Dissector Answers - Flexor compartment of the forearm, Superficial Hand, and Elbow joint

Learning Objectives:
Upon completion of this session, the student will be able to:
1. Identify the prominent features of the humerus, ulna, radius, carpals, metacarpals and phalanges of the associated extensor and
flexor compartments as given in the lab manual. (explanation)
2. Identify the flexor compartment of the forearm and hand, the nerve and vessels supplying their contents, and the functional
significance of the included muscles. (explanation)
3. Correlate any fractures or deep cuts of the forearm or hand with functional disruptions of associated muscular or neurovascular
structures. (explanation)
4. Describe the movements of elbow, wrist, and finger joints. (explanation)
5. Identify position of tendons and associated bursae beneath the palmar carpal ligament. (explanation)
6. Identify the prominent features of carpals, metacarpals and phalanges associated with the hand as listed in the lab manual.
(explanation)
7. Define the thenar, hypothenar, central, and adductor-interosseous compartments of the hand and the functional significance of
each. (explanation)
8. Correlate any fractures or deep cuts of the hand with functional disruptions of associated muscular and neurovascular
structures. (explanation)
9. Describe the movements of the fingers and thumb. (explanation)
10. Describe the collateral circulation of the hand. (explanation)

Learning Objectives and Explanations:

1. Identify the prominent features of the humerus, ulna, radius, carpals, metacarpals and phalanges of the associated extensor and
flexor compartments as given in the lab manual. (W&B 127-129, 143-145, 154156, N420, N421, N436, N439, N440, N450, N451, N452, N456, TG2-04, TG2-31, TG2-32)

humerus: the bone of the upper arm. Its parts also serve as the origin for many muscles of the forearm.
The medial epicondyle is the attachment site for the common flexor tendon, which gives rise to the
superficial group of forearm flexor muscles (See #2 below). The lateral epicondyleis the attachment site for
the common extensor tendon, which is the origin of some forearm extensor muscles (See #2 below).
The lateral supracondylar ridge gives rise to thebrachioradialis muscle and the extensor carpi
radialislongus muscle.

ulna: the medial bone of the forearm. It is more firmly connected to the humerus than the radius, but it is
only indirectly articulated with the wrist and hand. Note that the head of the ulna is locateddistally.
The tuberosity of the ulna is a point of insertion for the brachialis tendon along with thecoronoid
process, which also forms part of the trochlear notch.

radius: the shorter, laterally-placed bone of the forearm. Its head is located on its smaller proximalend, and
its lower end broadens to take almost the full contact of the bones of the wrist. Thetuberosity of the
radius is the insertion point for the biceps brachii tendon. The interosseous crest is a point of attachment
for the interosseous membrane, and the dorsal radial tubercleacts as a pulley point for the tendon of
extensor pollicislongus, separating it from the tendons of the extensor carpi radialislongus and brevis
muscles.

carpals: These eight small bones of the wrist are held together by ligaments and arranged in two rows,
proximal and distal. The bones of the proximal row, listed from the radial to the ulnar side, are the scaphoid,
the lunate, the triquetrum, and the pisiform. In the distal row, from radial to ulnar side, are the trapezium,
the trapezoid, and capitate, and the hamate. Read across the proximal layer of
bones: Send Louis To Paris. Read across the distal layer of bones: To Tame CarnalHunger. (Note that the
pisiform bone is a sesamoid bone in the tendon of the flexor carpi ulnaris.)

metacarpals: There are five metacarpal bones, numbered from 1 (the thumb) to 5 (the little finger). These
bones are just distal to the carpals.

phalanges: There are fourteen of these "bones of the fingers." The thumb has only two phalanges, a
proximal and distal, where as the other digits each have three phalanges, proximal, middle, and distal.

2. Identify the extensor and flexor compartments of the forearm and hand, the nerve and vessels supplying their contents, and the
functional significance of the included muscles. (W&B 135143, N434, N439, N441,N444, N445, N446, N447, N448, N449, N450, N451, N452, N454, N456, N459, N460, N461, N462,N463, N46
4, N465, N466, N468, N470, N472A, N472B, N475, N476, N478, N481, TG2-23, TG2-24,TG2-25, TG2-26A, TG2-26B, TG2-27A, TG227B, TG2-28B, TG2-28C, TG2-29, TG2-30)
The forearm is organized into anterior and posterior compartments separated by the interosseous membrane that connects the
radius and ulna. The anterior compartment contains the flexor muscles, together with the median nerve (and branches), the ulnar nerve,
and accompanying vessels. The posterior compartment contains the extensor muscles (with the exception of the brachioradialis, which
is an elbow flexor), the radial nerve, and its branches. There are nineteen muscles in the forearm. Within both the posterior and anterior
compartments there are two and three layers of muscle groups, respectively. A good way to memorize the muscles is by group level.
The tables immediately below are listed according to that. Further below is a list of the muscles sorted by function.
superficial extensors:

Muscle

Origin

Insertion

Action

Innervation

Blood
Supply

brachioradialis

upper two-thirds of the lateral

supracondylar ridge of the
humerus

lateral side of the base of the flexes the elbow, assists in radial nerve
styloid process of the radius pronation &supination

radial
recurrent a.

extensor carpi
radialislongus

lower one-third of the lateral

supracondylar ridge of the
humerus

dorsum of the second

metacarpal bone (base)

radial a.

extends the wrist; abducts

the hand

radial nerve

extensor carpi
radialisbrevis

common extensor tendon (lateral

epicondyle of humerus)

dorsum of the third

metacarpal bone (base)

extends the wrist; abducts

the hand

deep radial
nerve

radial a.

extensor
digitorum

common extensor tendon extensor expansion of

(lateral epicondyle of the digits 2-5
humerus)

extends the metacarpophalangeal,

deep
proximal interphalangeal and distal
radial
interphalangeal joints of the 2nd-5th digits; nerve
extends wrist

interosseous
recurrent a. and
posterior
interosseous a.

extensor
digitiminimi

common extensor tendon joins the extensor

(lateral epicondyle of the digitorum tendon to the
humerus)
5th digit and inserts into
the extensor expansion

extends the metacarpophalangeal,

proximal interphalangeal and distal
interphalangeal joints of the 5th digit

deep
radial
nerve

interosseous
recurrent a.

extends the wrist; adducts the hand

deep
radial
nerve

ulnar a.

extensor carpi common extensor tendon medial side of the base of

ulnaris
& the middle one-half of the 5th metacarpal
the posterior border of
the ulna

deep extensors:

Muscle

Origin

Insertion

Action

Innervation Blood Supply

supinator

lateral epicondyle of the

humerus, supinator crest &
fossa of the ulna, radial
collateral ligament, annular
ligament

lateral side of proximal one- supinates the forearm

third of the radius

deep radial
nerve

recurrent
interosseous
a.

abductor
pollicislongus

middle one-third of the

posterior surface of the

radial side of the base of the

first metacarpal

deep radial
nerve

posterior
interosseous

abducts the thumb at

carpometacarpal joint

radius, interosseous
membrane, mid-portion of
posterolateral ulna

a.

extensor
pollicisbrevis

interosseous membrane and

the posterior surface of the
distal radius

base of the proximal phalanx extends the thumb at the

of the thumb
metacarpophalangeal joint

deep radial
nerve

posterior
interosseous a

extensor
pollicislongus

interosseous membrane and

middle part of the
posterolateral surface of the
ulna

base of the distal phalanx of

the thumb

extends the thumb at the

interphalangeal joint

deep radial
nerve

posterior
interosseous a

extensor
indicis

interosseous membrane and

the posterolateral surface of
the distal ulna

its tendon joins the tendon of

the extensor digitorum to the
second digit; both tendons
insert into the extensor
expansion

extends the index finger at the

metacarpophalangeal, proximal
interphalangeal and distal
interphalangeal joints

deep radial
nerve

posterior
interosseous a

superficial flexors:

Muscle

Origin

Insertion

Action

Innervation

Blood
Supply

pronator teres

common flexor tendon and

(deep or ulnar head) from
medial side of coronoid
process of the ulna

midpoint of the lateral

side of the shaft of the
radius

pronates the forearm

median nerve

ulnar a.,
anterior ulnar
recurrent a.

flexor carpi radialis

common flexor tendon from

base of the second and

flexes the wrist, abducts the

median nerve

ulnar a.

the medial epicondyle of the

humerus

third metacarpals

hand

palmarislongus

common flexor tendon from

the medial epicondyle of the
humerus

distal half of flexor

retinaculum and
palmarisaponeurosis

flexes hand (at wrist) and

tightens palmar aponeurosis

flexor carpi ulnaris

common flexor tendon &

(ulnar head) from medial
border of olecranon & upper
2/3 of the posterior border of
the ulna

flexor
digitorumsuperficialis

humeroulnar head: common

flexor tendon; radial head:
middle 1/3 of radius

median nerve
(C7 and C8)

ulnar a.

pisiform, hook of hamate, flexes wrist, adducts hand

and base of 5th metacarpal

ulnar nerve

ulnar a.

shafts of the middle

phalanges of digits 2-5

median nerve

ulnar a.

flexes the
metacarpophalangeal and
proximal interphalangeal
joints

deep flexors:

Muscle

Origin

Insertion

Action

Innervation

Blood Supply

flexor
digitorumprofundus

posterior border of the

ulna, proximal two-thirds
of medial border of ulna,
interosseous membrane

base of the
distal phalanx
of digits 2-5

flexes the metacarpophalangeal,

proximal interphalangeal and
distal interphalangeal joints

median nerve (radial

one-half) via anterior
interosseous n.; ulnar
nerve (ulnar one-half)

ulnar a.,
anterior
interosseous a.

flexor pollicislongus

anterior surface of radius

and interosseous
membrane

base of the
distal phalanx
of the thumb

flexes the metacarpophalangeal

and interphalangeal joints of the
thumb

median via anterior

interosseous n.

anterior
interosseous a.

pronator
quadratus

medial side of the anterior surface of

the distal one-fourth of the ulna

anterior surface of the distal

one-fourth of the radius

pronates the
forearm

median via anterior

interosseous n.

Sorted by function:
flexor division:

muscles which rotate the radius on the ulna:

o

pronator teres (superficial group, anterior compartment - pronates)

pronator quadratus (deep group, anterior compartment - pronates)

supinator (deep group, posterior compartment - supinates)

muscles which flex the hand at the wrist:

o

flexor carpi radialis (superficial group, anterior compartment)

flexor carpi ulnaris (superficial group, anterior compartment)

palmarislongus (superficial group, anterior compartment)

muscles which flex the digits:

o

flexor digitorumsuperficialis (intermediate group, anterior compartment)

flexor digitorumprofundus (deep group, anterior compartment)

flexor pollicislongus (deep group, anterior compartment)

anterior
interosseous a.

3. Correlate any fractures or deep cuts of the forearm or hand with functional disruptions of associated muscular or neurovascular
structures. (N461,N466,N472,N475,N477,N478N481, TG2-23, TG2-24, TG2-25, TG2-26A, TG2-26B, TG2-27A, TG2-27B, TG228B, TG2-28C, TG2-29, TG2-30)

The flexor digitorumsuperficialis has four tendons, which at the wrist lie in two layers. The tendons
destined for the third and fourth fingers lie superficially in the compartment; the second and fifth digits are
more deeply placed. As a result, a deep cut to the wrist would more likely leave the third and fourth flexor
tendons injured. (Note that a cut to this part of the wrist, a frequently attempted spot for suicide, would be
more likely to cause injury to cutaneous veins or flexor tendons 3 and 4 than to an artery. No major artery is
located at this position.)

The radial nerve may be injured in its groove on the posterior aspect of the humerus. By this level the nerve
has given off all its branches to the triceps muscle so there is no loss of extension at the elbow. However, all
postaxial muscles (forearm extensors) below this level would be paralyzed, resulting in "wrist-drop" and the
inability to extend the hand or digits. (The interphalangeal joints canstill be extended by the unaffected
interosseus and lumbrical muscles.) There will be sensory loss in the areas served by the posterior
antebrachial cutaneous and superficial radial nerves.

Injury to the median nerve at the wrist emphasizes the importance of opposition in the activities of the hand.
Loss of the motor or recurrent branch of the median nerve paralyzes the muscles of the thenar
eminence, with subsequent wasting of this area. The thumb can no longer be opposed to the other digits
and the normal grasp of the hand is lost. There is also important sensory loss in the areas of distribution of
the proper digital branches of the median nerve to the digits.

Injury to the ulnar nerve at the wrist produces a deformed "claw-hand". The thumb is strongly abducted and
all the metacarpophalangeal joints are hyperextended. There is marked wasting through the hand, as well as
sensory defects in the little finger and medial half of the ring finger.

4. Describe the movements of elbow, wrist, and finger joints. (N436,N439A,N439B,N453A,N453B,N453C,N458, TG2-43A, TG243BC, TG2-44A, TG2-44B, TG2-44C,TG2-45A, TG2-45B)

The wrist joint, also called the radiocarpal articulation, has great movement ability because of its convex oval
articular surface. The joint can flex, extend, abduct, adduct and circumduct. Rotary motion is prohibited.

The "knuckles", or metacarpophalangeal joints (MP), are characterized by loose articular capsules.
Movements of flexion and extension, abduction and adduction and circumduction are permitted at these
joints. Extension is making a flat hand; flexion is making a fist. The metacarpophalangeal joint of the thumb
is limited to the actions of flexion and extension. (The thumb's freedom of movement is a result of its
carpometacarpal joint).

The elbow joint is essentially a hinge joint (ginglymus). However, the elbow joint also includes within a
common articular capsule the proximal radioulnar joint, an articulation which is described with other
radioulnar articulations. The movements of the elbow joint are flexion and extension. The freedom with which
the hand can be elevated in flexion at the elbow is due to the slight medial rotation of the humerus and the
semipronated position of the forearm, which is habitual. Flexion of the elbow joint is produced by the action
of the biceps and brachialis muscles with the assistance of brachioradialis and those forearm muscles
arising from the medial epicondyle (common flexor tendon). Extension of the elbow is due to the pull of the
triceps and anconeus muscles. Please refer to Woodburne and Burkel pages 174-5 for good diagrams and a
complete description of this joint.

5. Identify position of tendons and associated bursae beneath the extensor retinaculum and palmar carpal ligament. (W&B 149154, N461, N462, N463,N470, TG2-40A, TG2-41A, TG2-34B)

Images from "Anatomy of the Human Body" by Henry Gray are provided by:

Synovial sheaths, like bursae, reduce the frictional effects of the passage of the tendons through tight compartments of the wrist. A
sheath is formed like a double-walled tube, the delicate inner wall closely attached to the tendon and its outer wall lining the
compartment in which the tendon lies. The two layers are continuous with one another at the ends of the tube.
Each of the compartments on the dorsum of the wrist contains a synovial sheath investing the tendon(s) included in the
compartment. The upper ends of the sheaths on the dorsum of the hand lie at the upper border of the extensor retinaculum, and they
extend variable distances distal to it. They end just short of the inserting tendon (For example, the extensor carpi radialislongus and
brevis, and the extensor carpi ulnaris sheaths end just short of their insertions on the bases of the metacarpal bones.)
On the palmar aspect of the wrist the tendons of the palmarislongus and flexor carpi ulnaris are not provided with synovial
sheaths. The digital flexors, however, are protected at the wrist by complex synovial coverings: The radial bursa is a long synovial
sheath for the tendon of flexor pollicislongus, which extends along this tendon from several centimeters above the flexor retinaculum to
just proximal to its insertion on the distal phalanx of the thumb. The ulnar bursa is the complex covering of the digital flexor tendons. It
occupies the center of the fibro-osseous tunnel of the wrist and also extends above the flexor retinaculum for several centimeters. This
sheath exhibits the invaginated character of synovial sheaths. The general sheath for these eight tendons continues to about the middle
of the palm and terminates there, except for the portion concerned with the fifth digit, which continues as far as the insertion of the
profundus tendon on the base of the distal phalanx.
Cultural enrichment: Check out these sections from the 1918 version of Gray's Anatomy of the Human Body! Some of the terms are (of course)
out-of-date, but the illustrations are timeless.
The Anterior Divisions (nerves) - The Veins of the Upper Extremity and Thorax - The Brachial Artery- The Radial Artery - The Ulnar
Artery - The Muscles and Fascia of the Forearm - Surface Anatomy of the Upper Extremity - Surface Markings of the Upper Extremity

6. Identify the prominent features of carpals, metacarpals and phalanges associated with the hand as listed in the lab manual. (W&B
154-156, N452, N456, TG2-31, TG2-32)

carpals: These eight small bones of the wrist are held together by ligaments and arranged in two (irregular)
rows, proximal and distal. The bones of the proximal row, listed from the radial to the ulnar side, are
the scaphoid, the lunate, the triquetrum, and the pisiform. In the distal row, from radial to ulnar side, are
the trapezium, the trapezoid, the capitate, and the hamate. Read across the proximal layer of
bones: Send Louis To Paris. Read across the distal layer of bones: To TameCarnal Hunger, or the more
racey: Some Lovers Try Positions That They Can't Handle. Can you guess which is the favorite of medical
students? (Note that the pisiform bone is a sesamoid bone in the tendon of the flexor carpi ulnaris, so it sits
on the volar surface of the triquetrum.)

metacarpals: There are five metacarpal bones, numbered from 1 (the thumb) to 5 (the little finger). These
bones are just distal to the carpals.

phalanges: There are fourteen of these "bones of the fingers." The thumb has only two phalanges, a
proximal and distal, whereas the other digits each have three phalanges, proximal, middle, and distal.

7. Define the thenar, hypothenar, central, and adductor-interosseous compartments of the hand and the functional significance of each.
(W&B 158-169, N447, N448, N459, N460, N461, N465, N466, N468,N472A, N472B, N459, N460, N462, TG2-34A, TG2-34B, TG235A, TG2-35BC)
The hand is entirely wrapped in fascia, with the palmar and dorsal fascia being continuous with one another on both sides. This
fascia is relatively thin, except in a triangular area on the middle of the palm. Here the fascia, which is also connected to the flexor
retinaculum and palmarislongus tendon (if present) is called the palmar aponeurosis. Furthermore, just like in the lower limb and in the
arm and forearm, there are septa that further divide the space into compartments.
In the palm of the hand, there are three important septa. The lateral fibrous septum runs from the lateral part of the palmar
aponeurosis to the deep aspect of the third metacarpal. This septum is the border between the thenar compartment lateral to it
(towards the thumb) and the central compartment medial to it. Similarly, the medial fibrous septum runs from the medial aspect of the
palmar aponeurosis to the deep part of the fifth metacarpal. It separates the hypothenar compartment, which is medial, towards the
little finger, from the aforementioned central compartment. Finally, a septum runs medially from the medial side of the first metacarpal
to the deep part of the third metacarpal. It separates the more superficial thenar compartment from the deeper adductor
compartment.

The intrinsic muscles of the hand are listed below, divided by compartment.
thenar compartment:

Muscle

Origin

Insertion

Action

Innervation

abductor
pollicisbrevis

flexor retinaculum,
scaphoid, trapezium

base of the proximal

phalanx of the first
digit

abducts thumb

recurrent branch of superficial palmar

median nerve
br. of the radial a.

flexor
pollicisbrevis

flexor retinaculum,
trapezium

proximal phalanx of
the 1st digit

flexes the carpometacarpal and

metacarpophalangeal joints of the
thumb

recurrent branch of superficial palmar

the median nerve
br. of the radial a.

opponenspollicis

flexor retinaculum,
trapezium

shaft of 1st
metacarpal

opposes the thumb

recurrent branch of superficial palmar

median nerve
br. of the radial a.

adductor/interosseous compartment:

Muscle

adductor
pollicis

Insertion

oblique head: capitate

and base of the 2nd and
3rd metacarpals;
transverse head: shaft of
the 3rd metacarpal

base of the proximal

phalanx of the thumb

adducts the thumb

ulnar
nerve, deep
branch

deep palmar
arterial arch

base of the proximal

phalanx and the

flex the metacarpophalangeal

joint, extend the proximal and

ulnar
nerve, deep

dorsal and
palmar

dorsal
four muscles, each
interosseou arising from two

Action

Innervation

Blood
Supply

Origin

Blood Supply

s (hand)

adjacent metacarpal
shafts

palmar
three muscles, arising
interosseou from the palmar surface
s
of the shafts of
metacarpals 2, 4, & 5 (a
palmar interosseous for
the thumb is usually
fused with the adductor
pollicis m.)

extensor expansion on
lateral side of the 2nd
digit, lateral & medial
sides of the 3rd digit,
and medial side of the
4th digit

distal interphalangeal joints of

branch
digits 2-4, abduct digits 2-4
(abduction of digits in the hand is
defined as movement away from
the midline of the 3rd digit)

metacarpal
aa.

base of the proximal

phalanx and extensor
expansion of the
medial side of digit 2
and lateral side of
digits 4 & 5

flexes the metacarpophalangeal,

extends proximal and distal
interphalangeal joints and
adducts digits 2, 4, & 5
(adduction of the digits of the
hand is in reference to the
midline of the 3rd digit)

palmar
metacarpal
aa.

ulnar
nerve, deep
branch

hypothenar compartment:

Muscle

abductor digitiminimi
(hand)

Origin

pisiform

Insertion

Action

Innervation

Blood
Supply

base of the proximal

phalanx of the 5th digit on
its ulnar side

abducts the 5th digit

ulnar nerve,
deep branch

ulnar a.

flexor digitiminimibrevis hook of hamate &

(hand)
the flexor
retinaculum

proximal phalanx of the

5th digit

flexes the carpometacarpal and

metacarpophalangeal joints of the 5th
digit

ulnar nerve,
deep branch

ulnar a.

opponensdigitiminimi

shaft of 5th metacarpal

opposes the 5th digit

ulnar nerve,
deep branch

ulnar a.

hook of hamate and

flexor retinaculum

central compartment:

Muscle
lumbrical
(hand)

Origin
flexor
digitorumprofundus
tendons of digits 2-5

Insertion

Action

Innervation

extensor expansion on flex the metacarpophalangeal joints,

the radial side of the
extend the proximal and distal
proximal phalanx of
interphalangeal joints of digits 2-5
digits 2-5

Blood Supply

median nerve(radial 2) via superficial

palmar digital nerves
palmar arterial
& ulnar nerve (ulnar 2) via arch
deep branch

And finally, we have poor little palmarisbrevis muscle. As if it isn't bad enough that the palmarislongus muscle is highly variable,
its little brother, the palmarisbrevis muscle, is thin, largely insignificant mechanically, and is superficial to, not in, the hypothenar
compartment. It does serve to protect the ulnar nerve and artery, which it does valiantly, as well as give you that funny little skin pucker
when you make a tight fist.

Muscle

Origin

palmarisbrevis fascia overlying the

hypothenar eminence

Insertion

skin of the palm near the

ulnar border of the hand

Action

draws the skin of the ulnar side of the

hand toward the center of the palm

Innervation

superficial br. of
theulnar n.

Blood
Supply
ulnar a.

To summarize innervation, there are two main nerves. The median nerve gets the thenar muscles via its recurrent (motor)
branch, as well as half of the lumbricals. The deep branch of the ulnar nerve gets all of the rest, with the exception of the
palmarisbrevis muscle, which is innervated by a superficial branch of the ulnar nerve.
8. Correlate any fractures or deep cuts of the hand with functional disruptions of associated muscular and neurovascular structures.
The two classic examples here both involve the median nerve:

Injury to the median nerve at the wrist, in, say, a case of carpal tunnel syndrome, results in severe paralysis of some hand
motions and loss of cutaneous sensation. Most noticeable is the loss of the ability to oppose the thumb, since the only muscle that does
this for the thumb is an intrinsic hand muscle innervated by the median nerve, the opponenspollicis muscle. (Other intrinsic muscles
of the hand can call for back-up from forearm muscles, to, for example, flex the thumb or little finger. These actions will, of course, be
weakened somewhat.)(Hint: Know about carpal tunnel syndrome.)
Often, farm equipment, switchblades, or broken glass can produce a direct wound to the thenar eminence, possibly injuring
the recurrent (motor) branch of the median nerve itself. This also paralyzes the muscles of the thenar eminence, and causes
subsequent wasting of the area. But, depending on what branches had already been given off, the lesion may be less severe than one
caused farther up the chain at the wrist.
Other injuries are of course possible. Use your imagination to figure out what things one could cut when falling with arms
outstretched through a plate-glass window, then use the tables to figure out how that person would present to you in the Emergency
Department.
9. Describe the movements of the fingers and thumb. (W&B 13-14, N463, N464, N465, TG2-45, TG2-24)
The flexion and extension of the fingers is pretty straightforward. Abduction andadduction of them is the same as with the toes,
with the third digit (2nd finger, "middle" finger) held as the axial line. The other three fingers either move toward (adduction) or away
from (abduction) this finger.
The thumb gets to be a little tricky. Opposition is where you bring the pad of the thumb into contact with the pad of another digit,
often specifically the little finger. This "simple" motion, which sets us apart from all but our closest monkey cousins, is really quite
complex. But, the rest of the "standard" motions of the thumb are defined differently than for the other digits.Abduction is bringing the
thumb out, away from the plane of the palm. Make a hand puppet, then straighten your MP joints. Your thumb is abducted. Clearly,
bringing it back, then, is adduction. Extension of the thumb takes place as you move it away from the other digitswithin the plane of
the palm, like when hitchhiking or making the "L for loser" sign on your forehead. Flexion is not only bringing it back, but then further
moving it such that it is lying across the palm.
10. Describe the collateral circulation of the hand. (W&B 185, N466, N469, TG2-37A, TG2-37B)
There are a bunch of places in the hand where arterial anastomosis occurs:

both the superficial and deep palmar arches get blood from both the radial and ulnar arteries

palmar metacarpal arteries with the common palmar digital arteries

the perforating branches of the dorsal metacarpals with both the deep palmar arch and the common palmar
digital arteries

the proper dorsal arteries with the palmar digital arteries

Cultural enrichment: Check out these sections from the 1918 version of Gray's Anatomy of the Human Body! Some of the terms are (of course)
out-of-date, but the illustrations are timeless.
The Anterior Divisions (nerves) - The Veins of the Upper Extremity and Thorax - The Brachial Artery- The Radial Artery - The Ulnar
Artery - The Muscles and Fascia of the Forearm - The Muscles and Fascia of the Hand - Surface Anatomy of the Upper Extremity - Surface
Markings of the Upper Extremity

Questions and Answers:

11. After removing the posterior antebrachial fascia (leaving the extensor retinaculum intact), do you see intermuscular septa? If not,
why?
The answer is no. At this distal part of the forearm, intermuscular septum would limit movement of the muscles contained.
12a. Carefully open a compartment and distinguish parietal and visceral layers. Where do they become continuous?
The parietal layer of a synovial sheath reflects onto the visceral layer (on the associated tendon) both proximally and distally to its
passage, deep to a retinaculum. (N462, TG2-40A,TG2-41A)

12b. How do bursae function?

Bursae and synovial sheaths are synovial bags containing synovial fluid, which gives these bags a lubricating quality, reducing the
friction on tendons.
12c. What is the posterior interosseous nerve?
The posterior interosseous nerve is the sensory continuation of the deep radial nerve, distal to its motor branches to the extensor
muscles. It reaches the wrist joint and carpal bones for proprioceptive sense from these structures. (N445,N478, TG2-30)
13. Review the radius, ulna, and the general arrangement of carpals, metacarpals, and phalanges in an articulated hand.
See #1 above. (N436,N439,N452,N456, TG2-04, TG2-31, TG2-32)
14. Note the differences between the palmar carpal ligament and the extensor retinaculum.
The extensor retinaculum extends from the lateral margin of the radius to the styloid process of the ulna, the pisiform bone, and the
triquetrum. The retinaculum has deep attachments to the ridges on the dorsum of the distal end of the radius. The palmar carpal
ligament is also a thickening of the antebrachialfascia, however, it is on the flexor side of the wrist. It is attached to the styloid
processes of both radius and ulna and crosses the tendons of the superficial flexor muscles and the ulnar nerve and blood vessels.
Deep to the palmar carpal ligament is the flexor retinaculum. (N459, N460, N461,N470, TG2-29, TG2-24)
15. What muscles lie within the fascial plane of the palmar carpal ligament?
The tendons of flexor carpi radialis, palmarislongus, and flexor carpi ulnaris muscles lie deep to the palmar carpal ligament at the wrist.
However, these tendons lie superficial to the flexor retinaculum. (N461, TG2-23, TG2-24)
16a. What muscles lie deep to the fascial plane of the palmar carpal ligament?
Deep to the palmar carpal ligament is the flexor retinaculum, under which the tendons of the flexor pollicislongus, the flexor
digitorumsuperficialis, and the flexor digitorumprofundus muscles pass. Note that at the wrist, the tendons to digits three and four pass
superficially to two and five from the flexor digitorumsuperficialis. (N461, TG2-24)

16b. Where are the arteries, veins and nerves in relation to the fascial plane of the palmar carpal ligament?
The median nerve passes under the flexor retinaculum. It lies radial to the superficial row of flexor tendons. The ulnar nerve and artery
lie within the palmar carpal ligament superficial to the flexor retinaculum. (N461, TG2-24)
16c. With what is the palmar carpal ligament continuous distally?
The fascia of the palm of the hand is continuous with the anterior antebrachial fascia by way of the palmar carpal ligament of the wrist.
(N459, TG2-23)
17. Note the two heads of origin of the pronator teres muscle, and their relation to the median nerve. Which structures cross its
insertion?
The pronator teres has both a humeral (superficial) and an ulnar (deep) head. The larger humeral head arises from the medial
epicondyle of the humerus by means of the common flexor tendon and from the adjacent septa and fascia. The smaller ulnar head
arises from the medial side of the coronoid process of the ulna and joins the deep aspect of the humeral head.Between these two
heads of origin passes the median nerve, which innervates the pronator teres muscle.
The pronator teres muscle is directed obliquely across the forearm, and its tendon passes under the brachioradialis to insert on a rough
impression on the shaft of the radius at the middle of its lateral surface opposite the supinator. The tendon is crossed by the superficial
radial nerve and the radial vessels at its insertion. (N447,N450,N475, TG2-24)
18. Do you have a palmarislongus?
The palmarislongus, taking origin from the medial epicondyle, adjacent muscles, and antebrachial fascia, is one of the more variable
muscles of the body, being absent in about 13% of cases. (N446, TG2-23)
19. Do any structures lie between the first two layers of muscles, i.e., between the separate heads of pronator teres?
As answered above: Yes, the median nerve passes between the two heads of the pronator teres. (N447,N475, TG2-24)
20. Note the fibrous arch spanning between the radius and the ulna. What passes beneath this arch? Trace three or four tendons as
they pass beneath the palmar carpal ligament. What is their arrangement?

This fibrous arch serves as part of the origin of the flexor digitorumsuperficialis. The median nerve passes distally immediately deep to
this arch, in contact with the deep fascia of flexor digitorumsuperficialis. The arrangement of the flexor digitorumsuperficialis tendons are
described above. (N447,N461, TG2-24)
21. From the cubital fossa trace the brachial artery distally as it divides into the radial and ulnar arteries. Where is the point of
bifurcation? Define the course and relations of the radial artery.
The central structure in the cubital fossa is the tendon of the biceps brachii muscle. Medial to the tendon lies the brachial artery, which
bifurcates into the radial and ulnar arteries opposite the neck of the radius, in the inferior portion of the fossa.
The radial artery, the smaller of the two branches, continues the direct line of the brachial trunk. The artery lies in the intermuscular cleft
of the lateral side of the forearm. In the upper one-third of the forearm it runs between the brachioradialis and pronator teres muscles. In
the lower part of the forearm the artery lies under the antebrachial fascia with the superficial radial nerve lateral to it. Its branches in the
forearm are the radial recurrent, muscular, palmar carpal, and superficial palmar arteries. At the wrist, the radial artery marks the
(manual) pulse point. It then continues to the extensor portion of the hand, and in its course lies deep within the anatomical snuffbox.
(N447,N466, TG2-24, TG2-26)
22a. Consider the collateral circulation of the elbow between branches of brachial, deep brachial, radial and ulnar arteries.
Like all moveable joints, there is ample collateral circulation around the elbow. The superior and inferior ulnar collateral branches of the
brachial artery anastomose with the anterior and posterior ulnar recurrent branches of the ulnar artery. The middle collateral and radial
collateral branches of the deep brachial artery anastomose with the radial recurrent branch of the radial artery and the interosseous
recurrent branch of the posterior interosseous artery. (N434, TG2-26, TG2-19)
23. Where do muscular branches to the flexor muscles arise? Locate precisely at the wrist.
See #3 above. (N475, N476, TG2-24)
24. What muscles does the anterior interosseous nerve supply? Where does it arise? What are its relations?
The anterior interosseous nerve supplies the flexor pollicislongus, the radial half of the flexor digitorumprofundus, and the pronator
quadratus muscles. It arises from the back of the median nerve in the cubital fossa and passes directly along the anterior side of the

interosseous membrane distally to the pronator quadratus. It then passes deep to this muscle to end in sensory twigs to the wrist joint.
(N448, TG2-25)
25. Locate the ulnar nerve at the wrist. Note its specific relations to flexor carpi ulnaris, to flexor digitorumsuperficialis and profundus,
and to the ulnar artery. What muscles does it supply? Where do these branches leave the ulnar nerve?
At the wrist the ulnar nerve is immediately to the radial side of the pisiform bone.
At the elbow it passes between the humeral and ulnar heads of the flexor carpi ulnaris. In the upper part of the forearm, the ulnar
nerve lies on flexor digitorumprofundus and is covered by flexor carpi ulnaris. It lies deep to the flexor digitorumsuperficialis. Distally, the
ulnar artery meets the nerve, and in the lower half of the forearm they lie side by side, the artery on the radial side of the nerve.
The muscular branches of the ulnar nerve supply the flexor carpi ulnaris and the ulnar portion (to digits 4 & 5) of the flexor
digitorumprofundus muscles.
The ulnar nerve, like the median nerve, has no branches in the arm. In the forearm it has articular, muscular, and cutaneous
branches. The articular branches are distributed at the elbow joint. In the upper portion of the forearm the muscular branches diverge.
In the lower half of the forearm two cutaneous branches are given off. The palmar branch arises from the ulnar nerve near the middle of
the forearm and runs downward superficial to the artery. Along the radial aspect of the pisiform bone, the ulnar nerve divides into its
terminal branches to the hand, the superficial and deep branches. (N447, N448,N468,N472A,N476,N481, TG2-24,TG2-25, TG2-27)
26. Locate the palmar digital branches of the median and ulnar nerves along the borders of the digits. Determine area of distribution. Do
they supply any portion of the dorsal side of the digit? How much? Significance? What do they accompany?
The proper palmar digital branches of median nerve reach the radial 3 and 1/2 digits, while the ulnar branches reach the remaining
ulnar 1 and 1/2 digits. Each palmar digital branch sends branches onto the dorsal surface of the distal phalanx, to supply the nail bed.
Proper palmar digital arteries, primarily from the superficial palmar arterial arch, travel with the nerves. (N468,N472A, TG2-33B, TG238A)
27. What is the relation of the palmar aponeurosis to palmarislongus tendon, the palmar carpal ligament, and the flexor retinaculum?
The palmarislongus tendon spreads to unite with the palmar aponeurosis. The tendon passes deep to the palmar carpal ligament, and
superficial to the flexor retinaculum. (N459, N460,N461, TG2-23, TG2-24)

28. Identify the superficial transverse metacarpal ligament and transverse fasciculi and note the gaps between them. What can be seen
in these gaps?
The common palmar digital neurovascular bundles can be found dividing into their proper palmar digital branches in these gaps.
(N459, TG2-33)
29a. What is the carpal tunnel and its associated syndrome?
The anatomy tables cover it well. It says that carpal tunnel syndrome: "results from any lesion that significally reduces the size of the
carpal tunnel. Fluid retention, infection, and excessive exercise of the fingers may cause swelling of the tendons or their synovial
sheaths. Median nerve is the most sensitive structure in the carpal tunnel and therefore is the most affected. Median nerve has sensory
branches to the lateral three and a half digits thus paresthesia (abnormal sensation), hypothesia (reduced sensation), or anesthesia
(loss of sensation) may occur. Furthermore, the main motor branch of the median nerve is the recurrent branch which serves three
thenar muscles (it also serves the radial 2 lumbricals via common palmar digitals). Continued compresion of the median nerve will lead
to weakness of the abductor pollicisbrevis and opponenspollicis. To relieve the symptoms, partial or complete surgical division of the
flexor retinaculum (carpal tunnel release) may be necessary. Clinically this syndrome can be tested for by tapping on the carpal tunnel.
If symptoms are elicited (positive Tinel's sign), the syndrome is likely." (N461,N472A,N475, TG2-34A, TG2-34B, TG2-35)
30. What artery completes the superficial palmar arterial arch?
The superficial palmar branch of the radial artery completes the superficial palmar arterial arch. (N466, TG2-37)
31a. How do median and ulnar nerves share in the cutaneous innervation of the digits (review)?
Median nerve branches reach the radial 3 1/2 digits, while ulnar branches reach the remaining ulnar 1 1/2 digits. This includes the
dorsal surface of the distal phalanx, to supply the nail bed. (N472, TG2-33, TG2-38)
32. Does the flexor pollicisbrevis muscle have a deep head?
Yes, the deep head arises from the trapezoid and capitate, while the superficial head arises from the flexor retinaculum and the
trapezium. (N465, TG2-34)

33. Trace the superficial palmar branch of the radial artery to the thenar compartment. Does it continue beyond the compartment?
Where?
The superficial palmar branch of radial artery completes the superficial palmar arch by passing into the central compartment, deep to
the palmar aponeurosis. (N466, TG2-37A, TG2-37B)
34. What is the source of innervation for the hypothenar muscles?
As discussed in #3 above, the deep branch of ulnar nerve innervates these muscles. It passes between the abductor digitiminimi and
flexor digitiminimibrevis muscles. (N465,N476, TG2-34A, TG2-34B)
35. Examine the contents of the carpal tunnel. How is it formed?
The carpal tunnel is formed by the attachment of the flexor retinaculum to the trapezium and scaphoid laterally, and the hook of the
hamate and the pisiform medially. (N461, TG2-34)
36. Into which digital sheath does the ulnar bursa continue distally?
The ulnar bursa continues into the sheath for the little finger flexor tendons, which means that an infection of the little finger involving its
flexor and synovial sheaths could lead to an infection within the carpal tunnel. (N464, TG2-34)
37. What are vincula?
Vincula (mesotendons) are folds of synovial membrane containing neurovascular pedicles supplying the flexor tendons. They are
located between the phalanges and the flexor tendons. (N464, TG2-45)
38. Identify the lumbrical muscles, noting origin. Trace them to their immediate and functional insertion. What is the course of
innervation?
The radial 2 lumbricals are innervated by the median nerve, via its palmar digital branches. The ulnar 2 lumbricals are innervated by the
ulnar nerve. (N463, N464,N475,N476, TG2-34A,TG2-34B)
39. Locate the flexor carpi radialis tendon. Is it in the carpal tunnel? What happens to it?

The tendon of flexor carpi radialis traverses a split in the flexor retinaculum to insert on the bases of the second and third metacarpals.
(N461, TG2-36)
40. Consider the complete blood supply to the hand, including sources and arches . How do the dorsal and palmar proper digital
arteries differ in their formation? What are perforating arteries? Where are they found? What is their function?
The superficial palmar arch is formed by the superficial branch of the ulnar artery and the superficial palmar branch of the radial artery.
The deep palmar arch is primarily formed by the radial artery anastomosing with the deep branch of the ulnar artery. Dorsal carpal
branches of radial and ulnar unite to form a dorsal carpal arch. This arch gives off dorsal metacarpal arteries which divide into the
dorsal digital arteries. Palmar digital arteries are branches of common digital branches of the superficial arch. Perforating arteries
connect the dorsal and palmar metacarpal arteries (from the deep arch) at the heads of the metacarpal bones. (N466,TG2-37A, TG237B)

M.P., a 28-year-old man, was horseback riding with his partner when the horse he was riding stumbled, throwing him from the
saddle. In order to break his fall, M.P. stretched out his right hand, injuring his wrist. M.P. remounted his horse and continued to
ride; however, his wrist continued to hurt, with the greatest pain in the region of the triangular depression on the dorsum of the
hand bounded by the tendons of the extensor pollicislongus and the extensor pollicisbrevis when the thumb was fully extended.
When the ride was finished, he went to the local emergency room to have his wrist examined. The emergency room was crowded
that afternoon, and the staff was extremely busy. When the resident came in, he gave M.P. a quick examination, decided that the
wrist was sprained, wrapped it in an ACE bandage, and gave M.P. a prescription for a pain-killer. M.P. left the emergency room and
for a couple of weeks, everything seemed to be healing fine. After the medication ran out, however, he began to experience more
pain and a loss of movement in the injured wrist. M.P. then went to see his own doctor, who ordered X-rays of the wrist. The
radiologist who examined the X-rays determined that M.P. had suffered a fracture of one of the bones of the wrist. The fracture
did not appear to be healing, so M.P. was referred to an orthopedic surgeon.

1. The case states that the greatest pain was "in the region of the triangular depression on the dorsum of the hand bounded by the tendons of the
extensor pollicislongus and the extensor pollicisbrevis when the thumb was fully extended." What is this region called?
A.Cubital fossa
B. Posterior compartment
C. Anterior compartment
D. Triangular space
E. Anatomical snuffbox
Answer: E.
A. The cubital fossa is the common site for phlebotomy in the crux of the elbow. Its boundaries are the line between the
humeral epicondyles superiorly, the pronator teres medially, and the brachioradialis laterally.

B. The posterior compartment, also called the extensor compartment, contains the extensors of the forearm and is separated
from the anterior compartment by the interosseous membrane.

C. The anterior compartment, also called the flexor compartment, contains the flexors of the forearm and is separated from
the posterior compartment by the interosseous membrane.
D. The triangular space is found in the posterior shoulder area. Its boundaries are the long head of the triceps tendon
laterally, teres minor superiorly, and teres major inferiorly, and it is traversed by the circumflex scapular artery.

2. What bone did M.P. break?

A.Capitate
B. Pisiform
C. Trapezoid
D. Hamate
E.Triquetrum
F. Scaphoid
G. Trapezium
H. Lunate
F. The scaphoid, the most frequently fractured of the carpal bones, can be palpated in the floor of the anatomical snuff box.
Usually following trauma as a result of a fall onto the palm when the hand is abducted, pain in this area is the classic
presentation of a fractured scaphoid bone.

3. Which of the following is LEAST likely to have contributed to the failure of the scaphoid bone to heal?
A. Nonunion of the fractured sections because of the traction produced by muscles attached to the bone
B. The fracture line may enter a joint with one of the other bones of the wrist, leading to leakage of synovial fluid into the space. The presence
of synovial fluid may prevent healing of the fracture
C. The scaphoid is not easily immobilized to promote healing, due to its small size and its location
D. The blood supply to the scaphoid bone frequently enters the bone only from its distal end; therefore, a fracture may deprive the proximal
fragment of blood, interfering with healing and possibly leading to necrosis of the proximal fragment
Answer: A.
Significant nonunion of the fractured sections is not generally a concern in scaphoid fractures. In fact, it is the tendency of the
two pieces to remain "together" that makes initial diagnosis of a scaphoid fracture by plain film radiograph difficult. Nonunion
due to traction is of concern in hamate fractures. In addition, because of the proximity of the hook of the hamate to the ulnar
nerve, the nerve may be injured in the case of a hamate fracture, manifesting itself in reduced grip strength of the hand on
the affected side.

B. This is of concern in the case of a scaphoid fracture.

C. This is of concern in the case of a scaphoid fracture.
D. This is of concern in the case of a scaphoid fracture.

4. Scaphoid fractures produce symptoms that are similar to strains and sprains (synovial effusion, joint pain, and limitation of movement) and may
share a common history -- falling on an outsretched hand. Which of the following injuries LEAST commonly results from a fall on an outstretched
hand?
A. Fracture of the clavicle
B. Fracture of the distal radius (Colles' fracture)
C. Posterior displacement of the distal radial epiphysis
D. Dislocation of the lunate bone
E. Fracture of the neck of the 1st, 2nd, or 5th metacarpal
Answer: E. Fractures of the metacarpals are more commonly associated with striking something (or someone) with a clenched fist
and, thus, are called "boxer's fractures."
Posterior displacement of the distal radial epiphysis is an injury of children, and Colles' fracture, the most common fracture of the
forearm, is most common in adults over 50 year of age.
A,B,D. This is an injury that can result from falling on an outstretched hand.
C. This is an injury that can result from falling on an outstretched hand. It is common in older children because of frequent falls,
and if the healing process results in misalignment of the epiphyseal plate, abnormal radial growth may occur.

A 28-year-old volleyball player fell on her right outstretched arm during a game. She felt an immediate pain in her wrist, and the
orthopedic surgeon at the emergency room described the deformity in her right wrist as similar to a "dinner fork." All wrist
movements were painful. A plain radiograph revealed a transverse fracture of the distal end of the radius, which was tilted
backwards and radially. The patient was diagnosed with a typical Colles' fracture.

5. What bone is LEAST likely to be fractured by a fall on an outstretched hand?

A. Clavicle
B. Distal end of the radius
C. Ulnar styloid
D. Distal phalanx of the thumb

E. Surgical neck of the humerus

F. Scaphoid
Ans. D. Fractures of the distal phalanges are most often the result of a crushing injury (e.g., when a finger is closed in a door). All
of the other listed bones can be fractured by a fall on an outstretched hand.

A. Fracture of the clavicle can occur from the impact of an outstretched hand hitting the ground during a fall or from a fall
directly onto the shoulder itself.

B. Fracture of the distal end of the radius is called a Colles' fracture, common in adults over the age of 50, often caused by falling

on an outstretched hand.
C. Avulsion of the styloid process of the ulna occurs in 40% of cases of Colles' fractures, which commonly occur from falling on an
outstretched hand.
E. Fracture of the surgical neck of the humerus is commonly in elderly adults with osteoporosis and may occur from a minor
fall on the hand.

F. Review case 1
6. Which of the following patients would be MOST likely to suffer from differential radial and ulnar growth subsequent to this type of injury?
A. This 28-year-old patient
B. A 38-year-old man
C. A 10-year-old girl
D. A 67-year old woman
Ans. C
This type of injury in young children may lead to crushing of the growth plate. This event may then result in differential radial and
ulnar growth.
A and B. Growth of both the radius and ulna has finished by the time an individual reaches this age.
D. Elderly individuals may be more prone to this type of injury due to instability in walking and development of osteoporosis, but
growth of both the radius and ulna has finished by the time an individual reaches this age.

Under general anesthesia, the fractured piece was disimpacted by traction. The palm was then flexed and the wrist is firmly
pronated. The lower radius was pressed to maintain reduction, plaster of Paris was applied with the wrist flexed, pronated, and in
ulnar deviation. The X-ray was checked one week post-reduction. The cast was removed at 6 to 8 weeks.

Practice Quiz - Forearm & Wrist

Below are written questions from previous quizzes and exams. Click here for a Practical Quiz - old format or Practical Quiz - new format.
1. Supination of the hand and forearm would be diminished by loss of radial nerve function. But one very powerful supinator would remain
intact and unaffected, namely:
Brachialis
Brachioradialis
Biceps brachii
Flexor carpi radialis
Supinator
The correct answer is:

biceps brachii

Biceps brachii supinates the arm, but it is not innervated by the radial nerve--instead, it is innervated by the musculocutaneous nerve. So, it
would not be affected by a radial nerve injury. Brachialis is also innervated by the musculocutaneous nerve, but it is only involved with
flexing the forearm--it is not a supinator. Brachioradialis flexes the elbow and assists in pronation and supination--it is innervated by the radial
nerve and would be paralyzed after a radial nerve injury. Flexor carpi radialis is a flexor, not a supinator--it is innervated by the median nerve.
Finally, supinator is innervated by the deep radial nerve.

2. A worker doing repetitive lifting develops an inflammation in the tendon of origin of the extensor carpi radialisbrevis
muscle, commonly called "tennis elbow". The focal point of pain would most likely be near which palpable bony landmark?
Coronoid process of ulna
Lateral epicondyle of humerus
Lateral supracondylar ridge of humerus
Medial epicondyle of humerus
Medial supracondylar ridge of humerus
Olecranon
Posterior (subcutaneous) border of ulna

The correct answer is:

lateral epicondyle of the humerus

The extensor carpi radialisbrevis muscle originates from the common extensor tendon off the lateral epicondyle of the humerus. So, an injury to this
tendon would result in pain near the lateral epicondyle. Tennis elbow is due to the repetitive use of superficial extensor muscles of the forearm--the
pain is often felt at the lateral epicondyle and it radiates down the posterior surface of the forearm. None of the other bony landmarks are associated
with the common extensor tendon, although the medial epicondyle is the origin of the common flexor tendon.

3. The anterior interosseous is a branch of which nerve?

Axillary
Median
Musculocutaneous
Radial
Ulnar

The correct answer is:

median

The anterior interosseous nerve is a branch of the median nerve that provides motor innervation to the deep muscles in the flexor compartment,
including flexor pollicislongus, the radial half of flexor digitorumprofundus, and pronator quadratus. The other related nerve to think about is the
posterior interosseous nerve, which is the terminal branch of the deep radial nerve. It provides sensory innervation to the wrist area.
4. What muscle is innervated by branches of both the median and ulnar nerves?
Flexor carpi ulnaris
Flexor digitorumprofundus
Flexor digitorumsuperficialis
Flexor pollicislongus
Pronator quadratus

The correct answer is:

Flexor digitorumprofundus

The median and ulnar nerve both innervate flexor digitorumprofundus. Flexor carpi ulnaris is innervated by the ulnar nerve only. Flexor
digitorumsuperficialis and flexor pollicislongus are innervated by the median nerve. Pronator quadratus is innervated by the anterior interosseus
nerve, which is a branch of the median nerve.

5. Interruption of the median nerve in the cubital fossa affects what movement(s) of the thumb?
Flexion
Opposition
Both
Neither

The correct answer is:

Both

The recurrent branch of the median nerve innervates the thenar compartment of the hand. This nerve innervates opponenspollicis, which opposes the
thumb, and flexor pollicisbrevis, which helps to flex the thumb. So, disrupting the median nerve would impair both flexion and opposition of the
thumb.
6. Compression of the median nerve in the carpal tunnel affects which hand muscle(s)?
Dorsal interossei
Flexor pollicisbrevis
Flexor pollicislongus

Opponensdigitiminimi
Palmar interossei

The correct answer is:

Flexor pollicisbrevis

The recurrent branch of the median nerve innervates the thenar compartment of the hand, including flexor pollicisbrevis, abductor pollicisbrevis, and
opponenspollicis. So, if the median nerve was compressed, all of these muscles might be affected. The dorsal interossei, palmar interossei, and
opponensdigitiminimi are all muscles of the hand which are innervated by the deep branch of the ulnar nerve. Flexor pollicislongus is innervated by
the median nerve, but it is a forearm muscle which is proximal to the carpal tunnel. Therefore, it would not be affected by compressing the median
nerve in the carpal tunnel.
7. Structures within the carpal tunnel include the:
Radial bursa
Ulnar bursa
Both
Neither

The correct answer is:

Both
The radial bursa and ulnar bursa are both found in the carpal tunnel. These bursae are complex synovial coverings that protect the flexor
tendons. The carpal tunnel is formed where the flexor retinaculum spans from the scaphoid and trapezium to the hamate and pisiform, deep
and slightly distal to the palmar carpal ligament. This creates a canal that covers the flexor digitorumsuperficialis tendons, the flexor
digitorumprofundus tendons, the tendon of flexor pollicislongus, and the median nerve. These tendons in the carpal tunnel are covered by the
ulnar and radial bursae. The flexor digitorumsuperficialis and flexor digitorumprofundus tendons are covered by the ulnar bursa, and the
tendon of flexor pollicislongus is covered by the radial bursa. So, both bursae are in the carpal tunnel.
8. A patient is severely limited in extension at the wrist joint after several months in a cast following a Colles fracture. Which
joint would be especially important in therapy to regain full extension?
carpometacarpal
distal radioulnar

midcarpal
radiocarpal
ulnocarpal

The correct answer is:

radiocarpal

The radiocarpal joint is the joint commonly known as the wrist joint--it is a condyloid (oval) type of synovial joint that allows for flexion and
extension, abduction and adduction, and circumduction. A Colles fracture is a fracture of the distal end of the radius--this is why this sort of
break would limit movement between the radius and carpals. The carpometacarpal joint is found between the distal row of carpals and the
metacarpals--these joints are mobile for the thumb and little finger, allowing extension, flexion, abduction, and adduction. However, the
carpometacarpal joints are quite immobile for the middle three fingers. The distal radioulnar joint is located between the distal ends of the
radius and ulna--this joint allows the radius and ulna to rotate around each other during pronation and supination. The midcarpal joint is
located between the proximal and distal row of carpals--this joint is important for flexion and extension of the hand. As for the "ulnocarpal
joint," the ulna does not articulate with the carpal bones--it articulates with the distal end of the radius only.
9. The victim of multiple shrapnel wounds to the upper limb must have his forearm amputated at midlength. Because of
concomitant damage in the patient's arm, the surgeon must ligate the main artery at some point. The best chance of
saving collateral circulation to the stump of the forearm would be when the ligature is placed just below which of the
following?
Beginning of brachial artery
Origin of the deep brachial artery
Origin of the superior ulnar collateral artery
Origin of the inferior ulnar collateral artery
Bifurcation of the brachial artery

The correct answer is:

bifurcation of the brachial artery

The brachial artery bifurcates near the elbow. It forms two branches that become the radial and ulnar arteries. If these arteries were ligated after this
bifurcation, there would be a chance at saving collateral circulation to the forearm because the ulnar artery might have already given off its common
interosseous branch, which could carry blood to the forearm through the anterior and posterior interosseus arteries. Ligating near the beginning of the
brachial artery would stop blood from flowing through the rest of the upper limb. Ligating near the origin of the deep artery, by the origin of the

superior ulnar collateral artery, or near the origin of the inferior ulnar collateral artery might preserve enough collateral circulation to supply the
elbow. However, there would not be collateral circulation to the forearm. For a better picture of these arterial connections, see Netter Plate 434.

10. During an industrial accident, a sheet metal worker lacerates the anterior surface of his wrist at the junction of his wrist
and hand. Examination reveals no loss of hand function, but the skin on the thumb side of his palm is numb. Branches of
which nerve must have been severed?
Lateral antebrachial cutaneous
Medial antebrachial cutaneous
Median
Radial
Ulnar

The correct answer is:

median nerve

The median nerve provides sensory innervation to the skin of the radial 3.5 fingers of the palm. So, the patient's loss of cutaneous sensation is
suggestive of a median nerve injury. The location of the injury also implies that there has been an injury to the median nerve--this nerve enters
the hand by crossing under the flexor retinaculum on the anterior side of the wrist.
The lateral and medial antebrachial cutaneous nerves provide cutaneous innervation to the anterior side of the forearm--the symptoms here are
not consistent with an injury to these nerves. The radial nerve innervates the radial side of the dorsum of the hand but does not innervate the
palmar side of the hand. The ulnar nerve innervates the medial (ulnar) side of both the dorsum and palm of the hand.
11. A middle-aged woman comes to you complaining of pain on the lateral side of her right elbow, so severe that she holds her
eating utensils in her left hand to eat. She says that she spent the weekend putting in a new garden plot and that it
involved loosening and turning over a large area of grass sods with a garden fork. You find that the region just proximal to
the lateral epicondyle of her humerus is painful to the touch. There is no sensory loss in her forearm or hand. You suspect a
localized tearing of the origin of a muscle producing the equivalent of "tennis elbow." The muscle most likely involved is

the:
brachioradialis
common flexor tendon
extensor carpi radialisbrevis
extensor digitorum
pronator teres

The correct answer is:

brachioradialis

Tennis elbow is usually caused by inflammation of the common extensor tendon on the lateral side of the forearm, but we know that that's not
what happened here. Instead, the patient tore a muscle at its origin, near the lateral epicondyle of the humerus. Brachioradialis originates from
the upper two-thirds of the lateral supracondylar ridge of the humerus, so this is the muscle that she probably tore. This also makes sense
given her activities--brachioradialis flexes the elbow and assists in pronation and supination, so she would have been using this muscle while
gardening.
The common flexor tendon is associated with the medial epicondyle, not the lateral epicondyle. Extensor carpi radialisbrevis and extensor
digitorum take origin from the common extensor tendon, which attaches to the lateral epicondyle. This tendon would be inflamed in a classic
case of tennis elbow, but the common extensor tendon is not the structure that was injured in this patient's case. Pronator teres takes origin
from the common flexor tendon and the medial side of the ulna.
12. A boy fell onto a sharp object and cut his deep radial nerve as it emerged from the supinator muscle. The artery joining it
at this point was also injured. The injured artery is the:
anterior interosseous
common interosseous
posterior interosseous
radial
ulnar

The correct answer is:

posterior interosseous

The deep radial nerve emerges from the supinator muscle and runs in the deep layer of the posterior forearm. It runs next to the posterior
interosseous artery, which, along with the anterior interosseous artery, is a branch of the common interosseous artery. The common
interosseous artery comes off the ulnar artery to give these two branches that supply the deep arm on the anterior and posterior sides. The
ulnar and radial arteries are branches of the brachial artery that run down the ulnar and radial sides of the anterior arm.

13. While going up for a rebound, a basketball player jams her middle finger against the ball. She experiences severe pain and

the trainer notes that she can no longer extend the distal phalanx of the finger. The injury has avulsed (torn away from the
bone) which structure from her distal phalanx to produce this condition?
extensor carpi radialisbrevis tendon
extensor carpi radialislongus tendon
extensor digitiminimi tendon
extensor expansion
extensor indicis tendon

The correct answer is:

extensor expansions

The extensor expansions are the expanded distal ends of the extensor tendons which wrap around the heads of the metacarpals and the bases of the
proximal phalanges and insert on the bases of the middle and distal phalanges. These extensor expansions hold the extensor tendon in the middle of
the digit and provide a place for the lumbricals and interossei to attach. If an extensor expansion was torn, the extensor tendon would not be held in
place and a lumbrical would be torn from its attachment. This would impair extension at the joint.
Extensor carpi radialisbrevis and longus are involved with extending the wrist and abducting the hand. These muscles do not produce extension at the
fingers. Extensor digitiminimi and extensor indicis help with extension at the 5th and 2nd finger, but they do not act at the third finger.

14. The tendons on the dorsal side of the wrist are held in place by a thickening of the antebrachial fascia called the:
bicipitalaponeurosis
extensor expansion
extensor retinaculum
interosseous membrane
palmar carpal ligament

The correct answer is:

extensor retinaculum

The extensor compartment is on the dorsal surface of the arm. The tendons of the muscles from this compartment pass onto the dorsal side of
the wrist by crossing under the extensor retinaculum. The bicipitalaponeurosis is the membranous band that runs from the biceps tendon
across the cubital fossa and merges with the antebrachial fascia over the forearm flexor muscles. An extensor expansion wraps around the
head of a metacarpal and the base of the proximal phalanx to hold the extensor tendon in place on the digit. The interosseous membrane
connects the radius to the ulna, and the palmar carpal ligament is a thickening of the antebrachial fascia over the palmar surface of the wrist.
The palmarislongus and ulnar neurovascular bundle pass deep to the palmar carpal ligament, and the flexor retinaculum lies deeper and more
distal, forming the carpal tunnel.
15. The function of the posterior interosseous nerve is:
motor to the brachioradialis
motor to the extensor carpi ulnaris
parasympathetic to the dorsum of the forearm
sensory from the wrist joint
sensory from the dorsum of the forearm

The correct answer is:

sensory to the wrist joint

The posterior interosseous nerve is the sensory continuation of the deep radial nerve, distal to its motor branches to the extensor muscles (this is at
odds with how the posterior interosseous nerve is considered clinically, that is, it is considered synonymous with the deep radial) . It reaches the wrist
joint and carpal bones for proprioceptive sense from these structures. Brachioradialis is innervated by the radial nerve, and extensor carpi ulnaris is

innervated by the deep radial nerve. There are no parasympathetic nerves in the forearm, and sensory innervation from the dorsum of the forearm is
carried by the radial nerve.
16. Development of "tennis elbow" (lateral epicondylitis) involves the origin of which muscle?
Abductor pollicislongus
Anconeus
Brachioradialis
Extensor carpi radialisbrevis
Triceps brachii

The correct answer is:

extensor carpi radialisbrevis

"Tennis elbow" is due to repetitive use of the superficial extensor muscles of the forearm. The pain is felt on the lateral epicondyle and
radiates down the posterior surface of the forearm. With tennis elbow, the repeated flexion and extension of the wrist strains the attachment of
the common extensor tendon, producing inflammation of the periosteum of the lateral epicondyle and the common extensor attachment of the
muscles. The only muscle listed which takes origin from the common extensor tendon is the extensor carpi radialisbrevis. So, that is the
correct answer. (Extensor carpi ulnaris also takes origin from the common extensor tendon, so it might be responsible for some of the
symptoms too.)
None of the other muscles take origin from the common extensor tendon. Abductor pollicislongus originates from the middle one-third of the
posterior surface of the radius, the interosseous membrane, and the mid-portion of posterolateral ulna. Anconeus originates from the lateral
epicondyle of the humerus. Brachioradialis originates from the upper two-thirds of the lateral supracondylar ridge of the humerus--it is not a
muscle from the common extensor tendon. Finally, triceps brachii is not really assoiciated with the lateral epicondyle or the common extensor
tendon--this muscle attaches to the olecranon process of the ulna.
17. In an industrial accident, the artery passing lateral to the pisiform bone is cut. This artery is the
Deep palmar arch
Radial
Superficial palmar arch
Superficial palmar branch of the radial artery
Ulnar

The correct answer is:

Ulnar artery

The ulnar artery runs on the medial side of the wrist, near pisiform and hamate. It supplies most of the blood to the superficial palmar arterial
arch in the hand, but gives a deep ulnar branch to complete the deep palmar arch in the hand. The radial artery runs on the lateral side of the
wrist, near scaphoid and trapezium. It supplies most of the blood to the deep palmar arterial arch, but gives off a superficial palmar branch of
the radial artery which completes the superficial palmar arch in the hand. The superficial and deep palmar arches are found more distal in the
hand, near the heads and bases of the metacarpal bones, respectively.

18. After suffering a gunshot wound to the forearm, it was determined that the posterior interosseous nerve was severed. What
function was lost?
Sensory from the wrist joint
Motor to brachioradialis
Motor to the extensor carpi radialislongus
Parasympathetic to the dorsum of the forearm
Motor to the flexor digitorumsuperficialis

The correct answer is:

Sensory to the wrist joint

The posterior interosseous nerve is the sensory continuation of the deep radial nerve, distal to its motor branches for the extensor muscles. It
reaches the wrist joint and carpal bones for proprioceptive sense from these structures. Brachioradialis and extensor carpi radialislongus are
innervated by the radial nerve, and extensor carpi radialisbrevis is innervated by the deep radial nerve. Flexor digitorumsuperficialis is
innervated by the median nerve. There are no parasympathetic nerves in the limbs or body wall.
19. When falling on an outstretched hand, the most commonly dislocated carpal bone is the
Scaphoid
Trapezoid
Lunate

Capitate
Hamate

The correct answer is:

Lunate

It is fairly common for the lunate to be dislocated anteriorly--this injury may result from a fall on an extended wrist. The lunate may be
pushed out of its place on the floor of the carpal tunnel and move toward the palm of the wrist. This dislocation may compress the median
nerve and lead to carpal tunnel syndrome. Also remember: scaphoid, the lateral bone in the proximal row of carpals, is frequently fractured
when someone falls on an outstretched wrist! Capitate, hamate, and trapezoid are not commonly injured in these falls.

20. If the musculocutaneous nerve is severed at its origin from the brachial plexus, flexion at the elbow is greatly weakened
but not abolished. What muscle remains operative and can contribute to flexion?
Brachialis
Brachioradialis
Coracobrachialis
Long head of biceps brachii
Short head of biceps brachii

The correct answer is:

Brachioradialis

Brachioradialis is a muscle innervated by the radial nerve--it flexes the elbow and assists in pronating and supinating the arm. Brachialis,
coracobrachialis, and both heads of biceps brachii are all muscles which flex the arm and/or forearm, but they are all innervated by the

musculocutaneous nerve. These muscles would be denervated if the musculocutaneous nerve was severed at its origin from the brachial
plexus.
21. After falling on the ice, it was determined that a patient had a Colles' fracture. Care must be taken to relieve tension on the
broken distal end of the radius created by the pull of which muscle?
Extensor carpi ulnaris
Brachioradialis
Extensor carpi radialislongus
Pronator quadratus
Extensor carpi radialisbrevis

The correct answer is:

brachioradialis

The Colles' fracture is a fracture to the distal end of the radius. It usually occurs when someone tries to catch themselves from falling on an
outstretched arm. So, you need to look in the answer choices for a muscle that inserts on the distal end of the radius. Brachioradialis inserts on
the lateral side of the base of the styloid process of the radius, so this muscle could pull the broken piece of the radius out of place. This is
why a cast over a Colles' fracture needs to extend up to the elbow--brachioradialis needs to be immobilized!
Extensor carpi ulnaris inserts on the medial side of the base of the 5th metacarpal. Extensor carpi radialislongus inserts on the dorsum of the
second metacarpal bone. Pronator quadratus extends between the distal ulna and radius-- it serves to pronate the hand. Although this muscle
attaches to the broken part of the radius, it is not the most important muscle to stabilize following the injury. Extensor carpi radialisbrevis
inserts on the dorsum of the third metacarpal bone. So, none of the other muscles would pull on the distal piece of the radius as much as
brachioradialis.

22. If the tendon of palmarislongus were transected, what movement would be affected?
Flexion of the MP and IP joints of the thumb
Flexion of the proximal IP joints of digits 2 and 5
Flexion of the proximal IP joints of digits 3 and 4

Flexion of the wrist

Extension of the wrist

The correct answer is:

Flexion of the wrist

Palmaris longus is a small muscle in the anterior compartment of the arm--it flexes the hand at the wrist and tightens the palmar aponeurosis.
If this tendon was cut, it would be more difficult to flex the wrist. Flexor pollicislongus flexes the MP and IP joints of the thumb. Flexor
digitorumprofundus and superficialis flex the proximal IP joints of digits 2, 3, 4, and 5. Extensor carpi ulnaris, extensor carpi radialislongus
and extensor carpi radialisbrevis all extend the wrist.

23. What muscle is supplied by both the median and ulnar nerves?
Flexor carpi ulnaris
Flexor digitorumprofundus
Flexor digitorumsuperficialis
Flexor pollicislongus
Pronator quadratus

The correct answer is:

Flexor digitorumprofundus

The radial half of flexor digitorumprofundus is supplied by the median nerve, while the ulnar half of flexor digitorumprofundus is supplied by
the ulnar nerve. The ulnar nerve also supplies flexor carpi ulnaris in the anterior forearm. (Remember--the ulnar nerve is the 1 1/2 nerve--it
supplies 1 1/2 muscles in the anterior forearm, and it supplies cutaneous innervation to 1 1/2 fingers on the ulnar side of the hand!)
Flexor digitorumsuperficialis, flexor pollicislongus, and pronator quadratus are innervated by the median nerve.
24. The pulse of the radial artery at the wrist is felt immediately lateral to which tendon?
Abductor pollicislongus
Extensor pollicislongus

Flexor carpi radialis

Flexor digitorumprofundus
Palmaris longus

The correct answer is:

Flexor carpi radialis

The radial artery runs on the radial side of the wrist, lateral to the tendon of flexor carpi radialis. So, the radial pulse will be felt immediately
lateral to this tendon. Remember--the radial artery enters the wrist on the anterior side. This means that the extensor tendons, which are on the
posterior side of the wrist, will not be involved with the radial artery! The tendons for flexor digitorumprofundus and superficialis are found
more towards the center of the wrist, not on the wrist's lateral side. These tendons cross under the flexor retinaculum to reach the hand.
25. If the medial epicondyle of the humerus is fractured and the nerve passing dorsal to it is injured, which muscle would be
most affected?
Extensor carpi ulnaris
Extensor digitorum
Flexor carpi ulnaris
Flexor digitorumprofundus
Flexor digitorumsuperficialis

The correct answer is:

Flexor carpi ulnaris

The nerve passing dorsal to the medial epicondyle of the humerus is the ulnar nerve. In the forearm, the ulnar nerve innervates flexor carpi
ulnaris and the ulnar side of flexor digitorumprofundus. So, flexor carpi ulnaris would be most affected if the ulnar nerve was disrupted. What
other symptoms might you see? Paralysis of hand muscles (except for the thenar compartment and the first two lumbricals) and numbness
over the ulnar 1.5 digits in the hand!
The extensor muscles (extensor digitorum and extensor carpi ulnaris) are in the posterior compartment of the forearm--they are innervated by
the radial nerve. Flexor digitorumsuperficialis is innervated by the median nerve only. Although the ulnar side of flexor digitorumprofundus
would be impaired following the injury, the radial side of flexor digitorumprofundus would still be innervated by the median nerve.