Download MBBS Anatomy PPT 8 Hand Split Notes

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Learning objectives

q Surface anatomy of Hand

q Bony landmarks

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q Compartments and Spaces of hand

q Flexor Retinaculum & Structures passing below

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& above FR

q Intrinsic muscles of hand

q Superficial & Deep Palmar Arches

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q Dorsum of hand & Dorsal venous Arch

q Nerves in hand

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q Applied anatomy

Surface Anatomy

Surface Anatomy

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Wrist Bones

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Wrist Bones

She
Looks

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Too
Pretty
Try
To
Catch

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Her

Hand Bones

Anatomical Snuff Box

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Compartments & Spaces


The Skin

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PALM: characteristics:
Flexure creases (lines of palm)
Papillary ridges (fingerprints): improve grip & increase

surface area

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Fibrous bands connecting it to palmar aponeurosis & dividing

subcutaneous fat into small loculi (water-cushion

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withstanding considerable pressure)

Abundant sweat gland

Superficial Fascia

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PALM: characteristics:
Contains: cutaneous nerves & vessels
Contains: Palmaris brevis (increases the hollow of palm to

get a firmer grip

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Deep Fascia

Palmar Aponeurosis
It is a thickening of deep fascia in the middle of the palm

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DESCRIPTION: It is triangular in shape:
Apex: directed proximally, continuous with tendon of palmaris

longus

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Base: directed distally, divided into 4 slips for the medial 4 fingers
Margins: send septa to metacarpal bones separating the structures

under the aponeurosis from thenar & hypothenar muscles

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FUNCTION: It protects the underlying tendons, vessels & nerves
CLINICAL ANATOMY: DUPUYTREN'S CONTRACTURE:

shortening of the medial part of aponeurosis resulting in flexion of

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the little & ring fingers


Deep Fascia
Flexor retinaculum:

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Definition
Attachments
Relations
Functions
Clinical anatomy:

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Carpal tunnel

syndrome

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Flexor Retinaculum
It is a thickening of deep fascia that lies over the front of the

carpal bones converting the carpal groove (formed by carpal

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bones) into a tunnel

ATTACHMENTS:
Lateral: by 2 laminae: superficial (to tubercles of scaphoid &

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trapezium) & deep (to the medial lip of the groove on the

trapezium)

Medial: to pisiform & hook of hamate

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Flexor Retinaculum
RELATIONS:
Superficial: from lateral to medial:
Superficial palmar branch of radial artery

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Palmar cutaneous branch of median nerve
Tendon of palmaris longus
Palmar cutaneous branch of ulnar nerve
Ulnar vessels
Ulnar nerve

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Deep: Structures passing through carpal tunnel
Tendon of FPL & its synovial sheath (radial bursa)
Tendons of FDS & FDP & their common synovial sheath (Ulnar bursa)
Tendon of FCR & its synovial sheath ( in a special compartment)
Median nerve

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Flexor Retinaculum
FUNCTION: It keeps the flexor tendons in position during

movement of wrist joint

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CLINICAL ANATOMY (CARPAL TUNNEL SYNDROME):

Compression of median nerve under the flexor retinaculum

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Deep Fascia
Fibrous flexor

sheaths

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Definition
Attachments
Function

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Fibrous Flexor Sheath
DEFINITION: It is a thickening of deep fascia in front of the

fingers

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ATTACHMENTS:
Proximal: to the slips of palmar aponeurosis
Distal: to the base of distal phalanx
On either side: to the side of phalanx
FUNCTION: It holds the long flexor tendons during flexion of

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the fingers

Intrinsic Muscles Of Hand

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Situated totally within the hand
Divided into 4 groups:-
?Thenar
?Hypothenar
?Lumbricals

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?Interossei muscles

Intrinsic Muscles

LATERAL GROUP:

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FOUR THENAR MUSCLES

MEDIAL GROUP:

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THREE HYPOTHENAR MUSCLES

PALMARIS BREVIS
CENTRAL GROUP:

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FOUR LUMBRICALS
FOUR PALMAR INTEROSSEI
FOUR DORSAL INTEROSSEI

ALL MUSCLES ARE SUPPLIED BY C8 & T1 SPINAL

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SEGMENTS THROUGH MEDIAN & ULNAR NERVES
Intrinsic Muscles
Thenar Muscles:
Abductor Pollicis Brevis

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Flexor Pollicis Brevis
Opponens Pollicis
Adductor Pollicis

Hypothenar Muscles:

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Abductor Digiti Minimi
Flexor Digiti Minimi
Opponens Digiti Minimi

The Thenar Group

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?Abductor Pollicis

Brevis

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?Flexor Pollicis Brevis

?Opponens Pollicis

?Adductor Pollicis

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Muscles

ABDUCTOR POLLICIS BREVIS

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Origin Scaphoid & Trapezium &

Flexor Retinaculum

Insertion Lateral side of base of

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proximal phalanx of thumb

Action Abducts thumb

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Innervation median nerve (C8 and

T1

Flexor Pol icis Brevis

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Origin S-Tubercle of Trapezium

D-Capitate & Trapezoid bones
Insertion Lateral side of base

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of proximal phalanx of thumb
Action Flexes thumb
InnervationRecurrent branch of

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median nerve (C8 and T1)
Opponens Pol icis

Origin Flexor retinaculum and

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Tubercles of Trapezium
Insertion Lateral side of 1st

metacarpal
Action Draws 1st metacarpal

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laterally to oppose thumb toward

center of palm
Innervation Recurrent branch of

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median nerve (C8 and T1)

Adductor Pol icis

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It has 2 heads that are separated by a

gap through which the radial artery

passes

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Origin: Oblique head ? capitate &

bases of 2nd and 3rd metacarpals,
Transverse head ? anterior surface of

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body of 3rd metacarpal bone
Insertion: medial side of base of

proximal phalanx of thumb
Innervation: ulnar nerve

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Action: adducts thumb towards middle

digit

The Hypothenar Group

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Hypothenar muscles

1. Opponens Digiti
Minimi

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2.Abductor Digiti Minimi
3.Flexor Digiti Minimi

Brevis
4.Palmaris Brevis

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Opponens Digiti Minimi

Origin Hook of hamate

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and flexor retinaculum
Insertion Medial border

of 5th metacarpal
Action Brings little finger

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(5th digit) into opposition

with thumb
InnervationDeep branch

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of ulnar nerve (C8 and T1)
Abductor Digiti Minimi

The most superficial of the

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hypothenar muscles forming

the hypothenar eminence
Origin : Pisiform bone

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Insertion: Medial side of

base of proximal phalanx of

5th digit

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Action:

Abducts 5th digit

Flexor Digiti Minimi Brevis

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Origin Hook of hamate

and flexor retinaculum
Insertion Medial side of

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base of proximal phalanx

of little finger
Action

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Flexes proximal

phalanx of little (5th) finger
Innervation

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ulnar

nerve

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Palmar Brevis

It lies in the fascia deep to the

skin of the hypo thenar em

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inence
A relatively unimportant mu scle

except that it covers and

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protects the ulnar nerve and

artery
Origi n: Flexor retinaculum and

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palmar aponeurosis
Inserti on: Skin on the medial side

of the palm

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Acti on: Wrinkles the skin on the

medial side of the palm and

deepens the hollow of the palm, as

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in cupping of the hand, thereby

aiding the grip

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INTEROSSEI MUSCLES

Interosseous Muscles

They are located between the

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metacarpal bones

Arranged in 2 layers: 4 Palmar

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and 4 Dorsal

Located between bones 1. Dorsal

interossei 1 to 4

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Origin: Adjacent sides of 2 metacarpal

bones

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Insertion : Extensor expansion's and

bases of proximal phalanges of digit 2

to 4

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Action: Abducts digits and assist

lumbricals

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2. Palmar interossei 1 to 4

Origin : Palmar surfaces of 2nd, 3th , 4th

and 5th metacarpal bones

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Insertion: Extensor expansion of digits

and bases of proximal phalanges of

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digits 2, 4, and 5

Action: Adducts digits and assist

lumbricals

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Lumbrical Muscles

They are named as such because

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of their elongated worml i ke

form

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1.Lumbri cal s 1 and 2
Ori gi n : lateral 2 tendons of flexor

digitorum profundus

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2.Lumbri cal s 3 and 4
Ori gi n: medial 3 tendons of flexor

digitorum profundus

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Insertion: lateral sides of extensor

expansions of digits 2 to 5
Acti on: To flex digits at MCP joints

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and extend IP joints

ARTERIAL ARCHES IN HAND
SUPERFICIAL PALMAR

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ARCH

DEEP PALMAR ARCH
Formation
Site

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Surface anatomy
Branches

Superficial Palmar Arch
FORMATION:

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Direct continuation of ulnar artery (mainly)
Superficial branch of radial artery
SITE: between palmar aponeurosis & long flexor tendons
SURFACE ANATOMY: level with the distal border of the fully

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extended thumb

BRANCHES: digital branches to the medial three & half fingers
N.B.: Radial artery gives 2 branches that supplies the lateral one &

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half fingers:

Radialis indicis: supplies lateral side of index
Princeps pollicis: supplies both sides of thumb

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Deep Palmar Arch
FORMATION:
Direct continuation of radial artery (mainly)
Deep branch of ulnar artery
SITE: between long flexor tendons & metacarpal bones

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SURFACE ANATOMY: lies one inch proximal to superficial

palmar arch

BRANCHES:

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Branches sharing in anastomosis around wrist joint
Articular & muscular branches


NERVES IN HAND

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Cutaneous innervation

Nerves In Hand

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Muscular innervation
ULNAR NERVE:
? Superficial Branch:
Palmaris brevis

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? Deep Branch:
Adductor pollicis
Hypothenar muscles
Interossei
Medial two lumbricals

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Ulnar nerve

Is responsible for the innervations

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of the following.

1. Flexor carpi ulnaris
2. Flexor digitorum profundus

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Nerves In Hand

Muscular innervations
MEDIAN NERVE:
Abductor pollicis brevis

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Flexor pollicis brevis
Opponens pollicis
Lateral two lumbricals

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Median nerve

Is responsible for the innervations of

the following soldiers.

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- 1. Flexor carpi radialis
- 2 .Flexor digitorum superficialis
- 3. Flexor digitorum profundus
- 4. Flexor pollicis longus

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- 5. Palmaris longus
- Gives humans the ability to oppose

the thumb joint

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Radial Nerve

- Is responsible for the innervations of

the following muscles

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- 1. Extensor Carpi Radialis Longus
- 2. Extensor Carpi Radialis Brevis
- 3. Extensor Digitorum
- 4. Extensor Carpi Ulnaris

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- 5. Abductor Pollicis Longus
- 6. Extensor Digiti Minimi
- 7. Extensor Pollicis Brevis
- 8. Extensor Pollicis Longus

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Arteries:
1. Deep palmar arch
2. Superficial palmar arch
3. Common palmar digital

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arteries

The Radial artery supplies blood to:
- 1. Flexor carpi radialis
- 2. Extensor carpi radialis longus

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- 3. Extensor carpi radialis brevis
- 4. Flexor pollicis longus
The Ulnar artery supplies blood to:
- 1. Flexor carpi radialis
- 2. Flexor carpi ulnaris

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- 3. Extensor carpi ulnaris
- 4. Flexor digitorum superficialis
- 5. Flexor digitorum profundus
- 6. Palmaris longus

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Waste Management

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- 1. Cephalic vein
- 2. Basillic vein
- 3. Superficial dorsal venous

arch (network)

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- 4. Deep dorsal venous arch

(network)

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Clinical Concerns

Carpal tunnel

Ganglion cyst

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- The transverse carpal ligament in the wrist - Is a fluid fil ed cyst that develops

puts pressure on the medial nerve

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out of a joint.

- - possible cause: overuse, hormonal

- - possible cause: joint trauma

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- http://www.youtube.com/watch?v=SGyKQ - http://www.youtube.com/watch?v=

chSEJ4

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mJ6oj3lkqm8

De Quervain's Tenosynovitis

-irritation of the sheath around the tendon

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- affects the tendons on the thumb side of the wrist
- possibly caused by repetitive actions, over use
- http://www.youtube.com/watch?v=q87zSRYHa1o

1. Nerve damage that impairs the flexion of distal

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interphalangeal joints of index and middle fingers also

produces which of the following conditions ?

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a) Atrophy of Hypothenar eminence

b) Loss of adduction of thumb

c) Similar impairment of flexion of distal I.P joint of little finger

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d) Weakness in pronation of forearm

2.A man is unable to hold a postcard between his index and

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middle fingers because of an injury to which of the

following nerves ?

a) Superficial branch of ulnar nerve

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b) Deep branch of ulnar nerve

c) Recurrent branch of median nerve

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d) Posterior interosseous nerve
3. All of the following muscles form the

boundry of the anatomical snuff box,

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EXCEPT :

a) Brachioradialis

b) Abductor pollicis longus

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c) Extensor pollicis longus

d) Extensor pollicis brevis

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4. Which is the longest metacarpal bone ?

a) Second metacarpal

b) Third metacarpal

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c) Fourth metacarpal

d) Fifth metacarpal

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5. After falling on his outstretched hand a patient

complains of tenderness in the space between

Extensor pollicis brevis and extensor pollicis

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longus tendons. Which bone is most likely

fractured by the injury ?

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a) Scaphoid

b) First metacarpal

c) Radial styloid process

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d) Trapezium

6. Which is the most frequently fractured carpal

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bone ?

a) Lunate

b) Scaphoid

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c) Capitate

d) Trapezium

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7. A middle aged woman suffering from myxedema, suddenly

woke up one night by a severe bout of pain in her right wrist

and middle finger. The pain seems to move up her forearm.

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After a thorough neurological check up her physician

diagnosed her condition as Carpal Tunnel Syndrome.Which

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nerve is involved in this syndrome ?

a) Median nerve

b) Palmar cutaneous branch of median nerve

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c) Ulnar nerve

d) Anterior interosseous nerve

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8. Examination of a patient reveals paralysis of the Abductor pollicis

brevis muscle. All of the following can be sites of lesion that

resulted in this paralysis , EXCEPT :

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One answer only.

a) Lower trunk of brachial plexus

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b) Lateral root of median nerve

c) Medial root of median nerve

d) Recurrent branch of median nerve

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9. A patient exhibits weakness of Pinch grip ;

other thumb movements are normal. There is no

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sensory loss in the hand. The probable cause is

da mage to :

a) Posterior interosseous nerve

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b) Anterior interosseous nerve

c) Deep branch of ulnar nerve

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d) Median nerve proximal to flexor retinaculum

10. In carpal tunnel syndrome which of the

follwoing conditions occur due to motor deficit ?

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a) Claw hand

b) Pointing index finger

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c) Benediction hand

d) Simian hand

Rx PG MCQ

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