Embryology of the

hand
Christian Dumontier, MD, PhD
Centre de la Main, Guadeloupe, FWI

Many figures belong to Kozin SH. Embryology of the Upper Extremity,

Green’s operative Hand Surgery, 6th ed.p1293-1301
 Epidemiology of congenital
anomalies
• Affect 1-2% of newborns

• ≈ 10% have upper extremity abnormalities. Second only after

cardiac abnormalities

• Incidence has not changed over the last decade.

• Most anomalies occur spontaneously or are inherited. Few are

attributed to teratogens.

• Most hand anomalies appear between 4 and 8 weeks after

fertilization. The error during limb formation can also disturb the
formation of other systems ☞ a pediatrician advice is mandatory
 Radial club hand
4,6 %
Brachydactyly Hypoplastic thumb
5,2 % 3,5 %
Clinodactyly Central defects
5,5 % Polydactyly
3,9 %
Amputation 14,6 %
6,8 %
Camptodactyly
6,9 %

Syndactyly
18,2 %
Other
30,8 %

% of live births with congenital defects

Terminology is based on Greek roots

Melos Limb Clino Bent

Cheir Hand Ectro Abortion

Dactylos Digit Megalo Giant
Phoke Seal
Micro Small
Hemi Half
Pero Deformed
A Without
Poly Many
Acro Summit or peak
Arachno Spider Syn(m) Together
 Embryogenesis
• Limb bud appears at 26 days (embryo is about
4mm length).

• Bud develops rapidly until 47 day (20 mm long)

• Digits are distinguishable at 41-43 days

• Fingers are separated between 52-53 days

(embryo 22-24 mm)

• Joints develop by condensation of chondrogen

to form dense plates between future bones. Joint
cavitation further forms the articulation,
although proper joint development requires
motion for modeling of the ultimate joint surface.

9 weeks human embryo (Wikipedia)

• Limb bud is an outgrowth of the
mesoderm into the overlying
ectoderm.

• Limb development begins very

early during embryogenesis. This
determine the number of limbs,
the position of limbs with respect
to the body axis, and the identity
(i.e. upper versus lower) of limbs.

• The signal that initiates induction

of the limb bud seems to arise in
the intermediate mesoderm.

• A candidate for this signal is

fibroblast growth factor 10 (FGF10)
 Mouse embryo. Alcian blue highlights mature cartilage, Alizarin red for mineralized bone.

• Cells from the lateral plate mesoderm become bone, cartilage, and
tendon.

• Cells from the somatic mesoderm form the muscle, nerve, and
vascular elements
 Signaling centers
• Three signaling centers control the three
spatial axes of limb development: proximal-
distal, anterior-posterior, and dorsal-
ventral.

• These are the apical ectodermal ridge

(AER), the zone of polarizing activity
(ZPA), and the Wnt (Wingless type)
signaling centers

• They are interdependent such that loss of From Tonkin MA. Failure of
Differentiation Part I: Syndactyly.
one signal results in compromise of the Hand Clin 25 (2009) 171–193

entire system.
Signaling centers are interconnected
• Before differentiation of the AER, two genes, Radical fringe (r-
Fng) and Wnt-7a, are expressed in the dorsal ectoderm.

• The AER forms at the interface of r-Fng-expressing and non-

r-Fng-expressing cells

• Expression of Wnt-7a in the dorsal ectoderm induces the

underlying mesoderm to express another transcription factor,
Lmx-1, that promotes the mesoderm to adopt dorsal
characteristics

• In the ventral ectoderm and mesoderm, expression of r-Fng

and Wnt-7a is blocked by the product of the gene Engrailed-1
(En-1). Mesoderm in which Wnt-7a expression is blocked by
En-1 becomes ventralized.

• Maintenance of the AER is dependent on a signal from the

ZPA. The signaling molecule of the ZPA is Sonic hedgehog
(Shh).
 Bamshad M et al. Reconstructing the history
of human limb development: Lessons from
birth defects. Pediatric Research 1999; 45:
291-299

• The Apical ectodermal ridge (AER) extends

from anterior to posterior along the dorsal/
ventral boundary of the growing limb bud
controls proximal/distal growth.

• Immediately proximal to the AER is a region of

rapidly proliferating mesoderm cells called the
progress zone (PZ)

• The zone of polarizing activity is located in the

posterior mesoderm and controls anterior/
posterior patterning of the limb bud.
Proximo-distal limb development

Below elbow transverse

deficiency attributed to loss of
AER function

• Controlled by AER that guides the mesoderm to differentiate

• Removal of the AER results in limb truncation, and ectopic

implantation of the AER produces additional limb formation
Proximo-distal limb development
• Elongation occurs through proliferation of the underlying mesenchyme
core, in which the AER plays a crucial role in ensuring that the
mesenchyme immediately underneath it remains undifferentiated. As
growth proceeds, the proximal mesenchyme loses signals from the AER
and begins to differentiate into the constituent tissues of the limbs.

• The AER itself is maintained by the Zone of Polarising Activity (ZPA)

which is found in the posterior base of the limb bud. The ZPA’s secondary
responsibility is to ensure asymmetry in the limbs.

• As elongation continues, the mesenchyme condenses into plates forming

the cartilaginous models of the future digital bones. The AER then breaks
up and is maintained only over the tips of the future digits. The
interdigital spaces are then progressively sculpted by cellular apoptosis
Proximo-distal limb development
• Secreted proteins are fibroblast growth factors.

• Evidence to suggest that bleeding or ischemia within the

AER results in failure of the AER to work properly.

• Transverse deficiencies are usually sporadic, not

inheritable, and future children are unlikely to be
affected.

• Concern for exposure to a teratogen is raised when

multiple limbs are involved
 Radio-ulnar development
• Also called anterior-posterior or preaxial-postaxial.

• Signaling pathway is the ZPA in the posterior margin

of the limb bud that polarizes the limb into a radial
margin and an ulnar border.

• The ZPA disappears by day 44 of embryonic

development, after which time the phalanges form

• Signaling molecule is the sonic hedgehog compound.

 Radio-ulnar development

• Transplantation of the ZPA or sonic hedgehog protein causes

mirror duplication of the ulnar aspect of the limb
 Radio-ulnar development

• Example of a mirror hand explained by transplantation of the

ZPA or sonic hedgehog protein
Dorso-ventral limb development
• Process of differentiation between the dorsum of the finger with
a fingernail and the volar surface abundant with pulp tissue

• The Wnt signaling pathway resides in the dorsal ectoderm and

produces a transcription factor, Lmx-1, that induces the
mesoderm to adopt dorsal characteristics.

• In the ventral ectoderm, the Wnt pathway is blocked by a

product of the gene Engrailed-1 (En-1).

• Loss of Lmx-1 is associated with nail-patella syndrome. These

•
abnormalities occur sporadically without any definable cause.
 Signaling centers
Responsible Responsible
Signaling
Axis ligands transcription Anomaly
center
proteins factors

Apical HOXA
Proximal to Fibroblast Transverse
ectodermal 10,11,13
distal growth factor deficiency
ridge TBX 4,5

Zone of Sonic
Anterior to HOXD 10,13
polarizing Hedgehog Mirror-hand
posterior GL 13
activity protein

Transcription LMX1 Nail patella

Wnt pathway Dorsal ventral
factor, lmx-1 Engrailed 1 syndrome
Signaling centers Target cells
AER Daluiski A et al. The Molecular Control of
ZPA Upper Extremity Development: Implications
for Congenital Hand Anomalies. J Hand Surg
Dorsal ectoderm 2001;26A:8 –22
 Programmed cell loss
• Programmed cell death is an active process genetically controlled.

• Seems to be mediated by the bone morphogenic protein (BMP) family

notably BMP4

• Apoptotic cells undergo a degenerative process consisting of DNA

fragmentation

• Interdigital necrosis is necessary for finger separation. Failure of

interdigital apoptosis results in syndactyly.

• By 8 weeks fingers are separated and ossification centers are

developing
 Genes and molecular
abnormalities
• Limb formation is not only dependent of the spatial axis of limb
development

• Mutations encoding signaling proteins, receptor molecules, and

transcription factors can alter normal limb arrangement and yield
anomalies.

• Only a small number of limb anomalies have been mapped to specific

chromosomal segments and are less defined at the molecular level.

• Many of these differences are genetically linked with variable

patterns of inheritance. Referral for genetic consultation is
warranted.
 Genes controlling bud development
• Antagonism between retinoid acid (RA) and FGF8 in the
flank participates in positioning the limb field along the
primary embryonic axis.

• Limb bud emergence from the flank is controlled by,

among others, TBX genes.

• TBX genes upregulate Fgf10 expression in the

mesenchyme

• FGF10 signalling from the mesenchyme and Fgf8

activation by the ectodermal progenitors of the AER
marketers establishes an epithelial-mesenchymal
feedback loop that participates in the initiation of limb
bud outgrowth.

• Antagonist interactions between RA, AER-derived

FGF8 and Ectodermal WNT3A participate in proximo-
distal patterning.

• CYP26B1 expression is unregulated by AER-FGF8

signaling and in turn degrades RA in the distal AER is in blue
mesenchyme.

Bamshad M et al. Reconstructing the history of human limb development: Lessons from birth defects. Pediatric
Research 1999; 45: 291-299
 Genes controlling bud development: AP patterning

• HAND2 controls the

establishment of a proximal,
anterior and posterior
compartment in the early
forelimb bud mesenchyme.

• HAND2 with HOX

transcription factors participates
in activating Shh expression.

• The inhibitory effect of TBX3

on GLI3R may be indirect
AER is in blue, ZPA is in red

Bamshad M et al. Reconstructing the history of human limb development: Lessons from birth defects. Pediatric
Research 1999; 45: 291-299
 Genes controlling bud development: PD patterning

• Distal limb outgrowth is propagated by an SHH/

GREM1/AER-FGF epithelial-mesenchymal
feedback signaling system.

• HOXD/HOXA transcriptional regulators

positively regulate Grem1 expression.

• SHH propagates the expression of Grem1 and

distal Hox genes.

• As BMP’s repress AER-FGF gene expression,

Grem1 is essential to propagate thes feedback
signaling interactions.

• Ultimately, the SHH/GREM1/AER-FGF loop is

terminated by down regulation of Grem1
expression by GI3R and increasing inhabitation by
AER-FGF.
AER is in blue, ZPA is in red

Bamshad M et al. Reconstructing the history of human limb development: Lessons from birth defects. Pediatric
Research 1999; 45: 291-299
Ahmed H et al. Genetic Overview of syndactyly and Polydactyly. Plast Reconstr Surg Glob Open 2017;5:e1549; doi:
10.1097/GOX.0000000000001549;
 Hox genes
• Hox encode transcription factors crucial for limb formation and exhibit some
control over upper limb formation.

• Mutations within the Hox gene locus have been identified as the cause of:

• Synpolydactyly (Central polydactyly (ring finger duplication) combined with

syndactyly has a familial inheritance pattern and has been linked to a gene
mutation (HOXD13 gene) on chromosome 2.)

• Hand-foot-genital syndrome

• Madelung’s deformity associated with Leri-Weill dyschondrosteosis

• Autosomal dominant conditions, although Leri-Weill dyschondrosteosis

affects females more severely.
•
example of a synpolydactylie due to Hox genes
 T-Box Genes
• T-Box genes encode transcription factors governing both limb
and organ system development.

• Altered expression of T-Box products can affect the anterior-

posterior development of the limb.

• Holt-Oram syndrome (cardiac defect and radial deficiency,

autosomal dominant trait with variable phenotype) is linked to
production of the transcription factor Tbx5

• Ulnar-mammary syndrome (TBX3 mutation) is associated with

postaxial limb anomalies.
 BMP (bone morphogenic
proteins)
• BMP’s are expressed in the developing limb.

• Deficiencies in cartilage-derived morphogenetic

protein are associated with various forms of
brachydactyly.

• Grebes’ and Hunter-Thompson chondrodysplasias

are associated with severe brachydactyly and have
been directly related to a deficiency of cartilage-
derived morphogenetic protein
 Clinical consequences:
classification of limb defects
• Limb defects can be classified according to anatomic
location of defect, specific limb axis perturbed, type of
molecule disrupted, isolated versus syndromic.

• However because our knowledge is limited, all of these

classifications are somewhat arbitrary.

• For example, anatomically similar defects can be caused

by mutations in many different genes. This is illustrated
by the mapping of genes on at least four different
chromosomes that cause split hand/foot malformations
• The National Institutes of Health website provides
a mechanism to keep abreast of current knowledge.

• Links to online Mendelian Inheritance in Man offer

valuable updated information regarding genes and
disease.