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Flexor tendons

Understanding the normal anatomy of the flexor tendons may be simplified by classifying them according to their location within and outside the carpal tunnel. The flexor tendons contained within the carpal tunnel, deep to the flexor retinaculum, include the flexor digitorum superficialis, flexor digitorum profundus, and flexor pollicis longus tendons (Fig. 1). A common tendon sheath surrounds the long flexor tendons of the digits, whereas the flexor pollicis longus traverses within its own tendon sheath [1].

*Corresponding author. E-mail address: [email protected] (J.T. Bencardino).

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Flexor Carpi Radialis Axial

Fig. 1. Normal anatomy of the tendons. Axial proton-density weighted image at the level of the distal forearm demonstrating the flexor tendons and extensor compartments (I-VI). fcr, flexor carpi radialis; fcu, flexor carpi ulnaris; fdp, flexor digitorum profundus; fds, flexor dig-itorum superficialis; fpl, flexor pollicis longus; pl, palmaris longus.

Fig. 1. Normal anatomy of the tendons. Axial proton-density weighted image at the level of the distal forearm demonstrating the flexor tendons and extensor compartments (I-VI). fcr, flexor carpi radialis; fcu, flexor carpi ulnaris; fdp, flexor digitorum profundus; fds, flexor dig-itorum superficialis; fpl, flexor pollicis longus; pl, palmaris longus.

The main flexors of the wrist, the flexor carpi radialis, flexor carpi ulnaris, and palmaris longus tendons, all travel outside the carpal tunnel (see Fig. 1). The flexor carpi radialis (FCR) travels within a fibro-osseous tunnel formed by a reflection of the flexor retinaculum just proximal to the trapezium. Within the tunnel, the FCR traverses along a groove on the trapezium. The FCR inserts via terminal slips into the trapezial tuberosity and into the bases of the second and third metacarpals.

The flexor carpi ulnaris (FCU) tendon, along with the pisiform bone, forms the ulnar boundary of Guyon's canal. The FCU tendon protects the ulnar nerve and artery at the wrist level. It also provides a clinical reference point when a local nerve block of the ulnar nerve is performed. The distal attachment sites of the FCU tendon include the palmar surface of the pisiform, hamate, and base of the fifth metacarpal.

Paratenon rather than a synovial sheath surrounds the palmaris longus tendon. The tendon has a straight course as it inserts into the flexor retinaculum and palmar aponeurosis. It is the most commonly used tendon for grafting during hand surgery. The palmaris longus is highly variable and ranges in size from a thin slip to a wide, flat tendon [2]. It is absent in 25% of the population. Occasionally the muscle belly of the tendon extends to the wrist level, forming the so-called ''reversed palmaris longus muscle.'' This variant may cause mechanical compression of the median nerve [3-5].

Extensor tendons

The extensor retinaculum, along with vertical septae, divides the extensor tendons into six separate compartments delineated laterally and medially by the distal radius and ulna, respectively (see Fig. 1). Although each extensor compartment contains a single tendon sheath, it may be traversed by as many as three tendons. The extensor compartments are numbered from one to six from the radial to the ulnar surface. The extensor pollicis brevis tendon and the abductor pollicis longus tendon compose the first compartment. The second compartment is traversed by the extensor carpi radialis longus and extensor carpi radialis brevis tendons. The extensor pollicis longus tendon occupies the third compartment proximal to the radioulnar joint; distal to the joint the tendon joins the second compartment tendons. The third and fourth compartments are separated by Lister's tubercle of the distal radius. The fourth compartment holds the extensor digitorum and extensor indicis tendons, whereas the fifth compartment contains the extensor digiti minimi tendon, typically made up of two slips. The sixth compartment contains the extensor carpi ulnaris tendon.

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