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 longitudinal 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 longitudinal 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 compartment 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 hypothenar 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 compartment 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). They descend first through the transverse fibres of the aponeurosis and then, as described above, between the flexor tendons and the lumbrical muscles, to insert on the deeper fasciae and ligaments of the hand and on the sides of the fibrous sheaths. 60 F. BOJSEN-MOLLER AND L. SCHMIDT The transverse fibres in the proximal part of the palm are completely covered by the longitudinal fibres, and lie between these and the flexor retinaculum, with which they exchange fibres. At this site they form part of the origin of the palmaris brevis muscle. Distal to this muscle is a zone where the transverse fibres are thin and sparse, but they subsequently increase in number and thickness to form finally a strong transverse ligament, which can be observed through the four longitudinal bands of the aponeurosis, and which limits the fenestrae proximally. In a similar fashion to the longitudinal fibres, the transverse fibres pass through the two marginal and seven intermediate septa to seek insertion into the deeper structures in

fasciculi longitudinales fasciculi transversi fascia interossea palm.

lig. metacarp. trans. superfic. lig. metacarp. trans. prof.

(a) ea

Nil

(b)

Fig. 5 (a). Drawing of the course of the fibres in the fasciae around the left third metacarpal bone and proximal phalanx viewed from the radial side. The deep transverse metacarpal ligament connects both with the metacarpal bone and with the longitudinal and transverse fibres of the palmar aponeurosis and, via their retinacula, with the skin. The palmar interosseous fascia is connected by means of a sagittal septum to the shaft of the third metacarpal bone. (b) Sagittal section through the centre of the third metacarpal bone. The fibrous sheath of the flexor tendonsextends for some distancebetween the transverse fascicles ofthepalmaraponeurosis and the deep transverse metacarpal ligament. Between the longitudinal fibres in the palmar aponeurosis, and the fibrous sheath, a connective tissue space affords cleavage for demonstration of the paratendinous septa by dissection (arrow, cf. Figs. 3, 4). Pa/mar aponeurosis and spaces of hand 61 fasciculi longitudinales vagina fibrosa

fasciculi transversi-- m.> (septum paratendinosum m. ig. metacarp. trans. prof.

m. initerosseus dors 1 ig. palmare

Fig. 6. Transverse section through the head of the third metacarpal bone showing the course of the fibres between the palmar aponeurosis and the deep transverse metacarpal ligament, and their attachments to the metacarpal bone (cf. Fig. 7). the hand. Some fibres thus pass over the tendons to one or two fingers before they enter a septum, while others run right across from the ulnar to the radial margin of the palm. Here the transverse fibres radiate into the skin, into the fasciae of the muscles and down to the metacarpal bones. The distal border of the transverse ligament is at the same level as the distal border of the deep transverse metacarpal ligament, and approximately opposite the joint line in the metacarpophalangeal articulation (Figs. 4, 5). The two ligaments thus lie opposite each other, separated by the central compartment, but connected by means of the paratendinous septa. The fibrous sheaths of the flexor tendons extend from the fingers up between the deep transverse metacarpal ligament and the transverse ligament of the palmar aponeurosis (Fig. 5). Here they exchange fibres with the two ligaments, and with the palmar ligaments of the articular capsules, after which they become thinner, and eventually form a proximal border. Weaker transverse fibres continue around the flexor tendons, however, for some distance up between the paratendinous septa. Between the longitudinal pretendinous slips and the fibrous sheaths is a connective tissue space affording cleavage when the paratendinous septa are demonstrated by dissection. After the skin has been removed, a longitudinal incision is made through the pretendinous slip (see arrow, Figs. 3, 4, 5b) at the level of the fenestrae. With scissors, a cut is then made proximally through the transverse fascicles until the origin of the lumbrical muscle is reached. Here the scissors are turned 180° and a cut is made distally over the middle of the lumbrical muscle, thus opening the lumbrical canal and permitting observation of the paratendinous septum and its fibres from both sides. With care, this can be done without damage to the vessels and nerves of the fingers. When the paratendinous septa have been dissected free, the contents of the central compartment can be removed and the space itself observed (Figs. 1, 4). The central compartment consists of a single space in the proximal part of the palm and a series of small compartments in the distal part. The compartment is lined with loose connective tissue, which is particularly abundant in the proximal part where it contains, superficial to the flexor tendons, the superficial palmar arch and median 62 F. BOJSEN-MOLLER AND L. SCHMIDT

dt S 1 s pa nv

r ~~~~~~~~~~~~~~~~~~~~~~~~~*. . Ib

Fig. 7. Transverse section through the head of the second, third and fourth metacarpals of a five month old fetus, stained with haematoxylin-eosin. The palmar aponeurosis (pa) is attached by means of the retinacula (r) to the skin. The fibres of the aponeurosis are connected via the paratendinous septa (s) and thin septa over the lumbrical muscles (I) to the deep transverse metacarpal ligament (dt). c: capsule of the metacarpophalangeal joint; nv: interdigital nerves and vessels. x 15. nerve and their branches, and deep to the tendons a fat body extending up into the carpal canal. The floor of the central compartment is formed by the palmar interosseous fascia, the deep transverse metacarpal ligament, and the adductor fascia. Its sides are formed by the two marginal septa of the palmar aponeurosis. The central compartment narrows proximally towards the carpal caaal and is connected via this canal to a space in the forearm. The latter space is bounded by the antebrachial fascia, the fascia covering the pronator quadratus, and two intermuscular septa. In this space are found the same structures as in the carpal canal and the proximal part of the central compartment, i.e. superficial and deep digital flexors, flexor pollicis longus and median nerve. In the distal part of the palm, the central compartment divides into four compartments housing the long flexor tendons and four housing the lumbrical muscles. These compartments continue respectively into the front of the fingers beneath the fibrous sheaths, and (as lumbrical canals) to the radial sides of the fingers. Separated from the lumbrical canals by fine sheets of tissue, the central compartment Palmar aponeurosis and spaces of hand 63

Fig. 8. Cross-section of a hand just distal to the thumb showing the central compartment divided by paratendinous septa, interosseous spaces (i) and adductor space (a). The contents of the spaces (except the first and second interosseous muscles) have been removed. The position of the flexor tendons in the central compartment is indicated by Roman numerals. The adductor fascia (af) extends from the third metacarpal bone to the fasciae covering the first dorsal interosseous muscle. The paratendinous septum on the ulnar side of the tendons to the index finger extends from the palmar aponeurosis to the middle of the adductor fascia. The palmer interosseous fascia (if) is connected by means of sagittal septa to the third, fourth and fifth metacarpal bones. has connexions along the vessels and nerves to the interdigital web of the second, third and fourth interstices. And finally, there is an extension through the radial marginal septum along the flexor pollicis longus tendon to the thumb (Figs. 4, 6 and 10). The adductor space (Figs. 8, 10) is bounded superficially by the adductor fascia, which extends radially from the third metacarpal bone. This fascia inserts on the first metacarpal bone just to the ulnar side of the tendon from the flexor pollicis longus. At the distal border of the adductor pollicis, the fascia continues into that which covers the first dorsal interosseous muscle. The adductor space is bounded dorsally by the fasciae covering the muscles of the first and second interosseous spaces. The space contains the adductor pollicis muscle, which is loosely connected with the limiting fasciae, and the beginning of the deep palmar arch. 64 F. BOJSEN-M0LLER AND L. SCHMIDT

Fig. 9. Section of the same hand as Fig. 8 at the level of the heads of the metacarpal bones. The subdivision of the distal part of the central compartment into eight narrow compartments is demonstrated. The interdigital nerves and vessels (nv) have been left to show their relation to the lumbrical compartments. dt: deep transverse metacarpal ligament; pa: palmar aponeurosis.

DISCUSSION After Kanavel's demonstration that accumulations of pus in the palm are often confined to the ulnar or the radial part of the layer under the flexor tendons, the central compartment of the hand has been described as being located in this layer, bounded superficially and deeply by special sheets, and divided into two spaces by a mid-palmar septum (Kanavel, 1934; Spalding, 1938; Anson & Ashley, 1940; Hollinshead, 1964; Kaplan, 1966; Cunningham, 1972). Such a description is not supported by our observations. Like Poirier (1901), Cordier & Coulouma (1934) and Grodinsky & Holyoke (1941), we conceive the central compartment to be the entire space between the thenar and hypothenar eminences, and between the superficial palmar aponeurosis and the deep palmar interosseous fascia and adductor fascia. In the proximal half of the palm this compartment consists of a single space, and in the distal part of eight contiguous compartments separated by sagittal septa. The compartment as a whole contains the flexor tendons with their synovial sheaths, the Palmar aponeurosis and spaces ofhand 65

Fig. 10. Dissection of left hand. A sagittal section is made between the middle and ring fingers to expose the radial part of the central compartment and marginal septum (ms). In the compartment the flexor pollicis longus tendon (fp) has been retained along with a small portion of the median nerve (mn) and superficial palmar arch (sa). Distal to the carpal canal is an opening in the marginal septum through which the flexor pollicis longus tendon passes. Distal to this the marginal septum is seen to be pierced by the motor branch from the median nerve to the thenar eminence, and by branches from the superficial palmar arch. The transverse fibres of the adductor pollicis are visible through the adductor fascia (af). is: intermediate septa. lumbrical muscles, and the digital vessels and nerves; all of these structures are embedded in the loose connective tissue which pervades the space. The demonstration of sagittal septa dividing the distal part of the palm provides sufficient explanation of why infections which have spread to this part of the palm from the fingers are less liable to spread across the hand than proximally, or towards the surface. The middle palmar septum, which according to Kanavel's original description extends from the middle metacarpal to the flexor tendons of the index finger, seems to correspond to one of the seven intermediate septa described here, presumably that on the ulnar side of the tendons of the index finger. The septum has been very differ- ently described with respect to both extent and thickness. It has been called 'very firm' and of 'considerable importance' (Kanavel, 1934; Spalding, 1938; Flynn, 1943), 'relatively fragile and often incomplete' (Cunningham, 1972) and 'as an anatomical entity poorly developed' (Gray, 1973). Even its existence has been questioned: thus Kaplan (1965) states that in normal hands there is no septum between the palmar aponeurosis and the third metacarpal. According to him there is a separation in the deep connective tissue layers produced by an attachment of the ulnar bursa to the third metacarpal bone. It should be noted, however, that this 5 ANA II7 66 F. BOJSEN-M0LLER AND L. SCHMIDT does not explain the limitation of infections which have arisen in the distal part of the palm. Jamieson (1950) describes an oblique septum, which loops around the tendons and lumbrical muscle of the index finger and anchors them to the third metacarpal bone, while separating the middle palmar space and the adductor space. He sees in this an expression of the specialization of the index finger relative to the others. We believe that it is a question of the anchoring of the paratendinous septa around the tendons of the index finger to the adductor fascia (Fig. 8), and do not find that these tendons differ from the others in their general relationships. The first extensive description of the paratendinous septa was given by Legueu & Juvara (1892). The septa are mentioned in Poirier's textbook (1901), and have been described in articles by Cordier & Coulouma (1934), Anson & Ashley (1940), Grodin- sky & Holyoke (1941), Skoog (1948) and Jamieson (1950). In 1929, Kanavel, Koch & Mason investigated a number of hands with Dupuytren's contracture. They agreed that in normal hands, in addition to the mid-palmar septum of Kanavel, there are other more tenuous longitudinal septa forming individual tunnels in which the flexor tendons lie, but they do not draw the obvious conclusion that these septa divide the two spaces into several compartments. Skoog (1967) describes the transverse fibres in the palmar aponeurosis as forming a special ligament - the transverse ligament - about 1 cm wide, and confined to the mid-palmar region. This ligament is said to be intimately related to the underlying paratendinous septa, and with these to constitute a separate anatomical structure, since the ligament and septa are not involved in a Dupuytren's contracture. The longitudinal elements in the palmar aponeurosis form pretendinous bands which, according to Skoog, have deep attachments of their own both proximal and distal to the transverse ligament. According to our observations, the deep attachments of both the longitudinal and the transverse fibres of the palmar aponeurosis form continuous septa in which the fibres from the two sources interweave while converging towards the deep transverse metacarpal ligament. In a normal anatomical context there seems to be no reason to describe the transverse fibres as a separate ligament distinct from the remaining parts of the palmar aponeurosis. The deep transverse metacarpal ligament occupies a central position in the function of the hand. It extends across the hand and is attached to the metacarpal bones, while being connected by means of the septa to both the longitudinal and transverse fibres of the palmar aponeurosis. The skin and the palmar aponeurosis are bound together by means of retinacula which are particularly closely packed in the distal part of the palm. With tangential pressure on the skin in any direction the force can be transferred through this system to the skeleton of the hand. The system is activated when the palmar aponeurosis is tensed by contraction of the palmaris longus muscle or by extension in the metacarpophalangeal joints or by both. When the aponeurosis is relaxed, movements of the skin can occur both in a proximo-distal direction and from side to side. A final remark on nomenclature: the term 'superficial transverse metacarpal ligament' is employed in this article as given in Nomina Anatomica, but it is a poor name because the ligament does not lie in the metacarpal region, and it does not complement the deep transverse metacarpal ligament, as do the transverse fibres in Palmar aponeurosis and spaces ofhand 67 the palmar aponeurosis. The appellation ought to apply to these transverse fibres (if they deserve a separate name), and the former ligament, as suggested by Poirier (1901), could be called the palmar interdigital ligament.

SUMMARY On the basis of dissection of 29 hands from normal adults, and histological exami- nation of hands from 6 fetuses 5-6 months old, the palmar aponeurosis, the course of its fibres, and its limitation of the central spaces, are described. It is demonstrated (1) that the palmar aponeurosis is connected to the deep transverse metacarpal ligament, palmar interosseous fascia and adductor fascia by means of nine paratendinous septa - two marginal and seven intermediate; (2) that the intermediate septa extend proximally from the interdigital web up into the acute angle between the flexor tendons and the lumbrical muscles; (3) that the septa on the ulnar side of the tendons to the index and middle fingers extend proximally almost to the superficial palmar arch; (4) that both the longitudinal and the transverse fibres of the palmar aponeurosis course through the septa to reach the deep transverse metacarpal ligament; (5) that the distal border of the deep transverse metacarpal ligament is at the same level as the most distal of the transverse fibres of the palmar aponeurosis, and that the fibrous sheaths of the flexor tendons extend some millimetres proximal to this level; (6) that there is a cleavage plane between the longitudinal (pretendinous) fibres in the palmar aponeurosis and the proximal part of the fibrous flexor sheaths, and that this cleavage can be utilized in the demonstration of septa by dissection; (7) that the skin and its retinacula, together with the palmar aponeurosis, nine septa, and the deep transverse metacarpal ligament, form an entity which under power grip is tensed and anchors the skin to the skeleton of the hand and (8) that the palmar aponeurosis and its septa contain a central compartment in the proximal part of the palm with four distal extensions along the flexor tendons, four along the lumbricals and three along the interdigital vessels and nerves.

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