بسم الله الرحمن الرحيم

1. بسم الله الرحمن الرحيم

2. THE HAND

3. THE SKELETON OF THE HAND • The skeleton of the hand is subdivided into three segments: the carpus, metacarpus and phalanges. • The carpus: Eight carpal bones made up of two rows of four. 1- Proximal row: Scaphoid, Lunate,Triquetral, Pisiform. 2- Distal row: Trapezium, Trapezoid, Capitate and Hamate.

5. Cutaneous nerve supply Palm of the hand: • Cutaneous branches of median nerve (lateral 2/3 of palm and lateral 3 ½ fingers) • Cutaneous branches of ulnar nerve (medial 1/3 of palm and medial 1 ½ fingers)

6. Cutaneous nerve supply Dorsum of the hand: • Cutaneous branches of radial nerve (lateral 2/3 and lateral 3 ½ fingers except the nail bed and adjacent skin by median nerve.) • Cutaneous branches of ulnar nerve (medial 1/3 and medial 1 ½ fingers).

7. Flexor Retinaculum • It is a thick and strong fibrous band that bridges over the carpal groove (made by carpal bones). • It converts the carpal groove into an osseo-fibrous tunnel (carpal tunnel). • The retinaculum is attached medially to pisiform and hamate, while laterally is attached to scaphoid and trapezium.

11. Structures superficial to flexor retinaculum: • Ulnar nerve. • Ulnar vessels. • Palmar cutaneous branch of mediannerve. • Cutaneous branch of radial nerve. • Tendon of palamarislongus.

12. Structures deep to the flexor retinaculum: • Median nerve. • Tendons of flexors of the forearm that insert into the hand with their synovial sheaths: a. Flexor carpi radialis. b. Flexor digitorumprofundus. c. Flexor digitorumsuperficialis. d. Flexor pollicislongus.

13. Palmar aponeurosis • It is a triangular thickening of the deep fascia of the palm. • Its apex is directs upwards while the base is divided into 4 slips; each for each of the medial 4 fingers. Function: • Protection of the underlying vessels and nerves of the palm of the hand. 

14. Muscles of the hand Thenar and hypothenarmuscles. -Abductor digitiminimi. -Flexor digitiminimi. -Opponensdigitiminimi. 1-Hypothenar group:

15. 2-Thenar group: • They are 4 muscles : 1,2,3- Muscles of thenar eminence (abductor pollicisbrevis, flexor pollicisbrevis and opponenspollicis). 4-Adductor pollicis.

16. 4-Adductor pollicis Origin. a-Transverse head. Third metacarpal bone b-Oblique head. Bases of 2nd , 3rd metacarpal bones

18. Nerve supply -Hypothenar muscles and adductor pollicis: Deep branch of ulnar nerve. -Other thenar muscles: Median nerve

19. Palmaris brevis Origin: Medial border of palmar aponeurosis. Insertion: Into the skin of the medial border of the hand. Nerve supply:Superficial branch of the ulnar nerve. Action: It deepens the hollow of the palm to make a firmer grip.

20. Central Muscles Of The Hand Interossei PalmarInterossei Dorsal Interossei Lumbricals

21. Palmar Interossei 2nd : Originmedial side of the 2nd metacarpal Insertion:medial side of the extensor expansion of the index finger. 3rd, 4th; Origin lateral side of the 4th and 5th metacarpals Insertionlateral side of the extensor expansion of ring and little fingers

22. Palmar Interossei Nerve supply: deep branch of ulnar nerve Action: Flexion of metacarpo- phalageal joint of index, ring and little fingers Adduction ofthe thumb , index, ring little fingers towards the midline of the hand

23. Dorsal Interossei 4 slender fleshy muscles each arises by 2 heads from the metacarpal bone Origin: 1st : mtcpl I II 2nd II III 3rd III IV 4th IV V

24. 1st dorsal interosseous muscle

25. Dorsal Interossei Insertion : -Extensor expansions Nerve supply: deep branch of ulnar nerve. Action: -Abduction of index, middle, and ring fingers towards the midline of the hand. -Flexion of the metacarpo- phalangeal joints and extensionof interphalangealjoints of lateral four fingers (writing position).

26. Central Muscles Of The Hand Lumbrical muscles 4 fleshy slender muscles originating as follows: 1st and 2ndfrom the lateral side of the tendons of flexor digitorumprofundus for index and middle fingers respectively. 3rdfrom the adjacent sides of the tendons of flexor digitorumprofundus for middle and ring fingers. 4rdfrom the adjacent sides of the tendons of flexor digitorumprofundus for ring and little fingers.

27. Lumbricals Nerve supply: Digital branch of median nerve Deep branch of ulnar nerve

28. Central Muscles Of The Hand Lumbricals Action: Flexion of metacrpo –phalngeal joint Extension of inter-phalngeal joint (writing position)

29. Some Clinical Applications

30. Arteries of the hand. Radial artery They form two arches: 1- Superficial palmar arch. 2- Deep palmar arch.

31. 1-Superficial palmar arch • It lies deep to palmar aponeurosis , at the level of fully extended thumb. • Origin: mainly from ulnar artery and completed by superficial palmar branch of radial artery. It gives 4 digital arteries.

32. 2-Deep palmar arch • -It lies 3 cm proximal to the superficial palmar arch. • Origin: mainly from radial artery, completed by deep branch of ulnar artery. • Branches: palmar metacarpal arteries. • Branches of radial artery: • 1-Dorsal arch: formed by radial and ulnar arteries, on dorsum of hand. • 2-Princeps pollicis: from radial artery (primary supply of thumb). • 3-Radialis indicis:from radial artery, supplies radial side of index.

33. Veins of the hand 1-Superficial veins. 2-Deep veins.

35. Digital veins

36. Cephalic vein: is the lateral continuation of dorsal venous arch. • Basilicvein: is the medial continuation of dorsal venous arch. The median cubitalvein in cubitalfossa.

37. Nerves of the hand 1-Median nerve A-origin

39. course:-It enters the hand by passing deep to the flexor retinaculum.-It divides into medial and lateral branches.

40. Branches in the hand The 2 branches give: 1- Cutaneous branches to the skin of: Lateral 2/3 of the palm, palmar aspect of the lateral 3 1/2 fingers, the nail beds and dorsum of terminal phalanges of these fingers. 2- Muscular branches (recurrent branch): to muscles of thenar eminence and the lateral 2 lumbricals.

41. Nerve injury

42. 2-Ulnar nerve A-Origin

43. B-course: - It enters the hand by passing superficial to the flexor retinaculum. - It divides into superficial and deep branches.

44. Branches in the hand 1-Superficial branch : • It givescutaneous branches to supply the skin of medial 1/3 of palm and dorsum of the hand, & medial 11/2 fingers (palmar and dorsal aspects). • Muscular branch  palmarisbrevis. 2-Deep Branch: It gives muscular branches to all muscles of the hand EXCEPT muscles of thenar eminence and the lateral two lumbricals.

45. 3-Radial nerve A-origin

46. B-course

47. Branches in the hand • Dorsum of the hand: • -Cutaneous branches of radial nerve (lateral 2/3 and lateral 3 ½ fingers except the nail bed and adjacent skin by median nerve)

50. Thank You