[Durgical](https://durgical.com/en/) › [DurgiPedia](https://durgical.com/en/durgipedia/) › [Anatomy](https://durgical.com/en/anatomy/) › [Upper limb](https://durgical.com/en/anatomy/region/upper-limb/) › Palmar aponeurosis [Muscular system](https://durgical.com/en/anatomy/system/muscular-system/) · [Upper limb](https://durgical.com/en/anatomy/region/upper-limb/) # Palmar aponeurosis The palmar aponeurosis is a tough sheet under the skin of the palm; it protects tendons and nerves and thickens into cords in Dupuytren disease. [See in 3D →](https://durgical.app/?from=durgipedia&lang=en#region=upper_limb&select=palmar_aponeurosis&side=r) Opens in the Durgical app, no sign-up needed. ## What it is A tough triangular sheet under the skin of the palm, fanning out to the fingers. ## What it does Protects the tendons and nerves of the palm and anchors the palm skin for grip. ## Key points - Dupuytren disease turns normal bands into cords: the pretendinous band becomes the pretendinous cord (MCP contracture); spiral band, lateral digital sheet and Grayson ligament form the spiral cord (PIP contracture) - The spiral cord pulls the digital neurovascular bundle towards the midline and the surface, where it is easily cut in surgery - Grayson ligaments (palmar to the bundle) are involved in Dupuytren disease; Cleland ligaments (dorsal) are spared - Vertical septa from it to the [deep transverse metacarpal ligament](https://durgical.com/en/anatomy/deep-transverse-metacarpal-ligament/) divide the distal palm into canals for the flexor tendons and for the lumbricals with the digital vessels and nerves ## Key facts **Attaches** Apex continuous with [palmaris longus](https://durgical.com/en/anatomy/palmaris-longus/) and the flexor retinaculum; slips to the fibrous sheaths of the fingers **Function** Protects palm structures; anchors the palm skin; thickens and contracts in Dupuytren disease ## Relations **Superficial** Palm [skin](https://durgical.com/en/anatomy/skin/), tightly bound to it by short fibrous bands; the palmaris brevis over its ulnar part **Deep** [Superficial palmar arch](https://durgical.com/en/anatomy/superficial-palmar-arch/), the common digital branches of the [median nerve](https://durgical.com/en/anatomy/median-nerve/) and [ulnar nerve](https://durgical.com/en/anatomy/ulnar-nerve/), the flexor tendons and the lumbricals **Above** [Palmaris longus tendon](https://durgical.com/en/anatomy/palmaris-longus-tendon/) and the flexor retinaculum at its apex **Below** Pretendinous bands to the bases of the fingers and their fibrous sheaths, and the natatory ligament across the web spaces ## How to find it With the fingers and wrist extended it is felt as firm, slightly ridged tissue in the centre of the palm. Its apex continues the palmaris longus tendon, which stands out at the wrist when the thumb and little finger pads are pressed together with the wrist slightly flexed. ## Examination - Hueston tabletop test: the hand is laid palm down on a table; if the palm and fingers cannot lie flat, the test is positive and indicates a Dupuytren contracture that limits function ## On imaging Dupuytren disease is diagnosed clinically. Ultrasound shows nodules as hypoechoic thickenings of the palmar fascia over the flexor tendons and cords running along the rays; MRI can show them too (low signal in mature cords, higher signal in active nodules) but is rarely needed. Radiographs show no specific sign. ## Common problems - Dupuytren's contracture: cords form in the palm and slowly pull the fingers into a bent position, most often the ring and little fingers. - Runs in families and is more common in men of northern European descent. ## How it is diagnosed Cords and nodules in the palm; the 'tabletop test' checks if the hand can lie flat. ## Treatment - Watchful waiting while the hand can still lie flat. - Needle release of the cord or enzyme injection where available. - Surgical removal of the diseased tissue (fasciectomy) for bigger contractures. ## Clinical notes - Dupuytren diathesis (early onset, family history, both hands, knuckle pads, plantar fibromatosis or Peyronie disease) predicts recurrence after treatment - Cords can be divided or removed by needle aponeurotomy, enzyme injection or limited fasciectomy; digital nerve injury and recurrence are the main concerns - Because palm skin is bound down to it, swelling from hand infections tends to show on the back of the hand - Deep to it, a septum to the [3rd metacarpal](https://durgical.com/en/anatomy/3rd-metacarpal/) divides the thenar space (over [adductor pollicis](https://durgical.com/en/anatomy/adductor-pollicis/)) from the midpalmar space (behind the flexor tendons); infection spreads via the [carpal tunnel](https://durgical.com/en/anatomy/carpal-tunnel/) and web spaces ## Anatomical variants - The palmaris longus tendon is absent in a notable minority (often quoted around 1 in 7; figures vary between populations); the aponeurosis is still present, anchored to the flexor retinaculum ## Memory aid Cleland is the Ceiling (dorsal to the digital bundle), Grayson is the Ground (palmar); Dupuytren grabs Grayson. ## Related conditions - [Dupuytren contracture](https://durgical.com/en/conditions/dupuytren-contracture/) ## Test yourself Think of the answer, then tap the question to see it. ## What happens to the palmar aponeurosis in Dupuytren disease? Normal bands become contracting cords: the pretendinous cord flexes the MCP, the spiral cord the PIP. ## Why is the spiral cord of the palmar aponeurosis dangerous in surgery? It pulls the digital neurovascular bundle towards the midline and the surface, where it is easily cut. ## Which digital ligaments are involved in Dupuytren disease, and which are spared? Grayson ligaments (palmar to the bundle) are involved; Cleland ligaments (dorsal) are spared. ## Why does swelling from palm infections tend to show on the back of the hand? The palm skin is bound down to the palmar aponeurosis, so swelling spreads to the looser dorsal skin. [Add to my cards (4)](https://durgical.app/estudiar/?add=/en/anatomy/palmar-aponeurosis/) Educational information, not medical advice. For any symptom, see a health professional. ## Its names **Official Latin (TA2)** aponeurosis palmaris TA2 2549 **Official Spanish (DeCS)** Aponeurosis palmar **English (TA2)** Palmar aponeurosis **Also called** palmar fascia ## Related - [Flexor retinaculum](https://durgical.com/en/anatomy/flexor-retinaculum/) - [Digital nerves](https://durgical.com/en/anatomy/palmar-digital-nerves/) - [Superficial palmar arch](https://durgical.com/en/anatomy/superficial-palmar-arch/) - [Middle phalanx, middle finger](https://durgical.com/en/anatomy/middle-phalanx-of-the-middle-finger/) - [Thumb sesamoids](https://durgical.com/en/anatomy/sesamoid-bones-of-the-thumb/) Sources: Terminologia Anatomica (TA2); [Anatomy, Shoulder and Upper Limb, Hand Long Flexor Tendons and Sheaths](https://www.ncbi.nlm.nih.gov/books/NBK546607/); Anatomía humana (4.ª ed.), tomo 1, cap. 58: Mano. ## **Spotted a mistake?** We are always improving for the community. Tell us what is wrong and our team will review it. Report a mistake Representative model, for educational purposes only. --- Source: https://durgical.com/en/anatomy/palmar-aponeurosis/ License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/anatomy/palmar-aponeurosis/