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CLINICALSYMPOSIA
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VOLU\IE 22 NU,N,fBER 3 S.qPTEA,TBER-OCTOBEN-NOVEMBER.DECEMBER 1970
His parents say:"U nmanageable, clu ffi sy, destructive..."
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Whatever the terms usedto ident i f y the a t f l i c t ion , manyinvesi igators conf i rm thatR i ta l in , as an ad junc t tospec ia l educat iona l measures andspec i I i c paren ta l a t t i tudes ,he lps cont ro l the ch i ld 's hvper -a r : t i v i t v i n c r e a s e h i s v e r b a lq v L , v , L t
produc t iv i t y and a t ten t ion span,improve h is behav iour andlearn ing ab i l i t ies .. F B P - F u n c i i o n a l B e h a v i o u r P r o b l e m s
NIBD - lV in ma l Bra n Dys func t ionl \ lCD * M n ima l Cerebra l Dys func t ion
For prescribing intormatian
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CLIi\ICALSYMPOSIA
L-
C I B A
v o L U M E 2 2 N u n a n r n 3
:lllEr\11ER - ocroBER l970
NovEMBER-DECEMBER '
SURCICAL ANATOMY OF THE HAND
ErnestW. Lampe, M.D.
Skin and Subcutaneous Fascia of the Hand
Blood and Lymph Vessels
Clinical Importarice of Osseous Blood Supply
Veins
Lymph Vessels
Nerves of the Hand
Muscles of the Hand
Tendons, Vessels, and Nerves at the Wrist
Intrinsic Muscles.of the Hand
Interosseous Muscles
Lumbrical Muscles
Radial, Median, and Ulnar Nerve Lesions
Ligaments of the Hand
Tendon and Muscle Sheaths of the Hand
Subtendinous Space
Lumbrical Muscle Sheaths
Thenar and Midpalmar Sppces
Surgical Incisions
Treatment of lland Injuribs
Published solely in tlce inte{est of the medicalCIBA COMPANY LIMITED,.
DORVAL, QUE,
l. Hmold Wabom, M.D,, Editor
COPYRIGIIT I97O EY CIBA COMPANY LIMITED
PRINT'ED IN CANADA
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profession by
S U R G I C A L A N A T O M Y O F T H E H A N DWith Special Reference to Infections and Trauma
E R N E S T . w . L A M P E , M . D . ( 1 8 9 6 - 1 9 6 6 )
Eorron's Norr: Dr. Lampe, author of this masterpiece which ffrst appeared in Cr,rNrcar SyMposr.q. in195I, at the time of his death was Associate Attending Surgeon at the New York Hospital, EmeritusClinical Professor of Anatomy, Cornell University Medical College, and Visiting Surgeon at BellevueHospital. Of all the honors received by Dr. Lampe the most touching appraisal of the man was madeby his own students in dedicating their 1962 Yearbook:
"To Ernest W. Lampe, teacher, who conscientiously clariffed the intricacies of anatomy,made beautiful its relations, and taught by example, the integrity, wisdom, and kindlinessof a true physician."
Although Ernest Lampe has now departed, his
Illustrations by Fner.lx H. Nnrrrn, M. D,
Chemotherapy and better early care
have decreased the incidence of serious
infections of the hand. Still, a consider-
able number become sufficiently severe to
warrant surgery. Add to these the vastly
increased number of traumatized hands
that demand repair, and it becomes quiteevident that surgery of the hand is still an
important part of surgical therapeutics.
Other qualifications being equal, the sur-
geon with the sounder knowledge of the
surgical anatomy of the hand shouid
achieve the better end-results.
While nothing especially new is pre-
sented in th is monograph, we have
attempted to emphasize, by figures, dia-
grams, and text, certain anatomical struc-
tures and relationships, which may be
found helpful to the surgeon called upon
to treat a serious tendon-sheath-space
infection or a badly lacerated hand.
SKIN AND SUBCUTANEOUS FASCIA
OF THE HAND
Figures I,2,3, and 25 demonstrate the
important structural difierences between
the subcutaneous tissue of the palm and
that of the dorsum of the hand.
66
work will live to benefft many future generations.
In the palm, innumerable minute, but
strong, fibrous fasciculi extend from the
palmar aponeurosis to the skin. Thesehold the skin close to the underlying pal-mar aponeurosis , permi t t ing compar-atively little sliding movement of oneupon the other. Also, these thread-likefibrous strands divide the subcutaneousfat into small, irregular masses. Numer-ous, minute blood vessels pass throughthis subcutaneous tissue to the derma.
Clinically, it is important to rememberthe relationship of the fibrous fasciculi to
the skin, fat, and blood vessels.InDupuy-
tren s contracture,hypertrophy and hyper-
plasia of this fibrous tissue result in ulti-
mate displacement of the fat masses and
partial obliteration of the blood vessels,thereby interfering markedly with the
nutrition of the skin. Obviously, this pointsto the wisdom of early surgical excision
of the palmar aponeurosis in Dupuytren's
contracture.
Contrast the tight relationship of the
palmar aponeurosis, subcutaneous tissue,
and skin of the palm with the looseness of
these structures on the dorsum of the
hand! Figures 3 and 25 show the loose-
ness of areolar tissue which creates the
so-called dorsal subcu
This tissue is so lar
skin grasped betweerindex finger can be elemeters off the under\
fact, it is so loose thatarated readily from 1
blunt dissection - qrthe palm where this m
sharp dissection. Thesory nerves, veins, andthis loose areolar layrin Figure 3.
It is important to erof the lymph from thrthe fingers, web-areathenar eminences florlymph channels andthe loose areolar laye:the hand (see pages i
This anatomic facl
marked lymphedema
quently seen on the bawhen the focus of inftmar aspect of the finge
thenar or thenar areaunwitting one mistake
of such a swollen hanrfinds lymphedema insl
Dorsal Deep Fascia
On the dorsum of Ifascia and extensor tethe roof for Ihe dorspace (Figures 3, 17, Jbarrier formed by thrand interosseous musc
of flow and locationthis space is not very Iin hand infections. Mrlitis and direct penetrby a sharp, contaminecauses for those rare arfound in this space.
C L I N I C A L S Y M P O IC I B A
so-called dorsal subcutaneous space.This tissue is so lax that a fold of the
skin grasped between one's thumb andindex finger can be elevated several centi-meters ofi the underlying deep fascia. Infact, it is so loose that the skin can be sep-arated readily from the deep fascia byblunt dissection - quite difierent fromthe palm where this must be done by verysharp dissection. The course of the sen-sory nerves, veins, and lymphatics throughthis loose areolar layer is clearly shownin Figure 3.
It is important to emphasize that mostof the lymph from the palmar aspects ofthe fingers, web-areas, hypothenar andthenar eminences fows into myriads oflymph channels and lacunae located inthe loose areolar layer on the dorsum ofthe hand (see pages 76 and 80).
This anatomic fact accounts for themarked lymphedematous swelling fre-quently seen on the back of the hand evenwhen the focus of infection is on the pal-mar aspect of the finger, web-space, hypo-thenar or thenar area. Occasionally, theunwitting one mistakenly incises the backof such a swollen hand and to his dismayfinds lymphedema instead of pus.
Dorsal Deep Fascia
On the dorsum of the hand, the deepfascia and extensor tendons fuse to formthe roof for the dorsal subaponeuroticspace (Figures 3, 17, 25). Because of thebarrier formed by the metacarpal bonesand interosseous muscles and the mannerof flow and location of the lymphatics,this space is not very frequently involvedin hand infections. Metacarpal osteomye-litis and direct penetration of the spaceby a sharp, contaminated instrument arecauses for those rare accumulations of pusfound in this space,
C L I N I C A L S Y M P O S I A
Palmar Deep Fascia
Figures I and 2 show the intimate con-tact of the deep fascia to the thenar andhypothenar groups of muscles. This rela-tionship prevents formation of a spaceover these muscles within which pus mayaccumulate.
The central, triangular-shaped part ofthe palmar aponeurosis has several ana-tomical features worthy of mention. InDupuytrens contracture, the clinical sig-nificance of its attachment to the dermaand its relationship to the subcutaneousfat and blood vessels have already beenmentioned. Figures on page 73 show thatthe proximal end is continuous with thetendon of the palmaris longus muscle. Itis this attachment that enables the pal-maris longus muscle to assist in flexion ofthe hand.
Figures I, 2, 4, and 25 demonstrate theprotective thickness of the central tri-angular part and also the manner of itsfusion medially and laterally with thedeep fascia covering the hypothenar andthenar muscles, respectively. An under-standing of this relationship helps onerealize why the great majority of handinfections, excluding fingers, are found inthe hollow of the palm between or distalto the hypothenar and thenar eminences.
At the base of the aponeurotic triangle,the interlacing fasciculi of the superficialtransverse metacarpal ligament add pro-tection to the underlying digital vesselsand nerves (Figure 2). Fasciculi extendto the proximal phalanges to fuse with thefibrous annular tendon sheath on its pal-mar, medial, and lateral aspects. Theseinsertions enable the palmaris longusmuscle to help in flexing the proximalphalanges.
In the distal part of the palm, septa
67
extend from the deep aspect of the palmar
aponeurosis to the deep transverse palmar
ligament forming the sides of annular
fibrous canals for the passage of the
ensheathed flexor tendons and lumbrical
muscles as well as blood vessels and
nerves ( Figures 4, 5, 25).
The semidiagrammatic cross section on
page 89 shows a septum extending from
the palmar aponeurosis to the third meta-
carpal. Frequently, but not always, this
septum separates the thenar space or
bursa from the midpalmar space or bursa.
The beginnings of the other less well-
developed septa are also shown in this
figure. Since this section is proximal to
the deep transverse metacarpal ligament,
located at the distal ends of the metacar-
pal bones, these septa appear unattached
on their deep aspect. However, iust distal
to the ends of the midpalmar and thenar
spaces, they are actually attached to thedeep transverse metacarpal ligament.
BLOOD AND LYMPH }'ESSELS
Figures 4, 6, and 7 show how the radialand ulnar arteries terminate by dividinginto superficial and deep branches. Theformer anastomose in the palm to formthe superficial palmar arterial arch, thelatter to form the deep arch.
A line drawn across the palm at the levelof the distal border of the fully abductedthumb marks the approximate location ofthe superffcial arterial arch. This is shownas a broken line in Figure 6. The deeparch is a ftnger's breadth proximal.
The pulsation of the ulnar artery canusually be felt just lateral to the pisiformbone. Immediately distal to this pointthe artery divides into its larger branchwhich forms most of the superficialarch and the smaller branch which forms
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the lesser part of the deep palmar arch.
Just proximal to the pisiform bone theulnar artery gives ofi volar and dorsal car-pal branches which unite with the volarand dorsal branches of the radial artery toform the arterial wristlet about the car-pal bones. Perforating branches passingbetween the proximal ends of the middlemetacarpal bones connect the deep pal-mar arch with the dorsal carpal arch, asshown in Figure 17. The latter sends smallbranches to the phalanges.
The pulsation of the radial artery is usu-ally palpated near the proximal volarcarpal skin crease. Here the superficialbranch arises to continue distally over orthrough the thenar eminence to the palmto complete the formation of the super-ffcial palmar arterial arch (Figures onpage 7B).
The much larger, deep radial branch,whose pulsat ions can be fel t in theanatomical snuffbox, Figures 17 and 20,passes under the "snuffbox" tendons andplunges between the two heads of the firstdorsal interosseous muscle to reach thepalm where it forms the greater part ofthe deep palmar arch, Figure 6.
It is to be remembered that the super-ftcial arterial arch is much larger andmore important than the deep arch.
The superficial arch gives ofi digitalbranches which bifurcate into phalangealbranches about a ffnger's breadth proxi-mal to the web-border of the hand, Fig-ures 6 and 7. The superficial arch and itsdigital branches are immediately deep tothe tough central part of the palmaraponeurosis and are superftcial to thebranches of the median and ulnar nerves.This relationship to the nerves is reversedin the fingers ( Figures 6,7 , 16) .
As shown in Figure 6, the rnetacarpalbranches of. the deep arch empty into the
digital branches of. tjust proximal to their
phalangeal arteries,
CLINICAL IMPORTA
BLOOD S'
The lunate bonemost frequently dislor
pal bones. Therefore,remember a few poi:supply. As shown in lfrom the dorsal and rreach the bone via iligaments from the rasurvive only if one li1
good results can bereduction is efiected.atrophic necrosis is tlments have been rup
Since the naoicularmost frequently fractbones, it is importantabout two-thirds of tvessels are evenly enrexpect survival of b<some chance for unio:third, however, so malsels are located neareother that necrosis ismeagerly supplied fra
A felon may cause rend of the terminal pJbiotics and supportiveistered very early, edtcause thrombosis of srbranches of the digitrinterfere sufficiently Iply of the bony tuft 1eventuate in its necromatically shows thesepta in the palmar 1phalanx - especially :terminal vessels are fo
C L I N I C A L S Y M P OC I B A
l
di,gi.tal branches of the superficinl arch
just proximal to their bifurcation into the
phalangeal arteries.
CLINICAL IMPORTANCE OF OSSEOUS
BLOOD SUPPLY
The lunate bone (semilunar) is the
most frequently dislocated of all the car-
pal bones. Therefore, it is important to
remember a few points about its blood
supply. As shown in Figure I0, branches
from the dorsal and volar carpal arteries
reach the bone via its dorsal and volar
ligaments from the radius. The bone can
survive only if one ligament is torn, and
good results can be expected if early
reduction is efiected. On the other hand,
atrophic necrosis is the rule if both liga-
ments have been ruptured (Figure 12 ).Since the nnrsicular (scaphoid ) is the
most frequently fractured of the carpal
bones, it is important to remember that in
about two-thirds of the cases the blood
vessels are evenly enough distributed to
expect survival of both fragments with
some chance for union. In the remaining
third, however, so many of the blood ves-
sels are located nearer one end than the
other that necrosis is apt to occur in the
meagerly supplied fragment ( Figure t3 ).A felon may cause necrosis of the distal
end of the terminal phalanx. Unless anti-
biotics and supportive therapy are admin-
istered very early, edema and toxins will
cause thrombosis of some of the terminal
branches of the digital arteries and thus
interfere sufficiently with the blood sup-
ply of the bony tuft (Figures 14, 16 ) to
eventuate in its necrosis. Figure 15 sche-
matically shows the numerous fibrous
septa in the palmar part of the terminal
phalanx - especially its distal half. The
terminal vessels are found in these irregu-
C L I N I C A L S Y M P O S I A
Iarly formed expansionless compartments.
It does not require much edema and toxin
to cause early thrombosis with subse-
quent necrosis of the tuft of the phalanx.
VEINS
The hand, like the remainder of the
upper extremity, is drained by two sets of
veins: a superficial group located on the
superficial fascia and a deep set associ-
ated with the arteries. These are illus-
trated in Figures 3, 4, 8, and 9.
The superficial oenous systern is the
more important of the two sets because it
is the larger, and most of the ffnger and
hand lymphatics accompany its tribu-
taries (Figures 3, 8, 9 ). A few small veins
are found in the tight superficial or sub-
cutaneous fascia of the palm and palmar
aspects of the fingers. However, they com-
pare neither in size nor number with those
located in the loose areolar subcutaneous
tissue of the dorsum of the hand and
fingers. While Figure 3 ofiers an idea of
the venous arrangement on the dorsum of
the hand, one needs but hang the hand at
the side for a moment to demonstrate
quite clearly the dorsal venous arch. This
arch receives digital veins from the fingers
and frequently becomes continuous with
the cephalic and basilic veins on the
radial and ulnar borders of the wrist. A
glance at the volar aspect not uncom-
monly reveals the distal end of the median
antebrachial vein near the carpal creases,
where it receives the few, small and usu-
ally invisible, superficial palrnar veins.
The above-mentioned veins - cephalic,
basilic, and medtan antebrachi.al - con-
tinue proximad; and they, with their trib-
utaries, make up the superficial venous
drainage of the upper extremity.
The deep oenous return is not difficult
69
to review if one recalls that the very small
digital veins, helping to drain the fingers,
empty into small superficial and deep
venous arches associated respect ive ly
with the superficial and deep arterial
arches, Figures 4 and 6. These two venous
arches help form the venae comites which
accompany the radial and ulnar arteries;
and they, with their tributaries, make up
the deep venous drainage of the forearm.
At the elbow the radial and ulnar venae
comites unite to form the venae comites
of the brachial artery, and they in turn
unite with the basilic vein at the pectoralfold to form the axillary vein.
In the hand, forearm, and arm the
superficial and deep sets of veins anasto-
mose with each other by means of a
variable number of communicating or
perforating veins.
LYMPII IIESSELS
If one knows the venous drainage of the
hand, one can easily visualize the lymph
drainage because, generally speaking, the
lymph vessels follow the veins, having
originated from the same mesenchymal
tissue. This implies the presence of a
superficial and deep set of lymph vessels
corresponding to the superficial and deep
sets of veins.
S up erfici.al LV "rph
Y e s s els
While some of the proximal phalangeal
and web-area lymph vessels proceed
palmward, most of them head for the dor-
sum of the fingers and hand (Figure 9).
Most of the lymph from the thenar and
hypothenar areas fows toward the vessels
and lacunae in the subcutaneous loose
areolar tissue - the so-called dorsal sub-
cutaneous space. This should remind one
again of the reason for the frequent swell-
70
ing (lymphedema) of the dorsum of the
hand in the presence of an infection onthe palmar aspect of a finger, web-area,
or edge of the thenar or hypothenar
eminence.
Most of the lymph from the dorsumleaves via lymph vessels accompanyingthe cephalic and basilic veins. This is
shown by the black arrows in Figure 3. In
theory at least, bacteria or tumor cellsfrom a focus on the thumb or index finger
have easier access to the thoracic ducts,since they tend to follow the cephalicvein. The lymph gland in the deltopec-toral triangle is the first sizable node
encountered by the lymph channels fol-lowing this vein. Contrast this relatively
gland-free pathway with the gland-studded route along the basilic and axil-
lary veins (Figure 8).
Deep LymphVessels
Figure 9 shows schematically how most
of the central palmar lymph vessels pro-ceed deeply to join the lymph vessels
associated with the superficial and deep
venous arches. From here lymph channels
follow the venae comites of the radial and
ulnar arteries.
NERVES OF THE IIAND
The median, ulnar, and radial nerves
furnish most of the motor and sensory con-
trol of the hand. The dorsal antebrachial
cutaneous and lateral antebrachial cuta-
neous nerves assist variably in supplying
sensory nerves.
Motor Neraes
The intrinsic muscles of the hand are
controlled by the ulnar and median nerves
(Figures 5, 6,'1 ,30 ). Since these muscles
are not the sole manipulators of the hand,
the radial nerve, whiching the extrinsic musclconsidered.
Ordinarily, the musclor volar-medial aspect creferred to as the volaand those on the posteriside as the dorsal groutell nothing more than t
It might be even mor,functional names werebecause they would alwwhat these important nFor example: It is kno'rof the hand (flexors culnaris ), Figures 21 andfingers (flexors digitorrprofundus), Figure 24; r(pronators radii teres ar:located in this so-callermuscles. Would it not brtical to think of the grrpronetor group-anamein a general way what t
The same applies to tlmuscles consisting of thrhand (extensors carpi rabrevis and extensor carp26; the extensors of thlanges and assistant rmiddle phalanges (extrcommunis, indicis prolquinti proprius); the extrtor of thumb (extensors 1longus and abductor pollures 20 and,26r and ffnisupinator of the forea:muscle (the supinator nto as the assistant suoinbiceps muscle, suppliedcutaneous nerve, is the ntant supinator), Therefcthe whole dorsal forearrcles the extensor-assistan
C L I N I C A L S Y M P O S IC I B A
the radial nerve, which assists in supply-ing the extrinsic muscles, must also beconsidered.
Ordinarily, the muscles of the anterioror volar-medial aspect of the forearm arereferred to as the volar forearm group,and those on the posterior or dorsolateralside as the dorsal group - names whichtell nothing more than their location.
It might be even more helpful if broadfunctional names were applied to thembecause they would always remind one ofwhat these important muscle groups do.For example: It is kno'rn that the fexorsof the hand (fexors carpi radialis andulnaris), Figures 21 and 28; flexors of thefingers (flexors digitorum sublimis andprofundus), Figure 24; and the pronators(pronators radii teres and quadratus) arelocated in this so-called volar group ofmuscles. Would it not be a bit more orac-tical to think of the group as the nu*or-pronator group-a name which would tellin a general way what these muscles do?
The same applies to the dorsal group ofmuscles consisting of the extensors of thehand (extensors carpi radialis longus andbrevis and extensor carpi ulnaris), Figure26; the extensors of the proximal pha-langes and assistant extensors of themiddle phalanges (extensors digitorumcommunis, indicis proprius, and digitiquinti proprius); the extensors and abduc-tor of thumb (extensors pollicis brevis andlongus and abductor pollicis longus ), Fig-ures 20 and 26; and finally, the assistantsupinator of the forearm or supinatormuscle (the supinator muscle is referredto as the assistant supinator because thebiceps muscle, supplied by the musculo-cutaneous nerve, is the much more imDor-tant supinator ), Therefore, why not callthe whole dorsal forearm group of mus-cles the extensor-assistant supinator group
C L I N I C A L S Y M P O S I A
- supplied by the extensor-assistant supi-nator nerve - the functional name for theradial nerceP
In his first course in surgical diagnosis,the junior medical student learns that theusual test for ulnar neroe palsy is tospread and approximate the fingers; andthe more common test for median nerzepalsy is to approximate successively thetip of the thumb to the tips of the fingers.
The ulnar nerve controls certain mus-cles which flex the hand and fingers(flexor carpi ulnaris and the ulnar half ofthe flexor digitorum profundus ) as well asthe intrinsic muscles of the hand exceptthose in the thenar eminence and twoadjacent lumbrical muscles.
Since the interosseous muscles whichspread and approximate the fingers areexclusively controlled by the ulnar nerve,this action of the interossei can serve as atest of ulnar nerve function. If the nerveis damaged, one will have difficulty inholding a piece of paper between adja-cent fingers which are fully extended.Thus, the action of these muscles gives tothe ulnar nerve a logical functionalname:the finger -spreader-approximnt or nerle.
The median nerve controls the wholeflexor-pronator group except one and one-half muscles ( the ulnar nerve controlsonly the flexor carpi ulnaris and ulnar halfof the flexor digitorum profundus), andbecause the median nerve innervates theIateral two lumbrical muscles and thethenar eminence muscles whose opponensmuscle is fhe important muscle in approx-imating the thumb-tip successively to thefinger tips, it seems reasonable to givethe median nerDe a functional nu*",1h"
flexor - pron&tor - thumb - finger - approxi-rnator nerDe - a rather long name, but itsummarizes the chief motor r6le of themedian nerve.
7T
Sensory Nenses
Figure 18 shows diagrammatically a
palmar view of the hand with the median
nerae stpplying the median or central
palmar area and the palmar surfaces of
the lateral three and one-half fingers; Fig-
ure 19, a dorsal view, charts the mediannerve distribution to the dorsum of the
distal two phalanges of the lateral three
and one-half fingers.
Note how the ulnnr neroe supplies sen-sory nerves to the volar and dorsal aspects
of the medial third of the hand and the
volar and dorsal aspects of the medial one
and one-half f ingers, Figures 3,7,17, 18,
and 19.
The radfuI nen)e co\veys sensation from
the lateral two-thirds of the dorsum of thehand and a portion of the thenar emi-nence area, as well as from the dorsum ofthe proximal phalanges of the lateral threeand one-half fingers.
Variations of the sensory distribution ofthe above three nerves are quite common.For example, on the palmar surface, themedian nerve may supply only the centralthird of the palm and the skin of two andone-half fingers, with the ulnar nerve
innervating the medial half of the palm
and two and one-half ffngers. Further-
more, the lateral antebrachial cutaneous(volar branch of musculocutaneous) occa-
sionally extends its control as far as the
web-area of the thumb, index, and middle
fingers. On the dorsum, the ulnar nerve
may give sensory nerves to the medialhalf of the dorsum of the hand as well asto the dorsum of two and one-half ffngers.
This leaves the radial nerve offering sen-sory nerves to only the lateral half of thedorsum of the hand and proximal pha-langes of two and one-half fingers. Occa-
sionally, the dorsal branch of the medial
72
antebrachial cutaneous nerve may extenddistally almost to the web-area betweenthe fifth, fourth, and third fingers; andsometimes the dorsal antebrachial cuta-neous nerve may reach the web-areas be-tween the second, third, and fourth fingers.
Figures 1 and 7 show the median andulnar nerves in the distal forearm givingof f thei r palmar cutaneous brancheswhich are destined to supply the skin ofthe proximal palm. The median nerve
passes under the tough transverse carpalligament and divides into (a ) three lat-eral branches - two supplying either sideof the thumb and the third to the lateralaspect of the index finger, and (b ) twomedial branches - one dividing to inner-vate adjacent surfaces of the index andmiddle finger and the other to the adia-cent aspects of the third and fourth fingers.
It is of considerable clinical importanceto remember that the main muscularbranch of the median nerve arises fromthe lateral cutaneous branch to the thumbjust distal to the transverse carpal liga-ment, Figure 7. Observe that en route tothe thenar eminence and its muscles (thefexor pollicis brevis, abductor pollicisbrevis, and opponens pollicis ) this smallbut important nerve passes over the fexor
pollicis longus tendon and its sheath, Fig-ures 4, 5, and 7. Every surgeon.openingthis sheath in a case of suppurative teno-synovitis must make certain that the prox-imal end of his thumb incision extends no
farther than the midpoint of the ftrst
metacarpal bone, thereby avoiding sec-
tion of the motor nerve to the thenar
eminence muscles (Figure 54).
From the nerves supplying the lateral
aspect of the index finger and adjacent
sides of the second and third ffngers arise
small branches respectively to the first
and second lumbrical muscles.
C I B A
CUTANEOUS BR, OFRADIAL N. TO LAT.THENAR AREA
PALMA,RBR. OF
THENAR
MOTORMEDIANTHENAR
CUTANEOUSMEDIAN N.
MUSCLES
BR.OFN. TOM.
FIGURE I
PALMAR AP(
DIGITAL AR']
SUPERFICIALMETACARPA
CUTANEOUSNERVE TO .
rnd
een
md
rta-
be-
3rs.
lnding
hes
r o f
'pal
lat-
ide
:ral
.woter-
rnd
lju-
3rs.
nce
rlar
om
mb0 2 -b*
l t o
theicis
rall
xorl io--o
ing
no-
ox-no
irstiec-
nar
CUTANEOUS BR. OF \RADIAL N. TO LAT.THENAR AREA
PALMAR CUTANEOUSBR. OF MEDIAN N.
THENAR MUSCLES
MOTOR BR.OFMEDIAN N. TOTHENAR M.
FIGURE I
PALMAR CUTANEOUS BR. OF ULNAR N.
P,A.LMARIS TONGUS TENDON
VOLAR CARPAL LIGAMENT
PISIFORM BONE
ULNAR ARTERY
HYPOTHENAR MUSCLES
PALMAR APONEUROSIS
MINUTE FASCICULI ADHERENT TO DERMA
lral
ent
:ise
irst
PALMAR APONEUROSIS
DIGITAL ARTERIES AND NERVES
SUPERFICIA,L TRANSVERSEMETACARPAL LIGAMENT
CUTANEOUS BRANCH OF ULNA,RNERVE TO 5th FINGER
FIGURE 2 iil,,,r ',4
The ulnar nerDe, shown in Figures 4,
6,7, and 30, passes lateral to the pisiform
bone, and just distally it bifurcates into
superficial and deep rami. The former,
after giving a filament to the unimportant
palmaris brevis muscle, promptly divides
into a branch to the medial aspect of the
fifth finger, a branch supplying contigu-
ous surfaces of the fifth and fourth fingers,
and finally a fine twig which unites with
the most medial branch of the median
nerve (Figure 7 ). The deep ramus of the
ulnar nerve fr-rrnishes muscular branches
to the hypothenar eminence muscles (the
abductor dig. quinti, flexor dig. quinti,
opponens dig. quinti) and to the three
volar and dorsal interosseous muscles, and
the adductor poll icis muscle (Figure 30).
The tiny branches to the third and fourth
lumbrical muscles and the deep head of
the flexor pollicis brevis muscle can be
seen,Lesions of the radial, median, and ulnar
nerves will be discussed after the muscles
have been reviewed.
MUSCLES OF THE I{AND
Muscles of the hand can be grouped as
extrinsic and intrinsic. While the muscle
bellies of the former are in the forearm,
their tendons, nevertheless, are in the
hand and play a very important part in its
movements.Supination of the hand, be it recalled,
is controlled chiefly by the biceps located
in the arm and inserted into the radial
tuberosity, assisted by the supinator mus-
cle originating from the proximal dorso-
lateral aspect of the ulna, wrapping itself
laterally around the proximal fourth of
the radius to insert on its volar aspect. As
previously mentioned, supination is con-
trolled mainiy by the musculocutaneous
n^a a
nerve supplying the powerful biceps and
assisted by the radial nerve supplying the
supinator muscle.
Pronation is controlled by the median
nerve which supplies branches to the pro-nator radii teres and pronator quadratusmuscles found respectively in the proxi-mal half and distal one-fourth of the
forearrn.
Adduction of the hand at the wrist is
produced by the combined action of the
flexor carpi ulnaris and the extensor carpi
ulnaris muscles - the former innervated
by the ulnar nerve and the latter by the
radial nerve. Figure 21 shows the ulnar
flexor tendon on its way to insert into the
pisiform, hamate, and fifth metacarpal
bones. In Figures 17 and 26, the ulnar
extensor tendon is seen proceeding to the
dorsum of the fifth metacarpal bone.
Abduction, like adduction, is efiected
by the combined action of two or more
muscles. To produce abduction, the flexorcarpi radialis contracts synergistically
with the extensors carpi, radialis longus
and brepis. Figure 21 shows the radial
flexor tendon en route to the volar aspectof the base of the second and third meta-
carpal bones. In Figures 17 and 20, the
terminal ends of the two radial extensors
are seen just before they insert into the
proximal dorsal parts of the second and
third metacarpal bones,In addition to producing abduction,
these three muscles have another impor-
tant r6le. Recall that the second and third
metacarpal bones are fixed proximally by
ligaments to each other and to the capi-
tate and lesser multangular bones of the
tran,soerse carpal arch. Distally, they arefirmly anchored to each other by the deep
tr&nsDerse metacarpal ligament. These
strong proximal and distal attachments of
the second and third metacaroal bones
mnkc them the most sl
of the hand.The extensors carpi r,
brcais insert into the do
mel end of the second a
pals; and, v'hile there
carpi ratlialis, it is vc
gains insertion into tht
the proximal ends of thr
metacarpal bones. Withit is easy to see how I
muscles, along with the
ligaments. aid in stabil i:
part of the hand, especr
extension movements o:
In many reconstructthe badly mutilated har
for the surgeon to rem
tant muscle-tendon-bor
nation. Flexion of the h
effected by the flexorsu lna r i s supp l i ed res ;
median and ulnar nerveinates from the mediadvle. the latter from th
plus the proximal three
Extension of the ha
produced by the exlen
longus and breois and
ulnari,s. 'Ihe radial efrom the lateral epiconrof the lateral epicondyJ
ext?trsor from the medmiddle half of the ulna
While the chief func,
muscles are extension
abduction and addur
together with their fel
they are also synergic
of the fingers because t
flexor efiect which t
would otherwise prodrFlexion of the fnge
produced mainly by th
C L I N I C A L S Y M P O SC I B A
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make them the most stable or fixecl partof the hand.
The extensors carpi rndialis /ongrrs andbreois insert into the dorsum of the proxi-mal end of the second and third metacar-
pals; and, rvhile there is only one flexorcarpi radialis, it is very powerful andgains insertion into the volar aspects ofthe proximal ends of the second and thirdmetacarpal bones. With this arrangement,it is easy to see how these three strongmuscles, along with the above-mentionedligaments, aid in stabilizing the most fixed
part of the hand, especially in flexion andextension movements of the fingers.
In many reconstructive procedures ofthe badly mutilated hand, it is imperativefor the surgeon to remember this impor-tant muscle-tendon-bone-ligament combi-nation. Flexion of the hand at the wrist isefiected by the flexors carpi radialis andulnar is suppl ied respect ive ly by themedian and ulnar nerves. The former orig-inates from the medial humeral enicon-dvle. the latter from the same epicondyleplus the proximal three-fifths of the ulna.
Extension of the hand at the wrist isproduced by the extensors carpi radialislongus and breois and the extensor carpiulnaris. The radial extensors originatefrom the lateral epicondyle and distal partof the lateral epicondylar ridge, the ulnarextensor from the medial epicondyle andmiddle half of the ulna.
While the chief functions of these threemuscles are extension of the hand, andabduction and adduction by workingtogether with their fellow carpal flexors,they are also synergic muscles for flexionof the fingers because they counteract theflexor effect which the digital flexorswould otherwise produce at the wrist.
Flexion of the fingers on the hand isproduced mainly by the flexors digitorum
C L I N I C A L S Y M P O S I A
sttblinils and profunclus. The assistantflexor rdle of the lumbrical ancl interosse-ons rnuscles ( flexion of proximal pha-langes) rvili be discussed in the paragraphsdealing with the intrinsic hand muscles.
The flexor cli git orum subllni,s originatesfrom the medial hr,rmeral epicondyle, thecoronoid process of ulna, and the prox-imal two-thirds of the volar rnargin of theratl ius. Proximal to the volar carpal l iga-ment, the muscle gives rise to four ten-dons inserting into the proximal thirds ofthe middle phalanges of the medial fourdigits. The vincula longa and breva giveadditional insertion into.the proximal andmiddle phalanges.
For c l in ica l reasons, the fo l lowingpoints regarding the tendons of this mus-cle deserve to be remembered:1. As is shown on pages 88 and 89, just
proximal and deep to the volar carpalligament, the third and fourth sublimistendons lie superficial to the secondand fifth tendons. This is a quite con-stant arrangement. However, in somecases the third, fourth, and fifth sub-limis tendons will be in the superficialplane with the second or index fingertendon deep to the third sublimis ten-don. Seldom are all four in one planein this region as are the flexor digi-torum profundus tendons.
2. Next, note the manner of insertion ofa sublimis tendon, Figures 5, 24, and34. The sublimis tendon first splits atthe proximal end of the first phalanxto permit passage of the profundus ten-don and then reunites, only to split asecond time to gain insertion on eachside of the proximal third of the sec-ond phalanx.
The flexor digitorum profundus origi-nates from the proximal two-thirds of theulna and the adjacent interosseous mem-
I D
RADIAL A. ANDVENAE COMITES
RADIAL BURSA
ABDUCTOR POLLICIS BREVIS
fruusvrnsrtrr*o* ,orr,.
:"sneAtH orFLEXOR
CARPAL TIG.
IS BREVISHOOK RAISING SKIN TO DEMONSTR,A,TELOOSE ATTACHMENT AND DORSALSUBCUTANEOUS SPACE
RADIAL NERVE (RAMUS SUPERFICIALIS)
CEPHALIC VEIN
POLLtCtSTONGUS
BASILIC VEIN
ULNAR NERVE (RAMUS
DoRSALTS MANUS)
DORSAL VENOUS ARCH
DORSAL DIGITAL NERVES
PROBE IN FIRSTLUMBRICALSHEATH
PALMARAPONEUROSISTURNED DOWN
FIGURE 4
DORSAL BRANCHESOF PROPER VOL,ARDIGITAL NERVES
PROBE IN THENAR SPAOR BURI
PROBE IN DORSAI EXTIOF THENAR SPACE BEIABDUCTOR POLLICIS
CRUCIATE AND ANNUL
INSERTION OF FLEXOR
INSERTION OF FLEXOR
Y r".-,",'1. :i \:.,1, riilt'
-
i ' , ' ' octs,\
RADIAL A. ,ANDVENAE COMITES
RADIAL BURSA
ABDUCTOR POLLICIS BREVIS-TRANSVERSE
CARPAT LIG.
:LEXOR POLLICIS BREVIS
.SHEATH OFFTEXORPOLLtCtSLONGUS
PROBE IN FIRSTLUMBRICALSHEATH
PALM,ARAPONEUROSISTURNED DOWN
FIGURE 4
ULNAR ARTERY AND VENAE COMITES
ULNAR BURSA
VOLAR CARPAL LIGAMENT
PISIFORM BONEP,ALMARIS LONGUS TENDONULNAR ARTERY ,AND NERVEDEEP DIVISION ULNAR NERVE ,AND ARTERY
SUPERFICI,A,L DIVISION ULNAR NERVE(SENSORY TO 4rh AND 5ih FTNGERS)
MEDTAN NERVE (D|G|TA,L SENSORY BRANCH)
ULNAR BURSA
SUPERFICIAL VOLAR ARTERIAL ANDVENOUS ARCHES
2Nd, 3rd AND 4ih LUMBRICAL MUSCLES
SEPTA
TENDONSHEATH
b';;
PROBE IN THENAR SPACEOR BURSA
PROBE IN DORSAL EXTENSIONOF THENAR SPACE BEHINDABDUCTOR POLLICIS
CRUCI,ATE AND ANNULAR LIGAMENTS
INSERTION OF FLEXOR DIG. SUBLIMIS
INSERTION OF FLEXOR DIG. PROFUNDUS
BRANCH OFMEDIAN N.TO THENARMUSCLES
ABDUCTORDIGIT V
FLEXORDIGIT V
OPPONENSDIGIT V
5th FINGERSHEATH
PROBE INMIDPALMARSPACE ORBURSA
rii'**F IGURE 5
RADIAL ARTERY
MEDIAN NERVESUPERFICIAL BRANCH OF RADIAL ARTERY
ANTERIOR CARPAL ARCH AND RETE
DEEP PALMAR ARTERIAL ,ARCH
SUPERFICIAL PALMAR ARTERIAL ARCH
lst VOLAR METACARPAL ARTERY
ULNARARTERY
ULNARNERVE
PISIFORMBONE
HOOK OFHAMATE
DEEP PALMARDrvrsroNs oF
AND NERVE
: . SUPERFICIALPALMARDIVISION OFULNAR NERVE
COMMUNI .CATIONBETWEENMEDIAN ,ANDULNAR NERVES
F IGURE 6
brane. It inserts into thrthe palmar aspect of theof the medial four di1ofier additional insertior
Figure 24 shows theprofundus as already haits four tendons. Actualhpoint it is not uncommcprofundus tendon to thethe large, distal fibrorthe remainder of the pwhich then divides aboudistad into the tendons trfourth, and fifth fingers.
Extension of the fing,produced by the combi:ertrinsi,c and intrinsic rnt
The extensor muscleand the compartment thrpass at the wrist are shThe chief extrinsic exteris the extensor digitorunextensor indicis propriusproprius assist in extenrthe index and fifth finger
The extensor digitorunnates from the lateral hurintermuscular septa, andcia. It divides into foupass through the fourthment. In this connectiormention that not uncornsor digitorum communitendons passing throughcompartment. The fourtlthe dorsum of the handfinger extensor and goesfifth finger. The extensotalso passes through this
The manner of theertensor digitorum cor,deserves special mention,the deep part of the extcommunis tendon inserti
C L I N I C A L S Y M P o S I T
-l
PROPER DIGITAL ARTERIESAND NERVES OF THUMB
DISTAT TIMIT OFSUPERFICIATARTERIAT ARCH
ULNAR ARTERY AND NERVE
RADIAL ARTERY
MEDIAN NERVE
PALMAR CUTANEOUS BRSUPERF[CIAL BRANCHOF R,ADdAL ,ARTERYABDI, 'CTOR POIL. , , : , ,BREVIS
OPPONENSPOI-LICIS ,: I
MOTOR BR..-
COMMON VOLAR DIGITAL ARTERIES AND NERVES
VOLAR METACARPAL ARTERIES{
' " l l t " " /
, b \ t l o o r
PROPER VOLAR DIGITAL fti.i*'ES AND NERVES
Kllir:t.rt;1
:::l:l;l rry- 1,ir:N|it!; i i f
O F M E D | A N " g l ,NERVE TO g"' '
VOLAR CARPAL LIGAMENT
DEEP PALM,AR DIVISIONS OF ULNAR A. AND N.SUPERFICIAL PALM,AR DIVISION OF ULNAR N.TRANSVERSE CARPAL LIGAMENTSUPERFICIAL PALMAR ARTERI,AL ARCHCOMMON VOLAR DIGIT,AL A. AND N.
COMMIJNICATNON EETWEENMEDIA.N AND ULNAR N.
PROPER VOLAR DIGITAL A. AND N.
THENAR $Mu5cLES,,;i
FLEXOR '];]:.
POLLICISI: lBREVIS .; :
PROPER DIGITALA. AND N.OF THUMB
F IGURE 7
brane. It inserts into the proximal half of
the palmar aspect of the terminal phalanxof the medial four digits. The vincula
ofier additional insertion.
Figure 24 shows the flexor digitorum
profundus as already having given rise to
its four tendons. Actually, however, at this
point it is not uncommon to see only the
profundus tendon to the index finger and
the large, distal fibromuscular part ofthe remainder of the profundus muscle,
which then divides about two centimetersdistad into the tendons going to the third,fourth, and fifth fingers.
Extension of the fingers and thumb is
produced by the combined action of theextrinsic and intrinsic muscles.
The extensor muscles, their tendons,
and the compartment through which they
pass at the wrist are shown on page 92.The chief extrinsic extensor of the fingersis the extensor digitorum commttnis. Theextensor indicis proprius and digiti quintiproprius assist in extending respectivelythe index and fifth fingers.
The extensor digi,toru.m communis origi-nates from the lateral humeral epicondyle,intermuscular septa, and antebrachial fas-cia. It divides into four tendons whichpass through the fourth dorsal compart-ment. In this connection, it is worthy ofmention that not uncommonly the exten-sor digitorum communis has only threetendons passing through the fourth dorsalcompartment. The fourth tendon arises onthe dorsum of the hand from the fourthfinger extensor and goes from there to thefifth finger. The extensor indicis propri,usalso passes through this compartment.
The manner of the insertion of theextensor digitorum communis tendonsdeserves special mention. Figure 35 showsthe deep part of the extensor digitorumcommunis tendon inserting into the dor-
C L I N I C A L S Y M P O S I A
sum of the proximal phalanx. This inser-
tion gives purchase to the muscle for the
performance of its chief functions: ( f ) toextend the proximal phalanx to extensionand hyperextension and (2) to stabilizethe proximal finger joints so that the intrin-
sic muscles (lumbricals and interossei)not only can extend the middle and distal
phalanges but are also able to give lateralmovement to the fingers.
As the extensor communis tendon con-tinues distally, it divides into three parts( shown on page 95 ). A central slip inserts
into the dorsum of the proximal end of themiddle phalanx. Two lateral tendinousslips unite with the tendons of the lum-brical and interosseous muscles and con-tinue distally to the proximal end of thedorsum of the terminal phalanx for inser-tion. Despite the insertions of the extensordigitorum communis into the middle andterminal phalanges, th is muscle canextend these two phalanges only veryslightly, if at all, when the proximal pha-langes are in extension. This occurs
because so much of each of the extensor
digitorum communis tendons is insertedinto the dorsum of the proximal phalangesthat when the muscle contracts, most ofits power is concentrated in extending the
proximal phalanges.Furthermore, this firm anchoring of the
tendons to the proximal phalanges per-mits but little extension of the middle andterminal phalanges by the extensor com-
_ munis when the proximal phalanges arein the extended position. The arrows on
page 95 show how the tendons of thelumbr ica l muscles and interosseoLrs
muscles, especially the volar interossei,inserted into the lateral slips of the exten-sor digitorum communis, are able to domost of the extending of the middle andterminal phalanges when the proximal
79
_, _ |
L Y M P H A T I C D R A I N A G E phalanges are extendechanges, however, as sordigitorum communis rrto permit the flexors diand profundus to begin 1and terminal phalangesthis causes the extensor,to be pulled distal to tllangeal joint just enoughlumbricals and interossthen flex the proximal pthe important flexors of 1langes are the lumbricalmuscles.
It seems almost palthese intrinsic musclesphalanges and extend thminal phalanges. But aures on page 95 will rdorsal expansion or "hoo
imally to the metacarpr( this occurs when the e;communis has extendrphalanges), contractiorcals and interossei exrand terminal phalangehand, when the "hood'
to the metacarpophalaroccurs wjth the synergithe extensor digitorumflexion of the digitorumfundus), contraction orand interossei results iproximal phalanges. Ncgers are flexed (for exanthe extensor digitorumIateral slips takes over altrol of the extension ofterminal phalanges; andare three-fourths flexed,torum communis assumthe extension of these pl
The interosseous musinsertion into not only tl
C L I N I C A L S Y M P O S l
DELTO PECTORAL NODE
AXILLARY NODES(ALONG AXtLTARY VEtN)
CEPHALIC VEIN
i
MEDIAN CUBITAL VEIN
BASILIC VEIN
CEPHALIC VEIN
F IGURE 8
EPITROCHLEAR NODES
VESSELSPASSINGTO DORSUMOF HAND
TO
VESSELS FROMCENTER OF PALA\DEEP TYMPHATICS
VESSELSAROUNDDORSUM
PASSINGWEB TOOF HAND
VESSELS PASSINGTO DORSUM OFFINGERS
FIGURE 9
w..phalanges are extended. The situationchanges, however, as soon as the extensordigitorum communis relaxes sufficientlyto permit the flexors digitorum sublimisand profundus to begin flexing the middleand terminal phalanges. Simultaneously,this causes the extensor communis ..hood,,
to be pulled distal to the metacarpopha_Iangeal joint just enough, so that *h"r, thelumbricals and interossei contract. thevthen flex the proximal phalanges. ln fact,the important flexors of the proximal pha_Ianges are the lumbricals urrd irrt"rorrlousmuscles.
It seems almost paradoxical to havethese intrinsic muscles flex the proximalphalanges and extend the middle and ter_minal phalanges. But a study of the fig_ures on page 95 wil l show that if thedorsal expansion or "hood,,is pulled prox_imally to the metacarpophalangeal joint( this occurs when the extensor digitorumcommtrnjs has extencled the nroximalphalanges) , contract ion of the hrmbr i -cals and interossei extends the middleand terminal phalanges. On the otherhand, when the "hood" is pullecl distalto the metacarpophalangeai joint (thisoccllrs with the synergistic relaxation ofthe extensor digitorum communis andfexion of the digitorum sublimis and pro_fundus ), contraction of the lumbrialsand interossei results in flexion of theproximal phalanges. Now when the fin_gers are flexed (for example,45 degrees),the extensor digitorum communis via itsIateral slips takes over about half the con_trol of the extension of the middle andterminal phalanges; and when the fingersare three-fourths flexed, the extensor Jgi-tonrm communis assumes full control inthe extension of these phalanges.
The interosseous muscles gain partialinsertion into not only the lateral aspects
C L I N I C A L S Y M P O S I A
of the proximal ends of the proximal pha_langes but also into the lateral
"rpe"i, of
the capsules of the metacarpophalangealjoints (Figures 33, 34, and 35). It is theseinsertions which enable the ulnar_nerve_controlled interossei to spread and approx_imate the fingers. N4ore will be said of thisin the discussion on the intrinsic musclesof the hand.
Needless to say, it is important to under_stand the synergistic play of extrinsic andintrinsic muscles in the production ofhand and finger movements; and it isequally obvious that it can be unclerstooclonly if one has a clear picture of thedetailed origins, insertioris, and nervesupply of these muscles.
The tendon of the fifth finger propriusmtrsc le (extensor d ig i t i qu inf i ) passesthrorrgh the fifth compartment rrnder thedorsal carpal l igameni, Figrrres 26 and 27.It arises by a thin, tendinous slip from thecommon extensor in the forearm, and itinserts into the dorsal aponeurotic expan_sion hood on the dorsum of the nroximalphalanx of the fi l th f inger. It aids inextending this phalanx ond th" hand atthe wrist.
The tendon of the extensor ind.icis pro_prius passes through the forrrth clorsalcompartment with the three or four exten_sor communis tendons, as the case may be,F igures !6 and 27.The muscle arise, iromthe dorsum of the ulna, near the iunctionof its proximal three-forrrths and distalone-fourth. It assists in extending theproximal phalanx of the index finqe,. andthe hand at the wrist.
Whenever a tendon transplant is neecledfor repair of the very important extensorpollicis longus tendon, the tendon of thepalmaris longus muscle is used. If the lat_ter is absent, the tendon ofthe extensor in-dicis proprius muscle serves the purpose.
IJ
RSUM{D
B1
t
l,i
DORSALLIGAMENT
B l o o d s u p p l y r e o c h e s l u n o t ebone v iq on ie r io r ond pos-f e r i o r l i g o m e n t s f r o m r o d i u s .
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Ar ter io r d ls locq t ion w i th rup ture \ 1o t cn .e l igomenl . Desp i te impo i red
-c* s f4 . i
b t o o d s u p p l y , e o r l y r e d u c r i o n . o y e i i , E * "p r e v e n l n e c r o s i s
F IGURE
BIFURCATION
COMMON DIGITAL ,A.
VOLAR INTEROSSEOUS A.
Anter io r d is locq f ion w i th rup tureo f b o t h l i g o m e n f s . S i n c e b l o o dsupp ly i s cu t o f f , o voscu lq rnecros is resu l ts .
NAIL
NA|L BED (MATR|X)
PARONYCHIUM
TERMINAL PHALANX
MINUTE ARTERIES
NERVES
SEPT,A,
DORSAL DIGITAL A. AND N.
The thumb is an exupart of the hand. Its metrrue 6, is the most mobilcarpal bones. Attachedits proximal end is the rabductor pollicis longttmay insert by one, two <dinous slips, Figures 2(this strong muscle can gias three tendinous sliprmay have as many as tlgin: the proximal partinterosseous membrane,of the radius. This rnrextends the first metacarthe first metacarpocarpalcould not ftinction witlA stenosing tenosynovbesets this tendon at thpasses through the firstthe radius, Figures 20,condition is also knownclisease. Surgical removthe compartment usuall
The extensor pollicis Iarises from the interosrand dorsum of the radiurabove-mentioned abductand inserts into the dorsmal end of the first phalaIt extends this phalanx aextcnding and abductin5wrist.
The extensor pollicis klarger and more powerfceding muscle, originatestltircl of the dorsum of thosseous membrane and isdorsum of the proximal tnal phalanx of the thurnterminal phalanx, and Ipollicis brevis, on contassists in extending the hThe tendon is quite freq
C L I N I C A L S Y M P O S I I
FIGURE ' I I
ANTERIORLIGAMENT
t . . , ..f
t ' l/ ' : . .l ,
1 A .i i : .
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I n i w o - t h i r d s o f i n d i v i d u o l s , b l o o ds u p p l y t o s c o p h o i d i s d i s t r i b u t e dt h r o u g h o u t b o n e ( A ) . I n o t h e r s ,v e s s e i s e n f e r o n l y d i s i o l h o l f ( B ) ; i nfhese coses necros is o f p rox imo lhq l f resu l ts q f ie r f roc iu re-
F IGURE I4
BRA,NCHES OF PROPER VOLAR DIGITAL,A. AND N. TO DORSUM OF 2ndAND TERMINAL PHALANGES
"* alt:
._'**':"*i
PROPER VOLAR DIGITAL A. AND N.
$r:.l';'il*;{ ocrn,t
F I G U R E I 6
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The tlrumb is an extremely important
part of the hand. Its metacarpal bone, Fig-Lrre 6, is the most mobile of all the meta-carpal bones. Attached to the dorsum ofits proximal end is the surprisingly stoutabductor pollicis longus tendon, whichmay insert by one, two or even three ten-dinous slips, Figures 20 and 26. Just asthis strong muscle can give rise to as manyas three tendinous slips for insertion, itmay have as many as three heads of ori-gin: the proximal part of the ulna, theinterosseous membrane, and middle thirdof the radius. This muscle abducts orextends the first metacarpal and stabilizesthe first metacarpocarpal joint. The thumbcould not function without this muscle,A stenosing tenosynovitis occasionallybesets thrls tendon at the point where itpasses through the first compartment onthe radius, Figures 20, 26, and 27. Thiscondition is also knorvn as de Queraain'sdiseaso. Surgical removal of the roof ofthe compartment usually effects a cure.
The extensor pollicis breais, Figure 20,arises from the interosseous membraneand dorsum of the radius just distal to theabove-mentioned abductor pollicis longusancl inserts into the dorsum of the proxi-mal end of the first phalanx of the thumb.It extends this phalanx and also assists inextending and abducting the hand at thewrist.
The extensor pollicis longus, Figure 20,larger and more powerful than the pre-ceding muscle, originates from the middletlilrcl of the dorsum of the ulna and inter-osseous membrane and is inserted into thedorsum of the proximal end of the termi-nal phalanx of the thumb. It extends theterminal phalanx, and like the extensorpollicis brevis, on continued action, itassists in extending the hand at the wrist.The tendon is quite freqr,rently ruptured
C L I N I C A L S Y M P O S I A
in a severe Colles' fracture; if not at thetime of fracture, it may occur five to sixweeks after the accident.
It should be observed that each of thethree bones associated with the thumb(first metacarpal bone, and proximal anddistal phalanges ) has a tendon of one ofthe above-mentioned mr-rscles insertedinto the dorsum of its proximal end, Fig-ures 7 and 20. The saddle-shaned surfaceof the greater nrrrltangrrlar bone, articrr-lating with the concavo-convex surface ofthe first metacarpal bone, permits a verywide range of movement of the thumbwhen acted upon by the above muscles,as well as the flexor pollicis longus andrelated intrinsic muscles of the hand,Figure 32.
Because lacerations involving tendons,vessels, and nerves about the wrist arequite common, it is important to reviewthe anatomic re lat ionships of thesestructures.
ARRANGEMENT OF
TENDONS) VESSELS, AND NERVES
AT THE WRIST
Figures 21 and 23 show schematicallythe general arrangement of the tendons,vessels, and nerves under the volar carpalligament. By clenching the fist tightly andflexing the wrist as though against resist-ance, one can usually palpate the palmarislongus tendon (absent in 10 per cent ofhands), the flexors carpi radialis andulnaris tendons, and the superficial ten-dons of the flexor digitorum sublimis.
Next palpate the median duo, consist-ing of the palmaris longus tendon ( super-ficial to the volar carpal ligament) andmedian nerDe, the latter being deep andslightly lateral to the tendon.
Palpation of the radial pulse reminds
@%
ffi83
MEDIAT ANTEBRACHIALCUTANEOUS NERVE
DORSAL ANTEBRACHIALCUTANEOUS BRANCHOF RADIAL NERVE
ULNAR NERVE-DORSAL BRANCH(RAMUS DORSALTS MANUS)
DORSAL CARPAL BRANCHOF ULNAR ARTERY
TENDON OF EXT. CARPI ULNARIS
DORSAL CARPAL ARTERIALARCH AND RETE
DORSAL MET,ACARPAL ARTERIES
DORSAL DIGIT,AL ARTERIES
DORSAL DIGITAL BRANCHESOF ULNAR NERVE
AREAS OF SKIN INNERVATIONOF HAND
DORSUM
LATERAL ANTEBRACHIAL CUTANEOUSBRANCH OF MUSCULOCUTANEOUS N,
RADIAL NERVE-SUPERFICIAL BRANCH
DORSAL CARPAL LIGAMENT
RADIAL ARTERY (IN "SNUFFBOX")
TENDON EXT. CARPI RAD. LONGUS
TENDON EXT. CARPI RAD. BREVIS
TENDON EXT, POLL. LONGUS
DORSAL DIGITAL BRANCHESOF RADIAL NERVE
FIGURE I7
T, j,ri,*i::n" '
" . ' "" @cIBA
PROPER VOLAR (PALMAR) DrGrT,A,rBR,ANCHES OF MEDIAN NERVE
F IGURE I9
MEDIANNERVE(PROPER VOLARDIG. BRANCHES)
tg
EXT.CARPIRADIALIS ,,sBevs,/LOt IOUS /
I st DORSAI.INTEROSSE(MUSCLE
ADDUCTOR(SEEN THRU
N .CUT. BR .
F IGURE I8
1
EXT.CARPIRADIALISBREVIS,LONGUS
I st DORSALINTEROSSEOUSMUSCLE
A D D U C T O R P O L L I C I S(SEEN THRU FASCIA)
SUPERFICIAL RAMUS OF RADIAL NERVE
DORSAL CARPAL LIGAMENT
STYLOID PROCESS OF RADIUS
SCAPHOtD (NAVICULAR) BONE
R.ADTAL ARTERY ( lN "SNUFFBoX")
INSERTION OF ,ABDUCTORPOLLICIS LONGUS
INSERTIONOF EXTENSORBREVISPOLL IC IS
INSERTION OFEXTENSCR POLLICIS
LONGUS
F IGURE 20
t-
one of the radial trio, consisting of theradial artery, and ulnarward from it, theradial flexor (fexor carpi radialis), anddeep and ulnarward of this stout tendon,the flexor poUicis longus tendon. With thefist tightly clenched and the wrist flexed,one has little difficulty in palpating accu-rately with one's thumbnail the sharp-bordered ulnar fl.exor tendon (fexor carpiulnaris ). If the ball of the thumb is usedfor palpation, it not only presses upon theulnar flexor but also upon the superficialtendons of the flexor digitorum sublimis.
Palpation of the sharp-bordered ulnarflexor tendon brings to mind the ulnar triowhich consists of the ulnar fl.exor tendon,the laterally placed ulnar nerae, and theadjacent ulnar artery. Again, with fistclenched and wrist fexed, one is remindedthat the two digital flexor tendon quartetsare medial to the centrally located pal-maris longus tendon. Figure 23 showsschematically the relationship of the sub-limis tendons. Those acting on the thirdand fourth fingers are superficial to thoseof the second and fifth fingers. This ismost easily remembered by piacing one'ssecond and fifth fingers behind the thirdand fourth fingers as in Figure 22 andhav-ing in mind that 34 is a higher numberthan 25. Not uncommonly, sublimis ten-dons to the third, fourth, and fifth fingersare in the superficial plane, and the indexfinger sublimis tendon is deep to the thirdsublimis tendon.
Figure 23 shows the four flexor digi-torum profundus tendons lying in oneplane which is deep to the sublimis ten-dons. As previously mentioned, it is notuncommon to find at this point onlv theprofundus tendon to the index firrg"r r"pu-rated from the distal fibromuscular endof the flexor digitorum profundus - theother three tendons arising one to two
86
centimeters distad. A, subtendinous space(Parona) exists between all the abovestructures and the slluare pronator mus-cle (pronator quadratus). In discussinghand infections, this space will again bementioned.
By insular attachments on the dorsalandlateral aspects of the radius and ulna,the dorsal carpal ligament creates six com-partments for the passage of extensor andabductor tendons to the hand and fingers.Figure 26 shows the three thumb tendonsbounding the anatomical snuffbor; theabductor pollicis longus and extensor pol-l icis breuis on the volar'boundary, andthe extensor pollicis longus on the dorsalboundary.
The first two tendons of the snufibox(abductor pollicis longus and extensorpollicis breois) are in the first compart-ment, and the third tendon of the snuffbox(extensor pollicis longus) is in the thirdcompartment. Thetuo radisl extensor ten-dons (ertensors carpi radialis longus andbreois) are in the second compartment.
One can associate the four communistendons with the fourth compartment;and, as one wag expressed it, the extensorindicis propri.us tendon is a "fellow-trav-
eler" accompanying these four tendons.As previously mentioned, the extensordig i torum communis may g ive r isedirectly to only three tendons, in whichcase the extenaor indicis proprius tendonwill be the fourth tendon. The tendinousslip to the fifth finger from the extensordigi,torum communis will then branch ofifrom the tendon going to the fourth finger.
The extensor digiti quinti proprius fitswell into the fffthcompartment.The ulnerertensor tendon (extensor carpi ulnaris)falls easily into the ulnar, or sixth com-partment.
Figures 20 and 26 show the anatomical
Because the first dorsal incle gives no notable tendtion to the lateral tendinfirst lumbrical muscle, itpractically no aid in the rmiddle and terminal phindex finger. Their ertenby the first lumbrical rnvolar interosseous musclrnous slips insert into themiddle and proximal pha
The second and tltird aous muscles insert respertubercles on the radial anthe proximal phalanx of tland into the lateral sliprexpansion hood which exthe middle and terminalinsertion. When the tendrsor digitorum communis e:imal phalanx of the th jsecond and third dorsal incles can extend the middphalanges via the lateralwag" the middle finger.respectively radialward rbecause of their insertionmal phalanx. The arrows c95 depict these movemrtendon of the extensor (
rrurnis to the third fingetraction of the second arinterosseous muscles causrproximal phalanx.
The fourtl't dorsal interinserts into the ulnar side
phalanx of the fourth fingeof the joint capsule, and tlthe dorsal expansion. Witphalanx extended, the fourosseous muscle will pull tlaway from the third fin1extending tlae middle andlanges via its attachmenl
C L I N I C A L S Y M P O S I A
a
C I B A
ad. A subtendinous spacebetween all the above
ihe square pronator mus-
ruadratus). In discussing
, this space will again be
.tachments on the dorsalcfs of the radius and ulna,I ligament creates six com-re passage of extensor andrs to the hand and fingers.; the three thumb tendonsTnatomical snuffbox: thes longus and extensor pol-the volar boundary, and',Iicis longus on the dorsal
tendons of the snuffboxcis longus and extensorare in the first compart-ird tendon of the snuffboxis longus) is in the thirdhetuo radi,al extensor ten-carpi raclialis longus andhe second compartment.ciate the four communishe fourth compartment;expressed it, the extensor
tenclon is a "fellow-trav-
ying these four tendons.mentioned, the extensor,Lmunis may g ive r ise
three tendons, in which,r indicis proprius tendonth tendon. The tenclinousfinger from the exten,sorrurzis will then branch ofigoing to the fourth finger.digiti quinti proprius frtsh compartme nt. The ulnar. (extensor carpi ulnaris)the ulnar, or sixth com-
il 26 show the anatomical
snuffbox and its important contents. The
tip of the styloid process of the radius can
be felt at its proximal end. A small part of
the extensors carpi radialis longus and
brevis tendons can be seen, as rvell as the
radial artery. Deep to the radial artery
is the capsule of the wrist joint and
navicular (scaphoid) bone. Because the
navicular bone (Figure 13 ) is the most
frequently fractured carpal bone, it is
clinically more important than the greatermultangular bone - a small part of which
also lies in the snuffbor. F igure 3 shows
sensory branches of the radial neroe,
which are found in the snufJbor. Aware-ness of their presence prompts the sur-
geon to preserve them in surgical proce-dures in this area.
INTRINSIC N,IUSCLES OF THE ILA.ND
These may be grouped into those form-ing the hypothenar eminence, the thenar
eminence, and a third group - the mus-
cles between these two eminences, Fig-
ures 2, 5, 30, 31, and 32.
Muscles of Hypothenar Eminence
'Ihe abductor digiti quinti, the flexordigiti quinti, breois and the opponens
digiti quinti comprise this group, Figures
I, 5, and 21. The abductor digiti quinti
originates chiefly from the pisiform bone
and pisohamate ligament and inserts into
the joint capsule of the fifth metacarpo-
phalangeal joint, the ulnar side of the base
of the proximal phalanx of the fifth finger,
and the ulnar border of the aponeurosis of
the extensor digiti qtLinti proprius. It is
supplied by the ulnar nerve, abducts the
fifth finger when its proximal phalanx is
extended, and flexes the proximal phalanxlvhen the long extensor is relaxed.
The flexor digiti qu,inti breuis arises
C L I N I C A L S Y N I P O S I A
from the hamate bone and transverse car-
pal ligament and is inserted into the ulnar
side of the base of the first phalanx. It is
innervated by the ulnar nerve and assists
in abducting the fifth finger and in flexing
the proximal phalanx.The opponens digiti quinti originates
from the hamate bone and transverse
metacarpal ligament. It is inserted into
the ulnar border of the fifth metacarpal
bone and innervated by the ulnar nerve.
It lies deep to the other two muscles, next
to the fifth metacarpal bone.
The fifth is the second most mobile of
all the metacarpal bones, being movable
about 15 degrees palmarward and dorsal-
ward, Figure 32. Because of this mobility,
the opponens digiti quinti is able to draw
the fifth metacarpal forrvzrrd, thereby
helping to deepen the hollow of the palm.The unimportant palmaris brevis merely
corrugates the skin on the ulnar side of
the palm.
Nluscles of Thenar Eminence
This grotrp consists of the abductor pol-
Iicis breuis, the flexor pollicis breuis, and
opponens poll icis muscles, Figures L, 4,7,
21, and 30. These muscles, which are func-
tionally much more important than those
of the hypothenar eminence, are supplied
almost entirely by the median nerve.
The abductor pollicis breois muscle
originates from the transverse carpal liga-
ment and from the navicular and greater
multangular bones. It inserts into the
radial side of the proximal phalanx of the
thurnb and into the capsule of the meta-
carpophalangeal joint. It aids in abduct-
ing the thumb away from the palm.
The opponens pollicis muscle originates
from the transverse carpal ligament and
greater multangular bone. It inserts into
the whole radial side of the first metacar-
C I B A 87
MEDIANDUO
RADIAL
TRIO
f eaL,ulnrs LoNGUsL
MEDIAN NERVE -\
RADIAL ART.FLEX. CARP. RAD.
FLEX. POLL. LONG
FLEX. CARP. RAD
RADIAL ART.
FLEX. cARp. uLNARrs IULNAR NERVE i ULNARULNAR ARTERy I TRlo
PROFU}
SHEATH OFPOLLICIS LC
PRoBE IN THENAR sPAcE -
LUMBRICAL MUSCLESAND TURNED DOWN
DORSAL SUBCUTANEOUS SPA,
DORSAL -SUBAPONEUROTICSPACE
HYPOTHEN,A,RMUSCLES
MID-PALMARSPACEOR BURSA
FIGURE 25
FLEXOR TENDONSIN SHEATHS
LUMBRICAL MUSCLESIN SHEATHS
VOLAR CARPAL LIG.TURNED BACK
TRANSVERSE CARPAL LIG.
OPPONENS POLLICIS
ABD. POLL.BREVIS
ADDUCTOR POLLICIS
FLEX. POLI . LONG.IN RADI,AL BURSA
MEDTAN f raL,ulnrs LoNGUSDUO
\ ueoAN NERVE\
F IGURE 2 I
ABDUCTOR DIGITI QUINTIFLEXOR DIGITI QUINTI
OPPONENS DIGITI QUINTI
SUPERFICIAL PALMAR ARTERIA|.
,4 { , , r ', f , U t , . , , { e ,
t ,
/ / '
LUMBRICAL MUSCLES
VOLAR CARPAL LIGAMENT
UtNA
{
ARCH il
RADIAL
TRIO
RADIUS
SIMPLE METHOD OF DEMONSTRATINGARRANGEMENT OF SUBLIMIS TENDONSAT WRIST.
F IGURE 22
(-
oF FLEX. I.rmrs A,ND lrwo rrNooNUS IN ULNAR I QUARTETS
I
PRONATOR QUADRATUS
DIVIDED TRANSVERSECARPAL LIGAMENT
RADIAL BURSA
uLNnnrs I'/E ) ULNAR
:RY J TRlo
I DIGITI QUINTI
GITI QUINTI
S DIGITI QUINTI
\L PALMAR ARTERIAL A,RCH
IICAL MUSCLES
FIGURE 23
RONATOR QUADRATUS
PROFUNDUS TENDONS
SHEATH OF FLEXORPOLLICIS LONGUS
PROBE IN THEN,AR SPACE
LUMBRICAL MUSCLES DIVIDED,AND TURNED DOWN
FIGURE 24
tt
w
DORSAL SUBCUTANEOUS SPACE
DORSAL SUBAPONEUROTIC
PROBE INMIDPALMAR SPACE
': .
. @ C I B A
LIGAMENT
fiA,.?-?l; )Ul_;,t*-
Nan anrrnv I
NAR NERVE I uLNnn
. rLrx. crne. I TRlo ]
ULNARTS )
SPACE
HYPOTHENARMUSCLES
,tii#
ADDUCTOR POLLICIS MUSCLE
THENAR SPACE OR BURSA
EXTENSOR POLL IC ISLONGUS TENDON
FLEXOR POLLICIS LONGUSTENDON IN SHEATH
FLEXOR TENDONSIN SHEATHS
LUMBRIC,A.L MUSCLESIN SHEATHS
SEPTA FORMING CANALS
DIGITAL A. AND N. PALMAR APONEUROSIS
pal bone and because of this is largely
responsib le for the movement which
enables the thumb to be approximated
successively to the tips of each of the
fingers. This is recognized as the thumb-
finger -appr oximator test, fr equently used
to test the motor function of the median
nerve.The flexor pollicis breai,s muscle con-
sists of two parts: (L) a superfici,al por-tion, innervated by the median nerve,
originating from the transverse carpal
ligament and greater multangular bone
and inserting into the radial side of the
proximal phalanx and (2) a deeTt and
very small portion, innervated by the
ulnar nerve, arising from the ulnar side
of the first metacarpal and inserting into
the ulnar side of the proximal end of the
first phalanx.All the hypothenar and thenar emi-
nence muscles, except the abductor digiti
quinti, get part of their origin from the
transverse carpal ligament - a purchasewhich enables them (abductor excepted)
to help preserve the carpal arch.
INTEROSSEOUS I{USCLES
There are seven interosseous muscles:
four interossei in the dorsal group and
three interossei in the volar group, Fig-
ures 31 and 32.The four dorsal i,nterosseous muscles
are bipennate rvith their mus.cular heads
of origin from adjacent sides of the meta-
carpal bones. From the figures on pages
92 and 94, one can see how the tendon
of one head of the muscle inserts into the
tubercle on the lateral aspect of the proxi-
mal phalanx or the capsule of the meta-
carpophalangeal jo int , or in to both
tubercle and joint capsule. The other
head inserts into the dorsal expansion and
90
its volar border - the lateral band which
continues distally to the dorsum of the
proximal end of the terminal phalanx. It
is not uncommon for the tendinous slip to
the capsule to arise from the tendon join-
ing the lateral band instead of the one
going to the tubercle.Because the tendon of one of these two-
headed or bipennate dorsal interosseous
muscles has a stout insertion into the lat-
eral aspect of the proximal end of the
proximal phalanx (and this insertion is
slightly more volar than dorsal ) and
because it fuses with the transverse fibers
of the hood, contraction of the muscle
belly associated with this tendon will
cause lateral motion of the proximal pha-
lanx. When the extensor digitorum com-
rnunis relaxes, fexion of this same phalanxoccurs.
Because the tendon of the other belly
blends with the lateral band of the dorsal
expansion (hood ) which continues dis-
tally to the dorsum of the middle and
terminal phalanges, contraction of its
associated muscle fibers will aid in extend-
ing the middle and terminal phalanges(Figures 33,34) .
It is to be noted, however, that the frsfdorsal interosseous is different from the
second, third, and fourth in that it has its
second metacarpal head inserting into the
lateral tubercle of the proximal phalanx
and its first metacarpal head inserting into
the dorsal expansion hood with no contri-
bution to the lateral band slip of the first
lumbrical muscle.This difierent mode of insertion enables
the second metacarpal component of the
first dorsal interosseous to be more efiec-
tive in flexing the proximal phalanx, and
the first metacarpal belly to be the more
important in lateral motion, especially so
in the pinching gesture with the thumb.
Because the first dorsalcle gives no notable tertion to the lateral tendfirst hrmbrical muscle, rpractically no aid in thrmiddle and terminal 1index finger. Their erteby the first lumbricalvolar interosseous mus(nous slips insert into ttmiddle and proximal pl
'fhe second and third
ous muscles insert resptubercles on the radial ithe proximal phalanx ofand into the lateral sliexpansion hood which ethe middle and termin,insertion. When the ten<sor tl igi to r r t m c ont mu nisimal phalanx of the t lsecond and third dorsal icles can extend the mid,phalanges via the laterawag" the middle fingerespectively radialwardbecalrse of their insertio:mal phalanx. The arrows95 depict these moventendon of the extensnrmunis to the third fingtraction of the second zinterosseous muscles caurproximal phalanx.
The fourth, dorsal inteinserts into the ulnar sidephalanx of the fourth fingrof the joint capsule, and Ithe dorsal expansion. Wiphalanx extended, the fouosseous muscle will pull taway from the third finextending the middle anrlanges via its attachmer
C L I N I C A L S Y T { P O S I AC I B A
tIateral band which
the dorsum of the
srminal phalanx. It
he tendinous sliP to
om the tendon join-
instead of the one
of one of these two-
dorsal interosseous
rsertion into the lat-
roximal end of the
.nd this insertion is
than dorsal) and
the transverse fibers
ction of the muscle
rh this tendon will
of the proximal Pha-nsor digi,torum conT'
r of this same Phalanx
rn of the other be1lY
ral band of the dorsal
which continues dis-
r of the middle and
i, contraction of its
rers will aid in extend-
d terminal Phalanges
however, that the frsf
is different from the
iourth in that it has its
head inserting into the
the proximal Phalanxrpal head inserting into
m hood with no contri-
al band sIiP of the first
rde of insertion enables
rpal component of the
seous to be more effec-
proximal Phalanx, and
al belly to be the more
al motion, esPeciallY so
esture with the thumb'
Because the first dorsal interosseous mus-cle gives no notable tendinous contribu-tion to the lateral tendinous slip of thefirst lumbrical muscle, it obviously givespractically no aid in the extension of themiddle and terminal phalanges of theindex finger. Their extension is effectedby the first lumbrical muscle and firstvolar interosseous muscle whose tendi-nous slips insert into the dorsum of themiddle and proximal phalanges.
The second and third dorsal interosse-ous muscles insert respectively into thetubercles on the radial and ulnar side ofthe proximal phalanx of the middle fingerand into the lateral slips of the dorsalexpansion hood which extend distally tothe middle and terminal phalanges forinsertion. When the tendon of the exten-sor digitorum communis extends the prox-imal phalanx of the th i rd f inger , thesecond and third dorsal interosseous mus-cles can extend the middle and terminalphalanges via the lateral slips and "wig-
wag" the middle ffnger, i.e., move itrespectively radialward and ulnarwardbecause of their insertion into the proxi-mal phalanx. The arrows on pages 94 and95 depict these movements. With thetendon of the extensor digitorum com-munis to the third finger relaxed, con-traction of the second and third dorsalinterosseous muscles causes flexion of theproximal phalanx.
The fourtl'r clorsal interosseous muscleinserts into the ulnar side of the proximalphalanx of the fourth finger, the ulnar sideof the joint capsule, and the ulnar side ofthe dorsal expansion. With the proximalphalanx extended, the fourth dorsal inter-osseous muscle will pull the fourth fingeraway from the third finger and aid inextending tlae middle and terminal pha-langes via its attachment to the hood,
C L I N I C A L S Y I { P O S I A
Figure 34. When the extensor tendon isrelaxed, the fourth dorsal interosseousmuscle flexes the proximal phalanx of thefourth finger, Figure 35.
Volar or palmar interosseous musclesare three in number. The first arises fromthe ulnar side of the volar asnect of thesecond metacarpal bone and is insertedinto the same side of the proximal end ofthe first phalanx and lateral band of thedorsal expansion hood of the index finger.The second and third arise respectivelyfrom the radial side of the fourth and fifthmetacarpal bones and are inserted intothe same side of the proximal phalanx ofthe fourth and fifth fingers and lateralbands of their dorsal expansion.
The red arrows in Figure 32 show howcontraction of these muscles results inapproximating the second, fourth, andfifth fingers toward the middle finger. Redarows on page 95 demonstrate how ten-dinous slips given to the lateral bands ofthe dorsal expansions enable these mus-cles to assist in extending the middle andterminal phalanges when the proximalphalanges are extencled by the extensordigitorum communis muscle.
Some prefer including the two-headedadductor pollicis muscle, Figure 30, withthe "median-nerve-controlled" thenar emi-nence muscle group. However, because itis functionally under the control of theulnar nerve as are the seven interossei andthe two lumbrical muscles on the ulnarside of the hand, it seems more logicalto include it with the latter group. Theoblique head of the adductor pollicismuscle arises chiefy from the capitatebone and the bases of the second andthird metacarpals. 'Ihe
transoerse partarises from the distal two-thirds of thevolar aspect of the third metacarpal bone.All of the transverse head and most of the
C I B A91
EXTENSOR CARPI \ULN,ARIS \
THROUGHCOMPARTMENT
J
EXTENS.R poLlrcrs LoNGUs ) .ollJooJ#*,t 3
oblique head insert intothe base of the proximithumb. A sesamoid bormonly found in this tenfibers from the obliqueh,pollicis brevis to insert irof the thumb's first phallocated a sesamoid bonrthe flexor pollicis longustwo points of insertion.
As the name implies, tladductor pollicis musclethe first metacarpal tcmetacarpal bone. Notebetween the action olpollicis, of the "medianthenar eminence group apollicis mascle supplie<nerve: The opytonens pothumb in an arcfu:ing ma
THROUGHCOMPARTMENT
6
FOUR COMMUNISTENDONS PLUSONE FELLOWTRAVELLER IN4th COMPART.
EXTENSOR DIGITIQUINTI PROPRIUS
THROUGHCOMPARTMENT
4
FOUR TENDONS OFEXTENSOR DIGITORUMCOMMUNIS PLUS EXTENSORINDICIS PROPRIUS(FETLOW TRAVETLER)
ABDUCTOR DIGITI QUINTI
TRANSVERSE FIBERS OFDORSAL EXPANSIONS (HOODS)
u(i.t: Jt l t. ' /@ctBA
, 3rd SNUFFBOXEXT. POLL. LONG. } TENDON IN
, 3rd COMpART.
RADtAt ARTERY (tN "SNUFFBOX.)
FIGURE 26
DORSAL INTEROSSEI
I rxr. oro.1 PLUS EXT.I PROPRTUS
COMMUNISrNDtcts
ULNAR 6 EXT. POLL. BR. I t$ AND 2nd
"l \ SNUFFBOXI ABD TENDONS IN* POLL. LONG.J lsr COMPART.
FIGURE 2I
EXTENSOR f rxr. clnprlN 6th I uLNeRrSCOMPART.
UI.NA RADIUSF IGURE 27
l
I THROUGH{GUS i coMpAxTMENT
Als BREVT5 I rxnoucttrs toNGUs I
coMPAxrMENr
crs LoNGUS I rxnoucxtcts BREVIS I
CoMPARTMENT
ARTERY (rN "SNUFFBOX")
oblique head insert into the ulnar side ofthe base of the proximal phalanx of thethumb. A sesamoid bone is not uncom-monly found in this tendon. Some of thefibers from the oblique head join the flexorpollicis brevis to insert into the radial sideof the thumb's first phalanx. Here also islocated a sesamoid bone. The tendon ofthe flexor pollicis longus is between thesetwo points of insertion.
As the name implies,the function of theaclductor pollicis muscle is adduction ofthe first metacarpal toward the thirdmetacarpal bone. Note the difference,between the action of the opponens t
polli.cis, of the "median-nerve-supplied"
thenar eminence group and the adductorpollicis muscle supplied by the ulnarnerve: The opponens pollicis swings thethumb in an arching manner toward the
tips of the fingers, whereas the adductorpoll icis slides or scrapes the thumb acrossthe palm and bases of the fingers towardthe ulnar side of the hand.
With a functionless adductor pollicis,as in ulnar nerve paralysis, it is impossibleto make a perfect "O" with the thumb andindex ffnger or execute the pinch-move-ment between these digits.
In ulnar nerae paralysis, there is notonly a "hollowing-out" due to atrophy ofthe interosseous muscle bulges on the dor-sum of the hand, but there is a noticeablethinning of the thumb-index finger web-
' area due to atrophy of the adductor pollicismuscle. As stated previously, the ulnarneroe can be called the"finger-spreader-
approxi.mator-neroe" because spreading
and approximating the fingers by the dor-
sal and volar interossei, respectively, tests
. FIGURE 26tuORSAL INTEROSSEI
-u,',;i,V,t"'
JRE 27
RADIAL BURSA
ULNAR BURSA
INTERMEDIATEBURSA
THENARSPACE
OR BURSA
MIDPSPACEOR
, 3rd SNUFFBOX. I T E N D O N r N
' 3rd COMPART.
r 2 RADIALAD. BREV. I rxrrNsons,D. LONG. I rN Zna
/ COMPART.
.1. BR. I Isr AND 2ndI sNurrsox/rrNooNs rN
roNG.J rsr GoMPART.)tt.
LUMBRICALMUSCLESIN SHEATHS
TENDONSHEATHS
i 1 ril,,,ilt'i;f
l , , t ' O c t m
FIGURE 29
r-FIGURE 28
l
I_j
RADIAL ARTERY
VOLAR CARPAL BRANCH RAD. A.
RADIUS
SUPERFICIAL BRANCH RAD. A.
HOOK HOLDING BACKTRANSVERSE CARPAL LIG.
OPPONENS POLLICIS M.
MEDIAN N. BRANCHESTO THENAR MUSCLESAND 'I AND 2LUMBRICALS
ABD. POLL. BR.
FLEX. POLL. BR.
ADDUCTORPOLLtCTS
BRANCHESDEEP DIV.ULN. N. TOINTEROSS. M.AND 3 AND 4LUMBRICALS
TUMBRICALMUSCLES TURNEDDOWN
ULNA
LUNATE
TRIQUETRAL
PISIFORM
HAMATE
ABDUCTORDIGITIQUINTIMUSCLE
RADIUS
NAVTCUTAR (SCAPHOtD)
LUNATEGR. MULTANGULAR
LESS. MUTTANGULAR
EXT.
PRONATOR QUADRATUS M.
ULNAR N. (F|NGER-SPREADER N.)
ULNAR ARTERY
CARPAL BRANCH ULNAR A.
TENDON FLEX. CARP. ULNARTS
PISIFORM BONE
VOLAR CARPAT RETE
ABDUCTOR DIGITI QUINTI M.
DEEP PALMAR BRANCH ULNAR A.AND DEEP DIVISION ULNAR N,
FLEXOR DIG. QUINTI BREV. M.
OPPONENS DIGITI QUINTI M.
METACARPAL ARTERIES
COMMON VOL, DIG. ARTERIES
DEEP TRANS. METACARP. LIG.
UtNA
TRIQUETRAT
PISIFORM
HAMATE
CAPITATE
VOLARINTEROSSEI
EXTENSORINSERTION TODISTAL PHALANX
COLLATERALLIGAMENTS
F I G U R E 3 5
INSERTION OF DEEP P(EXTENSOR TENDON TO
ATTACHMENT OFINTEROSSEOUS M. TO
-
BASE OF lst PHALANXAND JOINT CAPSUI-E
TRIANGUIILIGAMEN'
@EXTENSOR INSERTIONTO DISTAL PHALANX
EXIN2n
V
F I G U R E 3 0
VINCBREV
ABD. {RADIUS
LISTER'STUBERCLE
NAVICULARGR. MULT.
LESS. MULT.
CAPITATE
ABD. POLL. BR,
DORSALINTEROSSEI
DEEPTRANS.METACARP.LIG.
TENDINOUSSLIPS TO,HOOD'
VOLAR ASPECT
F IGURE 32
<-*
"9.:1r" ,
' a ; ' b " , " o )
. F , r 't'1fa"r"o
lsi LUMBRIC,AI TEND.
TEND. VOL. INTEROSSEI
F IGURE 33
F IGURE 34
DORSAL ASPECT
F IGURE 33
t
IOR QUADRATUS M.
N. (FTNGER-SPREADER N.)
ARTERY
CARPAL BRANCH ULNAR A.
.I FLEX. CARP. ULNARIS
M BONE
CARPAL RETE
OR DIGITI QUINTI M.
\LMAR BRANCH ULNAR A.iEP DIVISION ULNAR N.
DIG. QUINTI BREV. M.
ENS DIGITI QUINTI M.
METACARPAL ARTERIES
)N VOL. DIG. ARTERIES
RANS. METACARP. LIG.
ULNA
TRIQUETRAI
PISIFORM
HAMATE
CAPITATE
VOLARINTEROSSEI
TRIANGULARI-IGAMENT
SLIPS OF LONG EXT.TO LATERAL BANDS
INTEROSSEOUS
EXTENSORINSERTION TO2nd PHALANX
LATERALBANDS
DORSAT EXPANSTON (HOOD)
METACARPALBONE
INTEROSSEOUSMUSCTE
LONGEXTENSORTENDON
INTEROSSEOUSMUSCTE
LONGEXTENSORTENDON
INTEROSSEOUSMUSCLE
LUMBRICALMUSCLE
INTEROSSEOUSMUSCLE
EXTENSOR INSERTIONTO DISTAL PHALANX
EXTENSORINSERTION TODISTAL PHALANX
COLLATERALLIGAMENTS
F I G U R E 3 5
SLIP TO LAT. BAND
PORTION OF INTEROSSEOUS TENDON PASSING TOBASE OF lsr PHALANX AND JOINT CAPSULE
DORSAL EXPANSION (HOOD)
VINCULABREVA
VINCULALONGA
EXTENSORINSERTION TO2nd PHALANX
'2.LATERAL BAND
+
PROFUNDUSTENDON
FLEX. DIG. SUBLIMISTENDON (CUT OFF)
COLLATERALLIGAMENTS
METACARPAL BONE
SUBLIMISTENDON
DEEPTRANS.METACARP.LIG,
INSERTION OF DEEP PORTION OFEXTENSOR TENDON TO I st PI-IALANX
ATTACHMENT OFINTEROSSEOUS M. TOBASE OF lst PHALANXAND JOINT CAPSI.. jLE
Blqck ArrowsIndicote Pullof Long Extensor;Red Arrowslndicote Pullof Interosseiond Lumbricols
TENDINOUSSLIPS TO"HOOD'
[ -UMBRICAL MUSCLE
CORRECT POSITION FORSPLINTING "MALLETFINGER," NOTE RELAXEDLATERAL BAND
)LAR ASPECT
F IGURE 32
FLEX. DIG.PROFUNDUSTENDON(cur oFF)
F IGURE 36
TENDONENDS
APPROXIMATED
F IGURE 34
^ o$ -qfi*i=.
.l};$''fu,'r @clB.q,
quite efiectively the motor integrity of theulnar nerve.
LUMBRICAL MUSCLES
On the radial side of the palmar portionof each flexor digitorum profundus ten-don is a lumbricalis (worm-like ) muscle,page 77. The first and second lumbricalsoriginate respectively from the radial sideof the first and second fexor nrofundustendons, the thir-d Iumbrical orjqjnatesfrom the adjacent sides of the second anclthird profundus tendons, and the fourthfrom adjacent sides of the third trnd fourthprofundus tendons (Figure 2l). Figures34 and 35 show how these muscles sendtransverse fibrous elements to the dorsalexpansion hood, and a substantial tendi-nous slip to fuse with a similar contribu-tion from the interosseous muscles to formthe lateral bands inserting into the middleand terminal phalanges.
This insertion enables these musclesto flex the proximal phaltrnges when theextensor d ig i tomm longus muscle isrelaxed; ancl the middle and terminalphalangeal inser t ions enable them toextentl these phalanges when the extensordigitorurn longus is extending the proxi-mal phalanges.
The first ancl second or lateral two lum-bricals arising from the first and secondflexor profundus tendons are innervatedby the median nerDe, the third and fourthor medial hvo by the ulnar neroe. This isquite logical when one recalls that in theforearm the lateral half of the flexor disi-torrrm profrrndus. from which arise thetendons to the first and second fingers, isinnervated by the median nerve; themedial half, from which originate the ten-dons to the third and fourth fingers, issupplied by the ulnar nerve.
96
THE EFFECT ON TI{E HAND OF RADIAL,
MEDIAN, AND ULNAR NERVE LESIONS
Seoerance of Radial Nerae
Because of the frequency of arm injuriessuch as shoulder dislocations and frac-tures of the surgical neck and middlethird of the humerus, the radial is themost frequently injured of these threeimportant nerves.
Sensory examination will reveal hvpes-thesia in an area along the dorsum of theforearm about half the width indicated inFigure 19 and also on the hand in mostof the area cliagrammed in Figures 18 and19. There is usually anesthesia of theskin overlying the first dorsal interosseousmuscle.
hlotor examination reveals the tvpical"wrist drop" position of the hand. Theadducted position of the thtimb and theposition of the alreadv flexed hand makesflexion of the fingers somervhat difficult.The hand cannot be extended at the wrist,and the lateral moverlents of the handare difficult because the ulnar and radialextensors are paralyzed. The proximalphalanges of the four fingers cannot beextended because of the involvernent ofthe extensor digitorum communis; thethumb cannot be extended or abductedbecause of the paralysis of the abductorpollicis longus and of the extensors pol-licis longus and brevis. The bulge of thedorsal forearm group of muscles ( exten-sor-supinator group ) is flattened or evenhollowed. There is absence of the peri-osteal reflex on tapping the radius.
Seperance of tr[eclian Nense
While sensorll examination will revealvarving degrees of hypesthesia and anes-thesia as outlined in the medial nerve
'lsr PHALANX
COTLATERAL LIG.CORDLIKE PART
FANLIKE PART
VOLARACCESSORY LIG.
METACARPATBONE
THE COLLATERALAND VOLAR ACCESSORYLIGAMENTS IN ATYPICAL DIGIT
F I G U R E 4 I
HAND IN THE, ,POSITION OF FUNCTIOI .
LUMBRICAL MUSCIINTEROSSEOUS MUSCTE
C I B A
\I THE IIAND OF RADIAL,
ULNAR NERVE LESIONS
dial Nerue
r frequency of arm injuries
:r dislocations and frac-
Lrgical neck and middle
merus, the radial is the' injured of these three(
ination will reveal hypes-
r along the dorsum of the
alf the width indicated in
rlso on the hand in most'ammed in Figures 18 and
sually anesthesia of there first dorsal interosseous
wtion reveals the typical
rsition of the hand. The
cn of the thumb and the
lready fexed hand makes
ngers somewhat difficult.
t be extended at the wrist,
movements of the hand
ause the ulnar and radial
raralyzed. The proximal.e four fingers cannot bese of the involvement ofigitorum communis; the
re extended or abducted
paralysis of the abductor
lnd of the extensors pol-brevis. The bulge of the
group of muscles (exten-
oup) is flattened or even: is absence of the peri-tapping the radius.
zdian N eroe
7 examination will revealof hypesthesia and anes-
red in the medial nerve
'lst PHALANX
COTLATERAL LIG.CORDLIKE PART
FANLIKE PART
VOLARACCESSORY LIG.
METACARPALBONE
THE COLLATERALAND VOLAR ACCESSORYLIGAMENTS IN ATYPICAL DIGIT
LUMBRICAL MUSCLE
INTEROSSEOUS MUSCLE
F I G U R E 4 I
H A N D I N T H E
F I G U R E 3 7
ANTERIOR DISLOCATION OFPROXIMAL PHALANXDUE TO DIVISION OFCOLLATERAL LIGAMENTS
FIGURE 39
FRACTURE OFMETACARPALBONE. FLEXIONDEFORMITYCAUSED BYPULL OFINTEROSSEOUSMUSCLE
DEFORMITY DUE TO PULL OFLUMBRICAL AND INTEROSSEOUSMIJSCLES IN FRACTURE OFPROXIMAL PHALANX(HOOD REMOVED)
F I G U R E 4 0
F I G U R E 3 8
C I B A , ,POSITION OF FLJNCTION"
areas of Figures 18 and 19, complete anes-thesia will usually be present only on the
palmar and dorsal aspects of the terminal
phalanges and parts of the middle pha-langes of the index and middle fingers.
In a previolrs paragraph, it was sug-gested that the median nerve could alsobe known by its functional name: theflexor - pronator - thumb - finger - approxi-mator nerve. In a general way, this namesummarizes the motor control of the nerveancl suggests what to expect in divisionof the nerve.
LIotor examination in a case of sever-ance of the median nerve just above theelbow reveals weakness in wrist-fexionbecause of paralysis of the powerful flexorcarpi radialis muscle. The flexor carpiulnaris ( innervated by the ulnar nerve )has a tendency to flex the wrist ulnarward.There is inability to flex the thumb, index,and middle fingers. Pronation is veryweak because the pronator radii teres(round pronator) and the pronator quad-ratus ( square pronator ) muscles are par-alyzed. Because the thenar eminencemuscles are paralyzed, there is consider-able difficulty in trying to approximatethe tip of the thumb successively to thetips of the fingers. In attempting to claspthe unaffected hand, the index and mid-dle fingers will not fex as will the otherfingers. With the hand flat on a desk, theindex finger cannot scratch the desk.
Inspection reveals a hollowing-out ofmost of the normal forearm muscle bulgeof the volar or flexor-pronator group ofmuscles and a hollowing-out of the thenareminence or thumb-finger-approximatormuscle group.
It is easy to appreciate the importanceof the median nerve, since it has most ofthe motor and sensory control of thethumb, index, and middle fingers. It is no
9B
wonder that causalgia, which seems toafiect this nerve more than others, is sucha painfully disabling affiiction.
Seoerance of tlrc Ulnar Neroe
Sensory exarnination' reveals varyingdegrees of hypesthesia and anesthesia ofthe ulnar border of the hand and the volarand dorsal aspects of the fifth finger andulnar half of the fourth finger, Figures18 and 19. Total anesthesia is noted usu-ally in the fifth ffnger.
Motor Examination; If the division ofthe nerve is trbove the elbow, there is lossof ulnar flexion due to paralysis of theflexor carpi ulnaris (ulnar fexor) and ina-bility to flex the terminal phalanges of thefourth and fifth fingers because of paraly-sis of the ulnar half of the flexor digitorumprofundus muscle.
Since the ulnar nerve supplies the hypo-thenar eminence muscles, the interosse-ous muscles, the two medial lumbricalmuscles, the adductor pollicis muscle, andthe deep head of the flexor pollicis brevismuscle, there is a marked weakness orIoss of the so-called finger-spreading andapproximating movements of the fingers.There is inability to scrape the thumbacross the palm as well as the inability toform a perfect "O" with the thumb andindex finger. It is also difficult to holdtightly a piece of paper between thethumb and index finger.
Inspection will reveal a hollowing-outof the hypothenar eminence and themuscle bulges of the interosseous musclesbetween the metacarpals. The normalbulge along the proximal ulnar border ofthe forearm will also be flattened due toatrophy of the flexor carpi ulnaris and theulnar half of the fexor digitorum pro-fundus muscles.
The so-cal led "c law-hand" is most
noticeable when the ulnarin the distal half of the f<it has given motor branccarpi ulnaris and especi;half of the fexor digitrThe extensor digitorumplied by the radial nerveproximal phalanges of th,fingers. The ulnar half otorum profundus (supplnerve ) will flex the ternphalanges, thus producposition of the fourth anr
Seaerance of Median anc
S ensory exami.nation rramount of hypesthesia athe palm and of the vaspects of the fingers asures 18 and 19.
The findings in the mtdepend upon the level at,are cut. If severed abovtentire flexor-pronator otgroup of muscles, andmuscles of the hand wiWith the f exors carpi racparalyzed, the extensorrlongus and brevis andulnaris ( supplied by ra<tend to extend and slighhand at the wrist.
The extensor digitorunhyperextend the proximathe thumb abductor an<abduct the thumb and pslightly dorsal to that olparalysis of the intrinsichand causes a fattening cmetacarpal arches, creatlike" hand. The subsequerthe fexors digitorum pr,the sublimis and flexor poduces a moderate "claw"
C L I N I C A L S Y M P O S I AC I B A
t_lsalgia, which seems tomore than others, is suchling affiiction.
Ulnar Neroe
,ination ' reveals varying
;thesia and anesthesia of
of the hand and the volar:ts of the fifth ffnger and
e fourth finger, Figures
anesthesia is noted usu-inger.
wti,on: If the division of,e the elbow, there is loss
due to paralysis of the'is (ulnar flexor ) and ina-
:erminal phalanges of the
ingers because of paraly-rlf of the flexor digitorum
: nerve supplies the hypo-
: muscles, the interosse-
e two medial lumbrical
uctor pollicis muscle, and
: the flexor po)licis brevis
a marked weakness or
led finger-spreading and
rovements of the fingers.
ty to scrape the thumb
as well as the inability to'O"
with the thumb and
is also difficult to hold
of paper between the
r finger.
I reveal a hollowing-out
nar eminence and the
the interosseous muscles
etacarpals. The normal
proximal ulnar border of
also be flattened due to
:xor carpi ulnaris and there flexor digitorum pro-
J "claw-hand" is most
noticeable when the ulnar nerve is severedin the distal half of the forearm; i.e., atterit has given motor branches to the flexorcarpi ulnaris and especially to the ulnarhalf of the flexor digitorum profundus.The extensor digitorum communis ( sup-plied by the radial nerve ) will extend theproximal phalanges of the fourth and fifthffngers. The ulnar half of the fexor digi-torum profundus (supplied by the ulnarnerve) will fex the terminal and middlephalanges, thus producing a claw-likeposition of the fourth and fifth fingers.
Seoerance of Median and Ulnar Neraes
Sensory examinati,on reveals a variableamount of hypesthesia and anesthesia ofthe palm and of the volar and dorsalaspects of the fingers as outlined in Fig-ures 18 and 19.
The findings in the rnotor examinationdepend upon the level at which the nervesare cut. If severed above the elbow, theentire flexor-pronator or volar forearmgroup of muscles, and all the intrinsicmuscles of the hand will be paralyzed.With the flexors carpi radialis and ulnarisparalyzed, the extensors carpi radialislongus and brevis and extensor carpiulnaris (supplied by radial nerve) wilitend to extend and slightly supinate thehand at the wrist.
The extensor digitorum communis willhyperextend the proximal phalanges, andthe thumb abductor and extensors willabduct the thumb and pull it in a planeslightly dorsal to that of the hand. Theparalysis of the intrinsic muscles of thehand causes a flattening of the carpal andmetacarpal arches, creating a frat "ape-
like" hand. The subsequent contracture ofthe fexors digitorum profundus and ofthe sublimis and flexor pollicis longus pro-duces a moderate "claw" position of the
C L I N I C A L S Y M P O S I A
fingers and thumb. If the nerves aresevered in the distal part of the forearm,i .e . , a f ter they have suppl ied motorbranches to the flexors of the ffngers, the"claw" position of the fingers will be verymarked. This is understandable when onerecalls that the extensor digitorum com-munis muscle (supplied by radial nerve)will hyperextend the proximal phalanges,and that the finger flexors, unopposed bythe paralyzed intrinsic hand muscles, willsharply flex the middle and terminal pha-langes,.thus producing an extreme "claw"
appearance of the fingers.
LIGAMENTS OF TIIE HAND
A thick but loose articular capsule holdstogether the saddle-shaped joint betweenthe first metacarpal and greater multangu-lar bone. Because of the conffguration ofthese articular facets, the thumb enjoys avery wide range of movement, in fact, thewidest range of movement of any of themetacarpal bones.
The bases of the second, third, fourth,and fifth metacarpal bones are heldtogether by dorsal, volar, and interosse-ous ligaments.
The volar surfaces of the heads of thesecond, third, fourth, and fifth metacarpalbones are connected by a tough fibrousband - the deep trq.nauerse metocarpalligament, Figures 30 and 32. This liga-ment and the dorsal, volar, and interosse-ous carpometacarpal ligaments give thehand stability. They per:rnit the fifth meta-carpal a thirty-degree range of movement,the fourth about fifteen degrees. Theypermit practically no mobility to the sec-ond and third metacarpal bones, therebymaking this the most stable part of thehand. The deep transoerse metacarpalligament helps preserve the metacarpal
C I B A 99
b---_
PARONYCHIA
FELON(sHowrNG rNctstoN)
SUBCUTANEOUS ABSCESS(NOTE I.OC,AL/ZED SWELLTNG)
TENOSYNOVITIS(DEMONSTRATTNG KANAVEL'S
4 CARDINAL POINTS)
FIGURE 42
TECHNIQUE IF LOCAL-IZED TO ONE SIDE
FIGURE 43
PUILING DOWN NAIL FIAP AFTER REMOVALAND EXCISING NAIL ROOT. OF NAIL ROOT
FIGURE 45
SAGITTAL SECTIONsHowrNG PUS (GREEN)BETWEEN SEPTA
MIDPALMAR SPACEINFECTION SECONDARY TOTENOSYNOVITIS OF MIDDLE(FOCUS rS TNFECTED LACERAAT DISTAL CREASE)
SCHEMATIC CROSS SECTIONsHowrNG HOW tNCtStONDIVIDES SEPTA
3
PATHOGENESIS OF"HORSESHOE ABSCESS"WITH RUPTUREINTO PARONA'SSUBTENDINOUSSPACE
FIGURE 44
^{ rrNoeRNess ALoNG SHEATH
MIDPATMAR
FIGURE 49
LYMPHEDEMA OFDORSUM, SECONDARY
TO PATMAR SPACE
nffiFIGURE 43
AFTER REMOVALOF NAIL ROOT
\Trc cRoss sEcTtoNNG HOW TNC|S|ONSEPTA
IAPfoT.
INFECTION SECONDARY TOTENOSYNOVITIS OF MIDDLE FINGER,(FOCUS IS INFECTED LACERATIONAT DISTAL CREASE)
1 SLIGHTI FLEXION
+, i't,'H''"il 11;'
lcrursrs orIESHOE ABSCESS"RUPTURETARONA',S
f DrNous
II
MIDPALMAR SPACE
THENAR SPACE INFECTIONFROM TENOSYNOVITISOF INDEX FINGER.(FOCUS rS DEEPPUNCTURE WOUND)
MIDPALMAR
4,{ffi/ ' f , '6l, I /sg1sgBUTTON ABSCESS
tarch, and its rupture weakens the hand to
a marked degree. As shown in Figtires 30
and 32, the lumbrical tendons lie on the
palmar aspect and the interosseous ten-
dons on the dorsal aspect of this ligament.
Mention should be made of the acces-
sorg aolar ligament and the two collateral
ligaments which strengthen the metacar-
pophalangeal joints. These are clinically
important because, whether by rupture or
capsulotomy, they may permit the base
of the proximal phalanx to slide onto the
palmar aspect of the head of the meta-
carpal bone, thereby creating a painfullydisabling condition in the hand, Figures
37 and 38.
TENDON AND MUSCLE SI{EATHS
OF TIIE IIAND
Figure 54 shows the palmar creases.
Figures 4,5,28, and 29 show the tendon
sheaths of the second, third, and fout'thfingers. In most hands these sheaths ex-
tend from the terminal phalanges approx-
imately to a line drawn across the palm
from the medi,al end of the distal palmar
crease to the lateral end of the proximal
crease. Note how the proximal ends of
these sheaths overlie the distal ends of
the thenar and midpalmar spaces or bur-
sae, Figures 28 and 29. Any one of these
sheaths occasionally may extend to the
wrist.If one remembers the extent of these
sheaths, it is not difficult to realize how a
suppurative tenosynovitis involving them
can account for Kanaoe|s four cardinal
points which are utilized in diagnosing
pus in flexor tendon sheaths. Figure 48
illustrates Kanarsel's four cardinal signs
and symptoms:
1. The finger is held in slight fexion for
comfor t . In contrast i t can be held
L02
straight without much pain in a local-
ized inflammation (furuncle ).2. The finger is uniformly srvollen in ten-
clon sheath infections in contrast to Io-
calized swelling in local inflammation.
3. Intense pain accompanies any attempt
to extend the partly flexed finger; this
is absent in local involvement.
4. Tenderness is marked along the course
of the inflamed sheath in contrast to its
absence in a localized inflammation.
The flexor sheath of the thumb usually
extends from the terminal phalanx to a
point two or three centimeters proximalto the proximal volar crease of the wrist.
The proximal half is commonly referred
to as the radial bursa, Figures 4, 24, 28,
and 29. Occasionally the proximal half of
the flexor pollicis longus sheath is sepa-
rated by a septum from the distal half of
the sheath, making them entirely separatesheaths.
The fifth-finger flexor sh,eath com-
mences at its terminal phalanx and, on
reaching a point half way up the palm,
expands laterally ( Figures 4, 5, 24, 28,
and 29) to envelop the tendons of the
fourth, third, and second fingers. This
expanded portion extends two or three
cent imeters prox imal to the proximal
volar crease of the wrist and is usually
called the ulnar bursa. Occasionally the
distal unexpanded part of the fifth-finger
sheath is separated by a septum from the
ulnar bursa.In a much smaller number of hands, the
sheath of the index finger may extend to
and communicate with the ulnar bursa.
The third-finger sheath or the fourth-
finger sheath may occasionally do this.
These are variations the surgeon should
always keep in mind. In a large number of
hands, a communication exists between
the radinl and, ulnar bursa. This accounts
for the so-cal led "horr
(Figure 49) following a ssynovitis of the thumb o
SIIBTENDINOUS
(ranoue's sr
The potential space br
poll icis Jongus tendon, tum profundus tendons, r
quadratus muscle is kn
tendinous space ol the'space. It is easy to see hc
pollicis longus sheath infrthe radial bursa and elinto this space. The sar:r:suppurative tenosynovittendon sheath of the fiftlbursa. Figure 24 shows Ifor pus from a thenar almar abscess to rupture inl
LUMBRICAL MUSCL
F i g u r e s 4 a n d 5 s h o ulumbrical muscles withopened first lumbrical shis adherent to the "roo
bursa or space with ropening into it. The sefourth lumbrical sheathseasily demonstrated, buusually overlie the midspace. Figures 25,28, atmat ica l ly these re lat isheaths extend from thecenter of the palm. They rmost easily in the handand are surprisingly str<being thin and semitransrecalled that the enshemuscles and flexor tendformed by septa fromneurosis, Figures 4,5, a:
C L I N I C A L S Y M P O S I ,C I B A
)ut mu('h fain in a local-
rt ion (furuncle ).uniformly swollen in ten-
'fections in contrast to io-
ng in local inflammation.
accompanies any attempt
partly f lexed finger; this
lcal involvement.rmarked along the course
d sheath in contrast to its
localized inflammation.
nth of the thumb usually
re terminal phalanx to a
ree centimeters proximalvolar crease of the wrist.
alf is commonly referred
bursa, Fig:rres 4, 24, 28,
nally the proximal half of
is longus sheath is sepa-
Lm from the distal half of
ng them entirely separate
ger flexor sheath com-
:rminal phalanx and, on
t half way up the palm,[y (Figures 4. 5. 24, 28,'elop the tendons of the
nd second fingers. This
rn extends two or three
oximal to the proximalthe wrist and is usually" bursa. Occasionally the
ed part of the fifth-finger
ted by a septum from the
rller number of hands, the
dex finger may extend to
rte with t}re ulnar bursa.
r sheath or the fourth-
ray occasionally do this.
tions the surgeon should
nind. In a large number of
unication exists between,lnar bursa. This accounts
for the so-cal led "horseshoe abscess"(Figure 49) following a suppurative teno-synovitis of the thumb or fifth finger.
SI.IBTENDINOUS SPACE
(eanoNa's seecn)
The potential space between the flexor
pollicis longus tendon, the flexor digitor-um profundus tendons, and the pronatorquadratus muscle is known as the sub-tendinous space of the wrist or Parona'sspace. It is easy to see how pus in a flexorpollicis longus sheath infection can ascendthe radial bursa and eventually ruptureinto [his space. The sflme cAn occur in asuppurative tenosynovitis involving thetendon sheath of the fifth ffnger and ulnarbursa. Figure 24 shows how it is possiblefor pus from a thenar abscess or midpal-mar abscess to rupture into Parona's space.
LUMBRICAL MUSCLE SI{EATIIS
Figures 4 and 5 show the ensheathedlumbrical muscles with a probe in theopened first lumbrical sheath. This sheathis adherent to the "roof" of the thenarbursa or space with no demonstrableopening into it. The second, third, andfourth lumbrical sheaths are not nearly soeasily demonstrated, but when present,usually overlie the midpalmar bursa orspace. Figures 25, 28, and 29 show sche-mat ica l ly these re lat ionships. Thesesheaths extend from the web-area to thecenter of the palm. They are demonstratedmost easily in the hand of a heavy toilerand are surprisingly strong despite theirbeing thin and semitransparent. It will berecalled that the ensheathed lumbricalmuscles and flexor tendons lie in canalsformed by septa from the palmar apo-neurosis, Figures 4, 5, and 25. From this
C L I N I C A L S Y M P O S I A
description, it is not difficult to visualizehow pus from a web-area infection canascend the first lumbrical canal and sheathand rupture into the thenar bursa or space;the second, third, and fourth rupture intothe midpalmar bursa or space. In the "pre-
antibiotic" days when serious hand infec-tions were more common, cases were seenin which pus from a thenar or midpal-mar space abscess would erode into anddescend a lumbrical sheath and canalfinally to rupture through the skin in the
dorsal web-area.
THENAR AND' MIDPALMAR SPACES
There is some disagreement about theexistence of these spaces. According toKanavel, the thenar space extends medio-laterally from the third metacarpal boneto the thenar eminence and proximodis-tally from the transverse carpal ligamentto a line about a thumb's breadth prox-imal to the webs of the fingers. The mid-
palmar space extends lateromedially fromthe third metacarpal bone to the hypo-thenar eminence and proximodista l lyabout a centimeter more proximally than
the thenar space. Figures 24,25,28, and29 show schematically the approximateextent of these spaces.
The use of the word "space" in the terms
thenar space and midpalmar space is notentirely accurate. They are only potentialspaces, demonstrable only when injected
with a radiopaque fluid. Figures 4, 5, and24 show rents in a thin, almost transparent,membranous layer colored green. In orderto depict these so-called spaces in relationto surrounding structures, the artist hadto make the membranes appear muchthicker than they actually are. In fact,they are so thin that, unless extreme careis taken in palmar dissection, the mem-
C I B A i03
o'tffi
brane covering the thenaremoved with the skinfascia. This no doubt ,infrequency with whichseen. With careful dissectransparent membrane rdemonstrated. In fact, tlthese figures from a diss
probes in the rents of theering the so-called thenaspaces" As stated prevdemonstrated best in hrdone hard and roughreason, it seems logicalmembranes as parts ofwhich develop as a resull
tion to which laborers'jected. Therefore, why rtherwr and midpalmar I
purposeless spaces?Recall that in the fin
the proximal palmar andflexor tendons have shealmake their sliding moverure 24. Unlike the flexothumb and fffth ftnger, wland bursae, the fexor terond, third, and fourth fi
or no sheath or bursal prcentral palmar portions.and 25 show how the ther
posed between the deeindex-fi nger fexor tendonfirst lumbrical muscle, araspect of the adductorAlso, note in Figure 5 adorsal extension of the
space interposed betweerof the adductor poll icispalmar aspect of the first
ous muscle, the second r
and the first palmar inteFigure 24 shows the er
butting against the pror
C L I N I C A L S Y M P O S I ,
TENDONSHEATHS
MIDPALMARSPACE
RADIAL ANDULNAR BURSA
(PROXTMAL ENDS)AND PARONA'S
SPACE
MOTOR BR,ANCHOF MEDIAN NERVETO THENARMUSCLES
ti,iY;;F IGURE 54
COMMONLY USEDINCISIONS IN HANDINFECTIONS
F IGURE 55
@W
VOLAR DIGITALARTERY AND NERVE
THENARSPACE
brane covering the thenar space is usually
removed with the skin and superficial
fascia. This no doubt accounts for the
infrequency with which this membrane is
seen. With careful dissection, a thin, semi-
transparent membrane can be definitely
demonstrated. In fact, the artist sketched
these figures from a dissected palm with
probes in the rents of the membranes cov-
ering the so-called thenar and midpalmar
spaces. As stated previously, they are
demonstrated best in hands which have
done hard and rough work. For that
reason, it seems logical to think of these
membranes as parts of modified bursae
which develop as a result of the extra fric-
tion to which laborers' palms are sub-jected. Therefore, why not call them the
thenar and midpalmar bursae instead of
purposeless spaces?Recall that in the fingers proper and
the proximal palmar and wrist regions, the
flexor tendons have sheaths and bursae to
make their sliding movement easier, Fig-
ure 24. Unlike the fexor tendons of the
thumb and fifth finger, which have sheaths
and bursae, the flexor tendons of the sec-
ond, third, and fourth fingers have little
or no sheath or bursal protection in their
central palmar portions. Figures 4, 5, 24,
and 25 show how the thenar bursa is inter-
posed between the deep aspect of the
index-ffnger fexor tendons, the ensheathed
first lumbrical muscle, and the superficial
aspect of the adductor pollicis muscle.
Also, note in Figure 5 a probe within the
dorsal extension of the thenar bursa or
space interposed between the deep aspect
of the adductor pollicis muscle and the
palmar aspect of the first dorsal interosse-
ous muscle, the second metacarpal bone,
and the first palmar interosseous muscle.
Figure 24 shows the end of the probe
butting against the proximal end of the
C L I N I C A L S Y M P O S I A
thenar bursa.
Figures 5 and 24 show a rent in the
membrane covering the so-called midpal-
mar space. Actually, there is no space
here; it is also a potential space in what
can be more logically called the midpal-
mnr bursa. This bursa is not nearly so easy
to expose as the thenar bursa; and, simi-
larly, it can be demonstrated only in a
hand that has done hard, rough work.
Figure 24 shows probes butting against
the proximal ends of the thenar and pal-mar bursae.
The author has had an opportunity to
dissect many hands, varying from those of
delicate type to those which have obvi-
ously been exposed to hard, rough usage.
In the former, the thenar bursa could usu-
ally be exposed, but the midpalmar bursa
could not be demonstrated satisfactorilyenough to be called a bursa. In the strong,
tough hand, however, there was consist-ently a thenar bursa and usually a mid-
palmar bursa - or excellent imitations of
bursae.
Considering the tremendous amount of
friction to which the palm is subjected, it
seems natural enough to have a thennr
bursapresent to enhance the sliding move-
ments of the index-finger flexor tendons
and ensheathed first lumbrical muscle over
the underlying adductor pollicis muscle.'[he thenar bursa also minimizes fric-
tion between the adductor pollicis and
that part of the palmar skin between the
index-finger tendons and thenar eminence.
The dorsal extension of the thenar bursa
makes smoother the movements between
the adductor pollicis and the ffrst dorsal
interosseous muscle. the second metacar-
pal bone, and the first palmar interosseous
muscle. Similarly, the midpalmar bursa
when present minimizes friction between
the fexor tendons of the third, fourth, and
105
fifth fingers, the ensheathed lumbricalmuscles, the underlying metacarpal bones,and interosseous muscles. As stated pre-viously, in delicate hands both bursaeseem to be absent or very difficult todemonstrate.
Figures 4, 5, and 24 show a sizableulnar bursa. However, it fails to cover allof the palmar portions of the flexor ten-dons - especially that part of the palmwhere these tendons are subiected to con-siderable pressure and fricti,on,
F igu res 4 ,5 ,24 ,25 ,28 , and 2g showsomewhat schematically how the proxi-mal end of the index-finger sheath and thesheath of the ffrst lumbrical muscle are incontact with the thenar bursa. The proxi-mal ends of the third, fourth, and fifthtendon sheaths. and associated lumbricalsheaths and canals are in contact with themidpalmar bursa. This enables one tounderstand how a suppurative tenosyno-vitis of the index-finger tendon sheath canrupture through its proximal end into thethenar bursa if present and cause theso-called thenar-space abscess, the clinicalappearance of which is shown in Figure53. On the same page is shown a midpal-mar space abscess which can be producedby rupture of a suppurative tenosynovitisof the sheaths of the third, fourth, or fffthffngers into the so-called midpalmar bursa.
As previously mentioned, the loose areo-lar tissue of the dorsalsubcutaneous spaceis loaded with minute lymph vessels whichreceive much of the lymph from the fin-gers, web-areas, and edges of the palm.Such lymphedema caused by a palmarspace infection is shown in Figure 51.This occurs quite commonly and is onoccasion mistakenly incised. The dorsalsubaponeurotic space is an area not fre-quently involved in hand infections.
A clear picture of the muscle and ten-
106
don sheaths, the thenar and midpalmarspaces or bursae and their locations, andtheir extent and relation to each othershould make it much easier to visualizethe anatomic course which can be takenby acute pyogenic infections of the hand.
Figure 49 shows the uniform swellingwhen the tendon sheath of the ,""ondlthird, or fourth finger is infected anddepicts by arrows the spread of a suppu-rative tenosynovitis from the flexor pol-licis longus sheath and radial bursa via theintermediate sheath to the ulnar bursa,fffth-finger sheath with eventual ruptureinto Parona's subtendinous space.
Figure 50 illustrates the appearance ofa midpalmar abscess following a suppura-tive tenosynovitis of the third finger. Theappearance of the palm is similar whenabscess is due to infection of the fourthfinger.
Figure 53 shows a thenar abscess withits swollen thenar area and abductedthumb resulting from an index finger sup-purative tenosynovitis. In Figure 5l isshown the dorsal lymphedema which maydevelop with either thenar or midpalmarabscesses. Figure 52 illustrates how a sub-cutaneous abscess in the palmar web-areacan erode through the palmar aponeurosisto reach the dorsum of the web-area toform a so-called "collar button abscess."
SURGICAL INCISIONS
Most surgeons prefer a general anes-thetic for the patient and the use of atourniquet (a blood pressure cufi infatedto 250 mm. ) to obtain a bloodless ffeld. Itis axiomatic that the incision should beadequate and properly placed, and thatutmost care be exercised in handling thesmall nerves, tendons, joints, and Jtherpertinent structures. It goes without say-
ing that chemotherapy, I
tion, position of function t
physiotherapy be includttreatment.
Some of the more comrsions are illustrated in F
44, 46,54, and 55.In treating paronychia
nof necessary to use an in
proximalward on the dorr
phalanx. Figure 42n showelevating the skin from t}
proximal end of the naidrop or two of pus found i
of a paronychia. This, '
therapy of heat, rest, aniusually cures the infectic
Should a paronychia be
stage of abscess formatiotof the nail, gentle elevatof the skin, Figure 43, ancor all of the loosened root
supportive therapy handadequately.
A felon is no longer <mouth" or "hockey stick"have been replaced byincision, Figures 44 and tthe formation of a tenderger tip.
Figure 54 shows the plrsions for draining a suppuoitis of the second, third,Observe that the incisionr
placed at the dorsal l imcreases in order to avodigital nerves and arteryure 55.
The dotted line on thFigure 54 represents theincision as it is on the rafifth finger. The reason fothe radial side of the fifthside of the second finge:
e thenar and midpalmar: and their locations, andd relation to each othermuch easier to visualize,urse which can be takenric infections of the hand.
rws the uniform swellingrn sheath of the second,r f inger is infected andi's the spread of a suppu-dtis from the flexor pol-lh and radiai bursa via theeath to the ulnar bursa,th with eventual rupturebtendinous space.strates the appearance ofcess following a suppura-Ls of the third finger. Thehe palm is similar wheno infection of the fourth
ws a thenar abscess withrar area and abductedfrom an index finger sup-rovitis. In Figure 51 islymphedema which mayher thenar or midpalmarr 52 illustrates how a sub-;s in the palmar web-areah the palmar aponeurosis'sum of the web-area to" collnr button ab scess."
CAL INCISIONS
; prefer a general anes-rtient and the use of arod pressure cufi infatedbtain a bloodless field. It: the incision should be'operly placed, and thatxercised in handling therdons, joints, and otherres. It goes without say-
ing that chemotherapy, heat, rest, eleva-
tion, position of function (Figure 41), and
physiotherapy be included in the plan of
treatment.
Some of the more commonly used inci-
sions are illustrated in Figures 42s, 43t,
44,46,54, and55.In treating paronychia, as a rule, it is
??ot necessary to use an incision extending
proximalward on the dorsum of the distal
phalanx. Figure 42n shows the knife-point
elevating the skin from the dorsum of the
proximal end of the nail to release the
drop or two of pus found in the early stage
of a paronychia. This, with supportive
therapy of heat, rest, and chemotherapv,
usually cures the infection.
Should a paronychia be advanced to the
stage of abscess formation under the root
of the nail, gentle elevation of the edge
of the skin, Figure 43, and excision of part
or all of the loosened root of the nail, plus
supportive therapy handles the situation
adequately.
A felon is no longer drained by "fish
mouth" or "hockey stick" incisions. These
have been replaced by a simple lateral
incision, Figures 44 and 46, which avoids
the formation of a tender scar on the ffn-
ger tip.
Figure 54 shows the placement of inci-
sions for draining a suppuratioe tenosyno-
uitis of th,e second, thi,rd, or fourth finger.Observe that the incisions are along lines
placed at the dorsal limit of the finger-
creases in order to avoid injuring the
digital nerves and artery depicted in Fig-
ure 55.The dotted line on the fifth finger in
Figure 54 represents the position of theincision as it is on the radinl side of the
fifth finger. The reason for the incision onthe radial side of the fifth finger and ulnar
side of the second finger is obvious: to
C L I N I C A L S Y M P O S I A
have the scars where they will be sub-jected to the least friction and trauma.
The incision for draining a thenar
ab,scess is placed on the dorsal aspect of
the web between the thumb and index
finger, Figure 55.
The incision for draining a midpalmar
abscess is shown on Figure 54. This inci-
sion can be made along or slightly proxi-
mal to the dirtal palmar crease. Once
through the palmar aponeurosis en route
to the more deeply situated midpalmar
abscess, it is important for the surgeon to
avoid injuring the digital branches of the
medial and ulnar nerve shown in Figure 7.
Pus from a suppurative tenosynovitis of
the fifth-finger sheath may progress proxi-
mally to the ulnar bursa extending from
the palm to a point four or five centi-
meters proximal to the crease of the wrist.
Figure 54 depicts the three incisions which
might be necessary to promote adequate
drainage. Certainly the incision along the
radialborder of the fifth finger and radial
border of the hypothenar eminence would
be required. If swelling and tenderness
are presented cephalad to the proximal
wrist creasd, a third incision extending
five centimeters proximally from the
crease and along the medial border of the
ulna would be necessary. These three inci-
sions usually allow eficient drainage.
Figures 24 and 28 demonstrate the
pathway of pus from a thumb sheath
infection to the proximal end of the radial
bursa - four or five centimeters cephalad
to the proximal crease of the wrist. In
Figure 54 is seen an incision for opening
the flexor pollicis longus sheath and the
distal part of the radial bursa.
To avoid injuring branches of the
median nerve that supply the thenar mus-
cle, it is best not fo extend the incision
along the ulnar border of the thenar emi-
C I B A 107
nence proximally beyond the mid-point of
the first metacarpal bone. To go fartherjeopardizes the motor branches of the
median nerve, Figure 54. If swelling and
tenderness are noted over the proximalend of the radial bursa, it can be drained
by using the same incision suggested for
draining the proximal end of the ulnar
bursa, Figure 54, or, as some surgeons
prefer, a similarly placed incision on theradial side - making sure to hug the lat-eral border of the radius to avoid cuttingthe radial artery.
If pus from either the ulnar or radial
bursa ruptures into Parona's subtendi-nous space (between the flexor tendonsand pronator quadratus muscle, Figure23), it can be drained by the same inci-
sion used for releasing pus from the proxi-mal end of the ulnar bursa, Figure 54.
The so-called "horseshoe abscess," Fig-ure 49, has to be drained by a combina-tion of fifth finger-ulnar bursa and fexor
pollicis-radial bursa incisions as depictedin Figure 54.
Infection from a human bite poses asomewhat difierent problem. The pres-ence of anaerobes with the usual strepto-cocci and staphylococci alters the patternof treatment. The metacarpophalangealjoint and adjacent tissues and spaces aremost commonly involved because theteeth of the opponent are struck with theknuckle of the clenched fist. When thehand is unclenched. the skin woundretracts proximally covering the deeperpart of the wound within which the bac-teria have been deposited. Obviously, thisairless, traumatized areaforms an ideal sitein which anaerobic organisms can fourish.
Treatment calls for excising a few milli-meters of devitalized skin and underlyingtraumatized tissue so as to lay the woundwide open for thorough surgical cleansing
of the tissues with generous amounts ofnormal saline solution. Penicillin usu-ally helps to subdue the streptococci andstaphylococci but exerts no effect uponthe anaerobes. Based on the theory thatnascent oxygen helps overcome the anaer-obes, Meleny has suggested the use ofmoistened zinc peroxide powder. Theother principles of treatment are the sameas outlined for tendon sheath and fascialspace infections, i.e., adequate heat, ele-vation, and rest with the hand splinted inthe position of function, Figure 41.
If a tendon has been severed, no attemptshould be made to repair it at the time ofthe cleansing procedure. It is best to waituntil several weeks after the .wound has
completely healed.If a bone has been involved, no attempt
should be made to curette the infected
part. It is better to let the sequestrumseparate spontaneously, thereby minimiz-ing the chances of spreading the infection.
TREATMENT OF IIAND INIURIES
It goes without saying that the detailedtreatment of the various types of injurieswhich beset the hand cannot be includedin this article; but, as in the paragraphsdealing with the treatment of hand infec-tions, the general principles involved willbe briefy described.
The ideal time to clean any recently sus-tained wound is the ftrst time. Therefore.the immediate emergency treatmentshould consist of no more than the appli-cation of a sterile dressing (with pressureif there is bleeding) and immobilizationwith a splint. The patient should be takenat once to a well-equipped dressing roomor operating room,where gloved, gowned,and masked, the surgeon can do a thor-ough job of cleansing so as to permit pri-
mary closure, if conditi,Before the advent of
duration of the so-called'for treatment of an averaincised. contaminated wc
eight hours after the inju
period, a wound with nosue or gross foreign bodier
which the devitalized tisbodies can be removed
should be g iven a thorcleansing with generous r
mal saline solution sloshrwound with a piece of garor anything hard ). If therindications, a primnry clotmade. While antibioticsextension of the "Gold
several hours, the generremoval of devitalized tis
bodies, followed by thorcgical cleansing of the wor
Within the "Golden Itendons or nerves can uslif the wound has beercleansed. Because of lostendon or nerve ends sobe approximated with tl
position of function. Themay then have to be flexas the case may be, in ormate the ends of these strtension.
The sutures approxin
edges should not be undsafer to apply a split grasurface than to have I
suture line.
The so-called secondnr,used if the wound is see"Golden Period" has elalthis time, the wound is 5oughly cleansed with geof normal saline solution i
vith generous amounts of
solution. Penicillin usu-
bdue the streptococci and
rut exerts no effect upon
Based on the theory that
helps overcome the anaer-
has suggested the use of
: peroxide powder. The
iof treatment are the same
tendon sheath and fascial
s, i.a., adequate heat, ele-
:with the hand splinted in
function, Figure 4I.
rs been severed, no attempt
l to repair it at the time of
rocedure. It is best to wait
eeks after the .wound has
led.
been involved, no attempt
le to curette the infected
:er to let the sequestrum
,neously, thereby minimiz-
of spreading the infection.
YT OF rrAND rNJttRrES
ut saying that the detailed
e various types of injuries
: hand cannot be included
but, as in the paragraphse treatment of hand infec-
al principles involved will'ibed.
,e to clean any recently sus-
s the fust time. Therefore.
e emergency treatment
rf no more than the appli-
Lle dressing (with pressureding) and immobilization
he patient should be taken
ll-equipped dressing room
)m, where gloved, gowned,re surgeon can do a thor-
ansing so as to permit pri-
mary closure, if conditions warrant it.
Before the advent of antibiotics, the
duration of the so-called "Golden Period"
for treatment of an average lacerated or
incised, contaminated wound was six to
eight hours after the injury, During this
period, a wound with no devitalized tis-
sue or gross foreign bodies (or a wound in
which the devitalized tissue and foreign
bodies can be removed with certainty)
should be g iven a thorough surg ical
cleansing with generous amounts of nor-
mal saline solution sloshed gently in the
wound with a piece of gauze (not a brush
or anything hard). If there are no contra-
indications, a primary closure can then be
made. While antibiotics have permittedextension of the "Golden Period" by
several hours, the general principle of
removal of devitalized tissue and foreign
bodies, followed by thorough, gentle sur-
gical cleansing of the wound still applies.
Within the "Golden Period." severed
tendons or nerves can usually be sutured
i f the wound has been sat is factor i ly
cleansed. Because of loss of tissue, the
tendon or nerve ends sometimes cannot
be approximated with the hand in the
position of function. The hand or fingers
may then have to be flexed or extended,
as the case may be, in order to approxi-
mate the ends of these structures without
tension.
The sutures approximating the skin
edges should not be under tension. It is
safer to apply a split graft over the raw
surface than to have tension on the
suture line.
The so-called secondnry closure can be
used if the wound is seen iust after the"Golden Period" has elapsed. If seen at
this time, the wound is gently and thor-
oughly cleansed with generous amounts
of normal saline solution (soap and water
C L I N I C A L S Y M P O S I A
if there is grease in the wound) and then
a gauze pack moistened in normal saline
is placed in the wound. After 24 to 48
hours, the pack is removed and the wound
inspected. If the tissues look clean and
viable, closure is then made with fine silk
sutures.
Following either primary or secondary
closure, the hand is adequately dressed
and put in the position of function in a
comfortably applied splint. The treatment
of extensive injuries with much loss of
skin or segments of tendons, nerves, or
muscles is much more compl icated.
Hence, the reader is referred to articles
and books by the authors mentioned in
the conclusion below.
CONCLUSION
Regardless of the pathologic change
that one encounters in the hand, it is
quite obvious that intelligent treatment
demands, ffrst of all, a sound knowledge
of structure. Therefore. this article has
been designed simply as a review of the
surgical anatomy. The author has men-
tioned only enough of the pathology and
surgery to assist in visualizing the perti-
nent anatomy.The reader who expects to be charged
with responsibility for surgical proce-
dures involving the hand is referred to the
works of Kanavel, Auchinchloss, Koch,
Mason, Bunnell, Littler, and others who
have outlined in far greater detail the
management of infections and the various
complicated procedures that are neces-
sary for the rehabilitation of hands that
have been badly damaged.
Brief as this article has been, the author
hopes that it will help the reader to visual-
ize, and to remember, the rather intricate
details of the surgical anatomy of the hand.
C I B A 109
-F6-.t.EE'
provides more'livingtimei forthehypdrtensive
withtlsixke1action.Increiblood 1.Slows.Mainlblood 1.Relier.Calm.Loweeffecti'Fot prcscribing intomation, plei
- c )is)reor thee
with thesesix keyactions.lncreases renalblood flow.Slows rapid heart rate.Maintains cerebralblood flow.Relieves edema.Cal ms tense patients"Lowers blood pressureeffectively
Fot prescribing intormation, piease see back covet fold-out page.
{
LOCACORTEN%VIOFORM'modern skin therapythat elicitsexcellent response
Stops itchingand burningRelievesinflammationQuickly
o Promotes healingo Prolonged in effecto Broad spectrum of actiono Well toleratedo Sensitizalion is rareo Virtually non-toxic
DRAMATIC
ffiilffiFor pre
DOSAGEOne or two tab le tthen ad jus t as neelowest effective d(
Prescribing Note
Ser-lI N DI CATI ONSHyper tens ion , espanx ie ty , impa i rededema.
SI DE-EFFECTSThe s ide e f fec ts a lcomponent d rugs ,dosages o f each cthe f requency o f t l
Serpas i / ; Lass i tudd ia r rhea, inc reasercongest ion may b(headache, b izar reNasa l congest ion isecre t ions somet i rt rea ted w i th the d lsuch as top ica l apcons t r i c to rs and/ocomes th is p rob le l
Aprcsoline: Tachyld izz iness , weakne lhypotens ion , numlex t reml t ies , f lush i rt ion , con junc t iva lsymptoms, rash , dhemoglob in and r€and a lupus- l i ke s )cases fo l low ing ad
Esldr/xr Nausea, anr t rogen re ten t ion ,hypoka lemia . Rar€sk in rash , photosecy'tos\s.
CAUTI ONSSe/paslir Depressunmasked by resesomet imes ac t iveiza t ion fo r e lec t ro rd r u g s h o u J d b e w ie lec l rve surgery ; (E lec t roshock therdrawal o f the dru(w i t h d i g i t a l i s , q u i r
Apreso/ lne ; Use cadvanced rena l decerebra l i schemianarcotic effects ofPer iphera l neur i t i sn u m b n e s s a n d t i nPub l ished ev idencef fec t and add i t io ri f symptoms deve l
Esidrlx; With Esidand/or labora toryleve ls shou ld be scor rec ted . Excessprevented by adecporass um suppte lpa t ien ts on d iq i taadvanced rena l farecent card iac o r (d iabetes . Hydrochs iveness to exoge(norep inephr ine) €tubocurar ine . Hypanesthes ia have brece iv ing th iaz ider
Use SerAp-Es w l tcoronary artery dirvascu la r acc idents
CONTRAI NDICATFor Es id r ix , o l igurFor Serpas i l , a h is
S U P P L I E DTab le ts (p ink) , ea(( reserp ine) 0 .1 mghydroch lo r ide) 25ch lo ro th iaz ide) 15
L
INFECTED ECZEMABefore t reatment wi thLOCACORTEN-vtoFoF[,4
After 2 weeks't reatment wi thLOCACORTENVIOFORM
For p resc t ib ing in fa rmat ian , p /ease see back cover lo ld 'ou t page
f'
)FORM' Ser-Ap-EsPrescribing Notes
I N D I C A T I O N SH y p e r t e l s i o l , e s p e c i a l l y w h e n c o m p ' c a - e d b yanx ie ty , impa i red or degenera t ing rena l Junc t ion ,edema.
DOSAGEO n e o r t w o t a b l e t s , b . i . d . , i n i t i a l l y , f o r t w o v r ' e e k sthen ad jus t as needed. For ma in tenance, thel ^ , ^ / a a t a l f a . t \ / a d ^ . . ^ a
SI DE-EFFECTSThe s ide e f fec ts a re those o f the ind iv idua lc o m p o n e n t d r u g s , a i t h o u g h w i t h t h e r e d u c e ddosages o f each componen l in the combina t ionthe f requency o f the s ide-e f fec ts i s reduced.
Serpas l / r Lass i tude, d rows iness , depress ion ,d ia r rhea, Inc reased gas t r i c secre t ion , o r nasa lcongest jon may be ev ident . Ny 'o re ra re ly anorex ia ,h e a d a c h e , b r z a r r e d r e a m s , n a u s e a , d i z z l n e s s .Nasa l congest ion and increased t racheobronch ia lsecre t ions somet imes occur in bab les o f motherst rea ted w i th the drug . Symptomat ic t rea tment ,s u c h a s t o p i c a l a p p l i c a t i o n o f n a s a l v a s o -cons t r i c to rs and lo r an t ih is tamines usua l ly over -c o m e s t h i s p r o b l e m .
Apreso l ine : Tachycard ia , headache, pa lp i ia t ion ,d r z z i n e s s , w e a k n e s s , n a u s e a , v o m i t i n g , p o s t u r a lh y p o t e n s i o n , n u m b n e s s a n d t i n g l i n g o i t h ee x t r e m r t r e s , f l u s h i n g , n a s a l c o n g e s t i o n , l a c h r y m a -t i o n , c o n l u n c t i v a l i n j e c t i o n , d y s p n e a , a n g i n a lsymptoms, rash , d rug fever , reduc t ion inh e m o g l o b i n a n d r e d c e l l c o u n t , g i a n t u r t i c a r i a ,a n d a l u p u s - i i k e s y n d r o m e ( a r t h r a l g l a ) i n s o m ec a s e s f o l l o w i n g a d m i n i s t r a t i o n f o r l o n g p e r i o d s .
F s l d f l { r N a u s e a , a n o r e x . a . h e a d a c l e . e s r ' e s s n e s s ,n i t rogen re ten t ion , hyperur icemia , hyperg ycemia ,h \ p o r a l o n , a . R a r e v , l h r o r b o c y t o p e l c p - r p u a .sk in rash , photosens i t i v i t y , u r t i car ia and agranu lo-cy tos is .
CAUTI ONSSerpas / / : Depress ion may be aggravated orunmasked by reserp ine ; usua l ly revers ib le , bu ts o m e t i m e s a c t i v e t r e a t m e n t , i n c l u d i n g h o s p i t a l -i za t ion fo r e lec t roshock , may be needed. Thedrug shou ld be wt thdrawn two weeks pr io r toe l e c l , v e s u r g e ' y i o t h e l w i s e a d v , s e a l e s t h e t i s l .E lec t roshock therapy w i lh in seven days o f w i th -drawal o f the drug is hazardous . Use caut lous lyw i t h d i g i t a l i s , q u i n i d i n e o r g u a n e t h i d i n e .
Aprcsa l ine : Use caut ious ly in the presence o fadvanced rena l damage and recent coronary o rcerebra l i schemia . The drug may po ten t la te thenarco t rc e f fec ts o f barb i tu ra tes and a lcoho l .P e ' p h e r a l r e L r ' t : s , e v , d e . c e d b y p a ' e s r l - e s i a s ,n u m b n e s s a n d t i n g l i n g , h a s b e e n o b s e r v e d .P u b l i s h e d e v j d e n c e s u g g e s t s a n a n t i - p y r i d o x i n eef lec t and add i t ion o f py ldox ine to the reg imeni f symptoms deve lop .
Es ld r ry ; Wi th Es id r ix , jn p ro longed therapy , c l in ica land/or labora tory f ind ings fo r f lu id and e lec t ro ly tel e v e l b s l - o J ' d b e s t L d i e d r e g u a r l y , a 1 d i T b a l a n c e scor rec ted . Excess ive po tass ium loss can beprevented by adequate in take o f J ru i t ju ices orp o t a s s i u m s u p p l e m e n t s . U s e c a u t i o u s l y i npat ien ts on d ig i ta l i s , and in the presence o fadvanced rena l fa i lu re , impend ing hepat ic coma,recent card iac o r cerebra l i schemla , gout , o rd a b e t e s . H y d r o c h l o r o t h i a z . d e d a c r e a s e s r e s p o n -srveness to exogenous ly admin is te red Ievar te reno l(norep inephr ine) and increases respons iveness totubocurar ine . Hypotens ive ep isodes underanes thes ia have been observed in some pat ien tsrece iv ing th iaz ides . Use caut ious ly in p regnancy .
Use Set rAp-Es w i th caut ion in pa t ien ts w i thcoronary a r te ry d isease, a h is to ry o f cerebra lv a s c J J a . a c c i d e n l s , p e p t i c L l c e r .
CONTRAI N DI CATI ONSF o r E s i d r i x , o l i g u r i a o r c o m p l e t e r e n a l s h u t d o w n .For Serpas i l , a h is to ry oJ pept ic u lcer ; o r over tdepressr on .
S U P P L I E DTab le ts (p ink) , each conta in ing Serpas i l@(reserp ine) 0 .1 mg. , Apreso l ine@ (hydra laz inehydroch lo r jde) 25 mg. , and Es id r ix@ (hydro-ch lo ro th iaz ide) 15 mg. i bo t t les o f 100 and 500.
Slow-l(INDICATIONS A l l c i rcumstances in wh lchpotass ur sLpp lemenla l io r i s necessary . andpar t i cu la r ly dur ing pro longed or in tens ivedrure t ic therapy .
Patients at special risk are those wlth advanced hepat ic c r rhos is o r chronrc rena d isease, pa t ien ts w i th cons iderab le edema (par -l r u u a t l y ' J r r 1 a . y o u l p J l 5 , a r g e J . p a t e n t s o 1a sa t restricted diet and patients receiv ng dig-i ta ls (a lack o f po tass ium sens i t zes the myo-card ium to the tox ic e f fec ts o f d ig i ta l i s ) .
The range o f ind ica t ions fo r S ow-K may besu mmar zed as f o l lows
As a supp lement to d iu re t i csHypoch loremic a lka los isCush ing 's SyndromeStero id therapyL iver c l r rhos isD iseases charac ter ized by pers is ten t vom t ing
or o tarrneaD g italis therapyUlcera t ve co l i t i sSteatorrheaChron ic d ia r rheaReg iona l i le t i sCon l inuous w i thdrawal o f gas t ro in tes t ina l
f lu idsI eosro myNeoplasms or obstructions referable to the
g d J U u I r v 5 { i l r a u a L I
DOSAGE-The dosage is de le rmined accord-ing to the needs o f the ind iv idua pa t ien t .When admin is te red as a po tass ium supp le-ment dur ing d iu re t i c therapy , a dose ra t io o fone S low-K tab le t w i th each d iu re t i c tab le t w i l lusda l y su ' l i cp . ou l may be Increased as necessary In genera l , a dosage range be twee l2-6 S low K tab le ts (approx lmate ly 1 6 -48 mEqK +) da i l y , o r on a l te rna te days , w i l l p rov ideadequate supp lemenlary po tass lum in mostcases . Pre ferab ly , admln is te r a f te r mea ls .
Warning-A probable assoclation ex sts between the use o f coa ted tab le ts conta in ing po-tass ium sa ts , w i th o r w i thout th az ide d iu re t i cs ,and the inc idence o f ser ious smal l bowel u lcera t lon . Such prepara t ions shou ld be usedon ly when adequate d ie ta ry supp lementa t lonis no t p rac t ca l , and shou ld be d iscont lnued i fabdorn ina l pa ln , d i s ten t ion , n ausea, vomi t ingor gas t ro ln tes t ina l b leed ng occurs .
S IDE EFFECT-To da te , near lyI 000,000,000 tab le ts o f S ow K and CIBA thazide tab ets cofta ning the slow release po-tass ium core have been used. On ly one caseof smal l bowel u lcera t ion fo l low ing t rea tmentw i th a comb nat ion tab e t con ta in ng cyc lop e n l l - , a 1 d e . r e s e r o i n e . a n d K C r h a s b e e n r e -por led .
CAUTIONS-Admin is te r cau t ious ly to pa t ien tsin advanced rena l fa i lu re to avo id poss ib , le hy-perka lemia . S low-K shou ld be used w i th cau-t on in diseases associated with heart blocks nce in { reased sprJm po lass iJn may in
u c g r E c u r u , u u ^ .
CONTRAIN DICATIONS-Fena i impa i rmen lw i th o l igur ia o r azo temla , un t rea ted Add ison 'sD isease, myoton ia congen i ta , hyperadrena-l i sm assoc ia ted w i th adrenogen i ta syndrome,acute dehydra t ion , heat c ramps and hyperka-lemia o f any e t io logy .
SUPPLIED Tab le ts (pa le o range, coated)each conta in ing 600 mg. o f po tass ium ch lo -r ide in a s ow- re lease, iner t wax core ; bo t t leso f 1 00 and 1 000.
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INFECTED ECZEMABefore t reatment wi thLOCACORTEN-V IOFORM
After 2 weeks't reatment wi thLOCACOFTEN-V IOFORM
Presctibing Notes
LOCACORTENgVIOFORM'I N D I C A T I O N SLocacor ten-V io fo rm is recommended in thet rea tment o f sk in d isorders compl ica ted bybac ter ia l and/or funga l in fec t ions .Locacor ten-V io fo rm is recommended fo r con-t ro l l ing secondary in fec t ions , espec ia l l y thoseassoc ia ted w i lh occ lus ive dress ing therapy . l t i si n d i c a t e d i n :
d e r m a t o m y c o s i s l i c h e n s i m p l e x c h r o n i c u spyoderma a top ic dermat i t i sfo l l i cu l i l i s chron ic neurodermat i t i simpet igo nummular dermal i t i sl i chen p lanus in fec t ious dermat i t i ss t a s i s d e r m a t i t i s s e b o r r h e i c d e r m a t i t i sneurodermat i t i s eczemato id dermat i t i sacne anogen i ta l Prur i tusp s o r . a s i s c o n t a c t d e r m a t i t i sin te r t r ,go (dermat i t i s venenata)a n d m a n y s i m i l a r c o n d i t i o n s
Locacor ten-V io fo rm Cream has a s l igh t ly d ry ingef fec t , p r imar i l y use fu l fo r mo is t , weep ing les ionsand in in te r t r ig inous areas . The Oin tment i sespec ia l l y ind ica ted fo r d ry les ions accompan iedby th icken ing and sca l ing o f the sk in .
A P P L I C A T I O N A N D D O S A G ELocacor ten-V io fo rm shou ld be app l ied to theaf fec ted areas in a th in f i lm th ree or Jour t imesda i ly . The s i te may, i f necessary , be covered bya p r o t e c t i v e d r e s s i n g . T r e a l m e n t s h o u l d b econt inLed lo r a t leas t a few days a f te r c lear ingo f t h e l e s i o n s .
SI DE-EFFECTSRare ly , m i ld i r r i ta t ion . Wi th occ lus ive dress ings ,a few cases o f s t r iae o l the sk in have beenrepor ted . A l though ra re , a sens i t i v i t y to V io fo rmmay deve lop . l i an exacerbat ion or a l le rg ic typereac t ion occurs , t rea tment w i th Locacor ten-V o f o r m s h o L l d b e d : s c o n t i n u e d .
P R E C A U T I O N SVio form, as we l l as o ther iod ine-conta in ingcompounds, in te r fe res w i th some thyro id func t iont e s t s ( s u c h a s P B l , r a d i o a c t i v e i o d : n e u p t a k e a n db J - a 1 o l - e x t r a c t a b l e i o d i n e ) , w h : c h s h o u l dthere fore no t be per fo rmed w i th in a per iod shor te rthan th ree months Jo l low ing the use o i Locacor ten-V io fo rm. Other thyro id Junc t ion tes ts , such asthe T3 res in sponge tes l , o r the T ! de termina t ion ,are unaf fec ted by V io fo rm.
I n p r o l o n g e d o c c l u s i v e t h e r a p y , l h e p o s s i b i l i t y o fmetabo l ic sys temic e l fec ts shou ld be kepti n m i n d .
Locacor ten-V io fo rm may cause s ta in ing o f thes k i n , n a i l s , h a i r , o r f a b r i c s .
C O N T R A I N D I C A T I O N STubercu los is o t the sk in , ch icken-pox , p regnancy ,s k i n e r u p t i o n s f o l l o w i n g v a c c i n a t i o n , o r i n v i r a ld iseases o f the sk in in genera l . Locacor ten-Vro form shou ld no t be employed to t rea t eyed isorders , o r syph i l i t i c a f fec t ions o f the sk in .
S U P P L I E DCream, conta in ing 37o V io fo rm@ ( iodoch lor -hyd roxyq u i n ) a r d 0 .02o/o Locacor ten@ ( f I u m e th a .sore p iva la te ) i r a water -washab le base; tubeso f 1 5 a n d 5 0 G m .
Ointment, containing 37o Vioform@ and o.02o/oLocacor ten@ in a pe t ro la tum base i tubes o f1 5 a n d 5 0 G m . a n d j a r s o f 1 l b .
I N D I C A T I O N SOral: Mild to moderate depression/anxiety;fa t ;gue, le thargy ; d rug- induced sedat ion ,neuroses ; apathy , w i thdrawal ; m i ld sen i le con-{us ion , de tachment , and in func t iona l behav io rprob lems in ch i ld ren (hyperac t iv i t y , s tu t te r ing , e tc . )
Parenteral: Effective in sedative overdosageemergenc ies , has ten ing recovery f rom anes thes ia ,inc reas ing response to psychotherapy , a lcoho l ismand overcoming drug- induced Ie lhargy .
DOSAGEOtal:l n i t i a l l y , t w o 1 0 - m g . t a b l e t s i n t h e m o r n i n g , o n eat noon, and one more , i f necessary , a t 5 i00 p .m.For ma in tenance, rev ise as needed.
SI DE.EFFECTSNervousness or insomnia , i f p resent , can beavo ided by dosage- reduc t ion or by omi t t ingRi ta l in in the a f te rnoon. Repor ts no te a Jew casesof anorex ia , d izz iness , headache, pa lp i ta t ions ,drows iness , sk in rash , over t psychot ic behav io rand psych ic dependency .
CAUTI ONSNot recommended fo r severe depress ions , exceptin hosp i la l under c lose superv is ion . Pat ien ts w i thag i ta t ion may reac t adverse ly . Use caut ious ly inthe presence oJ marked anx ie ty o r tens ion .F l i ta l in may po ten t ia te the e f fec t o f p ressor agents iexerc ise care in use w i th ep inephr ine , levar te reno l ,o r a n g i o t e n s i o n a m i d e . W h i l e o r a l R i t a l i n h a sl i t t le o r no e f fec t on normal b lood pressure , usecaut ious ly in pa t ien ts \ ryho have hyper tens ion .R i ta l in i s s tab le indef in i le ly in l yoph i l i zed fo rmbu l shou ld be used w i th in 2 months a l te r theso lu t ion is p repared. Do no t in jec t Parentera lSo lu t ion th rough tub ing or a sy r inge wh ichconta ins a barb i tu ra te o r s t rong ly a lka l ineso lu t ion , s ince a heavy prec ip i ta te i s to rmed.
C O N T R A I N D I C A T I O N SG l a u c o m a , e p i l e p s y .
SIJPPLI EDAl l io rms conta in methy lphen ida te hydroch lo r ide .Tab le ts o f 10 mg. (pa le b lue , scored) ; bo t t les o l100 and 500.Tab le ts o ' 20 mg. (peach. scored) : bo t t les o f1 0 0 a n d 5 0 0 .A m p o u l e s o f 2 0 m g . ( l y o p h i l i z e d ) t b o x e s o f1 0 a n d 1 0 0 .
I WKa winnerfor'K-losers'
"Slow-K (pofassium chloride)tablets are the onlysaiisf,actory method ofgiving potassiu* by mouth."O ' D r s c o B . J , P o t a s s i u m C h l o r i d e w t h D u r e t c sB r t . l v e d . J ( l 9 6 6 ) , 2 3 4 8
Slow-Kslow-release potasslum chlor ide tablets
cSlow-K provides a steady K+ absorpt iono v e r 3 t o 4 h o u r s .
s For the 3-4 hours of Slow-K absorpt ion anyunder ly ing K* loss is countered , e .9 . ,dur ing diuret ic therapy
e SIow-K tablets are sugar-coated, palatableand easi ly swal lowed.r Slow-K contains Cl ion which is physiological lyessent ial to ensure K* absorpt ion andretent ion in pat ients with a tendency to developmetabol ic alkalosis,
And now CIBA introduces
r No b icarbonate in Slow-K which cannottherefore accentuate metabol ic a lka los is .
r Slow release of K + f rom Slow-K is lessl ike ly to produce hyperkalemia in cases ofrena l impa i rmen t .
r Each Slow-K tablet prov ides 600 mg.KCI (8mEqK+) rn an easi ly- taken tablet .
r S low-K is economical
C I B ADORVAL 780, QUEEECF a t p L a s c r D t n q t n l a r o t a l i a n f / . n s a s . . ' b i t . : k c a v e t l e l . l a u t D a g (