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Apr 13, 2018

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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

    http://www.pncl.co.uk/~belcher/tenosyn.htm

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    Surface anatomy ofhand

    http://www.pncl.co.uk/~belcher/tenosyn.htm

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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