Transcript
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Elraiah Mohamed MakieElraiah Mohamed Makie
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Objectives By the end of this presentation audience should beBy the end of this presentation audience should be
able to :able to :
1.1. DescribeDescribe the surface anatomy of the hand.2. the fascial compartment of the hand.
3.3. UnderstandUnderstand the muscles of the hand.
4.4. UnderstandUnderstand how the nerves and blood vessels
arraned in the hand .!.!. UnderstandUnderstand the common clinical correlations of the
hand..
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Case study35 years old lady presented to her
GP complaining of numbness of the
hand in the thumb region ,She wasknown case of hypothyroidism Shewas diagnosed as carpal tunnel
syndrome
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!uestions"hat are the attachments of the #e$orretinaculum
"hat are the structures passes in andoutside the tunnel
"hat is the classical presentation
%n this case the thinner muscles was wasted
while the sensation is preserved, why&"hat is the deformity called and why it took
place&
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The skeleton of thehand
1/Carpal bones(8)
2/Metacarpal bones(5)
3/Phalenges(14)
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Fracture of the Scaphoid'he scaphoid is the most
fre(uently fractured carpalbone%t often results from a fall
on the palm when thehand is abducted,
the fracture occurringacross the narrow part ofthe scaphoid)
Owing to the poor bloodsupply to the pro$imal part
of the scaphoid, union ofthe fractured parts maytake long time to healing
*vascular necrosis of thepro$imal fragment of thescaphoid may occur
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Fracture of the scaphoidFracture of the scaphoid:
occurs after a fall on the
outstretched hand and maydamage the radial artery and
cause avascular necrosis of
the bone.
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Surface anatomy ofhand
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Surface anatomy ofhand
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Surface anatomy ofhand
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Surface anatomy of ha
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Surface anatomy of
hand
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Surface anatomy
of hand
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Surface anatomy of hand
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Surface anatomy of hand
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Dermatomes of the upperlimb
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+utaneous %nnervations of the and
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Palm of hand
Flexor retinaculumFlexor retinaculumThicening o! deep !ascia in the hand"ttached laterally to scaphoid and trape#iun
and medially to pisi!orm and hamate bone $
Carpal tunnelCarpal tunnelFormed by %exor retinaculum and carpal
groo&eTransmits'
Median nMedian n$ F*+FPF*+FP enclosed by common %exor sheath FP,FP, FC-FC-
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Carpal tunnel
%s formed anteriorly by the #e$or retinaculum and posteriorly by the ca'ransmits the median ner&e and the tendons o! %exor pollicis lopro!undus. and %exor digitorum super/cialis muscles$
l
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Palmaraponeurosis
palmar aponeurosis
%s a triangular -brous layeroverlying the tendons inthe palm and is continuouswith thepalmaris longus tendon,
the thenar and hypothenarfasciae, the #e$orretinaculum, and thepalmar carpal ligament
Protects the super-cialpalmar arterial arch, thepalmar digital nerves, andthe long #e$ortendons
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Palmar Spaces
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Fascial spaces o! thepalm*re fascial spaces deep to the palmar
aponeurosis and divided by a midpalmar)obli(ue. septum into the thenar space andthe midpalmar space$
1. Thenar space %s the lateral space thatcontains the #e$or pollicis longus tendon andthe other #e$or tendons of the inde$ -nger
2. Midpalmar space %s the medial spacethat contains the #e$or tendons of the medialthree digits
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P/0P SP*+1 On the palmar side of the tip of -ngers and thump
+ontains fatty tissue that is divided into numerouscompartments by -brous septa that pass between thedistal phalanges and skin+ontaining terminal arteries andnerves
'he space is limited pro$imally by the -rm adherence of skin todistal #ection crease to underlying tissue
'his prevent spread of infection
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*yno&ial %exor sheaths
1. Common synovial e!or sheath "ulnarbursa#
1nvelops or contains the tendons of both the
#e$or digitorum super-cialis and profundusmuscles
2. Synovial sheath for e!or pollicislon$us "radial bursa#
1nvelops the tendon of the #e$or pollicis longusmuscle
Flexor tendons common flexor sheath fibrous
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Flexor tendons, common flexor sheath, fibrous
digital sheaths, and synovial sheaths of digits
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2uscles of the and Thenar group 'Thenar group '4le$or pollicis brevis4le$or pollicis brevis*bductor pollicis brevis*bductor pollicis brevis
Opponence pollicisOpponence pollicis
0ypothenar0ypothenargroup 'group '
4le$or digiti minimi4le$or digiti minimi
*bductor digitidigiti*bductor digitidigitiminimiminimi
opponence minimiopponence minimi
,umbricals
"dductor pollicis
nterossei
palmar
dorsal
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2pponen2pponens polliciss pollicis
4le$or retinaculum and tubercles4le$or retinaculum and tuberclesof scaphoid and trapeiumof scaphoid and trapeium
0ateral side0ateral sideof 6stof 6st
metacarpalmetacarpal
7ecurre7ecurrentnt
branchbranchofof
medialmedialnervenerve
))C8C8,,'6'6..
'o oppose thumb,'o oppose thumb,it draws 6stit draws 6stmetacarpalmetacarpal
medially to centermedially to centerof palm andof palm and
rotates it mediallyrotates it medially
"bductor"bductorpollicispollicis
bre&isbre&is
4le$or retinaculum and tubercles4le$or retinaculum and tuberclesof scaphoid and trapeiumof scaphoid and trapeium
0ateral side0ateral sideof base ofof base of
pro$imalpro$imalphalan$ ofphalan$ of
thumbthumb
7ecurre7ecurrentnt
branchbranchofof
medialmedialnervenerve
))C8C8,,'6'6..
*bducts thumb8*bducts thumb8helps oppose ithelps oppose it
FlexorFlexorpollicispollicisbre&isbre&is
4le$or retinaculum and tubercles4le$or retinaculum and tuberclesof scaphoid and trapeiumof scaphoid and trapeium 0ateral side0ateral sideof base ofof base ofpro$imalpro$imal
phalan$ ofphalan$ ofthumbthumb
7ecurre7ecurrentntbranchbranch
ofofmedialmedialnervenerve
))C8C8,,'6'6..
4le$es thumb4le$es thumb
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%bductor di$iti%bductor di$itiminimiminimi
PisiformPisiform 2edial side of base of2edial side of base ofpro$imal phalan$ ofpro$imal phalan$ of
5th -nger5th -nger
9eep9eepbranch ofbranch of
ulnarulnarnerve )+:nerve )+:,,
T1T1..
*bducts 5th -nger8*bducts 5th -nger8assists in #e$ion of itsassists in #e$ion of its
pro$imal phalan$pro$imal phalan$
Fle!or di$itiFle!or di$itiminimi brevisminimi brevis
ook ofook ofhamate andhamate and
#e$or#e$orretinaculumretinaculum
2edial side of base of2edial side of base ofpro$imal phalan$ ofpro$imal phalan$ of
5th -nger5th -nger
9eep9eepbranch ofbranch of
ulnarulnarnerve )+:nerve )+:,,
T1T1..
4le$es pro$imal phalan$4le$es pro$imal phalan$of 5th -ngerof 5th -nger
&pponens di$iti&pponens di$iti
minimiminimi
ook ofook of
hamate andhamate and#e$or#e$or
retinaculumretinaculum
2edial border of 5th2edial border of 5th
metacarpalmetacarpal
9eep9eep
branch ofbranch ofulnarulnar
nerve )+:nerve )+:,,T1T1..
9raws 5th metacarpal9raws 5th metacarpal
anterior and rotates it,anterior and rotates it,bringing 5th -nger intobringing 5th -nger intoopposition with thumbopposition with thumb
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'umbricals
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0umbricals0umbricals originorigin insertioninsertion innervatiinnervationon
actionaction
st and ;ndst and ;nd 0ateral two0ateral twotendons oftendons of#e$or#e$or
digitorumdigitorumprofundusprofundus
)as)asunipennateunipennate
musclesmuscles..
0ateral0ateralsidese$tensorsidese$tensorofof
e$pansions ofe$pansions of;nd5th;nd5th
-ngers-ngers
2edian2ediannervenerve)+:)+:,, T1T1..
4le$4le$metacarpopmetacarpophalangealhalangealjoints8joints8e$tende$tend
interphalaninterphalangeal jointsgeal joints
ofof;nd5th;nd5th
-ngers-ngers
rd and ?thrd and ?th
2edial three2edial threetendons oftendons of
#e$or#e$ordigitorumdigitorumprofundusprofundus
)as)as
bipennatebipennate
0ateral sides0ateral sidesof e$tensorof e$tensor
e$pansions ofe$pansions of;nd5th;nd5th
-ngers-ngers
9eep9eep
branch ofbranch ofulnarulnarnervenerve
)+:)+:,, T1T1..
4le$4le$
metacarpopmetacarpophalangealhalangealjoints8joints8e$tende$tend
interphalaninterphalan
geal jointsgeal joints
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interossei
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DorsalDorsalinterosseiinterossei
, 6st?th, 6st?th
*djacent sides of*djacent sides oftwo metacarpalstwo metacarpals
)as bipennate)as bipennatemusclesmuscles..
@ases of@ases ofpro$imalpro$imal
phalanges8phalanges8e$tensore$tensor
e$pansions ofe$pansions of
;nd?th -nger;nd?th -nger
9eep branch of9eep branch ofulnar nerve )+:ulnar nerve )+:,,
T1T1..
*bduct ;nd?th*bduct ;nd?th-ngers from a$ial-ngers from a$ial
line8 act withline8 act withlumbricals inlumbricals in
#e$ing#e$ing
metacarpophalanmetacarpophalangeal joints andgeal joints ande$tendinge$tending
interphalangealinterphalangealjointsjoints
PalmarPalmarinterosseiinterossei
. 1. 1stst3rd3rd
Palmar surfacesPalmar surfacesof ;nd, ?th, andof ;nd, ?th, and5th metacarpals5th metacarpals)as unipennate)as unipennate
musclesmuscles..
@ases of@ases ofpro$imalpro$imal
phalanges8phalanges8e$tensore$tensor
e$pansions ofe$pansions of
;nd, ?th, and;nd, ?th, and5th -ngers5th -ngers
9eep branch of9eep branch ofulnar nerve )+:ulnar nerve )+:,,
T1T1..
*dduct ;nd, ?th,*dduct ;nd, ?th,and 5th -ngersand 5th -ngers
toward a$ial line8toward a$ial line8assistassist
lumbmetacarAlumbmetacarA
pophalangealpophalangealricals in #e$ingricals in #e$ing
joints andjoints ande$tendinge$tending
interphalangealinterphalangealjoints8 e$tensorjoints8 e$tensor
e$pansions ofe$pansions of;nd?th -ngers;nd?th -ngers
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*ctions of muscles of the
hand
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%rteries of the
(andThe ulnar artery enters the hand anterior to the flexor retinaculum
between the pisiform and the hook of the hamate via the ulnar
canal (Guyon canal). The ulnar artery lies lateral to the ulnar The
artery divides into two terminal branches, the superficial palmar
arch and the deep palmar branch. The superficial palmar arch,
the main termination of the ulnar artery, gives rise to three
common palmar digital arteries that anastomose with the palmar
metacarpal arteries from the deep palmar arch. Each common
palmar digital artery divides into a pair of proper palmar digital
arteries that run along the adacent sides of the !nd"#$%thfingers
)lnar %rtery
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-adial "rtery
%t curves dorsally around the scaphoid and trapeiumand the #oor of the enters the palm by passingbetween the heads of the 6st dorsal interosseousmuscle and then turns medially, passing between the
heads of the adductor pollicis 'he radial artery endsby anastomosing with the deep branch of the ulnarartery to form the deep palmar arch, which is formedmainly by the radial artery 'his arch lies across themetacarpals just distal to their bases. 'he deep
palmar arch gives rise to three palmar metacarpalarteries and the princeps pollicis artery 'he radialisindicis artery passes along the lateral side of the inde$-nger %t usually arises from the radial artery, but it
may originate from the princeps pollicis
Blood supply
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Blood supply
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palmar archespalmar arches
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Super-cial palmar archSuper-cial palmar arch
4ormed by ulnar artery andsuper-cial palmar branch ofradial artery
+urve of arch lies across thepalm, level with the distalborder of fully e$tendedthumb
Gives rise to three commonpalmar digital arteries eachthen divides into two properpalmar digital arteries
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9eep palmar arch9eep palmar arch
4ormed by radial artery and deeppalmar branch of ulnar artery
+urve of arch lies across upper part
of palmar at level with pro$imalborder of e$tended thumb
Gives rise to three palmar
metacarpal arteries
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Beins of the and
Super-cial and deep venouspalmar arches, associated withthe super-cial and deep palmar)arterial. arches, drain into thedeep veins of the forearm 'hedorsal digital veins drain intothree dorsal metacarpal veins,which unite to form a dorsal
venous network. Super-cial tothe metacarpus, this network isprolonged pro$imally on thelateral side as the cephalic vein
'he basilic vein arises from themedial side of the dorsal venous
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0ymphatic 9rainage
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Cerves of handMedian nMedian n$$thenar except adductor pollicis. /rst to
lumbricals sin o! thenar. central part o! palm.
palmar aspect o! radial three and onehal! /ngers.including middle and distal /ngers on dorsum6lnar n$6lnar n$ hypothenar muscles. interossei. 3rd and
4th lumbricals and adductor pollicis sin o!hypothenar. palmar sur!ace o! ulnar one and onehal! /ngers
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-adial n$-adial n$ sin o! radial sideo! dorsum o! hand and radialto and onehal! /ngers
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"natomical snu7"natomical snu7
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s a triangular inter&al bounded mediallyby the tendon o! the extensor pollicislongus
muscle and laterally by the tendons of thee$tensor pollicis brevis and abductor pollicis
longus muscles
%s limited pro$imally by the styloid process ofthe radius
as a #oor formed by the scaphoid andtrapeium bones and crossed by the radial
artery$
"natomical snu7"natomical snu7
Anatomical snuff boxAnatomical snuff box
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Anatomical snuff boxAnatomical snuff box
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2allet 4ingerMallet/nger)ammer or baseball -nger.Dis a -nger with permanent #e$ion of the
distal phalan$ due to an avulsion of the
medial and lateral bands of the e$tensortendon to the distal phalan$
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upuytrenscontracture' is aprogressi&e
thicening. shortening.and /brosis o! thepalmar fascia, especiallythe palmar aponeurosis,producing a #e$iondeformity of -ngers inwhich the -ngers arepulled toward the palm)inability to fully e$tend
-ngers., especially the
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Trigger Fingerresults from stenosing tenosynovitis or occurs when the#e$or tendon develops a nodule or swelling thatinterferes with its gliding through the pulley, causing anaudible clicking or snapping Symptoms are pain at the
joints and a clicking when e$tending or #e$ing the joints
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+arpel tunnel syndrome * 2echanismD overuse, congenital, trauma @ PathologyD +ompression of the median
nerve in the tunnel
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Carpal tunnel syndrome ' is caused bycompression o! the median ner&e due to thereduced sie of the osseo-brous carpal tunnel,resulting from in#ammation of the #e$or retinaculum,
arthritic changes in the carpal bones, or in#ammationor thickening of the synovial sheaths of the #e$ortendons%t leads to pain and paresthesia )tingling, burning,
and numbness. in the hand in the area supplied bythe median nerve and may also cause atrophy of thethenar muscles in cases of severe compressionowever, no paresthesia occurs over the thenareminence of skin because this area is supplied by the
palmar cutaneous branch of the median nerve
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The "llens test' is a test !or occlusion o! the radial orulnar artery either the radial or ulnar artery
is digitally compressed by the e$aminer after blood has beenforced out of the hand by making a tight -st8 failure of the bloodto return to the palm and -ngers on opening indicates that theuncompressed artery is occluded
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%njury to 7adial Cerve
%njured in the radialgroove, the triceps isusually not completelyparalyed
Posterior compartmentof the forearm that aresupplied by more distalbranches of the radial
nerve are paralyed+haracteristic clinicalsign of radial nerveinjury is wristAdrop
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/lnar nerve injury ,Partial
claw hand
If the nerve divided in laceration of the wrist .
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2edian nerve injury, *pe
hand%n the elbow regionresults in loss of #e$ionof the pro$imal anddistal interphalangealjoints of the ;nd and 3rddigits 'he ability to #e$themetacarpophalangealjoints of these digits isalso aEected
*pe handrefers to a
deformity in whichthumb movements arelimited to #e$ion ande$tension of the thumbin the plane of the palm
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"ood luck