HAND ANATOMY

Some Lovers Try Positions That They Can’t Handle Mnemonic for Carpal bones Some Lovers Try Positions That They Can’t Handle Scaphoid, Lunate, Triquetrum, Pisiform Trapezium, Trapezoid, Capitate, Hamate

“Trapezium is under the thumb!” How to remember which is trapezium and which is trapezoid

1 – Scaphoid 2 – Trapezium 3 – Trapezoid 4 – 5th Metacarpal 5 – Proximal Phalanx 6 – Middle Phalanx 7 – Distal Phalanx 8 – Capitate 9 – Lunate 10 – Hamate 11 – Pisiform 12 - Triquetrum

The hand is innervated by three nerves (ulnar, median and radial): The ulnar nerve enters the hand at the wrist with the ulnar artery through Guyon’s canal and is responsible for sensation over the palmar and dorsal ulnar one a half fingers and along these lines into the palm and dorsum of the hand. The median nerve enters the hand at the wrist via the carpal tunnel along with nine flexor tendons and is responsible for sensation over the palmar aspect of the radial three and a half fingers and palm as well as the distal dorsal aspect of the same fingers. The radial nerve enters the hand dorsally and provides sensation over the proximal, dorsal aspect of the radial three and a half fingers as well as that area of the dorsum of the hand that extends along these lines.

Musculature of the Hand Thenar Hypothenar Adductor Flexor Pollicis Brevis Flexor Digiti Minimi Abductor Pollicis Brevis Abductor Digiti Minimi Adductor Pollicis Opponens Pollicis Opponens Digiti Minimi MEDIAN NERVE ULNAR NERVE ULNAR NERVE!!! Superficial Deep Lumbricals – Median (1 & 2), Ulnar (3 & 4) – Flex MCP, Extend IPs Interossei – Ulnar (Palmar - AD, Dorsal - AB) Remember – Forearm muscles in the hand!!! Nerve Supply & Action? Nerve Supply & Action?

Carpal Tunnel Contents… 4 x Flexor Digitorum Profundus Tendons 4 x Flexor Digitorum Superficialis Tendons Flexor Pollicis Longus Tendon Median Nerve Signs & Symptoms? – Tingling, Pain, Thenar Wasting

Clinical Case 1 A 30-year-old man presents to A&E with incised wounds to the anterior aspect of his wrist and forearm following a suicide attempt. Preliminary inspection reveals that the patient has four deep, linear incised wounds involving the palmar region of the wrist. The thumb and medial three fingers are noted to be gently flexed while the index finger is held in extension. Q - What specific anatomical structures do you think are injured? Since the index finger is in extension as the hand lies relaxed, it is likely that both the FDS and FDP of the index finger have been severed. Further physical examination is required to check the other tendons, the vascular supply, and neurological integrity of the hand. A - FDS and FDP of the index finger

Clinical Case 2 A 16-year old male presents to A&E after slipping on ice. He states that he attempted to break his fall and fell on an outstretched hand. He complains of pain and swelling in the area indicated by the arrow in the photograph below.

Q - What are possible complications of this condition? 1- One of the most common fractures incurred after falling on an outstretched hand in young, healthy people is a fracture of the scaphoid bone. Clinically, pain in the anatomical snuffbox is an indication that there may be a fracture of the scaphoid. To examine this, the physician applies pressure gradually to this area, and compares the pain elicited in the injured hand to the uninjured hand. It is also helpful to palpate for scaphoid tenderness from the volar aspect of the wrist. 2 – The scaphoid has a poor blood supply and is completely covered by hyaline cartilage. Healing can be prolonged and avascular necrosis or arthritis may result if the fracture is not recognized or malunites. The scaphoid receives the majority of its blood supply from the dorsal vessels that enter the bone near its waist (middle of bone). As the circulation of this bone is from distal to proximal, scaphoid waist fractures may be complicated by the development of avascular necrosis of the proximal pole. Q - What is the most common injury sustained by falling on an outstretched hand in young, healthy individuals? A – Scaphoid fracture Q - What are possible complications of this condition? A – Avascular Necrosis, Osteoarthritis, Malunion, Non-union

Colle’s vs Smith’s # Dorsum Palm Distal Radius Fractured Q – Dorsal angulation of the distal bone fragment… A – Colle’s Q – Palmar angulation of the distal bone fragment… A – Smith’s – More dangerous due to the neurovascular structures in this direction!

Boutonniere’s vs Swan Necking Boutonniere’s – PIP & DIP… PIP flexed, DIP Hyper-extended Swan Necking – PIP & DIP… PIP Hyper-extended, DIP Flexed

Which nerve innervates the lateral half of the muscle that flexes the fingers at the DIP joint? ulnar nerve radial nerve median nerve musculocutaneous nerve

Which of the following structures does not pass through the carpal tunnel? Median nerve Flexor carpi ulnaris Flexor digitorum superficialis Flexor digitorum profundus Flexor pollicis longus

Which part of the scaphoid is most commonly affected by avascular necrosis following a fracture? scaphoid waist proximal pole distal pole whole bone

“Skier’s Thumb” Skier’s Thumb is caused by a traumatic force on the thumb that forces it out (radial deviation is the anatomical direction). It often occurs with skiing and football. Signs and symptoms include pain in the knuckle of the thumb, swelling, and an unstable joint. X-rays often show a small fragment of the metacarpal that has been pulled off by the ligament (called an avulsion fracture). Treatment usually consists of bracing or splinting of partial tears and in some cases, surgical repair if the tear is complete.

“Mallet Finger” This fracture results from a trauma to tip of the finger forcing it into flexion (rapidly bending it down toward the palm) and avulsing the extensor tendon. This injury commonly occurs in baseball and basketball when attempting to catch a ball. Signs and symptoms include pain, swelling, and an inability to straighten out the last digit of the involved finger. Treatment includes splinting of the finger in the straight position for 6-8 weeks. In some cases, surgical pinning of the finger in a straight position along with splinting is necessary. Mallet finger

FOOT ANATOMY

1 – Talus 2 – Calcaneus 3 – Cuboid 4 – Navicular 5 – Cuneiforms 6 – Sesamoid Bone 7 – Calcaneus 8 – Phalanges 9 – Metatarsal 10 – Navicular

Musculature of the Foot Remember – Leg muscles in the foot!!! 1st Layer of Sole: Medial Plantar Nerve Lateral Plantar Nerve

Musculature of the Foot Remember – Leg muscles in the foot!!! 2nd Layer of Sole: 1st – Medial Plantar Nerve 2nd – 4th – Lateral Plantar Nerve Lateral Plantar Nerve 25

(Like Ulnar in Adductor Pollicis) Musculature of the Foot Remember – Leg muscles in the foot!!! 3rd Layer of Sole: Lateral Plantar Medial Plantar Lateral Plantar Nerve (Like Ulnar in Adductor Pollicis) 26

Musculature of the Foot 4th Layer of Sole: Lateral Plantar Nerve PAD, DAB 27

Structures Behind the Medial Malleolus Tom Dick And Nervous Harry & 28

Q – Which muscles invert the foot? A – Tibialis Anterior (Deep Fibular Nerve) & Tibialis Posterior (Tibial Nerve) FIBULAR = PERONEAL Q – Which muscles evert the foot? A – Fibularis Longus & Fibularis Brevis (Superficial Fibular Nerve)

Foot Drop Q – How would someone with foot drop walk? A – High Stepping Gait Q – Where could a nerve problem be localised? Deep fibular – Supplies Ant. Compartment (Tib Ant, EDL, EHL) Common Fibular Nerve - Affects Deep & Superficial Fibular nerves Sciatic – Affects Deep & Superficial Fibular & Tibial nerves….i.e. every muscle below the knee

Hallux Valgus – “Bunion” What is this? Hallux Valgus – “Bunion”