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Thenar eminence

The thenar eminence is the fleshy, muscular mound located on the radial aspect of the palm at the base of the thumb, formed by the intrinsic muscles of the thumb that facilitate its opposition, abduction, and flexion.^[1] It derives its name from the Greek word "thenar," meaning the palm of the hand.^[2] Composed primarily of three short muscles—the abductor pollicis brevis, flexor pollicis brevis, and opponens pollicis—the thenar eminence enables precise thumb movements essential for grasping, fine motor tasks, and human dexterity in tool use and manipulation.^[1]

Anatomy

Location and boundaries

The thenar eminence is the prominent, fleshy mound located on the radial (thumb) side of the palm, formed by the underlying thenar muscles that provide bulk to this region.^[1] It occupies the base of the thumb, spanning the area where the thumb metacarpal articulates with the carpal bones.^[3] Anatomically, the thenar eminence extends proximally to the flexor retinaculum (also known as the transverse carpal ligament) and distally to the thumb's web space near the metacarpophalangeal joint.^[1] Its boundaries are precisely defined: the medial (ulnar) border is marked by the thenar crease, separating it from the central palm; the lateral (radial) border follows the first metacarpal and the trapezium bone; the proximal limit is at the flexor retinaculum, anchoring the origins of the contributing muscles; and the distal limit reaches the web space between the thumb and index finger.^[1]^[4] In surface anatomy, the thenar eminence is visible as a subtle, rounded elevation in the relaxed hand, becoming more pronounced and palpable when the thumb is abducted or opposed due to contraction of the underlying muscles.^[1] It relates closely to the skin creases of the palm, lying proximal to the distal palmar crease and bordered laterally by the thenar crease, a curved fold that outlines the base of the mound and facilitates thumb mobility.^[5] This palpability aids in clinical assessment, as the eminence can be easily identified by pressing at the thumb base on the palmar surface.^[3]

Muscles

The thenar eminence is composed primarily of three intrinsic hand muscles that provide its characteristic bulk: the abductor pollicis brevis, flexor pollicis brevis, and opponens pollicis. The adductor pollicis lies deep to these muscles in the palm.^[1]^[6] The abductor pollicis brevis is the most superficial of these muscles and lies laterally; it originates from the flexor retinaculum and the tubercles of the scaphoid and trapezium bones, inserting into the lateral aspect of the base of the thumb's proximal phalanx.^[1]^[7] The flexor pollicis brevis has two heads: a superficial head originating from the tubercle of the trapezium and the flexor retinaculum, and a deep head arising from the ulnar side of the first metacarpal or adjacent structures; both heads insert into the lateral base of the thumb's proximal phalanx.^[1]^[8] The opponens pollicis, the largest thenar muscle, is located deep and originates from the flexor retinaculum and the tubercle of the trapezium, inserting along the anterolateral surface of the first metacarpal shaft.^[1]^[7] The adductor pollicis, a deep palmar muscle that contributes to thumb adduction, consists of transverse and oblique heads; the transverse head originates from the anterior surface of the third metacarpal, while the oblique head arises from the capitate bone and the bases of the second and third metacarpals, with both inserting into the medial base of the thumb's proximal phalanx.^[6]^[7] These thenar muscles are organized into superficial and deep layers. The superficial layer includes the abductor pollicis brevis and the superficial head of the flexor pollicis brevis, while the deep layer encompasses the opponens pollicis and the deep head of the flexor pollicis brevis.^[1]^[8] Origins generally arise from the flexor retinaculum, scaphoid, trapezium, and capitate bones, with insertions primarily on the proximal phalanx or first metacarpal of the thumb.^[7]^[6] Anatomical variations in these muscles include accessory heads or slips, particularly in the abductor pollicis brevis and flexor pollicis brevis, as well as occasional absence or fusion of the opponens pollicis and fascicular differences in the adductor pollicis, observed in certain populations based on cadaveric studies.^[9]^[6]

Vascular supply

The vascular supply to the thenar eminence is primarily arterial, ensuring adequate perfusion to the underlying muscles and overlying skin at the base of the thumb. The main arterial source is the superficial palmar branch of the radial artery, which arises proximal to the flexor retinaculum and courses superficially across the thenar region to nourish the area.^[1] Additional contributions come from the princeps pollicis artery, a branch of the radial artery that supplies the base of the thumb and forms recurrent branches around the first metacarpal bone.^[10] These vessels anastomose with the deep palmar arch, primarily formed by the radial artery with ulnar contributions, providing collateral circulation that enhances regional blood flow and supports surgical considerations for flap transfers.^[1] Venous drainage parallels the arterial supply, with superficial palmar veins collecting blood from the thenar eminence and directing it toward the cephalic vein system along the radial aspect of the hand.^[3] Deep venous drainage follows the accompanying arteries, contributing to overall hand venous return via the dorsal venous network.^[11] Lymphatic drainage from the thenar eminence proceeds along the radial side of the hand toward the cubital lymph nodes in the cubital fossa, before ultimately reaching the axillary nodes and returning to the central lymphatic system.^[12] Anatomical variations in the palmar arches can affect thenar perfusion; for instance, a complete superficial palmar arch, formed by ulnar and radial contributions, occurs in approximately 75% of cases, while incomplete arches are seen in 25%, potentially influencing collateral flow in vascular compromise.^[13]

Nerve supply

The primary motor innervation of the thenar eminence is provided by the median nerve (C6-T1), specifically through its recurrent motor branch, which emerges in the distal portion of the carpal tunnel and supplies the abductor pollicis brevis, opponens pollicis, and superficial head of the flexor pollicis brevis muscles.^[1]^[14] The recurrent motor branch typically originates from the radial side of the median nerve just distal to the flexor retinaculum, then loops volarly around the distal edge of the retinaculum in an extraligamentous fashion (most common variant), traveling superficially toward the thenar muscles and passing near the tubercle of the scaphoid, where it is particularly vulnerable to injury during surgical procedures.^[14]^[15] The ulnar nerve (C8-T1) contributes to the motor supply via its deep branch, innervating the deep head of the flexor pollicis brevis and the adductor pollicis (a deep palmar muscle).^[1]^[16] In approximately 12-30% of cases, variations occur where the adductor pollicis receives partial or full innervation from the median nerve instead of the ulnar nerve.^[17] Sensory innervation to the skin overlying the thenar eminence is supplied by the palmar cutaneous branch of the median nerve, which arises proximal to the carpal tunnel and provides sensation to the central palm and thenar region; the thumb web space receives additional sensory input from the digital branches of the median nerve.^[18]^[19] Anatomical variations in thenar innervation are common, with the Martin-Gruber anastomosis—a connection where motor fibers from the median nerve in the forearm join the ulnar nerve—occurring in 15-20% of individuals and potentially altering the expected distribution of thenar motor supply by providing median-derived fibers to ulnar-innervated muscles.^[20]

Function

Primary movements

The trapeziometacarpal (TMC) joint, a saddle joint between the trapezium and the base of the first metacarpal, enables multiplanar motion of the thumb through three degrees of freedom: flexion-extension, abduction-adduction, and axial rotation. This configuration allows the thenar eminence muscles to facilitate precise thumb positioning essential for hand dexterity. Typical ranges of motion at the TMC joint include approximately 41° for flexion-extension, 51° for abduction-adduction, and 21° for axial rotation.^[21] Abduction of the thumb, primarily mediated by the abductor pollicis brevis muscle, involves radial deviation at the carpometacarpal (CMC) joint, moving the thumb away from the plane of the index finger.^[1] This muscle originates from the tubercles of the scaphoid and trapezium and the flexor retinaculum, inserting on the lateral aspect of the proximal phalanx base, thereby drawing the thumb perpendicular to the palm in the radial direction.^[8] Flexion at the thumb is achieved by the flexor pollicis brevis muscle, which acts on both the CMC and metacarpophalangeal (MCP) joints to bend the thumb toward the palm.^[1] Comprising superficial and deep heads, this muscle originates from the trapezium tubercle, flexor retinaculum, and base of the second metacarpal, inserting on the base of the proximal phalanx to produce palmar flexion.^[8] Opposition is driven by the opponens pollicis muscle, which rotates and adducts the thumb at the CMC joint, positioning the thumb pad toward the fingertips.^[1] Originating from the tubercle of the trapezium and the flexor retinaculum, it inserts along the anterolateral shaft of the first metacarpal, facilitating medial rotation and flexion to enable the thumb to cross the palm.^[8] These primary movements collectively contribute to the thumb's opposition capability, allowing touch between the thumb and other digits.^[1]

Role in grip and opposition

The thenar eminence plays a pivotal role in the opposition mechanism, enabling the thumb to position its palmar surface against the fingers for precision grips such as pinching or writing. This movement, primarily driven by the opponens pollicis muscle within the eminence, allows the thumb tip to contact other digits, facilitating fine motor tasks essential for dexterity.^[1]^[22] In grip types, the thenar eminence contributes to both power and precision actions through synergistic muscle activity. During power grip, such as grasping a cylindrical object, the thenar muscles adduct the thumb to provide stability against the palm, supporting forceful extrinsic muscle contractions. In contrast, tip-to-tip pinch relies on thenar-mediated flexion and abduction synergy to align the thumb precisely with fingertips, enabling controlled manipulation.^[22] Evolutionarily, enhanced opposition in the human thenar eminence distinguishes Homo species from other primates, promoting advanced tool use and cultural development around 2 million years ago. Unlike chimpanzees, whose thumb opposition yields only about 44% of human torque efficiency due to smaller muscle cross-sections, human adaptations in the trapeziometacarpal joint and thenar musculature support superior precision grasping for dietary and technological advancements.^[23] Biomechanically, the thenar eminence integrates with the hypothenar complex and interossei muscles to maintain stable hand posture during prehensile activities. This coordination ensures balanced force distribution across the palm, with thenar adduction countering hypothenar abduction and interossei stabilizing metacarpophalangeal joints for sustained grip integrity.^[22]

Clinical significance

Common disorders

One of the most prevalent disorders affecting the thenar eminence is thenar atrophy, which results from chronic compression of the median nerve, most commonly in carpal tunnel syndrome (CTS).^[24] In advanced CTS, the recurrent motor branch of the median nerve becomes compromised, leading to denervation and wasting of the thenar muscles, manifesting as a flattened appearance of the eminence and progressive weakness in thumb opposition and abduction.^[25] CTS affects approximately 3.8% of the general adult population, with thenar involvement typically occurring in severe, untreated cases.^[26] Thenar atrophy can also indicate early amyotrophic lateral sclerosis (ALS) through the "split hand" sign, where preferential wasting of thenar muscles occurs compared to hypothenar, aiding differentiation from ulnar neuropathy or other motor neuron diseases.^[1] Median nerve injury at or proximal to the carpal tunnel may cause ape hand deformity, featuring loss of thumb opposition, abduction, and a flattened thenar eminence due to unopposed action of extrinsic extensors.^[1] De Quervain's tenosynovitis involves inflammation and thickening of the tendon sheaths enclosing the abductor pollicis longus and extensor pollicis brevis, which, although extrinsic to the thenar eminence, produces pain radiating to the radial aspect of the wrist and base of the thumb.^[27] This condition often arises from repetitive thumb and wrist motions, resulting in swelling and tenderness over the thenar region that impairs grip strength and thumb mobility.^[28] Trigger thumb, or stenosing tenosynovitis of the flexor pollicis longus tendon, causes mechanical locking or catching during thumb flexion, indirectly affecting thenar function by limiting smooth opposition and pinch.^[29] The pathology stems from nodular hypertrophy within the tendon sheath at the metacarpophalangeal joint, leading to pain and stiffness that can extend to the thenar eminence with prolonged episodes.^[30] Fractures and dislocations involving the trapezium or base of the first metacarpal frequently lead to deformity and dysfunction of the thenar eminence due to its anatomical proximity and reliance on these structures for stability.^[31] Such injuries, often from high-energy axial loading or falls, present with localized pain, swelling, and ecchymosis over the thenar mound, accompanied by reduced thumb range of motion and potential malunion that flattens the eminence contour.^[32]

Diagnostic and therapeutic approaches

Diagnosis of thenar eminence-related issues typically begins with a thorough physical examination to assess muscle atrophy, strength, and sensory deficits. Key maneuvers include Phalen's test, which involves wrist flexion to provoke median nerve compression symptoms indicative of carpal tunnel syndrome affecting the thenar muscles, and Froment's sign, where compensatory thumb flexion during key pinch reveals ulnar nerve involvement impacting thenar function.^[33]^[34] Inspection for thenar wasting and palpation for tenderness further guide initial evaluation.^[26] Imaging modalities such as magnetic resonance imaging (MRI) are employed to visualize thenar muscle atrophy and rule out structural causes like masses or nerve entrapment, while ultrasound assesses vascular flow and dynamic tendon pathology in conditions like de Quervain's tenosynovitis.^[35]^[36] Electromyography (EMG) and nerve conduction studies provide objective data on innervation deficits, confirming median nerve dysfunction with sensitivities up to 85% in moderate cases.^[37] Conservative therapies form the first-line management for early or mild thenar eminence involvement, emphasizing rest and symptom relief. Splinting, particularly thumb spica orthoses, immobilizes the wrist and thumb to alleviate pressure on the median nerve or extensor tendons, often combined with nonsteroidal anti-inflammatory drugs (NSAIDs) to reduce inflammation in de Quervain's tenosynovitis or early atrophy.^[33]^[27] Physical therapy incorporates stretching, strengthening exercises, and modalities like ultrasound to improve opposition and grip without invasive measures.^[38]^[39] Surgical interventions are indicated for persistent or severe cases, with carpal tunnel release being the standard for median nerve compression to preserve the recurrent motor branch supplying the thenar muscles.^[1] For thumb basal joint arthritis contributing to thenar pain, trapeziectomy with ligament reconstruction and tendon interposition (LRTI) removes the arthritic trapezium and stabilizes the joint.^[40] Tendon repairs address specific injuries like de Quervain's release, involving incision of the first dorsal compartment.^[41] Outcomes of these approaches vary by intervention and severity, with carpal tunnel release achieving symptom relief in 80-90% of patients and partial reversal of thenar atrophy in many cases, though full muscle recovery may take 6-12 months.^[42]^[43]^[35] Trapeziectomy yields high satisfaction rates of 89-96%, with significant pain reduction and improved pinch strength at long-term follow-up.^[40]^[44] Rehabilitation protocols post-surgery focus on progressive opposition exercises to restore thumb function, typically spanning 6-8 weeks.^[45] Emerging therapies include botulinum toxin (Botox) injections for spasticity affecting the thenar eminence, targeting overactive muscles to enhance function in neurological conditions with reported improvements in hand dexterity.^[46] Regenerative options like platelet-rich plasma (PRP) injections show promise for thumb carpometacarpal osteoarthritis, reducing pain and potentially delaying surgery with effects lasting 6-12 months in preliminary studies.^[47]^[48]

References

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