WRIST AND HAND

PART OF THE HAND

BONES OF THE HAND

CARPAL BONES

INTRINSIC MUSCLES

THENAR MUSCLES OF THE HAND

HYPOTHENAR MUSCLES OF THE HAND

EXTRINSIC MUSCLES OF THE HAND- Muscles from the forearm inserting on wrist and
hand
EXTRINSIC MUSCLES: ANTERIOR COMPARTMENT

EXTRINSIC MUSCLES: LATERAL COMPARTMENT

EXTRINSIC MUSCLES: POSTERIOR COMPARTMENT

WRIST: ANTERIOR ASPECT

Superficial to the Flexor
Retinaculum (medial to lateral)
FCU tendon
Ulnar nerve
Ulnar artery
Palmar cutaneous
branch of ulnar nerve
Palmaris longus tendon
Palmar cutaneous
branch of median nerve
Passing below the Flexor
Retinaculum (medial to lateral)
FDS tendons (4) and FDP
tendons (4) common sheath
Median nerve

 Flexor pollicis longus tendon

Flexor carpi radialis (thru a split in the retinaculum)
WRIST: POSTERIOR ASPECT
Superficial to the Extensor Retinaculum
Dorsal cutaneous branch of the ulnar nerve
Basilic vein
Cephalic vein
Superficial branch of radial nerve
Beneath the Extensor Retinaculum
ECU tendon
EDM tendon
Extensor digitorum and Extensor indicis tendons common sheath
Extensor pollicis longus tendon
Extensor carpi radialis longus
Abductor pollicis longus and extensor pollicis brevis

LONG FLEXOR TENDONS

LONG EXTENSOR TENDONS

Fan out from external
retinaculum
Together with deep
fascia, they form the
subfascial space.
Tendons of middle, ring
and small fingers are
connected by fibrous
bands.
Tendon to the index
finger is joined medially
by the extensor indicis.
Extensor digiti minimi
lies medial to the
extensor digitorum tendon to small finger.
On the finger, extensor
expansions join the
tendon.
Near the PIP joint, it splits
into three, Central tendon
inserts on the base of
middle phalanx. The two
lateral slips insert at the
base of distal phalanx.

The dorsal extensors also receive the interosseous tendons and lumbrical
tendons.

VASCULAR SUPPLY TO THE HAND

PALMAR ARCHES

RADIAL ARTERY AT THE PALM

Leaves the dorsum between 1st and 2nd
metacarpals.
Continues as deep palmar arch between oblique
and transverse head of adductor pollicis
Curves medially between the long flexors and
interosseous muscles to form the deep palmar
arch
Has anastomosis at the wrist joint and also digital
branches of the superficial palmar arch
Branches
Arteria radialis indicis lateral side of index
finger
Arteria princeps pollicis lateral and medial sides of the thumb

 RADIAL ARTERY OF THE DORSUM

From the lateral side of the wrist
Beneath the extensor pollicis tendon to reach the
interval between first and 2nd interossei.
Branches take part of the anastomosis around the
wrist
Digital arteries to the thumb and index fingers
DORSAL VENOUS ARCH
Lies on the subcutaneous tissue proximal to MCP
Drains on the cephalic and basilic veins

NERVE SUPPLY TO THE HAND

MEDIAN NERVE AT THE PALM
Starts at the fusion of the medial and lateral cords
Continues down the arm initially on the lateral side of the brachial artery then
crosses over it to lie medial to it.
Continues down in the cubital fossa
In the forearm, the nerve travels between the flexor digitorum profundus and
flexor digitorum superficialis muscles.

Enters the carpal tunnel

Palmar cutaneous branch branches
out before the retinaculum and
supplies the lateral part of the palm
After the carpal tunnel, it divided into
medial and lateral branches
Muscular branch recurrent course
to about one fingerbreadth distal to the
scaphoid tubercle and supply the
abductor pollicis brevis, flexor pollicis
brevis and opponens pollicis and the 1 st
lumbricals
Cutaneous branch to the lateral three and
half digits and 2nd lumbricals
ULNAR NERVE OF THE PALM
Superficial branch
Between pisiform and hook of hamate
Ulnar artery is on the lateral side
Passes thru the tunnel of Guyon with
the artery
Muscular branch to palmaris brevis
Cutaneous branch to medial one
and half fingers
Deep branch
Between abductor digiti minimi and
flexor digiti minimi
Muscular branches to
abductor digiti minimi,
flexor digiti minimi
opponens digiti minimi
interossei muscles
3rd and 4th lumbricals
both heads of the adductor
pollicis
Palmar cutaneous branch medial
part of the palm
RADIAL NERVE COURSE
Deep branch of the Radial Nerve
Arise from radial nerve in front of the lateral epicondyle
Winds around the lateral aspect of the neck
Descends between the superficial and deep groups of muscles
Branches

Muscular ECRB, supinator, Extensor digitorum, extensor digiti

minimi, ECU, Abductor pollicis longus, Extensor pollicis brevis
and longus, and extensor indicis
Articular branch to the wrist and carpal bones

RADIAL NERVE
Enters the snuff box then supplies the lateral half of the dorsum and dorsum
of the lateral 3 and half fingers up to the middle phalanx

PALMAR INNERVATIONS

DORSUM OF HAND
Sensory nerve supply:
Superficial branch of the radial nerve
Supplies the lateral 2/3 of the dorsum
Supplies the lateral 3 and half fingers
Posterior cutaneous branch of the ulnar nerve
Supplies the medial third of the dorsum
Supplies the medial 1 and half fingers
Dorsal digital nerves never extend beyond the proximal phalanx.
DORSAL INNERVATIONS

FASCIAL SPACES OF THE HAND

Potential space with loose connective tissues
Limits the spread of infection

Thenar space
separated by second septum from mid palmar space
Contains 1st lumbrical muscle and posterior to long flexor tendons of
index finger and in front of adductor pollicis muscle
Mid palmar space
Contains 2nd, 3rd and 4th lumbricals
Posterior to long flexors of middle, ring and little fingers
In front of interossei and 3rd 4th and 5th metacarpal bones
Lumbrical canal surrounds each lumbrical muscle and continuous with one
of the palmar spaces.

PALM OF THE HAND: SKIN

Palmaris brevis
From flexor retinaculum and palmar
aponeurosis to skin of the palm
Nerve: superficial branch of the ulnar nerve
Action: corrugate the skin at the base of the
hypothenar eminence thus improving the
grip
Sensory supply
Palmar cutaneous branch of median nerve
Palmar cutaneous branch of ulnar nerve
Thenar eminence lateral cutaneous nerve
of the forearm or superficial branch of radial
nerve
PALM OF THE HAND: PALMAR APONEUROSIS

Triangular, at the center of palm

Apex attached to distal border of the
palmaris longus
Base divides the base of finger (four slips)
Each slip has two bands, one passing
superficial to the skin, the other deep to the
root of the finger
Deep band divides into two around the
flexor tendons and fuse with the fibrous
flexor sheath and deep transverse
ligaments.
Medial and lateral borders are continuous
with the thenar and hypothenar muscle
fascias
Function: firm attachment of the skin, improve grip and protect the tendons

CARPAL TUNNEL
Concave anterior carpal surface
Converted to tunnel by flexor
retinaculum
Contents: FPL, FDS (4), and FDP
tendons (4) and Median nerve
FS and FDP tendons have
common synovial sheath form
lateral side
SYNOVIAL FLEXOR SHEATH
Starts at the lateral side
Small finger: continues distally without
interruption
Ring middle and index fingers: ends at the
middle of the palm. Digital synovial sheath for
the phalanges.
Thumb: FPL has its own sheath (in 50% of pop,
they communicate with FDS and FDP sheath
FIBROUS FLEXOR SHEATH
From head of metacarpal to distal phalanx

Open proximal end, closed distal end(base of

distal phalanx)
Thumb: FPL tendon
Fingers: FDS and FDP tendons

JOINTS OF THE WRIST AND HAND

DISTAL RADIOULNAR JOINT
Articulation: between round head of ulna to ulnar
notch of the radius
Synovial pivot joint
Enclosed in capsule
Ligaments: anterior and posterior ligaments
Articular disc: triangular with apex at the styloid process and base at the
lower border of the ulnar notch
With synovial membrane
Nerve supply: Anterior interosseus nerve and deep branch of the radial nerve
Pronation pronator teres and pronator quadratus
Supination biceps brachii and supinator
More powerful than pronation
Relations:
Anterior: tendons of FDP
Posterior: tendons of extensor digiti minimi.
WRIST JOINT- RADIOCARPAL
Between the distal end of the radius and articular disc above and scaphoid,
lunate and triquetral bone
Synovial ellipsoid joint
Proximal is ellipsoid concave and distal surface is ellipsoid convex.
With capsule distal end of radius to proximal carpus
Ligaments Anterior and posterior ligaments
Medial ligaments attached to ulnar styloid and triquetral bones
Lateral ligaments from radial styloid to scaphoid bones
With Synovial membrane
Nerve supply Anterior interosseous nerve and deep branches of the radial
nerve.
Flexion FCR, FCU and palmaris longus
Extension ECRL, ECRB, ECU. Assisted by Extensor digitorum, Extensor
indicis, extensor digiti minimi and EPL
Abduction (radial deviation) FCR and ECRL and ECRB. Assisted by Abductor
pollicis longus and extensor pollicis longus and brevis
Adduction (ulnar deviation) FCU and ECU

 CMC AND INTERCARPAL JOINTS

Synovial plain joints
Common joint cavity
CMC of the thumb
Between the trapezium and base
Synovial saddle shaped
Encapsulated
MCP JOINTS
Head of metacarpal and base of proximal
phalanx
Synovial condyloid
Encapsulated
Ligaments:
Palmar ligaments
2nd to 5th joints joined together by
deep transverse metacarpal
ligament
Collateral ligament at the sides of the
joint
Taut in flexion and lax in extension
Flexion lumbricals and interossei assisted by FDS and FDP
Extension ED and EI and EDM
Abduction dorsal interossei
Adduction palmar interossei
Thumb MCP is only Flexion-extension
INTERPHALANGEAL JOINTS
Distal interphalangeal joint
Between Distal phalanx and middle phalanx
Proximal interphalangeal joints
Between middle phalanx and proximal phalanx
Thumb has one interphalangeal joint
Index, middle, ring and small fingers
Flexion
DIP flexor digitorum profundus
PIP flexor digitorum profundus, flexor digitorum superficialis
Extension
Extensor digitorum
Extensor indicis proprius

Thumb
Flexion Flexor pollicis longus
Extension extensor pollicis longus

IMPORTANT STRUCTURES AROUND THE WRIST- SURFACE ANATOMY

VOLAR SURFACE
Radial Artery
Distal third of the radius lateral to the flexor carpi radialis
Tendon of Flexor Carpi Radialis
Tendon of Palmaris Longus
Tendon of Flexor Digitorum Superficialis
Tendon of Flexor Carpi Ulnaris
Ulnar Artery
Ulnar Nerve
LATERAL STRUCTURES
Anatomic Snuffbox
Medial border
Extensor Pollicis Longus
Lateral border
Extensor Pollicis brevis
Abductor Pollicis longus
Floor
Radial styloid
Scaphoid
Trapezium
1st metacarpal
Contents
Radial Artery
Superficial branch of radial nerve
Cephalic vein
DORSUM
Lunate
FUNCTIONAL POSITION OF THE HAND
Semiprone
Wrist more extended than at rest
All finger flexed at the same degree
Index and thumb in apposition

MOVEMENTS OF THE HAND

CLINICAL CONDITIONS
COMPARTMENT SYNDROMES
Carpal tunnel syndrome

Dupuytren's disease/ dequervain

Trigger fingers

Tenosynovitis

FRACTURES
Distal

Radius Fractures
Smiths Fracture
Colles' Fracture
Bartons Fracture

Carpal Bone fractures

Scaphoid

Metacarpal fractures
Base of Metacarpal

Metacarpal Shaft

Phalangeal fractures

DEFORMITIES

Heberden's Nodes
Distal interphalangeal joints
Bouchards Nodes
Proximal interphalangeal joints
Mallet Deformity

Boutonnieres Deformity
Rupture of the extensor central slip
Volar displacement of the lateral slips
Changes the direction of the pull
PIP extension to PIP flexion
Lateral slips still functions as DIP extensor

NERVE INJURIES
Ulnar Nerve
Motor - Intrinsic muscles of the hand
Sensory Medial 1 and half fingers

Median Nerve (Ape hand deformity)

Motor Thenar Muscles, 1ST and 2ND Lumbricals
Sensory Lateral 3 and half fingers

Radial Nerve
Motor - none
Sensory lateral dorsum of the hand

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