Elraiah Mohamed Makie

Objectives
By the end of this presentation audience should be
1.
2.
3.
4.
5.

able to :
Describe the surface anatomy of the hand.
the fascial compartment of the hand.
Understand the muscles of the hand.
Understand how the nerves and blood vessels
arranged in the hand .
Understand the common clinical correlations of the
hand..

Case study
35 years old lady presented to her

GP complaining of numbness of the

hand in the thumb region ,She was
known case of hypothyroidism. She
was diagnosed as carpal tunnel
syndrome.

Questions

What are the attachments of the flexor

retinaculum
What are the structures passes in and
outside the tunnel
What is the classical presentation
In this case the thinner muscles was wasted
while the sensation is preserved, why?
What is the deformity called and why it took
place?

The skeleton of the

hand

Carpal bones(8)/1
Metacarpal bones(5)/2
Phalenges(14)/3

Fracture of the Scaphoid

The scaphoid is the most

frequently fractured carpal

bone.
It often results from a fall
on the palm when the
hand is abducted,
the fracture occurring
across the narrow part of
the scaphoid(
Owing to the poor blood
supply to the proximal part
of the scaphoid, union of
the fractured parts may
take long time to healing
Avascular necrosis of the
proximal fragment of the
scaphoid may occur

Fracture of the scaphoid

Fracture of the scaphoid:

occurs after a fall on the

outstretched hand and may
damage the radial artery and
cause avascular necrosis of
the bone.

Surface anatomy of
hand

Surface anatomy of
hand

Surface anatomy of
hand

Surface anatomy of han

Surface anatomy of
hand

Surface anatomy
of hand

Surface anatomy of hand

Surface anatomy of hand

Dermatomes of the upper

limb

Cutaneous Innervations of the Hand

Palm of hand
Flexor retinaculum
Thickening of deep fascia in the hand
Attached laterally to scaphoid and trapeziun
and medially to pisiform and hamate bone .
Carpal tunnel
Formed by flexor retinaculum and carpal
groove
Transmits:-

Median n.
n
FDS&FDP enclosed by common flexor sheath
FPL
FCR

Carpal tunnel

Is formed anteriorly by the flexor retinaculum and posteriorly by the ca

Transmits the median nerve and the tendons of flexor pollicis lon
profundus, and flexor digitorum superficialis muscles.

Palmar
aponeurosis

palmar aponeurosis
Is a triangular fibrous layer
overlying the tendons in
the palm and is continuous
with the
palmaris longus tendon,
the thenar and hypothenar
fasciae, the flexor
retinaculum, and the
palmar carpal ligament.
Protects the superficial
palmar arterial arch, the
palmar digital nerves, and
the long flexor
tendons.

Palmar Spaces

Fascial spaces of the

palm
Are fascial spaces deep to the palmar
aponeurosis and divided by a midpalmar
(oblique) septum into the thenar space and
the midpalmar space.
1. Thenar space Is the lateral space that
contains the flexor pollicis longus tendon and
the other flexor tendons of the index finger.
2. Midpalmar space Is the medial space
that contains the flexor tendons of the medial
three digits.

PULP SPACE
On the palmar side of the tip of fingers and thump.
Contains fatty tissue that is divided into numerous
compartments by fibrous septa that pass between the
distal phalanges and skin.Containing terminal arteries and
nerves.
The space is limited proximally by the firm adherence of skin to
distal flection crease to underlying tissue.
This prevent spread of infection.

Synovial flexor sheaths

1. Common synovial flexor sheath (ulnar

bursa)
Envelops or contains the tendons of both the
flexor digitorum superficialis and profundus
muscles.
2. Synovial sheath for flexor pollicis
longus (radial bursa)
Envelops the tendon of the flexor pollicis longus
muscle.

Flexor tendons, common flexor sheath, fibrous

digital sheaths, and synovial sheaths of digits

Muscles of the Hand

Thenar group :

Flexor pollicis brevis

Abductor pollicis brevis
Opponence pollicis
Hypothenar

group :
Flexor digiti minimi
Abductor digitidigiti
minimi
opponence minimi

Lumbricals
Adductor pollicis
Interossei

palmar
dorsal

Opponen
s pollicis

Flexor retinaculum and tubercles

of scaphoid and trapezium

Lateral side
of 1st
metacarpal

Recurre
nt
branch
of
medial
nerve
(C8, T1)

To oppose thumb,
it draws 1st
metacarpal
medially to center
of palm and
rotates it medially

Abductor
pollicis
brevis

Flexor retinaculum and tubercles

of scaphoid and trapezium

Lateral side
of base of
proximal
phalanx of
thumb

Recurre
nt
branch
of
medial
nerve
(C8, T1)

Abducts thumb;
helps oppose it

Flexor
pollicis
brevis

Flexor retinaculum and tubercles

of scaphoid and trapezium

Lateral side
of base of
proximal
phalanx of
thumb

Recurre
nt
branch
of
medial
nerve
(C8, T1)

Flexes thumb

Abductor digiti
minimi

Pisiform

Medial side of base of

proximal phalanx of
5th finger

Deep
branch of
ulnar
nerve (C8,
T1)

Abducts 5th finger;

assists in flexion of its
proximal phalanx

Flexor digiti
minimi brevis

Hook of
hamate and
flexor
retinaculum

Medial side of base of

proximal phalanx of
5th finger

Deep
branch of
ulnar
nerve (C8,
T1)

Flexes proximal phalanx

of 5th finger

Opponens digiti
minimi

Hook of
hamate and
flexor
retinaculum

Medial border of 5th

metacarpal

Deep
branch of
ulnar
nerve (C8,
T1)

Draws 5th metacarpal

anterior and rotates it,
bringing 5th finger into
opposition with thumb

Lumbricals

Lumbricals

origin

insertion

innervati
on

action

st and 2nd

Lateral two
tendons of
flexor
digitorum
profundus
(as
unipennate
muscles)

Lateral
sidesextensor
of
expansions of
2nd5th
fingers

Median
nerve
(C8, T1)

Flex
metacarpop
halangeal
joints;
extend
interphalan
geal joints
of
2nd5th
fingers

rd and 4th

Medial three
tendons of
flexor
digitorum
profundus
(as
bipennate

Lateral sides
Deep
Flex
of extensor
branch of metacarpop
expansions of
ulnar
halangeal
2nd5th
nerve
joints;
fingers
(C8, T1)
extend
interphalan
geal joints

interossei

Dorsal
interossei
, 1st4th

Adjacent sides of
two metacarpals
(as bipennate
muscles)

Bases of
proximal
phalanges;
extensor
expansions of
2nd4th finger

Deep branch of
ulnar nerve (C8,
T1)

Abduct 2nd4th
fingers from axial
line; act with
lumbricals in
flexing
metacarpophalan
geal joints and
extending
interphalangeal
joints

Palmar
interossei
, 1st 3rd

Palmar surfaces
of 2nd, 4th, and
5th metacarpals
(as unipennate
muscles)

Bases of
proximal
phalanges;
extensor
expansions of
2nd, 4th, and
5th fingers

Deep branch of
ulnar nerve (C8,
T1)

Adduct 2nd, 4th,

and 5th fingers
toward axial line;
assist
lumbmetacarpophalangeal
ricals in flexing
joints and
extending
interphalangeal
joints; extensor
expansions of
2nd4th fingers

Actions of muscles of the

hand

Arteries of the
Ulnar Artery
Hand
The 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 adjacent sides of the 2nd4th
fingers

Radial Artery
It curves dorsally around the scaphoid and trapezium
and the floor of the enters the palm by passing
between the heads of the 1st dorsal interosseous
muscle and then turns medially, passing between the
heads of the adductor pollicis. The radial artery ends
by anastomosing with the deep branch of the ulnar
artery to form the deep palmar arch, which is formed
mainly by the radial artery. This arch lies across the
metacarpals just distal to their bases). The deep
palmar arch gives rise to three palmar metacarpal
arteries and the princeps pollicis artery. The radialis
indicis artery passes along the lateral side of the index
finger. It usually arises from the radial artery, but it
may originate from the princeps pollicis

Blood supply

palmar arches

Superficial palmar arch

Formed by ulnar artery and
superficial palmar branch of
radial artery
Curve of arch lies across the
palm, level with the distal
border of fully extended
thumb
Gives rise to three common
palmar digital arteries each
then divides into two proper
palmar digital arteries

Deep palmar arch

Formed by radial artery and deep
palmar branch of ulnar artery
Curve of arch lies across upper part
of palmar at level with proximal
border of extended thumb
Gives rise to three palmar
metacarpal arteries

Veins of the Hand

Superficial and deep venous
palmar arches, associated with
the superficial and deep palmar
(arterial) arches, drain into the
deep veins of the forearm The
dorsal digital veins drain into
three dorsal metacarpal veins,
which unite to form a dorsal
venous network.). Superficial to
the metacarpus, this network is
prolonged proximally on the
lateral side as the cephalic vein.
The basilic vein arises from the

Lymphatic Drainage

Nerves
of
hand
Median n. thenar except adductor pollicis, first two

lumbricals; skin of thenar, central part of palm,

palmar aspect of radial three and one-half fingers,
including middle and distal fingers on dorsum
Ulnar n. hypothenar muscles, interossei, 3rd and
4th lumbricals and adductor pollicis; skin of
hypothenar, palmar surface of ulnar one and onehalf fingers

Radial n. skin of radial side

of dorsum of hand and radial

two and one-half fingers

Anatomical snuff

Anatomical snuff
Is a triangular interval bounded medially

by the tendon of the extensor pollicis

longus
muscle and laterally by the tendons of the
extensor pollicis brevis and abductor pollicis
longus muscles.
Is limited proximally by the styloid process of
the radius.
Has a floor formed by the scaphoid and
trapezium bones and crossed by the radial
artery.

Anatomical snuff box

Mallet Finger

Mallet finger (Hammer or baseball finger):

is a finger with permanent flexion of the

distal phalanx due to an avulsion of the

medial and lateral bands of the extensor
tendon to the distal phalanx.

Dupuytren's
contracture: is a
progressive
thickening, shortening,
and fibrosis of the
palmar fascia, especially
the palmar aponeurosis,
producing a flexion
deformity of fingers in
which the fingers are
pulled toward the palm
(inability to fully extend
fingers), especially the

Trigger Finger

results from stenosing tenosynovitis or occurs when the

flexor tendon develops a nodule or swelling that

interferes with its gliding through the pulley, causing an
audible clicking or snapping. Symptoms are pain at the
joints and a clicking when extending or flexing the joints.

Carpel tunnel syndrome

A. Mechanism: overuse, congenital, trauma
B. Pathology: Compression of the median

nerve in the tunnel

Carpal tunnel syndrome : is caused by

compression of the median nerve due to the
reduced size of the osseofibrous carpal tunnel,
resulting from inflammation of the flexor retinaculum,
arthritic changes in the carpal bones, or inflammation
or thickening of the synovial sheaths of the flexor
tendons.
It leads to pain and paresthesia (tingling, burning,
and numbness) in the hand in the area supplied by
the median nerve and may also cause atrophy of the
thenar muscles in cases of severe compression.
However, no paresthesia occurs over the thenar
eminence of skin because this area is supplied by the
palmar cutaneous branch of the median nerve.

The Allen's test: is a test for occlusion of the radial or

ulnar artery; either the radial or ulnar artery
is digitally compressed by the examiner after blood has been
forced out of the hand by making a tight fist; failure of the blood
to return to the palm and fingers on opening indicates that the
uncompressed artery is occluded.

Injury to Radial Nerve

Injured in the radial

groove, the triceps is

usually not completely
paralyzed .
Posterior compartment
of the forearm that are
supplied by more distal
branches of the radial
nerve are paralyzed.
Characteristic clinical
sign of radial nerve
injury is wrist-drop

Ulnar nerve injury ,Partial

claw hand

If the nerve divided in laceration of the wrist .

Median nerve injury, Ape

hand
In the elbow region
results in loss of flexion
of the proximal and
distal interphalangeal
joints of the 2nd and 3rd
digits. The ability to flex
the
metacarpophalangeal
joints of these digits is
also affected.
Ape hand refers to a
deformity in which
thumb movements are
limited to flexion and
extension of the thumb
in the plane of the palm.

Good luck