Transcript nerve

手外科簡介
奇美醫學中心
整形外科、高壓氧中心
授課教師：劉 澄 DDS. MD. PhD
2015-02-11
Dr. Orange
Introduction : Boundaries & Divisions
In response to the demand for flexibility of the upper limb.
★ The long bones of upper limb are of slender ones and
more lighter than that of lower limb.
★ The capsules of joints are loose and lack of strong
ligament.
Division:
The shoulder－－axilla, scapular region, pectoral region.
The arm －－ －anterior region, posterior region.
The elbow －－ －
The foerarm －－ anterior region, posterior region.
The hand －－ －palm, dorsum, fingers or digits.
Bones of Forearm
He
ad
Inteross
eous
membra
ne
Radi
us
Hume
rus
The radius proximally articulates
with the humerus at the elbow
joint. Distally it articulates with the
scaphoid and lunate bones of the
carpus, and with the ulna at the
distal radioulnar joint.
Ulna
He
ad
The ulna is the more medial of the
two bones. Its proximal end
articulates with the humerus at
the elbow joint. Distally it
articulates with the radius. It is
excluded from the wrist joint by
the articular disc.
The interosseous membrane bind
the radius and the ulna together.
Ulnar Styloid palpation
Lister’s Tubercle palpation
Ulnar styloid
THUMB CMC FRACTURE DISLOCATION
(BENNETT’S FRACTURE)


Anatomy:
 Anterior oblique
carpometacarpal ligament
holds palmar fragment in
normal anatomic position
 Abductor pollicis longus
(APL) pulls metacarpal
shaft fragment radial &
dorsal
Treatment
 Reduction (TAPE)
 Traction, abduction,
extension, pronation
 Often unstable, requires
surgery
ROLANDO’S FRACTURE
ANATOMY
 3 part fracture at
metacarpal base
 Comminuted with “Y”
or “T” fragment
 TREATMENT
 May be non-surgical if
highly comminuted
 Surgery if fragments are
large and amenable

The superficial structures of upper limb
Ⅰ.The skin
The thick in palm;
The thin in other parts.
Ⅱ.The superficial fascia
Ⅰ) The superficial veins
1. The cephalic vein
2. The basilic vein
3. The median cubital vein
Cutaneous Nerves: Anterior Surface:
1. Supraclavicular nerve
2. Superior lateral brachial cutaneous nerve
3. Inferior lateral brachial cutaneous nerve
4. Medial brachial cutaneous nerve
5. Intercostobrachial nerve
6. Lateral anterbrachial cutaneous nerve
7. Medial anterbrachial cutaneous nerve
8. Superficial branch of radial nerve
9. Median nerve
10. Superficial branch of ulnar nerve
The Deep Structures of Upper Limb
Ⅰ. The deep fascia
The bicipital aponeurosis
The flexor (extensor) retinaculum
The inter-muscular septum
The neurovascular sheath
The osseo-fibrous sheath
(osteofascial compartment)
Palm Fascia
Palmar Aponeurosis
 Flexor Retinaculum, transverse carpal ligament
Radial - Scaphoid tubercle, ridge of Trapezium
Ulnar – Pisiform, hook of Hamate
 Superficial relations, ulnar to radial
Ulnar Nv., Ulnar Art., Covered by fascia giving
origin to the hypothenar ms. – Guyon’s canal
Palmar br. Ulnar nv , PL tendon, Palmar br.
Median nv, Superficial palmar br. Radial art.

Palmar Spaces
Thenar and Mid Palmar Spaces –
Located dorsal to FT and volar to
MC and Int. ms. Fascia
Midpalmar oblique Septum
Thenar Space between the thenar
eminence and third metacarpal.
Extends dorsally IbI the Int. ms.
And Add. Pollicis .Mostly contains
the first lumbrical
Midpalmar Space IbI thenar and
hypothenar space overlying the
3,4,5 MC
Hypothenar Space Dorsal Sub
aponeurotic Space Interdigital Web
Space Radial,Ulnar bursa,Parona’s
Trigger Finger
Stenosing flexor
tenosynovitis
 Painful snap or lock
 Palpate nodule as digit
flexed and extended

Ligaments of the hand
Collateral Ligaments

collateral ligaments, are
found on either side of
each finger and thumb
joint. The function of the
collateral ligaments is to
prevent abnormal
sideways bending of
each joint.
GAMEKEEPER’S THUMB

MECHANISM
 Hyperabduction of
thumb
 >30 degrees or > 20
degrees difference
 EXAM:
 Weak, painful pinch
 Pain over ulnar
thumb
 XRAYS BEFORE
STRESS
Volar Plate
This ligament connects
the proximal phalanx to
the middle phalanx on
the palm side of the joint.
 The ligament tightens as
the joint is straightened
and keeps the PIP joint
from bending back too
far (hyperextending).

Flexor Tenosynovitis
Tendon sheath infection
 Usually due to a puncture wound
 Bacterial skin flora
 Relative surgical emergency

Flexor Tenosynovitis
4 Cardinal Signs of Kanavel
Uniform swelling of the
finger
 Sensitivity along the
course of the tendon
sheaths
 Pain upon passive
extension
 Fingers held in flexion

Muscles : Pectoral Region
1. The extrinsic muscles
Pectoral major, Subclavius,
Pectoral minor, Serratus anterior.
2. The intrinsic muscles
Inter-costales externi
(anterior intercostal membrane)
Inter-costales interni
(posterior intercostal membrane)
Intercostales intimus
Shoulder Region
deltoid, supra-spinatus, infraspinatus,
tere minor, tere major, subscapularis.
Arm (brachium) Region
1. Anterior group
biceps brachii, coracobrachialis, brachialis.
2. The posterior group
triceps brachii.
Forearm Region : Anterior group
1.The superficial layer (6)
brachioradialis pronator tere
flexor carpi radialis, palmaris longus
flexor digitorum superficialis
flexor carpi ulnaris
2) The deep layer (3)
flexor pollicis longus
flexor digitorum profundus
pronator quadratus
Superficial Muscles of Ant. Compartment.
1
2
Brach
io-
3
radial
is
The superficial muscles of the anterior
compartment include pronator teres,
flexor carpi radialis, palmaris longus,
and flexor carpi ulnaris. Also included in
this group is flexor digitorum
superficialis. The superficial group of
muscles all have the same origin, which
is attached to the medial epicondyle of
the humerus.
1. Pronator teres
4
2. Flexor carpi radialis
3. Flexor carpi ulnaris
Fig 2. Showing superficial muscles of the
posterior compartment.
4. Flexor digitorum
superficialis
Flexor carpi radialis, palmaris longus,
and flexor carpi ulnaris
Pron
ator
teres
Flexo
r
carpi
radial
is
Palm
aris
longu
s
Fle
xor
car
pi
uln
aris
Flexor carpi radialis
Origin:- Medial epicondyle of the humerus.
Insertion:- Base of the second and third metacarpal
bones.
Nerve supply:- Median nerve, C6 and C7.
Action:- Flexes the hand at the wrist joint.
Abducts the hand at the wrist joint.
Palmaris longus
Origin:- Medial epicondyle of the humerus.
Insertion:- Flexor retinaculum and palmar
aponeurosis.
Nerve supply:- Median nerve, C7 and C8
Action:- Flexes the hand at wrist joint.
Flexor carpi ulnaris.
Origin:Humeral head- Medial epicondyle of the humerus.
Ulnar head- Medial aspect of the olecranon
process of the ulna and the posterior border of the
ulna.
Insertion:- Pisiform bone, hook of the hamate, and
base of the fifth metacarpal bone.
Nerve supply:- The ulnar nerve, C7, C8, and T1.
Action:- Flexes the hand at wrist joint.
Adducts the hand at wrist joint
29
Flexor Tendons
Flexor Digitorum Profundus
Flexor Digitorum Superficialis
Chiasma
Flexor Tendons
Flexor Tendons - Zones


ORIGIN
 #1 and #2: radial surface of flexor
profundus tendons of index and
middle fingers, respectively.
 #3: adjacent sides of tendon of
flexor digitorum profundus
tendons of middle and ring
fingers
 #4: adjacent sides of tendon of
flexor digitorum profundus of
ring and little fingers
INSERTION
Into the radial border of the extensor
expansion on the dorsum of the
respective digits
LUMBRICALS


ACTION
Extend the interphalangeal joints and
simutaneously flex the metacarpophalangeal
joints of the second through fifth digits. The
lumbricales also extend the interphalangeal
joints when the metacarpophalangeal joints are
extended. As the fingers are extended at all
joints, the flexor digitorum profundus tendons
offer a form of passive resistance to this
movement. Since the lumbricales are attached
to the flexor profundus tendons, they can
diminish this resistive tension by contracting
and pulling these tendons distally, and this
release of tension decreases the contractile
force needed by the muscles that extend the
finger joints.
NERVE
I, II: median nerve, C(6), 7, C8, T1 III, IV:
ulnar nerve – C(7), C8, T1
LUMBRICALS




ORIGIN
 First, lateral head: Proximal one half of ulnar
border of first metacarpal bone
 First, medial head: radial border of second
metacarpal bone
 second, third, and fourth: adjacent sides of
metacarpal bones in each interspace
INSERTION
into extensor expansions and to base of proximal
phalanges as follows:
 First: radial side of index finger, chiefly to base
of proxiaml phalanx
 Second: radial side of middle finger
 Third: ulnar side of middle finger, chiefly into
extensor expansion
 Fourth: ulnar side of ring finger
ACTION
Abducts the index, middle, and ring fingers from the
axial line through the third digit. Assists in flexion of
metacarpophalangeal joints and extension of
interphalangeal joints of the same fingers. The first
assists in addition of the thumb
NERVE
ulnar nerve - C8, T1
DORSAL
INTEROSSEI




ORIGIN
 First: base of first metacarpal bone, ulnar side
 Second: length of second metacarpal bone, ulnar
side
 Third: length of fourth metacarpal bone, radial side
 Fourth: length of fifth metacarpal bone, radial side
INSERTION
Chiefly, into the extensor expansion of the respective
digit, with possible attachement to base of proximal
phalanx as follows
 First: ulnar side of thumb
 Second: ulnar side of index finger
 Third: radial side of ring finger
 Fourth: radial side of little finger
ACTION
Adduction of thumb, index , ring, and little finger
toward the axial line through the third digit. Assist in
flexion of metacarpophalangeal joints, and extension of
interphalangeal joints of the three fingers
NERVE
ulnar nerev C8, T1
PALMAR
INTEROSSEI
Superficial Muscles of Post. Compartment
Ancon
eus
3 2
1
The superficial muscles of the anterior
compartment are mainly concerned with the
extension at wrist joint and of the digit. The
muscles in this group comprise of the Extensor
carpi radialis brevis, extensor digitorum, extensor
digiti minimi, extensor carpi ulnaris, and the two
more lateral lying brachioradialis and extensor carpi
radialis longus.
NB- The anconeus also lies in the posterior compartment
but is functionally very different to the rest of the
muscles in this group. Its action are to aid the
triceps in extension at the elbow joint.
2
4
Fig 11. Superficial muscles of the posterior
compartment.
1. Extensor carpi radialis
longus
2. Extensor digitorum
3. Extensor carpi ulnaris
4. Extensor digiti minimi
Brachioradialis & extensor
carpi radialis brevis are not
included in the figure.
Divide into six
compartments by
fibrous septa to
the bone
 Separate
synovial sheaths
for all the
tendons except
the EDC and EI

1st Dorsal Compartment
Abductor Pollicis Longus and
Extensor Pollicis Brevis
 Radial border of Anatomic Snuff
Box
 Site of stenosing tenosynovitis
 De Quervain’s Tenosynovitis
 Finkelstein’s Test

DeQuervain’s Tenosynovitis
Inflammation of EXT
Pollicis Brevis and
ABD Pollicis Longus
tendons
 Tenderness - 1st
Dorsal Compartment
 Finkelstein’s Test

2nd Dorsal Compartment
Extensor Carpi Radialis Longus
and Extensor Carpi Radialis
Brevis
 Make fist—becomes prominent

3rd Dorsal Compartment
Extensor Pollicis Longus
 Ulnar side of Anatomic Snuff
Box
 Can rupture secondary to Colles’
Fracture or Rheumatoid Arthritis
 Extensor Pollicis Longus
Tenosynovitis

4th Dorsal Compartment
Extensor Digitorum Communis
and Extensor Indicis
 Palpate from the carpus to the
metacarpophalangeal joints
 Frequent site of ganglion cysts

5th Dorsal Compartment
Extensor Digiti Minimi
 May become involved in
rheumatoid arthritis
 May be subject to attrition
 friction due to dorsal
dislocation of the ulnar head
 synovitis

6th Dorsal Compartment
Extensor Carpi Ulnaris
 Tendinitis -repetitive wrist motion
or snap of wrist
 May dislocate over the styloid
process of the ulna
 Seen with Colles’ fracture with
associated fracture of the distal
ulnar styloid
 Audible snap

Vessels and Nerves
1. Arteries (main trunk)
Axillary a. … Brachial a. …
Radial a. : superficial palmar arch
Ulnar a. : deep palmar arch proper
common palmar digitial a. palmar digitial a.
Arteries and Nerves of Ant. Compartment.
Radial
nerve
Brachial
artery
Posterior interosseous artery- arises from the
common interosseous artery and and enters the
posterior compartment.
Radial artery:- It begins in the cubital fossa when
Superficial
radial nerve
Median
nerve
Ulnar nerve
Ulnar artery
Radial
artery
Median
nerve
Fig 10. Arteries and nerves of the
anterior compartment.
the brachial artery divides into the radial and
ulna artery. It passes distally, travels under the
brachioradialis, resting on the deep flexor
muscles. The artery briefly travels on the lateral
side of the radius, before travelling over the
anterior surface of the radius. The artery then
winds around the lateral aspect of the wrist,
before entering the palm of the hand to form the
deep palmer arch.
BranchesMuscular branches: to the neighbouring muscles.
Branches to the anastomosis around the wrist and
elbow joint.
Superficial palmer joint: arises just above the wrist,
frequently joins the ulnar artery to give rise to
the superficial palmer arch.
Anatomy - Nerve
Median nerve – Mixed nerve
 Sensory – Volar aspect of palm and radial 3 ½
fingers
 Motor – Major finger and wrist flexors, thenar
muscles and radial lumbricals
 Ulnar nerve – Mixed nerve
 Sensory – Ulnar aspect of volar and dorsal palm
and ulnar 1 ½ fingers
 Motor – Ulnar wrist and finger flexors and
intrinsic muscles of the hand

Median Nerve
Enters the palm through the carpal tunnel
 Three branches
 Medial – Common digital to the ring and
middle and common digital to the middle and
index – gives a br to the second lumbrical
 Lateral – Radial digital to the index and the
whole of thumb – gives a br to the first
lumbrical
 Recurrent br./ muscular br. – thenar muscles

Sensation Testing
Dorsal hand
Radial hand
Carpal Tunnel
Deep to palmaris
longus
 Contains median
nerve and finger
flexor tendons
 Most common
overuse injury of
the wrist

Carpal Tunnel Syndrome
Entrapment of the median nerve
 Phalen’s and Tinel’s Test
 2 point discrimination
 Symptoms
 Aching in hand and arm
 Nocturnal or AM paresthesias
 “Shaking” to obtain relief

Carpal Tunnel Tests
Neurologic exam
 Median nerve
sensation and
motor
 Phalen’s Test:
both wrists
maximally flexed for
1 minute
 Tinel’s Test

Ulnar Artery and Nerve
Deep and radial to Ulnar nv and FCU
 Superficial br.- Superficial palmar arch
 Deep br.- Deep palmar arch
 Ulnar nv ulnar and more superficial
 Superficial br. Ulnar side of little and common
digital nv to the little and ring
 Deep br. Supplies the hypothenar muscles
Curves around the hook of hamate and pierces
the opponens digiti minimi along with the
deep br. Ulnar A. to supply the 3,4th lumbricals
and all interossei to end in the Adductor
pollicis

Tunnel of Guyon
Depression between
pisiform and hook of
hamate
 Contains ulnar nerve
and artery
 Site of compression
injuries
 unusually tender if
pathology is
present

Ulnar Nerve Compression
Tunnel of Guyon
 Seen in direct or repetitive trauma,
fractures of hamate or pisiform, or sports
related
 Operating a jackhammer
 repetitive power gripping (ex. Cycling)
 Sx= pain, weakness, paresthesias in ulnar
sensory distribution

Arteries and Nerves in Posterior Compartment
Arteries
Oblique head
of supinator
(cut)
Posterior
interosseous
artery
Extensor
carpi ulnaris
Posterior interosseous artery:As discussed previously, in the cubital
fossa, the common interosseous artery
divides in the anterior and posterior
interosseous muscle. The posterior
interosseous artery lies between the
Posterior
superficial and deep extensor muscles. It
interosseous terminates by anastomosing with the
anterior interosseous muscle and taking
nerve
part in the anastomosis around the wrist
joint.
Extensor
Branches:
Muscular branch- to the neighbouring muscles.
carpi
Recurrent branch- takes part in the
anastomosis around the wrist joint.
radialis brevis
Anterior interosseous artery (discussed
earlier):Enters the posterior compartment in the
distal third of the forearm. Supplies
branches to neighbouring muscles.
Radial artery (discussed earlier)
Has branches that supply the muscles in
the lateral aspect of compartment.
Microsurgery 顯微手術
 The
reconstruction of
missing tissues usually
by the transfer of tissue
from another part of the
body.
 Called microsurgery
because the doctor uses a
microscope in order to
see the vessels and fibres
he/she needs to connect
after the tissue has been
transferred.
Mallet Finger
Hyperflexion injury
 Ruptured terminal
extensor mechanism
at DIP
 Incomplete
extension of DIP
joint or extensor lag
 Treatment:
 stack splint

Dupuytren’s Contractures
Palmar or digital
fibromatosis
 Flexion contracture
 Painless nodules near
palmar crease
 Male> Female
 Epilepsy, diabetes,
pulmonary dz,
alcoholism

Thank You for Your Attention !