M1 – Anatomy •Deep Hand Dorsum of the Hand & Forearm Extensor Region
Dr. Simpson
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1898 Nobel Prize: Elizabeth Blackwell: •Pierre Curie •Marie Sklodowska-Curie* First Female Physician in the U.S.
•1847. Geneva, New York. Students thought it was a prank engineered by a rival school when they were asked to vote •1st radiograph whether Elizabeth Blackwell should be allowed to enroll. It was no joke, she graduated 1st in the class. •1st to use the term radioactivity • 1868. Established her own women's medical college •1st woman in Europe to receive Ph.D. in science •1st woman to win Nobel Prize (Physics) •1st woman to win second Nobel Prize (Chemistry) (*her daughter won a Nobel in 1935)
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Motions of the Hand* Three Keys to the Anatomy of the Hand Fingers
•Movements of the thumb* Thumb •Movements of the non-thumbs*
*If you can keep track of these anatomical conventions you will be able to more rapidly absorb the complex anatomy of the hand and be able to remember the correct name for many of the intrinsic muscles under consideration today. *If you can keep track of these anatomical conventions you will be able 5 6 to name many of the muscles under consideration in this lecture. C5 Medial Epicondyle Superior Trunk Lateral Cord Musculocutaneous Pronator Teres Flexor carpi radialis C6 Palmaris longus Axillary Nerve Flexor carpi ulnaris
Middle Trunk Posterior Cord C7 Median Nerve Flexor digitorum superficialis
*** Radial Nerve C8 Inferior Trunk Medial Cord Ulnar Nerve Flexor digitorum profundus Flexor pollicis longus Pronator Quadratus T1 Ulna Radius Robert Taylor Drinks.. Cold….. Beer *** Ulnar artery and nerve separate the 7 superficial and deep anterior compartments 8
The Hand Central Compartment
1. Central Palmar aponeurosis The hand is 2. Thenar subdivided into five regions, 3. Hypothenar •Deep, Superficial Flexor & generally Pollicis tendons separated from 4. Adductor-Interosseous one another by •Median & Ulnar nerves fascia* 5. Dorsum •Radial & Ulnar artery
*Infection tends to travel within the compartments 9 10
Neurovascular Axillary Radial Ulnar Considerations Brachial
Profunda Superficial Palmar Arch Deep Palmar Arch
Common Palmar Digital Radial Ulnar Branches
Common Interosseus Proper Digital Branches Posterior Anterior
11 12 Neurovascular Relationships Ulnar Nerve
Passes with ulnar collateral artery behind the medial epicondyle to enter forearm. Passes between the two origins of the flexor carpi ulnaris. Traverses forearm, meets ulnar artery in the plane between the superficial and deep compartments. Ulnar artery passes over the flexor retinaculum to form the superfical palmar arch. The radial artery passes posterior to the thumb, passes
behind the adductor pollicis and contributes to the formation of the 13 14 deep palmar arch.
Ulnar Nerve Median Nerve
•Enters hand Enters forearm via lateral to ulnar cubital fossa. Passes artery, passing between the heads of over the flexor pronator teres and retinaculum with travels in the plane that the ulnar artery. separates the superficial Supplies some and deep anterior muscle stuff and compartments of the the palmar forearm. Enters hand surface of ulnar passing under flexor 11/2 digits retinaculum.
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Median Nerve Carpal Tunnel
•Enters hand in a medial position and passes under the flexor retinaculum. Supplies some muscle stuff and the palmar surface, radial 31/2 digits.
17 18 Carpal Superficial and Deep Flexor tendons pass Tunnel through the ulnar bursa and continue into the fibrous digital tendon sheaths. Flexor pollicis longus Carpal Tunnel Syndrome tendon enters a separate bursa-the • Numbness, tingling & pain in hand radial bursa • Inability to oppose thumb • Muscle atrophy may be evident • Usually no specific injury at onset 19 20
Carpal Tunnel Syndrome Lumbricals •Origin Radial radial side of flexor digitorum profundus tendons •Insertion Dorsum of extensor hood.
Risk Factors: •Innervated by the nerve that innervates the •More common in women tendon of origin-ulnar 2 by ulnar, radial 2 •Repetitive motion injury by median •Age, Diabetes, Thyroid dysfunction Flex metacarpophalangeal joints, extend the and Rheumatoid Arthritis interphalangeal joints via attachment to dorsal hood Goals of Treatment/Surgery: •Eliminate pain •Restore gliding capacity of median nerve •Relieve compression if tissue is bulky & displaces flexor tendons 21 22
Lumbricals •Origin Radial radial side of flexor digitorum profundus tendons
•Insertion Dorsum of extensor hood.
•Innervation Lumbricals cannot abduct or By the nerve that innervates adduct-they lack mechanical the tendon of origin-ulnar 2 advantage (fiber orientation) Flex metacarpophalangeal joints, Extend the interphalangeal joints, in by ulnar, radial 2 by median and are not attached to the conjunction with the (intrinsic) interossei and the (extrinsic) extensors 23of metacarpals 24 the fingers via attachment to dorsal hood Medial Epicondyle C5 Pronator teres Superior Trunk Lateral Cord Musculocutaneous •Flexor carpi radialis C6 •Palmaris longus •Flexor carpi ulnaris
Flexor digitorum superficialis C7 Middle Trunk Median Nerve •1 Lumbrical ** •2 Lumbrical Flexor digitorum profundus Flexor pollicis longus C8 Ulnar Nerve Pronator quadratus Inferior Trunk Medial Cord Ulna Radius •3 Lumbrical T1 •4 Lumbrical Innervation of the anterior compartment by ulnar nerve 25 26
The Hand Thenar Compartment
1. Central Contents: The hand is •Abductor pollicis brevis subdivided into 2. Thenar five regions, •Flexor pollicis brevis generally 3. Hypothenar separated from •Opponens pollicis 4. Adductor-Interosseous one another by •tendon of flexor pollicis longus fascia 5. Dorsum
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Motions of the Hand Abductor pollicis brevis •Origin: Flexor retinaculum, some fibers from Fingers trapezium Thumb •Insertion: Radial surface of proximal phalanx •Innervation: Median Nerve Action: Abduction
29 30 Flexor pollicis brevis Opponens pollicis
•Origin: •Origin: Flexor retinaculum & Flexor retinaculum & trapezium trapezium •Insertion: •Insertion: Radial surface at base Radial surface at base of proximal phalanx of first metacarpal •Innervation: •Innervation: Median Nerve Median Nerve Actions: Flexion Action: Opposition
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C5 Thenar Compartment Superior Trunk Lateral Cord Musculocutaneous C6 Contents: •Abductor pollicis brevis C7 Middle Trunk Median Nerve •Flexor pollicis brevis •Thenar Compartment* •Opponens pollicis C8 Inferior Trunk Medial Cord Ulnar Nerve •tendon of flexor pollicis longus T1 * Via the recurrent median branch
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The Hand Hypothenar Mirror image of the thenar compartment: 1. Central •Abductor digiti minimi The hand is subdivided into 2. Thenar •Flexor digiti minimi five regions, generally 3. Hypothenar •Opponens digiti minimi separated from one another by 4. Adductor-Interosseous fascia 5. Dorsum All innervated by the ulnar nerve
35 36 Abductor digiti minimi Flexor digiti minimi •Origin: Pisiform •Origin: Flexor retinaculum & Insertion: hamate bone. Ulnar side of the small digit •Insertion: Fuses with abductor and Innervation: inserts more palmar. Ulnar nerve supply. •Innervation: Ulnar nerve
Action: Abduction 37 Action: Flexion 38
C5 Opponens digiti minimi Superior Trunk Lateral Cord Musculocutaneous •Origin: Flexor Retinaculum and the C6 hook of the hamate •Insertion: Medial border and palmar C7 Middle Trunk Median Nerve surface of the 5th metacarpal Innervation: Ulnar Nerve C8 Inferior Trunk Medial Cord Ulnar Nerve T1 •Hypothenar Compartment
In dissection usually must reflect flexor and Action: Opposition 39 40 abductor to observe opponens digiti minimi
Adductor Pollicis The Hand Transverse head •Origin: Shaft of 3rd metacarpal 1. Central •Insertion: The hand is Base of proximal phalanx subdivided into 2. Thenar Oblique head five regions, •Origin: generally 3. Hypothenar Base of 2nd & 3rd metacarpals separated from •Insertion: one another by 4. Adductor-Interosseous Base of proximal phalanx fascia Adduction 5. Dorsum
41 42 Adductor Pollicis Palmar interossei Interossei 1 arises from Adductor has two heads. ulnar surface of index The transverse arises from finger, interossei 2 and 3 the shaft of the third arise from the radial side of metacarpal. The oblique digits 4 and 5. head from the bases of the 2nd and 3rd metacarpals. PAD: Insertion is on the thenar Palmar interossei adduct. side of the first digit. In the digits adduction is in Moves thumb toward palm. the plane of the palm Unlike other thenar towards the resting position muscles it is supplied by a of the middle finger. deep branch of the ulnar nerve ! All ulnar nerve 43 44
•Actions of the dorsal Dorsal interossei interossei. The first interossei abducts the index Arise from adjacent finger. The second and third metacarpals and insert on the abduct the middle finger in bases of the promixal opposite directions. The phalanges of digits 2 to 4. Join fourth abducts the ring with extensor tendons to form finger. extensor aponeurosis.
DAB: •Interossei can also flex the Dorsal interossei abduct. metacaropophalangeal Abduction is in plane of palm joints and extend the away from the resting position interphalangeal joints. of middle finger.
Note: the 2nd and 3rd interossei All ulnar nerve 45 abduct and adduct the middle finger.46
C5 Dorsal Interossei Superior Trunk Lateral Cord Musculocutaneous C6
C7 Middle Trunk Median Nerve
3 2 1 4 C8 Inferior Trunk Medial Cord Ulnar Nerve •Palmar interossei T1 Adductor-Interosseous Compartment •Dorsal interossei •Adductor pollicis
Page47 4 48 Pronator teres Radial nerve Posterior cord Change Reels Ulna Bicep Ulnar artery Axillary artery Radius
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