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University of Dundee DOCTOR of PHILOSOPHY Cutaneous University of Dundee DOCTOR OF PHILOSOPHY Cutaneous innervation of the hand Sulaiman, Sara Award date: 2014 Link to publication General rights Copyright and moral rights for the publications made accessible in the public portal are retained by the authors and/or other copyright owners and it is a condition of accessing publications that users recognise and abide by the legal requirements associated with these rights. • Users may download and print one copy of any publication from the public portal for the purpose of private study or research. • You may not further distribute the material or use it for any profit-making activity or commercial gain • You may freely distribute the URL identifying the publication in the public portal Take down policy If you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediately and investigate your claim. Download date: 04. Oct. 2021 DOCTOR OF PHILOSOPHY Cutaneous innervation of the hand Sara Sulaiman 2014 University of Dundee Conditions for Use and Duplication Copyright of this work belongs to the author unless otherwise identified in the body of the thesis. It is permitted to use and duplicate this work only for personal and non-commercial research, study or criticism/review. You must obtain prior written consent from the author for any other use. Any quotation from this thesis must be acknowledged using the normal academic conventions. It is not permitted to supply the whole or part of this thesis to any other person or to post the same on any website or other online location without the prior written consent of the author. Contact the Discovery team ([email protected]) with any queries about the use or acknowledgement of this work. College of Art, Science and Engineering Centre for Anatomy and Human Identification CUTANEOUS INNERVATION OF THE HAND By: MS. SARA SULAIMAN Supervised by: PROFESSOR ROGER SOAMES DR CLARE LAMB A thesis Submitted in fulfillment of the requirement of the degree DOCTOR OF PHILOSOPHY IN SCIENCE IN HUMAN ANATOMY March 2014 II Table of Contents Content Page number I. Table of Content II II. List of figures V III. List of tables XX IV. List of abbreviations XXIII V. Acknowledgments XXIV VI. Declaration XXVI VII. Summary XXVII 1. Introduction 1 1.1. The development of the sensory innervation pattern 5 1.2. Peripheral nerves internal anatomy and injury 7 1.3. Hand landmarks 18 1.3.1. Flexion creases 18 1.3.2. Bony landmarks 22 1.3.3. Relationship of superficial landmarks to deeper 25 structures of the hand 1.4. Palmar surface of the hand 27 1.4.1. Median nerve 31 1.4.1.1. Palmar cutaneous branch of the 31 median nerve 1.4.1.2. Digital nerves 46 1.4.2. Ulnar nerve 49 1.4.3. Palmar communication branch between the 53 median and the ulnar nerve 1.5. Dorsum of the hand 67 1.5.1. Superficial branch of the radial nerve 71 1.5.2. Dorsal branch of the ulnar nerve 88 1.5.3. Dorsal communication branch between the ulnar 93 and radial nerve 1.6. Thesis aims and objectives 96 III Content Page number 2. Methods 98 2.1. Sample 98 2.2. Anatomical landmarks 98 2.3. Measurements 102 2.4. Dissection process 103 2.5. Photographs and visual illustrations 126 2.6. Statistics 127 3. Results 128 3.1. Intra-observer results 128 3.2. Palmar cutaneous branch of the median nerve 129 3.3. Common digital nerve 144 3.4. Ulnar nerve 149 3.5. Palmar communicating branch between the median and 159 ulnar nerve 3.6. Superficial branch of the radial nerve 165 3.7. Dorsal branch of the ulnar nerve 188 3.8. Sensory distribution in the dorsum of the hand 189 3.9. Dorsal communicating branch between the radial and 194 ulnar nerve 4. Discussion 198 4.1. Palmar surface of the palm 198 4.1.1. Palmar cutaneous nerve of the median nerve 198 4.1.2. Common digital nerves 206 4.1.3. Ulnar nerve 209 4.1.4. Communicating branch between the median and 212 the ulnar nerve 4.2. Dorsal Surface of the hand 224 4.2.1. Superficial branch of the radial nerve 224 4.2.2. Dorsal branch of the ulnar nerve 237 4.2.3. Sensory distribution in the dorsum of the hand 240 IV Content Page number 4.2.4. Dorsal communicating branch between the 245 superficial branch of the radial nerve and the dorsal branch of the ulnar nerve 5. Conclusion 249 6. References 257 7. Appendix I 287 8. Appendix II 313 V List of Figures Figure Page number Figure 1.1: An illustration of a cross section of the hand at the carpal 1 tunnel level showing the different compartments, spaces and fascia in the hand (Agur et al., 2008). Figure 1.2: The internal organization of the peripheral nerve (Moore 8 et al., 2011). Figure 1.3: Illustrations of fascicular organization in the peripheral 11 nerves. (A) The cable structure; (B) The plexiform structure (Stewart, 2003). Figure 1.4: Diagrammatic illustration of the five degrees of nerve 13 injuries as described by Sunderland. 1, first degree of injury; 2, second degree of injury; 3, third degree of injury; 4, fourth degree of injury; 5, fifth degree of injury (Campbell, 2008). Figure 1.5: An illustration shows the process of Wallerian 15 degeneration. (A) Injury occurs to the axon but the endoneurial tube is still intact; (B) Degeneration of axonal and myelin components of the distal segment. Elipsoids are formed by Schwann cells to facilitate phagocytosis by macrophages; (C) Degeneration and clearing of the distal segment are achieved. Regeneration of the axon begins guided by bands of Büngner (columns of Schwann cells); (D) regeneration continues in the endoneurial tube distal to the site of injury; (E) Full regrowth of axonal and associated myelin components (Nowak and Handford, 2003). Figure 1.6: Hand flexion creases. 19 Figure 1.7: Important bony landmarks in the palmar surface of the 22 hand. Figure 1.8: Important landmarks in the dorsum of the hand. LT, 23 Lister’s tubercle; APL, abductor pollicis longus; RSP, Radial styloid process; ASB, anatomical snuff box; EPB, extensor pollicis brevis; EPL, extensor pollicis longus; ECRL, extensor carpi radialis longus; ECRB, extensor carpi radialis brevis; ECU, extensor carpi ulnaris; USP, ulnar styloid process; LF, lunate fossa (Doyle and Botte, 2003). VI Figure Page number Figure 1.9: Kaplan system. (1) Radial artery; (2) Flexor carpi radialis 11 tendon (3) trapezium; (4) recurrent motor branch of the median nerve; (5) deep palmar arch; (6) hamate; (7) pisiform; (8) ulnar artery; (9) median nerve; (10) superficial palmar arch; A, cardinal line; B, vertical line crosses the cardinal line at the hook of hamate; C, vertical line crosses the cardinal line at the point of the recurrent motor branch of the median nerve penetrating the thenar eminence (Doyle and Botte, 2003; figure 10.3, page 535). Figure 1.10: Palmar cutaneous branch of the median nerve and palmar 27 cutaneous branch of the ulnar nerve innervation territory (Tubbs et al., 2011). Figure 1.11: Sensory nerves supplying the palmar surface of the hand. 28 Figure 1.12 Schematic drawings of the branching patterns of the first 48 common digital nerve. (A) Type I; (B) Type II; (C) Type III (Doyle and Botte, 2003). Figure 1.13 Schematic drawings of the branching patterns of the 61 palmar communicating branch according to Ferrari and Gilbert classification. (1) Group I; (2) Group II; (3) Group III; (4) Group IV; u, ulnar nerve; m, median nerve; b, communicating branch (Stančić et al., 1999). Figure 1.14 Risk area where the palmar communicating branch is 62 most likely to be found as described by Ferrari and Gilbert (1991) (Triangular area) and Don Griot et al. (2000) (trapezoidal area) (Don Griot et al., 2000). Figure 1.15 Schematic drawing of some of the branching patterns of 63 the palmar communicating branch (CB) between the median and ulnar nerve as described in the literature. (1) The CB originate from the fourth common digital nerve (CDN) proximally and joins the third CDN distally; (2) the CB originates from the third CDN proximally and joins the fourth CDN distally; (3) The CB travels transversally between the third and fourth CDNs; (4) The CB is formed by multiple branches from both the third and fourth CDNs. (Tagiel et al., 2007) VII Figure Page number Figure 1.16 Risk area where the palmar communicating branch (CB) 65 is most likely to be found as described by Loukas et al. (2007). Light grey area indicates the range where all palmar CBs were found; dark grey area indicates the area where the majority (83%) of the palmar CBs were found (Loukas et al., 2007). Figure 1.17 Schematic drawing showing the innervation territory 68 classically described in the literature. Figure 1.18 Risk area where the dorsal CB is most likely to be found 95 as described by Loukas et al. (2008). Light grey area indicates the range where all dorsal CB were found; Dark grey area indicates where the majority (85%) of the dorsal CB were found; mean percentage is indicated by the dotted line at 41% (Loukas et al., 2008). Figure 1.19 The suggested safe area where no major nerve passes as 96 described by Mok et al. (2006). Dark lines outline the course of the SBRN supplying the lateral two and half digits and the DBUN supplying the medial two and half digits; CMCJ, metacarpophalangeal joint (Mok et al., 2006).
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