Section 2
Surface & pertinent
anatomy
Naming the digits
The Birmingham Hand Centre Assessment and Early Management of the Injured Hand
University Hospitals Birm...
Naming the digits
•Thumb
Naming the digits
•Thumb
•Index
Naming the digits
•Thumb
•Index
•Middle
Naming the digits
•Thumb
•Index
•Middle
•Ring
Naming the digits
•Thumb
•Index
•Middle
•Ring
•Small
Skin landmarks
Skin landmarks
•Wrist crease
Skin landmarks
•Wrist crease
•Distal palmar crease
Skin landmarks
•Wrist crease
•Distal palmar crease
•Proximal digital
crease
Skin landmarks
•Wrist crease
•Distal palmar crease
•Proximal digital
crease
•PIPJ flexor crease
Skin landmarks
•Wrist crease
•Distal palmar crease
•Proximal digital
crease
•PIPJ flexor crease
•DIPJ flexor crease
Flexor tendon zones
•Zone 1
Flexor tendon zones
•Zone 1
•Zone 2
Flexor tendon zones
•Zone 1
•Zone 2
•Zone 3
Flexor tendon zones
•Zone 1
•Zone 2
•Zone 3
•Zone 4
Flexor tendon zones
•Zone 1
•Zone 2
•Zone 3
•Zone 4
•Zone 5
Naming the bones in the hand
Naming the bones in the hand
Proximal phalanx
(P1) of index finger
Naming the bones in the hand
Middle phalanx
(P2) of ring finger
Naming the bones in the hand
Terminal or distal
phalanx (P3) of
middle finger
Naming the bones in the hand
Metacarpal of
small finger
Naming the joints
Naming the joints
Naming the joints
Metacarpo-
phalangeal joint
(MCPJ) of index finger
Naming the joints
Naming the joints
Proximal
interphalangeal joint
(PIPJ) of small finger
Naming the joints
Naming the joints
Distal interphalangeal
joint (DIPJ) of ring
finger
Naming the joints
Naming the joints
Metacarpo-
phalangeal joint
(MCPJ) of thumb
Naming the joints
Naming the joints
Interphalangeal
joint (IPJ) of thumb
Naming the bones in the wrist
Naming the bones in the wrist
Naming the bones in the wrist
• Scaphoid
Naming the bones in the wrist
• Scaphoid
Naming the bones in the wrist
• Scaphoid
• Lunate
Naming the bones in the wrist
• Scaphoid
• Lunate
Naming the bones in the wrist
• Scaphoid
• Lunate
• Triquetrum
Naming the bones in the wrist
• Scaphoid
• Lunate
• Triquetrum
Naming the bones in the wrist
• Scaphoid
• Lunate
• Triquetrum
• Pisiform
Naming the bones in the wrist
• Scaphoid
• Lunate
• Triquetrum
• Pisiform
Naming the bones in the wrist
• Scaphoid
• Lunate
• Triquetrum
• Pisiform
• Hamate
Naming the bones in the wrist
• Scaphoid
• Lunate
• Triquetrum
• Pisiform
• Hamate
Naming the bones in the wrist
• Scaphoid
• Lunate
• Triquetrum
• Pisiform
• Hamate
• Capitate
Naming the bones in the wrist
• Scaphoid
• Lunate
• Triquetrum
• Pisiform
• Hamate
• Capitate
Naming the bones in the wrist
• Scaphoid
• Lunate
• Triquetrum
• Pisiform
• Hamate
• Capitate
• Trapezoid
Naming the bones in the wrist
• Scaphoid
• Lunate
• Triquetrum
• Pisiform
• Hamate
• Capitate
• Trapezoid
Naming the bones in the wrist
• Scaphoid
• Lunate
• Triquetrum
• Pisiform
• Hamate
• Capitate
• Trapezoid
• Trapezium
Naming the bones in the wrist
• Scaphoid
• Lunate
• Triquetrum
• Pisiform
• Hamate
• Capitate
• Trapezoid
• Trapezium
Surface anatomy of the wrist bones –
volar
Surface anatomy of the wrist bones –
dorsal
The anatomical snuffbox
Scaphoid tenderness?
Scaphoid tenderness?
Scaphoid tenderness
Flexor retinaculum
• Scaphoid tuberosity
• Ridge of trapezium
• Hook of hamate
• Pisiform
• “Postage stamp”
The dorsal aspect of the wrist
The extensor compartments of the
wrist
• 6 extensor
compartments
The extensor compartments of the
wrist
• 6 extensor
compartments
• Under extensor
retinaculum
The extensor compartments of the
wrist
• 6 extensor
compartments
• Under extensor
retinaculum
• Junctura
tendinae
The extensor compartments of the
wrist
1st APL & EPB
2nd ECRL & ECRB
3rd EPL
4th EDC & EIP
5Th EDM
6th ECU
The extensor tendons in the digits
The extensor tendons in the digits
• Extensor tendon
The extensor tendons in the digits
• Extensor tendon
• Extensor hood
The extensor tendons in the digits
• Extensor tendon
• Extensor hood
• Sagittal band
The extensor tendons in the digits
• Extensor tendon
• Extensor hood
• Sagittal band
• Central slip
The extensor tendons in the digits
• Extensor tendon
• Extensor hood
• Sagittal band
• Central slip
• Lateral bands
The volar aspect of the wrist
The volar aspect of the hand
• FDP
The volar aspect of the hand
• FDP
• FDS
The volar aspect of the hand
• FDP
• FDS
• Metacarpal head
The volar aspect of the hand
• FDP
• FDS
• Metacarpal head
• Flexor
retinaculum
The fibrous flexor sheath
• A1 pulley
The fibrous flexor sheath
• A1 pulley
• A2 pulley
The fibrous flexor sheath
• A1 pulley
• A2 pulley
• A4 pulley
The radial aspect of the wrist
Cutaneous innervation of the wrist &
hand
• Superficial radial
nerve
• Dorsal branch of
ulnar nerve
Cutaneous innervation of the wrist &
hand
• Ulnar nerve
Cutaneous innervation of the wrist &
hand
• Ulnar nerve
• Median nerve
Cutaneous innervation of the wrist &
hand
• Ulnar nerve
• Median nerve
• Motor branch of
median nerve
Cutaneous innervation of the digits
• Trifurcation of
the digital
nerve
Section 9
What is an emergency referral?
Bleeding
• Practically all upper limb bleeding will
stop!
• EXCEPTION: partially injured large artery
• Treat bleeding wit...
Amputation
•Proximal amputations, speed is of the essence
•Warm ischaemic time <6hours
•This is an emergency
•Quick purpos...
Replantation
The decision of whether to replant lies with
the surgeon in conjunction with the patient.
• Urgent transfer, ...
De-vascularised parts / doubtful
vascularity
• Speed important
• Often venously congested
• Align digits correctly
• No ti...
Compartment syndrome
• Interossei
• Flexor compartment forearm
• High index of suspicion
• Examine by stretching muscles o...
Hydrofluoric acid burns
• Lethal due to precipitation of Ca++
• Calcium gluconate
• pain relieving
• Emergency transfer to...
High pressure injection injuries
• Grease, oil, paint, hydraulic fluid, air
• Ischaemia/necrosis
• Mechanical
• Toxic effe...
Infections
• Calor - warmth
• Rubor - redness
• Tumor - swelling
• Dolor - pain
• Functio laesa
• Pus (or blood) under pre...
Infections – flexor sheath
Kanavel’s signs
• Slight flexion
• Uniformly swollen
• Pain on passive extension
• Tenderness a...
Infections – Web-space/Deep Palmar
Space• History of FB/ gardening
• Fingers separated
• Anatomically volar, but most easi...
Infections
Pulp-space (Felon)
Paronychia
• Not usually an emergency
• May be able to treat within emergency department
Her...
Hand surface anatomy
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Hand surface anatomy

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Hand anatomy by examination, surface anatomy of hand, hand surgery examination, hand surgery

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Hand surface anatomy

  1. 1. Section 2 Surface & pertinent anatomy
  2. 2. Naming the digits The Birmingham Hand Centre Assessment and Early Management of the Injured Hand University Hospitals Birmingham NHS Foundation Trust
  3. 3. Naming the digits •Thumb
  4. 4. Naming the digits •Thumb •Index
  5. 5. Naming the digits •Thumb •Index •Middle
  6. 6. Naming the digits •Thumb •Index •Middle •Ring
  7. 7. Naming the digits •Thumb •Index •Middle •Ring •Small
  8. 8. Skin landmarks
  9. 9. Skin landmarks •Wrist crease
  10. 10. Skin landmarks •Wrist crease •Distal palmar crease
  11. 11. Skin landmarks •Wrist crease •Distal palmar crease •Proximal digital crease
  12. 12. Skin landmarks •Wrist crease •Distal palmar crease •Proximal digital crease •PIPJ flexor crease
  13. 13. Skin landmarks •Wrist crease •Distal palmar crease •Proximal digital crease •PIPJ flexor crease •DIPJ flexor crease
  14. 14. Flexor tendon zones •Zone 1
  15. 15. Flexor tendon zones •Zone 1 •Zone 2
  16. 16. Flexor tendon zones •Zone 1 •Zone 2 •Zone 3
  17. 17. Flexor tendon zones •Zone 1 •Zone 2 •Zone 3 •Zone 4
  18. 18. Flexor tendon zones •Zone 1 •Zone 2 •Zone 3 •Zone 4 •Zone 5
  19. 19. Naming the bones in the hand
  20. 20. Naming the bones in the hand Proximal phalanx (P1) of index finger
  21. 21. Naming the bones in the hand Middle phalanx (P2) of ring finger
  22. 22. Naming the bones in the hand Terminal or distal phalanx (P3) of middle finger
  23. 23. Naming the bones in the hand Metacarpal of small finger
  24. 24. Naming the joints
  25. 25. Naming the joints
  26. 26. Naming the joints Metacarpo- phalangeal joint (MCPJ) of index finger
  27. 27. Naming the joints
  28. 28. Naming the joints Proximal interphalangeal joint (PIPJ) of small finger
  29. 29. Naming the joints
  30. 30. Naming the joints Distal interphalangeal joint (DIPJ) of ring finger
  31. 31. Naming the joints
  32. 32. Naming the joints Metacarpo- phalangeal joint (MCPJ) of thumb
  33. 33. Naming the joints
  34. 34. Naming the joints Interphalangeal joint (IPJ) of thumb
  35. 35. Naming the bones in the wrist
  36. 36. Naming the bones in the wrist
  37. 37. Naming the bones in the wrist • Scaphoid
  38. 38. Naming the bones in the wrist • Scaphoid
  39. 39. Naming the bones in the wrist • Scaphoid • Lunate
  40. 40. Naming the bones in the wrist • Scaphoid • Lunate
  41. 41. Naming the bones in the wrist • Scaphoid • Lunate • Triquetrum
  42. 42. Naming the bones in the wrist • Scaphoid • Lunate • Triquetrum
  43. 43. Naming the bones in the wrist • Scaphoid • Lunate • Triquetrum • Pisiform
  44. 44. Naming the bones in the wrist • Scaphoid • Lunate • Triquetrum • Pisiform
  45. 45. Naming the bones in the wrist • Scaphoid • Lunate • Triquetrum • Pisiform • Hamate
  46. 46. Naming the bones in the wrist • Scaphoid • Lunate • Triquetrum • Pisiform • Hamate
  47. 47. Naming the bones in the wrist • Scaphoid • Lunate • Triquetrum • Pisiform • Hamate • Capitate
  48. 48. Naming the bones in the wrist • Scaphoid • Lunate • Triquetrum • Pisiform • Hamate • Capitate
  49. 49. Naming the bones in the wrist • Scaphoid • Lunate • Triquetrum • Pisiform • Hamate • Capitate • Trapezoid
  50. 50. Naming the bones in the wrist • Scaphoid • Lunate • Triquetrum • Pisiform • Hamate • Capitate • Trapezoid
  51. 51. Naming the bones in the wrist • Scaphoid • Lunate • Triquetrum • Pisiform • Hamate • Capitate • Trapezoid • Trapezium
  52. 52. Naming the bones in the wrist • Scaphoid • Lunate • Triquetrum • Pisiform • Hamate • Capitate • Trapezoid • Trapezium
  53. 53. Surface anatomy of the wrist bones – volar
  54. 54. Surface anatomy of the wrist bones – dorsal
  55. 55. The anatomical snuffbox
  56. 56. Scaphoid tenderness?
  57. 57. Scaphoid tenderness?
  58. 58. Scaphoid tenderness
  59. 59. Flexor retinaculum • Scaphoid tuberosity • Ridge of trapezium • Hook of hamate • Pisiform • “Postage stamp”
  60. 60. The dorsal aspect of the wrist
  61. 61. The extensor compartments of the wrist • 6 extensor compartments
  62. 62. The extensor compartments of the wrist • 6 extensor compartments • Under extensor retinaculum
  63. 63. The extensor compartments of the wrist • 6 extensor compartments • Under extensor retinaculum • Junctura tendinae
  64. 64. The extensor compartments of the wrist 1st APL & EPB 2nd ECRL & ECRB 3rd EPL 4th EDC & EIP 5Th EDM 6th ECU
  65. 65. The extensor tendons in the digits
  66. 66. The extensor tendons in the digits • Extensor tendon
  67. 67. The extensor tendons in the digits • Extensor tendon • Extensor hood
  68. 68. The extensor tendons in the digits • Extensor tendon • Extensor hood • Sagittal band
  69. 69. The extensor tendons in the digits • Extensor tendon • Extensor hood • Sagittal band • Central slip
  70. 70. The extensor tendons in the digits • Extensor tendon • Extensor hood • Sagittal band • Central slip • Lateral bands
  71. 71. The volar aspect of the wrist
  72. 72. The volar aspect of the hand • FDP
  73. 73. The volar aspect of the hand • FDP • FDS
  74. 74. The volar aspect of the hand • FDP • FDS • Metacarpal head
  75. 75. The volar aspect of the hand • FDP • FDS • Metacarpal head • Flexor retinaculum
  76. 76. The fibrous flexor sheath • A1 pulley
  77. 77. The fibrous flexor sheath • A1 pulley • A2 pulley
  78. 78. The fibrous flexor sheath • A1 pulley • A2 pulley • A4 pulley
  79. 79. The radial aspect of the wrist
  80. 80. Cutaneous innervation of the wrist & hand • Superficial radial nerve • Dorsal branch of ulnar nerve
  81. 81. Cutaneous innervation of the wrist & hand • Ulnar nerve
  82. 82. Cutaneous innervation of the wrist & hand • Ulnar nerve • Median nerve
  83. 83. Cutaneous innervation of the wrist & hand • Ulnar nerve • Median nerve • Motor branch of median nerve
  84. 84. Cutaneous innervation of the digits • Trifurcation of the digital nerve
  85. 85. Section 9 What is an emergency referral?
  86. 86. Bleeding • Practically all upper limb bleeding will stop! • EXCEPTION: partially injured large artery • Treat bleeding with elevation and firm dressing • DO NOT attempt to tie off bleeders in A&E • RARELY should a tourniquet be used
  87. 87. Amputation •Proximal amputations, speed is of the essence •Warm ischaemic time <6hours •This is an emergency •Quick purposeful action, not cutting corners
  88. 88. Replantation The decision of whether to replant lies with the surgeon in conjunction with the patient. • Urgent transfer, only if the patient is stable • Correct packaging of parts • X-ray limb & amputated part • Cold not frozen • Damp not soggy
  89. 89. De-vascularised parts / doubtful vascularity • Speed important • Often venously congested • Align digits correctly • No tight bandages • Resting Volar POP for comfort in transit
  90. 90. Compartment syndrome • Interossei • Flexor compartment forearm • High index of suspicion • Examine by stretching muscles of compartment
  91. 91. Hydrofluoric acid burns • Lethal due to precipitation of Ca++ • Calcium gluconate • pain relieving • Emergency transfer to regional burns unit • Accept advice from patient –if they work with the stuff they probably know about it!
  92. 92. High pressure injection injuries • Grease, oil, paint, hydraulic fluid, air • Ischaemia/necrosis • Mechanical • Toxic effect • Early transfer • Early washout
  93. 93. Infections • Calor - warmth • Rubor - redness • Tumor - swelling • Dolor - pain • Functio laesa • Pus (or blood) under pressure destroys tissue (necrosis) • Skin, subcutaneous fat, tendon, cartilage….
  94. 94. Infections – flexor sheath Kanavel’s signs • Slight flexion • Uniformly swollen • Pain on passive extension • Tenderness along line of sheath • Management • Elevation • Antibiotics • Surgical washout
  95. 95. Infections – Web-space/Deep Palmar Space• History of FB/ gardening • Fingers separated • Anatomically volar, but most easily seen from dorsal • Management • Elevation • Antibiotics • Surgical washout
  96. 96. Infections Pulp-space (Felon) Paronychia • Not usually an emergency • May be able to treat within emergency department Herpetic Whitlow
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