Hand Anatomy
Riche Cannieu anastomosis
Communication between deep ulnar branch to the recurrent median thenar branch and results in ulnar innervation of the thenar muscles.
Berretini anastomosis
Communication between the ulnar 4th common digital nerve and the median 3rd common digital nerve
Marinacci anastomosis
Communication between ulnar and median nerve in the forearm reverse Martin Gruber
Check rein ligaments are most often implicated in:
Contracture development
ECRL 4 tail Brand's Intrinsic Transfer
Free tendon graft sutured t teh distal end of the eCRL tendon and divided into 4 slips.
Egwas's sign
Indicator of ulnar nerve and interosseus muscle paralysis which means the patient is able to flex the MF but not able to RD pr UD
Saddle syndrome
Interosseous and lumbrical tendons join distal to the deep transverse metacapral ligament. Has pain with Bunnell test (passive lfexion of the IPJ's while MCPJs are supported in extension).
Rupture of the transverse retinacular ligament of PIPJ results in:
Swan neck deformity The transverse retinacular ligament is a stabilization structure of the lateral bands of PIPJ Dorsal migration of lateral bands
Difference between Wartenberg SIGN and SYNDROME
Sign = Small finger assumes abduction. Absent 3rd volar interosseous muscle creates an implace with the intact extensor digti minimi Syndrome = Compression of radial sensory nerve with possible dysthesia over the dorsal fist web space. Egawa's sign = inability to ABduct and ADDuct LF Benediction sign = ADDuction of thumb and the extension of the 2nd and 3rd MCP joints due to lumbrical paralysis in median nerve injuries.
PIN innervates which 8 muscles
Supinator Extensor carpi radialis brevis Extensor digitorum Extensor pollicis longus + brevis Extensor indicis proprius Extensor digiti minimi Abductor pollicis longus
Positive external rotation lag sign
Tear of suprapinatus and infaspinatus ER lag test: ER humerus and abduct humerus to 20 degrees while supporting at the wrist.
What finger function do sagittal bands perform
The centralize the common extensor tendons over the MCP & extend MCPs On both the radial and ulnar side of each MCP They keep the ED tendons in place on dorsal side Sagittal band AKA shroud fiber
Extensor indicis proprius innervation
posterior interosseous nerve
palmaris brevis innervation
superficial branch of ulnar nerve
2 structures form the roof of the cubital tunnel
Fascia of the FCU Arcuate ligament of Osborne
Quadrigia
Tethering effect causing decrease in flexion of adjacent finger
Which muscles arise from common flexor origin
PT PL FCR FCU FDS
Artery that passes through the anatomical snuffbox
Radial artery
Base of snuff box
Scaphoid APL/EPB (radial) and EPL (ulnar)
Bouvier test
Used to determine if PIPJ capsule and extensor mechanism are working normally
Space of Poirier
Weakness from an absence of ligamentous support of the lunate/capitate articulation The arrangement of the volar extrinsic ligaments can be thought of as a V within a V formation.
Secretan's syndrome
aka Wallbanger's dx Edematous process over dorsal metacarpal area S's: self inflicted / secretan's syndrome
Pronator quadratus innervation
anterior interosseous nerve
Adductor pollicis innervation
deep branch of ulnar nerve
Brachioradialis innervation
radial nerve
Blood vessels requires ___ - ___ weeks of splint protection
1-2 weeks of orthosis wear Injury to vascular structures of the UE are typically accompanied by injury to other soft issues such as tendon and nerve. Be aware of arterial insufficency signs: skin pallor, decreased temp, pain, slow capillary refill, cyanosis and loss of pulse.
Scapholunate ligament complex consists of:
1. Dorsal and volar ligamentous portions 2. Central membranous portion *Dorsal portion considered strongest for kinematics during wrist motion. If disrupted may cause DISI. Widening of the scapholunate interval of greater than 4mm, a scaphoid "ring" sign. Scaphoid lunate lig injury = pain and clunk (1 cm distal to Lister's tubercle). SCAPHOID SHIFT TEST will reproduce clunk.
What is a pseudo boutonniere
= Flexion deformity of PIP without DIP involved which is caused by proximal avulsion of the volar plate. Jamming hyperextension injury tearing volar plate. Pt holds finger in protectice flexed posture and volar plate heals in shortened position.
Strongest muscle of anteposition (opposition)
Abductor pollicis brevis
Tigthens with extension of the PIPJ and loosens in flexion
Accessory collateral ligament
Intrinsic minus position
Claw hand occurs when intrinsic muscles are too injured to be repaired at surgery. The distal portion becomes ischemic and causes loss of muscle function and may scar the intrinsic tendons into their canals in a lengthened position.
Linburg's sign
Anatomic interconnection of the Flexor pollics longus and flexor digitorum profundus of index finger Lindburg syndrome can occur when this interconnection leads to pain and aggravation with activity. Discomfort located over the radiopalmar aspect of the distal forearm and thumb. To assess Linburg's sign have pt flex thumb IPJ; look for involuntary motion at the index finger DIP.
Function of the TFCC
Assist in stabilizing DRUJ and control force transmission through ulna during WB and gripping activities
Kienbock's disease
Avascular necrosis of the lunate proximal row carpectomy performed as first line intervention
Veins of the "M" shaped pattern in volar forearm
Basilic, cephalic and median cubital vein. Cephalic is raidal Basilic is ulnar
Lacertus fibrous refers to which FA muscle
Bicipital aponeurosis
Major arterial supply to the forearm and hand
Brachial artery continues from the axillary artery and travels distally along the medial arm. At the AC fossa, the brachial artery dives below the lacertus fibrosis and splits into radial and ulnar arteries. *The brachial artery is the major inflow vessel to the forearm and hand
Mobile Wad of Henry
Brachioradialis Extensor carpi radialis brevis Extensor carpi radialis longus AKA mobile wad of three
Quadrigia phenomenon
Can occur if the flexor digitorum profundus is advanced more than 1cm during repair, thus resulting in limited proximal excursion of the remaining flexor digitorum profundus tendons.
Which 2 structures are involved in a Boutonniere deformity
Central slip Triangular ligament *6 weeks PIP full extn orthotic with DIP free Goal to rebalane lateral bands during orthotic period *Boutonniere deformity results from volar migration of lateral bands.
Stabilizes the MCP volar plate
Deep transverse metacarpal ligament
Terminal tendon tenotomy also known as:
Dolphin or distal Fowler tenotomy Performed primarily to improve DIPJ flexion when PIPJ is supple and passively correctable.
Which muscle is commonly affected in lateral epicondylitis
ECRB Pain with: passive wrist flexion Activ wrist extension Resisted wrist extension 5 mm distal to epicondyle COZENS TEST - resistance with elbow in flexion and extension
Has greater capacity for sustained work: ECRB or ECRL
ECRL Longest muscle fibers and largest mass, therefore has a greater capacity for sustained work. ECRL is more efficient as a RD of the wrist.
Steindler procedure
Entire flexor origin is elevated including a piece of the medial epicondyle.
Superficial group of three
Extensor carpi ulnaris Extensor digitorum Extensor digti minimi
Which structure more commonly involved in TF?
FDS - swelling and thickening This causes the tendon to bunch up at the distal end of the pulley interrupting the normal excursion. A1 pulley is more frequent site of pathology
FDS Lasso Zancolli's LAsso procedure
FDS tendon divided at level of proximal phalanx of each finger. Proxomal stump of each tendon is pulled back, looped around the A1 pulley and sutured on itself at the level of the MCP joint. Passive technique based on tenodesis principles.
Modified Stiles, Bunnell Transfer FDS 4 tail
FDS tendon to LF is splint longitudinally into 4 equal tails. Each slip passed through the lumbrical cancal of each finger and inserted into the radial lateral bands of the MF, RF and SF and the ulnar lateral bands of the IF. *Dorsal block orthosis may be indicated after cast removal.
Bicepital aponeuros aka
Lacertus Fibrosis
Oblique retinacular ligament is sometimes called:
Landsmeer's ligament Arises from flexor fibro-osseous sheath of the proximal phalanx and passes palmarly to axis of rotation of PIPJ. It inserts onto the dorsal base of the distal phalanx next to the terminal tendon. ORL is taut in flexion
Thumb low median nerve palsy causes what major functional deficit:
Loss of opposition
Only muscle that arises and inserts into tendon
Lumbricals O: FDP I: Extensor expansion of the digit Known as the workhorses of the hand
Contractures of this ligament prevent MCP flexion
MCP collateral ligaments
Joint capsular tightness test
Measure AROM and PROM. If the same, joint capsular tightnesss is present.
Elbow's main stabilizer to valgus strain
Medial collateral ligament composed of: Transverse Anterior band Posterior band
Structures that pass through carpal tunnel (10)
Median nerve FDP tendons - 4 FDS tendons - 4 FPL
Arcade of Froshe
Most common impingement site for PIN It's a fibrious band that arises as a semi circular structure from the tip and medial aspect of the lateral epicondyle clinical presentation commonly called radial tunnel syndrome
Martin Gruber anastomosis
Nerve communication between the median and ulnar nerves in the forearm, which is known as Martin-Gruber anastomosis, causes transfer of nerve fascicles from the median nerve to the ulnar nerve. This gives rise to alteration of the normal anatomical pattern of the motor and sensory innervation of the hand.
ECRB origin and insertion
O: Lateral epi I: Base of 3rd metacarpal *Strongest and most efficient wrist extensor Longest extension moment arm and largest cross-section
Grayson's ligament O & I
O: Volar aspect of the flexor tendon sheath runs volar to the neurovascular bundle I: into the skin Grayson's ligament contributes to PIPJ contracture in Dupuytren's dx
Cleland's ligament
Passes dorsally to the neurovasular bundle and inserts into the skin. Cleland's ligament tightens in flexion further contributing to skin stability during grasping activities. C (Cleland's) before D (dorsal)
Extrinsic FLEXOR tightness test
Passively extend wrist, keeping digits in full extension. If flexor tension develops and digits pulled into flexion, extrinsic flexor tightness proximal to the wrist exists.
Extrinsic EXTENSOR tightness test
Passively hold digits in composite flexion while passively flexing wrist If digits are pulled into extension as the wrist is passively flexed, extrinsic tightness proximal to the wrist exists.
Tightens in flexion, looses in extension
Proper collateral ligament of the PIPJ
Centralizes the extensor digitorum tendon over the MCP joint
Sagittal bands
What soft tissue structure is torn in dorsal dislocation of PIPJ?
The volar plate "critical corners"
Roof of carpal tunnel
Transerve carpal ligament Prevents the long flexors of the fingers from bowstringing when the wrist flexes and serves as an attachment site for the thenar and hypothernar muscles.
Provides the pulley mechanism for the flexor tendon sheath
Transverse carpal ligament
PREVENTS DORSAL SHIFTING OF THE LATERAL BANDS
Transverse retinacular ligament
Prevents volar shifting of lateral bands
Triangular ligament
Abductor pollicis brevis innervation
median nerve