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THE SKIN
1. Flexure creases (lines of palm)
2. Papillary ridges (fingerprints): improve grip & increase surface area
3. Abundant sweat gland
DEEP FASCIA
• PALM: thickened at 3 sites:
Palmar aponeurosis:• Definition• Description• Function• Clinical anatomy:
Dupuytren’s contracture
PALMAR APONEUROSIS• DEFINITION: It is a thickening of deep fascia in the
middle of the palm• DESCRIPTION: It is triangular in shape:1. Apex: directed proximally, continuous with tendon of
palmaris longus2. Base: directed distally, divided into 4 slips for the
medial 4 fingers3. Margins: send septa to metacarpal bones separating
the structures under the aponeurosis from thenar & hypothenar muscles
• FUNCTION: It protects the underlying tendons, vessels & nerves
• CLINICAL ANATOMY: DUPUYTREN’S CONTRACTURE: shortening of the medial part of aponeurosis resulting in flexion of the little & ring fingers
DEEP FASCIA
Flexor retinaculum:• Definition• Attachments• Relations• Functions• Clinical anatomy:
Carpal tunnel syndrome
FLEXOR RETINACULUM
• DEFINITION: It is a thickening of deep fascia that lies over the front of the carpal bones converting the carpal groove (formed by carpal bones) into a tunnel
• ATTACHMENTS: 1. Lateral: by 2 laminae: superficial (to
tubercles of scaphoid & trapezium) & deep (to the medial lip of the groove on the trapezium)
2. Medial: to pisiform & hook of hamate
FLEXOR RETINACULUM• RELATIONS: • Superficial: from lateral to medial:1. Superficial palmar branch of radial artery2. Palmar cutaneous branch of median nerve3. Tendon of palmaris longus4. Palmar cutaneous branch of ulnar nerve5. Ulnar vessels6. Ulnar nerve• Deep: Structures passing through carpal tunnel1. Tendon of FPL & its synovial sheath (radial bursa)2. Tendons of FDS & FDP & their common synovial sheath
(Ulnar bursa)3. Tendon of FCR & its synovial sheath ( in a special
compartment)4. Median nerve
FLEXOR RETINACULUM
• FUNCTION: It keeps the flexor tendons in position during movement of wrist joint
• CLINICAL ANATOMY (CARPAL TUNNEL SYNDROME): Compression of median nerve under the flexor retinaculum
FIBROUS FLEXOR SHEATH
• DEFINITION: It is a thickening of deep fascia in front of the fingers
• ATTACHMENTS: 1. Proximal: to the slips of palmar
aponeurosis2. Distal: to the base of distal phalanx3. On either side: to the side of phalanx• FUNCTION: It holds the long flexor
tendons during flexion of the fingers
INTRINSIC MUSCLES
• LATERAL GROUP:LATERAL GROUP: FOUR THENAR MUSCLES• MEDIAL GROUP:MEDIAL GROUP: THREE HYPOTHENAR MUSCLESPALMARIS BREVIS• CENTRAL GROUP:CENTRAL GROUP: FOUR LUMBRICALSFOUR PALMAR INTEROSSEIFOUR DORSAL INTEROSSEI• ALL MUSCLES ARE SUPPLIED BY C8 & T1 SPINAL ALL MUSCLES ARE SUPPLIED BY C8 & T1 SPINAL
SEGMENTS THROUGH SEGMENTS THROUGH MEDIAN & ULNAR NERVESMEDIAN & ULNAR NERVES
THENAR MUSCLESTHENAR MUSCLES
THENAR MUSCLESTHENAR MUSCLES1. Abductor pollicis brevis2. Flexor pollicis brevis3. Opponens pollicis4. Adductor pollicisN.B.:• Muscles # 1, 2, 4 are inserted into the
proximal phalanx of thumbproximal phalanx of thumb: act on MP & CM joints of thumb
• Muscle # 3 is inserted into 11stst metacarpal metacarpal bonebone: opposition of CM joint of thumb (abduction + flexion + medial rotation)
HYPOTHENAR MUSCLESHYPOTHENAR MUSCLES
HYPOTHENAR MUSCLESHYPOTHENAR MUSCLES• Abductor digiti minimi• Flexor digiti minimi• Opponens digiti minimiN.B.:• Muscles # 1, 2 are inserted into the
proximal phalanx of little fingerproximal phalanx of little finger: act on MP joint of little finger
• Muscle # 3 is inserted into 55thth metacarpal metacarpal bonebone: rotates 5th metacarpal bone
LUMBRICALSLUMBRICALS
1.1. Origin:Origin: tendons of FDP
2.2. Insertion:Insertion: tendons of ED
3.3. Action:Action: Writing positionWriting position (flexion of MP & extension of IP joints of medial 4 fingers
INTEROSSEIINTEROSSEI• PALMAR INTEROSSEIPALMAR INTEROSSEI
1.Origin: metacarpal bone
2.Insertion: proximal phalanx
3.Action: Adduction of fingers (PAD)(PAD)• DORSAL INTEROSSEIDORSAL INTEROSSEI
1.Origin: adjoining sides of 2 metacarpal bone
2.Insertion: proximal phalanx
3.Action: Abduction of fingers (DAB)(DAB)
PALMARIS BREVIS
1.1. Origin:Origin: Palmar aponeurosis
2.2. Insertion:Insertion: skin of medial border of hand
3.3. Action:Action: deepening the hollow of palm to get a firmer grip
ARTERIAL ARCHES IN HAND
• SUPERFICIAL PALMAR ARCH
• DEEP PALMAR ARCH
1. Formation
2. Site
3. Surface anatomy
4. Branches
SUPERFICIAL PALMAR ARCH
• FORMATION:FORMATION:1. Direct continuation of ulnar artery (mainly)2. Superficial branch of radial artery• SITE:SITE: between palmar aponeurosis & long flexor
tendons• SURFACE ANATOMY:SURFACE ANATOMY: level with the distal border
of the fully extended thumb• BRANCHES:BRANCHES: digital branches to the medial three &
half fingers• N.B.: Radial artery gives 2 branches that supplies
the lateral one & half fingers:1.1. Radialis indicis:Radialis indicis: supplies lateral side of index2.2. Princeps pollicis:Princeps pollicis: supplies both sides of thumb
DEEP PALMAR ARCH
• FORMATION:FORMATION:1. Direct continuation of radial artery (mainly)2. Deep branch of ulnar artery• SITE:SITE: between long flexor tendons &
metacarpal bones• SURFACE ANATOMY:SURFACE ANATOMY: lies one inch
proximal to superficial palmar arch• BRANCHES: BRANCHES: 1. Branches sharing in anastomosis around
wrist joint2. Articular & muscular branches
ULNAR NERVE IN THE HANDULNAR NERVE IN THE HAND
• MUSCULAR BRANCHES:MUSCULAR BRANCHES: 1. Palmaris brevis2. Adductor pollicis3. Hypothenar muscles4. Interossei5. Medial two lumbricals• CUTANEOUS BRANCHES: CUTANEOUS BRANCHES:
Palmar digital to medial 1 ½ fingers