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WRIST COMPLEX Bones and Joints of the Wrist. Proximal Row of Carpal Bones Review- testable Review- testable Scaphoid: Scaphoid: Most lateral. Forms floor.

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Presentation on theme: "WRIST COMPLEX Bones and Joints of the Wrist. Proximal Row of Carpal Bones Review- testable Review- testable Scaphoid: Scaphoid: Most lateral. Forms floor."— Presentation transcript:

1 WRIST COMPLEX Bones and Joints of the Wrist

2 Proximal Row of Carpal Bones Review- testable Review- testable Scaphoid: Scaphoid: Most lateral. Forms floor of anatomical snuff box. Most commonly fractured wrist bone. Fractures may compromise radial artery in snuff box. Articulates with radius.

3 Proximal Row of Carpal Bones Lunate: Lunate: Articulates with radius Triquetral: Triquetral: Articulates with ulna (via articular (ulnar) disc) during extreme ulnar deviation. Pisiform: Pisiform: Sesamoid bone Forms in tendon of the flexor carpi ulnaris

4 Distal Row of Carpal Bones: Trapezium: Trapezium: Most lateral Trapezoid Trapezoid Capitate Capitate Hamate Hamate

5 Distal Row of Carpal Bones: Entire complex enclosed in a common synovial membrane. Entire complex enclosed in a common synovial membrane. Articulations are plane joints that perform gliding motions. Articulations are plane joints that perform gliding motions.

6 Radiocarpal Joint Condyloid (ellipsoidal) synovial joint. Condyloid (ellipsoidal) synovial joint. Two degrees of freedom. Two degrees of freedom. Articular surfaces: Articular surfaces: Scaphoid (convex) Lunate (convex) Distal radius: Two concave fossae (lateral and medial) Triquetral (convex) Only during extreme ulnar deviation

7 Radiocarpal Joint Ligaments Lateral (radial) collateral ligament. Lateral (radial) collateral ligament. Medial (ulnar) collateral ligament. Medial (ulnar) collateral ligament. Dorsal radiocarpal ligament. Dorsal radiocarpal ligament. Palmar radiocarpal ligament. Palmar radiocarpal ligament. Strengthen capsule Strengthen capsule

8 Radiocarpal Joint Functions Some flexion and extension Some flexion and extension Ulnar deviation Ulnar deviation

9 Radiocarpal Joint Arteries Articular arteries Articular arteries Arise from dorsal and palmar carpal arches. Arise from dorsal and palmar carpal arches.

10 Radiocarpal Joint Nerves Anterior interosseous branch of median nerve. Anterior interosseous branch of median nerve. Posterior interosseous branch of radial nerve. Posterior interosseous branch of radial nerve. Dorsal and deep branches of the ulnar nerve. Dorsal and deep branches of the ulnar nerve.

11 Radiocarpal Joint Injuries Colle’s fracture Colle’s fracture Scaphoid fracture Scaphoid fracture Usually at “waist” Compromises radial artery in snuffbox

12 Midcarpal Joint Made up of intercarpal joints: Made up of intercarpal joints: Between proximal and distal rows of carpals and between carpals. Movements: Movements: Some flexion and extension. Radial deviation (abduction). Especially due to movement of head of capitate in its socket. Enclosed within synovial capsule. Enclosed within synovial capsule.

13 Midcarpal Joint Ligaments: Ligaments: Dorsal ligaments. Palmar ligaments. Interosseous ligaments. Nerves and arteries: Nerves and arteries: Same as for radiocarpal.

14 Palmar Structure Sequence (radial to ulnar) Radius Radius Radial artery Radial artery Flexor carpi radialis tendon Flexor carpi radialis tendon Median nerve: Median nerve: Under palmaris longus tendon

15 Palmar Structure Sequence (radial to ulnar) Flexor digitorum superficialis tendons Flexor digitorum superficialis tendons Ulnar artery Ulnar artery Ulnar nerve Ulnar nerve Flexor carpi ulnaris tendon Flexor carpi ulnaris tendon

16 HAND

17 Carpometacarpal Joints Plane synovial joints: Plane synovial joints: Motion: Motion: None for digits 2-3 Limited for 4 More mobile for 5

18 Carpometacarpal Joints Saddle (sellaris) joint between metacarpus and trapezium: Saddle (sellaris) joint between metacarpus and trapezium: Movements: Movements:Abduction/adductionFlexion/extensionCircumductionOpposition

19 Metacarpophalangeal Joints Condyloid synovial joints Condyloid synovial joints Movements: Movements:Flexion/extensionAbduction/adduction Some opposition at MCP 5 Capsular ligaments: Capsular ligaments: Palmar ligaments (pads) Collaterals

20 Interphalangeal Joints Synovial hinge joints Synovial hinge joints Only flexion/extension allowed Only flexion/extension allowed Ligaments: Ligaments: Strong collaterals Proximal interphalangeal joints (PIPs) Proximal interphalangeal joints (PIPs) Distal interphalangeal joints (DIPs) Distal interphalangeal joints (DIPs)

21 Dorsal Venous Drainage Dorsal venous arch drains hand dorsum. Dorsal venous arch drains hand dorsum. Medially drains into basilic. Medially drains into basilic. Laterally drains into cephalic. Laterally drains into cephalic.

22 Lymphatic Drainage Medial via lymph vessels accompanying basilic vein to: Medial via lymph vessels accompanying basilic vein to: Supratrochlear nodes to: Lateral axillary nodes. Lateral via lymph vessels accompanying cephalic vein to: Lateral via lymph vessels accompanying cephalic vein to: Infraclavicular nodes to: Lateral axillary nodes.

23 Arterial Supply to Dorsum Via dorsal arterial arch from: Via dorsal arterial arch from: Radial and ulnar arteries. Dorsal metacarpals. Dorsal metacarpals. Dorsal digitals. Dorsal digitals.

24 Muscles of Dorsum of Hand Long extensor tendons. Long extensor tendons. Dorsal interosseous muscles (4): Dorsal interosseous muscles (4):Attachments:DAB:Abductors Middle finger is reference Middle finger has two First and fifth digits have none.

25 Long Extensors

26 Superficial Palm Palmar aponeurosis Palmar aponeurosis Flexor retinaculum Flexor retinaculum Palmaris brevis Palmaris brevis

27 Palmar Aponeurosis Triangular layer of deep fascia located between two eminences. Triangular layer of deep fascia located between two eminences. Provides protection for superficial vessels, nerves, and tendons. Provides protection for superficial vessels, nerves, and tendons. Anchored to skin and flexor retinaculum. Anchored to skin and flexor retinaculum. Splits into four slips that blend with fibrous flexor sheaths of four medial digits (II – V). Splits into four slips that blend with fibrous flexor sheaths of four medial digits (II – V).

28 Flexor Retinaculum = Transverse carpal ligament. = Transverse carpal ligament. Laterally attaches to tubercles of scaphoid and trapezium. Laterally attaches to tubercles of scaphoid and trapezium. Medially attaches to hook of hamate and pisiform. Medially attaches to hook of hamate and pisiform.

29 Palmaris Brevis Muscle O:Flexor retinaculum and palmar aponeurosis. O:Flexor retinaculum and palmar aponeurosis. I:Skin on medial side of palm. I:Skin on medial side of palm. A:Tenses skin on palm. A:Tenses skin on palm.

30 Carpal Tunnel Contents Long flexor tendons of: Long flexor tendons of: Flexor digitorum superficialis Flexor digitorum profundus Flexor pollicis longus Median nerve Median nerve Note: ulnar nerve and artery pass through Guyon’s canal. Note: ulnar nerve and artery pass through Guyon’s canal.

31 Long Flexors

32 Intrinsic Muscles of the Thumb Thenar eminence: Thenar eminence: Adductor pollicis: Adductor pollicis:Innervation: Deep branch of ulnar nerve (C8, T1).

33 Thenar Eminence Muscles Abductor pollicis brevis Abductor pollicis brevis Flexor pollicis brevis Flexor pollicis brevis Opponens pollicis Opponens pollicis Innervation: Innervation: Recurrent branch of median nerve (C8, T1).

34 Thenar Muscles

35 Hypothenar Eminence Intrinsic muscles for digit V. Intrinsic muscles for digit V. Abductor digiti minimi Abductor digiti minimi Flexor digiti minimi brevis Flexor digiti minimi brevis Opponens digiti minimi Opponens digiti minimi Innervation: Innervation: Ulnar nerve

36 Hypothenar Muscles

37 Long Digital Flexors Flexor digitorum superficialis Flexor digitorum superficialis Flexor digitorum profundus Flexor digitorum profundus

38 Flexor Digitorum Superficialis Flexes PIP (and MCP and wrist). Flexes PIP (and MCP and wrist). Each tendon passes through fibrous flexor sheath. Each tendon passes through fibrous flexor sheath. Each tendon bifurcates opposite proximal phalanx. Each tendon bifurcates opposite proximal phalanx. Each tendon inserts on middle phalanx. Each tendon inserts on middle phalanx.

39 Flexor Digitorum Profundus Flexes DIP (and PIP and MCP). Flexes DIP (and PIP and MCP). More active than superficialis. More active than superficialis. Each tendon inserts on distal phalanx. Each tendon inserts on distal phalanx.

40 Vinculae Small vascular bundles connecting palmar surface of phalanges with long flexor tendons. Small vascular bundles connecting palmar surface of phalanges with long flexor tendons. Long and short Long and short

41 Long Flexors

42 Dorsal Interossei Four bipennate muscles. Four bipennate muscles. Each arises via two heads from adjacent sides of two metacapals. Each arises via two heads from adjacent sides of two metacapals.

43 Dorsal Interossei Insertion: Insertion: Onto extensor expansions and: Radial sides of proximal phalanges 2 and 3; Ulnar sides of proximal phalanges 3 and 4. Note: digit has two dorsal interossei. Abducts MP joints of digits 2-4: Abducts MP joints of digits 2-4: Reference is line through middle finger.

44 Interossei Muscles

45 Palmar Interossei Four unipennate muscles: Four unipennate muscles: First is sometimes considered part of flexor pollicis brevis. Supply each digit except third: Reference is middle finger. Innervation for all interossei (incl. dorsal): Innervation for all interossei (incl. dorsal): Ulnar nerve

46 Interossei Muscles

47 Lumbricals Four small, narrow, elongated muscles. Four small, narrow, elongated muscles. Each arises from the radial side of a flexor digitorum profundus tendon. Each arises from the radial side of a flexor digitorum profundus tendon. Innervation: Innervation: Two on radial side: Median nerve Two on ulnar side: Ulnar nerve Flex MCP joints and extend IP joints. Flex MCP joints and extend IP joints.

48 Arterial Supply to Hand Superficial palmar arch: Superficial palmar arch: Continuation of ulnar artery. Deep palmar arch: Deep palmar arch: Continuation of radial artery.

49 Route of Radial Artery Smallest terminal branch of brachial artery. Smallest terminal branch of brachial artery. Passes proximally deep to brachioradialis muscle. Passes proximally deep to brachioradialis muscle. Distally the artery lies against the radius lateral to the tendon of the flexor carpi radialis, where it can be felt (radial pulse). Distally the artery lies against the radius lateral to the tendon of the flexor carpi radialis, where it can be felt (radial pulse). Passes across scaphoid in anatomical snuff box. Passes across scaphoid in anatomical snuff box.

50 Route of Radial Artery Wraps around the dorsum of first metacarpus: Wraps around the dorsum of first metacarpus: Gives off arteries to the thumb and index finger. Pierces the first dorsal interosseous muscle and reappears in the palm of the hand. Pierces the first dorsal interosseous muscle and reappears in the palm of the hand. Gives rise to the deep palmar arch. Gives rise to the deep palmar arch.

51 Deep Palmar Arch

52 Boundaries of the Anatomical Snuff Box Lateral (anterior): Lateral (anterior): Tendons of the: Abductor pollicis longus. Extensor pollicis brevis. Medial (posterior): Medial (posterior): Tendon of the: Extensor pollicis longus.

53 Ulnar Nerve in the Hand Enters hand superficial to flexor retinaculum. Enters hand superficial to flexor retinaculum. Superficial branch: Superficial branch: Muscular branch to palmaris brevis Cutaneous to palmar aspect of ulnar side of little finger and adjacent sides of little and ring fingers, including tips and dorsum.

54 Ulnar Nerve in the Hand Deep branch: Deep branch: Supplies hypothenar muscles, all interossei, two ulnar side lumbricals, and adductor pollicis.

55 Nerve Supply to Hand

56 Median Nerve in the Hand Enters palm deep to flexor retinaculum. Enters palm deep to flexor retinaculum. Divides into lateral and medial branches: Divides into lateral and medial branches: Lateral branch: To thenar muscles and first lumbrical. Cutaneous to anterior surface of thumb and radial side of index finger. Medial branch: To second lumbrical. Cutaneous to adjacent sides of digits 2-4, including nail-bed and finger tips.

57 Spaces in the Hand Thenar space: Thenar space: Located between the palmar side of the adductor pollicis muscle and the long flexor tendons to the index finger and the thumb. Midpalmar space: Midpalmar space: Located between metacarpals 4-5 and the long flexor tendons to digits 4-5.

58 Clinical Notes Mallet finger: Mallet finger: Avulsion by long flexor tendon. Results in hyperflexion of DIP. Dupuytren’s contracture: Dupuytren’s contracture: Progressive fibrosis of palmar aponeurosis. Results in marked flexion of fingers at MP joints. Colle’s fracture. Colle’s fracture. Fracture of scaphoid. Fracture of scaphoid.

59 Clinical Notes Median nerve injury: Median nerve injury: Loss of thumb opposition. Atrophy of thenar muscles. Ape hand. Ulnar nerve injury: Ulnar nerve injury: Paralysis and atrophy of interossei. Guttering Loss of thumb adduction. Clawhand.

60 EXTENSOR MECHANISM

61 Components Hood Hood Lateral bands: Lateral bands: To bases of distal phalanges. Central band: Central band: To base of middle phalanx. Function: Function: Flexion at MCP joint. Extension at PIP, DIP joints.

62 Functional Notes Extension of the PIP is always accompanied by the simultaneous extension of the DIP. Extension of the PIP is always accompanied by the simultaneous extension of the DIP. When the PIP is flexed, the DIP may be extended or flexed When the PIP is flexed, the DIP may be extended or flexed

63 Clinical Notes If lateral bands detach: If lateral bands detach: Lateral bands will flex the PIP and hyperextend the DIP.


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