Anatomy, Shoulder and Upper Limb, Wrist Flexor Retinaculum


Article Author:
Nathaniel Deak


Article Editor:
Bruno Bordoni


Editors In Chief:
Kranthi Sitammagari
Mayank Singhal


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
8/18/2019 10:05:58 PM

Introduction

The flexor retinaculum is a fibrous connective tissue band that forms the anterior roof of the carpal tunnel. Many experts consider the flexor retinaculum synonymous with the transverse carpal ligament and the annular ligament; for this discussion, they will be considered as the same structure. The flexor retinaculum serves to protect nine of the forearm flexor tendons and median nerve as they pass through the carpal tunnel.[1] If this tissue becomes inflamed, swollen or fibrotic, the median nerve can become irritated or compressed, leading to the condition of the carpal tunnel. 

Structure and Function

The flexor retinaculum begins when the longitudinally oriented fibers of the forearm's antebrachial fascia fibers abruptly thicken and change direction. The fibers change orientation to a transverse orientation. The flexor retinaculum thickens proximally to distally, ranging in thickness from 1.5 mm to 6.0 mm.[1] The structure is about 3 centimeters long and about 2.5 centimeters wide. The flexor retinaculum attaches laterally and medially to the carpals bone. Specifically, the flexor retinaculum attaches to the scaphoid tuberosity and trapezial ridge radially and the pisiform and the hook of hamate ulnarly.[2] The flexor retinaculum forms the volar boundary of the carpal tunnel, while the carpal bones form the dorsal boundary. Contained below the flexor retinaculum within the carpal tunnel are the four flexor digitorum superficialis tendons,  the four flexor digitorum profundus tendons, the single flexor pollicis tendon, as well as the median nerve.[1] 

Its front face gives rise to some muscles of the eminence thenar and of the eminence hypothenar and is related to the tendon of the long palmar muscle that adheres to it. The upper margin continues in the palmar carpal ligament, and the lower margin merges with the palmar aponeurosis.

Its principal function is to serve as a pulley for the carpal flexor muscles and to stabilize the morphology of the carpal system.

Embryology

Its constitution is mainly of collagen fibers, whose embryological origin is the mesodermal leaflet (hypaxial myotome).

Blood Supply and Lymphatics

The ulnar artery is one of the major blood vessels in the upper extremity and is close to the flexor retinaculum. The ulnar artery is a continuation of the brachial artery and is underneath the flexor carpi ulnaris muscle. It lies on top of the flexor retinaculum lateral to the ulnar nerve. The ulnar artery supplies the medial aspect of the forearm and forms the superficial palmar arch providing blood to the hand.[3] In some patients, there is a branch of the ulnar artery that passes over the retinaculum.

Nerves

The flexor retinaculum is best known for sheltering the median nerve in the carpal tunnel. The median nerve originates from the cervical spinal cord roots C5-C7 and C8-T1.[4] These cervical roots merge to form the medial and lateral cords of the brachial plexus, ultimately forming the median nerve. The median nerve then courses down the anterior arm, forearm, and eventually into the hand. While traveling through the forearm between the flexor digitorum superficialis and flexor digitorum profundus, the median nerve passes deep to the flexor retinaculum and through the carpal tunnel.[4] In addition to the median nerve, the ulnar nerve is near the flexor retinaculum. The ulnar nerve, which primarily innervates the intrinsic muscles of the hand, is located superficial to the flexor retinaculum on its medial edge.[5] 

Muscles

There are several muscles associated with the flexor retinaculum. Situated deep to the flexor retinaculum are the four tendons of the flexor digitorum superficialis. The flexor digitorum superficialis, which is in the anterior compartment of the forearm, originates at the medial epicondyle of the humerus as well as parts of the radius and ulna. The flexor digitorum superficialis inserts on the base of the second to fifth middle phalanges.[6] The innervation of the flexor digitorum superficialis is the median nerve. The main action of the flexor digitorum superficialis is flexion of the phalanges, primarily at the proximal interphalangeal joints. Deep to the flexor digitorum superficialis is the flexor digitorum profundus. The origin and insertion is the proximal anteromedial surface of the ulna and the distal interphalangeal joints of the phalanges, respectively.[6] The flexor digitorum profundus is innervated medially by the ulnar nerve and laterally by the median nerve. The main action is the flexion of the distal interphalangeal joints, then secondarily flexes proximal interphalangeal joints, metacarpal phalangeal joints, and wrist. Below the flexor retinaculum and lateral to the flexor digitorum superficialis lies the flexor pollicis longus. The origin of the flexor pollicis longus is the middle half of the volar radius, and the insertion is the base of the distal phalanx of the thumb.[6] The innervation of the flexor pollicis longus is a branch of the median nerve, the anterior interosseous nerve. 

Physiologic Variants

The main anatomical variations concerning the flexor retinaculum have to do with the median nerve. As previously stated, the median nerve enters the carpal tunnel deep to the flexor retinaculum. In some humans, a bifid median nerve occurs which occurs when the median nerve splits proximally to the flexor retinaculum instead of distally like normal anatomy.[2] Several studies have demonstrated a wide range of variations in the motor branch of the median nerve.[2] These different courses may explain why patients present differently in cases of severe compression of the median nerve. 

Surgical Considerations

If conservative management for carpal tunnel does not work, surgical options are available.[1] If the flexor retinaculum is the cause of a patients carpal tunnel symptoms, often surgical release is necessary. This procedure releases the compression put on the median nerve and can often relieve or eliminate the patient's symptoms. Like any surgery, there are risks involved, knowing your anatomy is key to avoiding damaging any surrounding structures. Because so many vital structures surround the flexor retinaculum, one must be aware of where each tendon, artery, and nerve are relative to the flexor retinaculum. 

If the patient suffers from systemic diseases, the rate of recurrence of the disorder after surgery is very high.

Clinical Significance

The flexor retinaculum can entrap and compress the median nerve causing the condition of carpal tunnel.[7] Carpal tunnel is the most common compression neuropathy in the upper extremity. There are several causes for compression of the median nerve that ranges from repetitive motions, space-occupying lesions, or certain health conditions like diabetes mellitus or hypothyroidism. Clinically patients may present with numbness and tingling in the radial three fingers.[7] Often symptoms are worse at night. Patients may have difficulty holding objects and regularly report dropping items. Clinically patients frequently will have thenar atrophy and weakness. Evaluating sensations in the fingers may show decreased sensation in radial three fingers.[7] Compression of the flexor retinaculum and therefore, the median nerve may reproduce the patient's symptoms. A classic physical exam maneuver used to diagnose carpal tunnel is the Tinel test. The Tinel test is performed by repeatedly tapping on the flexor retinaculum and seeing if it reproduces the patient's symptoms. Treatments to consider include wrist splinting, work-related ergonomic modification, NSAIDs, steroid injections, and surgical management. 

Other Issues

When the retinaculum compresses the underlying nerve, it undergoes a thickening, reducing its elastic capacity. According to a recent study, there is a difference in size between male and female. In women, the retinaculum is smaller; in the female sex, the carpal tunnel syndrome has a higher prevalence.

In carpal tunnel syndrome, in the early stages of the disorder, the proliferation of myofibroblasts seems to play an important role, which not only increases inflammatory responses but reduces tissue elasticity.


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    Contributed by Bruno Bordoni, PhD
Attributed To: Contributed by Bruno Bordoni, PhD

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Anatomy, Shoulder and Upper Limb, Wrist Flexor Retinaculum - Questions

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A 64-year-old patient comes to the office with complaints of numbness and tingling in her radial three fingers. In addition to these symptoms, she also experiences pain at night in both of her wrists. She is an editor at the local newspaper and spends many hours on the computer. The structure that is compressing the nerve causing her symptoms attaches to what bony structures?



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A patient presents to the healthcare provider's office with numbness and tingling in the radial three fingers on his palmar side. The provider proceeds with a physical exam and finds that the patient has significant thenar atrophy. What is likely the cause of these symptoms?



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A 65-year-old female patient presents with numbness and tingling in the radial three fingers. She reports that she is having difficulty opening pickle jars. Her husband has also noticed that she has been dropping items frequently for the past few months. The patient is becoming increasingly worried and is afraid that she will soon be unable to use her hands. The nerve that is most likely causing her symptoms is being compressed by what structure?



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A patient presents to the healthcare provider with symptoms of numbness and tingling in the right radial three fingers. After evaluation, surgery is recommended to release the structure that causes compression of the median nerve in the carpal tunnel. During the dissection, what fiber orientation and thickness will be found?



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While working on a computer, a patient finds his hands frequently falling asleep. He goes to his clinician and asks to be examined. The clinician performs a test where he repeatedly taps on the volar surface of his wrist. This test reproduces his symptoms. What tendons pass deep to the likely structure causing the symptoms?



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Anatomy, Shoulder and Upper Limb, Wrist Flexor Retinaculum - References

References

Goitz RJ,Fowler JR,Li ZM, The transverse carpal ligament: anatomy and clinical implications. Journal of wrist surgery. 2014 Nov;     [PubMed]
Presazzi A,Bortolotto C,Zacchino M,Madonia L,Draghi F, Carpal tunnel: Normal anatomy, anatomical variants and ultrasound technique. Journal of ultrasound. 2011 Mar;     [PubMed]
Epperson TN,Varacallo M, Anatomy, Shoulder and Upper Limb, Brachial Artery 2019 Jan;     [PubMed]
Chauhan M,M Das J, Cubital Tunnel Syndrome 2019 Jan;     [PubMed]
Pester JM,Varacallo M, Median Nerve Block Techniques 2019 Jan;     [PubMed]
Mitchell B,Whited L, Anatomy, Shoulder and Upper Limb, Forearm Muscles 2019 Jan;     [PubMed]
Sevy JO,Varacallo M, Carpal Tunnel Syndrome 2019 Jan;     [PubMed]

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