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The Hand

Dr. Waleed Renno


wrenno@hsc.edu.kw
Dept of Anatomy
2
Bones of the
Hand
Hand is distal to carpal
bones

5 metacarpal bones: 1 to
5 for thumb, the index,
the middle, the ring and
the little finger

Each phalanx has a base,


shaft and head

Head articulates with


phalanx.

Clin Ana 11ed Fig. 125


3
Netter 439

Bones of the Hand

Fingers have 3 phalanges:


proximal, middle and distal

Thumb has 2 phalanges:


proximal and distal

Note sesamoid bones with


the thumb

Joints: MCP, PIP and DIP.


4
Netter 439
1st CM
Bones of the Hand Saddle (btwn
trapeszium &
base of 1st
metacarpel
CM joints-plane

MP joints condyloid

IP joints - hinge
Carpal Bones
Proximal Row Distal Row

Carpal Tunnel
Red Star indicates
position of tendon
of flexor carpi
radialis
6 Netter 464
Palmar Cutaneous Nerves Netter 455

The ulnar and


median nerves

Palmar branch
Common and
proper palmar
digital
branches

Note the small


area by the
superficial branch
of the radial nerve.
7

Palmar Aspect
Palmar branch of both the median
and ulnar nerves

Superficial to the flexor


retinaculum

Patients presenting with carpal


tunnel syndrome do not exhibit
symptoms such a pain or
paresthesia (a sensation of
pricking, tingling, or creeping), in
the palm of the hand or in the 1
medial fingers. Netter 442
Recurrent Branch of the Median Ulnar
Nerve

recurrent
branch of the
median n.

Median
Nerve

Common and proper


Netter 442 palmar digital branches Netter 449
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Dorsal Cutaneous Netter 464

Nerves
The radial nerve: superficial Superficial branch of the radial nerve
branch to dorsal aspect of the
proximal 3 lateral fingers (to
about middle phalanges)
Dorsal branch of the ulnar nerve
The median nerve: proper
palmar digital nerves to distal
3 lateral fingers

The ulnar nerve: Dorsal


branch of the ulnar nerve:
emerges from under the
flexor carpi ulnaris tendon, on
the medial aspect of the distal
forearm, and winds around
the wrist to provide
cutaneous innervation to the
dorsal aspect of the 1
medial fingers
10

Veins cephalic vein

Recall that the cephalic vein


originates from the lateral
aspect and the basilic from
the medial aspect of the
dorsal venous arch.

Median cubital vein joins the


cephalic vein to the basilic
vein in the superficial fascia
Basilic v
of the cubital fossa

Netter 463
Movements
Abduction and
adduction of the
fingers: in reference to
an axis passing
through the middle
finger.

Thumb: movements
are in reference to the
plane of the palm of
the hand, abduction
vs adduction, flexion
vs extension,
opposition.
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Netter 442
12

Palmar aponeurosis
Palmar aponeurosis
Fibrous band from skin to deep fascia
attached to flexor retinaculum, 4 fibrous slips
extending to each finger,
passage for flexor tendons, digital vessels
and nerves

Palmaris brevis

Intrinsic vs Extrinsic muscles.

Thenar and Hypothenar


Eminence

Hypothenar
Thenar Eminence
Eminence
Thenar Eminence

Abductor
pollicis brevis

Flexor pollicis
brevis

Opponens
pollicis
brevis.

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Netter plate 448
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Abductor Pollicis Brevis


Superficial and anterior position
in the thenar eminence

Origin: the flexor retinaculum and


the carpal bones

Insertion: is on the lateral aspect


of the base of the proximal
phalanx of the thumb (with the
flexor pollicis brevis).

Abducts the thumb at the


carpometacarpal and
metacarpophalangeal joints. Netter 448
15

Flexor Pollicis Brevis


Medial to the abductor pollicis brevis
muscle

Origin: lateral and anterior surface of the Netter 448


flexor retinaculum

Insertion: into the lateral aspect of the


base of the proximal phalanx of the
thumb with the abductor pollicis brevis
(note the sesamoid bone in the common
tendon)

Flexes metacarpophalangeal joint of the


thumb.
16

Opponens Pollicis Brevis


Deep to the abductor pollicis brevis
muscle

Origin: lateral and anterior surface


of the flexor retinaculum

Insertion: in the entire length of


the lateral border of the shaft of
the first metacarpal bone

Performs important movement of


opposition.
Netter 448
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Adductor Pollicis
Is the 4th short muscle of the thumb, not
included in the thenar eminence, has 2
heads, (oblique and transverse)

Origins: oblique head from the anterior


surfaces of the base of 2nd and 3rd Oblique
Head
metacarpal with transverse head from
the anterior surface of the 3rd metacarpal

Insert on the medial side of the base of


Transverse
the proximal phalanx of the thumb. Head

Adducts the carpometacarpal and


metacarpophalangeal joints.

Netter 448
Hypothenar Eminence

Abductor
digiti
minimi

Flexor
digiti
minimi

Opponens
digiti
minimi

18
19 Superficial and medial
Abductor Digiti Minimi in the hypothenar
eminence

Origin: from the


pisiform bone

Insertion: into the


medial side of the base
of the proximal phalanx
of the little finger

Abducts the
metacarpohalangeal
joint of the little finger.
Netter 448
20 Origin: from the
Flexor Digiti Minimi lateral portion of the
anterior surface of the
flexor retinaculum

Insertion: into the


medial side of the
base of the proximal
phalanx of the little
finger

Flexes the
metacarpophalangeal
joint of the little
finger.
Netter 448
21 Origin: from the
Opponens Digiti Minimi lateral portion of
the anterior
surface of the
flexor retinaculum

Insertion: into the


entire length of
the medial border
of the 5th
metacarpal bone

Brings the little


finger into
opposition to the
thumb.
Netter 448
Intrinsic Muscles
of the Hand

Lumbrical muscles (4)


Dorsal interossei muscles (4)
Palmar interossei muscles (3).

22
23

Lumbricals
Origin: from the tendons of the
flexor digitorum profundus
Tendons Of
Each lumbrical muscle inserts on Flexor
the lateral side of the Digitorum
Profundus
corresponding extensor expansion

Note that the first 2 lumbrical have


one head whereas the 3rd and the
4th lumbrical muscles have 2 heads

Flex the metacarpophalangeal


joints and extend the
interphalangeal joints.
Netter 446 Netter 447
24

Dorsal Interossei
Have two heads

Origin: from adjacent sides of the


metacarpal bones

Insertion: into the proximal


phalanges and extensor expansions
of the index, middle and ring fingers,
with the two muscles being
dedicated to the middle finger

Abduct the index, middle and ring


fingers, flex the
metacarpophalangeal joints and
extend the interphalangeal joints of
these 3 fingers. Netter 448
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Palmar Interossei
Only one head

Origin: from the anterior surface of


the shaft of the 2nd, 4th and 5th
metacarpal bones

Insertion into the proximal


phalanges, on the side closest to
the middle finger, and on the
extensor expansions of the index,
ring and little fingers

Adduct the index, ring and little


fingers, also flex the
metacarpophalangeal joints and
extend the interphalangeal joints
of these 3 fingers.
Netter 447 Netter 448
Synovial Sheaths Extensor
Retinaculum
Synovial tendon
sheath of flexor
pollicis longus
(Radial Bursa)
Common synovial
sheath of finger flexors
(Ulnar Bursa)
Cross-section
27

Thenar space: the first


lumbrical, is posterior to Fibrous septum
the long flexor tendon of
the index finger and Midpalmar space Thenar space
anterior to the adductor
pollicis muscle

Midpalmar: most medial


3 lumbrical muscles, is
found posterior to the
long flexor tendons of the
middle, ring and little
fingers and is immediately
anterior to the 3rd, 4th and
5th metacarpal bones.
Netter 445
Palmar Arches Deep & Superficial
Radial artery Ulnar artery

Superficial Palmar Arch

Netter 449 both

Deep Palmar Arch


29

Superficial Palmar Arch


Ulnar artery passes superficial to the flexor
retinaculum, lateral to the ulnar nerve and
pisiform.

Gives a deep palmar branch, curving deep to


the palmar aponeurosis but anterior to the
long flexor tendons to form the superficial
palmar arch

Anastomoses with the superficial palmar


branch of the radial artery

Branches: 3 common palmar digital arteries,


dividing themselves in the proper palmar
digital arteries to the fingers and 1 proper
palmar digital artery to the little finger.
Netter 449
30

Radial Artery
Radial artery swings from the
anterior aspect of the wrist to
the lateral side and then
posterior aspect of the hand
by passing beneath the
tendons of the abductor
pollicis longus and extensor
pollicis muscles (both longus
and brevis)
Dives between the two heads
of the first dorsal
interosseous muscle to pass
between the transverse and
oblique heads of the adductor
pollicis muscle. Grants dissector 4.46
31

Deep Palmar Arch


Forms by the anastomosis of the radial
artery with the deep branch of the ulnar
artery to form the deep palmar arch

Arch: deep to the long flexor tendons


but anterior to the metacarpal bones
and
interosseous muscles

princeps pollicis
3 small palmar metacarpal arteries
anastomose with the matching arteries
from the superficial arch

Radialis indicis artery to the lateral side


of the index finger and the princeps
Radialis indicis
pollicis artery to both sides of the
thumb. Netter 449
Innervation Brachial Plexus

Cutaneous innervation is by radial,


median and ulnar nerves

Motor innervation is only by median


and ulnar nerves. Netter 413

Ulnar n. supplies all the muscles of


the hand except for the LLOAF
Muscles which are supplied by
branches of the median nerve.

LLOAF muscles are the lateral two


lumbricals, opponens pollicis,
abductor pollicis brevis and flexor
pollicis brevis (thenar mscules).

Netter 448 32
33

Median Nerve
Passes between the flexor digitorum
superficialis and the flexor carpi radialis,
deep to the palmaris tendon

Passes under the flexor retinaculum

Gives a motor recurrent branch to the 3


muscles of the thenar eminence

Proper palmar digital nerves

Two common palmar digital branches


dividing into proper palmar digital nerves

Innervation to 1st and 2nd lumbrical. Netter 458


Injury of median nerve at different
34

levels cause different syndromes:


Above the elbow
Injury of this nerve at a level above the
elbow results in loss of pronation and a
reduction in flexion of the hand at the wrist.
At the elbow
Severing the median nerve at this level or
higher (at above the elbow) causes "the
Blessed Hand," or "Hand of Benediction."
Entrapment at the level of the elbow or the
proximal forearm could be due to the
pronator teres syndrome.
Lesions of compression of the Median
Nerve can also leads to Median Nerve Palsy
Within the forearm
Injury to the anterior interosseous branch in
the forearm causes the anterior
interosseous syndrome.

Netter 458
Injury of median nerve at different
35

levels cause different syndromes:


At the wrist
Injury by compression at the
carpal tunnel causes carpal
tunnel syndrome.
In the hand, thenar muscles are
paralyzed and will atrophy over
time.
Opposition and flexion of the
thumb are lost.
Sensory is lost:
Palm - 3 1/2 Fingers
Dorsal - Finger tips
The thumb and index finger are
arrested in adduction and
hyperextension.
This appearance of the hand is
collectively referred as 'ape hand
deformity'
Ulnar Nerve
36

Superficial to the flexor retinaculum but


runs distally in a groove between the
pisiform and the hook of the hamate
(tunnel of Guyon)

In the palm, it divides into a superficial


branch and a deep branch

Superficial branch: motor to a small


muscle, the palmaris brevis, and
cutaneous to the medial aspect of the
medial 1 fingers

Deep branch: to the 3 hypothenar


muscles, all dorsal and palmar interossei
muscles, the 2 most medial lumbrical
muscles and the adductor pollicis. Netter 463
37

Injury to Ulnar Nerve


In the tunnel of Guyon: lose the cutaneous
innervation to the palmar aspect of their medial 1
fingers and ability to contract all the intrinsic muscles
of the hand, except for the 5 muscles innervated by
the median nerve

Flexor and extensor extrinsic muscles will be


unopposed and the fingers will take the very
characteristic position of the clawed hand

All interossei are paralyzed: the MCP joint present in


an extended position with both PIP and DIP joints in
flexion

Only 2 medial lumbrical muscles are paralyzed:


contribute to this position but note that the extension
at the MCP and flexion at both the DIP and PIP of the
index or ring and middle fingers will be less dramatic.
Why?

Adductor pollicis brevis is non-functional: thumb will


stay abducted.
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Injury to Ulnar Nerve

Another example of ulnar nerve injury Paralysis of Adductor Pollicis

Haymaker 180
39

Injury to Ulnar Nerve at the Elbow

What do you think would happen if the ulnar


nerve injury happened behind the medial
epicondyle of the humerus?

Can you think of any difference in cutaneous


innervation when comparing high and low ulnar
nerve injuries?
Dupuytrens
Contracture
is a localized thickening
and contracture of the
palmar aponeurosis.

It commonly starts
near the root of the
ring finger and draws
that finger into the
palm, flexing it at the
metacarpophalangeal
joint.
Dupuytrens Contracture
Later, the condition involves the
little finger in the same manner.

In long-standing cases, the pull


on the fibrous sheaths of these
fingers results in flexion of the
proximal interphalangeal joints.

The distal interphalangeal joints


are not involved and are actually
extended by the pressure of the
fingers against the palm.

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