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Unilateral absence of Palmaris longus muscle – A case report
a p o l l o m e d i c i n e 1 1 ( 2 0 1 4 ) 2 9 7 e2 9 9
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/apme
Case Report
Unilateral absence of Palmaris longus muscle e A case report Nitya Waghray a,*, Aruna Jyothi b a
Tutor, Department of Anatomy, Apollo Institute of Medical Sciences and Research, Hyderabad, Telanganna, India Professor and Head of the Department, Apollo Institute of Medical Sciences and Research, Hyderabad, Telanganna, India
b
article info
abstract
Article history:
Ethnic variations in the prevalence of absence of the palmaris longus (PL) are well known. It
Received 29 October 2014
is not uncommon in individuals to have unilateral or bilateral absence of palmaris longus,
Accepted 13 November 2014
a structure which is often used in reconstructive plastic surgeries mainly in the grafting of
Available online 15 December 2014
tendons, although it has also been used for a wide variety of procedures including lip augmentation,1 ptosis correction2 and in the management of facial paralysis.3,4
Keywords:
During the routine dissection procedure being carried out for the 1st year MBBS stu-
Palmaris longus
dents at Apollo Institute of Medical Sciences and Research, we found the absence of Pal-
Variations
maris longus muscle unilaterally in the left upper extremity of a 58 year old male cadaver.
Reconstructive
Authors have compared their findings with the presence of palmaris longus muscle of
Lip augmentation
other limb and possible variations of palmaris longus muscle reported in the literature. The
Ptosis correction
importance of variation in absence of palmaris longus muscle has also been discussed. Copyright © 2014, Indraprastha Medical Corporation Ltd. All rights reserved.
1.
Introduction
Palmaris longus muscle is one of the superficial flexor muscles of the forearm. It is a slender muscle that acts on the skin and distal digital webs.5 It arises from the medial epicondyle of the humerus by the common flexor tendon, from the intramuscular septa between it and the adjacent muscles, and from the antebrachial fascia.6 It ends in a slender, flattened tendon, which passes distally lying on the medial side of the flexor carpi radialis.7 At the wrist it passes over the upper part of the flexor retinaculum and is inserted into the central part of the flexor retinaculum and lower part of the palmar aponeurosis, frequently sending a tendinous slip to the short muscles of the
thumb. It is supplied by the C7 and C8 fibers of the Median Nerve.6,8 Palmaris longus is described as one of the most variable muscles in our body and is classified as a phylogenetically retrogressive (i.e., a muscle with a short belly and a long tendon) metacarpophalangeal joint flexor. Palmaris longus though vestigial in man, it served a purpose in the lower vertebrates. However, as we evolved it lost its purpose gradually. In vertebrates, Palmaris Longus is found only in mammals and is best developed in those where the forelimbs are used for ambulation. It is variably absent in higher Apes such as Chimpanzees and Gorillas but always present in Orangutan.5 Numerous variations of Palmaris longus are reported in literature, the muscle being variable both in number and
* Corresponding author. E-mail address: [email protected] (N. Waghray). http://dx.doi.org/10.1016/j.apme.2014.11.005 0976-0016/Copyright © 2014, Indraprastha Medical Corporation Ltd. All rights reserved.
298
a p o l l o m e d i c i n e 1 1 ( 2 0 1 4 ) 2 9 7 e2 9 9
form.5,8,9 Concerning the kind of muscle, it may be fleshy throughout its entire length or may be digastrics. The muscle may have a proximal tendon or a distal one or may have muscle belly in center and tendon above & below or finally may consist solely of a tendinous band.8,10 It may be fleshy distally and tendinous proximally (Palmaris longus inversus), being known as the reversed Palmaris longus muscle (RPL).11 A three headed reversed Palmaris longus has also been reported as a surgical finding.8,5,12 Palmaris longus can be palpated by touching the pads of 5th & 1st fingers & flexing the wrist, the tendon, if present, will be visible. This test is known as Schaeffer's Test13 (Fig. 1).
2.
Case report
During the routine dissection being carried out for the 1st year MBBS students at Apollo Institute of Medical Sciences and Research, we found the absence of Palmaris longus muscle unilaterally in the left upper extremity of a 58 year old male cadaver. The forearm was observed for other structures such as the presence, origin and insertions of other flexor muscles which were found to be normal. Authors also observed the attachment of flexor retinaculum as well as the palmar aponeurosis which were found to be normal. The Palmaris longus muscle was found to be normally present on the right limb.
3.
Discussion
The text books on hand surgery explain the absence of Palmaris longus muscle as rare variation accounting to only about 15%, however this figure varies largely in the ethnic groups. The agenesis or absence of Palmaris longus muscle may be attributed to the Mendelian characteristics. According to the previously reported literature the absence of this muscle is said to be ranging from as low as 4% to as high as 25% with the lowest seen in the Mongoloid population and the highest in the white Causcasian population. On an average about 10% absence of this muscle has been universally accepted as reported in literature by Pai et al.14 Owing to the length and diameter of its tendon as well as its
advantage in which it doesn't lead to any functional deformities, the Palmaris longus muscle is very frequently used as a tendon graft for the wrist.15 Palmaris longus tendon is very frequently used as a graft for the ruptured flexor digitorum superficialis and profundus as well as the ruptured flexor pollicis longus. Prevalence of absence of Palmaris longus has been extensively studied following the first report of its absence in 1559 by Colombos in De Re Anatomica Libri. In their study of 800 living subjects; it was bilaterally absent in 7.7% cases, absent on right side in 4.5% cases and absent on left side in 5.2%.5,11 Reimann et al conducted a large scale study on about 1600 cadaveric limbs in the year 1944, in which they found that 12.8% of the patients had an absence of Palmaris longus muscle and about 9% of the patients expressed variations in the location and the type of muscle belly of Palmaris longus muscle. Bergmann (1988), in his study conducted on Palmaris longus observed the absence of this muscle more often in females as compared to males and usually the absence of the muscle was observed to be frequent in the left upper limb in both the sexes. Schaeffer in 1953 and Richard in 2003 reported the absence of PL in 10% cases either unilaterally or bilaterally, double Palmaris longus with a tendinous slip was reported by Saadeh in 1986, bifid reverse muscle by Regan in 1988, bilateral accessory muscle by Yildiz in 2000, duplication of the muscle by Kawashima in 2002 and conjoined tendon of Palmaris longus and flexor carpi ulnaris by Lemon in 2002. The absence of Palmaris longus has been studied in various ethnic and racial groups as well. The prevalence of its absence in Chinese population was found to be about 4.6%, in Caucasians 16.2%, in Nigerians 31.25%, in Ugandans 1.02%, in Zimbabweans 1.5%, in Congolese 3%, in Japanese 3.4%, in Germans 20.4%, in Americans 12.8%, in Indians 17.8% and in Turkish about 26.6%.5,11 In general there is low prevalence of its absence in Asians, Black and Native Americans. However different studies in the same population have also indicated different figures. The overall presence of Palmaris longus is found to be 70e85%. Apart from its ethnic and racial variations, its absence is more common in women, the bilateral absence being more common, and the unilateral absence is more common on left side.
Fig. 1 e Schaeffer's Test for testing the presence or absence of Palmaris longus muscle.
a p o l l o m e d i c i n e 1 1 ( 2 0 1 4 ) 2 9 7 e2 9 9
299
Fig. 2 e Absence of Palmaris longus. FCR: Flexor Carpi Radialis, FDS: Flexor Digitorum Superficialis, FR: Flexor Retinaculum, FCU: Flexor Carpi Ulnaris, UN: Ulnar nerve.
The present study is suggestive of the unilateral absence of Palmaris longus muscle on the left upper extremity of the 58 year old male cadaver (Fig. 2). This is comparable to a study conducted by Bergmann in 1988 in which he showed the unilateral absence of the muscle to be more frequent on the left side.
4.
Conclusion
The tendon of Palmaris longus is considered as an ideal donor for grafting of tendons as it can be used without causing major functional impairment; it is superficial in its location as well as insignificant in nature. It can be used as a replacement for the ruptured tendons of flexor digitorum superficialis and profundus, flexor pollicis longus and for the extensors of fingers. The significance of the tendon doesn't end with just the tendon grafting. It can as well be used as a simple static support in the treatment of facial paralysis. It is also used as a digital pulley for various reconstructive surgical procedures. It is a weak flexor and not a significant muscle but a little miracle used in various surgeries, hence proving that there is nothing created by nature that is insignificant.
Conflicts of interest All authors have none to declare.
references
1. Davidson BA. Lip augmentation using the palmaris longus tendon. Plast Reconstr Surg. 1995;95:1108e1110.
2. Kurihara K, Kojima T, Marumo E. Frontalis suspension for blepharoptosis using palmaris longus tendon. Ann Plast Surg. 1984;13:274e278. 3. Naugle Jr TC, Faust DC. Autogeneous palmaris longus tendon as frontalis suspension material for ptosis correction in children. Am J Ophthalmol. 1999;127:488e489. 4. Atiyeh BA, Hashim HA, Hamdan AM, Kayle DI, Musharafieh RS. Lower reconstruction and restoration of oral competence with dynamic palmaris longus vascularised sling. Arch Otolaryngol Head Neck Surg. 1998;124:1390e1392. 5. Sharma DK, Shukla CK, Sharma V. Clinical assessment of absence of palmaris longus and its association with gender, body sides, handedness, and other anomalies in population of central India. J Anat Soc India. 2012;61:13e20. 6. Gray H, Bennister LH, Berry MM, Williams PL. Gray's Anatomy: The Anatomical Basis of Medicine and Surgery. 38th ed. London: Churchill Livingstone; 1999:853. 7. Jones FW. The Principles of Anatomy as Seen in the Hand. Baillere, Ondon, Tindall and Cox; 1941. ria, Fazan Sassoli. Reversed palmaris longus 8. Paula Vale muscle and median nerve relationships: case report and literature review. Braz J Morphol Sci. 2007;24:88e91. 9. Nayak SR, Krishnamurthy A, Lakshmi AR, et al. Multiple muscular anomalies of upper extremity: a cadaveric study. Rom J Morphol Embryol. 2008;49:411e415. 10. Mobin N, Saraswati G. Anatomical variations of palmaris longus muscle. Anatomica Karnataka. 2010;4:74e77. 11. Cope JM, Looney EM, Craig CA, Gawron R, Lampros R, Mahoney R. Median nerve compression and reverse palmaris longus. Int J Anat Var. 2009;2:102e104. 12. Yildiz M, Sener M, Aynaci O. Three-headed reversed palmaris longus muscle: a case report and review of the literature. Surg Radiol Anat. 2000;22:217e219. 13. Roohi SA, Choon-Sian L, Shalimar A, Tan GH, Naiker AS. A study on absence of palmaris longus in a multi-racial population. Malays Orthop J. 2007;1:26e28. 14. Pai MM, Prabhu LV, Nayak SR, et al. The palmaris longus muscle: its anatomic variations and functional morphology. Rom J Morphol Embryol. 2008;49:215e217 [PubMed]. 15. Carroll Will, Gorman Thomas. Inside Tommy John Surgery. Baseball Prospectus; June 2009. Retrieved February 2012.
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/apme
Case Report
Unilateral absence of Palmaris longus muscle e A case report Nitya Waghray a,*, Aruna Jyothi b a
Tutor, Department of Anatomy, Apollo Institute of Medical Sciences and Research, Hyderabad, Telanganna, India Professor and Head of the Department, Apollo Institute of Medical Sciences and Research, Hyderabad, Telanganna, India
b
article info
abstract
Article history:
Ethnic variations in the prevalence of absence of the palmaris longus (PL) are well known. It
Received 29 October 2014
is not uncommon in individuals to have unilateral or bilateral absence of palmaris longus,
Accepted 13 November 2014
a structure which is often used in reconstructive plastic surgeries mainly in the grafting of
Available online 15 December 2014
tendons, although it has also been used for a wide variety of procedures including lip augmentation,1 ptosis correction2 and in the management of facial paralysis.3,4
Keywords:
During the routine dissection procedure being carried out for the 1st year MBBS stu-
Palmaris longus
dents at Apollo Institute of Medical Sciences and Research, we found the absence of Pal-
Variations
maris longus muscle unilaterally in the left upper extremity of a 58 year old male cadaver.
Reconstructive
Authors have compared their findings with the presence of palmaris longus muscle of
Lip augmentation
other limb and possible variations of palmaris longus muscle reported in the literature. The
Ptosis correction
importance of variation in absence of palmaris longus muscle has also been discussed. Copyright © 2014, Indraprastha Medical Corporation Ltd. All rights reserved.
1.
Introduction
Palmaris longus muscle is one of the superficial flexor muscles of the forearm. It is a slender muscle that acts on the skin and distal digital webs.5 It arises from the medial epicondyle of the humerus by the common flexor tendon, from the intramuscular septa between it and the adjacent muscles, and from the antebrachial fascia.6 It ends in a slender, flattened tendon, which passes distally lying on the medial side of the flexor carpi radialis.7 At the wrist it passes over the upper part of the flexor retinaculum and is inserted into the central part of the flexor retinaculum and lower part of the palmar aponeurosis, frequently sending a tendinous slip to the short muscles of the
thumb. It is supplied by the C7 and C8 fibers of the Median Nerve.6,8 Palmaris longus is described as one of the most variable muscles in our body and is classified as a phylogenetically retrogressive (i.e., a muscle with a short belly and a long tendon) metacarpophalangeal joint flexor. Palmaris longus though vestigial in man, it served a purpose in the lower vertebrates. However, as we evolved it lost its purpose gradually. In vertebrates, Palmaris Longus is found only in mammals and is best developed in those where the forelimbs are used for ambulation. It is variably absent in higher Apes such as Chimpanzees and Gorillas but always present in Orangutan.5 Numerous variations of Palmaris longus are reported in literature, the muscle being variable both in number and
* Corresponding author. E-mail address: [email protected] (N. Waghray). http://dx.doi.org/10.1016/j.apme.2014.11.005 0976-0016/Copyright © 2014, Indraprastha Medical Corporation Ltd. All rights reserved.
298
a p o l l o m e d i c i n e 1 1 ( 2 0 1 4 ) 2 9 7 e2 9 9
form.5,8,9 Concerning the kind of muscle, it may be fleshy throughout its entire length or may be digastrics. The muscle may have a proximal tendon or a distal one or may have muscle belly in center and tendon above & below or finally may consist solely of a tendinous band.8,10 It may be fleshy distally and tendinous proximally (Palmaris longus inversus), being known as the reversed Palmaris longus muscle (RPL).11 A three headed reversed Palmaris longus has also been reported as a surgical finding.8,5,12 Palmaris longus can be palpated by touching the pads of 5th & 1st fingers & flexing the wrist, the tendon, if present, will be visible. This test is known as Schaeffer's Test13 (Fig. 1).
2.
Case report
During the routine dissection being carried out for the 1st year MBBS students at Apollo Institute of Medical Sciences and Research, we found the absence of Palmaris longus muscle unilaterally in the left upper extremity of a 58 year old male cadaver. The forearm was observed for other structures such as the presence, origin and insertions of other flexor muscles which were found to be normal. Authors also observed the attachment of flexor retinaculum as well as the palmar aponeurosis which were found to be normal. The Palmaris longus muscle was found to be normally present on the right limb.
3.
Discussion
The text books on hand surgery explain the absence of Palmaris longus muscle as rare variation accounting to only about 15%, however this figure varies largely in the ethnic groups. The agenesis or absence of Palmaris longus muscle may be attributed to the Mendelian characteristics. According to the previously reported literature the absence of this muscle is said to be ranging from as low as 4% to as high as 25% with the lowest seen in the Mongoloid population and the highest in the white Causcasian population. On an average about 10% absence of this muscle has been universally accepted as reported in literature by Pai et al.14 Owing to the length and diameter of its tendon as well as its
advantage in which it doesn't lead to any functional deformities, the Palmaris longus muscle is very frequently used as a tendon graft for the wrist.15 Palmaris longus tendon is very frequently used as a graft for the ruptured flexor digitorum superficialis and profundus as well as the ruptured flexor pollicis longus. Prevalence of absence of Palmaris longus has been extensively studied following the first report of its absence in 1559 by Colombos in De Re Anatomica Libri. In their study of 800 living subjects; it was bilaterally absent in 7.7% cases, absent on right side in 4.5% cases and absent on left side in 5.2%.5,11 Reimann et al conducted a large scale study on about 1600 cadaveric limbs in the year 1944, in which they found that 12.8% of the patients had an absence of Palmaris longus muscle and about 9% of the patients expressed variations in the location and the type of muscle belly of Palmaris longus muscle. Bergmann (1988), in his study conducted on Palmaris longus observed the absence of this muscle more often in females as compared to males and usually the absence of the muscle was observed to be frequent in the left upper limb in both the sexes. Schaeffer in 1953 and Richard in 2003 reported the absence of PL in 10% cases either unilaterally or bilaterally, double Palmaris longus with a tendinous slip was reported by Saadeh in 1986, bifid reverse muscle by Regan in 1988, bilateral accessory muscle by Yildiz in 2000, duplication of the muscle by Kawashima in 2002 and conjoined tendon of Palmaris longus and flexor carpi ulnaris by Lemon in 2002. The absence of Palmaris longus has been studied in various ethnic and racial groups as well. The prevalence of its absence in Chinese population was found to be about 4.6%, in Caucasians 16.2%, in Nigerians 31.25%, in Ugandans 1.02%, in Zimbabweans 1.5%, in Congolese 3%, in Japanese 3.4%, in Germans 20.4%, in Americans 12.8%, in Indians 17.8% and in Turkish about 26.6%.5,11 In general there is low prevalence of its absence in Asians, Black and Native Americans. However different studies in the same population have also indicated different figures. The overall presence of Palmaris longus is found to be 70e85%. Apart from its ethnic and racial variations, its absence is more common in women, the bilateral absence being more common, and the unilateral absence is more common on left side.
Fig. 1 e Schaeffer's Test for testing the presence or absence of Palmaris longus muscle.
a p o l l o m e d i c i n e 1 1 ( 2 0 1 4 ) 2 9 7 e2 9 9
299
Fig. 2 e Absence of Palmaris longus. FCR: Flexor Carpi Radialis, FDS: Flexor Digitorum Superficialis, FR: Flexor Retinaculum, FCU: Flexor Carpi Ulnaris, UN: Ulnar nerve.
The present study is suggestive of the unilateral absence of Palmaris longus muscle on the left upper extremity of the 58 year old male cadaver (Fig. 2). This is comparable to a study conducted by Bergmann in 1988 in which he showed the unilateral absence of the muscle to be more frequent on the left side.
4.
Conclusion
The tendon of Palmaris longus is considered as an ideal donor for grafting of tendons as it can be used without causing major functional impairment; it is superficial in its location as well as insignificant in nature. It can be used as a replacement for the ruptured tendons of flexor digitorum superficialis and profundus, flexor pollicis longus and for the extensors of fingers. The significance of the tendon doesn't end with just the tendon grafting. It can as well be used as a simple static support in the treatment of facial paralysis. It is also used as a digital pulley for various reconstructive surgical procedures. It is a weak flexor and not a significant muscle but a little miracle used in various surgeries, hence proving that there is nothing created by nature that is insignificant.
Conflicts of interest All authors have none to declare.
references
1. Davidson BA. Lip augmentation using the palmaris longus tendon. Plast Reconstr Surg. 1995;95:1108e1110.
2. Kurihara K, Kojima T, Marumo E. Frontalis suspension for blepharoptosis using palmaris longus tendon. Ann Plast Surg. 1984;13:274e278. 3. Naugle Jr TC, Faust DC. Autogeneous palmaris longus tendon as frontalis suspension material for ptosis correction in children. Am J Ophthalmol. 1999;127:488e489. 4. Atiyeh BA, Hashim HA, Hamdan AM, Kayle DI, Musharafieh RS. Lower reconstruction and restoration of oral competence with dynamic palmaris longus vascularised sling. Arch Otolaryngol Head Neck Surg. 1998;124:1390e1392. 5. Sharma DK, Shukla CK, Sharma V. Clinical assessment of absence of palmaris longus and its association with gender, body sides, handedness, and other anomalies in population of central India. J Anat Soc India. 2012;61:13e20. 6. Gray H, Bennister LH, Berry MM, Williams PL. Gray's Anatomy: The Anatomical Basis of Medicine and Surgery. 38th ed. London: Churchill Livingstone; 1999:853. 7. Jones FW. The Principles of Anatomy as Seen in the Hand. Baillere, Ondon, Tindall and Cox; 1941. ria, Fazan Sassoli. Reversed palmaris longus 8. Paula Vale muscle and median nerve relationships: case report and literature review. Braz J Morphol Sci. 2007;24:88e91. 9. Nayak SR, Krishnamurthy A, Lakshmi AR, et al. Multiple muscular anomalies of upper extremity: a cadaveric study. Rom J Morphol Embryol. 2008;49:411e415. 10. Mobin N, Saraswati G. Anatomical variations of palmaris longus muscle. Anatomica Karnataka. 2010;4:74e77. 11. Cope JM, Looney EM, Craig CA, Gawron R, Lampros R, Mahoney R. Median nerve compression and reverse palmaris longus. Int J Anat Var. 2009;2:102e104. 12. Yildiz M, Sener M, Aynaci O. Three-headed reversed palmaris longus muscle: a case report and review of the literature. Surg Radiol Anat. 2000;22:217e219. 13. Roohi SA, Choon-Sian L, Shalimar A, Tan GH, Naiker AS. A study on absence of palmaris longus in a multi-racial population. Malays Orthop J. 2007;1:26e28. 14. Pai MM, Prabhu LV, Nayak SR, et al. The palmaris longus muscle: its anatomic variations and functional morphology. Rom J Morphol Embryol. 2008;49:215e217 [PubMed]. 15. Carroll Will, Gorman Thomas. Inside Tommy John Surgery. Baseball Prospectus; June 2009. Retrieved February 2012.