elements are collectively referred to as the lateral root
of the ulnar nerve. The lateral root of the ulnar nerve joins
the ulnar nerve proper at or distal to the inferior border of
the subscapularis muscle. The lateral root nerve fibers may
provide innervation to the flexor carpi ulnaris (8).
Arcade of Struthers
As the ulnar nerve passes from the anterior to the posterior
muscle compartment of the arm, it may encounter a myofi-
brous or fasciomyofibrous tunnel, the arcade of Struthers.
This common structure, first described by Struthers in
1854 (18), should not be confused with the rare (1%) unre-
lated anatomic structure, the ligament of Struthers (which
is seen in association with a supracondylar process and can
result in median neuropathy in the arm; see earlier, under
Median Nerve in the Axilla and Arm). The arcade of
Struthers is common, and has been shown to occur in 70%
of specimens (192,193). The arcade of Struthers is a fibrous
or fascial sheet located in the distal third of the medial
aspect of the humerus. When the arm is in the anatomic
position, the roof of the arcade faces medially. It is formed
by a thickening of the deep investing fascia of the distal part
of the arm, by superficial muscular fibers of the medial head
of the triceps, and by attachments of the internal brachial
ligament (6). (The internal brachial ligament is a relatively
long, longitudinal ligament originating from the region of
the coracobrachialis tendon.) The anterior border of the
arcade of Struthers is the medial intermuscular septum. The
lateral border of the arcade is formed by the medial aspect
of the humerus covered by deep muscular fibers of the
medial head of the triceps. Spinner has noted that the pres-
ence of the arcade of Struthers should be suspected if, at the
time of operative exposure of the proximal portion of the
ulnar nerve, the muscle fibers of the medial head of the tri-
ceps are seen crossing obliquely, superficial to the nerve.
This is in the area where the nerve traverses from the ante-
rior to posterior compartment. When no muscular fibers
can be seen crossing the ulnar nerve approximately 5 to 7
cm proximal to the medial epicondyle, the arcade probably
is not present (193). The arcade of Struthers may be a
potential area of ulnar nerve compression. If decompression
or transposition of the ulnar nerve is performed, awareness
of this structure is important for through decompression.
Compression of the ulnar nerve can occur above the elbow
at the arcade at the level of the medial epicondylar groove,
or distally as the nerve passes between the ulnar and
humeral heads of the flexor carpi ulnaris (17,78,193).
The First Branch
The first branch of the ulnar nerve usually originates in
the cubital tunnel. However, variation in the articular
and first muscular branches is common. The articular
branch, normally the first branch of the nerve, exits from
the main trunk in the ulnar groove and passes horizon-
tally into the joint. One or several articular branches may
originate in the arm, up to approximately 1 cm proximal
to the medial epicondyle. The first muscular branch, usu-
ally to the flexor carpi ulnaris, usually exits immediately
distal to the articular branch. However, division as high
as 4 cm proximal to the medial epicondyle has been
reported (189,194).
The Medial Antebrachial Cutaneous Nerve
and the Ulnar Nerve
The medial antebrachial cutaneous nerve may arise from
several slightly different points. It usually arises from the
medial cord of the brachial plexus, just proximal to the ori-
gin of the ulnar nerve. It usually arises just distal to the ori-
gin of the medial brachial cutaneous nerve, which is the
smallest branch of the brachial plexus (194) (see Fig. 3.1).
The medial antebrachial cutaneous nerve also may arise
from the lower trunk of the brachial plexus, from the first
thoracic nerve root (T1), or from the ulnar nerve itself. The
medial antebrachial cutaneous nerve commonly communi-

cates with the intercostobrachial nerve in the axilla and the
medial cutaneous nerve of the arm proximally (195).
Clinical Correlations: Ulnar Nerve in the
Axilla and Arm
Arcade of Struthers
During exploration of the ulnar nerve at the elbow for
neuropathy, awareness of the possible presence of an
arcade of Struthers is important because this may be a
potential area of nerve compression (see earlier). The
nerve should be explored proximally to the level of where
the nerve passes from the anterior to posterior compart-
ments. Muscle fibers of the medial head of the triceps
that cross obliquely superficial to the nerve usually indi-
cate the presence of an arcade of Struthers. If present, the
fascial sheet of the arcade of Struthers should be incised.
If the nerve is transposed anteriorly, it should be con-
firmed that an arcade of Struthers is not present or is not
causing tethering or compression of the proximal aspect
of the transposed nerve.
The Arcade and the Ligament of Struthers
The arcade of Struthers should not be confused with the
ligament of Struthers. The arcade of Struthers, present in
approximately 70% of studied specimens, is located at the
medial intermuscular septum, and can cause compression
of the ulnar nerve. The ligament of Struthers, in contrast, is
rare, occurring in only 1%, and consists of a ligament or
extension of the pronator teres muscle from the medial epi-
condyle to an (anomalous) supracondylar process. The lig-
ament of Struthers is a possible site of compression of the
medial nerve (6,17,18,20–22,78,192).
Ulnar Nerve in the Elbow and Forearm
Ulnar Nerve in the Cubital Tunnel
The cubital tunnel at the elbow is a fibroosseous tunnel
(189,196,197). The lateral border consists of the humerus,
ulna, and elbow joint. The medial and inferior border con-
sists of a fascial sheath confluent with the brachial and ante-
brachial fascia of the adjacent muscles. The distal medial
border consists of the aponeurosis or fascia between the two
heads of the flexor carpi ulnaris (6,17,78). As noted by
Siegel and Gelberman, the tunnel can be divided geograph-
ically into three parts (189).
Ulnar Nerve in the First Part of the Cubital Tunnel
The first part of the cubital tunnel is the entrance of the tun-
nel, formed by the ulnar groove in the medial epicondyle. At
this entrance, the ulnar nerve lies in the extensor side of the
arm. In the first part, the ulnar nerve usually provides one
branch or several small articular branches to the elbow joint.
3 Nerve Anatomy 205
These branches usually are proximal to the branches given
off to innervate the flexor carpi ulnaris (189).
Ulnar Nerve in the Second Part of the Cubital Tunnel
The second and middle part of the tunnel consists of a fas-
cial arcade. (This arcade should not be confused with the
arcade of Struthers, which is a separate fascial arcade located
more proximally in the arm; see earlier.) The fascial arcade
of the second part of the cubital tunnel attaches to the
medial epicondyle and to the olecranon. It connects the
ulnar and humeral heads of the origin of the flexor carpi
ulnaris muscle. In this area, the nerve crosses the medial
surface of the elbow. It lies on the posterior and oblique
portions of the ulnar collateral ligament. The nerve usually
gives off two branches to innervate the flexor carpi ulnaris.
One branch usually supplies the humeral head and one sup-
plies the ulnar head. The first branch exits the main nerve
trunk horizontally. The second branch continues distally for
several centimeters before entering the flexor carpi ulnaris.
Up to four motor branches to the flexor carpi ulnaris may
be given off, exiting the main nerve at a point between 4 cm
proximal and 10 cm distal to the medial epicondyle (13).
The motor branches enter the flexor carpi ulnaris on its
deep surface. The first motor branch of the flexor carpi
ulnaris divides in 5% of limbs to supply the flexor digitorum
profundus as well (63) (see Table 3.2). In the second portion
of the cubital tunnel, the distance between the medial
humeral epicondyle and the olecranon is shortest with elbow
extension. This distance increases with elbow flexion (198).
The roof of the cubital tunnel is formed by the fascial
arcade, which becomes taut with elbow flexion (189).
Ulnar Nerve in the Third Part of the Cubital Tunnel
The third and most distal part of the tunnel consists of the
muscle bellies of the flexor carpi ulnaris. The flexor carpi
ulnaris provides a portion of the roof in this area. Although
the ulnar nerve enters the cubital tunnel on the extensor
side of the arm (in the first part of the tunnel), it comes to
lie on the flexor surface on exiting the tunnel in the third
part. The nerve courses through the interval between the
humeral and ulnar heads of the flexor carpi ulnaris or
between the flexor carpi ulnaris and flexor digitorum pro-
fundus muscles (189).
The volume of the tunnel decreases with elbow flexion,
and the pressure within it increases, even in the normal
elbow when the aponeurotic arch or surrounding soft tis-
sues are not thickened.
The nerve then continues distally in the forearm
between the flexor digitorum profundus, located dorsally
and laterally to the nerve, and the flexor carpi ulnaris,
located anteriorly and medially. The nerve maintains this
relationship with the muscles through the proximal to mid-
dle forearm. In general, the nerve runs a straight course
through the forearm from the level of the medial epicondyle
of the distal humerus to the pisiform–hamate groove in the
206 Systems Anatomy
carpus. In the distal third of the forearm, the ulnar nerve
courses more superficially, lying just radial and deep (dor-
sal) to the flexor carpi ulnaris muscle (6,189).
Motor Branches of the Ulnar Nerve in the
Forearm
In the forearm, and distal to the exit of the motor branches
to the flexor carpi ulnaris, the ulnar nerve usually has three
additional main branches. These are (a) the motor branch
to the flexor digitorum profundus (to the ring and small
fingers), (b) the palmar cutaneous portion of the ulnar
nerve, and (c) the dorsal branch of the ulnar nerve
(189,199).
Motor Branch to the Flexor Digitorum Profundus (to
the Ring and Small Fingers)
The motor branch to the flexor digitorum profundus from
the ulnar nerve usually innervates the ulnar half of the mus-
cle, which includes the muscle bellies to the ring and small
fingers. (The anterior interosseous nerve from the median
nerve usually innervates the radial half of the flexor digito-
rum profundus, including the muscle bellies to the long
and index fingers, as well as the flexor pollicis longus.) The
motor branch from the ulnar nerve is located proximally in
the forearm. It arises approximately 3 cm distal to the
medial epicondyle and usually exits the ulnar nerve trunk
just distal to the branches to the flexor carpi ulnaris. The
motor branch passes distally for approximately 2.5 cm, usu-
ally lying on the anterior surface of the flexor digitorum
profundus (1–4,11,13,189,191). It then enters the muscle
at approximately 6 cm distal to the medial epicondyle (6),
whereas the anterior interosseous nerve enters the flexor
digitorum profundus to the index and long fingers approx-
imately 4 to 7 cm more distally (6). In 80% of upper limbs,
a single branch from the ulnar nerve supplies the flexor dig-
itorum profundus. In approximately 20%, two or more
branches supply the muscle. There may not be a direct
branch from the main ulnar nerve trunk that supplies the
flexor digitorum profundus. In these specimens, the flexor
digitorum profundus may by innervated by the branch of
the ulnar nerve to the flexor carpi ulnaris or by a branch
from the median nerve.
In the forearm, the ulnar nerve lies medial and adjacent
to ulnar artery.
Traditionally, the ulnar nerve is described as innervating
the flexor digitorum profundus to the ring and small fin-
gers, and the anterior interosseous nerve from median nerve
is described as innervating the flexor digitorum profundus
to the index and long fingers. This pattern, however, has
been noted actually to comprise only 50% of upper limbs
(32). In several studied specimens, the median nerve or
derived branches was found to innervate the flexor digito-
rum to the ring and little fingers. In addition, the ulnar
nerve was found occasionally to supply the flexor digitorum
profundus to the long finger (32,189). The flexor digito-
rum profundus to the index finger, however, does seem to
be innervated consistently by the median nerve.
Sympathetic Fibers from the Ulnar Nerve in
the Forearm
In the middle forearm, the ulnar nerve supplies the accom-
panying ulnar artery with a segmental sympathetic nerve.
This is the nerve of Henle (200–202) (Fig. 3.3).
Palmar Cutaneous Branch of the Ulnar Nerve
The palmar cutaneous branch of the ulnar nerve is not as
consistent as its median nerve counterpart, the palmar cuta-
neous branch of the median nerve. When present, the pal-
mar cutaneous branch of the ulnar nerve arises at variable
levels from the ulnar nerve in the distal forearm, usually in
the vicinity of the junction of the middle and distal thirds
of the forearm. It courses distally on or in the epineurium
of the ulnar nerve on the palmar surface of the ulnar artery.
The nerve then perforates the antebrachial fascia just prox-
imal to the distal wrist flexion crease, and innervates the
skin in the hypothenar eminence, the ulnar artery, and,
occasionally, the palmaris brevis muscle (6) (see Figs. 3.3
and 3.4A).
Dorsal Cutaneous Branch of the Ulnar Nerve
The dorsal cutaneous branch of the ulnar nerve arises from
the medial aspect of main ulnar nerve trunk in the distal
forearm and curves dorsally to supply cutaneous innerva-
tion to the dorsal aspect of the small finger and ulnar ring
finger (199,203,204) (see Fig. 3.4B). Its point of origin is
an average of 6.4 cm from the distal aspect of the head of
the ulna and 8.3 cm from the proximal border of the pisi-
form. The cross-sectional shape of the nerve at its origin
usually is round or slightly oval, with a mean diameter of
approximately 2.4 mm. The point of nerve origin corre-
sponds to a point located at the distal 26% of the total
length of the ulna (199). The nerve extends distally and
medially, passing dorsal to the flexor carpi ulnaris, and
pierces the deep antebrachial fascia. The nerve emerges at
the dorsomedial border of the flexor carpi ulnaris at a mean
distance of 5 cm from the proximal edge of the pisiform. At
this point, the nerve pierces the deep antebrachial fascia to
become subcutaneous on the medial aspect of the distal
forearm. Proximal to the wrist, the nerve provides two to
three branches. A branch piercing the capsule of the ulno-
carpal joint usually is present. With the forearm in supina-
tion, the nerve branch passes along and close to the medial
aspect of the head of the ulna near the widest diameter of
the ulnar head (equator of the ulnar head). With the fore-
 3 Nerve Anatomy 207

arm pronated, the nerve branches displace slightly palmarly Variations in Innervation of the Flexor Carpi
to pass along the palmoulnar aspect of the ulnar head. In Ulnaris
the hand, an additional one or two branches usually are
The flexor carpi ulnaris usually receives two or three motor
given off. The total number of branches averages five, with
branches. Up to five branches have been noted (6). In iso-
a range from three to nine. Two branches typically extend
lated case reports, the flexor carpi ulnaris was found to have
to the small finger, one to the dorsoulnar aspect of the ring
a motor branch from the median nerve (6).
finger, and one or two branches to the dorsoulnar aspect of
the carpus and hand. The diameters of the branches range
from 0.7 to 2.2 mm (199). The branches of the dorsal Variations in Innervation of the Flexor
branch of the ulnar nerve continue to the level of the prox- Digitorum Profundus Muscle
imal interphalangeal joints, where the nerves arborize and
Variations in the innervation of the flexor digitorum pro-
become difficult to trace. There are no apparent further
fundus muscle have been reported (205). Traditionally, the
communications between the dorsal branch of the ulnar
ulnar nerve is thought to innervate the flexor digitorum
nerve and the ulnar nerve proper, with the palmar cuta-
profundus to the ring and small fingers, and the median
neous branch of the ulnar nerve, or with the nerve of Henle
nerve innervates the index and long fingers. However, this
(200).
pattern was found in only 50% of upper limbs (32). In sev-
In the proximal forearm, the posterior ulnar recurrent
eral specimens, the median nerve was found to innervate
artery, which arises from the ulnar artery close to the bifur-
the ring and little fingers and the ulnar nerve was found to
cation of the radial artery, courses ulnarly and proximally to
supply the long finger (32,189). It is more common for the
continue in proximity to the ulnar nerve and motor
median nerve to innervate muscles traditionally supplied by
branches to the flexor digitorum profundus, along the ulnar
the ulnar nerve than for the ulnar nerve to innervate mus-
border of the nerves (1–4,11).
cles usually supplied by the median nerve (32,35,63). This
The superior ulnar artery accompanies the ulnar nerve
may occur in the all–median nerve hand.
into the cubital tunnel. In the cubital tunnel, the superior
Many of the variations in branching occur in the muscle
ulnar collateral artery joins the posterior ulnar recurrent
belly of the flexor digitorum profundus, and therefore are
artery to form one of the vascular collateral pathways
difficult to identify by superficial visualization and exami-
around the elbow and bypassing the distal portion of the
nation of the muscle. The flexor digitorum profundus to
brachial artery (1,4).
the index finger, however, does seem to be innervated most
In the region of the junction of the proximal and middle
consistently by the median nerve. Sunderland has noted
thirds of the forearm, the ulnar artery joins the ulnar nerve
only one case in which the flexor digitorum profundus to
and continues on the radial aspect of the nerve. This rela-
the index finger was innervated by the ulnar nerve (44).
tionship is maintained as the nerve and artery emerge from
the radial edge of the flexor carpi ulnaris tendon, coursing
slightly radial to pass radial to the pisiform and enter Sensory Variations of the Dorsal Branch of the
Guyon’s canal at the wrist. Ulnar Nerve in the Forearm
The dorsal branch of the ulnar nerve usually arises from the
ulnar nerve trunk at approximately 6 to 8 cm from the wrist
Anomalies and Variations: Ulnar Nerve in joint (mean distance of 6.4 cm from the distal aspect of the
the Elbow and Forearm head of the ulna and 8.3 cm from the proximal border of
Anomalous Connections between the Ulnar the pisiform) (199). Several variations can occur. The
and Median Nerve branch may arise from the ulnar nerve as far proximal as the
elbow and continue subcutaneously along the entire length
In the distal forearm, a crossing of nerve fibers from the of the forearm (206). Alternatively, an entire nerve loop has
ulnar nerve to the median nerve can occur, although with been noted to form around the pisiform between the ulnar
less frequency than the more common crossing of fibers in nerve and a branch from the dorsal cutaneous nerve. This
the opposite direction from median nerve or anterior branch of the dorsal cutaneous nerve appeared to con-
interosseous nerve to ulnar nerve (the Martin-Gruber anas- tribute additional fibers to the ulnar digital nerve to the
tomosis). These anomalous connections between the ulnar small finger (207).
nerve and median nerve in the forearm are discussed in
detail earlier, under Nerve Anomalies and Variations:
Absence of the Dorsal Cutaneous Branch of
Median Nerve in the Forearm. In general, from the elbow
the Ulnar Nerve
to the wrist, the ulnar nerve shows relatively few anomalies
or deviations from its normal course. The division of its In 1 of 24 specimens, the dorsal branch of the ulnar nerve
branches is relatively consistent. was found to be absent (199). With complete absence of the
208 Systems Anatomy
dorsal cutaneous branch of the ulnar nerve, sensibility to
the dorsum of the ulnar hand can be supplied by the super-
ficial radial nerve (208), the musculocutaneous nerve (6), or
the posterior cutaneous nerve of the forearm.
Ulnar Nerve Compression by Anomalous
Anconeus Epitrochlearis
The ulnar nerve may be compressed at the elbow by an
anomalous muscle, the anconeus epitrochlearis. The
anconeus epitrochlearis originates from the medial border
of the olecranon and adjacent triceps tendon and inserts
into the medial epicondyle of the elbow. The muscle
appears as an auxiliary extension of the medial portion of
the triceps. The muscle crosses the ulnar nerve posterior to
the cubital tunnel. When present, it forms a portion of the
cubital tunnel, reinforcing the aponeurosis of the two heads
of the origin of the flexor carpi ulnaris (6).
The Posterior Cutaneous Nerve
The posterior cutaneous nerve of the forearm usually is a
branch of the radial nerve. Rarely, the posterior cutaneous
nerve may arise from the ulnar nerve (189).
Clinical Correlations: Ulnar Nerve in the
Elbow and Forearm
The ulnar nerve is at risk for compression or stretch at the
cubital tunnel of the elbow. Panas in 1878 described a con-
dition now known as tardy ulnar palsy (209). Several
anatomic and mechanical etiologic factors have been
described (6,17,78,189,208,210–218) (Table 3.3).
Neuropathy of the ulnar nerve as it passes through the
cubital tunnel posterior to the medial epicondyle of the
humerus may be associated with recurrent dislocation of
TABLE 3.3. ANATOMIC AND MECHANICAL
FACTORS CONTRIBUTING TO CUBITAL TUNNEL
SYNDROME
Idiopathic
Ganglion
Anomalous muscle (anconeus epitrochlearis)
Arcade of Struthers
Hypertrophic arthritis
Fracture malunion, nonunion
Fracture callus
Traumatic heterotopic ossification
Neurogenic heterotopic ossification
Cubitus valgus
Rheumatoid synovitis of elbow joint
Supracondylar process
Translocation, subluxation, or snapping of the triceps
Translocation, subluxation, or dislocation of ulnar nerve
Trauma (contusion, stretch, friction, repetitive traction)
the nerve. This condition was described by Collinet in
1896, followed by reports by Cobb and Momberg (both in
1903) (219–221).
In 1926, Platt discussed the pathogenesis of neuritis of
the ulnar nerve in the cubital tunnel, specifically in the
postcondylar groove (79,215).
The ulnar nerve also is subject to compression in the
cubital tunnel by the overlying fascia at the level of the
medial condyle, as well as by the fascia between the heads
of the flexor carpi ulnaris and in the muscle itself
(222–225). Spinner has suggested that the most common
cause for an idiopathic type of ulnar nerve paralysis is
entrapment of the nerve at the distal cubital tunnel where
the ulnar nerve enters the forearm posteriorly between the
two heads of the flexor carpi ulnaris. A fascial connection is
present between the two, and the proximal edge may at
times be thickened and act as a compressing band (6).
In the cubital tunnel, an articular branch (or branches)
is (are) usually given off by the ulnar nerve, followed by a
motor branch to the flexor carpi ulnaris (which exits the
nerve trunk just distal to the articular branch). Appreciation
of these two nerves and their respective functions and des-
tinations is relevant for ulnar nerve exploration in the
cubital tunnel. In performing an anterior transposition of
the ulnar nerve, the articular branch in the cubital tunnel
may tether the nerve trunk and prevent mobilizing the
ulnar nerve for transposition. This branch often is sacrificed
to allow anterior mobilization of the nerve, and causes min-
imal morbidity. Occasionally, a branch to the flexor carpi
ulnaris also is a limiting structure to anterior transposition.
Obviously, protection and preservation of this nerve is opti-
mal because morbidity may be substantial if the flexor carpi
ulnaris has no additional motor nerves and becomes dener-
vated by sacrifice of the motor branch. To mobilize the
ulnar nerve, distal nerve dissection and mobilization to
allow transposition is preferred over sacrifice of the motor
branch of the flexor carpi ulnaris.
With elbow flexion, the cubital tunnel decreases in vol-
ume and the aponeurosis becomes taut over the ulnar nerve
(196,198,213,214,226). During elbow flexion, the nerve
stretches and elongates approximately 4.7 mm. During flex-
ion, the medial head of the triceps has been noted to push
the ulnar nerve anteromedially 0.73 cm (227). When there
is fixation of the nerve, a traction neuritis can develop (6).
The ulnar nerve may be compressed at the elbow by an
anomalous muscle, the anconeus epitrochlearis (6). The
anconeus epitrochlearis is a muscle variant that originates
from the medial border of the olecranon and adjacent tri-
ceps tendon and inserts into the medial epicondyle of the
elbow. The muscle appears as an auxiliary extension of the
medial portion of the triceps. The muscle crosses the ulnar
nerve posterior to the cubital tunnel. When present, it
forms a portion of the cubital tunnel, reinforcing the
aponeurosis of the two heads of the origin of the flexor carpi
ulnaris (6). It has been found to be a factor in producing

ulnar compressive neuritis posterior to the elbow. Excision
of the muscle mass without translocation of the nerve has
relieved symptoms when it was the single factor in the
pathogenesis (6).
The flexor carpi ulnaris was found, in an isolated case, to
have a motor branch from the median nerve (6). With this
variant, weak action of the muscle could be observed when
a complete high ulnar lesion was present (6).
The flexor carpi ulnaris sometimes may receive an addi-
tional inconsistent motor branch from the ulnar nerve in
the mid-forearm.
Compression of the Dorsal Cutaneous Branch
of the Ulnar Nerve
The dorsal cutaneous branch of the ulnar nerve is vulnera-
ble to compression by external pressure in individuals who
write with their left hand. Often, these individuals write
with the ulnar border of the wrist against the firm writing
surface. If the dorsal cutaneous branch of the ulnar nerve
passes from its volar position to the dorsum of the hand
over the prominence of the distal ulna, external pressure can
cause symptoms of pain in the wrist and numbness of the
dorsoulnar aspect of the hand (6).
Absence of the Dorsal Cutaneous Branch of
the Ulnar Nerve
Complete absence of the dorsal cutaneous branch of the
ulnar nerve can occur (see earlier, under Anomalies and
Variations: Ulnar Nerve in the Elbow and Forearm). Sensi-
bility to the dorsoulnar hand can then be supplied by the
superficial radial nerve (208), by a dorsal division of the
musculocutaneous nerve (6), or by the posterior cutaneous
nerve of the forearm. With this variation, an injury or lesion
of the ulnar nerve at the elbow does not produce sensory
loss of the dorsum of the hand, but presents with sensory
findings similar to those of a low ulnar nerve lesion. This
variation should be suspected if electromyographic localiza-
tion of the nerve lesion is at the elbow when clinical find-
ings suggest a lesion at the wrist (6). The presence of this
variation can be evaluated by local anesthetic block of the
superficial radial nerve or the musculocutaneous nerve,
which produces anesthesia over the dorsoulnar hand.
Ulnar Nerve at the Wrist and Hand
Ulnar Nerve in the Ulnar Tunnel
The ulnar nerve and ulnar artery enter the ulnar tunnel
(Guyon’s canal) at the wrist. The artery usually is located
radial to the nerve (228). The nerve and artery pass radial
to the pisiform, anterior (superficial) to the transverse
carpal ligament (flexor retinaculum), and dorsal to the
superficial palmar carpal ligament. The ulnar nerve divides
3 Nerve Anatomy 209
into deep terminal and superficial palmar branches at the
base of the hypothenar eminence.
The ulnar nerve extends approximately 4 cm in its path
through the ulnar tunnel. The tunnel originates at the prox-
imal edge of the palmar carpal ligament and extends distally
to the fibrous arch of the hypothenar muscles. The tunnel
has been described in terms of having a floor (dorsal sur-
face), a roof (palmar surface), and two walls (medial and lat-
eral). The boundaries change from proximal to distal, and
the four walls are not distinct through the entire course.
The roof of the tunnel is composed of the palmar carpal lig-
ament, the palmaris brevis, and hypothenar fat and fibrous
tissue. The floor of the tunnel consists of tendons of the
flexor digitorum profundus, the transverse carpal ligament,
the pisohamate and pisometacarpal ligaments, and the
opponens digiti minimi. The medial wall consists of the
flexor carpi ulnaris, the pisiform, and the abductor digiti
minimi. The lateral wall is composed of the tendons of the
extrinsic flexors, the transverse carpal ligaments, and the
hook of the hamate (229,230). The distal ulnar tunnel has
been divided in three zones based on topography of the
nerve and its relationship to the surrounding structures
(230). Zone I consists of the portion of the tunnel proximal
to the bifurcation of the ulnar nerve. Zone II encompasses
the deep motor branch of the nerve and surrounding struc-
tures. Zone III includes the superficial branch and adjacent
distal and lateral tissues.
Ulnar Nerve in Zone I of the Ulnar Tunnel
In zone I, the nerve continues for approximately 3 cm,
stretching from the proximal edge of the palmar carpal lig-
ament to the nerve’s bifurcation. The palmar carpal liga-
ment, lying superficial (anterior to the ulnar nerve), is actu-
ally a thickening of the superficial forearm fascia that
becomes distinct approximately 2 cm proximal to the pisi-
form. The ligament arises ulnarly from the tendon of the
flexor carpi ulnaris and inserts radially on the palmaris
longus tendon and the transverse carpal ligament, forming
the roof (palmar surface of the proximal part of zone I). The
ulnar nerve, along with the ulnar artery, passes deep to the
palmar carpal ligament to enter the ulnar tunnel. At this
level, the ulnar artery lies slightly superficial and radial to
the nerve. The deep (dorsal) surface of zone I consists of
tendons of the flexor digitorum profundus and the ulnar
portion of the transverse carpal ligament. The lateral wall is
formed by the most distal fibers of the palmar carpal liga-
ment, which curve radially and posteriorly to wrap around
the neurovascular bundle and merge with the fibers of the
transverse carpal ligament. The pisiform and tendon of the
flexor carpi ulnaris comprise the medial wall of the tunnel
at this level (229,230). Distal to the palmar carpal ligament,
the roof of the ulnar tunnel consists of the palmaris brevis
muscle. This muscle originates from the distal palmar
aspect of the pisiform and hypothenar muscle fascia and
inserts on the ligament. The length of the palmaris brevis
210 Systems Anatomy
from the proximal to distal border is approximately 2.5 cm
(229,230). In this area, deep to the palmaris brevis, the
ulnar nerve bifurcates into the deep motor branch and the
superficial branch of the ulnar nerve. The point of nerve
branching is approximately 1 cm distal to the proximal edge
of the pisiform. Three to 7 mm distal to the bifurcation of
the nerve, the ulnar artery divides into two branches. The
larger of the arterial branches accompanies the superficial
branch of the nerve and becomes the superficial palmar
arch. The smaller arterial branch continues with the motor
branch into the deep space of the palm and terminates in
the deep palmar arch. Both arteries remain superficial and
radial to the nerves they accompany (230). The distal extent
of zone I terminates at the level of the bifurcation of the
ulnar nerve. At this level, the roof of the tunnel is formed
by the palmaris brevis and the floor formed by the pisoha-
mate and pisometacarpal ligaments. The pisohamate liga-
ment arises from the distal, radial, and dorsal aspects of the
pisiform and inserts on the proximal, ulnar, and palmar
aspects of the hook of the hamate. Ulnar to the pisohamate
ligament, the pisometacarpal ligament arises from the distal
aspect of the pisiform and inserts on the palmar radial
aspect of the base of the fifth metacarpal. The divergence of
these ligaments leaves an opening in the floor of the tunnel
that is filled with fibrofatty tissue overlying the capsule of
the triquetrohamate joint (229,230).
In zone I, the ulnar nerve carries both motor and sensory
fibers. The nerve fibers are arranged in two distinct groups
of fascicles. The palmar-radial fibers contain the fascicles
that become the superficial branch of the ulnar nerve,
whereas the dorsal-ulnar fibers become the deep motor
branch. Thus, in zone I, the ulnar nerve actually is two
nerves contained in a common epineurial sheath
(229–231).
Ulnar Nerve in Zone II of the Ulnar Tunnel
Zone II encompasses the portion of the ulnar tunnel distal
to the bifurcation, in the region where the deep (motor)
branch of the ulnar nerve passes. This zone usually is
located in the dorsoradial portion of the ulnar tunnel. The
palmar (superficial) aspect of zone II is bordered by the pal-
maris brevis and the superficial branch of the ulnar nerve.
The lateral border of zone II consists of transverse carpal lig-
ament, which forms a wall that merges with the floor of the
tunnel. The floor of zone II consists of the pisohamate and
the pisometacarpal ligaments. At the distal extent of zone
II, the fibrous arch of the hypothenar muscles lies palmar to
the nerve, the opponens digiti minimi lies posterior, the
hook of the hamate and flexor digiti minimi are located lat-
erally, and the abductor digiti minimi lies on the medial
aspect (230). The deep branch of the ulnar nerve passes
deep to the fibrous arch and between the muscles as it exits
the tunnel. The nerve to the abductor digiti minimi usually
is given off just proximal to its entrance into these muscles.
The motor branch innervates the opponens digiti minimi as
it continues radially and posteriorly around the hook of the
hamate. The nerve then continues deeply across the palm
(229,230). The ulnar artery enters zone II radially and pal-
marly, just distal to the level of the bifurcation of the nerve.
The artery follows the nerve, lying palmar and slightly
radial. Both structures continue distally and pass deep to
the arch of the origin of the hypothenar muscles. In zone II,
the deep branch of the ulnar carries motor fibers.
Ulnar Nerve in Zone III of the Ulnar Tunnel
Zone III encompasses the portion of the ulnar tunnel distal
to the bifurcation, in the region of the superficial branch of
the ulnar nerve, also referred to as the superficial palmar
branch (189). At the entrance to zone III, the palmaris bre-
vis comprises the palmar boundary, the abductor digiti
minimi comprises the medial border, and the
pisometacarpal ligament and capsule of the triquetrohamate
joint comprise the dorsal border. The lateral and dorsal bor-
ders are formed by zone II. As the superficial branch of the
ulnar nerve continues distally, it gives off two small
branches that innervate the palmaris brevis. This occurs
either in the ulnar tunnel or just distal to exiting it
(189,230). Distal to this point, the nerve usually contains
only sensory fibers. The nerve emerges from zone III by
passing over the fibrous arch of the hypothenar muscles.
The ulnar artery continues with the nerve throughout zone
III, remaining superficial and radial to the nerve. At the dis-
tal end of the zone, the superficial palmar branch of the
ulnar nerve lies between the hypothenar fascia posteriorly
and the artery and a fibrofatty layer deep to the subcuta-
neous tissues palmarly (229,230). The superficial palmar
branch in zone III contains mostly sensory fibers along with
motor fibers to the hypothenar muscles. Lesions in this
zone should produce primarily sensory deficits with possi-
ble motor weakness of the hypothenar muscles.
Superficial Palmar Branch of the Ulnar Nerve
The superficial palmar branch exits the distal ulnar tunnel
with the superficial terminal branch of the ulnar artery. The
nerve then provides several small twigs to innervate the skin
on the medial side of the hand. The motor branches to the
palmaris brevis may leave the nerve at this point (if not
branched more proximally in the ulnar tunnel). The nerve
continues distally and radially and divides into the proper
digital nerve to the ulnar side of the little finger and the
common palmar digital nerve to the fourth web space. At
the level of the metacarpal shafts, the common digital nerve
divides into two proper digital nerves, one each to supply
adjacent aspects of the fourth web space between the small
and ring fingers (see Fig. 3.3). In the palm, the nerves lie
dorsal to the superficial palmar arch and palmar to the
flexor tendons. Immediately after division, in the region of
the metacarpal necks, the proper digital nerves course ante-
riorly to lie palmar (superficial) to the digital arteries. The

neurovascular bundles are stabilized in the digits by the
retaining skin ligaments, Cleland’s ligaments located dorsal
to the neurovascular bundle, and Grayson’s ligaments
located palmarly. The proper palmar digital nerves supply
the palmar skin of the digits, and the skin distal to the dis-
tal interphalangeal joints on the dorsal surface (189).
Deep Terminal Branch of the Ulnar Nerve
The deep terminal branch of the ulnar nerve exits from
zone II of the ulnar tunnel dorsoulnar to the deep terminal
branch of the ulnar artery (1,3,159,232). The nerve passes
medial to the hook of the hamate, deep to the fibrous arch
of the hypothenar muscle origin. The nerve continues
between the abductor digiti minimi and flexor digiti min-
imi muscles, supplying motor branches to each. The nerve
then pierces and innervates the opponens digiti minimi
(41). The deep branch then crosses the palm with the ulnar
artery (which now forms the deep palmar arch). Along its
course, the nerve is deep to the extrinsic flexor tendons and
deep to the mid-palmar and thenar fascial clefts, but pal-
mar to the interossei (11). At the level of the third
metacarpal, the deep branch of the ulnar nerve and the
deep palmar arch cross between the oblique and transverse
heads of the adductor pollicis. Along its deep course, the
nerve innervates each of the seven interossei, the third and
fourth lumbricals, the adductor pollicis, the flexor pollicis
brevis and the hypothenar muscles (see Table 3.2 and Fig.
3.3). The deep terminal branch provides sensory afferent
nerves to the ulnocarpal, intercarpal, and carpometacarpal
joints (191).
Sympathetic Fibers from the Ulnar Nerve in
the Hand
At the wrist, sympathetic fibers arise from the distal ulnar
nerve and supply the proximal ulnar portions of the
superficial and deep vascular arches of the hand. The
deep vascular arch is segmentally innervated by fibers
from the ulnar nerve and the superficial radial nerve (the
median nerve and the superficial radial nerve also give
segmental supply to the superficial vascular arch in the
palm of the hand) (6).
Anomalies and Variations: Ulnar Nerve in
the Wrist and Hand
The Riche-Cannieu Communication
The Riche-Cannieu communication consists of a commu-
nication between the deep terminal branch of the ulnar
nerve and the motor branch of the median nerve (see ear-
lier, under Anomalies and Variations: Median Nerve in the
Wrist and Hand). Because it occurs in 50% to 77% of
hands (194), it can be argued whether this is a normal pat-
3 Nerve Anatomy 211
tern or a variation. The communication occurs at the ter-
minal portion of the deep branch of the ulnar nerve in the
radial aspect of the palm (41,233). The communicating
fibers pass radially from the deep ulnar branch between the
heads of the adductor pollicis, then pass deep to the flexor
pollicis longus tendon. The fibers continue proximally to
the radial side of the flexor pollicis longus tendon as they
approach the median motor branch. The communication
often occurs in the substance of the flexor pollicis brevis
(41). Through the Riche-Cannieu communication, the
median nerve may innervate the third lumbrical, or, rarely,
all of the lumbrical muscles (35,63). Conversely, the second
lumbrical may be innervated by the ulnar nerve (see earlier
under Anomalies and Variations: Median Nerve in the
Wrist and Hand). There is some question as to whether
there is a crossing of sensory fibers as well (39).
Variations of Innervation of the Flexor Pollicis
Brevis
Considerable variation exists as to the innervation of the
flexor pollicis brevis. Reports have suggested the muscle is
innervated by the ulnar nerve in 50%, the median nerve in
35%, and both in 15%. Each head may receive a different
contribution, with the deep head more commonly inner-
vated by the ulnar nerve and the superficial head more com-
monly innervated by the median nerve (11).
Variations of Innervation of the Abductor
Pollicis Brevis
The abductor pollicis brevis is innervated by the median
nerve in 95%, the ulnar nerve in 2.5%, and by both nerves
in 2.5% (9,41,189).
Variation of Innervation of the Opponens
Pollicis
The opponens pollicis muscle is innervated by the median
nerve alone in 83%, the ulnar nerve in 10%, and by both
nerves in 7% (153).
Variations in Sensory Innervation of the Ulnar
Nerve Proper in the Hand
Several variations in the sensory innervation of the ulnar
nerve have been noted. Distal to the wrist, the ulnar nerve
proper usually innervates the palmar aspect of the small fin-
ger and ulnar aspect of the ring finger. The pattern is vari-
able, and the area of ulnar innervation includes the volar
aspect of the entire ring finger, the ulnar aspect of the long,
or the entire long finger. Conversely, the ulnar nerve may
innervate only the volar aspect of the small finger. The ulnar
supply to the fourth web space (to the space between the
ring and small finger), instead of arising in its usual location
212 Systems Anatomy
at the distal end of the ulnar tunnel, has been observed to
arise in the mid-forearm and continue on an aberrant
course superficial to the transverse carpal ligament and the
palmar aponeurosis (234).
A communicating branch may exist between the super-
ficial branch of the ulnar nerve and the common digital
nerve of the third web space (common digital nerve of the
median nerve to supply adjacent sides of the long and ring
finger). This is a relatively common finding (189,191) and
leads to dual innervation to the adjacent sides of the long
and ring fingers.
Variations in Sensory Innervation of the
Dorsal Cutaneous Branch of the Ulnar Nerve
in the Hand
The dorsal aspect of the hand usually is innervated by the
dorsal branch of the ulnar nerve. However, this area may be
supplied partially or entirely by the radial nerve or by the
posterior cutaneous nerve of the forearm. Complete
absence of the dorsal branch of the ulnar nerve has been
found in 1 of 24 specimens (199). In these cases, the radial
nerve or posterior cutaneous nerve of the forearm supplies
the dorsoulnar hand sensibility. The dorsal branch of the
ulnar nerve may deviate palmarly at the pisiform, join the
superficial (sensory) branch, and supply the palmar surface
of the little finger. A nerve connection may exist between
the dorsal sensory branches of the ulnar nerve and the
superficial radial nerves. This communication between the
dorsal branch of the ulnar nerve and a subcutaneous
branch from the superficial branch of the radial nerve was
observed in 1 of 24 specimens. The communication was
noted on the dorsal aspect of the hand (199). An addi-
tional variation is the presence of a third dorsal digital
branch from the ulnar nerve. When present, this branch
from the ulnar nerve supplies the third web space in con-
junction with the radial digital nerve, providing dual
innervation (6).
Variations of Division and Recommunication
of the Ulnar Nerve into Deep and Superficial
Branches
Variations exist as to the point of division of the ulnar nerve
into its deep and superficial branches. The deep motor
branch may divide proximal to the hook of the hamate. The
radial division may enter the carpal tunnel (radial to the
hook of the hamate) and rejoin the ulnar division distal to
the hamate (235,236). Less commonly, the deep motor
branch may divide proximal to the pisiform, communicate
with the dorsal sensory branch, or rejoin the nerve distal to
the pisiform. In the event of nerve injury distal to an anom-
alous division, function is partially preserved. The ulnar
digital nerve to the ring finger may arise in the forearm,
passing superficial to the ulnar tunnel. Similarly, the dorsal
cutaneous branch may arise near the elbow, passing distally
in the subcutaneous tissue to reach the hand (41,189).
An anomalous terminal branch of the ulnar nerve has
been observed at the distal end of Guyon’s canal, which
joined the digital sensory branch to the medial aspect of the
small finger (237,238).
The Ulnar Palmar Cutaneous Nerve
The ulnar palmar cutaneous nerve is not a consistent
branch, as is its adjacent counterpart, the median palmar
cutaneous nerve (6,239) (see Fig. 3.4A). When present, it
arises at variable levels from the ulnar nerve in the distal half
of the forearm.
Clinical Correlations: Ulnar Nerve in the
Wrist and Hand
In zone I of the ulnar tunnel, the ulnar nerve carries both
motor and sensory fibers. A compression or traumatic
lesion in zone I has a high likelihood of producing both
motor and sensory deficits. If the lesion is in zone I, or in
the area just proximal to the entrance of the ulnar tunnel,
the dorsal sensor branch (which exits the ulnar nerve more
proximally in the distal forearm) is spared. Therefore, sensi-
bility to the dorsal aspect of the small and ulnar side of the
ring finger is spared. These findings, of palmar sensibility
loss (to the small and ulnar side of the ring) with intrinsic
motor loss and with sparing of dorsal sensibility, help local-
ize the area of compression or dysfunction (229,240–242).
In zone I of the ulnar tunnel, the ulnar nerve fibers are
arranged in two distinct groups of fascicles, with the pal-
mar-radial fibers containing fascicles that become the super-
ficial branch of the ulnar nerve (mostly sensory fibers),
whereas the dorsal-ulnar fibers become the deep branch
(motor branch). A lesion in zone I that involves the palmar-
radial aspect or the dorsal-ulnar aspect of the nerve may
involve mostly sensory or mostly motor fibers, respectively,
and thus produce an associated clinical presentation
(229–231).
In zone II of the ulnar tunnel, the deep branch of the
ulnar nerve carries motor fibers. A lesion in zone II should
produce only motor deficits. Conversely, if an occult lesion
or penetrating injury produces only motor loss, zone II
should be suspected as a site of the lesion.
In zone III of the ulnar tunnel, the superficial branch of
the ulnar nerve carries mostly sensory fibers, along with
motor fibers to the palmaris brevis and hypothenar muscles.
Therefore, it is technically incorrect to refer to this branch
at this point as the sensory branch of the ulnar nerve. The
superficial branch of the ulnar nerve is preferred.
In zone III of the ulnar tunnel, the superficial branch
contains mostly sensory fibers along with motor fibers to
the hypothenar muscles. Lesions in this zone should pro-
duce primarily sensory deficits with possible motor weak-
 3 Nerve Anatomy 213

ness of the hypothenar muscles. Conversely, if an occult Several variations of the palmaris longus have been
lesion or penetrating injury produces mostly sensory loss related to ulnar variations in Guyon’s canal and to ulnar
(or concomitant weakness of the hypothenar muscles), zone tunnel syndrome. These include a reversed muscle–tendon
II should be suspected as the site of the lesion. relationship with a distal muscle belly and proximal tendon
In carpal tunnel syndrome, the etiology often is (275), an anomalous extension into Guyon’s canal, an
unknown, and it is attributed to an idiopathic cause. How- accessory palmaris longus, and a duplicated palmaris longus
ever, in ulnar nerve compression in the ulnar tunnel, a cause (6,9,274,275).
more commonly is found. These include tumors in the An anomalous palmaris longus may have a reversal of its
ulnar tunnel (ganglions, lipomas, giant cell tumor, desmoid normal muscle relationship, with the tendon arising proxi-
tumors, rheumatoid synovial cysts), anatomic abnormalities mally from the medial epicondyle, and the muscle belly
that encroach on the ulnar nerve (anomalous muscles, attaching distally to the flexor retinaculum at the wrist.
thickened ligaments, anomalous hamulus), trauma with There may be an associated accessory musculotendinous
associated inflammation, edema, or hematoma (fractures, slip, approximately 1 cm thick, which inserts into the pisi-
repetitive trauma, edema after burns), vascular pathology, form (275). This anomalous palmaris can create an arch
or inflammatory conditions (rheumatoid arthritis or degen- that reinforces the roof of the tunnel. However, the ulnar
erative arthritis) (6,243–267) (Table 3.4). Ganglions are the nerve and artery must penetrate through this arch to reach
most common tumor related to ulnar tunnel syndrome, the wrist, and thus are more vulnerable to compression. The
accounting for 29% to 45% of reported caused of ulnar nerve and artery run their normal course deep to the pal-
tunnel syndrome. Other more common related factors maris brevis (275). Spinner has referred to this anatomic
include anomalous muscles (see later), fractures, and vascu- arrangement as the variant canal of Guyon (6).
lar abnormalities (230,268–273). An anomalous accessory palmar longus has been noted
Anomalous muscles reported to cause ulnar tunnel syn- in the ulnar tunnel. Thomas described a 1-cm-wide muscle
drome include the several variations of the palmaris longus arising from the palmaris longus tendon. The muscle
(274–276), an accessory flexor digiti minimi (262,277), an inserted into the soft tissues of the region of the hypothenar
accessory abductor digiti minimi (198,278), an accessory muscles and into the pisiform. This muscle passed through
muscle from the flexor carpi ulnaris tendon, and various the ulnar tunnel, and was thought to be responsible for
anomalous muscles located in the canal (see later) (279, clinical symptoms of fatigability of the hand (274).
280). King and O’Rahilly reported a duplication of the pal-
maris longus with either a separate muscular slip (accessory
palmaris) or a separate tendon that originated from the
TABLE 3.4. COMMON CAUSES OF ULNAR NERVE duplicated palmaris and extended to the abductor digiti
COMPRESSION AT THE WRIST BASED ON 135 quinti or the flexor digiti quinti. The accessory muscle
REPORTED CASES
passed volar to the ulnar nerve and ulnar artery. The mus-
Cause Number cle appeared to form part of the roof of the ulnar tunnel. An
associated tendinous slip that extended between the ulnar
Tumors
Ganglion 46 artery and nerve also was noted to occur. The artery crossed
Lipoma 3 anterior to the slip.
Giant cell tumor 2 As early as 1864, anomalies of the palmaris longus were
Desmoid tumor 1 noted, and associated with variations of the ulnar tunnel
Anatomic abnormalities
(276). A palmaris longus with a double origin was described
Anomalous muscles 22
Thickened ligaments 4 by Wood. From this palmaris longus tendon, there was an
Anomalous hamulus 3 associated anomalous flexor digiti quinti with a high origin
Trauma from the palmaris longus.
Fractures 19 Besides the palmaris longus, other aberrant muscles have
Repetitive trauma 8
been noted in the ulnar tunnel or its vicinity that place the
Edema after burns 10
Other trauma 3 ulnar nerve at risk for compression.
Vascular pathology 9 Schjelderup described an anomalous muscle 4 mm wide
Arthritis that extended in the canal and crossed over the ulnar nerve
Rheumatoid 4 before the nerve divided (279).
Degenerative 1
Turner and Caird also noted an anomalous muscle in the
Other
Dupuytren’s contracture 1 ulnar tunnel. The muscle originated from the pisiform,
136 total crossed through the ulnar tunnel passing between the deep
and superficial branches, and inserted into the transverse
From Botte MJ, Gelberman RH. Ulnar nerve compression at the
wrist. In: Szabo RM, ed. Nerve compression syndromes: diagnosis carpal ligament. This muscle passed between the motor and
and treatment. Thorofare, NJ: Slack, 1989:121–136. sensory branches of the ulnar nerve (280).
214 Systems Anatomy
Jeffery described an accessory hypertrophied abductor
digiti quinti that arose from the fascia of the distal forearm.
The muscle was thought responsible for isolated paralysis of
the intrinsic muscles without sensibility loss. The patient’s
symptoms improved after excision of the abnormal muscle
(6,278).
An accessory muscle arising from the tendon of the
flexor carpi ulnaris was noted by Kaplan. This muscles
inserted into the volar carpal ligament. It formed a thick-
ened roof of the ulnar tunnel, possibly increasing the vul-
nerability to the ulnar nerve (6,9; personal communication
to Spinner).
Swanson identified an accessory flexor digiti quinti aris-
ing from the forearm fascia. The muscle inserted into the
flexor digitorum brevis and caused symptoms of ulnar nerve
compression (6,277).
Hayes et al. described a ligamentous band that attached
to the pisiform and extended to the hook of the hamate.
The band was located anterior to the deep branch of the
ulnar nerve (6,281). The flexor and abductor digiti minimi
muscles arose in part from the ligamentous band.
In the vicinity of the ulnar tunnel, Lipscomb reported a
case of duplication of the hypothenar muscles (282). The
duplicated muscle simulated a tumor of the hand. The mus-
cle originated from the pisiform and the hook of the
hamate. The palmaris brevis was noted to be six times the
normal size. Proximally, these anomalous muscles formed
part of the ulnar tunnel (6), and potentially increased the
risk of nerve compression.
Harrelson and Newman described ulnar tunnel syn-
drome caused by a hypertrophied flexor carpi ulnaris mus-
cle in close proximity to the ulnar tunnel (283).
Most ganglia that cause ulnar tunnel syndrome arise
from the palmar aspect of the carpus and present in zone I
or II.
Although the deep terminal branch of the ulnar nerve
consists mostly of motor fibers, it also contains sensory
afferent nerves to the ulnocarpal, intercarpal, and car-
pometacarpal joints. It is thus not a purely motor nerve,
although it sometimes incorrectly is referred to as the deep
motor branch of the ulnar nerve. The correct names include
deep branch of the ulnar nerve and deep terminal branch of the
ulnar nerve (189,229,284).
The deep branch of the ulnar nerve and the deep palmar
arch cross between the interval between the oblique and
transverse heads of the adductor pollicis at the level of the
third metacarpal. This interval is useful in identifying the
neurovascular bundle during exploration for deep or severe
trauma. The neurovascular bundle also requires isolation
and protection in adductor pollicis recession, as often is per-
formed for correction of thumb-in-palm deformities in
spastic muscle disorders. Compression of the deep branch
of the ulnar nerve by the adductor pollicis also has been
noted (285).
Because the ulnar nerve on occasion may innervate the
third lumbrical muscle, a high ulnar nerve lesion can pro-
duce clawing in three fingers instead of two.
Although ulnar neuropathy is a relatively common cause
of intrinsic muscle atrophy, several other etiologies are pos-
sible: Charcot-Marie-Tooth disease, thoracic outlet syn-
drome, C8 to T1 root level impingement, anterior horn cell
disorders, and even compression at the foramen magnum
level (foramen magnum meningioma) (45,46,196,213,240,
241,273,286–289).
The ulnar supply to the fourth web space (to the space
between the ring and small fingers), instead of arising in its
usual location at the distal end of the ulnar tunnel, has been
observed to arise in the mid-forearm and continue on an
aberrant course superficial to the transverse carpal ligament
and the palmar aponeurosis (280). When present, it can be
vulnerable to injury during carpal tunnel decompression
(6).
RADIAL NERVE
Origin of the Radial Nerve
The radial nerve arises from the posterior cord of the
brachial plexus, posterior to the third portion of the axillary
artery (1–4,11) (see Fig. 3.1). It contains fibers from C5
through C8 (and occasionally T1) and is the largest termi-
nal branch of the brachial plexus. The lower trunk con-
tributes fibers from T1 in 8% of upper limbs (13).
Radial Nerve in the Axilla and Arm
In the proximal portion of the arm, the radial nerve courses
posterior to the brachial artery, anterior to the subscapularis
muscle, the teres major and latissimus dorsi muscle ten-
dons, and the long head of the triceps. At the junction of
the proximal and middle thirds of the humerus, the nerve
courses dorsolaterally, passing posterior to the medial head
of the triceps and anterior to the long head. The radial
nerve is accompanied by the profunda brachii artery, and
continues distally close to the posterior cortex of the
humerus (290). The nerve and artery pass through the
extensor compartment of the arm, between the medial and
lateral heads of the triceps muscle. The nerve continues dis-
tally, coursing slightly anteriorly as it spirals around the
humerus to reach the lateral intermuscular septum. The
nerve is separated from the humeral cortex by the medial
head of the triceps, which lies adjacent to but not in the spi-
ral groove of the humerus (291,292). The radial nerve
leaves the extensor compartment of the arm at the lateral
border of the medial head of the triceps muscle, sequentially
providing motor branches to the triceps long head, medial
head, and lateral head (Table 3.5 and Fig. 3.5). The nerve
enters the flexor compartment of the arm, piercing the lat-
 3 Nerve Anatomy 215

TABLE 3.5. LEVEL AND ORDER OF INNERVATION

OF MUSCLES SUPPLIED BY THE RADIAL NERVE

Range in cm from
Tip of Acromion
Muscle (Shortest to Longest)

Triceps
Long head 7.1
Medial head 9.5–11.2
Lateral head 10.1
Anconeus

Range in cm from
Humerus (from 10 cm
above Lateral Epicondyle)

Brachioradialis 8.2–10.0
Extensor carpi radialis longus 10.5–12.3
Extensor carpi radialis brevis 14.7–16.5

Range in cm from
Lateral Epicondyle

Extensor carpi ulnaris 10.2–10.6

Extensor digitorum communis 10.2–12.5
Extensor digiti minimi 11.7–12.0
Abductor pollicis longus 11.4–14.2
Extensor pollicis longus 13.9–17.6
Extensor pollicis brevis 15.9–16.4
Extensor indicis proprius 16.9–18.0

From Sunderland S, Hughes ESR. Metrical and non-metrical features

of the muscular branches of the ulnar nerve. J Comp Neurol
85:113–120, 1946; and Linnell EA. The distribution of nerves in the
upper limb, with reference to variabilities and their clinical
significance. J Anat 55:79, 1921.

eral intermuscular septum approximately 10 cm proximal

to the lateral humeral epicondyle (6). The radial collateral
artery (the terminal branch of the profunda brachii artery)
accompanies the radial nerve in this area. The radial nerve
continues deep in the intermuscular interval between the
brachialis and brachioradialis muscles. It continues distally,
and extends in the interval between the extensor carpi radi-
alis longus muscle and brachialis. The nerve exits the arm
anterior to the tip of the lateral epicondyle, dividing into
the superficial and deep terminal branches as it enters the
forearm (13,291,292). In the arm, the radial nerve sequen-
tially innervates the three heads of the triceps and the
anconeus. In the distal third of the arm proximal to the
elbow epicondylar line, the radial nerve innervates the bra-
chioradialis and extensor carpi radialis longus (see Table 3.5
and Fig. 3.5). Occasionally, the radial nerve provides a
motor branch to the radial portion of the brachialis (6,293),
which usually is supplied by the musculocutaneous nerve.
The motor branch to the extensor carpi radialis brevis can
have a variable source. In most limbs (58%), motor inner-
vation to the extensor carpi radialis brevis arises from the
sensory division of the radial nerve in the forearm, the FIGURE 3.5. Schematic illustration of the radial nerve and asso-
ciated branches and innervated muscles.
superficial radial nerve (294).
216 Systems Anatomy

Clinical Correlations: Radial Nerve in the
Axilla and Arm
Holstein-Lewis Fracture
The close proximity of the radial nerve to the surface of the
humeral diaphysis places the nerve at risk for injury with
humeral fractures (295–301). Transient nerve injury is the
most common type of complication associated with
humeral shaft fractures. Most nerve injuries are associated
with transverse or short oblique fractures. Transection of the
radial nerve is rare and associated most commonly with
open fractures, penetrating injuries, or spiral oblique frac-
tures (301).
Radial nerve compression in the arm has been attributed
to impingement by the triceps muscle (302,303).
Radial Nerve in the Forearm and Hand
The radial nerve passes anterior to the lateral epicondyle to
enter the forearm. At approximately the level of the elbow,
the radial nerve divides into the superficial and deep termi-
nal branches deep to the brachioradialis and extensor carpi
radialis longus and brevis (6,291) (see Fig. 3.5). The point
of bifurcation usually is at the level of the radiocapitellar
joint, but it may divide 2 to 5 cm proximal or distal to this
joint (6,13,304). The superficial branch passes anterior
(superior) to the supinator muscle in the proximal third of
the forearm and continues along the deep surface of the
brachioradialis muscle. Proximally, the nerve is adjacent to
the anterior third of the brachioradialis, but as it descends
distally, it courses laterally and anteriorly. The radial artery
passes palmar to the insertion of the pronator teres muscle
and comes to lie on the ulnar border of the brachioradialis
muscle in the middle third of the forearm. The superficial
branch, which descends more laterally, is lateral to the radial
artery, palmar to the origins of the radial head of the flexor
digitorum superficialis and flexor pollicis longus muscle.
The superficial branch continues distally on the deep sur-
face of the brachioradialis, crossing and descending along
the radius. The superficial branch pierces the antebrachial
fascia on the ulnar side of the brachioradialis tendon,
(between the tendons of the brachioradialis and extensor
carpi radialis longus). The nerve thus becomes subcuta-
neous at approximately 9 cm proximal to the wrist (291).
Superficial Branch of the Radial Nerve
Several patterns of the superficial branch of the radial nerve
have been noted (305,306). The superficial branch of the
radial nerve arose from the radial nerve at the level of the
lateral humeral epicondyle in 8 of 20 specimens, and within
2.1 cm of the lateral epicondyle in the remaining 12. The
superficial branch courses distally deep to the brachioradi-
alis muscle until it emerges between the tendons of the bra-
chioradialis and extensor carpi radialis longus to pierce the
antebrachial fascia. In 10% of specimens, the superficial
branch became subcutaneous by actually piercing the ten-
don of the brachioradialis. Table 3.6 shows relationships of
the superficial branch of the radial nerve to specific land-
marks. The superficial branch of the radial nerve becomes
subcutaneous at a mean of 9 cm proximal to the radial sty-
loid [range, 7 to 10.8 cm, standard deviation (SD) 1.4 cm].
When the nerve initially enters the subcutaneous tissue, its
mean width is 3 mm (SD 0.5 mm). The superficial branch
of the radial nerve continues distally and usually divides
into two branches (85% of specimens) or three branches
(15% of specimens). The first major branch point occurs at
a mean distance of 5.1 cm (range, 3.2 to 7.1 cm, SD 1.8
cm) proximal to the radial styloid. The point at which the
superficial branch of the radial nerve becomes subcutaneous
is, on average, the distal 36% of the distance from the lat-
eral humeral epicondyle to the radial styloid. The first
branch point of the superficial branch of the radial nerve
after it enters the subcutaneous tissue is, on average, the dis-
tal 20% of that distance. At the level of the extensor reti-
naculum, the width of the palmar and dorsal major
branches averages 2 mm (SD 0.4 mm) and 2 mm (SD 0.2
mm), respectively. The nearest branch to the center of the

TABLE 3.6. RELATIONSHIPS OF THE SUPERFICIAL BRANCH OF THE RADIAL NERVE TO SPECIFIC
LANDMARKS

Forearm SBRN-SQa to RS Branch to RSc Distance to Center Distance of Closest Branch

Length (cm) (cm/% Forearmb) (cm/% Forearm) of First DC (cm) to Lister’s Tubercle (cm)

Mean 25.5 9.0/36% 5.1/20% 0.4 1.6

Min. 21.5 6.1/25% 2.7/11% 0.0 0.5
Max. 11.6/40% 10.5/38% 1.6 2.9

DC, dorsal compartment; RS, radial styloid.

aSBRN-SQ is the distance from the RS to where the superficial branch of the radial nerve (SBRN) became subcutaneous.
b% forearm indicates the percentage of the distal forearm length at which the SBRN became subcutaneous or had its first major branch point.
cBranch to RS is the distance from the RS to the first major branch point.

From Abrams RA, Brown RA, Botte MJ. The superficial branch of the radial nerve: an anatomic study with surgical implication. J Hand Surg
[Am] 17:1037–1041, 1992.

first dorsal wrist compartment is within a mean transverse
distance of 0.4 cm (SD, 0.4 cm), and in 35% of specimens,
there is a branch lying directly over the center of the first
dorsal wrist compartment. All branches pass radial to Lis-
ter’s tubercle by a mean distance of 1.6 cm (SD 0.05 cm).
No branches pass closer than 0.5 cm to the tubercle (305).
In all specimens studied, the major palmar branch contin-
ues distally to become the dorsoradial digital nerve of the
thumb. In half of the specimens, before it reached the
thumb, the palmar branch divides into other smaller cuta-
neous branches that extend to the palmar radial thenar emi-
nence. In 35%, there were connections between these
branches of the superficial branch of the radial nerve and
branches from the lateral antebrachial cutaneous nerve. The
major dorsal branch, with numerous branching configura-
tions, continues distally, branching into the dorsoulnar dig-
ital nerve to the thumb and the dorsoradial digital nerve to
the index finger, and a third branch continues distally to
become the dorsoulnar and dorsoradial digital nerves of the
index and long fingers, respectively. The dorsoulnar digital
nerve to the long finger arises from the dorsal sensory
branch of the ulnar nerve in 90% of specimens (305). The
dorsoulnar digital nerve to the thumb parallels the thumb
metacarpal running superficial to the first dorsal
interosseous muscle, passing dorsoulnar to the metacar-
pophalangeal joint. The widths of the dorsoradial and dor-
soulnar digital nerves to the thumb at the level of the
metacarpophalangeal joints are 1.5 mm (SD 0.5 mm) and
1.4 mm (SD 0.3 mm), respectively (305). Despite pattern
variations, discernible features were as follows: The palmar
branch from the first major branch point always became the
dorsoradial digital nerve to the thumb. In 65%, the dor-
soulnar digital nerve to the thumb and the dorsoradial dig-
ital nerve to the index finger came from the same branch,
which emanated from the first main dorsal branch. In 30%,
the dorsoulnar nerve to the thumb and the dorsoradial
nerve to the index finger came from different branches off
the main dorsal branch, and in 1 specimen of 20, the dor-
soulnar nerve to the thumb was noted to arise from a tri-
furcating branch at the first major branch paint. In all spec-
imens, the continuation of the main dorsal branch
bifurcated distally, usually near the metacarpal heads, into
the dorsoulnar digital nerve to the index finger and the dor-
soradial digital nerve to the long finger (305).
Posterior Interosseous Nerve
The posterior interosseous nerve, the deep terminal branch
of the radial nerve, innervates the extensor muscles of the
forearm and contains sensory afferent fibers to the wrist
joint (307,308) (Table 3.7, and see Fig. 3.5). The posterior
interosseous nerve is one of the main continuing branches
after the bifurcation of the radial nerve (291,307,309). The
bifurcation usually occurs at approximately the level of the
radiocapitellar joint. The posterior interosseous nerve con-
3 Nerve Anatomy 217
TABLE 3.7. THE POSTERIOR INTEROSSEOUS
NERVE: ORDER OF MUSCLE INNERVATION AND
DISTANCE FROM THE DISTAL EDGE OF THE
SUPINATOR TO THE POINT OF MUSCLE
PENETRATION OF INNERVATED MUSCLE
Extensor carpi ulnaris 1.25 cm
Extensor digitorum communis 1.23–1.8 cm
Extensor digiti quinti 1.8 cm
Abductor pollicis longus 5.6 cm
Extensor pollicis brevis 6.5 cm
Extensor indicis proprius 6.8 cm
Extensor pollicis longus 7.5 cm
From Spinner M. Injuries to the major branches of peripheral nerves
of the forearm, 2nd ed. Philadelphia: WB Saunders, 1978.
tinues a few centimeters to enter the supinator muscle. Just
before entering the supinator, the motor branch to the
extensor carpi radialis brevis is given off. The motor branch
to the extensor carpi radialis brevis usually exits off the lat-
eral aspect of the posterior interosseous nerve. The extensor
carpi radialis brevis usually receives its innervation at the
level of the radial head or distal to it (6).
The supinator muscle, arising from the lateral epi-
condyle, radial collateral ligament, and the proximal ulna, is
divided into deep and superficial heads. The muscle is
approximately 5 cm broad. The posterior interosseous nerve
gives off one or more branches to the supinator muscle
before entering it; however, additional fibers may remain
within the epineurium of the main trunk for several cen-
timeters, supplying the muscle between its two heads. The
posterior interosseous nerve enters the supinator muscle at
the muscle’s proximal end, through a teardrop-shaped
opening in the superficial head of the muscle. The opening
leads the plane between the deep and superficial heads. The
opening in the superficial head contains a fibrous or mus-
cular thickening along its margin, referred to as the arcade
of Frohse (Frohse, 1908). The nerve enters the arcade of the
Frohse and continues distally to pass obliquely between the
superficial and deep muscle bellies. In its course through
the supinator, the nerve usually is somewhat perpendicular
to the direction of the line of the muscle fibers. The nerve
continues dorsolaterally around the neck of the radius and
innervates the supinator while coursing through it. The
nerve is separated from the radius by the deep head of the
supinator muscle, but may come into contact with the
bone, especially when the fibers of the deep head parallel
the course of the nerve (291,310). The nerve crosses the
proximal radius to exit the distal portion of the supinator
approximately 8 cm distal to the elbow joint (6). The nerve
thus emerges dorsally to enter the extensor compartment of
the forearm. As the nerve emerges from the supinator, it
divides into multiple branches, dividing in a somewhat
radial pattern resembling a cauda equina. There is a basic
pattern to the multiple branches, consisting of two major
components. These include those branches that supply the
218 Systems Anatomy
superficial layer of muscles (extensor digitorum communis,
extensor digiti quinti, and extensor carpi ulnaris) and those
branches coursing deep to the outcropping muscles (abduc-
tor pollicis longus, extensor pollicis longus and brevis, and
extensor indicis proprius). The branch pattern may be quite
variable. After leaving the supinator muscle, the nerve lies
between the abductor pollicis longus muscle (located
deeply) and the extensor carpi ulnaris, extensor digiti min-
imi, and extensor digitorum communis muscles (all located
superficially). The posterior interosseous nerve is joined on
the extensor surface of the forearm by the posterior
interosseous artery, a branch of the common interosseous
artery. Coursing distally in the forearm, the nerve passes
superficial to the extensor pollicis brevis and deep to the
extensor pollicis longus muscles (291). It penetrates deeply,
either over or through the extensor pollicis brevis muscle,
and comes to lie on the interosseous membrane between the
radius and ulna. Continuing distally on the interosseous
membrane, it divides into terminal branches that provide
sensory innervation to the wrist (291). The extensor carpi
radialis brevis muscle may be innervated by the radial nerve,
its superficial branch, or the posterior interosseous nerve.
Branches to this muscle most commonly originate 2 cm dis-
tal to the tip of the lateral epicondyle, but may arise
between 2 and 5 cm distal to it (35,291).
As noted previously, the branch pattern of the posterior
interosseous nerve is variable after it exits the supinator, and
variations exist as to the order and distance that muscles are
innervated (44) (see Fig. 3.5). In general, the nerve gives off
three short and two long motor branches after it leaves the
muscle (291). The general order of muscle innervation and
the distance from the distal edge of the supinator to the
point of innervation of the associated muscle is as follows:
extensor carpi ulnaris, innervated approximately 1.25 cm
distal to the supinator; extensor digitorum communis,
innervated approximately 1.25 to 1.8 cm distal to the
supinator; extensor digiti quinti, innervated approximately
1.8 cm distal to the supinator; abductor pollicis longus,
innervated approximately 5.6 cm distal to the supinator;
extensor pollicis brevis, innervated approximately 6.5 cm
distal to the supinator; extensor indicis proprius, innervated
approximately 6.8 cm distal to the supinator; and extensor
pollicis longus, innervated approximately 7.5 cm distal to
the supinator (6,291,311) (see Tables 3.5 and 3.7).
There are three short branches given off after the poste-
rior interosseous nerve exits the supinator. These innervate
the extensor digitorum communis, followed by the extensor
digiti minimi and the extensor carpi ulnaris muscles, and
arise in close succession and travel a variable distance before
entering their respective muscles (see distances above, Fig.
3.5). Although variation exists, there is a relatively constant
pattern in that the extensor carpi ulnaris and extensor digi-
torum communis muscles are innervated proximal to the
abductor pollicis longus and extensor pollicis brevis. One to
three terminal branches of the posterior interosseous nerve
supply the extensor carpi ulnaris. These branches pass hor-
izontally in a medial direction to reach the muscle. These
branches arise from the posterior interosseous nerve at
approximately the level just distal to the most distal portion
of the insertion of the anconeus (6). The branches then run
proximally and distally within the muscle. The extensor
digiti minimi is supplied by a branch of the posterior
interosseous nerve just radial to the innervation of the
extensor carpi ulnaris. These motor branches are vulnerable
to injury if the interval between the extensor carpi ulnaris
and the extensor digiti minimi, or between the extensor dig-
iti minimi and extensor digitorum communis in the mid-
forearm, is explored (6).
A long lateral branch supplies the abductor pollicis
longus 5.6 cm distal to the division and ends in the extensor
pollicis brevis, 6.8 cm distal to the division (311). Multiple
branches to these muscles are common (291) (Fig. 3.5).
A final long medial muscular branch provides innerva-
tion to the extensor indicis proprius 6.8 cm distal to the
nerve division and to the extensor pollicis longus 7.5 cm
distal to the division (see earlier). This medial branch may
divide and innervate both the extensor pollicis longus and
the extensor indicis proprius, or two separate nerves can
exist that each exit the posterior interosseous nerve, with
each muscle receiving its separate nerve (291).
After innervation of the extensor pollicis longus, the
nerve exits from the muscle belly or from its course super-
ficial to this muscle. The nerve comes to lie on the dorsal
aspect of the interosseous membrane between the radius
and ulna. The nerve continues distally on the interosseous
membrane, where it divides into terminal branches that
provide sensory innervation to the wrist (291). Specific
branches innervate the ligaments of the radiocarpal, inter-
carpal, and carpometacarpal joints (291,312).
The radial nerve and its branches also carry sympathetic
nerve fibers. The main trunk of the radial nerve, which
divides into several branches in the proximal forearm, sup-
plies sympathetic fibers to the radial artery at the elbow or
in the proximal forearm. More distally in the forearm, the
radial artery is supplied segmentally in the middle and dis-
tal portions by sympathetic nerve fibers from the superficial
radial nerve (313).
Anomalies and Variations: Radial Nerve
in the Forearm and Hand
Three patterns of variability are recognized in the course of the
radial nerve in the forearm. The first pattern concerns the ter-
minal branching of the radial nerve trunk. Most commonly,
the nerve bifurcates into superficial and deep branches at the
level of the tip of the lateral epicondyle. The level of division
may vary from 4.5 cm proximal to 4 cm distal to the epi-
condyle; the distal division is more common (205).
A second pattern of variability concerns the level of
innervation of the forearm muscles. The extensor carpi radi-

alis brevis muscle may be innervated directly from the radial
nerve trunk, from its bifurcation, from the posterior
interosseous nerve, or from the superficial branches. The
supinator muscle usually receives a single branch from the
posterior interosseous nerve before it enters the muscle and
several short branches within the muscle. However, several
branches have been noted to divide proximally to supply
the supinator muscle (17,35,44). As the posterior
interosseous nerve leaves the supinator, several branches
arise to supply the superficial and deep forearm extensor
muscles. Although the level of innervation and branching
described usually is adhered to, significant variation exists
among individuals. All of the branches may arise from one
common nerve, or may divide much like the cauda equina
(2,3,6,11,13,25,44,191,291).
Rarely, as noted by Linell, the motor branch to the
extensor carpi radialis longus can arise from the posterior
interosseous nerve and penetrate the supinator muscle to
reach its destination (205). In this situation, a lesion or
compression of the posterior interosseous nerve may pre-
sent not only with loss of digital extension, but also with
complete loss of wrist extension. The hand has no sensory
abnormalities, and there is no dysfunction of the brachiora-
dialis muscle.
The posterior interosseous nerve has been shown to have
variable patterns. The nerve may pass superficial to the
supinator, rather than through it. Distally, the nerve may
pass under, over, or through the extensor pollicis brevis
muscle before coming in contact with the interosseous
membrane. Krause and von Luschka have described the
motor branch to the abductor pollicis longus and extensor
pollicis brevis, extensor pollicis longus, and extensor indicis
proprius passing superficial to the superficial head of the
supinator, while the remaining major portion of the poste-
rior interosseous nerve, supplying the extensor digitorum
communis, extensor digiti quinti proprius, and extensor
carpi ulnaris, follows its usual course (6,314,315).
Froment-Rauber Nerve
The posterior interosseous nerve rarely may continue dis-
tally to innervate the first, second, and third dorsal
interosseous muscles. This was first described by Froment
in 1846 (316), and further noted by Rauber in 1865
(317,318), and by Shevkunenko in 1949 (312). Spinner has
referred to the anomaly as the Froment-Rauber nerve (6).
Froment-Rauber Anastomosis
An anastomosis may exist between the terminal branches of
the posterior interosseous nerve and the deep branch of the
ulnar nerve in the dorsal interosseous muscles of the hand.
Although originally described by Bichat in 1802 (319) and
again by Hovelacque in 1927 (73,74), the anastomosis usu-
ally is referred to as the Froment-Rauber anastomosis. Spin-
3 Nerve Anatomy 219
ner suggests that the name of Bichat should be added to the
eponym because of Bichat’s early description.
Anterior Interosseous Nerve to Posterior
Interosseous Nerve Anastomosis
Rauber described a communication between the anterior
interosseous nerve and the posterior interosseous, passing
through a foramen in the interosseous ligament. The ante-
rior interosseous nerve usually is divided into three long
branches. The main branch supplies the flexor pollicis
longus, the flexor profundus muscles to the index and long
fingers, and the pronator quadratus. The other two
branches pass adjacent to the interosseous membrane,
where they innervate the interosseous ligament and the
periosteum of the radius and ulna (6). Some of the branches
that travel along the interosseous ligament penetrate the lig-
ament to communicate with terminal branches of the pos-
terior nerve. In the distal forearm, a terminal branch of the
main anterior interosseous nerve branches posterior to the
pronator quadratus and passes through a foramen in the
interosseous ligament to anastomose with branches of the
posterior interosseous nerve. The latter communication can
occur at the distal border of the interosseous ligament. This
is a potential pathway for communication of nerve fibers
between the median nerve and radial nerve. It also is possi-
ble that the median nerve fibers that join the posterior
nerve actually may continue to reach the intrinsic muscles
of the hand (6). Spinner notes that this is an example of
neural plexification that occurs throughout the entire
peripheral nervous system.
The Superficial Branch of the Radial Nerve
The superficial branch of the radial nerve may wind around
the brachioradialis and continue on the superficial surface
of the muscle, rather than along the deep surface. It can
thus course from the elbow to the hand in the subcutaneous
tissue on the dorsolateral surface of the forearm (6,194).
Rarely, the brachioradialis and extensor carpi radialis
longus muscles share a common muscle belly, or have a con-
joined muscle. In these cases, the superficial branch of the
radial nerve has been reported to perforate a conjoined ten-
don that is shared by the two muscles (6).
Absence of the Superficial Branch of the
Radial Nerve
Complete absence of the superficial branch of the radial
nerve has been described (320). In this case, the area nor-
mally supplied by the radial nerve was supplied by the mus-
culocutaneous nerve (which extended more distally than
normal), and an enlarged ulnar dorsal cutaneous nerve
(320) was found to supply the autonomous zone of the
thumb.
220 Systems Anatomy
The superficial branch of the radial nerve may supply
sensibility to the thenar eminence in the region (normally
innervated by the palmar cutaneous branch of the median
nerve), and to the palmar aspect of the thumb (normally
innervated by the common digital nerves of the thumb
originating from the median nerve). Thus, it is possible for
an injury to the superficial branches of the radial nerve to
produce numbness or anesthesia of both the dorsal and pal-
mar aspects of the thumb.
The superficial branch of the radial nerve may supply the
entire dorsum of the hand. Learmonth has reported an
anatomic specimen in which the entire dorsal cutaneous
branch of the ulnar nerve was absent. The region normally
supplied by the ulnar nerve was supplied by an enlarged
superficial radial nerve, which had additional branches (208).
The Musculocutaneous Nerve
Spinner and colleagues noted several specimens and clinical
cases where the musculocutaneous nerve extended more
distally than traditionally depicted. The nerve can continue
into the hand to supply the anterior palmar aspect of the
thumb or thenar eminence (in the region of the thumb
metacarpal between the sensory region of the medial palmar
cutaneous nerve area and the more dorsal superficial radial
autonomous zone) (6).
The musculocutaneous nerve also may supply sensibility
to the dorsum of the thumb in the area usually supplied by
the superficial branch of the radial nerve (6).
It is not uncommon for there to be a communicating
branch between the superficial branch of the radial nerve
and the musculocutaneous nerve (205).
Spinner has pointed out that communicating branches
between the median and musculocutaneous nerves in the
arm and between the median and ulnar nerves in the intrin-
sic muscles probably pass distally through the posterior cord
to the posterior interosseous nerve rather than through the
usual medial cord to the ulnar nerve path (6).
Clinical Correlations: Radial Nerve in the
Forearm and Hand
Radial Tunnel Syndrome
The radial nerve may be compressed or develop neuritis along
its course in the radial tunnel, frequently between the head or
neck of the radius and the supinator muscle (321,322). The
radial nerve is particularly at risk at its entrance into the
supinator, at the arcade of Frohse. The arcade of Frohse is a
fibrous or fascial band resembling an oval-shaped window at
the proximal aspect of the supinator muscle. The nerve also
may be compressed in the muscle itself (see discussion of paral-
ysis of the posterior interosseous nerve, later). Mass lesions
such as synovial cysts, synovitis, or lipomas also can impinge
on the radial nerve and associated branches (323–326).
The radial nerve is at risk in the radial tunnel during
radial head excision or fixation of fractures (327–344).
During operative exposure of the radial head and neck,
rotation of the forearm in pronation rotates the nerve away
from and slightly more distal to the operative site, and pro-
vides additional safety. With the elbow in supination, the
posterior interosseous nerve passes the neck of the radius
with a minimal distance of approximately 2.2 cm (mean,
3.3 cm) distal to the radiocapitellar articulation. With the
elbow pronated, this minimal distance increases to 3.8 cm
(mean 5.2 cm), thus moving the nerve away from the oper-
ative area (345).
The Presence or Absence of the Wrist
Extensors
The presence or absence of the active wrist extension
(extensor carpi radialis longus and brevis and extensor carpi
ulnaris) is helpful in determining the level of nerve injury or
dysfunction. A high radial nerve injury that is above the
elbow usually results in loss of wrist and digital extension.
If wrist extension and radial deviation are present (indicat-
ing function of the extensor carpi radialis longus), the lesion
is distal to the branching of this nerve. A lesion of the pos-
terior interosseous nerve usually preserves the branch to the
extensor carpi radialis brevis, which branches from the
superficial branch of the radial nerve or from its own
branch proximal to the supinator muscle.
Posterior Interosseous Nerve Paralysis
A hand with a posterior interosseous nerve paralysis usually
dorsiflexes in a radial direction because of preservation of
the extensor carpi radialis longus (and brevis). On occasion,
the wrist may dorsiflex more neutrally. This can be due to
variation of the insertion of the radial extensors of the wrist.
The extensor carpi radialis longus can have a tendinous
attachment to the brevis tendon. The extensor carpi radialis
longus also can insert not only to the base of the index
metacarpal, but to the base of the long metacarpal. Either
of these conditions helps produce a more neutral wrist
extension with complete paralysis of the posterior
interosseous nerve.
Spontaneous Neuropathy of the Posterior
Interosseous Nerve
The most frequent cause of spontaneous neuropathy of the
posterior interosseous nerve probably is entrapment of the
nerve as it enters the supinator muscle at the arcade of
Frohse (346,347). Spontaneous neuropathy is well docu-
mented in the historical literature (73,111,208,316,327,
346,348–361). Two clinical pictures are described. The first
is a complete paralysis of all innervated muscles (the exten-
sor carpi radialis brevis often is spared because it often arises

separately from the superficial branch of the radial nerve, or
from the posterior interosseous nerve proximal to the
arcade of Frohse, and does not penetrate the muscle). The
second clinical picture is a slow, progressive paralysis of the
posterior interosseous nerve, usually commencing with
paralysis of one or several muscles. If untreated, it fre-
quently progresses to a complete paralysis.
Pseudoulnar Claw Hand
When there is an incomplete, spontaneous neuropathy of
the posterior interosseous nerve, the ring and small fingers
initially may be involved. There is lack of extension of these
digits, which assume a position of flexion at the metacar-
pophalangeal joints and the proximal and distal interpha-
langeal joints. The hand with these flexed digits may resem-
ble a claw hand (similar to ulnar neuropathy, without the
extension at the metacarpophalangeal joints). This partial,
spontaneous neuropathy of the posterior interosseous has
been described as a pseudoulnar claw hand (362).
Additional partial paralysis of the posterior interosseous
nerve includes loss of extension at the metacarpophalangeal
joints of single digits, combinations of digits, or the thumb
(350,351,354,356,357,363).
Differential Diagnosis in Loss of Digital
Extension
Loss of digital extension can occur from several etiologies,
especially in the patient with inflammatory arthritis. The
causes of digital extensor function loss include posterior
interosseous nerve paralysis, spontaneous rupture of extrin-
sic extensor tendon(s), extensor tendon subluxation into
the valley between metacarpal heads (such as can occur with
inflammatory arthritis that results in incompetence of the
sagittal bands for tendon centralization and stabilization),
and metacarpophalangeal joint subluxation (in inflamma-
tory arthritis). Partial posterior interosseous nerve paralysis
can be distinguished from the other causes by clinical exam-
ination, as follows:
Neuropathy of the Posterior Interosseous Nerve
Partial or complete posterior interosseous nerve paralysis
results in loss of active digital extension specifically at the
metacarpophalangeal joint. Active digital extension func-
tion remains intact at proximal and distal interphalangeal
joints because of ulnar nerve–innervated intrinsic muscles.
The tenodesis effect is intact (with digital extension occur-
ring when the wrist is passively flexed), and thus helps rule
out extensor tendon rupture. Radiographs help determine if
metacarpophalangeal joint subluxation is present.
Extensor Tendon Rupture
There is loss of active digital extension at the metacarpal
joints. The tenodesis effect is absent (showing no digital
3 Nerve Anatomy 221
extension occurring when the wrist is passively flexed). The
patient is unable to maintain digital extension at the
metacarpophalangeal joint when the joint is passively
placed in an extended position (helping to rule out extensor
tendon subluxation between the metacarpal heads). Radi-
ographs help determine if metacarpophalangeal joint sub-
luxation is present (364).
Extensor Tendon Subluxation
With extensor tendon subluxation, there is weakness or
inability actively to extend the digit at the metacarpopha-
langeal joint. However, the patient is able to maintain digital
extension when the digits are passively placed in extension.
This is possible because the tendon often centralizes when the
metacarpophalangeal joint is passively placed in extension.
The patient is able momentarily to maintain the extended
position. However, when the digit is flexed, the tendon
resubluxates, and digital extension no longer is possible.
Metacarpophalangeal Joint Subluxation
With metacarpophalangeal joint subluxation, as can
develop with rheumatoid arthritis, the patient is unable
fully to extend the digits. Passive extension of the digit may
not be possible, and this helps distinguish the condition
from tendon subluxation. Radiographs show metacar-
pophalangeal joint subluxation, and help distinguish the
condition from nerve palsy.
Innervation of the Posterior Interosseous
Nerve
There is clinical relevance to the order and distance of
innervation of the posterior interosseous nerve (see Table
3.7). These can be used in identifying the portion or level
of nerve injured from penetrating trauma. The order and
distances also have predictive usefulness post-nerve repair in
the evaluation of nerve regeneration success and expecta-
tions. After successful neurorrhaphy or neurolysis of the
posterior interosseous nerve, the earliest clinical sign of
impending recovery is the ability of the wrist to dorsiflex in
a neutral, or even ulnar, direction. This indicates recovery of
function of the extensor carpi ulnaris (and, to some extent,
of the extensor digitorum communis).
Safe and Unsafe Internervous Planes
Because of the transverse or horizontal branching of the
posterior interosseous nerve in the mid-forearm, motor
branches are vulnerable to injury if the intervals between
the extensor carpi ulnaris and the extensor digiti minimi, or
between the extensor digiti minimi and extensor digitorum
communis, are explored (6). Relatively safe internervous
planes in this area are between the anconeus and the exten-
sor carpi ulnaris and between the extensor digitorum com-
munis and the extensor carpi radialis brevis.
222 Systems Anatomy
Communication Between the Anterior
Interosseous Nerve and the Posterior
Interosseous
As noted earlier, Rauber described a communication
between the anterior interosseous nerve and the posterior
interosseous, passing through a foramen in the interosseous
ligament. When present, this explains the retained function
of the intrinsic muscles in a hand when the ulnar nerve has
been severed (6,317,318).
The Superficial Branch of the Radial Nerve
The superficial branch of the radial nerve may be com-
pressed distal to its exit from the radial tunnel and along its
course in the forearm and wrist. It may be impinged at its
passage from the subfascial to the subcutaneous level, where
its exits into the subcutaneous tissues between the brachio-
radialis and extensor carpi radialis longus. Dysfunction of
the superficial branch of the radial was described by
Wartenberg in 1932, and his name often is used in associa-
tion with the clinical syndrome (365,366).
The superficial branch of the radial nerve usually passes
dorsally from the deep surface of the brachioradialis to
become subcutaneous approximately 10 cm proximal to the
radial styloid. The nerve is especially vulnerable to external
injury or compression from this point distally. The nerve
has been compressed by external objects, such as tight wrist-
watches, bracelets, handcuffs, gloves, and casts (6,367). The
nerve also may be injured from iatrogenic causes, including
laceration from release of the first dorsal compartment in
De Quervain’s disease, from injury from a cutdown proce-
dure of a vein in the distal forearm, or from laceration from
tendon lengthening procedures involving the extensor carpi
radialis or longus (6).
Injury to the superficial branch of the radial nerve can
result in considerable pain and disability, and a full causal-
gia syndrome can develop (368). Neuromas or associated
regional pain syndromes from sympathetic-mediated nerve
dysfunction are particularly troublesome.
A communication branch between the superficial branch
of the radial nerve and the musculocutaneous nerve in the
distal forearm is not uncommon (205). Because of this, lac-
eration of the superficial branch of the radial nerve in the
proximal forearm (proximal to the communicating branch)
may not present clinically with the classic sensory loss
expected for superficial radial nerve injury.
MUSCULOCUTANEOUS NERVE
Origin of the Musculocutaneous Nerve
The musculocutaneous nerve originates from the lateral
cord of the brachial plexus and is derived from the ventral
rami of C5, C6, and C7. It branches from the lateral cord at
the level of and deep to the pectoralis minor (see Fig. 3.1).
Musculocutaneous Nerve in the Axilla
and Arm
The nerve extends distally on a course lateral to the remain-
ing brachial plexus and medial to the proximal humerus.
The nerve pierces the coracobrachialis and continues dis-
tally, in a lateral course between the biceps and brachialis to
the lateral side of the arm. The course of the nerve in this
part of the arm has been delineated by Williams and Latar-
jet et al., noting that the nerve projects along a line drawn
from the lateral side of the third part of the axillary artery
across the coracobrachialis and biceps to the lateral side of
the biceps tendon (3). The course is varied by its point of
entry into the coracobrachialis (369). The musculocuta-
neous nerve supplies the coracobrachialis, both heads of the
biceps, and most of the brachialis (see Fig. 3.2). The branch
to the coracobrachialis exits the musculocutaneous nerve
before it enters the muscle. The fibers from this branch (to
the coracobrachialis) are derived from the ventral ramus of
C7. This nerve may branch directly from the lateral cord.
The branches to the biceps and brachialis leave the muscu-
locutaneous after the nerve pierces the coracobrachialis.
The nerve branch to the brachialis also sends a branch to
the elbow joint for innervation. The nerve also supplies a
small branch to the humerus, where it enters the cortex
with the nutrient artery.
At a point just distal to the elbow, the musculocutaneous
nerve pierces the deep fascia lateral to the tendon of the
biceps. From this point, it continues as the lateral ante-
brachial cutaneous nerve (lateral cutaneous nerve of the
forearm).
Lateral Antebrachial Cutaneous Nerve
(Lateral Cutaneous Nerve of the Forearm)
The lateral antebrachial cutaneous nerve originates as a con-
tinuing branch of the musculocutaneous nerve (see Figs. 3.2
and 3.4). The musculocutaneous nerve in the arm passes deep
to the biceps and superficial to the brachialis, in a medial-to-
lateral direction. As the musculocutaneous nerve passes dis-
tally and laterally, it reaches the approximate level of the elbow
joint, and exits from the deep surface of the biceps to become
cutaneous. At this point, the musculocutaneous nerve
becomes the lateral antebrachial cutaneous nerve. The lateral
antebrachial cutaneous nerve continues distally in the fore-
arm, deep to the cephalic vein, and descends along the radial
border of the forearm to reach the wrist. In the forearm, the
nerve sends out small cutaneous branches to provide sensibil-
ity to the skin of the anterolateral forearm. The nerve may
have anastomoses distally with either the posterior cutaneous
nerve of the forearm or with the superficial branch of the
radial nerve (3). The nerve may give rise to a slender recurrent
branch that extends along the cephalic vein as far as the mid-
dle third of the arm, giving off several small branches to pro-
vide sensibility to the skin over the distal third of the antero-
lateral surface of the upper arm (370,371). This recurrent

branch rarely is mentioned in most descriptions of the ner-
vous anatomy in the upper extremity (3).
At the level of the wrist joint, the lateral antebrachial
cutaneous nerve is located anterior to the radial artery and
may have several small branches that pierce the deep fascia
and accompany the radial artery to the dorsum of the wrist.
The nerve then passes to the base of the thenar eminence
and ends in multiple small cutaneous rami. The nerve often
connects with the superficial branch of the radial nerve and
the palmar cutaneous branch of the median nerve.
Anomalies and Variations:
Musculocutaneous Nerve and Lateral
Antebrachial Cutaneous Nerve
Several variations of the lateral antebrachial cutaneous
nerve have been described.
n The musculocutaneous nerve may pass behind the cora-
cobrachialis (instead of passing through the muscle) (3).
n The musculocutaneous nerve may accompany or actu-
ally adhere to the median nerve in its course in the arm.
n The musculocutaneous usually supplies motor innerva-
tion to the coracobrachialis. The muscle, however, may
be innervated by its own nerve, and branch directly from
the lateral cord of the brachial plexus.
n Small branches of the median nerve may pass to the mus-
culocutaneous nerve and continue with the musculocu-
taneous nerve. Conversely, small branches of the muscu-
locutaneous nerve may pass to the median nerve, and
continue with the median nerve.
n The distal branches of the lateral antebrachial cutaneous
nerve may have anastomoses with the superficial branch
of the radial nerve or with the palmar cutaneous branch
of the median nerve.
n The lateral antebrachial cutaneous nerve may, through
these small distal branches, innervate or help innervate
the pronator teres.
n The lateral antebrachial cutaneous nerve may have small
branches that extend to the dorsum of the thumb and
supply sensibility to the overlying skin (replacing the
innervation of the terminal portion of the superficial
branch of the radial nerve) (3).
Clinical Correlations: Musculocutaneous
Nerve and Lateral Antebrachial
Cutaneous Nerve
Injury to the musculocutaneous nerve can occur from
fractures of the proximal humerus. Clinical findings
include weakness of elbow flexion (from paresis of the
biceps and brachialis) and sensory loss on the lateral aspect
of the forearm. Pain and paresthesia may be aggravated by
elbow extension, which can stretch the musculocutaneous
nerve.
The lateral antebrachial cutaneous nerve can be used as
a donor nerve for nerve grafting. However, because of
3 Nerve Anatomy 223
donor site morbidity with numbness on the lateral aspect of
the forearm, other donor nerves (such as the sural nerve)
usually are selected.
MEDIAL BRACHIAL CUTANEOUS NERVE
(MEDIAL CUTANEOUS NERVE OF THE ARM,
NERVE OF WRISBERG)
The medial brachial cutaneous nerve, often referred to as
the medial cutaneous nerve of the arm, or as the nerve of
Wrisberg (3,11), is a sensory nerve that supplies the medial
aspect of the arm from the axilla to the medial elbow. It is
considered the smallest true nerve branch that originates
from the brachial plexus.
Origin of the Medial Brachial Cutaneous
Nerve
The medial brachial cutaneous nerve originates from the
medial cord of the brachial plexus. It comprises mostly fibers
from the ventral rami of C8 and T1 (see Fig. 3.1). The nerve
branches from the medial cord at a point slightly proximal to
the point of origin of the medial antebrachial cutaneous nerve.
Medial Brachial Cutaneous Nerve in the
Axilla and Arm
From its origin from the medial cord, the medial brachial
cutaneous nerve passes through the axilla deep to the pec-
toralis insertion and anterior to the latissimus dorsi. In its
proximal course, it is located dorsal to the axillary artery
and vein. As it continues distally, it comes to lie medial to
these vessels. The nerve may pass posterior to the axillary
vein. In the axilla, it may anastomose with the intercostal
nerves. The medial brachial nerve may branch early and
consist of several branches as it exits the axilla. The nerve
and associated branches continue distally medial to the
brachial artery and basilic vein. The nerve descends distally
along the medial aspect of the arm and pierces the deep
brachial fascia to become cutaneous in the mid-portion of
the arm. It continues to branch and provides sensibility to
the medial aspect of the arm as far distally as the medial epi-
condyle and olecranon (11) (see Fig. 3.4).
Anomalies and Variations: Medial
Brachial Cutaneous Nerve
n The medial brachial cutaneous nerve may communicate
with the medial antebrachial cutaneous nerve through
the ulnar branch of the latter nerve.
n The medial brachial cutaneous nerve may originate as a
branch of the medial antebrachial cutaneous nerve (11).
n The anastomoses with the intercostal nerve in the proxi-
mal axilla may have so many branches that the connec-
tions assume a plexiform pattern in the axilla.
224 Systems Anatomy
n The intercostobrachial nerve communication may be
large (between the medial brachial cutaneous nerve and
the intercostal nerves) and may be reinforced by a part of
the lateral cutaneous branch of the third intercostal
nerve. When there is a large contribution or component
from the lateral cutaneous branch of the third intercostal
nerve, it may replace the medial cutaneous nerve of the
arm (3).
Clinical Correlations: Medial Brachial
Cutaneous Nerve
The medial brachial cutaneous nerve contains only sensory
fibers. Injury to the medial brachial cutaneous nerve results
in loss of sensibility to the medial aspect of the arm.
MEDIAL ANTEBRACHIAL CUTANEOUS
NERVE (MEDIAL CUTANEOUS NERVE OF
THE FOREARM)
The medial antebrachial cutaneous nerve, often referred to
as the medial cutaneous nerve of the forearm, is a sensory
nerve that supplies the medial aspect of the forearm from
the elbow to the wrist. It also supplies sensibility to the skin
overlying a portion of the anterior arm anterior to the
biceps muscle.
Origin of the Medial Antebrachial
Cutaneous Nerve
The medial antebrachial cutaneous nerve originates from the
medial cord of the brachial plexus. It comprises mostly fibers
from the ventral rami of C8 and T1 (see Fig. 3.1 and Appen-
dix 3.1). The nerve branches from the medial cord at a point
slightly distal to the point of origin of the medial brachial
cutaneous nerve.
Medial Antebrachial Cutaneous Nerve in
the Axilla, Arm, and Forearm
From its origin from the medial cord, the medial ante-
brachial cutaneous nerve passes through the axilla deep to
the pectoralis insertion and anterior to the latissimus dorsi.
In its proximal course, it lies medial to the axillary artery,
much closer to the artery than the medial brachial cuta-
neous nerve. It often is situated between the axillary artery
and vein. In the proximal portion, just distal to the axilla,
the nerve gives off a small branch that pierces the fascia over
the proximal and anterior aspect of the biceps muscle. This
branch supplies sensibility to the skin overlying the anterior
biceps muscle from the axilla to the level of the elbow. The
main nerve continues distally along the medial aspect of the
arm medial to the brachial artery. It pierces the deep fascia
with the basilic vein to become cutaneous in the mid-por-
tion of the arm. The nerve divides into an anterior and a
posterior (ulnar) branch (Fig. 3.4).
Anterior Branch of the Medial Antebrachial
Cutaneous Nerve
The anterior branch of the medial antebrachial cutaneous
nerve usually is a larger branch than the posterior (ulnar)
branch of the medial antebrachial nerve. The anterior
branch continues distally along the anteromedial aspect
of the forearm. Proximally in the forearm, it usually
passes superficial to the median basilic vein. The nerve
then continues on the anterior part of the ulnar forearm,
supplying the skin of the anteromedial forearm as far dis-
tally as the wrist. It often has an anastomosis with the pal-
mar cutaneous branch of the ulnar nerve (3,11) (see Fig.
3.4).
Posterior (Ulnar) Branch of the Medial
Antebrachial Cutaneous Nerve
The posterior (ulnar) branch of the medial antebrachial
cutaneous nerve continues obliquely distally along the
medial side of the basilic vein, anterior to the medial epi-
condyle of the humerus but curving posteriorly, and spiral-
ing around the ulnar aspect of the forearm to reach the dor-
sal portion of the medial forearm. It continues distally along
the ulnar aspect of the forearm as far distal as the wrist, sup-
plying the overlying skin as it extends distally (see Fig. 3.4).
It often has anastomoses with the medial brachial cutaneous
nerve (in the proximal forearm), with the dorsal ante-
brachial cutaneous nerve, and with the dorsal branch of the
ulnar nerve (3,11).
Anomalies and Variations: Medial
Antebrachial Cutaneous Nerve
The anterior branch of the medial antebrachial nerve
descends anteromedially in the forearm to reach the wrist.
In this area it often has an anastomosis with the palmar
cutaneous branch of the ulnar nerve.
The posterior branch of the medial antebrachial nerve
descends distally and posterior to the dorsal aspect of the
forearm, to reach the medial border of the wrist. Along its
course, it may have several anastomoses, including those
with the medial brachial cutaneous (in the proximal fore-
arm), or with the posterior cutaneous nerve of the forearm
or the dorsal branch of the ulnar nerve.
Clinical Correlations: Medial Antebrachial
Cutaneous Nerve
The medial antebrachial cutaneous nerve contains only sen-
sory fibers. Injury to the medial antebrachial cutaneous
nerve results in loss of sensibility to the medial aspect of the

forearm and a portion of the anterior arm overlying the
anterior biceps.
Injury to the medial cord or to the C8 or T1 nerve
roots results in dysfunction of the medial antebrachial
cutaneous nerve (as well as ulnar neuropathy), and is asso-
ciated with numbness along the medial aspect of the fore-
arm and a portion of the anterior arm overlying the ante-
rior biceps.
SENSORY ORGANELLES
Several sensory nerve endings (organelles) terminate in the
skin, usually in relatively high concentrations in the hand.
These are innervated by the sensory nerve endings of the
median, ulnar, and radial nerves. The nerve endings are
encapsulated and exhibit considerable variety in size, shape,
and distribution, but all share in common the feature of an
axon terminal encapsulated by nonexcitable cells. The
3 Nerve Anatomy 225
major end organelles include the pacinian corpuscles,
Meissner corpuscles, Ruffini nerve endings, and Merkel
receptors (3,372,373) (Fig. 3.6).
Pacinian Corpuscles
Pacinian corpuscles (corpuscles of Vater-Pacini) are relatively
large, lamellated structures located in the subcutaneous tissue.
They occur in high concentrations on the palmar surface of
the hand and digits (as well as in the plantar foot, periostea,
interosseous membranes, and periarticular areas). These are
rapidly adapting receptors, and their function usually is con-
sidered to be detection of vibration, pressure, or coarse touch
(3,373). They are oval, spherical, or irregular firm masses,
smooth and glistening white or yellow in color, up to 2 to 4
mm in size (approximately 100 to 500 µm across) (373), and
are easily seen with (or without) loupe magnification during
operative procedures on the palmar surface of the hand or dig-
its. Each has a capsule, an intermediate growth zone, and a
FIGURE 3.6. Sensory organelles.
226 Systems Anatomy
central core containing an axon terminal. The capsule is
formed by approximately 30 concentrically arranged lamellae
of flat cells. The axon terminal consists of an unbranched ter-
minal of a peripheral nerve, and is in contact with the inner-
most core lamellae (3,372,373).
Meissner Corpuscles
Meissner corpuscles (tactile corpuscles of Meissner) are found
in the dermis, usually in the superficial layers very close to the
epidermis. They are in relatively high concentrations in all
parts of the hand (and foot), especially in the distal digits
(373). They also are rapidly adapting and highly sensitive to
fluctuating mechanical forces acting on the surface of the skin.
Meissner corpuscles are particularly sensitive to vibration at
certain frequencies. The structures are somewhat cylindrical in
shape, with their long axes perpendicular to the skin surface.
They are much smaller than the pacinian corpuscles, measur-
ing approximately 80 µm long and 30 µm across. The
organelle has a connective tissue capsule and a central core, the
capsule being loosely attached to the core. Like the pacinian
corpuscle, the Meissner corpuscle has an axon terminal end-
ing inside of the capsule (3) (Fig. 3.6).
APPENDIX 3.1. DERMATOMES OF THE UPPER EXTREMITY
Ruffini Nerve Endings
Ruffini endings (type II slowly adapting cutaneous mech-
anoreceptors) occur in the dermis of hairy skin. These are
slowly adapting (compared with the rapidly adapting
pacinian and Meissner corpuscles) and responsive to con-
tinuous forces such as maintained stress or stretch of the
skin. They consist of highly branched nerve endings that
are distributed among bundles of collagen fibers in a
spindle-shaped structure. The structure is enclosed partly
by a fibrocellular sheath derived from the perineurium of
the nerve (3) (Fig. 3.6).
Merkel Receptors
Merkel receptors basically are nerve endings (type I slowly
adapting cutaneous mechanoreceptors), and occur in the
skin in the vicinity of the dermal–epidermal junction. The
nerve ending is located in the basement membrane and ker-
atinocytes of the epidermis, or near the hair follicle. The
Merkel receptors are sensitive to perpendicular pressure or
indentation of the skin, or to the bending of the hair folli-
cle (3,373).

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 4
VASCULAR SYSTEMS
MICHAEL J. BOTTE
This chapter discusses vascular systems of the upper extrem-
ity. Included are separate sections on the major arteries,
veins, lymphatics, and lymph nodes. Similar to the other
systems chapters (Chapters 1 to 3), this chapter is provided
as a reference for specific vascular structures. The discussion
of each vascular structure contains a gross anatomic descrip-
tion, followed by a description of the associated branches
and the area or structures supplied. The intraosseous vascu-
lar supply to the skeletal structures is covered in the chapter
on Skeletal Anatomy (Chapter 1). The vascular contribu-
tions to specific muscles are listed under each separate mus-
cle in the chapter on Muscle Anatomy (Chapter 2). Discus-
sions of variations and clinical correlations of the described
anatomy follow each section.
ARTERIAL ANATOMY
AXILLARY ARTERY
Gross Anatomic Description: Axillary
Artery
The axillary artery begins at the distal edge of the first rib
and ends at the distal edge of the teres major tendon (Figs.
4.1 and 4.2). It is formed as the continuation of the subcla-
vian artery. The subclavian artery crosses deep to the clavi-
cle and superior to the first rib to become the axillary artery
(1–10). Some authors consider the axillary artery to begin
at the distal edge of the clavicle (11,12). The axillary artery
is the central structure of the axilla and continues across the
axilla to the distal edge of the teres major tendon. At that
point, where it leaves the axilla, the axillary artery becomes
the brachial artery (1–12). From its beginning at the first
rib, the axillary artery continues in a distal and inferior
direction (when the arm is at the side) to reach the inferior
aspect of the proximal arm. The artery initially lies deep in
the axilla, inferior to the anterior border of the deltoid and
covered in part by the pectoralis minor and more distally by
the pectoralis major. As it crosses anterior to the teres major,
it becomes superficial and palpable in the axilla, just before
it becomes the brachial artery. In its most distal part, the
axillary artery is covered only by skin and fascia (1,2,3,6).
The axillary vein lies parallel to the axillary artery and is
positioned anterior or inferior to the artery along the
artery’s course through the axilla.
The axillary artery is conventionally divided into three
parts, based on its relationship to the pectoralis minor
(Table 4.1; see Fig. 4.2). The first part of the axillary artery,
also called the proximal part, is proximal to the pectoralis
minor. The second or posterior part is posterior to the mus-
cle. The third part, also called the distal part, is distal to the
pectoralis minor (3,4,11).
The First (Proximal) Part of the Axillary Artery
The first (proximal) part of the axillary artery is approxi-
mately 2.5 cm long and extends from the lateral border of
the first rib to the medial border of the pectoralis minor
(7,8,11). It is bordered superiorly by the anterior deltoid
muscle and covered anteriorly by the skin, superficial fas-
cia, platysma, supraclavicular nerves, deep fascia, a por-
tion of the clavicular part of the pectoralis major, and the
clavipectoral fascia. Anterior to the first part of the artery
lie the lateral pectoral nerve, the loop of communication
between the lateral pectoral nerve and the medial pectoral
nerve, and the thoracoacromial and cephalic veins. Poste-
rior to the first part of the artery are the first intercostal
space, the corresponding external intercostal muscle, the
first and second digitations of the serratus anterior, the
long thoracic and medial pectoral nerves, and the medial
cord of the brachial plexus. Lateral to the first part of the
artery are the posterior and lateral cords of the brachial
plexus, separated from the artery by the areolar tissue.
Medial to the first part of the artery lie the axillary vein
and a portion of the medial cord of the brachial plexus.
The first part of the axillary artery is enclosed with the
axillary vein and brachial plexus in a fibrous axillary
sheath that is continuous with the prevertebral layer of the
deep cervical fascia (1–4,8,12). The first part of the axil-
lary artery gives off the superior (supreme) thoracic artery
(see under Main Branches: Axillary Artery, later) (11)
(Table 4.2).
238 Systems Anatomy

FIGURE 4.1. The main arterial trunks of the upper extremity.

 4 Vascular Systems 239

FIGURE 4.2. The axillary artery and its six associated branches. From proximal to distal, these
include the superior (supreme) thoracic artery arising from the first part of the axillary artery; the
thoracoacromial and lateral thoracic arteries arising from the second part of the axillary artery;
and the subscapular artery and the anterior and posterior humeral circumflex arteries arising
from the third part of the axillary artery.

The Second (Posterior) Part of the Axillary
Artery
The second (posterior) part of the axillary artery is approx-
imately 3 cm long and consists of the portion of the artery
that lies deep to the pectoralis minor (7,8,11). This part
courses anterior to the subscapularis muscle and is sur-
rounded by the cords of the brachial plexus. Anterior to the
artery lie the skin, superficial and deep fascia, the pectoralis
major muscle, and, immediately anterior to the artery, the
240 Systems Anatomy
TABLE 4.1. BRANCHES OF THE THREE PARTS THE
AXILLARY ARTERY
First (proximal) part of the axillary artery
Superior thoracic artery
Second (posterior) part of the axillary artery
Thoracoacromial artery
Clavicular branch
Pectoral branch
Deltoid branch
Acromial branch
Acromial rete
Lateral thoracic artery
Lateral (external) mammary branches
Third (distal) part of the axillary artery
Subscapular artery
Circumflex scapular artery
Thoracodorsal artery
Posterior humeral circumflex artery
Acromial rete (anastomosis)
Anterior humeral circumflex artery
Bicipital branch
Pectoral branch
pectoralis minor. Posterior to the second part of the artery
are the posterior cord of the brachial plexus and the areolar
tissue that separates the posterior cord from the deeper-
lying subscapularis. Lateral to the second part of the artery
are the lateral cord of the brachial plexus and the coraco-
brachialis. Medial to the second part of the artery are the
axillary vein, the medial cord of the brachial plexus, and the
medial pectoral nerve. The cords of the brachial plexus
therefore surround the second part of the axillary artery on
three sides (posterior, lateral, and medial), with the relative
positions implied by their names, and separate the artery
from the axillary vein and adjacent muscles (1–4,8,12). The
second part of the axillary artery gives off the thoracoacro-
mial and lateral thoracic arteries (see later, under Main
Branches: Axillary Artery) (11) (see Table 4.1).
The Third (Distal) Part of the Axillary Artery
The third (distal) part of the axillary artery is approximately
7.5 cm long and extends from the lateral border of the pec-
toralis minor to the distal border of the tendon of the teres
major (7,8,11). Anterior to the proximal portion of this
third part is the pectoralis major muscle. Anterior to the
distal portion of the third part, the artery is covered only by
skin and superficial fascia. It is palpable in this subcuta-
neous location. Posterior to the third part of the artery are
the inferior part of the subscapularis muscle and the ten-
dons of the latissimus dorsi and teres major. Lateral to the
third part of the artery is the coracobrachialis muscle.
Medial to the third part of the artery is the axillary vein.
The branches of the brachial plexus have the following rela-
tionships to the third part of the axillary artery: On the lat-
eral aspect are the lateral root and trunk of the median
nerve, and, for a short distance, the musculocutaneous
nerve. On the medial aspect (between the axillary vein and
artery) lie the ulnar nerve and (to the medial aspect of the
vein) the medial brachial cutaneous nerve. Anterior to the
third part of the artery are the medial root of the median
nerve and the medial antebrachial cutaneous nerve. Poste-
rior to the third part of the axillary artery are the radial and
axillary nerves. The axillary nerve extends only as far as the
distal border of the subscapularis (1,2). The third part of
the axillary artery gives off the subscapular artery and the
anterior and posterior humeral circumflex arteries (see later,
under Main Branches: Axillary Artery) (11) (see Table 4.1).
The direction and shape of the axillary artery varies with
the position of the arm (3,4). When the arm is at the side,
the axillary artery becomes convex superiorly. In this posi-
tion, the third part of the artery is “clasped” by the two
heads of the median nerve (11). When the arm is raised
above the head, the axillary artery becomes concave superi-
orly. When the arm is abducted 90 degrees, the artery is
basically straight, and the two roots of the median nerve lie
loosely around the third part (3,4,11).
Main Branches: Axillary Artery
The first part of the axillary artery gives off the superior
(supreme) thoracic artery. The second part gives off the tho-
racoacromial and lateral thoracic arteries. The third part
gives off the subscapular artery and the anterior humeral
and posterior humeral circumflex arteries (see Table 4.1 and
Figs. 4.1 and 4.2).
Superior Thoracic Artery
The superior (supreme) thoracic artery arises from the prox-
imal part of the first part of the axillary artery (see Figs. 4.1
and 4.2). It is a small branch that usually originates just dis-
tal to the clavicle, but variations include its origin from the
thoracoacromial artery or its complete absence (1–4,11).
The artery extends downward or medially, usually posterior
to the axillary vein, and continues along the chest wall in
the first and possibly second intercostal spaces (see Fig. 4.1).
The superior thoracic artery pierces the clavipectoral fascia
and courses between the pectoralis minor and pectoralis
major, supplying both muscles. It continues along the chest
wall and anastomoses with the internal thoracic and upper
one or two intercostal arteries. It also reaches and supplies
the sternoclavicular joint (8). Besides supplying the pec-
toralis major and minor, the superior thoracic artery sup-
plies the associated intercostal muscles and the upper por-
tion of the serratus anterior (7).
Thoracoacromial Artery
The thoracoacromial artery, arising from the second part of
the axillary artery, is a short arterial trunk with several

branches of its own (3,4) (see Figs. 4.1 and 4.2). It origi-
nates deep to or just proximal to the proximal edge of the
pectoralis minor. Near the artery’s origin, it branches into
four terminal branches: the clavicular, humeral, acromial,
and pectoral branches. The artery or its separate branches
pierce the clavipectoral fascia and the branches radiate away
from each other to reach their respective destinations. The
thoracoacromial artery may initially divide into two short
trunks, one of which descends inferiorly and medially to
form the clavicular and pectoral branches, the other of
which ascends superiorly and laterally to form the acromial
and humeral branches.
The Clavicular Branch
The clavicular branch of the thoracoacromial artery usually
is relatively small and ascends or descends medially in a ret-
rograde direction between the clavicular part of the pec-
toralis major and the clavipectoral fascia. The branch sup-
plies the sternoclavicular joint, the subclavius muscle, and a
part of the thoracic wall (1,2,8). It may send a nutrient ves-
sel to the clavicle (7).
The Pectoral Branch
The pectoral branch of the thoracoacromial artery is the
largest branch of the thoracoacromial artery. It descends
with the lateral pectoral nerve between the pectoralis minor
and pectoralis major muscles. It supplies both muscles, as
well as the breast. The pectoral branch then forms anasto-
moses with the intercostal branches of the internal thoracic
and lateral thoracic arteries (2). It may send a deep branch
posterior to the pectoralis minor that may supply the adja-
cent part of the thoracic wall (7).
The Deltoid Branch
The deltoid branch of the thoracoacromial artery also is a
relatively large branch, and often arises with the acromial
branch. It crosses anterior to the pectoralis minor but deep
to the clavicular head of the pectoralis major as it ascends
toward the lateral aspect of the shoulder. The branch con-
tinues along with the cephalic vein between the pectoralis
major and deltoid. It may give branches that pass through
the interval between the pectoralis major and deltoid to
become superficial to both muscles. The deltoid branch
supplies both the pectoralis major and the deltoid as it con-
tinues along the deltopectoral groove (3,4,8).
The Acromial Branch
The acromial branch of the thoracoacromial artery is a rel-
atively small branch that often arises with the deltoid
branch. It ascends toward the superior aspect of the shoul-
der. The branch crosses over in the vicinity of the coracoid
process deep to the deltoid muscle. It either perforates the
deltoid or crosses through the interval between the deltoid
and the clavicular head of the pectoralis major. The acro-
mial branch supplies the deltoid and continues superiorly
4 Vascular Systems 241
toward the acromion. At the acromion, the artery forms
anastomoses with the branches of the suprascapular artery,
the deltoid branches of the thoracoacromial artery, and the
posterior humeral circumflex arteries. The anastomosis over
the acromion is called the acromial rete (from the Latin rete,
which means “net”) (8).
Lateral Thoracic Artery
The lateral thoracic artery arises most commonly from the
second part of the axillary artery, but may have several com-
mon variations (see Figs. 4.1 and 4.2). It originates from the
second part of the axillary artery in approximately 50% of
individuals, from the subscapular artery in approximately
30%, from the first part of the axillary artery in approxi-
mately 11%, and from the thoracoacromial artery in 7%
(7). It passes deep to the pectoralis minor and descends
along the lateral border of the muscle to reach the thoracic
wall, passing anterior to the lateral cutaneous branches of
the thoracic segmental nerves. It continues downward along
the superficial aspect of the serratus anterior. It usually has
a branch that extends laterally across the axilla to reach the
anterior surface of the subscapularis and the axillary lymph
nodes. The lateral thoracic artery forms anastomoses with
the internal thoracic, subscapular, and intercostal arteries
and the pectoral branch of the thoracoacromial artery. The
artery supplies the pectoralis minor and major, the serratus
anterior, the subscapularis, the second to fifth intercostal
spaces, and the axillary lymph nodes. In women, the lateral
thoracic artery is large and also forms the lateral mammary
branches (sometimes referred to as the external mammary
branches). These branches can be of considerable size, and
curve around the free lateral border of the pectoralis major
to supply the breast (1–4).
Subscapular Artery
The subscapular artery usually is the largest branch of the
axillary artery (see Figs. 4.1 and 4.2). It arises from the third
part of the axillary artery at the distal border of the sub-
scapularis muscle. It descends along the anterior surface of
the subscapularis muscle, deep to the latissimus dorsi. It
usually lies adjacent to the lower subscapular and thora-
codorsal nerves. The subscapular artery usually is accompa-
nied by several veins, which unite and communicate with
the circumflex scapular vein and continue to either the axil-
lary vein or the medial brachial vein. At approximately 2.5
to 4 cm from its origin point from the axillary artery, the
subscapular artery divides into the circumflex scapular and
thoracodorsal arteries (3,4).
The Circumflex Scapular Artery
The circumflex scapular artery usually is larger than the
thoracodorsal artery, and courses posteriorly and then
medially. It curves around the lateral border of the scapula
242 Systems Anatomy
to pass through the triangular space (bordered by the teres
minor and subscapularis superiorly, the teres major inferi-
orly, and the long head of the triceps laterally) (3,4). The
circumflex scapular artery then enters the infraspinous fossa
between the teres minor and the scapula, and remains close
to the posterior surface of the scapula. The artery then
forms anastomoses with the several intercostal arteries and
with the deep branch of the transverse cervical artery or
with the descending branch of the descending scapular
artery. The posterior portion of circumflex scapular artery
supplies the infraspinatus muscle. As the artery passes
through the triangular space, it usually gives a branch to the
subscapularis muscle. The circumflex scapular artery usually
also has another large branch that continues along the lat-
eral border of the scapula between the teres major and teres
minor. This branch may form anastomoses with the deep
branch of the transverse cervical artery (or descending
branch of the descending scapular at the inferior angle of
the scapula). The vessel supplies the teres major and minor
muscles as well as the long head of the triceps and the del-
toid (1,3,4). There also may be additional anastomoses with
other arteries in the shoulder region, and branches originat-
ing from the suprascapular artery may contribute to vascu-
larity of the rotator cuff (13) (Table 4.1 and Fig. 4.2).
The Thoracodorsal Artery
The thoracodorsal artery is the continuation of the scapular
artery and courses inferiorly across the axilla along the ante-
rior border of the latissimus dorsi muscle. The artery lies adja-
cent to the thoracodorsal nerve. The thoracodorsal artery
forms anastomoses with the circumflex scapular artery and
with the deep branch of the transverse cervical artery (or
descending branch of the descending scapular artery). The
thoracodorsal artery supplies the subscapularis as well as pro-
viding the principal vascular supply to the latissimus dorsi.
One or two large branches cross the axilla to supply the ser-
ratus anterior and intercostal muscles. These branches may
form anastomoses with the intercostal, lateral thoracic, and
thoracoacromial arteries. When the lateral thoracic artery is
small or absent, a branch of the thoracodorsal may supply the
associated muscles (1,3,4) (Table 4.1 and Fig. 4.2)
Additional subscapular branches may arise from the sec-
ond or third part of the axillary artery and descend to sup-
ply the subscapularis. One branch that usually is consistent
accompanies the upper subscapular nerve (7).
Anterior Humeral Circumflex Artery
The anterior humeral circumflex artery, along with the pos-
terior humeral circumflex artery, are the most distal arterial
branches from the axillary artery (see Table 4.1 and Figs. 4.1
and 4.2). It is much smaller than the posterior humeral cir-
cumflex artery and originates from the third part of the axil-
lary artery near the inferior border of the subscapularis mus-
cle. The posterior humeral circumflex artery also originates at
the same level on the axillary artery. The anterior humeral cir-
cumflex artery may arise from a common trunk with the pos-
terior humeral circumflex or consist of several small branches.
The anterior humeral circumflex artery leaves the axillary
artery along the superior or lateral margin of the arterial
trunk and ascends upward or laterally deep to the coraco-
brachialis muscle and short head of the biceps brachii. It
curves anterior to the neck of the humerus. As it reaches the
intertubercular sulcus of the humerus, the anterior humeral
circumflex artery gives off a branch, the bicipital branch of
the anterior humeral circumflex, that ascends in the sulcus to
supply the tendon of the long head of the biceps, the head of
the humerus, and the shoulder joint. A pectoral branch of the
anterior humeral circumflex artery may descend along the
tendon of insertion of the pectoralis major. This branch con-
tributes to the vascular supply of the pectoralis major tendon.
The main branch of the artery continues laterally, in close
proximity to the humerus, deep to the long head of the
biceps brachii and the deltoid. It forms an anastomosis with
the posterior humeral circumflex artery (3,4).
Posterior Humeral Circumflex Artery
The posterior humeral circumflex artery, along with the ante-
rior humeral circumflex artery, are the most distal arterial
branches from the axillary artery (see Table 4.1 and Figs. 4.1
and 4.2). It originates from the third part of the axillary
artery near the inferior border of the subscapularis muscle,
and is much larger than the anterior humeral circumflex
artery. The posterior humeral circumflex artery courses deep
and posteriorly, to pass through the quadrangular space (bor-
dered by the teres minor and subscapularis superiorly, the
long head of the triceps brachii medially, the teres major infe-
riorly, and the surgical neck of the humerus laterally). The
artery curves around the surgical neck of the humerus and
forms anastomoses with the anterior humeral circumflex
artery, the deltoid branch of the profunda brachii artery, and
the acromial branches of the suprascapular and thoracoacro-
mial arteries. The posterior humeral circumflex artery pro-
vides branches to the deltoid, the teres major and minor, the
long and lateral heads of the triceps brachii, the greater
tuberosity of the humerus, and the shoulder joint. The pos-
terior humeral circumflex may have anastomoses with the
acromial rete (3,4).
Anomalies and Variations: Axillary Artery
The axillary artery has considerable variations in its branch
patterns (14–18). The branches described previously may
arise together, or their subsequent smaller branches may be
given off directly by the main axillary artery. Instead of 6
branches, the axillary artery may have a total of 5 to 11 (8).
The axillary artery has been noted to pass posterior to the
medial cord of the brachial plexus (19).
Bilateral double axillary arteries have been noted (20).

A thoracoepigastric artery is a rare variation of a branch
that arises from the axillary artery (14). The branch leaves
the axillary artery and passes as a common trunk between
the roots of the median nerve, and divides into two
branches. The lateral one gives rise to muscular branches
that supply the shoulder and fasciae, whereas the medial
one descends on the anterior aspect of the axillary fossa,
reaching the hypogastric region. The artery forms an anas-
tomosis with the superficial epigastric artery, which is a
branch of the femoral artery (14).
An alar thoracic artery is a branch, usually from the sec-
ond part of the axillary artery, that specifically supplies the
fat and lymph nodes in the axilla (3).
The vascular supply to the serratus anterior muscle usu-
ally originates from the thoracodorsal artery and vein.
Goldberg et al. noted that the artery to the serratus anterior
could originate directly from the subscapular artery (21).
The thoracodorsal pedicle arose directly from the axillary
artery and separately from the subscapular vascular pedicle
in 3% of cases. This has implications for dissection and
transfer of the serratus anterior (21).
The lateral thoracic artery arises most commonly from
the second part of the axillary artery and is conventionally
illustrated as such in anatomy textbooks. This, however, is
observed only in approximately 50% of individuals. Its ori-
gin is variable, and includes the subscapular artery in
approximately 30%, from the first part of the axillary artery
in approximately 11%, and from the thoracoacromial
artery in 7% (7). The lateral thoracic artery has been noted
to originate proximal to the origin of the superior thoracic
artery (instead of its usual more distal origin point) (15).
The subscapular artery usually arises from the third part
of the axillary artery. Variations include point of origin from
the second part of the axillary in approximately 15%, or
from a common trunk with the posterior humeral circum-
flex artery in approximately 15% (7).
The subscapular, anterior and posterior humeral circumflex
arteries, and the profunda brachii artery may arise from a
common branch. The branches of the brachial plexus can
surround this anomalous artery instead of the axillary artery
(3,4,7). The posterior humeral circumflex and the subscapu-
lar arteries may share a common trunk in approximately 15%
(7). The posterior humeral circumflex artery may originate
from the profunda brachii artery, passing inferior to the teres
major instead of through the quadrangular space (3,4).
The axillary artery may give rise directly to the radial and
ulnar arteries in the axilla, sometimes referred to as the high
division axillary anomaly (22–34). The high origin of the
radial artery is among the most common of all vascular vari-
ations in the upper extremity (23,24). Celik and colleagues
noted this anomaly in 7 of 81 (8.6%) of arteriograms, and it
represented 86% of all variations noted in their series (24).
The radial artery can be connected to the axillary artery (or
occasionally to the brachial artery) through a long, slender
anastomotic artery, referred to as the vasa aberrantia (25).
4 Vascular Systems 243
High division of the ulnar artery from the axillary is rare
compared with the anomaly in the radial artery (24,26).
This has been observed in only approximately 1% to 2% of
cases (22,24,29), originating from the second part of the
axillary artery. High division of the ulnar artery can occur
concomitantly with a high division of the radial artery (22).
The high division involving the ulnar artery has been
referred to as a superficial ulnar artery (27–34). The superfi-
cial ulnar artery has been noted to cross ventral to the medial
root of the median nerve before continuing toward the
medial part of the arm (27,33,34). The superficial ulnar
artery may cross superficial to the median nerve and brachial
artery. In general, the anomalous ulnar artery is smaller than
the radial artery or interosseous arteries. When the ulnar
artery originates directly from the axillary artery, it has been
noted that the common interosseous artery (which usually
originates from the ulnar artery) originates from the radial
artery (30). These anomalies of the radial and ulnar arteries
may be bilateral (23,27,31).
The axillary artery also may give rise directly to an anterior
interosseous artery. Similarly, the axillary artery may divide in
the axilla into two main branches. The branches continue into
the arm, where one usually runs more superficially and may
represent the radial or ulnar arteries; the deeper branch usually
corresponds to the brachial artery proper (8).
Clinical Correlations: Axillary Artery
The axillary artery is easily palpable in its third (distal) part,
as it crosses anterior to the teres major and is covered on the
lateral axillary surface only by skin and fascia. This is a use-
ful landmark for the administration of local anesthesia for
the placement of an axillary block regional anesthetic
(35–38). The more proximal portions of the artery can be
mapped out, when the arm is raised, by a line drawn from
the point of artery palpation (distal part) to the mid-clavi-
cle (area of the proximal part). Although it is used as a land-
mark to identify the brachial plexus, pseudoaneurysm or
obliteration of the axillary artery can occur from injury to
the artery from axillary block (39,40).
In anatomic and operative dissections of the axilla, the
coracoid process and pectoralis minor are key landmarks for
identification of the axillary artery and surrounding
brachial plexus. The second part of the axillary artery lies
deep to the pectoralis minor. From this second part of the
axillary artery, the specific designation of the cords of the
brachial plexus has been made [the lateral cord lies lateral to
the axillary artery (second part), the medial cord lies medi-
ally, and the posterior cord lies posteriorly] (1–4,11). Thus,
the pectoralis minor can help with identification of the sec-
ond part of the axillary, and this also corresponds to the
level of the brachial plexus that contains the cords.
The second part of the axillary artery lies inferior to the
coracoid process, deep to the pectoralis minor. Risk of
injury to the artery may be lessened if the arm is adducted
244 Systems Anatomy
while performing operative procedures involving the cora-
coid process (6,8).
An appreciation of the relatively high incidence (8.6%) of
the anomalous radial artery or, less commonly, the ulnar
artery originating high in the axilla directly from the axillary
artery, is important during the operative exposure of the axilla
or forearm or in the interpretation of arteriograms (23,24).
These variations also may be relevant in the dissection for
pedicle and free flaps that are based on the forearm arteries.
The axillary artery is vulnerable to injury from a variety
of well documented trauma events. These include proximal
humeral fractures or dislocations, which can cause throm-
bosis (from torn intima), pseudoaneurysm, or rupture
(41–52). Clavicle fractures are a less common cause of axil-
lary artery injury (48). Penetration of the artery by the
proximal locking screws of humeral intramedullary nails
has been reported (50). In addition, chronic, incorrect use
of crutches has been associated with axillary artery stenosis,
aneurysm formation, and secondary axillobrachial throm-
boembolic disease (51,52).
Of all upper extremity emboli, up to 20% arise from an
arterial, not a cardiac source (51). Axillary artery throm-
boses contribute to a substantial number of these cases.
Sports-related trauma, especially that involving profes-
sional baseball pitchers, is well known to cause injury to the
axillary artery (53–57). Arterial aneurysm, thrombosis, or
occlusion can lead to hand ischemia from insufficiency or
emboli (57,58).
Several muscles or related structures can compress the
axillary artery. Thrombosis of the axillary artery has
occurred from compression by the pectoralis minor or from
an anomalous muscle in the axillary fossa (58–60).
Quadrilateral Space Syndrome
Quadrilateral space syndrome consists of compression of
the posterior humeral circumflex artery and the axillary
nerve by fibrotic bands as the artery and the nerve traverse
the quadrilateral space (61). Symptoms often are secondary
to compression of the axillary artery, not the posterior
humeral circumflex artery. Because of the vague, often non-
specific clinical presentation of patients with quadrilateral
space syndrome, diagnosis is challenging and requires a
high index of suspicion. Subclavian arteriography confirms
the diagnosis. Conservative treatment has been successful;
operative management is reserved for selected, refractory
patients (61).
BRACHIAL ARTERY
Gross Anatomic Description: Brachial
Artery
The brachial artery, which is a continuation of the axillary
artery, begins at the distal margin of the teres major and
continues approximately 1 cm distal to the elbow, where it
ends to form the radial and ulnar arteries (7,11) (Fig. 4.3;
see Figs. 4.1 and 4.2). It passes down the medial aspect of
the arm and becomes more anteriorly located as it descends
so that it is along the anteromedial aspect of the elbow
joint. It is superficial and palpable along its course, covered
only by skin and superficial and deep fascia. The artery
passes deep to the bicipital aponeurosis. In the proximal
part of the arm, the median nerve lies anterior to the
brachial artery. The median nerve crosses the brachial artery
in the mid-portion of the arm so that the nerve lies medial
to the artery at the elbow. The ulnar nerve lies immediately
medial to the brachial artery in the proximal part of the
arm. The brachial artery then curves anteriorly away from
the ulnar nerve so that the two structures are separated from
each other at the elbow.
In the proximal arm, located posterior to the brachial
artery, is the radial nerve and the profunda brachii artery,
and the long head of the triceps. The brachial artery then
passes along the medial head of the triceps, along the inser-
tion of the coracobrachialis, and then continues along the
brachialis. In the proximal arm, lateral to the brachial
artery, is the median nerve and coracobrachialis. More dis-
tally, the biceps brachii lies lateral to the artery. On the
medial aspect of the artery, in the proximal arm, are the
medial antebrachial cutaneous nerve and ulnar nerves.
More distally, the median nerve is located medially after it
crosses the artery. The basilic vein also lies along the medial
aspect of the brachial artery, but is separated from the artery
in the distal part of the arm by fascia. The brachial artery
usually is accompanied by two venae comitantes, which lie
in close contact to the artery and are interconnected at
intervals by short transverse branches (1–6,11).
At the elbow, the brachial artery courses anteriorly to
cross the mid-portion of the cubital fossa. It is covered ante-
riorly by skin, superficial fascia, and the median cubital
vein. At the level of the radial neck, the brachial artery
divides into the radial and ulnar arteries. In the cubital
fossa, the brachialis lies posterior and lateral to the brachial
artery. The median nerve lies medial to the artery as it
divides into the radial and ulnar arteries (3).
TABLE 4.2. BRANCHES OF THE BRACHIAL ARTERY
Profunda brachii (deep brachial artery)
Deltoid (ascending) branch
Radial collateral artery
Middle collateral artery
Nutrient (accessory) branch to the humerus
Principal nutrient artery of the humerus
Superior ulnar collateral artery
Inferior ulnar collateral artery
Posterior branch
Anterior branch
Muscular branches

Main Branches: Brachial Artery
The brachial artery gives off the profunda brachii artery, the
superior and inferior ulnar collateral arteries, as well as a
principal nutrient artery of the humerus and several mus-
cular branches (3) (see Figs. 4.2 and 4.3 and Table 4.2).
Profunda Brachii Artery
The profunda brachii artery (deep brachial artery) is the
largest and most proximal branch of the brachial artery (see
Figs. 4.2 and 4.3). It arises from the posteromedial aspect of
4 Vascular Systems 245
FIGURE 4.3. The brachial artery and major branches,
including the collateral circulation of the elbow.
the brachial artery just distal to the distal border of the teres
major. The profunda brachii artery initially spirals back-
wards into the posterior compartment of the arm between
the long and lateral heads of the triceps brachii. Proximally,
the profunda brachii gives off the deltoid ascending branch.
The profunda brachii artery then continues distally along
with the radial nerve in the spiral groove of the humerus
between the lateral and medial heads of the triceps. The
nerve and artery continue posterior to the humerus. The
profunda brachii artery divides into the radial collateral and
the middle collateral arteries. The profunda brachii also
gives off a nutrient branch to the humerus (3).
246 Systems Anatomy
The Deltoid Ascending Branch
The deltoid ascending branch of the profunda brachii is a
small artery that leaves the profunda brachii artery proxi-
mally and ascends between the long and lateral heads of the
triceps brachii. It anastomoses with a descending branch of
the posterior humeral circumflex artery (arising from the
axillary artery). In 7%, the anastomosis to the posterior
humeral circumflex artery may be the major or sole source
of the profunda brachii. In addition, this anastomosis may
be the major or sole source of the posterior humeral cir-
cumflex from the profunda brachii in 16% (7). The deltoid
ascending branch helps supply the brachialis and deltoid
muscles (1,3,7) (Table 4.2).
The Radial Collateral Artery
The radial collateral artery of the profunda brachii is one
of the terminal distal divisions of the profunda brachii
artery. [The middle collateral artery of the profunda is the
other terminal division (see later).] The radial collateral
artery, frequently described as the terminal portion of the
profunda brachii, continues along with the radial nerve,
along the humerus and on the surface of the lateral head of
the triceps brachii. It continues distal to the elbow to enter
the forearm, still in association with the radial nerve. The
artery lies deep to the lateral head of the triceps to the level
of the lateral supracondylar ridge of the humerus. Here it
courses anteriorly to cross through the lateral intermuscu-
lar septum into the flexor compartment of the arm, and
continues distally between the brachioradialis and the
brachialis muscles to the palmar aspect of the lateral epi-
condyle. The radial collateral artery terminates as it anas-
tomoses with the radial recurrent artery. Other branches
may follow the posterior antebrachial cutaneous nerve and
continue with the nerve to reach the skin. Before the radial
collateral artery pierces the intermuscular septum, it may
give a branch that continues distally to the posterior aspect
of the lateral epicondyle and contributes to the anasto-
moses around the elbow. The radial collateral artery usually
contributes to the intraosseous circulation of the capitel-
lum and the lateral aspect of the trochlea as well (62)
(Table 4.2 and Fig. 4.3).
The Middle Collateral Artery
The middle collateral artery of the profunda brachii usually
is larger than the radial collateral artery. Along with the
radial collateral, the middle collateral artery is the terminal
division of the profunda brachii artery. The middle collat-
eral artery passes through the long and medial heads of the
triceps muscle and continues distally posterior to the
humeral diaphysis and lateral epicondyle. At the distal
humerus, the middle collateral artery forms an anastomosis
with the interosseous recurrent artery and contributes to the
anastomoses around the elbow (3,4). This anastomosis has
been referred to as the olecranon articula rete (7) (Table 4.2
and Fig. 4.3).
An Accessory Nutrient Artery
An accessory nutrient artery of the profunda brachii usually
is given off of the profunda brachii artery, which supports
the principal nutrient artery from the brachial artery. This
accessory nutrient artery usually enters the humerus
through a nutrient canal located posterior to the deltoid
tuberosity. This branch may be absent (3,4) (Table 4.2).
Principal Nutrient Artery of the Humerus
The humerus has one main or principal nutrient artery.
This artery arises directly from the brachial artery in the
mid-portion of the arm, often near the origin of the supe-
rior ulnar collateral artery or, less frequently, from the supe-
rior ulnar collateral artery itself (7). The nutrient artery
enters the humerus through a nutrient canal located near
the insertion of the coracobrachialis, near or distal to the
middle of the humerus but anterior to the proximal end of
the medial supracondylar ridge (3,4,7) (Table 4.2).
Superior Ulnar Collateral Artery
The superior ulnar collateral artery arises from the brachial
artery at a level just distal to the mid-portion of the arm (see
Table 4.2 and Figs. 4.2 and 4.3). It also may originate from
the proximal part of the profunda brachii in up to 22% (7).
It is a long, slender vessel that pierces the medial intermus-
cular septum to reach the posterior compartment of the
arm. The artery joins the ulnar nerve and both structures
continue distally along the medial head of the triceps
brachii. The artery and nerve course posteriorly behind the
medial epicondyle in the interval between the epicondyle
and the olecranon. The vessel continues deep to the flexor
carpi ulnaris. Traditional textbooks usually show or discuss
an anastomosis of the superior ulnar collateral artery with
the posterior ulnar recurrent artery (1–4); however, recent
studies demonstrated no identifiable direct anastomosis
between these arteries in 20 of 22 specimens (62). There
usually is a more proximal anastomosis with the inferior
ulnar collateral artery just proximal to the medial epi-
condyle (Fig. 4.2). The superior ulnar collateral artery also
may anastomose with the anterior ulnar recurrent artery
and may provide a branch to the medial epicondyle (1,2).
The superior ulnar collateral artery (along with the inferior
ulnar collateral and the posterior ulnar recurrent arteries)
provides a segmental extraneural and intraneural vascular
supply to the ulnar nerve (62–64).
Inferior Ulnar Collateral Artery
The inferior ulnar collateral artery originates from the
medial side of the brachial artery approximately 5 cm prox-
imal to the medial epicondyle (see Table 4.2 and Figs. 4.2
and 4.3). It continues medially on the surface of the
brachialis and divides into anterior and posterior branches.

The posterior branch crosses through the medial intermus-
cular septum to the posterior compartment of the arm. This
branch passes laterally on the dorsal aspect of the distal
humerus, deep to the triceps brachii to reach the lateral
aspect of the posterior humerus. This branch anastomoses
with the middle collateral branch of the profunda brachii at
the lateral margin of the humerus. By this junction with the
middle collateral branch, the inferior ulnar collateral artery
forms an arterial arch just proximal to the olecranon fossa.
At the medial margin of the humerus, the posterior branch
also may provide a branch that communicates with the supe-
rior ulnar collateral and the posterior ulnar recurrent arteries
(posterior to the medial epicondyle). The anterior branch of
the inferior ulnar collateral artery, which leaves the trunk at
the medial aspect of the humerus, continues distally and
passes anterior to the distal humerus and medial epicondyle
to communicate with the anterior ulnar recurrent artery.
The inferior ulnar collateral also contributes to the vascular
supply to the medial aspect of the trochlea through a cir-
cumferential vascular ring that originates from the inferior
ulnar collateral artery at the level of the elbow (62).
Recent studies have shown that the inferior ulnar collat-
eral artery (along with the superior ulnar collateral and the
posterior ulnar recurrent arteries) provides a segmental
extraneural and intraneural vascular supply to the ulnar
nerve (63). The inferior ulnar collateral artery provides the
only direct vascularization to the nerve in the region just
proximal to the cubital tunnel (62–64).
Muscular Branches
There are usually three or four muscular branches that orig-
inate from the brachial artery to supply the coracobrachialis,
biceps brachii, and the brachialis muscles (Table 4.2).
Anastomoses of the Brachial Artery
The branches of the brachial artery form an anastomotic
network posterior and anterior to the elbow, with intercon-
nections to branches from the radial and ulnar arteries (see
Fig. 4.3). These have been described individually previ-
ously. For descriptive purposes and to summarize, these
have been divided by Clemente into those that pass anterior
and those that pass posterior to the medial and lateral epi-
condyles of the humerus (3).
The branches that anastomose anterior to the medial epi-
condyle include the anterior branch of the inferior ulnar col-
lateral, the anterior ulnar recurrent, and (possibly) an ante-
rior branch of the superior ulnar collateral. The branches
that anastomose posterior to the medial epicondyle include
the inferior ulnar collateral, the posterior ulnar recurrent,
and the posterior branch of the superior ulnar collateral.
The branches that anastomose anterior to the lateral epi-
condyle include the radial recurrent and the radial collateral
branch of the profunda brachii artery.
4 Vascular Systems 247
The branches that anastomose posterior to the lateral
epicondyle include the middle collateral branch of the pro-
funda brachii, the interosseous recurrent artery, and the ter-
minal portion of the inferior ulnar collateral artery as it
reaches the lateral aspect of the humerus.
A transverse arch is formed on the posterior aspect of the
humerus proximal to the olecranon fossa. This arch is
formed by the anastomoses of the inferior ulnar collateral,
posterior ulnar recurrent, the middle collateral branch of
the profunda brachii, and the interosseous recurrent arter-
ies (1).
Yamaguchi and colleagues have divided the extraosseous
vascular patterns of the elbow into three vascular arcades:
medial, lateral, and posterior. The medial arcade is formed
by the superior and inferior ulnar collateral arteries and the
posterior ulnar recurrent artery. The lateral arcade is formed
by the radial and middle collateral, radial recurrent, and the
interosseous recurrent arteries. The posterior arcade is
formed by the medial and lateral arcades and the middle
collateral artery (62).
Anomalies and Variations: Brachial
Artery
High (proximal) divisions of the brachial artery: Several
anomalous branches or variations of branches of the
brachial artery have been described (22,33,65–85). Most
common are the more proximal divisions of the brachial
artery, occurring in 12% to 15% (7,83). These are often
referred to as high divisions. (See also earlier discussion of
high division of the axillary artery, which includes several
analogous branches from the axillary artery.) The superficial
brachial artery is an anomalous artery that originates from
a high division of the brachial artery (1,7,73–75,78), usu-
ally proximal in the arm, and has been observed to occur in
as low as 1% and as high as 17% of individuals (66–69,
72,83). It can continue into the forearm as the superficial
antebrachial artery or may rejoin the brachial artery distally
(66,69). In addition, a high division of the brachial artery
can form the radial, ulnar, and common interosseous arter-
ies more proximally, at the level of the arm. Considered to
be among the most frequent of the high divisions, the radial
artery can branch high in the arm, occurring in up to 7%
to 15% (7,22,65,70,76,78,79,81). When the radial artery
arises high from the brachial artery, the other limb of the
bifurcation consists of the ulnar and common interosseous
arteries. In some cases, the ulnar artery can arise more prox-
imally than normal, and the radial and common
interosseous form the other limb of the bifurcation (33,
80,81,86,87). The incidence of the high division of the
ulnar artery is much less than that of the radial artery,
occurring only in approximately 2% (7). Occasionally the
common interosseous arises at a more proximal level (1), or
may be absent in the presence of a high radial artery divi-
sion (77).
248 Systems Anatomy
A distal division of the radial and ulnar arteries has been
noted to occur 8 cm distal to the antecubital fossa (82).
This distal division has implications in preparing the radial
forearm flap.
Absent brachial artery and branches: Agenesis of the
brachial artery, profunda brachii artery, and superior and
inferior ulnar collateral arteries has been noted. The axillary
artery supplies collateral circulation to the forearm (88).
Vasa aberrantia: The vasa aberrantia is an anomalous
series of long slender vessels that anastomose with the
brachial or axillary artery and radial or ulnar arteries (or one
of their branches). Interconnections with the radial artery
are more common (1–4).
If there is a supracondylar process present with the com-
monly associated ligament of Struthers, the brachial artery
(with the median nerve) often passes deep to the ligament
(the ligament often is a proximal extension of the pronator
teres). The brachial artery, along with the median nerve,
takes a medial course along the border of the biceps toward
the medial supracondylar area. The structures then pass
deep to the pronator teres to reach the elbow region. [Note:
In the presence of the ligament of Struthers, the median
nerve may pass deep to the ligament, accompanied by the
inferior ulnar collateral artery (with the brachial artery
assuming its usual course) (1–4,7,89)].
The profunda brachii has considerable variation in its
origin. It exists as the classic artery as described earlier only
in approximately 55%, in which it arises as a single trunk
from the posteromedial aspect of the brachial artery. The
site of origin is at or slightly distal to the level of the teres
major (1,2,7). Variations include the vessel originating as a
common trunk with the superior ulnar collateral artery in
22%, from the axillary artery in 16%, or as a branch of the
posterior humeral circumflex artery in 7% (7).
Clinical Correlations: Brachial Artery
Collateral Circulation
As described previously, there is a well established series of
anastomoses around the elbow and shoulder. This provides
a substantial collateral circulation. If there is laceration or
mechanical block (e.g., from a ligature) of the brachial
artery in the proximal third of the arm (proximal to the ori-
gin of the profunda brachii), blood can possibly flow
through branches from the anterior and posterior humeral
circumflex and subscapular arteries to communicate with
the ascending branches of the profunda brachii artery. If the
main trunk of the brachial artery is blocked distal to the
level of the profunda brachii and the superior ulnar collat-
eral arterial origins, circulation may possibly be maintained
by branches through these vessels, which anastomose with
the inferior ulnar collateral, posterior ulnar recurrent, the
radial recurrent, and the interosseous recurrent arteries (3).
Brachial Artery, Supracondylar Process, and
the Ligament of Struthers
In the presence of a supracondylar process and associated
ligament of Struthers, the median nerve and brachial artery
often pass deep to the ligament. Although median nerve
compression under the ligament is discussed more com-
monly, potential arterial compromise also is possible (89).
The brachial artery usually takes a more medial course
along the medial aspect of the biceps if it passes deep to the
ligament of Struthers. It then passes deep to the pronator
teres at the level of the elbow.
ULNAR ARTERY
Gross Anatomic Description: Ulnar Artery
The ulnar artery is formed as one of the two main termi-
nating branches of the brachial artery (Fig. 4.4; see Fig.
4.3). The brachial artery bifurcates approximately 1 cm dis-
tal to the elbow joint into the ulnar and radial arteries. The
ulnar artery usually is the larger of the two, originating on
the ulnar side of the brachial artery at the level of the radial
neck and distal base of the coronoid process. From its point
of origin it courses distally and medially, and reaches the
ulnar margin of the forearm approximately midway
between the elbow and wrist joints. The ulnar nerve joins
the ulnar artery in the proximal quarter of the forearm, with
the nerve located ulnar to the artery. The nerve accompa-
nies the ulnar artery through the forearm to the wrist. From
the mid-forearm distally, the artery continues along the
ulnar margin of the distal half of the forearm. The artery
and nerve cross the wrist superficial to the flexor retinacu-
lum, with both structures on the radial side of the pisiform.
The artery supplies a portion of the flexor retinaculum as it
continues distally (90). The artery and nerve pass through
the ulnar tunnel (Guyon’s canal), and the distal part of the
ulnar artery forms the superficial palmar arch (1–4,7,11).
In the proximal half of the forearm, the ulnar artery is
located deep to the pronator teres, flexor carpi radialis, pal-
maris longus, and flexor digitorum superficialis muscles. It
lies superficial to the brachialis for a short distance, and
continues distally throughout the forearm superficial to the
flexor digitorum profundus muscles. Proximally, the
median nerve is located medial to the artery for a short dis-
tance. At approximately 2 to 3 cm distal to the origin point
of the ulnar artery, the median nerve crosses superficial to
the ulnar artery (separated from the artery by the ulnar half
of the pronator teres). The median nerve then continues on
the lateral side of the artery (1–4,11).
In the distal half of the forearm, the ulnar artery lies
superficial to the flexor digitorum profundus, between the
flexor digitorum superficialis (located radially) and the
flexor carpi ulnaris (located ulnarly). The ulnar nerve

remains ulnar to the artery throughout the distal forearm
and gives off the palmar cutaneous branch of the ulnar
nerve, which continues distally along the distal ulnar artery
to reach the palm. The ulnar artery has a superficial course
in the distal forearm, covered anterior by the deep and
4 Vascular Systems 249
FIGURE 4.4. The main arteries of the
palmar forearm and hand.
superficial fascia, and skin. The ulnar artery usually has two
adjacent venae comitantes (1–4,11). Proximal to the wrist,
the ulnar artery forms anastomoses with the anterior
interosseous artery, and both provide vascularity to the dis-
tal ulna and associated soft tissues (91,92).
250 Systems Anatomy

At the level of the wrist, the ulnar artery crosses superfi- Anterior Ulnar Recurrent Artery
cial to the flexor retinaculum, with the ulnar nerve contin-
The anterior ulnar recurrent is the most proximal branch of
uing on the dorsoulnar aspect of the artery. Both structures
the ulnar artery, arising from the medial aspect of the ulnar
pass radial to the pisiform.
artery just distal to the ulnar artery origin from the brachial
The ulnar artery and nerve enter the ulnar tunnel
artery (see Figs. 4.3 and 4.4). The artery passes anteriorly
(Guyon’s canal), covered anteriorly by fascia, skin, and the
and proximally between the brachialis and the pronator
palmaris brevis muscle (1–4).
teres. It continues anterior to the medial epicondyle to anas-
tomose with the interior ulnar collateral artery. The anterior
Main Branches: Ulnar Artery ulnar recurrent artery supplies the brachialis and pronator
teres muscles.
The main branches of the ulnar artery can be divided into
three groups: those in the forearm, wrist, and palm (Table
4.3). The forearm branches include the anterior ulnar recur- Posterior Ulnar Recurrent Artery
rent artery, the posterior ulnar recurrent artery, the common
interosseous artery (which divides in the anterior and poste- The posterior ulnar recurrent usually is the second main
rior interosseous arteries), and several muscular branches. branch of the ulnar artery (see Figs. 4.3 and 4.4). The pos-
The wrist branches include the palmar carpal and dorsal terior ulnar recurrent artery usually is larger than the ante-
carpal arteries. The branches in the hand include the deep rior ulnar recurrent artery and arises more distally from the
palmar arch and the superficial arch (which give rise to the medial aspect of the ulnar artery. The posterior ulnar recur-
common palmar digital arteries). rent artery passes posteriorly and proximally between the
flexor digitorum superficialis and flexor digitorum profun-
dus, and continues in a proximal direction posterior to the
TABLE 4.3. BRANCHES OF THE ULNAR ARTERY medial epicondyle. As the artery ascends, it passes through
the interval between the medial epicondyle and the olecra-
Branches in the forearm non, with the artery passing adjacent to the ulnar nerve in
Anterior ulnar recurrent artery
Posterior ulnar recurrent artery
this region. The artery continues either deep to or between
Common interosseous artery the heads of the flexor carpi ulnaris. The posterior ulnar
Anterior interosseous artery recurrent artery continues proximally to anastomose with
Median artery the superior and inferior ulnar collateral and the
Muscular branches to forearm interosseous recurrent arteries. The posterior ulnar recur-
Nutrient vessels to radius and ulna
Palmar carpal branch
rent artery supplies the flexor digitorum superficialis, flexor
Palmar radiocarpal arch digitorum profundus, flexor carpi ulnaris, and elbow joint,
Palmar intercarpal arch as well as extending to several of the other neighboring
Palmar carpal network muscles (1–4). The artery also contributes to the vascular
Dorsal carpal network supply to the olecranon (along with vessels from the
Dorsal carpal branch
Dorsal radiocarpal arch
interosseous recurrent artery) from vessels given off that
Dorsal intercarpal arch course along the medial and lateral aspect of the distal end
Basal metacarpal arch of the humerus (62). In addition, the posterior ulnar recur-
Posterior interosseous artery rent artery (with the superior and inferior ulnar collateral
Interosseous recurrent artery arteries) provides a segmental extraneural and intraneural
Dorsal carpal network
Muscular branches
vascular supply to the ulnar nerve (62–64).
Branches at the wrist
Palmar carpal artery
Transverse arches at the carpus Common Interosseous Artery
Palmar radiocarpal arch
Palmar intercarpal arch The common interosseous usually is the third main branch
Dorsal carpal artery from the ulnar artery (see Figs. 4.3 and 4.4). It is a short, thick
Branches in the hand vessel, only approximately 1 cm long (93–96). The common
Deep palmar artery interosseous artery arises from the posterolateral aspect of the
Superficial palmar arch
ulnar artery from a point approximately 1 cm distal to the
Common palmar digital arteries
Proper palmar digital arteries branch point of the posterior ulnar recurrent artery. Its branch
Dorsal branches (to the dorsal digital arteries) point corresponds to the level of the radial tuberosity. A rare
Vinculum longum superficialis high division of the common interosseous artery has been
Vinculum brevis superficialis noted, arising from the brachial artery in the proximal or dis-
Vinculum longum profundus
tal third of the arm (77,96) (see later, under Anomalies and
Vinculum brevis profundus
Variations: Ulnar Artery and Its Branches). The artery divides

into two main branches, the anterior and posterior
interosseous arteries. Both of these arteries have received
attention in anatomic studies because of their relevance in
pedicle or free tissue flaps or grafts of the forearm (97–127).
The Anterior Interosseous Artery (Proximal Part)
The anterior interosseous artery arises a few centimeters
distal to the level of the radial tuberosity (see Fig. 4.4).
The diameter of the artery at its origin varies from 0.9 to
1.5 mm (101). It passes through the deep flexor compart-
ment of the forearm along the anterior interior
interosseous ligament. The anterior interosseous artery is
accompanied by the anterior interosseous nerve. Along its
course in the forearm, the artery passes deep to or through
the flexor digitorum profundus and flexor pollicis longus,
and gives off a small, inconsistent vessel of variable size,
the median artery, as well as several muscular branches
(3,4,7,8) (Table 4.3). The anterior interosseous artery
appears to be the main periosteal and endosteal supply of
the ulna, with its branches supplying the distal one-fourth
of both the ulnar and radius (91,92,128,129). [Other
contributing arteries that supply the ulna include the
ulnar artery proper, the ulnar recurrent artery, and the
recurrent interosseous artery (128).] The anterior
interosseous artery also gives off five to seven cutaneous
branches that reach the overlying skin in the posterior
aspect of the distal two-thirds of the forearm (101).
At the proximal border of the pronator quadratus,
branches separate from the anterior interosseous artery to
supply a portion of the triangular fibrocartilage and the dis-
tal radioulnar joint (100,130). These branches arborize in a
fanlike fashion around the distal radioulnar joint. Small ves-
sels are given off that penetrate and supply the capsule and
the triangular fibrocartilage from the palmar, dorsal, and
medial sides (130,131). These terminal branches of the ante-
rior interosseous artery are joined by the posterior
interosseous artery (101). The terminal branches of the ante-
rior interosseous artery usually also are joined by a small
branch of the ulnar artery to give the direct peridiscal vessels
that supply the palmar, medial, and dorsal margins of the tri-
angular fibrocartilage. These small vessels arborize and anas-
tomose with each other and form a terminal capillary net-
work that ends at the peripheral segments of the triangular
fibrocartilage. The small arteries are arranged radially in a
series of terminal capillary loops. The outer 15% to 20% of
the triangular fibrocartilage is vascularized, leaving the central
segments of the fibrocartilage devoid of vessels (130,131).
The dorsal branch of the anterior interosseous artery gives off
a terminal branch that forms an anastomosis with the poste-
rior interosseous artery at the distal part of the forearm, and
both continue to contribute to the vascular supply of the dor-
sal capsule of the distal radioulnar joint (100,130).
At its distal end, the anterior interosseous artery divides
into palmar and dorsal branches that continue distally to
supply the palmar and dorsal aspects of the carpus, respec-
4 Vascular Systems 251
tively. The palmar branch continues deep to the pronator
quadratus and bifurcates 5 to 8 mm proximal to the radio-
carpal arch (discussed later, under Radial Artery). The pal-
mar branch of the anterior interosseous artery usually con-
tributes at least one branch to the palmar radiocarpal arch
to supply the ulnar aspects of the lunate and triquetrum
(132–136). The palmar branch then terminates by anasto-
mosing with the recurrent vessels from the deep arch
(132,133) (Table 4.3 and Fig. 4.6).
The dorsal branch of the anterior interosseous artery
continues distally on the interosseous membrane to reach
the carpus, where it contributes to the dorsal radiocarpal
arch in 89% of studied specimens (discussed later, under
Radial Artery) (132). Small branches extend radially to sup-
ply the lunate and anastomose with several branches from
the radial artery that supply the dorsal ridge of the scaphoid
(137–140). The dorsal branch of the anterior interosseous
artery bifurcates at the intercarpal level, with each branch
contributing to the intercarpal arch (in 83% of specimens)
(132,133). The dorsal branch of the anterior interosseous
artery terminates by forming an anastomosis with the recur-
rent vessels from the basal metacarpal arch at the third and
fourth interosseous spaces (in 70% of specimens) (132)
(Table 4.3 and Fig. 4.5).
The Median Artery
The median artery is a long, thin vessel that usually arises in
the proximal part of the anterior interosseous artery and
passes anteriorly to reach the median nerve (141–172)
(Table 4.3). It is variable in size and occurrence, with a diam-
eter ranging from 0.7 to 2.7 mm (167). The incidence of a
substantial median artery has been suggested to be approxi-
mately 8% to 10% (7); however, reported incidences have
varied from 2% to 23% (158,161,167). It often is visible as
a small vessel in continuity with or adjacent to the median
nerve in the forearm or extending into the carpal canal.
Although it usually arises from the anterior interosseous
artery, it also can arise from the common interosseous trunk
directly from the ulnar artery (2%) (141,142,150). The
median artery continues along with the median nerve and
supplies the nerve in their course through the forearm. In
2%, the median artery has been noted to penetrate or split
the median nerve (141). The median artery is of variable
size, sometimes barely visible along the nerve or, conversely,
greatly enlarged and continuing through the carpal tunnel
into the palm to anastomose with the superficial palmar arch
(149). When enlarged or thrombosed, the median artery can
contribute to the formation of carpal tunnel syndrome or
can penetrate the median nerve in the forearm and produce
pronator syndrome (151–172). The median artery occasion-
ally contributes to the carpal arches, especially if the superfi-
cial and deep arches are absent or poorly developed (7,145).
The incidence appears higher in neonatal cadavers compared
with those of adults. It has been proposed that the median
artery may undergo regression even after birth (142).
252 Systems Anatomy
The Anterior Interosseous Artery (Distal Part)
The anterior interosseous artery continues distally along the
anterior surface of the interosseous ligament to reach the
proximal edge of the pronator quadratus. At this point, the
anterior interosseous artery gives off a small vessel, the pal-
mar carpal branch of the anterior interosseous artery, that
continues deep to the pronator quadratus to help form the
palmar carpal network. The palmar carpal network is a col-
lection of anastomosing vessels on the anterior surface of
the wrist (on the deep surface of the carpal canal) that
receives interconnections from the palmar carpal branches
of the anterior interosseous artery, ulnar artery, and radial
artery, and a retrograde branch from the deep palmar arch.
The anterior interosseous artery, after giving off the palmar
carpal branch, passes through a small foramen in the ante-
rior interosseous ligament to reach the extensor compart-
ment of the forearm. The anterior interosseous artery con-
tinues for a short distance along the posterior aspect of the
anterior interosseous ligament to form an anastomosis with
the radial artery and the posterior interosseous artery, and
contributes to the formation of the dorsal carpal network
(Fig. 4.5). These anastomosing branches between the ante-
rior and posterior interosseous arteries and ulnar artery con-
tribute to the vascular supply of the distal ulnar and dorsal
capsule of the distal radioulnar joint (91,92,130). Anasto-
moses with the anterior and posterior interosseous arteries
and the radial artery help supply vascularity to the distal
radius. These anastomoses form vessels used for the harvest
of distal radius vascularized bone grafts (91,92) (see later
discussion of vascularized bone grafts, under Clinical Cor-
relations: Radial Artery).
The terminal part of the anterior interosseous artery
continues distally on the posterior aspect of the anterior
interosseous ligament along with the terminal portion of
the posterior interosseous nerve to reach the dorsum of the
wrist and contribute to the dorsal carpal network (Fig. 4.5).
The Posterior Interosseous Artery
The posterior interosseous artery arises as the other termi-
nal branch of the common interosseous artery (along with
the anterior interosseous artery), and is formed at the level
of the radial tuberosity (Fig. 4.5; see Fig. 4.4). The poste-
rior interosseous artery usually is smaller than the anterior
interosseous artery, and passes dorsally between the
oblique cord and the proximal border of the interosseous
ligament to reach the posterior compartment of the fore-
arm. The posterior interosseous artery passes between the
adjacent borders of the supinator and the abductor polli-
cis longus. It then passes distally in the posterior compart-
ment of the forearm between the superficial and deep lay-
ers of the extensor muscles, and provides branches to both
groups of muscles. The posterior interosseous artery con-
tinues along the dorsal surface of the abductor pollicis
longus and the extensor pollicis brevis, and is accompa-
nied by the posterior interosseous nerve. In the distal fore-
arm, the posterior interosseous artery forms an anastomo-
sis with the terminal branches of the anterior interosseous
artery, the radial and ulnar artery, and the dorsal carpal
network. These anastomosing branches between the ante-
rior and posterior interosseous arteries and ulnar artery
contribute to the vascular supply of the distal ulnar and
dorsal capsule of the distal radioulnar joint (91,92,130).
Anastomoses with the radial artery and anterior
interosseous artery help supply the vascularity of the dis-
tal radius. These anastomoses form vessels used for the
harvest of distal radius vascularized bone grafts (91,92)
(see later discussion of vascularized bone grafts, under
Clinical Correlations: Radial Artery).
The Interosseous Recurrent Artery
The interosseous recurrent artery is one of the few main
branches of the posterior interosseous artery (see Table 4.3
and Figs. 4.3 and 4.5). It arises proximally from the poste-
rior interosseous artery, near its origin from the common
interosseous artery. At times, the interosseous recurrent
artery may arise directly from the common interosseous
artery. The interosseous recurrent artery passes on or
through the supinator muscle, then posteriorly between the
radius and ulna, and continues proximally in a retrograde
fashion posterior to the radial head to reach the interval
between the lateral epicondyle and the olecranon. Its course
is deep to the anconeus muscle. In the distal posterior com-
partment of the arm, the interosseous recurrent artery
forms an anastomosis with the middle collateral branch of
the profunda brachii artery, and the posterior ulnar recur-
rent and the inferior ulnar collateral arteries (1) (Fig. 4.3).
Besides muscular branches to neighboring muscles, the
interosseous recurrent artery usually contributes to the
intraosseous circulation to the radial head, capitellum, and
the lateral aspect of the trochlea through posterior perforat-
ing vessels (62). The vessels that supply the radial head pen-
etrate the elbow capsular insertion at the neck of the radius.
(Note: The radial head has a dual blood supply through
both the interosseous recurrent artery and the radial recur-
rent artery.) The interosseous recurrent artery also con-
tributes to the vascularity of the olecranon (along with ves-
sels from the posterior ulnar recurrent artery) from vessels
that course along the lateral and medial aspect of the
humerus (62) (Fig. 4.3).
Muscular Branches of the Ulnar Artery in the
Forearm
The ulnar artery supplies many of the muscles of the flexor
forearm, giving off multiple muscular branches as the artery
descends distally. These branches supply most of the ulnar
muscles of the flexor forearm, including the pronator teres,
flexor carpi radialis, flexor digitorum superficialis, flexor dig-
itorum profundus, flexor carpi ulnaris, and brachialis (173).
 4 Vascular Systems 253

FIGURE 4.5. The main arteries of the

dorsal forearm and hand.
254 Systems Anatomy
Palmar Carpal Branch of the Ulnar Artery
The palmar carpal branch of the ulnar artery is a small
branch that arises from the radial aspect of the ulnar artery
at the level of the wrist or near the distal border of the
pronator quadratus, just proximal to the carpal tunnel. It
courses radially toward the midline, deep to the flexor digi-
torum profundus on the palmar aspect of the proximal
wrist. It forms an anastomosis with the corresponding pal-
mar carpal branch of the radial artery (see Fig 4.4) (1). This
branch may correspond to the palmar radiocarpal arch,
described by Gelberman and colleagues in their classic
descriptions of the extraosseous vascular patterns of the car-
pus (see later) (132) (Fig. 4.6).
Palmar Radiocarpal Arch
The palmar radiocarpal arch is one of three vascular trans-
verse arches that provide vascularity to the carpus (132)
(Fig. 4.6). The other two arches include the palmar inter-
carpal arch and the deep palmar arch. The palmar radio-
carpal arch spans the radiocarpal joint, arising on the ulnar
side from the radial aspect of the ulnar artery, and on the
radial side from the ulnar aspect of the radial artery. It usu-
ally receives a central contribution from the distal end of
the anterior interosseous artery. The palmar radiocarpal
arch is the most proximal of the transverse arches, and it
extends 5 to 8 mm proximal to the radiocarpal joint at the
level of the distal metaphysis of the radius and the ulna. The
artery lies in the wrist capsule. It usually has an anastomo-
sis with the palmar intercarpal arch through a longitudinal
interconnection branch. The palmar radiocarpal arch was
found to be consistently present by Gelberman and col-
leagues, formed by branches from the ulnar, radial, and
interosseous arteries in 87% of specimens, and by the ulnar
and radial arteries alone in 13% (132). The palmar radio-
carpal arch supplies the palmar surface of the lunate and tri-
quetrum.
Palmar Intercarpal Arch
The palmar intercarpal arch is one of three vascular trans-
verse arches that provide vascularity to the carpus (132)
(see Fig. 4.6). The other two include the palmar radio-
carpal arch (more proximally; see earlier) and the deep
palmar arch (located distally; see later, under Radial
Artery). The palmar intercarpal arch is located between
the proximal and distal carpal rows, and arises from the
radial aspect of the ulnar artery and from the ulnar aspect
of the superficial palmar branch of the radial artery. It usu-
ally receives a contribution from the distal end of the ante-
rior interosseous artery. It is variable in occurrence. Gel-
berman and associates found it to be present in 53% of
specimens, formed by branches of the ulnar, radial, and
anterior interosseous arteries in 75%, and formed by the
ulnar and radial arteries alone in 25%. The arch is small,
and is not considered a major contributor of nutrient ves-
sels to the carpus (132,133).
Dorsal Carpal Branch of the Ulnar Artery
The dorsal carpal branch of the ulnar artery arises proximal
to the pisiform, between 1.6 and 4.4 cm proximal to the
ulnar styloid, and curves medially and dorsally to wind
around the wrist, crossing deep to the flexor carpi ulnaris
tendon (174) (see Fig. 4.4). The artery passes to the ulnar,
then dorsal aspect of the wrist and continues toward the
midline of the dorsal wrist, deep to the extensor tendons. It
forms an anastomosis with the corresponding dorsal carpal
branch of the radial artery (and dorsal radiocarpal arch,
Figs. 4.5 and 4.6). The dorsal carpal branch of the ulnar
artery supplies an area of skin overlying the ulnar
metacarpals and the ulnar hypothenar region (174). Just
distal to its origin, the dorsal carpal branch also gives a small
branch that courses along the ulnar aspect of the fifth
metacarpal to supply the ulnar aspect of the dorsal surface
of the small finger (1–4).
Deep Palmar Branch of the Ulnar Artery
The deep palmar branch of the ulnar artery is a small branch
that arises from the ulnar aspect of the distal ulnar artery at
the level of the carpal canal. It courses ulnarly a short dis-
tance on the anterior surface of the flexor retinaculum and
anterior to the ulnar nerve to reach the hypothenar muscles.
The arterial branch then continues between the abductor
digiti minimi and flexor digiti minimi brevis and through
the origin of the opponens digiti minimi. The vessel curves
laterally into the palm, along with the deep branch of the
radial nerve. The deep palmar branch of the ulnar artery
then forms an anastomosis with the radial artery to complete
the deep palmar arch (1) (Fig. 4.1). In 14% of cases, the
deep palmar branch of the ulnar artery gives rise to the per-
forating branch of the fourth interspace (175).
Superficial Palmar Arch
The superficial palmar branch is formed mainly by the ter-
minal portion of the ulnar artery, and often is completed
with contributions from the superficial branch of the radial
artery or, less frequently, from a branch of the princeps pol-
licis or by the radialis indicis; rarely, it is completed with
contributions from the median artery (11) (see Figs. 4.4
and 4.6). Several variations exist in the formation of the
superficial palmar arterial arch (176–201). The ulnar artery
enters the palm through Guyon’s canal with the ulnar nerve,
usually on the lateral aspect of the pisiform and superficial
to the flexor retinaculum. Initially, the artery usually is
located radial and deep to the ulnar nerve, although several
variations exist (176–183,202–212). The structures pass
through the ulnar tunnel (Guyon’s canal), deep to the pal-
 4 Vascular Systems 255

FIGURE 4.6. The arteries of the palmar wrist. Note the transverse carpal arches: the palmar
radiocarpal arch, palmar intercarpal arch, and deep palmar arch.

maris brevis, and continue medial to the hook of the
hamate. The artery remains superficial to the base of the
flexor digiti minimi brevis and opponens digiti minimi.
The artery then curves laterally, convex distally to cross the
palm deep to the palmar fascia. This corresponds to the
level of the metacarpal diaphysis, roughly at the level
slightly proximal to the distal transverse palmar crease
(2,4,41). As the superficial palmar arch crosses the palm
transversely, it usually is located at a level distal to the deep
palmar arch; however, it passes at a level proximal to the
level of deep arch in 14% (175). Its mean lumen diameter
is 1.8 mm (range, 1 to 3 mm) (191) (Table 4.4). As the
superficial palmar arch continues across the palm in a radial
direction, it remains superficial to the tendons of the flexor
digitorum superficialis and flexor digitorum profundus, the
lumbrical muscles, and the branches of the median and
ulnar nerves. The superficial palmar arch, along with its
common palmar digital arteries, supplies the superficial
256 Systems Anatomy
flexor tendons, flexor retinaculum, median and ulnar
nerves, flexor pollicis longus tendon, lumbrical muscles,
palmar aponeurosis, and the skin of the palm of the hand
(204–206,208,209). A terminal branch of the superficial
palmar arch helps supply the thumb as well, although most
of the thumb’s supply comes from the princeps pollicis
artery with contributions from the first dorsal metacarpal
artery (usually originating from the radial artery; see later,
under Radial Artery) (189,203,204,207). Erbil and col-
leagues noted in five cases that the first web space of the
hand and the associated portion of the thumb received
arteries only from the superficial palmar arch. None of the
branches was large enough to be considered a “princeps pol-
licis artery” (207).
Vascular contributions to the superficial (and deep) arch
are variable, and have been the subject of several investiga-
tions (145,146,184–200) (see earlier discussion of the
median artery, under Common Interosseous Artery). Sev-
eral authors have indicated that the superficial palmar arch
usually communicates with (or is completed by) the super-
ficial palmar branch of the radial artery (6,8,11,12).
Williams notes that in approximately one-third, the super-
ficial arch is formed by the ulnar artery alone; in an addi-
tional third, it is formed by the ulnar artery with significant
contributions from the superficial palmar branch of the
radial artery, and in the final third, the superficial arch is
formed by the ulnar artery with contributions from a
branch of the princeps pollicis or the radialis indicis, or,
more rarely, from the median artery (4). Tountas and
Bergman describe the contributions to the superficial arch
as those formed by the ulnar artery and completed by the
radial artery in 30%, completed by the union with the deep
palmar arch through the princeps pollicis artery in 42%,
and completed by a median artery in 8% (7).
Wilgis and Kaplan have presented an extensive classifica-
tion of the arterial patterns of the superficial palmar arch
(185). Three general patterns (or variants) are noted, each
with several subtypes.
In the first variant, the ulnar artery is responsible for the
formation of the superficial palmar arch, and this occurs in
TABLE 4.4. VESSEL LUMEN DIAMETERS OF
ARTERIES OF THE WRIST AND HAND
Vessel Diameter (Range)
Radial artery 2.6 mm (2.3–5 mm)
Ulnar artery 2.5 mm (1.4–4.5 mm)
Superficial palmar arch 1.8 mm (1–3 mm)
Deep palmar arch 1.5 mm (1–2.3 mm)
Common palmar digital arteries 1.6 mm (1–2 mm)
(of superficial palmar arch)
Common metacarpal arteries 1.2 mm (1–2 mm)
(of deep palmar arch)
From Gellman H, Botte MJ, Shankwiler J, et al. Arterial patterns of
the deep and superficial palmar arches. Clin Orthop 383:41–46,
2001, with permission.
approximately 66%. Seven subtypes of the first variant are
noted:
Type I: The ulnar artery is responsible for the formation
of all the digital arteries.
Type II: The ulnar artery ends as the radial collateral of
the index finger; the two collaterals of the thumb are
formed by the first palmar metacarpal artery of the radial
artery.
Type III: In this, the most frequent variation, the ulnar
artery ends in the second intermetacarpal space; the two
palmar collaterals of the thumb and the collateral radial of
the index are furnished by the radial artery.
Type IV: The ulnar artery runs vertically from the pisi-
form bone to the third intermetacarpal space. It supplies the
five collateral arteries to the fingers; the other five collateral
arteries are furnished by the first and the second palmar
metacarpal branches of the radial artery.
Type V: The ulnar artery runs vertically and reaches the
fourth intermetacarpal space, furnishing only three collat-
eral arteries for the fingers; the other seven are supplied by
the metacarpal branches of the radial artery.
Type VI: The ulnar artery, reduced in size, supplies only
the ulnar collateral to the fifth finger.
Type VII: The ulnar artery gives only insignificant
branches to the digital arteries, and the main supply is from
the radial artery.
In the second variant of the superficial arch, the super-
ficial palmar radial artery participates in the formation of
the arch, and this occurs in approximately 30%. This sec-
ond variant has five subtypes:
Type I: In this type, which occurs very frequently, it is
noted that before the anastomosis with the ulnar artery, one
or two collaterals for the thumb are furnished by the radial
artery.
Type II: In addition to the collateral of the thumb, there
are one or two collaterals from the radial artery to supply
the index finger.
Type III: In this, the most frequent type, there are regu-
lar anastomoses between the superficial radial palmar artery
and the ulnar artery.
Type IV: The superficial palmar radial artery supplies the
thumb, the index finger, and the radial side of the long fin-
ger, terminating directly in the radial branch of the long fin-
ger. It supplies the five digital branches (two to the thumb,
two to the index finger, and one to the long finger). The
ulnar artery supplies the remaining five digital arteries (two
to the small, two to the ring, and one to the long finger). It
ends as the ulnar branch to the long finger.
Type V: The ulnar artery either supplies only the ulnar
two digits, or none at all. If the ulnar artery does not sup-
ply the small or ring finger, the superficial branch of the
radial artery supplies all the fingers, and the ulnar artery
supplies mostly the hypothenar muscles.

In the third variant of the superficial arch, the median
artery contributes to the formation of the arch, and this was
seen in only 4%. In this variant, types similar to those pre-
viously described can occur, in which arteries participate in
the formation of the arch. Very infrequently, an additional
subcutaneous transverse anastomosis with the subcutaneous
branch of the superficial branch of the ulnar artery is found.
If present, it is located superficial to the palmar arch, and
may be mistaken for the superficial palmar arch if its posi-
tion is not properly assessed (185).
Coleman and Anson, in their classic study evaluating
650 limbs, noted the superficial arch to be complete in 80%
and incomplete in 20% (184). In the complete arch group,
five patterns (or types) were described.
Type I indicated an arch formed by the superficial pal-
mar branch of the radial artery and the (larger) ulnar artery.
This was found in 34.5%.
Type II (37%) indicated an arch formed entirely by the
ulnar artery.
Type III (4%) indicated an arch formed by an enlarged
median artery.
Type IV (1.2%) indicated an arch formed by the radial
artery, median artery, and the ulnar artery.
Type V indicated an arch formed by the ulnar artery
joined by a large vessel from the deep palmar arch joining the
superficial arch at the base of the thenar eminence (184). The
incomplete arch was divided into four patterns or (types).
Koman et al. have noted that the superficial palmar arch
is completed by branches from the deep palmar arch (39%),
the radial artery (34.5%), or the median artery (5%) (212).
Overall, the ulnar arch had communications with these arte-
rial contributions, and the superficial arch was considered to
have adequate collateral flow in a total of 78.5% of patients.
In the remaining 21.5%, the arch was “incomplete,” and col-
lateral flow was thought to be inadequate (212).
Gellman and colleagues also classified the superficial arch
as complete or incomplete in a study of 45 cadavers (191).
Complete superficial palmar arches were seen in 84.4% of
specimens. The complete arch was subdivided into five sub-
types (types A through E), and the incomplete arches were
subdivided into two subtypes (types F and G). In the com-
plete arches, the type A pattern was the most common, seen
in 35.5% of specimens, and consisted of a superficial arch
formed by anastomosis between the continuation of the ulnar
artery and the superficial palmar branch of the radial artery.
This is the variant most commonly described in anatomic
textbooks (1–4). In type B, the superficial arch was formed by
a continuation of the ulnar artery with formation of common
digital vessels to the thumb and index web space. It was con-
sidered a complete arch because it reached all the digits; how-
ever, it was formed entirely by the ulnar artery. This pattern
was seen in 31.1% of the specimens. In type C, the arch was
complete but formed by the continuation of the ulnar artery
with a contribution from the median artery. This pattern was
4 Vascular Systems 257
seen in 13.3% of the specimens. The type D pattern consisted
of a complete arch formed from contributions from all three
arteries (ulnar, radial, and median). This pattern was seen in
only 2.2% of the specimens. The last complete arch pattern,
type E, consisted of an arch formed largely by the continua-
tion of the ulnar artery, with a communication with the deep
palmar arch (instead of the more common anastomosis with
the superficial palmar branch of the radial artery). This varia-
tion was seen in 2.2% of the specimens. Gellman et al. also
noted two patterns designated as incomplete arches (types F
and G), where the ulnar artery failed to reach the thumb and
first web space, and there was a lack of anastomosis of the
radial or median artery with the ulnar artery. In type F, the
ulnar artery comprised most of the arch but did not reach or
contribute to the arterial supply to the thumb and index fin-
gers. This was the most commonly encountered type of
incomplete arch, seen in 11.1% of specimens. In type G, the
other type of incomplete arch, the ulnar artery supplied the
ulnar digits and the superficial palmar branch of the radial
nerve supplied the radial digits and thumb, and there were no
anastomoses between the two arteries. This type was seen in
4.4% of the specimens (191).
In 80 cadaver hands, Ozkus and colleagues (145) demon-
strated a superficial palmar arch formed by anastomosis of
both the ulnar and radial arteries in 80%, and a superficial
arch formed by the ulnar artery alone in 17%. In two speci-
mens, the arches were supplied by a median artery (145).
In Lippert’s study, a complete arch with contributions from
both the radial and ulnar arteries was found in 42%. In 58%,
there was no connection between the two arteries (213).
Further variation in the arches was demonstrated by
Ruengsakulrach and colleagues (146). In a study of 50
cadaver limbs, a superficial palmar arch was found to be
continuous with the radial artery in 34%, although every
hand had at least one major branch connecting the radial
and ulnar arteries.
Ikeda and colleagues conducted an investigation using
stereoscopic arteriographs of 220 cadaver hands (189). The
authors grouped the superficial palmar arch into complete
(96.4%) and incomplete (3.6%) types (189). Using the
Doppler flowmeter, Al-Turk and Metcalf showed the super-
ficial arch to be complete in 84% and incomplete in 14%
of cases (192). Similarly, using ultrasound techniques,
Doscher and colleagues noted the arch to be incomplete in
11% of 200 normal hands (193).
The lumens of the superficial arch and associated
branches are listed in Table 4.4 (191).
Branches of the Superficial Palmar Arch:
Common Palmar Digital Arteries and Proper
Digital Artery to the Ulnar Small Finger
Three common palmar digital arteries and the proper digi-
tal artery to the ulnar aspect of the small finger are usually
258 Systems Anatomy
given off by the superficial palmar arch as it crosses the
palm from medial to lateral (1–4,11,191) (Fig. 4.6).
The first branch usually is the proper palmar digital
artery for the ulnar aspect of the small finger, which arises
as far proximal as the level of and deep to the palmaris bre-
vis. This palmar digital artery continues superficial to and
in line with the fibers of the hypothenar muscles. It courses
in a fairly straight line to reach the ulnar aspect of the base
of the small finger. Proximal to the level of the metacarpal
neck, the artery usually is superficial to the associated digi-
tal nerve. As the artery continues distally, it becomes deep
to the proper digital nerve (usually at approximately the
level of the metacarpal neck). The artery continues in this
relationship dorsal to the nerve through the digit. In the
digits, the artery passes deep to Grayson’s ligaments and
superficial to Cleland’s ligaments (214–217).
After giving off the proper palmar digital artery for the
ulnar aspect of the small finger, the superficial palmar arch
gives rise to three common palmar digital arteries (see Figs.
4.4 and 4.6). These vessels leave the arch on its converse
side, cross superficial to the lumbricals, and continue dis-
tally toward the fourth, third, and second web spaces. Each
vessel receives a contribution from the corresponding pal-
mar metacarpal artery from the deep palmar arch. Proximal
to the level of the metacarpal neck, the common palmar
digital artery usually is superficial to the associated com-
mon digital nerve. As the artery continues distally, it
becomes deep to the proper digital nerve (usually at
approximately the level of the metacarpal neck). This rela-
tionship is maintained, with the artery remaining dorsal to
the nerve through the digit. Although the vascular supply
to the radial aspect of the index finger usually is not
described as being supplied by the branches of the superfi-
cial palmar arch (1–4,7,8,11), Gellman et al. noted that the
superficial arch actually did supply the radial border of the
index finger and radial aspect of the thumb as a common
pattern, occurring in 83% of specimens (191). The com-
mon palmar digital arteries, along with direct branches
from the superficial palmar arch, supply the superficial
flexor tendons, flexor retinaculum, median and ulnar
nerves, flexor pollicis longus tendon, lumbrical muscles,
palmar aponeurosis, and the skin of the palm of the hand
(204). The lumen size of the common palmar digital arter-
ies varies from 1 to 2 mm, with an average of 1.6 mm (191)
(see Table 4.4).
Each common palmar digital artery then divides into
two proper palmar digital arteries (see Figs. 4.4 and 4.8). In
the fourth web space, the common digital artery divides to
provide proper palmar digital arteries to the radial side of
the small finger and the ulnar side of the ring finger. In the
third web space, the common palmar digital artery divides
to provide proper palmar digital arteries to the radial side of
the ring finger and the ulnar side of the long finger. In the
second web space, the common digital artery divides to pro-
vide proper palmar digital arteries to the radial side of the
long finger and the ulnar side of the index finger. [Note:
The proper digital artery to the radial side of the index fin-
ger is usually a continuation of the radial index artery (arte-
ria radialis indicis), a branch from the radial artery, and the
palmar digital arteries to the thumb are supplied by the
princeps pollicis artery (arteria princeps pollicis), also
derived from the radial artery (1–4,218–232)].
The proper palmar digital arteries continue to the distal
aspect of each respective digit. The artery remains dorsal to
the corresponding proper digital nerve in the digit. The
artery also passes deep to Grayson’s ligament and superficial
to Cleland’s ligament. The digital arteries send several small
vessels throughout the digit to supply the soft tissues and
osseous structures, including the digital nerves and flexor
tendons (218) (discussed later and in Chapter 2). Vascular-
ization of the digital nerves is supplied by numerous anas-
tomotic vessels connecting the digital arteries, epineurial
vessels, and the periarterial network (venae comitantes and
vasa vasorum) (218–232).
The proper palmar digital arteries give rise to the vin-
cular system, which provides the segmental vascular sup-
ply of the extrinsic tendons in the flexor sheath
(233–249). The vincular system consists of long and short
vincular connections. The vincula, which attach directly
to the dorsal surface of the flexor tendons in the sheath,
are vessels in a mesentery that is flexible to allow move-
ment of the tendons. The vincula comprise the vinculum
brevis superficialis, the vinculum brevis profundus, the
vinculum longum superficialis, and the vinculum longum
profundus.
The vinculum longum superficialis arises as small branches
from the proper palmar digital arteries at the level of the
base of the proximal phalanx. The branches course anterior
toward the midline, deep to the tendons. The branches then
interconnect anterior to the phalanx, still deep (dorsal) to
the tendons. From these branches the vinculum longum
superficialis arises at the floor of the digital sheath. The vin-
culum longum superficialis passes anteriorly, then splits to
allow passage of the flexor digitorum profundus. The vin-
culum then passes anteriorly to attach directly to the dorsal
surface of the flexor digitorum superficialis (233–249).
The vinculum brevis superficialis is a small, triangular
mesentery that arises near the insertion of the flexor digito-
rum superficialis. The vinculum brevis superficialis arises
from the proper palmar digital artery, at the level of the
neck of the proximal phalanx. It supplies the flexor digito-
rum superficialis tendon near its insertion into the middle
phalanx. A portion of the vinculum brevis superficialis con-
tinues anteriorly, at the level of the proximal interpha-
langeal joint, toward the flexor digitorum profundus to
form the vinculum longum profundus. The vinculum
longum profundus also may arise as a separate vessel. The
vinculum longum profundus attaches to and supplies the
flexor digitorum profundus in the region of the middle pha-
lanx (233–249).

The vinculum brevis profundus also is a small mesentery
that arises from interconnecting branches that arise from
the proper palmar digital arteries at the level of the middle
phalanx. The branches interconnect dorsal to the flexor dig-
itorum profundus, form a mesentery, and attach to the dor-
sal surface of the tendon near its insertion into the distal
phalanx (249).
Because the vincula enter the tendon on the dorsal sur-
face, the vascularity of the dorsal half of the tendon in the
digits is richer than the palmar half. The vincula often are
variable in presence and configuration (249). In addition to
the vascular supply, the tendons in the synovial sheath
receive nutrition through synovial fluid diffusion.
The proper palmar digital arteries continue along the
palmar aspects of the radial and ulnar borders of each digit.
The diameters of the digital arteries have been evaluated
with arteriograms, clinical measurements, and high-fre-
quency ultrasound (219–220). The index and long fingers
have been shown usually to have a larger digital artery on
the ulnar border, whereas the ring and small fingers usually
have a larger digital artery on the radial border (220). Each
proper digital artery also usually gives off two dorsal cuta-
neous branches that form anastomoses with the dorsal dig-
ital arteries (derived from the dorsal metacarpal arteries; see
later, under Radial Artery) (221). These branches con-
tribute to the vascular supply of the soft tissues on the dor-
sum of the middle and distal phalanges, including the prox-
imal and distal interphalangeal joints (222).
The proximal interphalangeal joint is supplied chiefly by
small vessels that leave the proper digital artery on the
artery’s dorsal surface, although additional vascularity is
supplied by smaller vessels that leave the proper digital
artery on its palmar surface, or from vessels derived from
the dorsal digital arteries. The vessels that leave that proper
digital artery on its dorsal surface arise 1.5 to 2.5 cm prox-
imal to the proximal interphalangeal joint and divide into
branches to the dorsal skin, branches to the proximal pha-
lanx, those continuing to the vincular system, and those
supplying the lateral surface of the joint and the palmar
plate. Other branches arise distal to the proximal interpha-
langeal joint and provide branches to the palmar aspect of
the distal interphalangeal joint and to the vincular system
(223).
The proper digital arteries arborize in the distal phalanx
region to supply the matrix of the fingernail, and form the
complex anastomosis of the subcutaneous pulp of the digi-
tal tip (224).
Anomalies and Variations: Ulnar Artery
and Its Branches
The ulnar artery may arise more proximally than the stan-
dard bifurcation of the brachial artery in the proximal fore-
arm (3,24,25,29–34,68,76,80,81,250–259). This may
occur in the arm from a high division of the brachial artery,
4 Vascular Systems 259
or in the axilla from a high division of the axillary artery
(see earlier, under Anomalies and Variations for both the
brachial and the axillary arteries). The incidence of high
division of the ulnar artery is much less than that of the
radial artery, occurring in only approximately 2% (7). With
a high division of the ulnar artery, the artery may take a
more superficial course, and has been referred to as a super-
ficial ulnar artery (27–34). The superficial ulnar artery has
been noted to cross ventral to the medial root of the median
nerve before continuing toward the medial part of the arm
(27,33,34). The superficial ulnar artery may cross superfi-
cial to the median nerve and brachial artery. The anomalous
ulnar artery usually is smaller than the radial artery or
interosseous arteries. When the ulnar artery originates
directly from the axillary artery, the common interosseous
artery (which usually originates from the ulnar artery) has
been noted to originate from the radial artery (30). These
anomalies of the radial and ulnar arteries may be bilateral
(23,27,31).
A distal division of the radial and ulnar arteries has been
noted to occur 8 cm distal to the antecubital fossa (82).
This distal division has implications in preparing the radial
forearm flap.
Variations of the superficial palmar arch: The superficial
palmar arch shows several patterns and variations. These are
so common and numerous that they are described previ-
ously in the discussion of the anatomy of the superficial pal-
mar arch.
Although the radial index artery (radialis indicis arteria)
usually arises from the deep palmar arch, it may originate
independently from the superficial palmar arch in approxi-
mately 13% and in combination with the deep arch in
42%. When it arises in combination with the deep arch, the
superficial component is usually the larger of the two. The
princeps pollicis artery also may arise from the superficial
arch (7).
The common interosseous artery can arise more proxi-
mal than its normal origin from the ulnar artery. A high
division has been noted where the common interosseous
artery originated from the brachial artery, either in the
proximal third of the arm (96) or at the level of the humeral
intercondylar line (95). When arising from the proximal
arm, the common interosseous artery continued distally
and followed the brachial artery. It supplied muscular
branches, then formed the ulnar recurrent arteries, and in
the distal part of the cubital fossa it divided into anterior
and posterior interosseous arteries. The brachial artery
passed medially to the median nerve, gave off superior and
inferior ulnar collateral arteries, and, proximal to the supe-
rior border of the pronator teres muscle, the artery divided
into the ulnar and radial arteries (96).
The common palmar digital arteries usually arise sepa-
rately from the superficial palmar arch (1–4,11,213). There
usually are three common palmar digital arteries, given off
to the fourth, third, and second web spaces. The first and
260 Systems Anatomy
second common palmar digital arteries may arise as a com-
mon trunk from the superficial palmar arch (210).
Clinical Correlations: Ulnar Artery and Its
Branches
Thrombosis of the Ulnar Artery
The ulnar artery is among the most common upper extremity
arteries involved with occlusion or thrombosis (260–284).
The more common site for thrombosis is in the hypothenar
eminence, either in or just distal to the ulnar tunnel, although
thrombosis has been noted in several sites from the mid-fore-
arm to the digits (266). Associated factors include blunt
trauma (260,275,278) and anomalous muscles (267,270,
283), but it may occur spontaneously (274). Cases associated
with carpal tunnel syndrome (277) as well as bilateral sym-
metric thrombosis have been reported (276). The venae comi-
tantes to the ulnar artery also may be involved with thrombo-
sis (285). A variation of thrombosis of the ulnar artery is the
hypothenar hammer syndrome (212,286–338). This syn-
drome involves a posttraumatic aneurysmal dilatation with
associated thrombosis, and subsequent vascular insufficiency
or emboli to the ulnar digits. It is associated with repetitive
blunt trauma to the hypothenar eminence. Symptoms,
including pain, cold intolerance, numbness, and weakness,
develop secondary to thrombosis or occlusion. The etiology
responsible is repetitive trauma with disruption of the internal
elastic lamina, producing dilatation with mural thrombi,
complete occlusion, or distal emboli (212). The arterial dilata-
tion may take on a corkscrew configuration, seen by angiog-
raphy or at operative exposure.
True and False Aneurysm of the Ulnar Artery
Along with thrombosis, the ulnar artery is afflicted relatively
frequently with aneurysm (339–373). A true or false
aneurysm may result. A true aneurysm usually is the result of
repetitive trauma that leads to intimal damage to the media,
disruption of the internal elastic lamina, exposure of
endothelial collagen, and aneurysmal dilatation or thrombo-
sis (212). The wall of the vessel thus dilates to produce the
pulsatile mass that contains a true endothelium and the nor-
mal layers of an arterial wall. A true aneurysm usually is fairly
uniform in shape. A false aneurysm usually occurs after pen-
etrating trauma, in which local hemorrhage and extravasation
cause the surrounding soft tissues to organize, undergo fibro-
sis, and recanalize. The lumen of a false aneurysm is in con-
tinuity with a true vessel, but it lacks a true endothelial layer
(in contrast to the true aneurysm, which contains an
endothelial layer). The false aneurysm may not be uniform in
shape. There appears to be a similar incidence of true and
false aneurysms involving the ulnar artery (339).
Allen Test
The Allen test is a clinical test used to evaluate the patency
of the radial and ulnar arteries in the forearm and wrist
(374–386). The test consists of compressing both the radial
and ulnar arteries at the distal forearm or wrist, and then
emptying the hand of blood by the patient’s active flexion
and extension of the digits. The pressure is then removed
from the radial artery, and the hand is allowed to fill
(demonstrating flow from the radial artery). The test is
repeated by releasing the pressure to the ulnar artery, and
again the hand is allowed to fill (now showing flow from the
ulnar artery). If one of the two arteries is occluded or if one
of the palmar aches is incomplete, the compromised circu-
lation becomes evident. Gelberman and Blasingame have
evaluated a timed Allen test in 800 hands (378). The
authors found that the average ulnar artery fill time was 2.3
± 1.0 seconds, and the average radial artery fill time was 2.4
± 1.2 seconds. Seven percent of ulnar arteries and 2% of
radial arteries did not fill completely within 6 seconds.
Ninety-one percent of the hands tested were considered
complete, with uniform brisk refill (378). The Allen test is
valuable in the routine evaluation of the vasculature of the
hand, but is particularly valuable in preoperative assessment
before procedures that involve the vasculature or those per-
formed in the vicinity of these structures. It also is helpful
in posttraumatic vascular evaluation. The Allen test is diffi-
cult to perform in the setting of acute fracture or trauma.
Arterial Dominance
Arterial dominance in the hand has been the subject of sev-
eral anatomic studies (387–393). Authors continue to dis-
agree as to which artery, the ulnar or radial, is the major or
“dominant” artery of the hand, although most studies sup-
port the radial artery. In a study evaluating dynamic values
of vessel diameter, blood velocity, and flow rate in vivo,
Trager and colleagues found variability between individuals
in artery dominance, noting 11 with the ulnar artery dom-
inant, 7 with the radial dominant, and 2 with equal values
(388). With radionucleotide flow studies and anatomic dis-
sections, Tonks and colleagues found no difference in the
anatomic dimensions of the vessels, but that the radial
artery appeared to be the dominant vessel compared with
the ulnar (389). Using arterial pressure measured simulta-
neously in the thumb and in the contralateral arm by strain-
gauge plethysmography in 100 healthy subjects, Husum
and Palm showed radial artery dominance in 110 hands
(55%), ulnar artery dominance in 24 (12%), and neither
artery dominant in 66 (33%) (390). Patsalis et al. found a
ratio of radial artery dominance to ulnar artery dominance
of 13:4 by studying 164 hands in vivo using digital pulse
electronic oscillography and the Allen test (391). Kleinert
and associates studied 200 hands using pulse-volume
plethysmography amplitudes during radial or ulnar artery

compression. In their study, only 5% were found to have
ulnar artery dominance (i.e., pulse-volume plethysmogra-
phy amplitude larger during radial artery compression) in
all digits, and 28% were found to have complete radial
artery dominance. Ulnar artery dominance in three or more
digits was seen in 22%, compared with 57% with radial
artery dominance. Overall, 87% of thumbs and 71% of
index, 60% of long, 52% of ring, and 52% of small fingers
were found to be radial artery dominant (393). From lumen
diameters alone, the radial artery is slightly larger at the
wrist (mean, 2.6 mm; range, 2.3 to 5 mm) compared with
the ulnar (mean, 2.5 mm; range, 1.4 to 4.5 mm) (191) (see
Table 4.4).
Ulnar Artery Repair
In an evaluation of repair of injuries to the ulnar or the
radial artery, or both, it was shown that the overall success
rate for all repairs was 54%. It appears that, besides opera-
tive technique, back pressure in the distal arterial stump and
the extent of original ischemia of the hand relative to its
normal blood supply (a function of the completeness of the
palmar arches) are important factors influencing vessel
patency after repair (132).
Forearm Flaps and the Ulnar Artery
For soft tissue coverage and hand reconstructive procedures,
several forearm flaps are available, usually vascularized from
a distally based inflow from either the radial or ulnar artery
(252–254,266,386–404). The forearm flap also may be ele-
vated as a free flap, based on a proximal radial artery inflow
(402,403). For harvest of distally or proximally based radial
artery forearm flaps, an intact ulnar artery and a superficial
palmar arch that provides a strong contribution to the vas-
cularity of all the digits are prerequisite. Conversely, for har-
vest of a distally based ulnar artery forearm flap, an intact
radial artery to provide circulation to the hand is prerequi-
site. Clinical examination with the Allen test, Doppler
examination, or an arteriogram helps confirm these data.
Because several variations and anomalies of the ulnar and
radial arteries exist (as noted earlier, under Anomalies and
Variations), these have potential implications in the harvest
of the forearm flaps.
Persistent Median Artery and Carpal Tunnel
Syndrome or Pronator Syndrome
A persistent and enlarged median artery that extends into
the carpal canal is a known cause of median nerve com-
pression, especially if associated with thrombosis,
aneurysm, or calcification (151–170). The incidence of a
persistent median artery is approximately 2.2% to 4.4%,
with an overall incidence of related carpal tunnel syndrome
4 Vascular Systems 261
of 1.1% to 1.8% (161). A median artery also has been asso-
ciated with pronator syndrome (171), and has been noted
to pass through the substance of the median nerve in the
forearm just proximal to the origin of the anterior
interosseous nerve (172). The persistent median artery in
the forearm can give rise to a vascular leash to the flexor
muscles that can compress the median nerve (171).
Other Anomalies and Variations
Similar to the ulnar artery in Guyon’s canal and in the
hypothenar region, the superficial palmar artery is vulnera-
ble to several lesions. Besides trauma (sometimes associated
with carpal tunnel release), reports have noted aneurysm,
occlusion, or thrombosis (405–412). Its anatomic position
and vulnerability has become of greater interest with the
advent of endoscopic carpal tunnel release (410).
Compared with the ulnar artery in the palm, aneurysm
of the common and proper digital arteries is rare. True and
false aneurysms have been reported, usually as isolated cases
(413–434).
For soft tissue coverage in a digit, several local flaps have
been described, many based on a distal digital artery
(reverse digital artery flap) (435–442).
Spinner and colleagues have described a patient with
neurovascular symptoms due to penetration of a proper dig-
ital nerve by a common digital artery. The authors consider
this an underrecognized but possibly relatively common
anatomic variation (443).
Relationships Between the Digital Arteries
and Digital Nerves
In the region of the metacarpal shaft, the common digital
arteries are positioned palmar to the associated common
digital nerves. At approximately the level of the metacarpal
necks, this relationship is reversed, so that the digital
artery in the digit is located dorsal to the associated digi-
tal nerve.
RADIAL ARTERY
Gross Anatomic Description: Radial
Artery
The brachial artery bifurcates into the radial and ulnar
arteries at approximately the level of the neck of the radius,
usually approximately 1 cm distal to the elbow joint (see
Figs. 4.3 and 4.4). The radial artery appears to be a contin-
uing extension of the brachial artery because of its slightly
lateral direction. The radial artery may be slightly smaller
in diameter than the ulnar artery. The radial artery contin-
ues along the radial aspect of the forearm to the wrist to
reach the dorsum of the wrist, deep to the tendons of the
262 Systems Anatomy
abductor pollicis longus and the extensor pollicis longus
and extensor pollicis brevis. The radial artery continues dis-
tally and dorsally to the space between the dorsal bases of
the thumb and index metacarpals. The artery then passes
between the two heads of the first dorsal interosseous mus-
cle into the palm of the hand, joining the deep palmar
branch of the ulnar artery to form the deep palmar arch.
The radial artery has been divided into three parts for
descriptive purposes. These include the radial artery in the
forearm, in the wrist, and in the hand (3) (Table 4.5).
The radial artery in the forearm extends from the neck
of the radius to the anterior aspect of the styloid process. It
passes along the medial aspect of the radius in the proximal
forearm, and passes anterior to the radius in the middle and
distal portions (1–4,444). It is deep to the brachioradialis
proximally, then exits the deep surface of the muscle along
the medial border of the muscle. The radial artery then
becomes superficial, covered anteriorly by skin and superfi-
cial and deep fascia. Along its course in the forearm, the
artery passes superficial to the biceps tendon, the supinator
muscle, the pronator teres muscle, the radial origin of the
flexor digitorum superficialis muscle, the flexor pollicis
longus, the pronator quadratus muscle, and the distal end
of the radius. In the proximal third of its course, the artery
lies between the brachioradialis and the pronator teres mus-
cles. In the distal third of its course, it lies between the bra-
chioradialis and flexor carpi radialis muscles or associated
tendons. The superficial branch of the radial nerve joins the
TABLE 4.5. BRANCHES OF THE RADIAL ARTERY
Branches in the forearm
Radial recurrent artery
Muscular branches
Superficial palmar branch
Palmar carpal branch
Palmar radiocarpal arch
Branches at the wrist
Palmar intercarpal arch
Dorsal carpal branch
Dorsal radiocarpal arch
Artery to the dorsal ridge of the scaphoid
Dorsal intercarpal arch
Basal metacarpal arch
Dorsal metacarpal branches
Branches in the hand
Dorsal metacarpal branches (from the basal metacarpal arch)
First dorsal metacarpal artery
Princeps pollicis
Radial index artery
First palmar metacarpal artery
Deep palmar arch
Palmar metacarpal arteries
Perforating branches
Radial recurrent artery of the deep palmar arch
Ulnar recurrent artery of the deep palmar arch
Accessory ulnar recurrent artery of the deep palmar arch
(variable)
radial artery in the proximal third of the forearm and
remains adjacent and lateral to the artery in the middle
third of the forearm. Small branches of the lateral ante-
brachial cutaneous nerve may run along the distal part of
the artery as it winds around the wrist. The radial artery is
accompanied by a pair of venae comitantes through its
course. In the distal forearm, the radial artery lies on the
distal anterior aspect of the radius and is positioned super-
ficially, covered only by skin and antebrachial fascia. The
flexor carpi radialis is located medial to the artery at the dis-
tal forearm (3).
In the proximal forearm, the radial artery gives off the
radial recurrent artery. Throughout its course, it gives off
several small muscular branches. In the distal forearm, a
small palmar carpal branch arises. The radial artery forms
anastomoses with the anterior and posterior interosseous
arteries (which in turn form anastomoses with the ulnar
artery) in the distal forearm, which contribute to the vas-
cularity of the distal radius (91,92,129). Branches of these
anastomoses are used for harvest of distal radius–vascular-
ized bone grafts (91,92) (see discussion of vascularized
bone grafts, under Clinical Correlations: Ulnar Artery and
Its Branches, earlier). Just proximal to the wrist, the radial
artery gives off a branch that contributes to the palmar
radiocarpal arch, which contributes to the vascularity of
the carpus (132) (Figs. 4.6 and 4.8). A relatively small
branch, the superficial palmar branch (of the radial
artery), also is given off just distal to the carpus. This
branch continues into the palmar aspect of the wrist and
usually helps form the radial aspect of the superficial pal-
mar arch. The superficial branch of the radial artery also
contributes to form the palmar intercarpal arch (along
with contributions from the anterior interosseous artery
and the ulnar artery). The palmar intercarpal arch con-
tributes to the vascularity of the carpus. These branches
are discussed separately later (3) (see Tables 4.5 and 4.6).
At the wrist, the radial artery curves dorsally and dis-
tally to wind around the lateral aspect of the wrist to reach
the dorsal surface. It passes between the capsule of the
wrist and deep the tendons of the abductor pollicis longus
and extensor pollicis brevis. This interval, referred to as
the anatomic snuff-box, lies just distal to the extensor reti-
naculum, between the extensor pollicis longus and exten-
sor pollicis brevis. The radial artery crosses the snuff-box
superficial to the scaphoid and trapezium and deep to
both the extensor tendons. It also remains deep to the dis-
tal branches of the superficial radial nerve as the nerve
branches continue distally to the thumb and index finger.
The radial artery exits the distal edge of the extensor pol-
licis longus and continues distally toward the first dorsal
web space (1,2,445). The artery then dives abruptly
through the interval between the two heads of the first
dorsal interosseous muscle (3).
In the hand, the radial artery passes between the heads of
the first dorsal interosseous to reach the deep palmar surface

of the hand. The artery crosses the deep palm transversely
between the oblique and transverse heads of the adductor
pollicis muscle. The continuing artery pierces the transverse
head and reaches the base of the small finger metacarpal,
where it forms a variable anastomosis with the deep palmar
branch of the ulnar artery, completing the deep palmar arch
(446–451) (Figs. 4.4, 4.6, and 4.8).
Main Branches: Radial Artery
The branches of the radial artery can be roughly divided
into three groups for descriptive purposes (3). These groups
are the radial artery branches in the forearm, wrist, and
hand, although many of the arteries span more than one
region (see Table 4.5).
Radial Recurrent Artery
The radial recurrent artery is the first major branch of the
radial artery. It arises just distal to the radiocapitellar joint or
in the region of the neck of the radius (see Fig. 4.3). It origi-
nates from the lateral aspect of the artery and ascends proxi-
mally between the branches of the radial nerve. It passes
superficial to the supinator and continues between the bra-
chioradialis and brachialis muscles. The artery supplies these
adjacent muscles and the elbow joint, including vessels to the
radial head, capitellum, and the lateral aspect of the trochlea
(supplied by posterior perforating vessels arising from the
radial recurrent artery) (62,444). The artery continues prox-
imally, anterior to the elbow joint, to form an anastomosis
with the radial collateral artery branch of the profunda
brachii artery. Other branches may follow the posterior ante-
brachial cutaneous nerve and continue with the nerve to
reach the skin. Before the radial collateral artery pierces the
intermuscular septum, it may give a branch that continues
distally to the posterior aspect of the lateral epicondyle and
contributes to the anastomoses around the elbow. The radial
collateral artery usually also assists the radial recurrent artery
in supplying the intraosseous circulation to the capitellum
and the lateral aspect of the trochlea (62).
Muscular Branches of the Radial Artery
The radial artery provides several small muscular branches
to the brachioradialis and pronator teres muscles, and to a
portion of the superficial and deep flexor pronator muscles
located on the radial aspect of the forearm.
Superficial Palmar Branch (Artery) of the
Radial Artery
The superficial palmar branch arises in the distal forearm
from the radial artery proximal to the wrist (see Figs. 4.4,
4.6 and 4.8). It leaves the radial artery 5 to 8 mm proximal
4 Vascular Systems 263
to the radial styloid, usually from the medial or anterior
aspect of the radial artery (132,133). Because of its direc-
tion, it occasionally may appear as a small continuation of
the radial artery (as the main trunk of the radial artery con-
tinues distally, curving dorsally and laterally). The superfi-
cial palmar branch passes between the flexor carpi radialis
and the brachioradialis, and curves anteriorly and slightly
medially to pass superficial to the radial aspect of the trans-
verse carpal ligament. It reaches the base of the thenar mus-
cles. It then crosses the radial aspect of the carpus and forms
communications with the palmar intercarpal arch, which in
turn supplies the tubercle of the scaphoid and the radiopal-
mar surface of the trapezium. The superficial palmar branch
usually passes through the thenar muscles, but occasionally
may continue superficial to these muscles. It supplies the
thenar muscles and then, to a variable degree, forms an
anastomosis with the terminal portion of the ulnar artery,
completing the superficial palmar arch (see Superficial Pal-
mar Arch, under Main Branches: Ulnar Artery, earlier). The
superficial palmar branch of the radial artery is variable in
size and configuration. When small, it may not complete
the anastomosis with the superficial palmar arch, and can
terminate at the level of the thenar muscles. Conversely, it
may remain large and appear as a palmar continuation of
the radial artery (3).
Palmar Carpal Branch of the Radial Artery and
Palmar Radiocarpal Arch
The palmar carpal branch of the radial artery arises in the
distal part of the forearm, usually near the distal border of
the pronator quadratus and approximately 5 mm distal to
the point where the superficial palmar branch is given off.
The palmar carpal branch is a small artery and passes across
the palmar aspect of the wrist toward the ulna. It forms an
anastomosis with the palmar carpal branch of the ulnar
artery. The palmar carpal branches of the radial and ulnar
arteries are joined by the anterior interosseous artery, to
form the palmar radiocarpal arch (see earlier under Ulnar
Artery; see Fig. 4.6). The palmar radiocarpal arch is the
most proximal of three transverse vascular arches that pro-
vide vascularity to the carpus (132,133,452–458). The
other two arches include the palmar intercarpal arch and
the deep palmar arch (Fig. 4.6 and see later). The palmar
radiocarpal arch crosses the anterior aspect of the proximal
wrist at the level of the distal metaphysis of the radius and
the ulna. It lies in the wrist capsule and usually has an anas-
tomosis with the palmar intercarpal arch through a longitu-
dinal interconnection. The palmar radiocarpal arch was
found to be consistently present by Gelberman and col-
leagues, formed by branches from the radial, ulnar, and
interosseous arteries in 87% of specimens, and by the radial
and ulnar arteries alone in 13% (132). The palmar radio-
carpal arch (along with the palmar intercarpal arch and the
ulnar recurrent branch of the deep arch) contributes to the
264 Systems Anatomy
palmar vascular supply of the lunate (452). It also supplies
the palmar surface of the triquetrum (132).
Palmar Intercarpal Arch of the Radial Artery
The palmar intercarpal arch is a small branch that usually
arises from the superficial palmar branch of the radial artery
(or anastomoses with it), usually at the level of the scapho-
trapezial joint (see Fig. 4.6). It spans the palmar carpus
between the proximal and distal carpal rows. It is the most
variably occurring of the palmar carpal arches, and is found
in 53% of specimens studied (132). It is formed by
branches of the radial, ulnar, and anterior interosseous
arteries in 75%, and by the radial and ulnar arteries alone
in 25%. The arch is small and is not thought to be a major
contributor of vascularity to the carpus, although it does
contribute to the vascular supply to the lunate, capitate, and
triquetrum (132,133).
Dorsal Carpal Branch of the Radial Artery and
the Dorsal Radiocarpal Arch
The dorsal carpal branch of the radial artery usually origi-
nates at the level of the radiocarpal joint and runs dorsally
and ulnarly, penetrating the radiocarpal ligament deep to
the extensor tendons. It commonly forms an anastomosis
with the ulnar artery on the dorsum of the wrist. It con-
tributes to a dorsal carpal network of several small vessels
or vascular arches (see later) that supply the dorsal carpus.
It crosses the carpus transversely and supplies or forms the
dorsal radiocarpal arch, which also receives contributions
from the ulnar artery and from the dorsal branch of the
anterior interosseous artery (see earlier, under Ulnar
Artery; Fig. 4.7). The dorsal radiocarpal arch, studied in
detail by Gelberman and associates, was found to be pre-
sent in 80% of specimens, and is the most proximal of the
three dorsal carpal arches (the other two arches, the dorsal
intercarpal arch and the basal metacarpal arch, are
described later) (132). The dorsal radiocarpal arch is
located at the level of the radiocarpal joint, and lies deep to
the extensor tendons. The dorsal radiocarpal arch provides
the main vascular supply to the lunate and the triquetrum
(132). Although the dorsal radiocarpal arch usually is
formed by anastomosing branches of the radial and ulnar
arteries and the dorsal branch of the anterior interosseous
artery, it occasionally is formed by the radial and ulnar
arteries alone or by the radial and anterior interosseous
arteries (132,133).
Artery to the Dorsal Ridge of the Scaphoid
The artery to the dorsal ridge of the scaphoid is a direct
branch of the radial artery in 75% of specimens or originates
as a branch from the radiocarpal or intercarpal arch in 25%
of specimens (132) (Fig. 4.7). It arises at or near the level of
the scaphoid waist or distal scaphoid, usually at a level
between the dorsal radiocarpal arch (discussed previously)
and the dorsal intercarpal arch (discussed later), and takes an
ulnar retrograde course to reach the dorsal surface of the
scaphoid. In 70% of specimens studied, the dorsal ridge ves-
sel arose directly from the radial artery. In 23%, the dorsal
ridge vessels had their origin from the common stem of the
intercarpal artery. In 7%, the dorsal ridge vessels originated
from both the intercarpal artery and the radial artery. There
are consistent, well developed anastomoses between the dor-
sal ridge vessels of the scaphoid (from the radial artery) and
the dorsal branch of the anterior interosseous artery. On the
dorsum of the scaphoid, an oblique ridge lies between the
articular surfaces of the radius and of the trapezium and
trapezoid. The major dorsal vessels to the scaphoid are
attached to the scaphoid by a soft tissue leash. The vessels
enter the bone through small foramina located on this dor-
sal ridge, usually at the level of the scaphoid waist (although
occasionally vessels enter slightly proximal or distal to the
waist) (132,133,138,139). The artery to the dorsal ridge of
the scaphoid supplies 70% to 80% of the scaphoid in the
proximal and central portions. The remaining 20% to 30%
in the distal portion is supplied by several palmar vessels
from the radial artery that enter the scaphoid through the
region of the tubercle. These are the palmar scaphoid
branches, discussed in the following section (138,139).
Palmar Scaphoid Branches
The palmar scaphoid branches are small arteries that arise
directly from the radial artery (or, less commonly, from the
superficial palmar branch of the radial artery). These vessels
supply the distal palmar aspect of the scaphoid in the tuber-
cle region. When the branches arise directly from the radial
artery, the origin is just distal to that of the superficial pal-
mar branch of the radial artery. The palmar scaphoid
branches consist of several small branches that course
obliquely and distally over the palmar aspect of the
scaphoid to enter the bone through the region of the tuber-
cle (138,139) (Fig. 4.6). The small arteries further branch
into several smaller branches just before penetrating the
scaphoid. In 75% of specimens studied, these arteries arose
directly from the radial artery (138). In the remaining 25%,
they arose from the superficial palmar branch of the radial
artery. Consistent anastomoses exist between the palmar
division of the anterior interosseous artery and the palmar
scaphoid branch of the radial artery, when the latter arises
from the superficial palmar branch of the radial artery.
There are no apparent communicating branches between
the ulnar artery and the palmar branches of the radial artery
that supply the scaphoid. The palmar scaphoid branches
enter the palmar aspect of the tubercle and divide into sev-
eral smaller branches to supply the distal 20% to 30% of
 4 Vascular Systems 265

FIGURE 4.7. The arteries of the dorsal wrist. Note the transverse carpal arches: the dorsal radio-
carpal arch, dorsal intercarpal arch, and basal metacarpal arch.

the scaphoid. There are no apparent anastomoses between
the palmar and dorsal vessels (132).
Dorsal Intercarpal Arch
The dorsal intercarpal arch is the largest of the dorsal trans-
verses, and is consistently present (see Fig. 4.7). It arises
from the radial artery approximately 5 mm distal to the
branch point of the artery to the dorsal ridge of the
scaphoid (132), usually at the level of the distal carpal row
or between the proximal and distal carpal rows. It runs
transversely across the dorsal carpus either between the
proximal and the distal carpal rows, or across the trapezoid
and capitate. The dorsal intercarpal arch supplies the distal
carpal row and forms an anastomosis with the radiocarpal
arch to supply the lunate and triquetrum. Branches also
contribute to the vascular supply of the trapezoid, capitate,
and hamate. Like the radiocarpal arch, the dorsal inter-
carpal arch usually is formed by various contributions from
the radial, ulnar, and anterior interosseous arteries. It
receives contributions from all three arteries (radial, ulnar,
and anterior interosseous) in 53% of cadavers studied
(132). Alternatively, it may be formed by the radial and
ulnar arteries alone in 20%, by the radial and anterior
interosseous arteries in 20%, and by the ulnar and anterior
interosseous arteries in 7% (see also under Ulnar Artery,
earlier) (132).
266 Systems Anatomy
Basal Metacarpal Arch
The basal metacarpal arch is the most distal of the dorsal
transverse arches and is located at the base of the
metacarpals, just distal to the carpometacarpal joints (see
Fig. 4.7). It is the smallest and most variable of the dorsal
transverse arches and actually is considered a series of vas-
cular retia. It is complete in 27% of specimens, and present
in its radial aspect alone in 46% (132). It is formed by inter-
connecting branches of the radial and ulnar arteries, from
perforating arteries from the second, third, and fourth
intraosseous spaces, as well as from anastomoses with the
dorsal intercarpal arch. It contributes to the vascularity of
the distal carpal row through anastomoses with the inter-
carpal arch (132,133).
Dorsal Metacarpal Branches
The dorsal metacarpal branches (with the exception of the
first dorsal metacarpal artery) arise from the dorsal carpal
network or from contributions from the basal metacarpal
arch (see Fig. 4.7). (Note: The first dorsal metacarpal arises
directly from the radial artery and is described later.) Three
thin dorsal metacarpal arteries usually are present but vari-
able, and run distally on the second, third, and fourth dor-
sal interosseous muscles (3,459–464). At the level of the
second, third, and fourth digital web spaces, the dorsal
metacarpal arteries bifurcate into dorsal digital branches,
supplying adjacent dorsal sides of the index, middle, ring,
and small fingers. Each dorsal metacarpal artery has four to
eight cutaneous branches (459). The dorsal digital branch
vessels form anastomoses with the proper palmar digital
branches of the superficial arch. The dorsal metacarpal
branches also form anastomoses with the deep palmar
branch through the (proximal) perforating branches,
located proximally at the bases of the metacarpal. Further
anastomoses are formed with the dorsal metacarpal
branches near their points of bifurcation, where communi-
cations are formed with the common palmar digital vessels
of the superficial palmar arch by the (distal) perforating
arteries (3,4) (Figs. 4.5 and 4.7).
First Dorsal Metacarpal Artery
The first dorsal metacarpal artery arises separately at the
base of the thumb and index metacarpal just before the
radial artery passes anteriorly between the two heads of the
first dorsal interosseous muscle. The artery then forms two
branches, one of which continues along the index
metacarpal to supply the dorsoradial aspect of the index fin-
ger. The other branch continues distally along the dorsora-
dial aspect of the thumb to approximately the level of the
thumb metacarpal head. It then further divides into two
branches, one directed radially and one ulnarly to supply
the dorsal aspect of the thumb. The radial aspect of the dor-
sal thumb may receive a separate branch that arises directly
from the radial artery (3,4,189,459,462) (Fig. 4.7).
Princeps Pollicis Artery
The princeps pollicis artery arises from the radial artery or
from the most radial part of the deep palmar arch (Fig. 4.8).
As the radial artery passes between the heads of the first dor-
sal interosseous to enter the deep palm, it then turns medi-
ally to form the deep palmar arch. The princeps pollicis
forms from the anterolateral aspect of the radial artery (or
deep arch), and then continues distally toward the thumb
along the ulnar aspect of the thumb metacarpal (465). It
passes between the first dorsal interosseous muscle and the
oblique head of the adductor pollicis, crossing deep to the
tendon of the flexor pollicis longus. The princeps pollicis
then divides into the two proper palmar digital arteries of
the thumb. These branches continue distally toward the
thumb, with the ulnar proper digital artery passing to the
ulnar side of the insertion of the adductor pollicis and the
radial proper digital artery passing to the radial aspect of the
muscle. The proper palmar digital arteries continue to reach
the pulp of the thumb, supplying branches to the soft tis-
sues and interphalangeal joint (202,203,466). Similar to
the digits, complex anastomoses occur between the two dig-
ital arteries at the level of the distal phalanx (3). The prin-
ceps pollicis is one of the principal arteries to supply the
thumb; however, variations are common (189,192,207,
210,467). The vascular supply to the thumb also may come
from the superficial branch of the radial artery (8%), the
first palmar metacarpal artery (18%), and the dorsal
metacarpal artery (8%) (467).
Radial Index Artery (Arteria Radialis Indicis)
The radial index artery usually is the second branch from
the radial artery as the radial artery enters the deep palm.
The radial index artery arises just ulnar and in close prox-
imity to the princeps pollicis artery, usually originating
between the first dorsal interosseous muscle and the trans-
verse head of the adductor pollicis muscle. The radial index
artery continues distally along the radial aspect of the index
finger to reach the level of the distal phalanx. The radial
index artery then forms a complex anastomosis with the
ulnar-sided proper palmar digital artery. Although the
radial index artery usually arises directly from the radial
artery (or deep arch), variations are common, and it also
may originate from a common trunk shared by the proxi-
mal portion of the princeps pollicis artery (3,4,192,202,
203,210). This trunk is then called the first palmar meta-
carpal artery (3,4,202,203,468).

Deep Palmar Arch
The deep palmar arch is the terminal part of the radial artery,
which crosses transversely across the deep palm (11) (see Figs.
4.4, 4.6 and 4.8). It is located at the level of the metacarpal
bases, 5 to 10 mm distal to the palmar carpometacarpal
joints. The deep palmar arch is located proximal to the super-
ficial palmar arch in 83%, but is distal to the superficial arch
in 15% (201). The lumen diameter of the deep palmar arch
varies between 1 and 2.3 mm, with an average of 1.5 mm
(191) (see Table 4.4). It is nearly consistently present and
usually forms an anastomosis with the deep palmar branch of
the ulnar artery, although variations in vascular patterns are
not uncommon. The most frequent variations are with the
complete or incomplete formation of the deep arch, with or
4 Vascular Systems 267
FIGURE 4.8. The arteries of the pal-
mar hand. S, superficial palmar arch;
D, deep palmar arch.
without anastomoses of the radial artery with the deep
branches of the ulnar artery (see later under Anomalies and
Variations: Radial Artery) (3,4,7,198,201,208,209,213,446,
448,450). The deep palmar arch is deeply situated in the
palm, superficial to the interosseous muscles, but deep to the
extrinsic flexor tendons, lumbricals, and the oblique head of
the adductor pollicis (8). In approximately two-thirds of
cases, the deep palmar arch lies deep to the ulnar nerve; in
one-third, the deep arch lies superficial to the nerve (to the
palmar side) (3). The deep palmar arch rarely may be dou-
bled, and encircle the ulnar nerve. The deep palmar arch
crosses the palm in a radial-to-ulnar direction. It gives off
three (or four) palmar metacarpal arteries, several perforating
branches, and two recurrent branches (Fig. 4.8).
268 Systems Anatomy
The three or four palmar metacarpal arteries arise from
the distal convex edge of the deep palmar arch. These ves-
sels course distally, usually toward the intermetacarpal
spaces of the index and long, the long and ring, and the ring
and small fingers. The palmar metacarpal arteries, like the
deep arch, are deeply situated, superficial to the inter-
osseous muscle but deep to the extrinsic flexor tendons and
associated lumbrical muscles. The palmar metacarpal arter-
ies reach the web spaces of the digits and form an anasto-
mosis with the common palmar digital arteries (which are
derived from the superficial palmar arch) (3).
The deep palmar arch gives rise to the perforating
branches. Three perforating branches pass directly from the
deep palmar arch in a dorsal direction, through the second,
third, and fourth interosseous muscle spaces. The perforat-
ing branches form an anastomosis with the dorsal meta-
carpal arteries.
The deep palmar arch also gives rise to the radial and
ulnar recurrent branches (arteries). These branches originate
from the proximal concave aspect of the deep arch, and con-
tinue in a proximal direction along the anterior aspect of the
wrist. These vessels supply the carpal bones (mainly distal
carpal row), intercarpal articulations, and end in the palmar
carpal network. The radial recurrent branch contributes to
the vascular supply of the trapezoid and trapezium (132).
The ulnar recurrent branch contributes to the vascular sup-
ply of the capitate, hamate, and lunate (132). Theses
branches also send perforating branches to the dorsal basal
metacarpal arch and the palmar metacarpal arteries (3,132).
In 27% of specimens studied, an accessory ulnar recurrent
artery was present. It originates from the deep arch 5 to 10
mm medial to the ulnar recurrent artery and supplies the
medial aspect of the hook of the hamate. When this vessel is
not present, the medial aspect of the hamate is supplied by
direct branches from the ulnar artery (132) (Fig. 4.8).
Anomalies and Variations: Radial Artery
The radial artery may arise more proximal than usual, either
proximal to the elbow, or from various locations directly
from the brachial or axillary artery (23,79,95,469–471).
This may occur in as much as 12% of specimens (3), can be
associated with a high origin of the common interosseous
artery in the same extremity (95), and has been noted to be
bilateral (79). In the forearm, variations of the radial artery
are less frequent than those of the ulnar artery.
Various anomalies in the configuration of the radial
artery in the forearm have been noted, including tortuous
configurations (5.2%), hypoplasia (1.7%), and a radioulnar
loop (0.9%) (472).
In the region of the anatomic snuff-box, the radial artery
has been noted to pass superficial to the extensor tendons of
the thumb (instead of deep to these structures) (3,473–475).
The anomaly has occurred bilaterally (474). The superficial
radial artery at the wrist has been referred to as the arteria
antebrachialis superficialis dorsalis (476) or the arteria radialis
superficialis (473).
Absence of the Radial Artery
In its absence, a normal ulnar artery or an enlarged anterior
interosseous or median artery can replace the radial artery.
The anterior interosseous and median artery can contribute
directly to the formation of the palmar arches (3,477–480).
Absence of the radial artery also is observed in radial preax-
ial hemimelia, and in specific genetic and chromosomal dis-
orders (Fanconi’s anemia, Holt-Oram syndrome) (480).
Anomalous Course of the Superficial Branch
Anomalous course of the superficial branch of the radial
artery: An abnormal course of the superficial branch of the
radial artery passing through the carpal tunnel was noted in
2 of 70 (2.85%) cadaver extremities studied (481). This
anomaly can potentially cause or contribute to carpal tun-
nel syndrome (481).
Accessory Radial Artery
In the arm and forearm, an accessory radial artery has been
noted that had a high division, passed lateral to the brachial
artery and lateral to the radial artery, and ultimately formed
an anastomosis with the princeps pollicis artery in the hand
(482).
The radial artery has been noted to pass along the fore-
arm superficial to the deep fascia, as opposed to the normal
position deep to the antebrachial fascia (3).
The radial artery has been noted to pass superficial to the
brachioradialis instead of deep to its medial border (3).
Variations of the Deep Palmar Arch
Although consistent data indicate that the deep palmar arch
is less variable than the superficial arch, several variations
have been described. The incidence of a complete arch
(with contributions from both the radial artery and the
deep branch or branches of the ulnar artery) varies from
79% to 100% (175,213,448–450). Wilgis and Kaplan note
the most frequent pattern is the deep palmar arch existing
as an anastomosis between the radial artery and the deep
branch of the ulnar artery (185). The anterior interosseous
artery may participate in the formation of the deep palmar
arch with the radial artery alone or with the ulnar artery
alone (185). Mezzogiorno and associates noted the deep
arch formed from contributions from both the radial and
ulnar arteries in 89%, with formation by the radial artery
alone in 8% and by the ulnar artery alone in 3% (448).
Gellman and associates found less variability in the deep
palmar arch than in the superficial palmar arch; however, in
their study, the deep arch was complete and anastomosed

with the ulnar artery in all specimens (191). Three general
patterns were noted in the communication of the radial
artery with the ulnar artery, with the radial artery commu-
nicating with the inferior deep branch of the ulnar artery in
44%, with the superior deep branch of the ulnar artery in
33%, or with both deep branches of the ulnar artery in
20% (191).
Olave and Prates noted in a study of 60 cadaver hands
that although the radial artery usually passed through the
first interosseous space to form the deep arch (85% of spec-
imens), an anomalous route of the radial artery passing
through the second interosseous space was noted in as
much as 13% of specimens (449).
Absence of the Princeps Pollicis
In the absence of the princeps pollicis (noted in 2.4% of
220 cadavers), the vascular supply for the thumb was pro-
vided by the terminal branches of the superficial palmar
arch or the first dorsal metacarpal artery, both of which
originate from the radial artery (189).
Clinical Correlations: Radial Artery
Soft Tissue Forearm Flaps and the Radial
Artery
For soft tissue coverage and hand reconstructive procedures,
several forearm flaps are available, usually vascularized from
a distally based inflow from either the radial or ulnar arter-
ies, or associated branch arteries (483–502). The forearm
flap also may be elevated as a free flap, based on a proximal
radial artery inflow (117,402,403). For harvest of a distally
or proximally based radial artery forearm flap, an intact
ulnar artery and superficial palmar arch that provides a
strong contribution to the vascularity of all the digits are
prerequisite. Conversely, for harvest of a distally based ulnar
artery forearm flap, an intact radial artery to provide circu-
lation to the hand is prerequisite. Recent investigations have
led to the development of forearm flaps that do not sacrifice
a major forearm artery (483,487). Clinical examination
with the Allen test, Doppler examination, or an arteriogram
helps confirm these data. Several variations and anomalies
of the ulnar and radial arteries exist (as noted in the previ-
ous section) and have potential implications for the harvest
of forearm flaps.
Vascularized Bone Grafts and the Radial
Artery
The use of pedicled vascularized bone grafts for reconstruc-
tion of carpal nonunions or dysvascular conditions has
become more popular and feasible, especially in the last two
decades (503–524). These usually are based on the ulnar,
radial, or anterior or posterior interosseous arteries, or their
4 Vascular Systems 269
branches. Roy-Camille described the transfer of the
scaphoid tubercle with attached abductor pollicis brevis
muscle to assist healing of a scaphoid fracture (91,92,522).
Beck transferred a decorticated pisiform on a vascular pedi-
cle in the revascularization of the lunate in a patient with
Kienböck’s disease (91,92,523,524). Braun used a distal
radius bone graft based on the pronator quadratus muscle
and anterior interosseous artery pedicle to successfully treat
five established scaphoid nonunions (504). Detailed and
concise descriptions of several reverse-flow, pedicled, vascu-
larized bone grafts from the dorsal distal radius have now
been applied to difficult scaphoid fractures, nonunions, or
avascular necrosis of carpal bones. These and related tech-
niques have shown significant potential. Shin and Bishop
have summarized the harvest of several of these distal radius
vascularized bone grafts based on anastomosing vessels
between the radial artery, the anterior and posterior
interosseous arteries, and carpal arch vessels. The radial
artery and posterior division of the interosseous artery usu-
ally are the primary sources. When harvested with retro-
grade anastomosing vessels, a vascularized graft of greater
reach is provided (91,92). These have been used for
scaphoid nonunion and Kienböck’s disease.
Radial Artery and Aneurysm, Thrombosis, and
Emboli
Although not as common as in the ulnar artery, aneurysm
(true and false), thrombosis, and embolization of the radial
artery are well reported (523–534). These have been noted
at the level of the forearm or wrist (525,528,530) or at the
anatomic snuff-box (534). The most common cause of true
aneurysm is blunt trauma (526). Other reported causes of
true and false aneurysm have been idiopathic, iatrogenic
(528,529), and penetrating trauma (530). In the region of
the anatomic snuff-box, the radial artery passes deep to the
extensor pollicis longus tendon. Compression of the artery
against the proximal epiphysis of the first metacarpal was
thought to be the etiology of emboli that resulted in
ischemic changes of the thumb and index finger (534).
Approximately 25% of those with true aneurysms of the
extremity have shown secondary problems with throm-
boembolism (526).
Metacarpal Arteries and Soft Tissue or Bone
Tissue Transfers
Anatomic studies have evaluated the dorsal metacarpal
arteries and anastomosing branches with regard to soft tis-
sue and bone transfer procedures. The first or second dorsal
metacarpal artery can be used for an axial or retrograde
nutrient supply to vascularize a pedicled soft tissue flap for
hand reconstruction (221,222,440, 460,463,464). The sec-
ond metacarpal has been described as a vascularized graft
for thumb reconstruction (461,513).
270 Systems Anatomy

VENOUS ANATOMY TABLE 4.6. VEINS OF THE UPPER EXTREMITY

Superficial veins
The veins of the upper extremity are divided into two Venous network of the dorsal hand
groups, superficial and deep (535–547). The superficial Dorsal digital veins
veins are subcutaneous in the superficial fascia. Both Intercapitular veins
Dorsal metacarpal veins
groups exhibit substantial variability, and disagreement Superficial venous palmar arch
exists in the described patterns and names of veins. Many Palmar digital veins
of the superficial veins remain unnamed. The deep veins Intercapitular veins
accompany the arteries, including the palmar arches and Transverse anastomoses
the dorsal arterial arch, and pass deep to the deep fascia Cephalic vein
Accessory cephalic vein
to continue between the muscles. The deep veins include Basilic vein
the venae comitantes. The deep veins often are doubled, Median antebrachial vein
and the larger veins often are named after their corre- Median cubital vein
sponding artery, but usually are slightly smaller in caliber Deep veins
than the artery. The deep veins not only run parallel with Deep veins of the hand
Common palmar digital veins
the arteries, but often cross the arteries at various angles Palmar metacarpal veins
(185). Both the superficial and deep veins have extensive Dorsal metacarpal veins
interconnections, and often form several parallel channels Superficial palmar venous arch
of drainage from any single region. Both groups have Deep palmar venous arch
valves, but valves are more numerous in the deep veins Deep veins of the forearm
Venae comitantes of the radial artery
(4,185). Venae comitantes of the ulnar artery
For descriptive purposes, the superficial veins are Venae comitantes of the posterior interosseous artery
described first, followed by the deep veins. The veins are Venae comitantes of the anterior interosseous artery
discussed from distal to proximal, in the direction of Brachial veins
blood flow. Because variations of the venous system are so Axillary veins
Brachial vein
common, only the few well established variations are dis- Basilic vein
cussed. Posterior humeral circumflex vein
Circumflex scapular vein
Long thoracic vein
SUPERFICIAL VEINS Subscapular vein
Thoracodorsal vein
Gross Anatomic Description: Superficial Thoracoepigastric vein
Veins Lateral thoracic vein
Superior thoracic vein
The superficial veins include the venous network on the Cephalic vein
dorsum of the hand, the superficial venous palmar arch, the
cephalic and accessory cephalic vein, the basilic vein, the
median antebrachial and cubital vein, and their associated
branches (Table 4.6).

veins, which end in the venous network on the dorsum of

Venous Network of the Dorsal Hand
The venous network of the dorsal hand forms initially from
venules of the distal digits and dorsal digital venous arches
that coalesce to form the dorsal digital veins (535,537,541)
(Fig. 4.9). The dorsal digital veins pass along the sides of the
digits and are joined to one another by additional oblique
communicating branches. There are frequent communica-
tions between the superficial and deep venous arches, and
between the palmar and lateral vessels (541). The digital
veins from the adjacent sides of the digits coalesce and also
receive interconnections from the palmar digital veins
through the intercapitular veins located in the digital web
space (see Fig. 4.10) (537). The dorsal digital veins and
intercapitular veins coalesce to form three dorsal metacarpal
the hand (3,4,537). The radial part of the network is joined
by the dorsal digital vein from the radial side of the index
finger and by the dorsal digital veins of the thumb. These
eventually coalesce to form the distal aspect of the cephalic
vein (which arises on the radial aspect of the hand. The
ulnar part of the network receives the dorsal digital vein of
the ulnar side of the small finger and hand to contribute to
the formation of the basilic vein. An additional venous
interconnection often forms with either the cephalic or
basilic vein in the forearm (3,537).
These digital veins have valves that prevent the flow of
blood from the dorsum to the palmar aspect, from proximal
to distal, and from the ulnar to radial digits in the proximal
venous arches (537).

Superficial Venous Palmar Arch
The superficial venous palmar arch is a more delicate net-
work than the venous network of the dorsal hand. It is ini-
tially formed by the palmar digital veins that drain into
venous networks located over the palmar digits and thenar
and hypothenar eminences (Fig. 4.10). The palmar digital
veins interconnect with the dorsal digital veins and dorsal
metacarpal veins through the intercapitular veins located
in the digital web spaces (see Fig. 4.9). There are trans-
verse anastomoses between the intercapitular veins at the
base of the digits on the palmar side. The palmar digital
vessels with their interconnections in turn drain proxi-
mally over the palmar surface of the wrist and contribute
to the median antebrachial vein (centrally in the palmar
forearm) and the cephalic vein (on the radial aspect) and
the basilic vein (on the ulnar aspect) (3,4) (see Figs. 4.10
and 4.11).
4 Vascular Systems 271
FIGURE 4.9. The veins of the dorsal hand
and digits.
Cephalic Vein
The cephalic vein is formed on the radial aspect of the wrist,
often in the region of the anatomic snuff-box. It arises from
the lateral contributions of the dorsal venous networks and
the superficial venous palmar arch (Figs. 4.9 through 4.11). It
courses proximally and winds along the radial aspect of the
forearm, receiving contributions from both the palmar and
dorsal surfaces of the hand and forearm (548–550). In the
palmar forearm, the cephalic veins communicate with the
median antebrachial vein (median cubital vein) and subse-
quently with the basilic vein. The main trunk of the cephalic
vein continues proximally along the radial side of the antecu-
bital fossa in the groove between the brachioradialis and the
biceps brachii muscles (Fig. 4.12) . Here it crosses superficial
to the lateral antebrachial cutaneous branch of the musculo-
cutaneous nerve. The cephalic vein enters the arm and con-
tinues proximally in the groove along the lateral border of the
272 Systems Anatomy
biceps brachii. In the proximal third of the arm, the cephalic
vein passes between the pectoralis major and deltoid muscles,
where it lies adjacent to the thoracoacromial artery (Fig.
4.13). From the interval between the pectoralis major and del-
toid muscles and the clavicle (the deltopectoral triangle), the
cephalic vein passes deep to the clavicular head of the pec-
toralis major muscle to pierce the clavipectoral fascia. It
crosses anterior to the axillary artery, coursing in a medial
direction to reach the axillary vein. It connects with the axil-
lary vein just inferior to the clavicle. The cephalic vein usually
has a valve near its junction with the axillary vein. The
cephalic vein may communicate with the external jugular vein
by a connection that ascends anteriorly to the clavicle (3,4).
Accessory Cephalic Vein
The accessory cephalic vein is located on the radiopalmar
forearm (see Fig. 4.11). It arises from the small vessels on
FIGURE 4.10. The veins of the pal-
mar hand and digits.
the dorsum of the forearm or from the ulnar side of the dor-
sal venous network in the hand. The accessory cephalic vein
continues proximally, remaining on the radial aspect of the
cephalic vein, and joins the cephalic vein in the proximal
forearm just distal to the elbow. The accessory cephalic vein
may arise form the cephalic vein, proximal to the wrist, and
then join it again in the proximal forearm. A large oblique
anastomosis often connects the cephalic and basilic veins on
the dorsum of the forearm (3,4).
Basilic Vein
The basilic vein arises on the dorsoulnar aspect of the hand,
initially formed from contributions of the dorsal venous net-
work (see Figs. 4.9 and 4.10). The basilic vein continues prox-
imally on the dorsal surface of the ulnar side of the forearm. It
curves toward the medial aspect of the forearm in the middle
third of the forearm to reach the anterior medial forearm just
 4 Vascular Systems 273

FIGURE 4.11. The veins of the palmar forearm. Vari-

ation exists as to the venous patterns.
274 Systems Anatomy
proximal to the elbow (551–561) (Fig. 4.11). Here the basilic
vein receives the median antebrachial vein. The basilic vein
then continues obliquely in a proximal direction in the groove
between the biceps brachii and the pronator teres. The vein
crosses the brachial artery, separated by the bicipital aponeuro-
sis. Small nerve branches of the medial antebrachial cutaneous
nerve pass both anteriorly and posteriorly to the basilic vein in
this area. The basilic vein continues proximally in the antero-
medial arm, along the medial aspect of the biceps brachii (Fig.
4.12). The vein perforates the deep fascia in the middle third
of the arm, usually slightly distal to the mid-portion. The vein
then continues proximally on the medial side of the brachial
artery to the distal border of the teres major. It joins the
brachial vein to help form the axillary vein (3,4) (Fig. 4.13).
FIGURE 4.12. The veins of the anterior elbow.
Median Antebrachial and Median Cubital
Veins
The median antebrachial vein drains the central part of
the venous plexus on the palmar surface of the hand (see
Fig. 4.11). It continues proximally toward the ulnar side
of the anterior forearm. The median antebrachial vein
reaches the proximal forearm and either empties into the
basilic vein or forms the median cubital vein. It may
divide into two vessels, one of which joins the basilic vein
and the other joining the cephalic vein distal to the ante-
cubital fossa (545–547). The median antebrachial vein
also has interconnections with the deep veins of the fore-
arm (3).

FIGURE 4.13. The veins of the axilla, including the brachial, cephalic, and axillary veins.
DEEP VEINS
Gross Anatomic Description: Deep Veins
The deep veins of the upper extremity consist of the deep
veins of the hand and forearm, the brachial veins, and the
axillary vein (see Table 4.6). In general, the deep veins fol-
low the associated arteries as the venae comitantes. These
veins often are arranged in pairs along both sides of the
artery. There usually are several short transverse or diagonal
intercommunicating branches between the veins.
Deep Veins of the Hand
The superficial palmar arch and the deep palmar arch of the
hand usually are accompanied by a pair of venae comitantes
that form the superficial and deep palmar venous arches.
These venous arches receive the veins corresponding to the
branches of the arterial arches.
Interestingly, the proper palmar digital arteries usually
are not accompanied by double venae comitantes (185).
The proper digital artery may be accompanied by a single
4 Vascular Systems 275
palmar digital vein, but this is not consistent. Frequently,
small veins unrelated to the palmar digital arteries are found
in the subcutaneous layers of a digit. These drain either into
the superficial system or into the deep veins of the palmar
arches. The superficial system, which is more abundant,
collects into lateral veins over the dorsum of the digits and
is then directed toward the interdigital spaces to form the
venous network over the dorsum of the hand (see earlier,
under Superficial Veins).
The common palmar digital veins drain into the super-
ficial venous arch and the palmar metacarpal veins flow into
the deep palmar venous arch. The dorsal metacarpal veins
receive perforating branches from the palmar metacarpal
veins and end in the radial veins and the superficial veins on
the dorsum of the wrist (3,4).
Deep Veins of the Forearm
The deep veins of the forearm consist of the venae comi-
tantes of the radial and ulnar arteries. The deep veins of the
palm, including the superficial and deep palmar venous
276 Systems Anatomy
arches, drain into these veins. The deep palmar venous arch
drains principally into the radial veins. The superficial pal-
mar arch drains into the ulnar veins. The radial and ulnar
venae comitantes coalesce at the level of the elbow to form
the brachial veins. The radial veins usually are smaller than
the ulnar veins, and usually receive the dorsal metacarpal
veins. The ulnar veins receive small connections from the
deep palmar venous arch and communicate with the super-
ficial veins at the wrist. At the level of the elbow, the ulnar
veins receive the anterior and posterior interosseous veins.
There also usually is a communicating branch to the
median cubital vein.
Brachial Veins
There usually are two brachial veins, located on the medial
and lateral aspects of the brachial artery (see Figs. 4.12 and
4.13). The brachial veins usually are formed by the union
of the radial and ulnar venae comitantes near the level of the
elbow. These brachial veins receive branches that corre-
spond to the branches given off by the artery. Near the dis-
tal margin of the subscapularis muscle, these veins join the
axillary vein. The medial brachial vein often flows into the
basilic vein. The basilic vein may take the place of the
medial brachial accompanying vein. These deep veins have
numerous anastomoses (with each other and with the
superficial veins); there are frequent variations, and the
nomenclature of the veins is not consistent among text-
books or studies (1–11).
Axillary Vein
The axillary vein begins at the union of the basilic and
brachial veins, usually located at the distal border of the
teres major muscle (see Fig. 4.13). The axillary vein termi-
nates to become the subclavian vein at the distal outer bor-
der of the first rib. The branches of the axillary vein are vari-
able, but roughly correspond to the associated branches of
the axillary artery. These branches include the circumflex
scapular vein, long thoracic vein, subscapular vein, thora-
codorsal vein, thoracoepigastric vein, and superior thoracic
vein (see Table 4.6 and Fig. 4.13). In addition, the cephalic
vein joins the axillary vein proximal in the axilla, near the
first rib. The axillary vein is located on the medial aspect of
the axillary artery. In the proximal axilla, between the axil-
lary vein and the axillary artery, are the medial cord of the
plexus and the medial pectoral nerve. More distally in the
axilla, between the axillary vein and artery, are the median
and ulnar nerves and the medial cutaneous nerve of the
forearm. The medial cutaneous nerve of the arm is located
medial to the vein. The lateral group of the axillary lymph
nodes is located posteromedial to the axillary vein. The axil-
lary vein has a pair of valves near its distal end, at the bor-
der of the subscapularis muscle. Valves also are located near
the ends of the subscapular veins. As with the brachial
veins, there are frequent variations in the descriptions of the
axillary vein, and the nomenclature, branching, and pat-
terns depicted between the veins are not consistent among
reports or textbooks (1–11).
Anomalies and Variations: Superficial
and Deep Veins
Absence of the Cephalic or Basilic Veins
Because of the substantial variation of the superficial veins
of the forearm, there often is a reciprocal relationship in the
size of the cephalic and basilic veins. Either one may pre-
dominate or be lacking. Absence of the cephalic vein has
been observed in 3% of men and 1% of women in a study
of 170 men and 96 women (546). With absence of the
cephalic vein, the median antebrachial vein usually is
enlarged to drain the area of the cephalic vein (3,4).
Absence of communication between the cephalic and
basilic veins has been noted in 9% of men and 7% of
women (546)
Absence of the Median Antebrachial Vein
The median antebrachial vein may be absent (1,2).
Median Cephalic Vein and Median Basilic Vein
The median cubital vein may be split into a distinct “Y”
pattern, with one arm of the Y draining into the cephalic
and the other into the basilic vein. In this case, one branch
is called the median cephalic vein and the other the median
basilic vein (3,4).
Clinical Correlations: Superficial and
Deep Veins
In the elbow region, the basilic vein passes in the groove
between the biceps brachii and the pronator teres. In this
area, small nerve branches of the medial antebrachial cuta-
neous nerve pass both anteriorly and posteriorly to the
basilic vein, and are vulnerable to injury if the vein is mobi-
lized, explored, or harvested for venous graft.
The cephalic, basilic, and median cubital veins are clini-
cally important from the standpoint of venipuncture, for-
mation of arteriovenous fistulas for vascular access, the use
of pedicled flaps on the upper extremity, and the pathologic
formation of hemangiomas or aneurysms (551–571). The
median cubital vein is commonly used for venipuncture.
Because it has substantial anastomosing branches with the
deep veins, it is “anchored down,” and this helps facilitate
placement of a needle by preventing the vein from slipping
or rolling away.

LYMPHATIC VESSELS AND
NODES
The lymphatic system is a widely dispersed network of thin-
walled lymphatic vessels, larger lymph vessels, and associ-
ated nodes. The system drains fluid formed in the intersti-
tial spaces and the tissue spaces of most organs. The lymph
fluid is then returned to the venous system for recirculation.
Peripherally, the lymphatic vessels do not communicate
with the blood vessels, but the lymph eventually empties in
to the venous system at the junction of the jugular and sub-
clavian veins at both sides of the neck. The endothelium at
this point is continuous with that of the lymphatic vessels
(3,4).
Lymph fluid consists of an ultrafiltrate of blood that
contains plasma proteins. On its way to the venous system,
the lymph fluid is circulated through lymphatic tissue and
lymph nodes. The lymph nodes contain phagocytes that
function to remove foreign matter. Lymphocytes also enter
the lymphatic fluid at the nodes, as well as immunoglobu-
lins or antibodies, playing a role in immunologic protection
(3,4,8).
In the upper extremity, lymphatic drainage is directed
along the routes of the major vascular channels. The lym-
phatic vessels are divided into superficial and deep lym-
phatic vessels. The superficial lymph vessels are present in
greater numbers than the deep (572). The lymph nodes are
similarly divided into superficial and deep lymph nodes.
The superficial lymphatics generally follow the veins,
whereas the deep lymphatics usually follow the arteries.
Most of the lymph from the upper limbs drains to the axil-
lary nodes; in addition, two groups of superficial lymph
nodes, the supratrochlear node(s) located proximal to the
medial elbow and the deltopectoral node(s) located at the
deltopectoral grove, assist with lymph drainage. In general,
the hand, forearm, and arm have very few lymph nodes,
and those present are very small (3,4,572,573).
SUPERFICIAL AND DEEP LYMPHATIC
VESSELS
Gross Anatomic Description: Superficial
Lymphatic Vessels
The superficial lymphatic vessels include the digital
plexuses, the palmar plexus, and the radial, median, and
ulnar channels (3,4,572,573) (Table 4.7). The superficial
vessels arise in a complex lymphatic plexus that courses
throughout the skin of the entire limb (Figs. 4.14 and
4.15). Commencing in the each digit, vessels arise distally
and course in a proximal direction along the sides of each
finger to form a digital plexus. The meshes of vessels are
denser on the palmar aspect of the digit, but head in a
4 Vascular Systems 277
TABLE 4.7. LYMPHATIC VESSELS AND LYMPH
NODES OF THE UPPER EXTREMITY
Superficial lymphatic vessels
Digital plexus
Palmar plexus
Radial vessels
(Some to deltopectoral nodes)
Median lymph vessels
Ulnar lymph vessels
(Some to supratrochlear nodes)
Deep lymphatic vessels
Deep radial lymphatic vessels
Deep ulnar lymphatic vessels
Deep anterior interosseous lymphatic vessels
Deep posterior interosseous lymphatic vessels
Deep brachial lymphatic vessels
Superficial lymph nodes
Supratrochlear lymph nodes
Deltopectoral lymph nodes
Deep lymph nodes
Axillary lymph nodes
Lateral group
Pectoral (anterior) group
Subscapular (posterior) group
Central group
Apical (subclavicular) group
slightly dorsal direction to reach the dorsum of the hand.
In addition, fine but dense meshes of plexuses form in the
palm to form the palmar plexus. The lymph in the palmar
plexus courses in different directions, proximally toward
the wrist, distally to join the digital vessels, medially to
join the vessels on the ulnar border of the hand, and lat-
erally to the vessels of the thumb (3). In addition, a pal-
mar trunk is formed from several vessels that arise in the
central part of the palmar plexus and unite to pass around
the metacarpal of the index finger to join the vessels on
the back of the index finger and thumb. Continuing in a
proximal direction, lymphatic vessels at the wrist form
three roughly parallel channels, the radial, median, and
ulnar lymphatic vessels. These vessels course, respectively,
along the cephalic, median, and basilic veins in the fore-
arm. Some of the ulnar lymph vessels end or pass through
the small supratrochlear node(s), located on the medial
elbow, proximal to the joint level (see Fig. 4.15). Some of
the radial lymph vessels continue proximally to form a
trunk that ascends with the cephalic vein to reach the del-
topectoral nodes. [Some of these vessels may continue
with the cephalic vein to penetrate the clavipectoral fascia
to enter the apical group of the axillary nodes in the infr-
aclavicular region, or may ascend as far as the lower deep
cervical nodes proximal to the clavicle (3,572,573).] Most
of the superficial lymph vessels of the upper extremity,
however, continue proximally to reach the lateral group of
axillary nodes (see Figs. 4.15 and 4.16).
278 Systems Anatomy

FIGURE 4.14. Schematic illustration of the fine super-

ficial lymph vessels on the dorsum of the digits and
hand.

Gross Anatomic Description: Deep the superficial vessels. These include the supratrochlear and
Lymphatic Vessels deltopectoral nodes (see Table 4.7).
The supratrochlear nodes consist of one to five small
The deep lymphatic vessels include the deep radial, deep
nodes located on the medial distal arm, just proximal to the
ulnar, deep anterior and posterior interosseous, and deep
medial epicondyle of the elbow (see Fig. 4.15). Located in
brachial lymphatic vessels (see Table 4.7). The deep lym-
the superficial fascia, these nodes usually are medial to the
phatic vessels accompany the deep blood vessels. In the
basilic vein. The supratrochlear nodes receive lymph flow,
forearm, there are four sets, which correspond to and follow
usually through the (superficial) ulnar lymphatic vessels
the radial, ulnar, and anterior and posterior interosseous
that follow the basilic vein, to drain fluid from the middle,
arteries. These deep lymphatic vessels communicate at
ring, and small fingers, the medial portion of the hand, and
intervals with the superficial lymphatic vessels, and some
the superficial areas over the ulnar side of the forearm.
may end in the associated nodes. In the arm, these deeper
Because these vessels intercommunicate with the other
lymphatic vessels follow the brachial artery. Some vessels
lymph vessels of the digits and fingers, it is conceivable that
terminate in small nodes along the artery, but most con-
the supratrochlear nodes can receive fluid from other parts
tinue proximally to reach the axillary nodes (3,4,574,575)
of the upper extremity as well.
(see Figs. 4.15 and 4.16).
The deltopectoral nodes consist of only a few nodes
located along the cephalic vein in the deltopectoral grove,
between the pectoralis major and deltoid muscles, just infe-
Gross Anatomic Description: Superficial
rior to the clavicle (Fig. 4.16; see Fig. 4.15). The deltopec-
Lymph Nodes
toral nodes can receive lymph flow from the (superficial)
Although most of the lymph nodes of the upper extremity radial lymph vessels, which follow the cephalic vein (3,4,8,
are grouped in the axillary nodes, several nodes exist along 575).
 4 Vascular Systems 279

FIGURE 4.15. Schematic illustration of the fine superficial lymph vessels on the palmar hand and
forearm. The supratrochlear, deltopectoral, and axillary nodes are shown.
280 Systems Anatomy
FIGURE 4.16. The several groups of lymph nodes comprising the axillary nodes.
Gross Anatomic Description: Deep Lymph
Nodes
The deep lymph nodes are located and mainly comprise the
axillary lymph nodes. There are, however, sporadic, vari-
able, isolated deep lymph nodes in the forearm along the
course of the radial, ulnar, and interosseous arteries, and in
the arm along the medial side of the brachial artery (3).
The axillary nodes are relatively large, and vary from 20
to 30 in number. These are divided into several groups,
including the lateral, pectoral (anterior), subscapular (poste-
rior), central, and apical (subclavicular) nodes (3,4,575,576)
(see Table 4.7 and Fig. 4.16).
Lateral Group of the Axillary Lymph Nodes
The lateral group consists of four to six axillary nodes
located medial and posterior to the axillary vein (575,576)
(see Fig. 4.16). This group includes among the most distal
of the axillary nodes and receives lymph vessels from nearly
the entire upper limb (with the exception of those vessels
that accompany the cephalic vein, some of which drain into
the deltopectoral nodes). The lymph vessels also pass to the
central and apical group of the axillary nodes (located deep
and proximal to the lateral group) (3,4,8).
Pectoral (Anterior) Group of the Axillary
Lymph Nodes
The pectoral group of lymph nodes is located inferior to the
lateral group and consists of four or five nodes that lie along
the lateral border of the pectoralis minor muscle, close to
the lateral thoracic artery (see Fig. 4.16). The lymph vessels
that drain into the pectoral group arise in the skin and mus-
cles of the anterior and lateral thoracic walls, and from the
central and lateral parts of the mammary gland. These ves-
sels also connect to the central and apical groups of lymph
nodes (3,4,8).
Subscapular (Posterior) Group of the Axillary
Lymph Nodes
The subscapular lymph nodes are located along the lower
margin of the posterior wall of the axilla, close to the sub-
scapular artery (576,577) (see Fig. 4.16). These usually are

inferior to the central and lateral groups of nodes. The sub-
scapular group consists of six or seven axillary nodes. The
lymph vessels that drain into the subscapular group arise in
the skin and muscles of the posterior neck and the posterior
thoracic wall. The lymph vessels then continue to the cen-
tral group of nodes (3,4,8).
Central Group of the Axillary Nodes
The central group of lymph nodes is located deep in the
axilla, in the adipose tissue (576,577) (see Fig. 4.16). The
central group consists of three or four nodes. Because of its
central location, this group does not drain a specific part of
the upper extremity directly, but does receive vessels from
the lateral, pectoral, and subscapular groups of nodes. Ves-
sels that enter the central group may continue proximally
and superiorly to reach the apical nodes (3,4,8)
Apical (Subclavicular) Group of the Axillary
Nodes
The apical group of nodes is located superiorly and prox-
imally in the axilla, and consists of 6 to 12 nodes (576)
(see Fig. 4.16). The nodes lie partly deep to the superior
part of the pectoralis minor and partly in the apex of the
axilla, medial and superior to the superior border of the
muscle. The lymph vessels that drain into the apical
nodes follow the cephalic vein. The apical lymph nodes
usually receive a few vessels from those draining the supe-
rior part of the mammary gland. The apical nodes also
receive communicating vessels from the other axillary
nodes. The vessels from the apical nodes unite to form
the subclavian trunk, which continues either directly into
the junction of the internal jugular and subclavian veins
or into the jugular lymphatic trunk. On the left side, the
subclavian trunk may end in the thoracic duct. A few ves-
sels from the apical nodes also may pass to the inferior
deep cervical nodes (3,4,8).
Anomalies and Variations: Lymphatic
Vessels and Nodes
Because of the normal variations in the lymphatic system,
these are described in the sections on normal anatomy of
the vessels and nodes (see the Gross Anatomic Description
sections for the superficial and deep lymph vessels and
nodes, earlier).
Clinical Correlations: Lymphatic Vessels
and Nodes
Unilateral upper extremity lymphedema is a well recognized
potential occurrence after operative axillary node dissection
(i.e., performed with mastectomy for breast carcinoma)
(573,577,578).
4 Vascular Systems 281
Palpable enlargement and possible tenderness of the axil-
lary or supratrochlear nodes can follow infection or
metastatic disease, an important finding in the clinical eval-
uation of these problems.
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4 Vascular Systems 293
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23–28, 1986.
 6
ARM
JAMES R. DOYLE
Compared with the anatomic and functional complexities
of the shoulder region, forearm, wrist, and hand, the arm is
remarkably less complex. The arm in large part is presented
exclusive of the shoulder and the elbow, which are discussed
elsewhere. This arbitrary division is meant to facilitate the
presentation of the necessary information for the region and
should not be taken as a failure to recognize the important
interactions among all parts of the upper extremity. As with
all such divisions, there may be omissions or additions
made for the sake of clarity and the descriptive process.
DESCRIPTIVE ANATOMY
Contents
Bone: The humerus.
Blood Vessels: The cephalic and basilic veins and the
brachial artery and its branches.
Nerves: The median, musculocutaneous, ulnar, radial,
and superficial cutaneous nerves.
Muscles and Septa: The biceps, brachialis, coraco-
brachialis, and triceps muscles and medial and lateral inter-
muscular septa.
External Landmarks
Lateral Arm
Useful lateral landmarks include the prominent deltoid
muscle covering the proximal half of the arm, the lateral
biceps groove that contains the cephalic vein, the lateral and
long heads of the triceps, and the lateral epicondyle and
olecranon (Fig. 6.1).
Posterior Arm
Posteriorly, the long and lateral heads of the triceps that
cover the deep medial head form a bulky muscle mass over
the shaft of the humerus. The olecranon process of the ulna
is a prominent bony landmark, as is the posterior aspect of
the acromion process and the medial and lateral humeral
condyles (Fig. 6.2).
Anteromedial Arm
Useful anteromedial landmarks include the coracoid
process of the scapula inferior to the outer aspect of the
clavicle, the long head of the biceps tendon, and the greater
tuberosity of the humerus palpable just lateral and superior
to the biceps tendon (Fig. 6.3). The deltopectoral groove is
marked by the cephalic vein. The biceps is the prominent
and relatively mobile muscle mass on the front of the arm
that overlies the brachialis. The medial biceps groove, which
contains the basilic vein, marks the medial margin of the
biceps and defines the interval between the anterior and
posterior compartments of the arm.
Skeletal Anatomy
Humerus
The humerus is the longest and largest bone in the upper
extremity, with expanded proximal and distal articular ends
joined by a long shaft.
Humeral Shaft
The humeral shaft is almost round in its proximal aspect
and becomes triangular (apex anterior) in its distal aspect.
Proximal and Anterior Surface of the Humerus
The proximal and anterior surface demonstrates two
prominent ridges or crests flanking the bicipital or intertu-
bercular groove that are distal continuations of the greater
and lesser tuberosities (Fig. 6.4A). The crest from the
greater tuberosity, which is lateral, provides an insertion for
the pectoralis major, and the crest of the lesser tubercle,
which is medial, receives the insertion of the teres major.
The intertubercular groove contains the tendon of the long
 A

FIGURE 6.1. A: Lateral arm. B: external landmarks and

muscles.

316
 6 Arm 317

A B
FIGURE 6.2. A: Posterior arm. B: external landmarks and muscles.

head of the biceps and also provides a point of attachment
for the latissimus dorsi.
The deltoid tuberosity is a laterally situated prominence at
approximately the mid-portion of the shaft that is the inser-
tion point of the deltoid muscle. Just distal to the deltoid
tuberosity and beginning posteriorly and spiraling distally
and laterally is a groove for the radial nerve. At approximately
the level of the deltoid tuberosity, the cross-sectional shape of
the humerus begins to change from circular to triangular,
with the apex of the triangle being anterior. As this triangu-
lar configuration continues distally, it begins to narrow in the
anteroposterior plane while simultaneously widening in the
medial and lateral aspects to form the medial and lateral
supracondylar ridges. The anteriorly situated ridge of the tri-
angular configuration courses between the coronoid and
radial fossae to end between the trochlea and capitellum.
Hueter’s line, also known as the interepicondylar line, is a
straight line drawn from the tips of the humeral epicondyles
in the coronal plane (1). It is a useful landmark for locating
the possible site of division of the radial nerve into motor and
sensory components at the elbow (see discussion of distal
radial nerve division, later).
318 Regional Anatomy

FIGURE 6.3. A: Anteromedial arm. B: external landmarks and muscles.

Posterior Surface of the Humerus Humeral Torsion

The posterior aspect of the humerus is relatively flat from the
region of the deltoid tuberosity to the distal articulation (see
Fig. 6.4B). Posteriorly, a prominent oblique ridge begins
medially just distal to the surgical neck and runs laterally to
end near the deltoid tuberosity. This ridge represents the
point of origin of the lateral head of the triceps (2).
When the humerus is viewed along its longitudinal axis
from proximal to distal, the proximal and distal articular
axes are divergent by approximately 15 degrees (see Fig.
6.4C). The articular axis of the proximal humerus looks
posteriorly by 15 degrees in relationship to the distal inter-
condylar axis, which is in the coronal plane (2).
 6 Arm 319

FIGURE 6.4. A: Anterior view of humerus

with external landmarks and cross-sectional
anatomy. Observe the changes in the
medullary canal, external shape, and cortical
thickness from proximal to distal. B: Posterior
humerus, external landmarks. C: Humeral tor-
sion. The proximal and distal axes of the
humerus are divergent by approximately 15
degrees. The articular axis of the proximal
humerus looks posteriorly by 15 degrees in
relationship to the distal intercondylar axis,
which is in the coronal plane.
320 Regional Anatomy
ANATOMIC RELATIONSHIPS
Veins of the Arm
Two major veins are present in the arm: the cephalic and
the basilic, which run in the biceps groove on each side of
the arm (Fig. 6.5). The cephalic continues proximally to
the deltopectoral groove, where it acts as a useful land-
mark for identification of the interval between the deltoid
and pectoralis muscles (3). At the deltopectoral triangle
(the infraclavicular fossa) just inferior to the clavicle, the
cephalic vein perforates the clavipectoral fascia and emp-
ties into the axillary vein. The cephalic vein in the del-
topectoral groove is accompanied by the deltoid branch
of the thoracoacromial artery, which exits from the del-
topectoral triangle and gives muscular branches to the
deltoid and clavicular head of the pectoralis major. In
contrast to the more superficial course of the cephalic
vein, the basilic vein pierces the brachial fascia at approx-
imately the mid-aspect of the arm, where it ascends
medial to the brachial artery in the neurovascular bundle
to the lower margin of the teres major, where it becomes
the axillary vein (2).
FIGURE 6.5. Veins of the arm and forearm, ante-
rior view. The cephalic and basilic veins mark the
division between the flexor and extensor compart-
ments of the arm and the location of the medial
and lateral intermuscular septa. The cephalic vein
continues proximally to the deltopectoral groove,
where it may act as a useful landmark to identify
the interval between the deltoid and the pectoralis
muscles. In the forearm, the cephalic and basilic
veins flank the median antebrachial vein in the
forearm. Note the median cubital vein in the region
of the antecubital fossa.

Cutaneous Nerves of the Upper Extremity
Lateral Antebrachial Cutaneous Nerve
The musculocutaneous nerve from the lateral cord of the
brachial plexus pierces the coracobrachialis, which it inner-
vates, and descends laterally between the biceps and
brachialis, which it also innervates, to exit from the lateral
margin of the biceps, where it becomes the lateral ante-
brachial cutaneous nerve (LACN) of the forearm (Fig. 6.6).
The LACN is discussed in detail in Chapter 8.
Medial Antebrachial Cutaneous Nerve
The counterpart of the LACN on the medial aspect of the
arm, the medial antebrachial cutaneous nerve (MACN),
was studied by Masear et al. in 50 cadavers (4) (Fig. 6.7).
They found that the MACN arises in the axilla from the
medial cord in 78% and from the lower trunk in 22%. In
54%, the MACN and medial brachial cutaneous nerve
(MBCN) had a common origin from either the medial cord
or the lower trunk. When a common origin was present,
the MBCN divided from the MACN an average of 6 cm
(range, 1 to 20 cm) distal to the origin from the medial cord
or lower trunk. Twenty-six percent (13 of 50) had a second
MBCN branch off the MACN. In 8 of these 13, the high-
est medial brachial branch arose from the plexus separate
from the origin of the MACN. Four percent had three
MBCN branches of the MACN in the proximal two-thirds
of the arm. One specimen had no MBCN, and a thoracic
nerve sent cutaneous branches to the posteromedial arm
into the distribution ordinarily supplied by the MBCN. In
two specimens, the MBCN, MACN, and medial pectoral
nerve had a common trunk off the medial cord. The
MACN communicated with the medial brachial nerve in
4% and with the ulnar nerve in 6%. No communication
was found with the palmar cutaneous branch of the ulnar
nerve in the distal forearm. This nerve is adjacent to the
basilic vein as it descends along the medial side of the
brachial artery and then pierces the brachial fascia to
become superficial at the middle or distal arm. The rela-
tionship of the nerve to the basilic vein is variable because
half of the nerves cross deep and the other half superficial
to the median cubital vein at the elbow. In the distal arm,
the MACN divides into anterior and posterior branches at
an average of 14.5 cm (range, 1 to 31 cm) proximal to the
medial humeral epicondyle, with most (92%) branching
between 7 and 22 cm proximal to the medial epicondyle.
The anterior branch traverses the elbow between the medial
epicondyle and the biceps tendon, usually lying 2 to 3 cm
anterolateral to the epicondyle but sometimes crossing
directly over it. The anterior branch gives off variable cuta-
neous branches (two to five) to the antecubital fossa and the
proximal and distal anterior arm. Most of these branches
arose 6 cm proximal and 5 cm distal to the elbow. The main
anterior branch then continues distally superficial to the
6 Arm 321
flexor carpi ulnaris (FCU) and is traceable to an average of
5.6 cm from the wrist flexion crease. The posterior branches
(one to four) were found to course posteriorly from 6 cm
proximal to 4 cm distal to the epicondyle. Most (90%)
crossed at or proximal to the epicondyle. Anteromedial
articular branches were found in 34% (17 of 50), with 6
from the anterior and 11 from the posterior branches (3,4).
Clinical Significance
The MACN is a useful nerve graft for brachial plexus recon-
struction (4). The MACN is a long nerve, similar in diame-
ter to the sural, and is readily accessible in the surgical expo-
sure of the plexus. If the length of only one sural nerve is
needed, the MACN usually suffices, and surgical time may
be shortened. In the 50 dissected specimens of Masear et al.,
the average graft length was 18.7 cm (range, 10 to 26 cm)
(4). Graft diameter proximally averaged 3.15 mm with 10.2
groups of fascicles, and in the mid-brachium near the bifur-
cation, the average diameter was 2 mm with 7 fascicular
groups. If the MACN is selected as a graft for a digital or
cutaneous nerve of the hand or wrist, a good size match is
obtained by using the anterior branch just proximal to the
elbow. Graft diameter may be increased or decreased by
moving proximally or distally as needed (4). Masear et al.
advise against taking the posterior branch because this
results in numbness over the olecranon, and the resulting
neuroma is in an area subjected to trauma (4). Cheney has
noted the MACN is a branching nerve of appropriate length
and diameter that matches the surgical requirements for cra-
nial nerve reconstruction in head and neck surgery (5). He
noted that the MACN closely resembles the distal facial
nerve in terms of diameter and branching (5).
Medial Brachial Cutaneous Nerve
The other major medial cutaneous nerve of the arm is the
MBCN. It arises from the medial cord of the brachial
plexus and passes medial and posterior to the ulnar nerve as
it courses distally. Two to 3 cm proximal to the medial epi-
condyle, the nerve arborizes into two to five branches that
terminate over the medial epicondyle in 80% of specimens;
in the remaining 20%, the branches end in the mid-portion
of the medial arm (6).
Clinical Significance
Both the MACN and the MBCN send multiple branches
to the medial side of the elbow, which is the location of the
standard incision for ulnar nerve transposition. Race and
Saldana noted that 100% of the terminal branches of the
posterior arborization of the MACN and 80% of the
MBCN are in the fascia directly over the medial epicondyle
and the flexor pronator mass (7). The authors note that
unless these three to seven branches are carefully dissected,
any incision placed over the medial cubital tunnel will tran-
sect these nerves and result in anesthesia over the medial
322 Regional Anatomy

FIGURE 6.6. Palmar (A) and Dorsal (B) views of the cutaneous nerves of the arm and forearm.
All but one (the axillary) of the five terminal branches of the brachial plexus contribute branches
to the hand. The musculocutaneous nerve ends in the lateral antebrachial cutaneous nerve
(LACN); the median nerve ends as a major component of sensibility to the palmar and radial
aspect of the hand; the ulnar nerve ends as its medial counterpart; and the radial nerve ends by
sharing innervation of the dorsum of the hand with the median and ulnar nerves. The cutaneous
branch of the axillary nerve is the upper lateral brachial cutaneous nerve, which innervates the
skin over the outer and inferior aspect of the deltoid and upper aspect of the arm.
 6 Arm 323

FIGURE 6.6. (continued) The posterior cord of the plexus is represented by five cutaneous
nerves, including the axillary nerve branch already mentioned. The remaining four are the pos-
terior brachial cutaneous, the lower lateral brachial cutaneous, the posterior antebrachial cuta-
neous, and the superficial branch of the radial nerve. The LACN and medial antebrachial cuta-
neous (MACN), as well as the medial brachial cutaneous (MBCN), are the most significant nerves
on the anterior and medial aspects of the arm. The LACN, the distal sensory continuation of the
musculocutaneous nerve, innervates the skin on the flexor and radial one-half of the forearm.
The LACN is useful as a digital nerve graft and the MACN as a nerve graft for brachial plexus
reconstruction. Both the MACN and the MBCN send multiple branches to the medial side of the
elbow that may be at risk during surgery in this region (see text).
324 Regional Anatomy

FIGURE 6.7. A: Origin and distribution of

medial antebrachial cutaneous nerve
(MACN). This nerve arises most often from
the medial cord of the brachial plexus in the
axilla and descends adjacent to the basilic
vein to become superficial at the middle or
distal arm, where it divides into anterior and
posterior branches. The anterior branch tra-
verses the elbow between the medial epi-
condyle and the biceps tendon, usually lying
1 to 3 cm anterolateral to the epicondyle,
where it gives off branches to the antecubital
fossa and proximal forearm. It then contin-
ues distally to innervate the flexor and ulnar
one-half of the forearm. The posterior
branch continues distally to innervate the
skin over the ulnar and dorsal aspect of the
forearm.

B
FIGURE 6.7. (continued) B: Fresh cadaver dissection of the MACN in the right arm. Note the
size and distribution of this cutaneous nerve.
epicondyle and olecranon (7). Review of the authors’
patients with the standard incision for ulnar nerve transpo-
sition revealed a number with dense anesthesia over the ole-
cranon and posteromedial aspect of the forearm. Painful
neuromas were not encountered, but this problem has been
reported by others (8). Because of their anatomic studies
and the findings on their patients who had undergone ulnar
nerve transposition, the authors now use a posterior
approach that affords better protection to the branches of
the MACN and MBCN (7).
Intercostobrachial Cutaneous Nerve
The intercostobrachial cutaneous nerve from the lateral
cutaneous branch of the second thoracic nerve is joined by
the MBCN from the medial cord of the brachial plexus to
innervate the skin on the proximal posteromedial aspect of
the arm. The intercostobrachial cutaneous nerve may be
sacrificed as part of the axillary portion of a modified radi-
cal mastectomy.
Muscles and Intermuscular Septa of the
Arm
Biceps Brachii
The biceps brachii is a fusiform muscle that derives its name
from its two proximal parts or heads: a long head that arises
by means of a tendon from the supraglenoid tubercle of the
6 Arm 325
scapula, and a short head that arises from the apex of the
coracoid process of the scapula (2,9) (Fig. 6.8). The long
head starts in the shoulder joint capsule as a long, round
tendon and arches over the humeral head to descend in the
intertubercular groove, where it is retained by the transverse
humeral ligament and a fibrous expansion of the pectoralis
major tendon. The tendon is surrounded by a synovial
sheath in the groove. The two heads lead into the muscle
bellies that, although closely applied, may be separated to
within 7 cm of the elbow joint (2). The muscle ends in a
flattened tendon that attaches to the rough posterior aspect
of the radial tuberosity. The bicipitoradial bursa separates
the tendon from the smooth portion of the radial tuberos-
ity. As it approaches its insertion, the biceps tendon spirals
or twists, with its anterior surface becoming lateral. The
biceps is covered proximally by the pectoralis major and the
deltoid. Its medial margin touches the coracobrachialis and
it covers the brachial artery and median nerve. The lateral
border is adjacent to the deltoid proximally and the bra-
chioradialis distally. The biceps is the main supinator of the
forearm and an elbow flexor, and it may play a role in pre-
venting proximal migration of the humerus with contrac-
tion of the deltoid during abduction.
Brachialis
This muscle arises from the anterior and distal half of the
humerus, beginning in a “U”-shaped fashion from around
326 Regional Anatomy
the deltoid insertion (Fig. 6.9). It also arises from the inter-
muscular septa, more from the medial than the lateral
because it is separated from the lateral septum by the bra-
chioradialis and the extensor carpi radialis longus. Although
it begins under cover of the biceps in its mid-portion, it is
uncovered anterolaterally. Its insertion is by a broad tendon
to the ulnar tuberosity on the anterior aspect of the coro-
noid process. The brachialis is a flexor of the elbow.
Coracobrachialis
This muscle arises from the coracoid process of the scapula,
which it shares as a point of origin with the short head of
the biceps (see Fig. 6.9). The muscle also arises from the
FIGURE 6.8. Anterior arm muscles, the biceps. Note
the relationship of the biceps to the brachialis, the
coracobrachialis, and the medial intermuscular septum.
proximal 10 cm of the short head of the biceps. Insertion is
into an impression, 3 to 5 cm in length, on the medial
aspect of the mid-portion of the humerus between the tri-
ceps and brachialis (2). The coracobrachialis flexes the arm
forward and medially, and in abduction it acts with the
anterior deltoid (2).
Triceps
This muscle, like the biceps, takes its name from the num-
ber of heads of origin: the long, lateral, and medial (9). The
long and lateral heads are superficial and cover the deep
medial head; thus, the triceps may be considered to have
two layers (Fig. 6.10).

FIGURE 6.9. Anterior arm muscles, brachialis and coraco-
brachialis. Note the relationship of the coracobrachialis and the
brachialis.
Long Head
The long head arises by a flat tendon from the infraglenoid
tubercle of the scapula (see Fig. 6.10A). Its muscle fibers
descend medial to the lateral head and superficial to the
medial or deep head to join them to form a large, common
posterior tendon.
Lateral Head
The lateral head arises from a long, narrow ridge that begins
medially and distal to the surgical neck and continues dis-
tally and laterally to end posterior to the deltoid tuberosity
(see Fig. 6.10A).
6 Arm 327
Medial Head
The medial head, which is covered in large part by the long
and lateral heads, arises from the proximal and posterior
shaft of the humerus just distal to the teres major and fol-
lows the medial margin of the radial groove to continue its
broad origin on the remainder of the posterior humeral
shaft down to the region of the elbow joint capsule (see Fig.
6.10B). It also arises from the medial intermuscular septum
and from the distal part of the lateral intermuscular septum.
The tendon of the triceps begins near the middle of the
muscle and has two layers, one superficial in the distal half
of the muscle and one deep in the substance of the muscle.
However, after receiving all the muscle fibers distally, the
two layers become one and insert on the olecranon. The tri-
ceps is the major extensor of the forearm. The medial head
is active in all forms of extension, whereas the lateral and
long heads are minimally active except in extension against
resistance.
Intermuscular Septa
The distal half of the arm is divided into anterior and pos-
terior compartments by the lateral and medial intermuscu-
lar septa (Fig. 6.11). The lateral intermuscular septum arises
from the lateral epicondyle and epicondylar ridge of the
humerus and ends at the insertion of the deltoid. The
medial intermuscular septum, located in the distal two-
thirds of the arm, begins at the medial epicondyle and epi-
condylar ridge and blends proximally with the fascia of the
coracobrachialis near its insertion, to end at the medial lip
of the intertubercular sulcus distal to the teres major. The
radial and ulnar nerves pierce the lateral and medial septa,
respectively, as they change compartments in the middle
third of the arm.
Neurovascular Structures
Brachial Artery/Neurovascular Bundle
The brachial artery, a continuation of the axillary, which by
definition begins at the lower border of the teres major
muscle, continues distally to the neck of the radius, where
it bifurcates into the radial and ulnar arteries (3) (Fig. 6.12).
In the proximal arm, the artery is deep and medial and
gradually migrates to an anterior and central position as it
reaches the antecubital fossa. At this level, in the proximal
arm, the neurovascular bundle contains the brachial artery
and the median, ulnar, radial, medial antebrachial cuta-
neous, and medial brachial cutaneous nerves, as well as the
basilic vein. Spatial orientation at this level places the
median nerve anterior to the artery, the ulnar nerve medial,
and the radial nerve posterior. The median nerve gradually
crosses over the brachial artery as it descends so that it lies
medial to it in the antecubital fossa. The brachial artery is
flanked by brachial veins on either side. The anterior
328 Regional Anatomy

FIGURE 6.10. A, B: Triceps. This muscle, like the biceps, derives its name from the number of
heads of origin; the long, lateral, and the medial. Note that the medial or deep head is covered
by the long and lateral heads.

branches of the brachial artery are depicted in Figure 6.12B.
The brachial artery gives off numerous muscular branches
in the arm, mainly from its lateral side, and its major
branch is the deep brachial artery (its largest branch), from
the posteromedial aspect and arising distal to the teres
major (see Fig. 6.12C). This artery accompanies the radial
nerve through the spiral groove. On the posterior aspect of
the humerus, an ascending deltoid branch is given off that
communicates proximally with the posterior humeral cir-
cumflex artery. The deep brachial divides into the radial and
the middle collateral arteries. The middle collateral
descends in the substance of the medial head of the triceps
and participates in an anastomosis posteriorly in the supra-
condylar region between the laterally placed radial collateral
and a branch from the medially placed inferior ulnar collat-
eral artery, and then continues distally to anastomose with
the interosseous recurrent artery posteriorly in the proximal
forearm. The radial collateral artery continues distally
between the brachialis and brachioradialis anterior to the
lateral epicondyle to anastomose with the radial recurrent
artery. The superior ulnar collateral arises from the medial
side of the brachial artery in the mid-humeral region and
accompanies the ulnar nerve, piercing the medial intermus-
cular septum with that nerve to descend between the medial
 6 Arm 329

FIGURE 6.11. A: Intermuscular septa. The distal aspect of the arm is divided into anterior and
posterior compartments by the medial and lateral intermuscular septa. The lateral septum arises
from the lateral epicondyle and epicondylar ridge of the humerus and ends at the deltoid inser-
tion. The medial septum is located in the distal two-thirds of the arm and has similar but medial
epicondylar origins; it ends proximally by blending with the fascia of the coracobrachialis near its
insertion. B: Cross-section of the arm through the medial and lateral intermuscular septa. Note
the division of the distal arm into anterior and posterior compartments by the septa, and the
relationships of the various neurovascular structures to the septa.

A
FIGURE 6.12. A: The axilla and medial aspect of the arm. Note the brachial artery and its relation-
ship to the nerves in the axilla and medial aspect of the arm (see text). (continued on next page)
330 Regional Anatomy

FIGURE 6.12. (continued) B: Anterior

branches of the brachial artery. Note the
course and branching of the brachial artery
and its subsequent division into the radial
and ulnar arteries in the forearm.
 6 Arm 331

FIGURE 6.12. (continued) C: Posterior

branches of the brachial artery. Note the rela-
tionship of the posterior branches of the
brachial artery to the deltoid and triceps mus-
cles.
332 Regional Anatomy
epicondyle and the olecranon and ending deep to the FCU
by anastomosing with the posterior ulnar recurrent and
inferior ulnar collateral arteries. The inferior ulnar collateral
artery arises 3 to 4 cm proximal to Hueter’s line, passes
medially over the median nerve, and soon divides into a
posterior and a descending branch. The posterior branch
penetrates the medial intermuscular septum and anasto-
moses with the middle collateral artery posteriorly. The
descending branch anastomoses with the anterior ulnar
recurrent artery.
Intraosseous Arterial Supply of the Humerus
The following information is based on an injection study of
30 adult humeri performed by Laing (10) (Fig. 6.13). The
discussion of the intraosseous blood supply of the humerus
excludes the rich blood supply from the periosteum and the
muscular and ligamentous attachments, and the practical
relationship between these two sources is discussed later
under the section on Clinical Significance.
Arteries of the Humeral Head
A constant anterolateral artery from the ascending branch
of the anterior humeral circumflex enters the proximal
humerus either at the upper end of the bicipital groove or
by branches entering the greater and lesser tuberosities.
After entering the bone, this vessel (which may be multiple)
curves posteromedially just below the obliterated epiphyseal
line of the humeral head, and has been called the arcuate
artery. Additional contributions to the blood supply of the
humeral head were noted from the posterior humeral cir-
cumflex as posteromedial arteries. Inconsistent arteries also
were noted to enter the head posteriorly and anteriorly from
the attachment of the rotator cuff.
Arteries of the Humeral Shaft
Main Nutrient Artery
The main nutrient artery of the humeral shaft usually
arose directly from the brachial artery, and in this series
of 30 humeri was single in 28 and double in 2 instances.
In two-thirds of the specimens, this artery entered the
humerus anteromedially, medially in six cases, anteriorly
in five, and posteromedially in one case. The point of
entry of the main nutrient artery was at the junction of
the middle and distal thirds or in the lower part of the
middle third of the humerus in 24 cases, approximately
the mid-portion in 4 cases, and at the junction of the
third and fourth quarters in 2 bones. In all cases, the
course of the artery through the cortex was distalward,
and the length of the intracortical canal varied from 0.25
to 2 inches. When the nutrient artery was single it
divided into ascending and descending branches either in
the intracortical canal or in the medullary canal. In two
cases, the division took place outside the bone, and each
branch had its own canal and nutrient foramen. The
superior branch became the ascending artery of the shaft
and the inferior branch, the descending artery. The
ascending branch courses up the medullary canal and
anastomoses with any accessory nutrient arteries that may
be present. In some specimens this intramedullary artery
anastomosed with the periosteal arteries by small
transcortical vessels. The descending branch usually was
smaller than the ascending branch, and usually immedi-
ately divided into many fine arteries and continued dis-
tally in the intramedullary canal to reach the supracondy-
lar and epicondylar regions.
Accessory Nutrient Arteries of the Humeral Shaft
One to four accessory nutrient arteries of the shaft were
found in almost all specimens, but were never as large as the
main nutrient artery.
Accessory Arteries from the Profunda Brachii. In seven
specimens, one or several arteries from the profunda brachii
artery entered the posterior surface of the humerus in the
spiral groove. These vessels were all small and no nutrient
foramen was visible on the surface.
Accessory Arteries from the Humeral Circumflex. In nine
specimens, an accessory nutrient vessel from the descending
branch of the anterior humeral circumflex artery entered
the upper end of the shaft anterolaterally. In one specimen,
a branch from the posterior humeral circumflex entered the
proximal humerus posteromedially. Only one specimen
demonstrated a sizable accessory nutrient vessel laterally.
Thus, most of the accessory nutrient arteries entered the
upper third of the humeral shaft anteriorly or anteromedi-
ally. Also, no true accessory nutrient vessels were seen
between the site of the main nutrient artery and the epi-
condylar region.
Arteries of the Distal Humerus
In addition to the descending branch of the main humeral
nutrient artery that reached the epicondylar region, on each
side there were arteries that entered the epicondyles medi-
ally, laterally, and posteriorly. Arterial branches were noted
to enter the trochlea, capitellum, and olecranon fossa, but
no vessels were noted anteriorly.
Clinical Significance of the Blood Supply to the
Humerus
Fractures of the Shaft. Although the periosteum represents
a rich source of blood supply to the humerus, the intra-
osseous supply also is important and both sources of blood
 6 Arm 333

FIGURE 6.13. Interosseous arterial supply to the humerus.

Note the arterial supply to the humeral head from the
humeral circumflex arteries, and the main nutrient artery
from the brachial artery entering the humerus anteromedi-
ally at the junction of the middle and distal thirds and divid-
ing into ascending and descending branches and medial and
lateral branches to the epicondyles (see text).
334 Regional Anatomy
supply must be respected and preserved. Fractures of the
shaft at the junction of the middle and distal thirds most
likely will destroy the main nutrient artery, and the upper
margin of the distal component of the humerus then
depends on vessels from the periosteum and those intra-
medullary vessels ascending from the epicondyles. Exten-
sive stripping of the periosteum of the distal fragment in
open reductions in this region should be avoided to pre-
serve the remaining components of the blood supply. This
concept is illustrated by the potential for compromise of the
blood supply of the shaft of the humerus by insertion of an
intramedullary device in conjunction with an open reduc-
tion of the fracture. The intramedullary device has the
potential to compromise the intramedullary blood supply,
and in combination with extensive periosteal stripping at
the fracture site, may diminish the blood supply to the frac-
ture site.
Fractures of the Humeral Head/Metastatic Deposits.
The upper half of the humerus has an excellent blood
supply from the ascending branch of the main nutrient
artery and the accessory arteries, which may explain the
predilection of metastatic deposits for this part of the
humerus. Fractures of the surgical neck of the humerus
occur below the main blood supply of the humeral head
and above the main blood supply to the proximal shaft,
and thus both sides of the fracture interface have an excel-
lent blood supply. This may account for the rapid union
of these fractures. When operating in this region, it is
appropriate to remember that the main blood supply of
the humeral head enters it through the upper end of the
bicipital groove or from the adjacent parts of the greater
and lesser tuberosities.
Fractures of the Distal Humerus. The importance of pre-
serving the muscular and ligamentous attachments when
operating on the lower end of the humerus is well known.
Excessive stripping of soft tissues should be avoided to pre-
serve the periosteal blood supply to the distal humerus and
associated fracture fragments.
Nerves
Radial Nerve
The radial nerve arises from the posterior cord and is the
largest branch of the brachial plexus. The radial nerve leaves
the medial side of the arm accompanied by the deep
brachial artery and passes laterally between the long and
medial heads of the triceps to a shallow groove beneath the
lateral head. The radial nerve comes in contact with the
humerus in the spiral groove approximately 3 cm proximal
to the deltoid tuberosity. It continues in this groove laterally
and distally to pierce the lateral intermuscular septum and
enters the anterior compartment at approximately the junc-
tion of the middle and distal thirds of the humerus. It then
continues to descend toward the forearm in a groove
between the brachialis and brachioradialis. It is between
these two muscles that it enters the forearm.
Radial Nerve Division and Branches
Medial Branches. Muscular branches from the radial are
given off in medial, posterior and lateral locations. Medial
branches (Fig. 6.14A) include a branch to the long head of
the triceps and a branch to the medial half of the medial or
deep head of the triceps. The branch to the medial head is
a long, slender nerve that arises in the axilla and enters the
medial head two handbreadths distal to the acromion. It lies
close to the ulnar nerve as far as the distal third of the arm,
and is called the ulnar collateral nerve because of this prox-
imity (9).
Posterior Branches. Two posterior branches may be
found; the most proximal leaves the posterolateral aspect of
the radial nerve in a more transverse course than its parent
and enters the lateral head of the triceps (see Fig. 6.14A and
B). The second and more distal branch leaves the radial
nerve posteriorly to enter the lateral half of the medial or
deep head of the triceps. This nerve also may send a branch
to the lateral head. This branch to the medial head contin-
ues distally through the substance of the lateral half of the
medial head to end in the anconeus.
Clinical Significance. The fact that two parallel and suffi-
ciently separated radial nerve branches (the medially situ-
ated ulnar collateral and the laterally placed posterior
branch) innervate the medial or deep head of the triceps
results in a useful gap between the two nerves that allows
the surgeon to split the medial head to expose the posterior
aspect of the humerus without denervating the muscle (9).
Lateral Branches. These arise anterior to the lateral inter-
muscular septum and supply the lateral one-third or less of
the brachialis and all of the brachioradialis and extensor
carpi radialis longus (see Fig. 6.14C).
Distal Radial Nerve Division. At the elbow, the radial
nerve may divide into its motor and sensory branch at any
level within a 5.5-cm segment, from 2.5 cm above to 3 cm
below Hueter’s line (a line drawn through the tips of the
epicondyles of the humerus) (1) (see Fig. 6.14C).
Ulnar Nerve
The ulnar nerve arises from the medial cord, and after leav-
ing the axilla continues distally medial to the brachial artery
until it reaches the midarm, where it pierces the medial inter-
 6 Arm 335

FIGURE 6.14. A: Medial and pos-

terior branches of the radial nerve.
Note the medial and posterior
branches to the triceps. The main
stem of the radial nerve penetrates
the lateral intermuscular septum to
enter the anterior aspect of the
arm at approximately the junction
of the middle and distal thirds of
the arm. (continued on next page)
 336 Regional Anatomy
B the lateral half of the medial head (green triangles).
muscular septum (Fig. 6.15). It then descends anterior to the
medial head of the triceps, accompanied by the superior
ulnar collateral artery, to enter the cubital tunnel. The ulnar
nerve does not give off any muscular branches in the arm.
Musculocutaneous Nerve
This nerve arises from the lateral cord of the brachial plexus
opposite the inferior border of the pectoralis minor (Fig.
6.16). It supplies the coracobrachialis, both heads of the
biceps, and most of the brachialis. The branch to the cora-
cobrachialis is given off before the musculocutaneous nerve
enters that muscle. Branches to the biceps and the brachialis
are given off after the nerve exits the coracobrachialis. The
nerve continues distally between the biceps and brachialis
muscles, and exits from the lateral margin of these muscles
to continue distally as the lateral antebrachial cutaneous
nerve.
Anatomic Detail of the Musculocutaneous Nerve. Based
on dissections in 24 cadavers, Yang et al. studied the mus-
cular branches of the musculocutaneous nerve and
observed the distance from the coracoid, length, diame-
ter, and number of fascicles of the various branches of the
musculocutaneous nerve (11). Their findings are pre-
sented in Table 6.1.
FIGURE 6.14. (continued) B: Fresh cadaver dissection of the
posterior aspect of the right arm showing the main stem of the
radial nerve and its posterior branches to the lateral head and
Innervation of the Biceps and Brachialis
Yang et al. also identified anatomic patterns of innervation
of the biceps and brachialis (11).
Biceps. The authors found three anatomic types of
biceps innervation: Type I, found in 20 cases, demon-
strated a primary motor branch (mean length, 9 ± 2 mm)
that divided into two secondary branches, each of which
separately innervated the long and short heads of the
biceps. Type II, found in two cases, demonstrated two
primary motor branches from the main musculocuta-
neous trunk, with the proximal branch innervating the
short head and the distal branch the long head, with a
distance of 26 mm between the branches. Type III, found
in two cases, is a variation of type I, with a primary motor
branch from the main musculocutaneous nerve trunk
that divides into two secondary branches to innervate the
two heads of the biceps individually, plus an additional
primary branch distal to the former by an average dis-
tance of 85 mm that innervates the distal part of the
biceps at its common belly.
Brachialis. The motor branch to the brachialis demon-
strated two anatomic patterns: Type I, found in 23 speci-
mens, demonstrated a single primary branch innervating
 6 Arm 337

FIGURE 6.14. (continued) C: Lateral muscu-

lar (anterior) branches of the radial nerve. The
main stem of the radial nerve penetrates the
lateral intermuscular septum to enter the
anterior and lateral aspect of the arm at
approximately the junction of the middle and
distal thirds of the arm. Branches are given off
in this region to the lateral third or less of the
brachialis, the brachioradialis, and the exten-
sor carpi radialis longus. The radial nerve may
divide into its radial and sensory branches 2.5
cm proximal or 3 cm distal to the interepi-
condylar line of Hueter.
 338 Regional Anatomy

FIGURE 6.15. Ulnar nerve. The ulnar nerve arises from the medial cord of the plexus and, after
leaving the axilla, continues distally medial to the brachial artery to the midarm, where it pene-
trates the medial intermuscular septum and, accompanied by the superior ulnar collateral artery,
enters the posterior aspect of the arm on its way to the cubital tunnel. No muscular branches are
given off in the arm.

A
FIGURE 6.16. A: Musculocutaneous nerve (MSCN). This nerve arises from the lateral cord of the
brachial plexus opposite the inferior border of the pectoralis minor. It supplies the coraco-
brachialis, both heads of the biceps, and most of the brachialis. The branch or branches to the
coracobrachialis are given off before it enters the coracobrachialis, and the branches to the
biceps and brachialis are given off after it exits the coracobrachialis. After supplying these mus-
cles, it continues distally between them to exit from their lateral margin as the lateral ante-
brachial cutaneous nerve.
 6 Arm 339

C
FIGURE 6.16. (continued) B: Fresh cadaver dissection of the proximal and medial aspect of the
right arm. Note the MSCN (large green arrow) entering the coracobrachialis and three motor
branches arising superiorly and entering the proximal aspect of the muscle; and note the axillary
artery and the anterior (yellow arrowhead) and posterior (blue arrowhead) humeral circumflex
arteries and the median nerve. C: Fresh cadaver dissection of the MSCN in the right arm, middle
and distal thirds, as viewed from the lateral aspect. Note the green marker at left on the cora-
coid process, the cut tendon of the pectoralis major reflected laterally, the MSCN as it exits from
the coracobrachialis, the branches to the biceps and brachialis, and the continuation of the MSCN
as the lateral antebrachial cutaneous nerve. The biceps muscle is reflected superiorly and the lat-
eral intermuscular septum (LIMS) inferiorly. Note the radial nerve (green rectangular marker)
exiting from the LIMS on its way to the forearm between the brachioradialis and the brachialis.
340 Regional Anatomy

TABLE 6.1. MUSCULAR BRANCHES OF THE MUSCULOCUTANEOUS NERVE

Branch to Distance from Coracoida Length (mm) Diameter (mm) Fascicles

Biceps 122 ± 12 mm — 1.3 ± 0.3 —

Short head — 20 ± 8 0.9 ± 0.3 2.2
Long head — 29 ± 11 0.9 ± 0.3 2.4
Brachialis 170 ± 11 34 ± 14 0.8 ± 0.2 2.7
a
Mean length of humerus was 299 ± 11 mm.
Data from Yang Z-X, Pho RWH, Kour A-K, et al. The musculocutaneous nerve and its branches to the biceps and brachialis muscles. J Hand Surg
[Am] 20:671–675, 1995, with permission.

the brachialis; type II, found in 1 specimen, demonstrated
2 primary branches from the musculocutaneous innervat-
ing the brachialis, with a distance of 15 mm between the
branches.
Cross-Communications. Cross-communication between the
median nerve and the musculocutaneous nerve was found in
three cases, and in one specimen the musculocutaneous nerve
and the median nerve combined to form a common trunk
from the lateral and medial cords of the brachial plexus.
Clinical Significance. The authors stated that this study was
done to assist the surgeon who has elected to reinnervate the
elbow flexors in brachial plexus injuries. They noted that one
of the major problems when using the intercostal nerves to
reinnervate the elbow flexors is the inadequate length and the
small number of fascicles. However, with mobilization of the
proximal motor fascicles to the biceps and brachialis, the
intercostal nerves reach the nerve ends to allow direct repair
without using a nerve graft. The suture site may be as proxi-
mal as 60 mm below the coracoid process (11).

Motor Fascicles. The authors found that the primary motor
branch was contained in a continuous epineural sheath and
that independent motor fascicles could be dissected proxi-
mally between 9 and 103 mm for the biceps motor fascicles
and 53 mm for the brachialis motor fascicles.
Median Nerve
The median nerve arises from the medial and lateral cords,
which pass on either side of the third part of the axillary
artery and then unite anterior or lateral to it to form the
median nerve (Fig. 6.17). It enters the arm lateral to the

FIGURE 6.17. Median nerve. The median nerve arises from the medial and lateral cords, which
pass on either side of the third part of the axillary artery and then unite anterior or lateral to it
to form the median nerve. It enters the arm lateral to the brachial artery near the insertion of
the coracobrachialis and then crosses in front of the artery to descend medial to it to the cubital
fossa, where it is posterior to the biceps tendon and anterior to the brachialis.

brachial artery near the insertion of the coracobrachialis and
then crosses in front of the artery to descend medial to it to
the cubital fossa, where it is posterior to the biceps tendon
and anterior to the brachialis. In the arm, the median nerve
gives branches to the brachial artery, and the branch to the
pronator teres is given off at a variable distance from the
elbow joint.
SURGICAL EXPOSURES
Anterior Approach to the Humerus
Indications
This approach can provide a comprehensive exposure of the
humerus, although only portions of the incision usually are
used. This approach may be used for fracture management
or osteotomy.
Patient Position
The patient is supine, the arm extended on a hand table,
and the forearm in supination or with the elbow flexed to
90 degrees and the forearm resting on the patient’s chest
(Fig. 6.18A).
Landmarks/Incision
Landmarks include the coracoid process, the long head of
the biceps tendon, the cephalic vein, the deltopectoral
groove, and the lateral margin of the mobile biceps muscle
(see Fig. 6.18B). The cephalic vein follows the lateral or
outer margin of the biceps and the medial or inner margin
of the deltoid. The comprehensive and complete approach
is described with the understanding that all or any portion
of the approach may be used as required. The incision
begins at the coracoid process and continues distally in the
deltopectoral groove to the lateral margin of the biceps
muscle, which it follows to the elbow flexion crease. The
lateral margin of the biceps may be identified by noting its
relative mobility compared with the underlying brachialis.
If the incision is carried one fingerbreadth lateral to the
outer margin of the biceps, the cephalic vein may be spared.
Proximal Technique
In the proximal part of the approach, the cephalic vein pro-
vides a useful landmark to identify the deltopectoral groove,
and the vein may be carried with either the deltoid or the
pectoralis as this plane is developed (see Fig. 6.18C). This
interval is followed down to the deltoid insertion, with
identification of the long and short heads of the biceps and
the coracobrachialis in the proximal portion of the wound
and the pectoralis major insertion into the crest of the
6 Arm 341
greater tuberosity. Beginning near the deltoid insertion, the
periosteum is incised just lateral to the pectoralis major ten-
don and the long head of the biceps and continued proxi-
mally to identify the anterior humeral circumflex artery,
which traverses the line of dissection. This artery is located
approximately 1 cm superior to the proximal edge of the
pectoralis major tendon and may be ligated to complete the
exposure. Dissection is subperiosteal, and the insertion of
the pectoralis major may be detached to obtain further
exposure.
Distal Technique
The approach to the distal half of the humerus is achieved
by locating the interval between the biceps and brachialis
and incising the fascia to develop the interval (Fig. 6.19). It
must be appreciated that the brachialis cloaks the distal and
anterior aspect of the humerus from the region of the del-
toid insertion to the supracondylar region. The biceps is
retracted medially to reveal the underlying brachialis cover-
ing the humerus. The medial two-thirds or more of the
brachialis is innervated by the musculocutaneous nerve and
the remaining lateral portion by the radial nerve. The
brachialis muscle may be split longitudinally in the direc-
tion of its fibers, but not along its middle or anterior aspect
because this would denervate a significant portion of the
muscle. Splitting the muscle along its outer aspect not only
minimizes the potential for denervation but at the same
time protects the radial nerve, which lies along its lateral
border. The main nutrient artery to the humerus also is pro-
tected by this technique because its entrance into the
humerus usually occurs anteromedially near the junction of
the middle and distal thirds of the humerus. Flexion of the
elbow relaxes the muscle and facilitates the exposure. Gen-
tle retraction of the lateral aspect of the brachialis protects
the radial nerve. The medial two-thirds of the brachialis
muscle, after subperiosteal dissection, is retracted medially
to expose the humerus.
Caution: The radial nerve is at risk in the posterior aspect
of the humerus as it leaves the spiral groove and enters the
anterior compartment in the distal third of the arm; care
must be exercised when retracting the soft tissues or when
inserting fixation devices.
Anterolateral Approach to the Distal
Humerus
Indications
This approach is useful to expose the distal fourth of the
humerus and, compared with the anterior approach, has the
added advantage that it can be extended proximally and dis-
tally. This approach may be used for management of fractures
of the distal humerus and for exploration of the radial nerve.
342 Regional Anatomy

FIGURE 6.18. A: Patient position for the anterior approach to the humerus. B: Landmarks and
incision. Landmarks are the coracoid process, the deltopectoral groove, the lateral biceps groove,
and cephalic vein. The incision begins at the coracoid process and continues distally in the del-
topectoral groove to the lateral margin of the biceps, which it follows to the elbow flexion
crease.
 6 Arm 343

C
FIGURE 6.18. (continued) C: Technique for anterior approach to the humerus. The cephalic
vein provides a useful proximal landmark to identify the deltopectoral groove. This interval is fol-
lowed to the deltoid insertion with identification of the long and short heads of the biceps, the
coracobrachialis, and the pectoralis major. Beginning near the deltoid insertion, the periosteum
is incised just lateral to the pectoralis major tendon and continued proximally to identify the
anterior humeral circumflex artery approximately 1 cm superior to the proximal margin of the
pectoralis tendon.

Patient Position the brachioradialis. This interval is identified by noting the

comparative mobility of the biceps with regard to the fixed
The patient is supine, with the arm extended on a hand
brachialis.
table and the forearm in supination.

Landmarks/Incision
Landmarks include the biceps and brachioradialis muscles,
the biceps tendon, and the elbow flexion crease (Fig. 6.20).
The incision begins over the lateral border of the biceps in
the midarm and curves distally to end just proximal to the
elbow flexion crease in the interval between the biceps and
Technique
The lateral margin of the biceps is used to find the more
deeply situated brachialis muscle (Fig. 6.21). Identification
of the interval between these two muscles is aided by not-
ing the cephalic vein, which lies in this interval. The termi-
nal extension of the musculocutaneous nerve, the lateral
antebrachial cutaneous, exits from the interval between the
344 Regional Anatomy

FIGURE 6.19. A: The approach to the distal half of the humerus is achieved by locating the inter-
val between the biceps and brachialis and incising the fascia to develop the interval. B: The biceps
is retracted medially to reveal the underlying brachialis, which covers the humerus. The brachialis
muscle is split along its outer aspect. This not only minimizes the potential for denervation of the
brachialis but protects the radial nerve, which lies along its lateral border, and the entrance of
the main nutrient artery to the humerus located anteromedially. Flexion of the elbow relaxes the
muscle and facilitates the exposure. Gentle retraction of the lateral aspect of the brachialis pro-
tects the radial nerve. C: The medial two-thirds of the brachialis muscle, after subperiosteal dis-
section, is retracted medially to expose the humerus.
 6 Arm 345

FIGURE 6.20. A, B: Anterolateral approach to the distal humerus. The interval between the
biceps and brachialis is used to expose this region of the humerus. Identification of the interval
between these two muscles is aided by noting the cephalic vein, which lies in this interval, and
the mobility of the biceps compared with the more fixed brachialis.

biceps and brachialis and should not be misidentified as the
radial nerve, which is situated deeper and more lateral
between the brachialis and brachioradialis. The radial nerve
is most easily identified near the elbow joint by gentle blunt
separation of the brachioradialis and brachialis using both
thumbs, one on each muscle belly, as advised by Henry (9).
The interval is widened between the brachioradialis and the
biceps and these muscles retracted to expose the radial nerve
and the brachialis. The radial nerve is traced proximally to
where it exits from the lateral intermuscular septum at
approximately the junction of the middle and distal thirds
of the arm. Dissection may be extended proximally between
the brachialis and the lateral head of the triceps with care
taken to protect the radial nerve in the spiral groove behind
the humerus. Distal extension is made in the interval
between the brachioradialis and the pronator teres. With
the radial nerve under constant view, the lateral margin of
the brachialis is released by subperiosteal dissection and
retracted medially to expose the anterolateral aspect of the
distal humerus.
346 Regional Anatomy

FIGURE 6.21. Anterolateral approach to the distal humerus, deep dissection. A: As the interval
between the biceps and brachialis is entered, the cephalic vein and the lateral antebrachial cuta-
neous nerve are noted to exit between these two muscles, and the latter should not be misiden-
tified as the radial nerve, which is situated deeper and more lateral between the brachialis and
brachioradialis. B: The radial nerve is most easily identified near the elbow joint by gentle blunt
separation of the brachioradialis and brachialis using both thumbs, one on each muscle belly, as
advised by Henry (9). C: The radial nerve is traced proximally where it exits from the lateral inter-
muscular septum. With the radial nerve under constant view, the lateral margin of the brachialis
is released by subperiosteal dissection and retracted medially to expose the anterolateral aspect
of the distal humerus.

Medial Approach to the Arm
Indications
This approach is useful for exposure of the brachial artery,
the median, ulnar, and radial nerves, and the MACN.
Patient Position
The patient is supine, with the arm extended on a hand
table and the forearm in supination.
Landmarks/Incision
The medial epicondyle, the medial biceps groove, and the
basilic vein are landmarks for placement of the skin inci-
sion (Fig. 6.22A). A longitudinal incision is made cen-
tered over the medial biceps groove and in line with the
medial epicondyle. The incision may extend from the
medial epicondyle to the axilla, depending on the need for
exposure.
Technique
Before making the skin incision, the course and location of
the basilic vein may be identified by applying a tourniquet
proximally and the skin marked as required (see Fig. 6.22B
and C). The skin and subcutaneous tissues are incised and
the basilic vein located in the subcutaneous tissue of the dis-
tal arm. This vein, which lies anteromedially at the elbow,
ascends proximally in the medial bicipital groove accompa-
nied by the MACN. These structures are useful landmarks
 6 Arm 347

and guides to the more deeply situated neurovascular bun-
dle. In the distal arm, the basilic vein is in the subcutaneous
tissue and enters the deeper zone of the arm through an
opening in the brachial fascia in the middle third of the
arm. As the vein enters this opening, the brachial fascia is
split proximally and the vein followed to the underlying
neurovascular bundle in the proximal half of the arm. The
sheath of the neurovascular bundle is incised to expose the
various components.
Another useful landmark is the medial intermuscular
septum located in the distal two-thirds of the arm. It
extends from the medial lip of the intertubercular sulcus
distal to the teres major to the medial epicondyle. It thus
divides the arm into anterior and posterior compartments,
and should be identified as an aid to location of the various
components of the neurovascular bundle.
In the proximal arm, the neurovascular bundle con-
tains the brachial artery, basilic vein, and the median,
radial, and ulnar nerves. In the region of the teres major,
the radial nerve courses posteriorly, whereas the median
and ulnar nerves continue to accompany the brachial
artery. The median nerve is adjacent to the brachial artery
throughout the arm and crosses the artery from lateral to
medial as it descends from proximal to distal. The ulnar
nerve, situated medially in the sheath of the neurovascu-
lar bundle, pierces the medial intermuscular septum at
the mid-portion of the arm and descends posterior to the
medial intermuscular septum to pass posterior to the

A
FIGURE 6.22. A: Medial approach to the arm: landmarks and incision. Landmarks are the medial
epicondyle, the medial biceps groove, and the basilic vein. A longitudinal incision is made cen-
tered over the medial biceps groove and in line with the medial epicondyle. The incision may
extend from the medial epicondyle to the axilla, depending on the need for exposure. (contin-
ued on next page)
348 Regional Anatomy

FIGURE 6.22. (continued) B: Medial approach to the arm: technique. The skin and subcuta-
neous tissues are incised and the basilic vein located in the subcutaneous tissue of the distal arm.
In the distal arm, the basilic vein is in the subcutaneous tissue and enters the deeper zone of the
arm through an opening in the brachial fascia in the middle third of the arm. As the vein enters
this opening, the brachial fascia is split proximally and the vein followed to the underlying neu-
rovascular bundle in the proximal half of the arm.
 6 Arm 349

FIGURE 6.22. (continued) C: Medial approach to the arm: technique (continued). The sheath
of the neurovascular bundle is incised to expose the various components, including proximally,
the brachial artery, basilic vein, and the median, radial, and ulnar nerves. In the region of the
teres major, the radial nerve courses posteriorly, whereas the median and ulnar nerves continue
distally in the company of the brachial artery. The median nerve is adjacent to the brachial artery
throughout the arm and crosses the artery from lateral to medial as it descends from proximal to
distal. The ulnar nerve, situated medially in the sheath of the neurovascular bundle, pierces the
medial intermuscular septum at the mid-portion of the arm and descends posterior to the medial
intermuscular septum to pass posterior to the medial epicondyle.
350 Regional Anatomy

FIGURE 6.23. A, B: Posterior approach to the humerus: landmarks and incision. The acromion
and olecranon process are landmarks for placement of the skin incision, along with the long head
of the triceps. The long head of the triceps may be identified by noting its greater mobility com-
pared with the lateral head and the deltoid. The skin incision begins over the lateral margin of
the long head of the triceps in a direct line from the acromion to the olecranon, and begins 6 to
8 cm distal to the acromion to end at the olecranon.

medial epicondyle. The superior ulnar collateral artery
and the ulnar collateral branch of the radial nerve accom-
pany the ulnar nerve.
Posterior Approach to the Humerus
Indications
This approach is useful in the treatment of humeral frac-
tures that may be associated with radial nerve palsy, for
exploration of radial nerve injuries in the spiral groove, or
for exposure of the posterior aspect of the middle and distal
thirds of the humerus.
6 Arm 351
Patient Position
The patient is prone with the arm extended on a hand
table.
Landmarks/Incision
The acromion and olecranon process are landmarks for
placement of the skin incision, along with the long head of
the triceps (Fig. 6.23A and B). The long head of the triceps
may be identified by noting its greater mobility compared
with the lateral head and the deltoid. The skin incision
begins over the lateral margin of the long head of the triceps
in a direct line from the acromion to the olecranon, and
FIGURE 6.23 (continued). C: Posterior approach
to the humerus: technique. The inferior margin of
the deltoid is retracted superiorly to reveal the “V”-
shaped opening between the two superficial heads
(long and lateral) of the triceps. The surgeon’s index
finger is used bluntly to separate the long and lat-
eral heads of the triceps until sharp dissection is
required. The oblique fibers of the lateral head join
the vertically oriented fibers of the long head at a
fibrous tissue raphe, which is the appropriate plane
of dissection. The fibers of the lateral head are sep-
arated from this thick and prominent sheet of
fibrous tissue with a knife.
352 Regional Anatomy
begins 6 to 8 cm distal to the acromion to end at the ole-
cranon.
Technique
The inferior margin of the deltoid is retracted superiorly
to reveal the “V”-shaped opening between the two super-
ficial heads (long and lateral) of the triceps (Figs. 6.24
and 6.25; see Fig. 6.23C). The surgeon passes a finger
between these two heads and lifts and begins bluntly to
separate the long and lateral heads of the triceps until
sharp dissection is required (9). The oblique fibers of the
lateral head join the vertically oriented fibers of the long
head at a fibrous tissue raphe that is the appropriate plane
of dissection. The fibers of the lateral head are separated
from this thick and prominent sheet of fibrous tissue with
FIGURE 6.24. Posterior approach to
the humerus, radial nerve and deep
brachial artery. The radial nerve and
the deep brachial artery are identi-
fied in the spiral groove and their
course is parallel to the obliquely ori-
ented origin of the medial or deep
head of the triceps. The medial head
of the triceps is split in the direction
of its fibers to expose the remainder
of the humerus. Denervation of the
medial head does not occur if the
medial head is split in its central
aspect by aiming directly for the ole-
cranon (see text).

FIGURE 6.25. Posterior approach to the humerus, deep dissec-
tion. Dissection always is subperiosteal to protect the adjacent
ulnar nerve, which pierces the medial intermuscular septum as it
exits the anterior compartment to lie medially along the medial
head of the triceps. Limited mobilization of the radial nerve may
be performed if all muscular branches are protected.
a knife. The radial nerve and the deep brachial artery are
identified in the spiral groove, and their course is parallel
to the obliquely oriented origin of the medial head or
deep head of the triceps. The medial head of the triceps
is split in the direction of its fibers to expose the remain-
der of the humerus. Denervation of the medial head does
not occur if the medial head is split in its central aspect
(aim directly for the olecranon) because the medial half of
the medial head is supplied by a long, slender radial nerve
6 Arm 353
branch called the ulnar collateral nerve (because of its
proximity to the ulnar nerve), and the lateral half of the
medial head is supplied by a posterior branch of the radial
nerve. Dissection always is subperiosteal to protect the
adjacent ulnar nerve, which pierces the medial intermus-
cular septum as it exits the anterior compartment to lie
medially along the medial head of the triceps. Limited
mobilization of the radial nerve may be performed if all
muscular branches are protected.
Proximal Posterior Approach to the
Humerus
Indications
A more proximal approach has been described to expose
portions of the proximal humerus not accessible through
the standard posterior approach (12).
Patient Position
The patient is prone with the arm extended on a hand
table.
Landmarks/Incision
These include the posterior aspect of the acromion, the del-
toid tuberosity, and the deltoid and lateral head of the tri-
ceps (Fig. 6.26). The incision begins 5 cm distal to the pos-
terior aspect of the acromion and continues in the interval
between the deltoid and triceps muscles to the level of the
deltoid tuberosity.
Technique
The interval between the lateral head of the triceps and
the deltoid is developed by blunt dissection down to the
periosteum, which is incised longitudinally (Fig. 6.27).
The lateral head and the periosteal sleeve are retracted
medially with care taken to protect the radial nerve,
which lies beneath the lateral head as it comes in contact
with the periosteum approximately 3 cm proximal to the
level of the deltoid tuberosity. Next, the periosteum is ele-
vated laterally and retracted with the deltoid. The axillary
nerve and posterior circumflex artery are at risk proxi-
mally and must be protected. Further exposure may be
obtained distally by partial release of the deltoid inser-
tion. This approach allows exposure of approximately 8
cm of the proximal humerus and is limited proximally by
the axillary nerve and posterior circumflex artery and dis-
tally by the origin of the triceps muscle and the underly-
ing radial nerve (12).
354 Regional Anatomy

FIGURE 6.26. Posterior proximal approach to the humerus: landmarks and incision. Landmarks
include the posterior aspect of the acromion, the deltoid tuberosity, and the deltoid and lateral
head of the triceps. The incision begins 5 cm distal to the posterior aspect of the acromion and
continues in the interval between the deltoid and triceps muscles to the level of the deltoid
tuberosity.
 6 Arm 355

FIGURE 6.27. A, B: Proximal posterior approach to the humerus: technique. The interval
between the lateral head of the triceps and the deltoid is developed by blunt dissection down to
the periosteum, which is incised longitudinally. The lateral head and the periosteal sleeve are
retracted medially with care taken to protect the radial nerve, which lies beneath the lateral
head as it comes in contact with the periosteum approximately 3 cm proximal to the level of the
deltoid tuberosity. Next, the periosteum is elevated laterally and retracted with the deltoid. The
axillary nerve and posterior circumflex artery are at risk proximally and must be protected. Fur-
ther exposure may be obtained distally by partial release of the deltoid insertion.

CLINICAL CORRELATIONS Anatomic Factors

Radial Nerve Palsy in the Arm
Associated Injuries
Radial nerve palsy in the arm is associated most often with
fractures of the humerus in the middle third or at the junc-
tion of the middle and distal thirds. Radial nerve palsy at
this location is distinguished from the more proximal “Sat-
urday night palsy” and “crutch palsy” seen in the upper arm
and axilla, respectively.
At the level in the humerus under discussion, the radial nerve
is subject to injury based on at least two anatomic factors: (a)
the proximity of the radial nerve to bone in the spiral groove,
and (b) the relative fixation of the radial nerve in the spiral
groove and at the site of penetration of the nerve through the
lateral intermuscular septum on its way from the posterior to
the anterior aspect of the arm. Based on these anatomic find-
ings, it is appropriate to postulate the etiology of the neu-
rapraxia based on traction, contusion, or hematoma.
356 Regional Anatomy
Surgical Exploration
Although much discussion has been generated around the
issue of early versus late exploration of radial nerve palsy
associated with humeral fracture, most palsies recover spon-
taneously, and early surgical exploration is recommended in
only three circumstances: (a) open fractures, (b) fractures
that require open reduction and or fixation, and (c) frac-
tures with associated vascular injuries. The onset of radial
nerve palsy after fracture manipulation is not an indication
for early nerve exploration (13,14).
Surgical Exploration for the Holstein-Lewis
Fracture
In 1963, Holstein and Lewis described a spiral oblique frac-
ture of the distal humerus in seven patients, with radial
nerve paralysis in five and paresis in two (15). They noted
radial angulation and overriding at the fracture site. As the
radial nerve courses anteriorly through the lateral intermus-
cular septum, it is less mobile and subject to being injured
by the movement of the distal fracture fragment. Because of
the high incidence of radial nerve dysfunction, early opera-
tive intervention was advised. In a larger and more recent
study of this fracture associated with radial nerve palsy, 11
of 15 patients were treated without exploration of the radial
nerve and had complete recovery; in the 4 patients who
were explored, the nerve was in continuity and also demon-
strated complete recovery (14).
Radial Nerve Entrapment in the Arm
Etiology
Radial nerve entrapment in the arm is rare compared with
trauma-related palsy (6). Lotem et al. in 1971 described a
fibrous arch and accessory part of the lateral head of the tri-
ceps that they associated with nerve compression secondary
to swelling of the muscle after muscular effort (16). This
was a case report of exertional radial nerve palsy that was
not confirmed surgically, but the anatomic etiology was
postulated based on cadaver studies that found the radial
nerve passed through a fibrous tissue arch in the lateral head
of the triceps (16). Four other cases of radial nerve entrap-
ment in this region of the lateral head of the triceps have
been reported, some spontaneous in onset and some fol-
lowing strenuous muscular activity (6,17–19). Two of the
four cases demonstrated a fibrous arch at the time of
surgery (6,19). What appears to be a familial radial nerve
entrapment syndrome has been reported in a 15-year-old
girl with a total and spontaneous radial nerve palsy. Her sis-
ter had recently sustained an identical lesion that was
improving spontaneously, and her father also suffered from
intermittent radial nerve palsy (20). The authors of this
report agreed with the concept of a genetically determined
defect in Schwann cell myelin metabolism, noting that sites
along the course of a nerve that were subject to chronic or
intermittent compression may undergo segmental demyeli-
nation with resultant nerve palsy (21).
Treatment
Although a patient with entrapment neuropathy with an
acute onset after overactivity sometimes recovers sponta-
neously, entrapment in the advanced stage should be surgi-
cally decompressed because prolonged compression might
result in intraneural fibrotic changes secondary to long-
term compression (6,18). The surgical approach of choice is
posterior between the long and lateral heads of the triceps.
ANATOMIC VARIATIONS
Arcades
Arcades of Struthers’
John Struthers, an anatomist in Edinburgh, described a
series of nine abnormal arcades in the arm (Figs. 6.28
through 6.30). Eight were related to potential compression
of the median nerve/brachial artery, and one to the ulnar
nerve (22). Only two, or possibly three, of these arcades
have been found to be associated with clinical symptoms
(22–25). For the sake of clarity, these arcades are presented
in Table 6.2, followed by a more detailed discussion of the
three arcades that may have clinical significance.
Clinically Significant Arcades
The first six of the median nerve/brachial artery arcades are
of historical and anatomic interest, and at this time have no
reported clinical significance in terms of entrapment or
impingement of nerve or blood vessel. The following three
arcades are of clinical significance.
Arcade VII
Arcade VII is characterized by an abnormal proximal origin
of the superficial head of the pronator teres from the supra-
condylar ridge rather than the medial epicondyle (Fig.
6.31). This high origin also may be related to the presence
of a supracondylar process. This position results in lateral
displacement of the neurovascular bundle and has the
potential for compression of the underlying median nerve
and brachial artery. Arcade VII of Struthers should not be
confused with the so-called pronator teres syndrome as
described by Johnson and colleagues in 1977 (26). These
authors noted compression of the median nerve at one of
three levels, in the following order of frequency: the prona-
 6 Arm 357

FIGURE 6.28. Arcades of Struthers, I to

IVc. The arcades are median nerve/
brachial artery arcades. Arcade I is a
muscular slip from the latissimus dorsi to
the pectoralis major to the coraco-
brachialis muscle or biceps tendon;
arcade II is a muscular slip from the cora-
cobrachialis to medial intermuscular sep-
tum; and arcade III is an anomalous third
head of the biceps from the medial
intermuscular septum that inserts into
the biceps aponeurosis. (continued on
next page)
358 Regional Anatomy

FIGURE 6.28. (continued) Arcade IVa

is a musculotendinous slip from the
biceps to the pronator teres aponeuro-
sis; arcade IVb is a musculotendinous
slip from the bicipital tuberosity to the
pronator teres aponeurosis; and arcade
IVc is a musculotendinous slip from the
pectoralis major to the pronator teres
aponeurosis.
 6 Arm 359

FIGURE 6.29. Arcades of Struthers, V to

VII. Arcade V is an accessory brachial
head of the biceps surrounding the neu-
rovascular structures in the lower arm;
arcade VI is an accessory muscle slip from
the brachialis that inserts into the prona-
tor aponeurosis; and arcade VII is an
abnormal origin of pronator teres from
the medial supracondylar ridge rather
than the medial epicondyle.
360 Regional Anatomy

FIGURE 6.30. Arcades of Struthers, VIII and ulnar nerve arcade. Arcade VIII is a ligament passing
from a supracondylar process to the medial humeral condyle; the ulnar nerve arcade is a fibrous
tissue band from the medial intermuscular septum to the medial head of the triceps located 8 cm
proximal to the medial epicondyle of the humerus. It is described in detail in Chapter 7.

TABLE 6.2. MEDIAN NERVE/BRACHIAL ARTERY ARCADES OF STRUTHERS

Arcade Abnormal Muscle/Ligament Complex

I Muscular slip from latissimus dorsi to pectoralis major, coracobrachialis, or biceps tendon
II Muscular slip from coracobrachialis to medial intermuscular septum
III Anomalous third head of the biceps from the medial intermuscular septum that inserts into the biceps aponeurosis
IVa Musculotendinous slip from biceps to pronator teres aponeurosis
IVb Musculotendinous slip from bicipital tuberosity to pronator teres aponeurosis
IVc Musculotendinous slip from pectoralis major to pronator teres aponeurosis
V Accessory brachial head of the biceps surrounding the neurovascular structures in the lower arm
VI Accessory muscle slip from brachialis that inserts into the pronator aponeurosis
VII Abnormal origin of pronator teres from the medial supracondylar ridge rather than the medial epicondyle
VIII Ligament of Struthers passing from a supracondylar process to the medial humeral condyle
Ulnar nerve Fibrous tissue band from the medial intermuscular septum to the medial head
arcade of the triceps located 8 cm proximal to the medial epicondyle of the humerus
 6 Arm 361

FIGURE 6.31. Arcade of Struthers, VII. This arcade is characterized by an abnormal proximal ori-
gin of the superficial head of the pronator teres from the supracondylar ridge rather than the
medial epicondyle. This position results in lateral displacement of the neurovascular bundle and
has the potential for compression of the underlying median nerve and brachial artery.

tor teres, the flexor superficialis arch, and the lacertus fibro-
sus.
The pronator teres syndrome is discussed in detail in
Chapter 8.

Arcade VIII
Anatomy. This arcade, along with the ulnar nerve arcade
on the medial aspect of the arm, probably has the great-
est clinical significance (Fig. 6.32; see Fig. 6.30). Arcade
VIII consists of a supracondylar process and ligament of
Struthers that spans between the supracondylar process
and the medial epicondyle, thus creating an arcade that
contains the median nerve and brachial artery (27). The
supracondylar process is a hook-shaped projection of
bone from the anteromedial aspect of the distal humerus.
It arises 3 to 5 cm proximal to the medial epicondyle and
is 2 to 20 mm in length (2). Its incidence is approxi-
mately 1%, and it is a rare cause of pressure on the under-
lying median nerve and brachial artery (2,27). In climb-
ing animals, the supracondylar process normally is FIGURE 6.32. The ligament of Struthers. The ligament of
present and forms a foramen called the end-epitrochlear Struthers spans between the anomalous supracondylar process
foramen that serves to protect the neurovascular bundle and the medial epicondyle and thus creates an arcade that con-
tains the median nerve and brachial artery. The supracondylar
and provides attachment for the pronator teres (27,28). If process is a hook-shaped projection of bone from the anterome-
the ligament of Struthers extends to the fibrous arch of dial aspect of the distal humerus that arises 3 to 5 cm proximal
the two heads of the FCU as well as the medial epi- to the medial epicondyle and is 2 to 20 mm long. If the ligament
of Struthers extends to the fibrous arch of the two heads of the
condyle, it may produce compression of the median as flexor carpi ulnaris as well as the medial epicondyle, it may pro-
well as the ulnar nerve (29). The ligament of Struthers duce compression of the median as well as the ulnar nerve.
362 Regional Anatomy
has been reported without the usually associated supra-
condylar process, and the ligament alone may produce
median nerve compression (22,24). The humeral or
superficial head of the pronator teres may arise from the
supracondylar process and the ligament of Struthers in
some instances (24,27).
Clinical Picture. Symptoms may include aching pain in
the region of the elbow with proximal migration toward the
medial aspect of the arm and shoulder and diminished sen-
sibility in the median nerve distribution in the hand. Weak-
ness of grip may be noted, and sometimes the supracondy-
lar process may be palpable (24,27). An oblique radiograph
of the distal humerus may demonstrate the anteromedially
placed supracondylar process (27).
Treatment. Excision of the supracondylar process and lig-
ament of Struthers usually results in complete resolution of
the problem (24,25,27).
The Ulnar Nerve and Arcade of Struthers
This structure that occurs in the arm and which involves
the ulnar nerve must be distinguished from the ligament
of Struthers that involves the median nerve, usually in
association with a supracondylar process (see Fig. 6.30).
The arcade of Struthers as it relates to the ulnar nerve
occurs 8 cm proximal to the medial epicondyle and arises
from the medial intermuscular septum, crosses over the
ulnar nerve, and inserts into the fascial elements of the
medial head of the triceps (23). A detailed description of
the ulnar nerve arcade of Struthers is given in Chapter 7
in the section on surgical technique for ulnar nerve trans-
position.
Muscle
Biceps
In approximately 12% of arms, an accessory humeral head
is found in addition to the usual scapular sites of origin
(28). The most common accessory head arises from the
medial side of the brachialis and the medial intermuscular
septum near the insertion of the coracobrachialis, and
attaches to the medial side of the biceps aponeurosis and the
biceps tendon. A less common accessory head arises from
the proximal humerus in the region of the lesser tubercle
(2,28).
Clinical Significance
The most common form of an accessory head usually lies
behind the brachial artery as a single muscle belly, but
sometimes it has two heads or slips through which the neu-
rovascular bundle may pass. The two-headed form of the
muscle may represent arcade III in Struthers’ description of
nine arcades in the arm (2,3,25).
Brachialis
This muscle may split into two parts in its distal aspect, or
may be fused with the brachioradialis, pronator teres, or
biceps. Aberrant distal attachments have included the
radius, the elbow joint capsule, and the biceps aponeurosis
(2,28).
Triceps
Medial Aspect of Elbow
An anomalous musculotendinous slip may arise from the
triceps and run through a groove behind the medial epi-
condyle. During elbow flexion, the patient experiences a
painful snapping over the medial aspect as the abnormal
slip snaps forward. In some cases there may be progressive
numbness in the ulnar nerve distribution of the hand
(28,30).
Clinical Significance
This condition must be distinguished from ulnar nerve
neuritis or cubital tunnel syndrome because the treatment
is markedly different. This topic is discussed in Chapter 7.
Coracobrachialis
The coracobrachialis, which normally inserts on the medial
mid-portion of the humerus, may extend as far distally as
the medial supracondylar or epicondylar region, and in
such instances the muscle is called the coracobrachialis infe-
rior and coracobrachialis longus, respectively. The coraco-
brachialis brevis, in contrast, may insert on the bicipital
ridge of the humerus approximately 1 cm distal to the lesser
tuberosity (28).
Vasculature
Brachial Artery
The brachial artery extends from the distal margin of the
teres major to the antecubital fossa, where it normally
divides into the radial and ulnar arteries.
Variations
Superficial Brachial Artery. The superficial brachial
arises from the axillary or the proximal end of the brachial
artery and is superficial to the musculature of the arm. It
lies slightly more lateral than the normally placed brachial
artery. It divides into the radial and ulnar arteries in the
elbow region (28,31). Under these circumstances, the usual
brachial artery may be absent or give rise only to the deep
brachial and common interosseous arteries. The radial
artery, as a branch of the superficial brachial, has a normal
course, but the ulnar artery derived from the superficial

brachial usually courses superficially across the forearm flex-
ors to the medial side of the forearm (31).
High Origin of the Radial or Ulnar Artery. High origin
of the radial or ulnar artery is the most common variation
of the brachial artery (31). A high origin of the radial artery
may occur in 15% of individuals, and it may arise as high
as the axillary artery. A high radial artery usually lies ante-
rior to the median nerve and medial to the biceps, but in
the forearm is in its normal position. In contrast, a high ori-
gin of the ulnar artery only occurs in approximately 2% of
individuals, and it may arise from the axillary or brachial
artery. It usually lies superficial to the brachial artery and
median nerve and remains superficial in the antecubital
fossa, where it lies on the forearm flexors.
High or Low Division of the Brachial Artery. A high
division of the brachial artery has been reported, usually
near its origin, in 12% of individuals (28), and a low divi-
sion as late as 8 cm distal to the antecubital fossa also has
been noted (32).
Clinical Significance
High Origin of the Ulnar Artery. The ulnar artery courses
superficially across the forearm flexors and may be at risk
during venipuncture (33), as well as during surgical expo-
sures in the proximal forearm or during elevation of a radial
forearm flap.
Low Origin of Radial Artery. In this configuration, the
radial artery usually passes deep to the pronator teres and
does not have its usual skin and subcutaneous tissue con-
nections, which may be of significance in a radial forearm
flap (32).
Nerve
Musculocutaneous Nerve
Instead of piercing the coracobrachialis, the nerve may
travel with the median nerve for a variable distance and
then, either as a single branch or as several branches, pass
between the biceps and brachialis to innervate the biceps,
brachialis, and coracobrachialis (28). This variation was
found in 22% of arms. Sometimes, only a portion of the
musculocutaneous nerve pursues this course and then
rejoins the main trunk after penetrating and supplying the
coracobrachialis.
Other Variations
These include the finding that the musculocutaneous nerve
may be accompanied by fibers of the median nerve as it tran-
sits the coracobrachialis; instead of penetrating the coraco-
brachialis, the nerve may pass behind or between it and the
short head of the biceps; and, rarely, the lateral cord may
6 Arm 363
pierce the coracobrachialis and then divide into the muscu-
locutaneous and the lateral head of the median nerve (28).
Median Nerve
In cases of high division of the brachial artery, when the
resulting radial and ulnar arteries lie along the medial side
of the arm, the median nerve lies between these two vessels
(3,28).
REFERENCES
1. Fuss FK, Wurzl GH. Radial nerve entrapment at the elbow: sur-
gical anatomy. J Hand Surg [Am] 16:742–747, 1991.
2. Williams PL. Gray’s anatomy, 38th ed. New York: Churchill Liv-
ingstone, 1995.
3. Agur AMR. Grant’s atlas of anatomy, 9th ed. Baltimore: Williams
& Wilkins, 1991.
4. Masear VR, Meyer RD, Pichora DR. Surgical anatomy of the
medial antebrachial cutaneous nerve. J Hand Surg [Am] 14:
267–271, 1989.
5. Cheney ML. Medial antebrachial cutaneous nerve graft. In:
Urken ML, Cheney ML, Sullivan MJ, et al., eds. Atlas of regional
and free flaps for head and neck reconstruction. New York: Raven
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6. Nakamichi K, Tachibana S. Radial nerve palsy entrapment by the
lateral head of the triceps. J Hand Surg [Am] 16:748–750, 1991.
7. Race CM, Saldana MJ. Anatomic course of the medial cutaneous
nerves of the arm. J Hand Surg [Am] 16:48–52, 1991.
8. Dellon AL, MacKinnon SE. Injury to the medial antebrachial
cutaneous nerve during cubital tunnel surgery. J Hand Surg [Br]
10:33–36, 1985.
9. Henry AK. Extensile exposure, 2nd ed. Edinburgh: E. and S. Liv-
ingstone, 1966.
10. Laing PG. The arterial supply of the adult humerus. J Bone Joint
Surg Am 38:1005–1016, 1956.
11. Yang Z-X, Pho RWH, Kour A-K, et al. The musculocutaneous
nerve and its branches to the biceps and brachialis muscles. J
Hand Surg [Am] 20:671–675, 1995.
12. Berger RA, Buckwalter JA. A posterior surgical approach to the
proximal part of the humerus. J Bone Joint Surg Am 71:407–
410, 1989.
13. Green DP. Radial nerve palsy. In: Green DP, ed. Operative hand
surgery, 3rd ed. New York: Churchill Livingstone, 1993.
14. Szalay EA, Rockwood CA Jr. The Holstein-Lewis fracture revis-
ited. Orthop Trans 7:516, 1983.
15. Holstein A, Lewis G. Fractures of the humerus with radial nerve
paralysis. J Bone Joint Surg Am 45:1382–1388, 1963.
16. Lotem M, Fried A, Levy M, et al. Radial nerve palsy following
muscular effort. J Bone Joint Surg Br 53:500–506, 1971.
17. Manske PR. Compression of the radial nerve by the triceps mus-
cle: a case report. J Bone Joint Surg Am 59:835–836, 1977.
18. Mitsunaga MM, Nakano K. High radial nerve palsy following
strenuous muscular activity. Clin Orthop 234:39–42, 1988.
19. Yoshii S, Urushidani H, Yoshikawa K, et al. Radial nerve palsy
related to a fibrous arch of the lateral head of the triceps: a case
report. Cent Jpn J Traumatol 28:798–799, 1985.
20. Lubahn JD, Lister GD. Familial radial nerve entrapment syn-
drome: a case report and literature review. J Hand Surg[Am] 8:
297–299, 1983.
21. Mayer FR, Garcia-Mullin R. Hereditary neuropathy manifested
by pressure palsies: a Schwann cell disorder? Trans Am Neurol
Assoc 93:238–240, 1968.
364 Regional Anatomy
22. Struthers J. On some points in the abnormal anatomy of the arm.
Br Foreign Med Chir Rev 14:170–179, 1854.
23. Al-Qattan MM, Murray KA. The arcade of Struthers: an
anatomical study. J Hand Surg [Br] 16:311–314, 1991.
24. Smith RV, Fisher RG. Struthers’ ligament: a source of median nerve
compression above the elbow. J Neurosurg 28:778–779, 1973.
25. Vesley DG, Killian JT. Arcades of Struthers. J Med Assoc State Al
52:33–37, 1983.
26. Johnson RK, Spinner M, Shrewsbury MM. Median nerve
entrapment in the proximal forearm. J Hand Surg [Am] 4:
48–51, 1979.
27. Al-Qattan MM, Husband JB. Median nerve compression by the
supracondylar process: a case report. J Hand Surg [Br] 16:
101–103, 1991.
28. Tountas CP, Bergman RA. Anatomic variation of the upper extrem-
ity. New York: Churchill Livingstone, 1993.
29. Mittal RL, Gupta BR. Median and ulnar nerve palsy: an unusual
presentation of the supracondylar process. Report of a case. J
Bone Joint Surg Am 60:557–558, 1978.
30. Reis ND. Anomalous triceps tendon as a cause for snapping
elbow and ulnar neuritis: a case report. J Hand Surg[Am] 5:
361–365, 1980.
31. Weathersby HT. Anomalies of the brachial and antebrachial
arteries of surgical significance. South Med J 49:46–52, 1956.
32. Small JO, Millar R. The radial forearm flap: an anomaly of the
radial artery. Br J Plast Surg 38:501–503, 1985.
33. Hazlett JW. The superficial ulnar artery with reference to acci-
dental intra-arterial injection. CMAJ 61:249–251, 1949.
 7

ELBOW
JAMES R. DOYLE

The elbow joint is a compound synovial uniaxial joint that
allows a wide range of functional positions for the hand.
This joint permits 180 degrees of rotation of the forearm
and a flexion–extension arc of 140 degrees with intrinsic
stability that resists deformity in all planes in spite of long
moment arms and large forces acting through its joint axis.
Stability of this joint is based on its skeletal configuration as
well as its ligamentous support system (1). The ligaments
provide approximately 50% of the stability, and the exact
distribution varies between 45% and 55%, depending on
the flexion or extension position of the elbow (1). Strong
muscles and tendons also span this joint, which adds fur-
ther stability. The hingelike motion of the joint is provided
for by the articulation between the proximal ulna and the
trochlea, whereas rotation is provided for by the round and
concave radial head that articulates with the capitulum and
the radial notch of the ulna, thus allowing rotation of the
radius around the longitudinal axis of the ulna. These seem-
ingly contradictory movements are permissible because the
ulna flexes and extends only, whereas the radius not only
flexes and extends but rotates as well. Although the articu-
lation between the ulna and trochlea is more intrinsically
stable than the articulation between the radius and capitu-
lum, both joints are stabilized by strong ligaments (2).
DESCRIPTIVE ANATOMY
Contents
Bone: Distal humerus, proximal radius, and proximal ulna.
Blood Vessels: Brachial artery and its branches.
Nerves: Ulnar, median, radial, and cutaneous nerves.
Muscles: Elbow flexors and extensors, forearm flexor-prona-
tors, forearm extensor-supinators.
Fat Pads, Capsule, and Ligaments: Anterior and posterior
fat pads, anterior and posterior joint capsule, and anterior,
medial, and lateral joint ligaments.
External Landmarks
The major landmarks about the elbow are the medial and
lateral epicondyles and the olecranon process of the ulna.
All of these landmarks are bony prominences that are easily
identified by visualization and palpation. These three land-
marks form a triangle that allows for the accurate placement
of incisions and the identification of adjacent vital struc-
tures (Fig. 7.1).
Skeletal Anatomy
Articulations
The elbow joint includes three articulations: (a) the trochlea
of the humerus with the ulnar trochlear notch, (b) the
capitulum of the humerus with the radial head, and (c) the
proximal radioulnar joint (radial head to the radial notch of
the ulna). The trochlea is not a symmetric pulley because its
medial edge is approximately 6 mm longer than its lateral
counterpart; it also is wider posteriorly (2). The trochlear
notch of the ulna is not totally congruent with the humeral
trochlea because in flexion a portion of the lateral aspect of
the trochlear notch is not in contact with the humeral
trochlea, and in extension the medial part of the proximal
olecranon is not in contact with the humeral trochlea. The
proximal and distal halves of the trochlear notch are sepa-
rated by an area devoid of articular cartilage and covered by
fibroadipose tissue and synovium. The capitulum and radial
head are reciprocally curved, and closest contact occurs in
semiflexion and mid-pronation. During flexion, the radial
head is accommodated by the groove between the humeral
trochlea and capitulum and in full flexion by the radial fossa
just proximal to the capitulum. The coronoid process of the
ulna is similarly accommodated in flexion by the coronoid
fossa. Posteriorly, the apex of the olecranon avoids impinge-
ment by entering the comparatively large olecranon fossa
when the elbow is extended.
The Carrying Angle
When the forearm is supinated and in full extension, it
deviates laterally by approximately 17 degrees (2). This so-
called carrying angle is due to (a) the fact that the medial
trochlear edge is approximately 6 mm longer than its lat-
eral edge; and (b) the matching obliquity of the coronoid’s
366 Regional Anatomy

A B
FIGURE 7.1. A: The major posterior bony landmarks about the elbow are the medial and lateral
epicondyles and the olecranon process of the ulna. B: These three bony landmarks form a trian-
gle that allows for the accurate placement of incisions and the identification of adjacent vital
structures.

superior articular surface, which is not orthogonal to the Nonarticular Components

ulnar shaft (2). The carrying angle disappears when the
elbow is flexed because of slight spiral orientation of the
ridge in the trochlear notch and the companion groove in
the trochlea, and the fact that the tilt of the humeral and
ulnar articular surfaces is approximately equal (2). The
carrying angle is masked, if not obliterated, by pronation
of the forearm, which brings the hand into a more func-
tional position.
Distal Humerus
The distal humerus is a modified condyle that is wider than
it is thick and has articular and nonarticular parts.
Articular Components
The lateral and convex capitulum is less than half a sphere
that has anterior and inferior but not posterior articular sur-
faces. It articulates with the discoid radial head, which abuts
the inferior surface in full extension. The trochlea, the
medial and pulley-shaped humeral surface, articulates with
the trochlear notch of the proximal ulna. The trochlear
notch of the ulna has a mid-articular ridge that extends
from front to back and corresponds to a groove in the
trochlea of the humerus. The articular surface of the
trochlea is anterior, inferior, and posterior and is separated
from the capitulum by a shallow groove (2).
The nonarticular medial and lateral epicondyles and their
respective supracondylar ridges are sites of origin for the
flexor-pronator and extensor-supinator muscles, respec-
tively. The smooth posterior surface of the medial epi-
condyle is traversed by the ulnar nerve through a groove
before its entrance into the flexor carpi ulnaris (FCU). The
radial and coronoid fossae provide space for the radial head
and coronoid process of the ulna, respectively, to accom-
modate flexion of the elbow without impingement. Posteri-
orly, the olecranon fossa accommodates the apex of the ole-
cranon process when the elbow is extended (Fig. 7.2).
Radius
The radial head is discoid and its proximal surface is a shallow
cup to accommodate the adjacent capitulum. The disc is
widest medially, where it articulates with the ulna in the radial
notch (2). The neck is positioned between the head and the
medially placed biceps tuberosity (Fig. 7.3). The nonarticular
portion of the radial head is posterolateral when the arm is in
full supination. This nonarticular portion of the radial head is
characterized by a thin band of yellowish cartilage, in contrast
to the wider, white, and glistening cartilage of the articular
portion. This nonarticular zone is located in a 90-degree
quadrant as measured from the radial styloid and Lister’s
tubercle and projected proximally to the radial head (3).

FIGURE 7.2. Anterior and posterior views of the distal humerus.
Clinical Significance
This nonarticulating portion of the radial head represents a
safe zone for the application of a fixation device, such as a
plate and screws, without the danger of impingement.
Ulna
The proximal end of the ulna is a large hook process with a
trochlear or semilunar notch that is bounded proximally by
FIGURE 7.3. The radial head and proximal radius.
7 Elbow 367
the apex of the olecranon process and distally by the coro-
noid process. Just distal to the coronoid process is the site
of insertion of the brachialis muscle, the ulnar tuberosity,
and a rough impression on the anterior aspect of the coro-
noid process (Fig. 7.4).
FIGURE 7.4. The proximal ulna.
368 Regional Anatomy

ANATOMIC RELATIONSHIPS intraosseous vascular anatomy that were organized into

Extraosseous and Intraosseous Arterial
Anatomy of the Adult Elbow
Yamaguchi et al., based on injection studies of 22 fresh
cadaver elbows, found consistent patterns of extraosseous and
medial, lateral, and posterior arcades (4). The intraosseous cir-
culation of the elbow was derived mainly from perforating
branches from neighboring extraosseous arteries. The details
of this vascular complex are given in Figure 7.5 and Table 7.1.
The reader is referred to this comprehensive article for details.

A B

FIGURE 7.5. The extraosseous and intraosseous arterial anatomy of the adult elbow. A: The ante-
rior right elbow showing the superior ulnar collateral (SUC); inferior ulnar collateral (IUC); anterior
and posterior ulnar recurrent (AUR and PUR); common interosseous (CI) and its branches the ante-
rior and posterior interosseous (AI and PI) and the interosseous recurrent (IR); and the radial recur-
rent (RR) arteries. B: The posterior right elbow showing the radial and medial collateral branches (RC
and MC); the radial recurrent artery (RR); the interosseous recurrent artery (IR); the posterior ulnar
recurrent artery (PUR); and the inferior and superior ulnar collateral branches (IUC and SUC).
 7 Elbow 369

FIGURE 7.5 (continued). C: Medial view of the right

elbow showing superior and inferior ulnar collateral
branches (SUC and IUC); and the posterior and anterior
ulnar recurrent arteries (PUR and AUR). D: Lateral view of
the right elbow showing the radial and interosseous
recurrent arteries (RR and IR) and the medial and radial
collateral branches (MC and RC). (Redrawn after Yam-
aguchi K, Sweet FA, Bindra R, et al. The extraosseous and
intraosseous arterial anatomy of the adult elbow. J Bone
D Joint Surg Am 79:1653–1662, 1997, with permission.)
370 Regional Anatomy

TABLE 7.1. EXTRAOSSEOUS BLOOD SUPPLY TO THE ELBOW

Distance from
Medial Epicondyle
(cm)

Artery Origin Average Range Common Anastomoses Supplies

Profunda brachiia Brachial 21.6 18.2–25.2

Radial collateral Profundus 19.9 18.0–23.0 Radial recurrent Lateral aspect of trochlea,
capitellum, lateral epicondyle
Middle collateral Profundus 19.9 18.0–23.0 Interosseous recurrent Capitellum, medial aspect of
olecranon
Superior ulnar Brachial 17.2 13.5–23.0 Medial arcade, inferior Olecranon fossa, medial aspect
collateral ulnar collateral of trochlea
Inferior ulnar Brachial 6.7 2.0–11.5 Superior ulnar recurrent, Medial epicondyle, coronoid
collateral posterior ulnar fossa, medial aspect of
recurrent trochlea
Radial recurrent Radial 6.6 5.4–9.0 Radial collateral Radial head and neck,
capitellum
Interosseous recurrent Posterior interosseous 8.9 8.0–10.0 Middle collateral Lateral aspect of olecranon
recurrent radial neck, capitellum
Posterior ulnar Ulnar 7.3 5.8–9.7 Superior ulnar collateral, Medial aspect of olecranon
recurrent inferior ulnar medial aspect of trochlea
collateral
Anterior ulnar Ulnar 6.9 4.0–8.6 Inferior ulnar collateral Mostly muscular
recurrentb
aPresent in 19 (86%) of the 22 specimens.
bPresent in 11 (50%) of the 22 specimens.

Clinical Significance and lateral collateral ligaments. Anteriorly, the capsule

begins proximal to the coronoid and radial fossae and spans
The perforating branches from the extraosseous arteries are
the interval from the medial to the lateral epicondyle. Dis-
the main source of the intraosseous blood supply to the
tally, it is attached to the coronoid process and the annular
elbow and may be damaged by injury or indiscriminate dis-
ligament and spans the interval between the two condyles.
section during surgery. The radial head has a dual
Posteriorly, the capsule is thin and its attachments proxi-
extraosseous blood supply; the first source is from a single
mally are from the margins of the olecranon fossa and dis-
branch of the radial recurrent artery directly to the head,
tally from the olecranon process, the lateral epicondyle and
and the second source is from vessels from both the radial
annular ligament, and the medial epicondyle. A synovial
and interosseous recurrent arteries that penetrate the capsu-
membrane lines the articular capsule including the radial,
lar insertion at the neck of the radius. The vessel to the
coronoid, and olecranon fossae (2).
radial head enters at the noncartilaginous portion of the
head, which is the preferred area for placement of fixation
devices and may have vascular implications (4). The proxi- Fat Pads
mal ulna is well vascularized from posteromedial and pos-
terolateral sources (4). Between the capsule and synovial membrane are three fat
pads: the largest is at the olecranon fossa and is pressed into
the fossa by the triceps during flexion; the other two are at
Elbow Capsule, Fat Pads, and Ligaments the coronoid and radial fossae, and are compressed into the
The elbow joint is a compound uniaxial synovial joint with fossa by the brachialis during extension (2).
capsular and ligamentous fibrous tissue support. The cap-
sule is anterior and posterior; the fat pads are extrasynovial;
Anterior Ligament
and the ligaments are anterior (annular ligament of radius),
medial (ulnar), and lateral (radial). The annular ligament of the radius arises from the lateral
aspect of the coronoid process of the ulna and arches up and
over the head and neck of the radius to insert on the oppo-
Capsule
site side of the coronoid process. It is a strong band that
The fibrous tissue capsule is comparatively thin anteriorly forms a fibroosseous ring with the ulnar radial notch and
and posteriorly compared with the more substantial medial maintains the radial head in this notch. The annular band

forms approximately four-fifths of this ring. The radial col-
lateral ligament blends with the outer layers of the annular
ligament, and a portion of the supinator attaches to the
annular ligament (2). This ligament also is considered to be
the ligament of the proximal radioulnar joint, just as the tri-
angular fibrocartilage complex is considered to be the liga-
ment of the distal radioulnar joint and the interosseous
membrane the ligament of the so-called middle joint of the
forearm (2). Many authors have considered the annular lig-
ament to be part of the lateral ligament complex of the
elbow, although this differs from its classic description
(1,2,5–8). However, the fact that the fan-shaped radial lat-
eral ligament blends with and attaches to the superior and
lateral portion of the annular ligament so extensively gives
support to the concept of including the annular ligament as
part of the lateral ligament complex.
Medial Ligaments
The medial or ulnar collateral ligament of the elbow con-
sists of three parts, the anterior, posterior, and transverse lig-
aments (2) (Figs. 7.6 and 7.7).
Anterior Component of the Medial Ligament
This component is an obliquely oriented, cordlike segment
that arises from a depression in the inferior aspect of the
medial epicondyle of the humerus. It attaches to the coro-
noid process of the ulna adjacent to the sublimis tubercle
(9). The mean length of the anterior portion is 27.1 ± 4.3
mm and the mean width is 4.7 ± 1.2 mm (5). The anterior
ligament is divided into anterior and posterior parts. These
two parts tighten in reciprocal fashion as the elbow flexes
and extends. The anterior part is relaxed in flexion and tight
7 Elbow 371
in extension and the reverse is true for the posterior part of
the anterior ligament (9). In general, the anterior part of the
anterior ligament is tight from full extension to 60 degrees
of flexion, and the posterior part of the anterior ligament is
tight from 60 to 120 degrees of flexion (5).
Posterior Component of the Medial Ligament
The fanlike posterior ligament arises posterior to the origin
of the anterior ligament, slightly posterior to the most infe-
rior portion of the medial epicondyle, and inserts in a broad
depression on the ulna adjacent to the articular surface
(2,9). The mean length of the posterior portion is 24.2 ±
4.3 mm and the mean width is 5.3 ± 1.1 mm (5).
The posterior ligament resembles thickened joint cap-
sule when the elbow is extended, but as the elbow flexes, the
posterior ligament tightens and fans out to form a sharp
edge (9).
Transverse Component of the Medial Ligament
The transverse segment consists of horizontally oriented
fibers between the coronoid and the olecranon and partially
overlays the insertion of the fanlike component. The trans-
verse ligament is closely applied to the joint capsule and
contributes little or nothing to elbow stability because it
originates and inserts on the ulna (9).
Comparative Significance of the Anterior and
Posterior Ligaments of the Medial Ligament
The anterior component is the most prominent and can be
easily distinguished from the joint capsule (5,9,10). This
component of the medial collateral ligament resists valgus
as well as internal rotatory forces. Sequential sectioning of
FIGURE 7.6. The medial collateral elbow ligaments.
372 Regional Anatomy
the anterior and posterior parts of the anterior ligament and
the posterior ligament revealed that the anterior component
of the anterior ligament was the primary restraint to valgus
deformity at 30, 60, and 90 degrees of flexion, and was a
co-primary restraint at 120 degrees of flexion. The posterior
component of the anterior ligament was a co-primary
restraint at 120 degrees of flexion and a secondary restraint
at 30 and 90 degrees of flexion. The greatest amount of val-
gus deformity after sectioning of the anterior ligament was
with the elbow at 90 degrees of flexion. The anterior part of
the anterior ligament was more subject to valgus overload
when the elbow was extended and the posterior component
of the anterior ligament was more subject to overload when
the elbow was flexed. The posterior ligament was a sec-
ondary restraint at 30 degrees only and was not subject to
valgus overload unless the anterior ligament was completely
disrupted (9).
Clinical Significance
The authors of this study noted that the greatest amount of
valgus instability due to sectioning of the anterior ligament
was observed when the elbow was at 90 degrees of flexion.
They recommended that physical examination in patients
with a suspected injury to the anterior ligament of the
medial collateral ligament should be performed with the
elbow in 90 degrees of flexion for greatest sensitivity (9).
FIGURE 7.7. Fresh cadaver dissection of
the medial collateral elbow ligaments
(medial aspect of the right elbow). The
probe is beneath the anterior ligament;
the green marker is beneath the trans-
verse ligament, and the blue triangle is
beneath the proximal edge of the poste-
rior ligament.
Lateral Ligaments
The lateral ligament complex of the elbow arises from a
bare area just distal to the lateral epicondyle and fans out
distally to insert on the annular ligament of the radius lat-
erally and superiorly and on the lateral aspect of the coro-
noid process of the ulna inferiorly. It is blended with the
attachments of the supinator and the extensor carpi radialis
brevis (ECRB) (2). Its classic description is that of a single
triangular ligament called the radial collateral ligament (2).
Morrey and An identified three parts to the lateral ligament
complex: (a) the annular ligament, (b) the fan-shaped part
that originates from the lateral epicondyle and inserts into
and blends with the annular ligament, and (c) an invariably
present but often inconspicuous part of the inferior aspect
of the fan-shaped ligament that inserts on a tubercle of the
supinator crest of the proximal ulna. They named the latter
structure the lateral ulnar collateral ligament (LUCL) (5)
(Figs. 7.8 and 7.9). Based on studies of posterolateral rota-
tory instability of the elbow, some authors consider the
LUCL portion of the lateral collateral ligament complex the
most important in preventing posterolateral rotatory insta-
bility of the elbow (5,6). The lower than expected incidence
of objective varus laxity in cases of posterolateral rotatory
instability with varus stress when the LUCL is disrupted is
said to be due to the fact that the primary contributor to
stability is the ulnohumeral articulation rather than the

FIGURE 7.8. The lateral collateral ligaments of the elbow. LUCL,
lateral ulnar collateral ligament.
radial collateral ligament complex (5). The somewhat vari-
able incidence of varus instability after radial head excision
may be due to the inadvertent release of the LUCL rather
than to radial head excision alone (5).
These findings and conclusions are compared with a study
that focused on the muscular and ligamentous anatomy of
the lateral aspect of the elbow as it relates to rotatory insta-
bility (6). The dissections in this study revealed a broad con-
joined tendon of insertion of the lateral collateral and annu-
lar ligaments to the ulna. In 22 of the 40 specimens, the
insertion was bilobed, and it was broad in 18 specimens.
7 Elbow 373
Cohen and Hastings (8) did not identify a discrete ligament
spanning from the epicondyle to the ulna, the so-called
LUCL described by Morrey and An (5). A standardized rota-
tory force on the elbow joint was used to evaluate the role of
the various stabilizers of the elbow joint as they related to
rotatory stability. The stabilizers evaluated included the
extensor carpi ulnaris (ECU) fascial band, the annular liga-
ment, the lateral collateral ligament complex, the supinator
insertion, the supinator origin, and composite fibers of origin
of the extensors. Cohen and Hastings concluded that: (a) the
primary restraint to posterolateral rotatory instability of the
elbow is the combination of the lateral collateral and annular
ligaments that coalesce to insert broadly over a 2-cm area on
the proximal ulna; (b) the supinator tendon, which attaches
to the ulna and becomes confluent with the lateral collateral
ligament toward its origin, reinforces this structure; (c) the
principal secondary restraints of the lateral aspect of the
elbow are the extensor muscles with their fascial bands and
intermuscular septa; (d) rotatory instability involves attenua-
tion or avulsion of both the ligamentous and muscular ori-
gins from the lateral epicondyle; and (e) posterolateral rota-
tory instability spontaneously reduced with the forearm in
pronation even when all the restraints had been sectioned (8).
Clinical Significance
Cohen and Hastings made several clinical observations
based on their understanding of the anatomy of the lateral
ligament complex and the muscles arising from the lateral
region of the elbow:
1. Patients with acute lateral ligament disruption may be
managed with a hinged brace with the forearm in prona-
tion. If repair is elected, immobilization of the forearm
in pronation aids in protection of the repair.
FIGURE 7.9. Fresh cadaver dissection of
the lateral collateral ligament of the
elbow (lateral aspect of the right elbow).
The green diamond-shaped marker is on
the lateral epicondyle, and the probe is
beneath the radial collateral ligament,
which attaches to the supinator crest
marked with a dotted line.
374 Regional Anatomy
2. Overzealous debridement for recalcitrant lateral epi-
condylitis may result in posterolateral instability, and
may explain persistent complaints. Cohen and Hastings
advise debridement of tissue anterior to the palpable sep-
tum of the extensor digitorum communis and extensor
digiti quinti at the middle of the axis of the epicondyle.
This approach spares the posterior fibers of the lateral
collateral ligament and the extensor muscle origins and
maintains stability of the lateral aspect of the elbow (4).
3. The usual Kocher approach for radial head excision
between the anconeus and ECU muscles should be kept
in line with the fibers of the ECU to avoid section of the
fascial band of the ECU. Proximal extension of the
Kocher incision, if kept inferior to the epicondyle, pre-
serves the integrity of the extensor tendon from the
condylar and epicondylar regions. Excision of the radial
head requires incision of portions of the lateral ligament
complex. An incision slightly anterior to the center of
the radial head and carried distally for a short distance
preserves the inferior portions of the complex. Careful
repair of the these fibers is important (8).
Loci of Origin of the Medial and Lateral
Elbow Ligaments and Axis of Joint Rotation
The origins and insertions of the medial and lateral liga-
ments as well as the axis of rotation of the elbow joint are
presented in Figure 7.10. Little variation is noted in the
three-dimensional distance between the origin and inser-
tion of the radial collateral ligament complex from full
extension to 120 degrees of flexion. This is consistent with
the fact that the axis of rotation passes through the center
of this locus. The distance between the origin and insertion
of the anterior ligament of the medial collateral ligament
increased a mean of 4.8 mm from extension to 120 degrees
of flexion. This distance was even more pronounced in the
posterior ligament of the medial collateral ligament, which
demonstrated a mean distance of 9.4 mm after approxi-
mately 60 degrees of flexion. These changes are consistent
with the eccentric locus of the medial collateral ligament in
relationship to the elbow joint axis of rotation (5).
SURGICAL EXPOSURES
Posterior Approach
Indications
This approach is used for exposure of nonarticular and
intraarticular fractures of the distal humerus, removal of
loose bodies, and treatment of extension contractures of the
elbow requiring posterior capsulotomy and triceps length-
ening.
Landmarks
The landmarks for this approach are the olecranon process
and the two humeral condyles, which are readily palpated
and visualized.
Position/Incision
The patient may be positioned prone with the arm resting
on a well padded arm table and the elbow flexed to 90
degrees, or supine with the elbow flexed to 90 degrees and
FIGURE 7.10. Loci of origin of the medial and lateral
elbow ligaments and axis of joint rotation. A: Anterior
view of distal humerus showing radial collateral ligament
(RCL); anterior ligament of medial collateral ligament (A-
MCL); posterior ligament of medial collateral ligament
(P-MCL); and axis of joint rotation (Z); note that the
medial ligament originates from the epicondyle, not the
medial aspect of the trochlea. B: Lateral view of distal
humerus showing the concentric locus of the RCL com-
pared with the eccentric locus of the MCL in relationship
to the elbow joint axis of rotation (Z). C: Anterior view of
proximal radius and ulna showing loci of insertion of P-
MCL, A-MCL, and RCL. D: Lateral view of proximal ulna
and radius showing loci of insertion of RCL, A-MCL, and
P-MCL. (Redrawn after Morrey BF, An K-N. Functional
anatomy of the ligaments of the elbow. Clin. Orthop
201:84–90, 1985, with permission.)
 7 Elbow 375

the forearm supported on a well padded Mayo stand over
the patient’s chest (Fig. 7.11). These positions allow for
comprehensive exposure of the elbow, but the arm also may
be positioned on an arm table with the elbow flexed to 90
degrees and resting on a soft pad. This third position, how-
ever, may make it difficult to see all aspects of the medial
areas of the elbow and may be better suited for exposure of
the posterolateral aspect of the elbow. A straight-line inci-
sion is begun in the posterior aspect of the distal arm,
curved distally across the lateral edge of the olecranon
process, and then curved distally to end over the medial
subcutaneous margin of the ulna. This incision is designed
to avoid the potential for a bothersome scar over the pres-
sure or contact surface of the olecranon and also has the

FIGURE 7.11. A–C: Patient positions and incision for posterior approach to elbow.
376 Regional Anatomy
potential for providing better soft tissue cover over any fix-
ation devices that may be used as part of the procedure.
Technique
The skin, subcutaneous tissue, and superficial fascia are
incised down to the triceps aponeurosis, which is the plane
of dissection and provides a thick flap for coverage of the
operative site.
Ulnar Nerve
The ulnar nerve is palpated beneath the deep fascia in the
interval between the long head of the triceps and the medial
intermuscular septum. The fascia is incised and the nerve
freed distally and gently retracted with saline-moistened,
0.5-inch-diameter Penrose drains. The nerve usually is
accompanied by the posterior ulnar recurrent artery and
one or more small veins; if possible, these vascular struc-
tures should be left with the nerve to preserve its blood sup-
ply (Fig. 7.12).
Olecranon Osteotomy
In nonarticular fractures or in cases that do not require
exploration of the joint, the triceps mechanism may be
FIGURE 7.12. Posterior approach to the elbow. A: Skin incision. B: Deep dissection.
released by an oblique nonarticular osteotomy of the prox-
imal aspect of the olecranon (11) (Fig. 7.13A and B). If a
more complete exposure of the joint is required, as in
removal of loose bodies or in the management of intraar-
ticular fractures, the joint is exposed through a transverse
chevron-shaped osteotomy approximately 2.5 cm distal to
the proximal edge of the olecranon process (11). The apex
of the chevron is distal to lessen the chances of splitting
the proximal olecranon during fixation. The chevron
modification of the osteotomy makes fixation of the
osteotomy more accurate at the close of the procedure.
Accurate replacement and fixation of either osteotomy is
aided by predrilling the olecranon process before the
osteotomy and by making a longitudinal mark on the
medial and lateral side of the olecranon at right angles to
the intended osteotomy with an osteotome or the cutting
current of the Bovie unit. These marks are then realigned
at the time of fixation of the osteotomy. The transverse
osteotomy is performed at right angles to the longitudinal
axis of the ulna using a power saw with a thin blade. The
olecranon is cut nearly completely through and then the
osteotomy is completed by a thin osteotome. Before mak-
ing the osteotomy, a pilot hole is drilled in the ulna for
inserting a cancellous lag screw.
 7 Elbow 377

FIGURE 7.13. Posterior approach to the elbow (comprehensive with osteotomy). A: Accurate
replacement and fixation of either osteotomy is aided by predrilling the olecranon process
before the osteotomy. B: Oblique (a) and transverse chevron-shaped (b) osteotomies of the prox-
imal ulna. C: Subperiosteal dissection of the triceps muscle from the humerus allows an extensive
exposure of the posterior humerus and the posterior articular surface of the elbow joint.

Soft Tissue Release Landmarks

After the osteotomy, it is necessary to release the soft tissues
both medially and laterally adjacent to the olecranon
process while taking care that the soft tissue attachments to
the olecranon process are not disrupted. Subperiosteal dis-
section of the triceps muscle from the humerus allows an
extensive exposure of the posterior humerus and the poste-
rior articular surface of the elbow joint. Indiscriminate dis-
section of the muscle from bone is to be avoided because
the circulation to the bone may be compromised. Although
subperiosteal dissection may be performed around the
medial and lateral margins of the distal humerus to its ante-
rior aspect, care should be taken to avoid disruption of the
blood supply to the bone or injury to the brachial artery
and median nerve, which are nearby in the antecubital fossa
(see Fig. 7.13C).
Useful landmarks include the lateral epicondyle, the olecra-
non process and its proximal subcutaneous margin, and the
radial head, which usually is palpable with alternating
pronation and supination of the forearm.
Position/Incision
With the patient supine, the upper extremity draped free,
and the elbow resting on a well padded hand table, the fore-
arm is placed in pronation and the elbow flexed to 90
degrees. The radial head is approached through an oblique
incision made from the lateral epicondyle to the ulna that
parallels the interval between the anconeus and the ECU
(Fig. 7.14).

Technique
Radial Head Approach
The interval between the anconeus muscle and the ECU is
Indications identified distally and then traced proximally because these
This approach is used to expose the radial head for excision two muscles share a common fibrous origin. The origin of
or for management of fractures, including open reduction the anconeus from the lateral epicondyle may be detached
and internal fixation. to facilitate the exposure. The ECU and anconeus are
378 Regional Anatomy

FIGURE 7.14. Radial head approach; patient position (A) and incision (B). An oblique incision is
made from the lateral epicondyle to the ulna that parallels the interval between the anconeus
and the extensor carpi ulnaris.

retracted to reveal the underlying supinator muscle. Identi-
fication of the supinator is facilitated by noting that its
fibers run at approximately a 90-degree angle to the
anconeus fibers (Fig. 7.15).
Posterior Interosseous Nerve
The supinator contains the posterior interosseous nerve
(PIN), which enters the volar lateral face of the supinator
and courses obliquely in the fibers of the muscle to exit
dorsally near the distal margin of the supinator. The PIN
can be found on the back of the radius, three finger-
breadths distal to the radial head. Maintaining the fore-
arm in pronation during this approach rolls the PIN away
from the operative site and aids in its preservation (see Fig.
7.15). Dissection that does not extend beyond the annu-
lar ligament also avoids the potential for injury to the
PIN.
Radial Collateral Ligament
The radial collateral ligament complex shares an attach-
ment at the supinator crest with the supinator muscle. The
proximal margin of the supinator is incised and reflected
anteriorly to reveal more completely the lateral ligament
complex and elbow capsule. These structures are incised
longitudinally, beginning at the epicondyle, to enter the
joint. This incision is carefully repaired to maintain the
integrity of the lateral ligament. This approach is designed
to expose only the radial head and if exposure of the proxi-
mal radius is required, then another, more comprehensive
approach is used (see Chapter 8, Part 1, Flexor Forearm).
 7 Elbow 379

FIGURE 7.15. Radial head approach; deep dissection. A, B: The interval between the anconeus
muscle and the extensor carpi ulnaris (ECU) is identified distally and then traced proximally
because these two muscles share a common fibrous origin. The origin of the anconeus from the
lateral epicondyle may be detached to facilitate the exposure. The ECU and anconeus are
retracted to reveal the underlying supinator muscle. Identification of the supinator is facilitated
by noting that its fibers run at approximately a 90-degree angle to the anconeus fibers.

Medial Approach Technique

Indications
The medial approach may be used for removal of loose bod-
ies in the medial side of the joint as well as for reduction
and fixation of fractures of the coronoid process of the ulna
and medial aspect of the humerus.
Landmarks
Landmarks include the medial epicondyle, the medial inter-
muscular septum, and the olecranon process.
Position/Incision
With the patient supine, the forearm in supination, and the
upper extremity resting on a hand table with a soft pad
under the elbow, an incision is made between the anterior
and posterior muscular compartments of the arm in line
with the medial intermuscular septum. The incision aims
directly for the medial epicondyle but curves anteriorly
above the condyle to avoid placing a scar directly over this
bony prominence, and continues distally over the antero-
medial aspect of the forearm (Fig. 7.16).
In the arm, the muscular intervals used are between the
brachialis and the triceps, and in the forearm, between the
pronator teres (PT) and the brachioradialis.
Cutaneous Nerve Branches
Posterior branches of the medial cutaneous nerve of the
forearm are found in the subcutaneous tissues of the inci-
sion anywhere from 6 cm above to 6 cm below the medial
epicondyle, and should be preserved (12).
Ulnar Nerve
The ulnar nerve is found posterior to the medial intermus-
cular septum in the arm and in its groove behind the medial
epicondyle. The ulnar nerve is freed from above the elbow
to its entrance into the FCU muscle by incising the overly-
ing fascia and gently retracting it posteriorly with a saline-
moistened 0.5-inch Penrose drain.
Median Nerve/Brachial Artery
The interval between the PT and the brachioradialis is
entered and the median nerve and brachial artery identified.
380 Regional Anatomy

FIGURE 7.16. Medial approach to the elbow; patient position (A) and incision (B). The incision
aims directly for the medial epicondyle but curves anteriorly above the condyle and continues dis-
tally over the anteromedial aspect of the forearm

The underlying brachialis is gently separated from the PT
and all branches of the median nerve are noted and pro-
tected, including the branches to the PT.
Medial Epicondylotomy
These maneuvers are done as a preliminary to detach-
ment of the PT and the common flexor origin from the
medial epicondyle by osteotomy. The plane of this
osteotomy is between the anterior component of the
underlying medial collateral ligament and the flexor ori-
gin (Fig. 7.17). These flexors then may be retracted dis-
tally and the interval between the brachialis and triceps
may be developed further to expose the anterior aspect of
the elbow joint and distal humerus. Before detachment,
the medial epicondyle is predrilled to facilitate reattach-
ment with a screw.

FIGURE 7.17. Medial approach to the elbow. Deep dissection. A, B: In the arm, the muscular
intervals used are between the brachialis and the triceps, and in the forearm, between the prona-
tor teres (PT) and the brachioradialis (BR). The ulnar nerve is freed and gently retracted posteri-
orly. The interval between the PT and the BR is entered and the median nerve and brachial artery
identified. C: Medial epicondylotomy. The PT and the common flexor origin are detached from
the medial epicondyle by osteotomy. Before detachment, the medial epicondyle is predrilled to
facilitate reattachment with a screw.
7 Elbow 381
382 Regional Anatomy
Lateral Approach
Indications
The lateral approach may be used for fractures of the lateral
aspect of the elbow and surgical treatment of tennis elbow.
Landmarks
Useful landmarks are the lateral epicondyle and the lateral
supracondylar ridge.
Position/Incision
The patient is supine and the arm is flexed on the chest or
on a hand table with the elbow semiflexed and the forearm
in pronation. A longitudinal incision is made 5 cm proxi-
mal to the lateral epicondyle over the lateral supracondylar
ridge and continued distally over the lateral epicondyle, to
end 5 cm distal to the epicondyle over the proximal portion
of the extensor digitorum communis muscle (Fig. 7.18).
Technique
To expose the lateral border of the humerus, the interval
between the triceps and brachioradialis/extensor carpi radi-
alis longus (ECRL) is developed from distal to proximal by
subperiosteal dissection. Branches of the posterior ante-
brachial cutaneous nerve are identified and preserved. The
radial nerve is identified where it enters the interval
between the brachialis and brachioradialis muscles. In frac-
tures of the lateral condyle, the common origin of the
extensors is attached to the fracture fragment, which facili-
tates the exposure. In nonfracture cases, the common origin
is removed by osteotome with a thin wafer of bone to facil-
itate reattachment, or the origin may be divided distal to
the lateral epicondyle with an adequate cuff of substantial
tissue for repair. With either method, the extensor origin
should be separated from the lateral collateral ligament
complex. An alternative to removal of the common exten-
sor origin is to identify the interval between the anconeus
muscle and the ECU and retract these muscles to find the
underlying supinator. The origin of the anconeus from the
lateral epicondyle may be detached to facilitate the expo-
sure. If removal of the common extensor origin is elected,
the extensors are reflected distally to reveal the supinator,
lateral ligament complex, and joint capsule. The supinator
contains the PIN, which enters the volar lateral face of the
supinator and courses obliquely in the fibers of the muscle
to exit dorsally near the distal margin of the supinator. The
FIGURE 7.18. Lateral approach
to the elbow; patient position
(A) and incision (B). A longitu-
dinal incision is made 5 cm prox-
imal to the lateral epicondyle
over the lateral supracondylar
ridge and continued distally
over the lateral epicondyle to
end 5 cm distal to the epi-
condyle, over the proximal por-
tion of the extensor digitorum
communis muscle.
 7 Elbow 383

PIN can be found on the back of the radius three finger-
breadths distal to the radial head. Maintaining the forearm
in pronation during this approach rolls the PIN away from
the operative site and aids in its preservation (see Fig. 7.14).
The radial collateral ligament complex shares an attach-
ment at the supinator crest with the supinator muscle. The
proximal margin of the supinator is incised and reflected
anteriorly to reveal more completely the lateral ligament
complex and elbow capsule. These structures are incised
longitudinally, beginning at the epicondyle, to enter the
joint. The ligamentous and capsular incision is carefully
repaired to maintain the integrity of the lateral ligament. If
the common extensor origin was removed, it should be
securely reattached (Fig. 7.19).

FIGURE 7.19. Lateral approach to the elbow, deep dissection. A: The interval between the tri-
ceps and brachioradialis/extensor carpi radialis longus is developed from distal to proximal by
subperiosteal dissection. The radial nerve is identified where it enters the interval between the
brachialis and brachioradialis muscles. The common extensor origin may be divided distal to the
lateral epicondyle with an adequate cuff of substantial tissue for repair. B: Alternatively, the com-
mon extensor origin may be removed by osteotome with a thin wafer of bone to facilitate reat-
tachment. The radial collateral ligament and capsule are incised longitudinally beginning at the
epicondyle to enter the joint.
384 Regional Anatomy

FIGURE 7.20. The Kocher approach to the lateral aspect of the elbow. A: A longitudinal incision
is made 5 cm proximal to the lateral epicondyle over the lateral supracondylar ridge and contin-
ued distally over the lateral epicondyle to curve over the anconeus, ending posteriorly at the sub-
cutaneous margin of the ulna. B: The origin of the brachioradialis, extensor carpi radialis longus,
and extensor carpi radialis brevis is elevated subperiosteally, as is the triceps muscle posteriorly,
to expose the lateral epicondyle and supracondylar ridge.

Kocher or Lateral “J” Approach
Indications
This approach may be used for elbow joint capsulotomy for
contracture, fractures of the lateral aspect of the elbow,
drainage of the elbow joint, or reconstruction of the lateral
ligament complex.
Landmarks
Landmarks include the lateral supracondylar ridge, the lat-
eral epicondyle, the radial head, and the subcutaneous bor-
der of the proximal ulna.
Position/Incision
The patient is supine, with the elbow semiflexed and the
forearm in pronation. A longitudinal incision is made 5 cm
proximal to the lateral epicondyle over the lateral supra-
condylar ridge and continued distally over the lateral epi-
condyle to curve over the anconeus and end posteriorly at
the subcutaneous margin of the ulna. This approach is sim-
ilar to the lateral exposure just described, but differs in its
distal aspect, which curves from the radial head medially
and posteriorly to end at the posterior border of the ulna.
Distally, the interval between the ECU and anconeus is
used to expose the proximal and extensor aspect of the fore-
arm (Fig. 7.20).
7 Elbow 385
Technique
Proximal dissection is over the lateral supracondylar ridge
between the triceps posteriorly and the brachioradialis and
ECRL anteriorly to expose the lateral epicondyle. Distally, the
interval between the anconeus and the ECU is used to expose
the lateral ligament complex, joint capsule, and ulna. The ori-
gin of the brachioradialis, ECRL, and ECRB is elevated sub-
periosteally, as is the triceps muscle posteriorly. Distally, the
anconeus is retracted posteriorly after removing its origin from
the lateral epicondyle, and the ECU is retracted anteriorly.
The common origin of the extensors at the lateral epicondyle
may be reflected by subperiosteal dissection or by detachment.
The incision in the radial collateral ligament and capsule is
longitudinal. This allows later repair of this important liga-
ment at the time of closure (5). If it is necessary to dislocate
the joint, the lateral collateral ligament complex may be
removed from its proximal origin with a portion of bone to
facilitate reattachment. Dissection should be kept in line with
the fibers of the ECU to avoid section of the fascial band of
the ECU, which is a stabilizer of the joint (8). A modification
for proximal extension of the Kocher incision may be made by
staying inferior to the epicondyle. This preserves the attach-
ments of the extensor tendon from the condylar and epi-
condylar regions (8). Excision of the radial head requires inci-
sion of portions of the lateral ligament complex. An incision
slightly anterior to the center of the radial head and carried
distally for only a short distance preserves the inferior portions
of radial lateral ligament complex. Careful repair of these
fibers also is important (8) (Fig. 7.21).
FIGURE 7.21. The Kocher approach to the lateral
aspect of the elbow; deep dissection. Distally, the inter-
val between the anconeus and the extensor carpi
ulnaris (ECU) is used to expose the lateral ligament
complex, joint capsule, and ulna. The anconeus is
retracted posteriorly after removing its origin from the
lateral epicondyle, and the ECU is retracted anteriorly.
The common origin of the extensors at the lateral epi-
condyle is detached and reflected distally to expose the
radial collateral ligament and capsule.
386 Regional Anatomy

CLINICAL CORRELATIONS as 15 degrees of valgus angulation and may be 10 degrees

Activities of Daily Living and Elbow
Motion
Activities of dressing and personal hygiene require elbow
positioning from approximately 140 degrees of flexion to
reach the occiput to 15 degrees of flexion to tie a shoe.
Most of these activities are performed with the forearm in
0 to 50 degrees of supination. Most of the activities of
daily living are accomplished with 30 to 130 degrees of
elbow flexion, 50 degrees of pronation, and 50 degrees of
supination (13).
Imaging
Radiographic Skeletal Relationships
The long axis of the radius should point to the capitulum
in all views. If it does not, a lateral condyle fracture, a Mon-
teggia fracture or equivalent, or an elbow dislocation should
be considered. Normally, the radial neck may be in as much
anterior to the radial shaft (14) (Fig. 7.22).
The long axis of the ulna should be nearly parallel to and
slightly medial to the long axis of the humerus on a true
anteroposterior view (14). If it is not, and if the radial head
and capitulum remain in correct alignment, a transepiphy-
seal injury or displaced supracondylar fracture should be
considered. If the radius no longer is pointing to the capit-
ulum, an elbow dislocation should be considered.
The anterior humeral line should bisect the capitulum in
a true lateral view of the distal humerus. If the center of the
capitulum falls posterior to this line, an extension-type
supracondylar fracture is likely; a transepiphyseal fracture is
possible but rare. If the capitulum is anterior to the line, the
less common flexion-type supracondylar fracture or a
transepiphyseal fracture is likely. A true lateral view of the
distal humerus must be obtained because any rotation makes
the capitulum appear posterior to the anterior humeral line
(14) (Fig. 7.23A). The humeral capitular angle (Baumann’s
angle; see Fig. 7.23B) is a sensitive indicator of varus angu-
lation of the distal humerus and is used primarily to measure

FIGURE 7.22. Radiographic skeletal relationships. A: The long axis of the radius should point to
the capitulum in all views. B: If it does not, a lateral condyle fracture, a Monteggia fracture or
equivalent, or an elbow dislocation should be considered. Normally, the radial neck may be in as
much as 15 degrees of valgus angulation, and may be 10 degrees anterior to the radial shaft. C:
If the radius no longer is pointing to the capitulum, an elbow dislocation should be considered.
D: The long axis of the ulna should be nearly parallel and slightly medial to the long axis of the
humerus on a true anteroposterior view. If it is not, and if the radial head and capitulum remain
in correct alignment, a transepiphyseal injury or displaced supracondylar fracture (see B) should
be considered.
 7 Elbow 387

FIGURE 7.23. Anterior humeral line and Bau-

mann’s angle. A: The anterior humeral line should
bisect the capitulum in a true lateral view of the
distal humerus. B: The humeral capitular angle
(Baumann’s angle) is a sensitive indicator of varus
angulation and ranges from 9 to 26 degrees in
95% of normal elbows.

the adequacy of reduction in supracondylar and transepi-

physeal fractures (14,15). It ranges from 9 to 26 degrees in
95% of normal elbows and is relatively constant with respect
to humeral rotation, changing only 1.6 degrees for each 10
degrees of humeral rotation as long as a true anteroposterior
view of the humerus has been obtained (14–16).

Fat Pad Sign

Norell first described the fat pad sign in 1954 (17). Dis-
placement of the extrasynovial but intracapsular fat pads
due to distention of the synovial–capsular membrane sec-
ondary to an effusion associated with infection, fracture, or
spontaneously reduced dislocation may be a useful diagnos-
tic sign in infection or injuries about the elbow. Because of
the relative shallowness of the coronoid fossa, the anterior
fat pad may be seen under normal circumstances in a lateral
radiograph of the elbow taken at 90 degrees of flexion as a
triangular lucency just anterior to the humerus, in contrast
to the olecranon fat pad, which normally is not seen
because of the relative deepness of the olecranon fossa and
the containment of the fat pad by the overlying triceps mus-
cle (18). When a posterior fat pad is visible, an intraarticu-
lar injury is present 90% of the time (19) (Fig. 7.24). If the
elbow is extended, the olecranon fat pad usually is displaced
from the olecranon fossa by the olecranon process. FIGURE 7.24. The fat pad sign. Note the relatively radiolucent
zones indicated by the white arrows adjacent to the anterior and
Although the fat pad sign can be a useful indicator of effu- posterior aspect of the distal humerus in this contrast-enhanced
sion, it is not always present, and displacement of the ole- radiograph of the right elbow. This positive fat pad sign is due
cranon fat pad may occur without associated displacement to displacement of the extrasynovial but intracapsular anterior
and posterior fat pads secondary to joint effusion associated
of the anterior fat pad (18). An anterior and posterior fat with an undisplaced and barely detectable fracture of the neck
pad sign is demonstrated in Figure 7.24. of the radius (lower right arrow).
388 Regional Anatomy
Epicondylitis
Medial
Medial epicondylitis is much less common than its lateral
counterpart. Both conditions are characterized by epi-
condylar pain and tenderness and symptom aggravation by
movement against resistance of the respective flexor or
extensor muscle groups.
Pathology
The pathologic process includes a gross or microscopic tear
in the tendinous origin of the muscles involved due to
mechanical overload in normal or aging tendon fibers
(20,21). In medial epicondylitis, the fibers involved usually
are located in the flexor carpi radialis (FCR) and less fre-
quently in the flexor digitorum superficialis (FDS) origins.
Ulnar neuropathy may be differentiated by the well local-
ized findings of epicondylar tenderness and reproduction of
symptoms by resisted flexion of the wrist.
Treatment
Surgical treatment for those cases not responsive to conser-
vative management consists of excision of the involved por-
tion of the FCR or the FDS through a 4-cm incision that
begins over the medial epicondyle and continues distally
over the fibers of origin of the FCR. The tear usually is in
the substance of the tendon just distal to the epicondyle,
and the diseased portion of the tendon is excised through a
longitudinal incision and a small portion of the condyle
removed with an osteotome to produce a raw cancellous
surface, after which the tendon defect is closed, including
the portion over the raw portion of the condyle (21). Care
is taken to avoid injury to the anterior portion of the medial
collateral ligament complex.
Lateral
Provocative Test
A recognized provocative test for lateral epicondylitis is
reproduction of symptoms by resisted dorsiflexion of the
wrist with the elbow in extension, compared with the usual
absence of symptoms with the elbow in flexion.
Differential Diagnosis
This condition must be differentiated from radial tunnel
syndrome, although the two conditions may coexist. Dif-
ferentiation may be aided by noting in tennis elbow that the
site of maximum tenderness is at the lateral epicondyle, in
contrast to radial tunnel syndrome, in which the tenderness
is in the region of the radial head and proximal forearm
(22). In radial tunnel syndrome, some authors have noted
that pain may be produced by resisted dorsiflexion of the
long finger, which is said to produce secondary stress on the
ECRB, the leading edge of which can compress the radial
nerve (22,23). Radial tunnel pain also has been reported to
be reproduced by resisted supination of the extended fore-
arm (22). The radial tunnel syndrome is discussed in detail
in Chapter 8, Part 2, Dorsal Forearm.
Treatment
Surgical treatment for those cases not responsive to conser-
vative management is performed through a longitudinal
incision beginning at the lateral epicondyle and continuing
distally for 5 cm to expose the common extensor origin.
The usual site of pathology is in the substance of the ECRB
origin just distal to the lateral epicondyle. The common ori-
gin is split longitudinally for a distance of approximately 1
cm and reflected off the lateral epicondyle superiorly and
inferiorly. The tear along with necrotic tendon and granu-
lation tissue is excised. A small osteotome is used to remove
a portion of the lateral epicondyle, and then the defect is
sutured to overlay the raw bone on the epicondyle. Care
must be taken to avoid injury to the lateral ligament com-
plex because injury to this structure may result in postero-
lateral instability of the elbow (see discussion to follow,
under Lateral Insufficiency of the Elbow) (6).
Cubital Tunnel Syndrome
Definition
The term cubital tunnel syndrome was proposed in1958 to
identify a specific site of entrapment of the ulnar nerve and
to distinguish it from tardy ulnar palsy associated with post-
traumatic cubitus valgus (24).
Findings
Clinical findings include complaints of medial elbow pain,
numbness and tingling or burning in the ring and little fin-
gers, hand clumsiness, and weakness of pinch. Physical
findings may include tenderness behind the medial condyle
over the course of the ulnar nerve and a positive Tinel’s sign
over the nerve 2 cm proximal and distal to the cubital tun-
nel (22). Other physical findings include decreased sensi-
bility in the ring and little fingers, and decreased pinch and
grip strength. Claw deformity of the ring and little fingers
as well as intrinsic muscle atrophy are seen in severe and
prolonged cases.
Pathomechanics
The ulnar nerve at the elbow is subcutaneous throughout
much of its course and also is partially fixed in a
fibroosseous canal. Because of its exposed position and the
fact that it wraps around the medial condyle in flexion, pro-
longed elbow flexion, which stretches the nerve and nar-
rows the tunnel, combined with resting the elbow on a hard
surface may result in paresthesias in the ring and little fin-
gers even in normal persons (22). When swelling or elbow

inflammation or congestion of the flexor-pronator muscles
is added to this stretch–compression, the vascular supply of
the ulnar nerve may be compromised and nerve symptoms
may result (22). Sustained elbow flexion combined with
vigorous finger and wrist motion such as a musician might
perform also can result in ulnar nerve symptoms. The
motions used to throw a ball or to serve a tennis ball are
similar and can place significant stress on the ulnar nerve,
and may be associated with ulnar nerve symptoms (22).
Perioperative ulnar neuropathies are more common in men
than in women, and although there is no gross anatomic
difference between sexes regarding the course of the ulnar
nerve in the upper extremity, there is a significantly larger
(2 to 19 times greater) fat content on the medial aspect of
the elbow in women compared with men. Also, the tuber-
cle of the coronoid process on the ulna is 1.5 times larger in
men. The tubercle of the coronoid process is a likely area for
ulnar nerve compression and secondary ischemia of the
nerve because the nerve and its blood supply from the ulnar
recurrent artery are minimally covered in this area (25).
Sites of Compression
Surgical treatment of cubital tunnel syndrome is facilitated
by knowledge of the potential sites of compression and the
anatomy specific to each of those areas. The ulnar nerve
FIGURE 7.25. The arcade of Struthers. A: This potential site of entrapment of the ulnar nerve is
located 8 cm proximal to the medial epicondyle. (continued on next page)
7 Elbow 389
enters the posterior aspect of the arm at approximately the
midpoint of the arm and continues distally toward the
elbow behind the medial intermuscular septum on the
medial head of the triceps muscle.
Arcade of Struthers
There is a potential site of entrapment of the ulnar nerve
8 cm proximal to the medial epicondyle called the arcade
of Struthers (26). When the arcade is present, both the
ulnar nerve and the superior ulnar collateral vessels pass
through it. In a study of 25 arms, the arcade of Struthers
was present in 68% of the arms (26). The arcade has a roof
that faces medially, formed by the deep investing fascia of
the arm, superficial muscle fibers from the medial head of
the triceps, and the internal brachial ligament arising from
the coracobrachialis tendon. The floor, which is lateral, is
formed by the medial aspect of the humerus covered by
the deep muscular fibers of the medial head of the triceps.
The anterior border is the medial intermuscular septum
(Fig. 7.25). Atypical features of the arcade included mul-
tiple ligamentous bands arising from thickened deep fas-
cia and the medial intermuscular septum passing both
superficial and deep to the ulnar nerve. Thus, after inci-
sion of the roof of the arcade, these ligaments, which
remain deep to the nerve, can still compress the nerve.
390 Regional Anatomy

FIGURE 7.25. (continued) B: Detail of compo-

nents.

The same applies to the internal brachial ligament (Fig.
7.26C; see Fig. 7.25), which courses deep to the ulnar
nerve. Although the arcade of Struthers is a recognized
anatomic entity, it is said to be a rare cause of ulnar nerve
compression (26,27). However, Spinner and Kaplan
showed that the arcade can produce recurrent ulnar neu-
ropathy after anterior transposition of the nerve because
of tethering, and thus recommended lysis of the arcade as
part of the transposition (28). They also recommended
lysis of the arcade when mobilizing a lacerated ulnar nerve
in the forearm to reduce the gap in the nerve.
Medial Head of Triceps
Another atypical feature relates to the finding that when the
ulnar nerve is buried in the medial head of the triceps, the
overlying muscular roof may be a source of compression
and should be incised.

A
FIGURE 7.26. Fresh cadaver dissection of the arcade of Struthers (medial view of right elbow).
A: The arcade of Struthers is present but not readily apparent in this view of the ulnar nerve and
medial intermuscular septum.
 7 Elbow 391

C
FIGURE 7.26. (continued) B: Further dissection reveals the arcade of Struthers. Its proximal and
distal edges are marked with small triangles. Note the underlying ulnar nerve and the medial
intermuscular septum. C: The arcade has been incised and reflected anteriorly; note the internal
brachial ligament, which courses deep to the ulnar nerve.

Elbow (Cubital Tunnel)
The ulnar nerve in its passage from the arm to the forearm
transits the cubital tunnel, which is an osseous canal
formed by the medial epicondyle and the proximal ulna
and covered by a retinaculum formed by the deep invest-
ing fascia of the arm that is attached to the medial epi-
condyle and the olecranon. This cubital tunnel retinacu-
lum (CTR) is 2-3 cm wide (from proximal to distal), 0.5
to 0.75 mm thick and its distal margin blends with the
investing fascia of the humeral and ulnar heads of the
FCU. Osborne’s band and the arcuate ligament are other
names often used to describe this fibrous tissue roof of the
ulnar tunnel (29). Because of the somewhat eccentric ori-
gin of this fascial roof, the cubital tunnel changes contour
and volume during elbow flexion and extension. In flex-
ion, the cross-sectional contour changes from slightly
ovoid to elliptical (22). Any swelling in the canal or
inflammation or thickening of the fascial roof may com-
press the nerve or its vasculature (22) (Fig. 7.27).
392 Regional Anatomy
FIGURE 7.27. Changes in the cubital tunnel with flexion.
Because of the somewhat eccentric origin of the fascial roof of
the cubital tunnel, its contour and volume change during elbow
flexion and extension. In flexion, the cross-sectional contour
changes from slightly ovoid to elliptical.
Forearm
At the distal end of the cubital tunnel the ulnar nerve enters
the forearm through the flexor pronator group of muscles,
usually between the humeral and ulnar heads of the FCU.
The flexor-pronator muscles are arranged in two groups.
The superficial group is formed by five muscles (PT, FCR,
PL, FDS, and FCU) that originate from a common origin
created by the fusion of several fibrous septa that arise from
the anterior surface of the medial humeral epicondyle, the
ulnar collateral ligament, and medial surface of the coro-
noid process. These fibrous tissue septa form well defined
fascial compartments for the muscles as well as a common
aponeurosis from which adjacent muscles originate. These
septa fuse beginning approximately 3.5 to 4 cm distal to the
epicondyle (30). This fused structure is commonly known
as the flexor-pronator origin or the flexor-pronator aponeuro-
sis. Inserra and Spinner identified an additional aponeurosis
in this area between the FDS to the ring finger and the
humeral head of the FCU that did not fuse with the previ-
ously described common flexor pronator origin but rather
arose from the medial surface of the coronoid process 0.3 to
0.5 cm medial to it. They found it was not possible to trans-
pose the ulnar nerve adjacent to the median nerve in a rel-
atively straight course unless this septum was detached
along with the radial two-thirds of the flexor-pronator
group (28). Amadio and Beckenbaugh identified a structure
deep to the FDS and superficial to the flexor digitorum pro-
fundus (FDP) and FCU that provided a point of origin for
all of these muscles and that extended approximately 5 cm
distal to the epicondyle. They advised that this deep
aponeurosis of the FCU, which bridged and formed a com-
mon origin for muscle fibers of the FCU, FDS, and FDP,
should be released by separating the two heads of the FCU
and exploring the deep surface of the muscle for at least 5
cm distal to the epicondyle (31).
Surgical Technique for Cubital Tunnel
Release and Ulnar Nerve Transposition
The common denominator in ulnar nerve transposition is
elimination of compression or traction problems by
removal of the nerve from the fibroosseous tunnel and per-
manent transposition to an anterior location. Permanent
transposition has been achieved by subcutaneous transposi-
tion, subcutaneous transposition with some form of tether
to prevent the nerve from assuming its original position, or
submuscular or intramuscular transposition (22,32–35).
The sine qua non of ulnar nerve transposition is permanent
realignment of the ulnar nerve in an anterior position with-
out entrapment (absence of compression) or fixation (trac-
tion), which would prevent gliding of the nerve. It also
must be recognized that the ulnar nerve remains subcuta-
neous throughout most of its new course, and that even
submuscular or intramuscular transposition eliminates only
a portion of this subcutaneous position. The effectiveness of
transposition is based on decompression of the nerve and
elimination of any potential for traction injury.
Author’s Comment: The debate concerning the best tech-
nique for ulnar nerve transposition and the role of in situ
ulnar nerve neurolysis without transposition (with or with-
out medial epicondylectomy) is not addressed in this text.
Subcutaneous Transposition
Position/Incision
With the patient supine and the upper extremity supported
on an arm board and the elbow resting on a soft pad, a 14-
cm incision is begun on the medial aspect of the arm and
continued distally through the interval between the medial
epicondyle and olecranon process, to end on the flexor and
medial side of the forearm. The incision begins at least 8 cm
proximal to the medial epicondyle to verify the presence or
absence of the arcade of Struthers (26) (see Fig. 7.28A and B).
Technique
Cutaneous Nerves. After incision of the skin and subcuta-
neous tissue and superficial fascia, the posterior branches of
the medial antebrachial cutaneous nerve are identified on
the distal aspect of the wound. One to three branches may
be present and may cross the incision anywhere from 6 cm
proximal to 6 cm distal to the medial humeral condyle (12).
Injury to these branches may result in hypesthesia, a painful
scar, or hyperalgesia.
 7 Elbow 393

FIGURE 7.28. Subcutaneous transposition of the ulnar nerve; patient position (A) and incision
(B). A 14-cm long incision begins on the medial aspect of the arm and continues distally through
the interval between the medial epicondyle and olecranon process to end on the flexor and
medial side of the forearm. The incision begins at least 8 cm proximal to the medial epicondyle
to verify the presence or absence of the arcade of Struthers.

Ulnar Nerve. At this level in the distal arm, the ulnar nerve
lies posterior to the medial intermuscular septum and anterior
to the medial head of the triceps, having pierced the medial
intermuscular septum at approximately the midshaft of the
humerus. The nerve is most easily identified just proximal to
its entrance into the osseous groove and can be traced proxi-
mally from this area. The deep fascia is incised and the nerve
is noted to lie on the medial head of the triceps just posterior
to the medial intermuscular septum. The anterior flap is raised
at least 5 cm anterior to the medial epicondyle and the ulnar
nerve is dissected free a minimum of 8 cm proximal to the
medial epicondyle and 6 cm distal to the epicondyle to ensure
complete release of the nerve from the various structures as
previously described, including the arcade of Struthers, if pre-
sent proximally, the CTR, the FCU fascia, and additional
aponeuroses as previously described distal to the medial
condyle (22,26–28,30–32,36) (see Fig. 7.29A–C).
Vascular Plexus Accompanying Nerve. As the ulnar
nerve descends toward the elbow, it is accompanied by a
longitudinally oriented venous plexus with feeder veins
that may be mobilized with the nerve. Mobilization and
preservation of this plexus is said to promote optimum
postoperative microcirculation, and immediate postoper-
ative dysesthesias appear to be greatly reduced (22,32).
The superior ulnar collateral branch of the brachial artery
also accompanies the nerve and joins the inferior ulnar
collateral artery in the region of the medial epicondyle,
passes posterior to the medial supracondylar ridge, and
ends deep to the FCU by anastomosing with the poste-
rior ulnar recurrent artery. Preservation of these arterial
vessels is discussed later in the section on Medial Inter-
muscular Septum. Details of the arterial circulation of the
elbow were presented earlier, in the section on Anatomic
Relationships.
394 Regional Anatomy

Cubital Tunnel. The nerve enters the cubital tunnel in a
groove in the posterior aspect of the medial condyle that is
bordered medially by the medial epicondyle and laterally by
the olecranon.
The roof of the tunnel is formed by the CTR. Distally,
the nerve enters the area between the humeral and ulnar
heads of the FCU, where it is covered by thickened trans-
verse fascial fibers that join these two heads. Motor
branches to the FCU are given off at this level (see Fig.29).
Medial Intermuscular Septum. After complete release of
the nerve and performance of a trial anterior transposition,

FIGURE 7.29. The Cubital Tunnel Retinaculum (CTR) and the Medial Intermuscular Septum (MIS).
A: The Cubital Tunnel Retinaculum (CTR), the FCU fascia and Medial Intermuscular Septum (MIS)
prior to release or excision. B: Release of the CTR and proposed (dotted lines) release of the FCU
fascia and excision of the MIS.

FIGURE 7.29. (continued) C: After excision of the MIS and with the elbow flexed to 90
degrees, the nerve is transposed anteriorly at least 3 cm anterior to the medial epicondyle to
lie on the muscle fascia.
it is readily apparent that the ulnar nerve will impinge on
the medial intermuscular septum as it crosses over the sep-
tum. Therefore, complete excision of the medial intermus-
cular septum is required for a distance of 8 cm proximal to
the medial epicondyle (see Fig. 7.30A and B). The superior
ulnar collateral artery from the brachial artery runs along
the posterior surface of the medial intermuscular septum in
company with the ulnar nerve and may be dissected off the
nerve before transposition, or, if it is elected to attempt to
carry the artery with the nerve, the perforating vessels into
the septum must be dealt with as well as the anastomosis to
the inferior ulnar collateral artery. On the anterior surface
of the medial intermuscular septum, the inferior ulnar col-
lateral artery from the brachial artery is encountered along
with its branch, the anterior ulnar recurrent artery. The
inferior ulnar collateral artery pierces the medial intermus-
cular septum near the mid-portion of the medial epicondy-
lar ridge and may require ligation as the septum is resected
from the humerus (see Fig. 7.30C).
Author’s Comment: The concept of preservation of the
mesentery-like vessels from the ulnar collateral and ulnar
recurrent arteries to the ulnar nerve may be academic
because of the rich anastomotic microcirculation of the
nerve. Kleinman noted that it is this rich intrinsic blood
supply composed of an interconnecting meshwork of ves-
sels running among the fascicular bundles as well as along
each fascicle that allows microscopic hemodynamics to con-
tinue normally in spite of the elimination of multiple
mesentery-like feeding vessels (37).
7 Elbow 395
After removal of the medial intermuscular septum and
with the elbow flexed to 90 degrees, the nerve is transposed
anteriorly at least 3 cm anterior to the medial epicondyle to
lie on the muscle fascia. The nerve is inspected for impinge-
ment points, and then the anterior flap is positioned over
the nerve.
Permanent Transposition of Nerve. The nerve may be
maintained in its new position by one of two methods (Fig.
7.31A and B): With the nerve in its new anterior position,
three polyglycolic acid sutures are placed in the superficial
fascia of the flap and the muscle fascia to make a fat-covered
tunnel overlying the nerve. The length of this tunnel should
be at least 6 cm, and it must be large enough to admit the
surgeon’s little finger throughout its length. The elbow
should be flexed and extended to verify that the nerve is not
trapped or constrained in the new tunnel. The second
method is to raise a proximally based strip of antebrachial
fascia 1 cm wide and long from the region of the medial
epicondyle, which is then passed medial to the nerve and
sutured to the superficial fascia of the anterior flap (22,33).
This fascial curtain or septum in the mid-lateral plane lies
posterior and medial to the transposed nerve and prevents
the ulnar nerve from migrating back to its original site,
allows gliding of the nerve, and covers the nerve with fatty
subcutaneous tissue.
Submuscular Transposition. Submuscular transposition of
the ulnar nerve as described by Learmonth (35) has as its
396 Regional Anatomy

B
FIGURE 7.30. Subcutaneous transposition of the ulnar nerve; deep dissection. A: The ulnar nerve
lies posterior to the medial intermuscular septum, covered by fascia, and is most easily identified
just proximal to its entrance into the osseous groove. For clarity, the fascia that hides the nerve
has been removed in this depiction. Motor branches to the flexor carpi ulnaris are given off at
this level. B: After release of the nerve, excision of the medial intermuscular septum is performed
for a distance of 8 cm proximal to the medial epicondyle. After removal of the medial intermus-
cular septum and with the elbow flexed to 90 degrees, the nerve is transposed anteriorly at least
3 cm anterior to the medial epicondyle to lie on the muscle fascia.
 7 Elbow 397

FIGURE 7.31. Methods of maintaining the

transposed ulnar nerve in its new position,
and submuscular transposition. A: The
nerve is placed in its new anterior position,
the anterior flap is placed over the nerve,
and three polyglycolic acid sutures are
placed in the superficial fascia of the flap
and the muscle fascia. B: The second
method is to raise a proximally based strip
of antebrachial fascia 1 cm wide and long
from the region of the medial epicondyle,
which is then passed medial to the nerve
and sutured to the superficial fascia of the
anterior flap. This fascial curtain or septum
in the mid-lateral plane lies posterior and
medial to the transposed nerve. C: Submus-
cular transposition. The flexor-pronator
muscle group is removed from the medial
epicondyle with an osteotome and a small
amount of bone. The origin is reflected at
least 6 cm distal to the medial epicondyle.
The nerve is then transposed anteriorly and
the flexor-pronator origin reattached while
the elbow is flexed to 90 degrees.
398 Regional Anatomy
strongest indication revision surgery for ulnar neuropathy at
the elbow (32). Lesser indications include young, vigorous
people such as athletes and very thin individuals in whom
subcutaneous positioning of the ulnar nerve might make it
liable to repeat injury (22). Submuscular transposition is
identical to subcutaneous transposition with regard to the
release and mobilization of the nerve and removal of the
medial intermuscular septum (see Fig. 7.31C). The next step
in submuscular transposition is to define the antecubital
fossa margin of the PT and the brachial artery and median
nerve in the antecubital fossa before elevation of the origin
of the flexor-pronator group from the medial epicondyle. An
osteotome is used to remove the flexor-pronator origin from
the medial epicondyle with a small amount of bone, and
then the remainder of the origin is reflected for a distance of
at least 6 cm distal to the medial epicondyle. Part of the
flexor-pronator origin is from the medial collateral ligament
of the elbow, and care must be taken to avoid disruption of
this important structure. The nerve is then transposed ante-
riorly and the flexor-pronator origin reattached while the
elbow is flexed to 90 degrees. Because of the need for mus-
cle healing and restoration of elbow motion and strength,
the time for return to full activity is longer with this tech-
nique compared with subcutaneous transposition.
Intramuscular Transposition. Permanent positioning of
the transposed ulnar nerve has been achieved by placing the
nerve in a 5-mm-deep muscular trough cut into the flexor-
pronator mass, followed by tension-free closure of the mus-
cle fascia over the nerve. A recent report of this technique,
first described in 1918 (38), revealed a high percentage of
good to excellent results (34).
Snapping Elbow
To many physicians, snapping sensations or sounds about
the medial aspect of the elbow are synonymous with the rel-
atively common recurrent dislocation of the ulnar nerve
(39). However, the medial head of the triceps muscle or ten-
don also may dislocate over the medial epicondyle and
result in snapping as the elbow either is flexed or as it is
extended from a flexed position. Dislocation of the medial
head of the triceps can occur in combination with ulnar
nerve dislocation to produce the clinical finding of two
snaps at the elbow. This condition may be present with or
without ulnar neuropathy and with or without discomfort.
Physical Examination
Both passive and active flexion and extension from a flexed
position are performed while palpating the medial aspect of
the elbow (39–41). In a patient who has snapping of the
medial head of the triceps and dislocation of the ulnar nerve,
the ulnar nerve dislocates at 90 degrees and the medial head
of the triceps dislocates at approximately 110 degrees (39).
Sequential palpation of the ulnar nerve in the cubital tunnel
and the medial head of the triceps may allow the examiner to
determine if one or both of these structures is dislocating. The
diagnosis may be confirmed by magnetic resonance imaging
(MRI) or computed tomography (CT), or both (39).
Associated Conditions
Abnormalities confirmed by operative findings include
hypermobility of the ulnar nerve, varying amounts of tri-
ceps muscle fibers extending distal to the medial epicondyle
that dislocated over the medial epicondyle with the elbow
in flexion, thickening of the fascial edge of the medial head
of the triceps, accessory triceps tendon, and posttraumatic
cubitus varus deformity (39). Dislocation of the medial tri-
ceps and ulnar neuropathy has been reported in three gen-
erations of one family (42).
Clinical Significance
Dislocation of the medial head of the triceps may occur in
combination with dislocation of the ulnar nerve. Failure to
recognize that these two conditions can occur concurrently
may be the reason for persistent symptoms after an other-
wise successful transposition of the ulnar nerve. Patients
who have an ulnar nerve transposition, especially those who
have dislocation of the ulnar nerve, should be examined
during surgery with the elbow in flexion and extension to
be certain that the medial head of the triceps does not snap
over the medial epicondyle (39).
Snapping of the Triceps Tendon over the
Lateral Epicondyle
This unusual condition is manifested by anterior disloca-
tion of the lateral head of the triceps with passive or active
flexion beyond 90 degrees. The differential diagnosis may
include posterolateral rotatory instability, loose bodies,
intraarticular adhesions, osteochondral defects, ruptured
annular ligaments, and synovial folds or plicae (43).
Acute Elbow (Ulnohumeral) Dislocation
Complete
A complete dislocation may be either straight posterior or
posterolateral with the coronoid posterior to the trochlea
(44). Based on clinical experience, there is deficiency of the
medial collateral ligament observed with valgus stress and dis-
ruption of the ligament found at the time of surgery (44).
Incomplete
An incomplete dislocation or subluxation (so-called
perched subluxation) is characterized by the trochlea being

“perched” or balanced on the coronoid process (44). This
incomplete type of dislocation occurs in less than 10% of
elbow dislocations and has been shown experimentally to be
possible with disruption of the lateral collateral ligament
and maintenance of some continuity of the medial collat-
eral ligament (44).
Treatment
Treatment is immediate reduction. After reduction, stabil-
ity of the joint is tested through a range of motion to deter-
mine if instability is present and at what position. The
elbow is placed in the position of stability and range of
motion started in 5 to 7 days in the previously defined arc.
If the elbow is markedly unstable, it is placed in sufficient
flexion to obtain stability and brought into extension after
5 to 7 days, with progression of the extension over the next
3 to 4 weeks (44).
Surgical intervention has very little value in the manage-
ment of elbow dislocation without fracture (44,45).
Subluxation of the Radial Head (Pulled
Elbow Syndrome)
This injury occurs most commonly in children 2 to 3 years
of age when a longitudinal pull is applied to the upper
extremity. The child fails to use the extremity and the fore-
arm is most often in pronation. Plain radiographs usually are
normal. This condition is due to slippage of the annular lig-
ament over the head of the radius so that the ligament is
7 Elbow 399
interposed between the radial head and the capitulum.
Reduction is achieved by supination of the forearm; if this
fails to produce the characteristic snapping sensation of
reduction, the elbow is brought into maximum flexion until
the snapping sensation occurs (46).
Collateral Ligament Injuries
Acute Medial
An acute tear of the medial collateral ligament is the most
frequent isolated ligamentous injury of the elbow. It is seen
most commonly in throwing athletes such as baseball pitch-
ers and javelin throwers (47).
Diagnosis
The diagnosis is suspected by the history and mechanism of
injury. Regional ecchymosis and tenderness over the ante-
rior band of the medial collateral ligament just inferior to
the medial epicondyle are characteristic findings (44).
Instability Test
With the patient’s hand placed in the examiner’s axilla, the
elbow flexed to 25 degrees (Jobe test), and the humerus exter-
nally rotated and abducted, valgus stress is applied to the
elbow to demonstrate laxity or localized pain. This degree of
flexion unlocks the olecranon from its fossa (47,48). Morrey
flexes the elbow approximately 10 degrees to relax the ante-
rior capsule and remove the coronoid and olecranon from
their respective fossae (44) (Fig. 7.32). Stress views are useful
if there is any question about the diagnosis.
FIGURE 7.32. Test for medial collateral ligament
instability. With the patient’s hand placed in the
examiner’s axilla, the elbow flexed to 25 degrees, and
the humerus externally rotated and abducted, valgus
stress is applied to the elbow to demonstrate laxity or
localized pain.
400 Regional Anatomy
Other Diagnostic Tests
Azar et al. evaluated their patients with suspected ulnar col-
lateral ligament injuries by valgus stress testing and as well
as radiographic stress views, CT arthrograms, and, in some
instances, saline-enhanced MRI (49).
Treatment
Acute injury in patients with low-demand activities is best
managed by immobilization of the elbow for 3 weeks fol-
lowed by a hinged splint for another 4 to 5 weeks. The
splint is fashioned to promote slight varus angulation of
the elbow and the forearm is placed in supination. At 8
weeks, unrestricted flexion and extension exercises are
allowed, but valgus load is avoided (44). In patients with
high-demand activities, such as competitive pitchers,
immediate repair or reconstruction may be appropriate.
The surgical management is discussed later, under Medial
Insufficiency.
Acute Lateral
This is an infrequent acute injury because varus stress is not
often generated from routine or sports activities (44).
Diagnosis
Diagnosis is made after a history of acute varus stress asso-
ciated with point tenderness and varus instability on exam-
ination.
Treatment
Nonoperative management is similar to that for medial col-
lateral ligament acute tears, with the exception that the
forearm is pronated rather than supinated because this posi-
tion provides the optimum position for stability and heal-
ing. Protection for 3 months is provided because the lateral
collateral ligament often displays residual laxity (44).
Medial Insufficiency
In chronic medial collateral insufficiency, there may be no
frank instability but the patient may note pain at the medial
aspect of the elbow with stress, as in throwing.
Diagnosis
The diagnosis is confirmed by noting tenderness over the
anterior bundle of the medial collateral ligament and repro-
duction of pain or palpable instability with valgus stress.
Not surprisingly, approximately 40% of patients may expe-
rience ulnar nerve symptoms (47).
Treatment
Treatment is through ligament reconstruction (Jobe tech-
nique) (48). The medial aspect of the elbow is opened and
care is taken to protect the ulnar nerve and sensory nerves
in the skin. The flexor-pronator muscle group is split lon-
gitudinally and the anterior portion of the ulnar collateral
ligament exposed. Additional exposure is obtained by
detachment and distal reflection of the flexor-pronator
mass. The ulnar nerve is mobilized 2.5 cm distal to the
epicondyle to well above the medial epicondyle. The
medial intermuscular septum is removed to the point at
which no impingement on the ulnar nerve can be palpated
or visualized. These maneuvers are in preparation for sub-
muscular transposition of the ulnar nerve after ligament
reconstruction. A drill is used to make a tunnel in the epi-
condyle and ulna that corresponds to the points of attach-
ment of the original ligament. The tunnel in the ulna is 1
cm distal to the joint. The tunnel in the medial epicondyle
is at the point of isometry. A tendon graft from either the
palmaris longus or plantaris, or a strip of Achilles tendon
is used to pass through the tunnels to form a figure-of-
eight. The graft is pulled taut and sutured to itself. The
flexor-pronator origin is reattached and the elbow immo-
bilized in 90 degrees of flexion for approximately 2 weeks,
followed by a hinge splint for an additional 2 weeks (Fig.
7.33).
Lateral Insufficiency (Posterolateral Rotatory
Instability)
Posterolateral rotatory instability of the elbow was first
described in 1991 and is distinguished from recurrent radial
head dislocation (the radioulnar joint) or dislocation of the
elbow joint (the ulnohumeral and radiohumeral joints) (6).
This condition also has been observed after lateral release
for tennis elbow (6).
Diagnosis
The diagnosis is made from a history of elbow dislocation
followed by symptoms of chronic instability characterized
by complaints of a pop, catch, or “clunk” as the elbow goes
from full extension to flexion or from flexion to extension.
In some cases, pain over the lateral aspect of the joint may
be a more prominent feature than the symptoms of insta-
bility. Although the patient may complain of posterolateral
elbow pain, a varus stress test often is negative unless gross
instability is present (6,44).
Diagnostic Maneuver.
The test is performed with the patient supine and the arm
over the patient’s head (6,44). The diagnostic maneuver
involves supination of the forearm and application of a val-
gus moment and axial compression while simultaneously
flexing the elbow from a position of full extension. This
maneuver produces a rotatory subluxation of the ulno-
humeral joint as the semilunar notch of the ulna is dis-
placed from the trochlea of the humerus. This rotation dis-
locates the radiohumeral joint posterolaterally, and as the
elbow is flexed to approximately 40 degrees, the rotatory
displacement is at its maximum and a posterior prominence
 7 Elbow 401

FIGURE 7.33. Ligament reconstruction for medial insufficiency (Jobe technique). A: The medial
aspect of the elbow is opened and the flexor-pronator muscle group is split longitudinally and
the anterior portion of the ulnar collateral ligament exposed. B: Additional exposure is obtained
by detachment and distal reflection of the flexor-pronator mass. C: A tendon graft is passed
through tunnels to form a figure-of-eight, pulled taut, and sutured to itself.

with an associated dimple in the skin is noted proximal to
the radial head (Fig. 7.34). Additional flexion results in a
sudden reduction of the radiohumeral and ulnohumeral
joints accompanied by disappearance of the dimple, and the
radius and ulna visibly and palpably snap into place on the
humerus. Although the reduction can be performed by
pronation of the forearm, the reduction is not as dramatic
as that described in the standard maneuver. In some
instances, the patient notes only pain with this maneuver,
without demonstrable pivot. This type of response is
reported as “positive for pain” and is highly suggestive of the
presence of this lesion (44). Full external rotation of the
shoulder provides a counterforce for the supination of the
forearm and leaves one hand of the examiner free for appli-
cation of valgus stress. Routine physical examination is neg-
ative and the elbow joint is stable to varus and valgus stress
even under anesthesia. In no instance can the ulnohumeral
joint be frankly dislocated (6).
402 Regional Anatomy

FIGURE 7.34. Diagnostic maneuver for posterolateral rotatory instability (lateral insufficiency
test). The maneuver involves supination of the forearm and application of a valgus moment and
axial compression while simultaneously flexing the elbow from a position of full extension. This
maneuver dislocates the radiohumeral joint posterolaterally, and as the elbow is flexed to
approximately 40 degrees, the rotatory displacement is at its maximum and a posterior promi-
nence with an associated dimple in the skin is noted proximal to the radial head.

Abnormal Findings at Surgery
According to Nestor et al. (6), anatomic findings at time of
surgery consistently demonstrated laxity or avulsion of that
portion of the radial collateral ligament that they have
named the LUCL. Treatment depends on the status of the
LUCL and includes advancement and imbrication or
reconstruction with autogenous tendon graft.
Treatment/Surgical Technique
With the patient supine, the elbow semiflexed, and the
forearm in pronation on an arm board, a longitudinal
incision is made 5 cm proximal to the lateral epicondyle
over the lateral supracondylar ridge and continuing dis-
tally over the lateral epicondyle to curve over the
anconeus, ending posteriorly at the subcutaneous margin
of the ulna. Distally, the interval between the ECU and
anconeus is used to expose the proximal and extensor
aspect of the forearm, the supinator crest, and the inser-
tion of the LUCL. Two 3- to 4-mm drill holes are placed
at the tubercle on the proximal aspect of the supinator
crest approximately 7 to 10 mm apart. To determine the
proximal point of origin of the new ligament, the point
of isometry is determined by passing a suture through the
tunnel made in the proximal ulna and clamping the two
ends of the suture with a hemostat, which is used as a
pointer to identify the isometric point. This point usually
is in the mid-portion of the lateral epicondyle (6,44). A
tunnel is then made in the epicondylar ridge centered
about the isometric point and a free tendon graft using
the palmaris longus or the plantaris passed through these
tunnels so that a three-ply graft is obtained (Fig. 7.35).
The elbow is placed in 30 degrees of flexion and the graft
sutured to itself under tension. The elbow is immobilized
for 2 weeks, followed by protection in a hinge splint for
4 to 6 weeks. Thereafter, progressive activities are
allowed, but varus stress is avoided for 4 to 6 months
(44).
Flexion Contracture
Flexion contracture of the elbow may be associated with sig-
nificant loss of upper extremity function. An arc of motion
from 30 degrees short of full extension to 120 degrees flex-
ion (90 degrees of motion) is said to be essential for most
activities of daily living (50).
Etiology
Flexion contracture may be due to a variety of causes,
including fractures and dislocations about the elbow, burns,
heterotopic ossification, spasticity, or congenital or devel-
opmental conditions about the joint (50,51). This discus-
sion of anterior capsulotomy focuses on the release of flex-
ion contracture secondary to trauma.
Surgical Approaches
Although anterior capsulotomy may be performed through
an anterior (46) approach as well as a combined medial and
lateral (52) approach, there are several compelling reasons to
perform it through a lateral approach (50). These include the
ability to release both anterior and posterior structures
 7 Elbow 403

FIGURE 7.35. Ligament reconstruction for posterolateral rotatory instability (lateral insuffi-
ciency). A: A longitudinal incision is made 5 cm proximal to the lateral epicondyle over the lat-
eral supracondylar ridge and continued distally over the lateral epicondyle to curve over the
anconeus, ending posteriorly at the subcutaneous margin of the ulna. The interval between the
extensor carpi ulnaris and anconeus is used to expose the proximal and extensor aspect of the
forearm, the supinator crest, and the insertion of the radial collateral ligament. B, C: Drill holes
are placed at the tubercle on the proximal aspect of the supinator crest approximately 7 to 10
mm apart, and the point of isometry is determined by passing a suture through the tunnel made
in the proximal ulna to identify the isometric point. A second tunnel is then made near the epi-
condylar ridge centered about the isometric point, and a free tendon graft is passed through
these tunnels so that a three-ply graft is obtained.

through the same incision, the fact that the olecranon fossa
may be cleared or part of the olecranon excised to obtain
additional extension, and any enlargement of the coronoid
process that might produce impingement can be excised. Pos-
teriorly, tenolysis of the triceps and capsulotomy can be done
to increase flexion. After surgery, the lateral incision, which is
in the neutral axis of flexion–extension, is less likely to pro-
duce an unacceptable scar, and if immediate continuous pas-
sive motion is used, it will be less subject to tension (50).
Technique of Lateral Approach
Position/Incision
With the patient supine, the elbow flexed to 60 degrees,
and the forearm pronated, a Kocher approach is used begin-
ning along the lateral supracondylar ridge of the humerus
and continuing across the lateral epicondyle, to end at the
subcutaneous border of the ulna between the ECU and
anconeus (Fig. 7.36).
FIGURE 7.36. Lateral approach for elbow flexion contracture. A: A Kocher approach is used
beginning along the lateral supracondylar ridge of the humerus and continued across the lateral
epicondyle to end at the subcutaneous border of the ulna between the extensor carpi ulnaris
(ECU) and anconeus. B: Subperiosteal stripping is used to elevate the brachioradialis (BR) and
extensor carpi radialis longus (ECRL) from the supracondylar ridge to reveal the brachialis muscle
and the anterior capsule. C: Distally, the interval between the ECU and anconeus is used to
expose the lateral aspect of the elbow joint. Retractors are placed deep to the BR, ECRL, and
brachialis to expose the anterior capsule, which is incised from lateral to medial. D: The elbow is
brought into maximum extension and, if extension is incomplete, the triceps is dissected free and
retracted to look for soft tissue or bone in the olecranon fossa that might block full extension.

Deep Dissection
Subperiosteal stripping is used to elevate the brachioradi-
alis and ECRL from the supracondylar ridge to reveal the
brachialis muscle and the anterior capsule. Distally, the
interval between the ECU and anconeus is used to expose
the lateral aspect of the elbow joint. Retractors are placed
deep to the brachioradialis, ECRL, and brachialis to expose
the anterior capsule, which is incised from lateral to
medial. The fascia on the underside of the brachialis may
be incised as needed. The elbow is brought into maximum
extension and, if extension is incomplete, the triceps is dis-
sected free and retracted to look for soft tissue or bone in
the olecranon fossa that might block full extension or
enlargement of the olecranon. Flexion may be improved by
tenolysis of the triceps and posterior capsulotomy as
required. If adequate flexion still is not obtained, the coro-
noid fossa should be inspected and cleared, or if the coro-
noid process is enlarged, it should be trimmed as indicated
proximal to the brachialis insertion. The extensive nature
of this release requires careful reattachment of the lateral
sleeve of tissues, and the authors recommend drill holes in
the humerus to facilitate closure to restore lateral stability
to the elbow (50). The senior author (Hastings) of this
technique has noted that when radical debridement of the
joint is not required, preservation of the origin of the lat-
eral collateral ligament on the lateral epicondyle is recom-
mended (8). If this is possible, no postoperative protection
of the lateral ligamentous structures is required in the reha-
bilitation phase of recovery.
Myositis Ossificans and Heterotopic
Calcification and Ossification
True myositis ossificans should be differentiated from het-
erotopic calcification, the latter being a dystrophic process
(46). Myositis ossificans is ossification in the muscle (most
often the brachialis) after trauma such as an elbow dislo-
cation. This condition may lead to significant loss of
motion of the elbow and usually is seen 3 to 6 weeks after
injury (53). This condition is rare compared with hetero-
topic calcification in the ligaments and capsule of the
elbow joint, which is common, but rarely results in loss of
elbow function. The incidence of myositis ossificans can
be lessened by gentle and prompt reduction of elbow dis-
locations and by using gentleness during the rehabilitation
process (46). Heterotopic ossification is manifested clini-
cally as an intense inflammatory reaction about the joint
with redness, increased warmth, severe pain, and rapidly
decreasing range of motion (54,55). It is a complication of
traumatic brain injury and usually is detected within 2
months after the injury. The incidence of periarticular
heterotopic ossification after traumatic brain injury is
11%. The hips are involved most commonly, followed by
the shoulder and elbows (55). An increased incidence to
85% is noted in patients with concomitant musculoskele-
tal injuries (55).
7 Elbow 405
ANATOMIC VARIATIONS
Muscle
Anconeus Epitrochlearis
The anconeus epitrochlearis is a small anomalous muscle
near the origin of the FCU, proximal to the aponeurosis
joining the humeral and ulnar heads of the FCU. It arises
from the medial border of the olecranon and inserts into
the medial epicondyle. This muscle is superficial to the
ulnar nerve and takes the place of the fibrous arch of the
deep fascia. It may vary in size and shape from small and
fusiform to a thick, rectangular structure that is palpable on
physical examination (56,57). It has been reported to have
a variable incidence as high as 25% (56). It has been
described as an auxiliary extension of the medial portion of
the triceps, but it is anatomically distinct from the triceps
and is supplied by the ulnar nerve. This muscle often is seen
in other species and presumably is an atavistic anomaly in
humans. In humans, the muscle may be replaced by a liga-
ment called the epitrochleoanconeus ligament, and because its
course and attachments are similar to those of the anconeus
epitrochlearis, this ligament is believed to be a rudiment of
the muscle (58).
Clinical Significance
This muscle crosses over the ulnar nerve in the region of
the cubital tunnel and has been reported to be a source of
compression of the ulnar nerve in cubital tunnel syn-
drome (56,57). In cases of ulnar neuropathy due to the
anconeus epitrochlearis muscle, treatment is complete or
partial excision of the muscle to relieve any pressure on the
nerve (57).
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 C H A P T E R

8
FOREARM
JAMES R. DOYLE

P A R T
1 Similarly, the ventromedial group arises from the medial
FLEXOR FOREARM
The proximal and distal ends of the two-bone configura-
tion of the forearm are uniquely suited to allow a large arc
of flexion–extension movement while at the same time
permitting almost 180 degrees of rotation of the forearm.
The functional implications of this unique system are but
minimally illustrated by the use of a screwdriver or the act
of passing a curved surgical needle, which requires repeti-
tive and alternating pronation and supination of the fore-
arm in association with a stable elbow and wrist joint. The
radius, so aptly named, rotates around the long axis of the
ulna while the stability of the two bones is maintained by
their bony architecture, the interosseous membrane, and
proximal and distal ligamentous and muscular support.
The uniqueness of the forearm is further illustrated by the
relative ease of surgical exposure of the ulna, which is sub-
cutaneous throughout its length, compared with the
radius, which is surrounded by muscles and nerves that
make surgical approaches to this bone significantly more
complex.
The functional and purposeful movement of this bony
scaffold is effected by means of two forearm muscle groups,
the dorsolateral and the ventromedial, and also by the
biceps brachii, which is an elbow flexor as well as a primary
supinator of the forearm.
FOREARM MUSCLE GROUPS
Dorsolateral
The dorsolateral group arises from the lateral epicondyle of
the humerus and extends to the dorsal aspect of the fore-
arm, wrist, and hand. When the forearm is in neutral, iso-
lated contraction of the dorsolateral group tends to supinate
the forearm. This is especially true of the brachioradialis,
which inserts on the radial styloid and was formerly known
as the supinator longus.
Ventromedial
epicondyle and extends to the ventral aspect of the forearm,
wrist, and hand. These two groups sometimes are described
as the flexor-pronator and extensor-supinator groups because
of their combined functional roles in movement of the wrist
and forearm. The ventromedial group assists in pronation
of the forearm.
Pronation/Supination
The respective actions of pronation and supination are
facilitated by the oblique orientation and pull of the two
muscle groups. Although the biceps and supinator are rec-
ognized as the major supinators of the forearm, just as the
pronator teres (PT) and pronator quadratus (PQ) are rec-
ognized as the major pronators of the forearm, the fact that
other muscle groups also may participate in a given motion
illustrates the complex nature of movement in the upper
extremity. This complexity is further illustrated by the fact
that these two muscle groups that originate from the
humerus also may act as flexors of the elbow.
DESCRIPTIVE ANATOMY OF THE FLEXOR
FOREARM
Contents
Bones: The forearm contains the radius and ulna.
Blood Vessels: The forearm contains the brachial, radial,
ulnar, and interosseous arteries and superficial veins.
Nerves: The forearm contains the median, ulnar, and
radial nerves and cutaneous nerves.
Interosseous Membrane: The interosseous membrane
(IOM) spans the space between the radius and ulna.
Muscles: The forearm contains the primary flexors and
extensors of the wrist and fingers, the extrinsic finger and
thumb flexors and extensors, and the pronators and supina-
tors of the forearm.
External Landmarks
Important landmarks for the volar forearm include the
medial and lateral epicondyle, the biceps tendon, the
408 Regional Anatomy

“mobile wad of three” [brachioradialis, extensor carpi radi- Distal Humerus

alis longus (ECRL), and extensor carpi radialis brevis
(ECRB)] (1), the flexor-pronator group, the flexor carpi
ulnaris (FCU) tendon, the flexor carpi radialis (FCR) ten-
don, the pisiform bone, the radial styloid, and, if present,
the palmaris longus (PL) tendon (Fig. 8.1).
Skeletal Anatomy
Although the radius and ulna represent the major osseous
components of the forearm, the distal humerus also must be
included because of the important relationships between
these three bones (Fig. 8.2).
The distal humerus is a modified condyle that is wider than
it is thick and has articular and nonarticular parts.
Articular Components
The lateral and convex capitulum is less than half a sphere
that has anterior and inferior but not posterior articular sur-
faces. It articulates with the discoid radial head that abuts the
inferior surface in full extension. The trochlea, the medial
and pulley-shaped humeral surface, articulates with the
trochlear notch of the proximal ulna. The trochlear notch has
a mid-articular ridge that extends from front to back and cor-
responds to a groove in the trochlea. The articular surface of

A B
FIGURE 8.1. A, B: Flexor aspect of the right forearm, showing prominent landmarks.

the trochlea is anterior, inferior, and posterior and is sepa-
rated from the capitellum by a shallow groove (2).
Nonarticular Components
The nonarticular medial and lateral epicondyles and their
respective supracondylar ridges are sites of origin for the
8.1 Flexor Forearm 409
FIGURE 8.2. Radius and ulna. Note the bony landmarks
and changes in cross-sectional morphology from proxi-
mal to distal. Note the radial bow that allows rotation
of the radius about the long axis of the ulna without
impingement.
flexor-pronator and extensor-supinator muscles, respectively.
The smooth posterior surface of the medial epicondyle is tra-
versed by the ulnar nerve through a groove before its entrance
into the FCU. The radial and coronoid fossae provide space
for the radial head and coronoid process of the ulna to
accommodate flexion of the elbow without impingement.
410 Regional Anatomy
Posteriorly, the olecranon fossa accommodates the apex of the
olecranon process when the elbow is extended. A line in the
coronal plane drawn from the most external aspects of the
medial to the lateral epicondyle is called the interepicondylar
line or Hueter’s line, and is a useful landmark for identifica-
tion of the lateral antebrachial cutaneous nerve of the forearm
and the site of division of the radial nerve into motor and
sensory components (2,3).
Radius
The radius has expanded proximal and distal ends. The
shaft is convex laterally and concave anteriorly in the distal
one-half, a probable requirement of impingement-free
motion from full supination to full pronation. This biplane
bowing must be maintained in the treatment of fractures to
prevent loss of pronation or supination. The radial head is
discoid and its proximal surface is a shallow cup to accom-
modate the adjacent capitulum. The disc is widest medially,
where it articulates with the ulna in the radial notch (2).
The neck is positioned between the head and the medially
placed biceps tuberosity. A prominent anterior oblique line
extends from the tuberosity to the junction of the proximal
and middle thirds of the radius and is the site of origin of
the flexor digitorum superficialis (FDS). The middle third
of the radial shaft is triangular, in contrast to the proximal
third, which is more or less round, and the distal third,
which is a broad, four-sided oval. The radial styloid on the
lateral surface is a prominent landmark and projects beyond
that of the ulna. The complex distal articulation of the
radius and ulna is presented in Chapter 9.
Ulna
The proximal end of the ulna is a large hook and the ulna
progressively diminishes in size from its larger proximal end
to its distal end, which expands into a small, rounded head
and styloid process. The head of the distal ulna is visible in
pronation and its convex articular surface fits into the radial
ulnar notch. The styloid process of the ulna is a short,
round posterolateral projection of the end of the ulna. The
trochlear or semilunar notch is bounded proximally by the
apex of the olecranon process and distally by the coronoid
process. Just distal to the coronoid process is the site of
insertion of the brachialis muscle, the ulnar tuberosity. The
shaft is triangular in cross-section, in contrast to the
rounded distal end and the quadrangular proximal end.
Interosseous Membrane
The radius and ulna are joined by a syndesmosis called the
interosseous membrane (Fig. 8.3).
Gross Anatomy
The IOM begins proximally, approximately 2 to 3 cm dis-
tal to the radial tuberosity, and spans the space between the
radius and ulna from this area down to the distal articula-
tion. The proximal opening allows passage of the posterior
interosseous artery, and distally an opening is present to
allow passage of the anterior interosseous artery to the back
of the forearm (2). The oblique cord is a small, inconstant
flat band on the deep head of the supinator that extends
from the lateral side of the ulnar tuberosity to the radius a
short distance distal to its tuberosity (2). The IOM provides
attachments for the flexor pollicis longus (FPL) laterally
and the flexor digitorum profundus (FDP) medially on its
volar surface, and dorsally to the supinator, abductor polli-
cis longus (APL), extensor pollicis longus (EPL), extensor
pollicis brevis (EPB), and extensor indicis proprius (EIP).
The maximum thickness of 1 mm is noted 1 cm proximal
to the midpoint of the radius (4). This area of relative thick-
ness is called the central band (CB) and is three to four times
as thick as the IOM proximally and distally. The width of
this band is approximately 1 cm as measured perpendicular
to its fibers. In the metaphyseal region of the distal forearm,
the IOM is dorsal to accommodate the deep head of the PQ
(5). The fibers of the IOM originate on the radius (proxi-
mal) and insert on the ulna (distal) (6). Skahen et al.
described the IOM as a complex composed of a membra-
nous portion, a CB, accessory bands, and a proximal
interosseous band (6). The average length of the radial ori-
gin is 10.6 cm (range, 6 to 19.5 cm) and that of the ulnar
insertion, 10.6 cm (range, 8 to 13.5 cm). The CB has an
average width of 1.1 cm (range, 0.5 to 2.5 cm) measured
perpendicular to its fibers. The average site of origin is 7.7
cm (range, 6.5 to 8.7 cm) distal to the articular surface of
the radial head, and the insertion on the ulna is 13.7 cm
(range, 10 to 18.5 cm) distal to the tip of the olecranon.
The average fiber angle is 21 degrees (range, 11 to 38
degrees) to the longitudinal axis of the ulna. Accessory
bands were variable as to occurrence and number and were
less substantial than the CB, but fiber orientation was sim-
ilar to the CB. The proximal interosseous band was more
likely (17 of 20 specimens) to be present and, when present,
was found exclusively on the proximal dorsal surface of the
forearm. Its fibers are oriented nearly perpendicular to the
CB. The radial attachment is 7.7 cm (range, 6.7 to 8.7 cm)
from the articular surface of the radial head and the ulnar
attachment is an average of 9.6 cm (range, 7.7 to 11.8 cm)
distal to the tip of the olecranon. The width of the proximal
interosseous band is 0.4 cm as measured perpendicular to
its fibers (range, 0.2 to 0.8 cm).
Histology, Ultrastructure, and Biochemical
Composition
Based on histologic sections, the IOM appears to be com-
posed mostly of collagen with very little elastin (7). The col-
lagen fiber bundles are organized in a parallel arrangement
surrounded by an elastin covering. The collagen bundles
provide the tensile strength of the IOM and the elastin
sheath provides support and some elasticity. Electron
microscopy of portions of the CB revealed parallel collagen
 8.1 Flexor Forearm 411

FIGURE 8.3. The interosseous membrane (IOM). In addition to providing attachment areas for
several forearm muscles, the IOM, and especially the central band, is a secondary forearm stabi-
lizer and load transfer structure (see text).

fibers with a varying distribution of fibril diameters. The
biochemical composition, assessed using hydroxyproline
assay, yielded an average collagen content of 93.2% ± 7.1%.
Based on these findings of large amounts of collagen and an
ordered structure, McGinley and Kozin proposed that the
IOM functions similar to a tendon (7).
Function and Biomechanics
The CB of the IOM acts as a ligament and probably teth-
ers the radius longitudinally to prevent proximal migration
of the radius after radial head excision (4). Skahen et al.
agreed with Hotchkiss et al., who found that the CB was
responsible for 71% of the longitudinal stiffness of the
IOM after radial head excision (4,6). Rabinowitz et al. have
identified the mid-portion of the IOM as the most crucial
structural subdivision (8). They noted that although the
intact radius has been identified as the primary restraint to
proximal radial migration, both the triangular fibrocartilage
complex (TFCC) and the IOM have been identified as
important secondary forearm stabilizers. Based on their bio-
mechanical study and the observation that some patients
gradually acquire wrist symptoms after radial head excision,
it has been postulated that with subsequent dynamic phys-
iologic loading stretching of the IOM and TFCC may
412 Regional Anatomy
occur, allowing further proximal radial migration. This
study found that after radial head excision, if either the
TFCC or IOM alone were disrupted, little additional prox-
imal migration would occur. However, if both the mid-por-
tion of the IOM and the TFCC were incompetent, further
proximal radial migration would occur. They noted that
proximal migration of the radius greater than 6 to 7 mm
while under axial load implied disruption of both the
TFCC and the mid-portion of the IOM (8). Maximum
strain in the CB of the intact IOM occurs in neutral fore-
arm rotation. Absence of the radial head is associated with
increased strain throughout the arc of forearm rotation, and
maximum strain is noted in pronation (6). The interactive
dynamic anatomy of the IOM, radius, and ulna may be
summarized as follows: (a) normally, the IOM transfers
load from the distal radius to the proximal ulna, as mani-
fested by decreasing loads in the radius from distal to prox-
imal and increasing load values in the ulna from distal to
proximal, whereas after IOM division the proximal and dis-
tal load values become equal (9); (b) normally, the radial
head serves as the primary restraint to proximal migration
of the radius; (c) the CB and TFCC serve as secondary
FIGURE 8.4. The carrying angle. The carrying angle is most noticeable in supination and exten-
sion, and disappears in flexion and pronation.
restraints when the forearm is loaded; and (d) when the
radial head is absent, the CB and TFCC become the pri-
mary restraints as they attempt to resist proximal migration
of the radius by transferring load to the ulna (6,8).
Clinical Significance
The ability of the IOM to transfer load from the radius to
the ulna through fibers that run from the proximal radius
to the distal ulna and exert a proximal pull on the ulna
might explain patterns of injury as seen in both-bone frac-
tures of the forearm, Galeazzi and Monteggia fracture–dis-
locations, and the Essex-Lopresti injury, which are charac-
terized by a pattern of proximal radius to distal ulna
forearm injury (9).
Both-Bone Fractures. Linking of the radius and ulna by
the obliquely oriented IOM, especially the CB, may explain
the finding that the radial fracture is most often proximal
and the ulnar fracture distal. Synostosis is less common in
this configuration but more common if the ulnar fracture is
proximal. This is said to be due to the fact that in the more
proximal ulnar fracture, the IOM injury is perpendicular

rather than parallel to the fibers of the IOM. The small ves-
sels that course parallel to these fibers are more likely to be
torn and form a hematoma in the interosseous space, lead-
ing to synostosis.
Galeazzi and Monteggia Fracture–Dislocations and
Essex-Lopresti Injury. In a fall on the outstretched hand,
the radius is impacted between the ground and the capitu-
lum. Force transfer (mediated by the IOM) to the proximal
ulna would result in displacement of the ulnar column dis-
tally toward the ground and increased tension in the IOM.
The specific injury or lesion produced depends on the site
of force concentration; if proximal to the CB, it may result
in a Monteggia or Essex-Lopresti injury, and if distal, it may
result in a Galeazzi injury (9).
The Carrying Angle
When the forearm is supinated and in full extension, it
deviates laterally by approximately 17 degrees (2). This so-
called carrying angle is due to (a) the fact that the medial
trochlear edge is approximately 6 mm longer than its lat-
eral edge; and (b) the matching obliquity of the coronoid’s
superior articular surface, which is not orthogonal to the
ulnar shaft (2). The carrying angle disappears when the
elbow is flexed because of slight spiral orientation of the
ridge in the trochlear notch and the companion groove in
the trochlea, and because the tilt of the humeral and ulnar
articular surfaces is approximately equal (2,10). The carry-
ing angle is masked, if not obliterated, by pronation of the
forearm, which brings the hand into a more functional
position (Fig. 8.4).
ANATOMIC RELATIONSHIPS
For the sake of clarity, the superficial structures on the volar
side of the arm, elbow, and forearm are included in this sec-
tion on the volar forearm.
Veins
Although the dorsal veins of the hand and wrist are more
prominent than the volar veins, the opposite is true on the
volar aspect of the forearm, elbow, and arm. Three veins are
prominent in the forearm: the laterally placed cephalic vein,
the more centrally placed median vein of the forearm, and
the medially located basilic vein. In the region of the ante-
cubital fossa, the median vein of the forearm usually joins
the cephalic, which continues into the arm on its anterolat-
eral aspect near the interval of the biceps and brachialis
muscles, the so-called biceps groove. Sometimes, however,
the median vein of the forearm may join the basilic vein,
which continues into the arm along the medial biceps
8.1 Flexor Forearm 413
groove. In the proximal forearm, a branch from the cephalic
or the median vein of the forearm, depending on the par-
ticular configuration, called the median cubital vein, courses
proximally and medially to join the basilic vein on the
medial aspect of the arm. The confluence of these veins
often, but not always, forms an “M”-shaped pattern (Fig.
8.5A). The median cubital vein often is the site for
venipuncture because of its size and prominence. This vein
also crosses over the biceps tendon in the region of the
elbow flexion crease. These superficial veins are connected
to the deeper venous system by communicating veins that
may require ligation during surgery. Such a communicating
branch often is found near the junction of the cephalic and
median cubital veins. Much variation can occur in the size
and orientation of veins throughout the upper extremity,
and the preceding discussion is intended to depict some
common patterns or configurations. These veins are dis-
cussed in this section because they often must be retracted
or ligated in surgical approaches in the upper extremity, and
sometimes may represent landmarks for location of other
superficial structures, such as the lateral antebrachial cuta-
neous nerve of the forearm.
Cutaneous Nerves
Medial Antebrachial Cutaneous Nerve
The medial antebrachial cutaneous nerve (MACN) origi-
nates in the axilla between the axillary artery and vein and
courses down the arm medial to the brachial artery (see Fig.
8.5B). Based on a study of 50 cadavers, it was found to arise
from the medial cord in 78% and from the lower cord in
22% (11). In the distal arm, the MACN is adjacent to the
basilic vein and pierces the deep fascia in the middle or dis-
tal arm to become subcutaneous. In the distal arm, the
MACN divides into posterior and anterior branches at an
average of 14.5 cm proximal to the medial epicondyle; these
branches continue with the basilic vein for a variable dis-
tance before the posterior branch turns ulnarward and pos-
teriorly to cross over the medial intermuscular septum and
the ulnar nerve (11,12). Ninety percent of the posterior
branches cross at or proximal to the medial epicondyle, and
the number of branches ranges from one to four. The ante-
rior branch sends cutaneous branches to the anterior arm
distally, antecubital fossa, and proximal anterior forearm.
These branches are variable in number (two to five) and
location. Most of these cutaneous branches arise between 6
cm proximal and 5 cm distal to the elbow. The anterior
branch crosses the elbow anteriorly between the medial epi-
condyle and biceps tendon, usually lying 2 to 3 cm antero-
lateral to the epicondyle. The main anterior branch contin-
ues distally superficial to the FCU to within an average of
5.6 cm from the wrist flexion crease. The cutaneous distri-
bution of the MACN in the forearm is the antecubital fossa,
posterior olecranon region, and the medial half of the flexor
414 Regional Anatomy

A
FIGURE 8.5. A: Veins of the arm and forearm. In the forearm, the cephalic and basilic veins flank
the median antebrachial vein in the forearm. Note the median cubital vein in the region of the
antecubital fossa.

side of the forearm, as well as proximal portions of the Lateral Antebrachial Cutaneous Nerve of the
extensor surface of the forearm (11,12). Forearm

Clinical Significance
This nerve and its branches are at risk during surgical expo-
sures in this area of the forearm and should be identified
and preserved. The use of the MACN as a nerve graft is dis-
cussed in Chapter 6.
The lateral antebrachial cutaneous nerve of the forearm (the
cutaneous branch of the musculocutaneous nerve) enters
the antecubital fossa between the biceps and brachialis mus-
cles (see Fig. 8.5B). It emerges from beneath the lateral
aspect of the biceps tendon at the level of the interepi-
 8.1 Flexor Forearm 415

B
FIGURE 8.5. (continued) B: Cutaneous nerves of the arm and forearm.

condylar line (a line drawn between the medial and lateral
epicondyles) (13). It then becomes progressively more
superficial as it continues distally beneath the cephalic vein.
Because of the variability in the configuration of the veins
in this area, its relationship with the biceps tendon is a more
reliable landmark.
Clinical Significance
The lateral antebrachial cutaneous nerve has been found to
be a highly suitable autograft donor for digital nerve grafts,
and the resultant sensory loss is not considered to be clini-
cally significant (14). As it exits from between the biceps
and brachialis in the distal arm, it is deep in the lateral
416 Regional Anatomy
aspect of the arm and should not be confused with the adja-
cent radial nerve, which is in the interval between the
brachialis and the brachioradialis.
Volar Forearm Muscle Groups
There are three groups or layers of flexor forearm muscles:
superficial, intermediate, and deep. The muscular compo-
nents of the volar forearm are:
Superficial
n Brachioradialis
n Pronator teres
n Flexor carpi radialis
n Palmaris longus
n Flexor carpi ulnaris
Intermediate
n Flexor digitorum superficialis
Deep
n Flexor pollicis longus
n Flexor digitorum profundus
n Pronator quadratus
n Supinator
Superficial Group
Brachioradialis
The unipennate brachioradialis is the most superficial mus-
cle on the radial border of the forearm and arises from the
proximal two-thirds of the supracondylar ridge and from
the anterior surface of the lateral intermuscular septum
(Fig. 8.6). The muscle fibers end in the mid-forearm in a
flat tendon that continues distally to insert over a large area
on the radial styloid. The brachioradialis is an elbow flexor
and acts most effectively in this capacity when the forearm
is in mid-pronation. It is easily demonstrated when the
semipronated forearm is flexed against resistance. The bra-
chioradialis is minimally active in slow, easy flexions or with
the forearm in supination, but is very active in both flexion
and extension when movement is rapid and is a stabilizing
force during rapid movements of the elbow (15).
Pronator Teres
The PT has two heads of origin: the humeral, the larger and
more superficial of the two, arises just proximal to the medial
epicondyle from the common tendon of origin of the flexor
muscles, and from the intermuscular septum between it and
the FCR; the ulnar head arises from the medial side of the
coronoid process of the ulna, distal to the attachment of the
FDS (see Fig. 8.6). The median nerve usually enters the fore-
arm between these two heads. The muscle ends in a flat ten-
don that inserts on the middle third of the radius at the “sum-
mit” of its lateral bow. The PT forms the medial or ulnar side
of the antecubital fossa and the brachioradialis forms the lat-
eral or radial side. The PT acts as a pronator of the forearm
in rapid or forceful pronation, and because of its location at
the medial epicondyle it also is an elbow flexor.
Flexor Carpi Radialis
The FCR lies ulnar to the PT and arises from the medial
epicondyle via the common flexor tendon, the antebrachial
fascia, and adjacent intermuscular septa (see Fig. 8.6). Its
fusiform belly ends in a tendon at the middle third of the
forearm. This tendon passes through a groove in the trapez-
ium and inserts on the palmar surface of the base of the
index metacarpal, with an additional slip of attachment to
the middle finger metacarpal. In the distal aspect of the
arm, the radial artery lies radial to the FCR tendon. The
FCR is a wrist flexor and, in conjunction with the radial
wrist extensors, may aid in radial deviation of the hand.
Palmaris Longus
The PL is a fusiform muscle ulnar to the FCR that arises
from the medial epicondyle by the common flexor tendon
as well as adjacent intermuscular septa and deep fascia (see
Fig. 8.6). Its configuration and incidence are variable, and
it usually ends as a long tendon that inserts into the palmar
fascia. The PL may be an accessory wrist flexor.
Flexor Carpi Ulnaris
The FCU is the most ulnar of the superficial flexor group
and arises from two heads: the humeral and ulnar (see Fig.
8.6). The small humeral head arises from the medial epi-
condyle by the common tendon and the ulnar head arises
from the medial margin of the olecranon and the proximal
two-thirds of the posterior border of the ulna by an aponeu-
rosis shared with the extensor carpi ulnaris (ECU) and FDP
and from the intermuscular septum between it and the
FDS. The two heads are joined by a tendinous arch beneath
which the ulnar nerve and the posterior ulnar recurrent
artery pass. This arch, may be a source of compression of
the ulnar nerve.
A thick tendon forms radially in the mid-aspect of the
muscle and continues distally to attach to the pisiform bone
and then to the hamate and base of the little finger
metacarpal by means of the pisohamate and pisometacarpal
ligaments. Muscle fibers continue nearly to the level of the
pisiform. The FCU is a major wrist flexor and, along with
the ECU, ulnar deviates the hand.
Intermediate Group
Flexor Digitorum Superficialis
The superficial portion (middle and ring fingers) of the
FDS arises from the medial epicondyle, the proximal ulna,
and the proximal radius (Fig. 8.7). The deep portion (index
and little fingers) of the FDS arises from the medial epi-
condyle only. The deep portion of the FDS is trigastric with
a single proximal belly and two distal bellies that give ten-
dons to the index and little finger. The proximal and distal
 8.1 Flexor Forearm 417

FIGURE 8.6. The superficial layer of the forearm flexor muscles in longitudinal and cross-sec-
tional views.
418 Regional Anatomy

FIGURE 8.7. The intermediate layer of forearm flexor muscles. Note the relationship of the two
layers of the superficialis and the trigastric superficialis to the index and little fingers.
 8.1 Flexor Forearm 419

FIGURE 8.8. The trigastric flexor digitorum superficialis (FDS) to the index and little fingers.
Fresh cadaver dissection of the right forearm viewed from the ulnar-flexor aspect. Note the
ulnar nerve in the near foreground, the 9satellite9 median nerve coursing between Gantzer’s
muscle (accessory flexor pollicis longus), and the trigastric FDS to the index and little finger.
Note also the fibrous tissue linkage between the proximal and distal muscle bellies of this FDS.

bellies of the deep portion are joined in the mid-aspect of
the forearm by a prominent fibrous tissue linkage (Fig. 8.8).
After leaving the antecubital fossa, the median nerve
becomes a “satellite” of the deep part of the FDS (1). It lies
first to the radial side of the proximal belly and then to the
radial side of the fibrous tissue linkage between the proxi-
mal and distal bellies. Below this level, fascia binds the
median nerve in a lateral groove between the muscle bellies
and tendons of the middle and index fingers. Thus, the
median nerve stays with the FDS when the FDS and FDP
muscles are separated, as in the McConnell approach (see
section on Surgical Exposures, later). The median nerve can
be relied on to exit consistently from beneath the radial side
of the muscle belly of the middle finger in the distal fore-
arm. This is a useful reference point in identifying and
locating this structure when exploring wounds about the
wrist. A fibrous tissue arch is present in the proximal mar-
gin of the superficial portion of the FDS, and as the median
nerve and anterior interosseous nerve (AIN) course beneath
this arch, they may be subject to compression (Fig. 8.9).

FIGURE 8.9. Fibrous tissue arch of the superficial component of the flexor digitorum superficialis
(FDS). Fresh cadaver dissection of the proximal and flexor aspect of the right forearm (distal is to the
left). Note the median nerve and the anterior interosseous nerve coursing beneath the fibrous edge
of the FDS. A yellow marker is beneath the median nerve proximally and distally. A red marker is
beneath the collapsed brachial artery proximally; a red vessel loop is around the recurrent branch of
the radial artery; both the ulnar and radial arteries are immediately ulnar to this vessel loop.
 FIGURE 8.10. The deep layer of the forearm flexor muscles. Note the side-by-side configuration
of the flexor pollicis longus (FPL) and flexor digitorum superficialis tendons. Note also the acces-
sory FPL (Gantzer’s muscle).

420

The FDS inserts on the base of the proximal phalanges and
is a flexor of all the joints it passes over, including the prox-
imal interphalangeal (PIP), metacarpophalangeal (MCP),
and wrist joints. The fact that the FDS has independent
muscle slips to all four fingers accounts for its ability to flex
one PIP joint at a time (2).
Deep Group
Flexor Pollicis Longus
The FPL arises from the grooved flexor surface of the radius
in an oblique line of origin beginning just distal to the
biceps tuberosity to near the proximal margin of the PQ
(Fig. 8.10). Its proximal oblique origin is opposite the inser-
tion of the supinator. It also has origins from the adjacent
IOM and frequently by a variable slip from the lateral or,
more rarely, medial border of the coronoid process, or from
the medial epicondyle of the humerus (2). Its tendon arises
from the ulnar side of the muscle belly, courses through the
carpal canal, and then passes between the opponens pollicis
and the oblique head of the adductor pollicis to insert on
the palmar base of the distal phalanx of the thumb. The
anterior interosseous neurovascular bundle descends on the
IOM between the FPL and the FDP. The FPL is the deep-
est and most radial of the flexor tendons.
Flexor Digitorum Profundus
The FDP arises deep to the FDS from the anterior and
medial proximal two-thirds of the ulna. Its origin begins
near the attachment of the brachialis and ends just proximal
to the proximal margin of the PQ (see Fig. 8.10). It also has
origins from a depression on the medial side of the coro-
noid process, from the proximal two-thirds of the posterior
ulnar border by an aponeurosis shared with the flexor and
ECU, and from the ulnar half of the IOM. The four FDP
tendons lie in a single layer, in contrast to the two layers of
the FDS. The FDP tendons insert on the distal phalanges.
The portion of the muscle directed to the index finger usu-
ally is distinct throughout its course, which accounts for its
often independent action compared with the other fingers.
Pronator Quadratus
The PQ, as its name implies, is a quadrilateral muscle that
spans the flexor aspect of the distal ulna and radius (Fig.
8.11). It has two heads: the superficial, which arises from a
short tendon on the dorsoulnar border of the ulna and
inserts on a broad, flat facet on the volar surface of the
radius; and the deep, which also arises from the ulna, but
from a slightly less distinct tendon of origin and slightly
more volar than the superficial head. The insertion of the
deep head is to the ulnar border of the distal radius from the
IOM and filling the “axilla” of the distal radioulnar joint
(5). The nerve and blood supply is from the anterior
interosseous bundle, which consistently runs in a plane
deep to the head of the muscle on the IOM. The muscle
8.1 Flexor Forearm 421
FIGURE 8.11. The deep layer of the forearm muscles, pronator
quadratus. Note the two heads of this quadrilateral muscle and
the anterior interosseous nerve and vessels that supply this mus-
cle from deep to superficial.
bellies are supplied from deep to superficial. Some branches
run in a longitudinal direction between the two heads after
piercing the deep head before entering the superficial.
Function. Electromyography has clearly shown that the
PQ is the main pronator of the forearm, with the PT func-
tioning only in maximal pronation and resisted pronation.
These studies also revealed that the deep head consistently
functioned during supination and grip (5). These findings
confirm the concept of Johnson and Shrewsbury that the
deep head is a significant factor in preventing distal radioul-
nar joint diastasis during forearm rotation and grip (16).
Clinical Significance. Operative procedures have been
designed that use the PQ as a muscle or vascularized osseous
graft, as well as as a transfer to stabilize the distal radioulnar
joint or the distal ulna after partial resection (17,18).
Supinator
Although the supinator is considered to be a deep extensor
of the forearm, it is included here because it often is
encountered in approaches to the anterior or flexor aspect
of the forearm (Fig. 8.12). The supinator wraps around the
proximal one-third of the radius and has superficial and
deep layers. The superficial portion arises from the lateral
epicondyle of the humerus, the collateral ligament of the
elbow joint, and the annular ligament. The deep head arises
from the “supinator crest” of the ulna as well as portions of
the annular ligament and collateral ligament. It attaches to
the volar and lateral side of the proximal third of the radius
as far distally as the insertion of the PT. Its oblique insertion
parallels the origin of the FPL. The posterior interosseous
422 Regional Anatomy
FIGURE 8.12. The deep layer of the forearm muscles, supinator.
Note the deep and superficial heads that wrap around the prox-
imal one-third of the radius. The posterior interosseous nerve
(PIN) traverses the supinator between these two heads; note the
proximal branch to the deep head and the entrance of the main
stem of the PIN beneath the superficial head and its arcade of
Frohse.
nerve (PIN) courses between the two layers of the muscle at
almost a right angle to the muscle fibers. The supinator acts
in slow, unopposed supination of the forearm and together
with the biceps in fast or forceful supination.
“Mobile Wad of Three”
Henry found it useful to identify the brachioradialis,
ECRL, and ECRB as the “mobile wad of three” on the
dorsolateral side of the forearm (1). Although only the
brachioradialis in this group of muscles is considered to be
a flexor or volar muscle, it is part of this “mobile wad,”
which is an important landmark. These muscles can be
grasped between the examiner’s thumb and index finger
just distal to the lateral epicondyle, and when moved to
and fro, provide a useful guide to the deeper structures in
the forearm (Fig. 8.13). Henry also used a “manual
mnemonic” to aid identification and location of the volar
and medial superficial muscle group arising from the
medial epicondyle, which includes the PT, FCR, PL, and
FIGURE 8.13. The “mobile wad of three.” The brachioradialis
(BR), extensor carpi radialis longus (ECRL), and extensor carpi
radialis brevis (ECRB) form this mobile wad, which is an impor-
tant guide to surgical approaches in this area.
FCU (1). This mnemonic is illustrated in Figure 8.14.
Identification of the interval between the laterally situated
mobile wad of three and the medial superficial flexors per-
mits safe access to the deeper structures in the antecubital
fossa, including the radial, median, and ulnar nerves and
the vascular structures.
Antecubital Fossa
Landmarks/Boundaries
Entry into this area is facilitated by identification of the
biceps tendon, which bisects the base of the triangular ante-
cubital fossa. Using the biceps tendon as a guide, the lateral
and medial boundaries of the antecubital fossa are noted to
be formed by the brachioradialis and the PT, respectively
(Fig. 8.15).
Zones of the Antecubital Fossa
The biceps tendon is an important landmark or partition
that divides the antecubital fossa into a relatively “safe” lat-

FIGURE 8.14. Henry’s 9manual mnemonic9: The thumb through
the ring finger of the examiner’s hand, when laid on the forearm
as depicted, correspond to the four underlying superficial muscles.
eral zone and a more hazardous medial zone. The medial
zone contains the brachial, radial, and ulnar arteries and
their branches as well as the median nerve and its branches.
It also is helpful to remember that most of the branches
from the median nerve arise from its medial side (1).
Contents of the Antecubital Fossa
Reflection of the skin envelope and the superficial fascia
reveals the prominent biceps tendon and its aponeurosis,
called the lacertus fibrosus, coursing from the biceps tendon
to fan out medially and distally over the flexor-pronator
muscles. Incision of this aponeurosis allows a deeper view
into the antecubital fossa, where it is noted that the brachial
artery is immediately beneath the lacertus fibrosus. From
lateral to medial, the structures are the brachioradialis, the
8.1 Flexor Forearm 423
biceps tendon, the brachial artery with its venae comitantes,
the median nerve, and the PT.
Neurovascular Structures
Arteries in the Antecubital Fossa
Just distal to the lacertus fibrosus, the brachial artery divides
into the radial and ulnar arteries (Fig. 8.16).
Radial Artery Branches
Multiple arterial branches arise on the lateral side of the
radial artery, the largest of which is the radial recurrent
artery (see Fig. 8.16). Most of these multiple branches arise
distal to the radial recurrent, and along with the radial
recurrent supply the adjacent mobile wad muscles. The
radial recurrent branch of the radial artery continues proxi-
mally, where it joins the anterior branch of the profunda
brachii artery in the region of the lateral epicondyle. Soon
after its origin from the radial artery, the radial recurrent
sends a branch that enters the arcade of Frohse adjacent to
the PIN. It may be necessary to ligate some of these vessels
to mobilize the adjacent mobile wad of muscles and thus
expose deeper structures, including the radial nerve and
supinator, or to allow retraction of the vascular bundle to
the medial side, which aids in identification of the ulnar
artery and its branches (1). Henry has characterized these
branches arising from the radial side of the radial artery as
a fanlike leash that spreads from a common stem (the radial
recurrent artery) and thus can be dealt with as a single struc-
ture (1). Although Henry is correct in his observation that
the vessels making up this fanlike vascular leash seldom lie
in a single plane but rather diverge in a set of layers two or
three deep, these vessels do not always arise from a common
single stem and thus must be dealt with as individual ves-
sels. These vessels may arise as two to three individual
branches from the radial artery or as multiple branches aris-
ing from a common stem distal to the radial recurrent
artery. These vessels are separate and distinct from the radial
recurrent artery, and although the radial recurrent artery
also may send branches to the mobile wad muscles, the
arrangement of this vascular leash is different from that por-
trayed by Henry (1).
Ulnar Artery Branches
Ulnar artery branches include the medially situated anterior
and posterior ulnar recurrent arteries and the laterally
placed common interosseous artery, which divides into the
anterior and posterior interosseous arteries (see Fig. 8.16).
Identification of the Radial and Ulnar Arteries in the
Antecubital Fossa
The radial artery, a continuation of and in the same plane
as the brachial artery, is easily identified in the interval
between the brachioradialis and the FCR and on top of the
PT. In contrast to the more superficial radial artery, the
424 Regional Anatomy
ulnar artery, immediately after its origin from the brachial
artery, descends deep into the medial side of the antecubital
fossa, which it exits beneath the deep head of the PT to
enter the interval between the FDS and FDP. What must be
appreciated when exposing the radial and ulnar arteries in
the proximal forearm is that the radial artery, an easily iden-
tified extension of the brachial artery, is more superficial
than the deeply situated ulnar artery. The usual graphic
depiction of the ulnar artery indicates that it is medial to
the radial artery (it is) and in the same plane (it is not).
Unfortunately, the limitations of two-dimensional graphics
fail to characterize its true course, which is to descend
quickly into the depths of the antecubital fossa, which it
exits on the medial side beneath the deep head of the PT.
Major Forearm Nerves in the Antecubital
Fossa
The three major nerves leave the arm and enter the forearm
by coursing through or between a muscle belly: the ulnar
FIGURE 8.15. The antecubital fossa/landmarks and
zones. The biceps tendon divides the antecubital fossa
into medial and lateral zones bounded by the pronator
teres (PT) and brachioradialis (BR), respectively.
nerve through the two heads of the FCU, the median
between the two heads of the PT, and the radial (but only
the motor branch) through the supinator. Only the median
and radial nerves pass through the antecubital fossa (Fig.
8.17).
Identification of the Median and Radial Nerves in the
Antecubital Fossa
Identification of the median nerve in the antecubital fossa
usually is not a problem because it is on the same plane and
just medial to the brachial artery. However, identification of
the radial nerve is not as easy. The key to finding this nerve
is to identify the brachioradialis and the adjacent brachialis.
The brachialis lies just beneath the biceps, and it is in the
interval between the brachioradialis and the brachialis that
the radial nerve is found (1). Gentle and blunt separation of
these two muscle bellies reveals the radial nerve. The sur-
geon must not misidentify the musculocutaneous nerve,
which exits nearby between the lateral margins of the biceps
and brachialis muscle bellies, for the radial nerve.
 8.1 Flexor Forearm 425

FIGURE 8.16. A: Arterial branches in the

antecubital fossa. Note the division of
the brachial artery into radial and ulnar
arteries and their multiple branches. B:
Fresh cadaver dissection of this region.
The probe in the lower foreground is
tenting up the ulnar artery; the green
vessel loop is around the radial artery;
the green marker adjacent to the mid-
field retractor is beneath the radial recur-
rent artery; the green marker to the left
(distal) is beneath the radial artery; the
remaining vessels are either veins or
small arteries from the adjacent muscles.
Clinical significance: there are multiple
vessels in this region in addition to the
B radial recurrent vessel.
426 Regional Anatomy

FIGURE 8.17. Entrance of the three major nerves to the forearm. These nerves leave the arm and
enter the forearm by coursing through or between a muscle belly: the ulnar nerve through the
two heads of the flexor carpi ulnaris, the median between the two heads of the pronator teres,
and the radial (but only the motor branch) through the supinator. Only the median and radial
nerves pass through the antecubital fossa.

Radial Nerve strict sequence of muscle innervation, which may be of clin-

Site of Division into Motor and Sensory Branches.
Based on a study of 50 fresh cadaver upper extremities, Fuss
and Wurzl noted that the radial nerve divides into motor
and sensory branches near the lateral epicondyle at a level
that may range from 2.5 cm above or 3 cm below Hueter’s
line (a line drawn in the coronal plane between the tips of
the medial and lateral epicondyles) (3) (Fig. 8.18).
Radial Nerve Branches Proximal to the Division. Radial
nerve branches proximal to the division into motor and
sensory components (excluding the nerve to the anconeus,
which is even more proximal) were one to three branches to
the brachialis muscle that were 3 to 9 cm above Hueter’s
line; one to three branches to the brachioradialis that arose
2 cm below to 7.5 cm above Hueter’s line, but in most
instances arose 3 to 6 cm above Hueter’s line; and one to
three branches to the ECRL 2.5 below to 6 cm above
Hueter’s line, but in most instances these branches arose 0.5
to 4.5 cm above Hueter’s line (3) (see Fig. 8.18).
Fuss and Wurzl concluded that there is great variability
in the both the number and level of nerve branches to these
three muscles, and therefore it is impossible to assume a
ical importance when trying to determine the level or site of
nerve injury or patterns of muscular weakness after nerve
injury (3).
Radial Nerve Branching and Muscle Innervation
Sequence. These findings are compared with the study of
Abrams et al., who dissected the radial nerve motor
branches in 20 upper extremities and measured the shortest
and longest distances along the main radial trunk of the var-
ious radial nerve branches with respect to a point 10 cm
proximal to the medial epicondyle, the mean number of
branches, and innervation order or sequence (19). Their
findings are summarized in Tables 8.1 and 8.2. The only
nearly constant (19 of 20 specimens) consecutive order of
innervation was ECRL, supinator, ECRB. The ECRL
branch origin was variable; in 9 of 20 (45%), it originated
from the PIN; in 6 of 20 (30%), it originated from the
radial nerve as one branch of a trifurcation (the other
branches were the PIN and sensory branch of the radial
nerve). The ECRB branch came from the sensory branch of
the radial nerve in 5 of 20 (25%). Abrams et al. noted that
the innervation order is quite variable. Nonvariable findings
 8.1 Flexor Forearm 427

FIGURE 8.18. Division of the radial nerve into motor and sensory components. The interepi-
condylar line (Heuter’s line) is a useful landmark to begin a search for this division because the
nerve divides in a zone 2.5 cm above or 3 cm below this line.

included the fact that the extensor digitorum communis
(EDC) always was innervated before the EIP, APL, and
EPL, and almost always before the extensor digiti minimi.
The extensor digiti minimi was innervated before the EIP,
and the APL before the EPB. In 19 of 20 specimens, the
APL was innervated before the EPL. Regarding the ques-
tion of variation in branch number, Abrams et al. found
that regression analysis demonstrated a positive nonlinear
correlation between both muscle mass and branch number
and physiologic cross-sectional area and branch number,
but no correlation between fiber length and branch num-
ber. The muscle with the highest branch number was the
EDC, and Abrams et al. stated that this might be a mecha-
nism for regional muscle control unique to the EDC, which
has multiple, independently functioning tendon slips origi-
nating from a common muscle belly.
Origin of Extensor Carpi Radialis Brevis Branch. In a
study of 111 limbs regarding the origin of the motor
branch of the ECRB, Colborn et al. found that the most
common origin (56.7%) was from the PIN, followed by
31.5% from the sensory branch and 11.7% from the
428 Regional Anatomy

TABLE 8.1. MEAN DISTANCESa AND NUMBER OF RADIAL NERVE BRANCHES

Shortest Distance Longest Distance Mean Number

Muscles (mm/SD) (mm/SD) (Branches/SD)

BR 97.2/15.5 112.6/12.3 2.9/1.1

ECRL 117.4/11.5 132.6/13.9 3.8/1.4
SUP 157.3/10.5 172.8/13.8 3.9/1.4
ECRB 182.1/15.9 206.4/16.1 3.4/1.2
EDC 215.8/13.1 237.4/17.7 4.6/1.3
ECU 219.5/16.0 228.2/17.7 2.8/0.8
EDM 229.2/15.8 236.0/17.1 1.6/0.8
APL 235.0/12.5 253.0/17.1 2.7/0.7
EPL 253.3/11.6 278.4/22.4 2.5/1.2
EPB 285.8/21.9 289.0/23.1 1.3/0.5
EIP 299.8/17.3 300.7/18.0 1.1/0.3
aDistances measured along main trunk of radial nerve 10 cm proximal to the lateral humeral condyle.

APL, abductor pollicis longus; BR, brachioradialis; ECRB, extensor carpi radialis brevis; ECRL, extensor
carpi radialis longus; ECU, extensor carpi ulnaris; EDC, extensor digitorum communis; EDM, extensor
digiti minimi; EIP, extensor indicis proprius; EPB, extensor pollicis brevis; EPL, extensor pollicis longus;
SUP, supinator.
From Abrams RA, Ziets RJ, Lieber RL, et al. Anatomy of the radial nerve motor branches in the
forearm. J Hand Surg [Am] 22:232-237, 1997, with permission.

region of the bifurcation of the radial nerve (20). In con-
trast to the one to three nerve branches that innervate the
brachialis, brachioradialis, and ECRL, Colborn et al.
found that the ECRB has only one nerve branch. This
nerve branch was found to arise within 1 cm of the distal
edge of the humeroradial joint and to pass distally approx-
imately 3.5 cm before entering the ECRB muscle (20).
Regardless of its origin, the nerve to the ECRB is inti-
mately related to the radial recurrent artery, which may be
used to guide the surgeon to the location of the nerve to
the ECRB (20). The finding of a single nerve branch to the
ECRB is in contrast to the findings of Abrams et al., who

TABLE 8.2. PROXIMAL-TO-DISTAL RADIAL NERVE INNERVATION ORDER OF

20 SPECIMENS

Specimen Number Innervation Order

1 BR, ECRL, SUP, ECRB, EDC, APL, ECU, EPL, EDM, EPB, EIP
2 BC, BR, ECRL, SUP, ECRB, ECU, EDC, EDM, APL, EPB, EPL, EIP
3 BR, ECRL, SUP, ECRB, EDC, ECU, EDM, APL, EPB, EPL, EIP
4 BR, ECRL, SUP, ECRB, ECU, EDC, EDM, APL, EPL, EPB, EIP
5 BR, ECRL, SUP, ECRB, ECU, EDC, EDM, APL, EPB, EPL, EIP
6 BR, ECRL, SUP, ECRB, EDC, ECU, APL, EDM, EPL, EIP, EPB
7 BR, ECRL, SUP, ECRB, ECU, EDM, EDC, APL, EPL, EPB, EIP
8 BR, ECRL, SUP, ECRB, ECU, EDC, EDM, EPL, APL, EIP, EPB
9 BR, ECRL, SUP, ECRB, EDC, ECU, EDM, APL, EPL, EPB, EIP
10 BC, BR, ECRL, SUP, ECRB, EDC, ECU, EDM, APL, EPL, EPB, EIP
11 BC, BR, ECRL, SUP, ECRB, ECU, EDC, APL, EDM, EPL, EPB, EIP
12 BC, ECRL, BR, SUP, ECRB, EDC, ECU, APL, EDM, EPL, EIP, EPB
13 BC, BR, ECRL, SUP, ECRB, ECU, EDC, APL, EDM, EPL, EPB, EIP
14 BC, BR, ECRL, SUP, ECRB, ECU, EDC, EDM, APL, EPL, EPB, EIP
15 BR, BC, ECRL, SUP, ECRB, EDC, EDM, ECU, APL, EPL, EIP, EPB
16 BC, BR, ECRL, SUP, ECRB, EDC, ECU, EDM, APL, EPL, EPB, EIP
17 BC, BR, ECRL, SUP, ECRB, EDC, EDM, ECU, APL, EPL, EPB, EIP
18 BR, BC, ECRL, SUP, ECRB, EDC, ECU, EDM, APL, EPL, EPB, EIP
19 BR, ECRL, SUP, ECRB, EDC, ECU, APL, EDM, EPL, EPB, EIP
20 BR, ECRL, SUP, ECRB, EDC, ECU, APL, EDM, EPL, EIP, EPB

APL, abductor pollicis longus; BR, brachioradialis; ECRB, extensor carpi radialis brevis; ECRL, extensor
carpi radialis longus; ECU, extensor carpi ulnaris; EDC, extensor digitorum communis; EDM, extensor
digiti minimi; EIP, extensor indicis proprius; EPB, extensor pollicis brevis; EPL, extensor pollicis longus;
SUP, supinator; BC, brachialis.
From Abrams RA, Ziets RJ, Lieber RL, et al. Anatomy of the radial nerve motor branches in the
forearm. J Hand Surg [Am] 22:232–237, 1997, with permission.

noted a mean number of branches of 3.4 with a standard
deviation of 1.2 (19). The nerve branch to the ECRB is
superficial to its fascial origin (3).
Distal Course of the Sensory Branch of the Radial Nerve.
The radial nerve sensory branch travels beneath the mobile
wad of three and continues distally under cover of the bra-
chioradialis, exiting dorsally from between the tendons of
the brachioradialis and the ECRL a mean of 9 cm proximal
to the radial styloid (21). Complete absence of the sensory
branch has been noted, with most of the area normally
innervated by the radial nerve supplied by the lateral ante-
brachial cutaneous nerve (3).
Branches to the Supinator Arising Proximal to the
Arcade of Frohse. Two to five branches (most often two or
three branches) arise 0.5 cm above to 4.5 cm below Hueter’s
line. An anterior group of branches innervates the superfi-
A
FIGURE 8.19. Fibrous tissue arcades relative to the posterior interosseous nerve (PIN). A: Artist’s
depiction of the fascial origin of the extensor carpi radialis brevis (ECRB) and the arcade of
Frohse, potential sites of compression of the PIN.
8.1 Flexor Forearm 429
cial portion of the supinator and a posterior group (usually
only one branch) innervates the muscle layer deep to the
PIN (3).
Fibrous Arcades Relative to the Posterior Interosseous
Nerve. Extensor Carpi Radialis Brevis Fascial Origin. A fas-
cial layer that constitutes the fascial origin of the ECRB is
consistently present 0.5 to 1 cm proximal to the arcade of
Frohse (3). If tendinous, the proximal border of the fascia
may compress the PIN as well as its branches to the supina-
tor muscle (3). In some cases, this fascial origin may be lat-
erally positioned and not overlie the PIN or the arcade of
Frohse, but in most instances it covers the arcade of Frohse.
The inexperienced surgeon may confuse this arch with the
arcade of Frohse (22) (Fig. 8.19).
Arcade of Frohse. The arcade of Frohse is found 3 to 5 cm
distal to Hueter’s line. The proximal edge of the superficial
(continued on next page)
 430 Regional Anatomy

FIGURE 8.19. (continued) B: Fresh cadaver dissec-

tion of the proximal and flexor aspect of the right
forearm. The probe to the right (proximal) is tenting
up the main stem of the radial nerve; the sensory
branch is coursing obliquely to the left; the blue
marker is beneath the fibrous edge of the ECRB and
the green marker beneath the fibrous edge of the
supinator (the arcade of Frohse); the green marker
rests on the PIN as it begins its traverse of the supina-
tor. C: Same dissection as B. The small hook is retract-
ing the fibrous edge of the ECRB; the green marker
remains beneath the arcade of Frohse (fibrous tissue
edge of the superficial component of the supinator).
D: The fibrous edge of the ECRB is tented up on the
retractor; the smaller green marker is beneath the
leading edge of the supinator; fat has been removed
from around the PIN for clarity, and it rests on the
larger green marker; note the fibers of the deep
D head of the supinator muscle just radial to the PIN.

layer of the supinator is fibrous, especially the lateral side.
This fibrous tissue edge forms the arcade of Frohse, which
may compress the anterior radial nerve branches to the
supinator as well as the PIN.
Distal Course of the Posterior Interosseous Nerve. After
entering the supinator, the PIN continues distally between
the superficial and deep layers of the supinator on its way
to the dorsal or extensor surface of the forearm, where it
innervates the thumb and finger extensors as well as the
ECU.
Median Nerve
The median nerve exits the antecubital fossa through the
interval between the superficial and deep heads of the PT,
which arise from the medial epicondyle and proximal ulna,
respectively. It then becomes a “satellite” of the deep por-
tion of the FDS, lying first to the radial side of the proxi-
mal belly and then to the radial side of the fibrous tissue
linkage between the proximal and distal portions of the
FDS. Below this level, fascia binds the median nerve in a
lateral groove between the muscle bellies and tendons of the
middle and index fingers (Fig. 8.20). The superficial por-
tion of the FDS contains the middle and ring finger flexors
and the deep portion contains the index and little finger
flexors. In the distal forearm, the median nerve exits from
beneath the radial side of the muscle belly of the middle fin-
ger superficialis, where it is quite superficial and near to the
PL tendon, and it remains in this superficial position until
it enters the carpal canal.
Palmar Cutaneous Branch. The palmar cutaneous
branch of the median nerve arises from the distal and lateral
aspect of the median nerve 3 to 4 cm proximal to the flexor
retinaculum and provides sensation to the skin over the
thenar eminence (10).
Anterior Interosseous Nerve. The AIN branch arises pos-
teriorly from the main median trunk approximately 5 to 8
cm distal to the medial epicondyle (23) (Fig. 8.21). Its ori-
gin usually is just distal to the branches to the superficial
forearm flexors and just distal to the proximal border of the
superficial head of the PT (2,23). It then passes through the
two heads of the PT and continues distally beneath the
fibrous tissue arcade of the FDS to lie on the IOM. At
approximately the level of the junction of the PT and the
FCR, it sends one to several motor branches to the FPL.
Motor branches have been identified as far distal as 1 cm
proximal to the proximal edge of the PQ. These motor
branches are anterior and along the medial margin of the
FPL, and may be preserved during exposure of the radius by
8.1 Flexor Forearm 431
keeping to the lateral side of the muscle. The FPL and FDP
of the index are exclusively innervated by the AIN. The
FDP of the long finger is innervated by the AIN exclusively
only approximately half the time. In the remaining
instances, the FDP of the long finger is at least partially sup-
plied by branches from the ulnar nerve (23). The AIN con-
tinues distally on the volar surface of the IOM, where it
enters the proximal margin of the PQ and branches onto its
deep surface.
Ulnar Nerve
The ulnar nerve enters the forearm through the two heads
of the FCU, which it soon exits to lie on the FDP muscle
belly, where it is joined by the ulnar artery in the middle
third of the forearm (Fig. 8.22).
Dorsal Sensory Branch. The ulnar nerve gives off an
important dorsal sensory branch an average of 6.4 cm from
the distal aspect of the head of the ulna and 8.3 cm from
the proximal border of the pisiform. Its mean diameter at
origin is 2.4 mm. The nerve passes dorsal to the FCU and
pierces the deep fascia to become subcutaneous on the
medial aspect of the forearm at a mean distance of 5 cm
from the proximal edge of the pisiform. The nerve gives an
average of five branches with diameters between 0.7 and 2.2
mm (24).
Arteries of the Forearm
Radial Artery
The radial artery begins on the medial side of the biceps
tendon and continues its distal course along the lateral
aspect of the PT, which it soon overlies, and continues
under the muscle belly of the brachioradialis, to which it
sends multiple branches (see Fig. 8.22). The radial artery
courses away from the brachioradialis near its myotendi-
nous junction and becomes superficial in its course to the
radial aspect of the wrist, where it lies just lateral to the FCR
muscle belly and tendon.
Ulnar Artery
The ulnar artery, after giving off the medially situated ante-
rior and posterior ulnar recurrent arteries and the laterally
oriented common interosseus branch, which divides into
the anterior and posterior interosseous arteries, courses dis-
tally and ulnarward in the interval between the FDS and
the FDP, where it joins the ulnar nerve on its radial side in
the middle third of the forearm. The artery and nerve lie on
the FDP and continue distally as the ulnar neurovascular
bundle to the flexor and ulnar side of the wrist (see Fig.
8.22).
432 Regional Anatomy

FIGURE 8.20. Median nerve in the antecubital fossa and forearm. Note that most of the median
nerve branches in the antecubital fossa are medial. In the distal forearm, the median nerve
almost always exits from beneath the radial side of the muscle belly of the middle finger flexor
digitorum superficialis.
 8.1 Flexor Forearm 433

FIGURE 8.21. The course and muscle innervation of the anterior interosseous nerve.
434 Regional Anatomy

FIGURE 8.22. Arteries of the forearm and the ulnar nerve.


SURGICAL EXPOSURES
Antecubital Fossa
Anteromedial Approach
Indications
The contents of the antecubital fossa may be exposed
through an anterior approach, which provides excellent
exposure of the biceps tendon, median and ulnar nerves,
the brachial, radial, and ulnar arteries, and the radial nerve.
Landmarks
Landmarks include the biceps, mobile wad of three and PT
muscles, biceps tendon, and elbow flexion creases.
Patient Position/Incision
With the patient supine, the forearm in supination, and the
elbow extended, an incision is made 5 to 6 cm proximal to
FIGURE 8.23. Anteromedial approach to the antecubital fossa: patient position (A) and inci-
sion (B).
8.1 Flexor Forearm 435
the flexion crease along the medial edge of the biceps mus-
cle, which continues obliquely across the elbow flexion
crease to the lateral and flexor side of the forearm, where it
turns distally along the inner or medial edge of the mobile
wad of three (Fig. 8.23).
Technique
After dividing the superficial fascia and ligating the superficial
veins as required, the deep fascia is opened to enter the trian-
gular antecubital fossa. The guiding landmarks are the biceps
tendon and the lacertus fibrosus centrally and the brachiora-
dialis as part of the mobile wad of three laterally, along with
the PT and flexors medially (1). The lacertus fibrosus is
incised along the exposed edge of the PT and reflected prox-
imally. The biceps tendon divides the antecubital fossa into
medial and lateral compartments, with the medial compart-
ment’s major components being the vascular tree and the
B
436 Regional Anatomy

median nerve. The brachial artery lies close to the medial side
of the biceps tendon and divides into the radial and ulnar
arteries at the distal edge of the lacertus fibrosus. The vessels
may be gently mobilized by blunt dissection with scissors.
The ulnar artery is deeper than the radial and sometimes is
hidden by the more superficial radial artery. Similarly, the
common interosseous artery and its anterior interosseous
branch lie behind and somewhat deep to the parent ulnar
artery. These vessels may be mobilized as needed by ligating
their muscular branches. Multiple branches arise on the lat-
eral side of the radial artery, the largest of which is the radial
recurrent artery. Most of these multiple branches arise distal
to the radial recurrent and, along with the radial recurrent,
supply the adjacent mobile wad muscles. The radial recurrent
branch of the radial artery continues proximally, where it
joins the anterior branch of the profunda brachii artery in the
region of the lateral epicondyle. Soon after its origin from the
radial artery, the radial recurrent sends a branch that enters
the arcade of Frohse adjacent to the PIN. It may be necessary
to ligate some of these vessels to mobilize the adjacent mobile
wad of muscles and thus expose deeper structures, including
the radial nerve and supinator, or to allow retraction of the
vascular bundle to the medial side, which aids in identifica-
tion of the ulnar artery and its branches. Henry has charac-
terized these branches arising from the radial side of the radial
artery as a fanlike leash that spreads from a common stem (the
radial recurrent artery) and thus can be dealt with as a single
structure (1). Although Henry is correct in his observation
that the vessels comprising this fanlike vascular leash seldom
lie in a single plane, but rather diverge in a set of layers two or
three deep, these vessels do not always arise from a common
single stem and thus must be dealt with as individual vessels.
These vessels may arise as two to three individual branches
from the radial artery or as multiple branches arising from a
common stem distal to the radial recurrent artery. These ves-
sels are separate and distinct from the radial recurrent artery,

FIGURE 8.24. Anteromedial approach to the antecubital fossa: technique and deep dissection.
Passing the surgeon’s index finger down the lateral side of the biceps tendon is a useful tech-
nique to find the radial recurrent vessel(s). Tying these vessels allows medial retraction of the
radial artery and lateral retraction of the mobile wad muscles.
 8.1 Flexor Forearm 437

and although the radial recurrent artery also may send
branches to the mobile wad muscles, the arrangement of this
vascular leash is different from that portrayed by Henry (1).
These branches, including the radial recurrent, may be iden-
tified by running a finger down the lateral side of the biceps
tendon (Fig. 8.24). In contrast to the more superficial radial
artery, which is easily identified in the interval between the
brachioradialis and the FCR and on top of the PT, the ulnar
artery descends deep into the medial side of the antecubital
fossa, which it exits beneath the deep head of the PT to enter
the interval between the FDS and FDP. Mobilization of the
radial artery by this means allows it to be moved toward the
ulna, which may aid in uncovering the ulnar artery.
Anterolateral Approach
Indications
The anterolateral approach, although somewhat similar to
the approach described previously for exposure of the ante-
cubital fossa, probably is better suited to expose the lateral
half of the antecubital fossa and may be used to expose
radial nerve entrapment syndromes and biceps tendon rup-
ture.
Landmarks
Useful landmarks are the biceps and mobile wad of three
muscles, biceps tendon, and the elbow flexion crease.
Patient Position/Incision
With the patient supine and the forearm supinated, the skin
incision begins 4 to 5 cm proximal to the elbow flexion
crease in the interval between the brachialis and the bra-
chioradialis, curves into the elbow flexion crease, and then
continues distally into the forearm along the inner or
medial margin of the mobile wad of three (Fig. 8.25A and
B). The biceps tendon medially and the brachioradialis lat-
erally are landmarks.

B
FIGURE 8.25. Anterolateral approach to the antecubital fossa. Patient position (A) and incision
(B). Identification of the radial nerve usually is performed successfully by blunt separation of the
interval between the brachioradialis and brachialis.
438 Regional Anatomy
Technique
The lateral antebrachial cutaneous nerve of the forearm is
identified as it exits from beneath the lateral margin of the
biceps muscle and may be located as it becomes more
superficial near the lateral aspect of the biceps tendon.
Care must be taken not to mistake this nerve for the radial
nerve, which is deeper and lies between the brachialis and
brachioradialis. The radial nerve is located by blunt sepa-
ration of these two muscle bellies, beginning 1 to 2 cm
proximal to the elbow joint space. This interval is devel-
oped further by blunt dissection, and retraction of the
brachioradialis laterally and the brachialis medially pro-
vides additional exposure (see Fig. 8.25C and D). The
radial nerve is traced distally, where it divides into the PIN
and sensory branches. The PIN enters the supinator mus-
cle beneath the leading edge of the ECRB and the arcade
of Frohse accompanied by a branch of the radial recurrent
artery, whereas the sensory branch continues distally
under cover of the brachioradialis. The radial recurrent
artery and other branches may require ligation to mobilize
the mobile wad of three or the main trunk of the radial
artery, and it is found by running a finger down the radial
or lateral side of the biceps tendon as described for the
anteromedial approach to the antecubital fossa.
Shaft of the Radius
Indications
This approach may be used for fractures, tumors, or infec-
tions of the radius.
Landmarks
These include the biceps and the mobile wad of three mus-
cles, the elbow flexion crease, and the radial styloid.
Patient Position/Incision
With the patient supine and the forearm in supination, an
incision is begun in the interval between the distal and lat-
eral aspect of the biceps and the proximal origins of the
mobile wad of three. The incision continues obliquely
across the elbow flexion crease and then curves distally to
parallel the medial edge of the mobile wad of three, to end
near the radial styloid (Fig. 8.26A and B).
Technique
After opening the deep fascia and identifying the major
structures in the antecubital fossa, the radial recurrent
artery is ligated. Next, the supinator muscle is identified
along with its motor branch, which enters the muscle
belly proximally and anterolaterally. The motor branch of
the radial nerve, the PIN at this level, travels between the
deep and superficial portions of the supinator. Using the
biceps tendon as a guide, the proximal portion of the
obliquely oriented insertional edge of the supinator is
identified. The insertional edge of the muscle is detached
with a scalpel or sharp periosteal elevator as desired (see
Fig. 8.26C). Exposure of this region is facilitated by flex-
ion of the elbow and gentle retraction of the mobile wad
muscles. After the supinator is released, the forearm is
pronated to reveal an extensive expanse of radius. Addi-
tional exposure of the distal aspect of the radius is
obtained by reflection of the insertion of the brachioradi-
alis (see Fig. 8.26D). Caution: The AIN and its branches
may be at risk during this approach, and this is especially
true of the branches to the FPL.
Median and Ulnar Nerves
Volar Approach
Indications
Exposure of the median and ulnar nerves through a volar
approach is an extension of the approach to the radius
described previously. The median and ulnar nerves may
require exposure in the forearm for nerve suture or grafting
or nerve tumors. The volar approach is designed to expose
the nerves in the middle and distal thirds of the forearm.
Exposure of the median nerve in the proximal third of the
forearm is described under the antecubital fossa approach,
and exposure of the ulnar nerve in the proximal forearm is
described in the section on ulnar nerve transposition
(Chapter 7, Cubital Tunnel Syndrome).
Landmarks
Landmarks include the elbow flexion crease and the inter-
val between the PT and the FCR.
Patient Position/Incision
With the patient supine and the forearm in supination, an
incision is begun at the elbow flexion crease along the lat-
eral side of the PT and continued distally in the midline of
the forearm to the wrist flexion crease (Fig. 8.27).
Technique
Dissection to expose the median nerve begins by finding
the cleavage interval between the PT and the FCR (the
interval between the thumb and index finger in Henry’s
manual mnemonic) (1). The interval of separation is best
begun in the region of their respective tendons and then
carried proximally. The median nerve is identified in this
region beneath the distal edge of the PT and just before its
entrance between the deep and superficial portions of the
 8.1 Flexor Forearm 439

FIGURE 8.26. Exposure of the shaft of the radius. Incision (A) and proximal dissection (B).
(continued on next page)
440 Regional Anatomy
FIGURE 8.26. (continued) C: Using the biceps tendon as a guide, the insertional edge of the
supinator is incised and elevated along with the posterior interosseous nerve in this muscle enve-
lope.
FDS. If no interval exists between the PT and FDS (as
sometimes occurs), then the FDS muscle fibers must be
separated by blunt dissection to reveal the median nerve.
An alternative and more distal approach may be achieved at
the level of the myotendinous junction and in the interval
between the ring and little finger superficialis. The median
nerve lies beneath the muscle belly of the middle finger
superficialis, and by separation and retraction of the ring
and little finger superficialis muscle bellies, it may be
viewed in this region. After the median nerve exits from
beneath the oblique edge of the muscle belly of the middle
finger superficialis, it is not difficult to identify or locate.
This constant relationship between the median nerve and
the middle finger superficialis muscle belly is an important
identification landmark, especially in trauma cases. The
ulnar nerve is located in the interval between the superfi-
cialis and the underlying profundus. Retraction of the fin-
ger flexors is aided by flexing the wrist and fingers. Once
again, identification of the interval is easier at the
myotendinous junction followed by proximal dissection.
The interval between the FCU tendon and the FDS of the
little finger reveals the ulnar neurovascular bundle lying on
the FDP.
Medial Approach (McConnell Approach)
Indications
A more direct approach to the ulnar nerve that also allows
exposure of the median nerve in the middle and distal
thirds is obtained through the medial side of the forearm.
This approach, originally described by McConnell (25), is
 8.1 Flexor Forearm 441

recounted here with some modifications based on the

description by Henry (1).

Landmarks
The landmarks are the pisiform bone and the medial epi-
condyle.

Patient Position/Incision
With the patient supine and the forearm in supination, an
incision is made from the radial side of the pisiform to the
medial epicondyle (Fig. 8.28).

Technique
Beginning distally and opening the fascia along the radial
side of the FCU tendon, the ulnar neurovascular bundle is
found just radial to this tendon and traced proximally to the
junction of the proximal and middle thirds of the forearm.
At this location, the ulnar artery angles away laterally
toward its parent vessel, the brachial artery, whereas the
ulnar nerve continues proximally in a straight course
toward the medial epicondyle. If the median nerve also
must be exposed, the cleavage plane between the FDS and
the FDP is developed, which leads to the median nerve
closely applied in a shallow groove to the underside of the
FDS (1). The median nerve in this region, as noted by
Henry (1), lies first to the radial side of the proximal mus-
cle belly of the deep portion of the FDS and then to the
radial side of the fibrous tissue linkage between the proxi-
mal and distal bellies. Below this level, fascia binds the
median nerve in a lateral groove between the middle and
index finger muscle bellies and tendons.

Median Nerve in the Distal Forearm

Indications
The median nerve is relatively superficial in the distal aspect
of the forearm and may be subject to laceration because of
its exposed position. This incision also may be useful for
removal of median nerve tumors in this area.

D
Landmarks
FIGURE 8.26. (continued) D: Pronation of the forearm facili- Useful landmarks are the long axis of the middle finger and
tates exposure of the remainder of the radial shaft. the PL tendon, if present.

Patient Position/Incision
With the patient supine and the forearm in supination, a
longitudinal or gently curved incision is made at the wrist
flexion crease and continued proximally in line with the
middle finger axis for a distance of 10 to 12 cm, as needed
(Fig. 8.29).
 442 Regional Anatomy

FIGURE 8.27. Approach to the median and ulnar nerves. A: Incision. B: Proximal exposure of the
median nerve is in the interval between the pronator teres and the flexor carpi radialis. This
interval may be most easily identified at their distal zone of separation. The ulnar nerve is found
in the interval between flexor digitorum superficialis (FDS) of the little finger and the flexor carpi
ulnaris. C: The distal aspect of the median nerve may be identified beneath FDS to the middle
finger and in the interval between the FDS of the middle and ring fingers.
 8.1 Flexor Forearm 443

C
FIGURE 8.28. The McConnell approach to the median nerve (see also Fig. 8.7). A: Incision. B, C:
The interval between the flexor digitorum superficialis (FDS) and flexor carpi ulnaris is used to
expose the median nerve, which travels as a 9satellite9 on the undersurface of the FDS. This
approach also provides excellent exposure of the ulnar nerve and artery.
444 Regional Anatomy
Technique
The median nerve at this level is located between the mid-
dle and index finger components of the FDS and exits
from beneath the radial margin of the middle finger FDS
muscle belly. The palmar cutaneous branch leaves the
median nerve along its lateral aspect approximately 3 to 4
cm from the proximal margin of the transverse carpal lig-
ament (26).
Lateral Antebrachial Cutaneous Nerve
Indications
This nerve is a useful autograft donor nerve for digital nerve
repair (14).
Landmarks
It may be located just to the lateral aspect of the biceps ten-
don at the intersection of the biceps tendon and the
interepicondylar line of the humerus (13).
FIGURE 8.29. Exposure of the median nerve in
the distal forearm. The relatively superficial
location and the consistent exit of this nerve
from beneath the muscle belly of the flexor dig-
itorum superficialis to the middle finger facili-
tates this exposure.
Patient Position/Incision
With the patient supine and the forearm in supination, a
transverse incision is made in the elbow flexion crease cen-
tered over the biceps tendon (Fig. 8.30).
Technique
Staying to the lateral side of the tendon, the nerve is found
as it emerges from the anterior surface of the brachialis
muscle. The nerve is closely applied to the lateral aspect of
the biceps tendon, and in some instances appears to blend
with the lateral substance of the biceps tendon (13). The
nerve lies in the same coronal plane as the biceps tendon,
just deep to the antecubital veins and the antecubital fascia.
It is in this region that the posterior branch is given off. Dis-
tally, cutaneous branches ramify along the course of the
cephalic vein. Digital nerve grafts usually do not require
extensive amounts of graft, and this incision usually is ade-
quate to harvest a sufficient length of graft, but it may be
extended as needed.
 8.1 Flexor Forearm 445

FIGURE 8.30. Approach for the lateral antebrachial cutaneous nerve. The nerve most often is
found just lateral to the biceps tendon as it emerges from the interval between the biceps and
brachialis muscles.

CLINICAL CORRELATIONS the ulna proximally. In some instances fibrous bands were
noted on both heads, which formed a definite fibrous
Pronator Syndrome
arcade (28).
Sites of Compression
Flexor Superficialis Arch
There are four potential sites of proximal median nerve
A fibrous arcade was observed in approximately one-third
compression, one in the distal arm and three in the proxi-
of the dissections at the proximal margin of the FDS to the
mal forearm (27) (Fig. 8.31). The distal arm site has been
middle finger (28).
discussed under the section on Clinically Significant
Arcades in Chapter 6. In the forearm, the median nerve
Lacertus Fibrosus
may be compressed at one of three levels, in the following
Entrapment of the median nerve beneath the lacertus fibro-
order of frequency: the PT, the flexor superficialis arch, and
sus is the least common cause of median nerve entrapment
the lacertus fibrosus (27,28).
in the proximal forearm. It may be secondary to hypertro-
phy or enlargement of the lacertus (28).
Pronator Teres
Dissections of the proximal forearm have revealed either a
Localizing Tests
fibrous band on the dorsum of the superficial head of the
pronator overlying the median nerve, or a fibrous band as a Functional muscle testing may give some indication of the
component of the deep ulnar head of the pronator when site of compression (Fig. 8.32). If complaints are produced
the latter was present, or, when the deep head was absent, a by flexion of the elbow against resistance between 120 and
separate fibrous band attached to the coronoid process of 135 degrees of elbow flexion, compression may be in the
 446 Regional Anatomy
A
B
C associated with vague complaints of discomfort in the
D
FIGURE 8.31. Sites of compression in the pronator syndrome. A:
The ligament of Struthers from an anomalous supracondylar
process to the medial epicondyle, which may compress the
median nerve. B: The pronator teres. C: The lacertus fibrosus
(the least common cause). D: A fibrous arch in the flexor digito-
rum superficialis of the middle finger.
distal arm beneath a ligament of Struthers (see Chapter 6).
Compression by the lacertus fibrosus may be aggravated by
active flexion of the elbow against resistance with the arm
in pronation. If symptoms are increased by resisted prona-
tion of the forearm (usually combined with wrist flexion to
relax the FDS), the nerve may be compressed between the
pronator, and if the symptoms are aggravated by resisted
flexion of the FDS to the middle finger, compression may
be at the FDS proximal arch (27,28).
Treatment
Operative technique for treatment of pronator syndrome
includes complete exploration of the median nerve from the
distal arm to the proximal forearm. The median nerve is
explored from the region of a possible anomalous supra-
condylar process and associated ligament of Struthers to the
proximal edge of the FDS, with release of all potentially
constricting structures, including the ligament of Struthers
and the lacertus fibrosus (27). At the level of the PT, com-
pression may be due to muscle hypertrophy or constricting
muscle fascial bands. Further decompression of the median
nerve is achieved by tracing the median nerve into the sub-
stance of the PT and releasing any areas of constriction. The
final site of possible constriction is in the proximal edge of
the FDS, which may be exposed by entering the interval
between the FCR and the PT. The median nerve may be
constricted here beneath a fibrous tissue arch along the
leading edge of the FDS. A persistent median artery also has
been observed as a cause of pronator syndrome. Reported
cases have demonstrated penetration of the median nerve
by the median artery and constriction of the nerve by vas-
cular leashes from the median artery (29,30).
Anterior Interosseous Nerve Syndrome
Compression of the AIN characteristically results in com-
plete or partial loss of function of the FPL and the FDP of
the index finger and long fingers, as well as the PQ, with-
out any sensory deficits (31–33). These findings may be
proximal forearm. In the complete AIN syndrome
(AINS), the affected patient assumes an unusual pinch
posture with the distal joint of the index and thumb in
extension (32,33).
Anatomic Variations
Although the FPL and FDP of the index finger are inner-
vated exclusively by the AIN, the FDP of the long finger
is exclusively innervated by the AIN only 50% of the time.
In the remaining 50%, the long finger FDP is at least par-
tially innervated by the ulnar nerve (23). Variations from
the classic AINS include isolated paresis or paralysis in
either the index profundus or the FPL. In both the com-
 8.1 Flexor Forearm 447

A B

FIGURE 8.32. Localizing tests for the pronator syndrome. A: Test for presence of ligament of
Struthers. B: Test for lacertus fibrosus and pronator teres muscle compression. C: Test for
median nerve compression by a fibrous tissue arch in the flexor digitorum superficialis of the
middle finger.

plete and partial types, there often is an antecedent history
of unusual muscular exertion, blunt trauma, or edema in
the extremity (23).
Differential Diagnosis
AINS, especially the incomplete type, must be distin-
guished from flexor tendon rupture, flexor tendon adhe-
sion, and stenosing tenosynovitis. If a Martin-Gruber
connection is present between the AIN and the ulnar
nerve, there may be intrinsic muscle paresis or atrophy
(34). The incomplete type of AINS may be distinguished
from rupture of the FPL by noting passive flexion of the
interphalangeal joint of the thumb with wrist and MCP
joint hyperextension in AINS, in contrast to absence of
thumb interphalangeal joint flexion in rupture of the
FPL (35).
Compression Sites
The nerve usually is compressed by fibrous bands that run
from the deep (most common) or superficial head of the
PT to the brachialis fascia (23) (Fig. 8.33). Other sites of
compression have been identified, including the fibrous
tissue arcade of the FDS, which the AIN passes beneath to
lie on the IOM (27). Other reported causes of compres-
sion include enlarged bursae or tumors, aberrant or
thrombosed vessels, a double lacertus fibrosus overlying
the nerve, compression of the nerve as it runs deep to both
heads of the PT, and fractures of the forearm and distal
humerus (23,27). Three aberrant muscles have been iden-
tified in association with AINS, including an accessory
head of the FPL called Gantzer’s muscle, the palmaris pro-
fundus, and the flexor carpi radialis brevis (27,36,37).
Although an accessory head of the FPL (Gantzer’s muscle)
448 Regional Anatomy

A B C

D E

FIGURE 8.33. Anterior interosseous nerve compression sites. A: Deep head of the pronator teres.
B: Fibrous arch of the middle finger flexor digitorum superficialis. C: Gantzer’s muscle. Presence of
abnormal muscles in the form of flexor carpi radialis brevis (D) and palmaris profundus (E).
 8.1 Flexor Forearm 449

has been identified as an a cause of AINS (33,38), both Associated Injuries/Etiology

Dellon and Mackinnon (39) and Al-Qattan (40) have
The most common associated injuries are fractures of the
noted that Gantzer’s muscle always is posterior to the
elbow or forearm, soft tissue injuries, arterial injury, burns
median nerve and AIN. However, in dissections of the
(thermal and electrical), and injection injuries (41,42). The
forearm in which Gantzer’s muscle was present, the
pathophysiology of compartment syndrome is best
authors demonstrated the possibility of a pincer-like effect
explained by the arteriovenous (AV) gradient theory of
between this abnormal posterior head and the adjacent
Matsen and Rorabeck (43). The relationship between local
anterior FDS that could produce compression of the
blood flow and the AV gradient is expressed by LBF = Pa −
median nerve as well as the AIN. The median nerve and
Pv/R, in which the local blood flow in a compartment
AIN passed through the interval between these two mus-
equals the local arterial pressure minus the local venous
cles, which share a common origin on the medial epi-
pressure divided by the local vascular resistance. If the AV
condyle (see discussion of Gantzer’s muscle under the sec-
gradient is significantly reduced, the local vascular resis-
tion on Anatomic Variations, later).
tance becomes relatively ineffective and for practical pur-
poses can be ignored. Because veins are collapsible, the pres-
Pathogenesis sure inside them cannot be less than the surrounding local
tissue pressure; thus, when tissue pressure rises, so does the
The common denominators in this condition appear to be
pressure on the local veins, resulting in a decreased AV gra-
localized edema superimposed on an anatomic abnormality
dient. When this occurs, local blood flow is reduced to the
that is either congenital or acquired.
extent that it cannot meet the metabolic needs of the mus-
cles and nerves. The AV gradient theory explains why with
Treatment increased tissue pressure and a reduction in local arterial
pressure, as in hypotension, hemorrhage, peripheral vascu-
Patients who present with paresis may be observed because
lar disease, arterial occlusion, and limb elevation above the
most improve spontaneously without surgery (23). This is
heart, the net effect of any given increase in tissue pressure
especially true in children with AINS associated with frac-
is exaggerated by lowering the local AV gradient. Lowering
tures of the forearm and elbow region. Exploration and
of the AV gradient results in decreased oxygen perfusion of
decompression is advised in patients who present with com-
the muscles and nerves, with subsequent death of the mus-
plete paralysis of either muscle tendon unit and who have
cles and replacement by fibrous tissue, which in turn causes
shown no improvement as determined by physical exami-
“strangulation neuropathy.” The final result is a forearm
nation or repeat electromyography after 12 weeks of obser-
fixed in pronation, with the wrist flexed, the MCP joints
vation (23). The AIN is exposed through a curved incision
hyperextended, and the PIP and distal interphalangeal
beginning at the antecubital flexion crease just medial to the
(DIP) joints flexed (41,44). If the ulnar nerve also is
biceps tendon. The median nerve is traced distally to its
involved, total sensory loss is noted on the flexor side of the
entrance between the two heads of the PT, and the superfi-
hand. This is a classic description of Volkmann’s ischemic
cial head of the PT is mobilized and retracted to reveal the
contracture. Mubarak and Carroll believe that Volkmann’s
usual site of origin of the AIN from the posterior aspect of
contracture is caused by circulatory changes in a closed
the median nerve. The site of compression may be identi-
osteofascial compartment due to buildup of tissue fluid
fied by noting a pale discoloration in the nerve with or
pressure in the compartments (41). Their studies suggest
without a concomitant indentation of the nerve. All poten-
that the normal range of compartmental pressures is 0 to 8
tial sites of compression are released; it is not necessary to
mm Hg. In a compartment syndrome, pressures may rise to
perform an internal neurolysis. It may be necessary to
30 to 50 mm Hg or more. Failure to diagnose and treat a
divide the insertion of the PT to facilitate exposure of the
compartment syndrome early and adequately may result in
AIN at the superficialis fibrous arcade.
irreversible changes.

Compartment Syndrome
Compartment syndrome is a clinical complex that results
from increased pressure in a closed and limited space that
compromises the circulation and function in that space.
Although this condition may occur in any closed anatomic
space, it is most common and devastating in the volar
aspect of the forearm (41). The fact that the forearm mus-
cles are encased in a semirigid fascial tube makes such a pro-
gression possible; even the skin may act as a restricting
membrane in some instances.
Muscle Infarct
Seddon introduced the concept of the ellipsoid infarct, not-
ing that circulation in the central aspect of the muscle belly
was most severely impaired, in contrast to the periphery of
the muscle, where collateral circulation was less likely to be
impaired (44). The muscle infarct is most prominent in the
middle third of the muscle and is more severe next to the
bone along the course of the anterior interosseous artery.
The most severely affected muscles are the FDP and the
450 Regional Anatomy
FPL (the deeper muscles), followed by the FDS and PT.
Involvement of the wrist flexors, extensors, and brachiora-
dialis is less likely. Degeneration of the nerves that pass
through the area of muscle infarct is due not only to the ini-
tial ischemia but to the chronic compression, which results
in a nerve that is thin and cordlike (38). The muscle infarct
is replaced by dense fibrous tissue that contracts and pro-
duces the characteristic Volkmann’s deformity (41,44).
Most Important Facts
The most important facts to remember about compartment
syndrome are the clinical findings and the need for early
treatment. The clinical findings are based on muscle and
nerve ischemia and include pain that is persistent and pro-
gressive (45). Accentuation of the pain by passive muscle
stretching is a very reliable clinical test in making the diag-
nosis. Pain may be absent late in the course of the disorder
because of prolonged nerve ischemia, and pain also may be
absent when compartment syndrome is superimposed on a
central or peripheral sensory defect. Diminished sensation
is the second most important finding, and indicates nerve
ischemia as it passes through the involved compartment
(45). The third most important finding is muscle weakness,
which, when progressive, is very important in establishing
the diagnosis (45). The clinical assessment of elevated com-
partment pressure by palpation of the extremity may give
some indication of the presence or absence of compartment
syndrome, but this must be recognized as a qualitative fac-
tor in the decision-making process regarding fasciotomy.
Wick Catheter
Mubarak and associates have popularized the use of a
wick catheter to measure compartment tissue pressures
(41,42,46). The wick catheter is connected to a trans-
ducer and a recorder and can provide reliable objective
assessment of intracompartmental pressure. Based on
extensive clinical use and experience, the originators of
this technique have advised that fasciotomy is recom-
mended when the intracompartmental pressure is >30
mm Hg in normotensive patients and >20 mm Hg in
hypotensive patients, when associated with the typical
clinical picture of compartment syndrome (42).
Although the need for fasciotomy may be based in part
on the duration and intensity of the compartment syn-
drome, it seldom if ever is possible to determine accu-
rately the duration of the elevated pressure, and therefore
it must be assumed that the duration is equal to or has
exceeded the critical threshold of 8 hours (45).
Forearm Compartments
Cross-sectional anatomy of the forearm demonstrates three
major compartments, the volar, extensor, and mobile wad
(47) (Fig. 8.34). Pressure studies have revealed that these
three compartments are interconnected, unlike the com-
partments in the leg. Therefore, release of the volar com-
partment may be sufficient to release all three compart-
ments. However, if there is any indication that elevated
pressure is present in the remaining two compartments,
then release of the extensor compartment should be per-
formed, which almost always decompresses the mobile wad
compartment as well as the extensor compartment (47).
The PQ has been identified as a fourth forearm compart-
ment based on the findings of a well defined fascial cover-
ing measuring 0.4 to 0.5 mm in thickness, a compartment
floor formed by the IOM, and dye injection studies show-
ing its separation from the other forearm compartments
(48). A compartment syndrome involving this compart-
ment was noted after a crush injury with an associated frac-
ture of the distal radius (49).
FIGURE 8.34. The three compartments of the forearm:
volar, dorsal, and mobile wad.

FIGURE 8.35. Fasciotomy incision for forearm compartment syndrome.
Treatment Techniques
The volar incision is designed to preserve superficial veins
and nerves while allowing decompression of the underlying
superficial and deep muscle groups and subsequent cover-
ing of the vital structures, including nerves. The fasciotomy
incision may include the carpal tunnel and the antecubital
fossa, as indicated (45) (Fig. 8.35). All muscle compart-
ments and muscles are examined with the understanding
that the most severely involved muscles are deep and
include the FDP and FPL. The muscle fascia is split if the
muscle appears pale or ischemic. The skin incision is left
open, but the margins may be loosely reapproximated to
cover vital structures such as the median nerve. Delayed
skin closure or skin grafting is performed as indicated in 5
to 10 days.
Biceps Tendon Rupture at Distal
Insertion
This clinical entity is placed in this chapter on the forearm
rather than the elbow because the major points of anatomy
relate more to the forearm than to the elbow. Although rup-
ture of the distal biceps insertion is much less common than
that of the proximal origin (long head of the biceps), the
functional loss is much greater (2). Distal ruptures treated
nonoperatively have been reported to result in a 60%
decrease in strength of both elbow flexion and supination
(26).
Diagnosis
This injury usually occurs in men and often is associated
with a history of forceful contraction of the biceps against a
heavy load or against unexpected resistance (50). Weak and
painful elbow flexion and forearm supination are noted.
The biceps tendon cannot be palpated in its normal course
in the antecubital fossa, and there may be ecchymosis in the
forearm, elbow, and arm.
8.1 Flexor Forearm 451
Treatment
Most surgeons recommend reattachment of the biceps ten-
don using a two-incision approach originally described by
Boyd and Anderson (51).
Technique
The avulsed and retracted biceps tendon is identified through
a transverse incision in the antecubital fossa (Fig. 8.36). The
biceps tendon usually is retracted several centimeters proximal
to the antecubital flexion crease and may be located by inci-
sion of the deep fascia and retraction of the proximal margin
of the incision. The tendon is grasped and brought distally
into the operative site. A #1 Mersilene or similar suture is
passed through the biceps tendon using a Bunnell-type suture
technique, followed by identification of the bicipital tunnel
between the supinator and the flexor-pronator muscles. The
location of this tunnel is facilitated by supination of the fore-
arm, which brings the radial tuberosity into the bottom of the
operative site. Palpation of the radial tuberosity helps to guide
the surgeon’s finger or blunt instrument into the tunnel,
which is medial to the tuberosity. A second incision is made
on the posterolateral aspect of the elbow, through which the
muscles on the lateral surface of the olecranon are reflected to
expose the head and neck of the radius. The forearm is then
pronated, which brings the radial tuberosity into view. An
osseous trap door is made in the tuberosity and two drill holes
are made beneath the hinge. The Mersilene suture is then
passed from front to back using a curved clamp and the biceps
tendon is brought into the posterolateral operative site, where
the two ends of the suture are passed through the drill holes
and the tendon end passed into the trap door defect. Flexion
of the elbow facilitates placement of the tendon stump into
the trap door defect and tying the suture.
Postoperative Care
The elbow is flexed to 110 degrees and the forearm is placed
in mid-supination. This position is maintained for 2 weeks,
followed by progressive range-of-motion and progressive
resistance exercises.
452 Regional Anatomy

FIGURE 8.36. Distal biceps tendon rupture. Incision (A) and anterior exposure (B). Lateral inci-
sion (C) and reattachment of biceps tendon (D).
 8.1 Flexor Forearm 453

ANATOMIC VARIATIONS
Nerve
Martin-Gruber Connection
One of the most significant neural anomalies in the forearm
is the Martin-Gruber anastomosis or connection. Based on
a world literature review, Leibovic and Hastings identified
an overall incidence of 17% (34). Based on their review,
four types (I to IV) were identified (Fig. 8.37).
Type I
Type I was the most common (60%) and was represented
by motor branches from the median to the ulnar nerve to
innervate “median” muscles. Leibovic and Hastings further
subdivided type I into Ia and Ib (34). Type Ia is a branch
from the median nerve to the ulnar nerve in the forearm
that continues on into the hand to innervate the thenar
muscles (those ordinarily supplied by the median nerve).
These are median fibers traveling on the ulnar nerve to the
hand. In type Ia, these fibers innervate thenar muscles only,
and in type Ib they innervate ulnar intrinsic as well as
thenar muscles.
Type II
Type II (35%) sends motor branches from the median to
the ulnar nerve to innervate “ulnar” muscles.
Type III
Type III (3%) sends motor fibers from the ulnar to the
median to innervate “median” muscles.

FIGURE 8.37. The Martin-Gruber connection. Normal pattern and types of median-to-ulnar and
ulnar-to-median nerve connections. (Redrawn from Leibovic SJ, Hastings H II. Martin-Gruber
revisited. J Hand Surg [Am] 17:47–53, 1992, with permission.)
454 Regional Anatomy

Type IV median nerve lesion could be completely masked; a low

Type IV (1%) sends motor fibers from the ulnar to the
median to innervate ulnar muscles. Type IV is divided into
IVa and IVb. Type IV is a branch from the ulnar to the
median nerve in the forearm that continues into the hand
to innervate the ulnar intrinsic muscles. In IVa, these fibers
innervate ulnar intrinsic muscles only, whereas in IVb they
innervate ulnar intrinsic and thenar muscles.
Anatomy/Clinical Significance
The double lines in the median and ulnar nerves in Figure
8.38 indicate possible sites of nerve interruption that could
be partially or completely masked in the various types of
Martin-Gruber connections. In a type Ia connection, a low
median or high ulnar lesion would be masked in a type Ib
connection. In type II connection, a high ulnar lesion could
be completely masked. In the rare type III, a high median
lesion may be missed, and in the even rarer type IV, a low
ulnar lesion (IVa) or a low ulnar and high median (type
IVb) lesion may be missed.
Evidence to date indicates that Martin-Gruber connec-
tions carry only motor fibers. Uchida and Sugioka found
that the entry point of the crossing fiber from the median
to the ulnar nerve was 3 to 10 cm distal to the medial
humeral condyle (52). They noted that there might be a sig-
nificant risk of injury to this cross-over connection in ulnar
nerve transposition.

FIGURE 8.38. The Martin-Gruber connection. Normal pattern; the double lines represent sites of
nerve interruption that could be partially or completely masked in the various types of Martin-
Gruber connections. (Redrawn from Leibovic SJ, Hastings H II. Martin-Gruber revisited. J Hand
Surg [Am] 17:47–53, 1992, with permission.)

Radial Nerve
Sensory Branch
The sensory component of the radial nerve may be absent
in the forearm and only the motor component may be pre-
sent. In such cases, the lateral antebrachial cutaneous nerve
innervates the area normally supplied by the radial sensory
branch (3).
Motor Branch (Posterior Interosseous Nerve)
The PIN may pass over instead of through the supinator
(3).
Median Nerve
Although the median nerve usually passes between the two
heads of the PT, it may pass superficial or deep to the two
heads or it may pierce the superficial head. It also may lie
on the superficial rather than deep surface of the FDS. The
median nerve also may split in the forearm and allow pas-
sage of the ulnar artery or one of its branches (53).
Ulnar Nerve
The ulnar nerve may pass in front of the medial epicondyle.
The Nerve of Henle
In a study of 40 cadaver upper extremities, McCabe and
Kleinert found this nerve to be present as a branch of the
ulnar nerve in 23 (57%) of the extremities (54). In 18
(78%) of the 23 nerves of Henle identified, the branch
arose 16 cm proximal to the ulnar styloid from the radial
side of the ulnar nerve, near the site where the ulnar nerve
and artery lie parallel in the proximal forearm. This config-
uration was the more common of the two patterns, and the
authors called this pattern the typical or proximal pattern.
The nerve of Henle traveled distally on the palmar ulnar
surface of the ulnar artery and could be traced in most cases
distal to the wrist flexion crease. At a point 6 cm proximal
to the ulnar styloid, a branch arose from the nerve of Henle
that coursed superficially to pierce the antebrachial fascia
just radial to the FCU musculotendinous junction, pre-
sumably to innervate an area of skin of the distal, ulnar,
flexor surface of the forearm. This branch to the skin was
present in 13 of the 18 nerves of Henle that arose proxi-
mally. In the remaining five cases, the nerve of Henle arose
approximately 8 cm proximal to the ulnar styloid, and the
authors called this configuration the atypical or distal pat-
tern. This nerve traveled with the ulnar artery for 1 to 2 cm
before branching to the skin as previously described for the
typical or proximal nerve of Henle. The authors noted the
similarity between this distal variant and a prior description
of the palmar cutaneous branch of the ulnar nerve
8.1 Flexor Forearm 455
(PCBUN). They noted that no separate PCBUNs were
found in their 40 dissections.
They concluded that the nerve of Henle provided sym-
pathetic nerve fibers to the ulnar artery and sensory fibers
to the distal forearm and ulnar side of the palm. They
believed that the atypical or distal pattern of the nerve of
Henle and the PCBUN were the same structure, noting
that a previous description of the PCBUN showed it to be
similar in location and prevalence to the distal and atypical
pattern of the nerve of Henle (55).
The findings of McCabe and Kleinert are contrasted
to those of Martin et al., who studied the cutaneous
innervation of the palm in 25 hands and noted the
PCBUN to be present in 4 of 25 specimens and the nerve
of Henle as a sensory branch to be present in 10 of 25
specimens (56). See discussion on innervation of the
palm in Chapter 10A.
Muscle
Brachioradialis
Occasionally, the tendon of insertion at the radial styloid
may be represented by two or three slips.
Clinical Significance
The sensory branch of the radial nerve may pass between
these slips on its way to the dorsal aspect of the wrist, and
should be protected if the insertion of the brachioradialis is
to be detached for transfer or for purposes of exposure of
the distal radius (53).
Accessory Brachioradialis
An accessory brachioradialis, called the supinator longus
accessorius or brachioradialis brevis, arises adjacent to the
brachioradialis and inserts on the radial tuberosity to act as
a true supinator (53). It also may insert into the supinator
or the tendon of the PT, or onto the ulna (53).
Clinical Significance
Spinner described entrapment of the superficial branch of
the radial nerve by the brachioradialis brevis. The site of
compression is located 3 to 4 cm proximal to the arcade of
Frohse (33).
Supinator
The degree of separation of the superficial and deep layers
may vary from complete separation to fusion, and should
be appreciated when looking for the PIN in the supinator
(53). Accessory muscle fascicles may arise from the annular
ligament (53). A proximal fibrous band from the supinator
may be present that may cause PIN compression (27).
456 Regional Anatomy
Pronator Teres
A portion of the origin of the superficial head of the PT
may be extended proximally by direct extension of the mus-
cle to the medial supracondylar ridge or by a ligament that
connects the muscle to a supracondylar process on the
humerus (53).
Clinical Significance
Either the brachial artery and median nerve or just the
median nerve may pass beneath this abnormally located
portion of the PT to reach the antecubital fossa. In addi-
tion, the deep or ulnar head of the PT may be absent.
Flexor Carpi Radialis
The FCR, in addition to its normal insertion on the base of
the index and middle finger metacarpals, may insert on the
trapezium and scaphoid bone (53).
Flexor Carpi Radialis Brevis
The flexor carpi radialis brevis is a small muscle arising from
the radius that inserts into the sheath of the FCR tendon
and may be a source of compression in AINS (27).
Palmaris Longus
This muscle may be digastric or fleshy throughout its
length. It may have a proximal tendon as well as a distal ten-
don, or it may be fleshy distally and have a tendon proxi-
mally (palmaris longus inversus). The tendon of insertion
may comprise one, two, or three slips.
Incidence
This muscle is absent approximately 11% of the time (53).
It is absent more often in women, and on the left side in
both sexes.
Clinical Significance
All of these factors must be considered when the PL is cho-
sen for transfer, tendon graft, or other reconstructive pur-
poses. In addition, median nerve compression may result
from a reversed PL (57,58).
Palmaris Profundus
The palmaris profundus is an anomalous muscle arising from
the middle third of the radius on the lateral aspect that is
superficial to the FDS and deep to the PT (36,53,59). Its
tendinous portion passes through the carpal canal and inserts
onto the deep surface of the palmar aponeurosis (36,59).
Clinical Significance
Because it lies beneath the transverse carpal ligament and
adjacent to the median nerve, it may be a source of com-
pression of the median nerve (60). It also has been reported
to be a source of compression of the AIN proximally (27).
Flexor Carpi Ulnaris
An anomalous radial insertion of the FCU has been
reported in which a part of the ulnar nerve passed through
a split in the FCU tendon at the wrist (61).
Clinical Significance
This anomaly would be significant in surgical procedures
about the FCU tendon, such as opponens plasty, FCU
transfer, or excision of the pisiform, and the wary surgeon
identifies and protects the ulnar nerve when operating in
this area (61).
Anconeus Epitrochlearis
The anconeus epitrochlearis is a small anomalous muscle
near the origin of the FCU proximal to the aponeurosis
joining the humeral and ulnar heads of the FCU. It arises
from the medial border of the olecranon and inserts into
the medial epicondyle. This muscle is superficial to the
ulnar nerve and takes the place of the fibrous arch of the
deep fascia. It may vary in size and shape from small and
fusiform to a thick, rectangular structure that is palpable on
physical examination (62,63). It has been reported to have
a variable incidence as high as 25% (62). It has been
described as an auxiliary extension of the medial portion of
the triceps, but it is anatomically distinct from the triceps
and is innervated by the ulnar nerve. This muscle often is
seen in other species and presumably is an atavistic anom-
aly in humans. In humans, the muscle may be replaced by
a ligament called the epitrochleoanconeus ligament, and
because its course and attachments are similar to those of
the muscle, this ligament is believed to be a rudiment of the
muscle (64).
Clinical Significance
This muscle crosses over the ulnar nerve in the cubital tun-
nel and has been reported to be a source of compression of
the ulnar nerve in cubital tunnel syndrome (62,63). In cases
of ulnar neuropathy due to the anconeus epitrochlearis
muscle, treatment is complete or partial excision of the
muscle to relieve any pressure on the nerve (63).
Flexor Digitorum Superficialis
There may be muscular interconnections between the FDS
and the FPL. Occasionally, an accessory muscle is derived
from the FDS and arises from the coronoid process to
attach to one of the deep flexors (accessorius profundus dig-
itorum of Gantzer) (53).
Clinical Significance
This muscle may be a source of compression of the AIN
(27).

Flexor Digitorum Profundus
Intertendinous Connections
The degree of functional separation between the FDP of
the four fingers may vary, but if the profundus of the index
finger FDS is completely independent, it may be called the
flexor digitorum indicis. Intertendinous connections from
the FPL to the index FDP are comparatively common. Lin-
burg and Comstock found an incidence of 31% in one
extremity and an incidence of 14% in both extremities on
clinical examination of 194 patients. In 43 cadavers, the
unilateral incidence was 25% and the bilateral incidence
was 6% (65). This finding is known as the Linburg-Com-
stock anomaly.
Clinical Significance
This intertendinous connection, usually at the wrist or dis-
tal forearm level, may interfere with certain specific func-
tions, such as holding and simultaneously cocking the ham-
mer of a pistol. Although the FPL and FDP of the index
finger usually are independent, phylogenetically both ten-
dons are derived from a common mesodermal mass
(65,66).
Flexor Pollicis Longus
The FPL is said to be uniquely human because in primates
there is only one deep digital flexor muscle that provides a
tendon to the thumb as well as the four fingers, in contrast
to the anatomically distinct FDP and FPL musculotendi-
nous units in the human (2,53). Although the primate con-
figuration has been noted in humans, it is very rare com-
pared with the more common abnormality, in which the
tendon of the FPL sends connections to the index FDP
(67).
Gantzer’s Muscle
A more common anomaly is the presence of an accessory
head of the FPL called Gantzer’s muscle. In a study of 25
limbs, an accessory head was found in 52% (13 of 25 limbs)
(40). This accessory head was supplied by the AIN, arose
from the medial humeral epicondyle in 85%, and had a
dual origin from the epicondyle and coronoid process of the
ulna in the remainder. Gantzer’s muscle is posterior to both
the AIN and median nerve (39,40). Its usual insertion is to
the ulnar part of the FPL and its tendon (40).
Clinical Significance
Although the usual insertion of Gantzer’s muscle is the
ulnar side of the FPL (40), it may send anomalous slips to
the index FDP, which may result in pain in the distal fore-
arm as well as the inability to flex the interphalangeal joint
of the thumb without also flexing the DIP joint of the
index finger (40, 65). Although Gantzer’s muscle has not
been implicated as a cause of pronator syndrome
8.1 Flexor Forearm 457
(27,33,38), both Lister and Spinner (33,38) have listed
Gantzer’s muscle as a cause of AINS. Al-Qattan (40) and
Dellon and MacKinnon (39) agree that Gantzer’s muscle is
posterior to both the AIN and median nerve. Al-Qattan
demonstrated that the median nerve was closely related to
Gantzer’s muscle in two situations: (a) when the median
nerve passed deep to the deep head of the pronator, and (b)
when the deep head of the pronator was absent (40).
Kaplan and Spinner noted that there were two other situa-
tions in which Gantzer’s muscle might contribute to
median nerve compression in the forearm: (a) a division of
Gantzer’s muscle distally into a slip inserting into the
undersurface of the FDS in the vicinity of the superficialis
arch, and (b) perforation of the median nerve in the proxi-
mal forearm by Gantzer’s muscle (68).
Summary
There is some controversy as to the association of Gantzer’s
muscle with AINS. However, Gantzer’s muscle may be
related to median nerve compression in the unique circum-
stances noted previously, in which the authors dissected a
forearm in which Gantzer’s muscle was present and
demonstrated the possibility of a pincer-like effect between
this abnormal posterior head and the adjacent anterior
FDS that could produce compression of the median nerve
as well as the AIN. The median nerve and AIN passed
through the interval between these two muscles, which
share a common origin on the medial epicondyle. Gantzer’s
muscle may be a cause of inability to flex the interpha-
langeal joint of the thumb without also flexing the DIP
joint of the index finger.
Vascular
Radial Artery
Many of the anomalies of the radial and ulnar artery in the
forearm have been identified in conjunction with the
development of the radial forearm flap, which requires
sacrifice of the radial artery (69–72). The greatest concern
in harvesting the radial forearm free flap is the integrity of
the ulnar arterial supply of the hand (73,74). The ulnar
artery supplies the hand through the superficial palmar
arch, which is either “complete” in the sense that it pro-
vides branches to the thumb and four fingers, or com-
pleted through branches from the deep palmar arch (62).
In 265 specimens, Coleman and Anson found a complete
superficial arch in 77.3% of cases (75). The ulnar artery
supply to the long, ring, and little fingers is rarely if ever
compromised by anomalous patterns (74). However, the
index finger and thumb potentially are compromised by
the combination of two concurrent arterial anomalies.
The first anomaly is an incomplete superficial arch that
does not send branches to the thumb and index. The sec-
ond, which also must be present to produce digital
ischemia, is a complete lack of communication between
458 Regional Anatomy
the superficial and deep arches. The coexistence of these
two anomalies, which would put the thumb and index fin-
ger at risk for ischemia if the radial artery were sacrificed,
occurred in 12% of specimens (74,75). The fact that the
incidence of the predicted ischemia is much less may be
accounted for by the presence of the anterior interosseous
artery and a persistent median artery (73). The latter ves-
sel, which usually joins the superficial palmar arch, may
provide protective circulation to the hand after sacrifice of
the radial artery (68,74).
Other Reported Variations of the Radial Artery
1. The brachial artery has been noted to divide into the
radial and ulnar arteries 8 cm distal to the antecubital
fossa (72). In this configuration, the radial artery passed
deep to the PT and did not have its normal connections
with the skin and subcutaneous tissues in the proximal
half of the forearm. In this configuration, the survival of
the flap is based on a perforating vessel from the radial
artery that is 7 cm proximal to the radial styloid (76). If
the flap is designed proximal to this perforating vessel in
the presence of a deep radial artery, the radial forearm
flap may be devoid of significant blood supply.
2. A small branch of the radial artery was found in its nor-
mal position, but the main component was superficial to
the thumb extensors and entered the hand several cen-
timeters radial to its normal location (70).
3. An aberrant dorsal course of the artery has been reported
in which the radial artery passed around Lister’s tubercle
of the radius to enter the hand dorsal to the extensor
tendons (71).
Clinical Significance
Any of the aforementioned anomalies of the radial artery
may make it difficult if not impossible to use the radial
artery–based forearm flap as a viable source of composite
tissue for reconstructive purposes.
Ulnar Artery
The ulnar artery may arise proximal to the elbow and, if so,
it then passes superficially from the antecubital fossa over
the origins of the PT, FCR, and PL muscles. In this config-
uration, the brachial artery supplies the common
interosseous artery, which in turn supplies the recurrent
artery (2). In this superficial position, the ulnar artery is
commonly under the deep fascia, but rarely subcutaneous.
In some instances, the superficial ulnar artery, after passing
over the PT and FCR, passes beneath the proximal origin
of the PL muscle and then continue its superficial course
(77,78). In the mid-portion of the forearm, the superficial
ulnar artery comes into contact with the lateral or radial
margin of the FCU and then courses distally to assume its
normal course just before reaching the wrist (77,78).
Clinical Significance
The incidence of this anomaly is approximately 3%, and it
should be kept in mind when performing intravenous injec-
tions in the cubital fossa to avoid accidental intra-arterial
injection (77). In addition, recognition of such an anomaly
is essential to avoid catastrophic injury to the remaining
blood supply to the hand during harvest of the radial fore-
arm flap (69). If the surgeon is unaware of this anomaly, the
ulnar artery is at risk because the radial forearm flap usually
is raised under tourniquet control and the ulnar artery may
be mistaken for one of the superficial veins of the forearm.
Median Artery
Developmental Anatomy
The median artery is normally a transitory vessel that devel-
ops from the axial artery of the upper extremity during early
embryonic life (30). It maintains the superficial palmar
arterial arch while the radial and ulnar arteries are develop-
ing (2). When the radial and ulnar arteries develop, the
median artery usually involutes and does not persist into
postfetal life (30). The incidence of a persistent median
artery in adult life has been reported to range from 1% to
17% (30). It usually is a long, thin vessel that arises from
the anterior interosseous artery and passes distally between
the FDP and FPL to the median nerve, which it supplies
throughout its course in the forearm (2). However, in
approximately 8% of individuals, the median artery is a
large vessel that continues into the palm to help form the
superficial palmar arterial arch (53). Although the median
artery may contribute to the superficial palmar arch, if the
arch is incomplete, the median artery becomes the domi-
nant blood supply to the index and long fingers (30). The
median artery also has been shown to be the dominant
blood supply to the proximal median nerve in 30% of cases
(30).
Clinical Significance
The median artery has been associated with carpal tunnel
and pronator syndromes (27,29,30). In the pronator syn-
drome, the median artery has been noted to penetrate the
median nerve and also to form vascular leashes that con-
stricted the nerve (29,30). The median artery also may rep-
resent a significant source of circulation to the hand in
those cases at risk owing to an anomaly of the radial artery,
or after its sacrifice (74).
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 C H A P
8
FOREARM
JAMES R. DOYLE
P A R T
2 Henry used a manual mnemonic for identification of the
EXTENSOR FOREARM
DESCRIPTIVE ANATOMY
Contents
n Nerves: The dorsal forearm contains cutaneous nerves,
the terminal sensory branches of the radial and ulnar
nerves, and the posterior interosseous nerve (PIN).
n Muscles: The dorsal forearm contains the primary exten-
sors of the wrist, the extrinsic finger and thumb exten-
sors, the long abductor of the thumb, and the supinator
and anconeus.
External Landmarks
Important landmarks in the dorsal forearm are the lateral
epicondyle and supracondylar ridge of the distal humerus,
the olecranon process of the ulna, the radial head, the
“mobile wad of three” [brachioradialis, extensor carpi radi-
alis longus (ECRL), and extensor carpi radialis brevis
(ECRB)], the outcropping thumb muscles, the radial and
ulnar styloid, and Lister’s tubercle (Fig. 8.39).
ANATOMIC RELATIONSHIPS
The “Mobile Wad of Three”
Understanding of the anatomic relationships on the exten-
sor aspect of the forearm is best begun by reviewing the
mobile wad of three arising from the supracondylar ridge
and lateral epicondyle of the humerus (1). These three mus-
cles, the brachioradialis, ECRL, and ECRB, are called the
mobile wad of three because they may be grasped between
the surgeon’s thumb and index finger and provide a useful
landmark for placement of incisions and the identification
of deeper structures.
T E R
Extensor Mnemonic
superficial extensors (1). Using the opposite hand and
beginning with the thumb, which is placed behind the
forearm on the lateral epicondyle, we note that the
obliquely oriented thumb parallels the muscle fibers of the
anconeus. The index marks the extensor carpi ulnaris
(ECU), the middle finger the extensor digiti minimi, and
the ring finger the common finger extensors. The little
finger is not used (Fig. 8.40). These four muscles arise
from a conjoined fibrous origin from the lateral epi-
condyle. The extensor digitorum communis (EDC) and
extensor digiti minimi attach to the extensor mechanism
in the fingers, and the ECU to the dorsal and ulnar base
of the little finger metacarpal. The apex of the triangular
anconeus arises from the inferior edge of the lateral epi-
condyle and the base attaches to the proximal edge of the
ulna.
Extensor Forearm Muscle Groups
There are two groups or layers of extensor forearm muscles:
superficial and deep. The muscular components of the
extensor forearm are:
Superficial (Fig. 8.41)
n Anconeus
n ECRL
n ECRB
n EDC
n Extensor digiti minimi (EDM)
n ECU
Deep (Fig. 8.42)
n Supinator
n Abductor pollicis longus (APL)
n Extensor pollicis brevis (EPB)
n Extensor pollicis longus (EPL)
n Extensor indicis proprius (EIP)
462 Regional Anatomy

B
A
FIGURE 8.39. A, B: Landmarks on the extensor surface of the forearm.
 8.2 Extensor Forearm 463

FIGURE 8.40. Henry’s mnemonic for the superficial extensors of the forearm.
464 Regional Anatomy

FIGURE 8.41. A–C: Anatomic relationship

of the superficial extensors to the deep and
“outcropping” muscles of the forearm.
 8.2 Extensor Forearm 465

Superficial Muscle Group

Anconeus
The anconeus is a small, triangular muscle that arises by a
tendon from the posterior surface of the lateral epicondyle.
Its fibers course toward the ulna and on the way cover the
posterior aspect of the annular ligament. The fibers insert
on the lateral aspect of the olecranon and proximal one-
fourth of the posterior surface of the ulna. The anconeus
assists the triceps in elbow extension.

Extensor Carpi Radialis Longus

The ECRL is partially covered by the brachioradialis and
arises distal to the origin of the brachioradialis from the
remaining or distal third of the lateral supracondylar
ridge, from the anterior aspect of the lateral intermuscular
septum, and from the common tendon of origin of the
forearm extensors. The muscle fibers end at the junction
of the middle and proximal thirds of the forearm in a sub-
stantial tendon that continues distally to insert on the
radial side of the dorsal base of the index metacarpal. Its
course is deep to the APL and EPB, and over the dorsal
aspect of the radius it lies in a shallow groove. It is an
extensor of the wrist, and because of its insertion on the
index metacarpal produces radial deviation of the hand in
extension when unopposed by the more centrally located
ECRB.

Extensor Carpi Radialis Brevis

The ECRB is shorter than the ECRL and is partially cov-
ered by it. It arises from the lateral epicondyle, from a ten-
don of origin that it shares with the other forearm exten-
sors, and from the lateral collateral ligament of the elbow.
Its muscle fibers end at approximately the middle third of
the forearm and its substantial tendon continues distally,
similar to but ulnar to the ECRL. It also is an extensor of
the wrist, and because of its more central location produces
extension of the wrist without radial deviation. The inser-
tion of the ECRB is at the dorsal surface of the middle fin-
ger metacarpal on its radial side but distal to its styloid
process. Over the distal radius, it lies in a shallow groove
separated from its companion radial wrist extensor, the
ECRL, by a low osseous ridge.

Extensor Digitorum Communis

The EDC arises from the lateral humeral condyle by a com-
mon extensor tendon, the adjacent intermuscular septa, and
the antebrachial fascia. It divides into four tendons that pass
beneath the extensor retinaculum to insert into the dorsal
extensor expansion over the fingers.

Extensor Digiti Minimi

The EDM is a small muscle ulnar to and usually connected
FIGURE 8.42. Deep extensor muscle of the forearm. to the EDC. It arises from the common extensor tendon
466 Regional Anatomy
and from adjacent intermuscular septa. Its tendon, includ-
ing variations, is described in Chapter 10.
Extensor Carpi Ulnaris
The ECU arises from the lateral epicondyle by the common
extensor tendon, and from the posterior border of the ulna
by an aponeurosis shared with the flexor carpi ulnaris
(FCU) and flexor digitorum profundus. It ends in a tendon
that courses through a groove between the head and styloid
process of the ulna. It attaches to the tubercle of the ulnar
side of the little finger metacarpal. It acts as a wrist extensor
with the ECRB and ECRL, and along with these extensors
acts synergistically with the finger flexors to stabilize the
wrist during forceful grip. The ECU also is an adductor of
the wrist.
Deep Extensor Group
The deep extensor group is unique, according to Henry, in
that all of its tendons (except perhaps the proprius) can be
seen in one’s own hand and that all go to the thumb or
index finger. Henry has further noted that except for the
APL, which arises from both radius and ulna, the tendons
all point to their bone of origin. The EPB points to the
radius and the EPL and EIP to the ulna (1).
Supinator
The supinator was included in the deep muscle group in the
first part of this chapter (Flexor Forearm). Although the
supinator is considered to be a deep extensor of the forearm,
it was included there because it often is encountered in sur-
gical approaches to the flexor aspect of the forearm. The
supinator wraps around the proximal one-third of the
radius and has superficial and deep layers. The superficial
portion arises from the lateral epicondyle of the humerus,
the collateral ligament of the elbow joint, and the annular
ligament. The deep head arises from the “supinator crest” of
the ulna as well as portions of the annular ligament and col-
lateral ligament. It attaches to the volar and lateral side of
the proximal third of the radius as far distally as the inser-
tion of the pronator teres (PT). Its oblique insertion paral-
lels the origin of the flexor pollicis longus. The PIN courses
between the two layers of the muscle at almost a right angle
to the muscle fibers. The supinator acts in slow, unopposed
supination of the forearm and together with the biceps in
fast or forceful supination.
Abductor Pollicis Longus
The APL arises from the posterior shaft of the ulna distal
to the anconeus, from the adjacent interosseous mem-
brane (IOM), and from the posterior surface of the radius
distal but adjacent to the insertion of the supinator. It
curves over the radial aspect of the wrist to insert by mul-
tiple (two to four) tendons into the dorsal and palmar
base of the thumb metacarpal. It acts to abduct the
thumb along with the abductor pollicis brevis and, with
the EPL and EPB, extends the thumb at the carpometa-
carpal joint.
Extensor Pollicis Brevis
The EPB is ulnar to and closely applied to the APL. It
arises from the posterior surface of the radius and the IOM
distal to the origin of the APL. It inserts on the dorsal base
of the proximal phalanx of the thumb, where it extends the
proximal phalanx and the thumb metacarpal. Accompa-
nied by the APL, it travels through a synovium-lined
fibroosseous canal over the radial styloid (the first dorsal
compartment), where it and the APL may be involved with
de Quervain’s stenosing tenosynovitis (2). In one-third of
wrists, the EPB may travel in a separate canal, and both
canals must be released in de Quervain’s tenosynovitis to
relieve the condition (3). The APL and EPB, the so-called
outcropping muscles of the thumb, emerge from between
the muscle bellies of the EDC and ECRB and obliquely
cross over both the ECRB and ECRL tendons and their
synovial sheaths.
Extensor Pollicis Longus
The EPL arises from the IOM and the adjacent dorsal
aspect of the ulna in the middle third of the forearm. Its ori-
gin is distal to the origin of the APL and proximal and ulnar
to the EPB origin. It passes to the ulnar side of Lister’s
tubercle, which acts as a fulcrum point or “turning pulley”
to enable the EPL to change its course and thus end on the
dorsal aspect of the distal phalanx of the thumb. The action
of the EPL includes extension of the interphalangeal and
metacarpophalangeal (MCP) joints, elevation of the thumb
into the plane of the palm, and adduction of the extended
thumb.
Extensor Indicis Proprius
The EIP arises from the dorsal surface of the ulna and the
adjacent surface of the IOM distal to the EPL and ulnar to
the EPB. It continues to the extensor hood of the MCP
joint of the index finger. It almost always is situated to the
ulnar side of the EDC tendon to the index. The details of
the normal arrangement and anatomic variations are dis-
cussed in Chapter 10.
Intersection Zones
The extensor surface of the forearm demonstrates two zones
of muscle–tendon “intersection” (see Fig. 8.41B and C), the
first of which is the crossing over of the EPB and APL over
the radial wrist extensors. The second zone of intersection is
between the EIP and EPL with the overlying finger exten-
sors. Only the first zone has clinical relevance. This zone
and its clinical implications are discussed later, under the
section on Clinical Correlations.

SURGICAL EXPOSURES
Posterior Interosseous Nerve
Four surgical approaches have been described for expo-
sure of the PIN (4–9). The first is the anterolateral
approach in the antecubital fossa, the second is a trans-
brachioradialis, and the third and fourth are posterolat-
eral approaches.
Anterolateral Approach
Indications
The anterolateral approach has been described as an excel-
lent approach for exposure of all possible compressive struc-
tures in radial nerve compression syndromes and has been
advised as the approach of choice when the exact area of
FIGURE 8.43. Patient position (A) and incision (B) for the anterolateral approach to the posterior
interosseous nerve (PIN).
8.2 Extensor Forearm 467
compression is not clear from the preoperative evaluation
(4,6).
Landmarks
Useful landmarks are the “mobile wad of three,” the lateral
aspect of the biceps/brachialis muscles, the elbow flexion
crease and the biceps tendon.
Patient Position/Incision
With the patient supine and the forearm in supination the
incision begins 4-5 cm proximal to the elbow flexion crease
on the anterolateral aspect of the arm between the biceps/
brachialis and brachioradialis (Fig. 8.43). It crosses the
antecubital fossa to the inner or medial aspect of the
“mobile wad” where it continues distally. The biceps tendon
468 Regional Anatomy

provides a useful and readily palpable landmark to identify
the inner margin of the “mobile wad.”
Technique
Staying to the lateral side of the biceps tendon the radial
recurrent branch of the radial artery is identified, ligated
and retracted laterally to expose the interval between the
brachioradialis and the brachialis muscle belly (Fig.
8.44). Beginning at or proximal to the elbow flexion
crease the radial nerve is traced distally while looking for
potential sites of compression. Identification of the
fibrous edge of the ECRB as an impingement factor is
facilitated by pronation of the forearm and flexion of the
wrist. During this maneuver the radial nerve is viewed to
note any possible impingement by the fibrous edge of the
ECRB. If any impingement is noted or suspected the
fibrous margin of the ECRB is excised (see Fig. 8.18).
The fibrous arcade of Frohse is identified and incised (6).
Care is taken to avoid injury to the branch of the radial
nerve to the superficial head of the supinator while divid-
ing the arcade of Frohse. Complete division of the arcade
may also be accompanied by incision of the superficial
portion of the supinator from the arcade of Frohse to the
point of arborization and exit of the PIN from the distal
aspect of the supinator. Exposure of the distal course of
the nerve and its distal point of exit is facilitated by
pronation of the forearm and gentle retraction of the
“mobile wad.”

A
FIGURE 8.44. Deep dissection in the anterolateral approach to the posterior interosseous nerve
(PIN). A: The biceps is a useful guide to the radial recurrent artery, which may be 9hooked9 with
the surgeon’s finger before ligation.

B
FIGURE 8.44. (continued) B: Ligation of the radial recurrent vessels permits medial retraction
of the radial artery and lateral retraction of the brachioradialis and extensor carpi radialis longus
to expose the PIN and supinator muscle.
Transbrachioradialis Approach
Indications
This approach is said to be the most direct to the radial tun-
nel and with experience may be the most accessible (6–8).
Landmarks
The “mobile wad of three” and especially the brachioradi-
alis and the radial head.
Patient Position/Incision
With the patient supine, the elbow flexed and the forearm
pronated a 6 cm long incision is made directly over the bra-
chioradialis and centered over the neck of radius in the prox-
8.2 Extensor Forearm 469
imal forearm (Fig. 8.45). The incision may be associated
with a significant scar and the originator of the technique
has subsequently suggested a transverse incision (7,8).
Technique
Dissection is directly through the muscles fibers of the bra-
chioradialis down to the PIN (7,8). The longitudinal, blunt
muscle splitting is carried deeper until fat is seen in the
depths of the dissection, which signals the location of the
superficial branch of the radial nerve. Beneath this branch
is the arcade of Frohse and the PIN. The dissection is car-
ried proximally and distally to decompress the five potential
areas of compression (see section on Radial Tunnel Syn-
drome).
470 Regional Anatomy

FIGURE 8.45. Transbrachioradialis approach to the posterior interosseous nerve (PIN). A: A 6 cm

long incision is made directly over the brachioradialis and centered over the neck of radius. B:
Blunt muscle splitting is carried deep until fat is seen in the depths of the dissection, which sig-
nals the location of the superficial branch of the radial nerve. Beneath this branch is the arcade
of Frohse and the PIN.
 8.2 Extensor Forearm 471

Posterolateral Approaches Landmarks

Indications
It has been said that posterolateral approaches to the PIN are
best suited for exposure of the distal portion of the nerve due
to the limited proximal exposure, and that if the lesion is not
localized to the area of the Arcade of Frohse, the posterolat-
eral approach should not be used (4). This concept may not
be true if the fascial origin of the wrist and finger extensors is
carefully removed from the lateral epicondyle, which can pro-
vide a more comprehensive proximal exposure.
Useful landmarks are the lateral epicondyle, the “mobile
wad of three,” the EDC and the ECU.
Position/Incision
With the patient supine, the forearm in pronation and the
elbow slightly flexed a 7–8 cm long incision is made begin-
ning just distal to the lateral epicondyle in the interval
between the ECRB and the EDC (Fig. 8.46).

FIGURE 8.46. Posterolateral approach to the posterior interosseous nerve: incision and land-
marks. The incision is located between the extensor carpi radialis brevis (ECRB) and the extensor
digitorum communis (EDC). The greater mobility of the 9mobile wad of three9 (brachioradialis,
extensor carpi radialis longus and brevis) compared with the relatively fixed EDC aids in place-
ment of the incision.
472 Regional Anatomy
Technique
Standard Posterolateral Approach. The standard pos-
terolateral approach is begun by identifying the interval
between the ECRB and the EDC (Fig. 8.47). This is
done by grasping the “mobile wad” of muscles containing
the brachioradialis, ECRL and ECRB which move more
readily than the adjacent EDC. The comparative differ-
ence in mobility between the mobile wad and the EDC
indicate the interval of approach. After incision of the
fascia the interval is further verified by noting the muscle
separation distally between the ECRB and the EDC
which are separated by a long narrow “V” shaped inter-
val. The proximal portion or apex of this narrow triangle
begins at approximately the junction of the proximal and
middle thirds of the forearm and the base, which is distal,
contains the origins of the “outcropping” muscles of the
thumb. Working from this distal interval (the “back
door”), the muscles are split proximally to reveal the
underlying supinator. Release of the ECRB and ECRL
from the epicondyle and the supracondylar ridge respec-
tively will permit visualization of the radial nerve well
prior to its entrance into the supinator. Caution: If
release of these muscle origins is required, the radial col-
lateral ligament complex, especially the lateral ulnar col-
lateral ligament portion (see section on elbow ligaments
in Chapter 7), must not be released. The PIN is sand-
wiched between the two heads of the relatively thin
supinator and courses across the direction of its muscle
fibers. If required, identification of the PIN in the sub-
stance of the supinator may be made by making a small
incision in the direction of the muscle fibers at a spot
three fingerbreadths distal to the radial head on the back
of the radius (1). Further exposure is best achieved by
identification of the nerve proximally and releasing it
from its muscle envelope from proximal to distal. Great
care is taken at the distal end to avoid injury to the mul-
tiple branches as they exit the supinator to avoid postop-
erative paresis (5).
Modified Posterolateral Approach. A somewhat similar
approach between the muscles of the fifth and sixth exten-
sor compartments (EDM and ECU) has been described
and is said to allow complete visualization of: the nerve
through the supinator, all potential compressing struc-
tures, and the lateral humeral epicondyle (5). This
approach allows simultaneous management of the radial
nerve problem as well as a possibly coexistent lateral epi-
condylitis (5). The incision begins at the lateral epi-
condyle and continues distally on the mid-posterior aspect
of the forearm to approximately the mid-portion of the
forearm. The correct fascial incision is in the interval
between the EDM and the ECU. Identification of this
interval is aided by noting small vessels that exit the fascia
between these muscle groups (5). There is a septum
between these two muscles that is contiguous proximally
with the lateral collateral ligament, and staying just ante-
rior to this septum avoids injury to this structure (5).
Retraction of the EDM dorsally reveals the underlying
supinator. Identification of the PIN proximally as it enters
the supinator is aided by release of the conjoined tendon
of origin of the wrist and finger extensors from the lateral
epicondyle. This proximal release also allows identifica-
tion of any proximal fibers that may compress the PIN. In
my experience, this approach is not as easy as the standard
posterolateral approach.
FIGURE 8.47. Posterolateral approach to
the posterior interosseous nerve (PIN): deep
dissection. The interval between the exten-
sor carpi radialis brevis (ECRB) and the
extensor digitorum communis (EDC) is
found distally and these muscles are sepa-
rated proximally to reveal the underlying
supinator. Release of the ECRB and extensor
carpi radialis longus from the epicondyle
and the supracondylar ridge, respectively,
permits visualization of the radial nerve well
before its entrance into the supinator. The
PIN is sandwiched between the two heads
of the relatively thin supinator and courses
across the direction of its muscle fibers. If
required, identification of the PIN in the
substance of the supinator may be made by
making a small incision in the direction of
the muscle fibers at a spot three finger-
breadths distal to the radial head on the
back of the radius.
 8.2 Extensor Forearm 473

Approach to the Posterior Radius Position/Incision

Indications
Portions or all of this approach may be used for exposure of
the radius for fractures, fracture dislocations, tumors, or
infection.
With the patient supine, the elbow slightly flexed, and the
forearm in pronation, an incision is begun at the lateral epi-
condyle of the humerus and ending at Lister’s tubercle at
the distal radius (Fig. 8.48). The incision may be straight or
gently curved.

Landmarks Technique
Useful landmarks include the lateral epicondyle, the radial The interval between the ECRB and the EDC is used for
head, Lister’s tubercle, and the radial styloid. exposure of the radius, and this interval may be identified

FIGURE 8.48. Posterior approach to the radius: patient position, landmarks, and incision. The
interval between the extensor carpi radialis brevis and the extensor digitorum communis (EDC) is
used for siting the incision and is identified by grasping the muscles of the 9mobile wad of three9
(brachioradialis, extensor carpi radialis longus and brevis), which move more readily than the
adjacent EDC.
474 Regional Anatomy

by grasping the muscles of the mobile wad of three (the bra-
chioradialis, ECRL, and ECRB), which move more readily
than the adjacent EDC (Fig. 8.49). The comparative differ-
ence in mobility between the mobile wad and the EDC
indicates the interval of approach. After incision of the fas-
cia, the interval is further verified by noting the muscle sep-
aration distally between the ECRB and the EDC. Working
from this distal interval (the “back door”), the muscles are
split proximally to reveal the underlying supinator. The
supinator muscle encases the proximal third of the radius
and contains the PIN, which must be dealt with to com-
plete this exposure successfully. The approach to the PIN
depends on the requirements or goals of the surgery. If com-
plete exposure of the radius is required, the PIN is exposed
proximal to its entrance into the supinator; if a less than
complete exposure is required, the PIN may be identified at
its more distal exit point from the supinator (approximately
1 cm proximal to the distal edge of the supinator). If prox-
imal identification is required, the ECRB and ECRL are
partially detached from the lateral epicondyle and supra-
condylar ridge to identify the PIN before its entrance into
the supinator. Detachment of these muscles is done with
care to avoid injury to the lateral elbow ligaments, especially
the lateral ulnar collateral ligament component (see discus-
sion of elbow ligaments in Chapter 7). After identification
of the nerve proximally, the superficial half of the “supina-
tor sandwich” is opened by incising the supinator muscle
across its fibers along the course of the PIN. Multiple motor
branches from the PIN to the supinator are encountered
and should be preserved. After dissection of the PIN, the
forearm may be supinated to reveal the attachment of the
supinator along the volar surface of the radius, where it may
be removed by subperiosteal dissection. A suitable alterna-
tive to dissecting the PIN from the supinator would be to

FIGURE 8.49. Posterior approach to the radius: the interval between the extensor carpi radialis
brevis and the extensor digitorum communis (EDC) is identified distally, and the muscles are split
proximally to reveal the underlying supinator. After identification of the posterior interosseous
nerve (PIN), the superficial half of the 9supinator sandwich9 is opened by incising the supinator
muscle across its fibers along the course of the PIN. In the middle third of the radius, the inser-
tion of the pronator teres (PT) as it crosses over from the volar compartment is found near the
distal insertion of the supinator. A short longitudinal incision here, which is a nerve- and vascu-
lar-free zone, allows for easy identification and removal of the insertion of the PT. The muscle
bellies of the abductor pollicis longus and extensor pollicis brevis may be mobilized for retraction
by releasing their margins proximally and distally as required to facilitate exposure of the radius.
The interval between the radial wrist extensors and the nearby extensor pollicis longus and EDC
is used to expose the distal third of the radius.
 8.2 Extensor Forearm 475

detach the insertion of the supinator as just described with- Landmarks

out dissecting the PIN from its “sandwich,” but only if the
Useful landmarks are the olecranon process, the subcuta-
PIN was clearly identified first both proximally and distally.
neous margin of the ulna, and the ulnar styloid.
In the middle third of the radius, the insertion of the PT is
encountered as it crosses over from the volar compartment
and is found near the distal insertion of the supinator. The
point of insertion of the PT tendon is in a comparative bare Patient Position/Incision
spot on the radius between the distal margin of the supina-
With the forearm in pronation and the elbow flexed to 90
tor and the adjacent outcropping muscles of the thumb.
degrees and resting on a soft pad to elevate it above the
With the forearm in mid-position, this bare spot can be pal-
operating hand table, an incision is begun at the olecranon
pated and coincides with the longitudinal midpoint of the
and continued distally over the subcutaneous margin of the
radius. A short longitudinal incision here, which is in a
ulna to end at the styloid process at the wrist (Fig. 8.50).
nerve- and vascular-free zone, allows for easy identification
Portions or all of this incision may be used as required by
and removal of the insertion of the PT if needed for a ten-
the surgical exposure.
don transfer. The muscle bellies of the APL and EPB also
are encountered in this region and may be mobilized for
retraction by releasing their margins proximally and distally
as required to facilitate exposure of the radius. The interval Technique
between the radial wrist extensors and the nearby EPL and
The ulna represents the medial mid-axial line of the fore-
EDC is used to expose the distal third of the radius.
arm and has no wraparound or cross-over muscles to con-
Throughout this dissection, the branches of the PIN must
tend with in surgical exposures. The subcutaneous margin
be handled gently if at all to avoid neurapraxia or perma-
of the ulna distinctly separates the volar and dorsal surface
nent damage.
of the forearm and is easily palpable throughout its course,
making dissection and surgical approaches relatively easy.
The ECU and FCU, respectively, flank the dorsal and
Approach to the Ulnar Shaft volar aspects of the ulna (Fig. 8.51). Proximally, the expo-
sure is safe as long as the dissection is subperiosteal.
Indications
Although the ulnar nerve may be at risk in very proximal
Approaches to the ulna are used for management of frac- exposures as it passes through the two heads of the FCU,
tures, tumors, or infection. injury to this nerve may be avoided by exposing the nerve

FIGURE 8.50. Surgical approach to the ulna: patient position, landmarks, and incision.
476 Regional Anatomy

FIGURE 8.51. The extensor and flexor carpi ulnaris (FCU), respectively, flank the dorsal and volar
aspects of the ulna. Proximally, the exposure is safe as long as the dissection is subperiosteal. Dis-
tally, however, the dorsal or posterior cutaneous sensory branch of the ulnar nerve is at risk in
this exposure. This branch is on average 6.4 cm from the distal aspect of the head of the ulna and
8.3 cm from the proximal border of the pisiform. The nerve passes dorsal to the FCU and pierces
the deep fascia to become subcutaneous on the medial aspect of the forearm at a mean distance
of 5 cm from the proximal edge of the pisiform.

before it enters the FCU. Injury to other structures, such CLINICAL CORRELATIONS
as the ulnar artery, is unlikely as long as the dissection
De Quervain’s Tenosynovitis
remains subperiosteal. However, the dorsal or posterior
cutaneous sensory branch of the ulnar nerve is at risk in Description and Findings
this exposure. The ulnar nerve gives off the important dor-
In 1895, de Quervain published his description of tenosyn-
sal sensory branch an average of 6.4 cm from the distal
ovitis involving the first dorsal extensor compartment con-
aspect of the head of the ulna and 8.3 cm from the prox-
taining the APL and EPB tendons (2). The well known
imal border of the pisiform. Its mean diameter at origin is
condition that bears his name is characterized by pain over
2.4 mm. The nerve passes dorsal to the FCU and pierces
the region of the radial styloid and often is associated with
the deep fascia to become subcutaneous on the medial
swelling, tenderness, or crepitation in the fibroosseous
aspect of the forearm at a mean distance of 5 cm from the
canal.
proximal edge of the pisiform. The nerve gives an average
of five branches with diameters between 0.7 and 2.2 mm
Diagnosis
distal to its exit from beneath the FCU. These 5 branches
pass over the dorsal medial aspect of the wrist, hand, ring, The most pathognomonic objective sign is Finkelstein’s test,
and little fingers (10). which is correctly performed by grasping the patient’s
 8.2 Extensor Forearm 477

A B
FIGURE 8.52. Finkelstein’s test: the correct (A) and incorrect (B) technique. Finkelstein’s test is
correctly performed by grasping the patient’s thumb and then ulnar deviating the hand. A false-
positive test may result if the thumb is flexed in the palm and grasped by the patient’s fingers,
followed by ulnar deviation of the wrist.

thumb and then ulnar deviating the hand (11) (Fig. 8.52).
A false-positive test may result if the thumb is flexed in the
palm and grasped by the patient’s fingers, followed by ulnar
deviation of the wrist (12). The reader may be convinced of
the validity of this concept when this maneuver is tried on
his or her own wrist (see discussion of Finkelstein’s test in
the Appendix).
Relevant Anatomy of de Quervain’s
Tenosynovitis
The APL and EPB ordinarily share a common fibroosseous
canal (the first dorsal compartment), which contains two to
four slips of the APL and a single slip of the EPB. Surgical
release of the fibrous tissue roof of this canal usually is asso-
ciated with relief of the symptoms associated with this con-
dition. However, a second canal that contains the EPB has
been identified in 34 of 100 cadaver wrists (3). This sep-
tum, which formed a separate narrow compartment for the
EPB, ranged in length from 0.5 to 2 cm. Failure to appre-
ciate the relatively high incidence of a separate compart-
ment for the EPB may lead to the false assumption that one
of the multiple tendon slips of the APL noted at the time of
surgery is the EPB (3). If traction on one of the unroofed
tendons does not result in extension of the MCP joint of
the thumb, a separate canal or compartment must be
searched for (usually dorsally) and released. The presence of
a second canal may, in some instances, explain the failure to
improve after a steroid injection into the first compartment.
In those cases, a second and more dorsal injection may be
tried. In addition to the need for complete release of the
involved tendons, the sensory branches of the radial nerve
must be identified and protected during release of the first
dorsal compartment (Fig. 8.53).
Radial Tunnel Syndrome
Anatomy
In the mid-portion of the arm, the radial nerve passes
through the spiral groove to enter the anterolateral aspect of
the distal third of the arm on its way to the forearm, where
it lies between the brachioradialis laterally and the brachialis
medially. The ECRL covers it anterolaterally, and the
capitellum of the humerus is posterior. The radial tunnel
begins at the level of the radiohumeral joint and extends
through the arcade of Frohse to end at the distal end of the
supinator (6). Division of the radial nerve into motor (pos-
terior interosseous) and sensory (superficial radial) compo-
nents may occur at any level within a 5.5-cm segment from
2.5 cm above to 3 cm below Hueter’s or interepitrochlear
line (a line drawn through the tips of the epicondyles of the
humerus) (13). The superficial radial nerve remains on the
underside of the brachioradialis until it reaches the mid-
portion of the forearm and is not subject to compression in
the radial tunnel (6).
Symptoms
The radial tunnel syndrome (RTS) must be distinguished
from PIN syndrome (PINS): RTS is a subjective symptom
complex without motor deficit that involves a motor
478 Regional Anatomy
FIGURE 8.53. Relevant anatomy of de Quervain’s tenosynovitis.
The abductor pollicis longus (APL) and extensor pollicis brevis
(EPB) ordinarily share a common fibroosseous canal (the first
dorsal compartment) that contains two to four slips of the APL
and a single slip of the EPB. A second canal may be present that
contains the EPB tendon. If traction on one of the unroofed ten-
dons does not result in extension of the metacarpophalangeal
joint of the thumb, a separate canal or compartment must be
searched for and released. Note also the proximity of the dorsal
sensory branches of the radial nerve, which are at risk during
surgery.
nerve, in contrast to PINS, which is an objective complex
with motor deficit affecting a motor nerve (6). The symp-
toms in RTS are similar to lateral epicondylitis, with com-
plaints of pain over the lateral aspect of the elbow that
sometimes radiates to the wrist (5,9). Because the pain is
believed to be due to compression of a motor nerve, the
description of the pain as a deep ache is not surprising. A
dynamic state may exist in which pronation, elbow exten-
sion, and wrist flexion are combined with contraction of
the wrist and finger extensors to produce compression of
the PIN (9).
Physical Findings/Provocative Tests
These may include point tenderness 5 cm distal to the lat-
eral epicondyle. The absence of sensory or motor distur-
bances in RTS is characteristic. To a limited extent,
provocative tests may give some indication of the
anatomic location of the compression, but are not always
reliable. The so-called middle finger test involves exten-
sion of the middle finger with the elbow in extension and
the wrist in neutral. The test is considered to be positive if
pain is produced in the region of the proximal portion of
the ECRB (6). Sanders has modified this test as follows:
With the elbow in full extension, the forearm in full
pronation, and the wrist held in flexion by the examiner,
the patient is asked actively to extend the long and ring
fingers against resistance. According to Sanders, these
positional modifications produce maximum compression
on the PIN and represent a more reliable form of the test
(9). If symptoms are reproduced with the elbow in full
flexion, the forearm in supination, and the wrist in neu-
tral, then fibrous bands are suspected (6). Reproduction of
symptoms by passive pronation of the forearm with the
elbow in 45 to 90 degrees of flexion and the wrist in full
flexion indicates entrapment by the ECRB. Compression
at the arcade of Frohse is suspected if the symptoms are
reproduced by isometric supination of the forearm in the
fully pronated position (6).
Diagnostic Tests
Electrodiagnostic studies to date have not been useful in the
diagnosis because there are no motor deficits, and conduc-
tion velocity studies through the radial tunnel are not reli-
able. However, the most reliable test is the injection of 2 to
3 mL of 1% lidocaine without epinephrine into the radial
tunnel (4,6). Relief of pain and a PIN palsy confirms the
diagnosis. A prior injection into the lateral epicondylar
region without relief of pain also supports the diagnosis (4).
Anatomic Sites of Compression
The five structures in the radial tunnel that represent poten-
tial sites of compression may be recalled by a useful
mnemonic (Fig. 8.54): FREAS (6). The structures from
proximal to distal are: Fibrous bands, Recurrent radial ves-
sels (the leash of Henry), Extensor carpi radialis brevis,
Arcade of Frohse, and Supinator (the distal border). The
fibrous bands are anterior to the radial head at the begin-
ning of the radial tunnel and are the least likely cause of
compression. The radial recurrent vessels cross the PIN to
supply the adjacent brachioradialis and ECR muscles, and
it is postulated that engorgement of these vessels with exer-
cise may compress the nerve (6,9). The tendinous proximal
margin of the ECRB also may compress the PIN and may
be mistakenly identified as the arcade of Frohse, which lies
A

B
FIGURE 8.54. A: Artist’s depiction of potential radial nerve compression sites at the elbow and
forearm in radial tunnel syndrome. F, fibrous tissue bands; R, radial recurrent artery; E, extensor
carpi radialis brevis (fibrous leading edge); A, arcade of Frohse ; S, supinator. These potential sites
of compression may be recalled by a useful mnemonic: FREAS. B: Fresh cadaver dissection of right
arm anterolateral view (proximal is to the left) showing the radial nerve between the brachialis
and extensor carpi radialis longus muscle bellies. The angled probe is tenting up the fibrous tis-
sue bands that may compress the radial nerve in radial tunnel syndrome.

479
480 Regional Anatomy
deep to the proximal margin of the ECRB muscle (4,6).
The arcade of Frohse is the fibrous proximal border of the
superficial portion of the supinator (6–13). It is the most
common site of compression of the PIN and is located from
3 to 5 cm below Hueter’s line (14). Eversmann has found
that sometimes the tendinous margin of the ECRB and the
arcade of Frohse may overlap and form a scissors-like pin-
cer effect on the radial nerve in this area (4). It is appropri-
ate to continue the exploration to the distal border of the
supinator, although it is a rare site of compression. More
often, a mass such as a ganglion may be found beneath the
superficial portion of the supinator (4,6).
Posterior Interosseous Nerve Syndrome
In contrast to RTS, PINS is characterized by objective
motor signs of entrapment of the PIN manifested by weak-
ness or complete palsy of the finger and thumb extensors.
There usually is no history of antecedent trauma.
Physical Findings
In complete PINS, active extension of the wrist occurs with
radial deviation owing to loss of the ECRB, whereas the
more proximally innervated ECRL remains intact. There is
associated loss of finger and thumb extension. Partial loss of
function is more common, with lack of extension of one or
more fingers or isolated loss of thumb extension (4,6). Sen-
sation always is intact.
Diagnostic Tests
In contrast to RTS, electromyography is positive in the
muscles innervated by the PIN. Computed tomography
scans or magnetic resonance imaging may show a mass in
the radial tunnel (6).
Surgical Exposures
Surgical exposure for RTS or PINS is described in the sec-
tion on Surgical Exposures, earlier.
Radial Neuritis at the Wrist
Wartenberg in 1932 described an isolated neuritis of the
sensory branch of the radial nerve (15). Although a variety
of causes have been implicated, the most common causes
are iatrogenic or traumatic.
Anatomy
The sensory branch of the radial nerve (SBRN) begins in
the volar and proximal aspect of the forearm and continues
to the distal forearm under cover of the brachioradialis,
where it enters the subcutaneous layer of the dorsal-radial
aspect of the distal forearm between the tendons of the bra-
chioradialis and the ECRB (Fig. 8.55). Its exit point is a
mean 9 cm proximal to the radial styloid and it usually
bifurcates into two branches a mean of 5.1 cm proximal to
the radial styloid. These two branches pass close to the first
dorsal compartment over the radial styloid. The dorsalmost
branch divides into multiple branches and continues to the
thumb–index finger web space and the index and middle
fingers, whereas the volar branch becomes the dorsoradial
digital branch of the thumb (16).
Surgical Risks to the Sensory Branch of the
Radial Nerve
A recognized risk in the application of external fixator pins
for distal radius fractures is injury to the SBRN. The mean
distance of the nearest branch from the center of the first
dorsal compartment is less than 0.5 cm, and in many
instances a branch runs directly over the center of the first
dorsal compartment. This places the branches of the SBRN
at risk during release of the first dorsal compartment for de
Quervain’s tenosynovitis or when a distal radial bone graft
is taken from the area between the first and second dorsal
compartments. During repair or reconstruction of radial or
ulnar collateral ligaments at the thumb MCP joint, dorsal
digital branches are nearby. Similarly, the course of the
SBRN should be kept in mind during placement of arthro-
scopic portals, limited wrist arthrodesis, open reduction
and internal fixation of distal radius or scaphoid fractures,
or procedures on the basilar joint of the thumb (16).
Intersection Syndrome
Intersection syndrome presents with localized pain and
sometimes swelling where the muscle bellies of the APL and
EPB intersect the ECRL and ECRB tendons in the dorsal
and distal forearm. This area, approximately 4 cm proximal
to the radial styloid, also may show redness and crepitation
in severe cases.
Pathology
The condition has been variously referred to as peritendini-
tis crepitans, APL bursitis, and cross-over tendinitis. Grund-
berg and Reagan concluded, however, that the condition
was in fact tenosynovitis of the second dorsal compartment
(ECRL and ECRB) (17). They noted that the zone of cross-
over or intersection of the APL and EPB muscle bellies over
the ECRL and ECRB tendons represented the site of com-
plaint and physical findings, but not the site of the true
pathologic process (Fig. 8.56). They concluded that because
the ECRL and ECRB were encased in a tight compartment,
the symptoms and physical findings did not present at the
site of the true lesion, but rather proximal to it. Surgical
release of the second dorsal compartment revealed charac-
 8.2 Extensor Forearm 481

FIGURE 8.55. Sensory branch of the radial nerve. This

branch begins in the volar and proximal aspect of the
forearm and continues to the distal forearm under
cover of the brachioradialis to the dorsal-radial aspect
of the distal forearm, where it exits between the ten-
dons of the brachioradialis and the extensor carpi radi-
alis brevis at a mean of 9 cm proximal to the radial sty-
loid. It usually bifurcates into two branches a mean of
5.1 cm proximal to the radial styloid. These two
branches pass close to the first dorsal compartment over
the radial styloid. The dorsalmost branch divides into
multiple branches and continues to the thumb–index
finger web space and the index and middle fingers, and
the volar branch becomes the dorsoradial digital branch
of the thumb.
482 Regional Anatomy

B
 8.2 Extensor Forearm 483

teristic synovitis and uniformly corrected the problem.
They noted two similar conditions in which the site of the
lesion was distal but manifested itself proximally: flexor
tenosynovitis of the finger and flexor tenosynovitis of the
wrist flexors (17).
Treatment
If conservative measures for relief of the tenosynovitis are
not successful, release of the second compartment is per-
formed through a longitudinal incision centered over the
radial wrist extensors that starts over the wrist and contin-
ues proximally to the swollen area. The EPL crosses over the
ECRL and ECRB in this area through a separate sheath,
but may be at risk. Similar precautions are required for the
dorsal sensory branch of the radial nerve.
Extensor Indicis Proprius Syndrome
EIP syndrome usually manifests itself as dorsal wrist pain
that is localized to the musculotendinous junction of the
EIP. The pain is aggravated by use of the wrist and hand,
usually during strenuous activities. Symptoms are localized
to the dorsum of the wrist over the fourth dorsal compart-
ment.
don and that the musculotendinous junction was within
the confines of the fourth dorsal compartment in 75% of
the specimens. Four percent of the specimens had muscle
beyond the distal confines of the dorsal compartment
(18). Ritter and Inglis, who reported this syndrome in
1969, noted that the fourth extensor compartment was
small, measuring 8 to 10 mm wide. Their anatomic stud-
ies revealed that the four EDC and the EIP tendons were
loose inside the fourth compartment when the wrist and
fingers were extended, but with wrist and finger flexion,
the EIP musculotendinous junction would pass into the
fourth compartment so that a probe could not be passed
through the compartment. They concluded that any
increase in size of any of the contents of the fourth com-
partment, such as hypertrophy of the EIP in a training
athlete or synovitis of the surrounding tendon sheaths,
could produce pain and disability (19).
Diagnostic Test
In 1973, Spinner and Olshansky described a useful diag-
nostic test for this condition. With the wrist in complete
flexion, the patient is asked to perform extension of the
index finger MCP joint against resistance. Pain that is radial
and distal to Lister’s tubercle is considered to represent a
positive test for EIP syndrome (20).

Physical Findings
Pertinent physical findings include swelling and tenderness
localized to the radial side of the fourth dorsal compart-
ment. The swelling usually diminishes with wrist extension
and is most noticeable during wrist flexion. Crepitation
may be present with wrist and finger movement and local-
ized tenderness usually is present over the radial side of the
fourth compartment.
Pertinent Anatomy
In a study of 263 specimens, Cauldwell et al. noted that
the EIP usually had a 1:1 ratio between muscle and ten-
Extensor Pollicis Longus Tenosynovitis
Etiology/Pathogenesis
Tenosynovitis of the EPL is a relatively uncommon condi-
tion and, excluding rheumatoid arthritis, the most common
associated condition is a fracture of the distal radius. Sur-
prisingly, it is the anatomically reduced or initially undis-
placed fractures that usually are associated with this condi-
tion. The tendency for EPL rupture may be due to
pressure-induced ischemia in an intact and unyielding
fibroosseous canal, in contrast to those canals that are
decompressed because of the comminuted and displaced
Colles fractures (21).

FIGURE 8.56. Intersection syndrome. A: In intersection syndrome, the zone of cross-over or

intersection of the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) muscle bellies
over the extensor carpi radialis longus (ECRL) and brevis (ECRB) tendons (4 cm proximal to the
radial styloid) represents the site of complaint and physical findings, but not the site of the
pathologic process. The pathologic process (stenosing tenosynovitis) is in the second dorsal exten-
sor compartment, which contains the ECRL and ECRB and is distal to the intersection zone. These
tendons are encased in a tight fibrosynovial compartment. B: Fresh cadaver dissection of the
radiodorsal aspect of the right wrist showing the fibrosynovial sheath of the ECRL and ECRB,
which has been injected with a dilute solution of methylene blue. This compartment is the site
of the true lesion in intersection syndrome. Note that the APL and EPB to the right (proximal)
cross obliquely over the ECRL and ECRB tendons in a synovial-free zone; note also the extensor
pollicis longus (EPL) and sensory branch of the radial nerve to the right (proximal) and the EPL
tendon.
484 Regional Anatomy
Diagnosis/Treatment
The condition is associated with pain, swelling, tenderness,
and sometimes crepitation over the course of the EPL at the
distal radius. These findings usually are noted during the
rehabilitation period after the fracture. Unlike other forms
of tenosynovitis, the EPL tendon is likely to rupture, and
therefore early release and transposition of the EPL from its
normal course around Lister’s tubercle is required. The ten-
don is transposed to the radial side of the tubercle, where it
lies in the subcutaneous tissue (21).
ANATOMIC VARIATIONS
Muscles
Several anomalous muscle tendon units encountered in the
forearm are presented, along with the clinical relevance of
these structures. The list, although not comprehensive, is
representative of those variations most commonly encoun-
tered on the extensor surface of the forearm and that in the
author’s opinion match the scope of this text.
Extensor Carpi Radialis Intermedius
This anomalous muscle was termed the extensor carpi radi-
alis intermedius (ECRI) because of its origin between the
ECRL and ECRB (22). However, in a more recent study of
39 cases of this anomalous muscle, Wood found that in 19
the muscle belly arose on top of and toward the radial side
of the ECRL, in 17 the muscle arose between the ECRL
and ECRB (the intermedius position), and in 3 cases the
muscle arose on top of the ECRB (23) (see Fig. 10.104).
The incidence of this anomalous musculotendinous unit
was 12% in the 312 limbs. Thirty-two of the 39 anomalous
muscles had a good muscle belly, a strong tendon, and good
excursion and thus represented musculotendinous units
that would be suitable for tendon transfer (23). In a similar
study of 173 limbs, the ECRI was found in 24% of the
limbs, many of which were large enough to act as a tendon
transfer (24). In Wood’s series, the ECRI or the accessory
tendons mentioned later that originated with or near the
ECRL usually inserted on the middle finger metacarpal. If
the anomalous muscle originated nearest the ECRB, the
tendon usually inserted on the index finger metacarpal. In
addition to the ECRI musculotendinous unit, both Wood
(23) and Albright and Linburg (24) noted the presence of
accessory tendons from the radial wrist extensors. Wood
(23) noted 41 such tendons originating from the ECRB
and inserting with the ECRL on the index finger
metacarpal. Twenty-nine tendons originated from the
ECRL and inserted on the middle finger metacarpal with
the ECRB, and 24 tendons arose from the ECRL and
inserted alongside the normal tendon at the index finger
metacarpal. Only seven tendons originated from the ECRB
and inserted on the middle finger metacarpal. In two arms,
the ECRL and ECRB shared a common tendon that
inserted on both the index and middle finger metacarpal.
Clinical Relevance
These studies indicate that the ECRI or accessory tendons
are worth looking for, especially in patients with quadriple-
gia, because they can be used as transfers for thumb oppo-
sition, to motor the flexor pollicis longus or as a motor for
the EPL. Wood noted that there is a fairly high incidence of
bilateral variations of this type, and that 12% of individuals
have a good ECRI tendon and approximately 36% have at
least one and sometimes several accessory tendons that
might be available for transfer (23). Albright and Linburg
not only emphasized the usefulness of the ECRI and acces-
sory tendons as transfers in tetraplegia, but also noted the
importance of and high incidence (35%) of cross-connec-
tions between the ECRB and ECRL. They noted that iden-
tification and release of these interconnections was impor-
tant if either of these tendons were to be used as transfers
because failure to do so might result in loss of independent
excursion in the transfer and thus possible failure of the
transfer. These interconnections usually were found under
the outcropping muscles to the thumb and often were dif-
ficult to detect because they blended into the major tendons
except when traversing from one to another (24).
Extensor Medii Proprius
The extensor medii proprius (EMP) is a muscle analogous
to the EIP in that it has a similar origin but inserts into
the extensor aponeurosis of the middle finger. In a study
of 58 hands, von Schroeder and Botte noted the presence
of the EMP in 6 hands for an incidence of 10.3% (25).
The EMP usually is covered by the EDC and usually is
not seen until the EDC is retracted or removed. The EMP
was always distal and medial to the EIP on the IOM, and
in all cases the two muscles had a common origin. In 4 of
6 instances, the EMP was represented by a single tendon
(25). The insertion was palmar and ulnar to the EDC
insertion on the middle finger. The width of the tendon
ranged from 10 to 30 mm (25) (see Fig. 10.101).
Extensor Indicis et Medii Communis
The extensor indicis et medii communis (EIMC) is an anom-
alous EIP that splits and inserts into both the index and mid-
dle fingers. It was identified in the aforementioned study by
von Schroeder and Botte, who noted its presence in 2 of 58
hands for an incidence of 3.4% (25). The tendon split into its
index and middle finger components near the myotendinous
junction. In one specimen, the insertion into the index finger
was similar to the usual insertion of the EIP on the palmar
and ulnar aspect of the EDC. In the other specimen, a dou-
ble tendon was present, with one tendon inserting into the

usual EIP location and the second slip inserting into the deep
fascia near the MCP joint. In both specimens, the insertion
into the middle finger was not into the extensor hood but
into the joint capsule of the middle finger in one case and into
the deep fascia proximal to the MCP joint in the other. The
muscle belly of the EIMC was similar to the EIP, and like the
EIP had no juncturae tendinum (25) (see Fig. 10.102).
Clinical Relevance of the EMP and the EIMC
Awareness of the incidence of these two muscles and other
anomalous muscles may be helpful in extensor tendon iden-
tification as it relates to repair or reconstruction.
REFERENCES
1. Henry AK. Extensile exposure, 2nd ed. Edinburgh: E and S Liv-
ingstone, 1966.
2. de Quervain F. Ueber eine Form von chronischer Tendovaginitis.
Corresp Blatt F Schweizer Arz (Basel) 25:389–394, 1895.
3. Leslie BM, Ericson WB Jr, Morehead JR. Incidence of a septum
within the first dorsal compartment of the wrist. J Hand Surg
[Am] 15:88–91, 1990.
4. Eversmann WW Jr. Entrapment and compression neuropathies.
In: Green DP ed. Operative hand surgery, 3rd ed. New York:
Churchill Livingstone, 1993.
5. Foster RJ. Radial tunnel syndrome: decompression by a posterior
lateral approach. In: Blair WF, ed. Techniques in hand surgery.
Baltimore: Williams & Wilkins, 1996.
6. Gelberman RH, Eaton R, Urbaniak JR. Peripheral nerve com-
pression. J Bone Joint Surg Am 75:1854–1878, 1993.
7. Lister GD. Radial tunnel syndrome. In: Gelberman RH, ed.
Operative nerve repair and reconstruction. Philadelphia: JB Lip-
pincott, 1991.
8. Lister GD, Belsole RB, Kleinert HE. The radial tunnel syn-
drome. J Hand Surg [Am] 4:52–59, 1979.
8.2 Extensor Forearm 485
9. Sanders WE. Letter. J Bone Joint Surg Am 74:309–310, 1992.
10. Botte MJ, Cohen MS, Lavernia C, et al. The dorsal branch of the
ulnar nerve: an anatomic study. J Hand Surg[Am] 15:603–607,
1990.
11. Finkelstein H. Stenosing tendovaginitis at the radial styloid
process. J Bone Joint Surg 12:509–540, 1930.
12. Elliott BG. Finkelstein’s test: a descriptive error that can produce
a false positive. J Hand Surg [Br] 17:481–482, 1992.
13. Frohse F, Frankel M. Die Muskeln des menschlichen Armes. In:
Bardelben’s Handbuch der Anatomie des Mensch. Jena, Germany:
Fisher, 1908.
14. Fuss FK, Wurzl GH. Radial nerve entrapment at the elbow: sur-
gical anatomy. J Hand Surg [Am] 16:742–747, 1991.
15. Wartenberg R. Cheiralgia paraesthetica (Isolierte Neuritis des
Ramus superficialis Nervi radialis). Z Ges Neurol Psychiatr
141:145–155, 1932.
16. Abrams RA, Brown RA, Botte MJ. The superficial branch of the
radial nerve: an anatomic study with surgical implications. J
Hand Surg [Am] 17:1037–1041, 1992.
17. Grundberg AB, Reagan DS. Pathologic anatomy of the forearm:
intersection syndrome. J Hand Surg [Am] 10:299–302, 1985.
18. Cauldwell EW, Anson BJ, Wright RR. The extensor indicis pro-
prius muscle: a study of 263 consecutive specimens. Q Bull
Northwest Univ Med School 17:267–279, 1943.
19. Ritter WA, Inglis AE. The extensor indicis proprius syndrome. J
Bone Joint Surg Am 51:1645–1648, 1969.
20. Spinner M, Olshansky K. The extensor indicis proprius syn-
drome: a clinical test. Plast Reconstr Surg 51:134–138, 1973.
21. Wolfe SW. Tenosynovitis. In: Green DP ed. Operative hand
surgery, 4th ed. New York: Churchill Livingstone, 1999.
22. Wood J. Variations in human myology. Proc R Soc Lond
15:229–244, 1866.
23. Wood VE. The extensor carpi radialis intermedius tendon. J
Hand Surg [Am] 13:242–245, 1988.
24. Albright JA, Linburg RM. Common variations of the radial wrist
extensors. J Hand Surg[Am] 3:134–138, 1978.
25. von Schroeder HP, Botte MJ. The extensor medii proprius and
anomalous extensor tendons to the long finger. J Hand Surg
[Am] 16:1141–1145, 1991.
 9

WRIST
RICHARD A. BERGER
JAMES R. DOYLE
MICHAEL J. BOTTE

The wrist is a unique joint interposed between the distal
aspect of the forearm and the proximal aspect of the hand.
There are common or shared elements to all three regions,
which integrate form and function to maximize the
mechanical effectiveness of the upper extremity. The wrist
enables the hand to be placed in an infinite number of
positions relative to the forearm, and yet also enables the
hand to be essentially locked to the forearm in those posi-
tions to transfer the forces generated by the powerful fore-
arm muscles.
Although the wrist truly is a mechanical marvel when it
is intact and functioning, loss of mechanical integrity of the
wrist inevitably causes substantial dysfunction of the hand
and thus the entire upper extremity. It is vital that a thor-
ough understanding of the wrist be acquired by all who
treat the wrist, including efforts in diagnosis, treatment,
and rehabilitation. This chapter provides such a foundation
by exploring the general architecture of the wrist, the bones
and joints that compose the wrist, and the soft tissues that
stabilize, innervate, and perfuse the wrist. As with all
anatomic descriptions, a common nomenclature is desir-
able. Although the terms medial and lateral are the gold
standard from an anatomic point of view, to use them
requires the application of the “anatomic position,” in
which the dependent arm is held in neutral rotation, with
the elbow extended, the forearm supinated, the wrist in
neutral extension, and the digits extended. Because of the
mental gymnastics required to position the extremity in vir-
tual space in this manner to determine whether the term
medial or lateral is appropriate, it is often easier simply to
refer to structures distal to the elbow in reference to a more
local coordinate system based on the position of the radius
and ulna. Therefore, the authors may often preferentially
use the term radial when referring to the lateral direction
and ulnar when referring to the medial direction. The term
dorsal is used preferentially to describe the posterior direc-
tion. Finally, because the glabrous skin of the palm indeed
covers the entire region of the wrist, the term palmar is used
to describe the anterior direction.
DESCRIPTIVE ANATOMY
Contents
Bone: Distal radius, ulna, and eight carpal bones.
Ligaments: Palmar and dorsal extraosseous carpal liga-
ments, intraosseous carpal ligaments, flexor retinaculum
(FR), extensor retinaculum (ER), and triangular fibrocarti-
lage complex (TFCC).
Blood Vessels: Extraosseous and intraosseous carpal
blood supply from radial, ulnar, and interosseous arteries;
vascular supply of distal radius and ulna.
Nerves: Articular branches from radial, median, ulnar,
and interosseous nerves.
Tendons: Wrist and finger flexors and extensors.
Landmarks
Dorsal
Important landmarks on the dorsal aspect of the wrist
include Lister’s tubercle, the anatomic snuff-box, the lunate
fossa, the styloid process at the base of the middle finger
metacarpal, the radial styloid process, and the distal head of
the ulna (Fig. 9.1).
Lister’s Tubercle
This bony prominence on the dorsal aspect of the distal
radius is situated approximately 0.5 cm proximal to the dor-
sal margin of the articular surface of the radius. It is in line
with the cleft between the index and middle finger
metacarpals. The extensor pollicis longus (EPL), located in a
groove just ulnar to Lister’s tubercle, turns radialward around
Lister’s tubercle on its way to the dorsal aspect of the thumb.
The extensor carpi radialis brevis (ECRB) is just radial to Lis-
ter’s tubercle in a similar groove on the dorsum of the radius.
Anatomic Snuff-Box
The anatomic snuff-box, a narrow triangle with its apex
located distally, is bordered dorsoulnarly by the EPL, radi-
 9 Wrist 487

A B
FIGURE 9.1. A, B: Dorsal landmarks of the wrist.

ally by the abductor pollicis longus (APL) and extensor pol-
licis brevis (EPB) tendons, and proximally by the distal
margin of the ER. In its depths, it contains the dorsal
branch of the radial artery, and in the dorsoulnar corner, the
tendon of the extensor carpi radialis longus (ECRL); super-
ficially, it contains one or more branches of the superficial
branch of the radial nerve (1,2).
Lunate Fossa
The lunate fossa is a palpable central depression located on
the dorsum of the wrist in line with the longitudinal axis of
the third metacarpal, just ulnar and distal to Lister’s tuber-
cle, and begins immediately distal to the dorsal margin of
the radius. It is, on average, approximately the size of the
pulp of an examiner’s thumb and marks the location of the
carpal lunate. This palpable lunate fossa should not be con-
fused with the “lunate fossa” of the distal radius, which is a
depression of the articular surface of the radius that accom-
modates the lunate (1).
Styloid Process of the Middle Finger Metacarpal
The styloid process of the middle finger metacarpal, located
on the dorsal and radial base of this metacarpal, points to
the articular interface between the capitate and the trape-
zoid and is just proximal to the point of insertion of the
ECRB tendon.
Radial Styloid
The distal projection of the radial side of the radius forms a
visible and easily examined landmark that is palpable both
 488 Regional Anatomy
palmar and dorsal to the APL and EPB tendons, which
course across its apex.
Distal Head of Ulna
The slightly expanded distal end of the ulna has a head and
styloid process. The head is most visible and palpable when
the forearm is in pronation; the posteroulnar styloid is most
readily palpable in supination and is approximately 1 cm
proximal to the plane of the radial styloid (1).
Palmar
Important landmarks on the palmar surface of the wrist
include the pisiform, hook process of the hamate, scaphoid
tubercle, the thenar and hypothenar eminences, and the
thenar and wrist flexion creases (Fig. 9.2).
Hook Process of the Hamate
The hook of the hamate, located on the ulnar and palmar
aspect of the distal carpus, can be palpated approximately 1
cm radial and distal to the pisiform. Because of its deep
location, it may be difficult to palpate in some individuals.
The hook of the hamate lies between the ulnar tunnel
(Guyon’s canal) and the carpal tunnel. It thus provides a
landmark for the ulnar nerve and artery (located just ulnar
A B
FIGURE 9.2. A, B: Palmar landmarks of the wrist.
to the hook), and the ulnar boundary of the carpal tunnel.
Point tenderness in this area may indicate a fracture of the
hook process, a common injury in sports that use racquets,
clubs, or bats, such as tennis, golf, or baseball.
Scaphoid Tubercle
The scaphoid tubercle is in the distal palmar aspect of the
scaphoid. It projects into the palm and the tubercle is pal-
pable on the radial aspect of the base of the hand, usually
just distal to the distal palmar wrist crease. It becomes more
prominent with the wrist positioned in radial deviation,
since the scaphoid assumes a position of more palmar flex-
ion in this position. Conversely, the scaphoid tubercle is less
prominent and possibly not palpable when the wrist is in
ulnar deviation, since the scaphoid assumes a position of
decreased palmar flexion and lies more in the plane of the
radius and ulna.
Pisiform Bone
The pisiform bone, located on the ulnar and palmar
aspect of the base of the hand provides a visible and pal-
pable landmark that aids in the identification and location
of the flexor carpi ulnaris (FCU) tendon, the underlying
ulnar neurovascular bundle, and the hook process of the
hamate.

Thenar and Hypothenar Eminences
The thenar eminence is formed by the abductor and the flexor
pollicis brevis, which overlie the opponens pollicis. The less
prominent hypothenar eminence on the ulnar side of the hand
is formed by the corresponding muscles of the little finger.
Flexion Creases
The wrist and palmar flexion creases are skin flexion lines
seen in the vicinity of synovial joints, where the skin is
attached to the underlying fascia (1). McGrouther has
shown that the fascial attachments in the palmar creases are
greatest adjacent to the creases rather than directly under
them (3). These creases have been recognized as useful
anatomic landmarks because of their relationship to under-
lying structures (4).
Thenar Crease. The thenar crease usually intersects the
lateral side of the proximal palmar crease and curves
obliquely across the palm to intersect the distal wrist crease
near the wrist center. In the mid-portion of the palm, the
thenar crease is located directly over the long finger
metacarpal over half the time. In the proximal palm, the
thenar crease crosses the capitate nearly half the time and
FIGURE 9.3. Flexion crease landmarks of the wrist.
9 Wrist 489
the trapezoid approximately one-third of the time. Mean
distance from the thenar crease to the center of the
trapeziometacarpal joint is 22.6 mm. The thenar crease
passes 18.7 mm from the hamate hook on the medial side
of the carpus (5).
Distal Wrist Crease. Although there usually are three wrist
flexion creases, only the distal crease is of sufficient consis-
tency to be used as a reliable landmark. The distal wrist
crease is located over the proximal carpal row and passes over
the scaphoid waist in almost all instances and over the pisi-
form 80% of the time. The lunate is consistently proximal
to the distal wrist crease, with its center an average of 9.2
mm from the crease. The radiocarpal joint is 13.5 mm prox-
imal to the distal wrist crease and the center point of the dis-
tal radioulnar joint (DRUJ) is 21.1 mm proximal to the
wrist crease. On the lateral side of the wrist, the distal wrist
crease is within 1 mm of the center of the scaphoid waist.
The mid-portion of the trapeziometacarpal joint averages
19.4 mm distal to the wrist crease. On the ulnar side of the
wrist, the pisiform is directly under or slightly distal to the
crease. The base of the ulnar styloid is on average 11.7 mm
proximal to the distal wrist crease (5) (Fig. 9.3).
490 Regional Anatomy
SKELETAL ANATOMY
Distal Radius and Ulna
The distal surface of the radius articulates with the proxi-
mal carpal row through two articular fossae separated by a
fibrocartilaginous prominence oriented in the sagittal
plane, called the interfossal ridge. The scaphoid fossa is
roughly triangular and extends from the interfossal ridge
to the tip of the radial styloid process. The lunate fossa is
roughly quadrangular and extends from the interfossal
ridge to the sigmoid notch. On the dorsal cortex of the
distal radius, immediately dorsal and proximal to the
interfossal ridge, is a bony prominence called the dorsal
tubercle of the radius, or Lister’s tubercle. It serves as a
divider between the second and third extensor compart-
ments, and functionally behaves as a trochlea for the ten-
don of the EPL. The sigmoid notch forms an articular
concavity on the ulnar, or medial, aspect of the distal
radial epiphysis. It has considerable variation in terms of
depth, anteroposterior dimension, and dorsopalmar orien-
tation; however, it consistently exhibits an arc of curvature
greater than that of the corresponding ulnar head, with
which it articulates (Fig. 9.4). Under normal circum-
stances, the ulna does not articulate directly with the car-
pus. Rather, a fibrocartilaginous wafer called the triangu-
lar fibrocartilage (TFC) is interposed between the ulnar
head and the proximal carpal row. Even the ulnar styloid
process is hidden from contact with the carpus by the
ulnotriquetral ligament. The ulnar head is roughly cylin-
drical, with a distal projection on its posterior border
called the ulnar styloid process. Approximately three-
fourths of the ulnar head is covered by articular cartilage,
with the ulnar styloid process and the posterior one-fourth
exposed bone or periosteum. A depression at the base of
the ulnar styloid process is called the fovea and typically is
not covered in articular cartilage. A more comprehensive
description of the distal ulna is given later in the section
on the DRUJ.
Carpal Bones
There are eight carpal bones (Fig. 9.5), although many con-
sider the pisiform to be a sesamoid bone in the tendon of
the FCU, and thus not behaving as a true carpal bone. The
bones are arranged in two rows (proximal and distal carpal
rows), each containing four bones. All eight carpal bones
are interposed between the forearm bones and the
metacarpals to form the complex called the wrist joint. The
wrist joint is subdivided into the mid-carpal joint, which
comprises the articulation between the proximal and distal
carpal row, and the radiocarpal joint, which comprises the
articulation between the distal radius and the scaphoid and
lunate. The ulnocarpal joint comprises the theoretical artic-
ulation between the distal ulna and the lunate and tri-
quetrum and the interposed TFC.
Proximal Carpal Row
The proximal row is composed of, from radial to ulnar, the
scaphoid (navicular), lunate, triquetrum, and pisiform.
Scaphoid
Bony Architecture. The scaphoid is shaped somewhat like
a kidney bean. It is divided into regions called the proximal
pole, waist, and distal pole. The proximal pole has a convex
articular surface that faces the scaphoid fossa and a flat
FIGURE 9.4. Articular surfaces of the distal radius.
 9 Wrist 491

FIGURE 9.5. A, B: Osseous anatomy of the radiocarpal joint

B and the carpus.
492 Regional Anatomy
articular surface that faces the lunate. The dorsal surface of
the waist is marked by an oblique ridge that serves as an
attachment plane for the dorsal joint capsule. This ridge
passes from proximal-ulnar to distal-radial. The medial sur-
face of the waist and distal surface of the proximal pole is
concave and articulates with the capitate. The distal pole
also articulates with the capitate medially, but distally it
articulates with the trapezium and trapezoid. Often, there is
a change in the curved geometry of the distal pole articular
surface, reflecting its dual articulation with the trapezium
and trapezoid.
Ligament Attachments. The radial aspect of the scaphoid
has nonarticular surfaces to which the radioscaphocapi-
tate, dorsal intercarpal, and scaphotrapezium-trapezoid
(STT) ligaments attach. The palmar surface of the distal
pole serves as an attachment for the scaphocapitate liga-
ment, whereas the palmar surface of the proximal pole
serves as an attachment for the palmar region of the
scapholunate interosseous ligament. The scapholunate lig-
ament has a crescentic attachment zone along the palmar,
proximal, and dorsal edges of the ulnar surface of the
proximal pole of the scaphoid. Dorsally, the ridge serves as
an attachment for the dorsal joint capsule and the dorsal
intercarpal ligament.
Vascular Foramina. Most of the vascular foramina are
found along the radial aspect of the scaphoid at the ter-
mination of the dorsal ridge. There also may be foramina
on the palmar surface of the distal pole, and rarely along
the attachment zone of the scapholunate interosseous
ligament.
Lunate
Bony Architecture. The lunate is crescent-shaped in the
sagittal plane, such that the proximal surface is convex and
the distal surface concave, and somewhat wedge-shaped in
the transverse plane. With the exception of ligament attach-
ment planes on its dorsal and palmar surfaces, the lunate is
covered with articular cartilage. It articulates with the
scaphoid laterally, the radius and TFC proximally, the tri-
quetrum medially, and the capitate distally. In some indi-
viduals, the lunate has a separate fossa for articulation with
the hamate, separated from the fossa for capitate articula-
tion by a prominent ridge.
Ligament Attachments. The palmar and dorsal surfaces
are the principal zones of ligament attachment. The palmar
surface serves as the attachment region for the long and
short radiolunate ligaments, the ulnolunate ligament, as
well as the palmar regions of the scapholunate and lunotri-
quetral interosseous ligaments. Dorsally, the lunate attaches
to the dorsal regions of the scapholunate and lunotriquetral
interosseous ligaments, as well as the deep fibers of the dor-
sal radiocarpal ligament.
Vascular Foramina. The dorsal and palmar (nonarticular)
surfaces have numerous vascular foramina. Otherwise, the
lunate is devoid of perforating vessels.
Triquetrum
Bony Architecture. The triquetrum has a complex shape,
with a flat articular surface on the palmar surface for artic-
ulation with the pisiform, a concave distal articular surface
for the hamate, a flat lateral surface for articulation with the
lunate, and three tubercles on the proximal, ulnar, and dor-
sal surfaces. The proximal tubercle is covered in hyaline car-
tilage for contact with the triangular disc, whereas the
medial and dorsal tubercles serve as ligament attachment
surfaces.
Ligament Attachments. The dorsal tubercle serves as a
common attachment for the dorsal radiocarpal and inter-
carpal ligaments. The ulnar tubercle serves as an attachment
for the ulnotriquetral ligament. From the most palmar and
distal edge of the triquetrum emerge the triquetrohamate
and triquetrocapitate ligaments. The palmar region of the
lunotriquetral ligament and fibers from the ulnocapitate
ligament attach along the palmar and radial edge of the tri-
quetrum, whereas the dorsal and radial edge of the tri-
quetrum serves as an attachment zone for the dorsal region
of the lunotriquetral interosseous ligament. The palmar
region of the triquetrum has a horseshoe-shaped region of
attaching fibers from the pisotriquetral ligament along the
radial, distal, and palmar margins.
Vascular Foramina. Blood vessels enter the triquetrum
through the dorsal and ulnar tubercles.
Pisiform
Bony Architecture. The pisiform, which means “pea-
shaped,” is oval in profile with a flat articular facet covering
the distal half of the dorsal surface for articulation with the
triquetrum. The general orientation of the oval is such that
the major (long) axis is in the proximodistal direction.
Ligament Attachments. The pisotriquetral ligament has a
horseshoe-shaped attachment on the dorsal surface of the
pisiform, surrounding the radial, distal, and ulnar margins
of the articular facet. Otherwise, it is entirely enveloped in
the tendon of the FCU and serves as a proximal origin of
the flexor digiti minimi muscle.
Vascular Foramina. The pisiform is encircled by a vascu-
lar ring from the ulnar artery, and thus has a variable num-
ber of foramina located circumferentially on the nonarticu-
lar surfaces.

Distal Carpal Row
The distal carpal row is composed of, from radial to ulnar,
the trapezium, trapezoid, capitate, and hamate. Each bone
articulates with a metacarpal distally and a proximal row
bone proximally.
Trapezium
Bony Architecture. The trapezium has three articular sur-
faces. The proximal surface is slightly concave and articu-
lates with the distal pole of the scaphoid. The dorsoulnar
articular surface is flat and articulates with the trapezoid.
The distal surface is saddle-shaped and articulates with the
base of the first metacarpal. The remaining surfaces are
nonarticular and serve as attachment areas for ligaments, as
described later. The anterolateral edge of the trapezium
forms an overhang, referred to as the beak or trapezial ridge,
that is part of the fibroosseous tunnel for the tendon of the
flexor carpi radialis (FCR). The trapezial ridge that forms a
longitudinal projection on the palmar surface of the trapez-
ium serves as an attachment for a portion of the transverse
carpal ligament (TCL). The trapezial ridge is susceptible to
fracture and is best seen radiographically on carpal tunnel
views (6–8).
Ligament Attachments. Beginning on the radial surface,
the STT ligament partially attaches. There is essentially no
ligament on this surface that crosses the carpometacarpal
joint, immediately deep to the tendon of the APL. The dor-
sal surface has no prominent ligament attachment proxi-
mally, but distally the dorsoradial and posterior oblique lig-
aments of the carpometacarpal joint attach. In addition, the
dorsal trapeziotrapezoid ligament attaches. The palmar sur-
face serves as an attachment for the deep and superficial
anterior oblique ligaments of the first carpometacarpal
joint, as well as the palmar trapeziotrapezoid ligament. It
also has been reported that discrete ligaments can be traced
out connecting the palmar surface of the trapezium to the
second and third metacarpals. Only the ulnar collateral lig-
ament of the first carpometacarpal joint covers the distal
surface of the ulnar border of the trapezium.
Vascular Foramina. The dorsal, palmar, and radial sur-
faces have variable vascular foramina for transmission of
nutrient vessels originating from the radial artery and the
palmar and dorsal carpal arches.
Trapezoid
Bony Architecture. The trapezoid is a small bone with
articular surfaces on the proximal, lateral, medial, and dis-
tal surfaces for articulation with the scaphoid, trapezium,
capitate, and base of the second metacarpal, respectively.
There is an offset geometry on its ulnar articular surface,
which articulates with a similarly shaped radial articular
9 Wrist 493
surface of the capitate. In the “notch” of the offset, the deep
trapeziocapitate ligament attaches.
Ligament Attachments. The palmar and dorsal surfaces
serve as ligament insertion areas. Dorsally, the dorsal
trapeziocapitate and trapeziotrapezoid ligaments, as well as
the distally oriented dorsal carpometacarpal ligaments
attach. The dorsal intercarpal ligament also attaches on the
dorsal surface of the trapezoid. Palmarly, a similar set of lig-
ament attachments is found. Ulnarly, the deep trapeziocap-
itate ligament attaches to the trapezoid in the middle of the
articular surface of the trapezoid.
Vascular Foramina. Numerous foramina are found on the
dorsal and palmar nonarticular surfaces of the trapezoid.
Capitate
Bony Architecture. The capitate is the largest carpal bone
and is divided into head, neck, and body regions. The head
is almost entirely covered in articular cartilage and forms a
proximally convex surface for articulation with the scaphoid
and lunate. There often is a faint change in curvature on the
radial aspect of the head corresponding to the ridge on the
ulnar surface of the waist of the scaphoid. The neck is a nar-
rowed region between the body and the head, and is
exposed to the mid-carpal joint without ligament attach-
ment. The body is nearly cuboid, with articular surfaces on
its medial, lateral, and distal aspects for articulation with
the trapezoid, hamate, and base of the third metacarpal,
respectively. The radial surface, articulating with the ulnar
surface of the trapezoid, is “offset” with a ridge in the mid-
dle, which serves as an attachment of the deep trapeziocap-
itate ligament. Ulnarly, the articular surface of the capitate
for the hamate is shaped like a skillet, with the handle
extending distally along the dorsal third of the ulnar sur-
face. This leaves a relatively large square area on the palmar
and distal aspect of the ulnar surface, which serves as an
attachment for the deep capitohamate and carpometacarpal
ligaments.
Ligament Attachments. The large, flat palmar and dorsal
surfaces serve as ligament attachment areas. There are no
ligament attachments on the head or neck. Dorsally, the
dorsal trapeziocapitate and capitohamate ligaments attach,
as well as the distally oriented carpometacarpal ligaments.
Palmarly, the body of the capitate can be divided into prox-
imal and distal halves for the purposes of discussing liga-
ment attachments. Beginning radially and progressing
ulnarly on the proximal half of the palmar surface, the
scaphocapitate, radioscaphocapitate, ulnocapitate, and tri-
quetrocapitate ligaments attach. The distal half serves as an
attachment surface for the palmar trapeziocapitate, car-
pometacarpal, and capitohamate ligaments, respectively
progressing from radial to ulnar. The middle of the radial
494 Regional Anatomy
articular surface serves as the attachment for the deep
trapeziocapitate ligament, whereas the large square recess on
the ulnar articular surface serves a similar role for the deep
capitohamate and carpometacarpal ligaments.
Vascular Foramina. As with the other carpal bones, all
surfaces with ligament attachments also have numerous vas-
cular perforations. The nonarticular neck of the capitate has
a variable number of small vascular foramina on the dorsal,
radial, and palmar surfaces. There are no foramina on the
head of the capitate.
Hamate
Bony Architecture. The hamate has a complex geometry,
with a pole, body and hamulus (hook). The pole is a coni-
cal, proximally tapering projection that is nearly entirely
covered in articular cartilage for articulation with the tri-
quetrum, capitate, and variably with the lunate. The body
is relatively cuboid, with medial and distal articulations for
the capitate and fourth and fifth metacarpal bases, respec-
tively. The dorsal and palmar surfaces serve as ligament
attachment areas, except the most medial aspect of the
body, where the hamulus arises. The hamulus forms a pal-
marly directed projection that curves slightly lateral at the
palmar margin. The radial articular surface is matched to
the corresponding ulnar surface of the capitate, with a
square recess, which is nonarticular, on the palmar and dis-
tal aspect of the hamate.
Ligament Attachments. The palmar surface of the hamate
serves as an attachment for the palmar capitohamate and
carpometacarpal ligaments. The proximal aspect of the pal-
mar nonarticular surface of the hamate allows attachment
of the triquetrohamate ligament. The dorsal surface serves a
similar purpose for the dorsal counterparts of the capitoha-
mate and carpometacarpal ligament systems. There is no
dorsal counterpart to the triquetrohamate ligament. As
noted previously, the deep capitohamate ligament attaches
to the hamate in the recess on the radial surface. The hamu-
lus serves as an attachment for the pisohamate ligament (an
extension of the tendon of the FCU) and the FR.
Vascular Foramina. A large number of vascular foramina
are found on the body, as well as circumferentially about the
hamulus of the hamate. There are no foramina on the pole
of the hamate.
JOINT ANATOMY
Although 8 carpal bones comprise the wrist proper, the
wrist functionally should be considered as having a total of
15 bones. This is because of the proximal articulations with
the radius and ulna and the distal articulations with the
bases of the first through fifth metacarpals. The geometry of
the wrist is complex, demonstrating a transverse arch cre-
ated by the scaphoid and triquetrum/pisiform column
proximally and the trapezium and hamate distally. In addi-
tion, the proximal carpal row demonstrates a substantial
arch in the frontal plane.
From an anatomic standpoint, the carpal bones are
divided into proximal and distal carpal rows, each com-
posed of four bones. This effectively divides the wrist into
radiocarpal and mid-carpal joints. Although mechanically
linked to the DRUJ, the wrist normally is biologically sep-
arated from the DRUJ joint space by the TFC.
Radiocarpal Joint
The radiocarpal joint is formed by the articulation of conflu-
ent surfaces of the concave distal articular surface of the
radius and the TFC, with the convex proximal articular sur-
faces of the proximal carpal row bones. The radiocarpal joint
communicates with the pisotriquetral joint in approximately
80% of normal individuals. In addition to this orifice, there
is a consistent defect in the TFCC called the prestyloid recess.
It is filled with vascular villi and variably communicates with
the distal tip of the ulnar styloid process.
Mid-Carpal Joint
The mid-carpal joint is formed by the mutually articulating
surfaces of the proximal and distal carpal rows. Communi-
cations are found between the mid-carpal joint and the
interosseous joint clefts of the proximal and distal row
bones, as well as with the second through fifth car-
pometacarpal joints. Under normal circumstances, the mid-
carpal joint is isolated from the pisotriquetral, radiocarpal,
and first carpometacarpal joints by intervening membranes
and ligaments. The geometry of the mid-carpal joint is
complex. Radially, the STT joint is composed of the slightly
convex distal pole of the scaphoid articulating with the rec-
iprocally concave proximal surfaces of the trapezium and
trapezoid. Forming an analog to a ball-and-socket joint are
the convex head of the capitate and the combined concave
contiguous distal articulating surfaces of the scaphoid and
the lunate. In 65% of normal adults, it has been found that
the hamate articulates with a medial articular facet at the
distal-ulnar margin of the lunate, which is associated with a
higher rate of cartilage eburnation of the proximal surface
of the hamate. The triquetrohamate region of the mid-
carpal joint is particularly complex, with the mutual articu-
lar surfaces having both concave and convex regions form-
ing a helicoid-shaped articulation.
Interosseous Joints
Proximal Row
The interosseous joints of the proximal row are relatively
small and planar, allowing motion primarily in the flex-

ion–extension plane between mutually articulating bones.
The scapholunate joint has a smaller surface area than the
lunotriquetral joint. Often, a fibrocartilaginous meniscus
extending from the membranous region of the scapholu-
nate or lunotriquetral interosseous ligaments is interposed
into the respective joint clefts.
Distal Row
The interosseous joints of the distal row are more complex
geometrically and allow substantially less interosseous
motion than those of the proximal row. The capitohamate
joint is relatively planar, but the mutually articulating sur-
faces are only partially covered by articular cartilage. The
distal and palmar region of the joint space is devoid of artic-
ular cartilage, being occupied by the deep capitohamate
interosseous ligament. Similarly, the central region of the
trapeziocapitate joint surface is interrupted by the deep
trapeziocapitate interosseous ligament. The trapeziotrape-
zoid joint presents a small planar surface area with continu-
ous articular surfaces.
Distal Radioulnar Joint
Osseous Anatomy
The DRUJ is a uniaxial pivot joint between the convex dis-
tal head of the ulna and the concave ulnar notch of the
radius (1) (Fig. 9.6A). It has been described as a trochoid
FIGURE 9.6. A–C: Osseous anatomy of the distal radioulnar joint.
9 Wrist 495
(wheel-like) joint (9). The convex distal ulna is covered by
hyaline cartilage for 270 degrees of its total circumference.
It varies in proximal to distal height from 5 to 8 mm. It
articulates with the adjacent radius in the sigmoid notch.
Distally, the dorsopalmar height of the sigmoid notch is 1.5
cm, and proximally it is 1 cm (10). In the dorsopalmar
plane, the semicylindrical sigmoid notch has an angular
inclination distally and ulnarly of 7.7 degrees (average) (11)
(see Fig. 9.6B). This concave sigmoid notch has three dis-
tinct margins: dorsal, palmar, and distal. The dorsal margin
is acutely angular in cross-section, and the palmar less so.
The palmar margin may have an osteocartilaginous lip in
some instances (12). The prominent palmar beak of the
radius seen on a lateral radiograph represents the sigmoid
notch as well as the lunate facet of the radius. Thus, frac-
tures of the lunate facet are fractures of the DRUJ, and vice-
versa (9). The sigmoid notch and the lunate fossa of the
radius are separated by the attachment of the TFC to the
radius (6). The articular surface of the radius is inclined a
variable amount (15 to 21 degrees toward the ulna) (11).
The articulation of the ulnar head to the radius is not con-
gruent in that the radius of the shallow arc of the sigmoid
notch is greater than that of the ulnar convexity (13,14).
Because of this, pronation and supination of the forearm
include both a sliding and a rolling (rotational) component
(9). In addition, because of the differences in radii of the
ulna and the sigmoid notch, there is significant translation
of this joint. The maximum limits of translation have been
measured at 2.8 mm dorsal and 5.4 mm palmar in the zero-
496 Regional Anatomy
degree position of rotation (15) (see Fig. 9.6C). In this posi-
tion, 60 to 80 degrees of the articular surface of the ulna is
in contact with the sigmoid notch. However, in the
extremes of rotation, less than 10% of the ulna may be in
contact with the dorsal (in pronation) or palmar (in supina-
tion) margins of the sigmoid notch. In addition, the radii of
the articular head of the ulna may vary and add a camlike
effect to the rotation (15). Also, the articular inclination of
the sigmoid notch and the ulnar seat may not match (11).
The semicylindrical head of the ulna that faces the TFC is
flattened. The periphery of this flattened dome is covered
with articular cartilage. An eccentric concavity of the dome
lies at the base of the styloid and is the area of attachment
for the apex of the TFC and ulnocarpal ligaments. This
concavity is confluent dorsally onto the shaft–head junction
with the sulcus for the extensor carpi ulnaris (ECU) tendon
(9) (see Fig. 9.6A). The ulnar styloid is a continuation of
the prominent subcutaneous ridge of the dorsal shaft of the
ulna that projects distally for a variable distance of 2 to 6
mm (16).
Ligamentous Anatomy
Radioulnar Joint Ligaments
The reader also is directed to the section on Clinical Signif-
icance: Stabilizing Factors of the DRUJ, later.
A description of the anatomy of the palmar and dorsal
radioulnar ligaments is required to understand the origin of
the ulnocarpal ligaments. The dorsal and palmar DRUJ lig-
aments are believed to be the major stabilizers of the DRUJ.
These ligaments form the dorsal and palmar margins of the
TFCC in the region between the sigmoid notch of the
radius and the styloid process of the ulna. They attach radi-
ally at the dorsal and palmar corners of the sigmoid notch,
and converge ulnarly to pass in a cruciate manner such that
the dorsal ligament attaches near the tip of the styloid
process and the palmar ligament attaches near the base of
the styloid process in the region called the fovea. The pal-
mar ligament has substantial connections to the carpus
through the ulnolunate, ulnotriquetral, and ulnocapitate
ligaments. The dorsal ligament integrates with the sheath of
the ECU (Fig. 9.7).
The Triangular Fibrocartilage Complex
The center of this complex (TFC and ulnocarpal ligaments)
has been called the ulnocarpal complex by Taleisnik (17), the
TFCC by Palmer and Werner (18), and the ulnocarpal liga-
ment complex by Bowers (19). Based on historical and com-
mon usage, the TFC and ulnocarpal ligaments, taken
together, have been called the TFCC in this chapter.
Triangular Fibrocartilage. The anatomic structure that
spans the distal (carpal-facing) aspect of the DRUJ is called
the TFC. It should not be confused with the DRUJ menis-
cus (see section on Meniscus, later). The TFC is part of an
extensive fibrous system that arises from the carpal margin
of the sigmoid notch of the radius, cups the lunate and tri-
quetral bones, and extends to the palmar base of the small
finger metacarpal (9). The TFC is, as its name implies, tri-
angular and 1 to 2 mm thick at its base, which is attached
to the distal margin of the sigmoid notch. The biconcave
body of the TFC crosses the articular dome of the distal
ulna and its apex attaches to the eccentric concavity of the
head and projecting concavity, where it may be as thick as
5 mm (9) (see Fig. 9.7).
Microstructure of the Triangular Fibrocartilage. The
peripheral margins of the TFC are thick lamellar collagen
that is structurally adapted to bear tensile loading (20).
These often are referred to as the dorsal and palmar radioul-
FIGURE 9.7. Dorsal and palmar distal radioulnar
ligaments and the triangular fibrocartilage.

nar ligamentous margins, and the thin central portion as the
articular disc. The articular disc is chondroid fibrocartilage,
a type of tissue seen in structures that bear compression
loads (9,21). This central area occasionally is absent and
often so thin as to be translucent (22).
There is avascular, random criss-crossing of collagen
fibers in the central aspect of the TFC consistent with com-
pression load bearing, in contrast to a highly organized and
well vascularized collagen arrangement in the peripheral
marginal ligaments of the TFC (21).
Ulnocarpal Ligaments
The ulnocarpal ligament is discussed here because of its
close anatomic proximity to the TFC (Fig. 9.8). The ulno-
carpal ligament arises largely from the palmar margin of the
TFC, the palmar radioulnar ligament, and, in a limited
fashion, from the head of the ulna. It courses obliquely and
distally toward the lunate, triquetrum, and capitate. There
are three divisions of the ulnocarpal ligament, designated by
their distal bony insertions.
Ulnolunate Division. The ulnolunate ligament is essen-
tially continuous with the short radiolunate ligament, form-
ing a continuous palmar capsule between the TFCC and
the lunate.
Ulnotriquetral Division. Confluent with these fibers is
the ulnotriquetral ligament, connecting the TFC and the
palmar rim of the triquetrum. In 60% to 70% of normal
adults, a small orifice is found in the distal substance of the
ulnotriquetral ligament, which leads to a communication
9 Wrist 497
between the radiocarpal and pisotriquetral joints. Just prox-
imal and ulnar to the pisotriquetral orifice is the prestyloid
recess, which usually is lined by synovial villi and variably
communicates with the underlying ulnar styloid process.
Ulnocapitate Division. The ulnocapitate ligament arises
from the foveal and palmar region of the head of the ulna,
where it courses distally, palmar to the ulnolunate and
ulnotriquetral ligaments, and passes palmar to the head of
the capitate, where it interdigitates with fibers from the
radioscaphocapitate (RSC) ligament to form an arcuate lig-
ament to the head of the capitate. A few fibers from the
ulnocapitate ligament insert to the capitate.
Meniscus
This structure often may be confused with the TFC (9). It
is found in a minority of wrists and, when present, lies in
the ulnocarpal joint. The meniscus is concave and has a
free margin similar to the knee meniscus (9). When fully
developed, it overlies the TFC–ulnocarpal ligament–sty-
loid complex and extends from the dorsal aspect of the
TFC to the palmar and ulnar aspect of the triquetrum.
When the meniscus is more developed, it may contain an
ossicle (os lanula, 4%) that may be misdiagnosed as a sty-
loid fracture (9).
Arterial Anatomy
The vascular supply of the DRUJ/TFCC is from the ante-
rior interosseous and ulnar arteries (20) (Fig. 9.9). The
FIGURE 9.8. The three divisions of the ulnocarpal
ligament: ulnotriquetral, ulnocapitate, and ulnolu-
nate.
498 Regional Anatomy
FIGURE 9.9. The vascular supply of the triangular fibrocartilage.
AIA, anterior interosseous artery.
anterior interosseous divides into palmar and dorsal
branches proximal to the DRUJ. The dorsal branch supplies
most of the dorsal margin of the TFC and the palmar
branch the palmar margin near the radius. Dorsal and pal-
mar branches of the ulnar artery supply the styloid and the
ulnar half of the palmar margin of the TFC. Terminal
branches of these vessels penetrate only the outer 15% to
20% of the TFC, thus leaving its central portion avascular
(9,23).
Ulnar Variance
The relative lengths of the radius and ulna at the DRUJ
may vary, and this has been referred to as Hulten’s variance
(24). Ulna zero indicates equal length of the radius and
ulna in the anteroposterior plane; ulna minus indicates
the ulna is 1 to 6 mm shorter than the radius; ulna plus
indicates that the ulna is 1 to 5 mm longer than the
radius. The importance of ulnar variance is that positive
ulnar variance may be associated with Kienböck’s disease
(25) and degenerative changes in the ulnolunate joint
(18).
Clinical Significance: Stabilizing Factors
of the Distal Radioulnar Joint
William H. Bowers has best described the stabilizing factors
of the DRUJ, so we quote his work directly (9):
The TFC and the ulnocarpal ligaments provide the heart of
the TFCC. Stability of the radioulnar-carpal unit is addition-
ally influenced by the conformation of the sigmoid notch (12),
the interosseous membrane (9), the ER, the dynamic forces of
the ECU and the pronator quadratus (PQ), as well as the dor-
sal carpal ligament complex. The latter can be visualized as a
“star” centered over and blending with the dorsal peripheral
margin of the TFCC. The proximal and distal legs are the
ECU sheath extending from the ECU groove to the dorsal
base of the fifth metacarpal. The radial legs are the proximal
and distal radiotriquetral ligaments and the dorsal TCL. The
ulnar leg is a wide ligament band proceeding from the center
of the star around the ulnar aspect of the triquetrum distal to
the styloid and attaching to the pisotriquetral joint capsule.
I [Bowers] attach no functional or anatomical significance
to the oft-described “ulnar collateral ligaments” and “dorsal
and volar radioulnar ligaments,” except as terms used to
describe the dorsal and volar margins of the TFC. In my [Bow-
ers] opinion there are no structures that deserve this designa-
tion and they probably represent figments of the imagination.
The DRUJ capsule is uniformly thin and cannot be con-
strued to offer stability in the usual sense. Dorsally, the capsule
is minimally reinforced by the obliquely passing radiotrique-
tral capsular ligament. It offers no coverage to the ulnar head.
Spinner and Kaplan (26) have called attention to the impor-
tance of the ECU musculotendinous unit in stabilizing the
joint. The emphasis is warranted but should be shared by both
the rather strong sheath system through which it runs and the
strong volar ligament complex. Johnson and Shrewsbury (27)
have demonstrated that the dual structure of the PQ stabilizes
the radioulnar joint actively by maintaining coaptation of the
ulnar head in the notch in pronation and passively by vis-
coelastic forces in supination.
LIGAMENT ANATOMY
The ligaments of the wrist have been described in a number
of ways, leading to substantial confusion in the literature
regarding a variety of features of the carpal ligaments. Sev-
eral general principles have been identified to help simplify
the ligamentous architecture of the wrist. No ligaments of
the wrist are truly extracapsular. Most can be anatomically
classified as capsular ligaments with collagen fascicles clearly
within the lamina of the joint capsule. The ligaments that
are not entirely capsular, such as the interosseous ligaments
between the bones in the carpal row, are intraarticular. This
implies that they are not ensheathed in part by a fibrous
capsular lamina. The wrist ligaments show consistent histo-
logic features, which are to a degree ligament specific. Most
capsular ligaments are composed of longitudinally oriented
laminated collagen fascicles surrounded by loosely orga-

nized perifascicular tissue, which in turn is surrounded by
the epiligamentous sheath. This sheath usually is composed
of the fibrous and synovial capsular lamina. The perifascic-
ular tissue has numerous blood vessels and nerves aligned
longitudinally with the collagen fascicles. The function of
these nerves currently is not well understood. It has been
hypothesized that these nerves are an integral part of a pro-
prioceptive network, following the principles of Hilton’s
law of segmental innervation. The palmar capsular liga-
ments are more numerous than the dorsal, forming almost
the entire palmar joint capsules of the radiocarpal and mid-
carpal joints. The palmar ligaments tend to converge
toward the midline as they travel distally, and have been
described as forming an apex-distal “V.” The interosseous
ligaments between the individual bones in a carpal row usu-
ally are short and transversely oriented, and with specific
exceptions, cover the dorsal and palmar joint margins. Spe-
cific ligament groups are briefly described in the following
sections, and are divided into capsular and interosseous
groups.
Palmar Radiocarpal Ligaments
The palmar radiocarpal ligaments arise from the palmar
margin of the distal radius and course distally and ulnarly
toward the scaphoid, lunate, and capitate (Fig. 9.10).
Although the course of the fibers can be defined from an
9 Wrist 499
anterior view, the separate divisions of the palmar radio-
carpal ligament are best appreciated from a dorsal view
through the radiocarpal joint. The palmar radiocarpal liga-
ment can be divided into four distinct regions.
Radioscaphocapitate Ligament
Beginning radially, the RSC ligament originates from the
radial styloid process, forms the radial wall of the radio-
carpal joint, attaches to the scaphoid waist and distal pole,
and passes palmar to the head of the capitate to interdigi-
tate with fibers from the ulnocapitate ligament. Very few
fibers from the RSC ligament attach to the capitate.
Long Radiolunate Ligament
Just ulnar to the RSC ligament, the long radiolunate (LRL)
ligament arises to pass palmar to the proximal pole of the
scaphoid and the scapholunate interosseous ligament to
attach to the radial margin of the palmar horn of the lunate.
The interligamentous sulcus separates the RSC and LRL
ligaments throughout their courses. The LRL ligament has
been called the radiolunotriquetral ligament historically, but
the paucity of fibers continuing toward the triquetrum
across the palmar horn of the lunate renders this name mis-
leading.
FIGURE 9.10. Palmar radiocarpal ligaments: the
radioscaphocapitate, long and short radiolunate,
radioscapholunate, pisohamate, triquetrocapitate,
ulnocapitate, ulnotriquetral, and palmar radioulnar.
500 Regional Anatomy
Radioscapholunate Ligament
Ulnar to the origin of the LRL ligament, the radioscaphol-
unate “ligament” emerges into the radiocarpal joint space
through the palmar capsule and merges with the scapholu-
nate interosseous ligament and the interfossal ridge of the
distal radius. This structure resembles more a “mesocapsule”
than a true ligament because it is composed of small-caliber
blood vessels and nerves from the radial artery and anterior
interosseous neurovascular bundle. Very little organized col-
lagen is identified in this structure. The mechanical stabi-
lizing effects of this structure have been shown to be mini-
mal.
Short Radiolunate Ligament
The final palmar radiocarpal ligament, the short radiolu-
nate ligament, arises as a flat sheet of fibers from the palmar
rim of the lunate fossa, just ulnar to the radioscapholunate
ligament. It courses immediately distally to attach to the
proximal and palmar margin of the lunate.
Dorsal Capsular Ligaments
The dorsal wrist capsule is reinforced by two well defined
ligaments (Fig. 9.11). Otherwise, it is composed of a highly
pliable joint capsule, which no doubt contributes to the
range of motion allowed by the wrist during palmar flexion.
The two ligaments are referred to as the dorsal radiocarpal
(DRC) and dorsal intercarpal ligaments.
Dorsal Radiocarpal Ligament
The DRC ligament arises from the dorsal rim of the radius,
essentially equally distributed on either side of Lister’s
tubercle. It courses obliquely distally and ulnarly toward the
triquetrum, to which it attaches on the dorsal cortex. There
are some deep attachments of the DRC ligament to the dor-
sal horn of the lunate. Loose connective and synovial tissue
forms the capsular margins proximal and distal to the DRC
ligament. It is sometimes called the dorsal radiotriquetral lig-
ament.
Dorsal Intercarpal Ligament
The dorsal intercarpal ligament, originating from the dorsal
cortex of the triquetrum, crosses the mid-carpal joint
obliquely to attach to the scaphoid, trapezoid, and capitate.
The attachment of the dorsal intercarpal ligament to the tri-
quetrum is confluent with the triquetral attachment of the
DRC ligament. In addition, a proximal thickened region of
the joint capsule, roughly parallel to the DRC ligament,
extends from the waist of the scaphoid across the distal mar-
gin of the dorsal horn of the lunate to the triquetrum. This
band, called the dorsal scaphotriquetral ligament, forms a
“labrum” that encases the head of the capitate, analogous to
the RSC and ulnocapitate ligaments palmarly.
FIGURE 9.11. Dorsal radiocarpal ligaments: dorsal inter-
carpal, dorsal scaphotriquetral, and dorsoradiocarpal
(dorsoradiotriquetral).
 9 Wrist 501

Ulnocarpal Ligaments is found in the distal substance of the ulnotriquetral liga-

[Note: The ulnocarpal ligaments also are discussed earlier in
the section on the TFCC (under the main Distal Radioul-
nar Joint section; see Fig. 9.8)].
The ulnocarpal ligament arises largely from the palmar
margin of the TFCC, the palmar radioulnar ligament, and
in a limited fashion from the head of the ulna. It courses
obliquely distally toward the lunate, triquetrum, and capi-
tate. There are three divisions of the ulnocarpal ligament,
designated by their distal bony insertions.
Ulnolunate Ligament
The ulnolunate ligament is essentially continuous with the
short radiolunate ligament, forming a continuous palmar
capsule between the TFCC and the lunate.
Ulnotriquetral Ligament
Confluent with these fibers is the ulnotriquetral ligament,
connecting the TFCC and the palmar rim of the tri-
quetrum. In 60% to 70% of normal adults, a small orifice
ment that leads to a communication between the radio-
carpal and pisotriquetral joints. Just proximal and ulnar to
the pisotriquetral orifice is the prestyloid recess, which usu-
ally is lined by synovial villi and variably communicates
with the underlying ulnar styloid process.
Ulnocapitate Ligament
The ulnocapitate ligament arises from the foveal and pal-
mar region of the head of the ulna, where it courses distally,
palmar to the ulnolunate and ulnotriquetral ligaments, and
passes palmar to the head of the capitate, where it interdig-
itates with fibers from the RSC ligament to form an arcuate
ligament to the head of the capitate. A few fibers from the
ulnocapitate ligament insert to the capitate.
Mid-Carpal Ligaments
The mid-carpal ligaments on the palmar surface of the car-
pus are true capsular ligaments, and as a rule are short and
stout, connecting bones across a single joint space (Fig.
9.12).

FIGURE 9.12. Palmar mid-carpal and proximal and distal row interosseous ligaments. Mid-carpal
interosseous: STT, scaphotrapezium-trapezoid; SC, scaphocapitate; TC, triquetrocapitate; TH, tri-
quetrohamate. Proximal row interosseous: SL, scapholunate; LT, lunotriquetral. Distal row
interosseous: TT, trapeziotrapezoid; TC, trapeziocapitate; CH, capitohamate.
502 Regional Anatomy
Scaphotrapezium-Trapezoid Ligament
Beginning radially, the STT ligament forms the palmar cap-
sule of the STT joint, connecting the distal pole of the
scaphoid with the palmar surfaces of the trapezium and
trapezoid. Although no clear divisions are noted, it forms an
apex-proximal “V” shape.
Scaphocapitate Ligament
The scaphocapitate ligament is a thick ligament interposed
between the STT and RSC ligaments, coursing from the
palmar surface of the waist of the scaphoid to the palmar
surface of the body of the capitate. There are no formal con-
nections between the lunate and capitate, although the
arcuate ligament (formed by the RSC and ulnocapitate lig-
aments) has weak attachments to the palmar horn of the
lunate.
Triquetrocapitate Ligament
The triquetrocapitate ligament is analogous to the scapho-
capitate ligament. It is a thick ligament, passing from the
palmar and distal margin of the triquetrum to the palmar
surface of the body of the capitate.
Triquetrohamate Ligament
Immediately adjacent to the triquetrocapitate ligament, the
triquetrohamate ligament forms the ulnar wall of the mid-
carpal joint, and is augmented ulnarly by fibers from the
TFCC.
Proximal Row Interosseous Ligaments
The scapholunate and lunotriquetral interosseous ligaments
form the interconnections between the bones of the proxi-
mal carpal row and share several anatomic features (see Fig.
9.12). Each forms a barrier between the radiocarpal and
mid-carpal joints, connecting the dorsal, proximal, and pal-
mar edges of the respective joint surfaces. This leaves the
distal edges of the joints without ligamentous coverage.
Scapholunate Interosseous Ligament
The dorsal region of the scapholunate ligament is relatively
thick and composed of transversely oriented collagen fibers.
It merges distally with the scaphotriquetral band of the dor-
sal intercarpal ligament, and proximally with the fibrocarti-
laginous membrane of the scapholunate ligament. The
fibrocartilaginous membrane forms the proximal region of
the scapholunate ligament. It often is wedge shaped in
cross-section, extending into the scapholunate joint cleft
much as a meniscus. Palmarly, the radioscapholunate liga-
ment interrupts the continuity of the scapholunate liga-
ment, again with vascular villi extending into the palmar
aspect of the scapholunate joint cleft. The palmar region of
the scapholunate ligament is quite thin and obliquely ori-
ented in the transverse plane, from the relatively dorsal pal-
mar edge of the scaphoid to the more palmar anterior edge
of the lunate. It is completely separate from the dorsal sur-
face of the LRL ligament.
Lunotriquetral Interosseous Ligament
The dorsal region of the lunotriquetral interosseous liga-
ment is quite thin, transversely oriented, and superficially
integrated with the overlying dorsal radiocarpal ligament.
The proximal region is composed of fibrocartilage, similar
to the proximal region of the scapholunate interosseous lig-
ament. Palmarly, the lunotriquetral ligament is quite thick
and interdigitates with the longitudinally oriented fibers of
the ulnocapitate ligament.
Distal Row Interosseous Ligaments
The bones of the distal carpal row are rigidly connected by
a complex system of interosseous ligaments (see Fig. 9.12).
As is discussed in the following sections, these ligaments are
largely responsible for transforming the four distal row
bones into a single kinematic unit. The trapeziotrapezoid,
trapeziocapitate, and capitohamate joints each are bridged
by palmar and dorsal interosseous ligaments. These liga-
ments are composed of transversely oriented collagen fasci-
cles and are covered superficially by the fibrous capsular
lamina, also composed of transversely oriented fibers. This
lamina gives the appearance of a continuous sheet of fibers
spanning the entire palmar and dorsal surface of the distal
row.
Trapeziotrapezoid Interosseous Ligament
The trapeziotrapezoid ligament is composed of parallel dor-
sal and palmar sheets, spanning from the dorsal and palmar
cortices of each respective bone.
Trapeziocapitate Interosseous Ligament
The trapeziocapitate ligament is similar to the trapezio-
trapezoid ligament; however, the trapeziocapitate has an
additional component called the “deep” trapeziocapitate lig-
aments. This ligament is entirely intraarticular, spanning
the respective joint spaces between voids in the articular
surfaces. It is a true ligament, with dense, colinear collagen
fascicles, but also is heavily invested with nerve fibers. The
deep trapeziocapitate ligament is located midway between
the palmar and dorsal limits of the joint, obliquely oriented
from palmar-ulnar to dorsoradial, and measures approxi-
mately 3 mm in diameter. The respective attachment sites
of the trapezoid and capitate are angulated in the transverse

plane to accommodate the orthogonal insertion of the liga-
ment.
Capitohamate Interosseous Ligament
The dorsal and palmar bands of the capitohamate
interosseous ligament are similar to those of the other distal
row interosseous ligaments. As with the trapeziocapitate
interosseous ligament, there is a “deep” component to the
capitohamate interosseous ligament. The deep capitoha-
mate interosseous ligament is found transversely oriented at
the palmar and distal corner of the joint. It traverses the
joint from quadrangular voids in the articular surfaces and
measures approximately 5 × 5 mm in cross-sectional area.
RETINACULAR ANATOMY AND THE CARPAL
CANAL
Flexor Retinaculum
Nomenclature
Based on the observations of Cobb and associates, the
restraining or retinacular structure on the palmar aspect of
the wrist is most appropriately called the flexor retinaculum.
They noted, however, that others have considered the TCL
and FR to be synonymous (28). Cobb and associates iden-
tified three distinct and continuous segments that extended
from the distal part of the radius to the distal aspect of the
base of the long finger metacarpal. The proximal portion of
the FR is continuous with the deep investing forearm fascia
that lies deep to the antebrachial fascia. The TCL represents
9 Wrist 503
the central portion of the FR and is defined by its bony
attachments ulnarly to the pisiform and hook process of the
hamate, and radially to the tuberosity of the scaphoid and
ridge of the trapezium, and serves as the roof of the carpal
canal. The distal portion of the FR is composed of an
aponeurosis between the thenar and hypothenar muscles.
Anatomic Layers/Divisions
Two separate layers of fascia are present over the palmar
aspect of the carpal canal. The more superficial layer is the
thickened antebrachial fascia proximally and the palmar fas-
cia distally. The deeper layer, the FR, has three continuous
portions. The most proximal is represented by a thickening
in the deep investing fascia of the forearm. The central por-
tion is the TCL and the distal portion is formed by an
aponeurosis between the thenar and hypothenar eminences
(Fig. 9.13). Anteriorly, the proximal portion of the FR is
inseparable from the thickened antebrachial fascia. On the
ulnar and radial aspects, these two layers become separated.
The antebrachial fascia is more superficial and encloses the
FCR, FCU, and the ulnar neurovascular bundle. The deep
investing fascia encloses only the contents of the carpal
canal (28).
Dimensions of the Transverse Carpal Ligament
Portion of the Flexor Retinaculum
Based on the study of Cobb et al., the TCL portion of the
FR begins an average of 11 mm distal to the capitate-lunate
joint and extends an average of 10 mm distal to the car-
FIGURE 9.13. The flexor retinaculum.
504 Regional Anatomy

pometacarpal joint of the long finger. The mean width of

the carpal tunnel was 25 ± 1.2 mm proximally, 20 ± 1.2
mm at the hook of the hamate, and 25 ± 1.5 mm at its dis-
tal extent. The thickness of the TCL ranged from 0.8 to 2.5
mm, with a mean of 1.52 mm (28).

Histology
The fibers of the FR demonstrated large numbers of trans-
versely oriented collagen fibers and an overall thickness
approximately 10 times the thickness of the antebrachial
fascia. In contrast, the fibers of the antebrachial fascia were
oriented longitudinally.

Clinical Significance
Anatomically, there are two areas in the carpal canal where
median nerve compression may occur. The first is at the
level of the proximal edge of the TCL, where compression
is produced by acute flexion of the wrist. The comparative
thickness of the TCL relative to the adjacent fascia results in
impingement on the nerve. This configuration offers one
explanation for a positive Phalen’s test (wrist flexion test) in
carpal tunnel syndrome. The second area of potential com-
pression is at the level of the hook of the hamate, where the
canal is narrowest in both palmar-dorsal and ulnar-radial
planes. This second site of potential compression corre-
sponds to the authors’ clinical observation of the location of
the hourglass deformity in the median nerve seen at carpal
tunnel release in long-standing cases of carpal tunnel syn-
drome. The site of maximum indentation of the median
nerve is adjacent to the hook process of the hamate.
Carpal Canal
Boundaries
This fibroosseous canal is bounded ulnarly by the hook
process of the hamate, the triquetrum, and the pisiform,
and radially by the scaphoid, trapezium, and the fascial ele-
ments over the FCR tendon. The floor is formed by the
underlying portions of the scaphoid, lunate, capitate,
hamate, and trapezoid; the roof is formed by the FR (Fig.
9.14).
Contents
The contents of the carpal canal are the four tendons of the
flexor digitorum profundus, the four tendons of the flexor
digitorum superficialis (FDS), the FPL tendon, and the
median nerve. The FPL tendon is the most radial of the
flexors and the median nerve is the most palmar structure
in the canal. The finger flexor tendons in the carpal canal
are covered by a common sheath and the FPL by its own
synovial sheath. These synovial sheaths begin approximately
FIGURE 9.14. The carpal tunnel.
2.5 cm proximal to the proximal edge of the FR. Details of
the synovial tissues in the wrist and palm are presented in
Chapter 10.
The Carpal Canal as a Compartment
Although the carpal tunnel, as its name implies, is open
proximally and distally, it may act like a physiologic com-
partment and has its own distinct compartment pressure
levels (29–31). Cobb and associates studied the pressure
dynamics of the carpal tunnel and flexor compartment of
the forearm and found that it functions as a relatively closed
compartment with respect to transfer of pressure from the
flexor compartment of the forearm under conditions that
mimic elevated tissue pressure (32).
Clinical Significance of the Carpal Tunnel as a
Physiologic Compartment
When carpal canal pressure rises above a critical threshold
level, capillary blood flow is reduced below the level
required for median nerve viability and irreparable nerve
damage is likely to result (33).
Extensor Retinaculum
Anatomy
The wrist, thumb, and finger extensors gain entrance to the
hand beneath the ER through a series of six tunnels, five
fibroosseous and one fibrous [the fifth dorsal compartment,
which contains the extensor digiti minimi (EDM)] (34)
(Fig. 9.15). The ER is a wide, fibrous band that prevents
 9 Wrist 505

FIGURE 9.15. The six compartments of the extensor retinaculum.

bowstringing of the tendons across the wrist joint. Its aver- that provides a smooth gliding surface with mechanical
age width is 4.9 cm (range, 2.9 to 8.4 cm) as measured over strength (36).
the fourth compartment (34). At this level, the extensor
tendons are covered with synovial sheath. The ER consists Function
of two layers: the supratendinous and the infratendinous.
The basic function of the ER is to avoid bowstringing of the
The infratendinous layer is limited to an area deep to the
extensor tendons; this explains the presence of chondroid
ulnar three compartments. The six dorsal compartments are
metaplasia, which is an adaptation in response to friction
separated by septa that arise from the supratendinous reti-
and the dorsal forces produced by extensor tendon action.
naculum and insert onto the radius (35). Three distinct lay-
The ER has been found to be a useful tissue for flexor ten-
ers have been identified: (a) an inner gliding layer with high
don pulley reconstruction because of its histologic similar-
hyaluronic acid–secreting cells with isolated areas of chon-
ity to the native pulley in the fingers (37).
droid metaplasia; (b) a thick middle layer with collagen
bundles oriented in various directions, fibroblasts, and
Tendon Anatomy
elastin fibers; and (c) an outer layer of loose connective tis-
sue with vascular channels. This is the same histologic The tendons that cross the wrist can be divided into two
arrangement seen in anatomic pulleys throughout the body major groups: those that are responsible primarily for mov-
506 Regional Anatomy
ing the wrist and those that cross the wrist in their path to
the digits. Both groups impart some movement to the wrist,
but obviously those that are primary wrist motors have a
more substantial influence on motion of the wrist. The five
primary wrist motors can be grouped as either radial or
ulnar deviators and as either flexors or extensors.
The ECRL and ECRB muscles are bipennate and origi-
nate from the lateral epicondyle of the humerus from a
common tendon. Over the distal radius epiphysis, they are
found in the second extensor compartment, from which
they emerge to insert into the radial cortices of the bases of
the second and third metacarpals, respectively. The ECRL
imparts a greater moment for radial deviation than the
ECRB, whereas the opposite relationship is found for wrist
extension. Both the ECRL and the ECRB muscles are
innervated by the radial nerve.
The ECU muscle is bipennate, originates largely from
the proximal ulna, and passes through the sixth extensor
compartment. In the sixth extensor compartment, the ECU
tendon is contained in a fibroosseous tunnel between the
ulnar head and the ulnar styloid process. Distal to the ER,
the ECU tendon inserts into the ulnar aspect of the base of
the fifth metacarpal. The ECU muscle is innervated by the
radial nerve.
The FCR muscle is bipennate and originates from the
proximal radius and the interosseous membrane. The ten-
don of FCR enters a fibroosseous tunnel formed by the dis-
tal pole of the scaphoid and the “beak” of the trapezium,
and then angles dorsally to insert into the base of the sec-
ond metacarpal. This fibroosseous tunnel is separate from
the carpal tunnel. The FCR muscle is innervated by the
median nerve.
The FCU muscle is unipennate and originates from the
medial epicondyle of the humerus and the proximal ulna. It
is not constrained by a fibroosseous tunnel, in contradis-
tinction to the other primary wrist motors. It inserts into
the pisiform and ultimately continues as the pisohamate lig-
ament. The FCU muscle is innervated by the ulnar nerve.
VASCULAR ANATOMY
Vascular Anatomy of the Carpus
There are three dorsal and three palmar carpal arches from
the radial, ulnar, and anterior interosseous arteries. These
arches are named (proximal to distal) the radiocarpal, inter-
carpal, and basal metacarpal transverse arches (38). Anasto-
moses often are found between the arches, the radial and
ulnar arteries, and the interosseous artery system. All carpal
bones, with the exception of the pisiform, receive their
blood supply through dorsal and palmar entry sites, and
usually through more than one nutrient artery. Usually, a
number of small-caliber penetrating vessels are found in
addition to the major nutrient vessels. Intraosseous anasto-
moses can be found in three basic patterns. First, a direct
anastomosis can occur between two large-diameter vessels
in the bone. Second, anastomotic arcades may form with
similar-sized vessels, often entering the bone from different
areas. A final pattern, although rare, has been identified
where a diffuse arterial network virtually fills the bone.
Although the intraosseous vascular patterns of each carpal
bone have been defined in detail, studies of the lunate, cap-
itate, and scaphoid are particularly important because of
their predilection to the development of clinically impor-
tant avascular problems.
Extraosseous Vascular Patterns
The extraosseous vascularity of the carpus is from a series of
three dorsal and palmar transverse arches formed by the
radial, ulnar, and anterior interosseous arteries (38).
Dorsal Carpal Vascularity
The vascularity to the dorsal carpus is from three dorsal
transverse arches: the radiocarpal, the intercarpal, and the
basal metacarpal transverse arches (38,39) (Fig. 9.16). The
presence of each arch is variable. These arches are approxi-
mately 1 mm in diameter and their branches are less than 1
mm (40).
Radiocarpal Arch. The dorsal radiocarpal arch is the most
proximal and is present 80% of the time (38). It is located
at the level of the radiocarpal joint and lies deep to the
extensor tendons. This arch provides the main nutrient ves-
sels to the lunate and triquetrum. This arch usually is
formed by branches from the radial and ulnar arteries and
the dorsal branch of the anterior interosseous artery. Occa-
sionally, the radial and ulnar arteries supply the dorsal
radiocarpal arch alone, or it is supplied by the radial and
anterior interior osseous arteries (38).
Intercarpal Arch. The dorsal intercarpal arch is the largest
of the dorsal transverse arches and is consistently present
(38). It runs transversely across the carpus between the
proximal and distal carpal rows and supplies the distal
carpal row, as well as joining the radiocarpal arch to supply
the lunate and triquetrum. This arch is supplied by the
radial, ulnar, and anterior interosseous arteries 53% of the
time, by the radial and ulnar arteries alone in 20%, and by
the ulnar and anterior interosseous arteries in 7% (38).
Basal Metacarpal Arch. This is the most distal of the dor-
sal transverse arches and is located at the base of the
metacarpal just distal to the carpometacarpal joints. It is the
smallest of the dorsal arches and is represented by a series of
vascular retia; its presence is the most variable and is com-
plete in 27%, absent in 27%, and present in its radial aspect
alone in 46% (38). This arch is supplied by perforating
arteries from the second through fourth interosseous spaces
and contributes to the vascularity of the distal carpal row
 9 Wrist 507

FIGURE 9.16. Schematic drawing of the arterial supply of the dorsal wrist. (After Gelberman RH,
Panagis JS, Taleisnik J, et al. The arterial anatomy of the human carpus. Part I: the extraosseous
vascularity. J Hand Surg [Am] 8:367–375, 1983, with permission.)

through anastomoses with the intercarpal arch. The dorsal
arches are connected centrally by the dorsal branch of the
interosseous artery and radially and ulnarly by the radial
and ulnar arteries.
Palmar Carpal Vascularity
Like its dorsal counterpart, the palmar carpal vascularity is
formed by three transverse arches: the palmar radiocarpal,
the palmar intercarpal, and the deep palmar arch (38) (Fig.
9.17).
Palmar Radiocarpal Arch. This arch is the most proxi-
mal; it courses transversely 5 to 8 mm proximal to the
radiocarpal joint at the level of the distal metaphysis of the
radius and ulna and lies in the wrist capsule. It is consis-
tently present and is formed by branches of the radial, ante-
rior interosseous, and ulnar arteries in 87% of specimens,
and by the radial and ulnar arteries alone in 13%. This arch
supplies the palmar surface of the lunate and triquetrum
(41).
Palmar Intercarpal Arch. This arch, located between the
proximal and distal carpal rows, is the most variable in
occurrence and is present 53% of the time. It is formed by
branches of the radial, ulnar, and anterior interosseous
arteries in 75% of specimens and by the radial and ulnar
arteries alone in 25%. This small arch is not a major source
of vessels to the carpus (38).
508 Regional Anatomy

FIGURE 9.17. Schematic drawing of the arterial supply of the palmar wrist. (After Gelberman
RH, Panagis JS, Taleisnik J, et al. The arterial anatomy of the human carpus. Part I: the
extraosseous vascularity. J Hand Surg [Am] 8:367–375, 1983, with permission.)

Deep Palmar Arch. This most distal palmar arch is
located 5 to 10 mm distal to the palmar carpometacarpal
joints. It is consistently present and contributes to the
radial and ulnar recurrent arteries, as well as sending per-
forating branches to the dorsal basal metacarpal arch and
to the palmar metacarpal arteries (41). These three palmar
arches are connected longitudinally by the radial, ulnar,
anterior interosseous, and deep palmar recurrent arteries
(38).
Specific Vessels
The five major arteries that supply the carpus are the radial,
ulnar, anterior interosseous, deep palmar arch, and the
accessory ulnar recurrent (40). These arteries are discussed
separately as they relate to the vascularity of the carpus.
Radial Artery
The radial artery is the most consistent artery that supplies
the carpus. It has seven major branches, including three dor-

sal, three palmar, and a terminal branch that continues dis-
tally (40) (Fig. 9.18). The most proximal branch is the
superficial palmar artery, which leaves the main stem of the
radial artery 5 to 8 mm proximal to the tip of the radial sty-
loid, passes between the FCR and brachioradialis, and con-
tinues distally to contribute to the superficial palmar arch.
The second branch, which contributes to the palmar radio-
carpal arch, leaves the radial artery approximately 5 mm dis-
tal to the superficial palmar artery and courses toward the
ulna. A third branch originates at the level of the radiocarpal
joint and courses dorsally and ulnarly to penetrate the radio-
carpal ligament deep to the extensor tendons. This branch
supplies the dorsal radiocarpal arch. The fourth branch arises
palmarly at the level of the scaphotrapezial joint and supplies
the tubercle of the scaphoid, the trapezium, and the
radiopalmar surface of the trapezium. It then anastomoses
with the superficial palmar artery. This vessel is absent in
25% of specimens; in 25% it anastomoses with a branch of
the superficial palmar artery before entering the scaphoid
tubercle (38). The fifth branch of the radial artery, the
branch to the dorsal ridge of the scaphoid, originates directly
from the radial artery in 75% of specimens and from the
radiocarpal or intercarpal arch in 25%. It courses in an ulnar
retrograde fashion to supply the scaphoid. The sixth branch
leaves the radial artery 5 mm distal to the branch to the
scaphoid and contributes to the dorsal intercarpal arch. This
arch courses ulnarly across the trapezoid and the distal one-
half of the capitate and then branches and anastomoses with
the dorsal branch of the anterior interosseous artery and the
dorsal branches of the ulnar artery. The last branch of the
radial artery originates at the level of the trapezium and
courses distally to supply the trapezium and the lateral
aspect of the thumb metacarpal (38).
FIGURE 9.18. Schematic drawing of the arterial supply of the radial aspect of the wrist. (After
Gelberman RH, Panagis JS, Taleisnik J, et al. The arterial anatomy of the human carpus. Part I: the
extraosseous vascularity. J Hand Surg [Am] 8:367–375, 1983, with permission.)
9 Wrist 509
Ulnar Artery
At the level of the carpus, the ulnar artery gives off a lat-
ticework of fine vessels that span the dorsal and palmar
aspects of the medial carpus (see Figs. 9.16 and 9.17). Prox-
imal to the end of the ulna, there are three branches: a
branch to the dorsal radiocarpal arch, one to the palmar
radiocarpal arch, and one to the proximal pole of the pisi-
form and to the palmar aspect of the triquetrum. Several
small branches supply the lateral aspect of the pisiform, and
one branch joins the palmar intercarpal arch. Distally, a
branch supplies the distal pisiform and the medial hamate
and continues dorsally between the pisohamate and
pisometacarpal ligaments to contribute to the dorsal inter-
carpal arch. At the mid-carpal joint level, the medial branch
of the ulnar artery contributes to the intercarpal arch (see
Fig. 9.16). Distally, at the level of the metacarpal bases, the
basal metacarpal arch receives its contribution from the
medial branch of the ulnar artery. The medial branch of the
ulnar artery then continues distally toward the base of the
fifth metacarpal. A distal branch of the ulnar artery arises
proximal to the origin of the superficial palmar arch and
continues dorsally to supply the basal metacarpal arch. A
deep palmar branch is given off distally that contributes to
the deep palmar arch. The ulnar artery continues distally
and radially to contribute to the superficial arch.
Anterior Interosseous Artery
At the proximal border of the PQ muscle, the anterior
interosseous artery bifurcates into dorsal and palmar
branches. The dorsal branch continues distally on the
interosseous membrane to the carpus, where it supplies the
dorsal radiocarpal arch in 89% of specimens (38). Small
branches extend radially to supply the lunate and anasto-
510 Regional Anatomy
mose with several small radial artery branches supplying the
dorsal ridge of the scaphoid. The dorsal branch of the ante-
rior interosseous artery bifurcates at the intercarpal level,
each branch contributing to the intercarpal arch in 83% of
specimens (38). The dorsal branch of the interosseous
artery ends by anastomosing with recurrent vessels from the
basal metacarpal arch at the third and fourth interosseous
spaces in 70% of the specimens (38). The palmar branch of
the anterior interosseous artery continues deep to the PQ
and bifurcates 5 to 8 mm proximal to the radiocarpal arch.
It usually contributes at least one branch to the palmar
radiocarpal arch to supply the ulnar aspect of the lunate and
triquetrum, and then ends by anastomosing with recurrent
vessels from the deep palmar arch (41).
Deep Palmar Arch
The deep palmar arch provides the primary arterial supply
to the distal carpal row by means of two branches, the radial
and ulnar recurrent arteries (see Fig. 9.17). These branches
run in a distal-to-proximal direction and are consistently
present (38). The radial recurrent artery is slightly smaller,
originates from the arch just lateral to the base of the index
metacarpal, and courses proximally to bifurcate on the pal-
mar aspect of the trapezoid. It anastomoses with the ulnar
recurrent artery in 45% of the specimens. The ulnar recur-
rent artery originates from the deep arch between the bases
of the third and fourth metacarpals. It courses proximally in
the ligamentous groove between the capitate and the
hamate, supplying both bones. It anastomoses with the ter-
minal portion of the anterior interosseous artery in 80% of
the specimens (41).
Accessory Ulnar Recurrent Artery
In 27% of specimens, an ulnar recurrent artery is present
that originates from the deep arch 5 to 10 mm medial to the
ulnar recurrent artery and supplies the medial aspect of the
hook process of the hamate. When this vessel is absent, the
medial aspect of the hamate is supplied by direct branches
from the ulnar artery (38).
Posterior Interosseous Artery
The posterior interosseous artery does not reach the carpus
and thus does not contribute to the vascularity of the car-
pus (38). The contributions of the major arteries and arches
to the vascularity of the carpus are shown in Figures 9.19
and 9.20.
Intraosseous Vascular Patterns
Vascularity of the Scaphoid
The scaphoid receives most of its blood supply from the
radial artery by means of vessels that enter in limited areas
dorsally and palmarly that are nonarticular areas of liga-
mentous attachment (42). The dorsal vascular supply
accounts for 70% to 80% of the internal vascularity of the
bone, all in the proximal region (42). On the dorsum of the
FIGURE 9.19. Schematic drawing of the dorsal wrist show-
ing the various arterial contributions to the carpal bones.
(After Gelberman RH, Panagis JS, Taleisnik J, et al. The arte-
rial anatomy of the human carpus. Part I: the extraosseous
vascularity. J Hand Surg [Am] 8:367–375, 1983, with per-
mission.)
 9 Wrist 511

FIGURE 9.20. Schematic drawing of the palmar aspect of the wrist showing the various arterial
contributions to the carpal bones. (After Gelberman RH, Panagis JS, Taleisnik J, et al. The arterial
anatomy of the human carpus. Part I: the extraosseous vascularity. J Hand Surg [Am] 8:367–375,
1983, with permission.)

scaphoid, there is an oblique ridge that lies between the
articular surfaces of the trapezium and trapezoid, and the
major dorsal vessels enter the scaphoid through small
foramina located on this ridge (42). The dorsal ridge is in
the region of the scaphoid waist. At the level of the inter-
carpal joint, the radial artery gives off the intercarpal artery,
which immediately divides into two branches. One branch
courses transversely to the dorsum of the wrist and the
other courses vertically and distally over the index
metacarpal. Approximately 5 mm proximal to the origin of
the intercarpal vessel, at the level of the styloid process of
the radius, another vessel is given off that runs over the
radiocarpal ligament to enter the scaphoid through its waist
along the dorsal ridge. In 70% of specimens, the dorsal ves-
sel arises directly from the radial artery. In 23%, the dorsal
branch has its origin from the common stem of the inter-
carpal artery. In 7%, the scaphoid receives its dorsal blood
supply directly from the branches of the intercarpal artery
and the radial artery. There are consistent major communi-
cations between the dorsal scaphoid branch of the radial
artery and the dorsal branch of the anterior interosseous
artery in each specimen. No vessels enter the proximal dor-
sal region of the scaphoid through the dorsal scapholunate
ligament, and no vessels enter through dorsal cartilaginous
areas (42). Although the dorsal vessels usually enter the
scaphoid through foramina located on the dorsal ridge at
the level of the scaphoid waist, in a few specimens the ves-
sels entered just proximal or distal to the waist. The dorsal
vessels usually divide into two or three branches soon after
entering the scaphoid, and these branches run palmarly and
proximally, dividing into smaller branches to supply the
proximal pole as far as the subchondral region. The palmar
vascular supply accounts for 20% to 30% of the internal
vascularity, all in the region of the distal pole (42). At the
level of the radioscaphoid joint, the radial artery gives off
the superficial palmar branch, and just distal to the origin
of the superficial branch, several smaller branches course
obliquely and distally over the palmar aspect of the
scaphoid to enter the region of the tubercle (39,42). These
branches, called the palmar scaphoid branches, divide into
several smaller branches just before entering the bone. In
75% of the specimens, these arteries arise directly from the
radial artery (42). In the remainder of the specimens, they
arise from the superficial palmar branch of the radial artery.
Consistent anastomoses exist between the palmar division
and the anterior interosseous artery and the palmar
scaphoid branch of the radial artery, when the latter arises
from the superficial palmar branch of the radial artery.
512 Regional Anatomy
There are no apparent communicating branches between
the ulnar artery and the palmar branches of the radial artery
that supply the scaphoid. Vessels in the scapholunate liga-
ment do not penetrate the scaphoid. The palmar vessels
enter the tubercle and divide into several smaller branches
to supply 20% to 30% of the scaphoid. There are no appar-
ent anastomoses between the palmar and dorsal vessels (39).
Vascularity of the Lunate
The lunate receives its blood supply from either palmar and
dorsal sources or from the palmar aspect alone. In 80% of
specimens, the lunate receives nutrient vessels from palmar
and dorsal aspects. In 20% of the specimens, it receives
nutrient vessels from the palmar surface alone (42). Besides
these relatively small dorsal and palmar surfaces, the lunate
is covered by articular cartilage, and no other vessels enter
the bone. The vessels entering the dorsal surface are from
branches from the dorsal radiocarpal arch, the dorsal inter-
carpal arch, and occasionally from smaller branches of the
dorsal branch of the anterior interosseous artery (42–44).
On the palmar aspect, the lunate nutrient vessels are sup-
plied by the palmar intercarpal arch, the palmar radiocarpal
arch, communicating branches from the anterior
interosseous artery, and the ulnar recurrent artery. The ves-
sels that enter the lunate dorsally are slightly smaller than
those entering palmarly. Major vessels branch proximally
and distally after entering the bone and end in the sub-
chondral bone. The dorsal and palmar vessels anastomose
intraosseously just distal to the mid-portion of the lunate.
The proximal pole has relatively less vascularity. There are
three major intraosseous patterns of vascularity that occur
in the lunate (43) (Fig. 9.21).
These patterns are formed in the shape of the letters “Y,”
“X,” or “I.” The “Y” pattern is the most common, with an
incidence of 59%. The stem of the “Y” may occur dorsally
or palmarly with equal frequency. The “I” pattern occurs in
approximately 30% of specimens and consists of one dorsal
and one palmar vessel that anastomose in a straight line to
FIGURE 9.21. Patterns of interosseous blood supply to the carpal lunate.
form an “I”-shaped pattern. The “X” pattern occurs in 10%
of specimens and consists of two dorsal and two palmar ves-
sels that anastomose in the center of the lunate to form the
“X”-shaped pattern (41,43,44). In 20% of specimens stud-
ied, one palmar supply was present and consisted of one
large vessel that entered on the palmar surface of the lunate
and branched in the lunate to provide the only blood sup-
ply (41,43,44).
Vascularity of the Triquetrum
The triquetrum receives its blood supply from branches
from the ulnar artery, and the dorsal and palmar intercarpal
arches. Nutrient vessels enter through the intercarpal arch
as on its dorsal and palmar nonarticular surfaces. The dor-
sal surface of the triquetrum is rough for attachment of
associated carpal ligaments, and this dorsal surface contains
a ridge that runs from ulnar to radial. Two to four vessels
enter this dorsal ridge and radiate in multiple directions to
supply the dorsal 60% of the bone. This network is the pre-
dominant blood supply of the triquetrum as observed in
60% of the specimens (41,44). The palmar surface contains
an oval facet that articulates with the pisiform. One or two
vessels enter proximal and distal to the facet. The vessels
have multiple anastomoses with each other and supply the
palmar 40% of the triquetrum. This palmar vascular net-
work is predominant in 20% of specimens, and significant
anastomoses have been identified between the dorsal and
palmar networks in 86% of specimens (4).
Vascularity of the Pisiform
The pisiform receives its blood supply through the proximal
and distal poles from branches of the ulnar artery. The prox-
imal blood supply enters in the area where the FCU
attaches to the pisiform. One to three vessels enter the bone
inferior to the triquetral facet and divide into multiple
branches. Two superior branches run parallel beneath the
articular surface of the facet. One or two branches run
along the palmar cortex and anastomose with the superior

branches (44). The distal vascular supply includes one to
three vessels that enter inferior to the articular facets and
divide into superior and inferior branches that run parallel
to the palmar cortex. These distally entering vessels anasto-
mose with the proximal vessels. The superior vessels run
deep to the articular facet and communicate with the prox-
imal superior vessels, forming an articular ring deep to the
facet. There are multiple anastomoses between the proximal
and distal vascular networks.
Vascularity of the Hamate
The hamate has three main sources of supply: the dorsal
intercarpal arch, the ulnar recurrent artery, and the ulnar
artery. The vessels enter through the three nonarticular sur-
faces of the hamate, including the dorsal surface, the palmar
surface, and the ulnar aspect through the hook process of
the hamate. The dorsal surface is triangular and receives
three to five vessels that branch in several directions to sup-
ply the dorsal 30% to 40% of the hamate (41,44). The pal-
mar surface also is triangular and usually receives one large
vessel that enters through the radial base of the hook
process of the hamate. It then branches and anastomoses
with the dorsal vessels in 50% of the specimens (41,44).
The hook process of the hamate receives one or two small
vessels that enter through the ulnar base and tip of the
hook. These vessels anastomose with each other but usually
not with the vessels to the body of the hamate.
Vascularity of the Capitate
The capitate receives its blood supply from dorsal and pal-
mar sources. The main vascularity arises from vessels from
the dorsal intercarpal and dorsal basal metacarpal arches
and from significant anastomoses between the ulnar recur-
rent and palmar intercarpal arches. The vessels that enter
the capitate do so through the two nonarticular surfaces on
the dorsal and palmar surfaces. This dorsal surface is rela-
tively wide and contains a deeply concave portion where
two to four vessels enter its distal two-thirds. Smaller vessels
occasionally enter more proximally near the neck. The dor-
sal vessels course palmarly, proximally, and ulnarly in a ret-
rograde fashion to supply the body and head of the capitate.
This dorsal supply continues palmarly and proximally,
eventually to reach the convex, rough palmar surface. Ter-
minal vessels reach the proximal palmar head and terminate
just deep to the articular surface (41,44). The palmar vas-
cular contribution is through one to three vessels that enter
on the distal one-half of the capitate and course proximally
in a retrograde fashion. In 33% of the specimens, the ves-
sels to the capitate head originate entirely from the palmar
surface. There are notable anastomoses between the dorsal
and palmar vessels in 30% of the specimens (41,44).
Vascularity of the Trapezoid
This bone is supplied by branches from the dorsal inter-
carpal arch, the basal metacarpal arch, and the radial recur-
9 Wrist 513
rent artery that enter the trapezoid through its two nonar-
ticular parts on the dorsal and palmar surfaces. The main
blood supply of this bone is dorsal, by means of three to
four small vessels that enter the rough dorsal surface in the
central aspect. These vessels supply the dorsal 70% of the
trapezoid (44). The palmar blood supply is by means of one
to two small vessels that enter the central portion and
branch after entering to supply the remaining 30% of the
trapezoid. No anastomoses are present between the palmar
and dorsal vessels.
Vascularity of the Trapezium
This bone is supplied by vessels from distal branches of the
radial artery that enter the trapezium through its three
nonarticular surfaces. These nonarticular surfaces are dor-
sal, palmar, and lateral. Dorsally, one to three vessels enter
and divide to supply the entire dorsal aspect of the bone.
Palmarly, one to three vessels enter the trapezium at its mid-
portion and anastomose with the dorsal vessels. Laterally,
three to six very fine vessels penetrate the lateral surface and
anastomose with the dorsal and palmar vessels. The dorsal
vascular supply is dominant, and all three systems anasto-
mose (44).
Clinical Significance and Clinical Correlations of the
Intraosseous Vascularity of the Carpus
Based on their comprehensive studies of the intraosseous
blood supply of the carpal bones, Gelberman and associates
noted that carpal bones were divided into three groups
based on the number and location of their entry blood ves-
sels, the existence of large areas of bone supplied by a single
vessel, and the presence or absence of intraosseous anasto-
moses. Group I consisted of those carpal bones with vessels
entering only one surface or bones with large intraosseous
areas dependent on one artery. These bones were considered
to be at “greater risk” for avascular necrosis based on their
intraosseous vascular patterns. The capitate and scaphoid
are in this group, as well as those lunate bones supplied by
a single palmar vessel (20% of the cases in their studies)
(44,45).
Postfracture Osteonecrosis of the Carpus. One of the
most important clinical applications of the vascularity of
the carpus is the understanding it may give relative to post-
traumatic osteonecrosis. Some, but not all, of these condi-
tions are discussed. Based on vascular studies and clinical
correlations of osteonecrosis, the scaphoid, capitate, and
lunate are considered the bones most likely at risk for post-
traumatic osteonecrosis (45). The proximal pole of the
scaphoid has been compared with the head of the femur
and the talus because it is almost completely covered with
hyaline cartilage and has a vascular source that may be
interrupted by fracture (45). The common anatomic find-
ings in these bones at risk are either vessels that enter on
only one surface, or large portions of the bone that are
514 Regional Anatomy
dependent on one vessel, or both. The viability of the prox-
imal pole of the scaphoid depends on the dorsal ridge ves-
sels that flow in a retrograde fashion to supply the entire
proximal 70% to 80% of the bone. Thus, disruptions from
fracture may result in osteonecrosis of the scaphoid (46,47).
Idiopathic Osteonecrosis of the Scaphoid (Preiser’s Dis-
ease). Preiser in 1910 described five patients with what he
called rarefying osteitis of the scaphoid that was not associated
with fractures (48). Although scaphoid fractures were not
apparent in his cases, trauma was believed to be the cause.
There is no generally accepted definition of Preiser’s disease,
and several authors believe that it may develop only when
an occult fracture of the scaphoid has occurred (40). Ferlic
and Morin proposed a possible variant in vascularity that
predisposes patients to osteonecrosis with minimal trauma
(49).
Idiopathic Osteonecrosis of the Lunate (Kienböck’s Dis-
ease). This condition was first described by Peste in 1843
(50). However, it is Kienböck’s name that is most com-
monly associated with this condition (51). Many theories
have been proposed as to the etiology, but the exact cause of
the condition remains unknown. Studies support the con-
cept that repetitive trauma with compression fracture of the
lunate may cause vascular interruption, leading to Kien-
böck’s disease. Biomechanical studies support the concept
of abnormal radiocarpal loading patterns leading to the dis-
ease. Kramer and Lichtman believe that repetitive loading
or acute trauma to an at-risk lunate (the 20% of lunate
bones that are supplied by a single palmar vessel) is the
cause in most cases (44,52).
Vascular Anatomy of the Distal Radius
and Ulna
The arterial blood supply of the distal radius and ulna is
quite constant. The extraosseous vessels that contribute
nutrient vessels to the distal radius and ulna are consistently
spatially related to the surrounding landmarks and supply
bone with predictable groups of arteries. The interosseous
blood supply is less uniform, but has a recognized pattern
of regional bone supply for any given extraosseous vessel
(53). The distal radius and ulna receive contributions from
the radial, ulnar, and anterior and posterior interosseous
arteries. The radial, ulnar, anterior and posterior
interosseous arteries are consistently present, and the radial
artery is the largest, followed by the ulnar, anterior
interosseous, and posterior interosseous arteries. The ante-
rior interosseous artery has anterior and posterior divisions
that are consistently present. The posterior division of the
anterior interosseous artery consistently anastomoses with
the posterior interosseous artery over the dorsal distal ulna
by means of a small arch (53,54). The vessels supplying the
dorsal radius and ulna are best described by their relation-
ship to the extensor compartments and retinaculum. The
following detailed description of the vascular anatomy of
the radius and ulna is taken from a comprehensive study by
Sheetz and associates (53).
Dorsal Blood Supply
The vessels supplying the dorsal radius and ulna are best
described by their relationship to the extensor compart-
ments of the wrist and the ER. There are two compartmen-
tal arteries (one in the fourth and one in the fifth extensor
compartments) and two intercompartmental arteries super-
ficial to the ER between the first and second and second and
third compartments. These extracompartmental vessels are
located where the ER is adherent to the underlying bony
tubercle separating their respective compartments, and they
send nutrient vessels through the ER to penetrate bone. The
dorsal distal ulna is supplied by an artery coursing across the
diaphysis and neck of the ulna, called the oblique dorsal
artery of the distal ulna. The first/second intercompartmental
artery originates proximally from the radial artery a mean of
48 mm (range, 24 to 85 mm) proximal to the radiocarpal
joint and usually courses deep to the brachioradialis muscle.
It proceeds distally to become superficial to the ER at the
first/second intercompartmental septum and sends nutrient
vessels through the ER to enter cortical bone. Distal to the
ER, it passes beneath the extensor tendons of the first com-
partment and rejoins the radial artery (52%), the radiocarpal
arch (52%), or the intercarpal arch (19%). Thirteen percent
of the specimens have distal connections with both the radial
artery and radiocarpal arch. In addition, there is always at
least one anastomosis to other vessels running parallel to the
radial shaft via a portion of the dorsal supraretinacular arch,
and usually a second anastomosis proximal to the ER that
courses deep to the extensor tendons. In 56% of the speci-
mens, the first/second intercompartmental supraretinacular
artery has a branch that originates proximal to the ER and
proceeds onto the floor of the second extensor compart-
ment. The second/third intercompartmental supraretinacu-
lar artery originates proximally from the anterior
interosseous artery (48%), the posterior division of the ante-
rior interosseous artery (48%), or the anterior division of the
anterior interosseous artery (4%) and courses superficial to
the ER directly on the dorsal radial tubercle (Lister’s tuber-
cle) to anastomose with the dorsal intercarpal arch (94%),
the dorsal radiocarpal arch (52%), or the fourth extensor
compartment artery (38%). In addition, it has superficial
and deep transverse anastomoses with the first/second inter-
compartmental supraretinacular artery, as described previ-
ously. The nutrient arteries from the second/third intercom-
partmental supraretinacular artery often penetrate
cancellous bone. The more proximally the nutrient artery
enters the bone, the more likely it is to penetrate cancellous
bone and proceed proximally. In 91% of the specimens, the
second/third intercompartmental supraretinacular artery has

a proximal branch that enters the second extensor compart-
ment and penetrates the bone in the floor of the compart-
ment. All the specimens studied have a fourth extensor com-
partment artery that has a variable relationship to the
septum between the third and fourth compartments and lays
directly adjacent to the posterior interosseous nerve at the
radial aspect of the fourth compartment. Thirty-three per-
cent of specimens have this artery in the septum for most of
its course, and in 70% the artery is located in the compart-
ment. Proximally, this artery is supplied directly by the pos-
terior division of the anterior interosseous artery (55%) or
by the fifth extensor compartment artery (45%). It anasto-
moses with the dorsal intercarpal arch (94%), the dorsal
radiocarpal arch (59%), the second/third intercompartmen-
tal supraretinacular artery (38%), or the fifth extensor com-
partment artery (34%). The fourth extensor compartment
artery is the source of numerous nutrient vessels to the floor
of the fourth compartment that frequently penetrate cancel-
lous bone. The vessels entering more distally tend to supply
only a small area of cortical bone or go transversely into can-
cellous bone to supply the distal end of the metaphysis;
those more proximal are more likely to penetrate cancellous
bone and proceed proximally. All of the specimens studied
have a fifth extensor compartment artery that usually is the
largest of all the dorsal vessels supplying nutrient branches.
It has a variable relationship with the radial side of the
fourth/fifth septum. Thirty-three percent are in the septum
for most of their course, and 67% are located in the com-
partment. This vessel is supplied proximally by the posterior
division of the anterior interosseous artery and anastomoses
distally with the dorsal intercarpal arch in all of the speci-
mens. Distally, it also anastomoses with the fourth extensor
compartment artery (34%), the dorsal radiocarpal arch
(23%), the second/third intercompartmental supraretinacu-
lar artery (9%), or the oblique dorsal artery of the distal ulna
(9%). Thirty-nine percent of the fifth compartment arteries
have a branch that usually originates proximal to the ER and
supplies one or two nutrient vessels to the floor of the fourth
compartment. The nutrient arteries from this branch fre-
quently penetrate cancellous bone and are the only contri-
bution of the fifth extensor compartment to the intraosseous
blood supply.
A series of arches across the dorsum of the hand and
wrist provide anastomoses between the intercompartmental
and compartmental arteries. The dorsal intercarpal arch is
present in all specimens, always receives contributions from
the radial, ulnar, and fifth extensor compartment arteries,
and frequently anastomoses with the second/third inter-
compartmental supraretinacular artery (94%), fourth
extensor artery (94%), dorsal radiocarpal arch (67%), and
the first/second intercompartmental supraretinacular artery
(19%). The dorsal intercarpal arch does not contribute
nutrient vessels to the distal radius or ulna except indirectly
through arteries with which it anastomoses. The dorsal
radiocarpal arch is present in all specimens and always
9 Wrist 515
receives a contribution from the radial artery and at least
two additional sources such as the dorsal intercarpal arch
(67%), fourth extensor compartment artery (59%), the sec-
ond/third intercompartmental supraretinacular artery
(52%), the first/second intercompartmental supraretinacu-
lar artery (52%), or the fifth extensor compartment artery
(23%). Unlike the other dorsal arches, the dorsal radio-
carpal arch contributes significantly to the dorsal distal
radius through small nutrient arteries. These nutrient
branches usually enter bone just proximal to the radiocarpal
joint line and course perpendicularly to supply cancellous
bone in the extreme distal end of the metaphysis. All of the
specimens studied have a dorsal supraretinacular arch that
provides anastomoses between the arteries running parallel
to the radial and ulnar diaphyses. It originates from the
first/second intercompartmental supraretinacular artery
and proceeds transversely across the ER to the ulnar artery.
It usually connects to the first/second and second/third
intercompartmental supraretinacular arteries (97%) and
continues toward the ulnar artery, penetrating the ER at
two or more points to connect with the fifth (80%) or
fourth (62%) extensor compartment arteries as well as the
intercarpal arch (80%). It is not a single artery, but rather
an anastomotic arch connecting the dorsal arteries.
The dorsal distal ulna is supplied proximally by one to
three oblique dorsal arteries. In 78% of specimens, one of
these arteries originates from the anastomotic arch between
the anterior and posterior interosseous arteries. Other
sources include the anterior division of the anterior
interosseous artery (26%), the posterior division of the
anterior interosseous artery (13%), or the fifth extensor
compartment artery (9%). Distally, this artery frequently
ends by penetrating bone, but it usually anastomoses with
the fifth extensor compartment artery, the ulnar artery, or
the ulnar half of the palmar carpal arch. The oblique dorsal
artery to the distal ulna gives off nutrient vessels that usu-
ally enter the ulnar head and neck adjacent to joint cartilage
and frequently penetrate cancellous bone. The further prox-
imal that the vessel enters the metaphysis, the more likely it
is to penetrate cancellous bone. Any diaphyseal branches, if
present, supply a part of the ulna that is almost entirely cor-
tical bone (53).
Palmar Blood Supply
In contrast to the vascular patterns on the dorsal aspect of the
distal radius and ulna, where the arteries roughly parallel the
long axis of the bones and give off nutrient arteries, the pal-
mar side of the distal radius is supplied primarily by two large
transverse arches that course between the major arteries of the
forearm. In the study by Sheetz and associates, every speci-
men had at least one palmar metaphyseal arch that coursed
through the PQ muscle (53). Occasionally, instead of one pri-
mary proximal arch, two or more smaller arches were
observed. Its proximal source was either from the anterior
516 Regional Anatomy

division of the anterior interosseous artery (96%) or the ante-
rior interosseous itself (4%). It then arched across the palmar
aspect of the distal radius to anastomose with the radial artery
(100%), and usually sent a branch to the palmar radiocarpal
arch as well (57%). It supplied nutrient arteries to variable
locations on the palmar side of the radial metaphysis. Every
specimen in their study had a palmar carpal arch that con-
sisted of radial and ulnar halves bifurcated by the anterior
division of the anterior interosseous artery. The radial half of
the palmar carpal arch originated from the anterior division
of the anterior interosseous artery that arches across the distal
radius to anastomose with the radial artery. Frequently, there
were one or more branches that anastomosed with the palmar
metaphyseal arch (57%). The ulnar half of the palmar carpal
arch originated from the anterior division of the anterior
interosseous artery more proximally than the radial half of the
arch. It coursed obliquely across the distal ulna toward the
ulnocarpal joint and anastomosed with the ulnar artery
(69%) or the oblique dorsal artery to the distal ulna (25%),
or simply ended by penetrating bone (6%). Ninety-one per-
cent of the specimens studied had one or two arteries that
entered the ulna between the head and the styloid process at
the attachment of the TFCC and supplied the cancellous
bone in the head and styloid process of the ulna (53). The var-
ious arteries and arches of the dorsal and palmar blood sup-
ply of the distal radius and ulna are depicted in Figure 9.22.

A
FIGURE 9.22. Extraosseous blood supply to the distal radius and ulna. A: Dorsal: AIA, anterior
interosseous artery; aAIA, anterior branch anterior interosseous artery; pAIA, posterior branch
anterior interosseous artery; PIA, posterior interosseous artery; RA, radial artery; UA, ulnar artery;
ODA, oblique dorsal artery of distal ulna; dICA, dorsal intercarpal arch; dRCA, dorsal radiocarpal
arch; dSRA, dorsal supraretinacular arch; SRA, 1–2, supraretinacular artery between first and sec-
ond extensor compartments; SRA, 2–3, supraretinacular artery between second and third exten-
sor compartments; 2nd EC br of SRA, 1–2, second extensor compartment branch of supraretinac-
ular artery between the first and second extensor compartment; 2nd EC br of SRA, 2–3, second
extensor compartment branch of the supraretinacular artery between the second and third
extensor compartments; 4th ECA, fourth extensor compartment artery; 5th ECA, fifth extensor
compartment artery; 4th EC br of 5th ECA, fourth extensor compartment branch of the fifth com-
partment artery.
 9 Wrist 517

tures and dislocations, tendon disruption, extensor and

wrist synovitis, tumors, and infections.

Landmarks
Landmarks include the radial and ulnar styloid, Lister’s
tubercle, and the lunate fossa.

Patient Position/Incision
The upper extremity is positioned on a well padded arm table
with the forearm in pronation. The length of the incision
depends on the planned procedure, but often is 8 to 10 cm.
It is centered longitudinally over the dorsum of the wrist in
line with the middle finger metacarpal and begins 4 to 5 cm
proximal to the radiocarpal joint. Alternatives to the straight
longitudinal incision are a gently curved or an “S”-shaped
incision. A transverse incision also may be used if a less com-
prehensive exposure is required. The selection of the incision
is based on the requirements of the procedure and the per-
sonal preference and experience of the surgeon (Fig. 9.23).

B
FIGURE 9.22. (continued) B: Palmar: pMeta, palmar metaphy-
seal arch; rPCA, radial half of palmar carpal arch; uPCA, ulnar
half of palmar carpal arch. (After Sheetz KK, Bishop AT, Berger
RA. The arterial blood supply of the distal radius and its poten-
tial use in vascularized pedicled bone grafts. J Hand Surg [Am]
20:902–914, 1995, with permission.)

Clinical Significance
A detailed knowledge of the vascular anatomy of the distal
radius has allowed for the development of several vascularized
bone grafts used in the management of scaphoid nonunions,
avascular necrosis lesions of the carpus, or intercarpal
arthrodesis. The reader is invited to review the comprehen-
sive articles by Sheetz and associates and Shin and Bishop for
details of this complex anatomy and the current techniques
of vascularized bone graft based on this anatomy (53,54).

SURGICAL EXPOSURES
Dorsal Approach to the Wrist (Standard)
Indications
Dorsal approaches to the wrist joint provide excellent expo-
sure to the wrist and finger extensors, the dorsal aspect of
the wrist including the radiocarpal, intercarpal, and car-
pometacarpal joints, the distal radioulnar joint, and the dis- FIGURE 9.23. Dorsal approach to the wrist: landmarks and skin
tal radius and ulna, for the management of fractures, frac- incisions.
 518 Regional Anatomy

FIGURE 9.24. A, B: Dorsal approach to the wrist:

A B deep dissection.

Technique allows visualization of the dorsal 60% of the ulnar head

and the carpal face of the TFC, the lunotriquetral liga-
Because of the thinness of the dorsal skin and the minimal
ment, the meniscus (if present), the prestyloid recess, and
subcutaneous tissue on the dorsum of the hand and wrist,
most of the DRUJ synovial cavity. If carefully dissected and
the dissection down to the ER should be made cautiously.
replaced, this exposure should not alter joint mechanics or
The flaps are reflected at the level of the ER to keep them
stability (9).
as thick as possible and to carry the sensory branches of the
radial and ulnar nerves in the substance of the flaps. The
nature of the surgical procedure determines the site and Landmarks
direction of entry into the ER. In those cases where mini-
The landmarks are the ulnar head and styloid, the ECU
mal exposure is needed, the ER may be incised transversely
tendon, and the dorsal base of the small finger metacarpal.
in line with its fibers. In rheumatoid synovectomy, it is
helpful to detach the ER over the lateral aspect of the ulna
and then reflect it radially as an intact structure. At closure, Patient Position/Incision
the ER can be divided into proximal and distal halves; the
The patient is supine, the arm is extended on a padded arm
proximal half is placed beneath the extensor tendons and
table, and the forearm pronated. The incision begins three
used to cover any raw bone surfaces, such as the distal ulna,
fingerbreadths proximal to the styloid along the ulnar shaft
that may have been resected or hemiresected. The ulnar
and curves gently around the distal side of the ulnar head,
aspect of the ER also may be used as a soft tissue imbrica-
to end dorsally at the mid-carpus; for further distal exten-
tion over the distal radioulnar joint for stability. The
sion, the incision can be curved back ulnarly. The incision
remaining (distal) half of the ER is placed over the extensor
lies just dorsal to the dorsal sensory branch of the ulnar
tendons and sutured to its site of original release to prevent
nerve, which must be found and protected.
bowstringing of the extensors (Fig. 9.24). In other
instances, the ER may be divided in the direction of the
longitudinal skin incision over the fourth extensor com- Technique
partment and reflected to each side to expose the distal
The dissection is carried to the ER. Beneath the proximal
radius and the dorsal capsule of the wrist joint. The capsule
border of the ER, the capsule of the ulnar head passes
is incised in the direction of the skin incision to expose the
between the EDM and ECU tendons (Fig. 9.25). The
joint. The ER is carefully repaired at time of closure.
proximal and ulnar half of the ER is released at its ulnar
margin and reflected radially to uncover the ECU and
Bowers Approach to the Distal EDM tendons. Care is taken to avoid entering the fourth
Radioulnar Joint extensor compartment, if possible. The EDM is retracted
radially to reveal the TFC and the dorsal margin of the
Indications
sigmoid notch of the radius. The capsule is sharply
This approach is designed specifically for operative expo- divided at the radius, leaving a 1-mm cuff for repair at clo-
sure of the DRUJ, as proposed and used by Bowers. It sure, and reflected ulnarly. Further exposure of the TFC

A B
FIGURE 9.25. A–C: Bowers approach to the distal radioulnar joint (DRUJ).
may be obtained by releasing the EDM and EDC from
their compartments by reflecting the distal half of the ER
toward the ulna opposite the first flap of ER. This flap of
ER is divided along the EDM septum, and the base of this
flap is the attachment of the ECU compartment nearest
the ulna. The ECU should be fully released only if it is
pathologically involved. The unviolated sixth compart-
ment should be subperiosteally dissected from the ulnar
shaft for exposure without disturbing its stabilizing func-
tion. The dorsal radiotriquetral ligament may be incised
for a better view of the lunate and triquetral surfaces of the
TFC. Exposure of the ulnar styloid may be achieved by
full supination of the forearm. Important components of
the closure include returning the ECU to its anatomic
position in its dorsal groove over the ulna, and the first ER
flap may be used to stabilize its position as needed. Bow-
ers has proposed and used a more comprehensive dorsal
ulnar approach for TFCC repair that uses subperiosteal
reflection of the ECU in its compartment to provide
greater exposure.
9 Wrist 519
C
Palmar Radial Approach to the Wrist
Indications
This approach may be used for the palmar approach to
scaphoid fractures or bone grafts, excision of the radiocarpal
ganglion, open reduction and internal fixation of distal
radius fractures, and for lacerations of the radial artery.
Landmarks
These include the FCR tendon, the radial artery, and the
distal wrist flexion crease.
Patient Position/Incision
The patient is supine with the arm extended on a well
padded arm table and the forearm in supination. The lon-
gitudinal incision (straight or slightly curved) begins at the
distal wrist crease and is carried proximally 6 to 8 cm or
longer as needed in the interval between the radial artery
520 Regional Anatomy
and the FCR tendon. An alternative to the longitudinal
incision is a 3- to 4-cm-long transverse incision approxi-
mately 1 cm proximal to the distal wrist flexion crease. The
same interval of dissection between the radial artery and
FCR tendon is followed. Such a transverse incision may
limit the exposure and should be used based on the needs
of the procedure and the experience and preference of the
surgeon. The longitudinal incision may be extended distally
as needed by an oblique radial extension from the distal
wrist crease to the base of the thumb metacarpal. Before
inflation of the tourniquet, the course of the radial artery
may be identified by palpation and its course indicated by
a skin marker to aid in placement of the incision.
Technique
The wrist and forearm fascia is incised in the interval
between the radial artery and FCR tendon (Fig. 9.26).
Under tourniquet control, the inexperienced surgeon may
not appreciate how closely the radial artery resembles a
vein. In the distal half of the wound, the radial artery passes
dorsally and radially beneath the APL and EPB tendons
onto the floor of the anatomic snuff-box, and gains the dor-
sal aspect of the wrist. The palmar branch exits from the
ulnar side of the main stem of the radial artery before it
ascends into the snuff-box, and may be electively ligated at
the surgeon’s discretion. The FRC tendon sheath may be
incised and the FRC tendon retracted ulnarly for exposure.
Excision of a palmar carpal ganglion may be aided by injec-
tion of the cyst with a small amount of a dilute solution of
A B
FIGURE 9.26. A, B: Palmar radial approach to the wrist.
methylene blue using a 30-gauge needle passed obliquely
through the capsule of the ganglion to avoid leakage of the
dye. Marking the cyst in this manner facilitates complete
excision, including the neck and base of the lesion. In treat-
ing fractures of the radius with open reduction and internal
fixation, the proximal portion of the longitudinal incision
may need to be extended and the PQ muscle released from
its radial attachments and reflected ulnarly as needed for
exposure of the radius. For exposure of the scaphoid, the
capsule is incised longitudinally with the intent to minimize
injury to the RSC and LRL ligaments.
Palmar Central Approach to the Wrist
Indications
This approach is useful in tumors or lacerations of the
median nerve, exposure of the PQ muscle, and in procedures
on the distal radius that may require wider exposure, includ-
ing the distal radius and portions of the palmar DRUJ.
Landmarks
These include the FCR tendon, the radial artery, the pal-
maris longus (PL) tendon, if present, and the distal wrist
flexion crease and the thenar flexion crease.
Patient Position/Incision
The patient is supine with the arm extended on a padded
arm table and the forearm in supination. For limited expo-

sure of the distal forearm/wrist, the incision begins at the
distal wrist flexion crease and continues proximally for 6 to
8 cm or more, depending on the requirements of the pro-
cedure. The incision begins over the PL tendon, if present,
and if not, it begins at the intersection of the thenar crease
and the wrist flexion crease. The incision may be straight
longitudinal, curved, or slightly “S”-shaped. Procedures
that require opening of the carpal canal require extension of
the incision to the midpalm. This is accomplished by cross-
ing the wrist flexion crease obliquely or by offsetting the
palmar and wrist/forearm components of the incision and
joining them by a transverse limb at or near the wrist flex-
ion (Fig. 9.27A).
Technique
The technique for the more comprehensive exposure is
given (see Fig. 9.27B). After opening the skin in the palm
and wrist/forearm, the subcutaneous tissue in the
wrist/forearm is incised and the median nerve identified as
it exits from beneath the radial aspect of the muscle belly of
A B
FIGURE 9.27. A, B: Palmar central approach to the wrist.
9 Wrist 521
the middle finger FDS (55). The palmar cutaneous branch
of the median nerve (PCBMN) is identified as it leaves the
main stem of the median nerve on its radial aspect; it is var-
iously reported as originating in a range of 4 to 8 cm prox-
imal to the distal wrist crease (56–58). The median nerve is
retracted with a saline-moistened Penrose drain to either
side, depending on the exposure and needs of the proce-
dure. This approach also allows exposure of the underlying
finger flexor tendons, which may be retracted radially or
ulnarly to expose the floor of the distal forearm. The ante-
rior interosseous nerve and vessels are found on the
interosseous membrane before their entry into the PQ mus-
cle. Release of the FR is facilitated by identification of its
proximal and distal ends. Distally, the superficial palmar
arch is a reasonably reliable deep landmark that is located
distal to the distal edge of the FR. The FR is released on its
ulnar aspect. A smooth elevator may be placed in the canal
before incision of the FR gently to retract and protect the
nerve. The various configurations of the median nerve
about the wrist are presented in Chapter 10 (Palmar Hand),
and the reader is referred there for these details.
522 Regional Anatomy
Approach to the Carpal Tunnel
Indications
This approach is useful in tumors or lacerations of the
median nerve in the carpal canal, and for carpal tunnel
release.
Landmarks
These include the FCR and PL (if present) tendons, the
pisiform, hook process of the hamate bone, the distal wrist
flexion crease, the thenar flexion crease, and the thenar and
hypothenar eminences.
Patient Position/Incision
The patient is supine with the arm extended on a padded
arm table and the forearm in supination. Authors vary in
their recommendation for placement of this incision
(56,57). There is no truly internervous plane in the region,
and four cutaneous nerves are at risk, including the
PCBMN, the palmar cutaneous branch of the ulnar nerve
(PCBUN), branches from the nerve of Henle, and trans-
verse branches of the PCBUN. Watchmaker et al., in an
effort to find the ideal location of the incision for carpal
tunnel release, identified the depression between the thenar
and hypothenar eminences in the proximal palm as a useful
landmark, and noted that the PCBMN traveled an average
of 5 mm radial to this interthenar depression (57). The
reader is referred to the section on Cutaneous Innervation
of the Palm in Chapter 10 (Palmar Hand) for a compre-
hensive review of this topic. Our recommended incision
begins at the mid-palmar crease in line with the central axis
of the ring finger and continues proximally to the distal
wrist flexion crease, where it angles ulnarward for 2 cm. The
incision may be straight longitudinal or slightly curved (Fig.
9.28A).
Technique
After incision of the skin and subcutaneous fat, the under-
lying FR is noted as a transversely oriented fibrous tissue
layer that is contiguous radially with the thenar muscles and
ulnarly with the hypothenar fat pad (see Fig. 9.28B). The
PL, if present, is freed from the underlying FR and retracted
ulnarly. The distal edge of the FR is identified by noting a
fat pad at its distal margin. This fat pad hides the median
nerve and its branches centrally and radially and the trans-
versely oriented superficial palmar arterial arch distally.
Gentle blunt dissection is used to identify these structures,
and a blunt probe or curved mosquito clamp is passed prox-
imally along the ulnar side of the carpal canal (see Fig.
9.28C). The canal may be identified by noting the promi-
nent hook process of the hamate bone, which provides the
ulnar and distal anchor point for the FR. The TCL portion
of the FR is incised along its ulnar border using the probe
or clamp as a guide. The TCL is relatively thick compared
with the proximal portion of the FR, and their junction is
near the distal wrist flexion crease (see Fig. 9.28D). The
proximal portion of the FR is exposed through the ulnar
oblique limb of the incision and may be incised with a
scalpel under direct vision or divided by scissors after first
freeing the adjacent tissues palmarly and dorsally. The sur-
geon’s little finger should pass freely from the distal wrist
flexion crease to at least 3 cm into the distal forearm to
ensure complete division of the proximal portion of the FR.
Both the recurrent or motor branch of the median nerve
and the superficial palmar arterial arch should be inspected
before release of the tourniquet and wound closure (see Fig.
9.28E).
Approach to Guyon’s Canal
Indications
This approach is useful for exposure of the ulnar neurovas-
cular bundle in the wrist and hand, the FCU tendon, the
pisiform, and the hook process (hamulus) of the hamate.
Landmarks
The FCU tendon is easily demonstrated by asking the
patient forcefully to flare or abduct the fingers, and the pisi-
form as well as the hook process of the hamate may be pal-
pated. The ulnar artery may be palpable before inflation of
the tourniquet.
Patient Position/Incision
The patient is supine with the arm extended on a well
padded hand table and the forearm in supination. The inci-
sion begins in the distal and ulnar aspect of the palm and
courses proximally over the proximal hypothenar eminence
in the interval between the hook process of the hamate and
the pisiform to gain the distal wrist flexion crease. It con-
tinues proximally just radial to the FCU tendon for a dis-
tance of 6 to 8 cm, as required by the procedure (Fig.
9.29A).
Technique
The subcutaneous tissues and antebrachial fascia are incised
just radial to the FCU tendon to expose the neurovascular
bundle, which is deep and radial to the FCU tendon. The
ulnar artery, like its radial counterpart, usually is accompa-
nied by venae comitantes. The sheath surrounding the
ulnar artery and nerve is incised to facilitate following these
structures into Guyon’s canal. The ulnar artery approaches
the wrist just beneath and radial to the FCU tendon, is
radial to the ulnar nerve, and lies in the interval between the
 9 Wrist 523

C
FIGURE 9.28. Approach to the carpal tunnel, fresh cadaver dissection, right hand and wrist. A:
Landmarks and skin incision. B: The transverse carpal ligament (TCL) portion of the flexor reti-
naculum (FR). C: A curved mosquito clamp has been passed from distal to proximal, and the
green triangle points to the dotted incision line.
(continued on next page)
524 Regional Anatomy

F
FIGURE 9.28. (continued) D: The TCL has been incised and the probe is tenting up the proxi-
mal portion of the FR. E: The FR has been completely incised, the blue marker to the right is
beneath the main stem of the median nerve, and the blue triangle points to the superficial pal-
mar arch and the green triangle to the motor branch of the median nerve. F: The blue markers
indicate the origin and course of the palmar cutaneous branch of the median nerve (PCBMN;
note that the recommended carpal tunnel release (CTR) incision has been extended proximally to
define the course of this nerve).
 9 Wrist 525

C
FIGURE 9.29. Approach to Guyon’s canal: fresh cadaver dissection of the left wrist/hand. A:
Landmarks and incision. B: Incision of roof of Guyon’s canal. C: Division of the ulnar nerve.
(continued on next page)
526 Regional Anatomy

E
FIGURE 9.29. (continued) D: Branches of the ulnar nerve in Guyon’s canal. E: Course of the
deep motor branch of the ulnar nerve around the hamulus.

FCU and the FDS to the ring and little fingers. It enters the
hand accompanied by the ulnar nerve on top of the FR
radial to the pisiform bone. This entryway, called the loge de
Guyon or Guyon’s canal, is a triangular space that begins at
the proximal edge of the palmar carpal ligament and
extends to the fibrous arch of the hypothenar muscles. The
anatomic details of Guyon’s canal and its contents are dis-
cussed in Chapter 10 (Palmar Hand). The palmar carpal
ligament (formed by the antebrachial and fascial elements
from the FCU) is incised along with the palmaris brevis
tendon, if present, to continue the exposure (see Fig.
9.29B). The neurovascular structures in Guyon’s canal are
surrounded by a thick fat pad and must be carefully identi-
fied in this fat. The ulnar nerve divides into its motor and
sensory components in the region of the pisiform (see Fig.
9.29C). Just distal to this division there are numerous
branches to the skin as well as to the palmaris brevis muscle
(see Fig. 9.29D). The motor component courses dorsally
around the base of the hook process (hamulus) of the
hamate, where it is at risk for injury during excision of the
hamulus (see Fig. 9.29E). The main trunk of the ulnar
artery continues distally after this branch to form the super-
ficial palmar arch (59).
ANATOMIC VARIATIONS
Fourth Carpometacarpal Joint
Of the second to fifth carpometacarpal joints, the fourth
articulation demonstrates the greatest skeletal morphologic
variability (60,61). Viegas and colleagues have described
five different shapes to the base of this metacarpal: (a) a
broad base that articulates with the hamate and one dorsal
FIGURE 9.30. Type I and II lunate configurations. (After Viegas SF. Variations in the skeletal mor-
phological features of the wrist. Clin Orthop 383:21–31, 2001, with permission.)
9 Wrist 527
facet extension that articulates with the capitate (39% of
specimens); (b) a broad base that articulates with the
hamate and two facet extensions (one dorsal and one pal-
mar) that articulate with the capitate (8% of specimens); (c)
a relatively narrow base that articulates only with the
hamate (9% of specimens); (d) a relatively narrow base that
articulates with the hamate and a separate single dorsal facet
that articulates with the capitate (34% of specimens); and
(e) a large base that articulates with the hamate and the cap-
itate but without any separate dorsal or palmar facets (9%
of specimens) (60,61).
Mid-Carpal Joint
In addition to double ossification centers for the lunate
(62,63), total absence of the lunate has been reported
(64). Carpal coalitions of the lunate are discussed in a fol-
lowing section. Ossification of the lunate may be delayed
in syndromes such as epiphyseal dysplasias and homo-
cystinuria (65). Two types of lunates have been identified
based on the presence or absence of a medial facet and the
alignment of the lunate to the capitate (60,66). Type I
does not have a medial facet, and type II has a medial
(ulnar) facet that articulates with the hamate (Fig. 9.30).
The size of this medial facet may range from a shallow, 1-
mm facet to a deep, 6-mm facet (66). In type II lunates,
Viegas et al. noted significant cartilage erosion with
exposed subchondral bone at the proximal pole of the
hamate in 44% of their dissections, compared with a 0%
to 2% incidence in type I lunates (66). A companion
study of the kinematics of wrist has shown significant dif-
ferences between wrists with type I and type II lunate
bones (67).
528 Regional Anatomy
A second area of variability in the mid-carpal joint has
been found at the distal articulation of the scaphoid (68). In
81% of the scaphoids studied, there was a distinct and sep-
arate facet for the trapezoid articulation and another dis-
tinct facet for the trapezium, with an interfacet ridge that
was visible and palpable in 56% of the wrists. In the
remaining 19% of the scaphoids, there was a smooth distal
articular surface without an interfacet ridge (68).
A third area of variability relates to the variations in the
shape of the lunate at its proximal aspect. Based on the
studies of Shepherd, Taleisnik, and Atuna Zapico, three
types of lunate have been identified (69–71). In a study of
100 lunate bones, Atuna Zapico noted that when viewed
from the palmar aspect, some lunates were largely rectan-
gular, whereas in others the proximal and ulnar surfaces
formed a peak or apex, resulting in a conical shape. Atuna
Zapico proposed an angle of inclination as an expression of
these variations. The angle is drawn between the lateral
(scaphoid) and proximal (radial) surfaces (Fig. 9.31). Based
on this concept of angles, Atuna Zapico classified the lunate
into three types: in type I, the angle of inclination was 130
degrees or more (30% of his specimens); in type II, the
angle of inclination was approximately 100 degrees (50%);
and type III, the least common (18%), was characterized by
FIGURE 9.31. Lunate angles of inclination, types I to III. (After Atuna Zapico JM. Malacia del
semilunar. Doctoral Thesis, Universidad de Valladolid, Spain, 1966, with permission.)
two distinct proximal facets, one for the radius and one for
the TFC (71).
Proximal Wrist Joint
Viegas et al. identified a plica in the proximal wrist arising
from the dorsal capsule and the interfossal ridge of the
radius in 4% of 393 wrists (72).
Clinical Significance
This plica can be seen arthroscopically, and the arthro-
scopist who is not aware of its existence may be disoriented
the first time it is encountered (60,72).
Carpal Coalitions
Carpal coalitions usually are diagnosed as asymptomatic,
incidental radiologic findings, and are more common in
blacks than whites. Familial predisposition and bilaterality
are common (73). Lunotriquetral coalition is the most
common carpal coalition, and has been divided into four
types by de Villiers Minaar (74). Type I is a proximal
pseudarthrosis of the lunotriquetral junction; type II is a

proximal osseous bridge with a distal notch; type III is a
complete fusion; and type IV is fusion with other “carpal
anomalies.” In a series of 36 cases, Delaney and Eswar
found 32 cases of lunotriquetral coalition, 2 capitohamate,
1 scapholunate, and 1 trapeziocapitate (73). Bilateral capi-
tohamate coalition has been reported as a rare coincidence
with extensor digitorum brevis manus (75).
Bipartite Scaphoid
True or congenital bipartite scaphoid is a developmental
anomaly of the carpal scaphoid that was first described by
Gruber in 1877 (76). Its existence has been challenged by
others who have suggested that it represents a pseudarthro-
sis after a fracture of the waist of the scaphoid (77). A doc-
umented bilateral case followed from early ossification to
skeletal maturity has established a more objective basis for
suggesting that congenital bipartite scaphoid is a true devel-
opmental condition (78). On magnetic resonance imaging,
this bilateral case revealed cartilage surrounding the cir-
cumference of the bipartite scaphoids and the absence of
degenerative changes. The incidence of congenital bipartite
scaphoid probably is less than 0.5% (78).
Bipartite Hamulus (Hook Process of the
Hamate)
Although the name hamate is derived from the Latin hamu-
lus, meaning “hook,” hamulus as used in this brief discus-
sion refers to the hook process of the hamate bone. The
hamate normally has one ossification center that begins to
ossify at the end of the third month. Bipartite hamulus is a
rare condition. Bogart reported 1 case in 1,452 routine
wrist radiographs over an 8-year period (79). Dwight in
1907 stated that Thelineus might have been the first to
describe this condition (80). Both Wilson and Hart and
Gaynor reported single cases of bipartite hamulus, and rec-
ommended carpal tunnel views to make this diagnosis
(81,82). A bipartite hamulus has been reported in associa-
tion with ulnar tunnel syndrome (83). Kohler and Zimmer
in 1956 described several peculiarities of the hamate,
including the fact that the hamulus (hook process) may
remain separate from the body of the hamate to form an os
hamuli proprium, which may give the impression of an
accessory bone or fracture at first glance (63) (see the dis-
cussion of the hamate in Chapter 1).
Clinical Significance
A bipartite hamulus may be confused with a fracture of the
normal hamulus. It is important to distinguish between
these two conditions because excision of displaced or
nonunited fractures of the hook process currently is the
treatment of choice to avoid late complications such as ten-
don rupture (84).
9 Wrist 529
Accessory Ossicles
Accessory ossicles are discussed with each upper extremity
bone in Chapter 1, and only one carpal accessory bone is
discussed here.
Os Centrale Carpi
This bone is said to be the most common carpal accessory
bone (85). The os centrale is an additional or accessory ossi-
fication center located at the distal and ulnar aspect of the
scaphoid that fails to unite with the scaphoid and thus
forms an accessory carpal bone. It rarely may fuse with the
capitate or trapezoid (86). It usually appears in the sixth
week of gestation and fuses with the main body of the
scaphoid in the eighth week. It remains as a small, irregular
prominence in the adult scaphoid on the distal and ulnar
aspect (70).
Clinical Significance
An os centrale carpi may be confused with a scaphoid
nonunion or bipartite scaphoid. A tomogram or computed
tomography scan is recommended to differentiate these
entities (86,87).
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SUGGESTED READING
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Hand Ther 9(2):84–93, 1996.
Berger RA. The ligaments of the wrist. a current overview of anatomy
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human wrist joint: a roentgenstereophotogrammetric analysis. J
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complex: an anatomic and biomechanical study. J Hand Surg
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Landsmeer JMF. Atlas of anatomy of the hand. New York: Churchill
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period. Anat Rec 166:499–516, 1970.
Lewis OJ, Hamshire JR, Bucknill TM. The anatomy of the wrist
joint. J Anat 106:539–552, 1970.
Mizuseki T, Ikuta Y. The dorsal carpal ligaments: their anatomy and
function. J Hand Surg [Br] 14:91–98, 1989.
O’Rahilly R. A survey of carpal and tarsal anomalies. J Bone Joint
Surg Am 35:616–642, 1953.
O’Rahilly R. Developmental deviations in the carpus and the tarsus.
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O’Rahilly R, Meyer DB. Roentgenographic investigations of the
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 C H A P
10
HAND
JAMES R. DOYLE
P A R T
1 Muscles and Fascia: The intrinsic muscles, the thenar
PALMAR HAND
The complex and compact nature of the hand, the terminal
organ of the upper extremity, illustrates the need for a clear
understanding of the anatomy of this organ. Although the
hand cannot be functionally separated from the upper
extremity, it is the hand that obtains information from the
environment, which it passes to the brain and ultimately exe-
cutes a given function in conjunction with the remaining
components of the upper extremity. Positioning this func-
tional unit in space is made possible from a mechanical view-
point by three joints that provide a series of mobile yet con-
strained linkages that allow an extraordinary selection of
positions to achieve multiple functional demands. The most
mobile, the shoulder, is joined by the progressively less mobile
wrist and elbow joints. The unique design of the elbow and
two-bone forearm allows a significant arc of flexion and
extension as well as pronation and supination of the forearm.
The hand is under central control, mediated by specialized
end organs and nerve endings in and beneath the skin, as well
as by joint receptors. Although the hand also may be under
visual control, this modality is a less effective control method
compared with the modalities of sensibility and propriocep-
tion. Witness the effective use of the hand by a blind person
compared with the relatively poor hand function in a sighted
person with loss of sensibility due to Hansen’s disease.
DESCRIPTIVE ANATOMY OF THE PALMAR
HAND
Contents
Bone: The metacarpals and phalanges of the five rays.
Blood Vessels: The terminal branches of the radial and
ulnar arteries.
Nerves: The terminal branches of the median and ulnar
nerves.
T E R
Tendons: The extrinsic flexor tendons of the five rays.
and hypothenar muscles, and the palmar fascia.
External Landmarks
Important superficial landmarks on the palmar surface of the
hand include the pisiform bone, the thenar and hypothenar
eminences, and the thenar, proximal palmar, distal palmar,
digital, and distal wrist flexion creases (Fig. 10.1).
Pisiform Bone
The pisiform bone, located on the ulnar and palmar aspect
of the base of the hand, provides a visible and palpable land-
mark, which aids in the identification and location of the
flexor carpi ulnaris (FCU) tendon, the underlying ulnar
neurovascular bundle, and the hook process of the hamate.
Thenar and Hypothenar Eminences
The thenar eminence is formed by the abductor pollicis
brevis (APB) and flexor pollicis brevis (FPB), which overlie
the opponens pollicis (OP). The less prominent hypothenar
eminence on the ulnar side of the hand is formed by the
corresponding muscles of the small finger.
Flexion Creases
The wrist, thenar, palmar, and digital flexion creases are skin
flexion lines seen in the vicinity of synovial joints, where the
skin is attached to the underlying fascia (1). McGrouther has
shown that the fascial attachments in the palmar creases are
greatest adjacent to the creases rather than directly under the
crease (2). These creases have been recognized as useful
anatomic landmarks because of their relationship to underly-
ing structures (3). Digital creases facilitate movement of the
digits without impingement by providing “folding points” in
the skin similar to the creases in a folded road map, and
because of strong attachments to the underlying fascia, they
also provide the stability to the skin required for forceful

A
FIGURE 10.1. A, B: Landmarks of the palmar hand.
grasping. These creases may begin as flexional skin folding of
the hand during fetal development (4). Dual creases are pre-
sent at the proximal interphalangeal (PIP) joints, no doubt to
accommodate for the comparatively increased demands of
flexion at these joints compared with the metacarpopha-
langeal (MCP) and distal interphalangeal (DIP) joints. The
proximal crease at the PIP joint is the most prominent and is
the crease used in measurements to determine the location of
the underlying joint. The approximate orientation of the
creases is at right angles to the longitudinal axis of the corre-
sponding digit and parallel to the flexion–extension joint axis.
Thus, the pronounced obliquity of the thenar crease is readily
apparent, as is the lesser obliquity of the proximal and distal
palmar creases. What is not so readily apparent, however, is
the fact that only 1 of the 17 creases (the thumb MCP joint)
is directly over the corresponding joint. This relationship, in
which most of the flexion creases do not correspond to their
respective joints, is confirmed by looking at one’s own hand
and noting the fact that the proximal digital creases (some-
times called the MCP flexion creases) are between the MCP
and the PIP joints (5).
Digital Skin Creases
The distal digital skin creases are located consistently prox-
imal to their corresponding DIP joints, lying at mean dis-
10.1 Palmar Hand 533
B
tances of 7 to 7.8 mm proximal to the joint. Middle digital
flexion creases also are located consistently proximal to their
corresponding PIP joints, with mean distances ranging
from 1.6 to 2.6 mm. Proximal digital skin creases are con-
sistently located distal to their corresponding MCP joints,
with mean values ranging from 14.4 to 19.6 mm distal to
the joint. In the thumb, the interphalangeal joint flexion
crease is located proximal to the interphalangeal joint by a
mean distance of 2.2 mm, whereas the MCP flexion crease
is found to pass obliquely and directly over the MCP joint
(5).
Palmar Skin Creases
The palmar skin creases, along with the proximal digital
creases, are related to the MCP joints. Although these
creases demonstrate a variable course in the palm, the distal
palmar crease, originating on the ulnar side of the palm, is
on average 7.9 mm proximal to the small finger MCP joint,
10.3 mm proximal to the ring finger MCP joint, and 6.9
mm proximal to the long finger MCP joint. The proximal
palmar crease, originating on the radial side of the hand, is
on average 9.1 mm proximal to the index finger MCP joint,
18 mm proximal to the long finger MCP joint, and 22.1
mm proximal to the ring finger MCP joint. A straight line
drawn joining the lateral border of the proximal palmar
534 Regional Anatomy
crease and the medial aspect of the distal palmar crease
accurately identifies the location of the metacarpal necks in
most hands. (5)
Thenar Crease
The thenar crease usually intersects the lateral side of the
proximal palmar crease and curves obliquely across the
palm to intersect the distal wrist crease near the wrist cen-
ter. In the mid-portion of the palm, the thenar crease is
located directly over the long finger metacarpal over half the
time. In the proximal palm, the thenar crease crosses the
capitate nearly half the time and the trapezoid approxi-
mately one-third of the time. Mean distance from the
thenar crease to the center of the trapeziometacarpal joint is
22.6 mm. The thenar crease passes 18.7 mm from the
hamate hook on the medial side of the carpus (5).
Distal Wrist Crease
Although there usually are three wrist flexion creases, only the
distal crease is of sufficient consistency to be used as a reliable
landmark. The distal wrist crease is located over the proximal
carpal row and passes over the scaphoid waist in almost all
instances and over the pisiform 80% of the time. The lunate
is consistently proximal to the distal wrist crease, with its cen-
ter being an average of 9.2 mm from the crease. The radio-
carpal joint is 13.5 mm proximal to the distal wrist crease, and
the center point of the distal radioulnar joint is 21.1 mm
proximal to the wrist crease. On the lateral side of the wrist,
the distal wrist crease is within 1 mm of the center of the
scaphoid waist. The mid-portion of the trapeziometacarpal
joint averages 19.4 mm distal to the distal wrist crease. On the
ulnar side of the wrist, the pisiform is directly under or slightly
distal to the crease. The base of the ulnar styloid is on average
11.7 mm proximal to the distal wrist crease (Fig. 10.2).
FIGURE 10.2. Digital, palmar, thenar,
and wrist flexion creases and their rela-
tionship to the underlying joints and
bones.

FIGURE 10.3. Relationship of deeper structures to skin reference lines. Kaplan described a
unique system of lines drawn on the palmar side of the hand that coincided with important
deeper structures (6). These lines may facilitate the recall and identification of important deeper
structures in the hand.
Relationship of Deeper Structures to
Superficial Landmarks
Kaplan described a unique system of lines drawn on the pal-
mar side of the hand that coincided with important deeper
structures (6). These lines may facilitate the recall and iden-
tification of important deeper structures in the hand. These
lines and corresponding underlying structures are depicted
in Figure 10.3.
Skeletal Anatomy
The Five Rays of the Hand
Thumb
The thumb is a continuation of the lateral column of the
carpus formed by the scaphoid and trapezium. The trapez-
ium and scaphoid longitudinal axis is at a 45-degree angle
to the index metacarpal and the carpus, which accounts for
the functional separation between the first and second rays.
This position and the sellar configuration of the trapezio-
10.1 Palmar Hand 535
metacarpal joint allows the thumb to oppose the tips of the
digits for pinch.
Thumb Metacarpal. The thumb metacarpal is short and
thick. Its dorsal or extensor surface is transversely convex
and the palmar or medial surface is longitudinally concave.
Fingers
Each of the four fingers is of different length. In flexion, the
centrally positioned long finger flexes in a line parallel with
the long axis of the hand, whereas the index, ring, and small
fingers converge toward the central digit. This may be con-
firmed by comparing finger motion in one’s own hand and
by noting the transverse orientation of the proximal digital
flexion crease of the long finger compared with the pro-
gressively oblique orientation of the index, ring, and small
fingers. Each of the MCP flexion creases are at approximate
right angles to the longitudinal arc of motion and thus con-
firm the fact that the longitudinal arcs of motion of the
index, ring, and small fingers are convergent (see Fig. 10.2).
536 Regional Anatomy
The obliquity of the proximal and distal palmar creases
(which converge in flexion) roughly parallels the oblique
transverse palmar axis, which forms an angle of 75 degrees
with the longitudinal axis of the long finger ray.
Index Metacarpal. The index metacarpal is the longest of
the metacarpals and has the largest base. The shaft is trian-
gular and longitudinally concave toward the palm. The dis-
tal dorsal surface is broad but proximally narrows to a
ridge.
Long Finger Metacarpal. The shaft of this metacarpal
resembles the index metacarpal. A short proximal styloid
process is present dorsally and laterally. The extensor carpi
radialis brevis (ECRB) attaches distal to this styloid process.
Ring Finger Metacarpal. The ring finger metacarpal is
shorter and thinner than the index and long fingers, but the
shaft is similar in configuration to the index finger.
Small Finger Metacarpal. The small finger metacarpal
differs on its medial surface, which is nonarticular and has
a tubercle for attachment of the extensor carpi ulnaris
(ECU). The shaft has a triangular dorsal area that almost
reaches the base.
Longitudinal and Transverse Arches
The normal hand is “cupped” in both its long and trans-
verse axes. The static aspects of this transverse cupping are
FIGURE 10.4. Longitudinal and transverse arches of the hand.
The normal hand is “cupped” in both its long and transverse
axes.
accounted for by the prominence of the thenar and
hypothenar eminences as well as by the transverse osseous
arches at the distal carpal row and at the neck of the
metacarpals. Further dynamic cupping is achieved by con-
vergent movement of the thumb and small finger. The sta-
tic aspects of the longitudinal cupping are due to the prox-
imal prominence of the thenar and hypothenar eminences
and the natural palmar concavity of the metacarpals and
phalanges. The dynamic aspects of the longitudinal cup-
ping relate to the powerful intrinsic and extrinsic flexors,
which maintain an attitude of flexion in the fingers (Fig.
10.4).
Comparative Mobility of the Metacarpals
The thumb metacarpal is the most mobile of the five
metacarpals, followed by the ring and small finger, with the
small finger ray being the most mobile of the fingers. The
comparative increased mobility of the thumb is explained
by the sellar nature of its carpometacarpal (CMC) joint,
which is discussed later. Compared with the more mobile
ring and small finger metacarpals, the index and middle fin-
ger metacarpals are relatively fixed. The comparative mobil-
ity of the ring and small finger metacarpals aids in cupping
the hand and in the mechanics of pinch between the ring
and small fingers and the thumb. This is readily demon-
strated on one’s own hand by noting the passive mobility of
the small and ring finger metacarpals compared with the
more rigid middle and index fingers, and the active mobil-
ity and palmar flexion of the small and ring finger
metacarpals when making a fist.
Phalanges of the Hand
There are 14 phalanges, 3 in each finger and 2 in the
thumb. Each has a head, shaft, and base. The shaft tapers
distally and its dorsal surface is transversely convex (1). The
palmar surface is longitudinally concave. The bases of the
proximal phalanges are concave and transversely oval to
accommodate the metacarpal head. The bases of the middle
phalanges have two concave facets arranged side by side and
separated by a vertical ridge to accommodate the dual artic-
ular condyles of the proximal phalanx. A similar but less
pronounced arrangement is present between the middle
and distal phalanges.
Carpometacarpal Joints
Thumb Carpometacarpal
Joint Type. The CMC joint of the thumb is classified as
a sellar joint, which means that its articular surfaces are
convex in one plane and concave in the second plane,
which is at approximately right angles to the first plane
(Fig. 10.5). The convexity of the larger surface is apposed
to the concavity of the smaller surface, and vice versa.
 10.1 Palmar Hand 537

to-pulp pinch with the small finger or properly grasp

objects such as a hammer. The thumb also needs to be in
neutral rotation when extended for wide grasp. If an inde-
pendent axis were used to achieve this pronation, at least
two more motors would be needed, and the base of the
thumb and the palm would be so full of thumb muscles
that grasp would be extremely awkward (7). A tendon that
crosses a two-axis joint has an effect on every hinge or axis
it crosses. Fortunately, in the normal situation, the resultant
forces are balanced, which results in stability and power
(Fig. 10.6).

FIGURE 10.5. Carpometacarpal joint of the thumb.

Although primary movements may occur in two orthog-

onal planes (flexion–extension and abduction–adduc-
tion), the articular shape also allows axial rotation (prona-
tion, supination), which is especially important in the
movement of opposition needed for pulp-to-pulp pinch
between the thumb and adjacent digits. A joint is said to
be in the position of “close pack” when its articular sur-
faces are in maximum congruence, maximum contact,
tightly compressed, or “screwed home,” and with the
joint capsule and ligaments maximally taut (1). Sellar sur-
faces are fully congruent in only one position, and in the
thumb CMC joint this position corresponds with full
opposition.

Joint Axes. The CMC joint of the thumb has two axes of
rotation, one in the trapezium (the flexion–extension axis)
and one in the thumb metacarpal (the abduction–adduc-
tion axis) (7). Two axis joints can be visualized as two hinges
welded together. If the two hinges are perpendicular to the
anatomic planes, only flexion–extension and abduction–
adduction can occur. However, if the axes of rotation are
offset (not perpendicular to the bones or to each other)
from the anatomic planes, flexion–extension may occur
with some varus/valgus and internal/external rotation. Sim-
ilarly, the second primary axis of abduction–adduction may
be associated with flexion–extension and internal/external
rotation. It is the offset of the hinges or axes that allows the
thumb to pronate with flexion and thus to perform pulp- FIGURE 10.6. Joint axes of the CMC joint of the thumb.
538 Regional Anatomy

Stabilizing Ligaments of the Carpometacarpal Joint of
the Thumb. In the CMC joint of the thumb, ligaments
provide joint stability during pinch and grasp (8). Loss of
ligamentous support is believed to be a primary cause of
degenerative arthritis (8–10). Based on a study of 30 hands,
Imaeda et al. identified five main ligaments as supporting
structures of the thumb CMC joint. Three were found to
be intracapsular, and two extracapsular (8). A more recent
study of 37 hands from the same laboratory divided 2 of the
initially described ligaments (anterior oblique and inter-
metacarpal) into 2 distinct ligaments, making a total of 7
stabilizing ligaments of the CMC joint of the thumb (11).
In both the Imaeda et al. and Bettinger et al. studies, the rel-
ative laxity or tautness of each ligament was tested in a vari-
ety of positions and the origin and insertion of each liga-
ment were determined. In the Imaeda et al. study, the status
of each ligament was correlated with the Eaton stage of
arthritis noted in the joint (8,12). The more recent study by
Bettinger et al. is presented in Table 10.1 and includes their
nomenclature and the origin, insertion, width, thickness,
and prevalence of the stabilizing ligaments of the thumb
CMC joint. The following descriptive comments are based
on the studies of the thumb CMC joint ligaments by
Imaeda et al. and Bettinger et al. (8,11).
Superficial Anterior Oblique Ligament. The superficial ante-
rior oblique ligament (SAOL) is a thick, broad structure
that is taut at the extremes of rotation, especially pronation,
and while the joint is extended (11). In addition, the SAOL
limits palmar subluxation in pronation, supination, or neu-
tral. Except in maximal extension, this ligament appears lax
and redundant in all hands regardless of the amount of
articular thinning or frank eburnation of the joint. This
may reflect the laxity required to accommodate pronation
during thumb opposition (11).
Deep Anterior Oblique Ligament. The deep anterior oblique
ligament (DAOL), also known as the beak ligament, is deep
to the SAOL and can be easily separated from it when
approached from within the CMC joint. It is said to be an
intraarticular ligament that lies in the concavity of the trapez-
ium, and is the closest ligament to the center of the joint. It
serves as a pivot point for rotation, specifically pronation; it
becomes taut in wide abduction or extension.
The DAOL prevents extreme ulnar subluxation during
abduction loading. Both the DAOL and SAOL stabilize the
thumb metacarpal against palmar subluxation. The DAOL is
taut in pronation and wide palmar and radial abduction (11).
Author’s comment: In the Imaeda et al. study, the SAOL
and DAOL were considered to be one ligament, the anterior
oblique ligament (AOL) (8). The AOL was consistently
observed in 24 normal joints of the 30 hands studied. In
seven specimens with degenerative changes, the AOL was
normal in one case of Eaton stage II, attenuated in three cases
(two cases of Eaton stage III and one case of Eaton stage IV),
and completely destroyed in two specimens in which adduc-
tion contracture was present (Eaton stage IV) (8).
Ulnar Collateral Ligament. The ulnar collateral ligament
(UCL) is an extracapsular ligament and is taut in extension,
abduction, and pronation. The UCL is slightly ulnar
(medial) to the SAOL, which it partially covers (11). In the
Imaeda et al. study, specimens with degenerative arthritis
demonstrated a consistently present ligament, but it usually
was elongated (8).
Palmar Intermetacarpal Ligament. The palmar component
of the intermetacarpal ligament (IML) is extracapsular and
is taut in abduction, opposition, and supination. It stabi-
lizes the thumb metacarpal during radiopalmar translation
of its base (11).
Dorsal Intermetacarpal Ligament. The dorsal component of
the IML (DIML) is an extracapsular ligament, and like the
palmar component is transversely oriented between the base
of the thumb and index metacarpals. It becomes taut in

TABLE 10.1. STABILIZING LIGAMENTS OF THE CARPOMETACARPAL JOINT OF THE THUMB

Ligament Prevalence Origin Insertion Width (mm) Thickness (mm)

SAOL 100% Palmar tubercle trapezium Palmar-ulnar metacarpal 8.59 ± 2.61 1.34 ± 0.25
DAOLa 70% Palmar tubercle trapezium Palmar-ulnar metacarpal 5.45 ± 0.45 1.17 ± 0.15
UCL 100% Transverse carpal ligament Palmar-ulnar metacarpal 3.35 ± 0.33 0.83 ± 0.12
DRL 100% Dorsoradial trapezium Dorsal base first metacarpal 11.39 ± 1.92 2.25 ± 0.33
POL 100% Dorsoulnar trapezium Dorsoulnar first metacarpal 4.97 ± 0.89 1.35 ± 0.28
IML 100% Dorsoradial 2nd metacarpal Palmar-ulnar first metacarpal 3.47 ± 1.26 1.03 ± 0.18
DIML 43% Dorsoradial 2nd metacarpal Dorsoulnar first metacarpal 3.70 ± 0.83 1.10 ± 0.08

SAOL, superficial anterior oblique ligament; DAOL, deep anterior oblique ligament; UCL, ulnar collateral ligament; DRL, dorsal radial ligament;
POL, posterior oblique ligament; IML, intermetacarpal ligament; DIML, dorsal intermetacarpal ligament.
aAttaches to articular margins of the trapezium and first metacarpal deep to SAOL.

After Bettinger PC, Linscheid RL, Berger RA, et al. An anatomic study of the stabilizing ligaments of the trapezium and trapeziometacarpal
joint. J Hand Surg [Am] 24:786–798, 1999.
 10.1 Palmar Hand 539

pronation and with dorsal and radial translation of the base
of the thumb metacarpal, and appears primarily to restrain
pronation of the thumb metacarpal (11).
Author’s note: In the Imaeda et al. (8) study, the ligament
complex between the base of the thumb and index
metacarpal was considered to be one ligament, the IML. In
23 of 30 specimens, it was a moderately thin structure and
its appearance did not correlate with the degree of degener-
ative joint changes. In the other 7 specimens, the IML was
large and resembled the fan portion of the collateral liga-
ment of the PIP joint. At the medial side of the CMC joint,
the IML and UCL form an L-shaped ligament that is an
important secondary stabilizer of the CMC joint.
Dorsoradial Ligament. This capsular ligament is the widest
and thickest of the stabilizing ligaments of the CMC joint
of the thumb. It is fan shaped and its origin on the trapez-
ium is narrower that its insertion on the metacarpal. The
dorsoradial ligament (DRL) is taut with a dorsal or dorso-
radial subluxating force in all positions of the CMC joint
except full extension. In addition, the DRL tightens in
supination regardless of joint position and tightens in
pronation when the CMC joint is concomitantly flexed.
According to Imaeda et al., it appears to serve mainly as a
check-rein to lateral CMC subluxation or dislocation (8).
Laxity of this ligament was observed only in Eaton stage IV
osteoarthritis (8) (Fig. 10.7).

Posterior Oblique Ligament. The posterior oblique ligament
(POL) is a capsular ligament and is partially covered by the
extensor pollicis longus (EPL) tendon. The POL is taut at
the extremes of abduction, opposition, and supination and
resists ulnar translation of the metacarpal base during
abduction and opposition (11). No attenuation of the liga-
ment was seen in arthritic specimens (8).
Clinical Significance. Imaeda et al. concluded that although
there is no single ligament that provides sole joint stability
in a normal thumb CMC joint, the AOL appears to be the
most important ligament and is commonly attenuated in
cases of arthritis (8). The IML (Imaeda et al. classification),
the POL, and the UCL are secondary stabilizers that
become attenuated after failure of the primary stabilizer, the

A B C
FIGURE 10.7. A–C: Carpometacarpal thumb joint ligaments. Dorsal view (B), Palmar view (C).
SAOL, superficial anterior oblique ligament; DAOL, deep anterior oblique ligament; AOL, ante-
rior oblique ligament; UCL, ulnar collateral ligament; IML, intermetacarpal ligament; DIML, dor-
sal intermetacarpal ligament; POL, posterior oblique ligament; DRL, dorsoradial ligament.
(Redrawn after Imaeda T, Kai-Nan A, Cooney WP III, et al. Anatomy of trapeziometacarpal liga-
ments. J Hand Surg [Am] 18:226–231, 1993, and Bettinger PC, Linscheid RL, Berger RA, et al. An
anatomic study of the stabilizing ligaments of the trapezium and trapeziometacarpal joint. J
Hand Surg [Am] 24:786–798, 1999, with permission.)
540 Regional Anatomy
AOL. The DRL acts as a check-rein for gross radiodorsal
subluxation or dislocation, but probably does not play a
major role in the initial stages of CMC joint instability. In
a normal joint, the direction of the resultant force in tip
pinch is directed radiodorsally and proximally (13). Com-
pression forces may reach 13 times the applied load. In
addition, shear forces may reach 2.5 to 3 times the applied
load and torsional loading of 4 to 6 kg/cm can produce
instability of the CMC joint of the thumb, which can be
resisted only by strong support from ligaments on the
medial side of the CMC joint of the thumb (8). Pellegrini
noted a strong association between advanced degenerative
arthritis and deterioration of what he calls the beak ligament
(10). This so-called beak ligament, the AOL (Imaeda et al.
classification) (8), and the DAOL (Bettinger et al. classifi-
cation) (11) in all probability are the same structure.
Author’s note: Anatomic studies have identified five to
seven stabilizing ligaments about the CMC joint of the
thumb. Relative importance has been given to these liga-
ments based on (a) observing the tautness of the ligaments
in various positions of the thumb metacarpal; (b) measur-
ing the length, width, thickness, and prevalence of the var-
ious ligaments; and (c) correlating the status of the liga-
ments in relationship to the presence and degree of arthritic
changes in the CMC joint (8,11). Future studies may
include serial sectioning of various ligaments to note the
effect on stability (11). In addition, a currently used and
established technique for restoration of ligamentous stabil-
ity at the thumb CMC joint reconstructs the palmar liga-
mentous complex as well as some element of the dorsal lig-
ament by means of a tendon graft (14). If the concept is
correct that ligament morphology (cross-sectional area),
fiber direction, and location reflect to some degree func-
tional demand secondary to direction and amount of force,
then relative importance may be attached to each of the lig-
aments. The fact that the Eaton and Littler reconstruction
is successful in restoring thumb CMC joint stability may
reflect this concept and allow the conclusion that both pal-
mar and dorsal ligaments are necessary to stabilize this com-
plex joint. Based on this concept, the palmar ligamentous
complex (AOL) and the DRL may be the primary stabiliz-
ers of the thumb CMC joint. Further information about
the relative stabilizing effect of all of the ligaments about
the CMC joint may come from evaluation of the ligament
status in acute as well as chronic subluxation or dislocation
of this joint.
Small to Index Finger Carpometacarpal Joints
Small. Examination of the CMC joints of the fingers
reveals that the small and ring finger CMC joints are
hinge joints, with the hamate presenting two concavities
for the convex bases of the small and ring fingers (1). The
lateral basal surface of the small finger metacarpal is trans-
versely concave and convex from palmar to dorsal, and
articulates with a shallow concavity in the hamate. The
medial side is nonarticular and has a tubercle for attach-
ment of the ECU.
Ring. The quadrangular articular surface of the ring finger
metacarpal, which articulates with the hamate, is convex
palmarly and concave dorsally.
Middle. The capitate has a comparatively plane base for
the middle finger metacarpal. The middle finger metacarpal
has a short styloid process that projects proximally from the
dorsal and lateral surface and is proximal to the attachment
of the ECRB.
Index. The index metacarpal is mortised between the cap-
itate and trapezium, and further stability is added by an
anteroposteriorly directed ridge on the trapezoid that fits
like a wedge into the base of the index metacarpal. The
index metacarpal is the longest and has the largest base.
Comparative Finger Carpometacarpal Joint Stability/
Mobility. The comparative stability of the index and espe-
cially middle finger metacarpal with the more mobile ring
and small finger metacarpals may be understood by noting
the CMC joint configurations of the fingers as just
described. The middle finger metacarpal is like a fixed keel
or spine that supports the movement of the more mobile
adjacent digits and thumb.
Ligaments. Dorsal. Prominent dorsal ligaments connect the
dorsal surfaces of the carpal and metacarpal bones. The index
metacarpal has two, one each from the trapezium and trape-
zoid. The middle finger also has two, one from the trapezoid
and one from the capitate. The ring finger has two ligaments,
one from the capitate and one from the hamate. The small
finger metacarpal has a single band from the hamate that is
continuous with a single palmar ligament (1).
Palmar. The palmar ligaments are similar except that the
middle metacarpal has three ligaments, a lateral from the
trapezium, an intermediate from the capitate, and a medial
from the hamate.
Interosseous. Interosseous ligaments are present between the
distal aspect of the capitate and hamate and the adjacent
surfaces of the ring and small finger metacarpals.
Intermetacarpal Joints
The second to fifth metacarpal bases articulate with each
other by small, cartilage-covered facets. These articulations
are connected by dorsal, palmar, and interosseous ligaments.
Thumb Metacarpophalangeal Joint
Joint Type. The MCP joint of the thumb is classified as an
ellipsoid joint, which is characterized by an oval convex sur-

face proximally that is opposed to an elliptical concavity
distally (1).
Joint Motion. The primary arc of motion is flexion and
extension, although limited abduction–adduction and pro-
nation–supination is present. The metacarpal heads of the
thumb and the fingers are not uniformly convex but are
adapted to shallow concavities on the base of the adjacent
phalanges. The convex metacarpal head is partially divided
on the palmar surface and thus almost bicondylar (1). The
distal articular surface of the thumb metacarpal, when
viewed from the dorsopalmar aspect, is only slightly curved,
in contrast to the finger metacarpals, which demonstrate a
significant curvature. This shape coincides with the limited
abduction–adduction seen in the MCP joint of the thumb.
Shape of the Articular Head of the Thumb Metacarpal.
The shape of the distal articular aspect of the thumb
metacarpal is different from the finger metacarpals in that
its dorsal side is slightly wider than the palmar side, and also
in that the articular surface is divided into two zones: one
that articulates with the proximal phalanx and another,
more palmar, that articulates with the sesamoids in the pal-
mar plate (6) (Fig. 10.8). The radial condyle of the
A B
FIGURE 10.8. Shape of the articular head of the thumb
metacarpal. The shape of the distal articular aspect of the thumb
metacarpal (A) is different from the finger metacarpals (B) in
that (a) its curvature in the anteroposterior plane is flatter; (b) its
dorsal side is slightly wider than the palmar side; (c) its articular
surface is divided into two zones, one that articulates with the
proximal phalanx and the other, more palmar, with the
sesamoids in the palmar plate; (d) the radial condyle of the
metacarpal head has greater dorsal-palmar height than the
ulnar condyle, which allows some pronation of the proximal and
distal phalanges during flexion.
10.1 Palmar Hand 541
metacarpal head has greater dorsopalmar height than the
ulnar, which allows some pronation of the proximal and
distal phalanges during flexion. Range of flexion varies from
thumb to thumb and is due to the variation in curvature of
the metacarpal head; more spherical heads are associated
with greater motion (15). There also is an increased inci-
dence of soft tissue injury in joints with poor range of flex-
ion (16).
Thumb Metacarpophalangeal Joint Stability. The MCP
joint of the thumb is stabilized by its capsule, ligaments,
and surrounding musculotendinous structures, and has lit-
tle intrinsic stability from its shape (15).
Joint Axes. Many joints such as the wrist, CMC, and MCP
joints have two axes of rotation that allow greater freedom
of movement (7). The flexion–extension axis is in the
metacarpal passing under the epicondyles, and the abduc-
tion–adduction axis passes between the sesamoids just prox-
imal to the beak of the proximal phalanx (7).
Ligaments. Palmar Plate. The palmar plate of the thumb
MCP joint is a thick, fibrocartilaginous structure that is
firmly attached to the base of the proximal phalanx and
forms the bottom of a two-sided box. The sides of the box
are made up of the collateral ligaments. The palmar plate
contains a radial and an ulnar sesamoid that articulate with
the palmar surface of the thumb metacarpal. These
sesamoid bones are buried in the substance of the palmar
plate, and their exposed dorsal articular surfaces are flush
with the inner surface of the palmar plate, covered with
hyaline cartilage, and articulate with the palmar facets on
the adjacent metacarpal head. The ulnar sesamoid is the
largest and its exposed palmar surface, which partially pro-
jects from the palmar plate, provides an insertion point for
a portion of the adductor pollicis. The smaller radial
sesamoid, which is similarly arranged in the palmar plate,
provides an insertion point for the tendon of the superficial
head of the FPB. In contrast to the largest sesamoid in the
body, the patella, which is imbedded in tendon (quadriceps
femoris), the hand sesamoid bones are imbedded in palmar
plates, and in the thumb provide attachments for tendons.
The palmar plate sesamoids in the thumb appear to provide
a stronger point of tendon attachment than the fibrocarti-
laginous palmar plate. The sesamoids also may react more
favorably than the fibrocartilaginous palmar plate to com-
pression or other forces during joint movement.
Collateral Ligaments. The collateral ligaments of the MCP
joint of the thumb and fingers as well as the PIP and DIP
joints are divided into proper and accessory collateral liga-
ments (17). The proper collateral ligaments are composed
of strong, substantial cords that flank the joints, arise from
the posterior tubercle and adjacent pit on the side of the
metacarpal head, and insert on the palmar aspect of the
542 Regional Anatomy
FIGURE 10.9. The mean locations of the origin and insertion of
the proper ulnar collateral ligament. (Redrawn after Bean CHG,
Tencer AF, Trumble TE. The effect of thumb metacarpopha-
langeal ulnar collateral ligament attachment site on joint range
of motion: an in vitro study. J Hand Surg [Am] 24:283–287, 1999,
with permission.)
adjacent phalanx. The accessory collateral ligaments span
between the cordlike proper collateral ligaments and the
palmar plate. The proper collateral ligaments become taut
in flexion because of the camlike arrangement of the
metacarpal head, as seen in the sagittal plane in both the
thumb and fingers because the palmar surface of the
metacarpal is wider than the dorsal surface. In contrast, the
accessory collateral ligaments are slack in full flexion. The
mean locations of the origin and insertion of the proper
UCL have been determined and are given in Figure 10.9.
The clinical significance of these findings are discussed in
the Clinical Correlations section.
Finger Metacarpophalangeal Joint
Joint Type. The finger MCP joints are structurally similar
to the thumb MCP joint. However, there is increased range
of abduction–adduction in the fingers compared with the
MCP joint of the thumb. The finger MCP joints are ellip-
soid joints characterized by an oval convex surface that is
apposed to an elliptical but shallow concavity. The
metacarpal condyle, which has a larger anteroposterior axis
(resulting in a so-called cam effect), articulates with the base
of the proximal phalanx, which is smaller and concave and
has a larger transverse axis. This configuration permits a sig-
nificant arc of flexion–extension as well as abduction–
adduction.
Joint Axes. Primary motion is about two orthogonal axes
(e.g., flexion–extension and abduction–adduction), which
may be combined as circumduction. When the MCP joints
are flexed, neither abduction nor adduction is possible
because the articular surface of the metacarpal is relatively
flat on the palmar surface and the collateral ligaments are
tight in flexion because of their eccentric attachments to the
heads of the metacarpals and the resultant camlike effect of
this arrangement (18). In addition, the palmar surface of
the finger metacarpal heads is wider than the dorsal side,
which also accounts for increased tension in the proper col-
lateral ligaments when the joint is flexed. In contrast, the
accessory collateral ligaments are slack in full flexion.
Ligaments. Palmar Plate. The finger MCP palmar plates
are thick, dense fibrocartilaginous structures attached
firmly to the palmar base of the proximal phalanx and the
neck of the metacarpals. The attachment to the
metacarpals is by (a) the vertical fibers of the accessory
collateral ligaments, which span between the lateral and
medial margins of the palmar plate and attach to the pal-
mar side of the proper collateral ligaments and the site of
origin of the proper collateral ligament; (b) the deep trans-
verse IMLs, which are contiguous with the palmar plate
on each side; and (c) obliquely oriented fibers that arise
from the proximal corners of the palmar plate and attach
to the interosseous fascia. The arrangement of the verti-
cally oriented accessory collateral ligaments may be com-
pared with the vertical element of a pendulum, which
allows the counterweight or pendulum to swing to and fro
in a constrained arc. A somewhat similar arrangement is
present between the sagittal bands that course between the
extensor tendon and the sides of the palmar plate. Side or
lateral stability is provided by the attachments of the
transverse metacarpal ligaments, and proximal restraint by
the corner ligaments (Fig. 10.10). This arrangement,
along with the compressibility of the MCP palmar plate,
allows flexion of the MCP joint without impingement of
the palmar plate. The comparative morphology and inter-
nal structure of the palmar plates of the MCP and PIP
joints is of significance, and Watson and Dhillon have
stated that the MCP palmar plate, because of its fiber
arrangement, is compressible by as much as one-third of
its length, whereas the PIP palmar plate is more rigid (19).
This concept, as well as differences between the palmar
plates of the MCP and PIP joints, was studied by Gagnon
and associates, who noted (a) the mean MCP palmar plate
length was twice the length of the PIP joint palmar plate
(11.2 ± 1.62 mm vs. 5.6 ± 1.35 mm); (b) the mean thick-
ness of the MCP palmar plate was 0.3 mm thinner than
the PIP palmar plate; and (c) the MCP palmar plate short-
ened 33.8% compared with 26.6% for the PIP palmar
plate during 90 degrees of flexion. Light and electron
microscopic examination of the MCP palmar plate
revealed loose connective tissue arranged in disorganized
strands, compared with the PIP joint palmar plate, which
consisted of more dense, homogeneous connective tissue.
Both palmar plates were relatively avascular and there was
no significant difference in cellularity either as to size or
numbers. Plate migration revealed that the MCP plate
migrated a mean of 7.85 mm or 79% of its length,
 10.1 Palmar Hand 543

FIGURE 10.10. Finger metacarpophalangeal (MCP) joint complex. A: Note the

proper and accessory collateral ligaments, the palmar plate, and proximal
annular pulleys. B: Note the extensor tendon, sagittal band, and transverse
metacarpal ligament. C: Fresh cadaver dissection, right middle finger palmar
view, looking distally, showing the palmar plate, the transverse metacarpal lig-
ament, and the proximal check-rein ligaments from the palmar plate. (contin-
C ued on next page)
 544 Regional Anatomy

FIGURE 10.10. (continued) D: Radial collat-

eral ligament (RCL) complex, MCP joint of right
index finger, showing comparative laxity of the
RCL in extension. E: RCL of same digit in flexion
showing comparative tightness in the ligament.
F: Base of proximal phalanx of right index fin-
ger with metacarpal removed, showing boxlike
arrangement of palmar plate and collateral lig-
ament complex (green marks). Note also the
articular depression in the RCL complex to
accommodate the radial condyle of the
F metacarpal.

whereas the PIP plate migrated a mean distance of 6.39
mm or 139% of its initial length with 90 degrees of flex-
ion. The fact that the PIP palmar plate is less compressible
probably accounts for its greater proximal migration (20).
The anatomic differences in the MCP and PIP palmar
plates, along with the presence of the more rigidly attached
check-rein ligaments at the PIP joint, may explain the
greater tendency of the PIP joint to develop palmar plate
contracture.
Transverse Metacarpal Ligaments. Three short, wide
fibrous bands connect the palmar plates of the index to
small finger metacarpals and prevent the metacarpals
from spreading. These ligaments often are referred to as
the deep transverse IMLs, perhaps to distinguish them
from the natatory ligaments, which are called the superfi-
cial transverse metacarpal ligaments. The convention
adopted in this text is transverse metacarpal ligaments and
natatory ligaments.
Collateral Ligaments. The collateral ligaments of the MCP
joint of the thumb and fingers as well as the PIP and DIP
joints are divided into proper and accessory collateral lig-
aments (17). The proper collateral ligaments are com-
posed of strong, obliquely oriented cords that flank the
joints and that arise from the posterior tubercle and adja-
cent pit on the side of the metacarpal head and insert on
the palmar aspect of the adjacent phalanx. The accessory
collateral ligaments are more vertical and course between
the cordlike proper collateral ligaments and the palmar
plate.
Clinical Significance. In the finger MCP joints, the cordlike
components of the collateral ligaments become taut in flex-
ion because of the camlike arrangement of the metacarpal
10.1 Palmar Hand 545
TABLE 10.2. RADIAL AND ULNAR DEVIATION OF
THE FINGERS
Radial Deviation Ulnar Deviation
Digit (Degrees) (Degrees)
Index 13 43
Middle 8 34.5
Ring 14 20
Little 19 33
head in the sagittal plane and because the palmar surface of
the metacarpal is wider than the dorsal surface. This
explains why abduction–adduction movements are limited
in flexion and free in extension and why the MCP joints
should not be immobilized or allowed to remain in exten-
sion or hyperextension, which could result in irreversible
contracture (21). The asymmetry of the finger metacarpal
heads as well as the difference in length and direction of the
proper collateral ligaments explains the rotational move-
ment of the proximal phalanx during flexion–extension and
why ulnar deviation of the digits is greater than radial devi-
ation (21).
In the MCP joint of the index finger, the origin of the
radial collateral ligament (RCL) is more distal and closer to
the center of the joint space than the UCL. The radial liga-
ment is longer—thus, more ulnar deviation is permitted
than radial deviation (21). The comparative range of radial
and ulnar deviation of the fingers at the MCP joint is given
in Table 10.2.
Proximal Interphalangeal Joint
Joint Type. The PIP joints are uniaxial hinge joints (1)
(Fig. 10.11). In contrast to the finger MCP joints, the PIP
joints are stable in all positions because of strong and sym-
FIGURE 10.11. The proximal interphalangeal
(PIP) joint. The PIP joint is a uniaxial hinge joint
and, in contrast to the finger metacarpopha-
langeal joints, is stable in all positions because of
strong and symmetric proper collateral ligaments,
the palmar plate, and the osseous architecture in
the form of side-by-side concentric condyles that
articulate with matching glenoid concavities,
forming a dual shallow tongue-and-groove
arrangement.
 546 Regional Anatomy
metric proper collateral ligaments, the palmar plate, and
the osseous architecture in the form of side-by-side con-
centric condyles that articulate with matching glenoid
concavities, forming a dual shallow tongue-and-groove
arrangement.
Ligaments. Palmar Plate/Check-Rein Ligaments. The pal-
mar plate of the PIP joint is a thick, short fibrocartilaginous
structure that is firmly attached both to the base of the mid-
dle phalanx and the neck of the proximal phalanx (Fig.
10.12). The attachments to the base of the middle phalanx
are most dense at the lateral margins, where the attachment
is confluent with the insertion of the collateral ligaments.
The palmar tubercle at the base of the middle phalanx,
which is prominent on a lateral radiograph, is devoid of sig-
nificant insertion by the palmar plate. In its central 80%, the
palmar plate attaches by blending with the palmar perios-
teum of the middle phalanx. The attachments to the proxi-
mal phalanx (the check-rein ligaments) arise from bone and
begin just inside the distal edge of the second annular (A2)
pulley. The origins of the first cruciform (C1) pulley are on
the outside of the A2 pulley. The swallowtail configuration
of these proximal attachments of the palmar plate provides a
tension-relieving access route under the flexor sheath for the
branches of the digital vessels to reach the axial vincula.
Bowers et al. view the palmar plate as a static restraint limit-
ing PIP joint extension (17). Sequential sectioning of the
A cula by a route under the flexor sheath.
various components of the complex suggested that the major
static resistance to hyperextension is offered by the confluent
distal lateral insertion of the palmar plate–collateral ligament
complex, where it cups the lateral flared margin of the pha-
langeal condyle. Based on biomechanical studies, Bowers et
al. suggested that the site and nature of injury to this com-
plex depended on the rate of application of the deforming
force: Rapid rates produce rupture at the distal attachment
and slow rates attenuate the proximal check-rein ligaments.
Instability sufficient to permit dorsal dislocation occurred
only if there was interruption of the main collateral and
accessory collateral ligament complex in addition to disrup-
tion of the lateral attachments of the palmar plate from the
base of the middle phalanx (17).
Collateral Ligament. The collateral ligaments of the PIP
joints are divided into proper and accessory collateral lig-
aments (17) (Fig. 10.13). The proper collateral ligaments
are composed of strong cords that flank the joints and
arise from a concave fossa on the lateral aspect of each
condyle and then pass obliquely to insert on the palmar
side of the middle phalanx and distal-lateral margin of
the palmar plate. The accessory collateral ligaments span
between the cordlike proper collateral ligaments and the
palmar plate. The cordlike components of the collateral
ligaments demonstrate equal tension in flexion and
extension, in contrast to the proper collateral ligaments of
FIGURE 10.12. Proximal interphalangeal
(PIP) joint palmar plate and check-rein lig-
aments. A: The palmar plate of the PIP
joint is a thick, short, fibrocartilaginous
structure that is firmly attached both to
the base of the middle phalanx and the
neck of the proximal phalanx. The attach-
ments to the proximal phalanx (the check-
rein ligaments) arise from bone and begin
just inside the distal edge of the second
annular (A2) pulley. The swallowtail con-
figuration of these proximal attachments
of the palmar plate provides a tension-
relieving access route for the branches of
the digital vessels to reach the axial vin-

C must be disrupted in at least two planes.
the finger MCP joints. The key to PIP joint stability is
the strong conjoined attachment of the collateral liga-
ments and the palmar plate. This ligament–box configu-
ration results in three-dimensional strength that resists
PIP joint displacement. For displacement to occur, the
ligament–box arrangement must be disrupted in at least
two planes (22).
Clinical Significance. In contrast to the finger MCP joints,
which should be immobilized in flexion to avoid contrac-
ture of the proper collateral ligaments, the PIP joints are
10.1 Palmar Hand 547
FIGURE 10.12. (continued) B: Fresh cadaver
dissection of PIP joint, right middle finger,
“exploded” palmar radial view, proximal is to
the right. Note the distal aspect of the A2 pul-
ley, remnants of the first cruciform (C1) pulley,
the check-rein ligaments, the palmar plate,
and the detached radial collateral ligament
complex (green marks). The extensor digito-
rum communis central slip (CS) attachment has
been incised and reflected distally. Note the
dorsal plate at the site of the CS attachment.
C: Same joint with proximal phalanx removed
and viewed from proximal-dorsal, showing
the boxlike configuration of the palmar plate
and collateral ligament complex (green
marks), central fenestration in the palmar
plate at the base of the middle phalanx, and
the check-rein ligaments (purple marks) and
the dorsal plate on the reflected CS. The key to
PIP joint stability is the strong conjoined
attachment of the collateral ligaments and the
palmar plate. This ligament–box configuration
results in three-dimensional strength that
resists PIP joint displacement. For displace-
ment to occur, the ligament–box arrangement
immobilized in full extension to avoid irreversible contrac-
ture. The proper collateral ligaments at the PIP joints are
under relatively uniform tension in flexion and extension
and therefore are not a factor in irreversible contracture.
However, the check-rein ligaments at the proximal end of
the palmar plate at the PIP joint may hypertrophy and con-
tract, resulting in a fixed flexion contracture.
Distal Interphalangeal Joint
The DIP joints are uniaxial hinge joints. The DIP joint is
structurally similar to the PIP joint, but demonstrates
 548 Regional Anatomy

FIGURE 10.13. The proximal interphalangeal

(PIP) joint collateral ligament complex. A: The
accessory collateral ligaments span between the
cordlike proper collateral ligaments and the
palmar plate. B, C: Ulnar lateral view of the PIP
showing the cordlike components of the collat-
eral ligaments that are under equal tension in
flexion and extension, in contrast to the proper
collateral ligaments of the finger metacar-
pophalangeal joints.
C

hyperextension during pulp contact, as in pinch, or during
forceful pressure on the distal aspect of the finger.
ANATOMIC RELATIONSHIPS
Arterial Supply of the Hand
The arterial supply to the hand is variable. The accuracy of
anatomic observations may be limited by many factors,
including observer bias, which may be expressed as the exam-
iner’s willingness or unwillingness to perceive order amidst
diversity; quality of the specimen or injection technique; or
the lack of a sufficient number of specimens to verify a given
pattern or distribution (23). Large numbers of specimens in
a study may allow the observer to detect the influence of the
factors of parallel dominance/nondominance and range of
expression as seen especially in the arterial anatomy of the
hand. An example of parallel dominance/nondominance
relates to the palmar arches in the hand: As the dominance of
the superficial arch increases with an associated increase in
the size and number of its branches, the common and palmar
digital arteries, the dominance of the deep arch and its
branches, the palmar metacarpal arteries (PMAs), decreases.
And, of course, the reverse may be true, with the deep arch
and its branches becoming larger at the expense of the super-
ficial arch and its branches. This dominance/nondominance
see-saw may be an explanation for the variations observed in
a particular study group or between groups. Vessels in the
hand may be seen to pass through a range of expression if suf-
ficient numbers of hands are examined (24). Thus, a vessel
may be represented by a few tiny branches or it may reach its
maximum limit of distribution, and between these two
extremes a variety of intermediate stages may be seen (24).
Most of the arterial supply of the hand comes through
two main arteries, the radial and the ulnar. Other sources
include the median artery, which enters into formation of
the superficial palmar arch in approximately 10% of speci-
mens, and the interosseous arteries, mainly the anterior,
which arise in the proximal forearm from the common
interosseous branch of the ulnar artery. The interosseous
arteries usually are unimportant under normal circum-
stances but may become significant if either the radial or
ulnar artery is injured. The typical or usual arrangement of
the arteries is presented in this section, along with anatomic
variations. The largest (650 cases) and relatively contempo-
rary (1961) collection of dissections of the arterial patterns
in the hand is represented by the study of Coleman and
Anson, and much of the information that follows is based
on that study (25). The reader will soon appreciate that the
“textbook normal” configuration of the circulation in the
hand does not always represent the most common pattern.
The usual course, branching, and arch formation of the
radial and ulnar arteries in the hand are discussed, along
with common variations in these patterns. The arterial sup-
ply of the thumb and index finger is discussed last.
10.1 Palmar Hand 549
Radial Artery
The radial artery, near the radial styloid, lies to the radial side
of the flexor carpi radialis (FCR) and at approximately this
level gives off the palmar carpal branch, which usually joins a
companion vessel from the ulnar artery and the anterior
interosseous artery to form the palmar carpal arch (Fig.
10.14). At this level, the radial artery gives off the superficial
palmar branch, which passes through and occasionally over
the thenar muscles, which it supplies, and in approximately
one-third of individuals it joins the ulnar artery to aid in the
formation of the superficial palmar arch (1,25,26). The main
component of the radial artery passes dorsally beneath the
abductor pollicis longus and extensor pollicis brevis (EPB)
tendons to enter the anatomic snuff-box. After entering the
snuff-box, the radial artery gives off the dorsal carpal branch
to form part of the dorsal carpal arch. It then runs distally
beneath the EPL, passes between the bases of the thumb and
index metacarpals, through the first dorsal interosseous (DI)
muscle and into the palm, to end as a contributor to the deep
palmar arterial arch. The deep arch lies on the proximal ends
of the metacarpals and interossei, beneath the finger flexors
and the adductor pollicis (see Fig. 10.14).
Dorsal Carpal Arch
This dorsal plexus, which supplies the carpal bones, is
formed variously by radial, ulnar, or interosseous artery
branches (Fig. 10.15). Coleman and Anson identified 6
patterns in 75 specimens (25) (Fig. 10.16).
Type 1 (50%)
This pattern is formed by the dorsal carpal branch of the
radial artery, the carpal branches of the dorsal interosseous,
and the terminal branch of the palmar interosseous.
Type 2 (30%)
This pattern is formed by the dorsal carpal branches of the
radial and ulnar and interosseous arteries. The dorsal carpal
branch of the radial artery passes medially from the snuff-
box under the EPL and radial wrist extensors to join the
dorsal carpal branch from the ulnar artery, which passes
over the head of the ulna and beneath the FCU and the
ECU to join its radial artery counterpart near the distal
carpal row. Dorsal branches from the anterior interosseous
and the dorsal interosseous complete the plexus.
Type 3 (8%)
This pattern is formed exclusively by the dorsal carpal
branch of the radial artery.
Type 4 (5%)
This pattern is formed by the dorsal carpal branches of the
radial and ulnar arteries.
550 Regional Anatomy
Type 5 (3%)
This pattern is formed by the dorsal carpal branches of the
ulnar artery and the carpal branches of the palmar and dor-
sal interosseous arteries. The dorsal carpal branch of the
radial artery pierces the intermetacarpal musculature to join
the deep palmar arch.
Type 6 (4%)
No dorsal plexus is present.
Dorsal Metacarpal Arteries (Five in Number)
At the distal aspect of the dorsal carpal arch, three dorsal
metacarpal arteries (the second, third, and fourth) are
given off and course distally in the second, third, and
fourth intermetacarpal spaces (see Fig. 10.15). According
to Coleman and Anson, in their series of 75 specimens the
incidence of these arteries was second metacarpal artery,
99%; third metacarpal artery, 92%; and the fourth
metacarpal artery, 83%. The first dorsal metacarpal artery
arises from the main stem of the radial near its entry into
the first DI muscle. It usually is a small artery that bifur-
cates to send branches to the adjacent sides of the thumb
and index finger. Sometimes it is quite large and passes as
a single vessel over the dorsal surface of the first DI mus-
cle to the distal margin of the adductor pollicis, where it
FIGURE 10.14. Palmar view of right hand showing
radial and ulnar arteries, palmar carpal arch, and
superficial palmar arch.
usually joins branches of the superficial palmar arch. Its
incidence in Coleman and Anson’s series was 18%. The
fifth dorsal metacarpal artery, which usually arises from
the dorsal carpal branch of the ulnar artery or occasionally
from the carpal branches of the interosseous arteries, was
found in 81% of Coleman and Anson’s series. It passes
distally along the outer margin of the small finger
metacarpal and usually extends as far as the PIP joint. At
approximately the same level of origin as the dorsal carpal
branch, the radial artery gives off the dorsal pollicis artery
to the dorsoradial aspect of the thumb. In Coleman and
Anson’s series, it was small but rather constant (83:100)
and rarely coursed further than the MCP joint of the
thumb. When the radial artery enters the palm between
the two heads of the first DI, it turns medially across the
base of the hand deep to the oblique head of the adductor
pollicis and then passes between its oblique and transverse
heads at the middle finger metacarpal or through its trans-
verse head to the base of the small finger metacarpal
(1,25).
Deep Palmar Arch
At the base of the small finger metacarpal, the main stem of
the radial artery anastomoses with the deep branch of the
ulnar artery to form the deep palmar arch (Fig. 10.17). The
 10.1 Palmar Hand 551

FIGURE 10.15. Dorsal carpal arch, type I (the most common configuration), and the dorsal
metacarpal arteries, after Coleman and Anson (25). This dorsal carpal plexus that supplies the
carpal bones is formed variously by radial, ulnar, or interosseous artery branches.
552 Regional Anatomy
deep palmar arch lies on the proximal ends of the metacarpals
and interossei and is covered by the flexor tendons and
adductor pollicis. Most anatomists have found the deep arch
to be quite variable in size and usually inversely proportional
to the caliber of the superficial arch and its branches.
The deep palmar arch is represented by two groups: group
I, in which the arch is complete (97%), and group II, in which
the arch is incomplete (3%). Coleman and Anson defined a
complete arch as one formed by anastomoses of the con-
tributing arteries, or when the ulnar artery extends to the
thumb and index finger. An incomplete arch occurs when the
contributing arteries do not anastomose or when the ulnar
artery fails to reach the thumb and index finger (25).
Group I: Complete Arch (97%) (Fig. 10.18)
Type A (34.5%). The deep volar arch is formed by the
main stem of the radial artery, which joins the superior
ramus of the deep branch of the ulnar artery.
Type B (49%). The deep palmar arch is formed by the
main stem of the radial artery, which joins the inferior
ramus of the deep branch of the ulnar artery.
FIGURE 10.16. The six patterns of the
dorsal carpal arch, after Coleman and
Anson (25). See text for details.
Type C (13%). The deep palmar arch is formed by the
main stem of the radial artery, which joins both the inferior
and superior branches of the deep branch of the ulnar
artery.
Type D (0.5%). The deep palmar arch is formed by the
superior deep branch of the ulnar artery, which joins an
enlarged superior perforating artery of the second inter-
space.
Group II: Incomplete Arch (3%) (Fig. 10.19)
Type A (1.5%). The inferior deep branch of the ulnar artery
joins the perforating artery of the second interspace. The deep
supply to the thumb and radial side of the index is derived
from the deep palmar branch (main stem) of the radial artery.
Type B (1.5%). The deep arterial supply to the thumb
and index are from the deep palmar branch (main stem)
of the radial artery, which joins with the perforating
artery of the second interspace. The arch is not complete
because the deep branch of the ulnar artery ends in an
anastomosis with the perforating artery of the third inter-
space.
 10.1 Palmar Hand 553

FIGURE 10.17. Deep palmar arch and its branches. At the base of the small finger metacarpal,
the main stem of the radial artery anastomoses with the deep branch of the ulnar artery to form
the deep palmar arch. See text for details of branching. RC, recurrent carpal artery; PMA, palmar
metacarpal artery; PF, perforating branch; asterisk indicates anastomosis with superficial arch.

Branches of the Deep Palmar Arch
Proximal. These are the recurrent carpal vessels, two or
three in number, which course proximally to end in the pal-
mar carpal rete or join with the palmar carpal branches of
the palmar interosseous artery (see Fig. 10.17). Coleman
and Anson found these vessels in all specimens studied, but
in only 5% could an anastomosis be demonstrated by dis-
section between these small vessels and the carpal branches
of the palmar interosseous artery.
Distal. These include the so-called princeps pollicis, the
artery to the radial side of the index finger, which may arise
in common with the princeps pollicis and the three PMAs
(see Fig. 10.17). There is considerable variation in the
PMAs as to number, course, and area of supply, and in
Coleman and Anson’s series these arteries were found to be
the most variable vessels in the hand.
Palmar Metacarpal Arteries
Because of the extreme variability in the PMAs, Coleman
and Anson put forth the following conceptual guides: (a)
that a palmar metacarpal vessel is one that arises from the
deep arch and extends at least as far distal as the MCP
joint; (b) that the large artery to the thumb is considered
to be the first PMA, the large vessel that courses along the
palmar aspect of the second metacarpal bone is the sec-
ond PMA, and these vessels may arise from a common
trunk; and (c) the remainder of the vessels are best con-
sidered on the basis of type and number—the smallest
554 Regional Anatomy
number of vessels found was three and the largest was six
(25).
One consistent feature was found: the first and second
PMAs both were present in 95% of specimens; in only 2
instances of the 100 hands was the first PMA absent, and in
only 3 cases was the second PMA absent. In no specimen
were both vessels absent. Coleman and Anson also found that
FIGURE 10.19. Patterns of deep volar (radial) arterial arch,
types A and B, group II, incomplete arch, after Coleman and
Anson (25).
FIGURE 10.18. Patterns of deep volar (radial) arterial arch,
types A through D, group I, complete arch, after Coleman and
Anson (25).
the first and second PMA almost always traveled over the pal-
mar surfaces of the corresponding bones rather than over the
adjacent interosseous muscles, as classically described. The
remaining members of the PMAs were inconstant in their
relationship to the interspaces, the metacarpals, or the
interosseous muscles. Frequently, two metacarpal vessels
arose in the same interosseous space but passed distally to
adjacent MCP joint capsules or adjacent interdigital webs, or
both. Thus, the assignment of a specific number to the PMAs
is difficult except for the first and second, which are compar-
atively constant. Coleman and Anson classified the third,
fourth, and fifth PMAs based on number and type (25).
Type 1 (30%)
The PMA joins the appropriate common palmar digital
artery, as is classically described.
Type 2 (60%)
The artery ends in the capsule of the MCP joint.
Type 3 (10%)
The vessel bifurcates at the level of the head of the
metacarpal and joins with two separate common palmar
digital arteries or their branches.

Dorsal Metacarpal Arteries
These are perforating branches, three in number, from the
region of the second, third, and fourth interspaces, that pass
to the dorsum of the hand to join their respective dorsal
metacarpal arteries. Coleman and Anson dissected 25 hands
to study these structures, and 4 types were identified.
Type 1
These vessels, usually three in number, arise either from the
deep palmar arch or, less frequently, from a common trunk
with a PMA. They pass dorsally through the inter-
metacarpal spaces to join or form entirely the correspond-
ing dorsal metacarpal artery.
Type 2
Just proximal to the metacarpal head the PMA sends a per-
forating vessel to the dorsum that joins the corresponding
dorsal metacarpal artery.
Type 3
A vessel from the proper palmar digital artery passes dor-
sally to join the corresponding dorsal metacarpal artery or
one of its digital branches.
Type 4
This is the least frequent pattern and consists of vessels aris-
ing from the deep palmar arch that pass obliquely through
the interosseous muscles to join the corresponding dorsal
metacarpal artery near the MCP joint (25).
Ulnar Artery
The ulnar artery approaches the wrist just beneath and
radial to the FCU tendon (Fig. 10.20). It is radial to the
ulnar nerve and is in the interval between the FCU and the
flexor digitorum superficialis (FDS) to the ring and small
fingers. It enters the hand accompanied by the ulnar nerve
on top of the transverse carpal ligament (TCL) and radial to
the pisiform bone. This entryway, called the loge de Guyon
or Guyon’s canal, is a triangular space.
Guyon’s canal begins at the proximal edge of the palmar
carpal ligament and extends to the fibrous arch of the
hypothenar muscles. Beginning from proximal to distal, the
roof of the canal is formed by the palmar carpal ligament
and the palmaris brevis muscle. The floor is formed by the
TCL, the pisohamate and pisometacarpal ligaments, and
the opponens digiti minimi (ODM). The ulnar wall is com-
posed of the FCU, the pisiform, and the abductor digiti
minimi (ADM). The radial wall is formed by the tendons
of the extrinsic flexors, the TCL, and the hook of the
hamate (27). The average length of Guyon’s canal is 27 mm
(range, 20 to 34 mm) (27). The ulnar nerve and artery
branches in this region are covered by the palmaris brevis
muscle and surrounded by a thick fat pad.
10.1 Palmar Hand 555
Ulnar Artery Branching and Course
Konig et al., in a study of 23 cadaver hands, noted that the
ulnar artery in 17 hands after entering Guyon’s canal gave
off a small branch that accompanied the deep motor branch
of the ulnar nerve but ended in the hypothenar muscles
(28) (see Fig. 10.20). In these 17 cases, the deep branch of
the ulnar artery was given off more distally and entered the
retrotendinous mid-palmar space between the flexor sheath
of the small finger and the flexor digiti minimi (FDM), and
thus joined the course of the deep motor branch of the
ulnar nerve at a more distal level. The main trunk of the
ulnar artery continued distally after this branch to form the
superficial palmar arch. In four of the six remaining hands,
the deep motor branch was accompanied by the deep pal-
mar branch of the ulnar artery, and in these four cases no
other branch was found to enter the mid-palmar space dis-
tally (28). Thus, the origin of the deep palmar arterial
branch most often was distal to Guyon’s canal.
Lindsey and Watamull identified 2 patterns of ulnar
artery branching in Guyon’s canal in a study of 31 cadaver
hands (27). All arterial branches to the hypothenar muscles
occurred in Guyon’s canal in 30 of 31 cases. Only one arte-
rial branch to the hypothenar muscles occurred distal to the
canal.
In type 1 (17 of 31 cases), a major vascular branch passed
from the ulnar artery to the hypothenar muscles palmar to
the ulnar nerve. The average distance from the proximal
margin of the pisiform to the branch was 14 mm (range, 6
to 25 mm; see Fig. 10.14).
In type 2 (6 of 31 cases), the vascular branch passed pal-
mar to the motor branch and dorsal to the sensory branch
by an average distance of 15.2 mm from the proximal mar-
gin of the pisiform (range, 4 to 32 mm). There was no iden-
tifiable axial pedicle in the remaining eight cases.
No arterial branch was noted to travel with the motor
branch of the ulnar nerve around the hook of the hamate in
any specimen. The average distance between the
hypothenar muscle artery and the nearest hypothenar nerve
branch was 8.3 mm (range, 0 to 22 mm) (27).
These two studies are in agreement with those of
Farabeuf, Landsmeer, and Zeiss et al. (29–31) and indicate
that the first ulnar artery branch in Guyon’s canal most
often supplies the hypothenar muscles and the deep branch
of the ulnar artery that joins the radial artery to form the
deep palmar arch usually is distal to Guyon’s canal. Also, the
motor branch of the ulnar nerve that travels around the
hook process of the hamate usually is not accompanied by
an artery.
The deep branch of the ulnar artery most often enters
the depths of the hand between the flexor tendon sheath of
the small finger and the FDM, to a position deep to the
interosseous fascia, where it joins the main stem of the
radial artery to form the deep palmar arch. The palmar dig-
ital artery to the ulnar side of the small finger arises a few
millimeters distal to the origin of the deep branch. As the
556 Regional Anatomy

FIGURE 10.20. The ulnar artery and Guyon’s canal. The ulnar artery enters the hand accompa-
nied by the ulnar nerve on top of the transverse carpal ligament and radial to the pisiform bone.

main stem of the ulnar artery turns radially to cross the
palm as the superficial palmar arch, it gives rise to three
common palmar digital arteries that go to the three digital
web spaces, where they divide into proper digital arteries. In
their study of this region, Coleman and Anson observed
that two deep branches of the ulnar artery were present in
63.5% of their dissections (25). The superior branch was
present in all specimens and accompanied the ulnar nerve
deep to the origins of the FDM muscle. However, in half of
the specimens this branch ended in the hypothenar muscles
and did not join the deep arch. According to Coleman and
Anson, the inferior branch was present in 63.5% of the 200
specimens and invariably took part in formation of the deep
arch. This inferior ramus did not follow the course of the
ulnar nerve, but passed superficial to the FDM and deep to
the flexor tendons. Occasionally, both of these vessels
joined the deep arch (25).
Author’s Comment
Our dissections of Guyon’s canal and the anatomic zones
distal to this region indicate that the observations of Konig
et al. (28) and Lindsey and Watamull (27) are probably a
more accurate interpretation of the anatomy in this region.
Superficial Palmar Arch
This arch lies just beneath the palmar fascia and on top of
the superficialis tendons, and may be complete or incom-
plete (Fig. 10.21; see Fig. 10.14). Of the 650 hands in Cole-
man and Anson’s study, 510 or 78.5% possessed complete
arches, and 5 types were identified.
Coleman and Anson defined a complete arch as one
formed by anastomoses of the contributing arteries, or in
which the ulnar artery extended to the thumb and index
finger (25).
Group I: Complete Arch. Type A (34.5%). The classic or
textbook description of the superficial arch is formed by the
superficial palmar branch of the radial artery (SPBR) and
the main stem of the ulnar artery.
Type B (37%). The most common formation of the super-
ficial arch is entirely from the ulnar artery.
Type C (3.8%). The superficial arch is formed from the
ulnar artery and an enlarged median artery.
Type D (1.2%). The superficial arch is formed by the
SPBR, the main stem of the ulnar artery, and a persistent
median artery.
Type E (2.0%). This type consists of a well formed arch
begun by the ulnar artery and completed by a large vessel
derived from the deep arch that comes to the superficial
level at the base of the thenar eminence to join the ulnar
artery.
10.1 Palmar Hand 557
In no specimen did a palmar interosseous artery take
part in the formation of the superficial palmar arch, and no
example of complete absence of the arch was found.
Group II: Incomplete Arch. Coleman and Anson’s defini-
tion of an incomplete arch is when the contributing arter-
ies do not anastomose or when the ulnar artery fails to reach
the thumb and index.
Type A (3.2%). Although both the SPBR and the main
stem of the ulnar artery supply the palm and fingers, they
fail to anastomose and thus the arch is incomplete.
Type B (13.4%). The ulnar artery is the superficial palmar
arch but the arch is incomplete in the sense that it does not
provide any blood supply to the thumb and index finger.
Type C (3.8%). The superficial arch receives contributions
from both the median and ulnar arteries but without anas-
tomosis.
Type D (1.1%). The radial, median, and ulnar arteries all
give origin to the superficial vessels but do not anastomose.
Branches of the Superficial Palmar Arch
In a study of 265 specimens, Coleman and Anson classified
7 different patterns of the common palmar digital arteries
without regard to the peculiarities of the superficial arch
(Fig. 10.22; see Fig. 10.14).
Type 1 (77.3%). This type contains four common palmar
digital arteries, and in all cases a vessel supplying the ulnar
side of the thumb and the radial side of the index finger.
The remaining three arteries pass to the webs of the second,
third, and fourth interspaces.
Type 2 (8.8%). This type has three common palmar digi-
tal arteries that pass to the webs of the second, third, and
fourth interdigital spaces.
Type 3 (6.4%). In addition to three common palmar digi-
tal arteries noted in type 2, an artery passes to the thumb,
where it joins with or replaces one of the arteries of the
thumb but does not send a branch to the index.
Type 4 (1.9%). This type has three common palmar digi-
tal arteries that pass to the first, second, and fourth inter-
spaces but not to the third.
Type 5 (3.4%). This type has three common palmar digi-
tal arteries that pass to the second, third, and fourth inter-
spaces, as in type 2, and a branch to the lateral side of the
index finger.
Type 6 (1.5%). This type has only two common palmar
digital arteries that pass to the second and third interspaces.
 558 Regional Anatomy

FIGURE 10.21. The incidence, formation, and patterns of complete (A) and
B incomplete (B) superficial palmar arches, after Coleman and Anson (25).
 10.1 Palmar Hand 559

FIGURE 10.22. Branching of the superficial palmar arch, after Coleman and Anson (25).

Type 7 (0.7%). This type has common palmar digital
arteries only to the third and fourth interspaces (25).
Based on their findings, Coleman and Anson made the
following generalizations: (a) the vessel to the first inter-
space is sufficiently constant to be recognized as the first
common palmar digital artery; (b) when a common palmar
digital artery is small in caliber, the corresponding PMA
from the deep arch is enlarged; (c) the area of supply of an
absent branch of the superficial arch may be replaced by a
PMA; and (d) branches of the median artery or the super-
ficial branch of the radial artery rarely directly supply the
medial side of the hand.
artery often joins the superficial arch as a fibrotic thread or
a very small vessel that is barely detectable, and such cases
would not be included in a series. When the median artery
does join the superficial arch, it replaces no more than the
contribution of the radial artery to the arch. This is in keep-
ing with the developmental sequence because the radial
artery replaces the median during development (25).
Vessel Lumen Diameters
Gellman et al. in an injection study of 45 hands noted the
arterial lumen diameters listed in Table 10.3 (36).

Persistent Median Artery TABLE 10.3. AVERAGE LUMEN DIAMETERS OF THE

ARTERIES IN THE HAND
A persistent median artery may descend into the palm and
take part in the formation of the superficial palmar arch. Average Lumen Range
Such a finding was noted in 64 or 9.9% of Coleman and Vessel Diameter (mm) (mm)
Anson’s 650 specimens (25). The frequency of occurrence Radial 2.6 2.3–5
in other series was Jaschtschinski, 7.5% of 200 specimens; Ulnar 2.5 1.4–4.5
Tandler, 16.1% of 160 specimens; Adachi, 8% of 200 spec- Superficial arch 1.8 1–3
imens; and Gray, 1.1% of 452 specimens (32–35). Accord- Deep arch 1.5 1–2.3
Common palmar digital 1.6 1–2
ing to Coleman and Anson, these variations in frequency
Common palmar metacarpal 1.2 1–2
can be explained in part by the observation that the median
560 Regional Anatomy
Arterial Supply of the Fingers
Coleman and Anson noted that several generalizations
could be made regarding the arterial supply to the fingers.
There are three arterial sources to each finger: (a) the com-
mon palmar digital, (b) the palmar metacarpal, and (c) the
dorsal metacarpal. Two proper digital arteries are formed,
each of which supplies the adjacent sides of the fingers. In
most instances, the common palmar digital arteries are the
source of these digital arteries, but it is not uncommon for
a PMA to supplant a common palmar digital artery. In rare
instances, principally in the first and second interspaces, the
main supply may come from the dorsal metacarpal vessels.
The dorsal metacarpal arteries, joined by perforating
branches from the deep palmar arch or PMAs that pass
through and supply the interosseous muscles, pass distally
adjacent to the MCP joints to become the dorsal digital
arteries. When these vessels terminate near the neck of the
proximal phalanges, the terminal supply is taken over by the
proper palmar digital arteries (25).
Arterial Supply of the Digital Web Spaces
The following generalizations were given by Coleman and
Anson about the arterial supply to the various web spaces.
First Interspace
The arterial supply to the first interspace usually is derived
from the deep arch, either from the first PMA alone or from
both the first and second PMAs.
Second Interspace
This is derived approximately equally from the second
PMA or the second common palmar digital artery, thus
being shared almost equally by the superficial and deep
arches.
Third and Fourth Interspaces
These spaces are primarily supplied by the common palmar
digital branches of the superficial arch.
Thus, the thumb and index finger and the radial side of
the middle finger are supplied by the deep arch or radial
artery. The medial side of the middle finger, and the ring
and small fingers are supplied almost exclusively by the
superficial arch and the ulnar artery. The middle finger
therefore represents the dividing point between the supply
zones of the deep and superficial arches (25).
Digital Arterial Branches and Arches
In a study of 141 digits, Strauch and de Moura identified the
following arterial branches in the fingers (37) (Fig. 10.23).
Palmar Digital Arteries
The palmar branches of the digital arteries average 4 from
each side at the level of the proximal and middle phalanges,
but there were as many as 7 in one specimen from this study
of 141 digits. When there are more than four branches, they
usually arise from the dominant vessel.
Dorsal Digital Arteries
The dorsal branches of the digital arteries are of four types:
(a) condylar vessels, (b) metaphyseal vessels, (c) dorsal skin
vessels, and (d) transverse palmar arches.
First Set of Dorsal Digital Arteries. The first condylar
branch (a) to the head of the metacarpal may arise from the
common or proper digital vessel. It was present in 60% of
the dissections, varies in size from 0.1 to 0.5 mm, and occa-
sionally shares a common origin with the metaphyseal ves-
sel. The first metaphyseal vessel (b), which arises at the base
of the proximal phalanx, measures between 0.1 and 0.2
mm. The first dorsal skin vessel (c), in the middle portion
of the proximal phalanx, is a large branch that supplies the
overlying skin of the proximal phalanx. This vessel measures
0.4 to 0.5 mm in external diameter and was absent on one
side in 5% of the 141 digits studied. The proximal trans-
verse arch (d), at the neck of the proximal phalanx and at
the level of the C1 pulley, measures between 0.3 and 0.6
mm. These vessels from the opposing digital arteries join
centrally to form a slightly peaked arch. Branches from this
arch go to the vinculum longus and brevis, the profundus
and superficialis tendons, the dorsal skin proximal to the
PIP joint, and the distal metaphysis of the proximal pha-
lanx; a branch that crosses the PIP joint goes to the proxi-
mal metaphysis of the middle phalanx.
Second Set of Dorsal Digital Arteries. In the middle pha-
lanx, the second condylar branch (a) supplies the base of the
middle phalanx, and the major portion of the vessel supplies
the skin over the PIP joint. This condylar vessel was present
in 80% of the specimens and averages 0.2 to 0.5 mm in
external diameter. The second metaphyseal branch (b) is a
constant vessel that goes to the proximal metaphysis of the
middle phalanx; it is the largest of the three metaphyseal ves-
sels at 0.25 ± 0.05 mm. At the mid-portion of the middle
phalanx, the second dorsal skin vessel (c) arises and supplies
most of the dorsal skin over the middle phalanx. It was pre-
sent in all dissected specimens and is 0.45 mm in average size.
The second transverse palmar arch (d) arises at the neck of
the middle phalanx in relationship to the third cruciform
(C3) pulley, was present in 90% of the dissections, and is 1.5
times the size of the proximal arch, at an average size of 0.85
mm. Branches from this arch include the distal vinculum ves-
sel to the profundus tendon; a branch to the distal metaph-
ysis of the middle phalanx that goes on to supply the skin
over the DIP joint as well as continuing on to join the prox-
imal matrix arch dorsally at the level of the proximal growth
plate of the nail; and, finally, small branches that go across the
DIP joint to nourish the proximal metaphyseal area of the
distal phalanx.

Third Set of Dorsal Digital Arteries. The third condylar
vessel (a) supplies the condylar area of the distal end of the
middle phalanx and measures 0.14 mm. It originated as a
common vessel with the metaphyseal vessel in 20% of the
specimens. The proximal metaphyseal vessel (b) was uni-
formly present and averages 0.14 mm. The third dorsal skin
vessel (c) arises just proximal to the distal transverse palmar
arch and courses dorsally to form the proximal matrix arch
at the level of the proximal growth plate of the nail. This
vessel measures between 0.2 and 0.4 mm. The proximal
matrix arch at the DIP joint area is joined by the two ves-
sels that originally arose from the middle palmar arch and
traveled dorsally and distally. These vessels average 0.25 mm
10.1 Palmar Hand 561
FIGURE 10.23. Digital arterial branches and arches,
after Strauch and de Moura (37). There are three sets
of four dorsal branches of the digital arteries: A:
condylar vessels; B: metaphyseal vessels; C: dorsal skin
vessels; D: transverse palmar arches. See text for
details.
and unite on the dorsal surface with the proximal matrix
arch. The digital vessels then turn centrally to join each
other to form the distal transverse arch (d). Extending from
this arch in a longitudinal fashion are three relatively large
vessels averaging 0.58 mm that travel to the distal aspect of
the pulp and turn dorsally to join with the distal matrix
arch. Arising from the two lateral longitudinal vessels on
either side or, more commonly (60%), from two more cen-
trally placed longitudinal vessels is a branch that goes dor-
sally on either side. This branch averages 0.48 mm and, as
it nears the dorsal surface, it divides to join its counterpart
on the opposite side, thus forming the middle matrix arch
at the level of the lunula and the distal matrix arch that lies
562 Regional Anatomy

at the level of the distal third of the nail matrix. These Arterial Anatomy of the Thumb and
arches average 0.29 mm in size. Index Finger
The arterial anatomy of the thumb and radial side of the
Digital Vessel Diameters index finger is discussed in this section, and the reader will
soon note striking variations in reported series that have
Strauch and de Moura made some practical observations on
addressed this area of arterial anatomy (23,24,40). It there-
the external diameter of the digital vessels, and these mea-
fore seems appropriate to reiterate some of the observations
surements are given in Table 10.4.
of Coleman and Anson (25) previously cited in this chap-
These authors noted that of the two digital vessels in the
ter, and specifically to discuss their observations on the
thumb and index and long fingers, the ulnar vessel almost
PMAs. Coleman and Anson stated that there was consider-
always is larger, whereas the radial vessel almost always is
able variation in the PMAs as to number, course, and area
larger in the ring and small fingers. The common digital
of supply, except for the first and second PMA. They noted
vessel to the third web space divided into branches that
that the large artery to the thumb is considered to be the
were large on both sides of the web.
first PMA, that the large vessel that courses along the pal-
mar aspect of the second metacarpal bone is the second
Clinical Significance
PMA, and that these vessels may arise from a common
Strauch and de Moura noted several clinical implications
trunk. One consistent feature was found: The first and sec-
from their study:
ond PMAs both were present in 95% of specimens; in only
1. A high level of consistency in the distribution and loca- 2 instances of 100 hands studied was the first PMA absent,
tion of digital vessels was seen, not previously described. and in only 3 cases was the second PMA absent. In no spec-
2. In digital amputations of the thumb and index and long imen were both vessels absent. Coleman and Anson also
fingers, the surgeon should look for the ulnar vessel first found that the first and second PMA almost always traveled
because it is the larger of the two. The reverse is true for over the palmar surfaces of the corresponding bones rather
the ring and small fingers. than over the adjacent interosseous muscles, as classically
3. The middle and distal transverse arches are consistently described. Recognition of the relative constancy of the first
large (almost 1 mm) and may be used for arterial vessel and second PMA, which in general represent the stem ves-
repairs either proximally or distally; furthermore, these sels to the thumb and index finger, allows us now to address
two arches are easily located because of their uniform the specifics of the arterial supply to the thumb and index
relationship to the cruciate ligaments and the profundus finger. This topic has attracted much attention, and recent
tendon insertion (37). studies have emphasized differences from the classic
anatomic literature in the arrangement and relative domi-
Further perspective on the importance of transverse dig-
nance of the arterial vessels of the thumb, and specifically
ital arches is given by reported experiences with replanta-
that the so-called princeps pollicis artery may not be the
tion for transmetacarpal hand amputation. Successful revas-
major vessel to the thumb, and in fact may be a misnomer.
cularizations of all the fingers and thumb have been
Three studies are reviewed: the first by Parks et al., the
reported by attaching a single common digital vessel to a
second by Ames et al., and the third by Earley (23,24,40).
proximal arterial source. The ability of one common digital
artery to revascularize all the fingers and thumb was the
result of retrograde flow through the transverse arches
Findings of the Parks and Colleagues Study
(38,39).
In a study of 50 embalmed hands, Parks and coworkers
found that the first PMA was the principal artery of the
thumb in 80% of their dissections. They noted that the first
PMA was a major branch of the deep radial artery and closely
TABLE 10.4. DIGITAL VESSEL DIAMETERS corresponded to the PMA of the other fingers. The princeps
Finger Vessel Location Size (mm) pollicis artery divided at the level of the MCP joint and deep
to the flexor pollicis longus (FPL) tendon into radial and
Index Radial Base proximal phalanx 1.4 ± 0.10
ulnar digital arteries. The radial index artery arose from the
Ulnar 1.8 ± 0.15
Radial Base distal phalanx 0.76 ± 0.15 princeps pollicis in 50% of the dissections. Variations in the
Ulnar 0.86 ± 0.10 so-called princeps pollicis artery were noted in 25%, but
Ring and Radial MCP joint 1.75 ± 0.15 these variations were not described. The first dorsal
small Just distal to DIP joint 0.95 ± 0.15 metacarpal artery was the main artery to the thumb in 14%.
Ulnar MCP joint 1.35 ± 0.2
It originated before the radial artery pierced the first DI mus-
Just distal to DIP joint 0.85 ± 0.1
cle and passed to the thumb dorsal to the DI muscle. A
DIP, distal interphalangeal; MCP, metacarpophalangeal. branch from the second PMA formed the main artery to the

thumb in 6%. In 20%, a significant arterial contribution was
made by the superficial palmar vessels (40).
Findings of the Ames and Colleagues Study
In a study of 39 fresh cadaver hands, Ames et al. identified
what they considered to be the dominant vessel of the
thumb and radial side of the index based on relative size,
and described five patterns of arterial anatomy in the
thumb (23) (Fig. 10.24).
Vascular Pattern A: Incidence 21/39 (54%)
Both superficial and deep vessels were noted in the first
web. The origin of the superficial vessel was from the super-
ficial palmar arch in 18 specimens, from the SPBR in 2
specimens, and from the median artery in 1 specimen. The
deep vessel originated from the first PMA in 19 of 21 spec-
imens, and from the dorsal metacarpal artery in the other 2
A B
C, D
FIGURE 10.24. A–E: Patterns of arterial supply to the thumb, after Ames et al. (23).
10.1 Palmar Hand 563
specimens. The superficial and deep vessels joined, giving a
radial digital artery to the index and an ulnar digital to the
thumb. In 20 of the 21 specimens, the superficial and deep
vessels joined together in the first web space. The SPBR was
absent in 8 of the 21 specimens. Thus, it was clear that this
pattern did not have a dominant or princeps pollicis artery.
Vascular Pattern B: Incidence 3/39 (8%)
The SPBR was the dominant vessel. In two specimens it sup-
plied both sides of the thumb, together with the radial side of
the index finger. In the third specimen, the SPBR supplied a
vessel to the first web space with bifurcation only to the ulnar
side of the thumb and the radial side of the index finger. The
radial side of the thumb was supplied by the radial artery.
Vascular Pattern C: 7/39 (18%)
The first palmar metacarpal was the largest or dominant
vessel, and in three of these there did not appear to be a
E
564 Regional Anatomy
connection between the superficial and deep systems. The
authors noted that these three specimens were the only
specimens in their study that corresponded to the classic
description shown in anatomic textbooks (in this instance,
Gray’s Anatomy, 28th ed., 1969).
Vascular Pattern D: 3/39 (8%)
In three specimens, a large dorsal metacarpal artery was
considered to be the dominant vessel. In two instances there
was an anastomosis with the superficial system.
Vascular Pattern E: 5/39 (13%)
In 5 of 39 specimens there was no dominant vessel, and in
only 1 specimen was there an anastomosis between the
superficial and deep vessels. The deep vessel came from the
dorsal metacarpal artery, and in all five specimens the super-
ficial system supplied the ulnar side of the thumb, whereas
the deep system supplied the radial aspect of the thumb. In
one of these specimens the first PMA entered the FPL
sheath and divided into radial and ulnar digital vessels.
Other Findings of the Ames and Colleagues Study
In contrast to the dorsal branch of the radial artery, which,
after exiting the snuff-box, always passed through the two
heads of the first DI muscle, the SPBR either remained
deep in the substance of the thenar muscles or passed over
them. Variously, it could supply both aspects of the thumb
and the radial aspect of the index finger, become a vessel to
the first web space, participate in the formation of the
superficial arch, or terminate in the skin of the first web
space, in the thenar muscles, or as a radial digital vessel to
the thumb.
Summary and Conclusions of the Ames and Colleagues
Study
These findings indicate that the arterial supply in the hand
is variable. Five patterns were noted based on vessel domi-
nance. The most common pattern revealed a superficial and
deep system that frequently connected within the first web
space. The superficial palmar arch was complete in only
24% of this study group. The so-called princeps pollicis or
first PMA was dominant in only 18% of the specimens.
Findings of the Earley Study
The study by Earley of the arterial supply of the thumb and
index finger in 20 fresh and injected cadavers made the fol-
lowing observations (24).
The Superficial Arch
The superficial or main stem branch of the ulnar artery may
give rise to a common digital artery to each web space (4 of
20 dissections), and in 3 of these 4 specimens the first web
space common digital artery was the only supply to the ulnar
side of the thumb and the radial side of the index finger.
The Superficial Palmar Branch of the Radial Artery
1. The SPBR can vary from supplying only small branches
to the carpal ligament and thenar muscles to providing
the main blood to the thumb and radial side of the index
finger (Fig. 10.25);
2. The SPBR gave origin to (a) proximal (20 hands) and
distal (14 hands) thenar muscle branches; (b) carpal lig-
ament branches (6 hands); (c) APB branches (14 hands),
usually manifested as a large branch running superfi-
cially over the APB toward the radial sesamoid at the
thumb MCP joint and often (7 of 14) communicating
with the radial digital artery of the thumb at the so-
called sesamoid sink; in 2 hands it even formed the
radial palmar digital artery of the thumb; and (d) a
branch joining with the superficial and main stem of the
ulnar artery to form the superficial palmar arch (12 of
20 hands). In half of these, the communicating branch
gave origin to either the radial palmar index artery or to
the common digital arteries to the first and second webs.
Thus, in 6 of 20 hands, the SPBR supplied a significant
part of the circulation to the radial one-half of the hand.
The two arteries forming the superficial arch of the hand
were noted to contribute significantly to the thumb and
index finger blood supply.
The First Palmar Metacarpal Artery
1. This artery was present in all hands examined by Earley
and was the first branch of the radial artery on its return
to the palm (Fig. 10.26).
2. In three hands it shared a common origin with the sec-
ond PMA.
3. The usual course (18 of 20 hands) was on the ulnar side
of the thumb metacarpal on the interosseous muscle
belly, after which it passed deep to the FPB (deep head)
and exited in the interval between the adductor and the
deep head of the FPB.
4. Its classic division into digital arteries at approximately
this level beneath the FPL tendon was seen in only 8 of
the 20 hands, and in 2 hands the first PMA passed deep
to the deep head of the FPB and oblique head of the
adductor pollicis and emerged between the two adduc-
tor heads at the ulnar sesamoid.
5. The first PMA followed the usual patterns of arterial
variation from (a) one of least expression, where it sup-
plied only a communicating branch to the palmar digi-
tal arteries; to (b) one of intermediate expression, where
it gave origin to only one digital artery; and (c) one of
greatest expression, where it gave rise to both digital
arteries.
Branches of the First Palmar Metacarpal Artery
Branches of the first PMA included the following:
1. The thumb palmar digital arteries. In 8 of 20 hands,
both palmar digital arteries originated from the first
 10.1 Palmar Hand 565

FIGURE 10.25. A, B: Patterns of

branching of the superficial palmar
branch of the radial artery, after Ear-
A B ley’s study of 20 hands (24).

FIGURE 10.26. The first palmar metacarpal artery

(PMA), based on Earley’s study of 20 hands (24). This
artery is the first branch of the radial artery (17 of 20
hands) on its return to the palm, and its usual course is
shown here (A); in 3 hands, it shared a common origin
with the second PMA. Its usual course (18 of 20 hands)
is on the ulnar side of the thumb metacarpal on the
interosseous muscle belly, it then passes deep to the
flexor pollicis brevis (FPB; deep head) and exits in the
interval between the adductor and the deep head of
the FPB. Its classic division as shown here into digital
arteries at approximately this level beneath the flexor
pollicis longus tendon was seen in only 8 of the 20
hands, and in 2 hands (B) the first PMA passed deep to
the deep head of the FPB and the oblique head of the
adductor pollicis and emerged between the two adduc-
A tor heads at the ulnar sesamoid.
566 Regional Anatomy
PMA, and in 11 of 20 hands, the parent artery gave rise
to only 1 palmar digital artery and in one hand to none.
2. Branches at the level of the neck of the thumb meta-
carpal. These were constant, with vessels curving around
the neck to supply dorsal structures and the MCP joint.
3. Muscle branches to the adjacent thenar muscles.
4. Terminal communicating branches. These were seen in
8 of 20 hands, and in 7 of these there was a branch com-
municating with the opposite palmar digital artery while
the main vessel formed the other palmar digital artery.
In the eighth hand, no palmar digital branch was
formed, and the terminal branch of the first PMA was
only a small communicating branch with the ulnar
artery.
The Thumb Palmar Digital Arteries
In 18 of 20 hands, the ulnopalmar artery (average external
diameter, 1.8 mm) was larger than the radiopalmar digital
artery (average external diameter, 1.1 mm), ranging from
one-fourth to three times larger. In the remaining two
hands, the palmar digital arteries were the same size, and in
one hand the radiopalmar was three times larger than its
counterpart.
Ulnopalmar Digital Artery
The ulnopalmar digital artery was a terminal branch of the
first PMA (so-called princeps pollicis) in only half of the
specimens. In 6 of the 10 specimens it followed a course
emerging from the deep surface of the FPL tendon and
curving over the insertion of the adductor at the ulnar
sesamoid to follow the flexor sheath on its ulnar aspect. Ear-
ley named this configuration the pre-adductor type. In the
remaining four hands, the artery followed a course deep to
the adductor and thus was named the post-adductor type.
The vessels forming the other 10 ulnopalmar digital arter-
ies were:
1. One of the terminal branches of the main stem of the
ulnar (three hands)
2. A branch of the superficial palmar radial artery (three
hands)
3. Equal contributions of the first PMA and terminal
superficial arteries (one hand)
4. Equal contributions of the SPBR and terminal branch of
the main stem of the ulnar (one hand)
5. A large first dorsal metacarpal artery (one hand)
6. A hypertrophied ulnodorsal digital artery (one hand)
In spite of its various origins, once it reached the ulnar
sesamoid the ulnopalmar digital artery followed a superfi-
cial course in all hands.
Radiopalmar Digital Artery
1. The radiopalmar digital artery was a branch of the first
PMA in 18 of 20 hands.
2. Its initial course was deep to the FPL tendon, then curv-
ing over the free margin of the superficial head of the
FPB to the radial sesamoid.
3. In 2 of the 18 hands, the first PMA reached the radial
sesamoid by emerging between the adductor heads, and
then gave origin to the radiopalmar digital artery, which
had to reach the radial side of the thumb by passing
beneath the FPL in the region of the first annular (A1)
pulley.
4. In the remaining two hands, the radiopalmar digital
artery arose from the APB branch of the SPBR.
Arches of the Thumb Palmar Digital Arteries
Two arches were present between the thumb palmar digital
arteries (Fig. 10.27):
1. The digitopalmar arch was seen in all hands at the level
of the neck of the proximal phalanx in the retrocondylar
recess and beneath the oblique pulley. It gave branches
to the FPL through the vincula brevia, the palmar plate,
the interphalangeal joint, and the flexor sheath.
2. The pulp arch lay in the recess just proximal to the tuft
of the distal phalanx and gave off multiple branches sup-
plying the pulp and nail bed.
Index Radiopalmar Digital Artery
Three main origins for this artery were seen (Fig. 10.28):
1. A branch of the main stem or superficial ulnar artery (5
of 20 hands)
2. A branch of the second PMA (5 of 20 hands)
3. A branch of the SPBR (5 of 20 hands)
First Dorsal Metacarpal Artery
The first dorsal metacarpal artery was present in all hands
and originated from the radial artery just distal to the EPL
tendon (see Fig. 10.26). Three types were noted:
1. A superficial and axial fascial vessel parallel to the second
metacarpal and overlying the first dorsal interosseous
muscle (15 of 20 hands)
2. A deep or muscular vessel to the ulnar head of the first
DI muscle that followed a buried course in the groove
between the muscle origins and the second metacarpal,
but emerged after a variable distance to follow a more
superficial fascial course (3 of 20 hands)
3. A combination type consisting of both fascial and mus-
cle types (2 of 20 hands; 2 branches of 1 vessel in one
hand, but 2 separate vessels in the other)
The ulnodorsal thumb digital artery originated from the
first dorsal metacarpal artery in 6 of 20 hands.
Second Dorsal Metacarpal Artery
The second dorsal metacarpal artery was present in 19 of 20
hands.

1. It was smaller than the first dorsal metacarpal artery in
12 hands, the same size in 1 hand, and larger in 6 hands.
2. Its origin was variable, but it usually arose from the dor-
sal carpal arch (15 of 20 hands), then crossed under the
extensor indicis proprius to reach the second DI muscle,
where it followed a superficial course to reach the skin of
the second web.
Dorsal Thumb Digital Arteries
These vessels were extremely variable, and were small or
absent if the dorsal branches from the first PMA were large.
A–C
10.1 Palmar Hand 567
FIGURE 10.27. Arches of the thumb palmar digital
arteries. The digitopalmar arch is at the level of the neck
of the proximal phalanx in the retrocondylar recess
beneath the oblique pulley, and gives branches to the
flexor pollicis longus through the vincula brevia, the
palmar plate, the interphalangeal joint, and the flexor
sheath. The pulp arch is in the recess just proximal to the
tuft of the distal phalanx, and gives multiple branches
to the pulp and nail bed.
Ulnodorsal Digital Artery
The ulnodorsal digital artery was absent in six hands, in six
others it was branch of a fascial-type first dorsal metacarpal
artery, and in six others it was a branch of the radial artery
distal to the EPL tendon before the origin of the first dor-
sal metacarpal artery.
Radiodorsal Digital Artery
The radiodorsal digital artery was absent in 6 hands and
was represented by 1 vessel in 11 hands and 2 vessels in 3
hands. In all hands, the vessels originated from the radial
FIGURE 10.28. Index radiopalmar
digital artery. Three main origins for
this artery were seen identified in the
Earley study (24): (A) a branch of the
main stem or superficial ulnar artery
in 5 of 20 hands, (B) a branch of the
second palmar metacarpal artery in 5
of 20 hands, and (C) a branch of the
superficial palmar branch of the
radial artery in 5 of 20 hands.
568 Regional Anatomy
artery in the snuff-box and followed a course along the EPB
and abductor pollicis longus tendons, traveling toward the
dorsal skin at the thumb MCP joint.
Based on his study and a review of the related literature,
Earley made the observations that are summarized as fol-
lows:
1. Tandler (33) noted that the SPBR branch was as large as
the superficial or main stem of the ulnar artery in the
palm in over one-third of hands, and that in these hands
it often supplied the thumb ulnopalmar and index
radiopalmar digital arteries through a first web common
digital artery.
2. Tandler (33) stated that the first PMA was “certainly not
the main blood vessel of the thumb” and thus did not
deserve the name “arteria princeps pollicis.” Earley
noted that the ulnopalmar artery (the major artery to the
thumb) is derived from the first PMA in only half of the
hands he dissected (24).
3. Confusion has existed as to whether the origin of the
artery to the index finger is superficial or deep, but both
Weathersby (41) and Coleman and Anson (25) realized
that this depended on the relative dominance of either
arterial system. Weathersby, in a study of 256 palmar
arches, found that the main index finger supply comes
from the deep arch in 45%, the superficial arch in 13%,
and both in 42%, and believed that the name arteria
volaris indicis should be abandoned in favor of second
PMA or third common digital artery (41). Earley found
that the second PMA, which supplied the whole index
and middle finger radiopalmar digital artery, occurred in
5 of 20 hands (24).
Surgical Applications Based on the Earley Study
1. Interruption of the ulnar artery at the wrist may result in
loss of blood flow in the second through fourth inter-
digital cleft vessels and possibly lead to ischemia in the
fingers. Thumb viability would not be affected because
both sides of the thumb never are supplied only by the
superficial palmar artery.
2. Interruption of the radial artery at the wrist could be a
different matter, especially in those hands with a large
contribution from the SPBR (30% of hands in Earley’s
study), because the common digital as well as palmar
metacarpal arterial supply would be lost. However,
ischemia leading to necrosis might not occur if sufficient
interconnections were present from other arterial sys-
tems.
3. Landmarks for the arteries of the thumb are the FPL at
the metacarpal level, the sesamoid bones, and the
oblique pulley of the flexor sheath. The distal part of the
oblique pulley marks the level of the digitopalmar arch.
When looking for the ulnopalmar thumb digital artery,
it is helpful to remember the “preadductor” or “postad-
ductor” course of the artery and the possibility of its ori-
gin from the dorsal vessels. In 90% of cases, the ulnopal-
mar artery is the largest of the two thumb arteries and
should be considered as the first choice for anastomosis
in replantation. If the ulnopalmar artery is not suitable
for anastomosis, the A1 pulley area and the ulnar side of
the radial sesamoid should be examined to locate the
radiopalmar digital artery. By this means, the deep vari-
ety (seen in 50%) can be identified before it courses
deep to the flexor sheath.
Author’s Comments
There is no standard pattern of arterial supply to the thumb
or index finger. Although the use of fresh cadaver specimens
and injection techniques may add to our understanding,
the differences noted in the various studies are not easily
explained. The comments of Ames et al. (23) regarding the
factors that may limit an anatomic study are repeated here
and include (a) the quality of the specimen and injection,
and (b) the examiner’s ability to perceive order amidst
diversity. Finally, in reference to the arterial circulation to
the thumb, the term princeps pollicis probably is a misnomer
and should be abandoned.
Nerves of the Hand
Cutaneous Innervation of the Palm
Martin et al. studied the innervation of the proximal palm
in 25 fresh cadaver hands to determine the most appropri-
ate location for the incision for an open carpal tunnel
release (42). A carpal tunnel release incision was made in
each of the 25 hands curving in line with the axis of the ring
finger. The location of the nerve relative to the incision was
noted, and all nerves cut or passing within 2 mm of the
incision were considered to be at risk for injury.
Four nerves were identified, one from the median [the
palmar cutaneous branch of the median nerve (PCBMN)]
and three from the ulnar [the palmar cutaneous branch of
the ulnar nerve (PCBUN), the nerve of Henle, and trans-
verse palmar branches from the ulnar nerve in Guyon’s
canal] (Fig. 10.29).
Palmar Cutaneous Branch of the Median Nerve
This nerve was present in all specimens and originated from
the radial side of the median nerve an average of 5.9 cm
(range, 4.1 to 7.8 cm) proximal to the wrist flexion crease.
In two hands, two distinct nerves were identified. The
PCBMN coursed distally in the interval between the pal-
maris longus and the FCR tendons. In each specimen, the
nerve pierced the distal antebrachial fascia and palmar fas-
cia in its own tunnel, often weaving through the fibers of
the palmaris longus. In all cases the nerve became subcuta-
neous radial to the palmar incision. In one case, a large
branch of the nerve crossed the incision and would likely

have been transected during an open carpal tunnel release.
In another two specimens, the terminal ulnar fibers of the
PCBMN were identified at the incision margin. In each of
the three specimens in which the PCBMN was considered
at risk, ulnar palmar cutaneous nerves also were at risk.
Summary of PCBMN: Incidence, 25 of 25; at risk, 3 of 25.
Ulnar Nerve Branches
Palmar Cutaneous Branch of the Ulnar Nerve. This
nerve was identified in 4 of 25 specimens and originated an
average of 4.6 cm proximal to the pisiform (range, 3 to 7.8
cm). In each case the nerve traveled superficial to the pal-
mar carpal ligament. In one case, the PCBUN traveled
directly superficial to the palmaris brevis but gave no motor
fibers to the muscle. Each of these four nerves became sub-
cutaneous ulnar to the palmar incision, and two of the four
were transected by the incision toward their radial extent.
Summary of PCBUN: Incidence, 4 of 25; at risk, 2 of 4.
Nerve of Henle. This nerve, the nervi vasorum of the ulnar
artery, gave innervation to the forearm or palm in 14 of 25
hands, in addition to providing sympathetic innervation to
the artery. Eleven nerves of Henle providing innervation to
10.1 Palmar Hand 569
FIGURE 10.29. Cutaneous innervation of
the palm as it relates to open carpal tunnel
release [based on a study of 25 hands by
Martin et al. (42)]. Four nerves were identi-
fied to be at risk (all nerves cut or passing
within 2 mm of the incision): the palmar
cutaneous branch of the median nerve; the
palmar cutaneous branch of the ulnar
nerve; the nerve of Henle; and transverse
palmar branches from the ulnar nerve in
Guyon’s canal. See text for details of nerve
incidence and risk. Based on this study, the
authors concluded that there is no interner-
vous plane in this region of the palm.
the palm were noted in 10 of 25 specimens, with 1 artery
having two distinct bundles. These nerves originated an
average of 16.3 cm (range, 9 to 27 cm) proximal to the pisi-
form. In most, the nerve originated at a point in the proxi-
mal forearm where the ulnar nerve passes through the FCU
to lie alongside the ulnar artery. In one case, the nerve
received a substantial contribution from the median nerve
in the proximal forearm. The cutaneous component of
these nerves diverged from the ulnar artery near the proxi-
mal wrist crease, coursing between the tendons of the FCU
and FDS to the ring finger. Proximal to the palm, the
nerves pierced the distal antebrachial fascia, becoming sub-
cutaneous at the distal wrist flexion crease. In six specimens,
one or more branches of the cutaneous portion of the nerve
of Henle was either transected or at risk from the incision.
Summary of nerve of Henle: Incidence, 10 of 25; at risk,
6 of 10.
Transverse Palmar Cutaneous Branches of the Ulnar
Nerve. Multiple cutaneous nerves to the palm were noted
from the ulnar nerve, the ulnar motor branch to the
hypothenar muscles, and the common digital ulnar sensory
nerve as they coursed through Guyon’s canal. At least 1 such
570 Regional Anatomy
nerve was identified in 24 specimens (average, 1.8; range, 1
to 5). The origin of these nerves averaged 3 mm distal
(range, 1.8 cm proximal to 1.7 cm distal) to the center of
the pisiform and was variable with respect to the ulnar
nerve branch of origin. In two specimens, these nerves trav-
eled with the ulnar artery for less than 1 cm before becom-
ing cutaneous. Many of these nerves exited perpendicularly
from the longitudinal direction of the ulnar nerve, thus
prompting a description of them as transverse. These nerves
pierced the palmar carpal ligament to innervate the skin
and subcutaneous tissue of the hypothenar eminence and
midpalm, usually distal to that area innervated by either the
nerve of Henle or the PCBUN. The radial extent of these
nerves was very variable, but they routinely extended farther
radial than the site of the carpal tunnel release incision in
the axis of the ring finger. In 11 specimens, at least one of
these transverse palmar cutaneous branches was either tran-
sected or at risk by the palmar incision.
Summary of transverse PCBUN: Incidence: 24 of 25; at
risk, 11 of 24.
Clinical Significance
Based on this study, there is no internervous plane in this
region of the palm. Injury to these nerves may explain the
lower rate of painful incisions after endoscopic carpal tun-
nel release compared with open release.
Palmar Cutaneous Branch of the Median Nerve. Watch-
maker et al., in a study of 25 cadaver hands, noted the risks
of injury to the PCBMN during carpal tunnel surgery (43).
They identified what they considered to be a more reliable
landmark for placement of the carpal tunnel release incision
that was not based on the variable and ambiguous axis of
the ring finger or the thenar crease. They noted that the
PCBMN arose on average 41 mm proximal to the distal
wrist flexion crease (range, 27 to 63 mm), and at that level
was 2 mm radial to the thenar crease (range, 6 mm radial to
6 mm ulnar). The PCBMN could be traced 3.5 to 4 cm dis-
tal to the distal wrist crease. Further observations by the
authors revealed that the thenar crease did not extend prox-
imally to cross the wrist flexion crease but rather began an
average of 18 mm distal to wrist crease, and that the thenar
crease may turn radially at this point and bifurcate. The
PCBMN was noted to underlie or cross beneath the thenar
crease, making this crease a poor choice for a carpal tunnel
release incision. The authors’ incision of choice was identi-
fied as the depression between the thenar and hypothenar
eminences. They noted that the PCBMN courses an aver-
age of 4 to 4.5 mm radial to this depression. In no specimen
was the PCBMN ulnar to the depression. In two specimens,
a branch of the PCBMN passed beneath the depression;
thus, an incision placed several millimeters (the authors
advised 5 mm) ulnar to the depression was noted to provide
a safe territory for the incision.
Author’s Comment. The observation of Martin et al. (42)
that there is no internervous plane in this region of the
palm bears repeating. Based on the two studies just
reviewed, it seems apparent that most incisions in this zone
may affect at least one sensory cutaneous branch derived
from median or ulnar sources because the demonstrated
regions of innervation overlap.
Median Nerve
Classic Description of the Course and Branching of
the Median Nerve
The median nerve, as a single large nerve, enters the hand
beneath the TCL accompanied by nine flexor tendons (Fig.
10.30). Near the distal margin of the TCL, the median nerve
usually divides into three common palmar digital compo-
nents, although it often may divide first into a radial and ulnar
trunk (1). The motor branch most often arises from the radial
side of the most radial component of the nerve. The classic
description of the division of this most radial trunk is (a) a tri-
furcation of the radial trunk into proper digital nerves (PDNs)
to the radial and ulnar sides of the thumb and the radial side
of the index finger, or (b) a common nerve branch to the
thumb that divides into proper radial and ulnar digital nerves
to the thumb and a PDN branch to the radial side of the
index finger. The remaining central and ulnar common digi-
tal branches course distally and divide into the PDNs to the
ulnar side of the index finger, both sides of the middle finger,
and the ulnar side of the ring finger. The motor branch to the
index finger lumbrical arises from the proper sensory branch
to the index finger, and the branch to the middle finger lum-
brical from the common digital nerve to the index–long fin-
ger web space.
This classic description is appropriately compared with a
study by Jolley et al., who noted the following patterns of
branching in a study of 79 embalmed cadaver hands (44).
Their three patterns of branching are presented in order of
frequency.
Type A. This type consists of a PDN to the radial side of
the thumb and a common digital nerve of variable length to
the first web space that divides into a branch to the ulnar
side of the thumb and radial side of the index finger. This
was the most common configuration, seen in 54 of 79
hands (69%).
Type B. This type is a trifurcation pattern with PDNs aris-
ing from the median nerve to course to the radial and ulnar
aspects of the thumb and the radial side of the index finger,
seen in 20 of 79 hands (25%).
Type C. A common digital nerve to the thumb divides into
proper radial and ulnar nerves and a proper radial digital
nerve to the index finger (see Fig. 10.30B). This was the
least common pattern, seen in 5 of 79 hands (6%).
 10.1 Palmar Hand 571

B
FIGURE 10.30. A: Median and ulnar nerves and their most common pattern of branching. The
most common pattern of median nerve branching to the thumb and radial side of the index fin-
ger, as described by Jolley et al. (44), is at variance with the classic descriptions of branching. See
text for details of nerve branching. B: Patterns of median nerve sensory branching to the thumb
and index finger, after Jolley et al. (44).
(continued on next page)
 572 Regional Anatomy
C
FIGURE 10.30. (continued) C: Fresh cadaver dissection showing
an “accessory thenar nerve” (ATN) distal to the transligamentous
recurrent motor branch (bracketed by green markers) of the
median nerve. In Mumford and colleagues’ (48) study of the
recurrent motor branch, 15 of 20 specimens (75%), demon-
strated an ATN that innervated the flexor pollicis brevis and
arose from either the first common digital nerve (25%) or the
radial proper digital nerve to the thumb (50%).
Clinical Significance
The most common pattern of median nerve branching to
the thumb and radial side of the index finger as described
by Jolley et al. is at variance with the classic descriptions of
branching. Surgeons should be aware that the most com-
mon median nerve branching in the first web space is that
of a PDN branch to the radial side of the thumb and a com-
mon digital nerve that divides to innervate the ulnar side of
the thumb and the radial side of the index finger.
Digital Nerves
In general, the PDNs course distally in intervals adjacent to
the lumbrical muscles and flexor tendon sheaths (Fig. 10.31;
see Fig. 10.30). They are deep to the superficial palmar arte-
rial arch and its arterial branches and remain deep to these
vessels until they (the nerves) exit from beneath the transverse
fibers of the palmar fascia into a fat pad at the distal aspect of
the palm. The PDNs enter the digits beneath the natatory
ligament, palmar to the transverse metacarpal ligament, and
FIGURE 10.31. Relationship of the digital nerves and arteries to
each other and to the natatory ligament and the palmar fascia.
adjacent to the longitudinal fibers of the palmar fascia; in the
digits, the nerves are palmar to the arteries. In the fingers, the
PDN lies adjacent to the flexor sheath and level with the pal-
mar aspect of the phalanges. Each PDN gives off several
branches to the sides and palmar aspect of the finger, as well
as branches to the adjacent joints. These nerves supply the
flexor tendon sheaths, the digital arteries, and sweat glands
(1). In a study of 30 fresh cadaver hands, Bas and Kleinert
found that the dorsal branch of the PDN that supplied the
skin over the dorsum of the middle and distal phalanges
divided from the PDN more proximally than previously
described. In 62% of the PDNs for the index, long, ring, and
small fingers, the dorsal branch arose from the PDN in the
area of the A1 pulley or proximal to it (45). In the thumb, the
dorsal sensory branch, when present (11 of 30 thumbs), arose
distal to the A1 pulley (45).
Joint Innervation
In a study of 12 fresh cadaver hands using microdissection
and selective silver staining, Chen et al. found that the PIP

joints were innervated by two palmar articular nerves, one
proximal and one distal, that originated from the PDNs
and had a mean diameter of 0.21 to 0.53 mm (46). These
branches were found to innervate the palmar part of the
joint capsule, the head of the proximal phalanx, the tendon
sheath, and the lateral aspect of the capsule. The PIP joints
also had dorsal proximal articular nerves that originated
from the superficial branches of the radial nerve in the
index and long fingers and the ulnar nerve in the ring and
small fingers. Each MCP joint of the index through small
fingers was supplied by one palmar articular nerve (mean
diameter, 0.41 to 0.59 mm) that originated from the deep
branch of the ulnar nerve. Proximal to the A1 pulley, this
palmar articular nerve branches into the palmar and lateral
aspect of the MCP joint capsule, the metacarpal head, and
the tendon sheath. Two dorsal articular nerves (mean diam-
eter, 0.11 to 0.24 mm) were found that originated from the
radial and ulnar sides of the dorsal digital nerve and
branched into the dorsal capsule, sagittal band, and dorsal
aspect of the metacarpal head. The thumb MCP joint had
two dorsal articular nerves (mean diameter, 0.18 to 0.24
mm) and two palmar nerves (mean diameter, 0.29 to 0.31
mm). The thumb palmar articular nerve originated from
each side of the palmar digital nerve rather than from the
ulnar nerve, as in the fingers.
Index Finger Digital Nerves
In the most common pattern of index finger innervation
(74%), the nerves pass through the palm deep to the digi-
tal artery. The nerve to the ulnar side passes beneath the
natatory ligament and palmar to the transverse metacarpal
ligament. Both nerves in the index finger are palmar to the
digital arteries, in contrast to their deep position in the
palm. At the DIP crease, the nerves divide into three or four
branches supplying the pulp and nail bed. At or proximal to
the A1 pulley, the dorsal branch arises either deep or super-
ficial (approximately equally often) to the digital artery. The
dorsal branch of the PDN usually perforates Cleland’s liga-
ment and often connects with the terminal branches of the
radial nerve, called the dorsal sensory nerve, to supply the
skin over the dorsal aspect of the middle and distal pha-
langes (45). The depth of the palmar digital nerves in the
index finger was approximately 3 mm, and was even more
superficial at the digital creases (47).
Thumb Digital Nerves
These nerves pass distally on the radial and ulnar side of the
thumb palmar to the digital artery, and at the level of the
interphalangeal crease divide into three or four branches to
supply the pulp and nail bed (see Fig. 10.30). Wallace and
Coupland noted that no dorsal branches are given off;
although in approximately one-third of cases a short branch
to the skin over the radial side of the MCP joint arises from
10.1 Palmar Hand 573
the radial palmar digital nerve (47). These nerves supply
only the palmar aspect of the thumb, thumb pulp, and nail
bed. No crossovers or interconnections of the nerve were
noted (47). These findings are compared with those of Bas
and Kleinert, who noted both radial and ulnar dorsal
branches from the thumb PDN in 11 of 30 hands (45). The
digital nerve to the radial side of the thumb passes over the
FPL near the A1 pulley and is at risk during a trigger thumb
release.
Recurrent Motor Branch (Thenar Nerve)
Classic Configuration
The recurrent motor branch arises from the ulnopalmar
aspect of the radial division of the median nerve, usually
just distal to the TCL; it then curves proximally and pal-
marward to lie on the superficial portion of the FPB (see
Fig. 10.30A and B). It continues in this fashion until it
reaches the interval between the APB and the FPB, at which
junction it enters the interval between these two muscles
and continues through the APB to reach the underlying and
more radial OP.
The classic description of this branch is a single branch
with terminal branches, one each to the FPB, APB, and OP.
In a study of 20 cadavers, Mumford et al. found that 9 of
20 specimens (45%) demonstrated this classic pattern (48).
Variations in Origin of the Motor Nerve
In Mumford and colleagues’ study, the thenar nerve origi-
nated from the median nerve at or beyond the distal edge of
the TCL in 16 of 20 specimens (80%), and in 4 specimens
(20%) it originated a few millimeters proximal to the distal
edge of the TCL.
Spatially, the thenar nerve arose from the ulnopalmar
aspect of the radial division of the median nerve in 16 spec-
imens (80%), and in 4 specimens (20%) from the radiopal-
mar aspect of the radial division (48).
Mumford and colleagues’ description is appropriately
compared with the studies of Poisel, Lanz, and Tountas et
al. (49–51) in reference to the motor branch as well as other
variations of the median nerve in this region.
Variations in Relationship of the Motor Nerve to the
Transverse Carpal Ligament
Poisel, in 1974, studied the relationship of the thenar nerve
to the TCL in 100 cadaver hands, and the following fre-
quencies were noted: 46% extraligamentous, 31% subliga-
mentous, and 23% transligamentous (49). Less common
variations, noted by others, in the subligamentous category
include the thenar nerve leaving the median nerve on its
ulnar aspect (52), and bending of the thenar branch around
the distal edge of the TCL, where it then courses on top of
the TCL before entering the ligament (53).
Lanz, in 1977, published his findings in 246 hands, not-
ing the variations in the course of the motor branch, the
574 Regional Anatomy
TABLE 10.5. VARIATIONS IN RELATIONSHIP OF THE
MEDIAN MOTOR NERVE TO THE TRANSVERSE
CARPAL LIGAMENT
Findings/Frequency
Extra- Sub- Trans-
Study ligamentous ligamentous ligamentous
Retrospective 522 9 4
Prospective 272 8 6
Dissections 75 9 8
accessory branches at the proximal and distal ends of the
carpal canal, and high division of the median nerve (50).
Tountas et al. (51) studied the same categories as to fre-
quency and compared their findings with those of Poisel
and Lanz (49,50). The study by Tountas et al. was a com-
bined retrospective and prospective study. The operative
reports of 535 carpal tunnel releases were reviewed (retro-
spective study), and 286 cases were evaluated prospectively.
In addition, 92 cadaver hands were dissected. The results of
the Tountas et al. study are noted in Table 10.5. This study
was at significant variance with the Poisel findings.
Author’s Comments and Conclusions. A significant differ-
ence was noted by Tountas et al. between their study and
that of Poisel when comparing the course of the motor
branch and its relationship to the TCL (49,51). Whereas
Poisel found that the motor branch of the median nerve was
extraligamentous (probably the normal arrangement) in
46% of his cases, Tountas et al. found an incidence of 82%
in their dissections and 96% in their clinical cases. Simi-
larly, the incidence of transligamentous distribution of the
motor branch was 31% in Poisel’s series, compared with an
incidence of 9% in the dissections and slightly over 1% in
the clinical cases for Tountas et al. My surgical experience
more closely resembles the findings of Tountas et al.
Although differences in the frequency of anatomic varia-
tions have been noted in this area, it still is obvious that sig-
nificant variation in the course and branching of the
median nerve is present at the wrist and in the hand. It is
important to be aware of these variations and to note that
the most likely zone of safety when approaching the median
nerve in the carpal tunnel is to the ulnar side, although
branches from the ulnar side may arise proximally, in the
carpal tunnel, or distal to the tunnel.
Variations in Branching at the Distal Aspect of the
Carpal Tunnel
Variations identified by Mumford et al. included one main
trunk with two branches (one branch to the APB and one
to the OP, but no branch to the FPB) in six specimens
(30%) (48). The remaining five specimens (25%) demon-
strated four other patterns with either two, three, or four
TABLE 10.6. VARIATIONS IN BRANCHING OF THE
MEDIAN MOTOR NERVE AT THE DISTAL ASPECT
OF THE CARPAL TUNNEL
Study Findings/Frequency
Retrospective One double motor branch
Prospective Two double motor branches
Dissections Two double motor branches (one motor
branch arose distal to the transverse carpal
ligament, passed proximally, anterior to the
ligament, and entered the thenar muscles
proximal to the carpal tunnel)
branches off the main trunk. In addition, in 15 specimens
(75%), an “accessory thenar nerve”, which innervated the
FPB, arose from either the first common digital nerve
(25%) or the radial PDN to the thumb (50%). Lanz, based
on his study of 246 hands, commented that a true double
motor branch was a rare occurrence (50). He noted that the
thin branches sometimes seen arising from the palmar or
even the ulnar aspect of the nerve were sensory fibers based
on the results of intraoperative nerve stimulation and exact
dissection following the branches to the skin. He recom-
mended preserving these branches to avoid the possible
occurrence of neuromata (50).
The findings of Tountas et al. (51) regarding variations
in branching are given in Table 10.6.
Variations in Branching Proximal to the Carpal Tunnel.
Lanz, in his series of 246 carpal tunnel operations, identi-
fied 4 accessory nerves that originated proximal to the TCL
(50). The first nerve noted perforated the TCL and joined
the recurrent motor branch distally. The second accessory
branch (nonmotor) proximal to the TCL left the median
nerve at its ulnar aspect, perforated the TCL in its proximal
third, and joined the common digital nerve to the thumb
and radial side of the index finger. In the third and fourth
cases, an accessory motor branch arose proximal to the TCL
and coursed through the proximal aspect of the TCL to
enter the thenar muscles. This motor nerve branch was in
addition to the motor nerve arising from the distal aspect of
the carpal canal. Two cases of a similar configuration were
reported by Linburg and Albright (54). The findings of
Tountas et al. (51) regarding variations in branching proxi-
mal to the carpal tunnel are given in Table 10.7.
TABLE 10.7. VARIATIONS IN BRANCHING
PROXIMAL TO THE CARPAL TUNNEL
Study Findings/Frequency
Retrospective Two
Prospective Six
Dissections None
 10.1 Palmar Hand 575

High Division of the Median Nerve sory branch to the ulnar side of the small finger (the proper
palmar digital) and the common sensory nerve, which
Lanz, in 246 dissections, noted 5 high divisions of the
courses to the fourth web and divides there to become the
median nerve, which were associated with a median artery
PDN of the radial side of the small finger and the ulnar side
that was of variable size (50). Both parts of the nerve were
of the ring finger. The motor branch to the palmaris brevis
of the same diameter. Similar findings were reported by
usually arises from the sensory branch to the small finger
Eiken et al. (55). Kessler described a high division of the
(27). The communicating branch from the common sen-
median nerve without an associated median artery in which
sory (ulnar) courses distally to join the common median
the ulnar part of the nerve was larger than the radial (56).
sensory to the third web space.
Lanz noted that in two of his cases of high division of the
median nerve, the caliber relationship was just the opposite
Anatomy of Guyon’s Canal
(50). These findings are appropriately compared with those
Guyon’s canal, or the ulnar tunnel, is the space that the
of the Tountas et al. study; the findings of Tountas et al.
ulnar nerve and artery traverse to gain entrance to the hand
(51) regarding the incidence of high division of the median
from the forearm. Guyon’s canal begins at the proximal
nerve are given in Table 10.8.
edge of the palmar carpal ligament and ends at or beyond
the fibrous arch of the hypothenar muscles (formed mainly
Ulnar Nerve by the FDM). Beginning from proximal to distal, the roof
of the canal is formed by the palmar carpal ligament, por-
Classic Course and Configuration
tions of the palmar aponeurosis, and the palmaris brevis
The ulnar nerve, accompanied by the ulnar artery on its
muscle. The floor is formed by the TCL, the pisohamate
radial side, enters the hand on the radial side of the pisiform
and pisometacarpal ligaments, and the FDM. The ulnar
bone through Guyon’s canal (Fig. 10.32; see Fig. 10.20). At
wall is composed of the FCU, the pisiform, and the ADM.
this level, the ulnar nerve divides into motor and one or two
The radial wall is formed by the tendons of the extrinsic
sensory branches (see discussion to follow).
flexors, the TCL, and the hook process of the hamate (27,
28,57,58). According to Lindsey and Watamull, the average
Ulnar Motor Branches
length of Guyon’s canal is 27 mm (range, 20 to 34 mm),
The motor component of the nerve at the level of the pisi-
and according to Kuschner et al., it is approximately 40 mm
form is ulnar and dorsal. The motor branch gives off one to
in length (27,57). The ulnar nerve and artery branches in
three (usually two) branches to the hypothenar muscles
this region are covered by the palmaris brevis muscle and
before it enters the depths of the palm. Its course into the
surrounded by a thick fat pad. Konig et al. observed that the
palm has been variously described as passing between the
distal aspect of Guyon’s canal has both a superficial and a
origin of the FDM and ODM or beneath the proximal ori-
deep exit (28). The superficial exit conducts the superficial
gin of the FDM (1,28). It then courses around the ulnar
sensory nerve and main trunk of the ulnar artery over the
and distal aspect of the base of the hook process of the
ADM and FDM distally, whereas the deep or motor branch
hamate. The proximal edge of the FDM often (14 of 23
is conducted through a deep exit beneath the fibrous prox-
cases) demonstrates a fibrous arcade where the motor
imal edge of the FDM and thus into the mid-palmar aspect
branch may become entrapped (28). It then traverses the
of the hand (28).
hand to innervate the ring and small finger lumbricals, the
Gross and Gelberman divided Guyon’s canal into three
palmar and dorsal interossei, the adductor pollicis, and the
zones (58). Zone 1 was from the proximal edge of the prox-
deep head of the FPB.
imal commissural ligament (PCL) to the bifurcation of the
ulnar nerve. Zones 2 and 3 were parallel zones that began at
Ulnar Sensory Branches
the bifurcation of the nerve and, according to these authors,
After division into a sensory trunk and motor branch in
ended at the region just beyond the fibrous tissue arch of
Guyon’s canal, the sensory component divides into the sen-
the hypothenar muscles. Zone 2 contained the motor
branch of the ulnar nerve, and zone 3 contained the sensory
branch of the nerve. Zones 2 and 3 are comparable with the
TABLE 10.8. INCIDENCE OF HIGH DIVISION OF THE
MEDIAN NERVE deep and superficial exits, respectively, of Konig et al.

Study Findings/Frequency Author’s Comment. Zones 2 and 3 are not divided by an

Retrospective Two (median artery with bifid nerve)
Prospective Six (five median artery with bifid nerve,
one bifid nerve)
Dissections Two (one bifid nerve with median artery
and one bifid nerve that had a branch
coming off the radial division)
anatomic structure but rather are arbitrary divisions that
have useful clinical applications (see discussion to follow).
Also, at this distal aspect of Guyon’s canal, the motor and
sensory components of the ulnar nerve begin to separate in
both the radioulnar and the dorsopalmar direction. The
sensory branch exits the canal from beneath the distal edge
576 Regional Anatomy

A
FIGURE 10.32. The ulnar nerve in Guyon’s canal. A: Relationships of the ulnar nerve and artery
in Guyon’s canal. According to Lindsey and Watamull (27), the ulnar nerve may divide into motor
and sensory components proximal to, at, or in Guyon’s canal. The most common configuration
(approximately two-thirds in a study of 31 hands) is division into a main sensory and motor
branch in Guyon’s canal an average 8.6 mm from the proximal edge of the pisiform (range, 0 to
15 mm). See text for details.

B Patterns of Branching of Ulnar Nerve at the Wrist
FIGURE 10.32. (continued) B: Fresh cadaver dissection of
Guyon’s canal: The proximal blue marker is beneath the motor
component of the ulnar nerve and is just proximal to the piso-
hamate ligament; the green marker is beneath the motor
branch; the red marker is beneath the arterial branch to the
hypothenar muscles; and the distal blue marker is beneath a
motor branch to the hypothenar muscles. Note that the sensory
component of the nerve has been moved radially to expose the
motor branch. The sensory component divides into the proper
digital nerve to the ulnar side of the small finger and the com-
mon digital nerve to the small/ring web space.
of the palmaris brevis muscle and is palmar and ulnar to the
motor branch. Konig et al. called this exit the superficial dis-
tal hiatus (28). Thus, as far as the sensory branch is con-
cerned, Guyon’s canal ends at the distal edge of the palmaris
brevis muscle. Although the motor component also exits
from beneath the distal edge of the palmaris brevis muscle,
it soon enters either the interval between the FDM and the
adjacent ADM or courses beneath the proximal origin of
the FDM. This exit, termed the deep distal hiatus by Konig
et al., often (14 of 23 cases in Konig et al.) is bounded by a
fibrous tissue arcade (28). Although there is some described
variance in the exact exit route of the motor nerve, the
point of clinical relevance is that the motor branch at this
10.1 Palmar Hand 577
level may be subject to neuropathic influences. The fibrous
tissue arcade may play a role in compression neuropathy.
The motor branch then turns and descends dorsally around
the ulnar and distal aspect of the hook process of the
hamate on its way to the deeper aspects of the palm.
Because the motor branch is subject to neuropathic influ-
ences at this level, this region might be considered to be
part of Guyon’s canal. This concept matches to some extent
the anatomic descriptions and clinical implications of this
region proposed by Gross and Gelberman, Kuschner et al.,
and Konig et al. (28,57,58).
Clinical Significance of the Three Zones of Guyon’s
Canal. Kuschner et al. found these zones to be useful for
the localization and correct prediction of the cause of ulnar
neuropathy in Guyon’s canal (57). Based on their review of
ulnar compression cases, they noted the causes summarized
in Table 10.9.
Kuschner et al. concluded that their division of Guyon’s
canal into zones, along with a careful history and examina-
tion, including sensory and motor tests, Allen’s test, palpa-
tion for subtle masses, and diagnostic studies such as radi-
ographs of the carpal tunnel, would result in a more
accurate prediction of the cause of the ulnar deficit.
By determining the neurologic deficits (motor, sensory,
or both), one may discover the zone in which the lesion
may be found and form an appropriate differential diagno-
sis based on the history (57).
Ulnar Nerve Branching. Two patterns of division of the
ulnar nerve have been identified in a study of 31 cadaver
hands, types A and B (27) (Fig. 10.33).
Type A (80.6%). The ulnar nerve divided into a main sensory
trunk and motor branch. In 20 instances, the nerve divided in
Guyon’s canal (average, 8.6 mm from the proximal edge of the
pisiform; range, 0 to 15 mm). In the remaining five, the divi-
sion was proximal to the canal (average, 12.6 mm proximal to
the proximal edge of the pisiform; range, 7 to 25 mm).
Type B (19.4%). In this pattern, the ulnar nerve trifurcated
into two common digital sensory branches and a motor
branch. The trifurcation occurred in Guyon’s canal in all
specimens (average, 10 mm from the proximal edge of the
pisiform; range, 3 to 20 mm).
Similar findings of ulnar nerve division were noted by
Bonnel and Vila, who found that 39 of the 50 specimens
demonstrated the usual division of the ulnar nerve into 2
branches, 1 superficial (sensory) and 1 deep (motor) (59).
In 11 cases, the nerve divided into 3 branches consisting of
a deep motor branch, the proper digital branch to the ulnar
side of the small finger, and a common palmar digital nerve
of the fourth interosseous space.
 578 Regional Anatomy

TABLE 10.9. AREAS OF ULNAR NERVE COMPRESSION IN GUYON’S CANAL AND THEIR CAUSESa

Areas of Compression

Deficit Zone 1 Zone 2 Zone 3 Causes (%)

Motor and sensory 42 Ganglions (45)

Fractures (36)
Anomalous muscles (7)
Motor alone 1 42 Ganglions (60)
Fractures (12)
Thickened pisohamate ligament (7)
Sensory alone 7 10 Thrombosis (30)
Synovitis (24)
Anomalous muscles (12)
aThese causes represent the most frequent causes of ulnar nerve compression and do not add up to 100%. Those patients with combined

motor and sensory loss without a history of trauma had a ganglion as the cause of the ulnar deficit 70% of the time. Isolated motor deficits
occurred most frequently in zone 2 and were due to a ganglion 60% of the time. Isolated sensory deficits occurred most commonly from
compression in zone 3, but also may occur in zone 1; thrombosis of the ulnar artery was the most frequent cause.

FIGURE 10.33. Patterns of branching of ulnar nerve at the

wrist, after Lindsey and Watamull (27). I: Two patterns of
division of the ulnar nerve have been identified in a study of
31 cadaver hands. Type A (25 of 31 hands): The ulnar nerve
divided into a main sensory (S) trunk and motor (M) branch.
I
In 20 instances, the nerve divided in Guyon’s canal (average,
8.6 mm from the proximal edge of the pisiform; range, 0 to
15 mm); in the remaining 5, the division was proximal to the
canal (average, 12.6 mm proximal to the proximal edge of
the pisiform; range, 7 to 25 mm). Type B (6 of 31 specimens):
In this pattern, the ulnar nerve trifurcated into two common
digital sensory branches and a motor branch. The trifurca-
tion occurred in Guyon’s canal in all specimens (average, 10
mm from the proximal edge of the pisiform; range, 3 to 20
mm). II: Hypothenar muscle branches. Pattern type 1 (10 of
31 cases): This pattern was represented by a single nerve
branch that innervated the flexor digiti minimi and oppo-
nens digiti minimi through the abductor digiti minimi. Pat-
tern type 1 usually (80%) branched in Guyon’s canal, and its
origin from the main motor branch was 16 mm (average;
range, 11 to 25 mm) distal to the proximal edge of the pisi-
II form. However, in one case each it was noted to branch dis-
tal and proximal to the canal a distance of 30 and 25 mm,
respectively. Pattern type 2 (14 of 31 cases): This pattern was
represented by two branches from the main motor branch.
These branches originated in Guyon’s canal 68% of the time
(average, 18 mm distal to the proximal edge of the pisiform;
range, 0 to 32 mm). In 32%, the two branches arose 30 mm
distal to the canal (range, 27 to 46 mm). Pattern type 3 (7 of
31 cases): This pattern was represented by three or more
branches. All branches arose in the canal in 76% (average,
20 mm distal to the proximal edge of the pisiform; range, 3
to 30 mm). In 24%, the branches arose distal to the canal
(average, 31 mm; range, 30 to 40 mm). III: Innervation of
palmaris brevis (PB). In the type A division (one motor and
one sensory branch), the PB is innervated by a branch that
originates from the ulnar division of the sensory branch, and
in the type B division (one motor and two sensory branches),
III the PB branch originates from the most ulnar of the two
sensory branches.

Sympathetic Nerve Branching. Lindsey and Watamull
found that a sympathetic branch originated from the sen-
sory trunk or from the common digital nerve to the fourth
interosseous space and communicated with the superficial
palmar arch in 12 of 31 specimens (27). This branch, when
present, arose distal to Guyon’s canal in 11 cases, an average
of 34 mm from the proximal edge of the pisiform. In the
remaining case, it arose in Guyon’s canal 10 mm from the
proximal edge of the pisiform.
Innervation Patterns of the Hypothenar Muscles. Pattern
Type 1 (10 of 31 Cases). This pattern was represented by a
single nerve branch that innervated the FDM and ODM
through the ADM. This single branch arborized either before
or on contact with the abductor. In contrast, the flexor and
opponens muscles had identifiable separate nerve supplies in
pattern types 2 and 3, where two or more branches were pre-
sent. Pattern type 1 usually (80%) branched in Guyon’s
canal, and its origin from the main motor branch was an
average of 16 mm (range, 11 to 25 mm) distal to the proxi-
mal edge of the pisiform. However, in one case each it was
noted to branch distal and proximal to the canal by a distance
of 30 mm and 25 mm, respectively.
Pattern Type 2 (14 of 31 Cases). This pattern was repre-
sented by two branches from the main motor branch. These
branches originated in Guyon’s canal 68% of the time, an
average of 18 mm (range, 0 to 32 mm) distal to the proxi-
mal edge of the pisiform. In 32%, the two branches arose
an average of 30 mm distal to the canal (range, 27 to 46
mm).
Pattern Type 3 (7 of 31 Cases). This pattern was represented
by three or more branches. All branches arose in the canal
in 76%, an average of 20 mm (range, 3 to 30 mm) distal to
the proximal edge of the pisiform. In 24%, the branches
arose distal to the canal by an average of 31 mm (range, 30
to 40 mm).
Clinical Significance of the Variations in the Neurovascular
Pedicle to the Hypothenar Muscles. Preservation of the inner-
vation and circulation to the ADM is critical to the success
of the opposition transfer using this muscle described by
Huber (60). In Lindsey and Watamull’s study of the ner-
vous and vascular anatomy of Guyon’s canal in 31 hands,
73% of the hypothenar nerve branches were found in
Guyon’s canal; 25% occurred distal to the canal; and only 1
branch was found proximal to the canal. Ten of the 31
hands demonstrated a single nerve branch to the
hypothenar muscles, and thus it is theoretically possible to
denervate the FDM and ODM by performing a Huber-
type transfer of the ADM because their innervation may
depend (10 of 31 hands) on the arborization of a single
motor nerve. The arterial pedicle to the hypothenar muscles
was less variable and, when present, was in the canal in 22
10.1 Palmar Hand 579
of 23 hands. On average, the hypothenar muscle, nerve,
and nearest artery were separated by 8.3 mm (27).
Innervation of Palmaris Brevis. In the type A division (one
motor and one sensory branch), the palmaris brevis is inner-
vated by a branch that originates from the ulnar division of
the sensory branch, and in the type B division (one motor and
two sensory branches), the palmaris brevis branch originates
from the most ulnar of the two sensory branches.
Sensory Branch Divisions. Type A Ulnar Division. In the
type A ulnar nerve division, the sensory branch first sup-
plies the palmaris brevis (see preceding discussion) and the
skin overlying it (or the branch to the palmaris brevis may
originate from the ulnarmost nerve after division of the sen-
sory branch into two), and then divides into two branches,
an ulnar branch, which forms the proper palmar digital
nerve to the ulnar side of the small finger, and a radial
branch, which after a short distance gives off a communi-
cating branch that joins the ulnarmost branch of the
median nerve. It is the radial branch that forms the com-
mon palmar digital nerve of the fourth interosseous space
and subsequently divides into two terminal branches to
form the PDN to the radial side of the small finger and the
ulnar side of the ring finger.
Type B Ulnar Nerve Division. In the type B ulnar nerve
division, the most ulnar of the two sensory divisions gives
off the palmaris brevis branch and then continues to form
the proper palmar digital nerve to the small finger, whereas
the radial branch gives off the communicating branch and
then divides into the proper digital branches to the radial
side of the small finger and the ulnar side of the ring finger.
Communicating Branch. This branch courses from the
common digital nerve in the fourth interosseous space
(ulnar nerve origin) to the common digital nerve in the
third interosseous space (median nerve origin) (Fig. 10.34;
see Fig. 10.30). In two separate studies of 50 cadaver palms
each, this communicating branch was present in 80% and
92% (59,61). This communicating branch was located 38
mm distal to the bistyloid line of the wrist (59). Most often,
this communicating branch gave fibers to the radial digital
nerve of the ring finger, and in 20% of the dissections the
communicating branch gave fibers to both opposing sides
of the long and ring fingers. The diameter of the branch
averaged 25% of a PDN’s diameter at the finger base. Its
course often parallels the superficial palmar arterial arch,
and it may be at risk during carpal tunnel release or in
surgery along the fourth ray axis (61).
Somewhat similar findings were noted by Ferrari and
Gilbert, who found a 90% incidence in 50 cadaver palms
(62). They noted the proximity of the communicating branch
to the distal margin of the TCL and its consequent risk in
carpal tunnel surgery. Based on surface landmarks, these
580 Regional Anatomy

A B
FIGURE 10.34. Communicating branch of the ulnar nerve. A: Fresh cadaver dissection showing
communicating branch from the ulnar common digital nerve in the fourth interosseous space
(green marker) to the common digital nerve in the third interosseous space (blue marker). Its
course often parallels the superficial palmar arterial arch, and it may be at risk during carpal tun-
nel release or in surgery along the fourth ray axis. B: This nerve may be found in a triangular area
on the hypothenar eminence and palm bounded distally by the proximal palmar crease and on
the radial side by the longitudinal crease between the thenar and hypothenar eminence.

authors described a triangular area on the hypothenar emi-
nence of the palm where the nerve can be found. This area was
noted to extend from the middle half of the hypothenar emi-
nence and is limited distally by the proximal palmar crease
and on the radial side by the longitudinal crease between the
thenar and hypothenar eminence. They noted that the nerve
always crossed the longitudinal axis from the ring finger.
Clinical Significance of the Communicating Branch. Aware-
ness of this branch explains sensory findings that do not
conform to the classic 31⁄2 to 11⁄2 median–ulnar supply to the
fingers. This may explain persistent sensibility in the long
finger after complete laceration of the median nerve at the
wrist. Similarly, if a lacerated communicating branch is
overlooked, there will be permanent sensory loss even if
good recovery occurs in adjacent nerve repairs. This nerve
may be at risk with carpal tunnel release, ring finger flexor
tendon surgery, and Dupuytren’s fasciectomy. Unrecog-
nized injuries or lacerations to this nerve may explain some
instances of palmar pain commonly attributed to nerve
traction or scarring (61,62).
Deep (Motor) Branch of the Ulnar Nerve
The course of the deep branch into the palm has been vari-
ously described as passing between the origin of the FDM
and ODM (1) or beneath the proximal origin of the FDM
(28) (Fig. 10.35 see Fig. 10.33). It then courses around the
ulnar and distal aspect of the base of the hook process of the
hamate. The proximal edge of the FDM often (14 of 23
cases) demonstrates a fibrous arcade where the motor branch
may become entrapped (28). It then traverses the hand
accompanied by the deep arterial arch, palmar to the flexor
 10.1 Palmar Hand 581

FIGURE 10.35. The deep (motor) branch of the ulnar nerve. Note the course of the deep branch
into the palm beneath the proximal origin of the flexor digiti minimi. It then courses around the
ulnar and distal aspect of the base of the hook process of the hamate and traverses the hand pal-
mar to the flexor tendons. It innervates the ring and small finger lumbricals, the palmar and dor-
sal interossei, the adductor pollicis, and the deep head of the flexor pollicis brevis. The motor
branch enters the radial one-half of the hand through the interval between the transverse and
oblique heads of the adductor pollicis.

tendons. It innervates the ring and small finger lumbricals,
the palmar and dorsal interossei, the adductor pollicis, and
the deep head of the FPB. The motor branch enters the radial
one-half of the hand through the interval between the trans-
verse and oblique heads of the adductor pollicis (1).
Muscles of the Hand
The muscles of the hand may be divided into three groups
based on their relative and geographic location: (a) thenar, (b)
hypothenar, and (c) intrinsic. Although all the muscles con-
tained in the hand and thumb may be considered as intrinsic
muscles, for purposes of discussion in this section, the intrin-
sic muscles are considered to be the lumbrical and
interosseous muscles. The arbitrary nature of this division
may be subject to criticism; for example, the ADM that
forms the ulnar lateral band of the small finger is structurally
and functionally similar to a deep head of the dorsal
interosseous. Except for the radial two lumbricals, the APB,
the OP, and the superficial head of the FPB, these hand mus-
cles usually are innervated by the ulnar nerve. Although these
muscles have been grouped according to their location in the
hand, clinically, as in injury or disease, they are dealt with as
innervation groups, and thus ulnar nerve palsy is a distinct
entity that does not necessarily match the previously
described geographic or anatomic muscle compartments.
Principles of Muscle Insertion/Function and
Innervation
The DI muscle has an insertion into bone as well as an
insertion into the lateral bands, with both insertions
demonstrating a variable incidence. Salisbury, and later
Eyler and Markee, delineated the insertions and functions
of the DI and noted the fact that the DI had two separate
components (dorsal and palmar), but that this separation
was not always clearly apparent (63,64). Salisbury, in sup-
port of this concept, quoted Meckel’s law, which states that
a muscle may have only one function. Hepburn, in 1892,
also noted separation of the DI into dorsal and palmar com-
582 Regional Anatomy

ponents, and further noted separate nerve branches to the
two components (65). Eyler and Markee, using microdis-
section, found distinct nerve fibers to the dorsal and deep
components of the DI muscles (64). Eyler and Markee
noted that the classic electrophysiologic experiments of
Duchenne demonstrated the presence of the two compo-
nents of the DI. Duchenne noted abduction of the finger
with application of moderate current to the medial
interosseus, whereas stronger current caused flexion of the
MCP joint and extension of the interphalangeal joints.
Although Duchenne attributed the latter action to the lum-
brical, it was most likely due to stimulation of the motor
endplate of the palmar component of the DI (64). These
findings illustrate the fact that muscles that appear to be
one unit may, in fact, represent two or more functional
units. Prime examples would be the second DI, in which
the bipennate dorsal (most superficial or dorsal) component
inserts into the base of the proximal phalanx and the deep
(more palmar) component inserts into the lateral band, and
the three components of the adductor pollicis (see discus-
sion of adductor pollicis, later), which insert into the prox-
imal phalanx of the thumb, the ulnar sesamoid, and the
extensor expansion, respectively. Eyler and Markee noted
that all primates, except humans, have seven volar
interosseous muscles. In humans, the first, third, fourth,
and sixth palmar interossei are anatomically parts of the
first, second, third, and fourth dorsal interossei, respec-
tively. Thus, the second, fifth, and seventh interossei are
those muscles that now commonly are referred to as palmar
interossei one, two, and three in the human hand. These
findings give weight to the concept that the deep compo-
nents of the DI muscles might well be placed in the same
category as the palmar interossei because they both insert
into the lateral bands, share a unipennate form, and act as
primary extensors of the interphalangeal joints and secon-
darily as flexors of the MCP joints (66). These findings sug-
gest that muscles should be considered as functional units
based on their action or movement produced rather than by
their location. Although many muscles have been named
based on their function, we often are constrained by names
that reflect long-standing usage and familiarity.
Thenar Muscles
The thenar muscles are the APB, the OP, the FPB, and the
adductor pollicis (Fig. 10.36).

A B
FIGURE 10.36. (A,B) Thenar muscles. The four thenar muscles are the abductor pollicis brevis;
the opponens pollicis; the flexor pollicis brevis; and the adductor pollicis.
 10.1 Palmar Hand 583

Abductor Pollicis Brevis

The APB, the most superficial of the thenar group, arises
mainly from the TCL, although a few fibers may arise from
the tubercles of the scaphoid and trapezium. It inserts into
the radial side of the base of the proximal phalanx of the
thumb and into the dorsal expansion of the thumb.
Although its main function is to abduct the thumb, it also
may act to extend the interphalangeal joint of the thumb
because of its insertion into the dorsal expansion.

Opponens Pollicis
Immediately beneath the APB is the OP, which arises from
the TCL and the tubercle of the scaphoid to insert on a
large portion of the palmar (radial) surface of the thumb
metacarpal. The OP acts as a flexor and abductor of the
thumb.

Flexor Pollicis Brevis

The FPB has a superficial and deep portion. The superficial
portion arises from the distal aspect of the TCL and the dis-
tal part of the tubercle of the trapezium and inserts on the
radial side of the base of the proximal phalanx of the
thumb. The deep portion arises from the trapezoid and cap-
itate bones and from the palmar ligaments of the distal
carpal row and inserts on the ulnar side of the base of the
proximal phalanx of the thumb. The FPL tendon passes
between the two heads of the FPB. The FPB flexes the
MCP joint of the thumb.

Adductor Pollicis
The adductor pollicis has transverse, oblique, and accessory
heads (66). The triangular (or perhaps trapezoid) transverse
head arises from the palmar surface of the distal two-thirds
of middle finger metacarpal and inserts into the ulnar base
of the proximal phalanx of the thumb by a short tendon of
insertion. The similarly shaped oblique head arises from the
capitate bone and the palmar bases of the index and middle
finger metacarpals, the palmar ligaments of the carpus, and
the sheath of the FCR tendon. It inserts into the ulnar
sesamoid bone in the palmar plate at the MCP joint of the
thumb. The accessory head arises dorsal and radial to the
oblique head from the base of the index metacarpal and
inserts into the ulnar aspect of the dorsal thumb expansion
adjacent to the MCP joint.
Hypothenar Muscles
The hypothenar muscles are the palmaris brevis, the ADM,
the FDM, and the ODM (Fig. 10.37).
Palmaris Brevis
The palmaris brevis is a thin, quadrilateral muscle on the
proximal aspect of the hypothenar eminence. Its origin is
from the TCL and the ulnar border of the palmar fascia,
and it is attached to the skin on the ulnar border of the
FIGURE 10.37. The hypothenar muscles. The four hypothenar
muscles are the palmaris brevis; the abductor digiti minimi; the
flexor digiti minimi; and the opponens digiti minimi.
hand. It is superficial to the ulnar artery and nerve. Its
action is to assist in cupping the hand.
Abductor Digiti Minimi
The ADM arises from the pisiform bone, the tendon of the
FCU, and the pisohamate ligament. It attaches to the ulnar
side of the proximal phalanx of the small finger and forms
the ulnar lateral band of the small finger, which ends in the
dorsal digital expansion. As its name implies, it acts as an
abductor of the small finger and also has an intrinsic func-
tion through its attachment to the hood. Structurally and
functionally, it is similar to a deep head of the dorsal
interosseous.
Flexor Digiti Minimi
The FDM lies to the radial side of the ADM and arises
from the convex surface of the hook process of the hamate
and the adjacent TCL. It inserts into the ulnar side of the
base of the proximal phalanx of the small finger. The FDM
acts as a flexor of the small finger MCP joint.
584 Regional Anatomy

Opponens Digiti Minimi
The ODM, a narrow triangular muscle, lies under cover of
the ADM and FDM in its middle and distal thirds and
arises from the convexity of the hook process of the hamate
and the adjacent portion of the TCL. It inserts along the
ulnar and palmar aspect of the small finger metacarpal. The
ODM flexes the small finger metacarpal and to some extent
rotates (supinates) the small finger metacarpal into the posi-
tion of opposition.
Intrinsic Muscles
Interosseous Muscles
The interosseous muscles are located between the
metacarpal shafts and are either dorsal or palmar. Some
anatomists have concluded that there are three palmar
interosseous muscles, whereas others have described the
presence of four palmar interosseous muscles. The contro-
versy involves the presence or absence of a palmar
interosseous in the first web space. The convention adopted
in this text is that there are three palmar and four dorsal
interosseous muscles. The DI are divided into superficial
and deep components. In general, the superficial compo-
nents of the DI insert into bone; the deep components
(along with the palmar interosseous), except for the first DI,
insert into the extensor hood. The details of comparative
insertion percentages into bone or extensor hood are dis-
cussed later (64).
Dorsal Interosseous. The DI muscles are represented by
four bipennate muscles that arise from the opposing sides of
two metacarpal bones, beginning in the thumb–index fin-
ger web space and ending in the ring–small finger inter-
metacarpal space (Figs. 10.38 and 10.39). Each DI muscle

FIGURE 10.38. Superficial dorsal interosseous (DI). In general, the superficial head of the first
and second DI inserts by means of a tendon into the radial base of the proximal phalanx of the
index and middle fingers, respectively, whereas the third and fourth insert into the ulnar base of
the middle and ring fingers. The comparative percentages of insertions of the dorsal interossei
into bone of the proximal phalanx are noted.

FIGURE 10.39. Deep dorsal interosseous (DI) muscles (superficial components of the DI have
been partially removed).
has a superficial and deep head (see prior discussion).
Although Smith has declared that the third DI has only a
deep head, the assumption made in this text is that the third
DI has both a superficial and a deep head (67). The use of
the terms superficial and deep in reference to the component
portions of the DI may result in some confusion because
some authors (66,68) have viewed these muscles from the
palm, whereas others (67) have viewed these muscles from
the dorsum of the hand. The convention adopted in this
text is that the most dorsal component of the DI is termed
the superficial, whereas the deep portion is, as the name
implies, deep or palmar to the dorsal (superficial compo-
nent) and therefore termed deep. This convention seems
appropriate because these are DI muscles that are most eas-
ily viewed and approached surgically from the dorsum.
Linscheid et al. noted that it is not always possible to
cleanly or easily separate the superficial and deep heads by
10.1 Palmar Hand 585
dissection; they noted longer muscle fiber length in the
deep component compared with the superficial component
and an oblique direction of the superficial fibers compared
with the longitudinal course of the fibers in the deep com-
ponent (66). Thus, differences in fiber length and direction,
and insertions, support the concept that the DI does, in
fact, have two distinct components and functions. Similar
findings of a superficial and deep component of the DI
were made by Salisbury, and later by Eyler and Markee
(63,64). Salisbury, in support of this concept, quoted
Meckel’s law, which states that a muscle may have only one
function (63). Hepburn, in 1892, also noted separation of
the DI into dorsal and palmar components, and further
noted separate nerve branches to the two components (65).
Eyler and Markee, using microdissection, found distinct
nerve fibers to the dorsal and deep components of the DI
muscles (64). Eyler and Markee noted that the classic elec-
586 Regional Anatomy
trophysiologic experiments of Duchenne demonstrated
(perhaps unwittingly) the presence of the two components
of the DI when Duchenne noted abduction of the finger
with application of moderate current to the medial
interosseus, whereas stronger current caused flexion of the
MCP joint and extension of the interphalangeal joints.
Although Duchenne attributed the latter action to the lum-
brical, it was most likely due to stimulation of the motor
endplate of the palmar component of the DI (64).
Superficial Head. In general, the superficial heads (the most
dorsal of the two components) of the first and second DI
insert by means of a tendon into the radial base of the prox-
imal phalanx of the index and middle fingers, respectively,
whereas the third and fourth insert into the ulnar base of
the middle and ring fingers. The first DI inserts almost
exclusively into bone and may have a small and variable
deep belly component. The third DI is the least likely to
have a bony insertion (see following discussion regarding
comparative percentages of insertion into bone or hood).
The dorsal component of the DI is bipennate and origi-
nates from the two adjacent sides of the metacarpal. This
portion of the DI occupies approximately the dorsal one-
half of each interosseous space.
Deep Head. In general, the deep heads of the DI each form
a lateral band at the level of the MCP joint, and over the
middle of the proximal phalanx send fibers that join similar
fibers from the lateral band on the opposite side of the fin-
ger. The palmar component of each DI is phylogenetically
a palmar interosseous, is invariably fused to its dorsal com-
ponent, and may be partially fused to the palmar interossei.
The deep component of the DI is roughly fusiform and
often multipennate. In the index finger, the tendon of the
variably present deep component of the first DI may fuse
with the superficial component to attach to the proximal
phalanx, or the deep component may be a distinct muscle
with insertion into the hood (66). If present in this config-
uration, it, along with the lumbrical, forms the radial com-
ponent of the hood that joins the ulnar counterpart (lateral
band) of the first palmar interosseous to form the extensor
expansion. In the middle finger, the radial lateral band is
formed by the deep portion of the second DI, and the ulnar
lateral band from superficial and deep components of the
third DI. In the ring finger, the radial lateral band is from
the second palmar interosseous, and the ulnar lateral band
from the deep head of the fourth DI. In the small finger, the
radial lateral band from the third palmar interosseous joins
the lateral band extension of the ADM to form the exten-
FIGURE 10.40. Palmar interosseous mus-
cles. Comparative percentages of insertion
into the extensor hood of the palmar
interossei are noted. The balance of the
insertion of the various muscles, if not
100%, is into bone.

sor expansion. The first and largest DI muscle is sometimes
called the abductor indicis. In the distal third of the proxi-
mal phalanx, oblique fibers (spiral fibers) from the lateral
bands continue distally to insert onto the lateral tubercles at
the base of the middle phalanx and act to extend the mid-
dle phalanx.
Comparative Percentages of Insertion into Bone of the Dorsal
Interossei. Eyler and Markee (64) studied the comparative
percentages of insertions of the DI muscles into bone of the
proximal phalanx and noted the following approximate per-
centages (see Fig. 10.38) first DI (index), 100%; second DI
(middle), 60%; third DI (middle), 6%; fourth DI (ring),
40%. They noted a 90% bony insertion of the ADM. Only
the first DI was completely inserted into bone. The balance
of the insertion of the various muscles, if not 100%, was
into the extensor hood. Their results were similar to those
of Salisbury.
Function of Dorsal Interosseous. Superficial Heads. The
superficial heads of the DI abduct the fingers from an imag-
inary line through the central axis of the middle finger and
weakly flex the proximal phalanx of the index, middle, and
ring fingers. Because the DI has no bony insertion on the
10.1 Palmar Hand 587
small finger, abduction in this digit is performed by the
ADM and flexion by the FDM.
Deep Heads. The deep heads flex and abduct the proximal
phalanx and through the spiral or oblique fibers of the lat-
eral bands extend the middle phalanx. Extension of the dis-
tal phalanx is from the distal extension of the lateral bands
(the conjoined tendon).
Palmar Interosseous. The palmar interosseous muscles are
unipennate muscles (Fig. 10.40). Based on the chosen con-
vention of three, rather than four, palmar interosseous mus-
cles, the first palmar interosseous arises from the ulnar side
of the index metacarpal and is inserted into the extensor
expansion on the same side of the index finger, forming the
ulnar lateral band of the index finger. Transverse fibers arch
over the dorsum of the proximal phalanx to join similar
fibers from the opposite lateral band. The second palmar
interosseous arises from the radial side of the ring finger
metacarpal and inserts into the extensor expansion on the
same side of the ring finger. It forms the radial lateral band
of the ring finger and also sends transverse fibers over the
proximal phalanx of the ring finger. The third palmar
interosseous arises from the radial side of the small finger
FIGURE 10.41. The lumbrical muscles. The
usual pattern of insertion of the lumbricals is
into the radial side of the extensor hood, as
demonstrated by the second lumbrical.
588 Regional Anatomy
metacarpal and inserts almost exclusively into the extensor
expansion on the radial side of the small finger, forming the
radial lateral band of the small finger and sending fibers
dorsally to join the opposite lateral band. The third is the
only palmar interosseous that has any significant insertion
into bone. Except for the third, none of the palmar
interosseous muscles insert into bone in the proximal pha-
lanx, but all three of the palmar interossei send oblique or
spiral fibers to insert on the lateral tubercle of the middle
phalanx. In general, the three palmar interosseous muscles
“face” the middle finger metacarpal (64). The ulnar lateral
band of the small finger is formed by the tendinous contin-
uation of the ADM.
Comparative Percentages of Insertion into the Extensor Hood of
the Palmar Interossei. Eyler and Markee (64) studied the
comparative percentages of insertion of the palmar interos-
sei into the extensor hood and noted the following approx-
imate percentages (see Fig. 10.40): first palmar interosseous
(index), 100%; second palmar interosseous (ring), 100%;
third palmar interosseous (small), 90%. The balance of the
insertion of the various muscles, if not 100%, was into
bone. Their results were similar to those of Salisbury (63).
Function of Palmar Interosseous. Based on their
anatomic position and insertions, it is easy to recognize that
these muscles act as adductors of their respective fingers
toward the middle finger (the central axis), flex the proxi-
mal phalanx, and extend the middle phalanx through their
distal continuation. Because the deep portions of the distal
and the palmar interossei most often are inserted into the
hood mechanism, their action depends to some extent on
the position of the MCP joint and thus of the hood. When
the MCP joint is in extension, the hood is adjacent to the
MCP joint, and the interossei are under tension and extend
the middle and distal phalanges. When the MCP joint is in
flexion, the hood is more distal and acts as a sling about the
dorsal and proximal aspect of the proximal phalanx; when
the interossei contract, they act as flexors of the MCP joint.
When the MCP joint is flexed, the interossei cannot extend
the middle and distal phalanges (21).
Lumbrical Muscles
The lumbrical muscles are comparatively small intrinsics
that arise from the flexor digitorum profundus (FDP) ten-
dons (Fig. 10.41). The first and second lumbricals arise
from the radial and palmar surfaces of the index and long
finger FDP tendons, the third from the adjacent sides of the
long and ring finger FDP, and the fourth from the adjacent
sides of the ring and small finger FDP tendons. The first
and second lumbricals are unipennate and the third and
fourth bipennate. The tendon of each lumbrical passes pal-
mar to the transverse metacarpal ligament and, in general,
joins the radial lateral band of each finger.
Insertion of the Lumbricals. The usual pattern of inser-
tion of the lumbricals is into the radial side of the extensor
hood, as demonstrated by the second lumbrical. Exceptions
in the remaining lumbricals noted by Eyler and Markee
included: first lumbrical, small bony insertions into the
index; third lumbrical, insertion into the ulnar side of the
long finger, bifid insertion (radial side of ring finger and
ulnar side of long finger), bony insertion; fourth lumbrical,
ulnar side of ring finger, bifid insertion (radial side of small
FIGURE 10.42. Comparative angle of attack of the
interossei and lumbrical muscles, after Eyler and Markee
(64).

finger, ulnar side of ring finger), and part into bone and
part into expansion (64).
Function of the Lumbricals. Various functions have been
ascribed to the lumbricals, including the initiation of flexion
of the MCP joints, extension of the interphalangeal joints,
flexion of the MCP joint, radial deviation of the fingers, and
pulling the FDP distally to allow the interphalangeal joints to
be more easily extended (64). Pulling distally on the FDP
when this muscle is at rest permits a reduction in the vis-
coelastic resistance of the FDP and indirectly facilitates the
action of the common extensor on the middle and distal pha-
langes (21,69). In contrast to the interossei, the lumbricals
may extend the middle and distal phalanges with the MCP
joint in flexion. In a low ulnar nerve lesion, the lumbricals act-
ing alone may stabilize the MCP joints and extend the inter-
phalangeal joints of the index and middle fingers. When the
lumbrical contracts, it pulls the FDP distally and the lateral
band proximally, resulting in decreased force in the FDP,
which allows more effective extension of the PIP and DIP
joints by the lumbrical. When the lumbrical and FDP con-
tract together, interphalangeal joint flexion may be limited. As
the tips of the fingers close in a grasp, lumbrical tension
increases, and when grasp is almost complete, the lumbricals
contribute most to flexion. An important function of the lum-
bricals is to stabilize the MCP joint and to contribute to the
force of the final phase of grasp (64). Perhaps their most
important function is interphalangeal extension, after which
they may act as MCP flexors (21,70).
Intrinsic Muscle Function Based on the Comparative
Angle of Attack of the Interossei and Lumbricals
Eyler and Markee described the angle of attack of the vari-
ous components of the intrinsics (Fig. 10.42) and noted the
following:
1. The tendon of the dorsal component of the DI passes
almost directly over the axis of rotation of the joint and
thus may extend, flex, or abduct the phalanx; its angle of
attack is 0 to 5 degrees.
2. The palmar components of the dorsal and the palmar
interossei attack the joint well below the axis and thus
are capable of flexing the MCP joint more strongly, as
well as of extending the interphalangeal joints; their
angle of attack is 20 to 25 degrees.
3. Each lumbrical approaches the MCP joint palmar to the
transverse metacarpal ligament and is mechanically best
suited to initiate flexion of the MCP and to insert force
on the joint when in flexion; their angle of attack is 35
degrees (64).
Architectural Design of the Human Intrinsic Hand
Muscles
Definition. The architecture of skeletal muscle is defined
as the arrangement of muscle fibers relative to the axis of
force generation (71).
10.1 Palmar Hand 589
Important Architectural Properties of Intrinsic Hand
Muscles. The most important architectural properties of
muscle are muscle length (ML), muscle fiber length (FL),
and physiologic cross-sectional area (PCSA). Muscle excur-
sion and velocity are directly proportional to FL, and iso-
metric muscle force is directly proportional to the PCSA
(72). The intrinsic muscles of the hand are important for
efficient and balanced hand function, and a knowledge of
their architectural specialization has implications for ten-
don transfer, biomechanical modeling, prothesis design,
and analysis of normal function (72).
Intrinsic Muscle Lengths/Fiber Lengths. Based on a study
of the intrinsic muscles in nine hands, Jacobson et al. noted
that intrinsic MLs were relatively similar to one another
(average ML was 65 mm, compared with extrinsic average
ML of 162 mm), which the authors interpreted as repre-
senting a space constraint in the hand. However, specialized
architectural designs were noted: lumbrical muscles had an
extremely high FL/ML ratio, implying a need for high
excursion. Lumbrical muscle fibers extended 85% to 90%
of the ML, which represented a very high FL/ML ratio.
Lumbrical muscle FLs were similar to the FLs of the FDP,
FDS, and ECRB muscles. The result of such an arrange-
ment in the lumbrical is a flatter, broader length–tension
curve that implies a relatively constant contractile force over
a long range of FLs, depending on the position of the FDP
tendon. Thus, it can be argued that long lumbrical muscle
fibers might facilitate active muscle contraction, even dur-
ing FDP contraction, by allowing the lumbrical origin to
move without large changes in sarcomere length. If lumbri-
cal muscle FLs were short, FDP excursion could stretch the
lumbrical sarcomeres to the point where they would be
unable to generate active force (72). The FL/ML ratio can
be seen as a relative measure of design preference for excur-
sion (high ratio) or force (low ratio). The intrinsics have rel-
atively high FL/ML ratios, representing a design bias
toward excursion and velocity production and a relative bias
against force production. Although the interosseous mus-
cles have the lowest FL/ML ratio, it is surprisingly high for
their pennation. Their FL appears to represent a minimum
that is required to meet their functional requirements of
excursion and strength. Although Jacobson et al. did not
measure the differences between the superficial and deep
components of the DI, Linscheid et al. noted a distinct dif-
ference in fiber length and orientation between the two
components, which would support the concept that two
components of the DI have different FLs and thus different
excursions (66).
Physiologic Cross-Sectional Area. The most variable mea-
surement between the various intrinsic muscles is their PCSA.
The PCSA is proportional to maximum isometric tension.
The lumbrical PCSA is 0.1 cm compared with the adductor
pollicis PCSA of almost 2 cm (72). The first DI and adductor
590 Regional Anatomy
pollicis had PCSAs comparable with those of extrinsic muscles
and much greater than those of the other intrinsic muscles.
The mass of the adductor pollicis (1.94 g) was the largest of
the intrinsic muscles, followed by the DI, palmar interosseous,
thenar, and hypothenar muscles. The lumbrical muscles had
the lowest muscle masses in the hand, ranging from 0.23 to
0.57 g. The interosseous muscles had relatively high PCSAs
with low FL/ML ratios, suggesting their adaptation for high
force production and low excursion. Generally, the PCSAs of
the intrinsics were the lowest of all those measured in the
upper limb, with the exception of those muscles that had no
extrinsic synergist. For example, the adductor pollicis and first
DI are the primary providers of their functions in the hand
FIGURE 10.43. Relationship of the extrinsic extensors, dorsal aponeurosis, and intrinsic tendons.
and are responsible for key pinch, which requires the ability to
generate high forces (72).
Extrinsic Extensors and Dorsal Aponeurosis
Any discussion of the intrinsic muscles and their function
would be incomplete without including their relationship
to the dorsal aponeurosis and extrinsic extensors because
functionally, the two systems cannot be separated (Figs.
10.43 and 10.44). It was Landsmeer in 1949 (73) who
stated that the dorsal aponeurosis gave the morphologic
basis for the integration and coordination of the extensor
and interosseous muscles.
 10.1 Palmar Hand 591

impingement between the sagittal band and the lateral band

formed by the deep component of the DI or the palmar
interosseous.

Function of the Extrinsic Extensors

Contraction of the extensors results in extension of the
proximal phalanx by the proximal phalangeal attachments
of the sagittal bands. Hyperextension is avoided by the teth-
ering effect of the palmar plate and the intrinsic muscles,
which insert into the extensor expansion.

Distal Anatomy of the Extrinsic Extensors

Distal to the MCP joint, the extensor tendon divides into
three components: the central slip, which inserts into the
dorsal base of the middle phalanx, and two lateral slips that
join the lateral bands at the distal aspect of the proximal
phalanx. Smith has appropriately called this union of the
intrinsic muscle lateral bands and the lateral slips from the
extensor tendon the conjoined lateral bands (67). The lateral
bands, at approximately the middle portion of the middle
phalanx, send slips to the central tendon. However, this
exchange of slips between the central portion of the exten-
sor tendon and the lateral bands (and vice versa) is best
appreciated in special anatomic preparations, and may not
FIGURE 10.44. Extensor mechanism of a small finger (fresh
always be readily apparent in the operating room. The con-
cadaver dissection). The point of the distal arrow indicates the joined lateral bands fuse over the middle phalanx to form
oblique retinacular ligament adjacent to the transverse retinac- the terminal tendon, which inserts into the dorsal base of
ular ligament. The proximal arrow points to the sagittal band. the distal phalanx. The transverse retinacular ligament,
(From Milford LW Jr. Retaining ligaments of the digits of the
hand: gross and microscopic anatomic study. Philadelphia: WB which spans between the lateral bands and the flexor canal
Saunders, 1968:35, with permission.) at the PIP joint, prevents dorsal migration of the lateral
bands (Fig. 10.45). The triangular ligament maintains the
conjoined lateral bands dorsally over the proximal aspect of
the middle phalanx.
The extensor digitorum communis (EDC) and the index
and small finger proprius tendons join the extensor expan-
sion at the MCP joint (74). These tendons are maintained
over the apex of the MCP joint by a substantial dorsal sling
of transverse fibers, the sagittal band, which invest the ten-
don dorsally and pass palmarward on each side of the MCP
joint to attach to the palmar plate and the transverse
metacarpal ligament. The extensor mechanism at the level
of the proximal aspect of the finger is composed of a layered
criss-cross fiber pattern, which changes its geometric
arrangement as the finger flexes and extends. This arrange-
ment allows the lateral bands to be displaced volarly in flex-
ion and to return to the dorsum of the finger in extension
(75). The sagittal band acts as a static tether to prevent
radial or ulnar displacement of the extensor mechanism and
also acts as a dynamic tether that allows proximal and distal
gliding of the extensor tendons during finger flexion and
FIGURE 10.45. The transverse retinacular ligament (fresh
extension. The sagittal bands are positioned between the cadaver dissection). The tip of the angled probe is beneath the
tendons of insertion of the superficial and deep compo- transverse retinacular ligament. Cleland’s ligaments arise palmar
nents of the DI musculotendinous unit. This arrangement to this ligament and project proximally and distally. (From Mil-
ford LW Jr. Retaining ligaments of the digits of the hand: gross
allows freedom of movement to the sagittal band in the and microscopic anatomic study. Philadelphia: WB Saunders,
plane between the two components of the DI and avoids 1968:48, with permission.)
592 Regional Anatomy
Oblique Retinacular Ligament
The oblique retinacular ligament (ORL) is discussed in this
section because of its interaction with the intrinsic muscle
system (Figs. 10.46 and 10.47; see Fig. 10.43). This struc-
ture was first described by Weitbrecht in 1742 and named
retinaculum tendini longi, indicating its tendinous rather
than ligamentous character (6,76,77). Haines, Landsmeer,
and others have described its structure and functions
(68,73,78). Milford noted that Landmeer in 1949 called
attention to this ligament, followed 1 year later by a similar
report by Haines, who called this structure the link liga-
ment. Haines did not know of Landsmeer’s publication
until after his paper was written (77). Neither author appar-
ently knew of Weitbrecht’s description of a similar structure
over 200 years previously until Kaplan pointed it out in his
second edition of Functional and Surgical Anatomy of the
Hand (63). The ligament is present on both sides of the fin-
ger, and its proximal origins are from the outer and distal
aspect of the A2 pulley and the lateral surface of the distal
third of the proximal phalanx. The ORL origins may be
covered at times by the lateral bands (77). The ligament
passes distally parallel to the lateral bands and across the
region of the PIP joint, where it is deep to the transverse
retinacular ligament, and then inserts variably into the lat-
eral bands at approximately the level of the PIP joint or into
the terminal tendon in the distal half of the middle phalanx
(21,77). Milford noted that sometimes these fibers could be
seen to continue at the lateralmost part of the lateral band
as it inserted into the distal phalanx (77). It is consistently
palmar to the PIP and dorsal to the DIP joint axis of rota-
tion. The ORL is said to coordinate movement of the inter-
phalangeal joints because extension of the PIP joint places
the ORL under tension and acts as a dynamic tenodesis to
aid the conjoined or terminal tendon in extension of the
DIP joint. Based on this concept, the ORL is placed under
tension with DIP joint flexion. Thus, it is stated that the
FIGURE 10.46. The oblique retinacular ligament (ORL; fresh
cadaver dissection). The angled probe is tenting up the trans-
verse retinacular ligament and the hook to the left places ten-
sion on the ORL. (From Milford LW Jr. Retaining ligaments of the
digits of the hand: gross and microscopic anatomic study.
Philadelphia: WB Saunders, 1968:49, with permission.)
FIGURE 10.47. Origin of the oblique retinacular ligament (ORL;
fresh cadaver dissection). The white arrow points to the origin of
the ORL near the distal end of the second annular pulley. The
hook is retracting the extensor mechanism dorsally. The finger-
tip is to the left. (From Milford LW Jr. Retaining ligaments of the
digits of the hand: gross and microscopic anatomic study.
Philadelphia: WB Saunders, 1968:50, with permission.)
ORL does not permit easy active or passive flexion of the
DIP joint when the PIP joint is in extension (68). This may
be demonstrated on one’s own finger by noting that active
flexion of the DIP usually is not possible until the PIP joint
is flexed (unless the PIP joint is supported in extension to
allow the powerful FDP to overcome the normal situation).
Harris and Rutledge, based on their study of the extensor
mechanism and its relationship to the ORL, concluded that
in the normal finger, extension of the DIP joint was per-
formed entirely by the terminal extensor tendon (74). They
considered the ORL to be a stay or retaining ligament that
maintained the extensor on the dorsum of the finger.
Although the structure and extent of the ORL, and thus its
functional effect, may vary from finger to finger, when
thickened and contracted it may play a role in PIP and DIP
joint contracture, as noted in boutonniere deformity (21).
Clinical Significance of the Intrinsic Muscles
Although the specific function of each of the intrinsic,
thenar, and hypothenar muscles has been given in the pre-
ceding section, a broader and perhaps more useful under-
standing of their significance in hand function may be had
by (a) noting their overall function in the normal hand, (b)
noting the resultant hand deformities with intrinsic muscle
weakness or absence of function, and (c) noting the patterns
of hand deformity with contracture of the intrinsics.
Intrinsic Muscle Function in the Normal Hand
Strength and balance are the key terms that characterize the
function of the intrinsics in the hand. The interossei, lum-
bricals, FDM, and the bony insertion portion of the ADM
are flexors of the proximal phalanges, and grip strength may
be diminished if they are weak or absent (67).
 10.1 Palmar Hand 593

A B

FIGURE 10.48. Patterns of grasp without and with intrinsic muscle function. A, B: The so-called
claw or hook deformity due to absent intrinsic function results in inability to grasp objects such
as a ball. C: This is in contrast to normal grasp with intact intrinsic function.

Weakness or loss of intrinsic muscle function results in
an imbalance of the extrinsic flexors and extensors of the
three finger joints and a so-called claw deformity results at
rest. The absent function of the intrinsics as flexors of the
proximal and extensors of the middle and distal joints
results in hyperextension of the proximal joints and acute
flexion of the middle and distal joints during attempts at
extension of the fingers or grasp because of the unopposed
action of the EDC, FDS, and FDP, respectively (Fig.
10.48). Although so-called hook grasp, as in holding a
briefcase handle, is relatively undisturbed in intrinsic palsy,
all forms of grasp or pinch that require simultaneous MCP
flexion and interphalangeal joint extension are awkward, if
not impossible.
Patterns of Deformity and Functional Loss Due to
Intrinsic Muscle Weakness or Absence
Low Ulnar Nerve Palsy. This pattern refers to denervation
of the ulnar-innervated intrinsic muscles in the hand. Thus,
in general, the thenar muscles are spared along with the
radial lumbrical muscles. The resultant deformity is charac-
terized by clawing of only the ring and small fingers. Claw-
ing of the index and middle fingers would not occur
because of the median nerve innervation of the radial two
lumbricals. In addition to the clawing of the ring and small
fingers, there is loss of grip strength and abduction and
adduction of the fingers. Attempts to extend the ring and
small fingers are associated with hyperextension of the
MCP joints because of the unopposed action of the EDC.
High Ulnar Nerve Palsy. At this level, the innervation of
the FCU and FDP to the ring and small fingers is lost, in
addition to the intrinsics. The resultant effect on the fingers
is similar to the low ulnar nerve lesion, except that the claw-
ing is less severe, but the grip loss is more significant.
Low Ulnar and Median Nerve Palsy. In this lesion, the
function of all intrinsic, thenar, and hypothenar muscles is
lost.
There is significant loss of grip strength, clawing of all
fingers, loss of abduction and adduction of the fingers, and
loss of opposition of the thumb. The loss of intrinsic flex-
ion at the MCP joint allows the unopposed long extensors
to hyperextend the MCP joints during attempts at finger
extension. Extension of the middle and distal joints is lost,
and the unopposed action of the FDS and FDP accentuates
the claw deformity.
High Ulnar and Median Nerve Palsy. In this lesion, there
is loss of all intrinsic muscle function as well as the extrin-
sic flexors. Only the EDC is functional, and no claw defor-
mity is present. When the EDC contracts, the MCP joints
hyperextend, along with extension of the interphalangeal
joints. If the median and ulnar nerves are successfully
594 Regional Anatomy
repaired, clawing may develop as the FDS and FDP are
reinnervated (67).
Intrinsic Contracture
Definition. This condition is defined as any abnormal
contracture or shortening of the lumbricals, interossei, or
lateral band.
Etiology. Primary Causes. Intrinsic contracture may be
due to central nervous system disorders with spasticity, such
as cerebral palsy or after cerebrovascular accidents. It may
be a residual of traumatic incidents that produce hematoma
or edema with subsequent contracture in the intrinsic mus-
cles or lateral band, or traumatic incidents that produce sec-
ondary deformity such as the mallet finger. Intrinsic con-
tracture also may be associated with inflammatory diseases
such as rheumatoid arthritis.
Secondary Causes. The lateral band may be stretched or dis-
placed over an osteophyte or osteochondroma in the proxi-
mal phalanx, or the lateral band may be displaced dorsally
and shortened because of a chronic mallet finger deformity.
A B
FIGURE 10.49. A, B: The intrinsic tightness (IT) test.
Tests for Intrinsic Muscle Contracture (Intrinsic Tight-
ness or Bunnell Test). Zancolli (79) and Smith (67) credit
Finochietto (80) and Parkes (81) with the initial description
(Fig. 10.49).
The basic maneuver involved in testing for intrinsic con-
tracture or tightness is to place the intrinsic muscles at their
maximum length. This is achieved by passive hyperexten-
sion of the MCP joint. The PIP joint is then passively flexed
and the degree and ease of flexion noted. If easy and com-
plete passive flexion of the PIP joint is obtained, the test is
negative.
If, however, there is incomplete flexion of the PIP joint
in the first maneuver, the MCP joint is passively flexed and
the ease and degree of flexion of the PIP joint is again deter-
mined. If PIP joint flexion is improved when the MCP
joint is flexed, the test is considered to be positive.
Thus, in most cases of intrinsic tightness, there is less
flexion of the PIP joint when the MCP joint is held in
extension.
Other Causes of Limited Proximal Interphalangeal Joint
Flexion. If PIP joint motion is limited because of PIP joint

disease or contracture, or adhesion of the extensor tendon
over the proximal phalanx, the position of the MCP joint
will not influence PIP joint motion. If PIP joint motion is
limited because of extrinsic extensor tendon contracture or
adhesion on the dorsum of the hand, PIP joint motion will
be greater when the MCP joint is extended. In the extensor
plus syndrome, there is shortening or adherence of the
extensor mechanism proximal to the MCP joint, which
results in inability to flex the MCP and PIP joints simulta-
neously, although the joints can be flexed individually (82).
If flexion of the MCP joint is associated with absent or lim-
ited flexion of the PIP joint, the test is positive and is con-
firmed by noting improved or complete flexion of the PIP
joint with hyperextension of the MCP joint.
Intrinsic contracture may coexist with PIP joint stiffness,
extrinsic (flexor) contracture, and MCP joint subluxation
or dislocation with contracture. In MCP joint contracture,
it is impossible to compare PIP joint motion, but intrinsic
contracture nevertheless may be present.
Intrinsic “Plus” and “Minus” Hand. The terms intrinsic
plus and intrinsic minus have been used to describe the char-
acteristic postures of the fingers with spasm or contracture
of the intrinsic muscles and absence of function of the
intrinsics due to ulnar nerve laceration or disease, respec-
tively. The intrinsic plus deformity is seen most often in
rheumatoid arthritis, and the intrinsic minus deformity in
ulnar nerve dysfunction.
The term intrinsic plus also is used to describe the rec-
ommended position for splinting the fingers in a swollen
hand to prevent undesirable contractures. This position is
characterized by flexion of the MCP joints and extension of
the PIP joints. The rationale for this posture is discussed in
the section on Joints.
Lumbrical Plus Condition. Definition. Paradoxical
extension of the PIP joint occurs when flexion of the finger
is attempted (83).
Pathomechanics. If the profundus tendon is lacerated in the
finger, the proximal end of the tendon migrates proximally
because of the pull of its muscle belly. The lumbrical origin
is carried proximally, and this increased tension on the lum-
brical may produce increased tension in the lateral band
and thus extension of the PIP joint.
This condition also may develop after amputations of the
distal phalanx. It may be noted with flexor tendon grafts that
are too long. Wrapping the lumbrical about the repair site of
a lacerated flexor tendon also may be a cause of lumbrical
plus if the lumbrical subsequently contracts or shortens.
Diagnosis. This condition may be diagnosed if the intrinsic
tightness test is positive after a tendon graft, distal phalanx
amputation, or FDP tendon repair if the patient demon-
strates paradoxical extension of the PIP joint.
10.1 Palmar Hand 595
Author’s Comment. Although not a common condition,
lumbrical plus may provide an explanation for paradoxical
extension of the PIP joint in certain conditions.
Retinacular System
The retinacular system of the hand includes the TCL, pal-
mar fascia, natatory ligaments, palmar and digital pulley
system, and the retaining ligaments of the fingers. In this
context, retinacular structures are defined as fibrous tissue
structures that retain or keep in place [i.e., “halter” (Latin)].
Palmar Fascia
The palmar fascia is defined as the specialized fascial struc-
ture in the central portion of the palm with longitudinal,
transverse, and vertical fibers (Fig. 10.50). It is distin-
guished from the fascial covering of the thenar and
hypothenar eminences by its triangular shape and thick-
ness. The longitudinal fibers represent the distal continua-
tion of the palmaris longus (when present). These fibers,
which begin as a conjoined apex at the base of the palm,
form bundles in the middle and distal palm that course to
the corresponding four fingers and in some instances to the
thumb. The longitudinal fibers are more or less parallel to
the deeper flexor tendons, and because of this arrangement
sometimes are called pretendinous bands. The four bundles
of longitudinally oriented fibers overlay transverse fibers in
the palm that are located at the junction of the middle and
distal thirds of the palm and over the MCP joints.
McGrouther has noted that these longitudinal fibers divide
into three layers in the distal palm (2). Layer one, the most
superficial, inserts into the skin of the distal palm and onto
the proximal aspect of the flexor sheath. Layer two splits
and passes on each side of the flexor sheath, where it con-
tinues distally as the spiral band of Gosset (84) beneath the
neurovascular bundle and natatory ligaments to insert on
the lateral digital sheet. Layer three passes on each side of
the flexor sheath to the region of the MCP joint (85). The
transverse fibers of the palmar fascia course beneath the lon-
gitudinal cords from the ulnar side of the small finger to the
radial side of the index finger. In the thumb–index finger
web space, the proximal commissural ligament (PCL) is the
radial continuation of these transverse fibers. The more dis-
tal counterpart of the PCL is the distal commissural liga-
ment (DCL), which is more longitudinally oriented and
spans the space between the MCP joint of the thumb and
index finger (86). Both the PCL and DCL course toward
the thumb MCP joint, where they send attachments to the
undersurface of the skin in the region of the MCP joint; the
deep portion of the DCL sends fibers to attach on both
sides of the FPL sheath (87). The more longitudinal orien-
tation of the DCL may be a factor in its more likely involve-
ment in Dupuytren’s contracture, although both the DCL
and PCL may be involved in Dupuytren’s contracture (85).
596 Regional Anatomy

FIGURE 10.50. The palmar fascia,

natatory ligament, and commissural
ligaments. The transverse fibers of the
palmar fascia course beneath the lon-
gitudinal cords from the ulnar side of
the small finger to the radial side of
the index finger. In the thumb–
index finger web space, the proximal
commissural ligament (PCL) is the
radial continuation of these transverse
fibers. The more distal counterpart of
the PCL is the distal commissural liga-
ment, which is more longitudinally ori-
ented and spans the space between
the metacarpophalangeal joints of the
thumb and index finger. Natatory liga-
ments are located in the web spaces
between the fingers.

The PCL and DCL usually are thinner and less noticeable
than the transverse fibers between the fingers. Both the lon-
gitudinal and transverse fibers course through the vertical
septa to reach the transverse metacarpal ligament (88). The
third component of the palmar fascia consists of the nine
vertical (sagittal) septa (the fibers of Legueu and Juvara)
(89) located deep to the transverse fibers, which form the
sides of eight canals: four of which contain the underlying
finger flexor tendons, and four adjacent canals that contain
the lumbrical muscles and neurovascular bundles. These
paratendinous septa, along with the transverse fibers of the
palmar aponeurosis, form a fibrous tunnel system that has
been described as the palmar aponeurosis pulley (90,91).
These nine vertical septa are anchored to the transverse
metacarpal ligament, palmar interosseous, and adductor
fascia. Bojsen-Moller and Schmidt noted that these vertical
septa divided the distal portion of the central palmar space
into eight canals (88). Although these vertical septa are not

FIGURE 10.51. Distal palmar and digital fascia. The longitudinal fibers of the palmar fascia divide
into three layers in the distal palm. Layer one, the most superficial, inserts into the skin of the dis-
tal palm and onto the proximal aspect of the flexor sheath. Layer two splits and passes on each
side of the flexor sheath, where it continues distally as the spiral band beneath the neurovascular
bundle and natatory ligaments to insert on the lateral digital sheet. Layer three passes on each
side of the flexor sheath to the region of the metacarpophalangeal joint. The natatory ligaments
have transverse as well as curved fibers that follow the contour of the webs. The curved or distal
continuations of these fibers join the lateral digital sheet. The lateral digital sheet is a condensa-
tion of the superficial digital fascia on each side of the finger and receives fibers from the nata-
tory ligament, the spiral band, and Grayson’s ligament. The retaining skin ligaments of Grayson
and Cleland stabilize the skin during flexion and extension of the finger. Grayson’s ligaments are
palmar to the neurovascular bundles and pass from the skin to the flexor tendon sheath. These
ligaments form a tube from the proximal aspect of the finger to the distal interphalangeal joint,
where the digital nerves and vessels always can be found during surgical dissection.

classically considered as part of the palmar aponeurosis, the
authors consider them to be an integral component of the
palmar fascia, and they therefore are included here.
Natatory Ligaments
These ligaments, located in the web spaces between the fin-
gers, also are called the superficial transverse metacarpal liga-
ment (Fig. 10.51; see Fig. 10.50). They are the superficial
counterpart to the more proximal deep transverse meta-
10.1 Palmar Hand 597
carpal ligament, which spans between the palmar plates of
the four finger metacarpals.
Author’s Comment. In my opinion, much confusion could
be avoided if the deep and superficial components of these
names were deleted, so that transverse metacarpal ligaments
and natatory ligaments were the terms used. The natatory
ligaments were aptly named by Grapow the Schwimmband
(“swim ligaments”) because of their position in the inter-
digital webs (86). The natatory ligaments have transverse as
well as curved fibers that follow the contour of the webs.
The DCL may be the first web space counterpart of the fin-
ger natatory ligament.
Clinical Significance of the Palmar Retinacular
System
Compression Loading/Shock Absorbing
Any discussion of the role of the palmar retinacular struc-
tures must note that these structures are only a part of a
complex tissue consortium designed to meet a variety of
functional demands. This complex three-dimensional net-
work may be considered as a fibrous skeleton or framework
designed to assist in the hand’s mechanical functions (1,85).
Compression loading is a common force applied to the
hand and requires a system of shock absorption. In the
hand, one method of shock absorption is to contain some-
what compliant tissues such as fat or muscle in compart-
ments that can change shape but not volume. This is amply
demonstrated in the palm, with its various layers of multi-
directional fascia that contain and compartmentalize fat
and muscle while at the same time conforming to the shape
or contour of the object being grasped or manipulated.
Skin Anchorage
Skin is retained by fascial elements that allow the hand to
flex while maintaining the skin in position. The skin folds at
prominent creases that are minimally anchored, in contrast
to the skin on the adjacent sides of the crease, which possess
multiple strong anchor points. This allows the relatively
unanchored skin to fold while the anchored skin is held in
place. These fascial anchors may be vertical, horizontal, or
oblique, depending on the specific need of the skin enve-
lope. A good example is the horizontal attachments of the
superficial fibers of the pretendinous bands, which attach to
the dermis of the distal palm. This arrangement resists hori-
zontal shearing force in gripping actions such as holding a
hammer or golf club. The palmar aponeurosis, which
includes the nine vertical septa anchored to the deep trans-
verse metacarpal ligament, is tensed with power grip and
thus anchors the skin to the skeleton of the hand (88).
Skeletal Stability
Although not a part of the palmar fascia, the previously
mentioned transverse metacarpal ligament that attaches to
the palmar plates of the MCP joints plays a role in main-
598 Regional Anatomy

taining the transverse metacarpal arch, as do the transverse

fibers of the palmar fascia and the natatory ligaments.

Joint Stability
The fascial ligaments in the web space of the finger and
thumb may play a role in limiting abduction and thus may
indirectly limit the impact of potentially destabilizing forces
that might be applied to the digits.

Pulley Function
The transverse fibers of the palmar fascia, supported by the
vertical septa, form what is called the palmar aponeurosis pul-
ley, and is discussed later in the section on the Pulley System.

Vascular Protection and Pumping Action; Nerve

Protection
Vascular structures in the palm are protected by surround-
ing them with substantial fibrous tissue in combination
with fat pads. When the hand is compressed, as in making
a fist, the incompressible fascia may act as a venous pump-
ing mechanism. This is in contrast to the large dorsal veins
on the dorsum of the hand surrounded by loose areolar tis-
FIGURE 10.52. Grayson’s ligaments (fresh cadaver dissection).
sue. The nerves in the palm are protected by fascial struc- The vertically oriented black suture is passing beneath Grayson’s
tures, and near the base of the fingers by fat pads. ligament, which is seen as a thin fascial partition in the middle
phalanx. (From Milford LW Jr. Retaining ligaments of the digits
of the hand: gross and microscopic anatomic study. Philadelphia:
Digital Fascia WB Saunders, 1968:38, with permission.)

McGrouther has noted that the longitudinal fibers of the

palmar fascia divide into three layers in the distal palm (85)
(see Fig. 10.51). Layer one, the most superficial, inserts into
the skin of the distal palm and onto the proximal aspect of
the flexor sheath. Layer two splits and passes on each side of
the flexor sheath, where it continues distally as the spiral
band of Gosset (84) beneath the neurovascular bundle and
natatory ligaments to insert on the lateral digital sheet.
Layer three passes on each side of the flexor sheath to the
region of the MCP joint.
Natatory Ligaments
The natatory ligaments have transverse as well as curved fibers
that follow the contour of the webs. The curved or distal con-
tinuations of these fibers join the lateral digital sheet.
Lateral Digital Sheet
Gosset described these condensations of the superficial dig-
ital fascia on each side of the fingers (84). This structure
receives fibers from the natatory ligament, the spiral band,
and Grayson’s ligament.
Grayson’s and Cleland’s Ligaments (the Retaining Skin
Ligaments)
Both Cleland’s and Grayson’s ligaments stabilize the skin
during flexion and extension of the finger.
flexor tendon sheath (77) (Fig. 10.52; see Fig. 10.51).
Grayson reported that they were found in pairs at each
interphalangeal joint and that only the proximal pair of lig-
aments about the DIP joint could be demonstrated with
certainty (92). Those of the PIP joint came in two pairs,
with the proximal pair arising from the flexor sheath at the
distal third of the proximal phalanx and the distal pair aris-
ing from the sheath over the proximal third of the middle
phalanx. Milford, in his comprehensive dissections of the
retaining ligaments of the digits, found that Grayson’s liga-
ment was fragile and membranous and was strongest at the
middle three-fourths of the middle phalanx in the finger
and just proximal to the interphalangeal joint in the thumb.
Milford noted that the ligament originated from the palmar
aspect of the flexor tendon sheath and projected at right
angles (at variance with Grayson’s observation of an oblique
course) to the long axis of the finger. Milford concluded
that (a) Grayson’s ligament in the human probably is strong
enough to maintain the digital vessels and nerves in place
and prevent bowstringing when the finger is flexed; and (b)
clinically, Grayson’s and Cleland’s ligaments formed a tube
from the proximal aspect of the finger to the DIP joint,
where the digital nerves and vessels always can be found
during surgical dissection.

Grayson’s Ligaments. Grayson’s ligaments are palmar to Cleland’s Ligaments. Cleland’s ligaments, based on Mil-
the neurovascular bundles and pass from the skin to the ford’s dissections, consist of four conelike structures that arise

from the PIP joint on each side of the finger and the inter-
phalangeal joint of the thumb (77,93) (Fig. 10.53; see Fig.
10.51). These ligaments are dense fibrous bundles that
diverge from their origin to insert into the skin. The fibers are
arranged in two planes and form a structure somewhat like a
cone. They are dorsal to the neurovascular bundle and are
arranged proximal and distal to the transverse retinacular lig-
ament in the finger near its palmar insertion. The proximal
fibers are shorter than the distal fibers and are more perpen-
dicular to the long axis of the phalanx. The largest bundle
originates from the lateral margin of the middle phalanx over
its proximal fourth, from the joint capsule of the PIP joint,
and from the flexor tendon sheath. These fibers are strong,
project in straight lines, and fan out to insert in an area of
skin larger than their origin, but all fibers insert proximal to
the DIP joint. The most dorsal of the fibers become taut
when the PIP joint is flexed (lending some stability to the
skin) because of stretching of the fibers over the condyle of
the proximal phalanx. The most palmar fibers become taut
with PIP joint extension, with similar stability noted in the
skin. The two distal bundles of this ligament originate from
the DIP joint from the bone and capsule, over a small, 1- to
2-mm area just proximal and distal to the joint. The strongest
bundle of Cleland’s ligament in the thumb (the proximal)
arises from the flexor tendon sheath just distal to the MCP
joint and then courses distally to insert into the adjacent skin.
The distal two bundles arise at the interphalangeal joint from
the bone and capsule over a small area (77).
Pulley System of the Wrist, Hand (Palm),
and Digits
Wrist
Kline and Moore in 1992 proposed that the TCL was an
important component of the finger flexor pulley system
(94). This broad and substantial ligament, which spans the
10.1 Palmar Hand 599
FIGURE 10.53. Cleland’s ligament (fresh cadaver
dissection). The arrow points to the largest bundle of
Cleland’s ligament, and the probe is beneath the sec-
ond largest bundle. (From Milford LW Jr. Retaining
ligaments of the digits of the hand: gross and micro-
scopic anatomic study. Philadelphia: WB Saunders,
1968:40, with permission.)
palmar side of the carpus, was sectioned in fresh-frozen
cadavers, and the authors noted a 25% increase in the
required excursion for the profundus and a 20% increase in
the superficialis. They noted that the increased excursion
that was consumed after release of the TCL resulted in less
remaining excursion for flexion of the other joints and thus
might contribute to weakness of grip noted after carpal tun-
nel release. They concluded that the main purpose of the
TCL was to act as a flexor pulley at the wrist. The increased
flexor tendon excursion, however, was demonstrated only
when the wrist was in the flexed position. This could result
in decreased grip strength when the wrist was flexed,
although most power gripping is done with the wrist in
extension. This study further serves to point out the impor-
tance of knowing the status of all three components of the
system—the wrist, palm, and finger—before performing
flexor tendon surgery throughout the system.
Palmar Aponeurosis Pulley
Manske and Lesker, in 1983, described the palmar aponeu-
rosis pulley and noted its function as a pulley (90) (Fig.
10.54). This pulley is formed by the transverse fibers of the
palmar aponeurosis that are anchored on each side of the
flexor synovial sheath by vertical (sagittal) fibers or inter-
tendinous septa, which attach to the deep transverse
metacarpal ligament and thus form an archway over the
flexor tendons. Its average width is 9.3 mm, and its proxi-
mal edge begins 1 to 3 mm distal to the beginning of the
flexor synovial sheath (91). Although it is not as closely
applied to the flexor tendons as the digital pulleys, closer
approximation may occur with increased tension on the
palmar aponeurosis, as in grasping. This proximal tension
may be provided by the palmaris longus or the FCU, or
both (91). Manske and Lesker established the functional
significance of this structure as a pulley by noting a signifi-
600 Regional Anatomy

mar aponeurosis pulley. The authors concluded that as a

single functioning pulley, the A2 pulley was the most
important, followed closely by the A1 pulley. They noted
that although the position of the palmar aponeurosis pulley
was the least critical of the three, its importance as a pulley
was evident in the increased loss of flexion, from 5.7%
when it alone was present, to 12.6% when all three (palmar
aponeurosis, A1, and A2) pulleys were cut (90).

Digital Flexor Sheath

FIGURE 10.54. The palmar aponeurosis pulley. This pulley is
formed by the transverse fibers of the palmar aponeurosis,
which are anchored on each side of the flexor synovial sheath by
vertical (sagittal) fibers or intertendinous septa, which attach to
the deep transverse metacarpal ligament and thus form an arch-
way over the flexor tendons. Its average width is 9.3 mm, and its
proximal edge begins 1 to 3 mm distal to the beginning of the
flexor synovial sheath.
cant preservation of total range of finger motion if the pal-
mar aponeurosis pulley was intact in conjunction with sec-
tion of the critical A1 and A2 pulleys. Baseline total range
of motion was determined for each finger in 12 cadaver
hands, and the palmar aponeurosis and A1 and A2 pulleys
were sequentially cut in various orders. The results of these
studies indicated that functional loss associated with
absence of any one of the three proximal pulleys is minimal.
The loss of flexion associated with the absence of the A1 or
A2 pulley is insignificant as long as the palmar aponeurosis
pulley is present. The loss of flexion increases if the absence
of the A1 or A2 pulley is combined with absence of the pal-
The digital flexor tendon sheath is composed of synovial
(membranous) and retinacular (pulley) tissue components
(Fig. 10.55). The membranous portion is a synovial tube
sealed at both ends. The retinacular (pulley) portion is a
series of transverse (the palmar aponeurosis pulley), annu-
lar, and cruciform fibrous tissue condensations, which
begin in the distal palm and end at the DIP joint. The floor
or dorsal aspect of this tunnel is composed of the transverse
metacarpal ligament, the palmar plates of the MCP, PIP,
and DIP joints, and the palmar surfaces of the proximal and
middle phalanges. In the index, long, and ring fingers, the
membranous portion of the sheath begins at the neck of the
metacarpals and continues distally to end at the DIP joint.
In most instances the small finger synovial sheath continues
proximally to the wrist (95–97). Visceral and parietal syn-
ovial layers are present (37,95,98–100). A prominent syn-
ovial pouch is present proximally and represents the conflu-
ence of the visceral and parietal layers. A visceral layer
reflection or pouch also is noted between the two flexors at
the neck of the metacarpal, but is 4 to 5 mm distal to the
more visible proximal and superficial portions of the syn-
ovial sheath. The membranous or synovial portions of the
sheath are most noticeable in the spaces between the pul-
leys, where they form plicae and pouches to accommodate

FIGURE 10.55. Digital flexor sheath. The digital flexor tendon sheath is composed of synovial
(membranous) and retinacular (pulley) tissue components. The membranous portion is a synovial
tube sealed at both ends. The retinacular (pulley) portion is a series of transverse (the palmar
aponeurosis pulley), annular, and cruciform fibrous tissue condensations, which begin in the dis-
tal palm and end at the distal interphalangeal (DIP) joint. The floor or dorsal aspect of this tun-
nel is composed of the palmar plates of the metacarpophalangeal, proximal interphalangeal, and
DIP joints, and the palmar surfaces of the proximal and middle phalanges.

flexion and extension. The retinacular (pulley) portion of
the sheath is characterized by fibrous tissue bands of annu-
lar and cruciform configuration that are interposed along
the synovial sheath in a segmental fashion and maintain the
flexor tendons in a constant relationship to the joint axis of
motion. The cruciform fibers are sometimes single oblique
limbs or “Y”-shaped (ypsiliform). Five annular and three
cruciform pulleys have been identified. The first of the five
annular pulleys begins in the region of the palmar plate of
the MCP joint. Most of these fibers (approximately two-
thirds) arise from the palmar plate; the remainder arise from
the proximal portion of the proximal phalanx. Although the
most usual configuration of the A1 pulley is that of a single
annular pulley, which averages 7.9 mm in width, it some-
times is represented by two or three annular bands. A dis-
tinct separation between the A1 and A2 pulleys is the usual
configuration. This separation ranges from 0.4 to 4.1 mm
and is widest on the palmar aspect. In those cases that do
not have a distinct separation between A1 and A2 pulleys,
there is a pronounced thinness to the retinacular tissue for
a distance of several millimeters at the usual site of separa-
tion, or large triangular openings laterally. This allows for
flexion at the MCP joint without any buckling of the pul-
ley complex, and thus the potential for impingement of the
tendon is avoided. In contrast to the variability in configu-
ration of the A1 pulley, the proximal edge of the A2 pulley
is constant in shape with somewhat oblique fibers of origin
beginning at the proximal and lateral base of the proximal
phalanx, which join annular fibers to make a prominent
and thick leading edge. Synovial outpouching is common
in the spaces between the pulleys. The A2 pulley is 16.8
mm in average width and is thickest in the distal end. The
deeper annular fibers of the A2 pulley are overlaid with
oblique fibers that at the distal end of A2 cross over each
other to form the first cruciate pulley. The third annular
(A3) pulley is located at the PIP joint and is firmly attached
to the palmar plate. The A3 pulley is present in most cases,
and the average width is 2.8 mm. The fourth annular (A4)
pulley is located in the mid-portion of the middle phalanx
and is overlaid with oblique fibers that cross over each other
to form a cruciate pulley, C3, at the distal end. The C3 pul-
ley is not always a separate structure. The A4 pulley is 6.7
mm in average length and thickest in its middle aspect. The
fifth annular pulley is quite thin, 4.1 mm in average length,
and is attached to the underlying palmar plate at the DIP
joint. The membranous synovial sheath ends at the level of
the DIP joint, and no pulleys are present beyond the distal
joint (101).
Special Features of the Finger Flexor Sheath
Retinacular. Significant flexion of the finger is achieved
without buckling of the retinacular system or impingement
of the underlying tendons because (a) the broader pulleys,
A2 and A4, are located between joints, whereas the nar-
rower pulleys, A1 and A3, are located over joints; (b) the
10.1 Palmar Hand 601
pulleys are arranged in a segmental fashion with synovial
pouches and windows between them; and (c) the thinner
and narrower cruciform pulleys are located near joints, and
their narrow palmar aspect can easily accommodate to the
confined space produced by acute flexion. The functional
adaptation of the retinacular system also is apparent in the
region of the MCP joint, where some form of anatomic
accommodation always is present between the A1 and A2
pulleys either in the form of definite separation of these two
pulleys, thinning of the contiguous margins of A1 and A2,
or triangular openings in the lateral margins of the retinac-
ulum so that flexion can occur without buckling. Further-
more, compressibility of the various pulleys has been
reported and also may be a factor in accommodating joint
motion without buckling or impingement (102).
Membranous. Bunnell noted that a tendon sheath was an
adaptation that allowed a tendon to turn a corner. He
stated, “It glides around a curve on a thin film of synovial
fluid between two smooth synovial-lined surfaces, just as
metal surfaces in machinery glide on a thin film of oil.”
Bunnell further noted that a tendon sheath had two layers
of synovium, a visceral one investing the tendon and a pari-
etal layer lining the fascial (retinacular) tunnel through
which the tendon glided (98). Lundborg et al. noted a well
vascularized membrane with plicae and pouches at the mar-
gin of the pulleys that was important for flexion and
stretching of the sheath (103). They were not able to
demonstrate any continuity of the synovial cell layer on the
friction surface of the A2 pulley, but they did note chon-
drocyte-like cells in the superficial layers of this pulley.
Knott and Schmidt also observed cartilage-like tissue at the
distal end of the A2 pulley (104). In certain avascular areas
of the palmar portion of the tendons, visceral synovial tis-
sues were absent on histologic sections. Furthermore, in
some scattered areas of the palmar surface of the tendon,
there were areas with cartilaginous differentiation similar to
the findings in the A2 pulley. Lundborg et al. concluded
that the friction surface of the pulleys is devoid of vessels
and that friction and gliding in the digital sheath system
takes place between two avascular structures, namely, the
palmar aspect of the flexor tendons and the inner aspect of
the pulleys (103). These avascular gliding surfaces are nour-
ished by diffusion from the synovial fluid. Histologic stud-
ies by Lundborg et al. demonstrated that the vascular plexus
of the synovial sheath is in continuity on the outside of the
rigid pulleys, and by this arrangement the pulleys can meet
the mechanical forces associated with finger flexion while
the synovial membrane avoids vascular compression, and
thus the microcirculation is not compromised (103). The
well vascularized synovial elements of the sheath represent a
dialyzing membrane that produces a plasma filtrate, the
synovial fluid, which acts as a lubricating agent and also as
a nutritional agent for the relatively avascular retinacular
system and tendon (103). The findings of Lundborg et al.
602 Regional Anatomy
are appropriately compared with the findings of Cohen and
Kaplan, who in a study of the gross, microscopic, and elec-
tron microscopic (ultrastructure) structure of the flexor ten-
don sheath noted that the sheath consists of an uninter-
rupted layer of parietal synovium reinforced externally at
intervals by dense bands of collagen (the retinacular system)
(99). Cohen and Kaplan further noted that the contents of
the sheath were independently covered by a second similar
layer of visceral synovium, and that the two layers were con-
tinuous at the proximal cul-de-sac, the vincula origins, and
the tendon insertion (99). The synovial cells lining the pul-
ley and covering the tendon were quantitatively, but not
morphologically, different from the synovial cells of the
membranous (synovial) portion of the sheath. The thick-
ness of the synovial layers was greatest at the spaces between
the pulleys and thin or attenuated beneath the annular pul-
leys and on tendon surfaces distant from vincula and cul-
de-sacs (99). Additional nutritional pathways were noted by
Weber, who identified nonvascular channels in the flexor
tendons of dogs and chickens (105). These channels were
mainly on the palmar surface, which is the least vascular.
The channels appeared to be associated with nonparallel
collagen fibers. Body fluid marked by fluorescein dye was
observed to penetrate the tendon in its least vascular area.
Motion of the flexor tendon augmented dye penetration
into the central portion of the tendon. Weber concluded
that his findings supported the concept that synovial fluid
nourished the flexor tendons in the digital theca (105).
Amis and Jones focused on the interior of the flexor tendon
sheath and noted that the inner aspect of the sheath was not
a continuous smooth surface (106). They noted that the
thin (membranous) parts of the sheath did not attach
directly to the proximal and distal borders of the pulleys in
continuity, but often overlapped the superficial edges of the
pulleys. Thus, on the inner aspect of the sheath, the pulleys
often stood apart from their surroundings, with free edges
pointing both proximally and distally. The significance of
these observations is that these free pulley edges may be sites
for impingement or triggering of a partially cut tendon, a
bulky or irregular tendon suture site, or a prominent suture
knot (106). Although the fibrous portions of the sheath
become contiguous near the end of the flexion arc, it is
obvious that impingement could occur about any free pul-
ley edge during the act of flexion. This anatomic finding is
most noticeable about the distal end of the A2 pulley and
the proximal end of the A1 pulley (101).
Thumb
The flexor tendon sheath of the thumb, like the finger
sheath, contains membranous and retinacular compo-
nents (Fig. 10.56). The thumb flexor sheath is a double-
walled tube sealed at both ends, and its synovial tissues are
similar to the finger sheath, with parietal and visceral lay-
ers. The thumb synovial sheath begins approximately 2
cm proximal to the radial styloid and ends just distal to
the interphalangeal joint. Three constant pulleys have
been identified: two annular and one oblique. The A1
pulley is located at the MCP joint. Its proximal two-thirds
arises from the palmar plate of the MCP joint and its dis-
tal one-third from the base of the proximal phalanx. It is
7 to 9 mm wide and 0.5 mm thick. The second pulley (the
oblique pulley) begins at the ulnar side of the base of the
proximal phalanx and continues in a distal and oblique
direction to end on the radial side of the proximal phalanx
near the interphalangeal joint. This oblique pulley is 9 to
11 mm wide at its mid-aspect and slightly wider at its
proximal and distal ends. It ranges from 0.5 to 0.75 mm
in thickness. The proximal end of the oblique pulley
appears to be closely associated with a part of the insertion
of the adductor pollicis tendon. The third pulley, the A2
pulley, is located near the insertion of the FPL and is cen-
tered over the palmar plate of the interphalangeal joint. It
is relatively thin (approximately 0.25 mm in thickness), 8
to 10 mm wide, and transversely oriented. The synovial
sheath ends 3 to 4 mm distal to this last pulley (107).
Functional Anatomy
The relative value of these pulleys has been evaluated by ser-
ial resections and subsequent measurement of joint motion,
as given in Table 10.10. Excision of the A1 pulley did not
result in significant change in joint motion with 2.5 cm of
FPL excursion. However, significant loss of interphalangeal
joint flexion did occur with release of the A1 and oblique
pulley, although the total arc of motion was nearly the
same. Absence of the oblique pulley resulted in only slight
loss of motion if the A1 and A2 pulleys were intact. The
oblique pulley is the most important pulley in the thumb
because the FPB can provide adequate and independent
MCP joint flexion, and the A1 pulley often is released for
stenosing tenosynovitis without apparent loss of function.
The A2 pulley appears to be of no great practical signifi-
cance if the oblique pulley is intact (107).
Flexor Tendon Synovial Sheath Patterns
in the Hand
The preceding comments have focused on certain features
of the retinacular portion of the flexor tendon sheaths, but
it also is important to note the various patterns of the flexor
tendon synovial sheaths in the digits, palm, and wrist (see
Fig. 10.56).
Definitions
Radial Bursa
The radial bursa is the FPL synovial sheath that extends
from the region of the interphalangeal joint of the thumb
to 2.5 cm proximal to the wrist flexion crease (107).
 10.1 Palmar Hand 603

FIGURE 10.56. Composite view of the components of the synovial sheaths in the proximal fin-
gers, thumb, palm, and wrist. In the index, long, and ring fingers, the membranous portion of
the sheath begins at the neck of the metacarpals and continues distally to end at the distal inter-
phalangeal joint. In most instances, the small finger synovial sheath continues proximally to the
wrist. The radial bursa is the flexor pollicis longus synovial sheath, which extends from the region
of the interphalangeal joint of the thumb to 2.5 cm proximal to the wrist flexion crease. The
ulnar bursa is the synovial sheath that surrounds the flexor digitorum superficialis and profundus
tendons in the palm and wrist. It begins proximally at approximately the same level as the radial
bursa and continues distally to the region of the midpalm.

Ulnar Bursa Synovial Sheath Patterns

The ulnar bursa is the synovial sheath that surrounds the
FDS and FDP tendons in the palm and wrist. It begins Scheldrup, in a study of 367 hands using air inflation,
proximally at approximately the same level as the radial noted that in 85% there was a communication between the
bursa and continues distally to the region of the midpalm. radial and ulnar bursa. The tendon sheath of the small fin-
604 Regional Anatomy
TABLE 10.10. THUMB JOINT FLEXION AT 2.5 CM
TENDON EXCURSIONa
Metacarpophalangeal Interphalangeal
Pulleys Intact (Degrees) (Degrees)
A1, OBL, A2 48 31
OBL, A2 49 31
A2 57 22
A1, A2 51 26
A1, first annular; A2, second annular; OBL, oblique.
a
Excision of the A1 pulley did not result in significant change in
joint motion with 2.5 cm flexor pollicis longus excursion. However,
significant loss of interphalangeal joint flexion did occur with release
of the A1 and OBL pulley, although the total arc of motion was
nearly the same. Absence of the OBL pulley resulted in only slight
loss of motion if the A1 and A2 pulleys were intact. The OBL pulley is
the most important pulley in the thumb because the flexor pollicis
brevis can provide adequate and independent metacarpophalangeal
joint flexion, and the A1 pulley often is released for stenosing
tenosynovitis without apparent loss of function. The A2 pulley
appears to be of no great practical significance if the OBL pulley is
intact.
ger communicated with the ulnar bursa in 81%; the ring
finger in 3.5%; the middle finger in 4%; and the index fin-
ger in 5.2% (97). The most common arrangement of the
synovial sheaths of the fingers, thumb, palm, and wrist, as
well as the variations in descending order of frequency are
given in Figure 10.57.
Clinical Significance
These findings provide an anatomic basis or explanation for
the so-called horseshoe abscess and for other patterns of
infection in the hand.
Palmar and Wrist Spaces
In addition to the synovial-lined spaces in the hand that
may be involved by infection, there also are nonsynovial
actual and potential spaces that may be similarly involved.
Palmar Spaces
Historical Perspective
After noting that accumulations of pus in the palm often
were confined to the radial or ulnar side beneath the flexor
tendons, Kanavel named the most important spaces in the
palm the thenar and mid-palmar spaces (108). These were
potential spaces deep to the flexor tendons whose floor was
formed by the adductor fascia in the case of the thenar space
and the interosseous fascia in the case of the mid-palmar
space. Kanavel stated that these two spaces were separated
by a middle palmar septum that extended from the middle
finger metacarpal to the flexor tendons of the index finger
and thus formed a barrier between the two potential spaces.
According to Kanavel, these compartments represented
potential spaces into which infections might track (108).
Kaplan, however, noted that the central palmar compart-
ment was divided only by an attachment of the ulnar bursa
to the third metacarpal bone (6). Kaplan further noted that
the thenar space was not located over the thenar eminence
but rather over the adductor muscle, and suggested that this
potential space should be called the adductor (or deep pal-
mar radial) space. Similarly, he noted that the mid-palmar
space was not located over the midpalm, but over the ulnar
aspect of the palm, and thus could be called the palmar
ulnar space (6).
Current Perspective on the Central Palmar Spaces
Bojsen-Moller and Schmidt, in a study of the palmar
aponeurosis and the central spaces of the hand, reviewed the
previous work of Kanavel and Kaplan, who had noted the
presence of two palmar spaces (radial and ulnar), separated
by a middle palmar septum in the region of the third
metacarpal (88). Based on their study of 29 adult hands and
6 fetuses aged 5 to 6 months, Bojsen-Moller and Schmidt
described a central palmar space that was lined with loose
connective tissue and was bounded radially and ulnarly by
marginal septa that began as an extension of the side walls
of the carpal canal (Fig. 10.58). The floor was formed by
the palmar interosseous fascia, transverse metacarpal liga-
ment, and adductor fascia, and the roof by the palmar
aponeurosis. The radial marginal septum extended distally
to the proximal phalanx of the index finger and formed the
radial wall of the lumbrical canal. This radial septum was
pierced by the FPL and the recurrent motor branch of the
median nerve, the branch from the radial artery to the
superficial palmar arch, and the vessels and nerves to the
thumb. The ulnar marginal septum was attached to the
shaft of the small finger metacarpal bone and distal to the
carpal canal was pierced by the digital branch of the ulnar
nerve and by the ulnar artery where it forms the superficial
palmar arch. Between these two marginal septa were seven
intermediate septa that, along with the marginal septa,
divided the distal aspect of the central space into four canals
to accommodate the flexor tendons and four canals to
accommodate the lumbricals and neurovascular bundles.
The seven intermediate septa were rectangular with a free
falciform proximal edge. They were attached to the under-
side of the longitudinal and transverse fibers of the palmar
aponeurosis and anchored deep in the hand to the trans-
verse metacarpal ligament and interosseous fascia. Proxi-
mally, the intermediate septa extended into the acute angle
between the FDP and the lumbrical and were compara-
tively short or long to accommodate a distal or proximal
origin of the lumbrical. Thus, the central compartment was
a single space in the proximal palm and a series of small
compartments in the distal part. The middle palmar sep-
tum, previously described by Kanavel, was, in all probabil-
ity, the vertical septum on the ulnar side of the index finger.
Based on the study of Bojsen-Moller and Schmidt, the cen-
tral compartment is the entire space between the thenar and
 10.1 Palmar Hand 605

FIGURE 10.57. Variations in the synovial sheath patterns in the fingers, thumb, palm, and wrist
[after Scheldrup (97)]. A: The most common pattern. B–H: Other patterns in descending order of
frequency.

hypothenar eminences, and between the palmar aponeuro- authors is an actual space that encompasses the historical
sis and the deep palmar interosseous and adductor fascia, palmar spaces of Kanavel (thenar and mid-palmar) and the
and contains the flexor tendons and their synovial sheaths. later modifications in terminology (adductor and deep pal-
It is an actual and not a potential space (88). mar ulnar) advocated by Kaplan (6,108).

Author’s Conclusions Regarding the Palmar Spaces

Knowledge of the synovial-lined spaces in the hand and fin-
gers, along with the concept of potential palmar spaces, was
used by Kanavel to predict the likely pathways and localiza-
tion of infection in the fingers and hand. Such knowledge
allowed the surgeon to detect and appropriately drain infec-
tions that might point to or present in characteristic loca-
tions. Based on the study of Bojsen-Moller and Schmidt, it
appears appropriate to accept the concept that the central
space or compartment of the hand as defined by these
Wrist Space
The central compartment of the palm narrows proximally
toward the carpal canal and is connected through this canal to
a space in the palmar aspect of the wrist (88). The name
Parona has been associated most often with this non–synovial-
lined space on the flexor side of the wrist, which is located
between the flexor tendons and the pronator quadratus mus-
cle and bounded radially by the FCR and ulnarly by the FCU
and antebrachial fascia (109). In 85% of the 367 hands in
606 Regional Anatomy

FIGURE 10.58. Central palmar space [after Bojsen-Moller and Schmidt (88)] and Parona’s space.
In addition to the synovial-lined spaces in the hand that may be involved by infection, there also
are nonsynovial, actual and potential spaces that may be similarly involved. Central palmar space:
This space is bounded radially and ulnarly by marginal septa that begin as an extension of the
side walls of the carpal canal. The radial marginal septum extends distally to the proximal pha-
lanx of the index finger and forms the radial wall of the lumbrical canal. The radial septum is
pierced by the flexor pollicis longus and the recurrent motor branch of the median nerve, the
branch from the radial artery to the superficial palmar arch, and the vessels and nerves to the
thumb. The ulnar marginal septum is attached to the shaft of the small finger metacarpal bone,
and distal to the carpal canal is pierced by the digital branch of the ulnar nerve and by the ulnar
artery where it forms the superficial palmar arch. Between these two marginal septa are seven
intermediate septa that, along with the marginal septa, divide the distal aspect of the central
space into four canals to accommodate the flexor tendons and four canals to accommodate the
lumbricals and neurovascular bundles. These septa are attached to the underside of the longitu-
dinal and transverse fibers of the palmar aponeurosis (PA) and anchored deep in the hand to the
transverse metacarpal ligament and interosseous fascia. Proximally, the intermediate septa
extend into the acute angle between the flexor digitorum profundus and the lumbrical and are
comparatively short or long to accommodate a distal or proximal origin of the lumbrical. Thus,
the central compartment is a single space in the proximal palm and a series of small compart-
ments in the distal part. The central compartment is the entire space between the thenar and
hypothenar eminences, and between the PA and the deep palmar interosseous and adductor fas-
cia, and contains the flexor tendons and their synovial sheaths. It is an actual and not a potential
space. Parona’s space: The name Parona has been associated most often with this non–synovial-
lined space on the flexor side of the wrist that is located between the flexor tendons and the
pronator quadratus muscle and bounded radially by the flexor carpi radialis and ulnarly by the
flexor carpi ulnaris and antebrachial fascia.

Scheldrup’s study, there was a natural connection between the
radial and ulnar bursa at the wrist. Parona’s space, located
between the radial and ulnar bursae, thus has the theoretical
potential to act as a conduit between these two structures and
produce the so-called horseshoe abscess (97).
Tendons
Nine extrinsic flexor tendons enter the hand through the
carpal tunnel, the FDS and the FDP to the four fingers, and
10.1 Palmar Hand 607
the FPL to the thumb (Fig. 10.59). The synovial sheaths
and retinacular constraints of these nine tendons have been
presented in the preceding section.
Flexor Pollicis Longus
The most radial of the nine flexors enters the flexor side of
the thumb between the two heads of the FPB and inserts on
the palmar base of the distal phalanx.
FIGURE 10.59. Flexor tendons. Nine extrinsic
flexor tendons enter the hand through the
carpal tunnel, the flexor digitorum superficialis
(FDS) and flexor digitorum profundus (FDP) to
the four fingers, and the flexor pollicis longus
(FPL) to the thumb. The FPL is the most radial of
the nine flexors and enters the flexor side of the
thumb between the two heads of the flexor pol-
licis brevis and inserts on the palmar base of the
distal phalanx. The FDP lie deep and side by side
in the carpal tunnel and insert on the palmar
base of the distal phalanges of the four fingers.
The FDS tendons are oriented “two-by-two”
(middle and ring are palmar to index and small)
in the carpal tunnel, lie superficial to the pro-
fundus tendons in the palm and proximal pha-
lanx, and insert by a radial and ulnar division
into the palmar base of the middle phalanx. The
FDP passes through the FDS by a unique cleft or
division of the FDS that begins in the region of
the metacarpophalangeal joint. The first indica-
tion of division of the FDS is the appearance of a
shallow groove on its palmar surface, which sub-
sequently develops into complete separation of
the tendon. Before this separation, the FDS
begins to form into a flat ellipse with a concave
underside, which, after division, “cups” the FDP
between its two sides. These two divisions of the
FDS, while “cupping” the FDP, begin progres-
sively to separate and rotate outward on their
long axes so that in the region of the proximal
interphalangeal joint they are deep to the FDP,
have a broad, flat shape, and have rotated
almost 180 degrees on their long axis. The pro-
fundus tendon has thus passed through the FDS
and is now palmar to the FDS. The two divisions
of the FDS are rejoined for a distance of 1 to 2
cm by crossing over of some but not all of the
central fibers of the two divisions. This central
crossing over of these fibers forms a substantial
interdigitation known as Camper’s chiasma (see
Fig. 10.60). The FDS divisions then continue dis-
tally to insert on the lateral crest on each side of
the middle half of the palmar surface of the mid-
dle phalanx.
608 Regional Anatomy
Flexor Digitorum Profundus
These four tendons, lying deep and side-by-side in the
carpal tunnel, traverse the palm to insert on the palmar base
of the distal phalanges of the four fingers.
Flexor Digitorum Superficialis
These four tendons, oriented “two-by-two” (middle and
ring palmar to index and small) in the carpal tunnel, lie
superficial to the profundus tendons in the palm and
proximal phalanx and insert by a radial and ulnar division
into the palmar base of the middle phalanx. The FDP
passes through the FDS by a unique cleft or division of
the FDS that begins in the region of the MCP joint. The
first indication of division of the FDS is the appearance
of a shallow groove on its palmar surface that subse-
quently develops into complete separation of the tendon.
Before this separation, the FDS begins to form into a flat
ellipse with a concave underside that, after division,
“cups” the FDP between its two sides. These two divi-
sions of the FDS, while “cupping” the FDP, begin pro-
gressively to separate and rotate outward on their long
axes so that in the region of the PIP joint they are deep to
the FDP, have a broad, flat shape, and have rotated
almost 180 degrees on their long axis. The profundus ten-
don has thus passed through the FDS and is now palmar
to the FDS. The two divisions of the FDS are rejoined for
a distance of 1 to 2 cm by crossing over of some but not
all of the central fibers of the two divisions. This central
crossing over of these fibers forms a substantial interdigi-
tation known as Camper’s chiasma (Fig. 10.60; see Fig.
10.59). The FDS divisions then continue distally to
insert on the lateral crest on each side of the middle half
of the palmar surface of the middle phalanx.
Vascular Supply of the Flexor Tendons in Their
Sheath
Terminology
The following terminology must be introduced at this time:
a vinculum (singular) is a specialized form of vascularized
mesotenon adapted to function in the confines of the flexor
tendon synovial sheath. The plural of vinculum is vincula.
A vinculum may be long and filamentous (thus the words
longum for singular and longa for plural) or short and
mesentery-like (breve for singular and brevia for plural).
Having explained this terminology, which often is encoun-
tered in descriptions of this unique vascular system, the
authors of this text propose to adopt and occasionally use
the following conventions when addressing these special-
ized forms of mesotenon. Both singular and plural forms
may be abbreviated along with the tendon they enter; thus,
the notation VBP could represent the singular or plural
form. It may be interpreted as vinculum breve profundus or
vincula brevia profundus, but means “a short, specialized
form of mesotenon that enters the profundus tendon.”
These abbreviations may be used occasionally, and it is
hoped that the adoption of this convention will aid the
reader in his or her understanding of this system.
Sources of Vascular Supply
In general, the vascular supply to the flexor tendons in the
synovial sheath is from (a) intrinsic longitudinal vessels in
continuation from the palm region; (b) synovial attach-
ments to the enclosed flexor tendons in the proximal
sheath; and (c) specialized forms of mesotenon, the vincula,
located inside the sheath.
Intrinsic Longitudinal Vessels from the Palm. In the
palm, the flexor tendons are surrounded by very vascular
FIGURE 10.60. Camper’s chiasma. Fresh
cadaver dissection of right middle finger
viewed from ulnopalmar aspect. The profun-
dus tendon is retracted by a green rubber
band and the reflected third annular pulley
rests on a small green marker in the fore-
ground.

connective tissue called paratenon. In the palm, proximal to
the sheath, the tendons are covered by an extensive vascular
plexus in a mainly longitudinal direction with multiple
anastomoses (103). After entrance into the sheath, this vas-
cular pattern changes abruptly.
Proximal Synovial Sheath (Synovial Reflection) Vessels.
The proximal reflection of the synovial sheath is character-
ized by accordion-like synovial folds that allow longitudinal
movement without compromise of the circulation. Blood
vessels that originate from this area of the sheath form a well
defined vascular network on the surface of the tendons, but
end somewhat abruptly with numerous microvascular loops
approximately 1 cm from their origin. Distal to these loops,
the palmar aspect of the tendon surface appears to be more
or less avascular except for some small loops approaching
the surface from deeper aspects of the tendon, indicating
that there are internal vessels at this level.
Because of the differences in the vascular systems
between the FDS and FDP, these two tendons are discussed
separately.
Flexor Digitorum Superficialis Vascular Supply. In the
proximal part of the FDS there is a deep, well defined
intrinsic vascular pattern that ends at the base or mid-por-
tion of the proximal phalanx, which corresponds to the
beginning of the commissure of the FDS. In this zone, there
is a short avascular segment (approximately 1 to 2 mm)
until the tendon is again vascularized with vessels from the
vinculum breve (VB) in the region of Camper’s chiasma.
Thus, the FDS has a proximal zone of vascular supply in the
form of intrinsic longitudinal vessels in continuation from
the palm and synovial attachments in the proximal sheath,
and a distal zone from the vinculum breve at Camper’s chi-
asma.
Flexor Digitorum Profundus Vascular Supply. The prox-
imal zone vascular pattern from the longitudinal intrinsic
vessels from the palm and the synovial reflection continues
to the level of the FDS bifurcation, where many of these
vessels terminate in loop formations. The resultant avascu-
lar zone ends just distal to the FDS bifurcation, and the
FDP again demonstrates a vascular pattern (intermediate
zone) derived from a vinculum longum (VL) that sends
longitudinal branches proximally and distally on the dorsal
aspect of the tendon. These longitudinal vessels give off ver-
tical loops that pierce deep into the tendon. The palmar or
friction surface of the tendon is devoid of vessels for a dis-
tance of approximately 1 mm, which represents one-fourth
to one-third of the thickness of the tendon. A few millime-
ters distal to the VL, there is a second zone of relative avas-
cularity. The distal zone of vascular supply to the FDP is
represented by the VB at the distal tendon insertion and
consists mainly of longitudinal vessels with some vertical
loops.
10.1 Palmar Hand 609
Vincular Patterns in the Finger
Armenta and Lehrman, in a study of 116 cadaver fingers,
identified 4 groups of vincula that were based on their ori-
gin from what they considered to be 4 digital arterial arches
(110) (Fig. 10.61). Ochiai et al., in a study of 35 cadaver
hands, also identified 4 arterial transverse communicating
vessels that they believed played an important role in the
blood supply to the vincular system (111). These two stud-
ies are at variance, in terms of number and location, with
those of Strauch and de Moura, who identified only three
arches (37). Armenta and Lehrman noted that the first and
second arches and their respective vincula were the primary
carriers of circulation to the FDS, and the third and fourth
were the primary carriers to the FDP (110). Disregarding
for the moment the number and location of the digital arte-
rial arches, it is apparent that the vincula receive their cir-
culation from transverse communicating branches of the
digital artery, originating in a sequential fashion from the
region of the base of the proximal phalanx, the neck of the
proximal phalanx, the base of the middle phalanx, and the
neck of the middle phalanx. These four branches, from
proximal to distal, are called the branch to the vinculum
longum, proximal transverse digital artery, interphalangeal
transverse digital artery, and distal transverse digital artery
(111). The convention adopted by Armenta and Lehrman
was to name the vinculum according to its source; thus, the
vinculum from the most proximal of the transverse vessels
was V-1, and the vinculum from the distal transverse digi-
tal arch was V-4. Another convention, as published by
Lundborg et al. and Ochiai et al., was to note that, in gen-
eral, the superficialis and profundus had both a VL and VB
(103,111). It must be appreciated that these vincula are not
visible if the sheath is intact. Both Ochiai et al. and
Armenta and Lehrman noted variations in size, shape, inci-
dence, and position of origin (radial or ulnar) (110,111).
The following variations and arrangements of the vincula as
described by Ochiai et al. in their study of 35 hands are
noteworthy: (a) the VB was consistently found in all fin-
gers; and (b) the VL was found to vary in type, incidence,
and location, with three types of distribution of the VL
superficialis (VLS) and five types of distribution of the VL
profundus (VLP). The VLS arose from the radial or ulnar
side (approximately equally distributed, but 37 fingers had
both radial and ulnar types) of the base of the proximal pha-
lanx and attached to one or two slips of the superficialis ten-
don just proximal to the decussation, and received its blood
supply from the transverse communicating artery (the VLS
artery) at the base of the proximal phalanx. The VLS was
absent in 35 of 130 fingers (27%), usually in the long and
ring fingers. The five types of distribution of the VLP were
distal, middle, mixed, proximal, and absent. The most com-
mon (100 of 130 fingers) type was the middle, which was
characterized by a VLP that came between the two FDS
slips distal to Camper’s chiasma and entered the underside
of the FDP. Its vessel of origin was the proximal transverse
610 Regional Anatomy

B
FIGURE 10.61. Vascular supply of the flexor tendons in their sheath: the vincular system. A: A
vinculum may be long and filamentous (longum for singular and longa for plural) or short and
mesentery-like (breve for singular and brevia for plural). Each flexor tendon usually has a long
and short form of this specialized mesentery-like structure. VBP and VLP, the short and long vin-
culum to the profundus tendon; VBS and VLS, the short and long vinculum to the superficialis.
See text for discussion of the two other sources of intrinsic blood supply to the tendons by intrin-
sic longitudinal vessels from the palm and proximal synovial sheath vessels. The vincula receive
their circulation from transverse communicating branches of the digital artery called the branch
to the vinculum longum, proximal transverse digital artery, interphalangeal transverse digital
artery, and distal transverse digital artery. B: Fresh cadaver dissection of right middle finger as
viewed from the ulnar side. The green rubber band is looped around the profundus tendon and
the reflected third annular (A3) pulley rests on a green marker; the jeweler’s forceps is reflecting
the flexor digitorum superficialis to show the VBS, and behind the tip of the forceps is the VLP.
Note also the VBP to the left (distal) adjacent to the A4 pulley, and the VLS proximally adjacent
to the cleft between the A1 and A2 pulleys.
 10.1 Palmar Hand 611

C
FIGURE 10.61. (continued) C: Latex injection of right middle finger viewed from ulnar aspect
showing proximal transverse digital arch at the neck of the proximal phalanx (blue triangular
pointer), check-rein ligament (green marker), reflected A2 pulley, VBS, and VLP.

artery. Based on the observations of Ochiai et al., this mid-
dle type of VLP appears to represent a drastically modified
continuation of the VBS. The second most common (48 of
130 fingers) type of VLP was the proximal, in which the
VLP appeared to be a continuation of the VLS and entered
the underside of the FDP just proximal to Camper’s chi-
asma. The reader is referred to the classic article by Ochiai
et al. for details (111).
Thumb Vinculum
Armenta and Fisher, in a study of 76 cadaver thumbs,
found that approximately 90% had a VB (112). This vin-
culum had the shape of a truncated cone, was located in the
distal third of the proximal phalanx, continued over the pal-
mar plate of the DIP joint, and extended over a distance of
approximately 20 mm in the phalanx. Its insertion on the
underside of the FPL was approximately 18 mm wide (see
Fig. 10.27). The authors cut the FPL at the interphalangeal
joint but distal to the vincula, and noted that incomplete
flexion of the interphalangeal joint was possible because of
the attachment of the VB to the palmar plate. Clinically, the
flexion force generated by this vincular attachment is less
than normal, and such an arrangement can be detected by
opposing the flexion force and noting its decreased magni-
tude. The authors noted that a laceration of the FPL within
the range of 25.6 ± 6.3 mm proximal to the interphalangeal
joint could leave the FPL tethered at the laceration site
because of the vinculum attachment.
Clinical Significance of the Vascular Supply and the
Vincular System of the Flexor Tendons in the Sheath
Recent advances in the intraoperative and postoperative
management of flexor tendon injuries and a better under-
standing of tendon nutrition and the repair process may
be correlated with our knowledge of the vascular supply of
the flexor tendons in the sheath. The comparative role of
synovial nutrition and the vascular supply in tendon heal-
ing will not be debated here except to put into context the
value of avoiding damage to the vascularity of the tendons
in the sheath. This is illustrated by the following clinical
examples:
1. Removal of the FDS for a tendon transfer is best per-
formed proximal to or at the proximal edge of Camper’s
chiasma to preserve the VBS and the VLP. This may
have the incidental side benefit of avoiding the potential
for hyperextension deformity at the PIP joint in addi-
tion to the preservation of blood supply to the FDS and
FDP.
2. Core intratendinous sutures are placed in the relatively
avascular palmar aspect of the profundus tendon when
practical.
612 Regional Anatomy
3. The vincula may help to tether lacerated flexor tendons
near their site of injury, but this also may give a false-
negative result when testing for tendon function. It has
been suggested that the VBS at the PIP joint and the
VBP at the DIP joint may play an accessory role in flex-
ion because of their attachment to the palmar plate
(113), and this matches the observations of Armenta
and Fisher regarding the VB of the thumb (112).
Finally, the FPL has a synovial sheath that is longer than
the finger synovial sheath, but has only one mesotenon, the
VB, at its distal insertion (112).
SURGICAL EXPOSURES
General Principles
Elective Incisions in the Palm and Digits
Improperly placed incisions in the hand, especially in the
palm and flexor aspect of the fingers and thumb, have a
great potential not only for being cosmetically unacceptable
but also for producing thick, heavy scars that may limit
function. Incisions that cross palmar or digital flexion
creases at right angles uniformly result in a scar that limits
function. Incisions that parallel these creases or cross at
oblique angles are less likely to result in unfavorable scars.
In general, skin incisions should be centered over the oper-
ative site, but if moving the incision a few millimeters
would improve the cosmetic result, this should be consid-
ered. Skin incisions may be placed in skin creases as long as
invagination of the skin is avoided during closure. Skin
flaps should be as thick as possible, have broad bases, under-
mined only to the extent required, and handled gently,
especially at their tips.
Structures at Risk
Many important structures in the hand are immediately
beneath the skin. Four such structures are the proper sen-
sory nerves to the radial side of the index finger and the
FIGURE 10.62. Four nerves at risk.
Fresh cadaver dissection showing
three sensory and one motor nerve
(green triangles) at risk during inci-
sions in their region. These nerves are
the proper sensory nerves to the
ulnar side of the small finger and the
radial side of the index finger, the
radial digital nerve of the thumb
adjacent to the first annular pulley,
and the recurrent motor branch of
the median nerve at the base of the
thenar eminence. The small and
index finger nerves are at risk with
transverse incisions in the distal
aspect of the palm, the radial sensory
nerve of the thumb with trigger
thumb release, and the motor branch
of the median with any incision
about the base of the thenar emi-
nence. The sensory nerves are espe-
cially vulnerable because during
surgery the hand is made flat and the
digits extended by static holding
devices or by the surgeon’s assistant.
This brings these structures nearer to
the surface by compressing or flat-
tening the subdermal fat or areolar
tissues, placing them under increased
tension and making them more
liable to injury.
 10.1 Palmar Hand 613

ulnar side of the small finger; the recurrent motor branch of

the median nerve at the base of the thenar eminence; and
the radial digital nerve of the thumb adjacent to the A1 pul-
ley (Fig. 10.62). The index and small finger nerves are at
risk with transverse incisions in the distal aspect of the
palm. The motor branch is at risk with any incision about
the base of the thenar eminence, and the radial sensory
nerve of the thumb is at risk with trigger thumb release.
The sensory nerves are especially vulnerable because the
hand is made flat and the digits extended by static holding
devices or by the surgeon’s assistant. This brings these struc-
tures nearer to the surface by compressing or flattening the
subdermal fat or areolar tissues, places them under
increased tension, and makes them more liable to injury.
The vulnerability of these nerves reminds us that dissection
in the hand must proceed layer by layer with concurrent
identification of vital structures.

Indications
Surgical incisions in the palm and digits may be required
for the management of tumors, aneurysms, Dupuytren’s
disease, flexor tendon or blood vessel lacerations, tendon
grafts, sheath infections, stenosing flexor tenosynovitis, har-
vesting of full-thickness skin grafts, nerve injuries, and joint
dislocations. FIGURE 10.63. Vertical palmar incisions. Although incisions in
the palm often are transverse, they may be vertical if they do not
cross a flexion crease. Such vertical incisions are most useful in
Landmarks the distal palm for stenosing tenosynovitis of the flexor tendons.

Useful landmarks include the thenar and hypothenar emi-

nences, the thenar, proximal, and distal palmar creases, and
the proximal, middle, and distal digital flexion creases.
Patient Position
In general, the upper extremity is positioned on a well
padded arm table with the forearm in supination. The
required position of the upper extremity usually is evident
and is presented as required.
Elective Incisions in the Palm, Fingers,
and Thumb
Vertical
Although incisions in the palm often are transverse, they
may be vertical if they do not cross a flexion crease (Fig.
10.63). Such vertical incisions are most useful in the distal
palm for stenosing tenosynovitis of the flexor tendons of the
fingers.
The Zig-Zag
The zig-zag incision, initially designed for use in the
flexor aspect of the finger, is a useful incision in the palm
(114) (Fig. 10.64). This incision allows crossing of the
palmar creases at oblique angles and can provide a com-
prehensive exposure when needed. Ideally, the points or
tips of the skin flaps should form an angle of 90 degrees
or more.
Technique
The components of the incision are carried from the flex-
ion creases, alternating from one side to the other of the
finger. The incision may be easily adapted to accommo-
date an oblique or transversely oriented traumatic inci-
sion. The zig-zag incision also is suitable for the thumb.
This incision provides not only excellent exposure of the
flexor sheath, but access to both neurovascular bundles,
which may require repair concurrent with the flexor ten-
don. Although the mid-axial incision has the theoretic
advantage of placing the scar on the nontactile area of the
finger or thumb, the palmar zig-zag incision has not pro-
duced any problems of this sort in our experience. Pre-
cautions in using the zig-zag incision include carrying the
points of the triangles to the mid-axial line and recogniz-
ing that the neurovascular bundle lies beneath the point
of the skin triangle.
 614 Regional Anatomy
FIGURE 10.64. The zig-zag incision. The zig-zag incision, ini-
tially designed for use in the flexor aspect of the finger, also is
useful in the palm. This incision allows crossing of the palmar
creases at oblique angles and can provide a comprehensive
exposure when needed. Ideally, the points or tips of the skin
flaps should subtend an angle of 90 degrees or more.
B looked for and preserved.
Mid-Axial Incision
This incision was advocated by Bunnell and was used by
him for primary tendon repair and flexor tendon grafts (98)
(Fig. 10.65). It was used extensively by Boyes and Stark for
flexor tendon grafts (115).
The mid-axial incision centered over the respective joint
also may be used to expose the PIP and DIP joints.
Technique
The position of the mid-axial incision may be determined
by flexing the finger and drawing a line that joins the dor-
sal aspects of the flexion creases. This line represents the
zone of minimum skin tension, results in the least amount
of scar formation, and avoids contracture. Exposure is facil-
itated by placing the incision on the radial side of the index,
long, and ring fingers and the ulnar side of the small finger.
The neurovascular bundle is contained in the palmar aspect
of the flap. The dorsal sensory branch of the digital nerve in
the proximal phalanx crosses over the incision and may be
at risk in this incision, and should be looked for and pre-
served.
Skin Incisions for the Management of
Lacerations in the Palm and Fingers
Lacerations in the palm or fingers may require innovative
extensions to yield adequate exposure and at the same time
preserve the blood supply of the skin flaps and avoid scar
contracture (Fig. 10.66). Some lacerations are situated across
FIGURE 10.65. The mid-axial inci-
sion. A: The position of the mid-axial
incision may be determined by flex-
ing the finger and drawing a line that
joins the dorsal aspects of the flexion
creases. B: Exposure is facilitated by
placing the incision on the radial side
of the index, long, and ring fingers
and the ulnar side of the small finger.
The neurovascular bundle is con-
tained in the palmar aspect of the
flap. The dorsal sensory branch of the
digital nerve in the proximal phalanx
crosses over the incision and may be
at risk in this incision, and should be
 10.1 Palmar Hand 615

FIGURE 10.66. A, B: Skin incisions for the management of lacerations in the palm and fingers.
Lacerations in the palm or fingers may require innovative extensions to yield adequate exposure
and at the same time preserve the blood supply of the skin flaps and avoid scar contracture. Some
suggestions for extension of these lacerations are depicted. Extensions of lacerations may be
achieved as required by applying the principles of the mid-axial incision, the Bruner zig-zag, or a
combination of these incisions. The method of extension may be guided by the preoperative
evaluation and the anticipated requirements of the exposure. In general, the flaps should be
broad based, kept as thick as possible, and handled gently.

flexion creases, and surgical extensions of these wounds must Incision

be designed to minimize the adverse effects of the original
wound. Primary revision by a Z-plasty may be indicated if it
can be performed without compromise to the circulation of
the skin flaps. If primary resolution of an adverse laceration
cannot be achieved at the time of initial surgery, the lacera-
tion may be closed and the scar dealt with at a later date.
Extensions of lacerations may be achieved as required by
applying the principles of the mid-axial incision, the Bruner
zig-zag, or a combination of these incisions.
The method of extension may be guided by the preop-
erative evaluation and the anticipated requirements of the
exposure. In general, the flaps should be broad based, kept
as thick as possible, and handled gently.
Joints
Thumb Metacarpophalangeal Joint, Ulnar
Aspect
Indications
This exposure is useful for reconstruction or reattachment
of the UCL or for fractures of the MCP joint area.
Landmarks
A useful landmark is the dorsal bony prominence of the
thumb metacarpal at the MCP joint.
A gently curved dorsal radial incision, approximately 3 to 4
cm long with the apex of the curve situated toward the
thumb web, is centered over the MCP joint (Fig. 10.67A).
Sensory branches of the radial nerve should be identified
and preserved.
Technique
The UCL of the thumb MCP joint is covered by and vir-
tually hidden by the extensor hood (see Fig. 10.67B–E). It
is necessary to reflect this hood to gain appropriate exposure
of this area. Although partial exposure may be obtained by
separating the hood in the direction of its fibers, a more
comprehensive exposure that might be required for recon-
struction of the collateral ligament by graft may be achieved
by reflecting the extensor hood. The adductor pollicis
inserts into the extensor hood, the base of the proximal pha-
lanx, and the palmar plate. Reflection of the hood and its
specific adductor insertion exposes the ulnar side of the
MCP joint, including the UCL and the bone insertion of
the adductor that is just distal to the attachment of the
UCL into the proximal phalanx. The dorsal skin flap is ele-
vated to expose the EPL over the MCP joint. Beginning at
the proximal margin of the hood, a 1-mm-wide portion of
the EPL is dissected free with a scalpel in the direction of its
fibers for a distance of approximately 3 cm. The hood
 616 Regional Anatomy
A B,C
D cis longus.
mechanism then may be retracted away from the UCL to
expose its entire length. The UCL may be avulsed proxi-
mally or distally, and if avulsed distally may carry with it a
fragment of bone. This exposure allows complete evaluation
of the ligament and reattachment by a technique of the sur-
geon’s choice. Secondary reconstruction by free tendon
graft or capsular and adductor insertion advancement also
may be accomplished through this approach. The 1-mm
margin of the EPL is reattached to its site of origin, which
FIGURE 10.67. Surgical approach to the
ulnar aspect of the metacarpophalangeal
joint of the thumb. A: Dorsal ulnar inci-
sion. B, C: Incision and reflection of the
hood to expose the ulnar collateral liga-
ment (UCL). D: Fresh cadaver dissection of
the right thumb showing the extensor
hood and adductor expansion, the inci-
sion into the hood, and the extensor polli-
maintains the normal anatomic arrangement and balance of
the hood mechanism.
Thumb Metacarpophalangeal Joint, Radial
Aspect
Incision
A gently curved dorsal radial incision, approximately 3 to 4
cm long, with the apex of the curve situated toward the

E the hood to expose the UCL.
radial side of the thumb, is centered over the MCP joint
(Fig. 10.68A). Sensory branches of the radial nerve should
be identified and preserved.
Technique
The dorsal skin flap is elevated to expose the confluence of
the EPB and EPL over the MCP joint (see Fig. 10.68B–E).
Beginning at the proximal margin of the hood on its radial
side, a 1-mm-wide portion of the EPL is dissected free with
a scalpel in the direction of its fibers for a distance of
approximately 3 cm. Careful incision into the hood and
development of a narrow band of the EPL over the MCP
joint preserves the insertion of the EPB on the proxi-
modorsal aspect of the proximal phalanx. The lateral por-
tion of the APB inserts into the extensor hood and the
medial portion into the base of the proximal phalanx.
Reflection of the hood and its specific portion of the APB
exposes the RCL and the proximal phalangeal attachments
of the medial portion of the APB and the FPB. These inser-
tions are distal to the RCL attachment and may be detached
and reflected as required. Repair or reconstruction is per-
formed, followed by careful reapproximation of the hood.
Finger Metacarpophalangeal Joint (Mid-Axial,
Radial Aspect of Index)
Indications
This radial mid-axial approach may be used to repair a dis-
rupted RCL.
Incision
A gently curved, 3-cm incision is made over the radial
aspect of the index finger (Fig. 10.69A). Sensory branches
of the radial nerve are identified and preserved.
10.1 Palmar Hand 617
FIGURE 10.67. (continued) E: Reflection of
Technique
The skin flaps are developed and the underlying hood and
sagittal band identified (see Fig. 10.69B and C). Beginning
at the proximal edge of the sagittal band, a 1-mm-wide, 3-
cm-long strip of the extensor tendon is developed by sharp
dissection. The distal aspect of the hood is incised in the
direction of its fibers to release this flap distally. This
detached segment of the hood is then reflected to expose
the bony insertion of the first DI muscle and the RCL. Por-
tions of the insertion of the first DI may be reflected as
required and later reattached.
Proximal Interphalangeal Joint, Palmar
Indications
This incision is designed for approaches to the palmar
aspect of the PIP joint and may be used for palmar plate
arthroplasty or capsulectomy of the PIP joint that is con-
tracted in flexion.
Incision
The incision represents the central portion of the Bruner
incision and its apex is centered over the ulnar side of the
PIP joint flexion crease (116).
Technique
After elevation of this broad-based triangular flap, the flexor
sheath between the A2 and A4 pulleys is excised and the
flexor tendons retracted for exposure of the palmar plate
and check-rein ligaments. The VB to the FDS and the prox-
imal transverse digital arteries near the proximal edge of the
palmar plate are preserved, if possible.
 A B,C

FIGURE 10.68. Surgical approach to the

radial aspect of the metacarpophalangeal
(MCP) joint of the thumb. A: Dorsal radial
incision. B, C: Incision and reflection of the
hood to expose the radial collateral liga-
ment (RCL). D: Fresh cadaver dissection of
the radial side of the MCP joint of the right
thumb showing the extensor hood and
abductor expansion, the incision into the
hood, and abductor expansion. E: Reflec-
tion of the hood reveals the underlying
RCL. Portions of the capsule have been
E removed for clarity.

C repaired, the reflected hood is reattached to main-
Proximal Interphalangeal Joint, Mid-Axial
This approach represents a portion of the finger mid-axial
incision and is used to approach the PIP joint for fractures,
fracture dislocations, or collateral ligament injuries. After
incision of the skin, the underlying transverse retinacular
ligament is identified and incised, which allows undermin-
ing and dorsal retraction of the extensor mechanism and
exposure of the lateral aspect of the joint.
CLINICAL CORRELATIONS
Dupuytren’s Contracture
Dupuytren’s contracture, a disease of the palmar and digital
fascia, has an unknown etiology, and the focus of this pre-
sentation is on the changes that may occur in and about the
10.1 Palmar Hand 619
FIGURE 10.69. Surgical approach to the radial col-
lateral ligament (RCL) of the index finger. A: A gently
curved, 3-cm-long incision is made over the radial
aspect of the index finger. Sensory branches of the
radial nerve are identified and preserved. B, C: The
skin flaps are developed and the underlying hood
and sagittal band identified. Beginning at the proxi-
mal edge of the sagittal band, a 1-mm-wide, 3-cm-
long strip of the extensor tendon is developed by
sharp dissection. The distal aspect of the hood is
incised in the direction of its fibers to release the flap
distally. This detached segment of the hood is then
reflected to expose the bony insertion of the first dor-
sal interosseous (DI) muscle and the RCL. Portions of
the insertion of the first DI may be reflected as
required and later reattached. After the RCL is
tain balance in the extensor mechanism.
palmar and digital fascia. These normal tissues appear to
become diseased in response to increased tension. The nor-
mal anatomy of the palmar and digital fascia has been pre-
sented in the section on the retinacular system of the hand.
Terminology
This text uses the term bands for normal fascia and cords for
diseased fascia, as originally suggested by Luck (117) and
used by others (85,118) (Fig. 10.70A). The palmar fascia is
defined as the specialized fascial structure in the central por-
tion of the palm with longitudinal, transverse, and vertical
fibers. The longitudinal fibers represent the distal continu-
ation of the palmaris longus (when present). These fibers
begin as a conjoined apex at the base of the palm and form
bundles in the middle and distal palm that course to the
620 Regional Anatomy

corresponding four fingers and in some instances to the

thumb. The longitudinal fibers are more or less parallel to
the deeper flexor tendons, and because of this arrangement
are sometimes called pretendinous bands. The four bundles
of longitudinally oriented fibers overlay transverse fibers in
the palm that are located at the junction of the middle and
distal thirds of the palm and over the MCP joints.
McGrouther has noted that these longitudinal fibers divide
into three layers in the distal palm (85). Layer one, the most
superficial, inserts into the skin of the distal palm and onto
the proximal aspect of the flexor sheath. Layer two splits
and passes on each side of the flexor sheath, where it con-
tinues distally as the spiral band of Gosset (84) beneath the
neurovascular bundle and natatory ligaments to insert on
the lateral digital sheet. Layer three passes on each side of
the flexor sheath to the region of the MCP joint (85).

Clinical Significance
Recognition of the distinct anatomic separation of the longi-
tudinal (involved) and transverse (noninvolved) fibers of the
palmar fascia and the distal separation of the longitudinal
fibers into three layers allows the surgeon selectively to excise
the diseased tissue, in contrast to excision of all fascial tissue
and preservation of the neurovascular bundles (85,119).

Pretendinous Bands
The pretendinous bands of the palmar fascia are the most
common site for presentation of Dupuytren’s contracture. A
palpable nodule may progress to a prominent pretendinous
cord, which may produce a flexion contracture of the MCP
joint. Although the pretendinous cord is the primary cause of
flexion contracture of the MCP joint, it may join the central
cord of the finger that extends well beyond the PIP joint. The
origin of the central cord is from the superficial fibrofatty dig-
ital fascia on the flexor side of the finger. The central cord
always is in continuity with the pretendinous cord (118).

Transverse Fibers
Only the longitudinal fibers (pretendinous bands) of the
palmar fascia are involved, and the transverse fibers ideally
are left behind during excision of the diseased palmar fascia.
(85,119). However, the transverse fibers to the thumb web,
the PCL, and DCL, which are more obliquely oriented and
subject to tension, may contract and be responsible for loss
of abduction and extension of the thumb.
Natatory Ligament
The natatory ligaments frequently are diseased, and because
this ligament not only spans the finger web space but also
sends fibers distally into the fingers, it may be responsible
for web space contracture as well as PIP joint contracture.
A
FIGURE 10.70. Normal and pathologic anatomy of the palmar
and digital fascia. A: Normal components of the palmar and dig-
ital fascia.
Pathologic Anatomy of the Finger Fascia
The fibers in the finger that may become diseased are (a)
the fibrofatty fascia on the flexor aspect of the fingers; (b)
the distal continuation of the pretendinous fibers, called the
spiral band; (c) the distal (longitudinal) extension of the
natatory ligaments; (d) Grayson’s ligament (as terminal
 10.1 Palmar Hand 621

B C
FIGURE 10.70. (continued) B, C: Changes in the palmar and digital fascia that may be seen in
Dupuytren’s disease.

attachment for the spiral bands); and (e) the lateral digital
sheet (84) (see Fig. 10.70B and C).
Fibrofatty Fascia
This tissue forms the central cord in the finger and joins the
pretendinous cord of the palm to form a continuous cord
from the palm to the middle phalanx. It often divides into
two tails that attach to the flexor sheath and osseous middle
phalanx.
Spiral Band
These fibers (McGrouther’s layer two) are the deep and dis-
tal continuation of the pretendinous band on each side of
the flexor sheath. They pass deep to the neurovascular struc-
tures as they proceed to the lateral side of the finger, and
then migrate superficial to the neurovascular bundle to
attach to the middle phalanx by means of Grayson’s liga-
ment (85). This configuration progressively displaces the
neurovascular bundle with increasing PIP joint contracture,
622 Regional Anatomy

first toward the midline, then proximally, and then superfi-
cially. This places the neurovascular bundle at considerable
risk during surgery because the neurovascular bundle spirals
around this fascial structure, called the spiral cord. The spi-
ral cord is either a continuation of the spiral band or arises
from the musculotendinous junction of an intrinsic muscle;
it attaches distally to the flexor sheath and bone in the mid-
dle phalanx.
Natatory Ligament
Disease and contracture of the transverse elements of the
natatory ligaments form the natatory cords that produce
contracture of the finger web spaces, with loss of abduction
of the fingers. The distal digital extension of the natatory
ligament joins the spiral band, and these two bands subse-
quently join the lateral digital sheet to form the lateral cord.
Grayson’s Ligament
Grayson’s ligaments, located in the middle and proximal
phalanges, pass from the digital flexor sheath, palmar to the
neurovascular bundle, to the lateral digital sheet and are in
the same fascial plane as the natatory ligaments (84,118).
Grayson’s ligaments provide attachment for the spiral cords
to the middle phalanx (85,118).
Lateral Digital Sheet
The lateral digital sheet, named by Gosset, is a condensa-
tion of the superficial fascia on either side of the finger (84).
It receives fibers from the natatory and spiral ligaments as
well as from Grayson’s and Cleland’s ligaments (84,118).
When diseased, it is known as the lateral cord (118).
Retrovascular Cord
This cord lies deep to the neurovascular bundle and arises
from the periosteum of the lateral base of the proximal pha-
lanx, passes close to the PIP joint, and ends at the lateral
aspect of the distal phalanx. It is the usual cause of DIP
joint contracture and an occasional cause of PIP joint con-
tracture (85,118).
Isolated Digital Cord
Isolated cords may arise in the fingers as single or double
cords without any attachments in the palm. These cords
arise from the periosteum at the base of the proximal pha-
lanx in conjunction with adjacent ligaments. They pass dis-
tally to displace and then cross the neurovascular bundle,
inserting on the tendon sheath or bone of the middle pha-
lanx. These cords may result in a significant loss of exten-
sion of the PIP joint and cause isolated contractures (120).
Table 10.11 summarizes the relationship between fascial
bands/ligaments, cords, and the clinical result of cord for-
mation.
First Web Space Pathologic Anatomy
Although only the longitudinal fibers (pretendinous bands)
of the palmar fascia are involved in the hand, the transverse
fibers to the thumb web, PCL, and DCL are more obliquely
oriented and are subject to tension (Fig. 10.71). If diseased,
they may contract and be responsible for loss of abduction
and extension of the thumb (85).
Trigger Digits (in the Adult)

Lateral Cord Definition

The lateral cord runs from the natatory ligament to the lat-
eral digital sheet. It usually does not cause PIP joint con-
tracture except on the ulnar side of the small finger, where
it attaches to an abductor cord overlying the ADM and can
cause PIP joint contracture.
Wolfe has observed that tendovaginitis may be a more accu-
rate term than tenosynovitis to describe the inflamed and
thickened retinacular sheath that characterizes so-called
trigger digits and trigger thumb (121). This condition
results in painful catching or triggering of the involved

TABLE 10.11. DUPUYTREN’S DISEASE: FASCIAL BANDS THAT MAY FORM CONTRACTURE CORDS

Fascial Bands/Ligaments Cords Result

Palm Pretendinous bands of palmar fascia Pretendinous cord Metacarpophalangeal joint contracture
Commissure Natatory ligaments Natatory cords Digital web contracture
Proximal commissure ligament First commissure cords Thumb web contracture
Distal commissure ligament First commissure cords Thumb web contracture
Finger Spiral band Spiral cord Displaces neurovascular bundle, PIP joint
contracture
Fibrofatty fascia Central cord PIP joint contracture
Natatory ligament and lateral digital sheet Lateral cord PIP joint contracture V (see text)
Periosteum of proximal phalanx Retrovascular cord Distal interphalangeal contracture
Periosteum of proximal phalanx Isolated digital cord PIP contracture

PIP, proximal interphalangeal.


FIGURE 10.71. The proximal and distal commissural ligaments
in Dupuytren’s disease. In contrast to the transverse components
of the palmar fascia, the transverse fibers to the thumb web, the
proximal and distal commissural ligaments that are more
obliquely oriented and are subject to tension, may contract and
be responsible for loss of abduction and extension of the thumb.
flexor tendon as the patient flexes and extends the digit.
The digit may often catch or lock to the extent that passive
manipulation may be required to unlock or extend the
digit.
Pathologic Anatomy
This condition is due to impingement of the flexor tendon
at the level of the A1 pulley, with changes in the pulley that
include thickening and microscopic signs of degeneration.
Comparison of the ultrastructure of normal and trigger A1
pulleys revealed chondrocytes in the friction layer of the
normal pulley and chondrocyte proliferation and the pres-
ence of type III collagen in the abnormal pulleys (122).
These authors proposed that the contact surfaces of the pul-
ley and flexor tendon developed fibrocartilaginous metapla-
sia owing to repetitive compressive loads (122).
Treatment
Conservative treatment is by steroid injection into the
flexor sheath. Surgical treatment is by release of the A1 pul-
ley. Both transverse and longitudinal incisions may be used
10.1 Palmar Hand 623
for open release of the A1 pulley in the fingers, but in the
thumb a transverse incision is preferred. Percutaneous tech-
niques are being developed for release of trigger digits but
may be less safe in the thumb or index because of the prox-
imity of the digital nerves (123).
Congenital Trigger Digits
Trigger Thumb
Definition
Although a number of diagnoses may be considered when a
child presents with a thumb locked in flexion, including
congenital clasped thumb, arthrogryposis, spasticity, or
absent extensors, the most common cause is congenital trig-
ger thumb. This condition is characterized by a palpable
lump in the region of the A1 pulley; the thumb may be
flexed (the usual posture is interphalangeal joint flexion) or
extended, and rarely is seen to catch or trigger, as opposed
to the adult form of trigger thumb (121,124).
Pathologic Anatomy
The lesion is a nodular thickening in the FPL tendon
referred to as Notta’s node, named after the person who may
have been the first to describe this condition in children
(125). This finding is in distinct contrast to the pathologic
anatomy in the adult. In adults, it is unusual to find a
grossly visible nodule in the tendon, although there may be
some comparative size difference or pseudonodule forma-
tion in the tendon proximal to the leading edge of the A1
pulley. An annular indentation of the tendon due to sus-
tained compression of the thickened annular pulley may
result in comparative enlargement of the tendon proximal
to A1.
Treatment
Conservative treatment in the form of splinting, massage,
passive manipulation, and watchful waiting for sponta-
neous resolution has all been tried with low levels of success.
Surgery in the form of release of the A1 pulley is associated
with a high degree of success (121).
Trigger Fingers
Definition
This condition may be characterized by a history of trigger-
ing, decreased active range of motion with a flexion posture
of the PIP joint from 30 to 90 degrees, a palpable nodule
proximal to the A1 pulley, and, in some cases, the finger is
locked in flexion (124,126).
Pathologic Anatomy
Abnormal findings may include a visible nodule in the FDP
tendon, a nodule in the FDS, and bunching up or buckling
of one or both slips of the FDS.
624 Regional Anatomy

Treatment
Surgical exposure should be extensile to evaluate the flexor
sheath and tendons from the A1 to A3 pulleys. This permits
release of the A1 pulley, excision of tendon nodules, exci-
sion of one or both slips of the FDS, and release of the A3
pulley as required (124). Although Tordai and Engkvist did
not find tendon nodules in their cases, they noted that com-
plete release required more than just release of A1, and
included separation of the slips of insertion of the FDS and
release of the proximal portion of the A2 pulley (126).

Clinical Significance
Trigger fingers in children are much less common than trig-
ger thumbs. In a comparatively large series of trigger digits
in children, 86% were trigger thumbs and 14% trigger fin-
gers (124). In contrast to trigger thumb release in children,
release of the A1 pulley may be inadequate to release trig-
gering, and correction may require excision of tendon nod-
ules, one or both slips of the superficialis tendon, and
release of the A3 pulley. The incision for trigger finger
release should be extensile to allow, as required, thorough FIGURE 10.72. The rock climber’s technique of crimping, which
may be associated with rupture of the second annular pulley.
exploration of the flexor tendon sheath and its contents
(124).

Trigger Digits and Hurler’s Syndrome

The anatomic findings in trigger digits due to Hurler’s syn-
drome is rosary bead–like swelling along the entire tendon
with constrictions at the annular pulleys due to abnormal
deposition of mucopolysaccharide in connective tissues.
Treatment may require more extensive excision of involved
structures (124).
Finger Flexor Pulley Rupture
Incidence
The incidence of this relatively unusual condition appears
to be increasing, perhaps because of the growing popularity
of rock climbing.
Mechanism of Injury
The typical mechanism is a rapidly applied extension force
to an acutely flexed finger (127). This force may be applied
in a variety of conditions, but a typical circumstance has
been identified in rock climbers. Finger holds often are
wide enough to admit only the tips of the fingers, and the
posture required to admit two or more digits to this con-
fined space is with the DIP joints extended and the MCP
and the PIP joints flexed to 90 degrees or more. The
climber’s thumb is flexed over the top. This posture or tech-
nique is called crimping and often is used on vertical or
overhanging surfaces (128) (Fig. 10.72).
Biomechanical Factors
The crimping posture puts a large strain on the distal end
of the A2 pulley. Sudden loading of the finger in this pos-
ture may exceed the breaking strength of the pulley. Analy-
sis of the forces of a 70-kg man falling and putting his
weight through one finger in the crimping posture produces
a resultant force of 450 N. This force applied at approxi-
mately right angles to the long axis of the proximal phalanx
exceeds the mean force of 400 N at which the A2 pulley
failed in a study by Lin et al. (128,129).
Clinical Presentation
In rock climbers with isolated rupture of the A2 pulley,
their main complaint may be a bulge over the proximal
phalanx of the affected finger, and on examination there
may be bowstringing of the flexor tendons across the PIP
joint (128). In other cases there may be a history of some-
thing “tearing” in the finger, but with only moderate pain
and no bruising. Later, PIP joint flexion contracture and
bowstringing of the flexor tendons develop (127). Bowers et
al. noted rupture of the A2, A3, and A4 pulleys in seven of
their nine cases, in contrast to the usual isolated rupture of
the A2 pulley noted in rock climbers (127,128). Le Viet et
al. noted rupture of the A2 and A4 pulleys in four of seven
cases, the A2 pulley in two cases, and the A4 pulley alone in
one case (130).
 10.1 Palmar Hand 625

Diagnosis
In addition to the history and physical examination, the
diagnosis may be confirmed by tomogram, computed
tomography scan, or magnetic resonance imaging, although
the history and physical examination should be adequate to
make the diagnosis (127,130).
A B

Treatment
In acute cases, the pulley rupture may be repaired (131).
Pulley reconstruction may be elected to meet functional
demands. In late cases, PIP joint contracture may require
release (127).

Collateral Ligament Injuries

Thumb Metacarpophalangeal Ligament
Injuries
Ulnar Collateral Ligament Rupture or Avulsion
(Fig. 10.73)
Mechanism of Injury. This injury is due to sudden and
forceful radial deviation (abduction) of the proximal pha-
lanx of the thumb, often secondary to a fall on the out-
stretched hand with the thumb abducted. It may be associ-
ated with activities such as skiing or ball sports (132).

Anatomy of the Ulnar Collateral Ligament Injury. Dis-

ruption of the UCL at the distal insertion (with or without
a bone fragment) is five times more common than proximal
tears or disruptions (133). Tears in the substance of the
UCL occur with less frequency. Associated injuries include
tears of the dorsal capsule, partial avulsion of the palmar
plate, or a tear in the adductor aponeurosis. In addition to
providing lateral stability to the MCP joint, the UCL and
RCL play a role in suspending the proximal phalanx. There-
fore, disruption of the UCL may result in palmar migration
and rotation (supination) of the proximal and distal pha-
lanx on the intact RCL.
The Stener Lesion. In 1962, Stener described complete rup-
ture of the UCL with interposition of the adductor aponeu-
rosis between the distally avulsed UCL and its site of insertion
(134). This configuration is easy to understand based on the
fact that the UCL is deep to the adductor aponeurosis, and
with avulsion it is carried proximally while the leading edge of
the adductor aponeurosis is carried distally by the deforming
force of injury. When the force abates and the proximal pha-
lanx returns to its normal alignment, the UCL is external
rather than deep to the adductor aponeurosis. Even if this
configuration did not occur, the natural tension in the liga-
ment and subsequent contracture would place it well proxi-
mal to its distal attachment and beneath the aponeurosis.
FIGURE 10.73. A: Normal anatomy of the ulnar collateral liga-
ment (UCL) of the metacarpophalangeal (MCP) joint of the
thumb. B: The Stener lesion. Complete rupture of the UCL often
is associated with retraction of the avulsed UCL proximal to the
adductor aponeurosis. This configuration prevents reattachment
of the UCL and results in instability of the MCP joint.
Clinical Significance. Complete disruptions or tears of the
UCL, with or without the Stener lesion, are best treated by
surgical reattachment of the ligament, whereas partial tears
may be treated by closed methods.
Diagnosis and Treatment. The diagnosis is made by not-
ing the mechanism of injury; identifying tenderness,
swelling, or ecchymoses over the ulnar side of the MCP
joint; and noting laxity of the UCL with stress testing.
Local anesthesia may be used to facilitate the stress test. It is
beyond the scope of this text to discuss the methods of
stress testing in detail, except to note that with complete
UCL disruption the MCP joint may be opened with mini-
mal resistance. The basic principle of treatment in complete
ruptures is to reattach the UCL to its anatomic site of inser-
tion.
626 Regional Anatomy
Avulsion Fractures and the Ulnar Collateral Ligament
Injury. Conventional wisdom has indicated that the posi-
tion of an avulsion fracture as seen with UCL injuries marks
the distal aspect of the disrupted UCL. A widely displaced
fracture fragment would indicate significant displacement
of the UCL and suggest the need for surgical intervention.
A case report that reevaluated this concept revealed (a) a
patient with UCL instability and an undisplaced fracture at
the base of the proximal phalanx with a classic Stener lesion;
and (b) a patient with a minimally displaced fracture at the
ulnar base of the proximal phalanx and a displaced frag-
ment proximal to the adductor aponeurosis. Surgery
revealed the UCL to be attached to the proximal fragment.
The author of this study (quoting reports by Stener in 1963
and 1969) noted that fractures of this type are either avul-
sion fractures due to UCL disruption or shear fractures at
the base of the proximal phalanx by the palmar portion of
the radial condyle of the metacarpal and with continued
displacement after UCL rupture (135–137).
Clinical Significance. If the fracture seen on radiographs is
a shear fracture, its position is unrelated to the location of
the distal end of the avulsed UCL. A displaced ligament
may occur in the presence of an undisplaced fracture (137).
Treatment Controversies in Acute Ulnar Collateral Liga-
ment Injuries. Cited factors noted to be useful in the
choice of conservative or operative treatment of UCL
injuries are presence or absence of instability as noted by
varying degrees of angulation of the proximal phalanx on
the metacarpal, both clinically and by radiography (stress
testing); presence or absence of a palpable and displaced lig-
ament proximal to the MCP joint; and, if fractures are pre-
sent, the displacement or nondisplacement of the fragment
and the amount of displacement, the size of the fracture
fragment based on a percentage of the articular surface of
the proximal phalanx, and whether rotation of the fracture
fragment is present. Uncited factors include the personal
bias and favorable or unfavorable experience of the surgeon
with surgical and nonsurgical methods as applied to the
wide range of pathologic anatomy noted in this injury. A
similar controversy applies to stress testing of the UCL
when an undisplaced or minimally displaced fracture is pre-
sent at the base of the proximal phalanx (138,139). The
most uniformly agreed on indication for surgical interven-
tion is the presence of the Stener lesion, with or without
fracture (139,140).
Author’s Comment. The reader may appreciate the breadth of
this controversy by noting the widely divergent recommenda-
tions of Dinowitz et al., who in nine patients with small avul-
sion fractures associated with UCL injury noted the failure of
prompt and prolonged closed treatment in all instances (141).
All these patients were subsequently operated on with satis-
factory outcome (141). These findings are compared with
those of Kuz et al., who in a retrospective questionnaire study
of 30 patients treated by nonsurgical means noted that all
patients were satisfied with their results. Twenty of these
patients were reexamined; three had instability on stress test-
ing, and there was a 25% nonunion rate of the associated frac-
tures of the proximal phalanx (139).
The treatment of this condition may vary based on many
factors, including the patient’s and surgeon’s definition of
success, and the past experience and personal choice of the
surgeon.
The Effect of Repositioning the Origin and Insertion of
the Ulnar Collateral Ligament. The mean anatomic loca-
tions of the origin and insertion of the proper UCL were
determined as part of a study to note the effect of moving
the origin or insertion of the UCL on MCP joint range of
motion (142) (see Fig. 10.9).
Proximal Origin (Metacarpal Attachment) Repositioning.
The UCL was detached and repositioned, in sequence, 2
mm palmar and 2 mm proximal from its anatomic origin.
The following effects on radial deviation were noted: Pal-
mar placement of the origin of the UCL increased radial
deviation from a mean of 18 to 27 degrees; proximal place-
ment decreased it from 18 to a mean of 11 degrees. There
was no effect on flexion or extension from displacing the
proximal origins of the UCL.
Distal Insertion (Proximal Phalanx) Repositioning. The
UCL was detached and repositioned in sequence, 2 mm
dorsal, 2 mm distal, and 2 mm palmar. Dorsal displacement
of the UCL insertion (proximal phalanx) increased radial
deviation from 18 to 25 degrees, and distal positioning of
the insertion decreased it from 18 to 10 degrees. Distal
repositioning of the insertion of the UCL decreased MCP
joint flexion from 56 to 47 degrees, and palmar placement
decreased it from 56 to 49 degrees. Dorsal placement of the
insertion had no effect on flexion. Extension and ulnar
deviation were not affected by ligament repositioning.
Nonanatomic reattachment or reconstruction of the
UCL may alter normal MCP joint range of motion. The
origin and insertion landmarks developed by this study
should serve as useful guides in reattachment and recon-
struction surgery of the UCL.
Radial Collateral Ligament Disruption
Although injuries to the RCL are less common than UCL
injuries, they also are associated with significant disability.
Mechanism of Injury. The mechanism of injury in dis-
ruption of the RCL is forceful adduction or torsion on the
flexed MCP joint (132).
Anatomy of the Radial Collateral Ligament Injury.
Because of the relatively broader abductor aponeurosis

compared with the narrower adductor aponeurosis, there is
no potential for soft tissue interposition (the Stener lesion)
with RCL avulsion. In contrast to the UCL, the RCL is
torn with almost equal frequency proximally and distally,
and mid-substance disruption is more common in the RCL
than in the UCL (132,143,144). The abductor aponeurosis
may be disrupted in addition to the RCL (145). Disruption
of the RCL results in palmar migration and pronation of
the proximal phalanx and dorsoradial prominence of the
metacarpal head. In my experience, these findings may not
be as noticeable immediately after the injury, possibly
because of the initial swelling that might mask the defor-
mities, or because these findings occur progressively and
thus may not be prominent in the early phase of this con-
dition.
Diagnosis and Treatment. Diagnosis of the acute injury is
made based on the history of injury, findings of ecchymosis
or tenderness, and a positive instability test. In my experi-
ence, RCL injuries tend to be diagnosed late rather than
early compared with UCL injuries. This may be because a
complete disruption of the UCL results in immediate and
significant disability owing to the functional demands
placed on the ulnar side of the thumb, leading to early eval-
uation. The RCL injury and subsequent dysfunction does
not seem to be as disabling, at least in the beginning, but as
time passes, it becomes increasingly bothersome and is in
fact a significant source of patient complaint and disability.
The basic principle of treatment in complete ruptures is to
reattach the RCL to its anatomic site of insertion. Late diag-
nosis may require ligament reconstruction by tendon graft.
Dorsoradial Capsule Injury
The following information about this injury is based on a
study of 11 patients by Krause et al. (146).
Mechanism of Injury and Presenting Complaints. The
mechanism of injury includes a direct blow, sports activi-
ties, or breaking a fall (146). The primary complaint was
pain over the dorsum of the thumb and limited use.
Physical Findings. All patients in this study demonstrated
tenderness over the dorsoradial aspect of the thumb MCP
joint in the absence of laxity of either the RCL or UCL. In
4 of the 11 patients, there was mild palmar subluxation of
the proximal phalanx, and all 4 of these patients lacked full
active extension of the proximal phalanx.
Treatment and Findings at Surgery. Four patients were
treated successfully by immobilization. Surgery was per-
formed in seven patients because of persistent activity-lim-
iting complaints over the dorsoradial capsule and the find-
ings of palmar subluxation and extensor lag. The
dorsoradial capsule was noted to be redundant or thinned,
or to have an obvious defect. It was repaired by imbrication
10.1 Palmar Hand 627
or direct closure of the defect, followed by immobilization
for 5 to 9 weeks.
Anatomy of the Dorsoradial Capsule of the Thumb
Metacarpophalangeal Joint. Based on their findings, the
authors proposed two factors that may contribute to this
injury: (a) an anatomic variation in the collateral ligaments
that allows greater MCP flexion, and (b) an area of relative
thinness and weakness in the dorsoradial capsule compared
with the ulnar side of the joint (146). Regarding range of
motion, the authors noted 64 degrees of flexion in the
opposite thumb MCP joint of their patients, compared
with the published normal of 53 degrees (146,147).
Clinical Significance. This diagnosis should be consid-
ered in patients with persistent pain at the thumb MCP
joint. Thumbs with greater flexion of the MCP joint are
predisposed to capsular rather than collateral ligament
injuries. Conservative treatment is indicated if no palmar
subluxation or extensor lag exists.
Finger Metacarpophalangeal Ligament
Injuries
Incidence and Etiology
The overall incidence of rupture of the collateral ligaments
of the fingers is much lower than that of ruptures of either
the UCL or RCL. Ruptures most often occur in the small
finger, most likely because of its position as a border digit,
but finger MCP RCL ruptures have been reported in all the
fingers. The usual mechanism of injury is forced ulnar devi-
ation with the fingers flexed (132).
Diagnosis and Treatment
There usually is tenderness along the radial side of the joint
and pain on ulnar stress of the joint. An arthrogram may aid
in diagnosis. Treatment should be based on functional need
and may include primary reattachment, repair, or recon-
struction by tendon graft as needed (148).
Complex Dislocations
Three complex dislocations are suitable for discussion in the
context of this text on surgical anatomy: (a) dorsal disloca-
tion of the thumb MCP joint, (b) dorsal dislocation of the
index finger MCP joint, and (c) palmar dislocation of the
finger PIP joint.
Dorsal Dislocation of the Thumb
Metacarpophalangeal Joint
Most dorsal dislocations of the thumb MCP joint are
reducible; irreducible dislocations are due to variety of
interposed structures that either block or trap the proximal
phalanx from returning to its anatomic position.
628 Regional Anatomy
Mechanism of Injury
If the collateral ligaments are visualized as structures that
suspend the proximal phalanx during flexion and extension,
it is easy to speculate that any disruption of the proximal
attachments or restraints to hyperextension may result in
the proximal phalanx going “over the top” with a sufficient
hyperextension force and becoming locked or trapped on
the dorsal surface of the metacarpal. For this to occur, the
palmar plate attachment must be disrupted either at its
proximal aspect or at its insertion into the base of the prox-
imal phalanx. If the palmar plate is disrupted distally, the
accessory collateral ligaments are torn, and this allows the
proximal phalanx and the collateral ligaments to swing dor-
sally to the top of the metacarpal. If the palmar plate is
detached proximally, it, along with its imbedded sesamoid
bones, is carried dorsally along with the proximal phalanx.
A radiograph that demonstrates sesamoid bones on the dor-
sal aspect of the metacarpal and adjacent to the base of the
proximal phalanx usually indicates a complex irreducible
dislocation of this joint (Fig. 10.74).
Interposed Soft Tissues
In addition to the palmar plate, other structures that may
be pulled along in this excursion are the adductor pollicis
aponeurosis, including the bony insertion on the ulnar base
of the proximal phalanx; the abductor expansion; and the
two heads of the FPB, which, along with the intact proper
collateral ligaments, may form an entrapment noose around
the neck of the thumb metacarpal and prevent reduction.
The FPL may be entrapped in the joint but usually remains
in the sheath (149).
Treatment
Closed reduction may be attempted, under appropriate
anesthesia, by flexing the wrist and thumb interphalangeal
joint and then pushing the hyperextended proximal pha-
lanx distalward. Longitudinal traction is avoided because it
may “tighten the noose” represented by the various soft tis-
sues around the neck of the metacarpal and prevent reduc-
tion. If closed means are not successful, open reduction is
indicated through a dorsal or palmar approach.
Dorsal Dislocation of the Index Finger
Metacarpophalangeal Joint
Dorsal dislocation of the finger MCP joints is unusual. The
most common digit to be involved is the index, followed by
the small finger; dorsal dislocation of the MCP joints of the
central fingers is seen most often with border digit disloca-
tion (132,150).
Mechanism of Injury
The usual mechanism of injury is hyperextension of the fin-
ger, often due to a fall on the outstretched hand. The prox-
imal attachment of the palmar plate is torn, and the sus-
pensory effect of the collateral ligaments allows the
FIGURE 10.74. Complex dislocation of
the metacarpophalangeal joint of the
thumb. This radiograph reveals sesa-
moid bones on the dorsal aspect of the
metacarpal, indicating detachment of
the proximal palmar plate with its
imbedded sesamoid bones. These find-
ings usually indicate a complex irre-
ducible dislocation of this joint. In
addition to the palmar plate, other
structures that may be pulled along in
this excursion are the adductor pollicis
aponeurosis, including the bony inser-
tion on the ulnar base of the proximal
phalanx, the abductor expansion, and
the two heads of the flexor pollicis bre-
vis, which, along with the intact proper
collateral ligaments, may form an
entrapment noose around the neck of
the thumb metacarpal and prevent
reduction.
 10.1 Palmar Hand 629

hyperextension force to thrust the proximal phalanx and
palmar plate dorsally to rest on the dorsal aspect of the
metacarpal.
Interposed Tissues
Kaplan identified a four-sided complex of structures that
played a role in trapping the metacarpal head in the palm
(Fig. 10.75). These structures are as follows: radially, the
lumbrical; proximally, the transverse fibers of the palmar
aponeurosis; ulnarly, the flexor tendons; and distally, the
natatory ligaments and the palmar plate.
Diagnosis
It is important to distinguish between complete irreducible
dislocations and reducible subluxations because a subluxa-
tion may be converted to a complete and irreducible lesion
by inappropriate reduction maneuvers.
In complete dislocation (the irreducible lesion), the
MCP joint is held in slight to moderate extension; MCP
joint flexion is impossible and the finger is ulnarly deviated.
A prominence may be palpated in the palm that corre-
sponds to the metacarpal head, and the skin may be puck-
ered.
In subluxation (the reducible lesion), the findings are
similar except that the proximal phalanx usually is more
hyperextended, often to 60 to 80 degrees.
Radiographic Findings
In complete dislocations, the radiographic findings may be
minimal in the anteroposterior view; the oblique view usu-
ally demonstrates widening of the joint space, and the lat-
eral view may show the complete dislocation. Lateral or
dorsal displacement of the sesamoid in the oblique and lat-
eral views also is an important finding. A tangential Brew-
erton view of the metacarpal head may aid in detection of
avulsion or other fractures in the region of the metacarpal
head (151).
Treatment
Distinction must be made between subluxation and com-
plete dislocation because the former is reducible by closed
means and the latter is not (132). In subluxation, the prox-

B
FIGURE 10.75. Complete dorsal dislocation of the index metacarpophalangeal (MCP) joint. A, B:
Note the foreshortened and adducted index finger and the extended proximal phalanx seen in
dorsal dislocation of the index finger MCP joint. C: Note the structures that trap the metacarpal
head.
630 Regional Anatomy

A C

FIGURE 10.76. Radiographic appearance of dor-

sal dislocation of the index finger metacarpopha-
langeal (MCP) joint in the right hand. A: Antero-
posterior views of the hand show only minimal
changes in joint space symmetry. B: Oblique views
of the same injury show a widened MCP joint and
extension and adduction of the finger. C: Lateral
B view showing a complete dorsal dislocation.

imal edge of the palmar plate remains palmar to the
metacarpal head. If either hyperextension or traction is used
as part of the reduction technique, the palmar plate may be
drawn dorsally and result in a complete and irreducible dis-
location. The proper reduction maneuver is performed by
flexion of the wrist and distal and palmar force on the base
of the proximal phalanx that slides the phalanx over the
metacarpal head (152).
Irreducible dislocations are treated by open reduction.
Kaplan described a palmar approach for this condition
and Becton et al. have described a dorsal approach
(5,153).

Palmar Subluxation and Dislocation of the
Proximal Interphalangeal Joint
Rotatory Palmar Subluxation
This rare condition represents a longitudinal rent in the
extensor mechanism between the lateral band and the cen-
tral slip of the extensor tendon that allows the head of the
proximal phalanx to enter the separation and be trapped
(154,155). The displaced lateral band is trapped behind the
palmar aspect of the condyle, resulting in a rotatory defor-
mity of the middle and distal segment of the finger (154)
(Fig. 10.77).
Mechanism of Injury. The mechanism of injury is due to
a combination of forces, including rotation, flexion, and
lateral deviation (154). The PIP joint is most susceptible to
torsional force at 55 degrees of flexion, when the lateral
bands shift palmar to the mid-axis of the proximal phalanx
(156). Thus, the injury probably is sustained with the PIP
joint in moderate flexion. The term subluxation seems
appropriate because the PIP joint is not widely separated.
Diagnosis. The PIP joint is in moderate flexion, the mid-
dle and distal phalanges are rotated, and there is swelling
about the PIP joint. A true lateral radiograph of the proxi-
mal phalanx demonstrates partial separation of the PIP
joint and obliquity of the middle phalanx due to the rota-
tory component of this injury (155).
Treatment. Although this condition has been reported to
be irreducible, closed reduction under appropriate anesthe-
sia may be attempted by simultaneous flexion of the MCP
and PIP joints to relax the lateral band, followed by rotation
of the middle phalanx that is opposite to the deformity
accompanied by gradual extension (155,157). If this
maneuver is not successful, open reduction is performed.
10.1 Palmar Hand 631
Irreducible Rotatory Palmar Dislocation of the
Proximal Interphalangeal Joint
This condition is the more complete or severe form of rota-
tory palmar subluxation.
The clinical appearance is characterized by almost 90
degrees of flexion at the PIP joint, supination of the distal
aspect of the finger, and inability to reduce the deformity.
Pathologic Anatomy/Mechanism of Injury. Irreducibility
is due to soft tissue interposition of the central slip, which,
along with the ulnar lateral band, is displaced palmar to the
neck of the proximal phalanx (154) (Fig. 10.78). Findings
at surgery reveal the head of the proximal phalanx project-
ing through an oblique tear in the extensor expansion
between the central slip and the radial lateral band, and the
central slip and ulnar lateral band displaced to lie together
in front of the neck of the proximal phalanx, where they act
as a block to reduction. The UCL is avulsed and the RCL
is intact. As in rotatory palmar subluxation, the mechanism
of injury is a predominantly rotational force. A common
modality of injury is the still-moving and full spin clothes
drier that catches a finger; the finger most often involved is
the index (154).
Treatment of Irreducible Dislocation. The PIP joint is
exposed through a dorsal approach and reduction is
achieved by replacement of the displaced central slip and
lateral band, followed by repair of the rent in the extensor
mechanism.
Reducible Palmar Dislocation of the Proximal
Interphalangeal Joint
Based on clinical studies and cadaver experiments, the
reducible type of palmar dislocation is associated with
FIGURE 10.77. Rotatory subluxation
of the proximal interphalangeal joint.
This rare condition represents a longi-
tudinal rent in the extensor mechanism
between the lateral band and the cen-
tral slip of the extensor tendon that
allows the head of the proximal pha-
lanx to enter the separation and be
trapped and rotated between the dis-
placed lateral band and the central slip.
632 Regional Anatomy
injury to one collateral ligament, the palmar plate, and
extensor mechanism (usually the central slip insertion of
the extensor tendon) (158,159). Although usually
reducible, it is unstable because of loss of dorsal support
from the central slip and, more important, if not recognized
and treated properly, results in a boutonniere deformity
because of the central slip disruption. Unilateral injury to
the collateral ligament results in rotatory deformity because
of the suspensory effect of the intact collateral ligament.
The mechanism of injury is a varus or valgus stress followed
by a palmar force that dislocates the middle phalanx pal-
marly. Cadaver experiments that used only an anterior force
without varus or valgus force resulted in avulsion of the
central slip, usually with a fracture fragment and a lesser
incidence of collateral ligament rupture (158).
Clinical Significance
If an anterior dislocation can be reduced, it is important to
know that an injury to the central slip has occurred and
requires appropriate treatment (154,159). Peimer et al.
noted that palmar dislocations of the PIP joint always
injured the extensor mechanism (most often a tear of the
central slip), a collateral ligament, and the palmar plate.
The associated ligament and tendon injury, if not treated,
results in loss of both static and dynamic PIP joint support
manifested by palmar subluxation, malrotation, bouton-
niere deformity, and fixed flexion contracture (159). Irre-
ducible palmar dislocations usually are not associated with
central slip disruption and may have a more favorable prog-
nosis. Inability to reduce an anterior dislocation is most
FIGURE 10.78. Irreducible rotatory pal-
mar dislocation of the proximal interpha-
langeal (PIP) joint. The clinical appear-
ance is characterized by almost 90
degrees of flexion at the PIP joint, supina-
tion of the distal aspect of the finger, and
inability to reduce the deformity.
likely due to interposition of a part of the extensor mecha-
nism, and can be corrected by surgery. There are two forms
or stages of progression in rotatory injuries: The first or
stage I is a subluxation injury; the second or stage II is an
irreducible dislocation. Based on the experience of both
Eaton and Green and Butler, a closed reduction of stage I
injuries may be attempted in acute cases (155,157). In stage
II or complete dislocations, closed reduction is not advised
(154).
Proximal Interphalangeal Joint
Contracture
Movement in the middle or PIP joint of the fingers may be
the major component in useful finger function (160). Con-
ventional wisdom has taught that the collateral ligament
complex was essential to PIP joint stability and should be
partially removed to avoid PIP joint instability (161). Cur-
tis noted modest permanent improvement in PIP joint
motion after careful excision of a specific segment of the
scarred ligament system (162). Diao and Eaton published
their results with total excision of the PIP joint collateral
ligaments in 1993 (160).
Treatment
Treatment is best performed by the technique of Diao and
Eaton (160) (Fig. 10.79), total collateral ligament excision.
Through 2-cm ulnar and radial mid-axial incisions centered
over the PIP joint, the adjacent lateral bands are mobilized

B
dorsally and the scarred collateral ligaments are excised
from the proximal phalanx origin, the middle phalangeal
insertion, and the palmar plate attachments. Total collateral
ligament excision is supplemented with palmar plate distal
release, extensor tenolysis, and flexor sheath release as
needed.
Results
Diao and Eaton achieved, on average, over twice the preop-
erative range of motion (38 to 78 degrees) in a series of 16
patients with total collateral ligament excision. No postop-
erative instability was noted by manual testing and radi-
ographic examination. The authors surmised that the thick-
ening palpable in their postoperative patients lateral to the
condyles was scar that is capable of organizing and remod-
eling into a new collateral ligament. They also commented
that the fact that thickening could be palpated across the
joint line suggests that there is a postoperative traumatic
fibroblastic proliferation. In two patients not included in
the series who underwent subsequent surgery after initial
collateral ligament resection, the condylar fossa was occu-
pied by obliquely oriented fibrillated structures that
appeared to be very similar to normal collateral ligaments in
architecture, consistency, and function (160).
Compartment Syndrome
A compartment is an anatomic unit that may contain mus-
cle, nerve, or blood vessel with anatomic boundaries formed
by fascia or bone that is capable of sustaining increased
hydrostatic pressure. Compartment syndrome is defined as
a physiologic sequence manifested by increased hydrostatic
10.1 Palmar Hand 633
FIGURE 10.79. A, B: Total collateral ligament exci-
sion for proximal interphalangeal joint contracture.
pressure that occurs in a closed anatomic compartment and
that compromises tissue viability. The severity of the syn-
drome is related to the magnitude and duration of the pres-
sure. This abnormal increase in pressure results in ischemia
of both muscle and nerve. Compartments that may be
involved in compartment syndrome in the hand are the
thenar, hypothenar, adductor, lumbrical, central palmar,
and interosseous compartments (Fig. 10.80).
Thenar Compartment
The thenar compartment is covered palmarly by the thenar
fascia, which begins over the palmar surface of the thumb
metacarpal and wraps around the thenar muscles to return
to the deep surface of the thumb metacarpal. The radial
wall of the compartment is formed by the flexor surface of
the thumb metacarpal. The thenar muscles are the APB,
OP, and FPB. Clinical manifestations of thenar compart-
ment syndrome, in addition to the usual findings of
swelling and tenderness, include weakness or limited oppo-
sition and flexion of the thumb. The thumb may assume an
exaggerated posture of abduction and extension, and pas-
sive motion may cause pain in the thenar eminence.
Hypothenar Compartment
The hypothenar compartment is bound radially by the
ulnar septum of the central palmar compartment, which
blends with the hypothenar fascia (a thinner continuation
of the palmar fascia) and wraps around the hypothenar
muscles to attach to the ulnar and palmar aspect of the
small finger metacarpal. The small finger metacarpal forms
634 Regional Anatomy
FIGURE 10.80. Anatomy of the compartments of the hand. The recognized compartments of
the hand are the thenar, hypothenar, lumbrical, central palmar, adductor, and interosseous.
the floor of the hypothenar compartment. The hypothenar
muscles are the ADM, FDM, and ODM. Clinical manifes-
tations of hypothenar compartment syndrome, in addition
to the usual findings of swelling and tenderness, include
pain in the region with passive motion of the small finger.
Limited flexion and abduction of the small finger also may
be present.
Adductor Compartment
The adductor compartment contains the adductor pollicis
and is bounded palmarly by the adductor fascia, which
extends radially from the middle finger metacarpal and
inserts on the thumb metacarpal just to the ulnar side of the
FPL tendon. At the distal border, the adductor fascia blends
into the fascia over the first DI muscle. Dorsally, the adduc-
tor compartment is covered by the fascia covering the mus-
cles of the first and second interosseous spaces (88).
Clinical manifestations include swelling and tenderness
in the palm distal to the thenar eminence. Because of
swelling or spasm in the adductor, the thumb may rest in
the palm, in contrast to its usual position of moderate
abduction. Stretching the adductor by extension and
abduction of the thumb may produce complaints of pain in
the compartment, and there may be weakness of pinch
because of the adductor’s role in stabilizing the MCP joint
during this activity.
Lumbrical and Central Palmar Compartments
of the Hand
Because of their proximity and shared structural parts, the
lumbrical compartments (canals) are discussed with the
central palmar space of the hand.
The palm contains a triangular (apex proximal), three-
dimensional configuration of fascia that forms a space in
its proximal aspect and compartments (canals) in its distal
aspect. Radial and ulnar vertical marginal septa from the
palmar aponeurosis separate this central space from the
thenar and hypothenar compartments. The radial mar-
ginal septum begins as an extension of the side wall of the
carpal canal and extends distally over the fascia, covering
the adductor pollicis and first DI muscles. It ends at the
proximal phalanx, forming the radial and palmar margins
of the lumbrical compartment (canal) to the index finger.
Proximally, it separates the central palmar space from the
thenar compartment. The ulnar marginal septa begins on
the ulnar side of the carpal canal and is attached to the
shaft of the small finger metacarpal. Proximally, it sepa-
rates the central palmar space and hypothenar compart-
ment and distally, the flexor sheath. Between these two
marginal septa are seven intermediate septa that, along
with the marginal septa, divide the distal aspect of the
palm into four canals to accommodate the flexor tendons
and four canals to accommodate the lumbricals and neu-
rovascular bundles. The seven intermediate septa are rec-
tangular with a free falciform proximal edge. They are
attached to the underside of the longitudinal and trans-
verse fibers of the palmar fascia and anchored deep in the
hand to the deep transverse metacarpal ligament and
interosseous fascia. Proximally, the intermediate septa
extend into the acute angle between the FDP and the lum-
brical and are comparatively short or long to accommo-
date a distal or proximal origin of the lumbrical. The roof
of the central palmar space of the hand and the lumbrical
compartments is formed by the longitudinal and trans-
verse fibers of the palmar fascia, and the floor by the pal-
mar interosseous fascia and the adductor fascia.

Clinical Manifestations of Central Compartment
Syndrome
There may be associated swelling and tenderness in the cen-
tral palm. Increased pressure in the adjacent central space
may cause hypesthesia on the palmar surface of the fingers
because of ischemia in the nerves secondary to increased
pressure. The lumbrical muscles extend the proximal and
distal joints and assist in flexion of the MCP joints. Con-
traction of the lumbrical pulls the profundus tendon dis-
tally, decreases the effectiveness of the profundus, and
allows the lumbrical more easily to extend the PIP and DIP
joints. Compartment syndrome involving the lumbrical
muscles may produce partial reversal of the normal flexion
posture of the finger at the PIP and DIP joints; in more
severe cases, there may be pronounced flexion of the MCP
joint and extension of the PIP and DIP joints (the so-called
lumbrical plus posture). In some cases, the patient may be
unable actively to flex the proximal and distal joints, and
the test for intrinsic contracture may be positive.
Interosseous Compartments
Four interosseous compartments are present in the hand
that contain three palmar interosseous and four DI muscles.
The interosseous muscles are located between the
metacarpal shafts, which form the lateral wall of the com-
FIGURE 10.81. Surgical approaches to the hand compartments. A: Approach to the hypothenar
compartment. B: Approach to the lumbrical, central palmar, and adductor compartments.
C: Approach to the thenar compartment. D, E: Approach to the interosseous compartments.
10.1 Palmar Hand 635
partments, and the floor and roof are formed by the palmar
interosseous and DI fascia, respectively. Clinical manifesta-
tions of interosseous muscle compartment syndrome may
be associated with swelling and tenderness on the dorsum
of the hand and may result in an “intrinsic plus hand” man-
ifested by flexion of the MCP joints and extension of the
PIP and DIP joints. Passive extension of the MCP joints
and passive flexion of the interphalangeal joints are limited,
resisted by the patient, and associated with pain.
Treatment of Compartment Syndrome
Suitable incisions and surgical approaches for compartment
releases in the hand are depicted in Figure 10.81. The DI
and palmar interosseous muscles are approached dorsally
through longitudinal incisions. The radial aspect of the
hand is approached through an incision over the index
metacarpal and the ulnar side through an incision over the
ring finger metacarpal. Each space is entered by incision of
the DI fascia; the DI and palmar interossei as well as the
adductor pollicis may be released by this means. The thenar
and hypothenar compartments are approached through
longitudinal incisions over the radial aspect of the thumb
metacarpal and the ulnar aspect of the small finger
metacarpal, respectively. The lumbrical compartments may
be approached through a transverse incision near or in the
636 Regional Anatomy
proximal palmar crease, and the central space of the hand
may be approached through an incision at the thenar crease.
A more comprehensive approach that begins in the proxi-
mal palm and zig-zags distally allows access to the lumbri-
cal and central compartment as well as the adductor com-
partment. Digital fasciotomies are made through mid-axial
incisions positioned on the side of the digit that is less used
in everyday activities. The index, long, and ring fingers may
be opened on the ulnar aspect and the small finger and
thumb on the radial aspect. The plane of dissection is dor-
sal to the neurovascular bundles and palmar to the flexor
sheath, and the dissection is carried across the digit to
release all portions of the compartment.
ANATOMIC VARIATIONS
Nerve
Cannieu-Riche Anastomosis
This anastomosis, in its classic form, is between the motor
branch of the ulnar nerve and the motor branch of the
median nerve in the proximal and radial palm (163). It was
FIGURE 10.82. Cannieu-Riche anastomosis. A, Recurrent branch, median nerve; B, digital branch
to thumb; C, branch to deep head, flexor pollicis brevis; D, branch to adductor pollicis; E, anas-
tomosis.
described by Cannieu in 1896 and 1897 and by Riche in
1897 (164–166).
Anatomy
The classic description is of an anastomosis between a
ramus of the recurrent branch of the median nerve supply-
ing the superficial head of the FPB and the anastomotic
ramus of the deep branch of the ulnar nerve supplying the
deep head of the FPB (Fig. 10.82). The anastomotic branch
is present between the two heads of the adductor pollicis
and then circles round the FPL tendon on its lateral side.
Variations
Anatomists who have studied this anastomosis have identi-
fied the following variations (Fig. 10.83):
1. A separate branch of the median nerve to the superficial
head of the FPB may send a branch to the anastomosis;
in this type, the anastomosis can be located either on the
surface of or deep in the FPB.
2. The anastomosis may be with one or two digital nerve
branches of the thumb from the median nerve, and in
this type the anastomosis is located medial to the tendon

FIGURE 10.83. Variations of the Cannieu-Riche anastomosis. 1,
Ulnar nerve; 2, median nerve; 3, beep branch of ulnar nerve; 4,
branch to adductor pollicis; 5, branch to deep head of flexor pol-
licis brevis (FPB); 6, recurrent branch; 7, digital branch to thumb;
8, separate branch of median nerve to superficial head of FPB; 9,
digital branch to index finger.
of the FPL, and sometimes a double or triple anastomo-
sis may be found.
3. An anastomosis may occur between one of the branches
of the digital nerve to the thumb and the branch to the
adductor pollicis, coming from the deep ulnar nerve;
this anastomosis is medial to the FPL tendon and deep
in the adductor pollicis, and there is no ulnar innerva-
tion to the deep head of the FPB.
10.1 Palmar Hand 637
4. A deep branch of the ulnar nerve may pass through and
innervate the first lumbrical on its way to anastomose
with the digital branch to the index finger (163).
Incidence
In a study of the incidence of this anastomosis, 27 of 35
hands (77%) had a Cannieu-Riche anastomosis between
the median and ulnar nerve (163). Thirteen of the 27 hands
with the anastomosis demonstrated the anastomotic ansa
that circled around the lateral side of the FPL tendon as
described by Cannieu in 1897 (165). In the remaining 14
hands, the 4 variations mentioned previously were noted,
and in all of these the anastomosis lay medial to the FPL
tendon.
Clinical Significance
The FPB, in addition to its classic anatomic ability to flex
the MCP joint, also can abduct and pronate the first
metacarpal (167,168). Double (from median and ulnar)
innervation of the FPB muscle may explain a nonanatomic
persistence of function after median or ulnar nerve injury.
Adequate pinch may be retained and Froment’s sign may be
minimal or absent in the ulnar nerve–injured patient if the
deep head of the FPB has median nerve innervation; in
median nerve injury, opponensplasty may not be required if
the superficial head of the FPB is ulnar nerve innervated
(167).
Neural Loop of the Deep Motor Branch of the
Ulnar Nerve
A branch from the main motor component of the ulnar
nerve has been identified at the distal end of Guyon’s canal
as the nerve passed around the hook process of the hamate
(Fig. 10.84). The aberrant branch was noted to arise proxi-
mal to the hook process of the hamate and to rejoin the
nerve distally deep in the palm. This configuration was
noted in three cases of neurolysis of the ulnar nerve in
FIGURE 10.84. Neural Loop of the deep motor branch
of the ulnar nerve.
638 Regional Anatomy
Guyon’s canal. Based on these operative findings, an
anatomic study was performed that revealed 7 cases (1 case
was bilateral) in 77 cadavers, for an incidence of 9% (169).
Clinical Significance
The authors of this report noted that this variation should
be considered when there is an atypical presentation after
penetrating injuries or compression neuropathy of the ulnar
nerve at the wrist. In addition, knowledge of this configu-
ration is of value during decompression of Guyon’s canal or
excision of a nonunited fracture of the hook process of the
hamate (169).
Muscle
Palmaris Brevis Profundus
This is an anomalous muscle that courses transversely from
the flexor retinaculum and palmar fascia to the fascia in the
region of the pisiform. It is a thick muscle belly, parallel and
deep to the palmaris brevis. The muscle may lie between the
superficial and deep branches of the ulnar nerve.
Clinical Significance
This muscle may compress one or both segments of the
ulnar nerve in the region of Guyon’s canal and cause ulnar
neuropathy. It may represent a form of duplication of the
normal palmaris brevis (170).
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 C H A P
10
HAND
JAMES R. DOYLE
P A R T
2 brevis (EPB) tendons, and proximally by the distal margin
DORSAL HAND
DESCRIPTIVE ANATOMY
Contents
Bone: Metacarpals and phalanges of the five rays.
Nerves: Terminal branches of the median, radial, and
ulnar nerves.
Tendons: The extensor tendons of the five rays.
Fascia: The extensor retinaculum.
Blood Vessels: Dorsal veins.
Appendages: Nail matrix and nails.
Landmarks
Important superficial landmarks on the dorsum of the wrist
and hand include Lister’s tubercle, the anatomic snuff-box,
the lunate fossa, the styloid process at the base of the mid-
dle finger metacarpal, the radial styloid process, and the dis-
tal head of the ulna (Fig. 10.85).
Lister’s Tubercle
This bony prominence on the dorsal aspect of the distal
radius is situated approximately 0.5 cm proximal to the dor-
sal margin of the articular surface of the radius. It is in line
with the cleft between the index and middle finger
metacarpals. The extensor pollicis longus (EPL), located in a
groove just ulnar to Lister’s tubercle, turns radialward around
Lister’s tubercle on its way to the dorsal aspect of the thumb.
The extensor carpi radialis brevis (ECRB) is just radial to Lis-
ter’s tubercle in a similar groove on the dorsum of the radius.
Anatomic Snuff-Box
The anatomic snuff-box, a narrow triangle with its apex
located distally, is bordered dorsoulnarly by the EPL, radi-
T E R
ally by the abductor pollicis longus and extensor pollicis
of the extensor retinaculum. In its depths it contains the
dorsal branch of the radial artery; in its dorsoulnar corner,
the tendon of the extensor carpi radialis longus (ECRL);
and superficially, one or more branches of the superficial
branch of the radial nerve (1,2).
Lunate Fossa
The lunate fossa is a palpable central depression located on
the dorsum of the wrist in line with the longitudinal axis of
the third metacarpal, just ulnar and distal to Lister’s tuber-
cle, and beginning immediately distal to the dorsal margin
of the radius. It is, on average, approximately the size of the
pulp of an examiner’s thumb and marks the location of the
carpal lunate.
Styloid Process of the Middle Finger
Metacarpal
The styloid process of the middle finger metacarpal, located
on the dorsal and radial base of this metacarpal, points to
the articular interface between the capitate and the trape-
zoid and is just proximal to the point of insertion of the
ECRB tendon.
Radial Styloid
The distal projection of the radial side of the radius forms a
visible and easily examined landmark that is palpable both
palmar and dorsal to the abductor pollicis longus and EPB
tendons that course across its apex.
Distal Head of the Ulna
The distal aspect of the ulna is slightly expanded and contains
a head and a comparatively small styloid process. The head is
most visible and palpable with the forearm in pronation. The
styloid process is a short, rounded, dorsoulnar projection from
the ulnar head that is most readily palpable in supination and

A B
FIGURE 10.85. A,B: External landmarks on the dorsum of the hand.
is approximately 1 cm proximal to the plane of the radial sty-
loid. The apex of the triangular fibrocartilage attaches to the
palmar-radial base of the ulnar styloid. The ECU runs in a
fibroosseous groove along the dorsal aspect of the head (1).
ANATOMIC RELATIONSHIPS
Skin Coverage
The skin on the dorsum of the hand and fingers is compar-
atively thin and pliable; this may be demonstrated by
pinching the skin between the thumb and index finger and
tenting it up. This mobility is due to its comparative thin-
ness and lack of fibrous tissue attachments to the underly-
ing fascia. This comparison is made to the palmar skin,
10.2 Dorsal Hand 643
which is thick, firmly attached to the underlying fascia,
with folds along creases or flexion lines. The dorsal skin
glides and stretches with movement. The dorsal skin’s
accommodation to the requirements of flexion are most
noticeable over the wrist, metacarpophalangeal (MCP), and
proximal interphalangeal (PIP) joints, where the skin folds,
accordion-like, in extension and flattens out in flexion.
These accordion-like folds are the dorsal counterpart of the
palmar skin creases (1).
Clinical Significance
These characteristics of the dorsal skin make it less likely to
form an undesirable scar, even when incisions are placed at
right angles to the extension folds.
644 Regional Anatomy
Venous Drainage of the Digits
Fingers
Dorsal Digital Veins
Lucas, in an injection study of 36 fingers, noted that
although there is greater variability in the venous than in the
arterial system, there is a fairly consistent dorsal venous pat-
tern (3) (Fig. 10.86). The most consistent vessel found is a
small vein in the dorsal midline of the distal phalanx that
arborized over the surface of the nail matrix and was named
the dorsal terminal vein. Lateral terminations that parallel the
nail margins also are fairly constant. These veins are large
enough to reapproximate by microvascular techniques (3–5).
Proximally, a pair of dorsal veins (one ulnar and one radial)
are joined by transversely oriented connections that form a
“dorsal ladder” that ends at the digital cleft. Moss et al. stud-
ied the venous anatomy of the hand and fingers in nine fresh
cadaver hands and observed that the dorsal venous system of
each digit consists of a series of arches, one over each phalanx,
with the most proximal arch being consistently present in all
digits studied (6). These authors called the arch of veins run-
ning around the lateral nail wall and distal pulp the distal
venous arch. The distal arch is connected to a middle venous
arch by means of midline longitudinal vessels over the mid-
dle phalanx, and the middle arch is the most rudimentary of
the three arches. The middle arch is connected by multiple
longitudinal vessels, the largest of which are on either side of
the PIP joint, to the proximal venous arch over the proximal
phalanx. The proximal arch terminates in veins in the dorsal
web spaces on either side of the MCP joint, which in turn
join the veins on the dorsum of the hand. These veins form
a network that is connected proximally to the cephalic and
basilic veins (Fig. 10.87). This network is divided into two
systems: The first consists of interdigital communications
between the proximal arches of each digit that lie in the dor-
sal web spaces between the MCP joints; the second system
(the more dominant) consists of three distinct venous arcades
over the metacarpals. There is one metacarpal arcade for each
of the venous arches of the thumb and small finger. The prox-
imal venous arches of the remaining digits communicate with
a large central metacarpal arcade that extends from the radial
side of the index metacarpal to the ulnar side of the ring fin-
ger metacarpal (6).
Smith et al., in a comprehensive study that focused on
the veins distal to the PIP joint, sited and counted all of the
veins encountered at the PIP and distal interphalangeal
(DIP) joints and eponychial regions of 67 fingers (7). The
study was performed to note the regions at these various
locations that would be most likely to have suitable vessels
for anastomosis in cases of replantation.
FIGURE 10.86. Dorsal and palmar veins
of the digits: composite patterns of the
dorsal and palmar digital veins. The
small triangles indicate the site of valves.
The most consistent vessel found is a
small vein in the dorsal midline of the
distal phalanx that arborizes over the
surface of the nail matrix, called the dor-
sal terminal vein. Lateral terminations
that parallel the nail margins also are
fairly constant. Proximally, a pair of dor-
sal veins (one ulnar and one radial) are
joined by transversely oriented connec-
tions that form a “dorsal ladder” that
ends at the digital cleft. A similar “pal-
mar ladder” is present in the flexor
aspect of the finger, although the vessels
are somewhat smaller. (Redrawn after
Lucas GL. The pattern of venous
drainage of the digits. J Hand Surg [Am]
9:448–450, 1984, with permission.)

Proximal Interphalangeal Joint Level
Numerous large vessels were noted dorsally, with almost
total avascularity on the radial and ulnar aspects. For veins
that measured >0.8 mm, the dorsal/palmar vein ratio was
138:98. Thus, when performing a microvascular vein repair
(replantation) in this region, the surgeon should look first
for veins on the dorsum and next on the palmar side, but
not waste any time looking for veins on the radial or ulnar
aspects of the finger.
Distal Interphalangeal Joint Level
This amputation site is characterized by the dorsal termi-
nal vein, and in 68% in Smith and colleagues’ study it
was a single vessel that measured >0.5 mm 96% of the
time.
Thus, the surgeon always should look first in the area of
the middle one-third of the dorsal aspect of the digit; the
second-best choice is in the region of the commissural vein.
These are lateral veins connecting the palmar to the dorsal
system and were present in 49 of 67 fingers (73%); one vein
measured >0.8 mm. Medium-size veins (<0.7 to >0.5 mm)
were present an average of 1.1 veins per finger. These
medium-size veins were more common on the palmar side,
134 versus 74 on the dorsal side.
10.2 Dorsal Hand 645
FIGURE 10.87. Metacarpal venous arcades. The veins on the
dorsum of the hand form a network that is connected proxi-
mally to the cephalic and basilic veins.
Eponychial Level
This is a very distal level and if replantation is pursued, the
surgeon’s efforts to find a suitable distal vein may be optimized
by first finding the lateral commissural vein in the proximal
stump and then trying to identify its counterpart in the ampu-
tated part—topographically, a relatively small area. If not suc-
cessful, the surgeon should next look for the lateral ramifica-
tions of the dorsal terminal vein, also a small topographic area.
Last, the entire area of the palmar pulp should be searched.
Palmar Digital Veins
Lucas noted that a similar “palmar ladder” is present in the
flexor aspect of the finger, although the vessels are somewhat
smaller (3). These vessels do not travel with the digital arter-
ies as venae comitantes, but have a more random course in
and out of the fascial sheath formed by Grayson’s and Cle-
land’s ligaments. The longitudinal components of the palmar
ladder parallel the neurovascular bundle but are more super-
ficial. These two ladders are joined by oblique anastomotic
veins that are especially prominent in the proximal segment
of the finger. Both systems drain the bones of the fingers and
the vincular system. Both dorsal and palmar web veins are
present and interconnected. Moss et al. noted that palmar
venous drainage was composed of a superficial and a deep
646 Regional Anatomy

system (6). The deep system, according to Moss et al., corre- sent in all veins that pass from palmar to dorsal and are
sponded to the venae comitantes of the proper digital arter- arranged so that flow is from palmar to dorsal. Sequential
ies that join with the superficial palmar veins to form the angiographic studies by Moss et al. revealed flow from the
venae comitantes of the common digital arteries in the hand. dorsal distal arch to the middle and proximal arches. Flow
The superficial system consists of two networks overlying the from the proximal arch is into the next arch in an ulnar direc-
neurovascular bundles. Transverse and oblique communicat- tion and into the metacarpal arcade. The thumb metacarpal
ing veins join the two superficial palmar networks. These two arcade empties into the cephalic vein, but the central
superficial palmar networks are surrounded by a sheath of metacarpal arcade flows into the cephalic and basilic veins,
fine connective tissue that encases the veins in a cushion of with a preference for the ulnar-sided basilic system (6).
fat. This perivenous arrangement serves to support the super-
ficial veins; they collapse when this sheath is removed. These Thumb
superficial palmar digital veins unite in the web space to form
Matloub et al., in a study of 20 injected thumbs, identified
a common vein (the intercapitular vein), which then passes
a dominant longitudinal network, palmar veins in the pulp,
proximally and dorsally to join the dorsal metacarpal arcades.
oblique veins at the interphalangeal joint on the radial side,
A transverse natatory vein (also called the palmar venous arch)
and a web space (ulnar) vein (8). A layered pattern with a
courses along the margin of the natatory ligament to join
fine superficial network over a deeper system was found.
with each web space vein.
Cross-sections were made at the distal phalanx, the proximal
phalanx, and the MCP joint, and the location of the veins
Oblique Communicating Veins
noted in four quadrants. The most characteristic findings
Moss et al. identified communicating veins from the super-
were sizable palmar veins in the pulp, an oblique radial com-
ficial palmar venous system that pass obliquely, proximally,
municating vein arising at the level of the interphalangeal
and dorsally (the “dorsal oblique communicating veins”) to
joint, a web space (ulnar) vein, the relative dominance of the
join the dorsal digital venous system and that are larger and
dorsal system, and the presence of suitable veins (>0.5 mm)
more numerous in the mid-portion of the proximal phalanx
near the nail matrix. The authors’ cross-sections showed that
(6). Transverse sections revealed 10 to 12 veins at all levels
the dorsal system is dominant proximally and the palmar
of section. Palmar veins become smaller and less regular in
system is important distally. Veins were found to be present
the proximal phalanx compared with the middle phalanx;
at all palmar levels; the radial side of the interphalangeal
large, oblique communicating veins are present at the mid-
joint and proximal phalanx and the ulnar side of the web
dle third of the proximal phalanx.
space can be anticipated to be a reliable source of veins in
replantation surgery (8) (Fig. 10.88).
Venous Valves
Moss et al. noted that valves are present in all the digital veins
studied, including veins with cross-sectional diameters of
<0.1 mm (6) (see Fig. 10.86). These valves occur as far dis-
tally as the distal part of the distal phalanx, and their location
is identified by noting a clam-shaped node in the vein. These
valves are bicuspid with the valve leaflets arranged parallel to
the skin. This parallel orientation ensures their competence
with extrinsic pressure on the skin. The valves direct blood
flow from distal to proximal, palmar to dorsal, and radial to
ulnar. Valves are present on the dorsal surface of the fingers at
specific branch points and at the mouths of the tributaries
entering the three transverse arches. No valves are present in
the arches except for one at the ulnar end of the proximal
venous arch, which is oriented to direct flow ulnarly into the
proximal venous arch of the adjacent digit. More valves are
present on the palmar aspect and are arranged in series along
the superficial and deep systems; the highest density is in the
distal pulp.

Direction and Sequence of Venous Flow

A valve is present at either end of the transverse and oblique
veins that connect the radial and ulnar superficial palmar sys-
tems; they are arranged to direct flow into either one or the
other system, but prohibit flow between them. Valves are pre-
FIGURE 10.88. Venous anatomy of the thumb. Characteristic
pattern of the dorsal and palmar veins of the thumb [after Mat-
loub et al. (8)].

Dorsal Veins
The dorsal system of veins begins at the base of the thumb-
nail and coalesces into four to eight large vessels (usually <1
mm in diameter) at the level of the interphalangeal joint. As
these vessels approach the MCP joint, they decrease in
number but increase in size. At the level of the MCP joint,
there usually were two to three vessels with a diameter of 1
to 1.5 mm (8).
Palmar Veins
The palmar system is not as well developed as the dorsal
and begins as one or usually two 0.5-mm veins deep in the
pulp of the terminal phalanx. These vessels are beneath a
superficial plexus of much smaller vessels connected by
numerous small transverse anastomoses. Proximal to the
interphalangeal joint, these veins begin a dorsal course up
the radial and ulnar sides of the thumb to join the dorsal
veins (8).
Clinical Significance of the Anatomy of the
Venous Drainage of the Digits
In addition to the specific recommendations made by
Smith et al. (7) and noted previously, several observations
may be made in reference to the structure and arrange-
ment of this system based on the study of Moss et al. (6):
(a) The superficial and deep palmar veins along with the
neurovascular bundles are so placed that they escape com-
pression during grasp or pinch; (b) when pressure is
applied to the palm, the blood may easily pass to the dor-
sum by means of the oblique communicating veins, and
reflux is prevented by the valves; (c) the oblique commu-
nicating veins are concentrated at the mid-portion of the
proximal phalanx, which is the zone of least compression
when making a fist; (d) the shape of the soft tissues in the
middle and proximal phalanges changes from ovoid to a
more rectangular configuration during flexion, and the
vascular channels lie in the corners of this rectangle and
thus avoid compression; (e) in replantation, failure to rec-
ognize the presence of a valve at an anastomosis site may
impede flow; and (f ) in replantation, the practice of
lengthening veins by selectively dividing tributaries dis-
tally and placing them proximally should be done with
care to avoid incorporating a reversed valve that could
impede venous return (6).
Pumping Action and Venous Outflow of
the Hand
Simons et al. identified three independent venous out-
flow systems in the hand: superficial palmar, deep palmar,
and dorsal veins (9). Pumping action is achieved by mak-
ing a fist, which results in palm compression, isometric
intrinsic contraction, and dorsal compression and tight-
ening of the skin. Each of the three systems may increase
10.2 Dorsal Hand 647
venous blood velocity in both the cephalic and ulnar
veins. Digit abduction increased the volume of blood
being pumped (9).
Perforating veins were found to be distal (in the web
spaces near the MCP joints), proximal (near the base of the
metacarpals), and carpal (between the bases of the
metacarpals and a line drawn through the radial tubercle
and the midpoint of the ulnar head). The proximal perfo-
rators at the radial and ulnar aspect of the hand were large
and constant. Ultrasound studies revealed that blood could
be pumped effectively by each of the systems indepen-
dently, although the systems act in synergy. The deep pump
is more significant in the cold hand because of constriction
of the dorsal veins (9). These authors, citing the study of
Lavizzari and Ottolini, noted that the perforators probably
had valves that prevented reflux of blood from the dorsal to
the deep system (10).
Clinical Significance of Pumping Action
1. Effective venous filling is essential during venipuncture
to engorge the veins. Although normally accomplished
by fist-clinching, dorsal venous filling may be aug-
mented by repetitive finger abduction (activation of the
intrinsic muscle pump by isometric contraction).
2. Such maneuvers also may be of value when injecting
thrombogenic or sclerosing agents, where a high venous
flow is advantageous.
3. Edema after surgery or trauma is a common cause of
hand stiffness, and when ordinary means of control,
including elevation and active motion, are not possible,
the deep muscle pump may be activated by isometric
contraction of the intrinsic muscles (9).
Extensor Retinaculum
Gross Anatomy
The wrist, thumb, and finger extensors gain entrance to
the hand beneath the extensor retinaculum through a
series of six tunnels, five fibroosseous and one fibrous
[the fifth dorsal compartment, which contains the exten-
sor digiti minimi (EDM)] (11). The extensor retinaculum
is a wide fibrous band that prevents bowstringing of the
tendons across the wrist joint (Fig. 10.89). Its average
width is 4.9 cm (range, 2.9 to 8.4 cm) as measured over
the fourth compartment (11). At this level, the extensor
tendons are covered with a synovial sheath. The extensor
retinaculum consists of two layers: the supratendinous
and the infratendinous. The infratendinous layer is lim-
ited to an area deep to the ulnar three compartments. The
six dorsal compartments are separated by septa that arise
from the supratendinous retinaculum and insert onto the
radius (12).
648 Regional Anatomy

FIGURE 10.89. The wrist extensor retinaculum and the most common arrangement of the exten-
sor tendons and juncturae. The wrist, thumb, and finger extensors gain entrance to the hand
beneath the extensor retinaculum through a series of six tunnels, and at this level are covered
with a synovial sheath.

Histology presence of chondroid metaplasia, an adaptation in

response to friction and the dorsal forces produced by
Three distinct layers have been identified: (a) an inner glid-
extensor tendon action. The extensor retinaculum has been
ing layer with hyaluronic acid–secreting cells with isolated
found to be a useful tissue for flexor tendon pulley recon-
areas of chondroid metaplasia; (b) a thick middle layer with
struction because of its histologic similarity to the native
collagen bundles oriented in various directions, fibroblasts,
pulley in the fingers (14).
and elastin fibers; and (c) the outer layer of loose connective
tissue with vascular channels. This is the same histologic
arrangement seen in anatomic pulleys throughout the body
Extensor Tendon Anatomy
that provides a smooth gliding surface with mechanical
strength (13). The extensor mechanism arises from multiple muscle bel-
lies in the forearm. The EPL, EPB, extensor indicis proprius
(EIP), and EDM have a comparatively independent origin
Clinical Significance
and action (15). The proprius tendons at the MCP joint
The basic function of the extensor retinaculum is to avoid level usually (see discussion under Anatomic Variations,
bowstringing of the extensor tendons, which explains the later) are to the ulnar side of the communis tendons. The
 10.2 Dorsal Hand 649

small finger proprius tendon (EDM) over the metacarpal

and wrist level usually is represented by two distinct tendi-
nous structures. Kaplan and others, however, noted that the
variations in the disposition and the number of tendons are
numerous (15,16). Kaplan believed that the extensor digi-
torum communis (EDC) usually had four distinct tendons
and was characterized by limited independent action, in
contrast to the proprius tendons (15). My own operative
experience and cadaver dissections parallel the cadaver
observations of Schenck and von Schroeder and Botte, that
the EDC tendon to the small finger is present less than
50% of the time (17,18). When it is absent, it almost
always is replaced by a junctura tendinum from the ring fin-
ger to the extensor aponeurosis of the small finger (17,18).

Most Common Arrangement of the

Finger Extensor Tendons
Based on a study of 43 cadaver hands, the most common dis-
tribution pattern of finger extensors is: (a) a single EIP that
inserted ulnar to the EDC of the index finger; (b) a single
EDC to the index finger; (c) a single EDC to the long finger;
(d) a double EDC to the ring; (e) an absent EDC to the small
finger; and (f) a double EDM with a double insertion into
the small finger (18) (see Fig. 10.89). Variations in this
arrangement are given in the section on Anatomic Variations.
The concurrently accepted zones of injury are given in
Figure 10.90.
Tables 10.12 and 10.13 give the average thickness of the
extensor mechanism in the fingers and thumb.

Proximal Interphalangeal Joint Dorsal

Plate
A unique arrangement is present at the dorsal aspect of the
PIP joint, where the central slip of the extensor tendon
invests a fibrocartilage plate before its attachment to the
dorsal base of the middle phalanx. The average thickness of
the central slip at this level is 0.5 mm, but because of the
presence of this fibrocartilage plate, the thickness is doubled
FIGURE 10.90. The zones of extensor injury.

TABLE 10.12. AVERAGE THICKNESS OF EXTENSOR

MECHANISM IN FINGERS TABLE 10.13. AVERAGE THICKNESS OF EXTENSOR
MECHANISM IN THUMB
Finger Average Thickness of Average Thickness of
Zone Extensor (mm) Lateral Bands (mm) Thumb Average Thickness Average Thickness of
Zone of Extensor (mm) Lateral Bands (mm)
I 0.65 —
II 0.55 0.6 I 0.60 —
III 1.00a — II 0.80 0.3
IV 0.60 1.0 III 1.20 EPL —
V 1.40 — 0.85 EPB
VI 1.70 — IV 1.30 EPL —
0.95 EPB
aThis measurement was taken at the dorsal plate over the PIP joint.

The central slip just proximal to the dorsal plate measured 0.5 mm. EPL, extensor pollicis longus; EPB, extensor pollicis brevis.
650 Regional Anatomy

sue. Type I juncturae tendinum are seen most often in the

FIGURE 10.91. Type I junctura tendinum [after von Schroeder et
al. (20)]. Type I is a filamentous intertendinous fascia that con-
tains small bands of connective tissue and is seen most often in
the second and third interspaces. Its shape is square, rhomboidal,
or triangular. They do not connect to normal or aberrant exten-
sor indicis proprius tendons.
second and third interspaces, and are the only type seen in
the second interspace. Their shape is square, rhomboidal, or
triangular, and they usually are obliquely oriented. Type I
bands attached to the EDC tendon but did not connect to
normal or aberrant EIP tendons (Fig. 10.91).
Type II: This is a much thicker, primarily rhomboidal in
shape, and well defined intertendinous connecting band
most commonly seen in the third and fourth interspaces.
Type II juncturae tendinum are more distally located than
type I. Eight of the nine hands with type II juncturae that
occurred in the fourth interspace also had an EDC to the
small finger (19 of 40 hands had an EDC to the small fin-
ger). In all of these eight hands, the juncturae passed from
the small finger EDC to the ring finger EDC (Fig. 10.92).
Type III: This type consists of tendon slips from the
extensor tendons and is the longest, narrowest, and thickest
of the three types. They occur in the third and fourth (most
common) interspace and are classified into “y” or “r” sub-
types based on their shape. The y-subtype is defined as a
tendon that splits into two equal halves that insert into the
two tendons of adjacent digits. One slip is defined as the y-
junctura and the other as the continuation of the base ten-
don (Fig. 10.93). The r-subtype is a more oblique junctura
tendinum arising from a base tendon (Fig. 10.94). In all of
the hands with type III juncturae in the third space, the
interconnections ran from the EDC of the ring finger to the

over the PIP joint. Slattery named this structure the dorsal
plate and described its structure in detail, noting that its
function might relate to stability of the extensor tendon,
stability of the PIP joint, an increase of the moment arm of
the extensor tendon at the PIP joint, and prevention of
attrition of the central slip at the PIP joint (19). The simi-
larity of the dorsal plate and the patella is striking (19). In
my experience, the dorsal plate adds relative thickness and
substance to the extensor mechanism and aids in the place-
ment of sutures for lacerations in this area.

Juncturae Tendinum
The extensor tendons are interconnected on the dorsum of
the hand by intertendinous fascia and juncturae tendinum.
The intertendinous fascia is present between all tendons of
the fourth compartment and attaches to the paratenon of
the extensors. In contrast, the juncturae tendinum are nar-
row connective tissue bands that extend between the EDC
and EDM (but not the EIP) and attach to the tendons (see
Fig. 10.89). In a comprehensive study of the juncturae
tendinum in 40 cadaver hands, von Schroeder et al.
described three distinct morphologic types of junctura
tendinum (20): FIGURE 10.92. Type II junctura tendinum: This is a much thicker,
primarily rhomboidal, well defined intertendinous connecting
Type I: This consists of filamentous regions in the inter- band seen most commonly in the third and fourth interspaces.
tendinous fascia that contain small bands of connective tis- Type II juncturae tendinum are more distally located than type I.

tendon of the long finger. Twelve were of the r-subtype and
one was a y-subtype. In those hands with an EDC to the
small finger (19 of 40), 11 had a type III interconnection,
and in 8 of those 11 cases the junctura tendinum ran from
the EDC of the small finger to the ring finger. In 3 of the
11, cases the junctura tendinum ran from the ring finger
EDC to the small finger EDC. In the 11 hands with a type
III junctura tendinum and an EDC tendon to the small fin-
ger, 7 of the juncturae tendinum were of the y-subtype and
4 were r-subtype. In the absence of an EDC to the small
finger (21 of 40 cases), 19 of the 21 had an r-subtype junc-
tura tendinum from the ring finger EDC to the small fin-
ger that blended with the radial slip of the EDM or dorsal
hood.
Clinical Significance
Identification of the EIP when it is used as a tendon trans-
fer is aided by the fact that it does not have a junctura
tendinum. Laceration of the middle finger communis ten-
don over the metacarpal just proximal to the junctura may
result in only partial extension loss of the middle finger
FIGURE 10.93. Type III junctura tendinum: This type consists of
tendon slips from the extensor tendons and is the longest, nar-
rowest, and thickest of the three types. They occur in the third
and fourth (most common) interspace and are classified into “y”
or “r” subtypes based on their shape. The “y” type shown here
is defined as a tendon that splits into two equal halves that
insert into the two tendons of adjacent digits. One slip is defined
as the y-junctura and the other as the continuation of the base
tendon.
10.2 Dorsal Hand 651
FIGURE 10.94. Type III junctura tendinum (r-subtype). The r-
subtype is a more oblique junctura tendinum arising from a base
tendon.
(21). In a study of the role of long finger extensors and the
juncturae tendinum, von Schroeder and Botte noted that
traction on the EIP tendon could produce extension of
the middle finger in spite of the normal absence of the
juncturae tendinum (22). They noted that this extension
force was transmitted through the intertendinous fascia,
mesotenon, and web space fibers, including the transverse
metacarpal ligament and natatory ligaments, which may
partially insert into the extensor hood. The juncturae
tendinum were shown to have considerable interaction
between adjacent fingers, and also may decrease the stress
on the web. Sectioning the web virtually abolished any
movement between adjacent fingers, in contrast to tran-
section of the long extensors, which had no effect on the
interaction between the fingers. This finding is of signifi-
cance when evaluating an injured hand because a lacerated
tendon may be overlooked if finger extension is partially
maintained through juncturae, intertendinous fascia, or
the web structures between the adjacent fingers (22).
Although Gonzalez et al. did not identify a junctura tend-
inum between the index and middle finger EDC, but
rather a thin, wispy structure, their findings and conclu-
sions are at variance with other authors who have written
about the extensor mechanism and who have accepted it
as a junctura tendinum (20,22–24). Although this junc-
tura is thin, its presence and functional significance have
been demonstrated by Kitano and associates (24), who
noted that excision of this structure when it was present in
652 Regional Anatomy
its thicker and more substantial form was required to
maintain independent index finger extension after EIP
transfer.
Sagittal Bands
The extensor tendon at the MCP joint level is held in place
over the dorsum of the joint by the conjoined tendons of
the intrinsic muscles and the transverse lamina or sagittal
bands, which together tether and keep the extensor tendons
centralized over the joint (15) (see Fig. 10.89). The sagittal
bands arise from the palmar plate and the intermetacarpal
ligaments at the neck of the metacarpals (15,25). The fibers
of the sagittal bands are perpendicular to the EDC in neu-
tral position, angulated 25 degrees at 45 degrees of MCP
flexion, and angulated 55 degrees at full MCP flexion. Pres-
sure readings deep to the sagittal bands revealed that the
greatest pressure occurred during complete MCP joint flex-
ion and the least at 45 degrees of flexion. When MCP joint
radial or ulnar deviation was evaluated, the average mea-
surement was greatest in neutral MCP joint position and
least in 45 degrees of flexion (26). Serial sectioning of the
ulnar sagittal band failed to produce extensor tendon insta-
bility, whereas partial proximal but not distal sectioning of
the radial sagittal band produced tendon subluxation.
Complete sectioning of the radial sagittal band produced
tendon dislocation. Wrist flexion increased tendon instabil-
ity after radial sagittal band sectioning (26).
Clinical Significance
The sagittal band maintains the EDC tendon centralized
over the MCP joint during flexion and extension. During
hyperextension of the finger at the MCP joint, the sagittal
band prevents bowstringing of the EDC (27). The degree of
extensor tendon instability is determined by the extent of
radial sagittal band disruption, and proximal rather than
distal sagittal band compromise contributes to extensor
instability (26).
Functional Dynamics of the Extensor
Mechanism
Extension of the finger is a complex act and is considered to
be more intricate than finger flexion. This mechanism is
composed of two separate and neurologically independent
systems—namely, the radial nerve–innervated extrinsic
extensors and the intrinsic systems supplied by the ulnar
and median nerves (25).
At the MCP joint level, the intrinsic muscles and ten-
dons are palmar to the joint axis of rotation. At the PIP
joint, however, they are dorsal to the joint axis. The exten-
sor mechanism at the PIP joint is best described as a tri-
furcation of the extensor tendon into the central slip,
which attaches to the dorsal base of the middle phalanx
and the two lateral bands (28). The lateral bands pass on
either side of the PIP joint and continue distally to insert
at the dorsal base of the distal phalanx. The extensor
mechanism is maintained in place over the PIP joint by
the transverse retinacular ligaments. The extensor tendon
achieves simultaneous extension of the two finger joints
by a mechanism in which the central slip extends the mid-
dle phalanx and the lateral bands bypass the PIP joint to
extend the distal phalanx. The fibers overlying the PIP
joint are differentially loaded as the finger moves. In the
flexed position, the most central fibers are tensed, whereas
in extension the lateral fibers are tensed (29,30). The most
important feature of this mechanism is that the three ele-
ments are in balance (28,31). Specifically, the lengths of
the central slip and two lateral bands must be such that
extension of the PIP and DIP joints takes place together,
so that when the middle phalanx is brought up into align-
ment with the proximal phalanx, the distal phalanx
reaches alignment at the same time (28). This mechanism
depends on the relative lengths of the central slip and two
lateral bands. This precise and consistent length relation-
ship is what is so difficult to restore when the mechanism
has been damaged (28,31,32).
Patterns of Imbalance
Disruption of the extensor mechanism at the DIP joint
results in mallet finger; disruption of the central slip at the
PIP joint results in the characteristic boutonniere defor-
mity, and a swan neck deformity may be a secondary result
of the mallet finger (28) (Fig. 10.95).
Proprius Tendons
Traditional knowledge has suggested that independent
extension of the index and small fingers was due solely to
the proprius tendons to these digits. Loss of independent
extension, especially of the index finger, was said to be
highly probable if the index proprius was injured and not
repaired, or was transferred. This concept as it applies to the
index finger was not confirmed by Moore et al., who noted
independent index extension in 20 of 27 patients after
extensor indicis transfer (33). They suggested that the rea-
sons for the presence of independent action after extensor
indicis transfer were (a) the EDC in all cases had four dis-
tinct muscle bellies with separate and distinct innervation
from the posterior interosseous nerve, and (b) the junctura
tendinum between the index and long fingers was filamen-
tous and poorly developed compared with the more ulnar
digits, which had well developed and thick juncturae that
limited independent extension. They also noted that
despite complete release of the juncturae tendinum, full
independent excursion of the long or ring finger MCP joint
was not obtained, which suggested that extracapsular con-

C deformity.
straints limited independent extension of the long and ring
fingers when adjacent fingers were held in flexion. Index
finger extension and strength after EIP transfer was studied
by Noorda and associates in 34 patients (34). Twenty-four
of the 34 patients had extension lag in the index finger, and
all of the patients had reduced extension strength in the
donor index finger either measured dependently (with con-
current middle finger extension) or independently (without
middle finger extension). The authors concluded that the
reduction in strength of extension probably was not the
cause of the extensor lag, but that the extensor lag most
likely was due to disruption of the normal hood function or
excursion. Despite these findings, 30 of the 34 patients
described no limitations in their daily activities. The
authors noted that to prevent extension lag, the surgeon
10.2 Dorsal Hand 653
FIGURE 10.95. Deformities related to disruption
and imbalance of the extensor mechanism. A: Mal-
let finger. B: Boutonniere deformity. C: Swan neck
should avoid surgical trauma to the hood mechanism by
sectioning the EIP proximal to the hood (34). The issue of
independent index finger extension after indicis proprius
transfer also was studied by Kitano and associates, who also
noted that the EDC to the index finger was well separated
from the other EDC muscle bellies and received a distinct
and separate innervation from the posterior interosseous
nerve (24). In 13 hands with EIP transfer, they noted inde-
pendent extension of the index finger in all cases after exci-
sion of the junctura tendinum between the index and mid-
dle fingers. Based on this surgical experience and
companion cadaver studies, the authors concluded that
independent extension of the index was likely after transfer
of the EIP if the extensor hood was intact and the junctura
tendinum was excised.
654 Regional Anatomy
Nail Unit
Nomenclature
A standardized nomenclature and anatomic configuration
are given in Figure 10.96.
Macroscopic Anatomy
Nail Plate
The hard, often shiny, fingernail or thumbnail is called the
nail plate. The nail plate is homologous to the stratum
corneum of the epidermis and consists of compacted, anu-
cleate, keratin-filled squames with dorsal, intermediate, and
palmar layers (1). It is slightly convex in the longitudinal
axis and more convex in the transverse axis. The lunula is a
white opacity immediately distal to the central aspect of the
proximal nail fold and is said to be due to comparatively
poor vascularization of the germinal matrix (5,35).
Nail Fold
Proximally, the nail plate extends under the semilunar nail
fold, which is lined with dorsal and palmar epidermis. The
stratum corneum layer of the dorsal layer of epidermis
FIGURE 10.96. Anatomy and nomenclature of the nail unit. 1, Arcade of nail wall; 2, arcade of
germinal matrix; 3, arcade of sterile matrix.
extends distally over the nail plate to form the cuticle or
eponychium. The lunula is approximately at the junction
between the germinal and sterile matrix (5).
Nail Bed
The nail plate rests on the nail bed (matrix), which is
defined as all the soft tissue immediately beneath the nail
plate and that participates in nail generation and migration
(5). The nail bed is a specialized form of epithelium with a
proximal zone of germinal matrix and a distal zone of ster-
ile matrix. The distal margin of the lunula is approximately
at the junction between the germinal and sterile matrix (5).
A sagittal section of the distal phalanx reveals a wedge-
shaped collection of cells with the proximal portion of the
nail plate embedded in their substance. Thus, dorsal and
palmar components of the matrix are noted. The palmar
matrix cells are continuous distally with the nail bed. The
nail bed is grooved and ridged longitudinally, which
matches a similar pattern on the undersurface of the nail
plate and may be a factor in stabilizing the nail for func-
tional demands. Beneath the epithelium of the nail bed is a
dermis layer that is anchored to the underlying periosteum
of the distal phalanx by fibrous tissue. Keratinized cells are
 10.2 Dorsal Hand 655

extruded from the dorsal and palmar germinal matrix cells
to produce the nail plate, with the major production com-
ing from the palmar cells. The area of epidermis under the
distal edge of the nail plate is called the hyponychium. The
stratum corneum layer is undulant and constantly being
shed. The hyponychium provides an important barrier
against entry of bacteria.
Clinical Significance. A smooth nail bed is essential for
regrowth of a normal nail plate. In nail bed injuries, pri-
mary healing cannot occur if the bed is not accurately
reapproximated. If the scar is in the dorsal matrix, a dull
streak may appear in the nail plate; if the scar is in the
intermediate portion of the germinal matrix, a split or
absent nail may occur; if the scar is in the palmar nail or
sterile matrix, a split or nonadherence of the nail beyond
the scar may occur (5,36).
Blood Supply and Drainage
The arterial blood supply to the nail bed comes from two
dorsal branches from the common palmar digital artery; the
proximal vessel is a dorsal branch to the nail fold, and the
second courses along the lateral nail plate margin and sends
branches to the nail bed (Fig. 10.97). These vessels anasto-
mose dorsally with their counterparts to form arcades.
Branches from these vessels and the arcades form sinuses
surrounded by muscle fibers and help to regulate the blood
pressure and blood supply to the extremities (5,35,36).
These networks have been identified as papillary, reticular,
and subdermal and correspond to the general architecture
of the vessels of the skin. The dermis of the nail bed is well
vascularized and includes large arteriovenous shunts (glom-
era) (1). There is reduced vascular density in the region of
the germinal matrix, in contrast to an increased vascular
density in the sterile matrix. The comparatively less vascu-
larized germinal matrix demonstrates a well developed sub-
dermal network located near a zone of loose connective tis-
sue that is poorly vascularized near the proximal part of the
distal phalanx. This zone may be a sliding apparatus
between the nail and the distal attachment of the extensor
tendon (35). Venous drainage is by a coalescence of veins in
the skin proximal to the nail fold that course proximally in
a random fashion over the dorsum of the digit (4). These
veins are of sufficient size for microvascular anastomosis (4).
Nerve Supply
The nail unit is innervated by branches from the paired
digital nerves. The most common pattern (70%) was rep-
resented by a branch that passed beneath the nail plate
and into the nail bed at approximately the level of the

FIGURE 10.97. Arterial supply of the distal phalanx. The arterial blood supply to the nail bed
comes from two dorsal branches from the common palmar digital artery; the proximal vessel is a
dorsal branch to the nail fold; the second courses along the lateral nail plate margin and sends
branches to the nail bed. These vessels anastomose dorsally with their counterparts to form
arcades. Branches from these vessels and the arcades form sinuses surrounded by muscle fibers
and help to regulate the blood pressure and blood supply to the extremities. 1, Network of nail
wall; 2, arcade of germinal matrix; 3, arcade of sterile matrix.
656 Regional Anatomy
lunula and a second branch that passed distally to end at
the hyponychial area (4). There are numerous sensory
nerve endings, including Merkel discs and Meissner cor-
puscles (1).
Nail Plate Growth
Growth rate is determined by the turnover rate of the ger-
minal matrix, which varies with age, digit (the long finger-
nail grows faster than the small fingernail), environmental
temperature, season, time of day, and nutritional status.
Rate of growth in the long finger is approximately 0.1
mm/day. As the matrix cells enlarge, they grow distally
because of the confinement of the nail fold. As the matrix
cells enlarge, they are flattened by the pressure of newly
forming cells beneath them (5). This pressure and confine-
ment result in a nail plate that is flat and grows distally. The
dorsal layer of the germinal matrix produces nail cells that
are relatively shiny, and if these cells are removed or dam-
aged, the nail surface will appear dull (5).
Function of the Nail Unit
The nail unit assists in digital pad sensibility by providing
support and counterpressure for the digital pad. Both grasp
and pinch are aided by the nail unit, which provides dorsal
and peripheral anchoring and stability to the palmar pad.
The functional spectrum may span from the simple act
of scratching an itch to the manipulation and picking up of
small objects.
Relationship of the Germinal Matrix to the
Extensor Tendon Insertion
Based on microscopic dissection, the distance from the ter-
minal aspect of insertion of the extensor tendon and the
proximal edge of the germinal matrix was found to be on
average 1.2 mm (range, 0.9 to 1.8 mm) (37).
Clinical Significance
When the extensor tendon insertion is visualized during
operative procedures on the dorsum of the distal phalanx,
care should be taken to avoid damage to the germinal
matrix. Conversely, when the germinal matrix is being
removed for total ablation of a nail, dissection does not
need to be carried proximal to the distalmost fibers of the
extensor tendon (37).
SURGICAL EXPOSURES
Metacarpophalangeal Joint/Proximal
Phalanx
Indications
This surgical exposure has been found to be useful for
arthrotomy of the MCP joint for intraarticular fracture, for-
eign or loose body, fractures of the proximal phalanx, dislo-
cations of the MCP joint, dislocations of the extensor ten-
don, dorsal capsulotomy or capsulectomy, and arthroplasty
of the MCP joint.
Landmarks
Landmarks include the apex of the MCP joint and the
underlying extensor mechanism, which are most noticeable
when the MCP is flexed.
Incision
A straight or slightly curved longitudinal incision is suitable
for single or multiple exposures. An alternative choice is a
transverse incision centered over the MCP joint, and is
designed to be used when multiple MCP joints are to be
exposed either for release or arthroplasty (Fig. 10.98).
Technique
In both the longitudinal and transverse skin incisions, the
veins in the interosseous gutters between the metacarpal
heads must be protected and preserved. Sensory branches
of the radial or ulnar nerves are identified and preserved
based on the location of the incision. In cases of dorsal
capsulotomy or capsulectomy, the sagittal bands may be
elevated and retracted distally to expose the underlying
dorsal capsule and the proximal origins of the collateral
ligaments. In cases requiring more comprehensive expo-
sure, the extensor hood, beginning at or proximal to the
level of the sagittal bands, is split longitudinally in the
substance of the extensor tendon (38). This tendon-split-
ting incision is extended proximally and distally to meet
the needs of the particular condition being treated. The
benefit of this tendon/hood-splitting incision is to main-
tain balance between the incised parts so that with post-
operative motion, the extensor mechanism tracks nor-
mally and does not subluxate (38). In the index finger, this
incision is between the proprius and communis tendons.
In the small finger, it is centered over the apex of the joint
and between the two slips of the EDM or the EDC, based
on their presence or absence. Care is taken to avoid
detachment of the central slip of the extensor tendon at
the dorsal base of the middle phalanx, and the tendon
splitting should stop proximal to the PIP joint.
Proximal Interphalangeal Joint
(Fig. 10.99)
Indications
This incision may be used for exposure of the central slip of
the extensor tendon for lacerations, management of acute
and chronic boutonniere lesions, and bilateral capsulotomy
and capsulectomy of the joint.

B the extensor tendon.
Incision
The incision may be slightly curved or longitudinal, cen-
tered over the PIP joint.
Technique
The incision is carried down to the paratenon over the
extensor mechanism. The dorsal veins are cauterized or tied
and the flaps are developed and reflected to each side. Both
the dorsal as well as the radial and ulnar sides of the exten-
sor mechanism and the PIP joint may be exposed.
Distal Interphalangeal Joint (Dorsal)
Indications
This approach may be used for exposure of the DIP joint
for fracture, laceration of the extensor mechanism, or nail
matrix removal.
10.2 Dorsal Hand 657
FIGURE 10.98. Surgical approach to the
metacarpophalangeal (MCP) joint and
proximal phalanx. A: A straight or
slightly curved longitudinal incision is
suitable for single or multiple exposures.
An alternative choice is a transverse inci-
sion centered over the MCP joint
designed to be used when multiple MCP
joints are to be exposed either for release
or arthroplasty. B: The extensor hood is
incised longitudinally in the substance of
Incision
Dorsal approaches to the DIP joint region may be longitu-
dinal, a proximally or laterally based chevron, or a bayonet-
type incision (see Fig. 10.99). Precautions: Remember that
the distance from the terminal aspect of insertion of the
extensor tendon and the proximal edge of the germinal
matrix is on average 1.2 mm (range, 0.9 to 1.8 mm), and
when the germinal matrix is being removed for total abla-
tion of a nail, dissection does not need to be carried proxi-
mal to the distalmost fibers of the extensor tendon (37).
CLINICAL CORRELATIONS
Mallet Finger
Definition and Physical Findings
Loss of continuity of the conjoined lateral bands at the dis-
tal joint of the finger results in a characteristic flexion defor-
658 Regional Anatomy
mity of the distal joint called mallet, baseball, or drop finger.
The distal joint assumes varying degrees of flexion and the
patient cannot actively extend the distal segment, although
full passive extension usually is present. Hyperextension of
the middle joint also may be observed and is due to unop-
posed central slip tension at the PIP joint and joint laxity
(39). In recent injuries, there is swelling and tenderness over
the dorsum of the distal joint.
Anatomy of the Mallet Finger
The lateral bands from each side of the digit merge and
conjoin to form one tendon just distal to the dorsal tuber-
cle on the proximal portion of the middle phalanx. This
tendon continues distally to form a wide unit for insertion
into the dorsal base of the distal phalanx. The tendon
attaches to the dorsal part of the capsule and inserts into a
ridge distal to the articular cartilage from one collateral lig-
ament to the other (40). Warren and colleagues, in a study
of the microvascular anatomy of distal digital extensor ten-
don, noted an area of deficient blood supply in this area and
suggested that this zone of avascularity might have implica-
tions in the cause and treatment of mallet finger (41). The
pathologic anatomy is depicted in Figure 10.95A.
Boutonniere Lesion
Definition and Physical Findings
Disruption of the central slip of the extensor tendon at the
PIP joint level along with volar migration of the lateral
FIGURE 10.99. Surgical approaches to the proximal
(PIP) and distal interphalangeal (DIP) joints. Typical skin
incisions are shown that may be used to expose the PIP
and DIP joints.
bands results in the so-called boutonniere deformity, with
subsequent loss of extension at the middle joint and com-
pensatory hyperextension at the distal joint. This lesion
may be secondary to closed blunt trauma with acute force-
ful flexion of the PIP joint, producing avulsion of the cen-
tral slip from its insertion on the dorsal base of the middle
phalanx with or without fracture and laceration of the
extensor tendon at or near its insertion (42). The pathologic
anatomy is depicted in Figure 10.95B.
Early Diagnosis
In closed injuries, the characteristic boutonniere deformity
may not be present at the time of injury and usually devel-
ops over a 10- to 21-day period after injury. This condition
often is missed even in an open wound. A painful, tender,
and swollen PIP joint that has been recently injured should
arouse suspicion. Early diagnosis of this central slip injury
(before the classic deformity of PIP joint flexion and DIP
extension develops) is based on evaluation of the status of
the central slip attachment. Isolation of the effect of the
central slip of the PIP joint is achieved by maintaining the
PIP joint in flexion to rule out the contribution of the lat-
eral bands.
The Elson Test
In a study that used various published clinical tests to diag-
nose an early boutonniere, only the Elson test was said to be
reliable (43,44). This test relies on abnormal tone between

the PIP and DIP joints. Normally, with the PIP joint
blocked in flexion, there is limited active extension of the
DIP joint. Harris and Rutledge demonstrated that the lat-
eral bands are held distally by the central slip, and because
of this check-rein effect the extensor mechanism is unable
to extend the DIP joint (28). However, with disruption of
the central slip and loss of the check-rein effect, extension
of the DIP can occur by tightening the dorsal apparatus. In
a boutonniere lesion, attempted active extension of the fin-
ger with the PIP joint held in flexion increases the rigidity
of the DIP joint.
Technique. The finger to be examined is flexed comfortably
to a right angle at the PIP joint over the edge of a table and
firmly held in place by the examiner (Fig. 10.100).
The patient is then asked to extend the PIP joint against
resistance. Any pressure felt by the examiner over the mid-
dle phalanx can only be exerted by an intact central slip.
Further proof is that the DIP joint remains flail during the
effort because the competent central slip prevents the lateral
bands from acting distally. In the presence of a complete
rupture of the central slip, any extension effort perceived by
the examiner is accompanied by rigidity at the DIP joint
with a tendency to extension. This is produced by the
extensor action of the lateral bands. This test, however, does
A–B
C–D
10.2 Dorsal Hand 659
not demonstrate the presence of a partial rupture of the
central slip, and it may be impeded by pain or lack of
patient cooperation. Consideration may be given to nerve
block for pain relief as indicated.
Clinical Significance
Early diagnosis of boutonniere gives the best chance of a
satisfactory outcome. Once again, only the Elson test was
said to be reliable in an early diagnosis of boutonniere (see
Elson Test above).
“Pseudoboutonniere” Deformity
McCue et al., in 1970, used the term pseudoboutonniere
to describe a condition of PIP joint flexion contracture
with associated restricted flexion of the DIP joint (45).
Based on his study of PIP joint anatomy and hyperexten-
sion injuries of the PIP joint, Bowers noted that the con-
fluence of origin of the palmar plate, the first cruciform
pulley, and the oblique retinacular ligament could theo-
retically provide an anatomic basis for such a contracture
(46,47). Inflammation secondary to a hyperextension
injury could result in contracture of the check-rein liga-
ments, the oblique retinacular ligaments, and possibly the
first cruciform pulley to produce PIP joint flexion con-
FIGURE 10.100. The Elson test for detection
of the boutonniere lesion. A, B: The finger to
be examined is flexed comfortably to a right
angle at the proximal interphalangeal (PIP)
joint over the edge of a table and firmly held
in place by the examiner, and the patient is
asked to extend the PIP joint. Any pressure
felt by the examiner through extension of the
middle phalanx can be exerted only by an
intact central slip; further proof is that the dis-
tal interphalangeal (DIP) joint remains flail
during the effort because the competent cen-
tral slip prevents the lateral bands from acting
distally. C, D: If the central slip is disrupted,
any extension effort perceived by the exam-
iner is accompanied by rigidity at the DIP joint
with a tendency to extension. This test does
not demonstrate the presence of a partial
rupture of the central slip, and it may be
impeded by pain or lack of patient coopera-
tion.
660 Regional Anatomy
tracture as well as loss of flexion of the DIP joint owing
to contracture of the oblique retinacular ligament. The
pseudoboutoniere deformity must be distinguished from
the true boutonniere because the pathologic process and
treatment are different. Proper diagnosis is aided by a
detailed history of the injury as well as the initial physi-
cal findings.
Anatomic Pathomechanics of the Boutonniere
Deformity
The boutonniere deformity illustrates the problem of
imbalance in the finger, which is a chain of joints with
multiple tendon attachments. This chain collapses into
an abnormal posture or deformity when there is an
imbalance of the critical forces maintaining equilibrium
(42,48). Zancolli has divided this sequence into three
stages (49). At first, there is flexion of the PIP joint due
to loss of the central slip and the unopposed force of the
flexor digitorum superficialis. Later, with stretching of
the expansion (transverse retinacular ligament and trian-
gular ligament) between the central and lateral slips, the
lateral bands migrate volarward to a position volar to the
axis of joint rotation. Finally, in this position of the lat-
eral bands, the pull of the intrinsic muscles is directed
exclusively to the distal joint, which progressively hyper-
extends. The MCP joint also is hyperextended by action
of the long extensor tendon. Treatment of the early acute
boutonniere deformity is arbitrarily divided into closed
or avulsion injuries, and open injuries with laceration of
the extensor tendons at or near the PIP joint.
Methods of Treatment of Chronic
Boutonniere Deformity
Correction of this deformity depends on restoration of the
normal tendon balance and the precise length relationship
of the central slip and lateral bands. The various techniques
used to manage both acute and chronic boutonniere defor-
mity are published elsewhere, and the reader is referred to
these resources (50,51).
Swan Neck Deformity
Definition
Swan neck deformity is characterized by hyperextension of
the PIP joint and flexion of the DIP joint. In its primary or
acute form, it may occur because of rupture of the attach-
ments of the palmar plate, either proximally or distally. Its
secondary or progressive forms may be due to a chronic
mallet finger or conditions such as rheumatoid arthritis or
spasticity that result in imbalance of the forces working on
the PIP joint and extensor mechanism.
Pathologic Anatomy
Any condition that results in an imbalance in the forces act-
ing on the PIP joint, either from dynamic destabilizing
forces or loss of static restraints, may alter the force vectors
as applied to that joint. In swan neck deformity, the lateral
bands are translocated dorsally at the PIP joint. This results
in decreased tension in the extensor mechanism at the DIP
joint because of the fixed attachment of the central extensor
tendon at the PIP joint. In mallet finger deformity, the rel-
ative lengthening of the distal aspect of the extensor allows
dorsal migration of the lateral bands, and the deformity is
complemented by the powerful flexor digitorum profun-
dus, which becomes an unopposed deforming force at the
DIP joint. Treatment of this condition is based on restora-
tion of the critical balance between the extrinsic and intrin-
sic tendons involved and reestablishing the static integrity
of the PIP and DIP joints (see Fig. 10.95C).
Closed Sagittal Band Injuries
Definition and Physical Findings
Spontaneous rupture of the radial sagittal band with subse-
quent ulnarward subluxation or dislocation of the extensor
tendon in the nonrheumatoid patient may occur after
forceful flexion or extension of the finger (26,52–54). The
lesion is secondary to a tear of the sagittal band and oblique
fibers of the hood, usually on the radial side, although rup-
ture of the ulnar sagittal band and radial dislocation has
been reported (54,55). Ulnar subluxation or dislocation of
the extensor tendon, sometimes accompanied by painful
snapping of the extensor tendon when making a fist, is the
usual finding, and in some, but not all cases may be associ-
ated with incomplete finger extension and ulnar deviation
of the involved digit (54,56).
Pathologic Anatomy
The middle finger most commonly is involved. This may be
due to an inherent anatomic weakness because the extensor
tendon of the long finger is situated on top of the transverse
fibers and has a comparatively loose attachment at this level
(54). Ishizuki, in a series of 16 cases all involving the mid-
dle finger, classified 5 as traumatic and 11 as spontaneous
according to the provoking cause (53). Those classified as
spontaneous had no history of trauma and occurred during
a common daily activity such as flicking the finger or crum-
pling paper. Traumatic dislocations were caused by a direct
blow or forced flexion of the MCP joint as a result of a con-
tusion or fall. Ishizuki identified a superficial and deep layer
of the sagittal band and noted disruption only of the super-
ficial layer in spontaneous cases and of both layers in trau-
matic cases (53). The end result is ulnar displacement of the
affected tendon and loss of its normal moment arm, and
 10.2 Dorsal Hand 661

thus weak and diminished extension of the involved finger.

Treatment is directed at restoring the normal anatomic rela-
tionships by splinting in early cases or surgical repair in
chronic cases.

Carpometacarpal Boss
Definition and Physical Findings
This condition is an often prominent mass at the dorsal
base of the second or third metacarpals and the adjacent
trapezoid and capitate. It may or may not be painful.
It is a bony, hard, nonmobile mass that may be tender.
Lateral radiographs demonstrate a bone mass with a vertical
cleft arising from the opposing and dorsal surfaces of the
metacarpal and carpal bone.

Treatment
These osteoarthritic or hypertrophic bone formations may
be removed if symptomatic, but should not be confused
with the more common dorsal carpal ganglion.
ANATOMIC VARIATIONS
Extensor Medii Proprius
The extensor medii proprius (EMP) is a muscle analo-
gous to the EIP in that it has a similar origin but inserts
into the extensor aponeurosis of the middle finger (Fig.
10.101).
In a study of 58 hands, von Schroeder and Botte noted
the presence of the EMP in 6 hands for an incidence of
10.3% (57). The EMP usually is covered by the EDC and
usually is not seen until the EDC is retracted or removed.
The EMP was always distal and medial to the EIP on the
interosseous membrane and in all cases the two muscles had
a common origin. In four of six instances, the EMP was
represented by a single tendon (57). The insertion was pal-
mar and ulnar to the EDC insertion on the middle finger.
The width of the tendon ranged from 10 to 30 mm.
Extensor Indicis et Medii Communis
The extensor indicis et medii communis (EIMC) is an
anomalous EIP that splits and inserts into both the index
and middle fingers (Fig. 10.102).
It was identified in the aforementioned study by von
Schroeder and Botte, who noted its presence in 2 of 58
hands for an incidence of 3.4% (57). The tendon split
into its index and middle finger components near the
myotendinous junction. In one specimen, the insertion
into the index was similar to the usual insertion of the
EIP on the palmar and ulnar aspect of the EDC. In the
other specimen, a double tendon was present, with one
tendon inserting into the usual EIP location and the sec-
FIGURE 10.101. The extensor medii proprius (EMP). The EMP is
a muscle analogous to the extensor indicis proprius in that it has
a similar origin but inserts into the extensor aponeurosis of the
middle finger. The EMP usually is covered by the extensor digi-
torum communis (EDC) and usually is not seen until the EDC is
retracted or removed. (Redrawn after von Schroeder HP, Botte
MJ. The functional significance of the long extensors and junc-
turae tendinum in finger extension. J Hand Surg [Am] 18:
641–647, 1993, with permission.)
ond slip into the deep fascia near the MCP joint. In both
specimens, the insertion into the middle finger was not
into the extensor hood but into the joint capsule of the
middle finger in one case and into the deep fascia proxi-
mal to the MCP joint in the other case. The muscle belly
of the EIMC was similar to the EIP, and like the EIP had
no juncturae tendinum.
Clinical Significance of the EMP and the
EIMC
Awareness of the incidence of these two muscles and other
anomalous muscles may be helpful in extensor tendon iden-
tification as it relates to repair or reconstruction.
Extensor Digitorum Brevis Manus
The extensor digitorum brevis manus (EDBM) is an aber-
rant muscle on the dorsum of the hand that has an inci-
dence of 3.3% based on dissections of 845 hands (58) (Fig.
10.103).
662 Regional Anatomy
Clinically, the EDBM is a fusiform, usually soft mass,
on the dorsum of the hand between the index and middle
finger metacarpals. It becomes more noticeable and firm
when the wrist is slightly flexed and the fingers extended.
It may be associated with complaints of pain and may be
coincidentally associated with a dorsal wrist ganglion
(58,59). Ogura et al. identified 5 types (types I, IIa, b, and
c, and III) in their study of 17 EDBM muscles in 559
hands (58). The classification was based on the distal
insertion of the EDBM and the relationship of the muscle
to the EIP.
Type I: The EDBM inserted onto the dorsal aponeurosis of
the index finger, as would the EIP, but the EIP was absent.
Type II: Both the EIP and EDBM inserted on the index
finger.
Type IIa: A small or vestigial EIP arose from the ulna but
was confluent with the EDBM belly, which inserted on the
index.
Type IIb: The distal end of the EDBM belly joined the
EIP tendon.
Type IIc: The EIP inserted normally, but the thin EDBM
more ulnarly than the EIP, often with a membranous acces-
sory slip that inserted on the middle finger.
Type III: The EIP inserted on the index finger, but the
EDBM inserted on the middle finger with or without an
accessory EIP to the middle finger.
FIGURE 10.102. Extensor indicis et medii communis (EIMC).
The EIMC is an anomalous extensor indicis proprius that
divides and inserts into both the index and middle fingers. See
text for details. (Redrawn after von Schroeder HP, Botte MJ.
The functional significance of the long extensors and juncturae
tendinum in finger extension. J Hand Surg [Am] 18:641–647,
1993, with permission.)
The EDBM originated from the proximal portion of
the posterior radiocarpal ligament near the lunate, and the
proximal short tendon of origin could be traced as far
proximal as the distal margin of the radius in 16 of 17
cases. The muscle had a single belly in all instances and
formed a prominence between the EDC tendons of the
index and middle fingers. In 12 of 17 cases it inserted on
the index finger, and in the remaining 5 it inserted on the
middle finger. The nerve supply was the posterior
interosseous nerve in all instances. Blood supply was from
a terminal posterior branch of the anterior interosseous
artery (58).
Clinical Significance
The EDBM must be distinguished from a dorsal wrist
ganglion. In some patients with EDBM, complaints of
discomfort and swelling may be noted. Physical examina-
tion reveals a longitudinally oriented, fusiform mass that
does not transilluminate and becomes firm with wrist flex-
ion and finger extension (58,59). Although Ogura et al.
have suggested that in types I or IIa (absent or vestigial
EIP) division or partial release of the extensor retinaculum
may be considered rather than excision, I agree with
Dostal et al. that excision of the EDBM is appropriate
(58,59).

A B
FIGURE 10.103. Extensor digitorum brevis manus (EDBM). A: Artist’s depiction of type I EDBM
[after Ogura et al. (58)]. B: Intraoperative photograph of type I EDBM before excision.
Extensor Tendons of the Fingers—
Variations and Multiplicity
von Schroeder and Botte, in a study of 43 adult cadaver
hands, found that the most common pattern or arrange-
ment of the extensor tendons was (a) a single EIP that
inserted into the MCP extensor hood ulnar to the EDC
tendon; (b) a single tendon from the EDC to the index and
middle fingers; (c) a double tendon from the EDC to the
ring finger; (d) an absent EDC to the small finger; and (e)
a double EDM tendon to the small finger with a double
insertion into the MCP hood (18). Frequent variations
included a double EIP tendon, a double or triple EDC-
middle finger, a single or triple EDC-ring finger, and a sin-
gle or double EDC tendon to the small finger. Although
increased multiplicity of any tendon was not associated
with multiplicity of any other tendon, there was a thinner
type junctura tendinum between the index and middle fin-
gers in such instances of multiplicity. An absent EDC ten-
don to the small finger was associated with an increased
incidence of a double EDC tendon to the ring finger and a
thick type III junctura tendinum between the EDC of the
ring finger and the EDM or dorsal aponeurosis of the small
finger (18). Gonzalez and associates, in a study of the exten-
sor tendons to the index finger in 72 cadavers, found that
the classic description of the anatomy was present in 58 of
10.2 Dorsal Hand 663
72 hands (23). Sixty hands had a single EDC and EIP ten-
don, and the EIP tendon was ulnar to the EDC in 58 of 72
hands. In 10 hands, the EIP had a double slip, and in 2
hands the EDC to the index had a double slip. Two hands
had a single slip of the EIP, which was either volar or radial
to the EDC at the MCP joint. Overall, 14 hands (19%) dif-
fered from the most common pattern, with either a varia-
tion of the position or number of tendon slips at the MCP
joint.
Other anatomic variations in the EIP have been
described by Caudwell and colleagues, including double
tendon slips, an accessory slip to the long finger, and slips
to the index finger and thumb (60). An anomalous junctura
tendinum has been identified between the EPL and EDC
(61). Gonzalez and associates also studied the extensor ten-
dons to the small finger in 50 specimens and noted that the
EDC was present in 35, and of those hands without an
EDC, 12 had a junctura tendinum present that went to the
small finger (23). However, three hands lacked both EDC
and juncturae. In these three hands, the EDM was repre-
sented by a single slip in two and a double slip in one. The
authors cautioned that if the entire (one or both slips, as the
case might be) EDM were used as a transfer in the absence
of both the EDC and juncturae, loss of extension would
occur in the small finger. In the 50 hands, the EDM was
most often (84%) represented by 2 slips; in 10% by a sin-
664 Regional Anatomy

gle slip; and in 6% by a triple slip. The authors also noted

that only 22 of the specimens had either an attachment of
the EDM to the abductor tubercle on the proximal phalanx
(10 hands) or an unbalanced ulnar slip of the EDQP (12
hands), which would account for Wartenberg’s sign in ulnar
nerve dysfunction. This 44% incidence would explain why
Wartenberg’s sign is not always present even in complete
lacerations of the ulnar nerve (23,62).

Clinical Significance
Knowledge of the usual as well as the possible variations,
including multiplicity, in the extensor tendons is useful in
the identification and repair of these structures as well as in
their use in reconstructive procedures.

Accessory Tendons from the Radial Wrist

Extensors
In addition to the extensor carpi radialis intermedius
(ECRI) musculotendinous units, both Wood and Albright
and Linburg noted the presence of accessory tendons from
the radial wrist extensors (63,64) (Fig. 10.104).
Wood noted 41 such tendons originating from the
ECRB and inserting with the ECRL on the index
metacarpal. Twenty-nine tendons originated from the
ECRL and inserted on the middle finger metacarpal with
the ECRB, and 24 tendons arose from the ECRL and
inserted alongside the normal tendon at the index finger
metacarpal. Only seven tendons originated from the ECRB
and inserted on the middle finger metacarpal. In two arms,
the ECRL and ECRB shared a common tendon that
inserted on both the index and middle finger metacarpal.

Clinical Significance
Wood’s study indicates that the ECRI or accessory tendons FIGURE 10.104. Extensor carpi radialis intermedius (ECRI). The
are worth looking for, especially in patients with quadriple- most common origin and insertion of this anomalous forearm
muscle are shown.
gia, because they can be used as transfers for thumb oppo-
sition, to motor the flexor pollicis longus or the EPL. Wood
noted that there is a fairly high incidence of bilateral varia-
tions of this type, and that 12% of individuals have a good
ECRI tendon and approximately 36% have at least one and muscles to the thumb and often were difficult to detect
sometimes several accessory tendons that might be available because they blended into the major tendons except when
for transfer (63). Albright and Linburg not only empha- traversing from one to another (64).
sized the usefulness of the ECRI and accessory tendons as
transfers in tetraplegia but also noted the importance and
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 Appendix
aAI

ANATOMIC SIGNS,
SYNDROMES, TESTS, AND
EPONYMS
This Appendix is designed to supply the reader with a com-
prehensive array of anatomic signs, syndromes, tests, and
eponyms that may be encountered in the surgical literature.
The authors have sought succinctly to define or describe the
entity, along with its clinical relevance and relationship to
the underlying anatomy. These may be of practical as well
as historical interest. Original references have been given for
most of the items. Although some of this array appears else-
where in the text, it is believed that the reader will benefit
from the convenience of having these items collected in one
place. The authors believe that this Appendix does have a
logical connection with surgical anatomy, and that at the
minimum, the review of such a collection of material may
provide the reader with a nocturnal soporific at the end of
a long day.
ADSON’S MANEUVER (ADSON’S TEST)
Definition
Adson’s maneuver is a provocative test used in the evalua-
tion of thoracic outlet compression syndrome.
Technique
The patient is seated and the examiner palpates the radial
pulse with the patient’s arm dependent. The neck is turned
toward the side of the lesion and extended while a deep
breath is taken. The radial pulse is palpated. Diminution or
loss of pulse as well as reproduction of symptoms is consid-
ered a positive test.
Clinical Significance
This test is based on potential compression of neurovascu-
lar structures between the anterior and middle scalene mus-
cles. This test also is known as the scalene test and may be
positive in normal patients.
References
Adson AW, Coffey JR. Cervical rib: a method of anterior approach for
relief of symptoms by division of the scalenus anticus. Ann Surg
85:839–857, 1927.
Atasoy E. Thoracic outlet compression syndrome. Orthop Clin
North Am 27:265–303, 1996.
Leffert RD. Thoracic outlet syndrome. In: Omer GE, Spinner M,
Van Beek AL, eds. Management of peripheral nerve problems, 2nd
ed. Philadelphia: WB Saunders, 1998:494–500.
ALLEN TEST
Definition
The Allen test is a clinical test used to evaluate the patency
of the arteries in a double arterial supply system. It can be
used at the wrist to evaluate the radial and ulnar arteries, and
in a digit to evaluate the radial and ulnar digital arteries.
Technique
In the hand, the test consists of simultaneous occlusion of the
radial and ulnar arteries while emptying the hand of blood by
the patient’s active flexion and extension of the digits. The
occlusion is then removed from either the radial or ulnar
artery and the extent and speed of return of circulation are
noted. The test is repeated on the second artery, and the
results noted. If one of the two arteries is occluded or if there
is no connection between the two arterial systems, the com-
promised circulation will be evident. In the digit, the blood is
“milked” from the digit, and both digital arteries are com-
pressed and released in sequence, as with the test at the wrist.
An occlusion of a digital artery is evident by failure of the digit
to refill when the artery is released. A technical pitfall is failure
to apply sufficient pressure to the vessels, and at the wrist 11
pounds or greater is required to occlude the vessels.
Clinical Significance
The Allen test is useful in routine evaluation of the vascula-
ture of the digits and hand and is particularly valuable in
preoperative assessment of the digits or hand that have
compromised circulation and in procedures that have the
potential for compromise of the circulation. It also is help-
ful in vascular evaluation after previous trauma. The timed
Allen test is considered to be positive if refill does not occur
within 15 seconds, and refill that occurs within 6 to 15 sec-
onds is considered to represent delayed or partial refill.
670 Appendix
References
Allen EV. Thromboangiitis obliterans: methods of diagnosis of
chronic occlusive arterial lesions distal to the wrist with illustrative
cases. Am J Med Sci 178:237–244, 1929.
Gelberman RH, Blasingame JP. The timed Allen test. J Trauma 21:
477–479, 1981.
Koman LA. Diagnostic study of vascular lesions. Hand Clin 1:
217–231, 1985.
Wilgis EFS. Special diagnostic studies. In: Omer GE, Spinner M, Van
Beek AL, eds. Management of peripheral nerve problems, 2nd ed.
Philadelphia: WB Saunders, 1998:77–81.
ANDRE-THOMAS SIGN
Definition
The Andre-Thomas sign is an unconscious attempt to
extend the fingers by tenodesis of the extensors through pal-
mar flexion of the wrist.
Clinical Significance
This spontaneous maneuver is seen in ulnar nerve palsy
with claw deformity of the ring and small fingers. Wrist
flexion represents an effort to extend these fingers by means
of extensor tenodesis effect, but only increases the claw
deformity of these fingers.
References
Andre-Thomas T. Le tonus du poignet dans la paralysie du nerf
cubital. Paris Med 25:473–476, 1917.
Green DP, Hotchkiss RN, Pederson WC, eds. Green’s operative hand
surgery, 4th ed. New York: Churchill Livingstone, 1999.
Omer GW. Ulnar nerve palsy. In: Green DP, Hotchkiss RN, Peder-
son WC, eds. Green’s operative hand surgery, 4th ed. New York:
Churchill Livingstone, 1999.
ARCADE OF FROHSE
Definition
The arcade of Frohse is the fibrous tissue proximal edge of
the supinator muscle in the proximal and volar aspect of the
forearm, and is 3 to 5 cm distal to Hueter’s interepicondy-
lar line.
Clinical Significance
The proximal edge of the superficial layer of the supina-
tor is fibrous, especially the lateral side. This fibrous tis-
sue edge forms the arcade of Frohse, which may compress
the anterior radial nerve branches to the supinator as well
as the posterior interosseous nerve as they enter the
supinator.
References
Frohse F, Frankel M. Die Muskelen des menschlichen Armes. In:
Bardeleben K, ed. Handbuch der Anatomie des Menschen, vol 2, sec
2, part 2. Jena, Germany: Gustav Fischer Verlag KG, 1908.
Fuss FK, Wurzl GH. Radial nerve entrapment at the elbow: surgical
anatomy. J Hand Surg [Am] 16:742–747, 1991.
ARCADES OF STRUTHERS
Definition
In 1854, John Struthers, an anatomist in Edinburgh,
described a series of nine abnormal arcades in the arm.
Eight (I to VIII) were related to potential compression of
the median nerve/brachial artery, and one to the ulnar nerve
(I). Only two, or possibly three, of these arcades have been
found to be associated with clinical symptoms. A complete
compilation of these arcades is presented in Table 6.4. The
first six of the median nerve/brachial artery arcades are of
historical and anatomic interest, and at this time have no
reported clinical significance in terms of entrapment or
impingement of nerve or blood vessel. The following three
arcades are of clinical significance.
Arcade VII of Median Nerve/Brachial
Artery Type
Arcade VII (see Fig. 6.31) is characterized by an abnormal
proximal origin of the superficial head of the pronator teres
from the supracondylar ridge rather than the medial epi-
condyle. This high origin also may be related to the pres-
ence of a supracondylar process. This position results in lat-
eral displacement of the neurovascular bundle and has the
potential for compression of the underlying median nerve
and brachial artery.
Arcade VIII of Median Nerve/Brachial
Artery Type
Arcade VIII (see Figs. 6.30 and 6.32) consists of a supra-
condylar process and ligament of Struthers that spans
between the supracondylar process and the medial epi-
condyle, thus creating an arcade that contains the median
nerve and brachial artery. The supracondylar process is a
hook-shaped projection of bone from the anteromedial
aspect of the distal humerus that arises 3 to 5 cm proximal
to the medial epicondyle and is 2 to 20 mm in length. Its
incidence is approximately 1%, and it is a rare cause of pres-
sure on the underlying median nerve and brachial artery. If
the ligament of Struthers extends to the fibrous arch of the
two heads of the flexor carpi ulnaris as well as to the medial
epicondyle, it may produce compression of the median and
the ulnar nerve. Struthers’ ligament has been reported with-
out the usually associated supracondylar process, and the
ligament alone may produce median nerve compression.

Clinical Significance
These two median nerve/brachial artery arcades may be a
source of compression of these vital structures.
Arcade I of Ulnar Nerve Type
This is a potential site of entrapment of the ulnar nerve 8
cm proximal to the medial epicondyle, called the arcade of
Struthers. When the arcade is present, both the ulnar nerve
and the superior ulnar collateral vessels pass through it. In
a recent study of 25 arms, the arcade of Struthers was pre-
sent in 68% of the arms. The arcade has a roof that faces
medially, formed by the deep investing fascia of the arm,
superficial muscle fibers from the medial head of the tri-
ceps, and the internal brachial ligament arising from the
coracobrachialis tendon. The floor, which is lateral, is
formed by the medial aspect of the humerus covered by
the deep muscular fibers of the medial head of the triceps.
The anterior border is the medial intermuscular septum
(see Fig. 7.23).
Clinical Significance
Although the arcade of Struthers is a recognized anatomic
entity, it is said to be a rare cause of ulnar nerve compres-
sion. However, Spinner and Kaplan (1976) showed that the
arcade can produce recurrent ulnar neuropathy after ante-
rior transposition of the nerve because of tethering, and
thus recommended lysis of the arcade as part of the trans-
position. They also recommended lysis of the arcade when
mobilizing a lacerated ulnar nerve in the forearm to reduce
the gap in the nerve.
References
Al-Qattan MM, Murray KA. The arcade of Struthers: an anatomical
study. J Hand Surg [Br] 16:311–314, 1991.
Smith RV, Fisher RG. Struthers’ ligament: a source of median nerve
compression above the elbow. J Neurosurg 28:778–779, 1973.
Spinner M, Kaplan EB. The relationship of the ulnar nerve to the
medial intermuscular septum in the arm and its clinical signifi-
cance. Hand 8:239–242, 1976.
Struthers J. On some points in the abnormal anatomy of the arm. Br
Foreign Med Chir Rev 14:170–179, 1854.
Vesley DG, Killian JT. Arcades of Struthers. J Med Assoc State Al
52:33–37, 1983.
BARTON’S FRACTURE
Definition
In 1838, Barton described a fracture of the dorsal articu-
lar margin of the distal radius characterized by a separated
dorsal fragment, containing a margin of articular cartilage
that displaces upward and proximally onto the dorsal sur-
face of the radius. The fracture occurs from a fall onto the
Anatomic Signs, Syndromes, Tests, and Eponyms 671
outstretched hand with the hand forced into dorsiflexion,
pushing the carpus against the dorsal margin of the artic-
ular surface of the radius. A variation of this fracture also
was described that involved the volar articular margin of
the distal radius, secondary to a force applied against the
back of the hand. This is sometimes referred to as the
reverse Barton’s fracture. The term reverse Barton’s fractures
probably should be changed to “a Barton’s fracture involv-
ing the volar or anterior articular margin,” because it was
described in the original article. It was noted that,
although rare, the injury often occurred “in awkward
attempts to parry the blow from a fist, from pressure in
dense crowds and from falling on the back of the hand
whilst it is bent forward.”
Clinical Significance
This is an intraarticular fracture that, if significantly dis-
placed, usually is treated with operative fixation to restore
the articular surface. In addition, with significant dorsal or
palmar displacement of the detached fragment, the carpus
follows the fragment, with resultant dorsal or palmar sub-
luxation, respectively. Reduction of the carpus and opera-
tive fixation of the fragment usually are indicated.
References
Barton JR. Views and treatment of an important injury of the wrist.
Med Exam 1:365–368, 1838.
Barton JR. Views and treatment of an important injury of the wrist.
Am J Med Sci 26:249–253, 1839.
Schultz RJ. The language of fractures. Huntington, NY: RE Krieger,
1976.
BENNETT’S FRACTURE
Definition
Bennett’s fracture refers to an oblique intraarticular fracture
of the palmar aspect of the base of the thumb metacarpal in
which the smaller palmar fragment remains in its anatomic
position and the thumb metacarpal is displaced proximally
and dorsally.
Clinical Significance
The smaller fragment remains in place because of intact
trapeziometacarpal ligaments, whereas the metacarpal is
displaced proximally and dorsally owing to the deforming
force of the abductor pollicis longus, which attaches to the
dorsal base of the metacarpal. In addition, the adductor pol-
licis places an adduction force on the thumb metacarpal,
which tends to displace the base of the metacarpal radially.
These displacement forces currently are managed by inter-
nal fixation of the fracture.
672 Appendix
References
Bennett EH. Fractures of the metacarpal bones: reports of the Dublin
Pathological Society. Dubl J Med Sci 73:72–75, 1882.
Bennett EH. On fracture of the metacarpal bone of the thumb. BMJ
2:12–13, 1886.
BOUVIER’S SIGN OR MANEUVER
Definition
Bouvier’s sign is the ability actively to extend the proximal
interphalangeal joints of the ring and small fingers in ulnar
nerve palsy when the metacarpophalangeal (MCP) joints
are passively stabilized in neutral by the examiner’s fingers.
Technique
The hyperextended proximal phalanges of the ring and
small fingers as seen in ulnar nerve claw deformity are repo-
sitioned in neutral by the examiner’s fingers. The patient is
then asked to extend the fingers.
Clinical Significance
Repositioning and stabilizing the patient’s hyperextended
ring and small finger proximal phalanges in cases of
interosseous muscle palsy (ulnar nerve palsy) allows the
extensor digitorum communis (EDC) to extend the inter-
phalangeal joints. Bouvier’s maneuver demonstrates the role
of the interosseous muscles in stabilizing the MCP joints
during active extension of the fingers. This may be demon-
strated on one’s own hand by simultaneously extending the
proximal phalanges and flexing the interphalangeal joints of
the ring and small fingers, and then pushing the proximal
phalanges into flexion. The fingers spontaneously extend if
maximum force is maintained in the EDC.
Reference
Bouvier F. Note sur un cas de paralysie de la main. Bull Acad Med
27:125, 1851.
BOWLER’S THUMB
Definition
Bowler’s thumb is an incontinuity neuroma of the ulnar
digital nerve of the thumb.
Clinical Significance
This incontinuity neuroma is due to external pressure from
the margin of the thumb hole in a bowling ball. It usually
involves the ulnar nerve and is characterized by pain, pares-
thesias, and a tender mass on the ulnar aspect of the proxi-
mal phalanx of the thumb. A thrombosed aneurysm of the
digital artery due to bowling also has been seen [Pons
(1983)]. A variation known as cherry pitter’s thumb has been
described by Viegas (see later).
References
Dobyns JH, O’Brien ET, Linscheid RL, et al. Bowler’s thumb: diag-
nosis and treatment. A review of seventeen cases. J Bone Joint
Surg Am 54:751, 1972.
Pons RK. Bowler’s thumb [Letter]. J Hand Surg[Am] 1983;8:630.
BOYES TEST
Definition
This is a test for diagnosis of boutonniere deformity.
Technique
When the proximal interphalangeal joint is held in exten-
sion by the examiner, it normally is possible for the patient
actively to flex the distal interphalangeal (DIP) joint. How-
ever, if the central slip is ruptured, there is increasing diffi-
culty in actively flexing the DIP joint.
Clinical Significance
This test becomes positive only when the ruptured cen-
tral slip has retracted and the lateral bands have migrated
volarly and shortened. It is the contracted and shortened
lateral bands that prevent normal active flexion of the
DIP joint. Although a reliable test for boutonniere defor-
mity, it may not be positive in the early stages of the
deformity. Early diagnosis may be achieved by the Elson
test (see later).
References
Boyes J. Bunnell’s surgery of the hand, 5th ed. Philadelphia: JB Lip-
pincott, 1970:439–442.
Elson RA. Rupture of the central slip of the extensor hood of the fin-
ger: a test for early diagnosis J Bone Joint Surg Br 68:229–231,
1986.
Rubin J, Bozentka DJ, Bora FW. Diagnosis of closed central slip
injuries. J Hand Surg [Br] 21:614–616, 1996.
BREWERTON VIEW (RADIOGRAPH)
Definition
This tangential radiographic view of the metacarpal heads
was originally described as being useful for demonstration
of erosive changes in the metacarpal neck and head in
rheumatoid arthritis; it also is a valuable aid in detecting
fractures or avulsions of ligamentous insertions in the
region of the metacarpophalangeal (MCP) joint.

Technique
The radiographs are made with the palm up, the fingers flat
on the x-ray plate, the MCP joints flexed to 65 degrees, and
the x-ray beam angled from a point 15 degrees to the ulnar
side of the hand.
Clinical Significance
The Brewerton view may detect avulsion fractures of the
metacarpal head and neck that standard anteroposterior,
oblique, and lateral radiographs fail to detect.
References
Brewerton DA. A tangential radiographic projection for demonstrat-
ing involvement of the metacarpal heads in rheumatoid arthritis.
Br J Radiol 40:233, 1967.
Lane CS. Detecting occult fractures of the metacarpal head: the Brew-
erton view. J Hand Surg[Am] 2:131–133, 1977.
BUNNELL’S “O” TEST FOR ULNAR NERVE
PALSY
Definition
The thumb fails to produce a good circle or “O” when it
opposes the tip of the index finger.
Clinical Significance
Failure to form an “O” or circle between the thumb and
index finger indicates ulnar nerve palsy due to paralysis of
the adductor pollicis and deep head of the flexor pollicis
brevis. These muscles ordinarily stabilize the thumb meta-
carpophalangeal joint in flexion during pinch.
Reference
Bunnell SB. Surgery of the hand. Philadelphia: JB Lippincott, 1944:
247.
BUNNELL’S “SCRAPE” TEST FOR ULNAR
NERVE PALSY
Definition
The extended thumb cannot scrape across the extended fin-
gers and palm, but rather leaves (abducts away from) the
palm at the radial side of the index finger.
Clinical Significance
This finding indicates ulnar nerve palsy associated with loss
of function of the adductor, which normally would keep the
thumb closely applied to the palm and thus allow it to
scrape or remain closely applied to the palm during flexion.
Anatomic Signs, Syndromes, Tests, and Eponyms 673
Reference
Bunnell SB. Surgery of the hand. Philadelphia: JB Lippincott, 1944:
247.
CANNIEU-RICHE ANASTOMOSIS
Definition
This anastomosis, in its classic form, is between the motor
branch of the ulnar nerve and the motor branch of the
median nerve in the proximal and radial palm. It was
described by Cannieu in 1896 and 1897 and by Riche in
1897.
Anatomy
The classic description is of an anastomosis between a
ramus of the recurrent branch of the median nerve supply-
ing the superficial head of the flexor pollicis brevis (FPB)
and the anastomotic ramus of the deep branch of the ulnar
nerve supplying the deep head of the FPB. The anastomotic
branch is present between the two heads of the adductor
pollicis and then circles round the flexor pollicis longus
(FPL) tendon on its lateral side. Variations include (a) a sep-
arate branch of the median nerve to the superficial head of
the FPB that sends a branch to the anastomosis; in this
type, the anastomosis can be located either on the surface of
or deep in the FPB; (b) the anastomosis may be with one or
two digital nerve branches of the thumb from the median
nerve; in this type the anastomosis is located medial to the
tendon of the FPL, and sometimes a double or triple anas-
tomosis may be found; (c) an anastomosis may occur
between one of the branches of the digital nerve to the
thumb and the branch to the adductor pollicis, coming
from the deep ulnar nerve; this anastomosis is medial to the
FPL tendon, deep in the adductor pollicis, and there is no
ulnar innervation to the deep head of the FPB; and (d) a
deep branch of the ulnar nerve may pass through and inner-
vate the first lumbrical on its way to anastomose with the
digital branch to the index.
Clinical Significance
The FPB, in addition to its classic anatomic ability to flex
the metacarpophalangeal joint, also can abduct and
pronate the first metacarpal. Double (from median and
ulnar) innervation of the FPB muscle may explain a
nonanatomic persistence of function after median or
ulnar nerve injury. Adequate pinch may be retained and
Froment’s sign may be minimal or absent in the ulnar
nerve–injured patient if the deep head of the FPB has
median nerve innervation; in median nerve injury, oppo-
nensplasty may not be required if the superficial head of
the FPB is ulnar nerve innervated.
674 Appendix
References
Cannieu A. Recherche sur l’innervation de l’eminence thenar par le
cubital. J Med Bord 377–379, 1896.
Cannieu A. Note sur une anastomose entre le branche profunde du
cubital et le median. Bull Soc Anat Physiol Horm Pathol Bord
17:339–342, 1897.
Riche P. Le nerf cubital et les muscles de l’eminence thenar. Bull Mem
Soc Anat Paris 251–252, 1897.
CHASSAIGNAC’S TUBERCLE (CAROTID
TUBERCLE)
Definition
Chassaignac’s tubercle is the prominent anterior tubercle of
the transverse process of C6.
Clinical Significance
Chassaignac’s tubercle is a useful landmark in the adminis-
tration of stellate ganglion blocks.
Reference
Atasoy E, Kleinert HE. Surgical sympathectomy and sympathetic
blocks for the upper and lower extremities, and local and plexus
levels. In: Omer GE, Spinner M, Van Beek AL, eds. Management
of peripheral nerve problems, 2nd ed. Philadelphia: WB Saunders,
1998:157–171.
CHERRY PITTER’S THUMB
Definition
Cherry pitter’s thumb is digital nerve compression or neu-
ritis from repetitive external trauma to the thumb digital
nerves in cherry pitters. It is characterized by neuritic symp-
toms of pain and numbness, with possible positive percus-
sion test of the involved digital nerve.
Clinical Significance
This condition is similar to the Bowler’s thumb, and both
conditions are secondary to repetitive external trauma.
Reference
Viegas SF, Torres FG. Cherry pitter’s thumb: case report and review
of the literature. Orthop Rev 18:336, 1989.
CLELAND’S LIGAMENTS
Definition
These structures are retaining skin ligaments that stabilize the
skin during flexion and extension of the fingers and thumb.
Anatomy
Based on Milford’s dissections, they arise from the proximal
interphalangeal (PIP) joint on each side of the finger and
interphalangeal joint of the thumb. They are dense, fibrous
bundles that diverge from their origin to insert into the skin.
The fibers are arranged in two planes and form a structure
somewhat like a cone. They are dorsal to the neurovascular
bundle and are arranged proximal and distal to the transverse
retinacular ligament in the finger near its palmar insertion.
The largest bundle originates from the lateral margin of the
middle phalanx over its proximal fourth, from the joint cap-
sule of the PIP joint, and from the flexor tendon sheath.
These fibers are strong, project in straight lines, and fan out
to insert in an area of skin larger than their origin, but all
fibers insert proximal to the distal interphalangeal (DIP)
joint. The most dorsal of the fibers become taut when the
PIP joint is flexed (lending some stability to the skin) because
of the fibers over the condyle of the proximal phalanx. The
most palmar fibers become taut with PIP joint extension,
with similar stability noted in the skin. The two distal bun-
dles of this ligament originate from the DIP joint from the
bone and capsule, over a small 1- to 2-mm area just proximal
and distal to the joint. The strongest bundle of Cleland’s lig-
ament in the thumb (the proximal) arises from the flexor ten-
don sheath just distal to the metacarpophalangeal joint and
then courses distally to insert into the adjacent skin. The dis-
tal two bundles arise at the interphalangeal joint from the
bone and capsule over a small area.
Clinical Significance
These structures stabilize the skin during flexion and exten-
sion of the digits. They may be pictured as tethers and out-
riggers to prevent undue movement of the soft tissue enve-
lope about the underlying phalanges, in Cleland’s words,
“helping to retain the different parts of the integument in
the positions which they are adapted to occupy.”
References
Cleland J. On the cutaneous ligaments of the phalanges. J Anat Phys-
iol 12:526–527, 1878.
Milford LW. Retaining ligaments of the hand. Philadelphia: WB Saun-
ders, 1968.
CROSSED FINGERS TEST
Definition
This is a quick and reliable test to determine ulnar nerve
function.
Technique
The patient is asked to cross the long finger over the index
finger.

Clinical Significance
This maneuver tests the function of the ulnar nerve–inner-
vated first volar and the second dorsal interosseous muscles.
Inability to perform this maneuver indicates paralysis of these
muscles, as seen in ulnar nerve palsy. The chief usefulness of
the test is for screening patients with acute injuries for ulnar
nerve damage. The test’s specificity (not easily duplicated by
trick movements, and no anomalous innervation) and the
ease with which it can be demonstrated to the patient appear
to contribute to the test’s usefulness.
Reference
Earle AS, Vlastou C. Crossed fingers and other tests of ulnar nerve
motor function. J Hand Surg [Am] 5:560–565, 1980.
CHEIRALGIA PARAESTHETICA
See Wartenberg’s Syndrome.
CHAUFFEUR’S FRACTURE (BACKFIRE
FRACTURE, LORRY DRIVER’S FRACTURE)
Definition
This is an oblique intraarticular fracture of the distal radius
that extends from the articular surface to the lateral radial
metaphysis, separating the styloid from the shaft of the
radius. The fracture originally occurred from cranking a car,
in which a backfire forced the crank handle backward. The
fracture resulted from either the handle directly striking the
radial diaphysis or from forceful dorsiflexion and abduction
of the wrist.
Clinical Significance
The diagnosis may be delayed because of the minimal phys-
ical deformity and the fact that wrist edema may be the only
presenting sign. If displaced, this intraarticular fracture usu-
ally is treated optimally with operative fixation.
Reference
Schultz RJ. The language of fractures. Huntington, NY: RE Krieger,
1976.
COLLES’ FRACTURE
Definition
Colles’ fracture is a fracture of the distal radius with dorsal
comminution, dorsal angulation, dorsal displacement, and
radial shortening.
Anatomic Signs, Syndromes, Tests, and Eponyms 675
Clinical Significance
This most common wrist fracture in adults is manifested
clinically by a painful “silverfork” deformity that Colles
described in 1814, noting that “The carpus and base of the
metacarpus appear to be thrown backward so much as on
first view, to excite a suspicion that the carpus is dislocated.”
References
Colles A. On the fracture of the carpal extremity of the radius. Edin-
burgh Med Surg J 10:182–186, 1814.
Colles A. On the fracture of the carpal extremity of the radius. Med
Classics 4:1038–1042, 1940.
DE QUERVAIN’S DISEASE
Definition
de Quervain’s disease is stenosing tenosynovitis of the
abductor pollicis longus (APL) and extensor pollicis brevis
(EPB) tendons as they pass through a synovial-lined
fibroosseous tunnel at the styloid process of the radius at the
wrist. Signs of inflammation, manifested by swelling and
tenderness over the radial styloid, sometimes are accompa-
nied by crepitus with motion of the thumb. A confirmatory
diagnostic test is performed by grasping the thumb and
abducting the wrist (the Finkelstein test; see the entry on
Finkelstein’s Test for details of this maneuver).
Clinical Significance
This inflammatory disorder often is relieved by conservative
treatment, including rest to the thumb and wrist by splint-
ing, and injection of steroids into the involved sheath.
Surgery, in the form of release of the sheath of the APL and
EPB, is reserved for those patients who do not respond to
conservative treatment. Critical anatomic features relate to
the close proximity of branches of the radial sensory nerve
that are at risk and failure to recognize the fact that the EPB
may be in a separate fibroosseous tunnel. Failure to release
the EPB may be associated with an incomplete recovery.
Reference
de Quervain F. Uber eine Form von chronischer Tendovaginitis. Cor-
resp Blatt Schweiz Aerzte 25:389–394, 1895.
DE QUERVAIN’S FRACTURE
Definition
This is a transscaphoid, perilunate fracture dislocation of
the wrist in which the lunate and proximal pole of the
scaphoid dislocate as a unit palmarward, while the distal
676 Appendix
pole of the scaphoid and the remainder of the carpus
remain in relatively normal axial alignment.
Clinical Significance
Although this injury may be managed by closed reduction,
many surgeons choose to perform open reduction and
internal fixation because of the potential for delayed union
or nonunion of the scaphoid.
References
de Quervain F. Spezielle chirurgische Diagnostik fur Studierende und
Aerzte. Leipzig: FCW Vogel, 1907.
de Quervain F. Clinical surgical diagnosis for students and practitioners,
4th ed. Snowman J, translator. New York: William Wood, 1913.
DUCHENNE’S SIGN
Definition
Duchenne’s sign is claw deformity of the ring and small fin-
gers. The small finger cannot be adducted to the ring finger.
There is loss of ability to play high notes on the violin
because of inability to reach and press appropriately on the
strings.
Clinical Significance
This classic sign of ulnar nerve palsy is due to paralysis of the
intrinsic muscles in the presence of normal function of the
extrinsic extensors and flexors. The unopposed action of the
extensor digitorum communis results in hyperextension of
the proximal phalanx, while the extrinsic flexors produce
flexion of the proximal and distal interphalangeal joints,
which results in the claw deformity. In high ulnar nerve
lesions with associated paralysis of the ring and small finger
profundus, the claw deformity may be diminished. An
unconscious effort to extend the fingers by tenodesing the
extensor tendons by palmar flexion of the wrist increases the
deformity and is called the Andre-Thomas sign (see earlier).
Loss of adduction of the small finger is due to denervation of
the ulnar-innervated third palmar interosseous, which
attaches to the radial base of the small finger proximal pha-
lanx. The loss of ability to play high notes is due to loss of
function in the opponens digiti minimi and the flexor carpi
ulnaris that results in inability to flex and ulnar deviate the
wrist and thus to position the fingers over the strings. In addi-
tion, the diminished flexion arc of the clawed fingers prevents
appropriate contact of the fingertips with the strings.
Reference
Duchenne GBA. Physiology of motion [Physiologie des movements demon-
tree a l’aide de l’experimentation electrique et de l’oberservation clinique
et applicable a l’etude des paralysies et des degenerations. 1867.]. Kaplan
EB, translator and ed. Philadelphia: WB Saunders, 1959.
DUPUYTREN’S CONTRACTURE
Definition
Dupuytren’s contracture is a thickening of the palmar and dig-
ital fascia, resulting in nodules, cords, and digital contracture.
Clinical Significance
Progressive flexion contracture of the fingers results in sig-
nificant loss of function, and palmar and digital fasciectomy
is commonly performed.
Reference
Dupuytren G. De la retraction des doigts par suite d’une affection de
l’aponevrose palmaire—description de la maladie—operation
chirurgicale qui convient dans ce cas. Compte rendu de la clinique
chirurgicale de l’Hotel Dieu par MM les docteurs Alexandre Pail-
lard et Marx. J Univers Hebdom Med Chir Prat Inst Med
5:349–365, 1831.
EGAWA SIGN
Definition
The Egawa sign is the inability of the flexed long finger to
abduct radioulnarly or to rotate at the metacarpophalangeal
joint.
Clinical Significance
This is a sign of ulnar nerve dysfunction and is due to paraly-
sis of the interosseous muscles. Flexion of the finger prevents
the extensor digitorum communis from abducting the finger.
References
Egawa T. Electromyographic studies on finger motion. J Osaka Univ
Med School 11:1739–1758, 1959.
Mannerelt L. Studies on the hand in ulnar nerve paralysis. Acta
Orthop Scand Suppl 87:1–176, 1966.
ELBOW FLEXION TEST
Definition
This is a provocative test for diagnosing compression neu-
ropathy of the ulnar nerve at the elbow.
Technique
The test is performed by fully flexing the elbow for 1
minute. A positive test is manifested by paresthesias in the
ulnar nerve distribution.

Clinical Significance
This test may be useful in the diagnosis and staging [Dellon
(1989)] of ulnar nerve compression at the elbow. Rayan et
al. (1992) found that the test may be positive in 10% to
13% of the normal population based on various positions
of the wrist and shoulder.
References
Dellon AL. Review of treatment results for ulnar nerve entrapment at
the elbow. J Hand Surg [Am] 14:688–700, 1989.
Rayan GM, Jensen C, Duke J. Elbow flexion test in the normal pop-
ulation. J Hand Surg [Am] 17:86–89, 1992.
Wadsworth T. The external compression syndrome of the ulnar nerve
at the cubital tunnel. Clin Orthop 124:189–204, 1977.
ELSON TEST
Definition
This is a test for the early diagnosis of boutonniere defor-
mity.
Technique
The finger to be examined is flexed comfortably to a right
angle at the proximal interphalangeal (PIP) joint over the
edge of a table and firmly held in place by the examiner.
The patient is then asked to extend the PIP joint against
resistance. Any pressure felt by the examiner over the mid-
dle phalanx can be exerted only by an intact central slip.
Further proof is that the distal interphalangeal (DIP) joint
remains flail during the effort because the competent cen-
tral slip prevents the lateral bands from acting distally. In
the presence of a complete rupture of the central slip, any
extension effort perceived by the examiner is accompanied
by rigidity at the DIP joint with a tendency to extension.
This is produced by the extensor action of the lateral bands.
Note: This test will not demonstrate the presence of a par-
tial rupture of the central slip, and it may be impeded by
pain or lack of patient cooperation. Consideration may be
given to nerve block for pain relief as indicated.
Clinical Significance
Early diagnosis of boutonniere deformity gives the best
chance of a satisfactory outcome. Boyes test becomes posi-
tive only at a late stage. In a study that used various pub-
lished clinical tests to diagnose an early boutonniere, only
the Elson test was said to be reliable. The Elson test relies
on abnormal tone between the PIP and DIP joints. Nor-
mally, with the PIP joint blocked in flexion, there is limited
active extension of the DIP joint. Harris and Rutledge
demonstrated that the lateral bands are held distally by the
central slip, and because of check-rein effect, the extensor
Anatomic Signs, Syndromes, Tests, and Eponyms 677
mechanism is unable to extend the DIP joint. But, with dis-
ruption of the central slip and loss of the check-rein effect,
extension of the DIP can occur by tightening the dorsal
apparatus. On performing the Elson test with a ruptured
central slip, attempted active extension of the finger with
the PIP joint held in flexion increases the rigidity of the
DIP joint.
References
Elson RA. Rupture of the central slip of the extensor hood of the fin-
ger: a test for early diagnosis. J Bone Joint Surg Br 68:229–231,
1986.
Harris C, Rutledge GL. The functional anatomy of the extensor
mechanism of the finger. J Bone Joint Surg Am 54:713–726,
1972.
Rubin J, Bozentka DJ, Bora FW. Diagnosis of closed central slip
injuries. J Hand Surg [Br] 21:614–616, 1996.
ERB-DUCHENNE PALSY (PLEXOPATHY)
Definition
This is an upper brachial plexus palsy, usually involving the
C5 and C6 (and possibly C7) nerve roots.
Clinical Significance
The patient demonstrates paralysis of the supraspinatus,
infraspinatus, rhomboids, deltoid, biceps, and brachialis,
and weakness of the pectoralis major, triceps, and extensor
carpi radialis longus and brevis that results in loss of shoul-
der external rotation, elbow flexion, forearm supination,
and wrist extension. The upper extremity assumes a posi-
tion of shoulder adduction and internal rotation, elbow
extension, forearm pronation, and wrist flexion (the so-
called waiter’s tip position).
References
Duchenne GB. De l’electrisation localisee et de son application a la
pathologie et a la therapeutique, 3rd ed. Paris: Bailliere, 1872:357.
Erb W. On a characteristic site of injury in the brachial plexus [trans-
lated by Brody and Wilkins]. Arch Neurol 21:443, 1969.
ESSEX-LOPRESTI FRACTURE
Definition
An Essex-Lopresti fracture is a comminuted fracture of the
radial head associated with longitudinal injury of the fore-
arm interosseous membrane that is characterized by migra-
tion of the radial shaft, disruption of the distal radioulnar
joint, and relative positive ulnar variance. Fracture of the
radial head with dislocation of the distal radioulnar joint
was first described by Curr and Coe in 1946.
678 Appendix
Clinical Significance
Comminuted fractures of the radial head require careful
assessment of the interosseous membrane (for tenderness)
and physical and radiographic examination of the wrist.
The lesion may be present acutely, or may develop progres-
sively after excision of the comminuted radial head.
References
Curr JF, Coe WA. Dislocation of the inferior radio-ulnar joint. J Bone
Joint Surg 34:74–77, 1946.
Essex-Lopresti P. Fractures of the radial head with distal radioulnar
dislocation. J Bone Joint Surg Br 33:244–247, 1951.
EXTENSOR INDICIS PROPRIUS SYNDROME
Definition
Extensor indicis proprius (EIP) syndrome is a type of
tenosynovitis caused by the extension of the musculotendi-
nous junction of the EIP into the rigid confines of the
fourth extensor compartment. This syndrome usually man-
ifests itself as dorsal wrist pain that is localized to the mus-
culotendinous junction of the EIP. The pain is aggravated
by use of the wrist and hand, usually during strenuous
activities. Symptoms are localized to the dorsum of the
wrist over the fourth dorsal compartment and are associated
with localized swelling, tenderness, and often crepitus. The
swelling usually diminishes with wrist extension and is most
noticeable during wrist flexion. Resisted extension of the
index finger metacarpophalangeal joint with the wrist in
flexion usually produces dorsal radial wrist pain in this syn-
drome.
Clinical Significance
Although this is a rare form of tenosynovitis compared with
trigger digits or de Quervain’s tenosynovitis, it should be
added to the list of causes of wrist pain. This syndrome may
be the cause of dorsal wrist pain sometimes seen with a dor-
sal radial ganglion.
References
Ritter WA, Inglis AE. The extensor indicis proprius syndrome. J Bone
Joint Surg Am 51:1645–1648, 1969.
Spinner M, Olshansky K. The extensor indicis proprius syndrome: a
clinical test. Plast Reconstr Surg 51:134–138, 1973.
EXTENSOR PLUS SYNDROME OR TEST
Definition
This condition is characterized by the inability simultane-
ously to flex the metacarpophalangeal (MCP) and proximal
interphalangeal (PIP) joints, although individually the
joints can be flexed.
Technique
The examiner attempts passively and simultaneously to flex
the MCP and PIP joints. If both joints can be flexed nor-
mally, the test is negative. If flexion of the MCP joint is
associated with absent or limited flexion of the PIP joint,
the test is positive and is confirmed by noting improved or
complete flexion of the PIP joint with hyperextension of
the MCP joint.
Clinical Significance
A positive result in this test indicates shortening or adher-
ence of the extensor mechanism proximal to the MCP
joint.
Reference
Kilgore ES Jr, Graham WP, et al. The extensor plus finger. Hand
7:159–165, 1975.
FINKELSTEIN’S TEST
Definition
A diagnostic test for evaluation of stenosing tenosynovitis of
de Quervain.
Technique
The patient’s thumb is grasped by the examiner and the
hand quickly abducted (bent ulnarward). The test is inap-
propriately performed by placing the thumb in the palm
followed by wrist abduction because this often may produce
pain (a false-positive result) even in a normal wrist [Elliott
(1992)]. The latter technique was described in 1927 by
Eichhoff, and although used to diagnose stenosing tenosyn-
ovitis, probably is not as reliable as Finkelstein’s test.
Clinical Significance
The production of pain over the radial styloid by this
maneuver is the result of stretching inflamed tendons
(abductor pollicis longus and extensor pollicis brevis) in the
first extensor compartment and is a pathognomonic sign of
de Quervain’s tenosynovitis.
References
Eichhoff E. Zur Pathogenese der Tenovaginitis Stenosans. Bruns
Beitage Zur Klin Chir 139:746–755, 1927.
Elliott BG. Finkelstein’s test: a descriptive error that can produce a
false positive. J Hand Surg [Br] 17:481–482, 1992.

Finkelstein H. Stenosing tendovaginitis at the radial styloid process. J
Bone Joint Surg 12:509–540, 1930.
FROMENT’S SIGN
Definition
Froment’s sign is the occurrence of hyperflexion of the inter-
phalangeal joint of the thumb during key pinch between the
pulp of the thumb and the radial side of the index finger.
Technique
The classic photograph of the technique shows the compar-
ative posture of the two thumbs with the patient pinching
the margin of a newspaper.
Clinical Significance
Loss of pinch force due to denervation of the ulnar-inner-
vated adductor pollicis results in compensatory force from
the flexor pollicis longus, which is manifested by hyperflex-
ion of the thumb interphalangeal joint. Hyperextension at
the metacarpophalangeal joint also may occur. Froment’s
sign is a classic indicator of ulnar nerve palsy.
References
Froment MJ. La paralysie de l’adducteur du ponce et le signe de la
prehension. Rev Neurol 28:1236–1240, 1914–15.
Froment MJ. La prehension dan les paralysies du nerf cubital et le
signe du ponce. Presse Med 23:409, 1915.
GALEAZZI FRACTURE
Definition
This is a fracture of the radius at or near the junction of the
middle and distal thirds that is associated with subluxation
or dislocation of the distal ulna.
Historical
The French, as early as 1929, referred to this injury as a
reverse Monteggia fracture [Valande (1929)]. It also has
become known as the Piedmont fracture because of a report
on a series of cases from members of the Piedmont
Orthopaedic Society published by Hughston in 1957.
Clinical Significance
Galeazzi (1934) observed that the ulnar subluxation may be
present initially or may develop gradually during treatment.
Hughston (1957) noted four main deforming factors that
might contribute to loss of reduction of this complex fracture.
Anatomic Signs, Syndromes, Tests, and Eponyms 679
References
Galeazzi R. Ueber ein besonderes Syndrom bei Verltzunger im Bere-
ich der Unterarmknochen. Arch Orthop Unfallchir 35:557–562,
1934.
Hughston JC. Fractures of the distal radial shaft: mistakes in man-
agement. J Bone Joint Surg Am 39:249–264, 1957.
Valande M. Luxation en arriere de cubitus avec fracture de la diaphse
radiale. Bull Mem Soc Nat Chir 55:435–437, 1929.
GAMEKEEPER’S THUMB
Definition
Gamekeeper’s thumb is attenuation of the ulnar collateral
ligament (UCL) of the metacarpophalangeal (MCP) joint
of the thumb due to chronic stress on the UCL that even-
tually results in instability of the ulnar side of the thumb
MCP joint.
Clinical Significance
This deformity is the result of repeated injury or chronic
stress placed on the UCL, in contrast to the acute rupture
or avulsion of the UCL. The term gamekeeper’s thumb has
been used however to describe both acute and chronic
injuries to the UCL of the thumb MCP joint. Milch (1929)
first described chronic instability in this region in 1926;
Campbell (1955) described chronic UCL instability in
Scottish gamekeepers whose method of killing rabbits was
by a sudden and forceful stretching of the animal’s neck,
which was fixed in the keeper’s first web space. Repetitive
forces eventually resulted in attenuation of the UCL head.
References
Campbell CS. Gamekeeper’s thumb. J Bone Joint Surg Br
71:148–149, 1955.
Milch H. Recurrent dislocation of the thumb: capsulorrhaphy. Am J
Surg 6:237–239, 1929.
GRAYSON’S LIGAMENTS
Definition
Grayson’s ligaments are retaining skin ligaments that are
palmar to the neurovascular bundles and pass from the skin
to the flexor tendon sheath.
Anatomy
Grayson (1941) reported that they were found in pairs at each
interphalangeal joint and that only the proximal pair of liga-
ments about the distal interphalangeal (DIP) joint could be
demonstrated with certainty. According to Grayson, those of
the proximal interphalangeal joint demonstrated two pairs,
with the proximal portion arising from the flexor sheath at the
680 Appendix
distal third of the proximal phalanx and the distal pair arising
from the sheath over the proximal third of the middle pha-
lanx. Milford (1968), in his comprehensive dissections of the
retaining ligaments of the digits, found that Grayson’s liga-
ment was fragile and membranous in character and was
strongest at the middle three-fourths of the middle phalanx in
the finger and just proximal to the interphalangeal joint in the
thumb. Milford noted that the ligament originated from the
palmar aspect of the flexor tendon sheath and projected at
right angles (at variance with Grayson’s observation of an
oblique course) to the long axis of the finger.
Clinical Significance
Milford concluded that (a) Grayson’s ligament in the
human probably is strong enough to maintain the digital
vessels and nerves in place and prevent bowstringing when
the finger is flexed; and (b) clinically, along with Cleland’s
ligament, they formed a tube from the proximal aspect of
the finger to the DIP joint, in which the digital nerves and
vessels always can be found during surgical dissection.
References
Grayson J. The cutaneous ligaments of the digits. J Anat 75:164–165,
1941.
Milford LW. Retaining ligaments of the hand. Philadelphia: WB Saun-
ders, 1968.
GUYON’S CANAL
Definition
Guyon’s canal, or the ulnar tunnel, is the space that the
ulnar nerve and artery traverse to gain entrance to the hand
from the forearm.
Anatomy
Guyon’s canal begins at the proximal edge of the palmar carpal
ligament and ends at or beyond the fibrous arch of the
hypothenar muscles [formed mainly by the flexor digiti min-
imi (FDM)]. Beginning from proximal to distal, the roof of
the canal is formed by the palmar carpal ligament, portions of
the palmar aponeurosis, and the palmaris brevis muscle. The
floor is formed by the transverse carpal ligament (TCL), the
pisohamate and pisometacarpal ligaments, and the FDM. The
ulnar wall is composed of the flexor carpi ulnaris, the pisiform,
and the abductor digiti minimi. The radial wall is formed by
the tendons of the extrinsic flexors, the TCL, and the hook
process of the hamate.
Clinical Significance
Kuschner et al. (1988) divided Guyon’s canal into three
zones that they found to be useful for the localization and
correct prediction of the cause of ulnar neuropathy in the
canal (see discussion of Guyon’s canal and Table 10.9 in
Chapter 10). They concluded that their division of
Guyon’s canal into zones along with a careful history and
examination, including appropriate tests, would result in
a more accurate prediction of the cause of the ulnar
deficit.
References
Denman EE. The anatomy of the space of Guyon. Hand 10:69–76,
1978.
Guyon F. Note sur une disposition anatomique propre a la face
anterieure de la region du poignet et non encore decrite. Bull Soc
Anat Paris 6:184–186, 1861.
Kuschner SH, Gelberman RH, Jennings C. Ulnar nerve compression
at the wrist. J Hand Surg [Am] 13:577–580, 1988.
HAINES-ZANCOLLI TEST (THE RETINACULAR
PLUS TEST)
Definition
This is a test for contracture of the oblique retinacular liga-
ment and displacement of the lateral bands as seen in the
boutonniere deformity.
Technique
The proximal interphalangeal (PIP) joint is held in exten-
sion and passive flexion of the distal interphalangeal joint
(DIP) is attempted. If passive flexion can be obtained, the
test is negative. If passive flexion is significantly limited or
not possible, the test is positive.
Clinical Significance
This test may be used as part of the evaluation process of
patients with the history of a “jammed finger” that pre-
sents with swelling and tenderness about the PIP joint. It
may aid in the detection of the anatomic precursors of the
boutonniere deformity (central slip disruption of the
extensor digitorum communis at the PIP joint and pro-
gressive palmar migration of the lateral bands). This test
may be used to determine the stage of progression of the
boutonniere deformity. In the early stages of boutonniere,
the deformity is easily reducible and the Haines-Zancolli
test is negative. In late or fixed deformity, the fibers of the
retinacular ligament are contracted and passive flexion of
the DIP joint is not possible. If the PIP joint cannot be
fully extended, a positive retinacular plus test may be
masked.
Authors’ Comment
The authors of and the commentators [Tubiana et al.
(1996)] on this test emphasize the importance of contrac-

ture of the oblique retinacular ligament (ORL). Perhaps it
is the ORL that is the first structure to be contracted, fol-
lowed by contracture of the palmarly displaced lateral
bands. This test appears to be similar if not identical to the
Boyes test for boutonniere deformity.
References
Haines RW. The extensor apparatus of the finger. J Anat 85:251,
1951.
Tubiana R, Thomine JM, Mackin E. Examination of the hand and
wrist, 2nd ed. St. Louis: Mosby, 1996:220–222.
Zancolli E. Structural and dynamic basis of hand surgery. Philadelphia:
JB Lippincott, 1968:106–107, 121.
HENLE, NERVE OF
Definition
The nerve of Henle is a branch of the ulnar nerve that arises
in the proximal forearm and provides sympathetic nerve
fibers to the ulnar artery and sensory fibers to the distal
forearm and ulnar side of the palm.
Clinical Significance
McCabe and Kleinert (1990) found that this nerve has a
relatively high incidence and provides sympathetic nerve
fibers to the ulnar artery and sensory fibers to the distal
forearm and ulnar side of the palm. They noted similar-
ity between the distal components of this nerve and the
palmar cutaneous branch of the ulnar nerve (PCBUN),
and no separate PCBUNs were found in their dissections.
The findings of McCabe and Kleinert are contrasted to
those of Martin et al. (1996), who studied the cutaneous
innervation of the palm in 25 hands and noted the
PCBUN to be present in 4 of 25 specimens and the nerve
of Henle as a sensory branch to be present in 10 of 25
specimens.
References
Henle J. Handbuch der Systematischen Anatomic den Menschen. Braun-
schweig, Germany: von Friedrich Vieweg and Sohn, 1868.
Martin CH, Seiler JG III, Lesesne JS. The cutaneous innervation of
the palm: an anatomic study of the ulnar and median nerves. J
Hand Surg 21A:634–638, 1996.
McCabe SJ, Kleinert JM. The nerve of Henle. J Hand Surg [Am]
15:784–788, 1990.
HOFFMANN-TINEL SIGN
Definition
The Hoffmann-Tinel sign is a useful clinical sign to deter-
mine the level of nerve injury or recovery based on the pres-
ence of injured or regenerating axons.
Anatomic Signs, Syndromes, Tests, and Eponyms 681
Technique
This test is performed by percussion of the nerve distal to the
lesion with proximal advancement of the digital percussion
until the lesion is reached or the zone of regeneration identi-
fied. The percussion, performed gently with the examiner’s
fingertip, progresses along the course of the nerve until the
end point is identified by paresthesia either localized to the
zone of injury in cases of complete nerve interruption, or dis-
tally into the zone of cutaneous innervation. Some clinicians
prefer to percuss from proximal to distal to the site of the
lesion downward until the paresthesia disappears.
Clinical Significance
The paresthesia or “pins and needles” sensation noted with the
digital percussion is caused by the regenerating axons that are
sensitive to percussion, in part because of loss of the myelin
sheath as part of Wallerian degeneration. A positive response
over a long segment of nerve may be due to unequal rates of
growth of various sensory fibers. The sign may be absent in
the first 4 to 6 weeks after nerve suture, and the onset and
progress of the sign may be inversely proportional to the sever-
ity of the injury. The sign may be difficult to elicit beneath a
large muscle mass. Steady distal progression of the end point
is a favorable sign in nerve regeneration, but it must be recog-
nized that the sign is qualitative, not quantitative.
Historical Perspective
This sign was described in the same year (1915) by a Ger-
man physiologist, Paul Hoffmann (1884–1962) and Jules
Tinel (1879–1952), a French neurosurgeon. Hoffmann
published his first paper on the subject in March, 1915 and
Tinel in October, 1915. They served their respective coun-
tries on opposing sides of the Front in the First World War.
The references listed here are of more than historical
interest.
Reference
Buck-Gramcko D, Lubahn JD. The Hoffmann-Tinel sign. J Hand
Surg [Br] 18:800–805, 1993.
Hoffmann P. Uber eine Methode, den Erfolg einer Nervennaht zu
Beurteilen. Med Klin 11:359–360, 1915.
Hoffmann P. Weitres uber das Verhalten frisch regenerierter Nerven
und uber die Methode, den Erfolg einer Nervennaht fruhzeitig zu
Beurteilen. Med Klin 11:856–858, 1915.
Tinel J. Le signe du “fourmillement” dans les lesions des nerfs periph-
eriques. Presse Med 47:388–389, 1915.
HOLSTEIN-LEWIS FRACTURE
Definition
In 1963, Holstein and Lewis described a spiral oblique frac-
ture of the distal humerus in seven patients, in which radial
682 Appendix
nerve paralysis was present in five patients and paresis in
two. They noted radial angulation and overriding at the
fracture site. As the radial nerve courses anteriorly through
the lateral intermuscular septum, it is less mobile and sub-
ject to being injured by the movement of the distal fracture
fragment. Because of the high incidence of radial nerve dys-
function, early operative intervention was advised by these
authors.
Clinical Significance and Perspective
A larger and more recent study of this fracture that was
associated with radial nerve palsy revealed that 11 of the
15 who were treated without exploration of the radial
nerve had complete recovery, and in the 4 patients who
were explored, the nerve was in continuity and also
demonstrated complete recovery. Additional perspective
on management of radial nerve palsy is presented in
Chapter 6.
References
Holstein A, Lewis G. Fractures of the humerus with radial nerve
paralysis. J Bone Joint Surg Am 45:1382–1388, 1963.
Szalay EA, Rockwood CA Jr. The Holstein-Lewis fracture revisited.
Orthop Trans 7:516, 1983.
HORNER’S SYNDROME
Definition
1. Miosis (small pupil)
2. Enophthalmos (sinking in of the eyeball)
3. Ptosis (drooping of the upper lid)
Clinical Significance
These physical findings are seen in conjunction with a
brachial plexus injury and indicate avulsion of either or
both the C8 and T1 nerve roots proximal to the dorsal
root ganglion, and indicate that surgical repair is impos-
sible. Horner’s sign may be present immediately after
injury or may be delayed for 3 to 4 days after injury.
Horner’s syndrome also may be seen after stellate gan-
glion block.
References
Bernard C. Des phénomènes oculo-pupillairas produits par la section
du nerf sympathique cervical; ils sant indépendents des
phénomènes vasculaires coloriques de la tête. C Rend Acad Sci
Paris 55:381–388, 1862.
Horner F. Ueber eine Form von Ptosis. Klin Mbl Augenheilkd
7:193–198, 1869.
Mitchell SW, et al. Gunshot wounds and other injuries of the nerves.
Philadelphia: JB Lippincott, 1864.
HUBER TRANSFER
Definition
The Huber transfer is transfer of the abductor digiti minimi
(ADM) on its neurovascular bundle to restore or augment
opposition of the thumb. The procedure was described by
Huber and Nicholaysen, working independently, in 1921 as
a method to restore opposition after median nerve injury or
poliomyelitis.
Technique
The technique as performed by Manske and McCarroll
(1978) involves detachment of the insertion of the ADM,
freeing it from the adjacent muscle with preservation of the
neurovascular pedicle (by avoiding dissection on the proxi-
mal and radial side of the muscle) and preservation of its
origin from the pisiform. The muscle is then passed
through a subcutaneous tunnel and attached to the region
of the metacarpophalangeal joint of the thumb based on the
patient’s deformity.
References
Huber E. Hilfsoperation bei median Uslahmung. Dtsch Z Chir 162:
271–275, 1921.
Manske PR, McCarroll HR Jr. Abductor digiti minimi opponen-
splasty in congenital radial dysplasia. J Hand Surg[Am] 3:
552–559, 1978.
Nicholaysen J. In: Nordisk kirurgisk forenung fochandlingar, 13th
meeting, Helsingfoes, 1921:118
INTRINSIC TIGHTNESS TEST (FINOCHIETTO-
BUNNELL TEST)
Definition
This is a two-stage maneuver to test for abnormal tightness
or contracture of the intrinsic muscles and their tendons.
Technique
The test is valid only if passive mobility is retained in the
metacarpophalangeal (MCP) and proximal interphalangeal
(PIP) joints. First, the MCP joint is passively extended and
the degree of passive flexion noted in the PIP joint. The
MCP joint is then passively flexed and the PIP joint again
passively flexed. Normally there is slightly more passive PIP
joint flexion noted when the MCP joint is flexed. A signif-
icant increase in PIP joint flexion when the MCP joint is
flexed indicates intrinsic mechanism tightness.
Clinical Significance
Passive extension of the MCP joint places the intrinsic
mechanism on maximum stretch or tightness and, if it is

contracted, it is difficult if not impossible passively to flex
the PIP joint; however, when the MCP joint is flexed, the
tightness is released and it is possible passively to flex the
PIP joint.
References
Finochietto R. Retraccion de Volkman de los musculos intrinsicos de
los manos. Bol Trab Soc Circ Buenos Aires 4:31, 1920.
Smith RJ. Intrinsic muscles of the fingers: function, dysfunction, and
surgical reconstruction. Instr Course Lect 24:200–219, 1975.
JEANNE’S SIGN
Definition
Jeanne’s sign is hyperextension of the thumb metacar-
pophalangeal (MCP) joint by 10 to 15 degrees during key
pinch.
Clinical Significance
Paralysis of the adductor pollicis, a stabilizer of the thumb
MCP joint during pinch, is a sign of ulnar nerve palsy.
Reference
Jeanne M. La deformation du pouce dans la paralysie cubitale. Bull
Mem Soc Chir Paris 41:703–719, 1915.
KAPANDJI’S TEST OR SYSTEM
Definition
This is a method of numeric documentation to evaluate
thumb pinch and opposition using landmarks on the
patient’s hand as reference points.
Technique
The examiner notes the ability or inability of the patient to
place the thumb tip to various numbered locations in the
hand as follows:
Position 0: lateral aspect of the index proximal phalanx
Position 1: lateral aspect of the index middle phalanx
Position 2: lateral aspect of the index distal phalanx
Position 3: tip of the index finger
Position 4: tip of middle finger
Position 5: tip of ring finger
Position 6: tip of small finger
Position 7: distal interphalangeal flexion crease of small
finger
Position 8: proximal interphalangeal flexion crease of
small finger
Position 9: metacarpophalangeal flexion crease of small
finger
Anatomic Signs, Syndromes, Tests, and Eponyms 683
Position 10: distal palmar crease at base of small finger
Clinical Significance
This test or system provides a numeric, standardized, objec-
tive method for noting thumb movement.
References
Kapandji AI. Cotation clinique de l’opposition et de la contreopposi-
tion du pouce. Ann Chir Main Memb Super 5:67–73, 1986.
Kapandji AI. Clinical evaluation of the thumb’s opposition. J Hand
Ther 5:102–106, 1992.
LANDSMEER’S LIGAMENT
History and Synonyms
This structure was first described by Weitbrecht in 1742
and was called the retinaculum tendini longi; Landsmeer
called it the oblique band of the retinacular ligament; Haines
called it the link ligament, and Littler the oblique retinacular
ligament. Today it is most commonly known as Landsmeer’s
ligament or the oblique retinacular ligament (ORL).
Definition and Anatomy
These are ligamentous bands on either side of the finger
that arise proximally from the distal aspect of the second
annular pulley and the adjacent distal third of the proximal
phalanx. They continue distally and obliquely across the
proximal interphalangeal (PIP) joint parallel to the lateral
bands and deep to the transverse retinacular ligament, and
then insert variably into the lateral bands at approximately
the level of the PIP joint or into the terminal tendon in the
distal half of the middle phalanx. Milford (1968) noted that
sometimes these fibers could be seen to continue at the lat-
eralmost part of the lateral band as it inserted into the dis-
tal phalanx. It is consistently palmar to the PIP and dorsal
to the distal interphalangeal (DIP) joint axis of rotation.
Clinical Significance
The ORL is said to coordinate movement of the interpha-
langeal joints because extension of the PIP joint places the
ORL under tension and acts as a dynamic tenodesis to aid
the conjoined or terminal tendon in extension of the DIP
joint. Based on this concept, the ORL is placed under ten-
sion with DIP joint flexion. Thus, it is stated that the ORL
does not permit easy active or passive flexion of the DIP
joint when the PIP joint is in extension. This may be
demonstrated on one’s finger by noting that active flexion
of the DIP usually is not possible until the PIP joint is
flexed (unless the PIP joint is supported in extension to
allow the powerful flexor digitorum profundus to overcome
684 Appendix
the normal situation). Although the structure and extent,
and thus the functional effect of the ORL may vary from
finger to finger, when thickened and contracted it may play
a role in PIP and DIP joint contracture, as noted in bou-
tonniere deformity.
References
Haines RW. The extensor apparatus of the finger. J Anat 85:251–259,
1951.
Landsmeer JMF. Anatomy of the dorsal aponeurosis of the human
finger and its functional significance. Anat Rec 104:31–44, 1949.
Littler JW. The finger extensor system: some approaches to the cor-
rection of its disabilities. Orthop Clin North Am 17:483–492,
1986.
Milford LW. Retaining ligaments of the hand. Philadelphia: WB Saun-
ders, 1968.
Weitbrecht J. Syndesmology (Historia ligamentum corporis humani,
1742). Kaplan EB, transl. Philadelphia: WB Saunders, 1969.
LINBURG-COMSTOCK ANOMALY
Definition
This anomalous intertendinous connection between the
flexor pollicis longus (FPL) and the index finger flexor dig-
itorum profundus (FDP) results in independent loss of
movement or excursion of the FPL. This is clinically mani-
fested by inability to flex the interphalangeal joint of the
thumb without flexion of the index finger distal interpha-
langeal joint.
Clinical Significance
This intertendinous connection, usually at the wrist or dis-
tal forearm level, may interfere with certain specific func-
tions, such as holding and simultaneously cocking the ham-
mer of a pistol. Linburg and Comstock found this anomaly
in 25% cadaver limbs. Although the FPL and FDP of the
index finger usually are independent, phylogenetically both
tendons are derived from a common mesodermal mass.
References
Linburg RM, Comstock BE. Anomalous tendon slips from the flexor
pollicis longus to the flexor digitorum profundus. J Hand
Surg[Am] 4:79–83, 1979.
Takami H, Takahashi S, Ando M. The Linburg Comstock anomaly:
a case report. J Hand Surg [Am] 21:251–252, 1996.
LUMBRICAL PLUS SYNDROME
Definition
Lumbrical plus syndrome is paradoxical extension of the
proximal interphalangeal (PIP) joint that occurs when flex-
ion of the finger is attempted.
Anatomy and Pathomechanics
If the profundus tendon is lacerated in the finger, the prox-
imal end of the tendon migrates proximally because of the
pull of its muscle belly. The lumbrical origin is carried prox-
imally and this increased tension on the lumbrical may pro-
duce increased tension in the lateral band and thus exten-
sion of the PIP joint.
This condition also may develop after amputations of the
distal phalanx. It may be noted with flexor tendon grafts that
are too long. Wrapping the lumbrical about the repair site of
a lacerated flexor tendon also may be a cause of lumbrical plus
if the lumbrical subsequently contracts or shortens.
Clinical Significance
This condition may be diagnosed if the intrinsic tightness
test is positive after a tendon graft, distal phalanx amputa-
tion, or flexor digitorum profundus tendon repair if the
patient demonstrates paradoxical extension of the PIP joint.
Although not a common condition, lumbrical plus may
provide an explanation for paradoxical extension of the PIP
joint in certain conditions.
References
Louis DS, Jebson PJL, Graham TJ. Amputations. In: Green DP,
Hotchkiss RN, Pederson WC, eds. Green’s operative hand surgery,
4th ed. New York: Churchill Livingstone, 1999.
Parkes A. The “lumbrical plus” finger. Hand 2:164–167, 1970.
LUNOTRIQUETRAL BALLOTTEMENT TEST
(MANEUVER)
Definition
This is a test or maneuver to demonstrate a strain or disso-
ciation between the lunate and triquetrum.
Technique
The lunate is stabilized between the thumb and index fin-
ger of one hand and then attempts are made to displace the
triquetrum and pisiform dorsally and then palmarly with
the other hand.
Clinical Significance
A positive test demonstrates pain, crepitus, or abnormal
movement and may indicate a partial tear or complete dis-
sociation based on the degree of mobility demonstrated.
References
Kleinman WB, Graham TJ. Distal ulnar injury and dysfunction. In:

Peimer CA, ed. Surgery of the hand and upper extremity. New York:
McGraw-Hill, 1996:667–709.
Reagan DS, Linscheid RL, Dobyns JH. Lunotriquetral sprains. J
Hand Surg [Am] 9:502–513, 1984.
MANNERFELT HYPERFLEXION SIGN
Definition
In low ulnar nerve palsy, with forceful pinch between the
thumb, index, and long fingers, the metacarpophalangeal
(MCP) joints of the index and long fingers have a ten-
dency to extend while the interphalangeal joints hyper-
flex.
Clinical Significance
In ulnar nerve palsy, although the first and second lumbri-
cals are not denervated, they are the only barrier against
clawing of the index and long fingers. During forceful
pinch between the thumb and first two fingers, they are
unable completely to replace the function normally per-
formed by the ulnar-innervated interosseous muscles, and
the MCP joints of these two fingers tend to hyperextend
and the interphalangeal joints hyperflex.
References
Mannerfelt L. Studies on the hand in ulnar nerve paralysis: a clinical-
experimental investigation in the normal and anomalous innerva-
tion. Acta Orthop Scand Suppl 87:17–34, 91, 1966.
Tubiana R, Thomine JM, Mackin E. Examination of the hand and
wrist, 2nd ed. St. Louis: Mosby, 1996.
MASSE’S SIGN
Definition
Masse’s sign is a loss of the normal transverse metacarpal
arch and loss of elevation of the hypothenar eminence.
Clinical Significance
Paralysis of the opponens digiti minimi and the diminished
range of flexion of the small finger metacarpophalangeal
joint results in flattening of the hand. This appearance of
flattening is increased by the atrophy in the ulnar-inner-
vated hypothenar and interosseous muscles and is a sign of
ulnar nerve palsy.
Reference
Masse L. Contribution a l’etude de l’action des interosseux. J Med
Bord 46:198–200, 1916.
Anatomic Signs, Syndromes, Tests, and Eponyms 685
MATEV’S SIGN
Definition
This is an erosion seen on radiography (a depression with
sclerotic margins) of the posterior surface of the medial epi-
condylar ridge of the humerus due to pressure from a
translocated median nerve that has been entrapped for a
prolonged period after posterior dislocation of the elbow.
Clinical Significance
This finding may represent a late indication for surgical
exploration in median nerve dysfunction after elbow dislo-
cation.
References
Hallet J. Entrapment of the median nerve after dislocation of the
elbow. J Bone Joint Surg [Br] 63:408–412, 1981.
Matev I. A radiologic sign of entrapment of the median nerve in the
elbow joint after posterior dislocation. J Bone Joint Surg [Br] 58:
353–355, 1976.
MONTEGGIA FRACTURE
Definition
This is a fracture of the proximal third of the ulna with
associated anterior dislocation of the radial head. The
mechanism of injury is a fall onto an outstretched hand
while the elbow is partially flexed.
Clinical Significance
The radial head dislocation must not be overlooked. Treat-
ment in adults usually is by internal fixation of the ulna and
closed reduction of the radial head
Reference
Monteggia GB. Istituzioni chirugiche, 2nd ed, vol 5. Milan: Maspero
e Buocher, 1814:129–131.
MUMENTHALER SIGN
Definition
When abduction of the small finger is attempted against
resistance, there is absence of skin dimpling in the proxi-
mal portion of the hypothenar eminence in the region of
the palmaris brevis (PB) muscle. Ordinarily, there is wrin-
kling or dimpling of the skin at the site of insertion of the
PB into the dermis on the ulnar side of the palm with this
maneuver.
686 Appendix
Clinical Significance
Contraction of the ulnar-innervated PB muscle when
abducting the small finger against resistance often results in
dimpling or wrinkling of the skin in the proximal portion
of the hypothenar eminence. If such a finding is absent, it
may indicate ulnar nerve compromise. Although the PB
typically (two-thirds) is innervated by a superficial branch
of the ulnar nerve, it also may be innervated by a branch
from the deep division or from a branch originating near
the superficial and deep branches, and thus may not always
provide specific information about the site of an ulnar nerve
lesion.
References
Mannerfelt L. Studies on the hand in ulnar nerve paralysis: a clinical-
experimental investigation in the normal and anomalous innerva-
tion. Acta Orthop Scand Suppl 87:17–34, 91, 1966.
Mumenthaler M. Die Ulnarisparesen. Stuttgart: G Thieme, 1961.
OBLIQUE RETINACULAR LIGAMENT
See Landsmeer’s Ligament.
OLLIER’S PHENOMENON
Definition
This is “dimpling” of the skin in the region of Guyon’s canal
when pressure is applied to the hypothenar eminence due to
compression of the fat in Guyon’s canal. In 1861, Guyon
presented to the Anatomical Society of Paris his account of
the anatomic arrangement of the anterior aspect of the
wrist, which since has come to be known as Guyon’s canal.
This study was apparently prompted by a finding observed
by Ollier and pointed out to Guyon. Ollier’s phenomenon,
according to Ollier, was the appearance of two or three
swellings beneath the skin, like the edge of a distended sac,
when pressure was applied to the hypothenar eminence and
their disappearance when the pressure was released. Guyon
made his dissections to determine whether the swellings
were due to fat or “a condition of the synovial tendon
sheaths.”
Clinical Significance
Guyon’s investigation of Ollier’s phenomenon is a prime
example of the role of anatomy in the advancement of
surgery (see Guyon’s Canal).
References
Denman EE. The anatomy of the space of Guyon. Hand 10:69–76,
1978.
Guyon F. Note sur une disposition anatomique propre a la face
antereriure de la region du poiget et non encore decrite. Bull Soc
Anat Paris 6:184–186, 1861.
PARONA’S SPACE
Definition
This is a non–synovial-lined space on the flexor side of the
wrist located between the flexor tendons and the pronator
quadratus muscle. It is bounded radially by the flexor carpi
radialis and ulnarly by the flexor carpi ulnaris and ante-
brachial fascia.
Clinical Significance
In 85% of Scheldrup’s (1951) study of 367 hands, there was
a natural connection between the radial and ulnar bursa at
the wrist. Parona’s space, located between the radial and
ulnar bursa, thus has the theoretic potential to act as a con-
duit between these two structures and produce the so-called
horseshoe abscess.
References
Parona F. Dell’oncotomia negli accessi profundi diffusi dell’avambra-
chio. Annali Universali di Medicina e Chirurgia, Milano, 1876.
Scheldrup EW. Tendon sheath patterns in the hand: an anatomical
study based on 367 hand dissections. Surg Gynecol Obstet
93:16–22, 1951.
PHALEN’S TEST
Definition
This is a wrist flexion test to aid in the diagnosis of carpal
tunnel syndrome.
Technique
The wrist is maintained in full flexion for 60 seconds, and
the test is considered to be positive when the patient feels
symptoms similar to his or her nocturnal symptoms (pares-
thesias in the median nerve distribution).
Clinical Significance
The effect of wrist flexion is to increase pressure in the
carpal tunnel. The greater the slowing of nerve conduction,
the more likely Phalen’s test will be positive. However, some
patients with carpal tunnel syndrome have a negative
Phalen’s test, and some normal (asymptomatic) patients
have a positive test.

References
Bauman TD, Gelberman RH, Mubarak SJ, et al. The acute carpal
tunnel syndrome. Clin Orthop 156:151–156, 1981.
Phalen GS. The carpal tunnel syndrome: seventeen years experience
in diagnosis and treatment of six hundred fifty four hands. J Bone
Joint Surg Am 48:211–228, 1966.
PITRES-TESTUT SIGN
Definition
The transverse diameter of the hand is decreased. Radial or
ulnar abduction of the extended long finger is impossible,
and there is inability to bring the tips of the extended dig-
its together into a cone.
Clinical Significance
Severe atrophy of the ulnar-innervated hand muscles
results in loss of breadth or diameter of the hand. Because
of paralysis of the second and third dorsal interosseous
muscles, the extended long finger cannot be abducted to
either side. In ulnar nerve palsy, there is paralysis of the
adductor pollicis muscle as well as the hypothenar and
interosseous muscles, which, along with the claw defor-
mity of the ring and small fingers, makes it impossible to
form the digits into a cone.
Reference
Pitres A, Testut L. Les nerfs en schemas. Paris: Doin, 1925.
POLLOCK’S SIGN
Definition
This is the inability to flex the distal interphalangeal (DIP)
joint of the small finger.
Clinical Significance
Paralysis of the flexor digitorum profundus (FDP) of the
small finger due to ulnar nerve palsy results in loss of flex-
ion of the DIP joint of this finger and indicates an ulnar
nerve lesion in or proximal to the forearm. Although the
FDP of the ring finger also may be denervated, it may share
some innervation from the median nerve, and thus the sign
probably is more reliable as originally described (i.e., small
finger FDP only).
Reference
Pollock LJ. Supplementary muscle movements in peripheral nerve
lesions. Arch Neurol Psychiatry 2:518–531, 1919.
Anatomic Signs, Syndromes, Tests, and Eponyms 687
PRONATOR QUADRATUS SIGN
Definition
A radiolucent plane overlying the palmar aspect of the
pronator quadratus (PQ) was described by MacEwan in
1964 associated with undisplaced fractures of the distal
radius and ulna, septic arthritis of the wrist, or
osteomyelitis of a nearby bone. This radiolucent shadow,
seen on the lateral radiograph of the wrist, may change in
shape or position from its normal thin triangle with its
base distal and in contact with the palmar lip of the
radius to having its base reversed or its shadow displaced
palmarward.
Clinical Significance
Based on a study by Sasaki and Sugioka (1989), the PQ
sign was positive in 85% and 88%, respectively, of fresh
undisplaced fractures of the distal radius and acute
injuries of the distal radioulnar joint. In rheumatoid
arthritis with synovitis of the wrist joint, the shadow may
be blurred at the distal end of the radius. Thus, the PQ
sign may aid in the diagnosis of potentially occult injuries
about the wrist, infection in and about the wrist, and syn-
ovitis of the wrist joint.
References
MacEwan DW. Changes due to trauma in the fat plane overlying the
pronator quadratus muscle: a radiologic sign. Radiology 82:
879–886, 1964.
Sasaki Y, Sugioka Y. The pronator quadratus sign: its classification
and diagnostic usefulness for injury and inflammation of the
wrist. J Hand Surg [Br] 14:80–83, 1989.
ROLANDO FRACTURE
Definition
This is a “Y”-shaped, intraarticular fracture of the base of
the thumb metacarpal. Unlike Bennett’s fracture, there is
little tendency for the metacarpal to dislocate.
Clinical Significance
Nondisplaced fractures usually are managed by closed
methods. Displaced fractures may require open reduction
and internal fixation.
Reference
Rolando S. Fracture de la base du premier metacarpien. Presse Med
18:303–304, 1910.
688 Appendix
ROOS TEST [ELEVATED ARMS STRESS TEST
(EAST)]
Definition
This test is said by Roos to be the most reliable test for eval-
uation of the thoracic outlet compression syndrome,
including neurologic, venous, and arterial types.
Technique
The patient’s arms are placed in the “surrender” position
(arms elevated and elbows flexed to 90 degrees and the arm
externally rotated) for 3 minutes. During this time, the
patient opens and closes the hands every 2 seconds and
describes any symptoms that develop.
Clinical Significance
This position tends to close the costoclavicular space and
tense the neck and shoulder muscles to create the abnormal
compression mechanisms that may compress the brachial
plexus and subclavian vessels. In neurologic compression,
there may be a tingling sensation in the hand and forearm
with an aching sensation that makes the patient want to
lower the arms. In venous compression, the arm may
become cyanotic and the forearm and wrist veins distended.
In arterial compression, the radial pulse may be diminished
or occluded with signs of ischemia, and the arms may fall.
Reference
Roos DB. Thoracic outlet syndrome: update. Am J Surg 154:
568–573, 1987.
SEYMOUR’S FRACTURE
Definition
Seymour’s fracture is an epiphyseal fracture of the base of
the distal phalanx in a child with dorsal dislocation of the
nail plate and disruption of the nail matrix.
Clinical Significance
Physeal fracture of the distal phalanx of the finger as described
by Seymour (1966) is easily diagnosed because of the dislo-
cated nail plate that is dorsal to the proximal nail fold. The
injury by definition results in disruption of the nail matrix;
anatomic reduction of both the nail plate and nail matrix is
required. Toddlers may sustain a Salter type I injury of the dis-
tal phalanx without dislocation of the nail plate, which may
be missed initially because of the absence of the dislocated nail
plate. If untreated, this injury may result in derangement of
extensor tendon function, growth deformity of the distal pha-
lanx, and disruption of articular relationships.
References
Seymour N. Juxta-epiphyseal fracture of the terminal phalanx of the
finger. J Bone Joint Surg Br 347–349, 1966.
Waters PM, Benson LS. Dislocation of the distal phalanx epiphysis in
toddlers. J Hand Surg[Am] 18:581–585, 1993.
SKIER’S THUMB
Definition
Acute disruption of the ulnar collateral ligament (UCL) of
the metacarpophalangeal (MCP) joint of the thumb with or
without an avulsion fracture (see also Stener Lesion).
Clinical Significance
Avulsion of the UCL of the thumb MCP joint may occur
from a variety of mechanisms that produce a radial deform-
ing force at the MCP joint of the thumb. This injury often
is seen in snow skiers as a result of pole injury or falls, hence
its name.
Reference
Frykman G, Johansson O. Surgical repair of rupture of the ulnar col-
lateral ligament of the metacarpophalangeal joint of the thumb.
Acta Chir Scand 112:58–64, 1956.
SMITH’S FRACTURE
Definition
This is a fracture of the palmar aspect of the distal radius
with proximal displacement of the fracture fragment and
dorsal displacement of the distal ulna.
Clinical Significance
Smith distinguished this fracture from a carpal dislocation
and accurately described its nature based on the clinical
deformity, the relative ease of reduction followed by recur-
rence of the deformity after release of traction, the presence
of crepitus with traction, and the palpable and irregular
margin of the radius.
References
Smith RW. A treatise of fractures in the vicinity of joints and on certain
forms of accidental and congenital dislocation. Philadelphia: Lea and
Blanchard, Hodges and Smith, 1847:162.
Smith RW. Fractures in the vicinity of joints and on certain forms of acci-
dental and congenital dislocation. Philadelphia: Lea and Blanchard,
Hodges and Smith, 1850.

STENER LESION
Definition
In 1962, Stener described complete rupture of the ulnar
collateral ligament (UCL) at the thumb metacarpopha-
langeal (MCP) joint, with interposition of the adductor
aponeurosis between the distally avulsed UCL and its site of
insertion and associated instability of the MCP joint. This
configuration is easy to understand based on the fact that
the UCL is deep to the adductor aponeurosis and with avul-
sion is carried proximally, while the leading edge of the
adductor aponeurosis is carried distally by the deforming
force of injury. When the force abates and the proximal
phalanx returns to its normal alignment, the UCL is exter-
nal rather than deep to the adductor aponeurosis.
Clinical Significance
The recognition of complete (the Stener lesion) versus par-
tial tears of the UCL may aid the surgeon in selection of a
treatment plan based on the surgeon’s personal preference
and experience and the patient’s needs.
Reference
Stener B. Displacement of the ruptured ulnar collateral ligament of
the metacarpophalangeal joint of the thumb: a clinical and
anatomical study. J Bone Joint Surg Br 44:869–879, 1962.
STRUTHERS’ LIGAMENT
Definition
The ligament of Struthers is an anomalous structure that
spans between a supracondylar process on the anteromedial
aspect of the humerus and the medial epicondyle, and thus
creates an arcade that contains the median nerve and
brachial artery.
Clinical Significance
The median nerve may be compressed beneath the ligament
of Struthers with symptoms that may include aching pain
in the region of the elbow and diminished sensibility in the
median nerve distribution in the hand. Weakness of grip
may be noted, and sometimes the supracondylar process
may be palpable (see also Arcades of Struthers). The liga-
ment of Struthers is a component of arcade VIII of the
median nerve/brachial artery type arcades as originally
described by Struthers in 1854.
References
Al-Qattan MM, Husband JB. Median nerve compression by the
supracondylar process: a case report. J Hand Surg [Br] 16:
101–103, 1991.
Anatomic Signs, Syndromes, Tests, and Eponyms 689
Smith RV, Fisher RG. Struthers’ ligament: a source of median nerve
compression above the elbow. J Neurosurg 28:778–779, 1973.
Struthers J. On some points in the abnormal anatomy of the arm. Br
Foreign Med Chir Rev 14:170–179, 1854.
Vesley DG, Killian JT. Arcades of Struthers. J Med Assoc State Al
52:33–37, 1983.
STRUTHERS’ ARCADE
Definition
The arcade of Struthers is a fibrous tissue structure in the
arm that occurs 8 cm proximal to the medial epicondyle. It
arises from the medial intermuscular septum, crosses over
the ulnar nerve, and inserts into the fascial elements of the
medial head of the triceps. It is in fact arcade I of the ulnar
nerve type of arcades in the arm as originally described by
Struthers in 1854 (see Arcades of Struthers).
Clinical Significance
The arcade of Struthers may be a factor in compression of
the ulnar nerve in the arm.
References
Al-Qattan MM, Murray KA. The arcade of Struthers: an anatomical
study. J Hand Surg [Br] 16:311–314, 1991.
Struthers J. On some points in the abnormal anatomy of the arm. Br
Foreign Med Chir Rev 14:170–179, 1854.
SUNDERLAND’S SIGN
Definition
This is the inability to rotate, oppose, or supinate the small
finger toward the thumb during attempted opposition of
the thumb to the small finger.
Clinical Significance
This is a sign of ulnar nerve dysfunction due to paralysis of
the ulnar-innervated hypothenar muscles (abductor digiti
minimi, flexor digiti minimi, opponens digiti minimi).
Reference
Sunderland S. The significance of hypothenar elevation in movements
of opposition of the thumb. Aust N Z J Surg 13:155–156, 1944.
TERRY THOMAS SIGN
Definition
This is separation of the proximal pole of the scaphoid and
adjacent lunate as seen on an anteroposterior radiograph of
the wrist.
690 Appendix
Clinical Significance and Historical Note
This separation indicates a rotatory subluxation of the
scaphoid in which the proximal pole of the scaphoid is dis-
placed dorsally, a condition called scapholunate dissociation
(SLD). This is seen on anteroposterior radiographs as a
wide separation between the proximal pole of the scaphoid
and the lunate. Victor Frankel (1959) noted the similarity
between the dental diastema of the British comedian, Terry
Thomas, and the clinical entity of rotatory subluxation of
the scaphoid (SLD). He used Mr. Thomas’ dental diastema
as a useful anthropomorphic sign to be applied to the diag-
nosis of this wrist condition.
References
Frankel VH. The Terry-Thomas sign. Clin Orthop 129:321–322,
1977.
Thomas T. Filling the gap. Toronto: Clarke Irwin, 1959.
THURSTON HOLLAND’S FRAGMENT
Definition
This is a triangular metaphyseal fragment that accompanies
the epiphysis in a displaced epiphyseal fracture separation.
Clinical Significance
This fragment may be used to assess the accuracy of reduc-
tion after Salter type II fractures.
Reference
Holland CT. A radiographical note on injuries to the distal epiphysis
of the radius and ulna. Proc R Soc Med 22:695–700, 1929.
WARTENBERG’S SIGN
Definition
The small finger assumes an abducted posture and there is
inability to adduct the extended small finger to the
extended ring finger.
Clinical Significance
This posture of the small finger is seen in ulnar nerve palsy
and is due to the action of the extensor digiti minimi (EDM),
which is unopposed by the ulnar-innervated third palmar
interosseous. Gonzalez and associates (1995) studied the
extensor tendons to the small finger in 50 specimens and
noted that only 22 of the specimens had either an attachment
of the EDM to the abductor tubercle on the proximal phalanx
(10 specimens) or an unbalanced ulnar slip of the EDM (12
specimens), which would account for Wartenberg’s sign in
ulnar nerve dysfunction. This 44% incidence would explain
why Wartenberg’s sign is not always present even in complete
lacerations of the ulnar nerve.
References
Gonzalez MH, Gray T, Ortinau E, et al. The extensor tendons to the lit-
tle finger: an anatomic study. J Hand Surg [Am] 20:844–847, 1995.
Wartenberg R. A sign of ulnar palsy. JAMA 112:1688, 1939.
WARTENBERG’S SYNDROME
Definition
Wartenberg in 1932 described an isolated neuritis of the
superficial radial nerve in the distal forearm, which he
called cheiralgia paraesthetica, in five patients. The condi-
tion is characterized by persistent pain on the dorsal radial
surface of the distal forearm with radiation into the thumb,
index, and middle fingers. This isolated neuritis is associ-
ated with sensitivity to percussion over the radial nerve in
the region of the radial styloid along the dorsal aspect of the
brachioradialis muscle.
Clinical Significance
Isolated neuritis of the superficial branch of the radial nerve
may be associated with hemorrhage in the proximal fore-
arm, tumors of or about the radial nerve, and thrombosis of
the radial recurrent vessels. Neuritis also may be associated
with variety of traumatic or iatrogenic causes, including a
direct blow to the nerve, tight watchbands or jewelry, hand-
cuffs, or injury due to laceration or compression from
retraction during surgery.
References
Ehrlich W, Dellon AL, Mackinnon SE. Chieralgia paresthetica
(entrapment of the radial sensory nerve). J Hand Surg [Am]
11:196–199, 1986 [This article contains a translation in con-
densed form of Wartenberg’s original German text].
Wartenberg R. Cheiralgia paraesthetica (Isolierte Neuritis des Ramus
Superficialis Nervi Radialis). Z Ges Neurol Psychiatr 141:
145–155, 1932.
WATSON’S TEST (SCAPHOID SHIFT TEST)
Definition
This is a maneuver to evaluate the scapholunate joint of the
wrist.
Technique
Firm pressure is applied by the examiner’s thumb to the pal-
mar side of the distal pole of the scaphoid while the other
hand moves the wrist from ulnar to radial deviation.

Clinical Significance
In normal wrists, the scaphoid cannot flex because of the
pressure from the examiner’s thumb. This may produce
pain on the dorsal aspect of the wrist because of synovial
irritation at the scapholunate junction. A positive test is
seen in patients with a scapholunate tear or in hypermobile
(lax) joints. In scapholunate tear, the proximal pole of the
scaphoid migrates out of the scaphoid fossa, and when pres-
sure on the scaphoid is removed, it snaps back into position.
Reference
Watson HK, Ashmead D IV, Makhlouf MV. Examination of the
scaphoid. J Hand Surg [Am] 13:657–660, 1988.
WRIGHT’S TEST
Definition
This is an arm hyperabduction maneuver for diagnosis of
thoracic outlet compression syndrome.
Technique
The arm is externally rotated and abducted 180 degrees
with the elbow flexed. The patient is asked to inhale deeply
and the radial pulse is palpated. Diminution of the radial
pulse is considered to be a positive test, along with numb-
ness and tingling in the hand and weakness in the arms.
Clinical Significance
During hyperabduction, the costoclavicular space may be
narrowed by the upward and posterior movement of the
Anatomic Signs, Syndromes, Tests, and Eponyms 691
clavicular space. Neurovascular compression may occur
beneath a taut pectoralis minor muscle near its insertion.
References
Atasoy E. Thoracic outlet compression syndrome. Orthop Clin
North Am 27:265–303, 1996.
Wright IS. The neurovascular syndrome produced by hyperabduction
of the arms: the immediate changes produced in 15 normal con-
trols, and the effect on some persons of prolonged hyperabduction
of the arms, as in sleeping, and certain occupations. Am Heart J
29:1, 1945.
YERGASON’S TEST (SUPINATION SIGN)
Definition
This is a test for or a sign of tenosynovitis of the long head
of the biceps tendon.
Technique
The elbow is flexed to 90 degrees and the examiner holds
the forearm in pronation and asks the patient actively to
supinate the forearm against resistance. A positive test is
manifested by pain localized to the bicipital groove.
Clinical Significance
The biceps is the main supinator of the forearm, and its
action against resistance in the presence of tenosynovitis of
its long head results in localized pain in the bicipital groove.
Reference
Yergason RM. Supination sign. J Bone Joint Surg 13:160, 1931.
SUBJECT INDEX
 Page numbers followed by “f ” indicate an illustration; page numbers followed by “t” indicate a table.
A Adductor pollicis muscle, 154–155, 182t,
Abductor digiti minimi muscle, 155–156,
182t, 583, 583f
accessory, 214
transfer of, 682
Abductor indicis muscle, 161–162, 587
Abductor pollicis brevis muscle, 149–152,
182t, 582–583, 582f
actions and biomechanics of, 150, 151f
anomalies and variations of, 152
clinical correlations of, 152
gross anatomy of, 149–150
innervation of, 211
Abductor pollicis longus bursitis
(intersection syndrome), 133, 134,
146–148, 480, 482f, 483
Abductor pollicis longus muscle, 145–147,
181t, 465f, 466
innervation of, 427, 428t
in intersection syndrome, 480, 482f,
483
as landmark, 461, 462f
Abductor pollicis longus tendon, de
Quervain’s tenosynovitis of,
476–477, 477f, 478f
Abductor pollicis tertius muscle, 146
Accessories ad flexoram digiti minimi
muscle, 119
Accessory bone(s). See specific bones and
accessory bone names
Accessory muscle(s). See specific muscles
Acromial branch, of thoracoacromial artery,
241
Acromial portion, of clavicle, 4, 4f, 5f
Acromioclavicular joint, 5–6, 6f, 17
separation of, 7–8
Acromioclavicular ligament, 6, 6f
Acromion
as landmark, 315, 317f
ossification center for, 8–9, 9f
osteology of, 10, 10f–14f, 15t
Adductor compartment, compartment
syndrome of, 634, 634f, 635f
of forearm, 414–416, 415f
582–583, 582f as nerve graft, 444, 445f
Adductor (deep palmar radial) space, 604 surgical exposures for, 444, 445f
Adson’s maneuver (test), 669 medial, 224–225, 321, 322f–325f, 329f,
AIN. See Interosseous nerve(s), anterior 413–414, 415f
Alar thoracic artery, 243 anomalies and variations of, 204–205,
Allen test, 260, 669–670 223, 321
Ames classification, of thumb arterial anterior branch of, 223
patterns, 563–564, 563f in brachial plexus, 304f, 306
Anastomosis. See also specific arches clinical correlations of, 223–224
brachial artery, 247 course of, 200, 201f–203f, 204, 223
Froment-Rauber, 219 as nerve graft, 321
Martin-Gruber. See Martin-Gruber origin of, 223
anastomosis posterior (ulnar) branch of, 223
Riche-Cannieu, 163, 197–198, 211, posterior, 323f
636–637, 636f, 637f, 673–674 Antebrachial vein, median, 271, 272, 273f,
Anatomic neck, of humerus, 18, 20, 20f, 276, 320f, 413, 414f
21f, 25 Antecubital fossa
Anatomic snuffbox, 148–149, 262–263, arteries in, 423–424, 424f, 425f
486–487, 487f, 642 contents of, 423
Anconeus epitrochlearis muscle, 124, 208, landmarks of, 422, 424f
405, 456 median nerve in, 431, 432f
Anconeus muscle, 105–106, 180t, 461, muscles of, 422–423, 424f
463f, 464f, 465 surgical exposures for, 435–437, 435f, 436f
Anconeus sextus muscle, 106 zones of, 422–423, 424f
Andre-Thomas sign, 670, 676 Anterior interosseous nerve. See Interosseous
Aneurysm nerve(s), anterior
of radial artery, 269 Anterior interosseous nerve syndrome, 127,
of ulnar artery, 260 129, 193, 446–449
Angle(s) compression sites in, 447, 448f, 449
of attack, in intrinsic muscles, 588f, 589 differential diagnosis of, 194, 447
Baumann’s, 386, 387f pathogenesis of, 449
carrying, of elbow, 365–366 treatment of, 449
of scapula, 8–9, 9f–14f, 16–17 Anterior ligament, of elbow, 370–371
Annular ligament, of radius, 31f, 32f, Anterior oblique ligaments, of thumb,
370–371, 371f, 373f 538–540, 538t, 539f
Annular pulleys, 600–602, 600f Apical (subclavicular) group of axillary
Antebrachial cutaneous nerve lymph nodes, 280f, 281
lateral, 321, 322f, 323f APL muscle. See Abductor pollicis longus
anomalies and variations of, 223 muscle
in antecubital fossa, 424f Aponeurosis
clinical correlations of, 223 dorsal, 590–592, 590f, 591f
course of, 222–223 extensor, 135–136, 136f, 137f
696 Subject Index
Arcade(s), 356–362
in brachial artery anastomoses, 247
of Frohse, 144–145, 217, 429–430, 429f,
670
radial nerve branches above, 429, 430f
radial nerve compression by, 478, 479f
of nail unit, 655, 655f
of Struthers, 204, 205, 356–362,
670–671, 689
clinically significant, 356, 359f–361f,
361–362, 670–671
I to IV, 357f–358f, 360t, 671
ulnar nerve and, 362f, 362, 671,
389–390, 389f–391f
VII, 356, 361, 361f, 670
VIII, 360f, 360t, 361–362, 361f, 670
V to VII, 359f, 360t
venous, metacarpal, 644, 644f, 645f
Arches
of hand, 536, 536f
vascular. See specific arches
Arcuate artery, of humeral head, 332, 333f
Arm, 315–364. See also Forearm; specific
structures
anatomic relationships of, 320–341
brachial artery. See Brachial artery
cutaneous nerves, 321, 322f–325f, 325
humeral arterial supply, 332, 333f, 334
intermuscular septa, 327, 329f–331f,
394–395, 394f–396f
median nerve. See Median nerve, in
axilla and arm
muscles, 325–327, 326f, 328f
musculocutaneous nerve. See
Musculocutaneous nerve
radial nerve. See Radial nerve
veins, 320, 320f
anomalies and variations of, 356,
357f–361f, 360t, 361–363
anteromedial, landmarks of, 315, 318f
arcades of, anomalies and variations of,
356, 357f–361f, 360t, 361–362
clinical correlations of, 355–356
descriptive anatomy of, 315–318,
316f–319f
landmarks of, 315, 316f–318f
lateral, landmarks of, 315, 316f
medial cutaneous nerve of (medial
brachial cutaneous nerve), 223–224
median nerve in. See Median nerve, in
axilla and arm
muscles of, 325–327, 326f, 328f. See also
specific muscles
nerves of. See also specific nerves
cutaneous, 321, 322f–325f, 325
neurovascular structures of, 327–341. See
also specific arteries and nerves
posterior, landmarks of, 315, 317f
skeletal anatomy of, 315, 317–318, 319f.
See also Humerus
surgical exposures for, 341–353
anterior approach to humerus, 341,
342f–344f
anterolateral approach to distal
humerus, 341, 343, 345, 345f,
346f
medial approach, 346, 347, 347f–349f,
351
posterior approach, 351–353,
350f–353f
proximal posterior approach to
humerus, 353, 354f, 355f
ulnar nerve in. See Ulnar nerve, in axilla
and arm
vasculature of. See specific arteries and
veins
veins of, 320, 320f. See also Brachial
veins; Cephalic vein
Arteria antebrachialis superficialis dorsalis,
268
Arteria radialis superficialis, 268
Arteriovenous gradient theory, of
compartment syndrome, 449
Artery(ies)
alar thoracic, 243
of antecubital fossa, 423–424, 424f,
425f
arcuate, of humeral head, 332, 333f
axillary. See Axillary artery
brachial. See Brachial artery
carpal, recurrent, 238f, 267f
cervical, 301, 302f
circumflex subscapular, 238f, 239f, 242
digital. See Digital artery(ies)
of digital web spaces, 560
of elbow, 368, 368f–369f, 370, 370t
extensor compartment, 515, 516f
of fingers, 560–568, 561f, 562t, 563f,
565f, 567f. See also specific arteries
of forearm, 197, 431, 434f
of hand, 549–568
humeral circumflex, 238f, 239f,
242–244, 331f, 332, 333f
intercarpal, 45–46, 46f–49f, 511
intercompartmental, of wrist, 514–516,
516f, 517f
interosseous. See Interosseous artery(ies)
lumen diameters of
digital, 562, 562t
in hand, 256t, 559, 559t
main trunks of, 238f
median. See Median artery
metacarpal. See Metacarpal artery(ies)
of nail unit, 655–656, 655f
nutrient, 246, 332, 333f
palmar, 261, 509, 509f
of phalanges, l, 655–656, 655f
pollicis, 253f, 255f, 265f, 507f, 508f,
551f
princeps pollicis, 266, 267f, 269, 562
radial. See Radial artery
radial index, 259, 266–267, 562
radial recurrent. See Radial recurrent
artery
subclavian, 299f, 300f, 301f, 302f
subradicular, 301
subscapular, 238f, 239f, 241–243
supraretinacular, 514–515, 516f
suprascapular, 302f, 305
thoracic, 238f, 239f, 240–241, 243
thoracoacromial, 238f, 239f, 241
thoracodorsal, 238f, 239f, 242
thoracoepigastric, 243
of thumb, 562–568, 563f, 565f, 567f
ullnar collateral. See Ulnar collateral
arteries
ulnar. See Ulnar artery
ulnar recurrent. See Ulnar recurrent
artery(ies)
ulnodorsal digital, 567
ulnopalmar digital, 566
vs. veins, 270
of wrist. See Wrist, vascular anatomy of
Arthritis, of radioulnar joint, 36
Arthroplasty, of metacarpophalangeal joint,
656, 657f
Articular branches, of ulnar nerve, 204
Articular disc, of sternoclavicular joint, 6–7,
6f
Articularis cubiti, 104
Articular nerves, 573
Avascular necrosis
of carpus, 513–514
of lunate, 514
of scaphoid, 49, 514
Axilla
median nerve in. See Median nerve, in
axilla and arm
musculocutaneous nerve in, 222
ulnar nerve in. See Ulnar nerve, in axilla
and arm
Axillary artery, 237–244, 305
anomalies and variations of, 243
anterior humeral circumflex branch of,
238f, 239f, 242, 243
branches of, 238f, 239f, 240t, 240–243
circumflex scapular branch of, 238f, 239f,
242
clinical correlations of, 243–244
course of, 238–240, 238f, 239f
first (proximal) part of, 237, 238f, 239f,
240t
gross anatomy of, 237–240, 238f, 239f,
240t
high division of, 243, 244
injury of, 244
lateral thoracic artery branch of, 238f,
239f, 241, 243
posterior humeral circumflex branch of,
238f, 239f, 242–243

second (posterior) part of, 238f,
239–240, 239f, 240t
subscapular branch of, 238f, 239f,
241–243
superior thoracic artery branch of, 238f,
239f, 240–241
third (distal) part of, 238f, 239f, 240,
240t
thoracoacromial artery branch of, 238f,
239f, 241
thoracodorsal branch of, 238f, 239f, 242
Axillary lymph nodes, 279f, 280–281, 280f
Axillary nerve, 305f
anomalies and variations of, 314
in brachial plexus, 306
compression of, 244
in deltoid muscle innervation, 92–93
injury of, 310–311, 311f
surgical exposure for, 310–311
Axillary vein, 275f, 276, 300f
Axis of rotation, of elbow, 374, 374f
B in antecubital fossa, 424f, 425f
Backfire fracture, 41, 675
Bado classification, of ulnar fractures, 35
Bankart lesion, 26
Barton’s fracture, 41, 671
reverse, 671
Basal metacarpal arch, 48f, 255f, 265–266,
265f
Baseball (mallet) finger, 652, 653f, 658
Basilic vein, 272, 271f–275f, 274, 320,
320f, 324f
absence of, 276
in axilla and arm, 329f
in forearm, 413, 414f
median, 276
venous arches connected to, 644, 645f
Baumann’s angle, 386, 387f
Beak ligament, of thumb, 540
Bennett’s fracture, 671–672
Berrettini, palmar ulnar-median
communicating branch of, 198, 199
Biceps brachii muscle, 98–101, 99f, 180t,
325, 326f
accessory humeral head of, 362
groove of, as landmark, 315, 316f, 318f
innervation of, 336, 338f
as landmark, 315, 316f, 318f
Biceps brachii tendon
in antecubital fossa, 424f
as landmark, 408, 408f
repair of, 451, 452f
rupture of, at distal insertion, 451, 452f
Bicipital groove, 20, 21f, 23
Bipartite hamulus, 529
Bipartite scaphoid, 44, 50, 529
Bone(s). See Skeletal system; specific bones
Bone grafts, vascularized
radial artery in, 269
for scaphoid nonunion, 517
Boutonniere deformity, 652, 653f, 658–660
Boyes test for, 672
definition of, 658
diagnosis of, 658–659, 659f
Elson test for, 677
Haines-Zancolli test for, 680–681
pathomechanics of, 660
physical findings in, 658
vs. pseudoboutonniere deformity, 660
treatment of, 660
Bouvier’s sign, 672
Bowers approach, to distal radioulnar joint,
517–519, 518f, 519f
Bowler’s thumb, 672
Boyes test, 672
Brachial artery, 244–248, 324f, 327–328,
329f–331f
agenesis of, 248
anastomoses of, 247
anomalies and variations of, 247–248,
362–363
in arcade of Struthers, 356, 357f–361f,
360t, 361–362
branches of, 238f, 239f, 245–247, 245f,
240t, 331f
clinical correlations of, 248
in collateral circulation, 248
compression of, 248
in arcade of Struthers, 361–362, 361f
course of, 239f
deep (profunda), 238f, 239f, 245–246,
245f, 331f
accessory arteries from, 332, 333f
in forearm, 434f
gross anatomy of, 244, 245f
high division of, 247, 363
low division of, 363
median nerve near, 340–341, 340f
muscular branches of, 247
protection of, in elbow surgery, 379–380,
381f
superficial, 362–363
surgical exposures for, 346–347,
347f–349f, 351
Brachial cutaneous nerve(s), 202f–203f
intercostal, 323f
lateral, 323f
medial, 223–224, 321, 322f, 325, 329f,
415f
in brachial plexus, 304f, 306
Brachialis muscle, 101–103, 180t, 325–326,
326f, 327f
anomalies and variations of, 362
in antecubital fossa, 424f
capsularis, 103
innervation of, 336, 338f, 340
as landmark, 316f
Brachial lymph vessels, 278
Subject Index 697
Brachial plexus, 186f, 297–314
anatomic relationships of, 297, 300–306
branches, 301f, 303f, 304f, 306
cords, 300f, 301f, 303f–305f,
305–306, 309, 314
divisions, 301f, 305, 305f
roots, 300–301, 301f–303f, 303–304,
308f
trunks, 301f, 303f–305f, 304–305,
308f
anomalies and variations of, 185–186,
312, 313f, 314
clavicle relationship to, 7
clinical correlations of, 310–312, 311f
cords of, 300f, 301f, 303f–305f,
305–306, 309, 314
descriptive anatomy of, 297, 298f, 299f
divisions of, 301f, 305, 305f
infraclavicular portion of
anatomy of, 311f
surgical exposures for, 308–310, 308f
injuries of, 303, 310–312, 311f
Horner’s syndrome in, 682
medial brachial cutaneous nerve origin in,
223
median nerve origin in, 185, 186f
musculocutaneous nerve origin in, 222
nerves arising from, 302f
paralysis of, 101, 677
postfixed, 297, 312
prefixed, 297, 312
radial nerve origin in, 214
Randy Travis Drinks Cold Beer
mnemonic for, 297
rootlets of, 300
injury of, 308f
roots of, 300–301, 301f–303f, 303–304,
308f
supraclavicular portion of, 302f,
306–308, 306f
suprascapular portion of, 302f
surgical exposures for, 298f, 299f,
306–310
infraclavicular, 308–310, 308f
limited cosmetic incision in, 308
supraclavicular, 306–308, 306f
trunks of, 301f, 303f–305f, 304–305,
308f
ulnar nerve origin in, 200, 201f, 204
vascular structures associated with, 302f,
303
Brachial veins, 274f, 275f, 276
Brachiofascialis muscle of Wood, 103
Brachioradialis brevis muscle, 109, 455
Brachioradialis muscle (supinator longus
muscle), 106–110, 416, 417f
actions and biomechanics of, 108–109
anomalies and variations of, 109–110,
109f, 455
clinical implications of, 110
698 Subject Index
Brachioradialis muscle (supinator longus
muscle) (contd.)
as donor muscle, 110
gross anatomy of, 106–108
innervation of, 428t
as landmark, 316f, 318f
in “mobile wad of three,” 408, 408f, 422,
422f, 461, 462f
Brewerton view, in radiography, 672–673
Bunnell’s “O” test, 673
Bunnell’s “scrape” test, 673
Bunnell’s test, 594, 594f
Bursa, of flexor tendon sheath, 602–603,
603f
Bursitis, abductor pollicis longus
(intersection syndrome), 133, 134,
146–148, 480, 482f, 483
C contents of, 504
Calcification, heterotopic, of elbow, 405
Camper’s chiasma, 121, 607f, 608, 608f
Cannieu-Riche anastomosis, 163, 197–198,
211, 636–637, 636f, 637f, 673–674
Capitate, 41f, 42f, 57–59, 491f
accessory bones of, 57, 59
anomalies and variations of, 58
clinical correlations of, 59
derivation and terminology of, 57
joints associated with, 58
ligaments of, 493–494
muscle origins and insertions of, 59
ossification centers of, 43f, 57
osteology of, 57–58, 58f, 493
vascularity of, 59, 494, 513
Capitohamate ligament, 493, 494, 501f,
503
Capitulum, 21f, 23f, 24, 319f, 366, 367f
ossification centers for, 18, 19f
osteochondrosis of, 27
radiography of, 386–387, 386f, 387f
Capsularis brachialis muscle, 103
Capsular ligaments, dorsal, 500, 500f
Capsule
dorsoradial, injury of, 627
of elbow, 31f–32f, 370
surgical exposure of, 374, 384f, 385,
385f
of radioulnar joint, distal, 498
of sternoclavicular joint, 6–7
Carotid (Chassaignac’s) tubercle, 674
Carpal arches
dorsal, 549–550, 551f, 552f
palmar, 516, 517f
Carpal artery, recurrent, 238f, 267f
Carpal bones, 41–42, 41f–43f, 44t,
490–494, 491f. See also specific bones
accessory, 42, 43f, 44t
arrangement of, 41–42
coalitions of, 42, 43f, 54, 528–529
distal row of, 493–494
joints of, 495
ligaments of, 501–503
joints of, 41–42, 494–495
ossification centers of, 42, 43f
proximal row of, 490, 492
joints of, 494–495
ligaments of, 501f, 502
Carpal ligaments
palmar, 209
transverse, 493, 523f–524f, 595
flexor retinaculum and, 503–504
thenar nerve relationship to, 573–574
Carpal tunnel. See also Carpal tunnel
syndrome
bifid median nerves in, 199
boundaries of, 504, 504f
clinical significance of, 504
as compartment, 504
median nerve in, variations of, 196–197,
196t
surgical exposures for, 522, 523f–524f
thenar nerve branching and, 574, 574t
Carpal tunnel syndrome
anatomic aspects of, 198–200
compression sites in, 504
flexor digitorum superficialis involvement
in, 122
persistent median artery in, 261
Phalen’s test for, 686–687
surgical treatment of, 522, 523f–524f
Carpometacarpal boss, 661
Carpometacarpal joint(s), 536–540
fourth, anomalies and variations of, 527
index finger, 540
ligaments of, 494
dorsal, 493
finger, 540
thumb, 536–540, 537f, 538t, 539f
long finger, 540
ring finger, 540
small finger, 540
thumb, 536–540, 537f, 538t, 539f
Carrying angle, of elbow, 365–366
Central band, of interosseus membrane,
410–412, 411f
Central bands and slips, of extensor
aponeurosis, 590–592, 590f–592f
Central cord, in Dupuytren’s contracture,
621f
Central group of axillary lymph nodes,
280f, 281
Central palmar compartment, compartment
syndrome of, 634–635, 634f, 635f
Central palmar space, 604, 606f
Cephalic vein, 271, 271f–275f, 300f, 320,
320f
absence of, 276
accessory, 272, 273f
in forearm, 413, 414f
median, 276
venous arches connected to, 644, 645f
Cervical arteries, 301, 302f
Cervical artery, 301
Chassaignac’s tubercle, 674
Chauffeur’s fractures, 41, 675
Check-rein ligaments, of interphalangeal
joints, 546, 546f–547f
Cherry pitter’s thumb, 672, 674
Chieralgia paraesthetica (Wartenberg’s
syndrome), 690
Chondromalacia, of hamate, 57
Circumflex scapular vein, 275f, 276
Circumflex subscapular artery, 238f, 239f,
242
Clavicle, 3–8
absence of, 8
acromial portion of, 4, 4f, 5f
acromion process of
as landmark, 315
ossification center for, 8–9, 9f
osteology of, 10, 10f–14f, 15t
brachial plexus relationship with, 7
clinical correlations of, 7–8
derivation and terminology of, 3
dysostosis of, 8
fractures of, 7
gender differences in, 4
joints associated with, 5–7, 6f
lateral third of, 4–5, 4f, 5f
medial two thirds of, 5
muscle origins and insertions of, 4f, 7
ossification centers of, 3, 4f
osteology of, 3–5, 4f, 5f
osteolysis of, 8
sternal portion of, 5
sternoclavicular, 6–7, 6f
Clavicular branch, of thoracoacromial
artery, 241
Claw deformity
in intrinsic muscle dysfunction, 593,
593f
pseudoulnar, 221
Cleidocranial dysostosis, 8
Cleland’s ligaments, 596f–597f, 598–599,
599f, 674
Coalitions, of carpal bones, 42, 43f, 54,
528–529
Coleman and Anson classification
of deep palmar arch, 552, 554f
of dorsal carpal arch, 549–550, 552f
of superficial palmar arch, 557, 558f,
559, 559f
Collagen, in interosseous membrane,
410–411
Collateral artery, middle, 239f, 253f
of profunda brachial artery, 238f, 245f,
246
Collateral circulation, brachial artery in,
248

Collateral ligaments
of fingers, 543f–544f, 545
injuries of, 625–627, 625f
of interphalangeal joints, 546–547, 547f,
548f
lateral
injuries of, 400
insufficiency of, 400–402, 402f,
403f
medial, 371–372, 371f–374f, 374
injuries of, 399–400, 399f
insufficiency of, 400, 401f
radial, 372–374, 373f, 374f
of fingers, 544f
injuries of, 626–627
protection of, in elbow surgery, 378
of thumb, 541–542, 542f
injuries of, 625–627
ulnar. See Ulnar collateral ligament
Colles’ fractures, 36, 40–41, 675
reverse (Smith’s), 41
Commissural cords, in Dupuytren’s
contracture, 622, 623f
Commissural ligaments, proximal and
distal, 595, 596f
Communicating branch
of Berrettini, 198, 199
of ulnar nerve, 201f, 571f, 579–580,
580f, 571f
Communicating veins, oblique, 644f, 646
Compartment syndrome
of forearm, 449–451
anatomy of, 450–451, 450f
etiology of, 449
flexor digitorum superficialis
compression in, 122
important factors in, 450
muscle infarction in, 449–450
pathophysiology of, 449
pronator quadratus involvement in,
130
treatment of, 451, 451f
wick catheter in, 450
of hand, 633–636
adductor, 634, 634f, 635f
central palmar, 634–635, 634f, 635f
hypothenar, 633–634, 634f, 635f
interosseous, 634f, 635, 635f
lumbrical, 634–635, 634f, 635f
thenar, 633, 634f, 635f
treatment of, 635–636, 635f
Condylar branches, of digital arteries,
560–561, 561f
Conoid ligament, 6, 6f, 10f
Conoid tubercle, 4–5, 5f
Contracture
Dupuytren’s, 619–622, 620f, 621f, 622t,
623f, 676
of elbow, 403–405, 404f
of intrinsic muscles, 594–595, 594f
of proximal interphalangeal joint,
632–633, 633f
Volkmann’s, 449
Coracobrachialis inferior muscle, 362
Coracobrachialis longus muscle, 362
Coracobrachialis minor muscle, 97
Coracobrachialis muscle, 96–98, 180t, 326,
326f, 327f
anomalies and variations of, 362
inferior (coracobrachialis longus), 97
innervation of, 338f
Coracoclavicular ligament, 6, 6f
Coracoid process
as landmark, 17–18, 315, 318f
muscle origins and insertions of, 96, 98
ossification center for, 8–9, 9f
osteology of, 10, 10f–14f, 15t
Cords
of brachial plexus, 300f, 301f, 303f–305f,
305–306, 309, 314
in Dupuytren’s contracture, 619–620,
621f, 622t, 623f
Coronoid fossa, of humerus, 21f, 24
Coronoid process, of ulna, 29–30, 29f, 31f,
367, 367f, 409f, 410
fractures of, 35
muscle attachments of, 34
surgical exposures for, 379–380, 380f,
381f
Costoclavicular ligament, 6f, 7
Creases, flexion, 532–534, 533f, 534f
of fingers, 488f, 533, 533f, 534f
of wrist, 488f, 489, 489f
Crossed fingers test, 674–675
Cross-over tendinitis (intersection
syndrome), 133, 134, 146–148,
480, 482f, 483
Cruciform fibers, of digital flexor sheath,
600–601, 600f
Crutch palsy, 355
Cubital tunnel. See also Cubital tunnel
syndrome
anatomy of, 205–206
shape of, 391, 392f
ulnar nerve in, 205–206
Cubital tunnel syndrome, 106, 208–209,
208t, 388–398
clinical findings in, 388
compression sites in, 389–392,
389f–392f
definition of, 388
gender differences in, 389
pathomechanics of, 388–389
surgical treatment of, 392–395,
393f–397f
Cubital vein, median, 272, 273f, 274f, 276,
320f, 413, 414f
Cuneiform. See Triquetrum
Cutaneous nerve(s), 321, 322f–325f, 325.
See also Musculocutaneous nerve
Subject Index 699
antebrachial
lateral, 222–223
medial, 200, 201f–203f, 204–205
brachial, 202f–203f
medial, 223–224
courses of, 201f–203f
dorsal branch of, of ulnar nerve, 201f,
206–209, 212
of forearm, 413–414, 415f
of hand, palmar, 568–570, 569f
medial, 306
palmar branch of
of median nerve, 189, 191, 194, 195,
202f
of ulnar nerve, 201f, 206, 212
protection of, in elbow surgery, 379
D
Deep anterior oblique ligament, of thumb,
538, 538t, 539f, 540
Deep arches, palmar. See Palmar arches,
deep
Deep distal hiatus, of Guyon’s canal, 577
Deep motor branch, of ulnar nerve, 201f,
210–212
neural loop of, 637–638, 638f
variations in, 212
Deep palmar branch, of ulnar artery, 254
Deltoid ascending branch, of profunda
brachial artery, 246
Deltoid branch, of thoracoacromial artery,
241
Deltoid muscle, 92–96
anomalies and variations of, 94, 96
atrophy of, 96
clinical correlations of, 96
derivation and terminology of, 92
gross anatomy of, 92–93, 93f–95f
innervation of, 92–93
insertion of, 93, 93f–95f
as landmark, 317f, 318f
origin of, 92, 93f–95f
paralysis of, 96
vascular supply of, 92
Deltoid tuberosity, 23, 317, 319f
Deltopectoral fascia, in median nerve
compression, 188
Deltopectoral groove, 315, 318f, 320, 320f
Deltopectoral lymph nodes, 278, 279f
de Quervain’s fracture, 675–676
de Quervain’s tenosynovitis, 146, 476–477,
477f, 478f, 675
extensor pollicis brevis in, 148
Finkelstein’s test for, 476–477, 477f,
678–679
Dermatomes, 226
Digit(s). See Finger(s)
Digital artery(ies), 560–562, 561f
common, lesions of, 261
condylar branches of, 560–561, 561f
700 Subject Index
Digital artery(ies) (contd.)
digital nerve locations and, 261–262
distal transverse, 609, 610f
dorsal, 560–562, 561f
skin branches of, 560–561, 561f
of thumb, 567
interphalangeal transverse, 609, 610f
metaphyseal branches of, 560–561, 561f
in nail unit, 655–656, 655f
palmar, 560
common, 238f, 249f, 258–260, 267f,
655–656, 655f
proper, 238f, 249f, 258–259, 267f,
508f
of thumb, 566
proper, 238f, 249f, 258–259, 267f,
508f
lesions of, 261
proximal transverse, 609, 610f
radiodorsal, 567–568
radiopalmar, 566
third common, 568
transverse palmar arches arising from,
560–561, 561f
ulnodorsal, 567
ulnopalmar, 566
Digital cord, in Dupuytren’s contracture,
621f, 622
Digital creases, 488f, 533, 533f, 534f
Digital fascia, 598–599, 598f, 599f
Digital flexor sheaths, 600–602, 600f
Digital lymph vessels, 277
Digital nerves, 572–573, 572f
compression of, cherry pitter’s thumb in,
672, 674
digital artery digital locations and,
261–262
of index finger, 573
in nail unit innervation, 656
palmar, common, course of, 195
proper, 195–196, 572–573, 572f
radial, surgical risk to, 612f, 613
skin reference lines for, 535f
of thumb, 571f–572f, 573
neuroma of, 672
ulnar, surgical risk to, 612f, 613
Digital plexus (lymphatic vessels), 277
Digital sheet, lateral, 620f, 622
Digital veins, 270–271, 271f, 272f, 275
dorsal, 644, 644f, 645f
palmar, 644–646, 644f
valves in, 646
Digital web spaces, arterial supply of, 560
DIP. See Interphalangeal joint(s), distal
Dislocation(s), 627–632
of elbow, 386–387, 386f, 398–399
of extensor pollicis longus tendon, 149
of fingers
ring, 76
small, 78
of interphalangeal joint, proximal,
631–632, 631f
of metacarpophalangeal joint
index finger, 628–630, 629f, 630f
thumb, 627–628, 628f
of shoulder, 25, 26
of ulnar nerve, snapping elbow in, 398
of ulnohumeral joint, 398–399
Distal wrist crease, 488f, 489, 489f, 533f,
534, 534f
Divisions, of brachial plexus, 301f, 305,
305f
Dorsal aponeurosis, 590–592, 590f, 591f
Dorsal branch, of ulnar nerve, 323f
Dorsal carpal branch
of radial artery, 264, 265f
of ulnar artery, 238f, 249f, 254, 249f,
265f, 551f
Dorsal compartments, 145–146
extensor pollicis brevis in, 147
Dorsal cutaneous branch, of ulnar nerve,
201f, 206–208, 415f
absence of, 209
compression of, 209
variations in, 212
Dorsal interosseous muscles. See
Interosseous muscle(s), dorsal
Dorsal ladder, of venous system, 644, 645f
Dorsal metacarpal branches, of radial artery,
266
Dorsal plate, 649
Dorsal sensory branch, of ulnar nerve, 431,
434f
Dorsal sensory nerve, 573
Dorsal skin branches, of digital arteries,
560–561, 561f
Dorsoepitrochlearis muscle, 105
Dorsoradial capsule injury, 627
Dorsoradial ligament, of thumb, 538t,
539–540, 539f
Drop finger (mallet finger), 652, 653f, 658
Duchenne’s sign, 676
Dupuytren’s contracture, 619–622, 620f,
621f, 622t, 623f, 676
Dysostosis, clavicular, 8
E lateral approach, 382–383, 382f, 383f
ECRB muscle. See Extensor carpi radialis
brevis muscle
ECRL muscle. See Extensor carpi radialis
longus muscle
ECU muscle. See Extensor carpi ulnaris
muscle
EDC muscle. See Extensor digitorum
communis muscle
EDM muscle. See Extensor digiti minimi
muscle
Egawa sign, 676
EIP muscle. See Extensor indicis proprius
muscle
Elbow, 365–406. See also specific structures,
e.g., Humerus, distal; Ulna,
proximal
anatomic relationships of, 368–374,
368f–369f, 370t, 371f, 373f, 374f
anomalies and variations of, 405
arteries of, 368, 368f–369f, 370, 370t
articulations of, 365, 366
axis of rotation of, 374, 374f
capsular attachments of, 31f–32f
capsule of, 370
surgical exposure of, 374, 384f, 385,
385f
carrying angle of, 365–366
clinical correlations of, 386–405
cubital tunnel of. See Cubital tunnel;
Cubital tunnel syndrome
descriptive anatomy of, 365–366, 366f,
367f
dislocation of, 386–387, 386f, 398–399
fat pads of, 31f, 370, 387, 387f
flexion contracture of, 403–405, 404f
flexion of, test for, 676–677
fractures of. See also specific bones
radiography of, 386–387, 386f, 387f
surgical exposures for, 382–383, 382f
golfer’s, 26–27, 388
heterotopic ossification of, 405
imaging of, 386–387, 386f, 387f
landmarks of, 365, 366f
ligaments of, 31f–32f, 370–374, 371f,
373f, 374f
injuries of, 399–403, 399f, 401f–403f
motion of, for activities of daily living,
386
myositis ossificans of, 405
posterolateral rotatory instability of,
400–402, 402f, 403f
pulled, 399
skeletal anatomy of, 365–367, 367f
snapping, 398
subluxation of, 399
surgical exposures for, 374–385
in flexion contracture, 403–405, 404f
Kocher or lateral “J” approach, 374,
384f, 385, 385f, 403–405, 404f
for lateral collateral ligament
reconstruction, 402, 403f
medial approach, 379–380, 380f, 381f
in medial collateral insufficiency, 400,
401f
posterior approach, 374–377,
375f–377f
radial head approach, 377–378, 378f,
379f
tennis, 26, 388
ulnar nerve in. See Ulnar nerve, in elbow
and forearm
valgus load on, 372

Elbow disc, 105
Elevated arms stress test, 688
Elson test, 659, 659f, 677
Emboli, radial artery, 269
EPB muscle. See Extensor pollicis brevis
muscle
Epicondyles, of humerus. See Humerus,
epicondyles of
Epitrochleoanconeus ligament, 456
Epitrochleoanconeus muscle, 124, 208
Epitrochleocubital muscle, 106
Epitrochleoolecranonis anconeus
epitrochlearis muscle, 106
Epitrochleoolecranonis anconeus muscle,
124
EPL muscle. See Extensor pollicis longus
muscle
Eponychium, 654f
Erb-Duchenne palsy, 677
Erb’s point, 300f, 304, 304f
Essex-Lopresti fractures, 36, 40, 413,
677–678
Expansion, extensor (aponeurosis),
135–136, 136f, 137f
Extensor aponeurosis, 135–136, 136f, 137f
Extensor atque abductor pollicis accessorius
muscle, 146
Extensor carpi radialis accessorius muscle,
132
Extensor carpi radialis brevis muscle, 114t,
133–134, 181t, 465
innervation of, 427–429
in “mobile wad of three,” 408, 408f, 422,
422f, 461, 462f
origin of, 429, 429f, 430f
radial nerve branch to, 427–429
radial nerve compression by, 478, 479f,
480
radial nerve injury effects on, 220
Extensor carpi radialis brevis tendon, in
intersection syndrome, 480, 482f,
483
Extensor carpi radialis intermedius muscle,
132, 132f, 134, 484, 664, 664f
Extensor carpi radialis longus muscle, 114t,
130–133, 181t, 464f, 465
actions and biomechanics of, 131
anomalies and variations of, 131–132,
132f
clinical implications of, 132–133
in extensor retinaculum, 506
gross anatomy of, 131
innervation of, 426, 427f, 428t
as landmark, 316f
in “mobile wad of three,” 408, 408f, 422,
422f, 461, 462f
radial nerve injury effects on, 220
Extensor carpi radialis longus tendon, in
intersection syndrome, 480, 482f,
483
Extensor carpi ulnaris muscle, 114t,
143–144, 181t, 464f, 466
in extensor retinaculum, 506
identification of, 461, 463f
innervation of, 428t
radial nerve injury effects on, 220
Extensor compartment artery, 515, 516f
Extensor digiti minimi muscle, 142–143,
181t, 464f, 465–466
anomalies and variations of, 663–664
identification of, 461, 463f
innervation of, 428t
juncturae tendinum attachment to,
649–651, 650f, 651f
Extensor digiti minimi tendons, 138t,
648–649
Extensor digiti quinti muscle. See Extensor
digiti minimi muscle
Extensor digiti quinti (extensor digiti
minimi) tendons, 138t, 648–649
Extensor digitorum breves manus tendons,
138t
Extensor digitorum brevis manus muscle,
139, 140f, 141, 662–663, 663f
Extensor digitorum communis muscle,
134–141, 181t, 464f, 465, 591f
actions and biomechanics of, 138–139,
138t
anomalies and variations of, 138t, 139,
140f, 141, 663–664
clinical implications of, 141
extensor digiti minimi association with,
142–143
gross anatomy of, 135–138, 136f, 137f
identification of, 461, 463f
innervation of, 427, 428t
juncturae tendinum of, 135–136, 137f,
139, 141
vascularity of, 134
Extensor digitorum communis tendons
anatomy of, 649
anomalies and variations of, 139, 140f,
141
juncturae tendinum attachment to,
649–651, 650f, 651f
Extensor expansion (aponeurosis), 135–136,
136f, 137f
Extensor function, digital, loss of,
differential diagnosis of, 221
Extensor hood
lumbrical muscle insertion into, 159
palmar interosseous muscles insertion
into, 588
Extensor indicis et medii communis muscle,
139, 140f, 484–485, 661–662, 662f
Extensor indicis proprius muscle, 141–142,
181t, 465f, 466
innervation of, 427, 428t
Extensor indicis proprius syndrome, 483,
678
Subject Index 701
Extensor indicis proprius tendons, 138t,
652–654
anatomy of, 648–649
anomalies and variations of, 663–664
transfer of, junctura tendinum and,
651–652
Extensor medii et annularis communis
muscle, 139
Extensor medii proprius muscle, 138t, 139,
140f, 484, 661–662, 661f
Extensor plus syndrome or test, 678
Extensor pollicis brevis muscle, 181t,
147–148, 465f, 466
innervation of, 428t
in intersection syndrome, 480, 482f, 483
as landmark, 461, 462f
Extensor pollicis brevis tendon
anatomy of, 648–649
in de Quervain’s tenosynovitis, 476–477,
477f, 478f
Extensor pollicis longus muscle, 148–149,
181t, 465f, 466
innervation of, 427, 428t
Extensor pollicis longus tendon
anatomy of, 648–649
dislocation of, 149
as landmark, 461, 462f
tenosynovitis of, 483–484
Extensor retinaculum, 647–648, 648f
anatomy of, 504–505, 505f
extensor digitorum communis tendons
in, 135
function of, 505
surgical exposures for, 518, 518f
tendons of, 505–506
Extensor tendons. See also specific tendons
accessory, 664, 664f
anatomy of, 648–649
anomalies and variations of, 663–664,
664f
arrangement of, 649
germinal matrix relationship to, 656
sagittal band attachment to, 652
zones of injury of, 649, 649f
Extrinsic extensor muscles, 590–592,
590f–592f
F
Fascia
digital, 598–599, 598f, 599f
fibrofatty, in Dupuytren’s contracture,
621
of finger, pathologic anatomy of,
620–622
of flexor retinaculum, 503–504, 503f
palmar, 115–116, 595–597, 596f, 597f,
619, 620f
Fasciotomy, for compartment syndrome
of forearm, 451, 451f
of hand, 635–636, 635f
702 Subject Index
Fat pads, elbow, 31f, 370, 387, 387f
FCL muscle. See Flexor carpi ulnaris muscle
FCR muscle. See Flexor carpi radialis muscle
FDP muscle. See Flexor digitorum
profundus muscle
FDS muscle. See Flexor digitorum
superficialis muscle
Fibrofatty fascia, in Dupuytren’s
contracture, 621
Fibrous bands, radial nerve compression by,
478, 479f
Finger(s). See also subjects starting with
Digital
anomalies and variations of, 661–664,
661f–664f
arteries of, 560–568, 561f, 562t, 563f,
565f, 567f. See also specific arteries
boutonniere lesion in. See Boutonniere
deformity
carpometacarpal joints of. See
Carpometacarpal joint(s)
closed sagittal band injury of, 660–661
collateral ligaments of, injuries of,
625–627, 625f
creases of, 488f, 533, 533f, 534f
digital arteries of. See Digital artery(ies)
digital web spaces of, 560
drop (mallet), 652, 653f, 658
extensor function loss in, differential
diagnosis of, 221
extensor tendons of, 648–649, 649f. See
also specific tendons
anomalies and variations of, 663–664
functional dynamics of, 652
imbalance of, 652, 653f
fascia of, 598–599, 598f, 599f
pathologic anatomy of, 620–622
index
arteries of, 562–568, 562t, 563f, 565f,
567f
carpometacarpal joint of, 540
digital nerves of, 573
dorsal interosseous muscles of, 162,
163, 584–587, 584f–586f
lumbrical muscles of, 587f, 588
metacarpal arteries of, 562–563, 563f,
565f, 568
metacarpal of, 64–65, 65t, 68–71, 69f,
131, 536
metacarpophalangeal joint of,
dislocation of, 628–630, 629f,
630f
muscle origins and insertions of,
135–136, 137f, 138, 138t
palmar interosseous muscles of,
164–165, 587–588, 587f
phalanges of, 79, 82
radial collateral ligament of, surgical
exposures for, 617, 619f
radial deviation of, 545t
ray of, 535–536
synovial sheath of, 603f
ulnar deviation of, 545t
intermetacarpal joints of, 540–549,
541f–548f, 545t. See also
Interphalangeal joint(s);
Metacarpophalangeal joint(s)
interphalangeal joints of. See
Interphalangeal joint(s)
intrinsic plus or minus, 159, 164, 595
long
arteries of, 562, 562t
carpometacarpal joint of, 540
dorsal interosseous muscles of, 162,
163, 584–587, 584f–586f
lumbrical muscles of, 587f, 588
metacarpal of, 64–65, 65t, 71–74, 72f,
536
extensor carpi radialis insertion into,
133
styloid process of, 487, 487f, 642,
643f
muscle origins and insertions of,
135–136, 137f, 138, 138t
palmar interosseous muscles of,
587–588, 587f
phalanges of, 79, 81, 82, 83
radial deviation of, 545t
ray of, 535–536
sagittal band injury of, 660–661
synovial sheath of, 603f
testing of, in radial tunnel syndrome,
478
ulnar deviation of, 545t
vincula of, 610f–611f
lumbrical plus, 159–160, 595, 684
mallet, 652, 653f, 658
metacarpals of. See Metacarpal(s)
metacarpophalangeal joints of. See
Metacarpophalangeal joint(s)
middle. See Finger(s), long
nail units of, 654–656, 654f, 655f
phalanges of. See Phalanges
proprius tendons of, 652–654
pulley system of. See Pulley system
radial deviation of, 545t
rays of, 535–536
ring
arteries of, 562, 562t
carpometacarpal joint of, 540
dorsal interosseous muscles of, 162,
163, 584–587, 584f–586f
lumbrical muscles of, 587f, 588
metacarpal of, 64–65, 65t, 74–77, 75f,
536
muscle origins and insertions of,
135–136, 137f, 138, 138t
palmar interosseous muscles of,
164–165, 587–588, 587f
phalanges of, 81, 82, 83
radial deviation of, 545t
ray of, 535–536
sensory innervation of, 211–212
synovial sheath of, 603f
ulnar deviation of, 545t
ulnar nerve motor branch to, 206
skin coverage of, 643
small
arteries of, 562, 562t
carpometacarpal joint of, 540
digital artery to, 258–259
dorsal interosseous muscles of,
584–587, 584f–586f
extensor mechanism of, 591f
lumbrical muscles of, 587f, 588
metacarpal of, 64–65, 65t, 77–79, 77f,
143, 536
muscle origins and insertions of,
135–136, 137f, 138, 138t
palmar interosseous muscles of,
164–165, 587–588, 587f
phalanges of, 81, 82, 83
radial deviation of, 545t
ray of, 535–536
sensory innervation of, 211–212
synovial sheath of, 603f
ulnar deviation of, 545t
ulnar nerve motor branch to, 206
surgical exposures for, 656–658, 657f,
658f
in elective procedures, 613–614, 613f,
614f
in laceration repair, 614–615, 615f
swan neck deformity of, 652, 653f, 660
trigger, 622–624
ulnar deviation of, 545t
venous system of, 644–647, 644f, 645f
web spaces between, arterial supply of,
560
Finkelstein’s test, 476–477, 477f, 678–679
Finochietto-Bunnell test, 682–683
Flexion creases, 532–535, 533f, 534f
of fingers, 488f, 533, 533f, 534f
of wrist, 488f, 489, 489f, 533f, 534, 534f
Flexor carpi radialis brevis muscle, 115, 134,
456
anterior interosseous nerve compression
at, 447, 448f
as donor muscle, 115
Flexor carpi radialis muscle, 111–115, 180t,
416, 417f
actions and biomechanics of, 114
anomalies and variations of, 456
clinical correlations of, 115
in extensor retinaculum, 506
gross anatomy of, 112–114, 112f, 113f,
114t
identification of, 422, 423f
Flexor carpi radialis tendon, 113
skin reference lines for, 535f

Flexor carpi ulnaris muscle, 114t, 123–125,
180t, 416, 417f
accessory, 214
anomalies and variations of, 456
in extensor retinaculum, 506
hypertrophy of, 214
identification of, 422, 423f
innervation of, 207
Flexor digiti minimi muscle, 156, 182t,
583, 583f
accessory, 214
Flexor digiti quinti (flexor digiti minimi)
muscle, accessory, 214
Flexor digitorum profundus indicis muscle,
127
Flexor digitorum profundus muscle,
125–127, 181t, 421
anomalies and variations of, 457
innervation of, 198, 207
ulnar nerve motor branch to, 206
Flexor digitorum profundus tendon, 421,
607f, 608
in carpal tunnel, 504
vascular supply of, 609
Flexor digitorum sublimis (flexor
digitorum superficialis muscle),
120–123, 180t
Flexor digitorum superficialis muscle,
120–123, 180t, 416, 418f, 419,
419f, 421
accessory, 122
accessory motor supply to, 191
anomalies and variations of, 456
anterior interosseous nerve compression
at, 447, 448f
anterior interosseous nerve innervation
of, 190–191, 193–194
digastric, 122
median nerve compression at, 445–446,
446f, 447f
Flexor digitorum superficialis tendon, 420f,
421, 607f, 608, 608f
in carpal tunnel, 504
transfer of, 611
vascular supply of, 609
Flexor indicis profundus muscle, 127
Flexorplasty, Steindler, 101
Flexor pollicis brevis muscle, 152–153,
182t, 582–583, 582f
innervation of, 211
Flexor pollicis longus muscle, 127–129,
181t, 420f, 421
accessory (Gantzer’s muscle), 128, 191,
419f, 420f, 457
anterior interosseous nerve
compression at, 447, 448f, 449
anomalies and variations of, 457
in Linburg-Comstock anomaly, 684
Flexor pollicis longus tendon, 421, 607, 607f
nodular thickening of, 623
Flexor-pronator origin (aponeurosis), 392
Flexor retinaculum, 503–504, 503f
muscle origins and insertions of
abductor pollicis brevis, 149–150
flexor digiti minimi, 156
opponens pollicis, 153
palmaris brevis, 155
Flexor tendons, 607–612, 607f–611f. See
also specific tendons
rupture of, 624–625, 624f
sheaths of
patterns of, 602–604, 605f
in pulley system, 600–602, 600f
vascular supply of, 608–612
clinical significance of, 611–612
sources of, 608–609
terminology of, 608
of thumb, 611
vincular patterns in, 609, 610f–611f,
611–612
FLP muscle. See Flexor pollicis longus
muscle
Forearm. See also specific structures
cross-section of, 417f, 418f, 420f, 450,
450f
dorsal, 461–485
anomalies and variations in, 484–485
clinical correlations of, 476–484
de Quervain’s tenosynovitis and. See de
Quervain’s tenosynovitis
descriptive anatomy of, 461
extensor indicis proprius syndrome in,
483
extensor pollicis longus tenosynovitis
in, 483–484, 484f
intersection syndrome in, 133, 134,
146–148, 480, 482f, 483
landmarks of, 461, 462f
muscles of, 461–466
anomalies and variations of,
484–485
deep, 461, 464f, 465f, 466
identification of, 461, 463f
intersection zones of, 464f, 466
“mobile wad of three,” 408, 408f,
422, 422f, 461, 462f
superficial, 461, 464f, 465–466
posterior interosseous nerve syndrome
in, 480
radial neuritis in, 480, 481f
radial tunnel syndrome in. See Radial
tunnel syndrome
surgical exposures for, 467–476
flaps of
radial artery in, 269
ulnar artery in, 261
flexor, 407–460
anomalies and variations of, 453–458,
453f, 454f
anterior interosseous nerve syndrome
Subject Index 703
in. See Anterior interosseous nerve
syndrome
arteries of, 423–424, 424f, 431, 434f,
457–458
biceps tendon rupture in, 451, 452f
clinical correlations of, 445–461,
446f–448f, 450f–452f
compartment syndrome of, 449–451,
450f, 451f
cutaneous nerves of, 413–416, 415f
descriptive anatomy of, 407–413
landmarks, 407–408, 408f
skeletal, 408–413, 409f, 411f, 412f
muscles of, 416–423
anomalies and variations of, 453–457
in antecubital fossa, 422–423, 424f
deep group, 421–422, 420f–422f
dorsolateral, 407
intermediate group, 416, 418f, 419,
419f, 421
“mobile wad of three” group, 408,
408f, 422, 422f, 461, 462f
pronation/supination, 407
superficial, 416, 417f
ventromedial, 407
nerves of, 424–431, 426f, 427f, 428t,
429f, 430f, 432f, 434f
anomalies and variations of,
453–457, 453f, 454f
cutaneous, 413–416, 415f
pronator syndrome in. See Pronator
syndrome
surgical exposures for, 435–444
antecubital fossa, 435–438,
435f–437f
distal, 441, 444, 444f
lateral antebrachial cutaneous nerve,
444, 445f
median nerve, 438, 440–441,
441f–444f, 444
radial shaft, 438, 439f–440f
ulnar nerve, 438, 440–441,
441f–443f
veins of, 413, 414f
lateral antebrachial cutaneous nerve of,
222–223
medial cutaneous nerve of. See
Antebrachial cutaneous nerve,
medial
median nerve in. See Median nerve, in
forearm
muscles of. See also Forearm, extensor,
muscles of; Forearm, flexor, muscles of
ulnar nerve compression in, 391–392
musculocutaneous nerve in, 222–223
radial nerve in, 216–222, 216t, 217t
ulnar nerve in. See Ulnar nerve, in elbow
and forearm
veins of, 273f, 275–276
Forearm axis artery, 197
704 Subject Index
Fossa
antecubital. See Antecubital fossa
coronoid, of humerus, 21f, 24
lunate, 487, 487f, 490, 490f, 642, 643f
olecranon, 20f, 24, 319f, 366, 367f
radial, 21f, 366, 367f
FPL muscle. See Flexor pollicis longus
muscle
Fracture(s)
vs. accessory bones, 35–36
backfire, 41, 675
Barton’s, 41, 671
Bennett’s, 671–672
chauffeur’s, 41, 675
clavicular, 7
Colles’, 36, 40–41, 675
compartment syndrome in, 449–451,
451f, 452f
de Quervain’s, 675–676
elbow, radiography of, 386–387, 386f,
387f
Essex-Lopresti, 36, 40, 413, 677–678
Galeazzi, 36, 40, 679
hamate, 56–57
Holstein-Lewis, 26, 216, 356, 681–682
humeral. See Humerus, fractures of
lorry driver’s, 41, 675
Monteggia, 35, 685
nightstick, 35
olecranon, 35
Piedmont (Galeazzi), 36, 40, 679
pisiform, 55
radial. See Radius, fractures of
Rolando, 687
scaphoid, 49
Seymour’s, 688
Smith’s, 41, 688
styloid process, ulnar, 35
Tenosynovitis, 675–676
of thumb, 626, 671–672, 687
Thurston Holland’s fragment in, 690
trapezium, 62
trapezoid, 61
triquetrum, 54
ulnar. See Ulna, fractures of
wrist, de Quervain’s, 675–676
FREAS mnemonic, for radial tunnel
compression sites, 478, 479f
Free nerve endings, 225f
Frohse, arcade of, 144–145, 217, 429–430,
429f, 670
radial nerve branches above, 429, 430f
radial nerve compression by, 478, 479f
Froment-Rauber anastomosis, 219
Froment-Rauber nerve, 219
Froment’s sign, 679
G carpometacarpal joints of. See
Galeazzi’s fracture, 36, 40, 679
Gamekeeper’s thumb, 679
Ganglions, in ulnar tunnel, 213
Gantzer’s muscle (accessory flexor pollicis
longus muscle), 128, 419f, 420f,
457
anterior interosseous nerve compression
at, 447, 448f, 449
anterior interosseous nerve innervation
of, 191
Germinal matrix, of nail bed, 654–656,
654f
Glenohumeral joint, 17, 24
Glenoid
ossification center for, 9
osteology of, 10, 12f–14f, 15t, 17
Golfer’s elbow, 26–27, 388
Grasp, intrinsic muscle function in, 164,
592–593, 593f
Graves’ scapula, 8
Grayson’s ligaments, 596f–597f, 598, 598f,
620f, 621f, 622, 679–680
Gruber, anconeus sextus of, 124
Guyon’s canal, 555, 556f, 680
anatomy of, 575, 576f, 577
clinical correlations of, 212–214, 213t
skin dimpling at, in Ollier’s
phenomenon, 686
surgical exposures for, 522, 525f–526f,
527
ulnar artery in, 555, 556f, 576
ulnar nerve in, 209–210
compression of, 577, 578t
variant, 213
zones of, 577, 578t
H 541f–548f, 545t. See also
Haines-Zancolli test, 680–681
Hamate, 41f, 42f, 55–57, 491f
accessory bones of, 55, 57
clinical correlations of, 56–57
derivation and terminology of, 55
fractures of, 56–57
hook of, 488
bipartite, 529
joints associated with, 56
ligaments of, 494
muscle origins and insertions of, 56
ossification centers of, 43f, 55
osteology of, 55–56, 55f, 494
skin reference lines for, 535f
surgical exposures for, 522, 525f–526f,
527
vascularity of, 56, 494, 513
Hamulus, bipartite, 529
Hand. See also Finger(s); Thumb; specific
structures
arteries of, 549–568. See also specific
arteries
Carpometacarpal joint(s)
claw deformity of, 221, 593, 593f
cross-section of, 634f, 635f
dorsal, 642–666
anatomic relationships of, 642–656
anomalies and variations of, 661–664,
661f–664f
boutonniere lesion in. See Boutonniere
deformity
carpometacarpal bossing in, 661
clinical correlations of, 658–664
closed sagittal band injuries in,
660–661
descriptive anatomy of, 642–643, 643f
extensor retinaculum of. See Extensor
retinaculum
extensor tendons of, 648–649, 649f
functional dynamics of, 652
imbalance of, 652, 653f
juncturae tendinum of, 649–652,
650f, 651f
landmarks of, 642–643, 643f
mallet finger in, 652, 653f, 658
nail unit of, 654–656, 654f, 655f
proprius tendons of, 652–654
proximal interphalangeal joint dorsal
plate of, 649
sagittal bands of, 652
skin coverage of, 643, 642–656
surgical exposures for, 656–658,
657f–658f
swan neck deformity in, 652, 653f,
660
venous system of, 644–647, 644f,
645f
intermetacarpal joints of, 540–549,
Interphalangeal joint(s);
Metacarpophalangeal joint(s)
interphalangeal joints of. See
Interphalangeal joint(s)
median nerve in. See Median nerve, in
wrist and hand
palmar, 532–641
anomalies and variations of, 636–638,
636f, 637f
arches of, 536, 536f
arteries of, 549–568. See also specific
arteries
carpometacarpal joints of. See
Carpometacarpal joint(s)
clinical correlations of, 619–636
creases of, 488f, 489, 489f, 532–534,
533f, 534f
cutaneous nerves of, 568–570, 569f
deep palmar arch of. See Palmar arches,
deep
descriptive anatomy of, 532–549
digital nerves in. See Digital nerves
dorsal carpal arch in, 549–550, 551f,
552f
dorsal metacarpal arteries of, 550

flexor tendon synovial sheath patterns
in, 602–604, 605f
intermetacarpal joints of. See
Intermetacarpal joint(s)
joint innervation in, 572–573
landmarks of, 532–535, 533f
median nerve in, 570, 571f, 572, 572f,
575, 575t
metacarpal arteries of, 553–555
metacarpals of. See Metacarpal(s)
muscles of, 581–595
nerves of, 568–581
persistent median artery in, 555, 556f,
557, 558f, 559
phalanges of. See Phalanges
pulley system of, 599–602, 600f, 603f,
604t
radial artery in, 549, 550f
rays of, 535–536
retinacular system of, 595–599,
596f–699f
skeletal anatomy of, 535–549. See also
individually named bones
skin reference lines on, vs. deeper
structures, 535, 535f
spaces in, 604–607, 606f
surgical exposures for, 612–619
elective incisions in, 613–614, 613f,
614f
general principles of, 612–613, 613f
for joints, 615–619, 616f–619f
in laceration repair, 614–615, 615f
tendons of, 607–612, 607f–611f
thenar nerve in, 573–574, 574t
ulnar artery in, 555, 556f, 557, 558f,
559, 559f
ulnar nerve in, 575–581, 576f–578f,
578t, 580f, 581f
phalanges of. See Phalanges
radial nerve in. See Radial nerve, in
forearm and hand
ulnar nerve in. See Ulnar nerve, in wrist
and hand
Henle, nerve of, 201f, 569, 569f, 681
anomalies and variations of, 455
Henry, leash of, radial nerve compression
by, 478, 479f
Henry’s manual mnemonic, for superficial
forearm muscles
extensor, 461, 463f
flexor, 422, 423f
Heterotopic calcification and ossification, of
elbow, 405
High division axillary anomaly, 243, 244
Hill-Sacks lesion, 25–26
Hoffman-Tinel sign, 681
Holstein-Lewis fracture, 26, 216, 356,
681–682
Hook grasp, intrinsic muscle function in,
593, 593f
Horner’s syndrome, 304, 682
Hotchkiss classification, of radial head
fractures, 40
Huber transfer, 156, 682
Hueter’s line, 317, 319f, 410
radial nerve branches above, 426, 427f,
429f
Hulten’s variance, 36, 498
Humeral circumflex artery
accessory arteries from, 332, 333f
anterior, 238f, 239f, 242
posterior, 238f, 239f, 242–244, 331f
Humerus, 18–27
anatomic neck of, 18, 20, 20f, 21f, 25
articular components of, 408–409
in Bankart lesion, 26
bicipital groove of, 20, 21f, 23
bicipital ridges of, 20
capitulum of, 21f, 23f, 24, 319f, 366,
367f
ossification centers for, 18, 19f
osteochondrosis of, 27
radiography of, 386–387, 386f, 387f
clinical correlations of, 25–27
condyles of, fractures of, 386–387, 386f
coronoid fossa of, 21f, 24
cross-section of, 319f
deltoid tuberosity of, 23, 317, 319f
derivation and terminology of, 18
distal, 366, 367f
arteries of, 332
fractures of, 334
ossification centers for, 18, 19f
osteology of, 20f–23f, 24, 408–410
epicondyles of, 20f, 21f, 23f, 24, 366,
367f
extensor digitorum communis
attachment to, 135–136
inflammation of, 26–27, 388
as landmarks, 315, 316f–318f, 365,
366f, 408, 408f, 461, 462f
muscle origins and insertions of, 105
extensor carpi radialis brevis, 133
extensor carpi ulnaris, 143
extensor digiti minimi, 142
extensor digitorum communis, 135
flexor carpi radialis, 112–113
palmaris longus, 115–116
supinator, 144
ossification centers for, 18, 19f
osteotomy of, 380, 381f
epiphyseal lines of, 19f
fractures of, 25, 26
blood supply and, 332, 334
Holstein-Lewis, 26, 216, 356,
681–682
radiography of, 386–387, 386f, 387f
supracondylar, 26
surgical exposures for. See Humerus,
surgical exposures for
Subject Index 705
transphyseal, 386–387, 386f
grooves of, 20, 21f, 23, 319f
head of
arteries of, 332, 333f
fractures of, 334
in Hill-Sacks lesion, 25–26
in impingement syndrome, 25
intraosseous arterial supply of, 332, 332f,
334
joints associated with, 24
landmarks of, 319f
in lateral epicondylitis, 26, 388
in medial epicondylitis, 26–27, 388
medullary canal of, 18
metastasis to, blood supply and, 334
muscle origins and insertions of, 25, 315,
317
brachialis, 102
brachioradialis, 106, 110
coracobrachialis, 96
deltoid, 92, 95f, 97
extensor carpi radialis longus, 131
flexor carpi ulnaris, 123
flexor digitorum superficialis, 120–121
pronator teres, 110–111
triceps brachii, 103–104
nutrient canal of, 23–24
olecranon fossa of, 20f, 24, 319f, 366, 367f
ossification centers of, 18, 19f
osteochondrosis of, 27
osteology of, 18–24, 20f–23f, 315,
317–318, 319f, 408–410
principal nutrient artery of, 246
proximal
fractures of, 25
ossification centers for, 18, 19f
osteology of, 18, 20, 20f–23f
radial fossa of, 21f, 366, 367f
radial sulcus of, 20f, 22f, 23, 24
ridges of, 319f
shaft of, 315
arteries of, 332, 333f, 334
fractures of, 26, 332, 334
osteology of, 20f–22f, 23–24
in shoulder dislocation, 25, 26
supracondylar fractures of, 26
supracondylar process of, 26, 188
supracondylar ridges of, 20f, 21f, 24,
319f, 366, 367f
as landmarks, 461, 462f
surfaces of, 315, 317–318, 319f
surgical exposures for, 374–377,
375f–377f
anterior approach, 341, 342f–344f
anterolateral approach, 341, 343, 345,
345f, 346f
distal, 374–377, 375f–377f
posterior, 351–353, 350f–353f
proximal posterior approach, 353,
354f, 355f
706 Subject Index
Humerus (contd.)
surgical neck of, 18, 20, 20f, 21f, 25, 306
torsion of, 318, 319f
trochlea of, 20f, 21f, 23f, 24, 319f, 366,
367f
tuberosities of, 23, 24, 315, 317, 319f
ossification centers for, 18, 19f
osteology of, 20, 20f–22f
vascular supply of, 332, 332f, 334
Hurler’s syndrome, trigger digits in, 624
Hyponychium, 654f, 655
Hypothenar compartment, compartment
syndrome of, 633–634
Hypothenar eminence, 488f, 489, 532,
533f
Hypothenar hammer syndrome, 260
Hypothenar muscles, 503f, 583–584, 583f.
See also specific muscles
anomalies of, 214
arteries to, 267f
innervation of, 578f, 579
vascularity of, 508f
I 369f, 370t
Impingement syndrome
acromion in, 17
humerus in, 25
Incisions. See Surgical exposures
Index finger. See Finger(s), index
Infarction, muscle, in compartment
syndrome, 449–450
Infraglenoid tubercle, 16
Injury. See specific anatomic structure
Intercapitular veins, 270, 271, 271f, 272f,
644f
Intercarpal arches, 46f–49f, 53
basal, 253f
dorsal, 253f, 265–266, 265f, 506, 507f,
508f, 509, 509f, 512, 515, 516f,
551f
in hamate vascularity, 56
palmar, 254, 255f, 264, 507, 508f, 512
Intercarpal arteries, 45–46, 46f–49f, 511
Intercarpal ligaments, 492
dorsal, 492, 500, 500f, 538–539, 538t,
539f
palmar, 538, 538t, 539f
Interclavicular ligament, 6–7, 6f
Intercompartmental arteries, of wrist,
514–516, 516f, 517f
Intercostobrachial cutaneous nerve, 325f
Intercostobrachial nerve, 202f–203f
medial brachial cutaneous nerve
communication with, 224
Interepicondylar (Hueter’s) line, 317, 319f,
410
radial nerve branches above, 426, 427f,
429f
Interfossal ridge, of radius, 490, 490f
Intermediate septa, of hand, 604, 606f
Intermetacarpal joint(s), 540–549,
541f–548f, 545t. See also
Interphalangeal joint(s);
Metacarpophalangeal joint(s)
Intermuscular septa, of arm, 326f, 327,
329f–331f, 394–395, 394f–396f
Interosseous artery(ies)
anterior, 238f, 245f, 249f, 251, 252,
253f, 368f
dorsal branch of, 509–510
palmar branch of, 509–510
palmar carpal branch of, 249f
in triangular fibrocartilage supply, 497,
498f
in wrist and hand, 508f, 509–510,
514–516, 516f–517f
common, 238f, 245f, 250–252, 368f
in antecubital fossa, 425f
high division of, 259–260
posterior, 238f, 245f, 249f, 252, 253f,
368f, 510f, 511f
at wrist, 514–516, 516f–517f
recurrent, 245f, 249f, 252, 253f, 368f,
Interosseous compartment, compartment
syndrome of, 634f, 635, 635f
Interosseous joints, of wrist, 494–495
Interosseous ligaments, 33, 502–503
Interosseous lymph vessels, 278
Interosseous muscle(s), 584–588
dorsal, 584–587, 584f–586f, 588f
deep head of, 585f, 585–587
functions of, 587
insertions of, 582, 584f, 586f, 587
superficial head of, 584f, 585–587
palmar, 581–582, 587–588, 587f
Interosseous nerve(s)
anterior
anomalies and variations of, 446–447
compression of. See also Anterior
interosseous nerve syndrome
in forearm, 193–194
course of, 189
flexor digitorum superficialis and,
193–194
in forearm, 431, 432f, 433f
Martin-Gruber anastomosis and, 193
posterior interosseous nerve
communication with, 222
sympathetic fibers in, 188
variations of, 190–191
posterior, 217–218, 217t, 427f
anterior interosseous nerve
communication with, 222
clinical correlations of, 220–221
course of, 431
evaluation of, 221
fibrous tissue arcades and, 429, 429f,
430f
protection of, in elbow surgery, 378
safe and unsafe internervous planes
and, 221
surgical exposures for, 467–472,
467f–472f
syndrome of, 480
vs. radial tunnel syndrome, 477–478
Interosseous recurrent artery, 331f
Interosseous veins, 276
Interosseus membrane, 410–413
clinical correlations of, 412–413
function and biomechanics of, 411–412
gross anatomy of, 410, 411f
histology of, 410–411
Interosseus muscle(s)
dorsal, 158t, 160–164, 182t
actions and biomechanics of, 162–163
anomalies and variations of, 163
clinical correlations of, 163–164
gross anatomy of, 160–162
innervation of, 160, 162
origin and insertion of, 160
vascular supply of, 160
palmar, 158t, 164–165, 183t
Interphalangeal joint(s)
distal, 84, 549
flexion of, in swan neck deformity,
652, 653f, 660
surgical exposures for, 657–658, 658f
venous system at, 644f, 645
extension of
in Bouvier’s sign, 672
lumbricals in, 158–159, 158t
flexor pollicis longus action on, 128
Froment’s sign in, 679
proximal, 81f, 82, 545–547
contracture of, 632–633, 633f
dislocation of, 631–632, 631f
dorsal plate at, 649
extensor mechanisms at, 652
disruption of, 652, 653f
extensor tendon disruption at. See
Boutonniere deformity
hyperextension of, in swan neck
deformity, 652, 653f, 660
innervation of, 572–573
ligaments of, 546–547, 546f–548f
paradoxical extension of, 159–160
rotary subluxation of, 631, 631f
skin creases at, 533
surgical exposures for, 617, 619, 657,
658f
tightness of, 594–595, 594f
type of, 545–546, 545f
venous system at, 644f, 645
thumb, 86
Interphalangeal transverse digital artery,
609, 610f
Intersection syndrome, 133, 134, 146–148,
480, 482f, 483
Intersection zones, in forearm, 466

Interspaces, finger, arterial supply of, 560
Intrinsic function, 164
Intrinsic longitudinal vessels, from palm,
608–609
Intrinsic minus position, 159, 164, 595
Intrinsic muscle(s), 584–590, 584f–588f.
See also specific muscles
angle of attack of, 588f, 589
architectural features of, 150, 150t, 151f,
158t, 589–590
clinical correlations of, 592–595, 593f,
594f
contracture of, 594–595, 594f
cross-section of, 589–590
dorsal interossei as, 158t, 160–164, 182t
vs. extrinsic extensor muscles, 590–592,
590f–592f
fiber lengths of, 589
function of, 592–593, 593f
lengths of, 589
lumbricals as, 157–160, 158t, 182t
weakness of, 593–594
Intrinsic plus position, 159, 164, 595
Intrinsic tightness test, 594, 594f, 682–683
J Kiloh-Neven syndrome (anterior
Jeanne’s sign, 683
Jobe technique, for medial collateral
ligament reconstruction, 400, 401f
Jobe test, 399, 399f
Joint(s)
acromioclavicular, 5–6, 6f, 17
separation of, 7–8
of capitate, 58
of carpal bones, 41–42
distal row, 495
proximal row, 494–495
carpometacarpal. See Carpometacarpal
joint(s)
of elbow, 365
glenohumeral, 17, 24
of hamate, 56
of humerus, 24
interosseous, of wrist, 494–495
interphalangeal. See Interphalangeal
joint(s)
of lunate, 51
metacarpophalangeal. See
Metacarpophalangeal joint(s)
mid-carpal, 494, 501–502, 501f,
527–528, 527f, 528f
radiocapitellar, 24
radiocarpal, 489, 489f, 491, 494f, 533f,
534, 534f
radiolunate, 40
radioscaphoid, 40, 46
radioulnar. See Radioulnar joint
of radius, 31f–32f, 39–40
scaphocapitate, 46
of scaphoid, 46
scapholunate, 49
of scapula, 17
sternoclavicular, 6, 6f, 8
styloscaphoid, 40, 46
trapeziometacarpal, 489, 534
of trapezium, 62
of trapezoid, 60
triscaphe, 46, 49
of ulna, 28f–32f, 34
ulnohumeral, 24, 32f, 34, 398–399
of wrist, 494–498, 495f–498f, 527–529,
527f, 528f
Juncturae tendinum, 649–652
clinical significance of, 651–652
of extensor digitorum communis muscle,
135–136, 137f, 139, 141
types of, 649–651, 650f, 651f
K of carpometacarpal joint, 493, 494,
Kapandji’s test, 683
Kaplan skin reference lines, 535, 535f
Key pinch
dorsal interossei function in, 163
Froment’s sign in, 679
Kienbˆck’s disease, 36, 52, 514
interosseous nerve syndrome), 127,
129, 193
Kocher or lateral “J” approach, to elbow,
374, 384f, 385, 385f, 403–405,
404f
Krause’s end bulbs, 225f
L of fingers, 617, 619f, 625–627, 625f
Lacerations, incisions for, 614–615, 615f
Lacertus fibrosus, 423, 424f
median nerve compression at, 192–193,
445–446, 446f, 447f
LACN. See Antebrachial cutaneous nerve,
lateral
Landsmeer’s ligament, 683–684, 590f–592f,
592, 683–684
Langer’s muscle, 186
Lateral bands and slips, of extensor
aponeurosis, 135, 136f, 590–592,
590f–592f
Lateral cord, in Dupuytren’s contracture,
621f, 622
Lateral digital sheet, 598
Lateral epicondylitis (tennis elbow), 26, 388
Lateral group of axillary lymph nodes, 280,
280f
Lateral ligaments, of elbow, 372–374, 373f,
374f
Lateral thoracic branch, of subscapular
artery, 239f
Latissimocondyloideus muscle, 105
Leash of Henry, radial nerve compression
by, 478, 479f
Legueu and Juvara, fibers of, 596
Subject Index 707
Lesser multangular. See Trapezoid
Ligament(s)
acromioclavicular, 6, 6f
annular, of radius, 31f, 32f, 370–371,
371f, 373f
anterior, of elbow, 370–371
anterior oblique, of thumb, 538–540,
538t, 539f
beak, of thumb, 540
of capitate, 493–494
capitohamate, 493, 494, 501f, 503
capsular, 500, 500f
carpal
palmar, 209
transverse, 503–504, 573–574
of carpal bones
distal row, 501–503
proximal row, 501f, 502
536–540, 537f, 538t, 539f
check-rein, 546, 546f–547f
Cleland’s, 596f–597f, 598–599, 599f,
674
collateral. See Collateral ligaments
commissural, proximal and distal, 595,
596f
conoid, 6, 6f, 10f
coracoclavicular, 6, 6f
costoclavicular, 6f, 7
dorsoradial, of thumb, 538t, 539–540,
539f
of elbow. See Elbow, ligaments of
epitrochleoanconeus, 456
Grayson’s, 596f–597f, 598, 598f, 620f,
621f, 622, 679–680
of hamate, 494
intercarpal, 492
dorsal, 492, 500, 500f, 538–539, 538t,
539f
palmar, 538, 538t, 539f
interclavicular, 6–7, 6f
interosseous, 33, 502–503
of interphalangeal joints, 546–547,
546f–548f
Landsmeer’s, 683–684
link, 683–684, 590f–592f, 592
of lunate, 492
lunotriquetral, 492, 501f
metacarpal, transverse, 545, 604, 606f
superficial (natatory), 545, 595, 596f,
597, 597f, 598, 620, 620f, 622
metacarpophalangeal, 627
of mid-carpal joint, 501–502, 501f
natatory, 545, 595, 596f, 597, 597f, 598,
620, 620f, 622
oblique, of thumb, 538–540, 538t, 539f
oblique retinacular, 683–684, 590f–592f,
592
of pisiform, 492
708 Subject Index
Ligament(s) (contd.)
pisohamate, 210, 494, 499f
pisometacarpal, 210
pisotriquetral, 492
posterior oblique, of thumb, 538t,
539–540, 539f
quadrate, 32f
radiocarpal, 492, 499–500, 499f, 500f
radiolunate, 492, 499, 499f, 500
radiolunotriquetral (long radiolunate),
499, 499f
radioscaphocapitate, 492, 493, 499, 499f
radioscapholunate, 499f, 500
radiotriquetral, 500, 500f
of radioulnar joint
distal, 496–497, 496f
proximal, 370–371
of radius, 370–371, 371f, 373f
retinacular
oblique, 590f–592f, 592, 683–684
transverse, 590f, 591, 591f
scaphocapitate, 492, 501f, 502
of scaphoid, 492
scapholunate, 492, 501f
scaphotrapezium-trapezoid, 492, 493,
501f, 502
scaphotriquetral, 500, 500f
sternoclavicular, 6–7, 6f
of Struthers, 111, 361–362, 361f, 689
vs. arcade of Struthers, 205
median nerve compression at, 188,
445, 446f, 447f
of thumb, 538–540, 538t, 539f
trapeziocapitate, 493–494, 501f,
502–503
trapeziotrapezoid, 493, 501, 501f
of trapezium, 493
trapezoid, 6, 6f, 10f, 16
of trapezoid, 493
triangular, 590f, 591
triquetrocapitate, 492, 493, 499f, 501f,
502
triquetrohamate, 492, 494, 501f, 502
of triquetrum, 492
ulnocapitate, 493, 497, 497f, 499f, 501
ulnocarpal, 497, 497f, 501
ulnolunate, 492, 497, 497f, 501
ulnotriquetral, 497, 497f, 499f, 501
of wrist. See Wrist, ligaments of
Linburg-Comstock anomaly, 684
Linburg’s sign or Linburg syndrome, 128,
129
Lister’s tubercle, 30f, 34f, 39, 461, 462f,
486, 487f, 490, 490f, 642, 643f
Loge de Guyon. See Guyon’s canal
Long finger. See Finger(s), long
Longitudinal arch, of hand, 536, 536f
Longitudinal fibers, of palmar fascia, 595,
596f–597
Lorry driver’s fracture, 41, 675
Lumbrical compartment, compartment
syndrome of, 634–635, 634f, 635f
Lumbrical muscles, 135, 157–160, 158t,
182t, 587f, 588–589, 588f
actions and biomechanics of, 158–159
anomalies and variations of, 159
clinical correlations of, 159–160
extensor digitorum communis
relationship with, 135
gross anatomy of, 157–158
innervation of, 198
Lumbrical plus digit, 159–160, 595, 684
Lunate, 41f, 42f, 491f
absence of, 527
accessory bones of, 50, 52
anomalies and variations of, 50–51, 527,
527f, 528, 528f
avascular necrosis of, 514
clinical correlations of, 52
derivation and terminology of, 50
joints associated with, 51
ligaments of, 492
ossification centers of, 43f, 50, 52
osteology of, 50, 51f, 492
vascularity of, 51–52, 492, 512, 512f
Lunate fossa, of radius, 487, 487f, 490,
490f, 642, 643f
Lunotriquetral ballottement test, 684–685
Lunotriquetral coalition, 54, 528–529
Lunotriquetral interosseous ligaments, 492
Lunotriquetral ligament, 492, 501f
Lunula, of nail unit, 654, 654f
Lymph, 277
Lymphatic system, 277–281, 277t
anomalies and variations of, 281
clinical correlations of, 281
gross anatomy of
deep nodes, 277t, 279f, 280–281, 280f
deep vessels, 277t, 278
superficial nodes, 277t, 278, 279f,
280f
superficial vessels, 277, 277t, 278f,
279f
M in flexor digitorum profundus
McConnell approach, to median or ulnar
nerve, 440–441, 443f
MACN. See Antebrachial cutaneous nerve,
medial
Mallet finger, 652, 653f, 658
Mannerfelt hyperflexion sign, 685
Manubrium, 6–7, 6f
Martin-Gruber anastomosis, 189–190, 192
anatomy of, 454, 454f
anterior osseous nerve and, 193
clinical correlations of, 454, 454f
dorsal interossei function in, 163
types of, 453–454, 453f
Masse’s sign, 685
Matev’s sign, 685
MBCN. See Brachial cutaneous nerve(s),
medial
Medial collateral ligaments, 371–372,
371f–374f, 374, 399–400, 399f,
401f
Medial epicondylitis (golfer’s elbow), 26,
388
Median artery, 251–252
anomalies and variations of, 468
developmental anatomy of, 468
in forearm, anomalies and variations of,
468
persistent, 261, 559
in superficial arch, 257
Median lymph vessels, 277, 278
Median nerve, 185–200, 324f
anomalies and variations of, 363, 455
in antecubital fossa, 424, 424f, 431, 432f
in arcade of Struthers, 356, 357f–361f,
360t, 361–362
in axilla and arm, 329f, 330f, 340–341,
340f
anomalies and variations of, 185–186
clinical correlations of, 186, 188
course of, 185, 187f
bifid
in forearm, 191, 194
in wrist and hand, 197, 199
in brachial plexus, 299f, 301f, 304f, 306
in carpal tunnel, 196–197, 196t
common palmar digital branch of, 195
completely innervating hand, 189
compression of. See also Carpal tunnel
syndrome
in arcade of Struthers, 361–362, 361f
in axilla and arm, 186, 188
in forearm, 192–194
in pronator syndrome, 445–446, 446f,
447f
cutaneous branches of, 202f
digital nerves of
common, 199
proper, 195–196, 199
distal branching of, 196–197
innervation, 126
in flexor digitorum superficialis
innervation, 121, 191
in forearm, 426f, 431, 432f
anomalies and variations of, 189–192
anterior interosseus nerve branch of,
189–191, 193–194
clinical correlations of, 192–195
course of, 188
palmar cutaneous branch of, 189,
191–192, 194–195
in hand, branches of, 570, 571f, 572,
572f
high division of, 575, 575t
in forearm, 191, 194

in wrist and hand, 197, 199
laceration of, with Martin-Gruber
anastomosis, 192
in lumbrical innervation, 198
in Martin-Gruber anastomosis. See
Martin-Gruber anastomosis
musculocutaneous nerve communication
with, 340, 363
origin of, 185, 186f
anomalous, 185–186
palmar cutaneous branch of, 431, 432f,
521, 521f, 524f, 568–570, 569f
absence of, 191, 194
compression of, 194
course of, 189
distal exit of, 191
injury of, 194
in palmaris longus, 191–192
peripheral block of, 195
separate branches of, 191
variations of, 191–192
palmar ulnar-median communicating
branch of Berrettini, 198, 199
palsy of, low, 593
position of, relative to ulnar nerve, 185
pronator teres branch of, 188
in pronator teres innervation, 111
protection of, in elbow surgery, 379–380,
381f
recurrent
skin reference lines for, 535f
surgical risk to, 612f, 613
recurrent motor branch of, 571f,
573–574
absence of, 197
anomalies and variations of, 573–574,
574t
anterior origin of, 197
in carpal tunnel, 196, 199
course of, 195
multiple, 196
in Riche-Cannieu anastomosis, 163,
197–198, 211, 636–637, 636f,
637f, 673–674
subligamentous origin of, 196
transligamentous passage of, 196
transretinacular pattern of, 199
from ulnar aspect, 197
ulnar-sided exit of, 197
in wrist and hand, 199
Riche-Cannieu anastomosis of, 163,
197–198, 211, 636–637, 636f,
637f, 673–674
surgical exposures for
in forearm, 438, 440–441, 441f–444f,
444
medial, 346–347, 347f–349f, 351
territory of, ulnar nerve territory
overlapping with, 190
thenar branch of, absence of, 199–200
ulnar nerve anomalous connections with,
207
in wrist and hand
anomalies and variations of, 196–198,
196t
clinical correlations of, 198–200
course of, 195–196
recurrent motor branch of, 196–197,
199
skin reference lines for, 535f
Median recurrent nerve
skin reference lines for, 535f
surgical risk to, 612f, 613
Median vein, in forearm, 413
Meissner corpuscles, 225f, 226
Meniscus, of radioulnar joint, 497
Merkel receptors, 226
Mesotenon, vinculum as, 608
Metacarpal(s), 41f, 42f, 63–65, 63f, 64f, 65t
accessory bones of, 65
base of, bossing at, 661
heads of, 65
index finger, 64, 65t, 68–71, 69f, 131,
536
long finger, 64–65, 65t, 71–74, 72f, 133,
536
styloid process of, 642, 643f
mobility of, 536
muscle origins and insertions of,
112–113, 160
ring finger, 64–65, 65t, 74–44, 75f, 536
sesamoid bones of, 65
index finger, 71
small finger, 78
thumb, 68
small finger, 64–65, 65t, 77–79, 77f,
143, 536
styloid process of, 487, 487f, 642, 643f
thumb. See Thumb, metacarpal of
Metacarpal arcades, venous, 644, 644f, 645f
Metacarpal arches, basal, 48f, 255f,
265–266, 265f, 509
dorsal, 506–507, 507f
palmar, 508f
Metacarpal artery(ies)
dorsal, 253f, 550, 551f, 555
first, 266, 566
in index finger, 563f, 564, 566–567
in thumb, 563f
palmar, 238f, 249f, 265f, 553–555, 553f
first, 564, 565f, 566
in index finger, 562–563, 563f, 565f,
568
in thumb, 562–563, 563f, 565f, 568
in tissue transfer, 269–270
Metacarpal ligaments, transverse, 545, 604,
606f
superficial (natatory), 545, 595, 596f,
597, 597f, 598, 620, 620f, 622
Metacarpal veins, dorsal, 270, 271, 271f
Subject Index 709
Metacarpophalangeal joint(s), 81, 81f, 542,
543f–545f, 545, 545t
dislocation of, thumb, 627–628, 628f
extensor mechanisms at, 652
disruption of, 652, 653f
index finger, dislocation of, 628–630,
629f, 630f
innervation of, 573
lumbrical action on, 158–159, 158t, 589
skin creases at, 533
subluxation of, 221
surgical exposures for, 656, 657f
finger, 617, 619f
thumb, 615–617, 616f–618f
thumb, 85, 540–542, 541f, 542f
injury of, 679
surgical exposure for, 615–617,
616f–618f
ulnar collateral ligament disruption in,
688
Metacarpophalangeal ligament, injuries of,
627
Metaphyseal arches, palmar, 515–516, 516f
Metaphyseal branches, of digital arteries,
560–561, 561f
Metastasis, to humerus, blood supply and,
334
Mid-axial incision, in palm, 614, 614f
Mid-carpal joint, 494
anomalies and variations of, 527–528,
527f, 528f
ligaments of, 501–502, 501f
Middle finger test, for radial tunnel
syndrome, 478
Mid-palmar space, 604
“Mobile wad of three” muscle group, 408,
408f, 422, 422f, 423f, 461, 462f
Monteggia fracture, 35, 685
reverse (Galeazzi fracture), 36, 40, 679
Motor branches
of median nerve, recurrent. See Median
nerve, recurrent motor branch of
of radial nerve, 337f, 426, 426f, 427f,
429f, 455
of ulnar nerve, 201f, 206, 571f, 575,
576f–578f, 577, 578t, 579–581,
581f
deep, 201f, 210–212, 637–638, 638f
to ring finger, 206
MSCN. See Musculocutaneous nerve
Multangulum majus secundarium (os
trapezium secundarium), 60, 61, 63,
68, 71
Multangulum minus secundarium (os
trapezoideum secundarium), 59–61,
68, 71
Mummenthaler sign, 685–686
Muscle(s), 91–184
abductor digiti minimi, 155–156, 182t,
214, 583, 583f, 682
710 Subject Index
Muscle(s) (contd.)
abductor indicis, 161–162, 587
abductor pollicis brevis. See Abductor
pollicis brevis muscle
abductor pollicis longus. See Abductor
pollicis longus muscle
abductor pollicis tertius, 146
accessories ad flexoram digiti minimi,
119
accessory. See specific muscles
actions and biomechanics of, 180t–183t
adductor pollicis, 154–155, 182t,
582–583, 582f
anconeus, 105–106, 180t, 461, 463f,
464f, 465
anconeus epitrochlearis, 124, 208, 405,
456
anconeus sextus, 106
of antecubital fossa, 422–423, 424f
architectural features of, 107t, 108f, 184t.
See also specific muscles
intrinsic, 150, 150t, 151f, 158t
wrist extensors and flexors, 113, 114t
of arm, 325–327, 326f, 328f. See also
Forearm, extensor, muscles of;
Forearm, flexor, muscles of; specific
muscles
biceps brachii. See Biceps brachii muscle
brachialis. See Brachialis muscle
brachiofascialis, of Wood, 103
brachioradialis. See Brachioradialis muscle
(supinator longus muscle)
brachioradialis brevis, 109, 455
capsularis brachialis, 103
compartments of, 183t
coracobrachialis, 96–98, 180t, 326, 326f,
327f, 338f, 362
coracobrachialis inferior, 362
coracobrachialis longus, 362
coracobrachialis minor, 97
deltoid. See Deltoid muscle
dorsoepitrochlearis, 105
epitrochleoanconeus, 124, 208
epitrochleocubital, 106
epitrochleoolecranonis anconeus, 124
epitrochleoolecranonis anconeus
epitrochlearis, 106
extensor atque abductor pollicis
accessorius, 146
extensor carpi radialis accessorius, 132
extensor carpi radialis brevis. See Extensor
carpi radialis brevis muscle
extensor carpi radialis intermedius, 132,
132f, 134, 484, 664, 664f
extensor carpi radialis longus. See
Extensor carpi radialis longus muscle
extensor carpi ulnaris. See Extensor carpi
ulnaris muscle
extensor digiti minimi. See Extensor digiti
minimi muscle
extensor digitorum brevis manus, 139,
140f, 141, 662–663, 663f
extensor digitorum communis. See
Extensor digitorum communis
muscle
extensor indicis et medii communis, 139,
140f, 484–485, 661–662, 662f
extensor indicis proprius, 141–142, 181t,
427, 428f, 465f, 466
extensor medii et annularis communis,
139
extensor medii proprius, 138t, 139, 140f,
484, 661–662, 661f
extensor pollicis brevis muscle. See
Extensor pollicis brevis
extensor pollicis longus, 148–149, 181t,
427, 428t, 465f, 466
extrinsic extensor, 590–592, 590f–592f
fascial spaces of, 183t
flexor carpi radialis. See Flexor carpi
radialis muscle
flexor carpi radialis brevis, 115, 134, 447,
448f, 456
flexor carpi ulnaris. See Flexor carpi
ulnaris muscle
flexor digiti minimi, 156, 182t, 214, 583,
583f
flexor digitorum profundus. See Flexor
digitorum profundus muscle
flexor digitorum profundus indicis, 127
flexor digitorum sublimis (flexor
digitorum superficialis muscle),
120–123, 180t
flexor digitorum superficialis. See Flexor
digitorum superficialis muscle
flexor indicis profundus, 127
flexor pollicis brevis, 152–153, 182t, 211,
582–583, 582f
flexor pollicis longus. See Flexor pollicis
longus muscle
of forearm. See also Forearm, extensor,
muscles of; Forearm, flexor, muscles
of
dorsal, 461–466
flexor, 416–423
Gantzer’s. See Gantzer’s muscle (accessory
flexor pollicis longus muscle)
of hand, 581–595
hypothenar. See Hypothenar muscles
infarction of, in compartment syndrome,
449–450
innervation of, 180t–183t
insertions of, 180t–183t. See also specific
muscles and bones
in hand, 112f–113f, 581–582
interosseous. See Interosseous muscle(s)
intrinsic. See Intrinsic muscle(s); specific
muscles
Langer’s, 186
latissimocondyloideus, 105
lumbrical. See Lumbrical muscles
“mobile wad of three” group, 408, 408f,
422, 422f, 423f, 461, 462f
omohyoid, 297, 299f
opponens digiti minimi, 156–157, 182t,
583f, 584
opponens pollicis, 153–154, 182t, 211,
582–583, 582f
origins of, 180t–183t. See also specific
muscles and bones
in hand, 112f–113f
palmaris bitendinous, 117
palmaris brevis, 155, 182t, 578f, 579,
583, 583f
palmaris brevis profundus, 638
palmaris longus. See Palmaris longus
muscle
palmaris longus inversus, 117, 118f
palmaris longus profundus, 117
palmaris profundus, 198–199, 447, 448f,
456
pectoralis major, 299f, 300f
pectoralis minor, 299f, 300f
platysma, 307
pronator quadratus, 129–130, 181t, 421,
421f
pronator teres. See Pronator teres muscle
sternocleidomastoid, 297, 298f
subanconeus, 104, 106
supinator. See Supinator muscle
supinator longus. See Brachioradialis
muscle
tensor ligamenti anularis anterior, 145
thenar, 159, 503f, 582–583, 582f. See
also specific muscles
transversus manum, 154
trapezius, 297, 298f
triceps brachii. See Triceps brachii muscle
ulnaris digiti minimi, 144
ulnaris digiti quinti, 144
vascular systems of. See specific muscles
Wood’s, 97
Musculocutaneous nerve, 299f
anomalies and variations of, 220, 223,
312, 314, 363
in antecubital fossa, 424f
in axilla and arm, 222, 329f, 336, 338f,
339f
in biceps brachii muscle innervation,
98–101
in brachialis innervation, 102–103
in brachial plexus, 300f, 301f, 304f,
306
injury of, 311–312
clinical correlations of, 223
in coracobrachialis muscle innervation,
96–98
course of, 187f
in forearm, 222–223
injury of, 311–312

median nerve communication with, 340,
363
muscular branches of, 340t
origin of, 222
palsy of, 101
surgical exposures for, 312
variations of, 101
Myositis ossificans, of elbow, 405
N subscapular, 305f, 306
Nail units, 654–656
blood supply of, 655–656, 655f
extensor tendon insertion and, 654f, 656
function of, 656
injury of, 655
innervation of, 656
nail bed (matrix), 654–655, 654f
nail fold, 654, 654f
nail plate, 654, 654f, 656
nomenclature of, 654, 654f
venous system of, 644f, 645, 655
Natatory cord, in Dupuytren’s contracture,
621f, 622
Natatory ligaments, 545, 595, 596f, 597,
597f, 598, 620, 620f, 622
Navicular. See Scaphoid
Naviculocapitate syndrome, 59
Neck, triangles of, 297, 298f, 299f
Necrosis, avascular. See Avascular necrosis
Neer classification
of distal clavicle fractures, 7
of impingement syndrome, 25
Nerve(s)
antebrachial cutaneous. See Antebrachial
cutaneous nerve
in antecubital fossa, 431, 432f
articular, 573
axillary. See Axillary nerve
brachial cutaneous. See Brachial
cutaneous nerve(s)
in brachial plexus. See Brachial plexus
in carpal tunnel, 196–197, 196t, 199,
574, 574t
in cubital tunnel, 205–206
cutaneous. See Cutaneous nerve(s)
digital. See Digital nerves
endings of, 225f, 226
Froment-Rauber, 219
in Guyon’s canal, 209–210, 577, 578t
of Henle, 201f, 455, 681, 569, 569f
intercostobrachial, 202f–203f, 224
intercostobrachial cutaneous, 325f
interosseous. See Interosseous nerve(s)
median. See Median nerve
median recurrent, 535f, 612f, 613
motor branches of. See Motor branches
musculocutaneous. See Musculocutaneous
nerve
nerves of, 571f–572f, 573, 612f, 613
pectoral, 305
phrenic, 299f, 300f, 301, 302f, 307
accessory, 302f
radial. See Radial nerve
scapular, 301
sensory branches of. See Radial nerve,
sensory branch of; Ulnar nerve,
sensory branch of
spinal, as brachial plexus roots, 300–301,
301f–303f, 303–304, 308f
suprascapular, 18, 302f, 304–305, 305f,
310
sympathetic fibers in
in anterior interosseous nerve, 188
in radial nerve, 218
in ulnar nerve, 206, 211, 579
thenar, 572f, 573–574, 574t
thoracic, 301, 301f, 305f
thoracodorsal, 301f, 305f, 306
ulnar. See Ulnar nerve
in ulnar tunnel, 209–210, 212–214, 213t
of Wrisberg, 223–224
Nerve block, of palmar cutaneous nerve
branch, 195
Nerve graft
lateral antebrachial cutaneous nerve as,
415–416, 444, 445f
medial antebrachial cutaneous nerve as,
321
Neural loop, of deep motor branch of ulnar
nerve, 637–638, 638f
Neuritis
of Parsonage-Turner, 194
radial, 480, 481f
Neuroma, of thumb, 672
Neurovascular bundle, of arm, 327–328,
329f–331f. See also specific arteries
and nerves
Nightstick fractures, 35
Notta’s node, 623
Nutrient artery
accessory, of profunda brachial artery,
246
of humerus, 332, 333f
Nutrient canal, of humerus, 23–24
Nutrient foramina
of radius, 29f
of ulna, 29f
O 53, 55, 57, 59
Oblique communicating veins, 644f, 646
Oblique cord, of interosseus membrane,
410, 411f
Oblique dorsal artery of the distal ulna,
514, 516f
Oblique ligaments, of thumb, 538–540,
538t, 539f
Oblique retinacular ligament, 683–684,
590f–592f, 592
Olecranon, 367, 367f, 409f, 410
Subject Index 711
fractures of, 35
as landmark, 315, 316f–318f, 365, 366f,
461, 462f
muscle origins and insertions of, 34, 105
osteology of, 28, 30f, 31f
osteotomy of, 35, 376, 377f
Olecranon articula rete, 246
Olecranon fossa, 20f, 24, 319f, 366, 367f
Ollier’s phenomenon, 686
Omohyoid muscle, 297, 299f
Opponens digiti minimi muscle, 156–157,
182t, 583f, 584
Opponensplasty, for thumb paralysis,
152–154, 156
Opponens pollicis muscle, 153–154, 182t,
211, 582–583, 582f
Organelles, sensory, 225–226, 225f
Os acromiale, 9, 17
Osborne’s band, 416
ulnar nerve compression at, 391,
393–394, 394f
Os capitatum. See Capitate
Os capitatum secundarium, 57, 59, 71, 74,
77
Os carpometacarpale I (os praetrapezium),
61, 63
Os carpometacarpale II (multangulum
majus secundarium), 60, 61, 63
Os carpometacarpale III (os
parastyloideum), 57, 59, 68–69, 71,
74
Os carpometacarpale IV (os styloideum),
57, 59, 71, 74
Os carpometacarpale V (os capitatum
secundarium), 57, 59, 71, 74, 77
Os carpometacarpale VI (os gruberi), 57,
59, 71, 74, 77
Os carpometacarpale VII (os hamulare
basale), 55, 57
Os carpometacarpale VIII (os vesalianum
manus), 53, 55, 57, 77, 78
Os centrale, 42, 43f, 44, 49, 60, 61, 529
Os centrale dorsale, 42, 43f, 44, 49, 57, 59,
60, 61
Os centrale II (os epilunatum), 43f, 44, 50,
52, 57, 59
Os centrale III (os hypolunatum), 50, 52,
57, 59
Os centrale IV (os epitriquetrum), 50, 52,
Os epilunatum, 43f, 44, 50, 52, 57, 59
Os epipyramis (os epitriquetrum), 50, 52,
53, 55, 57, 59
Os episcaphoid (os centrale), 42, 43f, 44,
49, 57, 59, 60, 61
Os epitrapezium, 43f, 44, 49–50, 61, 63
Os epitriquetrum, 50, 52, 53, 55, 57
Os gruberi, 57, 59, 71, 74, 77
Os hamulare basale, 55, 57
Os hamuli proprium, 55, 57, 74, 77
712 Subject Index
Os hypolunatum, 50, 52, 57, 59
Os hypotriquetrum, 50, 52, 53, 55, 57, 59
Os intermedium antebrachii (os
triangulare), 27, 50, 52, 53
Os lunatum. See Lunate
Os magnum. See Capitate
Os metacarpale III (os parastyloideum), 57,
59
Os metapisoid (os pisiforme secundarium),
27, 35, 53, 54
Os metastyloideum, 57, 59, 60, 61, 68, 71
Os multangulum minus. See Trapezoid
Os parascaphoid (os radiale externum), 36,
43f, 44, 49, 61, 63
Os parastyloideum, 57, 59, 68–69, 71, 74
Os paratrapezium, 61, 63
Os pisiforme secundarium, 27, 35, 53, 54
Os praetrapezium, 61, 63
Os radiale externum, 36, 43f, 44, 49, 61, 63
Os radiostyloideum, 36, 43f, 44, 49
Ossa metacarpalia I, 65–68, 67f
Ossa metacarpalia II (index finger
metacarpal), 64–65, 65t, 68–71, 69f
Ossa metacarpalia III (long finger
metacarpal), 64–65, 65t, 71–74,
72f, 133
Ossa metacarpalia V (small finger
metacarpal), 64–65, 65t, 77–79,
77f, 143
Ossification, heterotopic, of elbow, 405
Ossification centers. See also specific bone,
ossification centers of
appearance of, vs. age, 80t
Os styloideum, 57, 59, 71, 74
Os subcapitatum, 57, 59, 71, 74
Osteochondrosis, of humeral capitulum, 27
Osteonecrosis. See Avascular necrosis
Osteotomy
of humeral epicondyles, 380, 381f
of olecranon, 35, 376, 377f
Os trapezium secundarium, 60, 61, 63, 68,
71
Os trapezoideum. See Trapezoid
Os trapezoideum secundarium, 59–61, 63
Os triangulare, 27, 35, 50, 52, 53
Os triquetrum secundarium (os triangulare),
27, 50, 52, 53
Os ulnare externum, 53, 55, 57
Os ulnostyloideum, 27, 35
Os vesalianum manus, 53, 55, 57, 77, 78
Os vesalii (os vesalianum manus), 53, 55,
57, 77, 78
P continuous muscle, 117, 119
Pacinian corpuscles, 225–226, 225f
Palmar aponeurosis pulley, 596, 599–600,
600f
Palmar arches
deep, 238f, 267–268, 267f, 249f, 255f,
267f, 510, 550, 552, 553f–554f
branches of, 553, 553f
complete, 552, 554f
incomplete, 552, 554f
skin reference lines for, 535f
variations of, 268–269
of digital arteries, 566, 567f
superficial, 238f, 249f, 254–259, 255f,
256t, 508f, 550f, 557, 558f
branches of, 238f, 255f, 258–259, 557,
559, 559f
complete, 557, 558f
incomplete, 557, 558f
skin reference lines for, 535f
variants of, 255–257
transverse, 560–561, 561f
veins accompanying
deep, 275
superficial, 271, 272f
Palmar artery, superficial, 509, 509f
lesions of, 261
Palmar branch
of radial artery, 249f, 263, 267f
of radial nerve, 322f, 415f
Palmar carpal branch
of anterior interosseous artery, 249f
of radial artery, 263–264, 508f, 550f
of ulnar artery, 254
Palmar creases, 488f, 489, 489f, 533–534,
533f, 534f
Palmar cutaneous branch
of median nerve. See Median nerve,
palmar cutaneous branch of
of ulnar nerve, 201f, 206, 569, 569f
transverse, 569–570, 569f
variations in, 212
Palmar digital arteries, arches of, 566, 567f
Palmar fascia, 595–597, 596f, 597f, 619,
620f
Palmar interosseus muscle(s), 158t,
164–165, 183t
Palmaris bitendinous muscle, 117
Palmaris brevis muscle, 155, 182t, 578f,
579, 583, 583f
Palmaris brevis profundus muscle, 638
Palmaris longus inversus muscle, 117, 118f
Palmaris longus muscle, 416, 417f, 596f
absence of, 115–120, 180t
accessory slips of, 119
actions and biomechanics of, 116–117
anomalies and variations of, 117, 118f,
119, 213, 456
central belly, 119
clinical correlations of, 119–120
continuous tendon, 119
digastric head of, 117, 118f
distal or reverse belly, 117, 118f
as donor muscle, 117, 120
gross anatomy of, 115–116
identification of, 422, 423f
innervation of, 116
intra-palmar accessory head of, 119
as landmark, 408, 408f
palmar cutaneous nerve branch in,
191–192
split or double belly, 117, 118f
substituting for digital flexors, 119
triple muscle bellies in, 119
vascularity of, 116
Palmaris longus profundus muscle, 117
Palmaris profundus muscle, 198–199
anomalies and variations of, 456
anterior interosseous nerve compression
at, 447, 448f
Palmar plates
of fingers, 542, 543f–544f, 546,
546f–547f
of interphalangeal joints, 546, 546f–547f
of thumb, 541
Palmar plexus (lymphatic vessels), 277
Palmar radiocarpal arch, 263–264
Palmar scaphoid branches, of radial artery,
264–265, 511
Palmar spaces, 604–605, 606f
Palmar ulnar-median communicating
branch of Berrettini, 198, 199
Palmar ulnar space, 604
Panner’s disease, 27
Papillar network, of nail unit blood supply,
655, 655f
Paralysis. See specific muscles and nerves
Paratenon, 609
Parona’s space, 605, 606f, 607, 686
Parsonage-Turner syndrome, 194
Patella cubiti, 105
PCBMN. See Median nerve, palmar
cutaneous branch of
Pectoral branch, of thoracoacromial artery,
241
Pectoral group of axillary lymph nodes, 280,
280f
Pectoralis major muscle, 299f, 300f
Pectoralis minor muscle, 299f, 300f
Pectoral nerves, 305
Perforating veins, of hand, 647
Peritendinitis crepitans (intersection
syndrome), 133, 134, 146–148,
480, 482f, 483
Perpendicular line, of ulna, 33
Phalanges, 79–86, 536
distal, 41f, 42f, 65t, 79, 79f, 83–85
arteries of, 655–656, 655f
muscle origins and insertions of,
125
nail unit and, 654f, 655f
ossification centers of, 43f
thumb, 86, 127–129
fractures of, Seymour’s, 688
joints of. See specific joints
middle, 41f, 42f, 65t, 79, 79f, 82–83

muscle origins and insertions of,
120–121
ossification centers of, 43f
muscle origins and insertions of
abductor pollicis brevis, 149–150
dorsal interosseous, 160, 587
extensor digitorum communis,
135–136, 136f, 137f
extensor pollicis brevis, 147
extensor pollicis longus, 148–149
flexor digitorum superficialis, 120–121
flexor pollicis longus, 127–129
proximal, 41f, 42f, 65t, 79–82, 79f, 80t,
81f
ossification centers of, 43f
surgical exposures for, 656, 657f
thumb, 85–86
thumb, 85–86
distal, muscle origins and insertions of,
127–129, 148–149
proximal, muscle origins and insertions
of, 147, 149–150
tubercles of, 84
tufts of, 84, 86
Phalen’s test, 686–687
Phrenic nerve, 299f, 300f, 301, 302f, 307
accessory, 302f
Piedmont (Galeazzi) fracture, 36, 40, 679
PIN. See Interosseous nerve(s), posterior
Pinch
dorsal interossei function in, 163
Froment’s sign in, 679
Kapandji’s test for, 683
PIP. See Interphalangeal joint(s), proximal
Pisiform, 41f, 42f, 54–55, 54f, 491f
as landmark, 408, 408f, 488, 488f, 532,
533f
ligaments of, 492
muscle origins and insertions of, 123
ossification centers of, 43f, 54
osteology of, 492
skin reference lines for, 535f
surgical exposures for, 522, 525f–526f, 527
vascularity of, 492, 507f, 508f, 512–513
Pisohamate ligament, 210, 494, 499f
Pisometacarpal ligament, 210
Pisotriquetral ligament, 492
Pitres-Testut sign, 687
Platysma muscle, 307
Plica, in wrist, 528
PL muscle. See Palmaris longus muscle
Pollicis artery, dorsal, 253f, 255f, 265f,
507f, 508f, 551f
Pollock’s sign, 687
Posterior interosseous nerve. See
Interosseous nerve(s), posterior
Posterior interosseous nerve syndrome,
477–478, 480
Posterior oblique ligament, of thumb, 538t,
539–540, 539f
Preiser’s disease, 49, 514
Prestyloid recess, of radiocarpal joint, 494
Pretendinous bands, 595, 596f, 620, 620f
Pretendinous cord, in Dupuytren’s
contracture, 621f
Princeps pollicis artery, 266, 267f, 562
absence of, 269
Process(es)
acromion. See Acromion
coracoid process. See Coracoid process
coronoid. See Coronoid process, of ulna
styloid. See Styloid process
supracondylar, of humerus, 26, 188
Profunda brachii. See Brachial artery, deep
(profunda)
Pronation, of forearm, muscles for, 407,
408f
Pronator quadratus muscle, 129–130, 181t,
421, 421f
Pronator quadratus sign, 687
Pronator ridge, of ulna, 33
Pronator syndrome, 111, 192–193, 445,
446f
persistent median artery in, 261
Pronator teres muscle, 110–111, 180t, 416,
417f
anomalies and variations of, 456
in antecubital fossa, 424f, 425f
anterior interosseous nerve compression
at, 447, 448f, 449
high origin of, 356, 361, 361f
identification of, 422, 423f
median nerve compression at, 192–193,
445, 446f
pronator quadratus working with, 129
Pseudoboutonniere deformity, 660
Pseudoulnar claw hand, 221
PT muscle. See Pronator teres muscle
Pulled elbow syndrome, 399
Pulley system, 599–602
annual, 543f
digital flexor sheaths in, 600–602, 600f
functional anatomy of, 598, 602, 604t
of interphalangeal joints, 546, 546f–547f
palmar aponeurosis as, 596, 599–600,
600f
rupture of, 624–625, 624f
of thumb, 602, 603f, 604t
of wrist, 599
Pulp arch, 567, 567f
Q in vascularized bone grafts, 269
Quadrate ligament, 32f
Quadrilateral space syndrome, 244
R 603f
Radial artery, 249f, 253f, 262–270
absence of, 268
accessory, 268
aneurysms of, 269
Subject Index 713
anomalies and variations of, 268–269,
457–458
in antecubital fossa, 423–424, 424f, 425f
in basal metacarpal arch, 265–266, 265f
branches of, 238f, 239f, 262t, 263–268,
265f, 267f
in carpal bone supply, 45–46, 46f–49f
clinical correlations of, 269–270
compression of, in Allen test, 260,
669–670
course of, 238f, 245f, 431, 434f
in deep palmar arch, 238f, 267–268, 267f
variations of, 268–269
distal division of, 248, 259
dominance of, 260–261
dorsal carpal branch of, 264, 265f
in dorsal intercarpal arch, 265–266, 265f
dorsal metacarpal branches of, 266,
269–270
in dorsal radiocarpal arch, 264, 265f
dorsal ridge of scaphoid artery, 264, 265f
emboli of, 269
first dorsal metacarpal artery of, 266
in flaps, 269, 457–458
in forearm, anomalies and variations of,
457–458
in forearm flaps, 269
gross anatomy of, 262–263, 262t
in hand, 549, 550f
high division of, 243, 244, 247
high origin of, 268, 363
index, 259, 266–267, 562
muscular branches, 263
origin of, in high division axillary
anomaly, 243
palmar carpal branch of, 263–264, 508f,
550f
in palmar intercarpal arch, 264
palmar radiocarpal branch of, 263–264
palmar scaphoid branches of, 264–265,
511
princeps pollicis artery of, 266, 267f
absence of, 269
recurrent, 238f, 239f, 263
in superficial arch, 256–257
superficial branch of
anomalous, 268
palmar, 238f, 249f, 263, 564, 565f
in thumb, 563f, 564, 565f, 567f
thrombosis of, 269
in trapezium vascularity, 62
at wrist, 265f, 507–509, 507f, 509f,
508f, 514–516, 516f–517f, 535f
Radial bursa, of flexor tendon sheath, 602,
Radial collateral artery, 238f, 239f, 245f,
246, 330f, 331f, 369f, 370t
Radial collateral ligament, 372–374, 373f,
374f, 544f
714 Subject Index
Radial collateral ligament (contd.)
injuries of, 626–627
protection of, in elbow surgery, 378
Radial deviation, of fingers, 545t
Radial fossa, 21f, 366, 367f
Radial index artery, 259, 266–267, 562
Radial lymph vessels, 277, 278
Radial marginal septum, of hand, 604,
606f
Radial nerve, 214–222
in anconeus innervation, 106
anomalies and variations of, 455
in antecubital fossa, 424, 424f
anterior interosseous branch of, posterior
interosseous nerve communication
with, 222
articular branches of, 573
in axilla and arm, 214–216, 215f, 215t,
329f, 334, 335f–337f
in brachial plexus, 299f, 301f, 306
branches of, 426, 427f, 428t
clinical correlations of, 334
compression of
in arm, 356
in brachioradialis variations, 110
in radial tunnel. See Radial tunnel
syndrome
cutaneous branches of, 202f–203f, 323f
distal division of, 334, 337f
division of, into motor and sensory
branches, 426, 427f
extensor carpi radialis brevis branch of,
427–429
fibrous arcades of, 429, 429f–430f
in forearm and hand, 216–222, 216t,
217t, 426–431, 427f, 428t,
429f–430f
anomalies and variations of, 218–220
clinical correlations of, 220–222
course of, 216–218
in Froment-Rauber anastomosis, 219
Froment-Rauber nerve and, 219
injury of, 355–356
in Holstein-Lewis fracture, 216
wrist extensors in, 220
lateral branches of, 334, 335f, 336f
medial branches of, 334, 335f–337f
motor branch of, 337f, 426, 426f, 427f,
429f
anomalies and variations of, 455
muscle innervation sequence of,
426–427, 428t
muscular branches of, 334, 335f–337f
neuritis of, at wrist, 480, 481f
origin of, 214
palmar branch of, 322f, 415f
palsy of, in humeral fracture, 26
posterior branches of, 334, 335f–337f
posterior interosseous branch of,
217–218, 217t
anterior interosseous nerve
communication with, 222
clinical correlations of, 220–221
evaluation of, 221
safe and unsafe internervous planes
and, 221
sensory branch of, 480, 481f, 482f
anomalies and variations of, 455
course of, 429, 429f, 430f
dorsal, 573
origin of, 426, 426f, 427f
superficial branch of, 216–217, 216t,
322f, 323f, 415f
anomalies and variations of, 219–220
injury of, 222
neuritis of, 690
supinator branch of, 429
surgical exposures for, 355–356,
467–468, 467f–469f
anterolateral, 341, 343, 345, 345f,
346f
medial, 346–347, 347f–349f, 351
posterior, 351–353, 350f–353f
sympathetic fibers in, 218
in triceps innervation, 104
Radial notch, of ulna, 29–31, 29f, 31f–33f,
367, 367f
Radial recurrent artery, 249f, 255f, 330f,
368f, 369f, 370t, 508f, 510
in antecubital fossa, 423, 424f, 425f
radial nerve compression by, 478, 479f
Radial sulcus, 20f, 22f, 23, 24
Radial tunnel syndrome, 220, 477–480
anatomy of, 477
compression sites in, 478, 480–481, 479f
diagnosis of, 478
vs. lateral epicondylitis, 388
surgical exposures for, 469, 470f
symptoms of, 477–478
tests for, 478
Radial veins, 275–276
palmar, 644f
of thumb, 646–647, 646f
Radiocapitellar joint, 24
Radiocarpal arches, 46f–49f
dorsal, 253f, 255f, 264, 265f, 506, 507f,
508f, 509, 509f, 509, 514, 516f,
551f
palmar, 238f, 254, 255f, 265f, 267f, 507,
507f, 508f, 509, 550f, 551f
Radiocarpal joint, 491f, 494
skin creases at, 489, 489f, 533f, 534,
534f
Radiocarpal ligaments, 492
dorsal, 500, 500f
palmar, 499–500, 499f
Radiodorsal digital artery, 567–568
Radiolunate joint, 40
Radiolunate ligaments, 492
long, 499, 499f
short, 499f, 500
Radiolunotriquetral (long radiolunate)
ligament, 499, 499f
Radiopalmar digital artery, 566
Radiopalmaris slip, of flexor digitorum
superficialis, 122
Radioscaphocapitate ligament, 492, 493,
499, 499f
Radioscaphoid joint, 40, 46
Radioscapholunate ligament, 499f, 500
Radiotriquetral ligament, dorsal, 500,
500f
Radioulnar joint
distal, 39, 495–498
arthritis of, 36
capsule of, 498
ligaments of, 496–497, 496f
meniscus of, 496–497, 497
osteology of, 495–496, 495f
stabilizing factors of, 498
surgical exposures for, 517–519, 518f,
519f
vascularity of, 497–498, 498f
proximal, 31f, 32f, 34
ligament of, 370–371
skin creases at, 489, 489f, 533f, 534,
534f
Radius, 36–41
accessory bones of, 36, 41
annular ligament of, 31f, 32f, 370–371,
371f, 373f
anterior oblique line of, 38
borders of, 29f, 30f, 38
clinical correlations of, 40–41
cross-section of, 409f
derivation and terminology of, 36
distal, 34f
fractures of, 41, 688
ossification centers of, 36, 36f, 37f
osteology of, 39, 490, 490f, 495–496,
495f
vascularity of, 514–517, 516f, 517f
epiphyseal lines of, 37f
fractures of, 40–41
Barton’s, 41, 671
Colles’, 36, 40–41, 675
distal, 671
Essex-Lopresti, 36, 40, 413, 677–678
Galeazzi, 36, 40, 679
Smith’s, 41, 688
surgical exposure for, 377–378, 378f,
379f
with ulnar fractures, 412–413
grooves of, 39
head of, 37, 366–367, 367f
fractures of, 36, 40, 677–678, 40
subluxation of, 399
surgical exposure for, 377–378, 378f,
379f
interosseous border of, 38

interosseous membrane attachment to,
410–413, 411f
joints associated with, 31f–32f, 39–40
lunate fossa of, 487, 487f, 490, 490f,
642, 643f
medullary canal of, 37
muscle origins and insertions of, 28f, 29f,
40
abductor pollicis longus, 145
biceps brachii, 98, 99f
brachioradialis, 106, 110
extensor pollicis brevis, 147
flexor digitorum superficialis, 120–122
flexor pollicis longus, 127–128
pronator quadratus, 129–130
pronator teres, 110–111
neck of, 37
nutrient foramina of, 29f, 38, 39
ossification centers of, 36, 36f, 37f, 43f
osteology of, 28f–30f, 37–39, 409f, 410
distal, 490, 490f, 495–496, 495f
proximal, 366–367, 367f
proximal, 366–367, 367f. See also Radius,
head of
ossification centers of, 36, 36f, 37f
osteology of, 28f–30f, 34
scaphoid fossa of, 40
shaft of
ossification centers of, 36, 36f, 37f
osteology of, 38–39
surgical exposures for, 438, 439f–440f
sigmoid notch of, 495
styloid process of, 29f, 34f, 39, 409f, 410,
487–488, 487f, 490, 490f
as landmark, 408, 408f, 461, 462f,
642, 643f
surfaces of, 38–39
surgical exposures for, 473–475, 473f,
474f
tuberosities of, 29f, 30f, 34f, 37–39,
409f, 410, 490, 490f
ulnar notch of, 39
Rays, of hand, 535–536
Recurrent motor branch, of median nerve.
See under Median nerve
Reticular network, of nail unit blood supply,
655, 655f
Retinacular ligaments
oblique, 590f–592f, 592, 683–684
transverse, 590f, 591, 591f
Retinacular plus test, 680–681
Retinacular system, 595–599, 596f–599f.
See also Extensor retinaculum; Flexor
retinaculum; specific components
clinical correlations of, 597–598
digital fascia in, 598–599, 598f, 599f
palmar fascia in, 595–597, 596f, 597f
Retrovascular cord, in Dupuytren’s
contracture, 621f, 622
Reverse Barton’s fracture, 671
Subject Index 715
Reverse Colles’ (Smith’s) fractures, 41 angles of, 8–9, 9f–14f, 16–17
Reverse Monteggia fracture (Galeazzi borders of, 10f–14f, 16
fracture), 36, 40, 679 clinical correlations of, 17–18
Rheumatoid arthritis, extensor pollicis congenital nonunion of, 17
longus tendon rupture in, 149 coracoid process of. See Coracoid process
Riche-Cannieu anastomosis, 163, 197–198, derivation and terminology of, 8
211, 636–637, 636f, 637f, 673–674 fossae of, 10f, 11f
Ring finger. See Finger(s), ring gender differences in, 10, 15t
Rock climbing, flexor pulley rupture in, Graves’, 8
624–625, 624f head of, 15t, 17
Rolando fracture, 687 in impingement syndrome, 17
Roos test, 688 joints associated with, 17
Rootlets, of brachial plexus, 300 as landmark, 17–18
injury of, 308f muscle origins and insertions of, 10f–12f,
Roots, of brachial plexus, 300–301, 17
301f–303f, 303–304, 308f biceps brachii, 98
Rotator cuff, impingement of, 17 deltoid, 92, 93f, 94f
Ruffini nerve endings, 225f, 226 triceps brachii, 103–104
notches of, 10f, 13f–14f, 26
S os acromiale of, 9, 17
Sagittal bands and slips ossification centers of, 8–9, 9f, 17
of extensor aponeurosis, 135, 136f, osteology of, 10–17, 10f–14f, 15t
590–592, 590f–592f processes of, 10f–14f, 12, 15t, 16
on extensor tendons, 652 scaphoid, 8
injury of, 660–661 suprascapular nerve entrapment at, 18
Saturday night palsy, 355 surfaces of, 11–12, 10f, 11f
Scaphocapitate joint, 46 tuberosities of, 98
Scaphocapitate ligament, 492, 501f, 502 winging of, 18
Scaphoid, 41f, 42–50, 42f, 491f Scapula alta (winged scapula), 18
accessory bones of, 42, 43f, 44, 49–50 Scapular nerve, dorsal, 301
anomalies and variations of, 45, 528, 529 Scapular vein, circumflex, 275f, 276
avascular necrosis of, 49, 514 Scapulothoracic articulation, 17
bipartite, 44, 50, 529 Semilunar. See Lunate
clinical correlations of, 49–50 Sensory branches
dorsal ridge of, vascularity of, 264, 265f, of radial nerve. See Radial nerve, sensory
509, 509f branch of
facets of, 45 of ulnar nerve. See Ulnar nerve, sensory
joints associated with, 46 branch of
ligaments of, 492 Sensory organelles, 225–226, 225f
muscle origins and insertions of, 49, Sesamoid bones, metacarpal, 65
149–150 index finger, 71
ossification centers of, 42, 43f, 44, 43f small finger, 78
osteology of, 41f, 42f, 44–45, 63f, 64f, thumb, 68
490, 492 Sesamum cubiti, 105
surgical exposures for, 519–520, 520f Seymour’s fracture, 688
tuberosities of, 44–45, 44f, 488 Shoulder. See also Clavicle; Humerus,
vascularity of, 45–46, 46f–49f, 492, 507f, proximal; Scapula
508f, 510–512 dislocation of, 25, 26
Scaphoid fossa, of radius, 40, 490, 490f Sigmoid notch, of radius, 490, 490f, 495
Scaphoid scapula, 8 Sign(s)
Scaphoid shift test, 690–691 Andre-Thomas, 670, 676
Scapholunate dissociation, Terry Thomas Bouvier’s, 672
sign in, 689–690 Duchenne’s, 676
Scapholunate joint, arthrodesis of, 49 Egawa, 676
Scapholunate ligament, 492, 501f Froment’s, 679
Scaphotrapezium-trapezoid ligament, 492, Hoffman-Tinel, 681
493, 501f, 502 Jeanne’s, 683
Scaphotriquetral ligament, dorsal, 500, 500f Linburg’s, 128, 129
Scapula, 8–18 Mannerfelt hyperflexion, 685
accessory bones of, 9, 17 Masse’s, 685
716 Subject Index
Sign(s) (contd.)
Matev’s, 685
Mummenthaler, 685–686
Pitres-Testut, 687
Pollock’s, 687
pronator quadratus, 687
Sunderland’s, 689
supination, 691
Terry Thomas, 689–690
Wartenberg’s, 690
Skeletal system, 3–91. See also specific bones
capitate, 41f, 42f, 57–59, 58f
carpus, 41–42, 41f–43f, 44t
clavicle, 3–8, 4f–6f
hamate, 41f, 42f, 55–57, 55f
of hand
dorsal aspect of, 42f
palmar aspect of, 41f
humerus, 18–27, 19f–23f
lunate, 41f, 42f, 50–52, 51f
metacarpals, 41f, 42f, 63–65, 63f, 64f,
65t
index finger, 64–65, 65t, 68–71, 69f
long finger, 64–65, 65t, 71–74, 72f,
133
ring finger, 64–65, 65t, 74–44, 75f
small finger, 64–65, 65t, 77–79, 77f,
143
thumb, 65–68, 67f, 535
overview of, 3
phalanges, 41f, 42f, 79–86, 79f
distal, 41f, 42f, 83–86
middle, 41f, 42f, 82–83
proximal, 41f, 42f, 79–82, 80t, 81f,
85–86
thumb, 85–86
pisiform, 41f, 42f, 54–55, 54f
radius, 36–41, 36f, 37f
scaphoid, 41f, 42, 42f, 44–50, 44f,
46f–49f
scapula, 8–18, 9f–14f, 15t
trapezium, 41f, 42f, 61–63, 62f
trapezoid, 41f, 42f, 59–61, 60f
triquetrum, 41f, 42f, 53–54, 53f
ulna, 27–36, 27f–32f, 34f
of wrist, 489–494, 490f–491f
accessory bones in. See specific bones
and accessory bone names
dorsal aspect of, 42f
palmar aspect of, 41f
Skiers thumb, 688
Skin
dorsal, 643
palmar, anchorage of, 597
sensory organelles in, 225–226, 225f
Small finger. See Finger(s), small
Smith’s fracture, 41, 688
Snapping elbow, 398
Snuffbox, anatomic, 148–149, 262–263,
486–487, 487f, 642
Spaces
palmar, 604–605, 606f
wrist, 605, 606f, 607
Spinal nerves, as brachial plexus roots,
300–301, 301f–303f, 303–304,
308f
Spine(s), scapular, 10, 11f, 13f–14f, 15t, 16
Spiral band, 621–622
Spiral cord, in Dupuytren’s contracture,
621f, 622
Steindler flexorplasty, 101
Stener lesion, 625, 625f, 689
Sterile matrix, of nail bed, 654, 654f, 655
Sternal portion, of clavicle, 5
Sternoclavicular joint, 6, 6f
separation of, 8
Sternoclavicular ligament, 6–7, 6f
Sternocleidomastoid muscle, 297, 298f
Stratum corneum, of nail unit, 654, 654f
Struthers
arcades of. See Arcade(s), of Struthers
ligament of, 111, 361–362, 361f, 689
vs. arcade of Struthers, 205
in median nerve compression, 188
median nerve compression at, 445,
446f, 447f
Styloid process
of metacarpal, long finger, 71, 72, 72f,
487, 487f, 642, 643f
of radius, 29f, 34f, 39, 409f, 410,
487–488, 487f, 490, 490f
as landmark, 408, 408f, 461, 462f,
642, 643f
of ulna, 29f, 30f, 34, 34f, 35, 409f, 410,
461, 462f, 490, 495–496, 495f,
496f
Styloscaphoid joint, 40, 46
Subanconeus muscle, 104, 106
Subclavian artery, 299f, 300f, 301f, 302f
Subclavian vein, 276, 299f, 301f
Subclavicular (apical) group of axillary
lymph nodes, 280f, 281
Subdermal network, of nail unit blood
supply, 655, 655f
Subradicular arteries, 301
Subscapular artery, 238f, 239f, 241–243
circumflex, 238f, 239f, 242
lateral thoracic branch of, 239f
Subscapular group of axillary lymph nodes,
280–281, 280f
Subscapular nerves, 305f, 306
Subscapular vein, 275f, 276
Sunderland’s sign, 689
Superficial anterior oblique ligament, of
thumb, 538, 538t, 539f
Superficial arches, of ulnar artery, 564
Superficial branch
of radial artery
in index finger, 563f, 564, 565f, 567f
in thumb, 563f, 564, 565f, 567f
of radial nerve, 216–217, 216t, 322f,
323f, 415f
anomalies and variations of, 219–220
injury of, 222
of ulnar nerve, 212–213
Superficial distal hiatus, of Guyon’s canal,
577
Superficial palmar branch
of radial artery, 564, 565f
of ulnar nerve, 210–211
Supination, of forearm, muscles for, 407, 408f
Supination sign, 691
Supinator branch, of radial nerve, 429
Supinator crest, 31f, 33, 144
Supinator longus muscle. See Brachioradialis
muscle
Supinator muscle, 144–145, 181t,
421–422, 422f, 465f, 466
anomalies and variations of, 455
innervation of, 426, 427f, 428t
radial nerve compression by, 478, 479f
Supracondylar fractures, of humerus, 26
Supracondylar process, of humerus,
ligament of Struthers and, 111
Supracondylar ridges, of humerus, 20f, 21f,
24, 26, 366, 367f
Supraglenoid tubercle, 17
Supraretinacular arches, dorsal, 515
Supraretinacular arteries, 514–515, 516f
Suprascapular artery, 302f, 305
Suprascapular nerve, 302f, 304–305, 305f
entrapment of, 18
injury of, 310
Supratrochlear lymph nodes, 278, 279f
Surfaces, of scapula, 11–12, 10f, 11f
Surgical exposures
for arm. See Arm, surgical exposures for
for axillary nerve, 310–311
for biceps tendon, distal, 451, 452f
for brachial artery, 346–347, 347f–349f,
351
for brachial plexus. See Brachial plexus,
surgical exposures for
for carpal tunnel, 522, 523f–524f
for compartment syndrome, 451, 451f
of forearm, 451, 451f
of hand, 635–636, 635f
for elbow. See Elbow, surgical exposures
for
for extensor retinaculum, 518, 518f
for fingers, 656–658, 657f, 658f
for forearm. See Forearm, dorsal, surgical
exposures for; Forearm, flexor,
surgical exposures for
for hamate, 522, 525f–526f, 527
for hand
dorsal, 656–658, 657f, 658f
palmar, 612–619, 613f–619f
for humerus. See Humerus, surgical
exposures for
 Subject Index 717

for interphalangeal joint
distal, 657–658, 658f
proximal, 657, 658f
for lateral antebrachial cutaneous nerve,
444, 445f
for median nerve
in forearm, 438, 440–441, 441f–443f
medial, 346–347, 347f–349f, 351
for metacarpophalangeal joint, 656
for musculocutaneous nerve, 312
for phalanx, proximal, 656, 657f
for pisiform, 522, 525f–526f, 527
for posterior interosseus nerve, 467–472
anterolateral, 467–468, 467f–469f
posterolateral, 471–472, 471f–472f
transbrachioradialis, 469, 470f
for radial nerve. See Radial nerve, surgical
exposures for
for radial shaft, 438, 439f–440f
for radioulnar joint, distal, 517–519,
518f, 519f
for scaphoid, 519–520, 520f
for ulnar nerve
in forearm, 438, 440–441, 441f–443f
medial, 346–347, 347f–349f, 351
for wrist. See Wrist, surgical exposures for
Surgical neck, of humerus, 18, 20, 20f, 21f,
25, 306
Swan neck deformity, of finger, 652, 653f,
660
Sympathetic fibers
in anterior interosseous nerve, 188
in radial nerve, 218
in ulnar nerve, 206, 211, 579
Sympathetic ganglia, brachial plexus
communication with, 303–304
Syndesmosis, interosseous membrane as,
410–413, 411f
Synovial fluid, in flexor tendon sheaths,
601–602
Synovial reflection vessels, 609
Synovial sheath, proximal, vessels of, 609
T Elson, 659, 659f, 677
Tardy ulnar palsy, 208
Tendinitis
bicipital, 101
cross-over (intersection syndrome), 133,
134, 146–148, 480, 482f, 483
Tendon(s)
abductor pollicis longus, 476–477, 477f,
478f
biceps brachii. See Biceps brachii tendon
extensor. See Extensor tendons; specific
tendons
extensor carpi radialis brevis, 480, 482f,
483
extensor carpi radialis longus, 480, 482f,
483
extensor digiti minimi, 138t, 648–649
extensor digitorum breves manus, 138t
extensor digitorum communis, 139, 140f,
141, 649–651, 650f, 651f
extensor indicis proprius, 138t, 648–649,
651–654, 663–664
extensor pollicis brevis, 476–477, 477f,
478f, 648–649
extensor pollicis longus. See Extensor
pollicis longus tendon
flexor, 607–612, 607f–611f. See also
specific tendons
flexor carpi radialis, 113, 535f
flexor digitorum profundus, 421, 504,
607f, 608, 609
flexor digitorum superficialis. See Flexor
digitorum superficialis tendon
flexor pollicis longus, 421, 607, 607f,
623
palmaris longus, 119
terminal, 590f
triceps brachii tendon, 398
Tendovaginitis, trigger digit in, 622–624
Tennis elbow, 26, 388
Tenosynovitis
de Quervain’s. See de Quervain’s
tenosynovitis
of extensor indicis proprius muscle, 678
of extensor pollicis longus, 483–484
Tensor ligamenti anularis anterior muscle,
145
Terminal tendons, 590f
Terminal veins, dorsal, 644, 644f
Terry Thomas sign, 689–690
Test(s)
Adson’s, 669
Allen, 260, 669–670
Boyes, 672
Bunnell’s, 594, 594f
Bunnell’s “O,” 673
Bunnell’s “scrape,” 673
crossed fingers, 674–675
elbow flexion, 676–677
elevated arms stress, 688
for extensor indicis proprius syndrome,
483
extensor plus, 678
Finkelstein’s, 476–477, 477f, 678–679
Finochietto-Bunnell, 682–683
Haines-Zancolli, 680–681
intrinsic tightness, 594, 594f, 682–683
Jobe, 399, 399f
Kapandji’s, 683
lunotriquetral ballottement, 684–685
middle finger, for radial tunnel syndrome,
478
Phalen’s, 686–687
for pronator syndrome, 445–446, 447f
retinacular plus, 680–681
Roos, 688
scaphoid shift, 690–691
Watson’s, 690–691
Wright’s, 691
Yergason’s, 691
TFCC (triangular fibrocartilage complex),
490, 496–498, 497f, 498f
function of, 411–412
Thenar compartment, compartment
syndrome of, 633, 634f, 635f
Thenar crease, 488f, 489, 489f, 533f, 534,
534f
Thenar eminence, 488f, 489, 532, 533f
Thenar muscles, 503f, 582–583, 582f. See
also specific muscles
atrophy of, 159
Thenar nerve
accessory, 572f
anomalies and variations of, 573–574,
574t
classic configuration of, 573
Thenar space, 604
Thoracic artery
alar, 243
lateral, 238f, 239f, 241, 243
superior, 238f, 239f, 240–241
Thoracic nerve, long, 301, 301f, 305f
Thoracic outlet syndrome
Adson’s test for, 669
Roos test for, 688
Wright’s test for, 691
Thoracic vein
lateral, 275f
long, 275f, 276
superior, 275f, 276
Thoracoacromial artery, 238f, 239f, 241
Thoracodorsal artery, 238f, 239f, 242
Thoracodorsal nerve, 301f, 305f, 306
Thoracodorsal vein, 275f, 276
Thoracoepigastric artery, 243
Thoracoepigastric vein, 275f, 276
Thrombosis
of radial artery, 269
of ulnar artery, 260
Thumb. See also subjects starting with
Thenar
action of, palmaris longus muscle in, 117
arteries of, 562–568, 563f, 565f, 567f
articular nerves of, 573
bowler’s, 672
carpometacarpal joint of, 536–540
axes of, 537, 537f
ligaments of, 538–540, 538t, 539f
type of, 536–537, 537f
cherry pitter’s, 672, 674
collateral ligaments of, injuries of,
625–627, 625f
digital nerves of, 571f–572f, 573
flexor tendon sheaths of, 602, 603f, 604t
fractures of
metacarpal, 671–672
718 Subject Index
Thumb, fractures of (contd.)
Rolando, 687
ulnar collateral ligament injury in, 626
gamekeeper’s, 679
metacarpal arteries of, 562–563, 563f,
565f, 568
metacarpal of, 65–68, 67f, 535
abductor pollicis longus insertion in,
145
dorsal interossei action on, 162
fractures of, 671–672
mobility of, 536
muscle origins and insertions of,
opponens pollicis, 153
Rolando fracture of, 687
metacarpophalangeal joint of, 540–542,
541f, 542f
dislocation of, 627–628, 628f
injury of, 679
surgical exposure for, 615–617,
616f–618f
nail unit of, 654–656, 654f, 655f
palmar plate of, 541
paralysis of, opponensplasty in, 152–154
phalanges of, 85–86
distal, muscle origins and insertions of,
127–129, 147
proximal, muscle origins and insertions
of, 147, 149–150
pulley system of, 602, 603f, 604t
radial digital nerve of, 612f, 613
ray of, 535
skiers, 688
Stener lesion of, 625, 625f, 689
trigger, 623–624
venous system of, 646–647, 646f
vinculum of, 611
web space of, Dupuytren’s contracture of,
622, 623f
Thumb-in-palm deformity, 154–155
Thurston Holland’s fragment, 690
Thyrocervical trunk, 300f
Transverse arch, of hand, 536, 536f
Transverse carpal ligament, 493, 523f–524f,
595
flexor retinaculum and, 503–504
thenar nerve relationship to, 573–574
Transverse fibers, 595, 596f–597f, 620, 620f
Transverse metacarpal ligament, 604, 606f
Transversus manum muscle, 154
Trapeziocapitate ligament, 493–494, 501f,
502–503
Trapeziometacarpal joint, skin creases at,
489, 534
Trapeziotrapezoid ligament, 493, 501, 501f
Trapezium, 41f, 42f, 61–63, 491f
accessory bones of, 61–63
clinical correlations of, 62–63
derivation and terminology of, 61
fractures of, 62
joints associated with, 62
ligaments of, 493
muscle origins and insertions of, 62, 153
ossification centers of, 43f, 61
osteology of, 61–62, 62f, 493
skin reference lines for, 535f
vascularity of, 62, 493, 507f, 508f, 513
Trapezius muscle, 297, 298f
Trapezoid, 41f, 42f, 59–61, 491f
accessory bones of, 59–61
clinical correlations of, 61
derivation and terminology of, 59
fractures of, 61
joints associated with, 60
ligaments of, 493
muscle origins and insertions of, 60
ossification centers of, 43f, 59
osteology of, 60, 60f, 493
vascularity of, 60–61, 493, 513
Trapezoid ligament, 6, 6f, 10f, 16
Triangular fibrocartilage complex, 490,
496–498, 497f, 498f
function of, 411–412
in pulley system, 599
Triangular ligament, 590f, 591
Triceps brachii muscle, 103–105, 180t,
326–327, 328f
anomalies and variations of, 362
as landmark, 315, 316f–318f
ulnar nerve compression in, in cubital
tunnel syndrome, 390
Triceps brachii tendon, snapping of, 398
Trigger fingers
congenital, 623–624
definition of, 622–623
Hurler’s syndrome and, 624
pathologic anatomy of, 623
treatment of, 623
Triquetrocapitate ligament, 492, 493, 499f,
501f, 502
Triquetrohamate ligament, 492, 494, 501f,
502
Triquetrum, 41f, 42f, 53–54, 53f, 491f
ligaments of, 492
ossification centers of, 43f, 53
osteology of, 492
vascularity of, 492, 507f, 508f, 512
Triscaphe joint, 46
arthrodesis of, 49
Trochlea, 20f, 21f, 23f, 24, 319f, 366,
367f
Trochlear notch, of ulna, 29–31, 29f, 31f,
32f, 366, 409f, 410
Trunks, of brachial plexus, 301f, 303f–305f,
304–305, 308f
Tubercle, Chassaignac’s, 674
Tuberosities. See specific bones
Tunnels
carpal. See Carpal tunnel; Carpal tunnel
syndrome
cubital. See Cubital tunnel; Cubital
tunnel syndrome
radial. See Radial tunnel syndrome
ulnar, 209–210, 212–214, 213t, 680
U
Ulna, 27–36
accessory bones of, 27, 27f, 35–36
articular circumference of, 29f
borders of, 28f–30f, 33
clinical correlations of, 35–36
coronoid process of, 29–30, 29f, 31f,
367, 367f, 409f, 410
fractures of, 35
muscle attachments of, 34
surgical exposures for, 379–380, 380f,
381f
cross-section of, 409f
derivation and terminology of, 27
distal
as landmark, 487f, 488
ossification centers of, 27, 27f
osteology of, 28f, 29f, 34, 34f, 490,
495–496, 495f
vascularity of, 514–517, 516f, 517f
epiphyseal lines of, 27f
fractures of, 35
Monteggia, 35, 685
with radial fractures, 412–413
head of, 28f, 29f, 34, 34f, 29f
as landmark, 642–643, 643f
interosseous membrane attachment to,
410–413, 411f
joints associated with, 28f–32f, 34
muscle origins and insertions of, 28f, 29f,
33–35, 99f
abductor pollicis longus, 145
brachialis, 102
extensor indicis proprius, 141
extensor pollicis longus muscle,
148–149
flexor carpi ulnaris, 123
flexor digitorum profundus, 125
flexor digitorum superficialis,
120–121
pronator quadratus, 129–130
pronator teres, 110–111
supinator, 144
triceps brachii, 103–104
negative variance of, 36
nutrient foramina of, 29f
olecranon of. See Olecranon
ossification centers of, 27, 27f
osteology of, 28–34, 28f–32f, 34f, 409f,
410
distal, 490, 495–496, 495f
proximal, 367, 367f
perpendicular line of, 33
positive variance of, 36
pronator ridge of, 33

proximal
ossification centers of, 27, 27f
osteology of, 28–31, 28f, 29f, 31f, 33,
367, 367f
radial notch of, 29–31, 29f, 31f–33f,
367, 367f
shaft of
ossification centers of, 27, 27f
osteology of, 28f–30f, 33–34
surgical exposures for, 475–476, 476f
styloid process of, 29f, 30f, 34, 34f, 409f,
410, 490, 495–496, 495f, 496f
fractures of, 35
as landmark, 461, 462f
supinator crest of, 31f, 33
surfaces of, 29f, 30f, 33–34
surgical exposures for, shaft, 475–476,
476f
trochlear notch of, 29–31, 29f, 31f, 32f,
366, 409f, 410
tuberosities of, 29f, 367, 367f, 409f, 410
variance of, 36, 498
Ulnar artery, 248–262, 249f, 255f
Allen test and, 260
aneurysms of, 260
anomalies and variations of, 259–260,
458
in antecubital fossa, 423–424, 424f, 425f
anterior ulnar recurrent branch of, 238f,
239f, 245f, 249f, 250
arterial dominance and, 260–261
branches of, 238f, 239f, 245f, 249f,
250–259, 250t, 253f, 555, 556f,
557, 558f, 559, 559f
in carpal bone blood supply, 53
clinical correlations of, 260–262
common interosseous branch of, 238f,
245f, 250–252
compression of, in Allen test, 260,
669–670
course of, 238f, 245f, 431, 434f
deep palmar branch of, 254
distal division of, 248, 259
dominance of, 260–261
dorsal carpal branch of, 238f, 249f, 254,
265f, 551f
in forearm, anomalies and variations of,
458
in forearm flaps, 261
in Guyon’s canal, 576
in hamate vascularity, 56
in hand, 550f, 555, 556f, 557, 558f, 559,
559f
skin reference lines for, 535f
high division of, 243, 244, 247, 259
high origin of, 363
muscular branches of, 254
origin of, in high division axillary
anomaly, 243
palmar carpal branch of, 254
in palmar intercarpal arch, 254, 255f
in palmar radiocarpal arch, 254, 255f
pisiform blood supply from, 54–55
posterior ulnar recurrent branch of, 238f,
239f, 245f, 249f, 250
recurrent, in hamate vascularity, 56
repair of, 261
superficial, 243, 244, 259, 564
in superficial palmar arch, 238f,
254–259, 256t
thrombosis of, 260
ulnar nerve location and, 248–250
in ulnar tunnel, 210
at wrist, 265f, 506, 507f, 508f, 514–516,
516f–517f, 535f
Ulnar bursa, of flexor tendon sheath, 603,
603f
Ulnar collateral arteries
inferior, 239f, 245f, 246–247, 253f, 330f,
368f, 369f, 370t, 425f
posterior, 253f
superior, 238f, 239f, 245f, 246, 330f,
338f, 368f, 369f, 370t
Ulnar collateral ligament, 371–372, 371f,
373f, 625f, 544f
injuries of, 625–626, 625f, 679
lateral, 372–374, 373f, 374f
repositioning of, 626
of thumb, 538, 538t, 539f, 541–542,
542f, 679
injury of, 688
Ulnar deviation, of fingers, 545t
Ulnare antebrachii (os pisiforme
secundarium), 27, 35, 53, 54
Ulnaris digiti minimi muscle, 144
Ulnaris digiti quinti muscle, 144
Ulnar lymph vessels, 277, 278
Ulnar marginal septum, of hand, 604, 606f
Ulnar nerve, 200–214
in abductor pollicis brevis innervation,
211
anomalies and variations of, 455
in antecubital fossa, 424f
arcade of Struthers and, 204, 205
articular branches of, 204
in axilla and arm, 329f–330f, 334, 336,
338f
anomalies and variations of, 204–206
clinical correlations of, 205
course of, 200, 201f–203f, 201t, 204
medial antebrachial cutaneous branch
of. See Antebrachial cutaneous
nerve, medial
muscles supplied by, 200, 200t, 201f
in brachial plexus, 299f, 301f, 304f
branches of, at wrist, 577, 578f,
579–581, 580f, 581f
classic course of, in hand, 575, 576f–577f
communicating branch of, 201f, 571f,
579–580, 580f
Subject Index 719
completely innervating hand, 189,
199–200
compression of
anomalous anconeus epitrochlearis in,
208
in arcade of Struthers, 205, 360f, 362
in cubital tunnel. See Cubital tunnel
syndrome
dorsal cutaneous branch, 209
at elbow, 676–677
in Guyon’s canal, 577, 578t
in ulnar tunnel, 213–214, 213t
deep branch of, 214
deep motor branch of, 201f, 210–211
neural loop of, 637–638, 638f
variations in, 212
deep terminal branch of, 211, 214
dislocation of, snapping elbow in, 398
dorsal branch of, 323f
dorsal cutaneous branch of, 201f,
206–208, 322f, 415f
absence of, 209
compression of, 209
variations in, 212
in elbow and forearm, 205–209
anomalies and variations of, 207–208
clinical correlations of, 208–209, 208t
course of, 205–207
evaluation of, crossed fingers test for,
674–675
first branch of, 204
in flexor digitorum profundus
innervation, 126
in flexor pollicis brevis innervation, 211
in forearm, 426f, 431, 434f
in Guyon’s canal, 525f–526f, 575, 577,
577f, 578t
in hand, 571f, 575–581, 576f–578f,
578t, 580f, 581f
laceration of, with Martin-Gruber
anastomosis, 192
lateral root of, 204
Martin-Gruber anastomosis of. See
Martin-Gruber anastomosis
medial antebrachial cutaneous branch of,
200, 201f–203f, 204
medial brachial cutaneous branch of,
201f, 202f
median nerve anomalous connections
with, 207
motor branch of, 201f, 206, 571f, 575,
576f–578f, 577, 578t, 579–581,
581f
muscles innervated by, 200, 200t, 201f
in opponens pollicis innervation, 211
origin of, 200, 201f, 204
palmar cutaneous branch of, 201f, 206,
569, 569f
transverse, 569–570, 569f
variations in, 212
720 Subject Index
Ulnar nerve (contd.)
palsy of
Andre-Thomas sign in, 670
Bouvier’s sign in, 672
Bunnell’s “O” test for, 673
Bunnell’s “scrape” test for, 673
Duchenne’s sign in, 676
Egawa sign in, 676
high, 593
low, 593
Mannerfelt hyperflexion sign for, 685
Mummenthaler sign in, 685–686
Pitres-Testut sign in, 687
Pollock’s sign in, 687
Sunderland’s sign in, 689
Wartenberg’s sign in, 690
position of, relative to median nerve, 185
protection of, in elbow surgery, 376,
376f, 379
in Riche-Cannieu anastomosis, 163,
197–198, 211, 636–637, 636f,
637f, 673–674
sensory branch of, 201f, 211–212, 571f,
575, 576f–578f, 577, 578t, 579
dorsal, 431, 434f
superficial branch of, 212–213
palmar, 210–211
surgical exposures for
in forearm, 438, 440–441, 441f–443f
medial, 346–347, 347f–349f, 351
sympathetic fibers in, 206, 211, 579
territory of, median nerve territory
overlapping with, 190
transposition of, for cubital tunnel
syndrome, 392–395, 393f–397f,
398
ulnar artery location and, 248–250
in ulnar tunnel, 209–210
variations of, 212–214, 213t
vascular plexus accompanying, 393
in wrist and hand, 209–214, 577, 578f,
579–581, 580f, 581f
anomalies and variations of, 211–212
clinical correlations of, 212–214, 213t
course of, 209–211
Ulnar notch, of radius, 39
Ulnar recurrent artery(ies), 255f, 510, 508f
accessory, 510
anterior, 238f, 239f, 245f, 249f, 250,
330f, 368f, 369f, 370t, 425f
in forearm, 434f
posterior, 238f, 239f, 245f, 249f, 250,
330f, 368f, 369f, 370t, 425f
Ulnar tunnel, 680
clinical correlations of, 212–214, 213t
ulnar nerve in, 209–210
variations of, 212–214, 213t
Ulnar veins, 274f, 275–276
palmar, 644f
of thumb, 646–647, 646f
Ulnocapitate ligament, 493, 497, 497f,
499f, 501
Ulnocarpal (triangular fibrocartilage)
complex, 411–412, 490, 496–498,
497f, 498f
Ulnocarpal ligaments, 497, 497f, 501
Ulnodorsal digital artery, 567
Ulnohumeral joint, 24, 32f, 34
dislocation of, 398–399
Ulnolunate ligament, 492, 497, 497f, 501
Ulnopalmar digital artery, 566
Ulnotriquetral ligament, 497, 497f, 499f,
501
V of thumb, 646–647, 646f
Valves, in digital veins, 646
Variant canal of Guyon, 213
Vasa aberrantia, 243, 248
Vascular systems. See also individually named
arteries and veins
of bones. See specific bones
of elbow, 368, 368f–369f, 370, 370t
of flexor tendons, 608–612, 610f–611f
of muscles. See specific muscles
of wrist. See Wrist, vascular anatomy of
Vein(s), 270–276. See individually named
veins
antebrachial, 271, 272, 273f, 276, 320f,
413, 414f
vs. arteries, 270
axillary, 275f, 276, 300f
basilic. See Basilic vein
brachial, 274f, 275f, 276
cephalic. See Cephalic vein
circumflex scapular, 275f, 276
communicating, 644f, 646
cubital, 272, 273f, 274f, 276, 320f, 413,
414f
deep, 270t, 274f, 275–277, 275f
digital. See Digital veins
of dorsal hand, 270–271, 271f, 644–647,
644f–646f
of fingers, 644–647, 644f, 645f
of forearm, 273f, 275–276, 413, 414f
of hand, pumping action of, 647
intercapitular, 270, 271, 271f, 272f, 644f
interosseous, 276
median, 413
metacarpal, 270, 271, 271f
of nail unit, 655
oblique communicating, 644f, 646
palmar arches associated with, 271, 272f,
275
perforating, of hand, 647
radial, 275–276, 644f, 646–647, 646f
scapular circumflex, 275f, 276
subclavian, 276, 299f, 301f
subscapular, 275f, 276
superficial, 270–274, 270t
accessory cephalic, 272, 273f
basilic, 272, 271f–275f, 274, 276
cephalic, 271, 271f–275f, 276
of dorsal hand, 270–271, 271f
median antebrachial, 271, 272, 273f,
276
median cubital, 272, 273f, 274f, 276
venous palmar arch, 271, 272f
terminal, 644, 644f
thoracic, lateral, 275f, 276
thoracodorsal, 275f, 276
thoracoepigastric, 275f, 276
ulnar, 274f, 275–276
palmar, 644f
Vena comitantes, in antecubital fossa,
424f
Venipuncture, of median cubital vein, 413
Venous arches, 275
distal, 644, 644f, 645f
dorsal distal, 271f
palmar, 646
Vertical fibers, of palmar fascia, 595–596,
596f
Vertical incision, in palm, 613, 613f
Vinculum (vincula)
definition of, 608
in finger, patterns of, 609, 610f–611f,
611
in thumb, 611
Vinculum brevis, 609
of thumb, 611
Vinculum brevis profundus, 121, 126, 259,
610f
Vinculum brevis superficialis, 121, 126,
259, 610f
Vinculum longum, branch to, 609, 610f
Vinculum longum superficialis, 121, 126,
258
Vinculum longus, 609
Vinculum longus profundus, 609, 610f
Vinculum longus superficialis, 609, 610f
Volkmann’s contracture, 449
W
Wartenberg’s sign, 690
Wartenberg’s syndrome, 690
Watson’s test, 690–691
Web spaces
digital, arterial supply of, 560
first, Dupuytren’s contracture of, 622,
623f
Wick catheter, for compartment syndrome,
450, 450f
Winging, of scapula, 18
Wood, brachiofascialis muscle of, 103
Wood’s muscle, 97
Wright’s test, 691

Wrisberg, nerve of (medial brachial
cutaneous nerve), 223–224
Wrist, 486–531
accessory bones of. See specific bones and
accessory bone names
anatomic snuffbox of, 148–149,
262–263, 486–487, 487f, 642
bones of. See Carpal bones; Radius, distal;
Ulna, distal; specific bones
carpal tunnel of. See Carpal tunnel
descriptive anatomy of, 486–489,
487f–489f
flexion creases of, 489–490, 489f, 533f,
534, 534f
fractures of, de Quervain’s, 675–676
joints of, 494–498, 495f–498f
anatomic variations of, 527–529, 527f,
528f
landmarks of, 486–489, 487f–489f
ligaments of, 492–494
dorsal capsular, 500, 500f
interosseous, 502–503
mid-carpal, 497, 497f, 501–502, 501f
palmar radiocarpal, 499–500, 499f
ulnocarpal, 497, 497f, 501
Lister’s tubercle of, 30f, 34f, 39, 486,
487f, 490, 490f, 642, 643f
median nerve in. See Median nerve, in
wrist and hand
nerves in. See Median nerve, in wrist and
hand; Ulnar nerve, in wrist and
hand
neuritis of, 480, 481f
overview of, 486
Parona’s space in, 686
plica in, 528
pulley system of, 599
retinacular anatomy of, 503–506, 503f,
505f. See also Extensor retinaculum;
Flexor retinaculum
rotatory subluxation of, Terry Thomas
sign in, 689–690
skeletal anatomy of, 41–42, 41f–43f, 44t,
489–494, 490f–491f. See also specific
bones
accessory bones in. See specific bones
and accessory bone names
anatomic variations of, 529
spaces in, 605, 606f, 607
surgical exposures for, 517–527
Subject Index 721
Bowers approach, 518–519, 519f
carpal tunnel approach, 522,
523f–526f
dorsal approach, 517–518, 517f, 518f
Guyon’s canal approach, 522,
525f–526f, 527
palmar central approach, 520–521,
521f
palmar radial approach, 519–520, 520f
terminology of, 486
ulnar nerve in. See Ulnar nerve, in wrist
and hand
ulnar variance at, 36, 498
vascular anatomy of, 506–514
of distal radius and ulna, 514–517,
516f–517f
extraosseous, 506–508, 507f, 508f
intraosseous, 510–514, 512f
major arteries, 508–510, 509f–511f
Y
Yergason’s test, 691
Z
Zig-zag incision, in palm, 613, 614f