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The Hand Plus Lecture Notes.Pptx The Hand Donald Sammut Hand Surgeon Kings Upper Limb Anatomy plus lecture notes GENERAL'PANORAMA'OF'THE'HAND' Two'hills'and'a'valley:' • Hills:'Thenar'and'hypothenar'eminences' • Valley:'palmar'aponeurosis'beneath'which'enter'most'neurovascular' structures'and'the'flexor'tendons'and'lumbricals.'The'interossei'lie'in'the' depths'of'this'valley,'level'with'the'metacarpals' • The'carpal'tunnel'is'the'main'portal'into'the'hand' • Dissection'and'removal'of'the'palmar'aponeurosis'(the'flattened'end' tendon'of'Palmaris'longus)'reveals'the'neurovascular'plane.' • The'tendons'emerge'through'the'carpal'tunnel'(which'forms'an' important'mechanical'pulley)'and'fan'out'to'the'digits' The'Hand'Skeleton' • The'metacarpals'articulate'proximally'with'the'carpal'bones'and'distally' with'the'phalanges.' • The'basal'joints'of'the'metacarpals'vary'in'their'mobility' • The'1st'Metacarpal'(the'thumb)'is'the'most'mobile'and'is'effectively'able' to'circumduct,'i.e.'the'thumb'column'can'rotate'about'the'base'through' 360°' • The'5th'(little'finger)'and'4th'(ring'finger)'metacarpals,'also'have'mobile' basal'joints'with'the'5th'more'mobile'than'the'4th.'' • The'2nd'(index)'and'3rd'(middle)'metacarpals'are'firmly'attached'to'the' carpus'and'to'each'other'and'have'practically'no'movement'at'the'base' • The'carpal'bones'are'curved'so'that,'as'a'group,''they'are'concave'in'the' palmar'aspect'and'convex'in''the'dorsal'aspect.' • This'curvature'is'reflected'in'the'metacarpal'heads.'The'metacarpals'flare' out'from'the'carpus'and'describe'a'gentle'curve,'concave'towards'the' palmar'aspect.' • The''metacarpal'bases'are'secured'to'the'carpus'and'the'heads'(distally)' are'secured'to'each'other'by'the'Deep'Transverse'Intermetacarpal' ligament.'' • This'ligament'is'immensely'strong'–'the'metacarpals'will'fracture'before' the'ligament'gives'way.'An'individual’s'entire'weight'can'hang'from'this' ligament'without'it'rupturing.' • It'holds'the'heads'of'the'metacarpals'bound'together'and'is'in'continuity' with'the'volar'plate'of'the'MCP'joints' The'Deep'Transverse'Intermetacarpal'Ligament' Phalanges' Metacarpals' • The'Deep'Transverse'metacarpal'ligament'receives'fibres'from'all'related' musculoskeletal'structures'which'pass'by:'Lumbricals,'interossei,'volar' plate,'collateral'ligaments,'flexor'tendon'sheath'–'all'contribute'to'a'mesh' of'collagen'fibres'which'is'called'the'ZANCOLLI'COMPLEX.'' • This'is'an'important'landmark'point'in'the'hand,'at'the'distal'border'of' the'palm'and'the'proximal'border'of'the'digit.' Extensors' Meta' Flexors' Zancolli'Complex' *' *' • Virtually'all'activity'of'the'hand'involves'an'increase'in'the'palmar' curvature'of'the'metacarpals.'' • Grip,'making'a'fist'and'most'manipulation'curves'the'hand'around'an' object' • The'gentle'curve'of'metacarpal'heads'is'increased.' • The'Intrinsic'muscles'in'the'hand'also'tend'to'curve'in'a'palmar'direction.' • Both'the'thenar'and'hypothenar'muscles'tend'to'oppose'their'respective' digits'so'as'to'curl'around'a'held'object.' • The'Thumb'skeleton:'two'phalanges'and'a'metacarpal.' • Developmentally,'all'three'bones'are'phalanges,'with'a'growth'centre'in' the'proximal'end'(as'all'phalanges).'‘True’'metacarpals'(index,'middle,' ring'and'little)'have'a'growth'plate'at'their'distal'end.' • The'embryonic'thumb'metacarpal'develops'into'the'trapezium'with'its' specialized'basal'joint'to'the'metacarpal.' DISTAL'PHALANX' PROXIMAL'PHALANX' Interphalangeal+Joint+ METACARPAL' Metacarpo1Phalangeal+ Joint+ Carpo1Metacarpal+ Joint+ TRAPEZIUM' MOVEMENT'PLANES'OF'THE'THUMB' Pure'movements:' • Abduction/Adduction:'Movement'away'and'towards'the'palm,'at'90°'to'the' palm' • Extension/Flexion:'Movement'away'and'towards'the'palm,'in'the'plane'of'the' palm' • Retropulsion:'With'hand'flat'on'a'surface,'palm'down,'the'thumb'can'lift'off' the'surface' Composite'Movements:' • Circumduction:'a'cascade'of'sequential'activity'of'flexion/extension/ abduction/adduction' • Opposition:'Similar'sequence'of'pure'movements'which'result'in'the'thumb' pulp'‘opposing’'the'digit'pulps.' Adduction' Abduction' Retropulsion' Composite'actions' Circumduction'and'Opposition' Circumduction' Opposition' • Basal'Joint'of'the'thumb'(1st'Carpoimetacarapal'joint)' • ‘Sellar’'or'‘Saddle’'joint' • Kapandji'stated'that'‘If'the'basal'joint'of'the'thumb'were'a'true'saddle,'it' would'be'a'saddle'for'a'scoliotic'horse’.' +(Scoliosis+is+the+abnormal+curvature+of+the+spine,+side+to+side)+ • The'saddle'is'asymmetric' Kapandji: Biomechanics of the Thumb, Vol 1, Philadelphia, 1981. WB Saunders Kucynski: Carpometacarpal joint of the Thumb, J Anat, 1974 • The'radial'condyles'on'both'the'trapezium'and'the'head'of'the' metacarpals,'are'relatively'larger'than'the'ulnar'condyles' ulnar radial Meta Trapz • This'asymmetry'means'that'when'the'thumb'is'abducted,'the'whole' thumb'skeleton'tends'to'turn'into'pronation' • This'tendency'is'purely'skeletal'and'not'mediated'by'muscle'movement' • The'skeleton'thus'tends'to'curve'the'thumb'naturally'towards'the'long' digits.' • The'strong'ligament'on'the'ulnar'side'of'the'basal'joint''i'the'beak' ligament'(see'wrist'lecture),'acts'as'a'fulcrum,'a'pivot,'around'which'this' pronation'rotates.' PRONATION'OF'THE' THUMB'COLUMN' WITH'ABDUCTION.' INDEPENDENT+OF++ MUSCLE+ACTION+ • The'MP'joints'(Metacarpophalangeal)'and'IP'joints'(Interphalangeal,' proximal'and'distal)'are'hinge'joints.' • The'metacarpal'heads'are'oval,'camishaped.'The'‘hinge’'is'not'pure'since' flexion'of'the'phalanx'also'means'a'migration'in'a'palmar'direction,'so' that'the'movement'is'actually'a'gentle'spiral.' • For'clinical'purposes'the'MP'and'PIP,'and'DIP'joints'are'hinge,'or'uniiaxial,' joints' The'Metacarpo'phalangeal'and'Interphalangeal'Joints' ' Uniaxial'(Hinge)'Joints:'' PIPJ'and'DIPJ'='True'Hinge;'' MCPJ'='Spiral' • The'cam'shaped'head'of'the'metacarpal'means'that:'' • In'extension,'the'collateral'ligament'is'slack.'' • In'flexion,'the'collateral'ligaments'are'taut' The'MetacarpoiPhalangeal'Joint' (all'digits'and'thumb)' Collateral'ligament'slack'in'extension' Collateral'ligament'tense'in'flexion' • The'PIP'joint'describes'a'pure'arc'of'a'circle'in'flexion'and'extension.'The' collateral'ligaments'are'taut'in'flexion'and'in'extension.' On'the'palmar'surface'is'the'VOLAR'PLATE'which'is'in'two'parts:' • The'distal,'rigid,'fibrocartilaginous'part' • The'proximal,'ligamentous,'flexible'part' The'PIP'Joint' Flexible'Part'of'Volar'Plate'' Rigid'Part'of'Volar'Plate'' (Ligamentous)' (Fibrocartilage)' • In'flexion,'the'flexible'part'rucks'up,'concertinas,'so'that'the'middle' phalanx'can'flex' • If'a'PIP'joint'is'allowed'to'stay'in'flexion'for'any'significant'time'(such'as' after'hand'injury,'when'movement'is'painful),'the'flexible,'rucked'part'of' the'volar'ligament,'soon'shrinks'and'contracts'into'scar.' • This'is'a'problem'that'is'easy'to'prevent'and'difficult'to'cure,'once' established' Fixed'Flexion'' Contracture' • The'safe'position'to'splint'any'joint'is'the'‘Close'Packed’'position'when' most'of'its'ligaments'are'on'full'stretch'(and'thus'unable'to'contract'and' scar'rigid).'' • In'the'hand:' • The'MPjoint'must'be'splinted'flexed'(with'all'collateral'ligaments'on'the' stretch)' • The'PIP'and'DIP'joints'must'be'splinted'extended'(with'the'volar'plate'at' full'stretch).' The'Safe'Position'of'the'Hand' ' ' All'Joints'in'‘CloseiPacked'Position’' Collateral'Ligament'tears' • Tear'of'the'ulnar'collateral'ligament'of'the'MP'joint.' • The'Skier’s'injury.'Also'known'as'the'Gamekeeper'thumb.' • This'is'a'debilitating'injury,'since'the'integrity'of'grip'requires'that'the' thumb'MP'joint'does'not'give'way'when'an'object'is'grasped.'The'ulnar' collateral'ligament'is'a'strong'ligament'resisting'distraction'of'the'MP' joint'in'a'radial'direction'(the'joint'gives'way).' Skier’s'Thumb' Torn'Ulnar'Collateral'Ligament' Stener'Lesion' Littler’s'‘Armchair’'arrangement'' of'stabilizing'ligaments'of'PIPJ' • The'PIP'joint'has'a'system'of'ligaments'which'give'it'great'stability,' considering'its'size.' 1. The'collateral'ligaments'either'side' 2. The'Volar'plate/ligament' The'triple'arrangement'surrounds'the'proximal'phalanx'head'on'three'sides.' Littler'has''called'this'the'‘armchair’'arrangement'of'stability'of'the'PIP'joint.' Littler’s'‘Armchair’'arrangement'' of'stabilizing'ligaments'of'PIPJ' THE'INTRINSIC'MUSCLES:'def:+all'muscles'distal'to'the'wrist'crease' ' ' THENAR'MUSCLES:' 'FLEXOR'POLLICIS'BRECVIS' X3 ' ''ABDUCTOR'POLLICIS'BREVIS' '''OPPONENS'POLLICIS' ' X1 ' ''ADDUCTOR'POLLICIS' ' HYPOTHENAR'MUSCLES 'FLEXOR'DIGITI'MINIMI' X3 ' ''ABDUCTOR'DIGITI'MINIMI' '''OPPONENS'DIGIT'MINIMI' ' LUMBRICALS' X4' ' INTEROSSEI ' '3'DORSAL'INTEROSSEI' X7 ' ''4'PALMAR'INTEROSSEI' iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii' TOTAL:'18'MUSCLES' ' ' ' The'Thenar'muscles' Thenar'muscles:' Flexor'Pollicis'Brevis:'' Origin:'Flexor'retinaculum'and'adjacent'trapezium' Insertion:'Radial'sesamoid'of'the'thumb'and'on'to'the'radial'border'of'the'proximal'phalanx' ' ' Abductor'Pollicis'Brevis:' Origin:'Flexor'Retinaculum'and'tubercle'of'the'scaphoid' Insertion:'Tendon'of'Extensor'Pollicis'longus'(Dorsal'expansion)' ' Opponens'Pollicis'(in'the'depths'of'the'thenar'eminence'and'only'visible'by'distracting'FPB'or' AdPB)' Origin:'Flexor'retinaculum'and'adjacent'trapezium' Insertion:'The'whole'of'the'radial'border'of'the'thumb'metacarpal.' ' ' Flexor'Pollicis'Brevis' Abductor'Pollicis'Brevis' APB' Abductor'Pollicis'Brevis' ABDUCTION' • The'true'opposer'of'the'Abductor'Pollicis'Brevis'is'not'the'Adductor' Pollicis' • It'is'the'Extensor'Pollicis'Longus'' • The'opposite'of'Adduction'in'the'thumb'is'retropulsion'and'this'is' produced'by'Extensor'Pollicis'Longus.'
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