Learning Objectives

By the end of this article, you should be able to:

Identify the major ligaments and fascial layers of the hand
Describe their attachments, functions, and relationships to neurovascular structures
Distinguish between palmar, dorsal, and digital fascial components
Apply anatomical knowledge to clinical conditions, particularly Dupuytren’s disease

The hand is a highly specialised anatomical structure, capable of fine motor control, powerful grip, and precise coordination. Its function is supported by an intricate network of muscles, bones, tendons, ligaments, and fascial layers, which together provide stability, guide movement, and protect vital neurovascular structures.

In this article, we will explore the ligaments and fascial structures of the hand, focusing on their anatomical organisation and functional significance.

Palmar Structures

Palmar Aponeurosis

The palmar aponeurosis is a dense, triangular thickening of deep fascia located in the central palm.

Apex – attaches proximally to the flexor retinaculum and the tendon of palmaris longus
Base – divides distally into four longitudinal slips known as pretendinous bands, each giving rise to:
- A superficial band attaching to the skin
- A deep band that surrounds the flexor tendons and blends with the fibrous flexor sheath and deep transverse metacarpal ligaments

Laterally, the palmar aponeurosis is continuous with the fascia covering the thenar and hypothenar muscles.

Function:

Anchors palmar skin to improve grip
Protects underlying flexor tendons, vessels, and nerves
Contributes to force transmission during grasping.

Flexor Retinaculum

The flexor retinaculum is a strong band of deep fascia spanning the anterior wrist, forming the roof of the carpal tunnel.

Lateral attachments – scaphoid tubercle and trapezium
Medial attachments – pisiform and hook of hamate

The carpal tunnel transmits:

The median nerve
The long flexor tendons of the forearm

Function:

Prevents bowstringing of flexor tendons during wrist flexion
Protects the median nerve

It is continuous proximally with the antebrachial fascia and distally with the palmar aponeurosis.

Superficial Transverse Palmar Ligament

The superficial transverse palmar ligament is a horizontal fibrous band across the distal palm.

Attaches to the tendinous bands of the palmar aponeurosis
Anchors the palmar skin

Function:

Maintains alignment of the flexor tendons
Enhances grip efficiency

Superficial Transverse Metacarpal Ligament (Natatory Ligament)

Also known as the natatory ligament, this structure spans transversely between adjacent metacarpal heads, connecting the volar plates of the metacarpophalangeal (MCP) joints.

Function:

Maintains the transverse arch of the hand
Limits excessive finger abduction

Palmar Carpal Ligament

The palmar carpal ligament is a transverse thickening of the antebrachial fascia, located superficial and proximal to the flexor retinaculum.

Extends between the pisiform and the flexor carpi radialis tendon
Forms the roof of Guyon’s canal, transmitting the ulnar nerve and artery

Function:

Stabilises the ulnar neurovascular bundle
Supports superficial wrist structures

Dorsal Structures

Extensor Retinaculum

The extensor retinaculum is a fibrous band across the posterior wrist that secures the extensor tendons.

Prevents tendon bowstringing during wrist extension
Sends septa to the radius, forming six extensor compartments

Dorsal Fascia

The dorsal fascia covers the dorsum of the hand and fingers.

Function:

Encloses and guides the extensor tendons
Allows smooth, low-friction tendon gliding during finger extension

Digital Structures

The fingers contain specialised fascial ligaments that stabilise the skin and protect the digital neurovascular bundles, while allowing coordinated movement.

Cleland’s Ligament

Located on the dorsolateral aspect of the fingers
Lies dorsal to the digital neurovascular bundles
Attaches from the periosteum of the phalanges to the lateral dermis

Function:

Stabilises dorsal finger skin
Prevents excessive skin movement during flexion and extension

Grayson’s Ligament

Located on the volar-lateral aspect of the fingers
Passes volar to the digital neurovascular bundles
Extends from the flexor tendon sheath and volar periosteum to the dermis

Function:

Stabilises volar skin
Limits anterior displacement of neurovascular structures

Clinical Relevance

Dupuytren’s Disease

Dupuytren’s contracture is a progressive fibroproliferative disorder of the palmar fascia, most commonly affecting the palmar aponeurosis.

Thickened collagen cords form along the tendinous bands
Progressive shortening leads to flexion deformities at the MCP and PIP joints

Notably, certain structures are typically spared:

Superficial transverse palmar ligament
Cleland’s ligament

This anatomical preservation is useful for surgical orientation.

Management Options

Needle fasciotomy
- Minimally invasive
- Faster recovery
- Higher recurrence rate
Fasciotomy or fasciectomy
- Open surgical excision of diseased fascia
- Lower recurrence in advanced disease
- Longer recovery and higher complication risk