1. upper limb
HAND
DR.RAJ
ANATOMY DEPT, WUSM

2. HAND
The hand is the region of the upper limb distal to the wrist joint.
It is subdivided into three parts:
1. Wrist
2.Metacarpus
3.Digits (five fingers including the thumb).
The hand has an anterior surface (palm) and a dorsal surface (dorsum of hand).

3. Carpal tunnel and structures at the wrist
The carpal tunnel is formed anteriorly at the wrist by a deep arch formed by the carpal bones and the flexor retinaculum.

4. Carpal arch
The base of the carpal arch is formed medially by the pisiform and the hook of the hamate and laterally by the tubercles of the scaphoid and trapezium.

6. Flexor retinaculum
flexor retinaculum is a thick connective tissue ligament that bridges the space between the medial and lateral sides of the base of the arch and converts the carpal arch into the carpal tunnel.

7. Structure and relations
Four tendons of the flexor digitorum profundus
Four tendons of the flexor digitorum superficialis
One tendon of the flexor pollicis longus
Median nerve

8. Carpal tunnel syndrome
Carpal tunnel syndrome is an entrapment syndrome caused by pressure on the median nerve within the carpal tunnel.

9. Carpal Tunnel syndrome
Common in computer professionals.
Due to constant dorsiflexion of wrist while typing the keyboard

10. Palmar aponeurosis
The palmar aponeurosis is a triangular-shaped condensation of deep fascia that covers the palm and is anchored to the skin in distal regions.
The apex of the triangle is continuous with the palmaris longus tendon.

11. Dupuytren Contracture of Palmar Fascia
Dupuytren contracture is a disease of the palmar fascia resulting in progressive shortening, thickening, and fibrosis of the palmar fascia and aponeurosis.

12. Compartments of palm 1. Hypothenar compartment 2. Thenar compartment
3. Central compartment
4. Adductor compartment
5.Interosseous compartment

13. Muscles
The intrinsic muscles of the hand are located in five compartments
All of the intrinsic muscles of the hand are innervated by the deep branch of the ulnar nerve except for the three thenar and two lateral lumbrical muscles, which are innervated by the median nerve.

14. Muscles of the Hand Thenar Muscles
Abductor Pollicis Brevis
Abducts thumb
Opponens Pollicis
To oppose thumb
Flexor Pollicis Brevis
Flexes thumb

15. Muscles of the Hand Hypothenar Muscles
Abductor Digit Minimi
Abducts digit 5
Flexor Digiti Minimi Brevis
Flexes proximal phalanx of digit 5
Opponens Digiti Minimi
bringing digit 5 into opposition with the thumb

16. Palmaris brevis
Action:
Improves grip

17. Thenar and hypothenar Muscles

18. Adductor pollicis
Action:
Adducts thumb towards middle digit

19. Movements of thumb

20. Movements of thumb
Extension: extensor pollicis longus, extensor pollicis brevis
Flexion: flexor pollicis longus and flexor pollicis brevis
Abduction: abductor pollicis longus and abductor pollicis brevis.
Adduction: adductor pollicis
Opposition: opponens pollicis.

21. Muscles of the Hand Short Muscles
Lumbricals
1 and 2
Flex digits at metacarpo-phalangeal joints and extends interphalangeal joints
3 and 4
Dorsal interossei
1-4
Abducts digits from axial line and act with lumbricals to flex metacarpo-phalangeal joints and extends interphalangeal joints
Palmar interossei
1-3
Adducts toward axial line & assist lumbriaclas in flexing the same joints as above

22. Lumbrical muscles

23. Dorsal interossei Action of Dorsal Interossei : DAB : Abduction
Little finger and thumb have no Dorsal interossei muscle

24. Palmar interossei Action of Palmar interossei : PAD :Adduction
Middle finger and thumb have no palmar interossei muscle

25. Arteries of hand
Blood supply to the hand is by the radial and ulnar arteries, which form two interconnected vascular arches (superficial and deep) in the palm.

26. Ulnar artery and superficial palmar arch
Ulnar artery+ palmar branch of radial artery

27. Radial artery and deep palmar arch
Deep palmar arch: Deep palmar branch of ulnar artery+ radial artery

28. Allen's test
To test for adequate anastomoses between the radial and ulnar arteries, compress both the radial and ulnar arteries at the wrist, then release pressure from one or the other, and determine the filling pattern of the hand.

29. Positive allen test

30. Nerves
The hand is supplied by the ulnar, median, and radial nerves.

31. Ulnar nerve
Immediately distal to the pisiform, ulnar nerve divides into a deep branch, which is mainly motor and a superficial branch, which is mainly sensory.
Deep branch: supplies the hypothenar interossei, adductor pollicis, and the two medial lumbricals.
Superficial branch: supply skin on the palmar surface of the little finger and the medial half of the ring finger

33. Ulnar nerve injury
The ulnar nerve is most commonly injured at two sites:
1. Elbow
2. wrist
Clawing of the hand:
Metacarpophalangeal joints of the fingers are hyperextended and the interphalangeal joints are flexed.

34. Clawing of the hand

35. Ulnar Canal Syndrome (Guyon Tunnel Syndrome)
Compression of the ulnar nerve may occur at the wrist where it passes between the pisiform and the hook of the hamate.

36. Median nerve
The median nerve is the most important sensory nerve in the hand because it innervates skin on the thumb, index and middle fingers, and lateral side of the ring finger.
Branches:
1. Recurrent branch: innervates the three thenar muscles
2. Palmar digital nerves: In addition to skin, the digital nerves supply the lateral two lumbrical muscles

38. Ape hand
Refers to a deformity in which thumb movements are limited to flexion and extension of the thumb in the plane of the palm.
Severance of median nerve paralyzes the thenar muscles and the thumb loses much of its usefulness.

39. Superficial branch of the radial nerve
The only part of the radial nerve that enters the hand is the superficial branch.
Innervates skin over the dorsolateral aspect of the palm and the dorsal aspects of the lateral three and one-half digits distally to approximately the terminal interphalangeal joints.

40. Superficial branch of the radial nerve

41. A 21 year old girl is brought to the emergency department with a puncture wound on the palmar side of her left index finger. Preservation of which of the following movements of her index finger will confirm the functional integrity of the flexor digitorum profundus muscle?
 Flexion of the metacarpophalangeal joint
Adduction
Abduction
Flexion of the distal interphalangeal joint
Flexion of the proximal interphalangeal joint

42. .
A 53-year-old African American man involved in a motor vehicle accident sustains a severe mid-shaft fracture of the right humerus. Vitals are Temp-100.0F, BP-120/88mm/Hg, pulse- 118/min, and RR- 14/min. Examination reveals wrist drop and no ulnar or radial pulses in the right arm. Examination reveals decreased sensation over the dorsal aspect of the lateral 3½ digits. The rest of the physical exam is otherwise unremarkable. What nerve is most likely injured given the findings in this patient?
A.Axillary nerve
B.Musculocutaneous nerve
C.Median nerve
D.Radial nerve
E.Ulnar nerve

43. 3
The figure below represents cutaneous innervation of wrist and hand. The area A in the figure represents which Nerve?
Superficial branch of radial nerve
Anterior interosseous nerve
Palmar branch of median nerve
Palmar branch of ulnar nerve
Lateral cutaneous nerve of fore arm