Transcript 11-Palm_of_the_Hand

Dr. Ahmed Fathalla Ibrahim
THE SKIN
1. Flexure creases (lines of palm)
2. Papillary ridges (fingerprints):
improve grip & increase surface
area
3. Abundant sweat gland
SUPERFICIAL FASCIA
1. Contains: cutaneous nerves &
vessels
2. Contains: Palmaris brevis
DEEP FASCIA
•
PALM: thickened
at 3 sites:
Palmar aponeurosis:
• Definition
• Description
• Function
• Clinical anatomy:
Dupuytren’s
contracture
PALMAR APONEUROSIS
•
•
1.
2.
3.
•
•
DEFINITION: It is a thickening of deep fascia in the
middle of the palm
DESCRIPTION: It is triangular in shape:
Apex: directed proximally, continuous with tendon
of palmaris longus
Base: directed distally, divided into 4 slips for the
medial 4 fingers
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
•
•
1.
2.
3.
4.
5.
6.
•
1.
2.
RELATIONS:
Superficial: from lateral to medial:
Superficial palmar branch of radial artery
Palmar cutaneous branch of median nerve
Tendon of palmaris longus
Palmar cutaneous branch of ulnar nerve
Ulnar vessels
Ulnar nerve
Deep: Structures passing through carpal tunnel
Tendon of FPL & its synovial sheath (radial bursa)
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
DEEP FASCIA
Fibrous flexor sheaths
• Definition
• Attachments
• Function
FIBROUS FLEXOR SHEATH
•
DEFINITION: It is a thickening of deep
fascia in front of the fingers
• ATTACHMENTS:
1. Proximal: to the slips of palmar
aponeurosis
2. Distal: to the base of distal phalanx
3. On either side: to the side of phalanx
• FUNCTION: It holds the long flexor
tendons during flexion of the fingers
INTRINSIC MUSCLES
• LATERAL GROUP:
FOUR THENAR MUSCLES
• MEDIAL GROUP:
THREE HYPOTHENAR MUSCLES
PALMARIS BREVIS
• CENTRAL GROUP:
FOUR LUMBRICALS
FOUR PALMAR INTEROSSEI
FOUR DORSAL INTEROSSEI
• ALL MUSCLES ARE SUPPLIED BY C8 & T1 SPINAL
SEGMENTS THROUGH MEDIAN & ULNAR NERVES
INTRINSIC MUSCLES
THENAR MUSCLES
THENAR MUSCLES
1. Abductor pollicis brevis
2. Flexor pollicis brevis
3. Opponens pollicis
4. Adductor pollicis
N.B.:
• Muscles # 1, 2, 4 are inserted into the
proximal phalanx of thumb: act on MP &
CM joints of thumb
• Muscle # 3 is inserted into 1st metacarpal
bone: opposition of CM joint of thumb
(abduction + flexion + medial rotation)
HYPOTHENAR MUSCLES
HYPOTHENAR MUSCLES
• Abductor digiti minimi
• Flexor digiti minimi
• Opponens digiti minimi
N.B.:
• Muscles # 1, 2 are inserted into the
proximal phalanx of little finger: act
on MP joint of little finger
• Muscle # 3 is inserted into 5th
metacarpal bone: rotates 5th
metacarpal bone
LUMBRICALS
1. Origin: tendons of FDP
2. Insertion: tendons of ED
3. Action: Writing position (flexion
of MP & extension of IP joints of
medial 4 fingers
INTEROSSEI
• PALMAR INTEROSSEI
1.Origin: metacarpal bone
2.Insertion: proximal phalanx
3.Action: Adduction of fingers (PAD)
• DORSAL INTEROSSEI
1.Origin: adjoining sides of 2 metacarpal
bone
2.Insertion: proximal phalanx
3.Action: Abduction of fingers (DAB)
PALMARIS BREVIS
1. Origin: Palmar aponeurosis
2. Insertion: skin of medial border of
hand
3. Action: deepening the hollow of
palm to get a firmer grip
ARTERIAL ARCHES IN HAND
•
•
1.
2.
3.
4.
SUPERFICIAL
PALMAR ARCH
DEEP PALMAR
ARCH
Formation
Site
Surface anatomy
Branches
SUPERFICIAL PALMAR ARCH
•
1.
2.
•
•
•
•
1.
2.
FORMATION:
Direct continuation of ulnar artery (mainly)
Superficial branch of radial artery
SITE: between palmar aponeurosis & long flexor
tendons
SURFACE ANATOMY: level with the distal border of
the fully extended thumb
BRANCHES: digital branches to the medial three &
half fingers
N.B.: Radial artery gives 2 branches that supplies
the lateral one & half fingers:
Radialis indicis: supplies lateral side of index
Princeps pollicis: supplies both sides of thumb
DEEP PALMAR ARCH
•
1.
2.
•
FORMATION:
Direct continuation of radial artery (mainly)
Deep branch of ulnar artery
SITE: between long flexor tendons &
metacarpal bones
• SURFACE ANATOMY: lies one inch
proximal to superficial palmar arch
• BRANCHES:
1. Branches sharing in anastomosis around
wrist joint
2. Articular & muscular branches
ULNAR NERVE IN THE HAND
•
1.
2.
3.
4.
5.
•
MUSCULAR BRANCHES:
Palmaris brevis
Adductor pollicis
Hypothenar muscles
Interossei
Medial two lumbricals
CUTANEOUS BRANCHES:
Palmar digital to medial 1 ½ fingers
MEDIAN NERVE IN THE HAND
•
1.
2.
3.
4.
•
MUSCULAR BRANCHES:
Abductor pollicis brevis
Flexor pollicis brevis
Opponens pollicis
Lateral two lumbricals
CUTANEOUS BRANCHES:
Palmar digital to lateral 3 ½ fingers