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The Palmar Aponeurosis and the Central Spaces of the Hand

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The Palmar Aponeurosis and the Central Spaces of the Hand J. Anat. (1974), 117, 1, pp. 55-68 55 With 1O figures Printed in Great Britain The palmar aponeurosis and the central spaces of the hand F. BOJSEN-MOLLER AND L. SCHMIDT Anatomy Department C, University of Copenhagen, Universitetsparken 1, 2100 Copenhagen 0, Denmark (Accepted 10 October 1973) INTRODUCTION Extending between the pretendinous bands of the palmar aponeurosis and the deep fasciae of the hand are a number of sagittal septa which subdivide the distal part of the central compartment into eight narrow, secondary compartments. Four of these contain the flexor tendons to the four ulnar fingers, while the other four contain the lumbrical muscles and accompanying digital vessels and nerves (Grapow, 1887; Legueu & Juvara, 1892; Poirier, 1901; Grodinsky & Holyoke, 1941; Jamieson, 1950). These sagittal septa, and the fact that they divide the central compartment, are not mentioned by Kanavel (1934), whose description of the spaces of the hand provides the basis for the description in many textbooks of anatomy (Gardner, Gray & O'Rahilly, 1963; Hollinshead, 1964; Cunningham, 1972; Last, 1972; Gray, 1973). According to Kanavel (1934), there are in the palm two preformed spaces, which he calls the middle palmar space and the thenar space. Kanavel states that the two spaces are situated under the layer of the flexor tendons, being completely separated by a middle palmar septum which extends from the third metacarpal bone to the flexor tendons of the index finger. The septum, which is described as very firm, was found to form an effective barrier to the spread of infections from one space to the other. According to Kaplan (1965), the central palmar compartment is divided only by an attachment of the ulnar bursa to the third metacarpal bone. Kaplan notes that the longitudinal septa which he had previously described in the normal palm are in fact found only in hands affected by Dupuytren's contracture. In other surgical works (Hueston, 1963; Flynn, 1966; Bunnell, 1970) the sagittal paratendinous septa are mentioned as normal features, but a full description is not given. According to Skoog (1948, 1967), the paratendinous septa, together with the transverse fibres of the palmar aponeurosis, form a fibrous tunnel system which he regards as a separate anatomical structure, partly because he has never found it (in contrast to the longi- tudinal fibres) to be the site of the pathological tissue changes characteristic of Dupuytren's contracture. These conceptions are incompatible, and adequate demonstrations of the spaces and septa are lacking. Our attention was drawn to the problem because in the avail- able literature the structures in question are illustrated only by means of drawings. 56 F. BOJSEN-M0LLER AND L. SCHMIDT The aim of the present investigation has been to reinvestigate the palmar aponeurosis and its deep attachments and to show the relationship between these and the spaces of the hand. MATERIALS AND METHODS The description is based on the dissection of 22 hands fixed in formalin or phenol and of 3 fresh specimens, all derived from normal adults. Four unfixed hands were deep-frozen and cut on a band-saw into transverse sections about i cm thick. In order to study the course of the fibres in the aponeurosis and ligaments, hands from 6 fetuses aged 5-6 months were fixed in Lillie's neutral formalin and examined histologically. The hands were decalcified in 5 % nitric acid with the aid of ultra- sound for a total of 3 hours, embedded in paraffin wax, sectioned, and stained in haematoxylin-eosin, Mallory's PTAH or Gomori's trichrome. OBSERVATIONS The palmar aponeurosis, along with the palmar interosseous fascia, the deep transverse metacarpal ligament and the fascia covering the adductor pollicis muscle (adductor fascia), bound the central compartment of the hand. The aponeurosis is connected to the deep structures by means of nine sagittal septa (two marginal and seven intermediate). Eight of these are paratendinous in location, situated one on each side of the long flexor tendons to the four ulnar fingers, while one is situated on the radial side of the first lumbrical (Figs. 1-4). The seven intermediate septa are rectangular, each with a superficial margin attached to the palmar aponeurosis, a deep margin attached to the deep fasciae in the hand, a proximal free falciform edge, and a distal limit where the septum continues into the fasciae of the fingers (Figs. 2, 10). Proximally, the intermediate septa extend into the acute angle between the flexor tendons and the origin of the lumbrical muscles. Septa are short where the lumbrical muscle originates distally on the flexor profundus tendons and long where the origin is more proximal (Figs. 1, 4). Thus there are short septa on the radial sides of the tendons of the index and middle fingers. On the ulnar side of the flexor profundus tendon to the index finger there is no lumbrical origin, and the septum extends proximally almost to the superficial palmar arch. The lumbrical muscle between the tendons of the middle and ring fingers is asymmetrical in its origin, originating more proximally on the middle finger's tendon than on the tendon of the ring finger. The septum between the muscle and tendons ofthe middle finger is correspondingly longer than the septum between the muscle and the tendons to the ring finger. The septa are composed of strong collagen fibres, emanating from both the longi- tudinal and the transverse fibres in the palmar aponeurosis, and anchored deep in the hand to the bony skeleton. The thickest of the fibres converge in the septa towards the deep transverse metacarpal ligament and are attached by means of the latter to the heads of the metacarpal bones (Figs. 5, 6, 7). Proximal to the ligament, the fibres in the five ulnar septa are attached to the palmar interosseous fascia and, via the three sagittal septa of this structure, are connected to the shafts of the third, fourth Palmar aponeurosis and spaces ofhand 57 Fig. 1. Dissection of left hand. The palmar aponeurosis and the contents of the central compart- ment have been removed. The two marginal (ms) and the seven intermediate (is) septa remain. A little of the palmar aponeurosis has been left attached to the intermediate septa, to allow the length of the individual septa to be appreciated. The radial marginal septum passes over the adductor fascia (af), and distal to it forms the palmar and radial boundaries ofthe lumbrical canal (Iu) ofthe index finger. The central compartment is seen to consist proximally ofa single space and distally of narrow compartments (cf. Fig. 4). dt: deep transverse metacarpal ligament; f: fat body in the floor of the central compartment; fr: flexor retinaculum; fs: fibrous flexor sheaths; n: nerve to thenar muscles; st: superficial transverse metacarpal ligament. 58 F. BOJSEN-MOLLER AND L. SCHMIDT ,~~~~~~~~~~~~~~~~~~1i., _-;:#am_af Fig. 2. Radial aspect of the hand shown in Fig. 1, illustrating the shape and extent of the seven intermediate septa. Note their proximal falciform edges. Abbreviations as in Fig. 1. and fifth metacarpal bones (Fig. 8). Distal to the ligament, the collagenous fibres are, with the fibrous flexor sheaths, attached to the articular capsules and margins of the proximal phalanges. Radial to the third metacarpal bone the septa are attached to the adductor fascia, and the deep transverse metacarpal ligament. The marginal septa separate the central compartment from the thenar and hypo- thenar compartments. Proximally, they begin as an extension of the side walls of the carpal canal. The radial marginal septum extends from this point over the fascia covering the adductor pollicis and first dorsal interosseous muscles and out over the proximal phalanx, forming the volar and radial limits of the lumbrical canal to the index finger (Fig. 1). The septum is pierced distal to the carpal canal by the flexor Palmar aponeurosis and spaces of hand 59 pollicis longus tendon, and then by the motor branch of the median nerve to the thenar eminence, the branch from the radial artery to the superficial palmar arch, and vessels and nerves to the thumb (Fig. 10). The artery and nerve to the radial side of the index finger are embedded in the septum. The ulnar marginal septum is attached to the shaft of the fifth metacarpal bone. Distal to the carpal canal, it is pierced by a digital branch from the ulnar nerve and by the ulnar artery where it enters the superficial palmar arch. The palmar aponeurosis consists of longitudinal, mainly superficial fibres, and transverse, mainly deep fibres. I T Fig. 3 Fig. 4 Fig. 3. Drawing of left hand showing the course of the fibres in the palmar aponeurosis. The position of the two marginal and the seven intermediate septa is marked with broken lines. Fig. 4. Drawing of left hand. The palmar aponeurosis and the contents of the central compart- ment have been removed to show the paratendinous septa and their individual extent. The distal part of the central compartment is divided into four compartments containing the long flexor tendons, four containing the lumbrical muscles, and three containing the interdigital vessels and nerves. The longitudinal fibres form four bands extending towards the four ulnar fingers. At the level of the fenestrae in the distal part of the palm, a large number of these fibres pass up to insert into the skin, others turn aside and continue in the superficial transverse metacarpal ligament, while a smaller number continue distally onto the fingers where they terminate in the skin and in the fibrous flexor sheaths above the proximal phalanx. From about the middle of the palm the fibres that participate in the formation of the paratendinous septa are given off (Fig. 3).
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