1. Dr. S. Nishan Silva (MBBS)
Wrist Hand and Fingers
Dr. S. Nishan Silva
(MBBS)

4. Surface Anatomy of Upper Limb
Carpal Tunnel
Carpals concave anteriorly
Carpal ligament covers it
Contains: long tendons, Median nerve
Inflammation of tendons = compression of Median nerve
Anatomical Snuffbox
Lateral = E.pollicis brevis
Medial = E. pollicis longus
Floor = scaphoid, styloid of radius
Contains Radial Artery (pulse)
Surface Anatomy of Upper Limb
Frolich, Human Anatomy,UpprLimb

5. Bones of the Wrist

6. Bones of the Wrist

9. Ligaments of Wrist (dorsal)

10. Triangular Fibrocartilage Ligament (TFCC)
Triangular Fibrocartilage Ligament (TFCC) *extends from ulnar side of distal radius & attaches to base of ulnar styloid process *disc provides stability to wrist *major stabilizer of distal radioulnar joint

11. Tendons of Wrist (dorsal)

12. Wrist (dorsal)

13. (dorsal)

14. Hand Anatomy
Flexor digitorum superficialis (FDS) insert into middle phalanx.
Flexor digitorum profundus (FDP) runs deep to the FDS until the level of the MP joint where FDS bifurcates.
FDP inserts at the base of the distal phalanx and acts primarily to flex the DIP joint as well as all other joints flexed by FDS. (Figure 268-5).

17. Ligaments of Wrist (palmar)

19. Flexor retinaculum
It is attached, medially, to the pisiform and the hamulus of the hamate bone; laterally, to the tubercle of the scaphoid, and to the medial part of the volar surface and the ridge of the trapezium.

21. Tendons of Wrist (palmar)

22. (palmar)

23. (palmar)

24. (palmar)

26. Bones of the Hand

27. Bones of the Hand

28. Carpal Tunnel

29. Joints of the Upper Extremity
Radiocarpal joint
Synovial-condyloid
Distal radius with proximal row of carpals
Intercarpal joints
Synovial-plane
Carpal-metacarpal (2-5)
Trapezium-metacarpal 1
Synovial-saddle
Metacarpal-phalangeal
Interphalangeal
Synovial-hinge
ALL DIARTHROSES

30. Carpal Tunnel

33. Anatomy Review Muscles & Tendons Extrinsic Flexor tendons
Flexor carpi ulnaris
Flexor carpi radialis
Palmaris longus
Flexor pollicis longus (FPL)
Flexor digitorum profundis (FDP)
Flexor digitorum superficialis (FDS)
The flexor carpi ulnaris and the flexor carpi radialis are the main flexors of the wrist and are located on the radial and ulnar side of the wrist, respectively.
The palmaris longus, a rudimentary muscle that runs down the center of the forearm, inserts the palmar fascia in the palm.
The remaining flexors of the hand pass beneath the transverse carpal ligament within the carpal canal and include the flexor pollicis lungus (FPL), flexor digitorum profundus (FDP), the flexor digitorum superficialis (FDS).
The FPL inserts on the distal phalynx and flexes the IP joint of the thumb. Each finger, excluding the thumb, has a flexor profundus and flexor superficialis.
The FDP inserts on each distal phalanx and flexes all three joints in the finger. The superficialis tendon insert on the middle phalanx and flexes the PIP.

34. Anatomy Review Muscles & Tendons Extrinsic Extensor tendons
Abductor pollicis longus
Extensor pollicis brevis
Extensor carpi radialis longus and brevis
Extensor digitorum
Extensor digiti minimi
Extensor carpi ulnaris

35. HAND & FINGER ANATOMY 9 Finger Flexors Median nerve
Transverse carpal ligament
5 deep flexors pass through superficialis tendons and insert on distal phalanx of each finger and thumb
4 superficial flexors insert on middle phalanx of digits 2-5
Annular ligaments = pulleys (A1-A5)
PREVENT BOWSTRINGING

36. Extrinsic Hand Muscles

37. Extensor Indicis O I N F Dorsal surface lower ½ body of ulna
Interosseus membrane I
Ulnar side of index finger N
Radial (posterior interosseus) F
MCP and IP Ext of 2nd digit

38. Extensor Pollicis Longus
Posterior 1/3 ulna
Interosseus membrane I
Posterior surface of base of thumb distal phalanx N
Radial (posterior interosseus) F
CMC, MCP and IP Ext of 1st digit

39. Extensor Pollicis Brevis
Dorsal 2/3 of radius I
Dorsal surface of base of proximal 1st phalanx N
Radial (posterior interosseus) F
CMC & MCP Ext of thumb
CMC ABD of thumb

40. Abductor Pollicis Longus
Posterior distal 2/3 of ulna
Posterior middle 1/3 of radius
Interosseus membrane I
Radial side of base of 1st metacarpal N
Radial (posterior interosseus) F
CMC ABD & Ext of thumb

41. Flexor Pollicis Longus
Anterior middle ½ of radius
Interosseus membrane I
Palmar surface of base of distal 1st phalanx N
Median (anterior interosseus) F
IP Flexion of thumb

42. Extensor Digiti Minimi
Lateral epicondyle of humerus I
Extensor expansion of 5th digit N
Radial (posteior interosseus) F
MCP and IP extension of 5th digit

43. Flexor Digitorum Superficialis
Medial epicondyle of humerus
Middle ½ anterior radius I
Four tendons separating into two parts that insert into sides of bases of middle 2-5 phalanxes N
Median F
MCP flexion digits 2-5
PIP flexion digits 2-5

44. Flexor Digitorum Profundus
Anteriomedial surface of ulna
Interosseus membrane I
Four tendons inserting into distal phalanges of digits 2-5 N
Median 2-3 digits
Ulna 4-5 digits F
DIP flexion of 2-5 digits

45. Intrinsic Hand Muscles
Thenar Eminance

46. Abductor Pollicis Brevis
Scaphoid tuberosity
Trapezium ridge
Transverse carpal ligament I
Lateral base of proximal 1st phalanx N
Median F
CMC & MCP ABD of thumb

47. Flexor Pollicis Brevis
Superficial head – trapezium
Deep head – trapezoid, capitate and palmar ligaments of distal carpal bones I
Base of prximal 1st phalanx on radial side
Extensor expansion N
Superficial – median
Deep – Ulnar F
CMC & MCP Flexion of thumb

48. Opponens Pollicis O I N F Trapezium Transverse Carpal Ligament
Radial side of 1st metacarpal shaft N
Median F
Opposition

49. Intrinsic Hand Muscles
Hypothenar Eminence

50. Abductor Digiti Minimi
Pisiform I
Ulnar side base of 5th proximal phalanx N
Ulnar F
MCP ABD of 5th digit

51. Opponen Digiti Minimi O I N F Hook of hamate
Transverse carpal ligament I
Ulnar border of entire 5th metacarpal bone N
Ulnar F
MCP flexion & rotation of 5th digit

52. Flexor Digiti Minimi O I N F Hamate bone Transverse carpal ligament
Ulnar side of proximal 5th phalanx N
Ulnar F
MCP Flexion of 5th digit

53. Other Intrinsic Hand Muscles

54. Adductor Pollicis O I N F Oblique Head Transverse Head
Capitate bone
Bases of 2-3 metacarpals
Transverse Head
Proximal 2/3 of palmar surface of 3rd metacarpal I
Ulnar side of base of 1st proximal phalanx N
Ulnar F
CMC ADD of thumb

55. Palmar Interossei O I N F 1st – ulnar side base of 1st metacarpal bone
2nd – ulnar side of 2nd MC bone
3rd – radial side of 4th MC bone
4th – radia side of 5th MC bone I
Extensor expansion of 2,4 and 5th digits N
Ulnar F
ADD of 1st, 2nd, 4th and 5th digits toward midline of hand

56. Dorsal Interossei O I N F
1st lateral head – ulnar side of 1st metacarpal bone
1st medial head – radial side of 2nd metacarpal bone
2nd, 3rd, 4th space between metacarpal bones I
1st – radial side 2nd proximal phalanx
2nd – radial side of 3rd
3rd – ilnar side of 3rd
4th – ulnar side of 4th N
Ulnar F
ABD of 2nd, 3rd, and 5th finger from midline

57. Lumbricales O I N F Tendons of FDP
Extensor expansion on dorsal aspect of each digits radial side N
1 and 2 – median
3 and 4 – ulnar F
MCP flexion 2-5 digits
DIP & PIP ext 2-5 digits

58. Palmaris Brevis O I N F Flexor retinaculum
Palmar surface skin on ulnar side of hand N
Ulnar F
Wrinkles skin of hand on ulnar side

59. Intrinsic Muscles of Hand
pg 297
Palmar Interossei
Dorsal Interossei
Lumbricals
3rd
ABduction
ADDuction
2nd
4th
1st
Interossei help the lumbricals to extend IP joints and flex MC-P joints

60. Movements

61. Joints Wrist joint 70 to 90 degrees of flexion
65 to 85 degrees of extension
15 to 25 degrees of abduction
25 to 40 degrees of adduction

62. Joints Each finger has 3 joints Metacarpophalangeal (MCP) joints
Proximal interphalangeal (PIP) joints
Distal interphalangeal (DIP) joints

63. Joints Thumb has 2 joints Metacarpophalangeal (MCP) joint
Full extension into 40 to 90 degrees of flexion

64. Joints Thumb has 2 joints Interphalangeal (IP) joint
Flex 80 to 90 degrees

65. Joints Thumb has 2 joints Carpometacarpal (CMC) joint of thumb
Unique saddle-type joint
50 to 70 degrees of abduction
Flex 15 to 45 degrees & extend 0 to 20 degrees

66. Thumb Movements

67. Movements Wrist Fingers Flexion & extension Abduction & adduction
Flex & extend
MCP joints also abduct & adduct

68. Movements Opposition Reposition
movement of thumb across palmar aspect to oppose any or all of the phalanges
Reposition
movement of thumb as it returns to anatomical position from opposition with hand and/or fingers

69. Anatomy Review Muscles & Tendons Extrinsic Intrinsic Extension of MP
Flex of IP
Intrinsic
Abduct and adduct fingers
Flexion of MP
Extension of IP
The intrinsic muscles of the hand are the interosseous muscles, the lumbricals, and muscles of the thenar and hypothenar region.
The intrinsic muscles of the hand provide the fingers with the ability to abduct and are involved with flexion at the MP joint and extension of the IP joints.
The extrinsic muscles extend the MP joint and flex the IP joints.
When the intrinsic system is weakened, the hand will take on an intrinsic minus posture (extension at the MP joints and flexion of the MPO joints).
An intrinsic plus posture is the reverse (flexion at the MP joints and extension of the IP joints).

70. Hand Grips
Grasps
Power grip is when an object needs to be held forcefully and then moved by more proximal muscles.
Precision Grip is when an object is manipulated with fingers

71. Hand Grips
Power grips
Cylindrical grip is fingers flexed around an object. Thumb on one side fingers on other, like gripping a hammer or racquet.
Spherical grip is fingers and thumb are together around an
object. Like grabbing
an apple or doorknob.

72. Hand Grips
Power Grip
Hook grip involves the second through fifth fingers flexed around an object in a hooklike manner. Thumb is extended and not involved at all. Only possible grip for
someone with no thumb or
median nerve ability.

73. Hand Grips Precision Grips- Pad to pad
Pinch grip is the thumb and one finger gripping
Three jaw chuck is holding a pencil, three fingers and thumb.

74. Hand Grips Precision Grips Tip to Tip grip
Pincer grip is tip of thumb against tip of a finger, like to pick up a coin. Difficult with long fingernails

75. Hand Grips Precision Grips
Lumbrical grip or plate grip has the MCP and PIP joint flexed and the DIP extended. The thumb opposes and this grip is used to hold something horizontal like a plate. Lumbricals is used they flex the MCP joint.

76. Nerve Innervation (dorsal)

77. Nerve Innervation (palmar)

78. Intrinsic Muscles of Hand
Nerve
Pinky (little finger)
All digiti minimi Ulnar (Flexor, Abductor, Opponens)
Thumb
Abductor pollicis brevis Median
Flexor pollicis brevis Median
Opponens pollicis Median
Adductor pollicis Ulnar
Other Intrinsic Muscles
Palmar + Dorsal Interossei Ulnar
Lumbricals Median, Ulnar

79. Hand Anatomy Blood supply (BS):
Hand and digits has dual (BS) with contributions from the radial and ulnar arteries.

80. Hand Anatomy Blood supply (BS):
Proximal portions of the hand (BS) come from the deep and superficial arches on the palmar and dorsal side.
BS of the fingers is distributed by the digital arteries that arises from the superficial palmer arch.

81. Hand Anatomy - Blood supply
The Allen's test.

82. Digital Allen Test (arterial compromise):
The examiner instructs pt. to rapidly open and close the hand 15 times
As soon as the athlete finishes the final repetition, the examiner places his or her thumb over the pt’s radial artery and index finger over the pt’s ulnar artery
If pt’s hand remains cyanotic until after the examiner removes the pressure, then the test is positive for poor, impaired, and/or depressed perfusion (circulation) through the distal extremities

83. Brachial Plexus innervation

84. Innervation by Posterior Cord
Radial Nerve (largest branch)
Course: Through arm, around humerus, around lateral epicondyle, then divides
Innervates: all posterior muscles of arm and forearm
Triceps brachii, anconeus, supinator, brachioradialis
Divides in forearm:
Superficial = skin of arm and dorsolateral surface of hand
Deep = extensor muscles of forearm (eg E. carpi radialis L + B)
Damage to Radial Nerve = wristdrop
Inability to extend the hand, st inability to fully extend forearm

85. Innervation by Posterior Cord (continued)
Axillary Nerve (runs w/ caudal humeral circumflex a.)
Innervates:
Deltoid and Teres minor (motor inn)
Capsule of shoulder, skin of shoulder (sensory inn)
Subscapular Nerve {branches of C5 + C6 rami}
Innervates: Subscapularis, Teres major
Thoracodorsal Nerve (runs w/thoracodorsal a+v)
Innervates: Latissimus dorsi

86. Innervation by Lateral Cord
Musculocutaneous
Course: branches to arm, distal to elbow becomes cutaneous for lateral forearm skin
Innervates
Biceps brachii, brachialis, coracobrachialis (motor inn)
Skin distal to elbow (sensory)
Suprascapular (runs w/suprascapular a+v) {C5, C6}
Innervates: Supraspinatus, Infraspinatus

87. Innervation by both Lateral and Medial Cords
Median
Course: middle of brachial plexus, does not branch in arm, distal to elbow provides many branches to most forearm flexors, passes through carpal tunnel to hand to lateral palmar intrinsics
Innervates: most muscles of anterior forearm (motor inn)
(eg) most flexors, some intrinsics (thumb)
Innervates: skin of lateral 2/3 hand on palm side, dorsum of fingers 2+3 (sensory inn)
Nerve Damage = “Ape” Hand
Inability to Oppose Thumb

88. Clinicals

89. Wrist drop - Radial

90. Ulnar claw hand

91. Testing Ulna nerve

92. Median Claw Hand

93. Carpal Tunnel Syndrome
Entrapment of the median nerve
Phalen’s and Tinel’s Test
2 point discrimination
Symptoms
Aching in hand and arm
Nocturnal or AM paresthesias
“Shaking” to obtain relief

94. Carpal tunnel Syndrome

95. Carpal tunnel Syndrome

96. Colles’ Fracture Most common fracture in Osteoporotic bones
Extra-Articular : 1 inch of distal Radius
Results from a fall on dorsi flexed wrist
Typical deformity : Dinner Fork
Deformity is : Impaction, dorsal displacement and angulation, radial displacement and angulation and avulsion of ulnar styloid process
Management is usually conservative : MUA and forearm POP

97. Colles’ Fracture

98. Scaphoid Fractures tenuous blood supply
high incidence of avascular necrosis in waist and proximal fractures
often require bone grafting

99. Scaphoid Fracture Pathoanatomy
Blood supplied from distal pole
In children, 87% involve distal pole
In adults, 80% involve waist

100. Scaphoid Bone Fractures :Treatment by compression Screw Fixation

101. Trigger Finger Stenosing flexor tenosynovitis Painful snap or lock
Palpate nodule as digit flexed and extended

102. Boutonniere Deformity
Tear or stretch of the central extensor tendon at PIP
Note: unopposed flexion at PIP
Extension at DIP
Trauma or inflammatory arthritis

103. Swan Neck Deformity Contraction of intrinsic muscles (trauma, RA)
NOTE: Extension at PIP

104. Mallet Finger Hyperflexion injury
Ruptured terminal extensor mechanism at DIP
Incomplete extension of DIP joint or extensor lag
Treatment:
stack splint

105. Dorsal Muscle Wasting

106. Dorsal Muscle Wasting

107. Rheumatoid arthritis

108. Rheumatoid arthritis

109. Summary

110. Muscles that move the arm (humerus)
Pectoralis major Flexes, adducts and rotates arm medially.
Latissimus dorsi Extends, adducts, and rotates arm medially; draws arm downward and backward.
Deltoid Abducts, flexes, extends, and medially and laterally rotates arm.
Subscapularis Rotates arm medially.
Supraspinatus Assists deltoid muscle in abducting arm.
Infraspinatus Rotates arm laterally; adducts arm.
Teres major Extends arm; assists in adduction and medial rotation of arm.
Teres minor Rotates arm laterally; extends and adducts arm.
Coracobrachialis Flexes and adducts arm.
Systematic Anatomy
Dept of Anatomy, Medical College, Qingdao University

111. Muscles that move the forearm (radius and ulna)
Biceps brachii Flexes and supinates forearm; flexes arm.
Brachialis Flexes forearm.
Brachioradialis Flexes forearm; semisupinates and semipronates forearm.
Triceps brachii Extends forearm; extends arm.
Anconeus Extends forearm.
Pronator teres Pronates forearm and hand and flexes forearm.
Pronator quadratus Pronates forearm and hand.
Supinator Supinates forearm and hand.
Systematic Anatomy
Dept of Anatomy, Medical College, Qingdao University

112. Dept of Anatomy, Medical College, Qingdao University
Muscles that move the wrist, hand, and fingers
Flexor carpi radialis Flexes and abducts wrist.
Palmaris longus Flexes wrist.
Flexor carpi ulnaris Flexes and adducts wrist.
Flexor digitorum superficialis Flexes middle phalanges of each
finger.
Flexor digitorum profundus Flexes distal phalanges of each
Flexor pollicis longus Flexes thumb.
Extensor carpi radialis longus Extends and abducts wrist.
Extensor carpi radialis brevis Extends and abducts wrist.
Extensor digitorum Extends phalanges.
Extensor digiti minimi Extends little finger.
Extensor carpi ulnaris Extends and adducts wrist.
Abductor pollicis longus Extends thumb & abducts wrist.
Extensor pollicis brevis Extends thumb & abducts wrist.
Extensor indicis Extends index finger.
Systematic Anatomy
Dept of Anatomy, Medical College, Qingdao University

113. Muscles that move the fingers
Abductor pollicis brevis Abducts thumb.
Flexor pollicis brevis Flexes and adducts thumb.
Opponens pollicis Draws thumb across palm to meet little finger
(opposition).
Adductor pollicis Adducts thumb.
Abductor digiti minimi Abducts little finger.
Flexor digiti minimi Flexes little finger.
Opponens digiti minimi Draws little finger across palm to meet thumb.
Lumbricals Extends interphalangeal joints and flexes
metacarpophalangeal joints.
Dorsal interossei Abducts fingers from middle finger; flexes
metacarpophalangeal joints; and extends
interphalangeal joints.
Palmar interossei Adducts fingers toward middle finger; flexes
Systematic Anatomy
Dept of Anatomy, Medical College, Qingdao University