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Authors: Doyle, James R.; Botte, Michael J.

1Skeletal Anatomy
Michael J. Botte
The skeletal anatomy of the upper limb is divided into the shoulder girdle, the arm, elbow, forearm,
carpus, and hand. The scapula, clavicle, and sternum comprise the skeletal shoulder girdle. The midportion of the humerus comprises the skeletal arm. The distal humerus and proximal ulna and radius
form the skeletal elbow. The radius and ulna and associated soft tissues comprise the skeletal
forearm. The carpus consists of the distal radius and ulna along with the eight carpal bones: the
scaphoid, lunate, capitate, trapezium, trapezoid, triquetrum, hamate, and pisiform. The hand contains
19 bones: 5 metacarpals, 5 proximal phalanges, 4 middle phalanges, and 5 distal phalanges.
The skeleton of the upper limb is attached relatively loosely to the trunk. The clavicle provides the
only direct skeletal connection of the upper limb to the axial skeleton, articulating through the
sternoclavicular joint. The upper limb is substantially stabilized to the thorax by muscles of the soft
tissue scapulothoracic articulation. This relatively loose attachment maximizes upper limb mobility
and flexibility, allowing rotation and translation of the scapula on the thorax. The loose connection
of the upper limb to the trunk is in contrast to the lower extremity, where the majority of the
stabilization is through the skeletal connection of the hip joint.
In the following sections, each bone and associated joint of the upper limb is discussed. The
ossification centers, descriptive osteology, articulations, muscle attachments, and clinical
implications are discussed. Osseous anomalies or variations, when significant, are described as well.
CLAVICLE
Derivation and Terminology
The clavicle derives its name from the Latin clavis, meaning key (1,2,3). 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).
Ossification Centers
The clavicle begins to ossify earlier than any other part of the skeleton (4,5). It has three ossification
centers, two primary centers for the shaft and one secondary center for the medial end (Fig. 1.1). The
primary centers for the shaft consist of a medial and a lateral center, both of which appear during the
fifth or sixth week of fetal life. The centers fuse to each other approximately 1 week later. The
secondary ossification center is located at the sternal end of the clavicle and first appears
approximately the eighteenth or twentieth year, usually about 2 years earlier in women. The
secondary center unites with the remaining portion of the clavicle at approximately the twenty-fifth
year. An acromial secondary center sometimes develops at 18 to 20 years of age, but it usually is
small and fuses rapidly with the shaft (2,6).
The clavicle does not ossify in quite the normal manner of endochondral ossification, as occurs in
most of the skeleton. Although the medial and lateral ends of the clavicle do undergo endochondral
ossification, the mid-portion is formed by a process that shares features of both endochondral and
intramembranous ossification. The clavicle is pre-formed of cartilage in embryonic life, but does not
proceed with endochondral ossification in the conventional manner. Instead, the cartilage model
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simply serves as a surface for the deposition of bone by connective tissues. Eventually, the cartilage
is resorbed and the clavicle becomes fully ossified (7,8,9,10). [The process is shared by the
mandible. The remaining long bones of the upper extremity are formed by conventional
endochondral ossification (7).]
Osteology of the Clavicle
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 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.

FIGURE 1.1. Illustration of right clavicle showing the three centers of ossification. There are two
primary centers (medial and lateral) for the shaft and one secondary center for the medial end.
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 persons who perform heavy manual labor, the
clavicle becomes thicker and more curved, and its ridges become more distinct 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 acromial portion, which contains the
articulation for the acromion of the scapula and the associated attachments of the acromial clavicular
ligaments. The acromial portion 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 portion.
The anterior surface of the acromial portion is concave 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 portion 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.
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FIGURE 1.2. Right clavicle, superior surface, showing muscle origins (red) and insertions (blue) .

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 attachment of the trapezius and
deltoid muscles, respectively. On its inferior surface in the lateral third, there is the conoid 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 ligament).

FIGURE 1.3. Right clavicle, inferior surface, showing muscle origins (red) and insertions (blue) .

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 pectoralis
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 attachment area for the origin of the sternohyoid muscle, which
extends into the sternal region. Also along the posterior border, on the superior margin, is the area of
origin of the sternocleidomastoid muscle. On the posterior border of the inferior 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 subclavius 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 clavicle 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
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groove, which gives attachment to the subclavius muscle. The clavipectoral fascia, which 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 convex 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 determination 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 articular
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 covered 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 costoclavicular ligament
attaches to the costal tuberosity.
Associated Joints
The clavicle articulates with the acromion of the scapula laterally (acromioclavicular joint), and with
the manubrium of the sternum and cartilage of the first rib medially (sternoclavicular joint; Fig. 1.4).

FIGURE 1.4. Superior portion of anterior manubrium showing medial clavicles and sternoclavicular
joints.
The acromioclavicular joint between the lateral end of the clavicle and the acromion of the
scapula is stabilized by several structures: the acromioclavicular ligaments, coracoclavicular
ligament, and joint capsule.
The acromioclavicular ligament crosses the acromioclavicular 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.
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The coracoclavicular ligament stabilizes the acromioclavicular joint by anchoring the clavicle to the
coracoid of the scapula. It is more efficient in stabilizing the acromioclavicular 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 ligament (located medially).
The trapezoid ligament, as its name implies, is quadrangular 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 posterior 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 undersurface of the lateral clavicle. It is a dense ligament, roughly triangular
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 sternoclavicular joint. The inferior
surface of the medial end of the clavicle articulates with a small portion of the first costal cartilage.
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 adjacent superior surface of the
first costal cartilage. An articular 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 (pertaining 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 superoposterior 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 sternoclavicular joint include the joint capsule, the
anterior sternoclavicular ligament, the posterior sternoclavicular ligament, the interclavicular
ligament, and the costoclavicular ligament (4,5) (see Fig. 1.4).
The joint capsule lies deep to the ligaments, and completely 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 anterior and posterior portions usually are thicker and stronger,
reinforced by the anterior and posterior sternoclavicular ligaments.
The joint capsule is reinforced by the interclavicular ligament superiorly. The inferior portion of the
sternoclavicular joint capsule is thin, and resembles areolar tissue (4).
The anterior sternoclavicular ligament is broad and covers the anterior portion of the sternoclavicular
joint (see Fig. 1.4). It is attached superiorly to the upper and anterior portion 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
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the anterior sternoclavicular ligament. The joint capsule and articular disc lie posterior to the anterior
sternoclavicular ligament.
The posterior sternoclavicular ligament also is broad, similar to the anterior sternoclavicular
ligament. The ligament 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 (similar
to the anterior sternoclavicular ligament), to attach inferiorly to the dorsal portion of the superior
manubrium. The articular disc and synovial membranes of the sternoclavicular joint lie anteriorly.
The sternohyoid and the sternothyroid 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 border 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 inferomedial clavicle to reach the
superior portion of the costal cartilage. 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 tendon 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
portion of the shaft. The deltoid originates from the anterolateral 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 compression of the brachial plexus can occur with
clavicular fractures (13).
Clavicle Shaft Fractures
The clavicle is one of the most commonly fractured bones (14). Fractures most often occur at the
junction of the lateral 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
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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
Type 1: A nondisplaced, nonarticular fracture of the distal clavicle, with the acromioclavicular joint
and ligaments intact.
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
acromioclavicular joint (due to stabilization of intact trapezoid ligament).
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 (17,18,19).
Acromioclavicular Separation
Injury at the acromioclavicular joint (AC separation) has been classified by several descriptions. One
of the most 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 acromioclavicular 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 coracoclavicular distance by 25% to 50%. Treatment also is
symptomatic, often with shoulder support with an immobilizing device. Type III is a complete
disruption of the ligaments with dislocation of the clavicle from the acromion. There is marked
widening of the acromioclavicular joint, usually greater than 1.5 cm. It often is treated surgically
with internal fixation and repair or reconstruction of the ligaments (17). Recently, these injuries have
been classified into six types (20,21,22). 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 displacement
of the upper extremity. There is more extensive stripping of soft tissues of the clavicle and the
patient usually has more pain than in the type III injury. The type VI injury involves a subcoracoid
dislocation of the distal clavicle. 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 dislocation 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 (20,21,22). 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 fracture of the
coracoid process (22).
Sternoclavicular Separation
Sternoclavicular separation is rare compared with AC separation. Posterior dislocations may cause
pressure on the great vessels or airway located posterior to the joint. Computed axial tomography is
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helpful in determining the direction 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
findings 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 border 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 present 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 cavity. 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 ossification 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, ossification 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
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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).

FIGURE 1.5. Illustration of right scapula showing several 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 portions of the glenoid cavity.
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 ossification 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 sixteenth and eighteenth years. An epiphyseal plate or
crescentic epiphysis also may appear for the lower part of the glenoid 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).
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, 1.7, 1.8). Its synovial articulations include those with the humerus and the clavicle. In
addition, the scapula is stabilized to the dorsal surface of the thorax by muscle, forming the
scapulothoracic articulation.

The main processes (acromion, coracoid, and subchondral portions of the glenoid) as well as the
thicker portions of the body contain trabecular bone (see Figs. 1.6, 1.7, 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
translucent or may have areas that are incompletely ossified, being filled with connective tissue.

FIGURE 1.6. Right scapula, anterior surface, showing muscle origins (red) and insertions (blue).
Osteology measurements are given in Figure 1.9 and Table 1.1. The mean length of the
scapulae from the superior 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
lateral (26,27).

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FIGURE 1.7. Right scapula, posterior surface, showing muscle origins (red) and insertions (blue).
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 attachments 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 superior 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 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 triangular. The latissimus dorsi muscle glides
over the lower region, and frequently a few muscle fibers arise at the inferior angle of the scapula.
11

11

The teres muscles are separated from each other by a fibrous septum that extends along an oblique
line from the lateral border of the scapula to an elevated ridge (2,4,5).

FIGURE 1.8. Right scapula, lateral view, showing glenoid cavity and profile of coracoid process,
acromion, and body.
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, 1.7, 1.8, 1.9).
The acromion is a lateral extension of the spine. The process becomes flattened as it extends
laterally, overhanging the glenoid, and forms the most superior portion or summit of the scapula
(see Fig. 1.9A-D and 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 convex and provides attachment for the thick acromioclavicular 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 muscle. The medial border is shorter than
the lateral and concave. 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 borders 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.

12 12

The coracoid process is a thick, curved projection of bone that projects anteriorly, superiorly, and
medially from the upper portion of the neck of the scapula (see Figs. 1.6, 1.7, 1.8, and 1.9A, D, E, G;
Table 1.1). It is located approximately 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
projects 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 distal 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 clavipectoral 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 anterior deltoid, and can
be used as a valuable bony landmark

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
measurements. 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
anteroposterior 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
spinoglenoid 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
measurement 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.
13 13

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 measurement 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: Dimensions 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 coracoid
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. Clin Orthop 383:131-139, 2001.)

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 anteroposterior 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 muscular attachments. The dorsal border forms the crest of the spine. The crest of the
spine is subcutaneous and easily palpable.
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 glenoid (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.
14 14

The suprascapular notch has been shown to exist as an osseous foramen in approximately 13% of
specimens (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 portion of the superior border adjacent to the notch also provides 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 provides insertion for the levator scapulae muscle above the triangular 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 superior 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 lateral 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 dorsal 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 approximately 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 concave 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 laterally facing articular surface is deepened
and broadened by the glenoid labrum, which is a circumferential rim of fibrocartilage. The glenoid
labrum plays an important role in stabilizing the shoulder. Superior to the glenoid, near the base of
15 15

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 (deltoideus), supraspinatus, infraspinatus, levator
scapulae, minor and major rhomboids (rhomboideus), serratus anterior, 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 infraspinatus (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 deltoid. The coracoid process contains the
origins of the coracobrachialis 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 levator
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 rhomboideus 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 inferior to the
glenoid. The long head of the biceps originates 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 ossification centers. Persistence of one of the
individual ossification 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 calcific tendinitis of the supraspinatus tendon. The os
acromiale 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
16 16

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 muscle 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 nerve, the coracoid is a valuable palpable landmark for orientation 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 addition, 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 conservative management (antiinflammatory
medications, possible cortisone injections, and activity modification). If it is refractory to medical
treatment or if localized atrophy is present, operative nerve decompression usually is warranted.
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 shoulder (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 epicondyle (Fig. 1.10). The
ossification center for the body appears near the central portion of the bone at approximately the
17 17

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 lateral epicondyle at approximately the twelfth or
thirteenth year. The lateral epicondyle and both portions of the articulating 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, 1.12, 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, 1.12, 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, 1.12, 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 narrows to separate the head from the greater and lesser
tuberosities. The circumference of the anatomic neck provides attachment for the articular capsule of
the shoulder joint. In this area, there are numerous foramina for nutrient vessels (4).

18 18

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 capsule.

FIGURE 1.11. Right humerus, posterior aspect.


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,
1.12, 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
19 19

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, 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 subscapularis.
The greater and lesser tuberosities are separated from each other by a deep groove, the bicipital
groove (intertubercular 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 portion of the bicipital groove is lined by a thin layer of cartilage 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 latissimus 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 portion 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.

FIGURE 1.12. Right humerus, anterior aspect.

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).
20 20

FIGURE 1.14. Distal humerus, inferior surface, showing articular surface and contours of trochlea
and capitulum.
Shaft of the Humerus
The shaft of the humerus, also anatomically referred to as the body, spans the portion of the humerus
from the surgical neck proximally and to the area just proximal to the portion referred to as the distal
extremity (see Figs. 1.11, 1.12, 1.13). (The distal extremity includes the condyles, capitulum, and
trochlea, as discussed later.) The shaft of the humerus is cylindrical in the proximal portion, but
becomes progressively flatter and somewhat triangular distally. In the distal portion of the shaft, the
bone actually has three surfaces, but two borders (the medial and lateral borders).
The surfaces of the shaft of the humerus consist of an anterolateral surface, an anteromedial surface,
and a posterior (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 epicondyle.
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 insertion 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 elevation. Distal and anterior to the deltoid tuberosity, extending 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 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 traversed 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.

21 21

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 posteriorly and slightly
laterally. The surface of the posterior surface of the humerus is nearly completely covered by the
lateral 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 border
of the bone and the medial distal border of the radial sulcus. This large origin area extends the length
of the posterior 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 epicondyle, just
proximal to the origin of the anconeus muscle.
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 midportion 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 second
nutrient canal may exist at the starting point of th radial sulcus. The anterior portion of the distal
third provides 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 supracondylar 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 dorsal 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, serving 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 anatomically as the distal extremity of the
humerus (see Figs. 1.11, 1.12, 1.13, 1.14). The distal portion is flat, widened, and ends distally in a
broad, articular surface. The distal portion contains 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
22 22

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 shallow 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 articular surface of the trochlea is shaped well to fit the articular surface of the trochlear notch of
the ulna. The trochlea is wider and deeper on the dorsal surface than on the anterior 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 posterior 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 epicondyles. These projections provide the attachment
for several muscles. The medial epicondyle is larger and more prominent than the lateral epicondyle.
The medial epicondyle 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 digitorum profundus, and flexor carpi ulnaris.
The ulnar collateral 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 traverses.
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 attachments to the lateral epicondyle include the supinator,
extensor carpi radialis longus, extensor carpi radialis brevis, extensor digitorum communis, extensor
carpi ulnaris, extensor 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 glenohumeral joint, with the ulna at the ulnohumeral
joint (trochleoulnar joint), and with the radius at the radiocapitellar 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 digitorum profundus, the flexor carpi ulnaris, and the anconeus.
23 23

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 fractures 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 condition 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
thickening or proliferation of the acromion, spurring at the anteroinferior aspect of the acromion,
degenerative changes 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)
Stage I: Local edema or hemorrhage; reversible condition. Usual age group: young, active
individuals involved in sports requiring excessive overhead use of arm.
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.
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):One-part
fractures of the proximal humerus are fractures with minimal or no displacement or angulation.
Two-part fractures consist of two major displaced fragments. This can include a displaced fracture of
either the greater or lesser tuberosity, fracture of the surgical neck, or fracture of the anatomic neck.
24 24

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.
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. Definitive 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 dislocated humeral head strikes
the inferior margin of the glenoid, producing a hatchet compression fracture defect of the humeral
head. It usually is demonstrated on the anteroposterior 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 glenohumeral 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 fracture 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 demonstrate the lesion (because the humeral head lies
directly posteriorly, and radiographs may appear unremarkable on standard 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 pectoralis 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.
25 25

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 (33,34,35,36). Most
nerve injuries represent a neurapraxia or axonotmesis, and 90% resolve in 3 to 4 months (37,38,39).
This injury often is referred to as the Holstein-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 fractures include the
brachial artery and median nerve anteriorly 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 proximal
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 neuropathy. The brachial artery
also may pass deep to the ligament (28,40,41,42,43).
Lateral Epicondylitis
Lateral epicondylitis commonly is referred to as tennis elbow. It is thought to consist of either
chronic inflammation, partial tear, or overuse injury of the common extensor origin. Chronic or
repetitive wrist or digital extension often is associated with the onset of symptoms. The extensor
carpi radialis brevis often is implicated as the main muscle 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 associated with symptoms.
Osteochondrosis
Osteochondrosis (osteochondritis dissecans, osteonecrosis) of the capitellum of the humerus is
referred to as Panner's disease.
26 26

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).
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-portion 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. Accessory bones associated with the distal ulna include the os
triangulare (os intermedium antebrachii, os triquetrum secundarium), the os ulnostyloideum, and the
27 27

os pisiforme secundarium (ulnare antebrachii, metapisoid) (see Fig. 1.27B) (44,45,46). The os
triangulare is located distal to the head of the ulna, between the ulnar head, lunate, and triquetrum.
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.
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, 1.18, 1.19, 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 thinner, 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 portions: the proximal end (proximal portion,
proximal extremity), the shaft (body), and the distal end (distal portion, 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 proximal 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-D, E-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
28 28

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
olecranon bursa. The superior (or most proximal) surface of 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, and is lined with articular cartilage to form the proximal portion of
the trochlear notch. There usually is a nonarticular zone in the mid-portion of the articular surface
(see later discussion of trochlear notch). The elbow joint capsule attaches to the anterior aspect of the
superior surface of the olecranon. The medial portion of the olecranon provides attachment for the
oblique and posterior parts of the ulnar collateral ligament. The medial aspect of the olecranon also
provides an area for the origin of a portion of the flexor carpi ulnaris muscle. The posteromedial
portion also provides a part of the origin of the flexor digitorum superficialis. The lateral portion of
the olecranon provides the insertion of the anconeus muscle (see Fig. 1.18).
FIGURE 1.17. Right ulna and radius, anterior aspect, showing muscle origins (red) and insertions
(blue).

FIGURE 1.18. Right ulna


and radius, posterior
aspect, showing muscle
origins (red) and insertions
(blue).
The coronoid process is a triangular eminence that projects 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
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, 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
29 29

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 humeroulnar heads of the flexor digitorum superficialis. Posterior 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).

FIGURE 1.19. Right ulna and radius, anterior aspect.

FIGURE 1.20. Right ulna and radius, posterior aspect.

30 30

FIGURE 1.21. A: Proximal right ulna, lateral aspect. B: Right elbow, medial aspect, showing
capsular attachment and medial ligaments. C: Right elbow, lateral aspect, showing capsular
attachment and lateral ligaments. D: Right elbow, sagittal section. E: Proximal radioulnar joint, with
radial head removed, showing annular ligament.
The trochlear notch of the ulna is a large concave depression 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 cartilage, 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, 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 attachment areas for the annular ligament.

31 31

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.
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 longitudinally 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 ligament 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 circular 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 origin 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 posterior to the styloid process. The posterior border is well defined along
32 32

its proximal one-third to three-fourths; however, as the ulna becomes more circular in cross-section
distally, 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
posterior surfaces of the ulna.
The interosseous border of the ulna is well defined and can be somewhat sharp in its central portion
(see Figs 1.17, 1.18, 1.19, 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
border and is thickest at its attachment in the central portion of the interosseous border. The
interosseous ligament provides a partition that separates the anterior and posterior surfaces of the
ulna.
There are three surfaces of the shaft of the ulna: the anterior, posterior, and medial surfaces. The
anterior surface of the ulna lies between the interosseous border (located laterally) and the anterior
border (located medially). The anterior surface is wide in its proximal portion and slightly concave
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 digitorum 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 dorsal 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 supinator, the
abductor pollicis longus, the extensor pollicis 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 profundus (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 twothirds. 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 threefourths of the medial surface of the ulna provides a portion of the origin of the flexor digitorum
profundus (Fig. 1.18).
Distal Ulna
33 33

The distal portion of the ulna consists of the head and styloid process (Fig. 1.22; see Figs. 1.17, 1.18,
1.19, 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.
Distally, it articulates with the proximal surface of the triangular fibrocartilage complex and
ulnocarpal ligaments. The lateral, anterior, and medial surfaces of the ulnar head articulate 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 triangular 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
radioulnar 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-D, E-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, 1.18,
1.19, 1.20, 1.21).
Distally, the head of the ulna articulates with the radius to form the distal radioulnar joint. This
synovial joint normally 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 origin of the flexor digitorum superficialis and flexor digitorum 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

34 34

digitorum profundus, and the origin of the abductor pollicis 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 proximal ulna, in the trochlear notch, there is an
area in the joint that is devoid of articular cartilage. In this area, the olecranon 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 fractures of the olecranon (17,47a). A
modification of the Colson classification recently has been popularized (48):
Type I: fracture of the olecranon that is nondisplaced
Type II: fracture of the olecranon that is displaced but without elbow instability
Type III: fracture of the olecranon that is comminuted, but without elbow instability
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):
Type I: fracture of the coronoid involving only the tip
Type II: fracture of the coronoid involving one-half or less of the coronoid
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 concomitant anterior dislocation of the radial
epiphysis was described by Monteggia in 1814 (52). The classification has been modified by Bado to
include four subtypes (53):
Type I: Anterior dislocation of the radial head with associated anteriorly angulated fracture of the
ulna shaft

35 35

Type II: Fracture of the ulnar diaphysis with posterior angulation at the fracture site and a
posterolateral dislocation of the radial head
Type III: Fracture of the ulnar metaphysis with a lateral or anterolateral dislocation of the radial head
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 avulsion fracture or concomitant injury to the triangular cartilage 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 distal 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 secundarium
(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 arising from
a secondary ossification center (from the ulna styloid). 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 emphasized 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 styloid. In a recent fracture, the fracture line is found dividing the ulna styloid without
the presence of dense opposing surfaces. 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 fracture).
Positive Ulnar Variance
Positive ulnar variance can be associated with shortening of the radius either from congenital or
traumatic causes. Positive variance can lead to increased force transmission through the ulnocarpal
joint or to impingement of the ulnar head on the lunate or triquetrum. Operative management can
consist of shortening of the ulna, distal ulna resection, or lengthening of the distal radius.
Negative Ulnar Variance
36 36

Negative ulnar variance is associated with Kienbck's disease. In the absence of arthritic or
degenerative changes, management may consist of lengthening the ulna or shortening 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).
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. Ossification
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 epiphysis fuses to the shaft between the seventeenth and twentieth
year. Occasionally, an additional center is visible in the radial tuberosity, which appears at
approximately the fourteenth 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 styloid. The os radiale
externum is located slightly distal to the site of the os radiostyloideum, between the radial styloid
and the scaphoid. An accessory bone, if present, usually 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 secondary or additional ossification center of the radial styloid (46) (see Fig.
1.27B). Accessory bones 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.

FIGURE 1.23. Schematic illustration of the radius, showing ossification centers. There are three
centers: one for the proximal portion, one for the body (shaft), and one for the distal portion.
37 37

FIGURE 1.24. Proximal and distal radius in a young adult, showing epiphyseal lines.
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 extremity), the shaft (body), and the distal portion (distal extremity).
The radius lies parallel to and is slightly shorter than the ulna (see Figs. 1.17, 1.18, 1.19, 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 radiocarpal 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, 1.18, 1.19, 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
trabeculae are crossed by transverse trabeculae that are oriented parallel to the surface of the fovea.
In a similar manner, the 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, 1.18,
1.19, 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 approximately 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
38 38

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 appearance. 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, distal 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.
Shaft of the Radius
The shaft of the radius, often referred to in anatomic textbooks as the body, consists of the major
portion of the bone between the head and the distal end (2,4,5). In the proximal 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 surface of the shaft. It separates the anterior and
lateral surfaces. 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 superficialis and flexor pollicis longus muscles. Proximal and lateral to the anterior
oblique line, the area on the radius provides 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 provides the insertion area of the
pronator quadratus and attachment of the dorsal carpal ligaments. The distal portion of the anterior
border continues distally and slightly laterally, and terminates in a small tubercle on the anterolateral
surface. This tubercle, located at the base of the styloid process, provides the insertion attachment for
the brachioradialis 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 posterior 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 distal 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
portion 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 posterior margins
39 39

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 insertional 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, connecting 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 quadratus, in the palmar aspect of the radial styloid, there is a triangular 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 metaphysis. 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
proximally directed course.
The posterior surface of the radius lies between the posterior 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
posterolateral 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 compartments (see later, under Distal Radius) (Fig. 1.18).
The lateral surface of the radius is a gently convex surface 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 insertion of the tendon of the pronator teres. In the distal
portion of the lateral surface, the surface is smooth where the tendons of the abductor pollicis longus
and extensor pollicis brevis muscles cross.
Distal Radius
The distal portion of the radius includes the metaphyseal and epiphyseal regions. This portion of the
radius is quadrilateral in cross-section and encompasses the widest portion of the radius. Anatomic
features include the anterior, posterior, medial, and lateral surfaces; the styloid process; the dorsal
(Lister's) tubercle; the ulnar notch; and the radiocarpal and distal radioulnar joint articular surfaces.
The lateral surface flares out gradually from the shaft, extending further along the lateral margin to
form the styloid process. The styloid process is conical. A rough area at the base of the styloid
provides the attachment for the brachioradialis. This lateral surface is slightly rough, and projects
distally to terminate in the tip of the styloid. The distal area of the styloid provides attachment for the
articular capsule and the capsular thickening of the collateral ligament. 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 palpable and serves as a useful anatomic landmark to mark the
lateral margin of the radiocarpal joint.
40 40

The anterior surface of the distal radius is concave, palmarly 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.
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 shallow, 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 extensor 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 radioulnar 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 concave 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 fibrocartilage.
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-D, E-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
41 41

end, the radius articulates with the scaphoid and the lunate at the radiocarpal joint. The scaphoid
articulates
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 significance 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 diaphysis 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 preserved until the latest stages (54,55,56,57,58,59,60).
Essex-Lopresti Lesion
Fracture of the radial head (which results in the loss of proximal 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 reconstruction 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 dislocation or subluxation of the distal
radioulnar joint was described by Galeazzi in 1934 (63,64,65). The fracture usually occurs at the
junction of the middle and distal thirds of the radius, and usually has a transverse or short oblique
42 42

configuration. Open reduction with internal fixation (ORIF) usually 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):
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 tolerated.
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.
Type III: Severely comminuted fracture of the radial head and neck, not reconstructible, and requires
excision for movement. Treatment usually is excision, with possible 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
shortening. There often is accompanying fracture of the ulnar styloid, which may signify avulsion of
the triangular fibrocartilage complex (67).
Barton's Fracture
Barton described this fracture of the distal radius in 1838 (68). The fracture is a fracture-dislocation
in which the rim of the distal radius, dorsally or palmarly, is displaced with the hand and carpus
(68,69). The fracture differs from the Colles' or Smith's fracture in that the dislocation is the most
clinically and radiographically obvious abnormality, with the radial fracture noted secondarily. The
volar Barton's fracture is similar to the Smith's type III fracture, where both involve palmar
dislocation of the carpus associated with an intraarticular distal radius component.
Smith's Fracture
Smith described an additional fracture pattern of the distal radius in 1854. In this fracture, often
called reverse Colles' fractures, the distal radial fragment is palmarly angulated or displaced,
producing a garden spade deformity (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 fracturedislocation (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
43 43

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 present, these accessory bones 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 from heterotopic ossification of
synovial tags (46,47) (see description earlier, under Ossification Centers and Accessory Bones).
CARPUS
General Aspects
The carpus consists of eight carpal bones, arranged in a proximal and a distal row, each row
containing four bones. The proximal row includes (from lateral to medial) the scaphoid, lunate,
triquetrum, and pisiform. The pisiform is located palmar to the plane of the remaining three carpal
bones of the proximal row, and the pisotriquetral joint is separated from the joining articulations. The
distal row includes (from lateral to medial) the trapezium, trapezoid, capitate, and hamate (Figs. 1.25
and 1.26).
The proximal row is convex proximally and concave distally. The proximal row articulates
proximally with the distal radius and with the triangular fibrocartilage complex, forming the
radiocarpal and ulnocarpal joint. The proximal row articulates distally with the distal carpal row,
forming the midcarpal joint.

FIGURE 1.25. Skeletal hand and wrist, palmar aspect.


44 44

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 articulations 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 concavity if formed, designated
the carpal groove. The carpal groove is accentuated by the palmar projection of the pisiform and
hook of the hamate medially, and by the projection of the scaphoid tuberosity and trapezial ridge
laterally.
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
(74,75,76) (Fig. 1.27). The specifics of ossification of each carpal bone are discussed 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 additional or anomalous secondary
ossification center, and therefor the accessory bones are described later under sections on
45 45

ossification. Accessory bones however, also can occur from other causes such as trauma (46) or
heterotopic ossification of synovial tags (47). Anomalous, irregular ossicles or ossicles of abnormal
size or shape thus may be encountered that do not fit a specific described accessory 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 ossification center fails to
unite, forming an accessory ossicle, the os centrale (centrale dorsale, episcaphoid). The os centrale
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.

FIGURE 1.27. A: Schematic illustrations showing times of ossification of the carpus and hand. B:
Accessory ossicles of the wrist: schematic illustration 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 the tarsus. Clin Orthop 10:9-18, 1957.)
46 46

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 (44,45,46).
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 distinguished from a fracture by the smooth cortical edges, lack of
history of trauma, and absence of displacement or degenerative changes (25).
Several other accessory bones can be associated with the scaphoid. These accessory bones, if
present, usually are the result of secondary or additional ossification centers 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 trapezium. 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 proximal to the lateral midportion of the scaphoid (46) (see Fig. 1.27B).

47 47

FIGURE 1.28. Right scaphoid. A: Dorsal aspect. B: Palmar aspect.


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 cancellous 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 portions include the tuberosity (located palmarly and distally), 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 finger. 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 deviated, 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 articulates with the trapezium. Each facet is covered with articular cartilage. The
articular surfaces of the proximal portion 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 distal articular surface of the scaphoid that
articulates with the trapezium and trapezoid. The joint may or may not contain 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
48 48

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 visually 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).
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 attachment (79,82,83,84) (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 immediately 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 dorsal 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 distally 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 specimens, these arteries arise
directly from the radial artery (79). In the remainder, they arise 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 direct communicating branches
between the ulnar artery and the palmar branches of the radial artery that supply the scaphoid.
Vessels in the palmar scapholunate ligament do not penetrate 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 anastomoses between the palmar and dorsal vessels (79).

49 49

FIGURE 1.29. A: Classic depiction of dorsal pericarpal arterial network.


Associated Joints
The scaphoid articulates with five bones: the radius proximally, 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 portion 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.

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

50 50

interosseous artery; DMCA, dorsal metacarpal artery; PF, perforating branches; PMA, palmar metacarpal artery; CPDA,
common palmar digital artery; PDA, proper palmar digital artery.

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.

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: 367, 1983.)
Muscle Origins and Insertions
A small portion of the abductor pollicis brevis may originate 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 tuberosity (see Fig. 1.37).
51 51

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.
Arthrodesis of the triscaphe joint stabilizes or anchors the distal portion of the scaphoid, and thus
prevents collapse into palmar flexion, as is seen when there is disruption of the scapholunate
ligaments. Therefore, triscaphe arthrodesis has been described for treatment of scapholunate
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 avascular necrosis of the scaphoid, usually
occurring in the proximal pole (87,88).
Accessory Bones
Several accessory bones can be associated with the scaphoid 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 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 tuberosity), the os epitrapezium (located between the scaphoid and
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 radiographic 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
52 52

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 ossification 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 hypolunatum is located between the lunate and the capitate, just ulnar to
the site of the os epilunatum. The os hypotriquetrum 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, triquetrum, and the distal ulna (46) (see Fig. 1.27B).
Osteology of the Lunate
The lunate is crescentic, concave distally and convex proximally (Fig. 1.30; see Figs. 1.25, 1.26,
1.37, and 1.38). It consists internally of cancellous bone, surrounded by a cortical shell (see Fig.
1.30A,B). The dorsal and palmar surfaces 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 distal 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 surface 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,93,94,95). 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 approximately 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 articulation, have been noted and described by Viegas and coworkers, Burgess, and
Sagerman et al. (81,94,95,96,97). A type I lunate is one in which there is no medial facet. Its reported
incidence is between 27% and 34.5% (81,94,95,96). A type II lunate has a medial facet that
53 53

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 associated ridging on the capitate
and hamate (81,95). When the facet is large, it is easily identifiable radiographically 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 proximal pole of the
adjacent, articulating hamate (see later, under Clinical Implications).

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 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, crescentshaped 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 articulation with the proximal portion of the hamate. A curved ridge
separates the articular surfaces for the hamate and capitate. Contact with the hamate is maximized
when the carpus is ulnarly deviated. Proximally, on the ulnar aspect of the proximal articular surface
of lunate, the lunate articulates 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 surface
alone. Except for these relatively small dorsal and palmar surfaces, the lunate is covered by articular
54 54

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 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 communicating 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 anastomose intraosseously just distal to the mid-portion of the lunate. The
proximal pole has relatively less vascularity.
There are three major intraosseous patterns. These patterns 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 palmar 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 (44,46,100,101,102,103,104).
Lunate ossification may be delayed in a variety of syndromes, including epiphyseal dysplasias and
possible homocystinuria (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 earlier, 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 articulation 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). Dislocation of the lunate (or perilunate
dislocation) is the most common type of carpal dislocation.
55 55

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 (Kienbck's
disease) is associated initially with increased radiodensity, followed by flattening or osseous collapse
with fragmentation/fracture in the later stages (110,111,112).
The Stages of Kienbck's Disease (110,111)
Stage I: Normal appearance on radiographs, possible linear or compression fracture on tomogram.
Avascular changes visualized on MRI. Bone scan shows abnormal uptake.
Stage II: Bone density changes (sclerosis), slight collapse of radial border.
Stage III: Fragmentation, collapse, cystic degeneration, loss of carpal height, capitate proximal
migration, scaphoid rotation (scapholunate dissociation).
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 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 lunate include the os epilunatum
(located between the lunate, scaphoid, and capitate), the os hypolunatum (located between the lunate
and capitate), the os hypotriquetrum (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 Accessory Bones).
TRIQUETRUM (OS TRIQUETRUM, TRIQUETRAL BONE, CUNEIFORM)
Derivation and Terminology
The name triquetrum is derived from the Latin for threecornered (1). The older British literature
refers to the triquetrum 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 ossification center that begins to ossify during the
third year (74) (see Fig. 1.27A).
Several accessory bones can be associated with the triquetrum. 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
epitriquetrum (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
56 56

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 proximoulnar 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 fibrocartilage 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 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.

FIGURE 1.31. Right triquetrum. Distoradial aspect.


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 palmarly. 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 triquetrum.
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 attachments 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 radiate 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).
57 57

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 palmar vascular networks have been found in
86% of specimens studied (99).
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 (44,46,100,101,102,103,104).
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 triquetrum, 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 triquetrum 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 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, meaning 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
58 58

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 articulates
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 surface 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 crescentshaped insertion that is convex proximally and concave distally. The abductor 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
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).

FIGURE 1.32. Right pisiform. Dorsal aspect.


The distal vascular supply includes one to three vessels that enter inferior to the articular facets,
divide into superior 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 articular
facet and communicate with the proximal superior vessels, forming an arterial ring deep to the facet.
There are multiple anastomoses between the proximal and the distal vascular networks.
Clinical Correlations: Pisiform

59 59

Fracture of the pisiform can occur with a fall on the dorsiflexed, 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 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).
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).

FIGURE 1.33. Right hamate. A: Medial aspect. B: Inferolateral aspect.


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 (5,74,75,76) (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 epitriquetrum (os epipyramis, os centrale IV), os
ulnare externum, os vesalianum manus (os vesalii, os carpometacarpale VIII), os gruberi (os
carpometacarpale VI), and os capitatum 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, adjacent to the lunate, capitate, and triquetrum. The os epitriquetrum 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 proximal 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 capitatum
secundarium is located just radial to the site of the os gruberi, at the radiodistal margin of the hamate
60 60

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 consists internally of cancellous bone, surrounded by a cortical 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 attachment 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 contact 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 relatively 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 distal 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 surface 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 originate from the palmar ulnar surface of the
hook of the hamate (see Figs. 1.37 and 1.38). In addition, a small portion 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).
61 61

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 vessels 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 sportsrelated 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 tunnel 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 a jagged fracture surface. A patient with a hook of the hamate
fracture may perceive pain on the dorsum of the hamate and palpation over the hook on the palmar
side usually elicits tenderness.
The incidence and location of arthrosis and chondromalacia (with cartilage erosions and exposed
subchondral bone) is among the highest at the proximal pole of the hamate. Chondromalacia was
found in 16.8%; arthrosis with exposed subchondral bone was found in 28.2% (94). Arthrosis at the
proximal pole of the hamate also is associated with the presence of a mid-carpal plica. A mid-carpal
plica was identified in 1% of 393 wrists. All wrists that had a mid-carpal plica also were found to
have arthrosis at the proximal pole of the hamate (94).
Accessory Bones
Several accessory bones may be associated with the hamate and can be mistaken for fractures (Fig.
1.27B). 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 hamate include the os hamuli
proprium (located in the area of the hook), the os hamulare basale (located at the distal margin of the
hamate, in the vicinity of the bases of the long and ring finger metacarpals), the os hypotriquetrum
(located proximal to the proximal pole of the hamate, adjacent of the lunate, capitate, and
62 62

triquetrum), the os epitriquetrum (located proximal to the proximal pole of the hamate, in the
vicinity of the lunate, capitate, and triquetrum, just ulnar to the site of the os hypotriquetrum), the os
ulnare externum (located ulnar to the body of the hamate, just distal to the triquetrum), the os
vesalianum manus (locate ulnar and slightly distal to the hamate, near the styloid process of the base
of the small finger metacarpal), the os gruberi (located at the distoradial corner of the hamate,
adjacent to the capitate and bases of the long and ring finger metacarpals), and os capitatum
secundarium (located at the distoradial corner of the hamate, adjacent to the capitate and bases of the
long and ring finger metacarpals, just radial to the site of the os gruberi; see Fig. 1.27B) (46) (see
descriptions earlier, under Ossification Centers and Accessory Bones).
CAPITATE (OS CAPITATUM, OS MAGNUM)
Derivation and Terminology
The name capitate is derived from the Latin caput, meaning head. Capitate denotes head-shaped
(1). It also has been suggested that the word capitate indicates the head of the wrist because it is
the largest bone of the carpus. The older British literature may refer to the capitate as the os
magnum, derived from magnum, indicating large (2).
Ossification Centers and Accessory Bones
The capitate usually is cartilaginous at birth. It has one ossification center that begins to ossify in the
second month. Of all the carpal bones, the capitate (or hamate) usually is the first to ossify, and
occasionally ossification already may have started at birth (5,74,75,76) (see Fig. 1.27A).
Several accessory bones can be associated with the capitate. 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 capitate include the os subcapitatum, os capitatum secundarium
(carpometacarpale V), os gruberi (os carpometacarpale VI), os hypotriquetrum, os epitriquetrum
(epipyramis, os centrale IV), os hypolunatum (os centrale III), os epilunatum (os centrale II), os
centrale (os centrale dorsale, os episcaphoid), os metastyloideum, os parastyloideum (os
carpometacarpale III), and os styloideum (carpometacarpale IV) (see Fig. 1.27B) (25,46). The os
subcapitatum is located adjacent to the central portion of the body of the capitate. The os capitatum
secundarium is located at the distoulnar corner of the capitate, adjacent to the distal hamate, and the
bases of the longer and ring finger metacarpals. The os gruberi is located just ulnar to the site of the
os capitatum secundarium, at the distoulnar corner of the capitate and adjacent to the bases of the
ring and long metacarpals. The os hypotriquetrum is located ulnar to the base of the capitate,
proximal to the proximal pole of the hamate, and adjacent to the triquetrum and lunate. The os
epitriquetrum is located just ulnar to the site of the os hypotriquetrum, proximal to the proximal pole
of the hamate, and adjacent to the triquetrum and lunate. The os hypolunatum is located just
proximal to the proximal margin of the capitate, between the lunate and adjacent to the proximal
pole of the scaphoid. The os epilunatum is located between the capitate, lunate, and scaphoid, just
radial to the site of the os hypolunatum. The os centrale is located between the capitate, scaphoid,
and trapezoid. The os metastyloideum is located at the distoradial aspect of the capitate, between the
trapezoid and base of the index finger metacarpal. The os parastyloideum is located at the distoradial
aspect of the capitate, slightly distal to the site for the os metastyloideum, between the capitate and
base of the index and long finger metacarpals. The os styloideum is 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. 1.27B).
Osteology of the Capitate
63 63

The capitate is the largest and centrally located carpal bone, containing articulations with the lunate,
scaphoid, trapezoid, the long, index, and ring finger metacarpals, the hamate, and the triquetrum
(Fig. 1.34; see Figs. 1.25, 1.26, 1.37, and 1.38). It consists internally of cancellous bone, surrounded
by a cortical shell (see Fig. 1.34). It is elongated in the proximo distal direction, and thus contains a
longitudinal axis. There is a slight concavity to the dorsal, radial, and ulnar surfaces, thereby
producing a waist that is narrowed and located slightly proximal to the transverse midline. The
dorsal surface is larger than the palmar surface. Both are rough for attachment of carpal ligaments.
The palmar 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 palmarly), 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 Variations).
The medial and lateral borders are somewhat concave. 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 (approximately 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, projects 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 surface of the capitate has a relatively large, concave facet for the hamate.

FIGURE 1.34. Right capitate. A: Medial aspect. B: Lateral aspect.


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 articulation with the base of the
ring finger metacarpal (94,117,118). The capitate-ring finger metacarpal articulation, 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 capitate 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 proximally,
where the capitate's proximal pole sits deep in the crescent-shaped fossa of the lunate, forming a
major portion 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 relatively 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 corner of the base of the index
metacarpal. Along a small strip of the distal ulnar corner of the capitate, there also is a narrow
64 64

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 pollicis (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 palmar aspects of the bone.
The dorsal surface of the capitate is rough for attachments of the dorsal carpal ligaments. The dorsal
surface is broad, relatively 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. Terminal 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
vascularity 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 position 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 capitate neck (119). (Also known as scaphocapitate
syndrome.)
Accessory Bones
Several accessory bones may be associated with the capitate 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 from heterotopic ossification of
synovial tags (46,47). The accessory bones associated with the capitate include the os subcapitatum
65 65

(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 epitriquetrum (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 parastyloideum (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 earlier, 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 tableshaped. 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 ossification 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 trapezoid. 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 (multangulum
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 trapezoideum 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 trapezoid, 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 somewhat 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 smallest 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 surface 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
66 66

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). 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 trapezium, where a convex surface of the lateral border of
the trapezoid sits in a concave articular surface of the trapezium. The four articular surfaces of the
trapezoid all connect with each other, each separated by a relatively sharp edge.

FIGURE 1.35. Right trapezoid. A: Medial aspect. B: Inferolateral aspect.


Muscle Origins and Insertions
The trapezoid gives origin to one, and possibly two muscles: 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 pollicis 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 distal 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 intercarpal 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 dorsal and palmar surfaces.
The main blood supply of the trapezoid is from the dorsal supply. The dorsal surface is broad and
flat, where the nonarticular surface serves for attachment of carpal ligaments. 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 penetrating the subchondral bone, the vessels branch to
67 67

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 approximately 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 vessels 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 trapezoid (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 difficult to visualize on routine posteroanterior, anteroposterior, or lateral views of the
wrist.
Accessory Bones
Several accessory bones may be associated with the trapezoid 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 multangular denotes many-sided.
Ossification Centers and Accessory Bones
The trapezium is cartilaginous at birth. It has one ossification 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 (multangulum
majus secundarium, carpometacarpale II), the os praetrapezium (carpometacarpale I), the os
68 68

paratrapezium, the os epitrapezium, the os radiale externum (parascaphoid), and the os trapezoideum
secundarium (multangulum 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
praetrapezium is located between the distal aspect of the trapezium 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 epitrapezium 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 cortical shell
(see Fig. 1.36). The trapezium has an irregular shape. The dorsal and palmar surfaces are rough. The
dorsal 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 palmar ulnar surface. The
groove forms the osseous portion of the fibroosseous tunnel containing the flexor carpi radialis
tendon. Radial to the groove is a distinct longitudinal ridge (trapezial ridge) running in the
proximodistal direction. 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 surface 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 articular surface articulates with the thumb metacarpal. This large sellar (saddleshaped) joint allows unique mobility. The surface shape has been found to be fundamentally
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 articular 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.

FIGURE 1.36. Right trapezium. A: Palmar aspect. B: Medial aspect.


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, 1.37, 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
trapezium with the index metacarpal. This joint surface on the trapezium is somewhat square or
rectangular.
69 69

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 lateral aspects, which are rough and serve as sites for ligamentous attachment, and
the prominent palmar tubercle from which the thenar muscles arise. Dorsally, one to three vessels
enter and divide in the subchondral bone to supply the entire dorsal aspect of the bone. Palmarly, one
to three vessels 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 vascularity. There are frequent anastomoses among all three systems. 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 produced 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 proximal 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 trapezoid 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
epitrapezium), and the os trapezoideum secundarium (located between the trapezium, trapezoid, and
basses of the index and thumb metacarpals; see Fig. 1.27B) (46) (see descriptions earlier, under
Ossification Centers and Accessory Bones).
70 70

FIGURE 1.37. Bones of right hand, palmar aspect, showing muscle origins (red) and insertions
(blue).
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, 1.38, 1.39; see Figs.
1.25, 1.26, 1.27A). Each has an expanded proximal base, an elongated diaphysis (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.

71 71

FIGURE 1.38. Bones of right hand, dorsal aspect, showing muscle origins (red) and insertions
(blue).

FIGURE 1.39. Right thumb metacarpal. A: Lateral (radial) aspect. B: Medial (ulnar) aspect.
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 finger metacarpal appearing longer
clinically. Posner and Kaplan have described the relative length relationships in terms of ratio of
metacarpal size to the corresponding phalanges (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 dorsally 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 adjacent palmar interosseous muscles. The dorsal
surface is flattened and somewhat triangular, with the apex proximal. The flattened dorsal surface
allows easy gliding of the overlying extrinsic extensor tendons. The triangular outline forms a ridge
72 72

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 tubercles 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 accommodates the overlying extrinsic
extensor tendon. The palmar aspect of the head contains a groove lying along the junction 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 Phalanx
Middl Phalanx
Proximal 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.
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 proximal 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 morphologic 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 (pronation) 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 metacarpophalangeal 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
metacarpophalangeal 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 ossification 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
73 73

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 accessory
bones located in the vicinity of the metacarpals, if present, 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 primary center in the midshaft and one
secondary center in the base (see Fig. 1.27A). This is in contrast to the remaining metacarpals, which
have one primary ossification center in the shaft and one secondary center in the head. Ossification
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 usually are secondary ossification centers of the trapezium.
These accessory bones include the os trapezium secundarium (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 trapezium. 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 confusion in describing the various
surfaces. Morphologic terms are used, but are supplemented in places by their topographic
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, 1.38, 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 surrounded 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 trumpetshaped expansion, with a prominent palmar lip and thickening 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
74 74

accommodate the saddle shape of the trapezial articular surface. The base of the thumb metacarpal
articulates only with the trapezium. 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 articulate 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, usually noticeably
thicker and wider than the other metacarpals. Its anteroposterior thickness is relatively less
pronounced, and in cross-section, the shaft is oval or somewhat triangular (apex palmar). It is mildly
longitudinally convex along its dorsal surface. It also is mildly longitudinally 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 opponens 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 convex 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 universal 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, 1.38, 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 origin 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.
75 75

FIGURE 1.40. Frontal section through articulations of the carpus.


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 trapezium, 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 adductor pollicis from the bases of the index and long finger
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 pollicis 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
76 76

at the metacarpophalangeal joint. In the thumb, it is the carpometacarpal joint that has the wider
range, and a basal epiphysis 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 impression.
Schultz provides guidelines for distinguishing sesamoids from fractures (25). 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 (25,131,132,133,134,135,136,137,138,139).
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 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 thumb metacarpal are usually in
the region of the base, representing secondary centers associated with the trapezium (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 Ossification
Centers and Accessory Bones).
INDEX FINGER METACARPAL (OSSA METACARPALIA II)
Ossification Centers and Accessory Bones
The index metacarpal (second metacarpal) has two ossification centers, one primary center in the
shaft and one secondary 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 sequentially 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 approximately 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 present, usually are the
result of a secondary or additional ossification 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
77 77

os trapezoideum secundarium is located at the radial base of the index metacarpal and the distal
radial corner 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 corner of the capitate.
The os parastyloideum is located between the ulnar base of the index metacarpal, the distoradial
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 proximal 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 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. Similar 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).

FIGURE 1.41. Right index finger metacarpal. A: Dorsolateral aspect. B: Medial aspect.
78 78

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, approximately 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 surface 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 tubercles, one on each side of the head for the
attachment of collateral 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 similarly, and is divided by a faint ridge into two areas: a palmar 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 be irregular, it has a smooth convex area that extends further in the palmardistal direction than in the mediolateral direction. The extraarticular areas of the head are roughened
and contain medial and lateral tubercles at the articular 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 capsule of the metacarpophalangeal joint. On the medial and lateral surface of
the metacarpal head are longitudinal furrows just proximal to the articular margin to assist the
passage of the tendons of the interosseous muscles. At the margin 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 addition, 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 neighboring long finger metacarpal. On the radial aspect
of the base of the index metacarpal, there also is a small articular surface 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 second 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).
79 79

The flexor carpi radialis inserts into the palmar aspect of the base of the index metacarpal. The
insertion point usually 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) originates 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 extensor 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 muscle helps stabilize
the index finger during pinch and grasp, resisting the force exerted by the thumb by producing
reciprocal abduction of the proximal phalanx of the index finger.
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
phalanx of the long finger, or the extensor aponeurosis (approximately 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 finger. 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 palmarly. 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 dislocation of the base of the index metacarpal is understandably
rare, usually prevented by the wide dorsal portion 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 mistaken for fractures, and can
themselves be fractured or develop as bipartite sesamoids, further confusing the clinical impression.
Schultz provides guidelines for distinguishing sesamoids from fractures. Multipartite sesamoids
80 80

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
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 ossification
of synovial tags (46,47). The accessory bones associated with the index metacarpal usually are in the
region of the base, representing secondary ossification centers associated 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 corner of the capitate), and the os parastyloideum (located between the ulnar base of
the index metacarpal, the distoradial corner of the capitate, and the radial base of the long finger
metacarpal; see Fig. 1.27B) (46) (see descriptions 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 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 ossification 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 present, usually are the
result of a secondary or additional ossification 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 parastyloideum (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 capitate. 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 corner of the capitate, and close to the
81 81

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 cancellous
bone.

FIGURE 1.42. Right long finger metacarpal. A: Lateral aspect. B: Medial aspect.
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 relationships 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 capitate. 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 intermetacarpal 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 palmar 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 surface 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 finger metacarpal contains a roughened or slightly raised
area for insertion of the extensor carpi radialis brevis. The insertion point is slightly radial to the
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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-section, the shaft of the long
finger metacarpal is oval or triangular, 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 converge
toward the proximal third of the dorsal surface. A single ridge continues proximally toward the base.
The extensor digitorum communis crosses close to the triangular portion 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 junction 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 tissues. Also in this region, at the margin of the articular surface, the bone is
rough, and there are multiple small vascular 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
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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 hand, it does not need a muscle to adduct it into this position.)
The long finger metacarpal also may receive attachments from the insertion of the flexor carpi
radialis (4,5). However, 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) originates 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 forming a
bipennate muscle. The second dorsal interosseous then inserts into either the lateral base of the
proximal phalanx of the long finger, or into the extensor aponeurosis (approximately 60% bone, 40%
extensor hood) (140).
The third dorsal interosseous muscle (radial head) originates along the shaft of the medial border of
the long finger 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 aponeurosis (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 originate 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 dorsally. With this configuration, subluxation or dislocation of the base
of the long finger metacarpal on the capitate usually occurs in a dorsal direction. Palmar dislocation
of the 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 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 long finger metacarpal usually are
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in the region of the base, representing secondary ossification 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 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 (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 finger 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 secundarium (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 similar 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 internally
of cancellous bone surrounded by a relatively thin cortical shell (see Fig. 1.43). The shaft consists of
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thicker cortical 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 quadrangular, is directed somewhat medially, and is convex anteriorly
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 finger metacarpal articulates
with the ulnar third of the distal 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 adjacent long
finger metacarpal base. On the ulnar side of the base of the ring finger metacarpal, there is an oval,
or narrow, oblong facet, usually with a concave surface, for articulation 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).

FIGURE 1.43. Right ring finger metacarpal. A: Lateral aspect. B: Medial aspect.
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 origin of the ulnar head of the third dorsal
interosseous muscle. On the lateral surface of the shaft of the ring finger metacarpal there is a faint
ridge that separates the attachments 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 triangular 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 surface, the
86 86

surface tends to form a slight longitudinal ridge along the midline of the cortical surface. There is no
consistent 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 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.
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 (81,94,108,117,142,143,144,145). The general shape of
the base, noted to be relatively flat or conical, usually is readily identifiable on standard radiographs
(117). With regard to articular morphology, the base of the ring finger metacarpal articulates with the
hamate and, to a variable degree, with the capitate (81,118,142,143, 146,147,148). 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.
Type I contains a broad base that articulates with the hamate and has a single dorsal facet extension
that articulates with the capitate. This type was present in approximately 39% of wrists.
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 present in approximately 8% of wrists.
Type III contains a relatively narrow base that articulates only with the hamate. Type III was present
in 9% of specimens.
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.
Type V contains a broad base that articulates with the hamate and the capitate. Type V was present in
approximately 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 hourglassshaped articular surface for articulation with the base of the small finger metacarpal. On the lateral
base of the long finger metacarpal, there is a similar strip or pair of circular articular areas for
articulation with the base of the long finger 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.
87 87

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 palmar interosseous (see Figs. 1.37 and 1.38).
The third dorsal interosseous muscle (ulnar head) originates 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) originates 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 (approximately 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 aponeurosis 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, compared with the relatively restricted motion of the
carpometacarpal 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
usually 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 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 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 long finger metacarpal and distoradial corner of the hamate), 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 capitate and hamate), and the os hamuli proprium (which is more closely associated with the
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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 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. The secondary
ossification centers usually 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 fifteenth or sixteenth year in women, and the eighteenth or nineteenth year in men
(127).
An accessory bone can be associated with the small finger metacarpal, the os vesalianum manius (os
vesalii, os carpometacarpale 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 secondary or
additional ossification center that does not fuse with the associated bone. That associated with the
small finger 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
medullary canal. At the base and at the neck, the medullary canal rapidly changes to cancellous bone
(127).

FIGURE 1.44. Right small finger metacarpal. A: Lateral aspect. B: Medial aspect.
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
89 89

tubercle for insertion of the extensor 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
transversely 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 laterally. 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 portion of the lateral aspect, there is a slight concavity for the 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 minimi. The dorsal surface of the shaft of the small metacarpal
is smooth to allow passage of the extrinsic extensor tendons. The dorsal surface of the shaft may
appear somewhat 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 thinner and smaller. It is rounded, and 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 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) originates 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
90 90

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 (approximately 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 aponeurosis 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 dorsomedial 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 border 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, compared with the relatively restricted motion of
the carpometacarpal 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, usually 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 impression.
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 ossification of synovial tags (46,47) (see Fig. 1.27B and descriptions earlier, under
Ossification Centers and Accessory Bones).

PHALANGES
Derivation and Terminology
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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 distal. 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 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 smallest. 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 shortest. The index finger usually is
slightly shorter than the ring finger, but may be equal to or longer than the ring finger (125).

FIGURE 1.45. Illustration of digit showing metacarpophalangeal and interphalangeal joints, palmar
aspect.
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
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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 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.
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
Adult Status
Sex
First Appearance (mos.) (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
93 93

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.
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

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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 finger 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 palmar 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.
Shaft of the Proximal Phalanx
The shaft of each phalanx is smooth, convex dorsally, and concave palmarly, and narrows slightly
medially and laterally from proximal to distal, terminating in the narrow neck. This tapering is more
pronounced in the middle phalanx 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
surfaces meet the palmar surface. The shaft of the phalanges tapers from proximal to distal in both
the frontal and sagittal 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 limited 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 direction, as is present in the heads of the metacarpals.
Associated Joints
The proximal phalanx articulates with the head of the associated metacarpal at each
metacarpophalangeal joint, and with the base of the associated middle phalanx at the proximal
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.

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FIGURE 1.46. Illustration of digit showing metacarpophalangeal and interphalangeal joints, lateral
aspect.
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 metacarpophalangeal 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 symmetric, 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 phalanges. 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 digiti 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 insertion 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
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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 approximately 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 associated 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 phalanx 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 similar (although either may be the longer), and the small finger 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 differences exist. The palmar aspect of the middle phalanx shaft is not as concave
as is the palmar aspect of the proximal phalanx. 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 narrow proximal to the head and widens to a steeper
degree toward the base. The dorsal aspect of the shaft is more convex, smooth, and more nearly
round than is the dorsal aspect of the proximal phalanx. The heads of the middle and proximal
phalanx are similar in configuration (125).
Base of the Middle Phalanx
The base of each phalanx flares out from the shaft on the dorsal, medial, lateral, and palmar surfaces.
On the dorsal aspect of the base, there is a transverse ridge along the most proximal rim, separating
the base from the articular surface. The ridge is more accentuated in its mid-portion, forming a
dorsal 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 terminates 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 palmar
surface of the base at the joint. This tubercle is just distal to the articular surface of the base. Just
distal to this tubercle 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 separated 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 dorsally, and toward the palmar tubercle on the base volarly
97 97

(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 superficialis (125). The presence of the nutrient foramina in the
protected areas under the tendon insertion is functionally advantageous 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
proximal 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 phalanx, along the radial and
ulnar portions of the proximal half, the cortex is rough for the insertion of the flexor digitorum
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 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 projection. 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
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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 approximately 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.
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, followed 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 phalanges 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 phalanges differs
slightly from those of the proximal and middle 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 distal phalanx terminates in the roughened distal tuft that is wider than the shaft. The
average length ratios of the middle 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 middle 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 dorsal 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 ligaments 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 palmar 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.
99 99

Shaft of the Distal Phalanx


The shafts of the distal phalanges are short and thin compared 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 phalanx 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 portion 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 phalanx, 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
proximally. 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 numerous on the palmar surface. The tuft provides for the
attachment 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 surface of the base of the distal phalanx. The
extensor digitorum 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). Ossification 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
10 100

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 fifteenth 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
finger.
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 borders the palmar surface of the base at the
metacarpophalangeal joint. On the palmar surface of the base of the proximal phalanges there is a
slight groove to accommodate the flexor tendons. This groove is better delineated in the proximal
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.
Shaft of the Thumb Proximal Phalanx
The shaft of the proximal phalanx of the thumb is approximately the length of the proximal phalanx
of the small finger (although it actually may be shorter). The shaft is relatively 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 proximal phalanges of the digits. Very
seldom can a small foramen 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 surface extends more palmarly,
and when viewed in the lateral projection, the articular surface appears symmetrically rounded.
(There is no increase in thickness in the anteroposterior 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 palmar surface, providing access for nutrient vessels.
Associated Joints

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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 others (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 stabilized 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 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). Ossification 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 approximately 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 characteristics 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 incorrectly 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, outlining 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 attachment 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.
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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-section, 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 diamond-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, stabilize, 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, stabilized 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 phalanx. 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.
REFERENCES

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Authors: Doyle, James R.; Botte, Michael J.


Title: Surgical Anatomy of the Hand and Upper Extremity, 1st Edition
Copyright 2003 Lippincott Williams & Wilkins
> Table of Contents > Section I - Systems Anatomy > 2 - Muscle Anatomy

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
(1,2,3,4,5,6,7,8,9,10,11,12,13,14). At the end of this chapter are several appendices for further
reference. Appendix 2.1 summarizes the general features of each muscle for muscle comparison.
Appendix 2.2 lists the skeletal muscles as to extremity compartments, from the standpoint of
compartment 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 differences (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 (3,4,5,6,7,8).
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 (3,4,5,6,7,8,9,10,11).
Principal Action. Abduction, forward flexion, and extension 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 Ushaped, with the open portion facing medially. The muscle has a broad origin, expanding anteriorly
from the lateral third of the anterior clavicle, laterally 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 muscle 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-diaphysis 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 portions 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 tendinous 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 (3,4,11,12,13,14). In addition, there is
interdigitation of the tendons from the clavicular and spinous portions. The septa are interconnected
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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 (9,10,11,12,13).
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 comprises mostly fibers from C5 and C6, it may contain a contribution 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 separately as well as together. When the entire muscle contracts, the humerus can be
abducted slightly beyond 90 degrees (3,4). (Additional humeral abduction actually is produced in
conjunction with scapular rotation.) The anterior (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
spinous portions can contract simultaneously to assist with stabilization of the humerus. The central
portion of the muscle 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 capsule is tense
inferiorly. The trapezius also assists the deltoid with humeral abduction. In general, the most
effective abduction takes place with the humerus in external rotation. 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, infraspinatus, and teres minor (3,4). Electromyography suggests that deltoid
contributes little to internal or external rotation, 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).

FIGURE 2.1. Anterior (A) and posterior (B) views of the scapula, showing muscle origins (red) and
insertions (blue).
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FIGURE 2.1. (continued)


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 insertion
has been noted to extend to the radial side of the forearm.

FIGURE 2.2. Anterior (A) and posterior (B) views of the humerus, showing muscle origins (red) and
insertions (blue).
The muscle belly of the deltoid may coalesce with adjacent muscles, and appear structurally joined
to these muscles. Coalescing muscles include the pectoralis major, trapezius, infraspinatus,
brachialis, and brachioradialis (11).
Clinical Correlations: Deltoid Muscle

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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 recognized 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 subluxation 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 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. 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 muscle 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 muscle 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 separated from that of the
deep part and may be closely associated with the tendon of the short head of the biceps brachii
(3,4,8,11,19,20,21,22,23,24,25). 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 insertion 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 musculocutaneous
nerve, followed by motor branches to the biceps and then the brachialis. After exiting from the
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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
coracobrachialis 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 average of 31 mm. The authors note that the frequently cited range of 5 to 8 cm below the
coracoid for the level of penetration 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 extension, 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 coracobrachialis, including those more proximal
and those more distal on the humerus. Those more proximal than the proximal diaphysis include
insertions into the surgical neck of the humerus or capsule of the shoulder joint (28). The
coracobrachialis brevis (or coracobrachialis superior, coracobrachialis 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 coracobrachialis 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 supracondylar ridge, medial epicondyle, or an anomalous supracondylar
process. The coracobrachialis inferior or coracobrachialis longus has been referred to as Wood's
muscle, based on Wood's descriptions of several muscle variations in 1870 (8,11,18).
Similar to the anomalous distal insertions, the coracobrachialis may have several accessory slips that
attach to the muscle distally. These include extensions to the medial epicondyle, the medial
intermuscular septum, or the distal medial aspect of the humerus (11,21).
Muscle or tendon slips have been noted to extend to various 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 coracobrachialis minor (le court coracobrachialis of
Cruveilhier), 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). Complete 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
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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
(11,21,26,27,29,30,31,32,33). 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 coracobrachialis 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 exposure of the coracoid process. The
musculocutaneous nerve and motor branches to the coracobrachialis muscle are at risk for injury.
The points of innervation of the musculocutaneous 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,
however, because of the established variability of the nerve. This variability should be kept in mind
when exposing or mobilizing the coracoid process, and the vicinity of the musculocutaneous 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 infraclavicular 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
(36,37,38,39). 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 musculocutaneous nerve before and inside the
coracobrachialis, and the high percentage of anomalies, emphasize the complexities and
irregularities of this anatomic region with regard to surgical approaches (11,21,26,27,30,31,32).
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 posterior 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 circumflex 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.
10 109

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 muscle has two heads,
arising from two separate origins. The muscle heads then partially coalesce into a single large
muscle 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 supraglenoid 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 muscle fibers then form a terminal tendon in the distal fourth of the
arm. The fibers coalesce and become tendinous, taking 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 actually 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 head chiefly on the deep surface, and the short head primarily
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 origin of the flexor-pronator muscles of the forearm. The tendon 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, respectively (3,4,10,11,12,13,42).

FIGURE 2.3. Anterior (A) and posterior (B) views of the radius and ulna, showing muscle origins
(red) and insertions (blue).
110 110

The biceps muscle is innervated by the musculocutaneous 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 branches may enter the muscle on the deep surface in the proximal
portion of the middle third. A distinct intramuscular 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 Chiarapattanakom 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 musculocutaneous nerve 119 mm distal to the coracoid process.
Variations 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 originating 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
musculocutaneous 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 intercostal 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. Flexion 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 interconnecting 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 separate 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 usually 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.
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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 anomalous slip arises from the humerus
near the insertion of the coracobrachialis and extends distally between the coracobrachialis 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). Supernumerary heads may extend to or from the biceps to the
brachialis, brachioradialis, pronator teres, flexor carpi radialis (FCR), flexor digitorum profundus
(FDP), intermuscular 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 radialis 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 coracobrachialis, 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,
29,30,31,32,33,41). Although the motor branch from the musculocutaneous 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 substance of the median nerve, travel distally along the
coracobrachialis, and then, as a single trunk or as several branches, pass between the biceps and
brachialis, supplying these muscles as well as the coracobrachialis from the more distal aspect. This
variation has been suggested to occur in approximately 20% of arms
(11,21,26,27,29,30,31,32,33,41).
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) (52,53,54,55,56), or distally, at or
near the insertion (57,58,59,60,61,62,63,64,65,66,67,68).
Bicipital tendinitis occurs in the tendon of the long head, usually along the anterior shoulder in the
intertubercular 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 (69,70,71,72,73,74,75,76).
The lacertus fibrosus is a structure known to cause or contribute to median nerve compression in the
forearm (49,50).
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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 (77,78,79,80). 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) (81,82,83,84,85), transfer of part or all of the pectoralis major (with or
without transfer of the pectoralis minor) (86,87,88,89), transfer of the latissimus dorsi
(90,91,92,93,94), anterior transfer of the triceps tendon (95,96,97), and transfer of the
sternocleidomastoid (98). Proximal transfer of the flexor pronator muscle origin is known as the
Steindler flexorplasty (81,82,83,84,85), 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 (36,37,38,39) or occur atraumatically (35).
Bilateral palsy also has been noted (40). Violent extension of the forearm may be a factor. The
syndrome features painless weakness of the biceps and brachialis, sensory loss in the distal lateral
forearm, and a history of recent vigorous upper extremity resistive exercises. 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,
P.102
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). Additional 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
attachment area of the origin is long and wide, commencing proximally 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
113 113

distal humerus on the anterior, lateral, and medial aspects to partially surround the shaft, covering
approximately two-thirds of the bone circumference. The muscle also arises from the medial
intermuscular septum 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 anteriorly 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 tendinous. This tendinous portion enlarges as the muscle extends distally, and
an additional tendinous portion joins the myotendinous junction on the anterior surface of the muscle
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 distal 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 musculocutaneous 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 variations have clinical significance for the operative exposure of
the musculocutaneous nerve, especially in performing intercostal 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 posterior to the deltoid insertion).
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If two or more muscle bellies exist, the distal insertion becomes more variable or irregular, to
include several additional 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 anomalous 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, including the brachioradialis, pronator teres, or
biceps. The brachialis may also be absent.
Variations in innervation may exist. The brachialis usually is innervated by the musculocutaneous
nerve. The radial nerve usually sends a small branch into the distal lateral 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 compressed 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 isolated palsy of the musculocutaneous has
been reported. It can follow heavy exercise (36,37,38,39) or can occur atraumatically (35). Bilateral
palsy also has been noted (40). Violent extension of the forearm may be a factor. The syndrome
features painless weakness of the biceps and brachialis, sensory loss in the distal lateral forearm, and
a history of recent vigorous 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 infraglenoid 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.
115 115

Vascular Supply. The triceps is supplied by the axillary artery through branches of the posterior
humeral artery, branches from the profunda brachial artery (including deltoid and middle collateral
branches), and from the superior and inferior ulnar collateral arteries and interosseous recurrent
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 extensive, complex origin
principally from the posterior humerus (3,4,8,9,11,13).
The long head of the triceps originates from the infraglenoid tubercle of the scapula (see Fig. 2.1). It
occasionally may extend along the axillary border of the scapula to varying 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 muscle bellies of the lateral and medial head to from a large, single 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 parallel 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 myotendinous junction is formed.
The long head of the triceps contributes to the formation of the well known quadrangular space and
the triangular space of the axillary region. From its origin, the long head extends distally anterior to
the teres minor and posterior 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 quadrangular 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 posterior 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 proximal 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 tendon (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 muscle head becomes most prominent when the elbow is actively
extended. The mass that is located medial to the lateral 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
116 116

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 exposure 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
common tendon, which extends distally to attach to the olecranon (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 separate 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 position.
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 neighboring 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 quadrangular 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 tendon, 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) (107,108,109,110,111,112,113,114,115,116).
The latissimocondyloideus or dorsoepitrochlearis is an anomalous muscle found in approximately
5% of individuals. 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 forearm (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
117 117

Ulnar neuropathy or neuritis at the elbow in conjunction with an abnormal triceps muscle slip or an
aberrant muscle belly is well documented (117,118,119,120,121,122,123,124,125). This type of
cubital tunnel syndrome has been related to either a separate or prominent medial head of the triceps
(119,123), an unstable, dislocating medial triceps tendon (117,118,124,125), or an abnormal
insertion or subanconeus muscle (an auxiliary extension of the medial portion of the medial triceps
that inserts into the joint capsule, fascia, or medial epicondyle) (120,122).
Radial nerve entrapment by the lateral head of the triceps has also been noted (126).
Complete avulsion or incomplete rupture of the triceps tendon is well documented
(107,108,109,110,111,112,113,114,115,116). It usually involves rupture at the distal tendon, but may
occur at the musculotendinous 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 association with a patella cubiti, a sesamoid bone in the triceps tendon (107). In a rare
case, it also has occurred in association with radial neuropathy (111). Similar to rupture of the biceps
tendon, operative repair for complete rupture usually is indicated (108,109,110,114,116). 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 conjunction with capsulotomy or tendon transfer, often is performed 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, middle 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 morphologically 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)
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 originates 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 transversely directly to the ulna, and the
more distal and lateral fibers extending more obliquely. The muscle covers the posterior 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 superior 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 stabilizing the ulna,
118 118

especially during rotation of the forearm. During pronation of the forearm, it has been postulated that
the anconeus moves the ulna laterally at the ulnohumeral 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 extensor 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 covers a portion of the anconeus, attaching to the posterior aspect of the
elbow capsule or blending with the antebrachial fascia (3,11).
The epitrochleoolecranonis anconeus epitrochlearis (epitrochleoanconeus, epitrochleocubital, or
anconeus sextus) 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, epitrochleoanconeus, 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 olecranon. 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, respectively, 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 profunda 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 margin 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, 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
119 119

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 brachioradialis because of its potential use as a rotation
musculocutaneous 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 corresponds 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 (15,134,135,136,137,138,139,140,141,142). Architectural features of a muscle
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
longitudinal vector of its tendon). Skeletal muscle architectural studies by Lieber, Friden, and
colleagues provide the data for the brachioradialis (135,136,137,138,139) (Table 2.1 and Fig. 2.4).
The brachioradialis has relatively long fibers arranged at a small 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 generation (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.
TABLE 2.1. ARCHITECTURAL FEATURES OF SELECTED MUSCLES OF THE UPPER
EXTREMITY
Muscle
Fiber
Pennation
CrossMuscle
Length
Length
Angle
Sectional Area Fiber Length/Muscle
Muscle Mass (g)
(mm)
(mm)
(Degrees)
(cm2)
Length 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) 12 2.1 207 10.7 68 2.8
6 0.2
1.71 .28
0.33 0.025
12 120

(n = 6)
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.

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-sectional areas from several studied muscles of the upper
extremity. Note that the flexors and extensors 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 parentheses next to it on the chart because it would actually place
off the graph. Similarly, the physiologic cross-sectional area for the combined FDP and FDS muscles
also is shown in parentheses. Muscles that cluster together in this graph are architecturally similar.
Because fiber length is proportional to muscle excursion (or velocity), and physiologic crosssectional area is proportional to force generation, the location of each muscle indicates its design
characteristics and specialization. (Muscles with higher fiber lengths are designed more for
12 121

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 brevis; ECRL,
extensor carpi radialis longus; ECU, extensor carpi ulnaris; FDS (I), flexor digitorum superficialis
(index finger); 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; 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; PT, pronator teres; PQ, pronator quadratus; BR,
brachioradialis. (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, 1992, with permission.)
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 the radial
nerve trunk proximal to the level of the elbow, as the radial nerve descends between the brachialis
and brachioradialis. 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 flexion. It has maximal mechanical advantage
when the forearm is in 0 degrees of pronation or supination, or in slight 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 forearm 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).

FIGURE 2.5. The normal brachioradialis (left) and some of its clinically relevant variations. The
12 122

split or duplicated muscle may cause confusion during harvest for tendon transfer. The split tendon
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).
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 (144,145,146) (see Fig. 2.5).
The supinator longus accessories or brachioradialis brevis 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 forearm. 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 origin of the brachioradialis) as well as the ECRL, pronator
P.110
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 insertion (11). The insertion point may be located more proximally 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
brachioradialis 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 brachioradialis 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 procedures, 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, properties, 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
excursion secondary to extrinsic soft tissue constraints and interconnections, which may limit its
potential true excursion when used in reconstructive procedures. These constraints include presence
of an internal tendon, as well as substantial 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 tendon transfer (Fig. 2.5).
The brachioradialis may be a major participant in spastic 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 flexion attitude of the elbow (155)
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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 indicating long and round (1,2).
Origin. Two heads exist. The humeral (principal) head originates from the anterior surface of the
medial epicondyle (common flexor origin) and from the intermuscular 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 superficial flexors of the forearm (which also
include the FCR, palmaris 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 intermuscular 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 attachment of the FDS. The ulnar head joins the humeral head at an acute
angle. The morphology of the ulnar head is variable. 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 muscle (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 (147,156,157,158,159,160,161,162,163,164,165). 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 proximal volar forearm in a medial-to-lateral direction. The muscle 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 surface 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 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
architectural studies by Lieber, Friden, and colleagues provide the data for the pronator teres
(135,136,137,138,139) (see Table 2.1 and Fig. 2.4). The pronator teres has a relatively large
physiologic cross-sectional area, indicating that its design is more optimal for force generation. It has
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a relatively short muscle fiber length, indicating 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 features. 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 separate 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
border. 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 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 (166,167,168). The brachial
artery also may pass deep to a ligament of Struthers, and brachial artery entrapment (presenting 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 (147,156,157,158,159,160,161,162,163,164,165).
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 supracondylar process of the humerus and attaches to the medial epicondyle
(166,167,168,169).
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).
Vascular Supply. The ulnar aspect by direct intramuscular branches; superior and inferior ulnar
collateral arteries; to a variable degree, contributions from the anterior and posterior ulnar recurrent
arteries; in the distal aspect, superficial 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 muscles of the superficial flexors of the forearm
(along with the pronator teres, palmaris longus, FDS, and FCU). The FCR lies in the superficial
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volar muscle compartment of the forearm (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 attachment 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 vertical 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 tendon. The mid-portion of the muscle belly lies in
the central portion of the proximal forearm. The myotendinous junction spans several centimeters
and gives rise to a long tendon.
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 tunnel, 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 its course, the tendon often has a synovial sheath. The tendon 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 proximovolar 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.

FIGURE 2.6. Anterior (A) and posterior (B) views of the skeleton hand, showing muscle origins
(red) and insertions (blue).
Architectural features of the FCR 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 longitudinal vector of its tendon). Skeletal muscle architectural studies
by Lieber, Friden, and colleagues provide the data for the FCR (135,136,137,138,139,174) (Table
2.2; see Fig. 2.4).
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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 muscles, 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 indicates 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).

FIGURE 2.6. (continued)


TABLE 2.2. ARCHITECTURAL FEATURES OF WRIST EXTENSOR AND FLEXOR
MUSCLES
Measured Properties of Muscles and Tendonsa One-Way ANOVA
Parameter
ECRB ECRL
ECU
FCR
FCU
Significance Levelb
Muscle properties
Muscle length (mm)
186.4 155.3 209.9 192.8 220.6 p < .01
4.5
6.9
6.0
4.8
8.6
Fiber length (mm)
70.8 1.7 127.3 58.8 59.8 41.9 1.6p < .0001
5.6
1.7
1.5
Physiological CSA
240.1 130.0 210.0 211.9 363.6 p < .0001
(mm2)
20.5
11.1
14.1
15.4
34.3
Predicted maximum
58.8 5.0 31.9 2.7 51.5 51.9 89.0 8.4p < .0001
tetanic tension (N)
3.4
3.7
Tendon properties
Aponeurosis length
101.3 81.9 153.7 126.5 160.6 p < .0001
(mm)
2.1
15.2
7.6
5.8
10.3
External tendon length
102.7 182.1 61.4 103.8 47.0 4.7p < .0001
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(mm)
Total tendon length
(mm)
Tendon length: fiber
length ratio
Tendon CSA (mm2)

4.6
5.1
8.7
7.4
204.0 264.1 215.1 230.3 207.6 p < .0001
4.4
15.7
4.9
5.6
9.1
2.89
2.10 3.67 3.86 4.96 p < .0001
0.11
0.18
0.13
0.12
0.18
14.6 0.7 14.2 0.5 15.7 17.7 27.4 3.6p < .01
1.4
1.6
Tendon stress at P0
4.06
2.30 3.36 3.06 3.54 p = .06
(MPa)
0.29
0.27
0.25
0.32
0.66
Tendon strain at P0 (%)
1.99
1.78 2.35 2.48 3.68 p < .005
0.20
0.14
0.30
0.45
0.31c
Modulus at P0 (MPa)
726.1 438.1 721.6 595.4 448.0 p > .2
73.5
93.7
167.3
93.0
95.7c
Ultimate stress (MPa) 71.3 6.4 67.9 4.4 70.8 74.0 51.6 p > .4
3.4
13.5
9.3c
Tangent modulus (MPa) 904.7 604.1 102.1 857.5 540.6 p > .1
161.2
113.6
131.9
142.1
152.6c
Safety factor ( P0)
18.0 1.7 31.8 4.4 21.4 23.7 16.8 p < .05
0.6
2.7
5.2c
Biochemical properties
Hydration (% dry mass) 77.0 1.5 74.4 2.9 80.3 79.3 83.6 2.0p = .06
2.0
1.8
Collagen (% dry mass) 77.0 2.0 78.4 2.1 79.6 74.0 69.4 5.4p > .3
1.0
5.1
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.
a
Values shown are mean standard error of n = 5 independent measurements.
b

Significance level from one-way analysis of variance (ANOVA).

Signifies 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 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 forearm, 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).
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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
surface 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 communis (EDC) to provide digital extension in patients with radial nerve palsy
(182,183,184,185). From an architectural standpoint, its design for greater excursion makes it
(architecturally) 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, anterior interosseous artery, and variable contributions from the anterior and posterior ulnar
recurrent arteries. Distal tendon: rami from the ends of the superficial arch (3,4,8,11, 187,188).
Principal Action. Flexion of the wrist. It also contributes to anchoring of the palmar fascia to resist
horizontal shearing 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 superficial volar muscle
compartment of the forearm (Appendix 2.2). The palmaris longus is small but clinically important .
It also is well documented as one of the most variable, in terms of presence (or absence) ) as well as
muscle variations and anomalies . 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 Anomalies. Its absence has been the subject of several anatomic investigations . 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) , or 5% to 15% of individual limbs ().
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 University for absence of the palmaris longus (198). Findings included, in
women, unilateral absence in 23% and bilateral absence in 45.3%. In men, unilateral absence was
found in 19.5% and bilateral absence in 42.1%. The overall percentage of absence was 63.9%. This
is among the highest reported absence rates (198).
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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 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 slender, 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
transverse 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 retinaculum to the
palmar fascia (193).
The tendon and palmar fascia continue distally to form a diverging sheet that splits longitudinally to
send thickenings 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 digital 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 palmaris 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
palmaris 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 frequently from the brachial artery
(23%). The arterial branches penetrate the muscle through the posterior surface, 63% in the proximal
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third and 34% in the middle third of the muscle. The most frequent patterns observed included one
or two branches of the ulnar artery penetrating 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 proximal part of the FDS. The nerve to the palmaris longus usually 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 purpose
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 longitudinal 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 contribute 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 tendon'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 synergistic 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 relatively common, the incidences are discussed
in more detail earlier, under Gross Anatomic Description.
Several variations have been reported (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 compression, including the median nerve in the forearm ) and
the carpal tunnel (), the palmar cutaneous branch of the median nerve (230,231,232), and the ulnar
nerve ( The more common variations 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
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(208,209,211). If the muscle reaches or enters the carpal tunnel, carpal tunnel syndrome can result
(212, 219). A reversed muscle also can lead to ulnar nerve compression (234).
Digastric Head
The palmaris longus may have a digastric head (two heads, one proximal and one distal, separated
by an intercalary tendon) (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 ).
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
operative finding without any clinical consequences. However, as it enters the carpal canal, it can
result in carpal tunnel syndrome (221). It has been reported to occur bilaterally (215,221,228). The
muscle also can cause ulnar nerve compression 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 insertion on the deep surface of the palmar aponeurosis, similar to the palmaris profundus. It
can result in median neuropathy 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 cause median neuropathy in the forearm or carpal tunnel (195).

FIGURE 2.7. The normal palmaris longus and some of its clinically relevant variations. The
palmaris longus with a distal muscle belly may be responsible for median or ulnar nerve
compression. 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 recognized.
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The digastric form also may contribute to median and ulnar nerve compression in the forearm (11).
Central Belly
The muscle belly may be located centrally between two tendons, 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 origin. It may have abnormal extensions,
anomalous slips, an abnormal split, and associated anomalous muscle bellies
(11,195,215,216,222,223,224,225,250). The palmaris longus may insert into the tendon of the FCU,
transverse carpal ligament, 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 attachments to
these muscles are so common they may be considered 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 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 identified 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 minimi. 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 function 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 discussed 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 associated with anomalous muscles include median
compression in the forearm and the carpal tunnel ,, compression of the palmar cutaneous branch of
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the median nerve (230,231,232), and compression of the ulnar nerve in the forearm or ulnar tunnel ()
(discussed in detail earlier, under Variations and Anomalies).
The possibility of absence is of clinical significance because of the common use of the palmaris
longus as a free graft or tendon transfer (263,264,265,266,267). 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 cadavers) (11,196,199) and absence
in individual limbs in 15%
P.120
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 syndrome (11,212,218).
For low median neuropathy, such as with severe, longstanding 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 fascia, to transfer
to the thenar muscles (.
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 sublimis, 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 diaphysis.
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 recurrent 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
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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 ).
The muscular fibers extend distally, with the fiber bundles of the ulnar head and the upper part of the
radial head converging. The ulnar fiber bundles extend distally in a vertical 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 tendinous or fibrous sheet (3,4).
The muscle belly of the FDS forms two separate submuscle bellies (). 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 tendons for the
long and ring fingers. Similarly, the deep plane of fibers further divides into two parts, which end in
the tendons for the index and small fingers (4). Of these muscles, the FDS belly to the long finger
may arise more independently 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 proximal phalanges, each tendon divides into two slips. The divergence 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 profundus 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 tendons at their osseous
insertions (285,286,287,288,289,290,291,292,293,294,295,296,297,298,299). 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 brevis profundus, the vinculum
longum superficialis, and the vinculum longum profundus. The vincula often are variable in presence
and configuration (299). In addition to the vascular 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 interconnect anterior to the
phalanx, but deep (dorsal) to the tendons. These branches form the vinculum longum superficialis
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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
(285,286,287,288,289,290,291,292,293,294,295,296,297,298,299).
The vinculum brevis superficialis and the vinculum brevis profundus consist of small triangular
mesenteries near the insertion of the FDS and FDP tendons, respectively. 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 profundus (285,286,287,288,289,290,291,292,293,294,295,296,297,298,299).
Because the vincula enter the tendon on the dorsal surface, 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 colleagues provide the data for the FDS to each digit
(135,136,137,138,139,174) (see Table 2.1 and Fig. 2.4). As can be seen in the figures, the digital
extrinsic flexor and extensor muscles 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 features. 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 carpometacarpal joint (11).
The FDS has independent muscle components to each of the four digits. It therefore can flex each
PIP independently (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 anomalies of the FDS (), the more common
involve muscle slips that interconnect the FDS with the other forearm 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
independent 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 additional distal muscle belly separated from the
main muscle belly by an intercalary tendon (11,302,303,304,329). The muscle may occur as an
accessory FDS, in the presence of a normal FDS (305,306).
An anomalous muscle, the palmar FDS accessories, may arise from the palmar fascia and distal
border of the transverse carpal ligament and end in a tendon that joins the flexor tendon of the index
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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 compression, 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 eliminate 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 anomalies 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 syndrome (303,316,317,318,319,320,322,327,331).
Holtzhausen and colleagues 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). Intermuscular
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 ligament and end in a tendon that joins the flexor tendon of the index finger
at the level of the MCP (309,310,311,312,313,319). 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 surface, 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 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.
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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 medical epicondyle through the common flexor
origin. Ulnar head: extensive origin from the medial margin of the olecranon and proximal twothirds 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 recurrent 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 flexors 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 compartment 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
attachments from the humeral head to the adjacent intermuscular 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
aponeurosis (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 extending 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 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 forearm, and a long solitary tendon that extends distally without
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 ligament). 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 aponeurosis, 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 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 longitudinal vector of its tendon). Skeletal muscle architectural studies
by Lieber, Friden, and colleagues provide the data for the FCU (135,136,137,138,139,174) (see
Table 2.2 and Fig. 2.4). The FCU has a relatively small fiber length and relatively large physiologic
cross-sectional area. This indicates that its design is more optimal for force generation (proportional
to cross-sectional area) than for excursion or velocity (proportional to fiber length). Its relative
difference index values compare it with other upper extremity muscles, based on architectural
features. These values are listed in Appendix 2.3. In comparing the architectural features of the FCU
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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 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 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 FCU is innervated by the ulnar nerve (C7, C8, T1). The muscle usually receives two to three
muscular branches 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, especially 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) (.
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 pisiform. 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 different muscle-tendon patterns should
be kept in mind when interpreting magnetic resonance images, during general operative exploration
for penetrating trauma, or when performing muscle-tendon lengthening procedures (.
Among the most common variations of the FCU is an accessory tendon or muscle slip that extends
from the coronoid 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 insertion 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 carpometacarpal 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 (346,347,348,349,350). These
anomalous muscles entering the ulnar tunnel also have been associated with ulnar artery thrombosis
(351).
The insertional tendon may extend to the proximal portion of the abductor digiti minimi.
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The epitrochleoanconeus [epitrochleoolecranonis or anconeus sextus of Gruber (11)] is a small


anomalous muscle 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 approximately 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 symptoms were produced with wrist hyperextension (352,353,354).
Clinical Implications: Flexor Carpi Ulnaris
Because the FCU is designed most optimally for force generation 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) .
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 anesthetic block, by infiltration of
the nerve deep to the palpable 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 borders 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 (346,347,348,349,350,355,356). In addition, a
split FCU tendon pierced by the ulnar nerve or one of its branches can lead to neuropathy
(352,353,354). An anomalous muscle extending into the ulnar tunnel also has been associated with
ulnar artery thrombosis (351).
Sarcomere length of a muscle can be measured using intraoperative laser diffraction techniques.
With these techniques, it is possible to show and measure the change of sarcomere 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 m) 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 demonstrate the feasibility of using intraoperative laser diffraction
techniques during tendon transfer as a guide for setting tension and the optimal placement and
sarcomere length of the transferred muscle (341,342,343).
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 forearm.
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, posterior and anterior interosseous arteries, palmar
carpal arch, palmar metacarpal arteries, common and proper digital palmar arteries. In addition, the
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lateral portion is supplied by the ulnar collaterals and the deep palmar arch, and the medial part is
supplied by the ulnar artery (3,4,11,13,68).
Principal Action. Flexion of the distal and interphalangeal 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, somewhat 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 surface 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 extensive origin then forms what resembles a single large muscle belly, although the belly to the
index finger usually is separate and may be discernible. The muscle then divides into four parts that
are more distinct. The myotendinous junction 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 separate 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 finger) (3,4,11) (see earlier, under Gross Anatomic Description:
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 throughout
their course from the muscle belly to the palm. In some, the FDP tendon to the small finger may be
more independent, and resemble that of the index finger. The tendons to the long and ring finger are
the least independent 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 proximal phalanx, the FDS tendons split and the associated FDP tendon passes through
the split. Each tendon continues distally to insert on the base of each of the distal phalanges
(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 Description: 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 vincular 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 insertions (285,286,287,288,289,290,291,292,293,294,295,296,297,298,299).
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 interconnect anterior to the
phalanx, but deep (dorsal) to the tendons. These branches form the vinculum longum superficialis
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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 superficialis, the vinculum brevis
profundus, the vinculum longum superficialis, and the vinculum longum profundus. The vincula
often are variable in presence and configuration
(285,286,287,288,289,290,291,292,293,294,295,296,297,298,299). 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, respectively. 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 profundus (299).
Because the vincula enter the tendon on the dorsal surface, 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 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 colleagues provide the data for the FDP to each digit
(135,136,137,138,139,174) (see Table 2.1 and Fig. 2.4). The digital extrinsic flexor and extensor
muscles have similar architectural 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 muscle. A branch of the
anterior interosseous nerve continues distally along the anterior surface of the interosseous ligament
to reach and enter the proximal border of the pronator 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 muscle that provides tendons to the ring and small fingers.
Considerable 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 bellies, 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 lumbricals 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 (3,4,11,360,361,362,363,364,365).
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
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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 profundus indicis (11).
An anomalous accessory FDP tendon may exist as a separate 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 congenital 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 pisotriquetral 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 paresis or palsy of the FDP to the index and long
(and occasionally 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) (368,369,370,371,372,373,374,375,376).
In 1979, Linburg and Comstock described an anomalous tendon slip from the FPL to the FDP to the
index finger (360). It appears that the anomaly is present in at least one extremity of 25% to 31% of
individuals, and in both extremities in 6% to 14%. If present it can be demonstrated when a patient
attempts to independently flex the interphalangeal joint of the thumb, and there is coexisting flexion
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 surface, the vascularity of the dorsal half of the
tendon in the digits is richer than in 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 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 (3,4,11,379,380,381,382,383,384).
Principal Action. Flexion of the thumb interphalangeal joint and MCP.
Gross Anatomic Description: Flexor Pollicis Longus
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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 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 middle third of the anterior surface of the radial diaphysis. It also has
attachments from the adjacent interosseous ligament, 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 tendon 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 tendons 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 pollicis
and the oblique head of the adductor pollicis. It continues 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 phalanx 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 longitudinal vector of its tendon). Skeletal muscle architectural studies by
Lieber, Friden, and colleagues provide the data for the FPL (135,136,137,138,139,174) (see Table
2.1 and Fig. 2.4). The digital extrinsic flexor and extensor muscles have similar architectural
features. The relative difference index values compare 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)
(387,388,389,390,391,392,393,394,395). There usually are at least two motor branches that enter the
proximal half of the muscle at its ulnar aspect.
Actions and Biomechanics: Flexor Pollicis Longus
The FPL is the only muscle that flexes the thumb interphalangeal 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 carpometacarpal 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 . The FPL can have interconnections of tendon
slips or muscle extensions with the FDS, the FDP, or the pronator teres (360,361,399,400,401). 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 epicondyle 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
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anterior interosseous nerves. Anatomic variations of Gantzer's muscle have contributed to median
nerve compression in the forearm (403,404,405,406,407).
Most commonly, there can be a tendon slip that connects the tendons of the FPL to the FDP.
Attempts at independent flexion of the thumb interphalangeal produce concurrent 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 (11,408,409,410,411,412,413,414,415,416,417). 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 (423,424,425). 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 flexion power of the thumb will then be present (424). The FPL may be conjoined
to the extensor pollicis longus (EPL) (425,426,427).
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 occasionally the ring) fingers, as
well as paresis of the pronator quadratus. The syndrome may be caused by trauma, tight-fitting casts,
neuritis, or anatomic structures that impinge on the anterior interosseous nerve, including fascial
bands, adhesions, or normal or anomalous muscle impingement (i.e., fibrous bands of the pronator
teres, Gantzer's muscle) (368,369,370,371,372,373,374,375,376,377).
The anomalous tendon slip from the FPL to the FDP to the index finger appears to be present in at
least one extremity 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 anomaly 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 indicating 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 appears to function more
during rapid or forceful pronation.
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 forearm. The muscle more accurately belongs in its own section. It is now
considered to occupy a separate compartment of the forearms, and should be addressed as such with
compartment syndromes (273,274,428,429,430,431,432) (Appendix 2.2).
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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 muscle inserts onto the palmar
20% of the distal radius, covering 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 capsule 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 crosssectional area of 0.95 cm2. The superficial head has a contractile 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 average length of 4.0 cm, average width of 3.2 cm,
and a thickness 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 contracting, 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 functions 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).
The pronator quadratus, located in the distal palmar forearm, has been shown to occupy a
functionally separate fascial compartment (428,429,430,432). 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 forearm compartments (430,432). Clinical correlations of compartment syndrome
involving the pronator quadratus support the concept of the muscle occupying its own compartment
(428,429,430,434).
The architectural features of the pronator quadratus, including the fiber length and physiologic crosssectional 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 pronator 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 stabilize 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 proximally, 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 capsule, 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 forearm, is considered to occupy a separate
compartment. Anatomic dye injection studies by Sotereanos and colleagues have demonstrated a
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distinct fascial space without communications to the deep or superficial volar compartment of the
forearm (273,274,430,431,432,433). Decompression of the volar compartment of the forearm
without specifically addressing the pronator quadratus may not consistently 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 (435,436,437,438,439,440,441,442).
From the standpoint of the use of the pronator as a muscle-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 pronator 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 combination 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 comprises 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 extensor origin of the lateral epicondyle, the lateral
intermuscular septum, and the anterior fascia of the ECRB and EDC (both of which arise from the
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common extensor origin 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 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 extensor indicis proprius (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 dorsal 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 surface 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 physiologic 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 (135,136,137,138,139,174) (see Table 2.2 and Fig. 2.4). The relative difference
index values compare the ECRL with other upper extremity muscles, 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 proximal 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 addition, 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 stabilize 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 anomalous 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
(445,446,447).
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 phalanx of the thumb, or
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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).

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.
Clinical Implications: Extensor Carpi Radialis Longus
Injury to the posterior interosseous nerve, including compression 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 proximal
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 extension 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 .
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
inflammation between the APL and EPB muscle bellies and the muscle bellies of the ECRL and
ECRB (451,452,453,454,455). 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 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 and 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). 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
attachments to the radial collateral ligament of the elbow, surrounding 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 collateral continuation of the profunda brachii artery (3,4,11, 13).
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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 cocontractions of the wrist
flexors) during powerful grasp functions (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 compartment of the forearm (12)
(Appendix 2.2). The muscle origin also includes attachments to the intermuscular septum, 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 second dorsal extensor
compartment of the extensor retinaculum. [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 compartment, it lies in a shallow
groove on the dorsal surface of the radius, medial to the tendon of the ECRL, and separated 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 tendon does not insert centrally on the
metacarpal, but rather attaches off center on the radial aspect of the dorsal surface 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 physiologic 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 (135,136,137,138,139,174) (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, 456,457,458).
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, several 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).
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 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).
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The FCR brevis muscle is a rare anomalous muscle associated 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 finger 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 usually implicated as the principal muscle
affected. Several methods for operative management have been described, including muscle release,
lengthening or debridement of its tendinous origin (459,460,461,462,463), or lengthening of the
muscle at the musculotendinous junction (462,463). Friden and Lieber have studied the physiologic
consequences of surgical lengthening of the ECRB at the tendon junction. The authors found that the
ECRB develops near-maximal isometric 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 shortening of the fibers, and ECRB sarcomere shortening of 0.3 m. This 0.3-m
sarcomere shortening, in turn, was predicted 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
inflammation between the APL and EPB muscle bellies and the muscle bellies of the ECRL and
ECRB (451,452,453,454). 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 muscle that is involved in the stretching out or straightening out of
a joint. Digitorum is from the Latin digitus or digitorum, indicating the digits. Communis is derived
from the Latin communis, meaning common, and is used to indicate a structure serving or
involving several branches or sections (1,2).
Origin. From the lateral epicondyle as part of the common 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 distal 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, juncturae, and anatomic variability, is a complex
structure and the subject of many investigations
(464,465,466,467,468,469,470,471,472,473,474,475,476,477,478,479,480,481,482,483,484,485,486
,487,488,489,490,491,492,493,494,495,496,497,498). It lies in the dorsal muscle compartment of the
15 151

forearm (Appendix 2.2). It arises from the common extensor origin at the lateral epicondyle 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 muscles (3,4,11,13). It is a relatively large
muscle, and its muscle belly is close to the muscle of the EDM. At the junction of the proximal twothirds and the distal one-third of the forearm, the myotendinous junction arises and four separate
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 tunnel 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 synovial 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)
(492,493,494,495,496,497,498). The tendons then continue into the digits to form the extensor
mechanism of each digit. The EDC tendon, through the extensor mechanism, 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 expansion (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 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 distally, 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 portion 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 continue
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 lumbricals to the ring and small
finger arise from the adjacent sides of the profundus tendons to the long, ring, and small fingers.
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 interconnected 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
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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 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 interconnections. The presence of certain
juncturae appears to be associated 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 multiple EDC ring finger tendons usually are present, the ulnar portion of the
double EDC ring finger tendon and, as mentioned, 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 tendons should be appreciated when tendon transfer or harvesting is
used (492,493).

FIGURE 2.9. The extensor aponeurosis (see text).

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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 present 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.)
Architectural features of the EDC 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 longitudinal vector of its tendon). Skeletal muscle architectural studies
by Lieber, Friden, and colleagues provide the data for the EDC (135,136,137,138,139,174) (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 difference 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 supinator 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.
TABLE 2.3. EXTENSOR TENDON VARIATIONS AND MULTIPLICITY
Incidence as %
Tendons or von Schroeder/Botte
Mestdagh et al. Leslie Ogura et al.
Tendon
Slips
(492)
Schenk
(479)
(478)
(500)
EIP
Absent
0
1
0
15 154

EIP to
middle
EMP
EDC
index
EDClong

EDCring

1
2
3

77
16
7

Present
Present

5
12

1
2
1
2
3
4
1
2
3
4

98
2
51
28
16
5
12
63
16
9

93
6
3

96
4
2

5
95
5
61
39
63
31
5
5

EDC
small

EDQ

Absent
1
2
3
1
2
3
4

54
19
26
2
2
84
7
7

56
44

91
9

7
84
7
2

16
84

97
3
4
94
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.
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 extension 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, involving 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 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 fascia between the extrinsic
tendons on the dorsum of the hand (491,492,493,494,495,496).
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 tendons,
each tendon usually can be traced back to a muscle belly that can be separated from the remaining
EDC muscle. Each of these four muscle bellies are similar, however. The EDCs to the long and ring
15 155

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 usually 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 incidences have been recognized in clinical and anatomic studies
(462,475,478,479,481) (Table 2.3). Because these variations are so common, it is difficult to label
these as anomalies; they perhaps are best considered as normal variations. 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 finger 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
longitudinal 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).
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 finger 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 variability 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). Similar 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 evolutionary remnant and not a variation of a normal arrangement (494).
The extensor medii et annularis communis is an anomalous 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
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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
deep to the extensor retinaculum. Excision of this anomalous muscle or decompression under the
extensor retinaculum may be performed if symptoms warrant (494, 499,500,501,502,503,504).

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 dorsal
aponeurosis of the long finger. The EMP is similar to the extensor indicis proprius (EIP); however,
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.
Clinical Implications: Extensor Digitorum Communis
Their frequent multiplicity and variability and the possible presence of many anomalous extensor
tendons should be appreciated during extensor tendon exploration for trauma repair or tendon
transfer.
The index finger has the greatest independent motion in extension. It has two independent tendons
(index finger EDC and EIP) that are the least variable of the extensor tendons. It also has the lowest
frequency of interconnecting juncturae tendinum. These anatomic findings help explain its relatively
15 157

independent extension capabilities compared with the more ulnarly located digits (e.g., the ring
finger).
Occasionally, an anomalous junctura tendinum may cross between the EDC and the EPL tendons.
This junctura restricts digital motion, making it impossible actively to extend the digits fully while
maintaining the interphalangeal joint of the thumb in flexion (483).
The extensor digitorum brevis manus (see earlier) can be mistaken for a ganglion or other tumor. It
may become symptomatic deep to the extensor retinaculum. Excision of this anomalous muscle or
decompression under the extensor retinaculum may be performed if symptoms warrant ) (see Fig.
2.12).
EXTENSOR INDICIS PROPRIUS
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. Indicis is from the Latin to indicate the index finger (1,2).
Origin. The dorsal surface of the distal ulna and adjacent interosseous ligament.
Insertion. The extensor hood of the index finger.
Innervation. Posterior interosseous nerve (C7, C8).
Vascular Supply. The posterior interosseous artery, interosseous recurrent artery and its
communicating vessels, 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).
Principal Action. Extension of the index finger. As with the index finger EDC, the principal action is
on the MCP joint.
Gross Anatomic Description: Extensor Indicis Proprius
The EIP is a relatively small and short extensor located deep to the EDC, EDM, and ECU. It lies in
the dorsal muscle compartment of the forearm (Appendix 2.2). The EIP originates from a diagonally
oriented origin on the ulnar aspect 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 adjacent interosseous ligament. Additional
attachments include the fascia or septum between the EIP and EPL. The muscle belly of the EIP lies
next to and ulnar to the muscle belly of the EPL. The tendon of the EIP passes deep to the EDM and
EDC tendons in an oblique fashion as it extends distally toward the index finger. It joins the tendons
of the EDC in the fourth dorsal compartment as it passes deep to the extensor retinaculum. As the
EIP enters the extensor retinaculum, it is located on the ulnar margin of the retinaculum, and
positioned ulnar and deep to the EDC. In the extensor retinaculum, the EIP tendon continues in a
diagonal course to cross deep to the EDC tendons, so that when the EIP emerges from the extensor
retinaculum, it is on the lateral aspect of the retinaculum. The tendon continues distally and laterally
toward the dorsal aspect of the index finger, and remains in close proximity and ulnar to the EDC to
the index finger. (This ulnar position of the tendon is important in identification of the tendon for
harvest for tendon transfer during such procedures as opponensplasty.) At the level of the index
metacarpal head and neck, the tendon of the EIP joins the tendon of the index EDC to form a
continuous extensor hood (3,4,11,13,68) (Fig. 2.6B).
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.
The EIP is innervated by the posterior interosseous nerve, predominantly C7, as well as C8.
Anatomic studies have shown that the branch to the EIP usually is the last or terminal motor branch
of the posterior interosseous nerve (505).
Actions and Biomechanics: Extensor Indicis Proprius
The EIP assists with extension of the index finger. It also assists with wrist extension. The separate
muscle of the EIP provided to the index finger assists with the strong independent motion of the
index finger. Principal action is on the MCP joint.
Anomalies and Variations: Extensor Indicis Proprius
See also Anomalies and Variations: Extensor Digitorum Communis.
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Despite the variability and multiplicity of the extensor tendons (see Table 2.3), the EIP usually exists
as a single 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 (478,490,506,507,508) (see also under Anomalies and Variations: Extensor Digitorum
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 positioning 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 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. 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 common extensor origin, as well as from the
adjacent intermuscular septum (between it and the ECU), and from the overlying 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
intermuscular 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 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 fifth dorsal
compartment is located dorsal to the distal radioulnar joint. The tendon continues distally 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
15 159

(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 muscle 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 finger. The most common pattern of the extensor tendons actually is an absent small
finger EDC, and a double tendon 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 (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 aponeurosis 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 distal 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
16 160

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 posterior surface of its belly (3,4,11).
The tendon reaches the extensor retinaculum to form the sixth 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).] 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 retinaculum
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 physiologic cross-sectional area of the muscle and the
fiber length. Skeletal muscle architectural studies by Lieber and colleagues provide the data for the
ECU (135,136,137,138,139,174) (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 posterior 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 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 distal
radioulnar joint complex, the ECU works with the interosseous ligament, the extensor retinaculum
and competence of the sigmoid notch of the distal radius, and the dynamic forces of the pronator
quadratus (510,511,512,513,514,515).
Anomalies and Variations: Extensor Carpi Ulnaris
The ECU may consists of a double muscle belly, or terminate 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 separate tendon slip arising from the tendon of the ECU. The ulnaris digiti minimi also
may have insertions into the dorsal 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 (519,520,521,522).
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).
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Origin. From the lateral epicondyle and the lateroposterior ulna.


Insertion. To the proximal radius, along the lateral, posterior, 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 rotation 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 muscles 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 dorsal 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 proximal 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
superficial and a deep layer. These layers are separated by a connective tissue septum through which
the posterior interosseous nerve courses. The two layers arise together, the superficial by tendinous
origin and the deep by muscular 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 aponeurosis 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 (524,525,526,527,528,529). 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 addition, Debouck and Rooze noted that the arcade was tendinous in
64% (525) and Papadopoulos et al. noted a tendinous arcade in 90% (528). The arcade of Frohse is a
well known area of possible nerve impingement resulting in posterior 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 perpendicular to the fibers of the muscle. The nerve often
branches within the muscle, and several branches often are seen exiting 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 posterior interosseous nerve before the nerve
passes through the arcade of Frohse. Theses branches usually carry contributions from C5, C6, and
C7 (3,4,11,13,505,531).
Actions and Biomechanics: Supinator
The supinator functions mainly for supination of the forearm (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).
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The tensor ligamenti anularis anterior muscle is an anomalous muscle that connects the supinator to
the annular 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 provides the opening of the muscle through which the posterior interosseous nerve
passes. The arcade of Frohse is a well known area of possible nerve impingement resulting in
posterior 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, indicating
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.
Insertion. The base of the thumb metacarpal, dorsal aspect.
Innervation. Posterior interosseous nerve (C7, C8).
Vascular Supply. The posterior interosseous artery; perforating 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 forearm. 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
central 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 manner 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 tendon becomes more superficial in the distal third of the
forearm. 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 compartment (3,4,533).
[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 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 second 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
pattern of a single APL and EPB occurs less than 20% of the time (451,534). This variability has
implications for the etiology and treatment of de Quervain's tenosynovitis
(534,535,536,537,538,539,540,541,542,543,544,545,546,547,548,549,550,551,552,553). The first
dorsal compartment may have more variations in tendon structure and organization than most other
muscles in the upper extremity (451). This is discussed 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
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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 multiple 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
potentially leads to persistence or recurrence of pain after operative 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), superficial 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 several variations as well. In 24% to 34% of
specimens in anatomic studies, the first compartment was found to be subdivided 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 (451,541,542,543). The reported incidence of separate
compartments at surgery is higher than that seen in anatomic specimens in several series
(539,548,550,551,552,554), 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 (). The disease often is referred to as stenosing tenovaginitis 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 (). The number of variations in tendon structure 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 compartment may also be related to the incidence of
stenosing tenosynovitis. The reported incidence of separate compartments at surgery is higher than
that seen in anatomic specimens in several series (). 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
compartments 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 compartment 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 dorsal 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 compartment 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,
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however, has two or three terminal divisions that lie superficial to the first dorsal compartment and
must be identified and protected during the surgical procedure (451,534,547). Radial neuroma 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
inflammation between the APL and EPB muscle bellies and the muscle bellies of the ECRL and
ECRB (). 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 straightening 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, continuation 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 distal 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 middle 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 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 comprise the first 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 tendon anatomy and
presence 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 longitudinal ridge and septum into two distinct
osteofibrous tunnels, the ulnar one for the EPB and the radial one containing one or more slips of the
APL (451,541,542,543). Muscle 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 tendon 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
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tendon. 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 border (11).
Actions and Biomechanics: Extensor Pollicis Brevis
The EPB functions mainly to extend the proximal phalanx of the thumb. Because it crosses the
thumb carpometacarpal joint, the tendon also assists with extension of the thumb metacarpal. In
addition, at extremes of contraction, 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).
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 phalanx. 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 Implications: 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
inflammation between the APL and EPB muscle bellies and the muscle bellies of the ECRL and
ECRB (451,452,453,454,455). 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 straightening out of
a joint. Pollicis is derived from the Latin pollex, thumb. Longus is derived from the Latin longus,
indicating 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
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, 11,13,559).
Principal Action. Extension of the distal phalanx of the thumb. Also contributes to extension of the
proximal phalanx and the thumb metacarpal through the MCP and carpometacarpal 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 muscle compartment of
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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 extensor retinaculum to form the
third 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 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 relatively 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
radiocarpal joint. It passes across the dorsal surface of the carpus, superficial to the tendon of the
ECRL and ECRB, to the dorsum 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 proximal 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 aponeurosis
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 usually 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 phalanx 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 deviation 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 finger (distal phalanx), to
the EPB, or to the extensor retinaculum (11,564,565,566,567,568,569). A double tendon or double
muscle belly may exist. An accessory EPL in the third dorsal compartment 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
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Closed rupture of the EPL is well documented (, and has been associated with tendon injury after
fractures of the distal radius (), 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 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 (613,614,615,616).
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, abductorpollicis 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 (). In terms of muscle compartments, it is one of the three muscles that comprise the thenar
muscle compartment of the hand. (The adductor pollicis has a separate compartment, Appendix 2.2).
The APB is located subcutaneously 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 superficial 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 continues 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 lateral 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
16 168

superficial division of the FPB and enters the deep surface of the APB in the middle third near its
ulnar border (11).
TABLE 2.4. ARCHITECTURAL FEATURES OF INTRINSIC MUSCLES OF THE HAND
Muscle
Fiber
Pennation
CrossMuscle (n Muscle
Length
Length
Angle
Sectional Area Fiber Length/Muscle
= 9)
Mass (g)
(mm)
(mm)
(Degrees)
(cm2)
Length Ratio
3.32
ADM
1.67
68.4 6.5 46.2 7.2
3.9 1.3
0.89 0.49
0.68 0.10
2.61
APB
1.19
60.4 6.6 41.6 5.6
4.6 1.9
0.68 0.28
0.69 0.09
9.96
160.4
APL
2.01
15.0
58.1 7.4
7.5 2.0
1.93 0.59
0.36 0.05
6.78
AP
1.84
54.6 8.9 34.0 7.5
17.3 3.4
1.94 0.39
0.63 0.15
4.67
DI 1
1.17
61.9 2.5 31.7 2.8
9.2 2.6
1.50 0.40
0.51 0.05
2.65
DI 2
1.01
62.8 8.1 25.1 6.3
8.2 3.1
1.34 0.77
0.41 0.13
2.01
DI 3
0.60
54.9 4.6 25.8 3.4
9.8 2.8
0.95 0.45
0.47 0.07
1.90
DI 4
0.62
50.1 5.3 25.8 3.4
9.4 4.2
0.91 0.38
0.52 0.11
2.25
105.6
EPB
1.36
22.5
55.0 7.5
7.2 4.4
0.47 0.32
0.54 0.13
1.54
FDM
0.44
59.2 10.4 40.6 13.7
3.6 1.0
0.54 0.36
0.67 0.17
2.58
FPB
0.56
57.2 3.7 41.5 5.2
6.2 4.5
0.66 0.20
0.73 0.08
0.57
Lum 1
0.19
64.9 10.0 55.4 10.2
1.2 0.9
0.11 0.03
0.85 0.03
0.39
Lum 2
0.22
61.2 17.8 55.5 17.7
1.6 1.3
0.08 0.04
0.90 0.05
0.37
Lum 3
0.16
64.3 8.9 56.2 10.7
1.1 0.8
0.08 0.04
0.87 0.07
0.23
Lum 4
0.11
53.8 11.5 50.1 8.4
0.7 1.0
0.06 0.03
0.90 0.05
1.94
ODM
0.98
47.2 3.6 19.5 4.1
7.7 2.9
1.10 0.43
0.41 0.09
3.51
OP
0.89
55.5 5.0 35.5 5.1
4.9 2.5
1.02 0.35
0.64 0.07
1.56
PI 2
0.22
55.1 5.0 25.0 5.0
6.3 2.2
0.75 0.25
0.45 0.08
1.28
PI 3
0.28
48.2 2.9 26.0 4.3
7.7 3.9
0.65 0.26
0.54 0.08
1.19
PI 4
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
16 169

intrinsic hand muscles. J Hand Surg [Am] 17:804-809, 1992, with permission.
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 therefore would have similar relative abilities for force generation,
velocity, and excursion (466) (Table 2.4 and Fig. 2.13).

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 disparity in
fiber length than in muscle length. This illustrates the relatively large excursions of the relatively
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 muscles, 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.)
Anomalies and Variations: Abductor Pollicis Brevis
The APB may have two separate heads (besides the two distal 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, opponens pollicis, palmaris
longus, ECRL (accessory ECR), or FPL (11,619,620). An entire third head may arise from the
opponens pollicis (11).
17 170

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 opponensplasty 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) (
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. Superficial 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 anterior 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 radialis 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 border 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
controversial (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 innervation 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
17 171

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 opposition). From its contributions into the extensor mechanism of the
thumb, the FPB contributes to extension of the distal 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 opponensplasty 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) .
OPPONENS POLLICIS
Derivation and Terminology. Opponens is the Latin indicating the movement against or toward an
opposing structure. 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.
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 pollicis, arteria radialis indicis, deep palmar arch (3,4,11,13,14).
Principal Action. Flexion, adduction, and median rotation of the thumb metacarpal (contributing to
the motion of opposition).
Gross Anatomic Description: Opponens Pollicis
The opponens pollicis is a deep thenar muscle covered anteriorly 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 (625,626,627). Because of the frequent duel innervation, it has been
suggested 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). Opposition 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.
17 172

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). Complete absence has been reported, but is rare (11).
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 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 opponensplasty 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) (.
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 capitate, 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 tendons and radial lumbricals. It occupies its
own muscle compartment (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 proximal
phalanx of the thumb. The fibers converge into a common 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 lateral 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 attachment that includes the distal two-thirds of the palmar surface of the long metacarpal
along the palmar ridge. It also may arise from the deep palmar fascia of the third interspace 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 converges in a radial direction toward the base of the proximal phalanx of the thumb.
Its distal border usually lies transverse 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.

17 173

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 transverse 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 deformity. Care
must be taken to protect the deep palmar arterial 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 eminence.
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 quadrangular 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. 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).
17 174

Principal Action. Abduction of the small finger (proximal 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).
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 forearm, or the tendon of the palmaris longus (11). A part of the muscle may insert onto
the metacarpal of the small finger (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
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 retinaculum.
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
adjacent 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 features of the muscle are listed in Table 2.4.
17 175

Actions and Biomechanics: Flexor Digiti Minimi


The flexor digiti minimi functions mainly to provide flexion 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 structure. 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 retinaculum.
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 digiti 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 convex surface of the hook of the hamate, the
adjacent pisohamate 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 therefore does not act on the
proximal phalanx of the small finger (3,4,7,8,11,13,14).
Anomalies and Variations: Opponens Digiti Minimi
The opponens digiti minimi may be divided into two layers 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 lumbrical 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).

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Innervation. The first and second lumbricals are innervated 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 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
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 palmar 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 aponeurosis 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 proprioceptive sensory information.
Each lumbrical muscle also is unique in that, by originating 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 attachmentsto 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 lumbrical pulls the lateral band proximally and the profundus tendon 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 (484,617,631,632,635,636,637).
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 (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 creating 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
compared 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 features of the lumbricals are listed in Table 2.4 (466).
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
Origin
Insertion
Function
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Group
Interossei (7)a
Dorsal (4)
Deep belly
Index and
(3)
long MC
Long and
ring MC
Ring and
small MC
Superficial
belly (3)

Lat tendon to lat band of DA,


radial side of long finger
Lat tendon to lat band of DA,
ulnar side of long finger
Lat tendon to lat band of DA,
ulnar side of ring finger

Abduct and flex MCP joint, extend IP


joints long finger
Abduct and flex MCP joint, extend IP
joints long finger
Abduct and flex MCP joint, extend IP
joints ring finger (abduction of small
finger by ADQ)
Abduct and weak flexion MCP joint,
index finger

Index MC Med tendon to lat tubercle of


prox phalanx, radial side of
index finger
Index and Med tendon to lat tubercle of Abduct and weak flexion MCP joint,
long MC prox phalanx, radial side of long long finger
finger
Ring and Med tendon to lat tubercle of Abduct and weak flexion MCP joint, ring
small MC prox phalanx, ulnar side of 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 Lat band of DA, radial side of Extension IP joints, weak flexion MCP
and ring ring finger
joint ring finger
FDP ring Lat band of DA, radial side of Extension IP joints, weak flexion MCP
and small small finger
joint small finger
a
Numbers 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.
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 discussed in detail by Smith and von
Schroeder and Botte (484,496). Roughly stated, the lumbricals provide extension 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 .
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
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joints through the dorsal aponeurosis (496,629,630,633,638,639,640,641,642). The origins,


insertions, and functions of the lumbricals are summarized in Table 2.5 (496).
The role of the lumbricals in interphalangeal joint extension 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 flexion. Low levels of
electrical stimulation produce only interphalangeal joint extension (629,630). Although the
lumbricals 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 important 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, electromyographic studies performed by Long and Brown
indicated that under normal circumstances, the lumbrical contributes 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 interphalangeal 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 performed solely by the FDP and FDS, MCP joint flexion would occur only
after interphalangeal joint flexion was complete ().
The fact that the lumbricals originate from the FDP tendons 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 interossei also contribute to flexion of the
MCP joints.
Anomalies and Variations: Lumbricals
Variations in sites of attachments of the lumbricals are relatively common. Each muscle may
originate by varying amounts from the adjacent FDP tendons. The first lumbrical may have
attachments that extend to the FPL tendon. Accessory tendon slips that attach to the adjacent FDS
tendon may be present (11).
Clinical Correlations: Lumbricals
The lumbricals and interossei work together to provide flexion of the MCP joints and simultaneous
extension of the PIP and DIP joints (see earlier, under Actions and Biomechanics: Lumbricals, and
later, under Actions and Biomechanics: 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 musclesthat 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 contrast, with paralysis of the intrinsics (due to ulnar nerve laceration or neuropathy), the
hand assumes a position opposite 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 function. Intrinsic minus also can occur with relative overpull of the extrinsic flexors
and extensors, in conditions such as ischemic contractures after severe compartment syndrome ).
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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. Dysfunction of the thenar muscles is
referred to simply as thenar paralysis or (if present) thenar atrophy.
After amputation of the distal phalanx (or untreated distal 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
lumbrical plus digit does not occur consistently. If it does develop, elective operative resection of the
lumbrical eliminates the 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 dorsal 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 extensor hood of the ring finger. The relative amounts of insertion 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 variable 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 additional 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 relative 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 (usually 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 usually 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
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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 interphalangeal 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
combined with simultaneous abduction of the index proximal phalanx, which helps stabilize the
MCP joint during forceful 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 section. 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 comprise four
separate dorsal interosseous muscle compartments 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 muscles 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 interossei then form a deep muscle belly and three have a superficial muscle belly
(484,496,655). The first and second dorsal 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 muscle 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 superficial and deep head of each muscle usually form
just proximal to the MCP joint and are the terminal divisions of each muscle. The deep and
superficial muscle bellies have different 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 bellies 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, 642,655,656,657). 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 lumbrical 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 performed by
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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 mechanism 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
discussed later.
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 abduction. Although the superficial
belly is a terminal division of the dorsal interossei, the muscle belly arises from the adjacent 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 superficial 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 lateral 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 increasingly 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 abductor 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 proximal 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, running 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 superficial 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 phalanx 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 function 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 simultaneous abduction of the index proximal
phalanx helps stabilize 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 approximately the proximal
two-thirds to three-fourths of the sides of the shafts of each associated metacarpal. The origin from
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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 second 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 oriented 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 dorsal 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 dorsal 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 central 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). Approximately 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 function 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 distinct small nerve branches
(484). It therefore is possible to contract the deep belly of a dorsal interosseous without contracting
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 flexion 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
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relative insertions of each dorsal interosseous into the proximal phalanx versus the extensor
aponeurosis. Eyler and Markee noted the following insertion ratios: first dorsal interosseous, 100%
proximal phalanx, 0% extensor aponeurosis; second dorsal interosseous, 60% proximal phalanx,
40% extensor aponeurosis; third dorsal interosseous, 6% proximal phalanx, 94% extensor
aponeurosis; 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 abduction versus interphalangeal joint extension provided by the
muscle can be extrapolated (475,484,496,655)
When the function of abduction of the digits is examined, it is understood that abduction refers to a
drawing away from the midline. In the digits, this refers to the midline of the hand, and the midaxis 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 relatively 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 therefore 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 finger 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 velocity) 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.
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 RicheCannieu 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 intercommunication between the musculocutaneous and median nerves (628). The presence
of these anomalies also explains continued function of the interosseous muscle in the presence 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 (compared 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
18 184

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 dorsal aponeurosis to reach the extensor hood. Thus, functionally, 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
advantageous 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 flexion of the MCP joints (475,484,496) (see earlier, under
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 component 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, followed 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 functional problem of the intrinsic minus hand.
Function of an intrinsic minus hand can be roughly simulated 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 forearm 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 relative 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 muscles. 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 (secondary to imbalance of the functioning muscles). This results in a position of extension
of the MCP joint and flexion 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
relative overactivity or contracture of the extrinsic muscles. This can be seen with ischemic
contracture after compartment syndrome of the forearm (662,663,664).
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. Dysfunction 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 Variations, Palmar Interossei). The
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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 aponeurosis
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 pollicis, arteria radialis indicis, palmar
metacarpal arteries, proximal and distal perforating arteries, common and proper digital (palmar)
arteries, common and proper palmar 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 separate 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 second 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 lateral 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% proximal phalanx (of ring
finger), 100% dorsal aponeurosis; third palmar interosseous, 10% proximal phalanx (of small
finger), 90% dorsal aponeurosis (634). Smith has emphasized 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 palmar interossei can still adduct and flex the proximal phalanx 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 phalanx 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 phalanx 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 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 phalanx of
the small finger. According to Eyler and Markee, a small amount, approximately 10% of the muscle,
18 186

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).
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 performed by the muscles' insertion into the dorsal aponeurosis (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 description 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 considered 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 palmar 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 direction, 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).
REFERENCES
APPENDIX 2.1
APPENDIX 2.1. MUSCLES OF THE HAND AND FOREARM AND ARM: ORIGIN,
INSERTION, ACTION, INNERVATION
Innervation (Nerve
Muscle
Origin
Insertion
Action
Roots)
Deltoid
Lateral one-third
Deltoid tuberosity of Abduction of
Axillary n. (C5, C6)
clavicle, acromion, humerus
humerus, forward
spine of scapula
flexion or
extension of
humerus
Coracobrachialis Coracoid process of Medial humeral
Forward flexion, Musculocutaneous n.
scapula
diaphysis
adduction of
(C5, C6)
humerus
Biceps brachii Short head from
Radial tuberosity,
Flexion,
Musculocutaneous n.
coracoid process, lacertus fibrosis
supination of
(C5, C6)
long head from
forearm
supraglenoid
tuberosity
Brachialis
Distal two-thirds of Coronoid process of Flexion of
Musculocutaneous,
anterior humerus
ulna
forearm
(and occasionally
radial) n. (C5, C6,
C7)
18 187

Triceps brachii

Long head from


Olecranon, deep fascia Extension of
Radial n. (C6, C7)
infraglenoid
of forearm
forearm,
tuberosity of
adduction of arm
scapula, lateral head
(long head)
from posterolateral
humerus, medial
head from distal
posterior humerus
Anconeus
Lateral epicondyle Lateral side of
Extension of
Radial n. (C7, C8)
of humerus,
olecranon and
forearm
posterior capsule of posterior surface of
elbow
ulna
Brachioradialis Lateral
Lateral, distal radius, Flexion or
Radial n. (C5, C6)
supracondylar ridge styloid process
forearm,
of humerus, lateral
assistance of
intermuscular
pronation of
septum
forearm (when
forearm is
supinated),
assistance of
forearm
supination (when
forearm is
pronated)
Pronator teres Humeral head from Central lateral radial Pronation of
Median n. (C6, C7)
medial epicondylar diaphysis
forearm,
ridge of humerus,
assistance of
ulnar head from
flexion of
medial side of
forearm
coronoid process of
ulna
Flexor carpi
Medial epicondyle Base of metacarpals of Flexion, radial Median n. (C6, C7)
radialis
of humerus
index and long fingers deviation of
(common flexor
wrist, assistance
origin)
with flexion and
pronation of
forearm
Palmaris longus Medial epicondyle Palmar fascia
Flexion of wrist, Median n. (C6, C7)
of humerus
(aponeurosis)
assists flexion,
(common flexor
pronation of
origin)
forearm
Flexor carpi
Humeral head from Pisiform (possible
Flexion, ulnar
Ulnar n. (C8, T1)
ulnaris
medial epicondyle extensions to hamate deviation of
of humerus
and base metacarpal of wrist, assistance
(common flexor
little finger)
with flexion of
origin), ulnar head
forearm
from proximal
dorsal ulna
Flexor digitorum Humeral head from Palmar middle
Flexion of
Median n. (C7, C8)
superficialis
medial epicondyle phalanges of digits
middle and
of humerus
proximal
(common flexor
phalanges,
18 188

origin), ulnar head


from coronoid
process of ulna,
radial head from
oblique line of
radial diaphysis
Flexor digitorum Medial anterior
Palmar distal
profundus
surface of ulna,
phalanges
interosseous
membrane, deep
fascia of forearm
Flexor pollicis
longus

Pronator
quadratus
Extensor carpi
radialis longus

Palmar surface of Base, palmar distal


radius, interosseous phalanx of thumb
membrane, medial
border of coronoid
process
Distal palmar ulna Distal palmar radius

assistance with
forearm and wrist
flexion

Flexion of distal Median n. to radial 2


(and middle and digits, ulnar n. to
proximal)
ulnar 2 digits (C7,
phalanges,
C8)
assistance with
wrist flexion
Flexion of distal Median n. (C8, T1)
(and proximal)
phalanx of thumb

Pronation of
Median n. (C8, T1)
forearm
Lateral
Dorsal base of index Extension, radial Radial n. (C6, C7)
supracondylar ridge metacarpal
deviation of wrist
of humerus, lateral
intermuscular
septum
Extension carpi Common extensor Dorsal base of long Extension, radial Posterior
radialis brevis origin from lateral finger metacarpal
deviation of wrist interosseous or radial
epicondyle of
n. (C6, C7)
humerus, radial
collateral ligament
of elbow joint,
intermuscular
septum
Extensor
Common extensor Dorsal bases of middle Extension of
Posterior
digitorum
origin from lateral and distal phalanges digits, assistance interosseous of radial
communis
epicondyle of
with wrist
n. (C6, C7)
humerus,
extension
intermuscular
septum
Extensor digiti Common extensor Dorsal base of distal Extension of
Posterior
minimi
origin from lateral phalanx of little finger little finger
interosseous of radial
epicondyle of
n. (C7, C8)
humerus,
intermuscular
septum
Extensor carpi Common extensor Dorsomedial base of Extension, ulnar Posterior
ulnaris
origin from lateral little finger metacarpal deviation of wrist interosseous of radial
epicondyle of
n. (C6, C7)
humerus, posterior
border of ulna
Supinator
Lateral epicondyle Radiopalmar surface Supination of
Radial n. (deep
of humerus, lateral of proximal radius
forearm
branch) (C6, C7)
capsule of elbow,
18 189

supinator crest and


fossa of ulna
Abductor pollicis Dorsal surface of
longus
mid-diaphysis of
radius and ulna,
interosseous
membrane
Extensor pollicis Dorsal surface of
brevis
radial diaphysis,
interosseous
membrane
Extensor pollicis Dorsal surface of
longus
ulnar diaphysis,
interosseous
membrane

Extensor indicis Dorsal distal ulnar


proprius
diaphysis,
interosseous
membrane
Abductor pollicis Transverse carpal
brevis
ligament, scaphoid
tubercle, palmar
trapezium
Opponens
Transverse carpal
pollicis
ligament, palmar
trapezium
metacarpal

Radial base of thumb Abduction of


Posterior
metacarpal
thumb, assistance interosseous or radial
of wrist
n. (C6, C7)
abduction
Base, proximal
phalanx of thumb

Dorsal proximal
phalanx of index
finger

Extension of
Posterior
proximal phalanx interosseous or radial
(and metacarpal) n. (C6, C7)
of thumb
Extension of
Posterior
distal phalanx of interosseous or radial
thumb, assists
n. (C6, C7)
extension of
proximal phalanx
and metacarpal
of thumb
Extension of
Posterior
proximal phalanx interosseous or radial
of index finger n. (C6, C7)

Radial side, base of


proximal phalanx of
thumb

Palmar abduction Recurrent branch of


of proximal
median n. (C8, T1)
phalanx of thumb

Dorsal base, distal


phalanx of thumb

Radiopalmar surface Opposition of


Recurrent branch of
of thumb
thumb to digits median n. (C8, T1)
(palmar
abduction,
pronation of
thumb)
Flexor pollicis Transverse carpal Base proximal phalanxFlexion of
Recurrent branch
brevis
ligament, palmar
of thumb
proximal phalanx median n. (C8, T1)
trapezium
of thumb
Adductor pollicisOblique head from Ulnar side, base of
Adduction of
Deep branch of ulnar
palmar trapezium, proximal phalanx of thumb, assistance n. (C8, T1)
trapezoid, and
thumb
with opposition
capitate
Transverse head
from palmar surface
of long finger
metacarpal
Palmaris brevis Ulnar side of
Skin on ulnar border Corrugation of Superficial branch of
transverse carpal
of palm
skin on ulnar
ulnar n. (C8, T1)
ligament, palmar
palm (deepening
aponeurosis
of palm)
Adductor digiti Pisiform, tendon of Ulnar side, base of
Abduction of
Deep branch of ulnar
minimi
flexor carpi ulnaris proximal phalanx of little finger from n. (C8, T1)
little finger,
palm
aponeurosis of
extensor digiti minimi
19 190

Flexor digiti
minimi

Transverse carpal
ligament, hook of
hamate
Opponens digiti Transverse carpal
minimi
ligament, hook of
hamate

Ulnar side, base of


proximal phalanx of
little finger
Ulnar side of
metacarpal of little
finger

Flexion of
Deep branch of ulnar
proximal phalanx n. (C8, T1)
of little finger
Opposition of
Deep branch of ulnar
little finger to
n. (C8, T1)
thumb, flexion of
metacarpal of
little finger
anteriorly out of
palm
Lumbricals
Four lumbricals
Join with interossei to Extension of the Median n. to radial
arise from tendons form lateral bands that middle
two lumbricals, ulnar
of flexor digitorum become dorsal hood phalanges,
n. to ulnar two
profundus
with the extensor
flexion of the
lumbricals (C8, T1)
digitorum communis proximal
tendons; ultimate
phalanges
insertions include base
of the middle phalanx
(central slip) and base
of distal phalanx
Dorsal interossei Four dorsal
First into radial side of Abduction of
Deep branch ulnar n.
interossei each from proximal phalanx of index, long, ring (C8, T1)
sides of adjacent
index finger; second fingers from
two metacarpals
into radial side of
midline of hand,
proximal phalanx of flexion of
long finger; third into proximal
ulnar side of proximal phalanges,
phalanx of long finger; extension of
fourth into ulnar side middle phalanges
of proximal phalanx of
ring finger
All interossei also
with variable
contributions to lateral
bands to form part of
the dorsal hood
Palmar interossei Three palmar
First into ulnar side of Adduction of
Deep branch ulnar n.
interossei: First
proximal phalanx of digits
(C8, T1)
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 of
metacarpal, third
proximal phalanx of
from radial side of little finger
little finger
metacarpal
P.183
APPENDIX 2.2
APPENDIX 2.2. MUSCLE COMPARTMENTS AND FASCIAL SPACES OF THE UPPER
EXTREMITY
Compartment
Principal Muscles
Deltoid compartment
Deltoids
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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.

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Authors: Doyle, James R.; Botte, Michael J.


Title: Surgical Anatomy of the Hand and Upper Extremity, 1st Edition
Copyright 2003 Lippincott Williams & Wilkins
> Table of Contents > Section I - Systems Anatomy > 3 - Nerve Anatomy

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 clinical correlations. For descriptive purposes, each nerve
discussion 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 anterior rami of C5, C6, C7, C8, and T1 (Fig. 3.1). The median nerve originates from
two branches, one each from the lateral 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 longitudinal level of the surgical neck of the humerus with the shoulder
abducted 90 degrees (1,2,3,4,5).
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 muscle. 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 supratrochlear 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 comitantes, 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 axillary artery, the nerve also has been noted rarely to be formed by the branches of
these cords uniting posterior to the axillary artery (7).
The median nerve usually is formed at the level of the third portion of the axillary artery. The nerve
also can originate 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
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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 musculocutaneous nerve, descends from lateral to medial between the brachialis and biceps
muscles, and joins the median nerve 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.

FIGURE 3.1. Schematic illustration of the brachial plexus and associated major branches. A, nerve
to subclavius; B, lateral pectoral nerve; C, subscapular nerves; D, thoracodorsal nerve; E, medial
antebrachial cutaneous nerve; F, medial brachial cutaneous nerve; G, medial pectoral nerve.
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:
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 hyperabducted (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 neurovascular 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).
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FIGURE 3.2. Schematic illustration of the median nerve and the musculocutaneous nerve, with
associated branches and innervated muscles.
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 shoulder (7,17).
The supracondylar process and associated ligament of Struthers may compress the median nerve in
the distal arm (7,18,19,20,21,22,23). The supracondylar process, a hook-shaped projection from the
medial aspect of the distal humerus, usually 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 ligament 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 epicondyle, 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
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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 traversing deep to the muscles to innervate the
pronator teres, flexor carpi radialis, palmaris longus, and the humeral portion 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 muscle. 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). Alternatively, 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 superficialis 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 profundus (28). The nerve usually is in the fascia of the flexor digitorum 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 palmaris longus (7,30). In the
proximal forearm, the median nerve innervates the pronator teres, flexor carpi radialis, palmaris
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
dorsoradial 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 portion of the flexor digitorum superficialis arises in the
mid-portion of the forearm, up to 20 cm distal to the medial epicondyle. (7). The muscular branches
of the median nerve arise primarily from its medial surface (7,33).
The median nerve and its branches supply the sympathetic 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 bifurcation 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
anterior interosseous artery (see later). The sympathetic branches from the median nerve continue
distally to provide sympathetic fibers into the palm to supply the superficial 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 digitorum profundus to the index
and long fingers (i.e., the radial half of the muscle), the flexor pollicis longus, and the pronator
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
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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 surface of the
interosseous ligament (interosseous membrane) and continues distally, usually close to the anterior
interosseous artery. The nerve eventually reaches the pronator quadratus, where it penetrates the
muscle proximally and passes deep to the belly to innervate the muscle. 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 consists initially of only one nerve
branch as it exits the main median nerve trunk, and usually can be identified approximately 5.5 cm
proximal to the radial styloid. Before branching, 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
transverse 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 ligament 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 connections 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
patterns 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 innervate 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 several variations of reported findings. These variations
probably are due to gradations between median and ulnar innervations, 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, particularly 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) supplies 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
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nerve (36,41,42,43,44). 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 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 forearms (39,50,51,52). 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 proximal, 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). Gruber 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 superficialis
and flexor digitorum profundus muscle bellies. In addition, a variant of the Martin-Gruber
anastomosis consists 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-Gruber
communication occasionally sends branches to the flexor digitorum profundus or the flexor
digitorum superficialis (54). There may be a loop-shaped connection, with convexity distally, that
contains motor fibers. Straight connections usually are sensory (7). Electrophysiologic and
electrodiagnostic studies have supported these anatomic findings, where investigators have identified
Martin-Gruber communications carrying median nerve fibers to the hand through the ulnar nerve
(55,56,57,58,59).
There is an increased incidence of the Martin-Gruber communication in some families, and an
autosomal dominant inheritance pattern of median-ulnar connections has been observed (60).
Comparative anatomy studies have shown that a communication 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 distinctly 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, Rowntree 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 additional 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 MartinGruber communication provides a pathway 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 communication, and the fibers therefore must cross over again in
the palm to reach their targets (6,41).

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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, palmar 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 common 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 profundus 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 separate 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 (67,68,69). 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 components at the level of the wrist or forearm.
Subsequently, two separate nerve branches, a medial and a lateral component, 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 proximal forearm (6,44). In
addition, Amadio found high branching of the median nerve in 3% of cases (70). Hartmann 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 communication 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 division of the median nerve can be
accompanied with multiple other variants, including the Martin-Gruber anastomosis, 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
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referred to in the literature (see also later discussion of bifid median nerve, under Anomalies and
Variations: Median Nerve in the Wrist and Hand).
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 superficialis arch to innervate a portion
of the flexor digitorum superficialis muscle. Similarly, the anterior interosseous nerve, which
supplies the flexor pollicis longus and flexor digitorum 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 location,
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 continue with the median nerve trunk to the very distal forearm flexor
compartment before crossing the transverse carpal ligament (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 palmar 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 musculocutaneous 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 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
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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 (55,56,57,58,59). 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 communication 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 electrodiagnostic studies (39,50,51,52).
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 muscle, and the proximal
origin or deep fascia of the flexor digitorum superficialis (17,76,77,78,79,80).
Pronator Syndrome
The pronator syndrome is a result of median nerve compression in the proximal forearm, most often
caused by or related to the pronator teres muscle (6,77,81,82,83,84). The clinical syndrome 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 weakness
of the median-innervated intrinsic muscles (thenar muscles and radial lumbricals); normal extrinsic
function of muscles 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 polyneuropathy). (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 pronator 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 flexion and forearm supination against resistance suggests
involvement of the lacertus fibrosus. Forearm pain reproduced by flexion of the long finger proximal
interphalangeal joint (flexor digitorum superficialis) suggests a site of compression 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 ():

Hypertrophied pronator teres


Fibrous bands in the pronator teres or associated tendons (93)

Median nerve passing posterior to both heads of the pronator teres


Thickened lacertus fibrosus (94)
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Hematoma deep to the lacertus fibrosus, resulting from blood sample drawn from antecubital
fossa with difficulty in patient on renal dialysis or anticoagulant therapy
Thickened flexor digitorum superficialis arch
An accessory tendinous origin of the flexor carpi radialis from the ulna
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 (). Because of
Kiloh and Nevin's early description of neuritis of the anterior interosseous nerve (114), the syndrome
also has been referred to as the Kiloh-Nevin syndrome, especially in the international literature
(115,116,117,118,119). 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 sensibility 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 phalanx of the ring and small fingers as well (6). Conversely, in
variations where the ulnar nerve innervates more of the profundi, 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
anterior interosseous nerve syndrome, the pronation power of the pronator teres must be eliminated.
This can be accomplished 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 electrodiagnostic studies.
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 penetrating 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 anterior interosseous
syndrome (122), and usually consist of either supracondylar fractures in children or forearm
fractures treated in either an open or closed fashion (6,123, 124). Iatrogenic injury also has been
reported after cutdown catheterization in the forearm (125) and from the flexor pronator slide
procedure (126). Causes of external compression include tight-fitting casts, especially the proximal
rim of the short arm cast. Several causes of intrinsic compression have been noted. Those involving
compression by muscle or tendon structures include (6):

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)
A tendinous origin of the flexor superficialis to the long finger
An accessory head of the flexor pollicis longus (Gantzer's muscle)
An accessory muscle and tendon from the flexor superficialis to the flexor pollicis longus
A tendinous origin of anomalous muscles such as the palmaris profundus or the flexor carpi
radialis brevis (127)
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An enlarged bicipital bursa encroaching on the median nerve near the origin of the anterior
interosseous nerve
Vascular structures such as thrombosis or dilation of crossing 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, including the first dorsal interosseous,
adductor pollicis, abductor digiti minimi, and, less commonly, the second and third dorsal
interosseous. Therefore, as noted by Spinner, in the presence 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 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 (ParsonageTurner 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 tendondamaging 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 confirm 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 interphalangeal joints of the index and long fingers, the differential diagnosis includes, besides
the anterior interosseous syndrome, 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. However, 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 anomalous 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 finger suggests the
occurrence of a bifid median nerve with laceration to the ulnar component (or perhaps a partial
laceration 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
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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 disabling. 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 possible, usually is warranted (more from the standpoint of
neuroma prevention than from that of sensibility restoration). 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 palmaris longus tendon. Associated symptoms included localized 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 musculocutaneous 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 radialis 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 superficialis, 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 corresponds to the volar
flexion crease of the wrist. The carpal tunnel 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 (132,133,134). 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
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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).
The median nerve usually passes through the carpal tunnel as the most palmar structure (volar to the
flexor tendons), with the transverse carpal ligament lying immediately 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 (1,2,3,4,11) (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 distal 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 supplies
the tissue deep to the nail. These nerves often communicate 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 superficial (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 deep and
superficial transverse metacarpal ligaments, maintaining their palmar relationship to the digital
arteries (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
(36,44,134,135,136,137,138,139). 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-tomedian 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 () (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 tunnel 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 performing carpal tunnel release because the recurrent motor
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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 1:2331, 1988.
A Transligamentous Passage of the Recurrent Motor Branch
A transligamentous (transretinacular) passage of the recurrent motor branch is a pattern where the
recurrent branch penetrates the transverse carpal ligament, usually in the distal 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 ligament is transected during carpal tunnel release
(70,134, 135,136,137,138,139). The relatively high frequency of this transligamentous course of the
recurrent branch has been well documented by several authors (134,135,136,137,138,139). Spinner
describes a separate tunnel for the nerve in its transligamentous course, where the nerve passes
through the transverse 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 (134,135,136,137,138,139). When the
transligamentous pattern is encountered during carpal tunnel release, the nerve branch should be
decompressed throughout 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 transverse carpal ligament and curves back to the thenar muscles in
a retrograde fashion. The nerve branch does not penetrate 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
recurrent course or through different aberrant paths. On occasion, 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 (138,146,147,148). 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
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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 distally in the palm, distal to the carpal tunnel. The nerve branch then loops back
proximally to reach the thenar muscles, 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 transverse
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 pollicis brevis or palmaris brevis has been
noted to occur commonly 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 pollicis
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 retrograde
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 ligament (44).
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 communication in which one or the other median nerve branch received a
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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 superficial head of the flexor pollicis brevis
and the fibers of the deep ulnar branch going to the deep head of the flexor pollicis 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 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
communicating 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
connection 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
virtually all of the fresh specimens contained the Riche-Cannieu communication, they concluded
that this nerve anastomosis 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, Mannerfelt 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 unresolved (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 Sekeles 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 destined 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):

An anastomosis in the substance of the adductor pollicis between the median and ulnar
nerves
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
Anastomosis between the two motor nerves across the first lumbrical
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 finger

Palmar Ulnar-Median Communicating Branch of Berrettini


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As noted previously, the Riche-Cannieu anastomosis usually 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. Several studies have confirmed the common presence of this
communicating branch (44,46,52,159). The communicating 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 encroaching on the ulnar nerve distribution. However, the ulnar nerve also can
encroach laterally to innervate the long finger 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 recognized (). Specific anatomic abnormalities
that can be factors in carpal tunnel syndrome include the following:

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)
An anomalous flexor digitorum superficialis, especially that with a muscle belly that extends
distally into the carpal tunnel (178,179,180,181,182,183,184)
Anomalous lumbrical muscles that extend proximally into the carpal tunnel (185)
An enlarged, inflamed, thrombosed, or calcified median artery in the carpal tunnel (186,187)
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
syndrome with atypical findings such as sensibility abnormalities 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
20 209

nerve is encountered or a median nerve found with high branches originating in the forearm, special
care is required during carpal tunnel release or median nerve exploration, both for nerve protection
and for adequate decompression. Release of the median nerve branches from separate fascial
channels in the transverse carpal ligament may be needed (36,135).
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 operative 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 transected
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 decompressed 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
deep to the superficial palmar arterial arch and usually pass deep to the common digital arteries as
the nerves and arteries 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 deeperlying 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 complete 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 sensibility 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 (1,2,3,4,11) (see Fig. 3.1).
TABLE 3.2. ORDER OF INNERVATION OF MUSCLES SUPPLIED BY THE ULNAR
NERVE
Muscle
Flexor carpi ulnaris
Flexor digitorum profundus
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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 anterior 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 intermuscular 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 distally 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 proximity 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 cutaneous 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
proximity to the ulnar nerve. The medial antebrachial cutaneous 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 flexion 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 antebrachial fascia in the middle third of the arm
with the basilic vein. The nerve divides into anterior and posterior branches approximately 15 cm
211 211

proximal to the medial epicondyle. The anterior branch passes anterior to the median cubital vein
between the medial epicondyle and biceps tendon, and innervates the mediopalmar skin of the
forearm (Fig. 3.4A and B). The terminal branches join the palmar cutaneous 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 cutaneous branch of the ulnar nerve (189,190) (Fig. 3.4A and B).

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

FIGURE 3.4. Cutaneous nerves of the upper extremity. A: Anterior aspect.


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P.203

FIGURE 3.4 (continued). B: Posterior aspect.


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 myofibrous 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%) unrelated
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 presence 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 triceps are seen crossing obliquely, superficial to the nerve. This is in the area where the nerve
traverses from the anterior 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
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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 horizontally 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, usually 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 origin of the ulnar nerve. It
usually arises just distal to the origin 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 communicates 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 compartments. Muscle fibers of the medial head of the triceps
that cross obliquely superficial to the nerve usually indicate 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 confirmed 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 epicondyle to an (anomalous) supracondylar process. The ligament of Struthers is a possible
site of compression of the medial nerve (6,17,18,20,21,22,78,192).
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 consists of a fascial sheath
confluent with the brachial and antebrachial 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 geographically 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 tunnel, 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. 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
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The second and middle part of the tunnel consists of a fascial 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
supplies 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 profundus 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 tissues 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 middle 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 carpus. In the distal third of the forearm,
the ulnar nerve courses more superficially, lying just radial and deep (dorsal) 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 muscle, 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
digitorum 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, usually lying on the anterior surface of the flexor digitorum profundus
(1,2,3,4,11,13,189,191). 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 approximately 4 to 7 cm more distally (6). In 80% of upper limbs, a single
branch from the ulnar nerve supplies the flexor digitorum 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
21 215

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 fingers, 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 digitorum 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 digitorum 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 accompanying ulnar artery with a segmental
sympathetic nerve. This is the nerve of Henle (200,201,202) (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 cutaneous branch of the median nerve. When present, the palmar 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 proximal 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 innervation 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
pisiform. 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 corresponds 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 ulnocarpal joint usually is present. With the forearm
in supination, 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 forearm pronated,
the nerve branches displace slightly palmarly to pass along the palmoulnar aspect of the ulnar head.
In the hand, an additional one or two branches usually are given off. The total number of branches
averages five, with a range from three to nine. Two branches typically extend to the small finger, one
to the dorsoulnar aspect of the ring 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 branch of the ulnar nerve continue to the level of the proximal interphalangeal joints, where
the nerves arborize and become difficult to trace. There are no apparent further communications
between the dorsal branch of the ulnar nerve and the ulnar nerve proper, with the palmar cutaneous
branch of the ulnar nerve, or with the nerve of Henle (200).
In the proximal forearm, the posterior ulnar recurrent artery, which arises from the ulnar artery close
to the bifurcation of the radial artery, courses ulnarly and proximally to continue in proximity to the
ulnar nerve and motor branches to the flexor digitorum profundus, along the ulnar border of the
nerves (1,2,3,4,11).
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The superior ulnar artery accompanies the ulnar nerve into the cubital tunnel. In the cubital tunnel,
the superior ulnar collateral artery joins the posterior ulnar recurrent artery to form one of the
vascular collateral pathways around the elbow and bypassing the distal portion of the brachial artery
(1,4).
In the region of the junction of the proximal and middle thirds of the forearm, the ulnar artery joins
the ulnar nerve and continues on the radial aspect of the nerve. This relationship 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 Guyon's canal at the wrist.
Anomalies and Variations: Ulnar Nerve in the Elbow and Forearm
Anomalous Connections between the Ulnar and Median Nerve
In the distal forearm, a crossing of nerve fibers from the ulnar nerve to the median nerve can occur,
although with less frequency than the more common crossing of fibers in the opposite direction from
median nerve or anterior interosseous nerve to ulnar nerve (the Martin-Gruber anastomosis). These
anomalous connections between the ulnar nerve and median nerve in the forearm are discussed in
detail earlier, under Nerve Anomalies and Variations: Median Nerve in the Forearm. In general, from
the elbow to the wrist, the ulnar nerve shows relatively few anomalies or deviations from its normal
course. The division of its branches is relatively consistent.
Variations in Innervation of the Flexor Carpi Ulnaris
The flexor carpi ulnaris usually receives two or three motor branches. Up to five branches have been
noted (6). In isolated case reports, the flexor carpi ulnaris was found to have a motor branch from the
median nerve (6).
Variations in Innervation of the Flexor Digitorum Profundus Muscle
Variations in the innervation of the flexor digitorum profundus muscle have been reported (205).
Traditionally, the ulnar nerve is thought to innervate the flexor digitorum profundus to the ring and
small fingers, and the median nerve innervates the index and long fingers. However, this pattern was
found in only 50% of upper limbs (32). In several specimens, the median nerve was found to
innervate the ring and little fingers and the ulnar nerve was found to supply the long finger (32,189).
It is more common for the median nerve to innervate muscles traditionally supplied by the ulnar
nerve than for the ulnar nerve to innervate muscles usually supplied by the median nerve (32,35,63).
This may occur in the all-median nerve hand.
Many of the variations in branching occur in the muscle belly of the flexor digitorum profundus, and
therefore are difficult to identify by superficial visualization and examination of the muscle. The
flexor digitorum profundus to the index finger, however, does seem to be innervated most
consistently by the median nerve. Sunderland has noted only one case in which the flexor digitorum
profundus to the index finger was innervated by the ulnar nerve (44).
Sensory Variations of the Dorsal Branch of the 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 joint (mean distance 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) (199). Several variations can occur. The branch
may arise from the ulnar nerve as far proximal as the elbow and continue subcutaneously along the
entire length of the forearm (206). Alternatively, an entire nerve loop has been noted to form around
the pisiform between the ulnar nerve and a branch from the dorsal cutaneous nerve. This branch of
the dorsal cutaneous nerve appeared to contribute additional fibers to the ulnar digital nerve to the
small finger (207).
Absence of the Dorsal Cutaneous Branch of the Ulnar Nerve
In 1 of 24 specimens, the dorsal branch of the ulnar nerve was found to be absent (199). With
complete absence of the dorsal cutaneous branch of the ulnar nerve, sensibility to the dorsum of the
ulnar hand can be supplied by the superficial 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
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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 condition now known as tardy ulnar palsy (209). Several anatomic and mechanical
etiologic factors have been described (6,17,78,189,208,210,211,212,213,214,215,216,217,218)
(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 the nerve. This condition
was described by Collinet in 1896, followed by reports by Cobb and Momberg (both in 1903)
(219,220,221).
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)
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 (222,223,224,225). 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 destinations 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 minimal 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 optimal because morbidity may be substantial if the flexor carpi ulnaris has no
additional motor nerves and becomes denervated by sacrifice of the motor branch. To mobilize the
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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 volume 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 flexion, 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 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). 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 additional 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 vulnerable 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). Sensibility 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 localization of the nerve lesion is at the elbow when
clinical findings 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 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 proximal 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 surface),
a roof (palmar surface), and two walls (medial and lateral). 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 ligament, 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
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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 structures. 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 ligament to the nerve's bifurcation. The palmar carpal ligament, lying superficial
(anterior to the ulnar nerve), is actually a thickening of the superficial forearm fascia that becomes
distinct approximately 2 cm proximal to the pisiform. 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 ligament,
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 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 pisohamate and pisometacarpal ligaments. The
pisohamate ligament 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
(229,230,231).
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 palmaris brevis and
the superficial branch of the ulnar nerve. The lateral border of zone II consists of transverse carpal
ligament, 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
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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 laterally, 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 palmarly, 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 brevis 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 borders 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 distal 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 subcutaneous 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 possible 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 anteriorly 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 distal
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 minimi 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 palmar
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
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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 communication between the deep terminal branch
of the ulnar nerve and the motor branch of the median nerve (see earlier, 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 pattern or a variation. The communication occurs at the
terminal 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 RicheCannieu 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 innervated
by the ulnar nerve and the superficial head more commonly 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 finger and ulnar aspect of
the ring finger. The pattern is variable, 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
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 superficial 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
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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 additional
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 conjunction 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 anomalous 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,
sensibility 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 localize the area of compression or dysfunction (229,240,241,242).
In zone I of the ulnar tunnel, the ulnar nerve fibers are arranged in two distinct groups of fascicles,
with the palmar-radial fibers containing fascicles that become the superficial 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 (229,230,231).
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 produce primarily sensory
deficits with possible motor weakness
P.213
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of the hypothenar muscles. Conversely, if an occult lesion or penetrating injury produces mostly
sensory loss (or concomitant weakness of the hypothenar muscles), zone II should be suspected as
the site of the lesion.
In carpal tunnel syndrome, the etiology often is unknown, and it is attributed to an idiopathic cause.
However, in ulnar nerve compression in the ulnar tunnel, a cause more commonly is found. These
include tumors in the ulnar tunnel (ganglions, lipomas, giant cell tumor, desmoid tumors, rheumatoid
synovial cysts), anatomic abnormalities that encroach on the ulnar nerve (anomalous muscles,
thickened ligaments, anomalous hamulus), trauma with associated inflammation, edema, or
hematoma (fractures, repetitive trauma, edema after burns), vascular pathology, or inflammatory
conditions (rheumatoid arthritis or degenerative arthritis) ) (Table 3.4). Ganglions are the most
common tumor related to ulnar tunnel syndrome, accounting for 29% to 45% of reported caused of
ulnar tunnel syndrome. Other more common related factors include anomalous muscles (see later),
fractures, and vascular abnormalities (230,268,269,270,271,272,273).
Anomalous muscles reported to cause ulnar tunnel syndrome include the several variations of the
palmaris longus (274,275,276), an accessory flexor digiti minimi (262,277), an accessory abductor
digiti minimi (198,278), an accessory muscle from the flexor carpi ulnaris tendon, and various
anomalous muscles located in the canal (see later) (279, 280).
TABLE 3.4. COMMON CAUSES OF ULNAR NERVE COMPRESSION AT THE WRIST
BASED ON 135 REPORTED CASES
Cause
Number
Tumors
Ganglion
46
Lipoma
3
Giant cell tumor
2
Desmoid tumor
1
Anatomic abnormalities
Anomalous muscles
22
Thickened ligaments
4
Anomalous hamulus
3
Trauma
Fractures
19
Repetitive trauma
8
Edema after burns
10
Other trauma
3
Vascular pathology
9
Arthritis
Rheumatoid
4
Degenerative
1
Other
Dupuytren's contracture
1
136 total
From Botte MJ, Gelberman RH. Ulnar nerve compression at the wrist. In: Szabo RM, ed. Nerve
compression syndromes: diagnosis and treatment. Thorofare, NJ: Slack, 1989:121-136.
Several variations of the palmaris longus have been related to ulnar variations in Guyon's canal and
to ulnar tunnel syndrome. These include a reversed muscle-tendon relationship with a distal muscle
belly and proximal tendon (275), an anomalous extension into Guyon's canal, an accessory palmaris
longus, and a duplicated palmaris longus (6,9,274,275).
An anomalous palmaris longus may have a reversal of its normal muscle relationship, with the
tendon arising proximally from the medial epicondyle, and the muscle belly attaching distally to the
flexor retinaculum at the wrist. There may be an associated accessory musculotendinous slip,
approximately 1 cm thick, which inserts into the pisiform (275). This anomalous palmaris can create
an arch that reinforces the roof of the tunnel. However, the ulnar nerve and artery must penetrate
22 224

through this arch to reach the wrist, and thus are more vulnerable to compression. The nerve and
artery run their normal course deep to the palmaris brevis (275). Spinner has referred to this
anatomic arrangement as the variant canal of Guyon (6).
An anomalous accessory palmar longus has been noted in the ulnar tunnel. Thomas described a 1cm-wide muscle arising from the palmaris longus tendon. The muscle inserted into the soft tissues of
the region of the hypothenar muscles and into the pisiform. This muscle passed through the ulnar
tunnel, and was thought to be responsible for clinical symptoms of fatigability of the hand (274).
King and O'Rahilly reported a duplication of the palmaris longus with either a separate muscular slip
(accessory palmaris) or a separate tendon that originated from the duplicated palmaris and extended
to the abductor digiti quinti or the flexor digiti quinti. The accessory muscle passed volar to the ulnar
nerve and ulnar artery. The muscle appeared to form part of the roof of the ulnar tunnel. An
associated tendinous slip that extended between the ulnar artery and nerve also was noted to occur.
The artery crossed anterior to the slip.
As early as 1864, anomalies of the palmaris longus were noted, and associated with variations of the
ulnar tunnel (276). A palmaris longus with a double origin was described by Wood. From this
palmaris longus tendon, there was an associated anomalous flexor digiti quinti with a high origin
from the palmaris longus.
Besides the palmaris longus, other aberrant muscles have been noted in the ulnar tunnel or its
vicinity that place the ulnar nerve at risk for compression.
Schjelderup described an anomalous muscle 4 mm wide that extended in the canal and crossed over
the ulnar nerve before the nerve divided (279).
Turner and Caird also noted an anomalous muscle in the ulnar tunnel. The muscle originated from
the pisiform, crossed through the ulnar tunnel passing between the deep and superficial branches,
and inserted into the transverse carpal ligament. This muscle passed between the motor and sensory
branches of the ulnar nerve (280).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 thickened roof of the ulnar tunnel,
possibly increasing the vulnerability to the ulnar nerve (6,9; personal communication to Spinner).
Swanson identified an accessory flexor digiti quinti arising 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 muscle 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 syndrome caused by a hypertrophied flexor carpi
ulnaris muscle 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 carpometacarpal 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
22 225

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 performed 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 produce clawing in three fingers instead of two.
Although ulnar neuropathy is a relatively common cause of intrinsic muscle atrophy, several other
etiologies are possible: Charcot-Marie-Tooth disease, thoracic outlet syndrome, 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, 241,273,286,287,288,289).
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 (1,2,3,4,11) (see Fig. 3.1). It contains fibers from C5 through C8 (and occasionally
T1) and is the largest terminal branch of the brachial plexus. The lower trunk contributes 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 tendons, 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 distally,
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 spiral 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 lateral
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 radialis 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 sequentially 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 brachioradialis 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 innervation to the extensor
carpi radialis brevis arises from the sensory division of the radial nerve in the forearm, the
superficial radial nerve (294).
TABLE 3.5. LEVEL AND ORDER OF INNERVATION OF MUSCLES SUPPLIED BY THE
RADIAL NERVE
22 226

Muscle
Triceps
Long head
Medial head
Lateral head
Anconeus

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


7.1
9.5-11.2
10.1

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.

FIGURE 3.5. Schematic illustration of the radial nerve and associated branches and innervated
muscles.

22 227

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 (295,296,297,298,299,300,301). 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 fractures
(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 terminal 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
surface 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 subcutaneous at
approximately 9 cm proximal to the wrist (291).
TABLE 3.6. RELATIONSHIPS OF THE SUPERFICIAL BRANCH OF THE RADIAL
NERVE TO SPECIFIC LANDMARKS
Forearm
Distance to
Distance of Closest
Length (cm) SBRN-SQa to RS Branch to RSc Center of First
Branch to Lister's
b
(cm/% Forearm ) (cm/% Forearm)
DC (cm)
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.
a
SBRN-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.
c

Branch 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.
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 brachioradialis muscle until it emerges between
the tendons of the brachioradialis and extensor carpi radialis longus to pierce the antebrachial fascia.
22 228

In 10% of specimens, the superficial branch became subcutaneous by actually piercing the tendon of
the brachioradialis. Table 3.6 shows relationships of the superficial branch of the radial nerve to
specific landmarks. The superficial branch of the radial nerve becomes subcutaneous at a mean of 9
cm proximal to the radial styloid [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 lateral 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 distal
20% of that distance. At the level of the extensor retinaculum, 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 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 Lister'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 continues 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
cutaneous branches that extend to the palmar radial thenar eminence. 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 configurations,
continues distally, branching into the dorsoulnar digital 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 metacarpophalangeal joint. The widths of
the dorsoradial and dorsoulnar 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 dorsoulnar digital nerve to the
thumb and the dorsoradial digital 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 dorsoulnar nerve to the thumb was noted to arise from a trifurcating branch at
the first major branch paint. In all specimens, 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 dorsoradial 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 continues 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 lateral 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).
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
22 229

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.
The supinator muscle, arising from the lateral epicondyle, 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 centimeters, 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 muscular 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 superficial layer of muscles (extensor digitorum communis,
extensor digiti quinti, and extensor carpi ulnaris) and those branches coursing deep to the
outcropping muscles (abductor 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 minimi, 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 distal 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
23 230

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 posterior 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 digitorum 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 horizontally 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
digiti 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 innervation 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 superficial 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, intercarpal, 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, supplies 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 distal 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 terminal 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 epicondyle; the distal division
is more common (205).
A second pattern of variability concerns the level of innervation of the forearm muscles. The
extensor carpi radialis 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 i