Palmaris Longus

Original Editor - Mudra Shah

Top Contributors - Mudra Shah and Mandeepa Kumawat

Description

Palmaris Longus muscle in the Flexor compartment of the forearm

The Palmaris longus (PL) muscle is a long, slender muscle which is usually present in the volar compartment of the forearm, interposed between the Flexor Carpi Ulnaris and the Flexor Carpi Radialis muscles.

However, it has been accepted as a vestigial muscle since studies have shown that almost 30% of the population could be lacking this muscle either in one forearm (unilateral) or both the forearms (bilateral) but the percentage can always vary. The peculiarity associated with this muscle is not merely its presence or absence, but it's high degree of anatomical variations even when present.Absence of the palmaris longus does not have an effect on grip strength.[1]

Apart from its anatomical anomalies, there are other categories of variations of the Palmaris Longus muscle in terms of its prevalence amongst different ethnicities and it's absence being more common in women than men. Also, prevalence of the muscle is higher bilaterally but if present unilaterally, it is usually in the left upper limb [2].It is classified as a phylogenetically retrogressive muscle i.e. muscles having a short belly with a long tendon.[3]

Anatomy

Origin[4]

Medial epicondyle of the Humerus via the common flexor tendon

Insertion[4]

Palmar Aponeurosis and Flexor Retinaculum at the wrist joint

Nerve supply[4]

It is innervated through the Median Nerve with root value C8 via the medial as well as lateral cords of the brachial plexus

Arterial supply[5]

Ulnar Artery

Function

  • Palmaris longus synergistically works with the long flexors of the forearm to bring about flexion at the wrist joint and small joints of the hand.
  • Apart from this, the muscle also helps in tightening and tensing up the palmar aponeurosis.
  • Its main function appears to be as an anchor for the skin and fascia of the hand in resisting horizontal shearing forces in distal direction.

Clinical tests to determine the presence of the muscle

Over the years, several clinical tests have been developed by practitioners from around the world to accurately detect the Palmaris Longus muscle. These tests merely rely upon certain positions of the wrist and hand in order to put the muscle in a state of tension so that it's tendon is both visible and palpable. The validity and reliability of the tests, however, show variations amongst each other[6].

1. Standard Test - Schaeffer's Test[6]

  • The first test developed in 1909
  • Involves maintaining the forearm at 90 degrees first followed by moving the thumb in opposition towards the little finger with the wrist partially flexed.
[7]

2. Thompson's Test[6]

  • Maneuver involves first making a fist with the testing hand, followed by wrist flexion against the resistance with the thumb flexed over the other digits.
[8]

3. Mishra's Test[6]

  • Involves passive hyperextension of the Metacarpophalangeal Joints along with mild active wrist flexion.

4. Gangata's Test[6]

  • The initial testing position is the thumb in abduction. The subject is then asked to resist both thumb abduction and wrist flexion.

5. "Two Finger Sign" - Pushpakumar's Test[6]

  • The subjects are made to completely extend the 2nd and 3rd digits, flex the 4th and 5th digits with the first digit fully opposed and flexed.

6. "Four Finger Sign"[6]

  • Combines forced anteduction and pronation of the thumb at the first MCP with full extension of the second to fifth digits.

Clinical Significance

  • Compression neuropathies at the wrist are commonly encountered conditions in the clinical practice which involve either the Median nerve or the Ulnar nerve. In case of median nerve neuropathies, most of the documented cases have no external cause to be attributed but there have been cases where the etiological factor has been the presence of hypertrophied/anomalous muscles. There are three muscles which have been documented: the Palmaris Longus, the first (or second) Lumbrical and the Superficial Flexor of the 1st digit. In case of ulnar nerve neuropathies, idiopathic ulnar tunnel syndrome is rare and extrinsic causes have been identified. Anomalous muscles include Palmaris Longus, Abductor Digits Minimi and Flexor Carpi Ulnaris. In both Median and Ulnar nerve neuropathies, Palmaris longus is seen to be a common contributor to the pathological process[9].
  • The Palmaris Longus tendon is of great importance for surgeons in particular, as it is widely utilized as a tendon graft for upper limb tendon repair and tendon transfer surgeries. Since this muscle is an accessory muscle and no functional loss in grip and pinch strength have been noted in its absence, this makes it ideal for use in surgical procedures[10].
  1. Palmaris longus tendon has been used for correction of claw-finger deformities because it is long enough (12-15cms.) & its tendon fibres are parallel & loosely held,
  2. Palmaris longus tendon was constantly used for correction of hand deformities in leprosy
  3. Palmaris longus tendon has been used in opponensplasty and radial palsy, the Palmaris longus muscle has been found to be of adequate strength to substitute for paralyzed lumbricals.
  • The attributes that make the Palmaris longus suitable for the above said procedures are:
  1. Palmaris longus muscle belly is less bulky & corresponds to that of lumbricals
  2. The muscle lies in direct line of required pull & this gives it the mechanical advantage.
  3. Being superficial it can be easily dissected.
  4. It passes through soft tissues avoiding congruity to fixed structures.
  5. The muscle can be spared without a significant deficit. (Malaviya, 2003)[11]

References

  1. Sebastian et al , J Hand Surg Br. Does the absence of the palmaris longus affect grip and pinch strength? - PubMed - NCBI Aug;30(4):406-8.
  2. Sebastin SJ, Lim AY, Wong H. Clinical assessment of absence of the palmaris longus and its association with other anatomical anomalies-a Chinese population study. Annals-academy of Medicine Singapore. 2006 Apr 1;35(4):249.
  3. Absence of the palmaris longus muscle: a population study. /www.ncbi.nlm.nih.gov/pmc/articles N W Thompson/PMC2449224/?page=1 The ulster medical journal ,Volume 70 ,No.1 ,pp. 22-24 ,May 2001
  4. 4.0 4.1 4.2 Snell RS. Clinical Anatomy By Regions. 9th edition. Philadelphia: Lippincott Williams & Wilkins; 2012.
  5. Derek Moore. Palmaris Longus. Available from: https://www.orthobullets.com/anatomy/10023/palmaris-longus [Accessed: 12 June 2018]
  6. 6.0 6.1 6.2 6.3 6.4 6.5 6.6 JWM Kigera, S Mukwaya - Annals of African surgery 2012 Clinical Assessment of the Palmaris Longus–Accuracy of common tests (accessed 12 June 2018)
  7. Schaeffer's Test for Palmaris Longus (CR) Available from https://www.youtube.com/watch?v=CXdSruxBM2g [last accessed 16/06/2018]
  8. Thompson's Test for Palmaris Longus (CR) Available from https://www.youtube.com/watch?v=oZXwD9i0bcQ [last accessed 16/06/2018]
  9. De Smet L. Median and ulnar nerve compression at the wrist caused by anomalous muscles. Acta orthopaedica belgica. 2002 Dec 1;68(5):431-8.
  10. Angelini Júnior LC, Angelini FB, Oliveira BC, Soares SA, Angelini LC, Cabral RH. Use of the tendon of the palmaris longus muscle in surgical procedures: study on cadavers. Acta ortopedica brasileira. 2012;20(4):226-9.
  11. Najma Mobin MORPHOLOGICAL VARIATIONS AND CLINICAL APPLICATIONS OF PALMARIS LONGUS MUSCLE:A CADAVERIC STUDY International Journal of Development Research,Vol.06, Issue,03,7144-7149,March, 2016