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Palmaris Longus Muscle Variations: Clinical Signifi Cance and Proposal of New Classifi Cations Georgi P

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Palmaris Longus Muscle Variations: Clinical Signifi Cance and Proposal of New Classifi Cations Georgi P DOI: 10.1515/folmed-2017-0035 ORIGINAL ARTICLE, MEDICINE Palmaris Longus Muscle Variations: Clinical Signifi cance and Proposal of New Classifi cations Georgi P. Georgiev1, Alexandar A. Iliev2, Iva N. Dimitrova3, Georgi N. Kotov2, Lina G. Malinova2, Boycho V. Landzhov2 1 Department of Orthopaedics and Traumatology, Queen Giovanna University Hospital-ISUL, Medical University of Sofi a, Sofi a, Bulgaria 2 Department of Anatomy, Histology and Embryology, Medical University of Sofi a, Sofi a, Bulgaria 3 Department of Cardiology, St. Ekaterina University Hospital, Medical University of Sofi a, Sofi a, Bulgaria Correspondence: Background: The palmaris longus muscle is one of the most variable muscles in Georgi P. Georgiev, Department the human body and there have been numerous variations reported. The diff er- of Orthopaedics and Traumato- ent palmaris longus variations are interesting not only from an anatomical point logy, Queen Giovanna University of view, but they could also have defi nite clinical signifi cance. Hospital-ISUL, Medical University of Sofi a, 8 Bialo more St., 1527 Sofi a, Aim: The aim of this study was to examine the diff erent types of variations of pal- Bulgaria maris longus muscle in the Bulgarian population. E-mail: [email protected] Materials and methods: Over a period of 15 years, 56 formol–carbol fixed human Tel: +359 884 493 523 cadavers were studied to investigate the diff erent variations of palmaris longus Received: 03 Nov 2016 muscle (PLM). Accepted: 12 Jan 2017 Results: Various anatomical variations of PLM have been reported: absence Published Online: 19 April 2017 (2.68%); reversed palmaris longus coexisting with an additional abductor digiti Published: 29 Sep 2017 minimi muscle (0.89%); digastric (0.89%); palmaris longus with intermediate mus- Key words: palmaris longus cle belly (1.79%) and duplication (1.79%). muscle, variation, classifi cation, Conclusions: To reveal the wide variety of the types of palmaris longus muscle clinical signifi cance, human and their importance for clinical practice, we make a brief literature review con- Citation: Georgiev GP, Iliev AA, cerning the diff erent types of variations, their role in the median and ulnar neu- Dimitrova IN, Kotov GN, Ma- ropathy in the wrist or as structures simulating a soft tissue tumour and the appli- linova LG, Landzhov BV. Palmaris cation of palmaris longus tendon in plastic and reconstructive surgery as grafting longus muscle variations: clinical material. We also present new systematic anatomical and clinical classifi cations of signifi cance and proposal of new classifi cations. palmaris longus variations by dividing them into two simple groups. Folia Medica 2017;59(3):289-297. doi: 10.1515/folmed-2017-0035 BACKGROUND abduction, when a slip extending from it attaches The palmaris longus muscle (PLM) is classically to the superfi cial surface of the abductor pollicis described as a slender, fusiform muscle situated brevis muscle.2 medially to the fl exor carpi radialis. It originates The palmaris longus muscle is one of the most from the medial epicondyle of the humerus and variable muscles in the human body and numerous from the adjacent intermuscular septa and deep anatomical variations have been reported.1,3-6 The fascia. It prolongs into a long tendon, which passes PLM may be agenetic, double, split, tendinous, anteriorly to the fl exor retinaculum. A few fi bres digastric and may have various insertions. It may separate from the tendon and interweave with the be inserted on the fl exor retinaculum, the fascia transverse fi bres of the retinaculum, but the largest of the forearm, the fascia and the muscles of the portion of the tendon passes distally. As the tendon hypothenar, the short abductor of the thumb, near crosses the retinaculum, it broadens out and turns the metacarpophalangeal joints, the tendon of the into a fl at sheath which then becomes incorporated fl exor carpi ulnaris muscle, the pisiform bone or the into the palmar aponeurosis. PLM is a weak acces- scaphoid bone.7 Due to its limited action in carpal sory fl exor of the wrist which tenses the palmar fl exion and the fact that there is no functional loss aponeurosis.1 PLM could also contribute to thumb in the forearm and hand after its removal, it is an Folia Medica I 2017 I Vol. 59 I No. 3 289 G. Georgiev et al ideal donor for plastic and reconstructive surgery.8 limb from a 69-year-old and a left upper limb from However, this muscle can also be responsible for me- an 85-year-old formol-carbol fi xed Caucasian males dian and/or ulnar nerve compression syndromes.9-11 cadaver) and one female (a right upper limb from a It may also simulate a tumour in the region of the 77-year-old formol-carbol fi xed Caucasian cadaver). antebrachium.9 Reversed PLM (Fig. 1b) was seen in one left In this report we present the occurrence of PLM forearm of a 73-year-old formol-carbol fi xed Cau- variations in the Bulgarian population for the fi rst casian female cadaver. The muscle had a long, thin time and also review the existing information on tendon, originating from the medial epicondyle different PLM variations and their possible clinical of the humerus, which prolonged into a slightly signifi cance. The new point of our study is presenting elongated, elliptical muscle body in the distal third simple and systematic anatomical and clinical clas- of the forearm. The length of the tendon was 13.6 sifi cations of the many PLM variations by dividing cm and its width was 0.5 cm. The length of the them into two simple groups. muscle belly alone was 8.9 cm and it measured 2.6 cm at its widest part. We also noted a coexistence MATERIALS AND METHODS of the reversed PLM with an additional abductor Over a period of 15 years, 56 formol–carbol fixed digiti minimi muscle (ADM) (Fig. 1b). In its distal human cadavers were studied to investigate the dif- end, the reversed PLM passed superfi cially above ferent variations of PLM. Of these 56 cadavers, 24 the fl exor retinaculum and inserted into the palmar were male in the age range of 53-85 yrs; 32 were aponeurosis by means of a short, slender tendon. female in the age range of 61-88 yrs. Dissections Several tendinous slips inserted into the proximal were approved by the Medical Legal Offi ce and part of the additional ADM. The median nerve gave Local Ethics Committee. off several branches to the reversed PLM before Skin and superfi cial antebrachial fascia were entering the carpal tunnel. dissected layer-by-layer and lifted to expose the A digastric PLM (Fig. 1c) was observed in one underlying superfi cial fl exor muscles of the forearm. left forearm from a 69-year-old formol-carbol fi xed The subcutaneous veins and nerves were observed. Caucasian male cadaver. It originated in a usual The deep forearm (antebrachial) fascia were dissected way through a short, fl at tendon from the medial and removed. The origin, course and insertion of epicondyle of the humerus which then prolonged PLM were observed and the different variations into a fusiform muscle belly. Approximately half- were reported. Photographs were taken to document way through the forearm, this muscle belly sharply the observed variations. transformed into a wide tendon, situated superfi cially along the midline of the forearm. In the distal fourth RESULTS of the forearm, this tendon gradually prolonged Of the 112 dissected and thoroughly observed up- into a second muscle belly with a thinner proximal per limbs, we found variations of the PLM only end and wider distal portion, which resembled a in 9 cases. The percentages of occurrence of these teardrop. This muscle belly arched over the fl exor variations were: absence (2.68%); reversed palmaris retinaculum and inserted into the palmar aponeurosis. longus coexisting with an additional abductor digiti The dimensions of the described structures were as minimi muscle (0.89%); digastric (0.89%); palmaris follows: proximal muscle belly – length 9.4 cm, longus with intermediate muscle belly (1.79%) and size at widest point 1.5 cm; intermediate tendon – duplication (1.79%). In the remaining 103 upper length 6.3 cm, size at widest point 0.8 cm; distal limbs we discovered a structure and position of the muscle belly – length 4.8 cm, size at widest point superfi cial muscles of the forearm conforming to 1.6 cm. The innervation of the two muscle bellies normal morphology, without any anatomical varia- was provided by multiple branches extending from tions. The documented variations were observed both the median nerve. in right and left forearms but only unilaterally in PLM with an intermediate muscle belly was each of the 9 cadavers. There was no evidence of discovered in two upper limbs (a 53-year-old formol- previous injury, surgical interventions or any sort carbol fi xed Caucasian male cadaver and a 63-year- of anomalies and diseases involving the musculo- old formol-carbol fi xed Caucasian female cadaver) skeletal system. (Figs 1 d,e). In the left limb the PLM originated Complete agenesis of the PLM (Fig. 1a) was with a long, wide tendon from the medial epicondyle observed in 3 upper limbs, two male (a right upper of the humerus. This variant of tendon was posi- 290 Folia Medica I 2017 I Vol. 59 I No. 3 Palmaris Longus Muscle Variations tioned along the midline of the forearm and gradu- median nerve and the ulnar artery and nerve at the ally prolonged into an elliptical, slightly elongated canal of Guyon. The length of the proximal tendon muscle belly in the middle third of the forearm.
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