Wrist and Hand

1. Wrist and Hand 山东大学医学院 解剖教研室 李振华

2. Surface anatomy of wrist and hand Anatomical “snuff box” 鼻烟壶 • Medial: tendon of the extensor pollicis longs • Lateral: tendons of the abductor pollicis longus and extensor pollicis brevis • Proximal: styloid process of radius • Floor: scaphoid and trapezium bones • Radial a. crosses the floor of the snuff, so may fell the radial pulse in this fossa

3. Anatomical “snuff box”

4. Deep fascia of the wrist • Palmar carpal ligament 腕掌侧韧带 • Flexor retinaculum 屈肌支持带 • Thickening of deep fascia in the hand • Attached laterally to scaphoid and trapezium and medially to pisiform and hamate • Ulnar carpal canal 腕尺侧管 • Formed by the distal part of palmar carpal ligament and flexor reticulum • Transmit the ulnar a., v. and n. • Radial carpal canal 腕桡侧管 • The radial end of flexor reticulum is attached to the tubercles of scaphoid and trapezium • Transmit tendon of flexor carpi radialis

5. ★Carpal tunnel • Composition:Formed by flexor retinaculumand carpal groove • Structures passing through the carpal tunnel • Median n. • The tendons of flexor digitorum superficialis and flexor digitorum profundus enclosed by common flexor synovial sheath • The tendon of flexor pollicis longus enclosed by synovial sheath for flexor pollicis longus

6. Common flexor synovial sheath Carpal tunnel Synovial sheath for flexor pollicis longus

7. Carpal tunnel Tendons of flexor digitorum superficialis Median n. Tendons offlexor digitorum profundus common flexor synovial sheath Tendon of flexor pollicis longus enclosed by synovial sheath for flexor pollicis longus

9. Posterior region of wrist 腕后区 Extensor retinaculum伸肌支持带 • Thickening of deep fascia of forearm a wrist • Attached laterally to radius and medially to styloid process of ulna and triquetral bone • Forms six fibrous compartments for extensor tendons passing from forearm into hand

10. Posterior region of wrist 腕后区 ① tendons of abductor pollicis longus and extensor pollicis brevis and their synovial sheaths; ② tendons of extensor carpi radialis longus and brevis and their synovial sheaths; ③ tendon of extensor pollicis longus and its synovial sheath; ④ tendons of extensor digitorum, extensor indicis and their synovial sheaths; ⑤ tendon of extensor digiti minimi and its synovial sheaths; ⑥ tendon of extensor carpi ulnaris and its synovial sheaths

11. Palm of hand 手掌 Deep fascia of the palm • Superficial layer • Thenar fascia 鱼际筋膜 • Hypothenar fascia 小鱼际筋膜 • Palmar aponeurosis 掌腱膜thick triangular membrane • Deep layer • palmar interosseous fascia 骨间掌侧筋膜

12. Adductor pollicis Osseofascial compartments of palm 手掌骨筋膜鞘 • Lateral compartment外侧鞘 • Medial compartment内侧鞘 • Intermediate compartment中间鞘 Laeral intermuscular septum Medialintermuscular septum Palmar aponeurosis Thenar fascia Hypothenar fascia Palmar interosseous fascia

13. Intermediate compartment 中间鞘 • Boundaries • Palmar aponeurosis • Laeral and medial intermuscular septum • Palmar interosseous fascia • Contents • superficial palmar arch, a., v.,n. • tendons of flexor digitorum superficialis and profundus • Lumbricales • common flexor sheath

14. Fascia spaces 筋膜间隙 • Thenar space 鱼际间隙: located between the fascia of the adductor pollicis and flexor tendon of the index finger. • Proximal: blind • Distally: continuous with the back of the index finger by the fist lumbrical canal • Midpalmar space掌中间隙: lies posterior to common flexor sheath • Proximal: continous with the posterior space of the antebrachial flexor through the carpl canal • Distally: continuous with the appropriate lumbrical canals Palmar intermediate septum Thenarspace Midpalmar space

15. Muscles of hand • Lateral group－thenar (4) • Medial group－hypothenar (3) • Intermedial group • Lumbricals 蚓状肌(4) • Palmar interossei 骨间掌侧肌 (3) • Dorsal interossei 骨间背侧肌(4)

16. Muscles of hand • Lateral group－thenar鱼际(4) • Abductor pollicis brevis拇短展肌 • Flexor pollicis brevis 拇短屈肌 • Opponens pollicis 拇对掌肌 • Adductor pollicis 拇收肌 • Action: flex, abduct, adduct and oppose thumb • Nerve supply: median n. except adductor pollicis which is supplied by ulnar n.

17. Muscles of hand • Medial group－hypothenar 小鱼际(3) • Abductor digiti minimi 小指展肌 • Flexor digiti minimi brevis 小指短屈肌 • Opponens digiti minimi 小指对掌肌 • Action: flex, abduct , and oppose little finger • Nerve supply: ulnar n.

18. Muscles of hand Intermedial group • Lumbricals 蚓状肌(4) • Action: flex fingers at MP joints; extend fingers at IP joints • Nerve supply: first two lumbricals supplied by median n., and 3rd and 4th lumbricals supplied by ulnar n.

19. Muscles of hand Intermedial group • Palmar interossei(3)骨间掌侧肌 • adduct fingers towards middle finger at MP joints • Dorsal interossei (4)骨间背侧肌 • abduct fingers away from middle finger at MP joints • Nerve supply: ulnar n.

20. Arteries of upper limb Superficial palmar arch掌浅弓 • Formed by ulnar artery and superficial palmar branch of radial artery • The curve of arch lies across the palm, level with the distal border of fully extended thumb • Gives rise to three common palmar digital arteries each then divides into two proper palmar digital arteries

21. Arteries of upper limb Deep palmar arch掌深弓 • Formed by radial artery and deep palmar branch of ulnar artery • The curve of arch lies across upper part of palmar at level with proximal border of extended thumb • Gives rise to three palmar metacarpal arteries to joint the distal ends of the corresponding common palmar digital arteries

22. Nerves of hand • Median n. 正中神经 • Muscular branches: supply thenar except adductor pollicis, first two lumbricales • Cutaneus branches: supply skin of thenar, central part of palm, palmar aspect of radial three and one-half fingers, including middle and distal fingers on dorsum Recurrent branch

23. Nerves of hand • Ulnar n.尺神经 • Muscular branches supply hypothenar muscles, interossei, 3rd and 4th lumbricales and adductor pollicis • Cutaneus branches supply skin of hypothenar, palmar surface of ulnar one and one-half fingers, ulnar half of dorsum of hand, posterior aspect of ulnar two and one-half fingers • Radial n. 桡神经 • Skin of radial side of dorsum of hand • Posterior aspect of radial two and one-half fingers

24. Dorsum of hand手背 Fascia of the dorsal hand • The superficial fascia • Dorsal venous rete of hand • Superficial lymph vessels • Superficial branches of radial n. and doesal branch of ulnar n. • Deep fascia－the dorsal fascia of hand • Superficial layer--dorsal aponeurosis 手背腱膜 • Deep layer--dorsal interosseous fascia 骨间背侧筋膜

25. Dorsum of hand手背 Two spaces • The dorsal subcutaneous space 手背皮下间隙 • The dorsal subaponeurotic space 手背腱膜下间隙 Dorsalsubaponeurotic space Superficial fascia Dorsal aponeurosis Dorsal subcutaneous space Dorsal interosseous fascia

26. Fingers手指 Pulp space of the fingers 指髓间隙 • The deep fascia of the pulp of each finger fuses with the periosteum of the terminal phalanx just distal to the insertion of the long flexor tendons and closes off a facial compartment known as the pulp space. • Each pulp space is subdivided by the presence of numerous septa, which pass from the deep fascia to the periosteum. • Through the pulp space, which is filled with fat, runs the terminal branches of the digital artery that supplies the diaphysis of the terminal phalanx.. • The pulp space is limited proximally by the firm adherence of skin and the distal flexion crease to the underlying tissue; this prevents pulp infection from spreading proximally along the finger.

27. Fingers 手指 • Vessels • Proper palmar digital a. • Nerves： • Proper palmar digital n.