Clinical Anatomy of Upper Limb

1. UL: Hand & Wrist
Lecture 6

2. Learning objectives
2. Surface
anatomy of hand
3. Deep fascia of hand 4. Compartmental organization of hand
5. Contents of each
compartment
6. Synovial sheaths of
FDs and FPL
7. Blood supply and
Innervation
8. Hand deformities
1. Skeleton and
articulation of hand

3. Wrist
joint
(ellipsoid
synovial)
Palmar/dorsal
radiocarpal ligg.
Carpo-
metacarpal
CMC
Metacarpo-
phalangeal
MP
Proximal IP
Distal IP
Collateral lig.
(plane:
gliding)
(hinge: fl-ext)
Inter-
phalange
al IP
1st: saddle:
fl-ex, abd-add,
cir, opp.
Deep
transverse
metacarpal lig.
Skeleton and Articulation of Hand

4. Bones & Joints of Wrist & Carpus
Flexion–extension
Adduction-abduction
+ Circumduction
Scaphoid
Lunate
Triquetrum
Pisiform
Trapezium
Capitate
Hamate
Trapezoid
Wrist
joint
(ellipsoid synovial)
Palmar/dorsal
radiocarpal ligg.
Collateral lig.
Wrist
joint
Plane
synovial
joints
Intercarpal joints
Gliding movements
Common
articular
cavity

5. The appearance of the thenar
and hypothenar eminences, and
the positions of the fingers
change when the ulnar and
median nerves are damaged.
Resting position:
Surface Anatomy and Skeleton of Hand

6. Surface Anatomy of Hand

7. NB!:
• no hypodermic fat under the skin;
• numerous fibrous fasciculi (bundles of
fibers) firmly attach skin to underlaying
aponeurosis forming specific pattern of the skin.
• Skin;
• Palmar aponeurosis (thickened
deep fascia).
Palmar aponeurosis
Flexor
retinaculumPalmaris longus
Palmaris brevis
Longitudinal fibers Transverse fibers
Dupuytren contracture
Deep Fascia of Hand

8. Compartments and Spaces of Palm
L
Palmar aponeurosis
L
Add pollicis
Thenar space
Thenar compartmentHypothenar
compartment
L
L
Midpalmar space
Superficial palmar arch
Deep palmar arch
Tendons of long flexors of fingers
Nerves
Interossei
Interossei Interossei
Interossei
Lateral
fibrous
septum
Medial
fibrous
septum
Deep leaf of the proper fascia
MC
Central compartment

9. Thenar Compartment
Innervation: recurrent branch of the median nerve
Opponens
pollicis (3)
Abductor
pollicis
brevis (1)
Adductor
pollicis (4)
Flexor
pollicis
brevis (2)
Thumb muscles: proximal and
distal attachments
Opposition:
4
1
1
2
2
3
3
4

10. Hypothenar Compartment
Flexor digiti
minimi brevis (2)
Abductor
digiti
minimi (1)
Opponens digiti
minimi (3)
The hypothenar muscles are innervated by the
deep branch of the ulnar nerve.
Palmaris brevis
Ulnar neuro-
vascular bundle
1
1
2
2
3
3
PB is supplied by the superficial branch of
the ulnar nerve
Origins and insertions of
hypothenar muscles

11. Interosseous compartments
Dorsal interossei (4/3) Palmar interossei (4)
Origin: shaft of metacarpal bones
Insertion: bases of proximal phalanges;
extensor expansions of the related digit
Abduct fingers Adduct of fingers
Nerve: all interossei are supplied by the deep branch of the ulnar nerve

12. Muscles of Central Compartment
Origin: tendons of flexor digitorum profundus
Insertion: textensor expantions (lateral sides)
F: flexion of MP and extension of IP joints
“Z-movement”
Ulnar ‘Claw hand’
MP joint are extended and pIP
joints flexed
Deep branch of ulnar nerve supplies 3rd
and 4th lumbricals
Ulnar n
Median ‘Claw hand’

13. Long Flexors of Fingers vs Lumbricals
“Make a fist!” “Open fingers!”
Flexor digitorum profundus Lumbricals

14. Tendons of Long Flexors of Fingers
Tenosynovitis – an infection of the synovial sheath.
Fibrous (digital) sheathSynovial sheaths

15. Anatomy of Fingers
Capillary blood test
Digital artery and nerve
Extensor expansion
Incision

16. Blood Supply of Hand
Superficial palmar arch Deep palmar arch
Radial a.Ulnar a.
(deep veins are faded)
(superficial palmar
arch is faded)

17. Ulnar Nerve in Hand
Function:
1. hypothenar muscles
2. adductor pollicis
3. all interossei
4. two medial lumbricals
Cutaneous innervation: the skin on the palmar and dorsal surfaces of the little
finger and the medial half of the ring finger.
Sensory fibers:
Motor fibers:
Superficial
branch
Dorsal
branch
Deep
branch
Dorsal digital
branches (3)
Ulnar n.
Palmar digital
branches (3)

18. Ulnar Nerve Injury
“ulnar claw hand” deformity
Flexor carpi ulnaris and ulnar half of flexor digitorum profundus (forearm); intrinsic muscles of hand
(adductor policis, 3rd and 4th lumbricals, hypothenar muscles); skin of hand medial to axial line of digit 4.
Structures
Innervated:
At rest: Hyperextension of the 4th
and 5th digits at the MP joint, and
flexion at the proximal IP joint.
Doing a fist: inability to flex distal IP
joins.
The claw hand deformity is more
prominent with injury at the wrist - the
ulnar half of the flexor digitorum
profundus is not affected – it pulls the
distal IP joints of the 4th and 5th digit into
a more flexed position - ulnar paradox.

19. Median Nerve in Hand
Muscles supplied:
• opponents pollicis,
• flexor pollicis brevis,
• abductor pollicis.
• lateral three and one-half digits
• dorsal aspects of the distal phalanges (nailbeds) of the same digits.
Palmar digital
branches
Common palmar
digital nn.
Median n.
Sensory fibers: Motor fibers:
Recurrent branch of median n.

20. Median Nerve Injury
Structures Innervated:
• muscles of anterior
forearm compartment
(except for flexor carpi
ulnaris and ulnar half of
flexor digitorum
profundus);
• five intrinsic muscles in
thenar;
• two lateral lumbricals in
the mid. palmar region;
• lateral half of palm and
palmar skin.
Hand of Benediction
Inability to flex 2nd and 3rd fingers
(flexor digitirum profundus). Inability to extend 2nd and 3rd
fingers (1st and 2nd lumbricals).
Distal median nerve lesion
“Ape-hand deformity“Proximal median nerve lesion
Atrophy of thenar muscles,
Loss of thumb opposition and
inability to abduct the thumb.
Median
Claw
hand

21. Carpal Tunnel
“Carpal tunnel syndrome”:
1) Altered sensation in the lateral three and a half digits
(but not over the palm and thenar eminence);
2) weakness and wasting of the thenar muscles, adducted
thumb;
3) clumsiness of the 2nd and 3rd fingers movement.
“Guyon canal syndrome”:
1) feeling of pins and needles in the ring and
little fingers;
2) “ulnar claw hand” (hyperextension at the
MP joint with flexion at the proximal IP
joint of the 4th and 5th fingers);
3) hypothenar athrophy;
4) Inability to adduct thumb.

22. Radial Nerve in Hand
“Wristdrop” hand deformityStructures Innervated:
All muscles of posterior
compartments of arm and forearm;
skin of posterior and inferolateral
arm, posterior forearm, and dorsum
of hand lateral to axial line of digit 4
Superficial
branch of
radial n.
Posterior
interosseous n.
Dorsal digital
branches (3)

23. Summary
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3191722/

24. Thank you for your attention!!!