1. The Hand & Lymphatics
Week 6 TA Review

2. Things to Know about The Hand
Osteology & Arthrology
Wrist (Carpal Bones)
Hand (Meta-carpals)
Digits (phalanges)
Muscles
Actions
Arteries & Nerves

3. The Wrist (Carpal) Bones
“Stop Letting Those People Touch The Cadaver’s Hand”
From lateral to medial; Proximal row - Scaphoid, Lunate, Triquetrum and Pisiform Distal row - Trapezium, Trapezoid, Capitate and Hamate.

4. Arthrology of the Wrist
Radiocarpal Joint
Intercarpal Joint
Carpometacarpal Joints

5. Radiocarpal Joint : Single Capsule
Formed by the:
Radius
Radioulnar disc
3 Proximal Carpal Bones
Scaphoid
Lunate
Triquetrum.

6. Intercarpal Joint Articulations b/w the individual carpal bones.
Plane synovial joints.
The small movement b/w carpal bones at these joints contributes to total wrist mobility

7. Carpometacarpal Joint
Formed by the articulations b/w the distal row of carpals & the bases of the 1st -5th metacarpals.

8. Intercarpal & Carpometacarpal Jt
Compound Joint
One joint capsule
Except the Pisotriquestral Joint
Planar Type of Synovial Joints
Lots of ligaments to keep integrity of joint.

9. The Joints of Hand & Wrist
Radiocarpal Joint
Carpometacarpal Joint
Metacarpophalangeal Joint.
Interphalangeal Joint of the Thumb.
Metacarpo-phalangeal joint.
Proximal inter-phalangeal joint (PIP).
Distal inter-phalangeal joint (DIP).

10. Ligaments of the Wrist

11. Collateral Ligaments

12. Arthrology of the Hand Carpometacarpal Joints
Metacarpophalangeal Joints
Interphalangeal Joints

13. Metacarpophalangeal Joints
Condyloid Synovial Joint
Ligaments

14. Interphalangeal Joint
Hinge Joint
Only one in 1st digit
Two in digits 2-5
PIPs
DIPs
Collateral Ligaments

15. Actions of Wrist and Hand
Flexion
Extension
AB-duction
AD-duction
Opposition (Hand)

16. Flexion/Extension Wrist/Hand Digits Radio-carpal jts Intercarpal jts
Carpo-metacarpal jts.
Digits

17. AB-duction/AD-duction
Wrist/Hand
Complex motion:
Radio-carpal jts
Intercarpal jts
Carpo-metacarpal jts
Digits
Reference is the 3rd digit

18. Opposition Distal ends of 1st and 5th digits brought together
Action is a combo of flexion and adduction
Primarily the 1st digit, lesser action of 5th

19. Skin & Fascia of Hand
Skin is relatively thin with a thickening on the palmar surface.
The Palmar Aponeurosis
Tough CT proper
Pt of insertion/origin for hand muscles
Acts like a retinaculum

20. More Hand Anatomy
Superficial Flexor Tendon= Flexor Digitorum Superficialis
on base of middle phalanx
Deep Flexor Tendon=
Flexor Digitorum Profundus
on distal phalanx.
Extensor Digitorum
On extensor expansion hoods
Extend the MCP joint

21. Common Extensor Hood Expansion or Hood Tendon divides into 3 bands
Wings
Tendon divides into 3 bands
Central band: base of middle phalanx
Lateral bands: base of distal phalanx
Lumbricals insert on the lateral bands.

22. Muscles of the Hand: Palmar Side
Thenar Eminence
Abductor Pollicis Brevis
Flexor Pollicis Brevis
Opponens Pollicis
Hypothenar Eminence
Palmaris Brevis
Abductor Digiti Minimi
Flexor Digiti Minimi (Brevis)
Opponens Digiti Minimi
Adductor Pollicis
Lumbricals
Interossei
Thenar means base of thumb
Hypothenar less than thenar-mini

24. Abductor Pollicis Brevis Thenar Muscle
Origin: Flexor retinaculum, scaphoid & trapezium
Insertion: Lateral side of base of proximal phalanx of 1st digit
Action: Abducts thumb and helps oppose it
Innervation: Recurrent branch of Median Nerve (C8 and T1)
Arterial Supply: Superficial palmar branch of the Radial A.

25. Flexor Pollicis Brevis Thenar Muscle
Origin: flexor retinaculum & tubercles of scaphoid and trapezium
Insertion: Lateral side of base of proximal phalanx of thumb
Action: abducts thumb and helps with opposition (flexes thumb)
Innervation: Recurrent branch of Median Nerve (C8 and T1)
Arterial Supply: Superficial palmar branch of Radial A.

26. Opponens Pollicis Thenar Muscle
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 and rotates it medially
Innervation: Recurrent branch of Median Nerve (C8 and T1)
Arterial Supply: Superficial palmar branch of the radial artery

27. Palmaris Brevis Hypothenar Muscle
Origin: flexor retinaculum and the palmar aponeurosis
Insertion: Hypothenar area skin
Actions: Tightens and wrinkles the hypothenar skin, may deepen the concavity of the palm; aids in gripping
Innervation: Ulnar Nerve
Artery: Superficial Arch of Ulnar A.

28. Abductor Digiti Minimi Hypothenar Muscle
Origin: Pisiform
Insertion: Medial side of base of proximal phalanx of 5th digit
Action: Abducts 5th digit
Innervation: Deep branch of Ulnar nerve (C8 and T1)
Arterial Supply:Ulnar artery

29. Flexor Digiti Minimi Hypothenar Muscle
Origin: Hook of hamate and flexor retinaculum
Insertion: Medial side of base of proximal phalanx of 5th digit
Action: Flexes proximal phalanx of 5th digit
Innervation: Deep branch of Ulnar Nerve (C8 and T1)
Arterial Supply: Ulnar A.

30. Opponens Digiti Minimi Hypothenar Muscle
Origin Hook of hamate and flexor retinaculum
Insertion: Medial border of 5th metacarpal
Action: Draws 5th metacarpal anteriorly and rotates it, bringing little finger (5th digit) into opposition with thumb
Innervation: Deep branch of ulnar nerve (C8 and T1)
Arterial Supply: Ulnar artery

31. Adductor Pollicis Origin:
Oblique head: bases of 2nd and 3rd metacarpals, capitate, and adjacent carpals
Transverse head: anterior surface of body of 3rd metacarpal
Insertion: Medial side of base of proximal phalanx of thumb
Action: Draws 1st metacarpal laterally to oppose thumb toward center of palm and rotates it medially (adducts thumb)
Innervation: Deep branch of Ulnar Nerve (C8 and T1)
Arterial Supply: Deep palmar arterial arch

32. Lumbricals
Origin:
1st & 2nd : Lateral two tendons of Flexor Digitorum Profundus
3rd & 4th : Medial three tendons of Flexor Digitorum Profundus
Insertion: Radial border (lateral side) of the extensor expansion on the dorsum of the respective digits.
Action:  Extend the IP joints and simultaneously flex the MCP joints of the
2nd -5th digits. 
Innervation:
Nerve to 1st & 2nd Lumbricals-Median Nerve Nerve to 3rd & 4th Lumbricals-Ulnar Nerve

34. Palmar Interossei (PAD)
Origin:
First:  Base of 1st MC, ulnar side.
Second:  Length of 2nd MC bone, ulnar side.
Third:  Length of 4th MC bone, radial side.
Fourth:  Length of 5th MC bone, radial side.
Insertion: Into the extensor expansion of the respective digit, with possible attachment to base of proximal phalanx as follows:
First: Ulnar side of 1st digit
Second: Ulnar side of 2rd digit.
Third: Radial side of 4th digit.
Fourth:  Radial side of 5th digit.
Innervation: Ulnar, C8, T1
Action :
Adduct 1st, 2nd, 4th & 5th digit toward the axial line through the 3rd digit. 
Assist in flexion of MCP joints, and extension of IP joints of the three fingers.
First is usually fused with Adductor Pollicis Muscle
MC= Metacarpal

35. Dorsal Interossei (DAB)
Origin:
First, lateral head:  Proximal one half of ulnar border of 1st metacarpal bone. First, medial head:  Radial border of 2nd MC bone.
Second, third, & fourth:  Adjacent sides of MC bones in each interspace
Insertion: Into extensor expansion and to base of proximal phalanx via the proximal wing tendons as follows:
First:  Radial side of 2nd digit, chiefly to base of proximal phalanx.
Second:  Radial side of 3rd digit.
Third:  Ulnar side of 3rd digit, chiefly into extensor expansion.
Fourth:  Ulnar side of 4th digit
Innervation: Ulnar, C8. T1
Action :
Abducts the index, and ring fingers
Radially and Ulnarlly deviates the 3rd digit from the axial line through the 3rd digit. 
Assists in flexion of MCP joints and extension of IP joints of the same fingers. 
The first assists in adduction of the 1st digit

36. Can you identify these muscles?
1. Abductor pollicis brevis
2. Flexor pollicis brevis
3. Oblique head of adductor pollicis
4. Transverse head of adductor pollicis
5. Flexor digiti minimi brevis
6. Abductor digiti minimi
7. Superficial palmar arch
8. Common palmar digital branches

37. Can you identify these muscles?
1. 1st lumbrical
2. 2nd lumbrical
3. 3rd lumbrical
4. 4th lumbrical
5. Adductor pollicis
6. Flexor pollicis brevis
7. Tendon of flexor pollicis longus
8. Tendons of flexor digitorum profundus
9. Tendon of flexor digitorum superficialis (cut)
10. Fibrous flexor sheath

38. 1.Flexor retinaculum
2.Median nerve
3.Median nerve
4.Muscular br. of median n. to thenar muscles
5.Proper palmar digital nerves to the thumb
6.Proper palmar digital nerve to index
7.Common palmar digital nerves
8.Common palmar digital nerves
9.Palmar digital branches of ulnar n.
10.Palmar digital branches of ulnar n.

39. Arteries of the Wrist and Hand
Deep Palmer Arch (1˚ formed by Radial A.)
Superficial Palmer Arch (1˚ formed by Ulnar A.)
SUPERFICIAL PALMAR ARCH
INTEROSSEOUS AA.
DEEP PALMAR ARCH
COMMON INTEROSSEOUS ARTERIES
DIGITAL ARTERIES
Common Interosseous Arteries
Digital Arteries

40. More Arteries… Dorsal Carpal Arch Connects to Radial and Ulnar AA
Posterior Interosseus Artery will supply the Posterior Interossei Muscles.

41. Nerves of the Hand

42. Ulnar Nerve Motor to muscles of the hand except for 1 ½ muscles
Fine motor movements
Exceptions:
Thenar Eminence
Lateral 2 Lumbricals

43. Median Nerve Recurrent branch to the muscle of the Thenar Eminence
Motor to the Lateral 2 Lumbricals

44. Radial Nerve
Just sensation to dorsum of hand: does not innervate any muscles of the hand

45. Lymphatics of Upper Limb
Purpose of Lymphatic System
returns excess interstitial fluid to the blood.
absorption of fats and fat-soluble vitamins from the digestive system and the subsequent transport of these substances to the venous circulation
defense against invading microorganisms and disease.

46. What is Lymph? fluid similar in composition to blood plasma
derived from blood plasma as fluids pass through capillary walls at the arterial end.
Accumulated fluid is picked up and removed by tiny lymphatic vessels and returned to the blood.
As soon as the interstitial fluid enters the lymph capillaries, it is called lymph.
Returning the fluid to the blood prevents edema and helps to maintain normal blood volume and pressure.

47. Lymphatic Vessels Lymph capillaries  Lymphatic vessels.
Lymphatic vessels  Lymphatic trunks
drain large regions.
Lymphatic trunks  Lymphatic ducts.
Right lymphatic duct drains lymph from the upper right quadrant of the body.
Thoracic duct drains all the rest.
Lymphatic tributaries have thin walls and have valves to prevent backflow of blood.
No pump in the lymphatic
to move lymph through the vessels pumping comes from the skeletal muscle action, respiratory movement, and contraction of smooth muscle in vessel walls.
Right lymphatic
Thoracic Duct

49. Lymphatic Vessels Carry fluid away from the tissues
The smallest lymphatic vessels are the lymph capillaries, which begin in the tissue spaces as blind-ended sacs.
Lymph capillaries are found in all regions of the body except the bone marrow, central nervous system, and tissues, such as the epidermis, that lack blood vessels.
The wall of the lymph capillary is composed of endothelium in which the simple squamous cells overlap to form a simple one-way valve.
permits fluid to enter the capillary but prevents lymph from leaving the vessel.

50. Lymph Nodes
Small bean-shaped structures that are usually less than 2.5 cm in length.
Widely distributed throughout the body
Lymph nodes are not present in the central nervous system.
3 superficial regions on each side of the body where lymph nodes tend to cluster.
inguinal nodes in the groin, the axillary nodes in the armpit, and cervical nodes in neck.

51. Lymph Node
Surrounded by a CT capsule and divided into compartments called lymph nodules.
nodules are dense masses of lymphocytes and macrophages
separated by spaces called lymph sinuses.
Afferent lymphatic vessels carry lymph into the node
Efferent vessel leaves the node at the hilum.
The lymph  lymph sinuses efferent lymphatic vessel
Because there are more afferent vessels than efferent vessels, the passage of lymph through the sinuses is slowed down, which allow time for the cleansing process.

52. Lymph Nodes of Upper Limb
Lymph from upper limb, shoulder & scapular regions, pectoral region (including the mammary gland) and upper abdomen drain through the axillary nodes.
There are some 15 to 20 nodes usually arranged into to five groups. The groups consist of:
A pectoral (anterior)
L lateral
P posterior
C central
Ap apical

53. HAND & FOREARM TO CUBITAL NODES
ARM DIRECT TO HUMERAL NODES
Breast Lymph Drainage:
Medial Half- drains to parasternal nodes- can cross mid-line
Lateral Half- drain to pectoral group
Axillary tail- drains into the pectoral and lateral groups

54. Lymph Drainage of Upper Limb
Right side:
Right Superficial Axillary Nodes (4 Groups) Deep Nodes (2 Groups)  Subclavian Lymphatic Trunk Right Lymphatic Duct Subclavian Vein Superior Vena Cava
Left side:
Subclavian Lymphatic Trunk  Thoracic Duct  Subclavian Vein Superior Vena Cava

55. Median Ulnar Musculocutaneous Radial
1. A patient complaining of difficulty picking up items. Physical examination shows weakness of grip in her left hand and that she is unable to abduct, flex, and oppose her left thumb with her 5th digit. There is loss of sensation on the palmar surface of the lateral side of the hand. Which one of the following nerves most likely has been damaged?
Median
Ulnar
Musculocutaneous
Radial a.

56. Review Questions

57. Median Ulnar Musculocutaneous Radial
1. A patient complaining of difficulty picking up items. Physical examination shows weakness of grip in her left hand and that she is unable to abduct, flex, and oppose her left thumb with her 5th digit. There is loss of sensation on the palmar surface of the lateral side of the hand. Which one of the following nerves most likely has been damaged?
Median
Ulnar
Musculocutaneous
Radial a.

58. Lateral group of axillary lymph nodes
2. Lymph originating in the area of the skin overlying trapezius would most likely first be drained into which of the following groups of lymph nodes?
Lateral group of axillary lymph nodes
Subscapular group of axillary lymph nodes
Pectoral group of axillary lymph nodes
Apical group of axillary lymph nodes b.

59. Lateral cord Medial cord Posterior cord Superior trunk
3. An 18-year-old high school basketball player had injured her right knee 2 weeks previously. The knee was immobilized and the athlete was fitted with crutches. After using the crutches for these last 2 weeks, she complains that the back of her right hand feels numb and that she finds it difficult to open (extend) the fingers of her right hand. Most likely the crutches were improperly fitted and put pressure on the brachial plexus. Which part of the brachial plexus most likely has been damaged?
Lateral cord
Medial cord
Posterior cord
Superior trunk c.

60. Flexion Pronation Adduction Abduction
4. A patient with a severe tear of the medial (ulnar) collateral ligament of the wrist would likely display increased wrist movement in which of the following actions?
Flexion
Pronation
Adduction
Abduction d.

61. Apical group of axillary lymph nodes Subclavian lymphatic trunk
5. Lymph from the lateral group of axillary lymph nodes primarily drains into which of the following?
Apical group of axillary lymph nodes
Subclavian lymphatic trunk
Central group of axillary lymph nodes
Pectoral group of axillary lymph nodes c.

62. 6. Which of the following carpal bones lies in the proximal row of 4?
Trapezoid
Scaphoid
Hamate
Capitate b.

63. Root of the neck in the region of the trapezius muscle Hand
7. A patient presents of general malaise, being tired, and with a fever. A physical examination is unremarkable except for enlarged lymph nodes palpated in the region of the lateral group of axillary lymph nodes. The only remarkable lab finding is an elevated with blood cell count. Most likely this patient has an infection in which one of the following places?
Root of the neck in the region of the trapezius muscle
Hand
Chest/breast region
Inferior border of the scapula b.

64. Dorsal interosseous muscle Extensor digitorum
8. Which of the following muscles extend the metacarpo-phalangeal joint?
Lumbrical
Dorsal interosseous muscle
Extensor digitorum
Palmar interosseous muscle c.

65. The fracture caused damage to the ulnar nerve
9. A 14-year-old boy falls while skateboarding and fractures the medial epicondyle of his right humerus. The bone is set and cast. After removal of the cast and a normal duration of rehabilitation his handwriting is noticeably more difficult to read than before the accident. What most likely is the cause of his handwriting deterioration?
The fracture caused damage to the ulnar nerve
The fracture caused damage to the radial nerve
The fracture caused damage to the median nerve
He had a stroke during his rehabilitation A.

66. 10. Which muscle acts to abduct the digits 2-5?
Abductor pollicis longus
Palmar interosseous
Dorsal interosseous
Opponens digiti minimi A.

67. 11. Which muscle acts to flex the proximal interphalangeal joint?
Flexor digitorum profundus
Lumbrical
Dorsal interosseous
Flexor digitorum superficialis D.

68. Central group of axillary lymph nodes
12. Lymph from the lateral aspect of the breast would first be drained into which of the following lymph nodes?
Central group of axillary lymph nodes
Lateral group of axillary lymph nodes
Apical group of axillary lymph nodes
Pectoral group of axillary lymph nodes D.

69. 12. A thrombus (blood clot) has occluded the brachial artery just proximal to the origin of the superior ulnar collateral artery. Trace the path a drop of blood would follow when flowing from the subclavian artery to the palmaris longus muscle, and then to the subclavian vein. D.

70. 12. A thrombus (blood clot) has occluded the brachial artery just proximal to the origin of the superior ulnar collateral artery. Trace the path a drop of blood would follow when flowing from the subclavian artery to the palmaris longus muscle, and then to the subclavian vein.
Subclavian a.
Axillary a.
Brachial a.
Deep brachial a.
Medial Collateral a.
Recurrent Interosseous a.
Common Interosseous a.
Ulnar a.
Capillary Bed
Palmaris Longus
Venae Comitantes
Brachial v.
Axillary v.
Subclavian v. D.