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