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Anatomy of hand



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  • 1. ANATOMY OF THE HAND Orthopedic Department Al-Gamhouria Hospital PREPARE BY : Dr. Anwar Al-Esayi (Resident Orthopedic Surgery)
  • 2. HAND BONE Total of 27 bones in hand and wrist. These are grouped into carpals, metacarpals, and phalanges. The wrist is the most complex joint in the body. It is formed by 8 carpal bones grouped in 2 rows with very restricted motion between them.
  • 3. Carpal bone All carpal bones participate in wrist function except for the pisiform. The scaphoid serves as link between each row; therefore, it is vulnerable to fractures. The distal row of carpal bones is strongly attached to the base of the second and third metacarpals, forming a fixed unit.
  • 4. Metacarpal bone The hand contains 5 metacarpal bone. First Metacarpal articulates proximally with the trapezium. The other 4 metacarpals articulate with the trapezoid, capitate, and hamate at the base. The hand contains 14 phalanges. All 4 distal carpal bones articulate with the metacarpals at the carpometacarpal (CMC) joints. At the metacarpophalangeal joints, lateral motion is limited by the collateral ligaments
  • 5. Gliding joint – allows one bone to slide over another Example: Wrist and Ankle Joint Shapes
  • 6. Joint Shapes Condyloid: egg-shape articular surface + oval concavity side-to-side, back+forth movement (eg) metacarpophalangeal (knuckle)
  • 7. Joint Shapes Saddle: articular surface both concave + convex side-to-side, back-forth movement (eg) carpometacarpal joint of thumb
  • 8. Joint Shapes Hinge Joint In between the Phalanges are Hinge Joints They move in flexion and extension
  • 9. A Ligament A Ligament attaches abone to bone An Injury to a Ligament is called a Sprain A Tendon Attaches a muscle to a bone An injury to a tendon or Muscle is a strain
  • 10. Collateral Ligaments collateral ligaments, are found on either side of each finger and thumb joint. The function of the collateral ligaments is to prevent abnormal sideways bending of each At the CMC joint, the volar plate is part of the joint capsule that attaches only to the proximal phalanx, allowing hyperextension. At the inter phalangeal joints: extension is limited by the volar plate, which attaches to the phalanges at each side of the joint. Radial and ulnar motion is restricted by collateral ligaments.
  • 11. palmar carpal lig ----Transvers carpal lig
  • 12. palmar ligament Palmar ulno carpal lig Ulno lunate lig Ulno triqouetral lig Radio scapho lunate lig Radio capitate lig Ulnocollateral lig Radial collateral lig Palmar radio ulnar lig Palmar carpometacarpal lig Palmar metacarpal lig Radiated capitate lig Piso humate lig ligpiso metacarple
  • 13. Dorsal ligament Dorsal ulnocarpal ligament Dorsal carpometacarpal lig Dorsal metacarpal lig Dorsal radio carpal lig Dorsal radioulnar lig
  • 14. The pulley The pulley system is critical to flexion of the finger. The retinacular system for each of the fingers contains 5 annular pulleys and 4 cruciate pulleys. The thumb has 2 annular pulleys and 1 oblique pulley. The system supplies mechanical advantage by maintaining the flexor tendons close to the joint's axis of motion. In doing so, the pulleys prevent bowstringing. .
  • 15. Intrinsic Situated totally within the hand Divided into 4 groups: the thenar, hypothenar, lumbrical, and interossei muscles.
  • 16. The thenar group The thenar group consists of: the abductor pollicis brevis, flexor pollicis brevis, opponens pollicis, and adductor pollicis muscles.
  • 17. Abductor Pollicis Brevis Origin scaphoid and trapezium Insertion Lateral side of base of proximal phalanx of thumb Action Abducts thumb Innervation median nerve (C8 and T1)
  • 18. Flexor Pollicis Brevis Origin Flexor retinaculum and tubercles of scaphoid and trapezium Insertion Lateral side of base of proximal phalanx of thumb Action Flexes thumb Innervation Recurrent branch of median nerve (C8 and T1)
  • 19. Opponens Pollicis Origin Flexor retinaculum and tubercles of scaphoid and trapezium Insertion Lateral side of 1st metacarpal Action Draws 1st metacarpal laterally to oppose thumb toward center of palm Innervation Recurrent branch of median nerve (C8 and T1)
  • 20. Adductor pollicis has 2 heads that are separated by a gap through which the radial artery passes origin: oblique head – bases of 2nd and 3rd metacarpals, capitate, and adjacent carpal bones transverse head – anterior surface of body of 3rd metacarpal bone insertion: medial side of base of proximal phalanx of thumb Innervation: ulnar nerve action: adducts thumb towards middle digit
  • 21. GroupThe hypothenar Hypothenar muscles Opponens Digiti Minimi Abductor Digiti Minimi Flexor Digiti Minimi Brevis Palmaris Brevis
  • 22. OPPONENS DIGITI MINIMI Origin Hook of hamate and flexor retinaculum Insertion Medial border of 5th metacarpal Action brings little finger (5th digit) into opposition with thumb Innervation Deep branch of ulnar nerve (C8 and T1)
  • 23. abductor digiti minimi most superficial of the 3 hypo thenar muscles forming the hypo thenar eminence origin: pisiform bon insertion: medial side of base of proximal phalanx of 5th digit action: abducts digit 5
  • 24. Flexor Digiti Minimi Brevis Origin Hook of hamate and flexor retinaculum Insertion Medial side of base of proximal phalanx of little finger Action Flexes proximal phalanx of little (5th) finger Innervation ulnar nerve
  • 25. palmar brevis lies in the fascia deep to the skin of the hypo thenar eminence a relatively un important muscle except that it covers and protects the ulnar nerve and artery origin: flexor retinaculum and palmar aponeurosis insertion: skin on the medial side of the palm action: wrinkles the skin on the medial side of the palm and deepens the hollow of the palm, as in cupping of the hand, thereby aiding the grip
  • 26. Interossei muscles . Interosseous Muscles - located between the metacarpal bones - arranged in 2 layers: 4 palmar and 4 dorsal - located between bones 1. dorsal interossei 1 to 4 - origin: adjacent sides of 2 metacarpal bones - insertion: extensor expansion's and bases of proximal phalanges of digit 2 to 4 - action: abducts digits and assit lumbricals 2. palmar interossei 1 to 3 - origin: palmar surfaces of 2nd, 3th , 4th and 5th metacarpal bones - insertion: extensor expansion of digits and bases of proximal phalanges of digits 2, 4, and 5 - action: adducts digits and assist lumbricals
  • 27. Lumbrical Muscles - named as such because of their elongated wormlike form 1. Lumbricals 1 and 2 - origin: lateral 2 tendons of flexor digitorum profundus 2. Lumbricals 3 and 4 - origin: medial 3 tendons of flexor digitorum profundus - insertion: lateral sides of extensor expansions of digits 2 to 5 - action: flex digits at MCP joints and extend IP joints
  • 28. Extrinsic extensors All extensors are extrinsic and supplied by radial nerve. Except for the interosseous-lumbrical complex. Group contains: 3 wrist extensors A larger group of thumb and digit extensors. The main extensors at wrist are: The extensor carpi radialis brevis (ECRB) extensor carpi radialis longus (ECRL) extensor carpi ulnaris (ECU)
  • 29. Extrinsic extensors At the digits, extension occurs due to: The extensor digitorum communis, extensor indicis proprius, and extensor digiti minimi
  • 30. Extensor Carpi Radialis Brevis The extensors of the wrist are on the Dorsal side of the forearm A majority of the wrist extensors begin at the lateral epicondyle Extensor Carpi Radialis Brevis Origin: Lateral epicondyle of humerus Insertion: Base of 3rd metacarpal Action: Extends and radially deviates the wrist Innervation: radial nerve (C7 and C8)
  • 31. Extensor Carpi Radialis Longus Origin Lateral supracondylar ridge of humerus Insertion Base of 2nd metacarpal Action Extends and radially deviates at the wrist Innervation Radial nerve (C6 and C7)
  • 32. Extensor Carpi Ulnaris Origin Lateral epicondyle of humerus Insertion Base of 5th metacarpal Action Extends and ulnar deviates hand at wrist joint Innervation Radial nerve
  • 33. Extensor Digitorum Origin Lateral epicondyle of humerus Insertion Extensor expansions of medial four digits Action Extends the four digits and the wrist Innervation Posterior interosseous nerve
  • 34. Extensor Digiti Minimi Origin Lateral epicondyle of humerus Insertion 5th digit Action Extends 5th digit at metacarpophalangeal and interphalangeal joints Innervation Posterior interosseous nerve
  • 35. Extensor Indicis Origin: Posterior sufrace of ulna and interosseous membrane Insertion: Extensor expansion of 2nd digit Action: Extends 2nd digit and helps to extend hand Innervation : Posterior interosseous nerve
  • 36. Extrinsic extensors Extension at the thumb is brought about by: The abductor pollicis longus, extensor pollicis brevis, and extensor pollicis longus
  • 37. Extensor Pollicis Brevis Origin : Posterior sufraces of radius and interosseous membrane Insertion : Base of proximal phalanx of thumb Action : Extends proximal phalanx of thumb at carpometacarpal joint Innervation: Posterior interosseous nerve
  • 38. Extensor Pollicis Longus Origin : Posterior surface of middle 1/3 of ulna Insertion : Base of distal phalanx of thumb Action: Extends distal phalanx of thumb at carpometacarpal and interphalangeal joints Innervation: Posterior interosseous nerve
  • 39. Abductor Pollicis Longus Origin Posterior surfaces of ulna, Insertion Base of 1st metacarpal Action Abducts thumb Innervation the radial nerve
  • 40. Extrinsic Flexors The muscles that flex your wrist are on the palmer side. A group of the begin at the medial epicondyle of the humerus at the elbow
  • 41. Extrinsic Flexors 3 wrist flexors A larger group of thumb and digit flexors Innervated by the median nerve Except for the FCU, and the FDP to the small and ring finger, which are innervated by the ulnar nerve.
  • 42. Extrinsic Flexors The main Flexors at the wrist joint are: The flexor carpi radialis the flexor carpi ulnaris and the palmaris longus
  • 43. Palmaris Longus Origin Medial epicondyle of humerus Insertion Distal half of flexor retinaculum and palmar aponeurosis Action Flexes hand at the wrist Innervation Median nerve (C7 and C8)
  • 44. Flexor Carpi Radialis Origin Medial epicondyle of humerus Insertion Base of 2nd metacarpal Action Flexes and radial deviates the hand (at wrist) Innervation Median nerve (C6 and C7)
  • 45. Flexor Carpi Ulnaris Origin medial epicondyle of humerus Insertion Pisiform bone, hook of hamate bone, and 5th metacarpal bone Action Flexes and ulnar deviates hand (at wrist) Innervation Ulnar nerve (C7 and C8)
  • 46. Flexor Digitorum Sauperficialis Origin medial epicondyle of humerus, Insertion middle phalanges of digits 2 - 5 Action Flexes middle phalanges at proximal inter phalangeal joints also flexes proximal phalanges at metacarpo phalangeal joints and hand Innervation Median nerve (C7, C8 and T1)
  • 47. Flexor Digitorum Profundus Origin Proximal 3/4 of ulna Insertion Base of the distal phalanx of digits 2 – 5 Action Flexes distal phalanges at distal interphalangeal joints Innervation Medial part: ulnar nerve Lateral part: median nerve
  • 48. Flexor Pollicis Longus Origin Anterior surface of radius and adjacent interosseous membrane Insertion Base of distal phalanx of thumb Action Flexes phalanges of 1st digit (thumb) Innervation Anterior interosseous nerve from median nerve (C8 and T1)
  • 49. Pronator Quadrates Origin Distal 1/4 of anterior surface of ulna Insertion Distal 1/4 of anterior surface of radius Action Pronates forearm; Innervation median nerve
  • 50. Pronator Teres Origin Medial epicondyle of humerus Insertion Middle of lateral surface of radius Action Pronates Innervation Median nerve (C6 and C7)
  • 51. Biceps Brachii Origin Short head: tip of coracoid process of scapula Long head: supraglenoid tubercle of scapula Insertion Tuberosity of radius and fascia of forearm via bicipital aponeurosis Action Supinates forearm and, when it is supine, flexes forearm Innervation Musculocutaneous nerve (C5 and C6 )
  • 52. Supinator Origin Lateral epicondyle of humerus, Insertion Lateral, posterior and anterior surfaces of proximal 1/3 of radius Action Supinates forearm Innervation Deep branch of radial nerve (C5 and C6)
  • 53. Compartments of the Hand 11 separate osteofascial compartments: dorsal interossei (4 compartments) palmar interossei (4 compartments) adductor pollicis thenar and hypothenar Typically can be released with carpal tunnel release and 2 dorsal incisions
  • 54. EXTENSOR COMPARTMENT Compartment 1 Extensor Pollicis Brevis Abductor Pollicis longs Compartment 2 Extensor carpi radials brevis Extensor carpi radials longus Compartment 3 Extensor Pollicis longus Compartment 4 Extensor digitorum Extensor induces Compartment 5 Extensor digiti minim Compartment 6 Extensor carpi ulnaris
  • 55. Carpal tunnel Dorsally: radio carpal lig. Radially: scaphoid & trapezium Palmary: transverse carpal lig. Ulnary: hooK of hamate & pisiform
  • 56. Guyon tunnel Guyon’s canal: floor: the transverse carpal ligament, and also the flexor digitorum profundus, pisohamate and pisometacarpal ligaments, and the opponens digiti minimi. The roof : the palmar carpal ligament and the palmaris brevis,
  • 57. STRUCTURE CHARACTERISTICS COMMENT Thenar Between flexor tendon and Adductor pollicis Potential space: site of possible infection Mid-palmar Between flexor sheath and metacarpal Potential space: site of possible infection Radial bursa Proximal extension of FPL sheath Infection can track proximally Ulnar bursa Communicates with SF, FDS, & FDP flexor tendon sheath Flexor sheath infection can track proximally into bursa Pulp space Multiple septae, nerves, arteries Felon is an infection of the pulp Space -- bursa --sheath
  • 58. Deep Fascia The Flexor Retinaculum The Palmar Fascia Fibrous flexor sheaths in fingers The Extensor Retinaculum
  • 59. Arteries - Radial and ulnar arteries and their branches provide all the blood to the hand A. Radial Artery - smaller of the 2 terminal branches of the brachial artery 1. superficial palmar branch  superficial palmar arterial arch 2. princeps pollicis artery – supplies the thumb 3. radialis indicis – supplies lateral side of digit 2 *4. deep palmar arterial arch – formed mainly by the radial artery which joins the deep branch of the ulnar artery palmar metacarpal arteries – arise from the deep palmar arch - run distally and join the common palmar digital arteries which arise from the superficial palmar arterial arch
  • 60. Dorsal artery of hand Dorsal carpal branch of ulna and radius Dorsal carpal arch Dorsal metacarpal artery Dorsal digital artery Middle & distal phalanges Palmar proper digital arteries
  • 61. Arteries B. Ulnar Artery - enters the palm on the lateral side of the ulnar nerve superficial to the flexor retinaculum - passes lateral to the pisiform bone 1. deep palmar branch deep palmar arterial arch - passes deep through the hypothenar muscles and anastomoses with the radial artery 2. superficial palmar arterial arch - formed mainly by the ulnar artery - located distal to the deep palmar arch - gives rise to the three common digital arteries that anastomoses with the palmar metacarpal arteries from the deep palmar arch  each common digital artery divides into a pair of proper palmar digital arteries which run along the sides of the 2nd to 4th digits
  • 62. Veins Veins generally follow the deep arterial system as venae comitantes. A superficial venous system also exists at the dorsum of the hand and contributes to the cephalic and basilic veins in the upper extremity.
  • 63. ULNAR NERVE 1. Ulnar (C(7)8-T1): through Guyon's canal, past hook of hamate Sensory: Medial palm & 1 1/2 digits via: palmar, palmar digital branches Medial dorsal hand & 1 1/2 digits via: dorsal, dorsal digital, & proper digital branches Nerve divides at hypothenar eminence Motor: Superficial Branch @[lateral to pisiform] Palmaris brevis Deep (Motor) Branch [around hook of hamate] Adductor pollicis THENAR MUSCLES Flexor pollicis brevis [FPB] [with median] HYPOTHENAR MUSCLES Abductor digiti minimi [ADM] Flexor digiti minimi brevis[FDMB] Opponens digiti minimi [ODM] INTRINSIC MUSCLES Dorsal interossei [DIO] [abduct DAB] Volar interossei [VIO] [adduct PAD] Lumbricals [medial two (3,4)]
  • 64. MEDIAN NERVE Median (C(5)6-T1) : runs through carpal tunnel, then cutaneous branches off at (risk in Carpal Tunnel release) Sensory: Palmar Cutaneous Branch Dorsal distal phalanges of 3 1/2 digits: via proper palmar digital branches Volar wrist capsule Volar 3 1/2 digits and lateral palm: via palmar & palmar digital branches (multiple variations of thumb sensory innervation) Motor: Motor Recurrent (Thenar motor) Branch: Usually branches off median before carpal tunnel THENAR Abductor pollicis brevis [APB] Opponens pollicis Flexor pollicis brevis [FPB] <l>(Joint innervation with ulnar nerve)</l> INTRINSIC Lumbricals [lateral two (1,2)]
  • 65. RADIAL NERVE Radial (C5-T1): Sensory: Dorsal 3 1/2 digits and hand: via superficial branch (dorsal digit branches) Dorsal wrist capsule Motor: NONE (in hand)
  • 66. Flexor zone of hand ZONE BOUNDARIES COMMENT I FDS insertion to distal tip Injuries amenable to repair (e.g. Jersey finger) II Midpalm fibroosseous tunnel to FDS insertion Called “No man's land” because high rate of complications. III Transverse Carpal ligament to fibro- osseous tunnel Injuries often associated with Median nerve or arterial arch injuries. Explore and repair all. IV Transverse carpal ligament (carpal tunnel) Uncommon site of injury. Repair usually requires carpal tunnel release and repair. Median nerve at risk. V Proximal to the TCL Injuries require end-to-end repair Thumb I Thumb IP to distal tip Similar to finger Thumb II Thumb CMC to IP Similar to finger Thumb III Thenar eminence Repair may require lengthening or graft procedure
  • 67. SKIN The skin of the dorsum of the hand is thin and pliable. It is attached to the hand's skeleton only by loose areolar tissue, where lymphatic's and veins course. explains why edema of the hand is manifested predominantly at the dorsum. The skin of the palmar surface of the hand is unique Thick Glabrous Less Pliable This enhances skin stability for proper grasping function. The skin is most firmly anchored to the deep structures at the palmar creases. Blood supply is through numerous small, vertical branches from the common digital vessels. High concentration of sensory nerve organs essential to the hand's normal function.
  • 68. THANK YOU