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The wrist and hand
 

The wrist and hand

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    The wrist and hand The wrist and hand Presentation Transcript

    • The Wrist and Hand Maribel G. Castro, MD CPU College of Medicine
    • Bones of the Wrist and Hand
      • Carpal groove – anterior concavity of the carpus
      • - converted into an osseoufibrous carpal tunnel by the flexor retinaculum, which is attached to the scaphoid and trapezium laterally and to the pisiform and hook of the hamate bone medially
      • Carpal Tunnel Syndrome – due to compression of the median nerve in the carpal tunnel
      • Extensor retinaculum – transverse band on the posterior part of the wrist formed from the thickened antebrachial fascia
      • - retains the extensor tendons in position, thereby increasing their efficiency
      • Flexor retinaculum – thickened deep fascia anteriorly
      • - converts the anterior concavity of the carpus into a carpal tunnel through which the flexor tendons pass
    • The Hand
      • Fascia of the Palm
      • - continuous proximally with the antebrachial fascia and at the borders of the palm with the fascia on the dorsum of the hand
      • - thin over the thenar and hypothenar eminences
      • - thick in the palm where it forms the palmar aponeurosis and in the digits where it forms the fibrous digital sheaths
    • The Hand
      • Palmar Aponeurosis
      • - strong, well-defined triangular part of the deep fascia of the hand
      • - covers the soft tissues and overlies the long flexor tendons of the palm
      • - proximal end continuous with the flexor retinaculum and palmaris longus tendon
      • - distal end divides at the roots of the digits into 4 longitudinal bands
      • - each band attached to the base of the proximal phalanx and is fused with the fibrous digital sheaths
    • The Carpal Tunnel
    • Palmar Spaces
      • - Surgically important
      • - Spaces bounded medially and laterally by fibrous septa
      • * medial septum – from the medial border of the palmar aponeurosis to the 5 th metacarpal bone
      • * lateral septum – from the lateral border of the palmar aponeurosis to the 1 st metacarpal bone
      • 1. Hypothenar compartment
      • - medial to the medial septum, containing the hypothenar muscles
      • 2. Thenar compartment
      • - lateral to the lateral septum containing the thenar muscles
    • Palmar Spaces
      • 3. Central compartment
      • - between the thenar and hypothenar compartments, containing the flexor tendons and their sheaths, the superficial palmar arch, and branches of the median and ulnar nerves
      • 4. Adductor compartment
      • - deepest muscular plane of the palm, contains the adductor pollicis muscle
      • Midpalmar space – medial and lateral
      • - created by a fibrous septum passing obliquely and posteriorly from the lateral border of the palmar aponeurosis to the 3 rd metacarpal bone
      • Retroadductor space – between the adductor pollicis and the 1 st dorsal interosseous muscle
    • Muscles of the Hand
      • The intrinsic muscles of the hand are on the palmar aspect and are innervated by the ulnar and median nerves
      • A. Thenar Muscles
      • - chiefly responsible for the movement of the thumb known as opposition
      • 1. abductor pollicis brevis
      • - forms the anterolateral part of the thenar eminence
      • - origin: flexor retinaculum and tubercles of scaphoid and trapezium
      • - insertion: lateral side of base of proximal phalanx of thumb
      • - action: abducts thumb and helps oppose it
      • 2. flexor pollicis brevis
      • - medial to the abductor pollicis brevis
      • - origin: flexor retinaculum and tubercle of trapezium
      • - insertion: lateral side of base of proximal phalanx of thumb
      • - action: flexes thumb
      • 3. opponens pollicis
      • - lies deep to the abductor pollicis brevis and lateral to the flexor pollicis brevis
      • - origin: flexor retinaculum and tubercle of trapezium
      • - insertion: lateral side of 1 st metacarpal bone
      • - action: opposes thumb toward center of palm and rotates it medially
      • * opposition is the most impt. movement of the thumb
      • 4. adductor pollicis
      • - has 2 heads that are separated by a gap through which the radial artery passes
      • - origin: oblique head – bases of 2 nd and 3 rd metacarpals, capitate, and adjacent carpal bones
      • transverse head – anterior surface of body of 3 rd metacarpal bone
      • - insertion: medial side of base of proximal phalanx of thumb
      • -action: adducts thumb towards middle digit
    • Thenar Muscles
      • B. Hypothenar Muscles
      • - concerned with movements of the 5 th digit
      • - produce the hypothenar eminence or the ball of the 5 th digit
      • 1. abductor digiti minimi
      • - most superficial of the 3 hypothenar muscles forming the hypothenar eminence
      • - origin: pisiform bone
      • - insertion: medial side of base of proximal phalanx of 5 th digit
      • - action: abducts digit 5
      • 2. flexor digiti minimi
      • - lateral to the abductor digiti minimi
      • - origin: hook of hamate and flexor retinaculum
      • - insertion: medial side of base of proximal phalanx of digit 5
      • - action: flexes proximal phalanx of digit 5
      • 3. opponens digiti minimi
      • - lies deep to the abductor and flexor muscles of the 5 th digit
      • - origin: hook of hamate and flexor retinaculum
      • - insertion: medial border of 5 th metacarpal bone
      • - action: draws 5 th metacarpal bone anteriorly and rotates it, bringing digit 5 into opposition with thumb
      • **4. palmar brevis
      • - lies in the fascia deep to the skin of the hypothenar eminence
      • - a relatively unimportant 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
    • Hypothenar Muscles
      • C. 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
      • D. Interosseous Muscles
      • - located between the metacarpal bones
      • - arranged in 2 layers: 3 palmar and 4 dorsal
      • - located between bones
      • 1. dorsal interossei 1 to 4
      • - origin: adjacent sides of 2 metacarpal bones
      • - insertion: extensor exapnsions 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 2 nd , 4 th and 5 th metacarpal bones
      • - insertion: extensor expansion of digits and bases of proximal phalanges of digits 2, 4, and 5
      • - action: adducts digits and assist lumbricals
    • Lumbricals and Interossei
    • Nerves
      • medial, ulnar and radial nerves supply the hand
      • A. Median Nerve
      • - enters the hand through the carpal tunnel
      • - supplies motor fibers to the 3 thenar muscles and the 1 st and 2 nd lumbricals
      • - sends cutaneous sensory fibers to the lateral palmar surface, the sides of the first 3 digits, the lateral half of the 4 th digit, and the dorsum of the distal halves of these digits
      • Carpal tunnel syndrome
      • - caused by any lesion that significantly reduces the size of the carpal tunnel (e.g. inflammation of the flexor retinaculum), resulting to compression of the median nerve
    • The Carpal Tunnel
      • B. Ulnar Nerve
      • - leaves the forearm by emerging from deep to the tendon of the flexor carpi ulnaris
      • - passes alongisde the lateral border of the pisiform bone and goes with the ulnar artery on its lateral side
      • - ulnar artery and nerve ar bridged over by a slender band of connective tissue, which forms a small tunnel ( canal of Guyon )
      • 1. palmar cutaneous branch
      • - arises just proximal to the wrist
      • - passes superficial to the flexor retinaculum and to the palmar aponeurosis
      • - supplies skin of the medial side of the palm
      • 2. dorsal cutaneous branch
      • - supplies medial half of dorsum of hand, 5 th digit and the medial half of 4 th digit
      • *At the distal border of the flexor retinaculum, the ulnar nerve ends by dividing into a superficial and deep branch
      • 4. superficial branch
      • - supplies cutaneous fibers to the anterior surfaces of the medial 1 ½ digits
      • 5. deep branch
      • - supplies motor fibers to the hypothenar muscles, the medial 2 lumbricals, the adductor pollicis and all the interosseous muscles
      • - also supplies several joints (wrist, intercarpal, carpometacarpal and intermetacarpal)
      • * Referred to as the nerve of fine movements – innervates muscles that are concerned with fine movements
    • Ulnar Nerve
      • C. Radial Nerve
      • - supplies no hand muscles
      • - deep branch is muscular and articular in distribution
      • - superficial branch is the direct continuation of the radial nerve along the anterolateral side of the forearm and is entirely sensory
      • - pierces the deep fascia near the dorsum of the wrist and supplies the skin and fascia over the lateral 2/3 of the dorsum of the hand, the dorsum of the thumb, and proximal parts of the lateral 1 ½ digits
      • Wrist drop
      • - due to radial nerve injury producing paralysis of the extensor muscles of the forearm
      • - hand is flexed at the wrist and lies flaccid
      • - digits are also flexed at the MCP joints
    • Arteries
      • Radial and ulnar arterues 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
      • B. Ulnar Artery
      • - larger of the 2 terminal branches of the brachial 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 2 nd to 4 th digits
    • Palmar Arteries
    • Superficial Palm
    • Veins
      • Superficial and deep palmar arterial arches are accompanied by venae comitantes
      • Superficial venous arch
      • Deep venous arch
      • Dorsal digital veins – drain into
      • (3) Dorsal metacarpal veins – unite to form a dorsal venous network (superficial to the metacarpus, this network is prolonged proximally as the cephalic vein )
    • Thank You and Good Luck! 