Mano
Mano
Mano
This textbook is a labor of love, and it comes at a great cost in wizard, Reid Malmquist, for computer solutions, video expertise,
terms of time and finances. During the time the authors contrib- and overall IT troubleshooting.
uted to write a chapter, they could have been working clinically To the publishing team at Elsevier, especially Maureen
and paid for at least 1 year of college tuition for one of their chil- Iannuzzi and Daniel Fitzgerald—thank you for babysitting us,
dren. Why do we write these textbooks? Because we learned a keeping us on track, and letting us add the “cool stuff” for this
substantial portion of our craft the hard way, and we remember third edition.
being up in the wee hours with that cold sweat trying figure out To all the editors and coauthors, as my friends and c olleagues—
how to get that impossible fracture back together or to conjure up we owe you a debt of gratitude for your leadership in our societies
a way to cover that ever-expanding soft-tissue defect. We wanted and your amazing contributions to this publication. You are the
to write our lessons into a practical book with detailed figures and “band of brothers and sisters” that I turn to when I have tough
videos to provide step-by-step instructions to help our c olleagues questions, and I know that you are always available to our readers
to solve tough problems for their patients to relieve pain and at meetings and on e-mail as that lifeline of support in this chal-
improve function. We also feel your pain when it comes to study- lenging world of medicine.
ing for “the boards.” This book contains all the core knowledge But most of all, I want to thank you as my friends and family.
to pass a board examination in hand surgery. Life is humbling, and I have enough sense at this point in my
To my wife Sara—thank you for your steadfast love, support, career to realize the mistakes that I have made and to give thanks
and organizational skills to launch a book during a perfect storm for your support so that I can learn from them and overcome
of life’s challenges. them.
To our team at Bellevue Hand Institute—I greatly appreci- In remembrance of Dorothy Mae Trumble (April 28, 1928 to
ate our family of Alan Boyd, Elle Busch, Keith Lemay, PA-C, April 13, 1996), a loving mother and wife who “always believed
and Derek Omori, PA-C for tracking down figures, assisting with in her boys.”
videos, and helping to edit. Of course, a shout-out goes to my IT
x
Anatomy and Examination of the Hand, Wrist, Forearm,
and Elbow
Patrick L. Reavey, MD, MS, Gregory Rafijah, MD
Video E1-1 Elbow Anatomy Video E1-4 General Examination of Hand and Wrist Tendon
See the video for a detailed anatomy of the elbow. Function
Video E1-2 Radius Anatomy See the video for a detailed demonstration of an exam for tendon
function in the wrist and digits.
See the video for a detailed anatomy of the distal radius.
Video E1-3 Wrist Anatomy
See the video for a detailed anatomy of the wrist.
Spiral groove
Medial Lateral
supracondylar supracondylar
ridge ridge
Coronoid
fossa Radial fossa
Lateral Medial
supracondylar supracondylar
Medial Lateral ridge ridge
epicondyle epicondyle
Olecranon
Capitellum fossa
Lateral
epicondyle
Trochlea Medial
Figure E1.1. The anterior aspect of the distal humerus. epicondyle
combine to insert onto the olecranon process of the ulna. The Sulcus for
Trochlea ulnar nerve
brachialis and biceps muscles lie on the anterior elbow. The bra-
chialis originates from the distal humerus, inserts into the proxi-
mal ulna (distal to the coronoid process), and flexes the elbow. Figure E1.2. The posterior aspect of the distal humerus.
The biceps originates in the shoulder, inserts into the radial
tuberosity of the proximal radius and the lacertus fibrosus, and
is responsible for supinating the forearm and flexing the elbow. (ECRL), and brachioradialis (BR), the latter two of which origi-
The elbow also serves as the origin to the extensor and flexor nate from the lateral supracondylar ridge of the humerus. As
muscles of the wrist and hand and to the pronators and supi- a group, the muscles of the mobile wad help to initiate elbow
nators of the forearm. The lateral epicondyle of the humerus extension; the ECRL and ECRB also extend and radially devi-
gives origin to the common extensor tendon—supinator, ate the wrist respectively. The medial epicondyle is the origin
extensor carpi ulnaris (ECU), extensor digiti minimi (EDM), of the common flexor tendon—origin of the humeral head of
and extensor digitorum communis (EDC)—and to the origin the pronator teres, flexor carpi radialis (FCR), palmaris longus
of the extensor carpi radialis brevis (ECRB). The “mobile wad (PL), and flexor carpi ulnaris (FCU)—and the humeral origin of
of three” includes the ECRB, extensor carpi radialis longus the flexor digitorum superficialis (FDS).
Anatomy and Examination of the Hand, Wrist, Forearm, and Elbow e3
Lateral
Triceps (cut) Annular supracondylar
Accessory ligament ridge
Olecranon collateral Radial
process ligament collateral
ligament
Radial notch Triceps (cut)
Semilunar of ulna
notch
Lateral ulnar
collateral
Radial Radial tuberosity Supinator crest ligament
Coronoid head
process Figure E1.5. The lateral collateral ligament complex of the elbow joint.
Annular prominent dorsal tubercle (Lister tubercle), which acts as a pulley for
Coronoid ligament the extensor policies longus (EPL) tendon, and the prominent radial
tubercle styloid. The distal radius articulates with the distal ulna, and both
articulate with the carpal bones (Fig. E1.6). The radiocarpal joint is
Radial a synovial ellipsoid joint in which the scaphoid and lunate articulate
tuberosity with two concavities on the distal radius, the scaphoid fossa and lunate
fossa. The sigmoid notch of the radius articulates with the distal ulna,
Oblique cord of
interosseous
forming the distal radial ulnar joint (DRUJ), allowing for 270 degrees
membrane Radius of rotation of the radius around the ulna. The radial articular surface
has 21 degrees of radial tilt and 11 degrees of palmar tilt.
Ulna
lnterosseous Ligaments
membrane The articulation of the distal ulna and carpal bones is bridged
by the triangular fibrocartilage complex (TFCC). It consists of
Figure E1.3. The proximal radioulnar joint.
an articular disk, a meniscus homologue, ulnocarpal collateral
ligament, dorsal and palmar radioulnar ligaments, and the ECU
tendon sheath (Figs. E1.7 and E1.8). The radioulnar ligaments
originate from attachments on the medial border of the distal
radius and insert both into the ulnar styloid and ulnar fovea. The
TFCC, especially the radioulnar ligaments, plays a crucial role in
Medial
supracondylar
stabilizing the DRUJ while allowing for forearm rotation.
ridge
Anterior bundle Musculature
Triceps (cut) Annular ligament The forearm is divided into two muscular compartments: anterior
or flexor compartment and posterior extensor compartment. The
flexor compartment contains the extrinsic flexors of the fingers and
Posterior
bundle wrist, as well as the pronators of the forearm. These muscles can be
subdivided into three groups: superficial, intermediate, and deep.
Transverse The superficial group includes the muscles originating from the
ligament medical epicondyle of the humerus: pronator teres, FCU, FCR,
Radial tuberosity and PL. The intermediate group includes only the FDS. However,
Figure E1.4. The medial collateral ligament complex of the elbow joint. in the mid-forearm this muscle has two distinct muscle bellies: the
more anterior functioning on the middle and ring fingers and the
posterior functioning on the index and small fingers. The deep
The superficial head of the supinator muscle originates from flexor group includes the flexor pollicis longus (FPL), flexor digi-
the lateral epicondyle, collateral ligament, and proximal ulna; this torum profundus (FDP), and pronator quadratus (PQ).
muscle’s deep head originates from the proximal ulna. The two The posterior or dorsal compartment can also be divided into
heads of the pronator teres originate from the medial humeral deep and superficial groups. The superficial group includes the mus-
epicondyle and medial border of the coronoid process of the ulna, cles of the common extensor tendon originating at the lateral epi-
respectively, inserting into the lateral shaft of the radius. condyle: BR, ECRL, ECRB, EDC, EDM, ECU, and anconeus. The
For additional information regarding the anatomy of the deep group includes the supinator, abductor pollicis longus (APL),
elbow, review Video E1-1, “Elbow Anatomy.” extensor pollicis brevis (EPB), extensor indicis proprius (EIP), and
EPL. In the distal forearm, the muscle bellies of the APL, EPB,
EPL, and EIP can be identified by their relative radioulnar posi-
Forearm Anatomy tion, with the APL being the most radial and the EIP most ulnar.
The APL and EPB muscle bellies cross over the ECRL and ECRB
Radius and Ulna in the distal forearm, and this intersection is the reason for the mis-
The radius and ulna are stabilized along the length of the forearm nomer of the “intersection syndrome” since the tendons actually do
by a dense, fibrous interosseous membrane. Distally the radius has a not touch. The tendonitis in this region is due to tendonitis in the
e4 Anatomy and Examination of the Hand, Wrist, Forearm, and Elbow
Sesamoid
Interphalangeal joint
Metacarpal
Metacarpal phalangeal joint
Capitate
V IV III II Carpometacarpal joint
Hamate
Trapezium
I
Pisiform
Trapezoid
Triquetrum
Scaphoid
Lunate
Ulna Radius
Figure E1.6. The osseous anatomy of the hand.
S Tq
UL
P UT
L
Radius Meniscal
homologue
Volar radioulnar
47–80° ligament
Dorsal radioulnar
ligament
15 mm Ulna
mm
10 R U
Tq V
EPB, APL (l)
Lunotriquetral P S Scaphocapitate
Ulnotriquetral L
ll ECRB insertion
Radioscaphocapitate at MC 3
Ulnocapitate
l
ECRL insertion
Ulnolunate Long radiolunate at MC 2
lV
Short radiolunate APL insertion
lll at MC 1
U R
Ulna Radius
Dorsal intercarpal Figure E1.11. The six dorsal compartments of the extensor tendons
Dorsal radiocarpal are demonstrated. The first dorsal compartment (I) contains the APL
and the EPB. The second dorsal compartment (II) contains the ECRL
Tp C
and the ECRB. The third dorsal compartment (III) contains the EPL. The
Tz H
fourth dorsal compartment (IV) contains the EDC and the EIP. The fifth
dorsal compartment (V) contains the EDM. The sixth dorsal compart-
ment (VI) contains the ECU.
S
L
proximal capitate, between the radioscaphocapitate and long radio-
lunate ligaments (named the space of Poirier).4,5 This space allows
concomitant extension at the midcarpal joint but is also the loca-
tion of lunate dislocation in perilunate instability. The radioscapho-
capitate ligament crosses the scaphoid at its waist and is crucial to
be preserved during proximal row carpectomy to prevent subse-
quent ulnar subluxation of the carpus. The radioscapholunate liga-
R U ment (also known as the ligament of Testut) is a vestigial remnant
that is considered to have played a role in the separation of the
Figure E1.10. The most significant dorsal ligaments include the dorsal radiolunate from the radioscaphoid articulations in the fetus.6 This
radiotriquetral and the dorsal intercarpal ligaments. The key dorsal structure is seen during wrist arthroscopy and is not thought to
ligaments (the intercarpal ligament and the radiocarpal ligament) guide provide significant stability to the wrist.
carpal rotation with radial and ulnar deviation. C, Capitate; H, hamate; The two key intracapsular ligaments include the scapholunate
L, lunate; R, radius; S, scaphoid; Tp, trapezoid; Tz, trapezium; U, ulna. interosseous ligament and lunotriquetral interosseous ligaments.
Both have dorsal and volar components and proximal membra-
nous extensions facing the radial scaphoid and lunate fossae. The
ligaments. In addition, when approached externally, most ligaments dorsal portion of the scapholunate ligament is more important in
do not appear as discrete structures but tend to blend with each other stabilizing flexion forces on the scaphoid, and the volar portion of
and with the synovial capsule, making their identification difficult. the lunotriquetral ligament resists extension forces on the trique-
Carpal ligaments are categorized into three main groups: extra- trum. When one of these ligaments is disrupted, the lunate will
capsular vs. intracapsular, extrinsic vs. intrinsic, and volar vs. dorsal. extend or flex through its remaining connection to the trique-
Other than the transverse carpal ligament and multiple soft tissue trum or scaphoid, respectively.
connections to the pisiform, all wrist ligaments are intracapsular— Dorsally the two key ligaments are dorsal intercarpal and dorsal
meaning they lie within the synovial lining of the wrist (see Fig. radiocarpal (see Fig. E1.10). The ligaments help to guide carpal rota-
E1.9). Extrinsic ligaments connect the radius and ulna to carpal tion, especially with radial and ulnar deviation. Injury to these liga-
bones, and intrinsic (or interosseous) ligaments connect the carpal ments is a key factor in developing volar intercalated instability (VISI).
bones to each other. In general the volar extrinsic ligaments provide For additional information regarding the bony and ligamen-
the majority of stability to the carpus. They form a double-chevron tous anatomy of the wrist, review Video E1-3, “Wrist Anatomy.”
pattern with the distal “V” connecting the ulna and radius to the
capitate and the proximal “V” connecting the ulna and radius to
the lunate (Fig. E1.9). This ligamentous arrangement initiates the
Extrinsic Extensor Tendons and Muscles
correct carpal rotation to compress the ulnar and radial height of The extensor tendons form six discrete compartments at the
the carpus during ulnar and radial deviation, respectively.3 This level of the wrist as they pass under the extensor retinaculum
configuration also leaves a weak spot at the volar aspect of the (Fig. E1.11). These compartments prevent the bowstringing
e6 Anatomy and Examination of the Hand, Wrist, Forearm, and Elbow
that would otherwise occur across the wrist joint during exten- the tendon during pronation and supination—as it moves from
sion. Knowing the anatomy of these compartments is impor- palmar to dorsal, respectively. The subsheath is an important
tant in treating various conditions, such as tenosynovitis, and component of the TFCC. Ruptures or tears of the ECU sub-
properly locating tendons when repairing tendon lacerations sheath can cause ulnar-sided wrist pain or characteristic snapping
or identifying tendons to use for transfers. The tendons in of the ECU tendon during pronation or supination as the tendon
each compartment and their innervation are summarized in subluxes out of the ulnar groove.
Table E1.1.
TABLE E1.1 Dorsal Compartments of the Extrinsic Extensor Tendons, Including Function and Innervation of the Muscles
Compartment Tendons Function Innervation
First Extensor pollicis brevis Extends thumb metacarpal phalangeal joint Posterior interosseous
branch of radial nerve
Abductor pollicis Extends and stabilizes trapeziometacarpal PIN
longus joint
Second Extensor carpi radialis brevis Extends the wrist Radial nerve
Extensor carpi radialis Extends and radially deviates the wrist Radial nerve
longus
Third Extensor pollicis longus Extends the thumb interphalangeal joint PIN
Fourth Extensor digitorum communis Extends all four fingers PIN
Extensor indicis Provides independent index finger PIN
proprius extension
Fifth Extensor digiti minimi Provides independent small finger extension PIN
Sixth Extensor carpi ulnaris Ulnarly deviates and extends the wrist PIN
PIN, Posterior interosseous nerve.
Anatomy and Examination of the Hand, Wrist, Forearm, and Elbow e7
the radial border of the volar wrist to attach onto the base of cle belly of the FDS can usually be independently flexed, except
the index metacarpal. It passes within a groove on the volar perhaps for that of the small finger. Approximately 7% of people
trapezium and is at risk for injury during trapeziectomy. It lack an FDS to the small finger, though this is bilateral only 60%
provides wrist flexion and some radial deviation. The FCU of the time.7
is located on the ulnar side of the volar wrist and is consid- Deep to the FDS is the FDP. The FDP originates from
ered the most powerful wrist flexor. It originates from the the proximal ulna and inserts on the palmar surface of the dis-
medial epicondyle and attaches primarily onto the pisiform. tal phalanx to cause distal interphalangeal (DIP) joint flexion.
This tendon provides a very powerful wrist flexion and ulnar The FDP has a single muscle to the middle, ring, and small
deviation force that is important in power activities, such as fingers, which prevents it from independently flexing each
hammering. digit. The FDP to the index finger usually does have indepen-
dent function.
Palmaris Longus Tendon (Fig. E1.17). The PL muscle origi- On the radial border of the carpal tunnel is the FPL tendon,
nates from the medial epicondyle of the humerus and inserts on which originates from the middle third of the radial shaft and
the palmar fascia. The increased tension on the fascia may help the lateral aspect of the interosseous membrane, attaches onto
with gripping activities. Approximately 20% of the population the base of the distal phalanx of the thumb, and generates thumb
does not have a PL tendon; in these individuals a broader inser- interphalangeal (IP) joint flexion.
tion of the FCR tendon has been described. In the distal forearm
and wrist, the PL tendon is in proximity and immediately overly-
ing the median nerve.
Hand and Digital Anatomy
Digital Flexors. The flexors to the thumb and fingers all en-
Metacarpals and Phalanges
ter the hand via the carpal tunnel. The FDS crosses the tunnel The index and middle finger carpometacarpal (CMC) joints
as four tendons, with those to the ring and middle finger being have minimal motion, and they form the stable central ray of the
superficial to the index and small finger tendons (Fig. E1.18). A hand; the mobile ring and small finger metacarpal joints can flex
tool to remember this arrangement is that “34” in reference to the and rotate toward the midline of the palm to enhance grip. This
third and fourth digits is greater than “25,” corresponding to the greater mobility is the reason that greater degrees of fracture
second and fifth digits (Fig. E1.18). The FDS muscle originates malalignment can be tolerated with metacarpal neck fractures of
from the medial epicondyle of the humerus and the proximal ra- the ring and small fingers as compared with the index and middle
dius and inserts on the palmar surface of the middle phalanx to fingers.
produce proximal interphalangeal (PIP) joint flexion. Each mus- The thumb metacarpal articulates with the trapezium on a
biconcave, saddle-shaped joint (Fig. E1.19A)—the trapezio-
metacarpal (TM) joint. This universal joint provides the thumb
with a wide arc of multiplanar motions, including flexion-
extension, abduction-adduction, opposition, circumduction,
and rotation.
The fingers have proximal, middle, and distal phalanges
whereas the thumb has only proximal and distal phalanges. Each
finger has three joints: metacarpal phalangeal (MCP), PIP, and
DIP. The thumb has a TM joint and only one IP joint. The
Figure E1.13. The radial wrist. The superficial radial nerve branches
crosses dorsally over the tendons of the first and third extensor com-
partments (solid arrow). The first compartment consists of the EPB
First dorsal compartment –
(marked with stitch) and the APL (asterisk). The third compartment EPB and APL tendons
consists of the EPL (double arrow).
Anatomic
Pressure snuff box
ECRB
Third dorsal
compartment –
ECRL EPL tendon
Resistance Figure E1.15. The anatomic snuffbox is the concavity formed with ex-
tension of the thumb between the tendons of the first and third dorsal
Figure E1.14. The second dorsal compartment contains the ECRB,
compartments. APL, Abductor pollicis longus; EPB, extensor pollicis
which extends and radially deviates the wrist, and the ECRL.
brevis; EPL, extensor pollicis longus.
e8 Anatomy and Examination of the Hand, Wrist, Forearm, and Elbow
Lumbricals
Palmar aponeurosis
with palmaris longus
tendon
Superficial
palmar
arch Adductor
pollicis
FPB
Flexor APB
digiti
minimi
Opponens
pollicis
Abductor
digiti Median nerve with
minimi motor branch
Transverse carpal
FCU ligament
Palmaris longus Radial artery
tendon
Ulnar nerve
FDS FCR
Ulnar artery FPL
Figure E1.17. Palmar anatomy under the transverse carpal ligament. The relationship between the branches of the median nerve, superficial palmar
arch, thenar muscles, and structures passing through the carpal tunnel may be appreciated. The wrist flexor tendons consist of the FCR and the
FCU. The PL mainly applies tension to the palmar fascia, possibly to improve gripping. APB, Abductor pollicis brevis; FCR, flexor carpi radialis; FCU,
flexor carpi ulnaris; FDS, flexor digitorum superficialis; FPB, flexor pollicis brevis; FPL, flexor pollicis longus.
Flexor retinaculum
Flexor digitorum
profundus Flexor carpi
ulnaris
Trapezium
Flexor digitorum
Trapezoid superficialis
Ulnar artery
Capitate
Ulnar nerve
Hamate
FDS
Palmaris longus Median nerve Ulnar artery
FCR
FCU
Triquetral
FPL
FDP Ulnar nerve
Figure E1.18. The median nerve, all the digital flexor tendons, and the FPL pass through the carpal tunnel. FCR, Flexor carpi radialis; FCU, flexor
carpi ulnaris; FDP, flexor digitorum profundus; FDS, flexor digitorum superficialis.
e10 Anatomy and Examination of the Hand, Wrist, Forearm, and Elbow
Forearm
Opposing
thumb to Flexion
Supination Pronation finger
Extension
Ulnar
deviation Wrist Radial deviation
Palmar O
Extension
abduction
PA
Wrist A
RA
Flexion
Abduction R
Radial PA
Adduction Hyperextension abduction
Tz
Finger RA O
Extension
MC I
A
R
A Flexion B
Distal
phalanx
Long segment
Ring finger Index
finger finger Middle
phalanx
Distal Small segment
interphalangeal finger
crease Proximal
phalanx
Proximal segment
Thumb
interphalangeal
crease ease
ar cr se Distal
Palmar ista l palm r crea
D lma phalanx
digital l pa segment
ma
ease
crease xi
Pro Proximal
ar cr
Hyp
phalanx
ar
en
Then
segment
othe
Th
nar
The APB originates from the palmar surface of the trape- by the ulnar nerve. It originates from the thumb metacarpal
zium and transverse carpal ligament and inserts on the radial and inserts on the radial side of the base of the thumb’s proxi-
side of the MCP joint and the proximal phalanx to provide the mal phalanx. The FPB produces MCP joint flexion. The OP
key motions for thumb opposition (flexion, pronation, and pal- lies deep to the APB and FPB. It also originates from the tra-
mar abduction) of the thumb metacarpal to allow opposition pezium and transverse carpal ligament and inserts along the
of the thumb to the digits. The FPB muscle is split by the FPL radial border of the thumb metacarpal and the radial sesamoid
into a large superficial head and small deep head, with differ- at the MCP joint to provide flexion of the thumb metacarpal
ent innervation. The superficial head of the FPB is innervated at the TM joint.
by the median nerve and originates from the transverse carpal The deeper AdP has an oblique head arising mainly from the
ligament and the trapezium and inserts into the radial side of base of the index and middle finger metacarpal bones and a trans-
the base of the thumb’s proximal phalanx. The radial sesa- verse head arising from the shaft of the third metacarpal. Both
moid bone is in its tendinous insertion. The deep head of the heads insert onto the volar plate of the MCP joint, base of the
FPB, on the ulnar side of the FPL tendon, and is innervated proximal phalanx, and ulnar sesamoid. This muscle plays a major
Anatomy and Examination of the Hand, Wrist, Forearm, and Elbow e11
role in key pinch. Without the function of the AdP such activities
as using scissors or turning an ignition key would be very difficult.
Electromyographic studies have emphasized the role of the
intrinsic thumb muscles in the facilitation of thumb manipula-
tive function. The first dorsal interosseous muscle is in a posi-
tion to stabilize the base of the thumb on its ulnar side; the FPB
contracts strongly on the radial side. The FPB and the AdP have
been described as evolutionary developments of a “missing” first
palmar interosseous muscle.
Hypothenar Muscles
These include the abductor digiti minimi (ADM), flexor digiti
minimi (FDM), and the deeper opponens digiti minimi (ODM).
The ADM originates from the palmar surface of the pisiform
Collateral and from the FCU tendon and divides into two slips; one is
ligament
inserted onto the ulnar side of the base of the proximal pha-
lanx of the small finger and the other onto the ulnar border of
the aponeurosis of the EDC tendon. It produces abduction of
the small finger (Fig. E1.23). The FDM is more radial than the
ADM, originates from the palmar surface of the hook of the
hamate, inserts onto the ulnar side of the base of the proximal
phalanx of the small finger, and flexes the small finger MCP
joint. The ODM is deep to the remaining two hypothenar
muscles; it originates from the body of the hamate and inserts
onto the ulnar border of the small finger metacarpal to flex the
metacarpal at the CMC joint and bring the small finger toward
Palmar the midline. This results in narrowing of the arch of the palm
ligament important for gripping activities.
(plate)
The palmaris brevis is a thin, superficial, quadrilateral muscle
Figure E1.20. The anatomy of the palmar plate of the PIP joint.
on the ulnar side of the palm of the hand. It originates from the
transverse carpal ligament and palmar aponeurosis and is inserted
into the skin on the ulnar border of the palm. It is of little func-
tional importance and is frequently encountered in the surgical
approach to the ulnar tunnel and carpal tunnel.
The muscles of the hypothenar eminence are innervated by
EPL
the motor (deep) branch of the ulnar nerve. The palmaris brevis
is innervated by the superficial (mainly sensory) branch of the
ulnar nerve.
Finger Flexors
The FDS divides into two slips near the level of the proximal
Figure E1.21. The third dorsal compartment contains the EPL, which phalanx to form Camper chiasm (Fig. E1.24). The two slips of the
extends the IP joint of the thumb and brings the thumb out of the plane FDS attach on either side of the middle phalanx to flex the PIP
of the palm. joint. At the level of the proximal phalanx, the FDP tendon passes
through the two slips of the FDS tendon (Fig. E1.25). The FDP
then lies superficial to the FDS and continues on to insert onto
the base of the distal phalanx to flex the DIP joint.
The direct arterial supply to the tendons is maintained on
their dorsal aspect by structures named vinculae (see Fig. E1.25).
The vinculum longum to the FDS tendon originates near the
middle of the PIP joint. The vinculum brevis to the FDS origi-
nates near the neck of the proximal phalanx and continues on
to form the vinculum longum to the FDP. The vinculum brevis
to the FDP originates near the neck of the middle phalanx and
provides blood supply to the distal end of the FDP. In addition,
synovial diffusion through the parietal paratenon facilitates pas-
sive nutrient delivery and waste removal from the flexor tendon
within the flexor sheath. The region proximal to the vinculae and
Figure E1.22. The dorsal hand and wrist. Note the ulnar location of distal to the lumbrical muscles is a relatively hypovascular area of
the EIP (solid arrow) and the multiple slips of the EDM (dotted arrow) the flexor tendons and called the watershed zone. This region is
in relation to the EDC tendons to the index and small fingers, respec- maintained by passive diffusion alone.
tively. The EDC tendon to the small finger (single asterisk) is typically The ulnar nerve innervates the FDP muscle-tendon units
less prominent than the EDM. Lister tubercle is marked with a dotted of the small, ring, and half of the middle fingers in the majority
circle. The extensor pollicis longus tendon curves around the tubercle of individuals. The anterior interosseous branch of the median
(double asterisk). The superficial radial nerve branches are marked with nerve innervates the FDP of the index and half of the middle
the double arrow. finger muscle. The median nerve innervates the FDS, and the
e12 Anatomy and Examination of the Hand, Wrist, Forearm, and Elbow
Branches to
ODM palmaris brevis
FDM Superficial
branch of
ulnar artery
ADM
Superficial
branch of
Deep (motor) ulnar nerve
branch of Hamate
ulnar nerve
Deep Transverse
branch of carpal
Ulnar
ulnar artery ligament
Pisohamate
Pisiform
ligament Dorsal
Ulnar artery Transverse Ulnar artery
and nerve carpal Location of fascicles for and nerve
A ligament B deep motor branch
Figure E1.23. (A) The ulnar nerve and artery enter the wrist through the Guyon canal (or ulnar tunnel). (B) The
ulnar nerve innervates the muscles of the hypothenar eminence. ADM, Abductor digiti minimi; FDM, flexor digiti
minimi; ODM, opponens digiti minimi.
Vinculum longus
to FDP Camper chiasm
Vinculum brevis
to FDP
FDS
FDP
D
Plate M Plate
Plate
P
Vinculum MC
brevis to
FDS Vinculum Lateral Accessory
longus to collateral ligament
FDS ligament
Figure E1.25. The FDP passes through Camper chiasm in the FDS
tendon. The vinculae provide the blood supply to the flexor tendons. D,
Distal phalanx; FDP, flexor digitorum profundus; FDS, flexor digitorum
superficialis; M, middle phalanx; MC, metacarpal; P, proximal phalanx.
Figure E1.24. The volar hand after excision of the digital flexor sheath
and pulleys. Camper chiasm is marked with the single arrow. After
crossing through the two limbs of the FDS tendon, the FDP becomes
(Fig. E1.26). The annular pulleys increase the mechanical advantage
superficial to it (and is lifted in the image by the scissors). The vinculae
by keeping the tendons close to the bone and to the centers of rota-
to the tendons is marked by the asterisk. The double asterisks mark
tion of the IP joints and maximize tendon excursion at the expense
the superficial palmar arch as it crosses over the tendons. The digital
of the moment of flexion. The odd-numbered annular pulleys are
neurovascular bundles to the middle finger are marked by the dotted
located over joints, whereas the two even-numbered pulleys (A2 and
arrows on both sides of the flexor tendons.
A4) are located over the shafts of the proximal and middle phalanges.
Frequently the A1 and A2 pulleys merge and appear as one structure.
anterior interosseous branch of the median nerve innervates the The A2 and A4 pulleys are the most important pulleys to prevent
FPL plus the PQ muscle. bowstringing of the tendons and should be preserved during flexor
tendon repairs. The A5 pulley is not consistently present. The three
Flexor Tendon Sheath. Proximal to the MCP joints the extrin- cruciate pulleys lie between adjacent annular pulleys, starting with
sic flexor tendons enter a fibroosseous sheath. The purpose of the the C1 pulley between the A2 and A3 pulleys. The cruciate pulleys
tendon sheath is to keep the flexor tendons close to the bone and collapse and expand, facilitating digital flexion and extension.
prevent them from bowstringing during finger and thumb flexion. The flexor tendon sheath of the thumb contains two annu-
In the fingers the tendon sheath is divided into a series of five an- lar and one oblique pulley. The oblique pulley lies over the mid
nular (designated A1 to A5) and three cruciate (C1 to C3) pulleys portion of the proximal phalanx, contains part of the insertion
Anatomy and Examination of the Hand, Wrist, Forearm, and Elbow e13
A1
EDC
A2
C1
A3
C2
Metacarpal phalangeal joint
A4
C3
A5 Proximal interphalangeal joint
digit. The deep head of the dorsal interossei joins with the ten- by the mnemonic PAD-DAB: palmar adduct-dorsal abduct. All
don from the volar interossei to form radial and ulnar lateral bands interossei are innervated by the motor branch of the ulnar nerve.
(Figs. E1.30 and E1.31). The small finger does not have a dorsal
interosseous muscle and is abducted by the ADM muscle. The first Lumbrical Muscles. The lumbricals are unique because they
dorsal interosseous muscle is large and is easily visualized on exami- are the only muscles in the body to originate from a tendon and
nation. It originates on the radial side of the second metacarpal and insert on a tendon (Fig. E1.32). They originate from the FDP
the proximal half of the ulnar side of the first metacarpal, inserting tendon and insert on the radial aspect of the lateral bands. The
on the radial side of the base of the second proximal phalanx (index lumbrical muscles of the small and ring fingers originate from
finger) and the extensor expansion. It is key for hand function pro- two adjacent flexor tendons, the FDP to the small and ring fin-
viding an opposing force to thumb flexion during key pinch. gers and the FDP to the ring and middle fingers, respectively.
There are three volar or palmar interossei; they are unipen- Both of these bipennate lumbricals are innervated by the ulnar
nate, originate from the metacarpals they insert on, and attach nerve. The lumbricals to the middle and index fingers originate
into the base of the proximal phalanges to provide adduction of solely from their respective FDP tendons. These unipennate
the fingers (see Figs. E1.30 and E1.31). Adduction and abduc- muscles are innervated by the median nerve.
tion of the digits are achieved in the radioulnar plane on both
sides of the middle finger metacarpus (which acts as the axis of Proximal Extensor Mechanism (The Extensor Hood). The
the hand). The functions of the interossei can be remembered extensor hood apparatus (or dorsal hood expansion) is a complex
of multidirectional fibers overlying the MCP joint (Figs. E1.33
and E1.34).9 The main portion of the proximal extensor hood
is the sagittal band, which is a very strong bundle of transverse
fibers that form a sling around the MCP joint. This band lies
deep to the lateral tendons of all the interossei and superficial to
the joint capsule. The extrinsic extensor tendons blend into the
central portion of the sagittal band, and thus it helps to stabilize
the extensor tendon and prevents it from displacing to one side of
the convexity of the metacarpal head.
Second dorsal
interosseous
Third dorsal
Second palmar First dorsal interosseous
interosseous interosseous
Third palmar First palmar Fourth dorsal
interosseous interosseous interosseous
III I I II III
IV II IV
V V
Adductor
pollicis
Palmar Dorsal
Figure E1.30. Four dorsal interossei provide abduction and three volar interossei provide adduction of the fingers.
Anatomy and Examination of the Hand, Wrist, Forearm, and Elbow e15
Transverse
retinacular
ligament
Transverse fibers
Extensor to Sagittal band
middle phalanx Oblique fibers Lateral tendon of
Lateral conjoint deep head of dorsal
band of extensor interosseous muscle
Oblique retinacular
ligament Interosseous
Terminal muscle
tendon of
extensor
A5 C3 A4 C2 A3 C1 A2 A1
Flexor digitorum Lumbrical
Flexor pulleys muscle
profundus
termination Flexor digitorum
profundus Flexor digitorum
superficialis
Figure E1.33. Lateral view of the intrinsic muscles and extensor hood components.
e16 Anatomy and Examination of the Hand, Wrist, Forearm, and Elbow
Flexor pulleys
Oblique fibers
of dorsal Transverse
aponeurosis fibers of dorsal Lumbrical muscle
aponeurosis and tendon
Intrinsic contribution
Figure E1.36. Sagittal bands of the extensor mechanism provide for
Dorsal view extension of the MCP joint. FDP, Flexor digitorum profundus; FDS,
Figure E1.34. Dorsal view of the intrinsic muscles and extensor hood. flexor digitorum superficialis.
Coordinated Grip
The interplay between relative extensor and flexor function, as
well as wrist position, plays an important role in coordinating
grip. Flexion strength of the digits is enhanced with wrist exten-
sion due to improved flexor excursion and laxity in the extensor
Lumbrical
tendons. The lumbrical muscles also play a crucial role in releas-
ing grip. When a lumbrical muscle contracts, it pulls the FDP
tendon distally and the lateral band proximally. By doing so it
decreases the flexion force of the FDP on the distal phalanx and
more effectively extends the IP joints. Therefore, the lumbri-
Figure E1.35. The lumbrical tendon attachment into the extensor cal muscle’s main function is to flex the MCP joint and extend
mechanism aids in MCP joint flexion. the PIP joint. Contraction of both FDP and lumbrical will lead
to counteracting flexion and extension forces on the PIP joint,
respectively. By this action the lumbricals attenuate or amplify
The intrinsic muscles with their attachments to the extensor grip, enabling the performance of a tight grip around a small
hood, proximal phalanx, and lateral bands cross the MCP joint object versus a grip around a larger object.
volar to the central axis of rotation; thus they assist with MCP When the lumbrical muscles are paralyzed, clawing of
joint flexion. The FDS and FDP tendons also cross the MCP the digits occurs due to the unopposed force of the extrinsic
joint and provide flexion at this joint. However, they exert their tendons. Without the lumbrical muscles, the extrinsic exten-
initial moment of flexion at the PIP and DIP joints, respectively. sor tendons cause hyperextension of the MCP joints, and the
Loss of the intrinsic contribution to MCP joint flexion can dis- extrinsic flexors cause digital IP joint flexion. The resulting
rupt the coordinated flexion arc of the digits, and patients will clawing with hyperextension of the MCP joint makes it dif-
experience substantial loss in grip strength. ficult to grip larger objects. Inflammatory diseases, such as
rheumatoid arthritis, and crush injuries can cause contractures
of lumbrical and interosseous muscles. Intrinsic contracture
Proximal Interphalangeal Joint causes the fingers to acquire a posture of MCP joint flexion
The central tendon of the EDC is the primary extensor of the PIP and PIP joint extension. Retraction of the FDP after its lac-
joint. However, the intrinsic lateral bands also cross the PIP joint eration may cause shortening or tightening of the lumbrical
dorsal to the axis of rotation and assist with extension. Normally muscle. This will cause a paradoxical extension of the finger
the FDS tendon is the major flexor of the PIP joint, with the FDP PIP joint with attempted flexion through the FDP, or a lumbri-
also assisting with flexion. As mentioned previously, any pathol- cal-plus phenomenon (see Fig. 10.8).
ogy that results in subluxation of the lateral bands volar to the
central axis of rotation will add to PIP flexion and PIP extension
leading to a boutonniere deformity.
Peripheral Nerves
Understanding the anatomy, variations, and patterns of the
motor and sensory nerve supply to the upper extremity is crucial
Distal Interphalangeal Joint in evaluating patients with hand complaints or dysfunction and
The terminal tendon of the conjoined lateral bands is the sole in planning surgical incisions to avoid injury to nerve branches
extensor of the DIP joint and the FDP tendon is the sole flexor. (Fig. E1.37; see also Fig. E1.13). Fig. E1.37 provides a summary
Anatomy and Examination of the Hand, Wrist, Forearm, and Elbow e17
• Supinator
• ECRB
Radial nerve • EDC
(C5–T1) Posterior cord • EDM
• APL
• EPB
• Triceps
• EPL
• Lateral brachialis
• Brachioradialis Superficial radial sensory
• ERCL
• Anconeus Dorsal radial aspect
• ECRB* of hand, first webspace
and thumb, index, middle and
radial half of index to DIP joints
Posterior cutaneous nerve of forearm
Palmar cutaneous
Dorsal sensory
Ulnar nerve
(C8–T1) Medial cord Dorsal ulnar aspect of hand and
small and ulnar ring to DIP joints
Deep motor
Figure E1.37. Summary of innervation of the forearm and hand. Blue boxes indicate the muscles innervated by each nerve branch listed in order
from proximal to distal. White boxes indicate areas of sensory innervation with bold text indicating areas of exclusive innervation useful for rapid
sensibility examination.
*The superficial sensory branch may have a branch to the ECRB in some individuals.
of the major nerves, their branches, and their motor and sensory brachial plexus and passes on the medial side of the cubital fossa,
innervation. accompanying the basilic vein. It innervates the volar and ulnar
aspects of the forearm. The posterior cutaneous nerve of the
forearm is a branch of the radial nerve and innervates the dorsal
Cutaneous Innervation of the Forearm elbow and forearm.
The musculocutaneous nerve terminates distal to the elbow as
the lateral antebrachial cutaneous (LABC) nerve after it passes
lateral to the biceps tendon and through the cubital fossa. It
Radial Nerve
innervates the volar and radial aspects of the forearm. The medial The radial nerve is the terminal branch of the brachial plexus pos-
antebrachial cutaneous (MABC) nerve arises directly from the terior cord (C5-T1) and branches into the posterior cutaneous
e18 Anatomy and Examination of the Hand, Wrist, Forearm, and Elbow
nerve of the forearm, posterior interosseous nerve (PIN), and the nerve of the forearm at this level. The radial nerve then perforates
superficial radial sensory nerve. In the arm the radial nerve lies in the lateral intermuscular septum never less than 7.5 cm from the
the interval between the long and lateral heads of the triceps mus- distal articular surface and courses between the brachialis and the
cle as it courses posterior to the humerus in the spiral groove from BR muscle just proximal to the elbow joint and innervates them
medial to lateral. The nerve has separate branches to the different both. As it passes anterior to the lateral epicondyle, the radial nerve
heads of the triceps muscle and gives off the posterior cutaneous innervates the anconeus and the ECRL muscles. At the level of
the humeroradial joint, the radial nerve divides into the superficial
radial sensory nerve and posterior (or deep) interosseous nerve. A
separate branch to the ECRB is an occasional variation.
The sensory branch of the nerve innervates the ECRB in
more than 50% of individuals and continues along the deep sur-
face of the BR muscle. The sensory branch exits from under the
BR tendon in a dorsal to radial direction and becomes superficial
to the tendon by passing between this tendon and the ECRL,
approximately 4 cm from the tip of the radial styloid. The nerve
then fans out into multiple branches to innervate the dorsum of
the hand, including nearly the entire dorsal surface of the thumb
and the dorsal surface of the index finger, middle finger, and the
radial half of the ring finger to the level of the DIP joints (see
Figs. E1.37 to E1.39).
After branching from the main radial nerve at the elbow, the
PIN passes beneath the fascia of the supinator muscle (the fas-
cia is known as the arcade of Frohse). This thick fascia of the
supinator muscle can cause compression of the nerve. The PIN
rapidly branches to innervate not only the supinator but also all
of the extensor muscles in the forearm. In most individuals the
Ulnar Median Radial Radial Ulnar EIP is the last muscle innervated by this nerve. This is useful in
nerve nerve nerve nerve nerve differentiating between partial and complete nerve injuries. At
Figure E1.38. The anatomy of the sensory nerves of the palm (left the level of the distal forearm the PIN lies on the interosseous
view) and dorsum of the hand (right view). membrane in the floor of the fourth extensor compartment and
is thought to provide pain and proprioception innervation to
the wrist joint.
Median nerve
Ulnar nerve Ulnar nerve
Palmar digital Proper palmar
branches digital branches
Proper
palmar
digital
branches
Palmar
cutaneous
Palmar branches
digital
branches
Dorsal
branch
and dorsal
digital
branches
Superficial
Palmar branch
branches Posterior
antebrachial
cutaneous
nerve
Palm Dorsum
Radial nerve
Median Nerve the dorsal sensory branch, deep motor branch, and the superfi-
The median nerve is formed by branches of the medial and lateral cial sensory branch, which terminates as the digital nerves to the
cords of the brachial plexus (C5-T1) and branches into the ante- small finger and ulnar nerve to the ring finger. The ulnar nerve
rior interosseous nerve (AIN), palmar cutaneous branch, recur- perforates the medial intermuscular septum approximately 8 cm
rent motor branch, and the digital nerves to the thumb, index, proximal to the medial epicondyle. The arcade of Struthers is an
middle, and radial aspect of the ring finger. The median nerve aponeurotic band between the medial intermuscular septum and
enters the forearm on the medial side of the biceps tendon lat- medial head of the triceps that lies superficial to nerve and can
eral to the brachial artery. The nerve travels deep to the lacer- cause its compression at this level. The ulnar nerve enters the
tus fibrosus, between the two heads of the pronator teres muscle forearm via the cubital tunnel, which is formed by the medial
(which it directly innervates), and then continues deep to the epicondyle of the humerus and the medial wall of the olecranon.
FDS muscle belly. The lacertus fibrosus, pronator teres, and FDS The tunnel’s roof is formed by a band of fibrous tissue (Osborne’s
are key structures that can cause a compression neuropathy of ligament), which is superficial to the FCU aponeurosis. The
the median nerve at the elbow or proximal forearm. The nerve nerve passes deep to the two heads of the FCU, giving off its first
continues between the FDS and FDP muscles, where it provides motor branches, to innervate the FCU. The ulnar nerve contin-
innervation to the entire FDS muscle. ues deep (dorsal) and radial to the FCU muscle. The nerve gives
In the proximal third of the forearm the median nerve gives off branches to the FDP muscle of the, ring, and small fingers.
off the AIN, which innervates the FDP muscles to the index and There is a great deal of overlap between the ulnar and median
middle fingers and the FPL and PQ. The AIN has special clinical innervation of the FDP middle finger.
importance because it lies in the deep compartment of the flexor In the proximal forearm, between 5 and 11 cm from the medial
tendons. It is frequently the first nerve involved in compartment epicondyle, the nerve of Henle (also called the palmar cutaneous
syndrome of the forearm or in proximal fracture-dislocations of branch) separates from the main ulnar nerve. The nerve of Henle
the forearm and elbow. travels in close proximity to the ulnar artery and gives off multiple
In the distal forearm, 4 cm proximal to the distal wrist crease, branches that provide sympathetic input to the vessel. Distally it
the median nerve becomes more superficial, passing just beneath supplies sensation to the hypothenar area.11
the flexor retinaculum. At this level, the palmar cutaneous nerve In the distal half of the forearm, the dorsal sensory branch
branches from the radial side of the median nerve and lies along of the ulnar nerve separates from the main nerve but continues
the sheath of the FCR on the ulnar side of the tendon. This to travel in proximity to it. Two to three centimeters proximal
branch usually perforates the palmar fascia and provides sensa- to the wrist crease, the sensory branch passes dorsal to the
tion to a critical area near the base of the thenar eminence. Injury FCU tendon, over the ulnar head to provide sensory inner-
to this nerve results in persistent paresthesias in the region of vation to the dorsum of the small and ring fingers, approxi-
the thenar eminence, which will make gripping difficult. For this mately to the level of their DIP joints. The main portion of
reason, most surgical incisions around the volar wrist are planned the ulnar nerve enters the hand via the Guyon canal ulnar
either ulnar to the PL (ie, carpal tunnel release) or radial to the to the artery. The Guyon canal is a fibroosseous tunnel that
FCR (eg, the common volar approach to the distal radius). begins at the proximal edge of the palmar carpal ligament and
The median nerve passes into the hand via the carpal tunnel is approximately 4 cm long. From proximal to distal the tunnel
by running directly beneath the transverse carpal ligament. The is bordered by the FCU, pisiform, and ADM on the ulnar side
motor branch to the thenar eminence takes off on the radial aspect and extrinsic digital flexors and the hook of the hamate on the
of the nerve, either within the carpal tunnel by piercing the trans- radial side. The roof is composed of the palmar carpal liga-
verse carpal ligament or just distal to the ligament by traveling ment, the pisohamate arcade, and the palmaris brevis distally.
distally as a recurrent nerve to innervate the thenar muscles: the The floor is formed by the transverse carpal ligament and the
APB, OP, and superficial head of the FPB. The median nerve then hypothenar muscles (see Fig. E1.23).
separates into four branches, forming the common digital nerve to Within or just after leaving the Guyon canal, the ulnar nerve
the thumb (which quickly divides into the radial and ulnar digital divides into the motor (or deep) branch and the sensory (or
nerve to the thumb), proper digital nerve to the index finger (which superficial branch). The motor branch passes close and distal to
becomes the radial digital nerve to the index finger), common digi- the hook of the hamate and innervates the hypothenar muscles
tal nerve to the second web space (which becomes the ulnar digital (ADM, FDM, and ODM) and all of the interosseous muscles. It
nerve to the index finger and the radial digital nerve to the middle is accompanied across the hand by the deep palmar arterial arch.
finger), and common digital nerve to the third web space (which The last muscles innervated by the motor branch of the ulnar
becomes the ulnar digital nerve to the middle finger and the radial nerve are the AdP and the deep head of the FPB.
digital nerve to the ring finger) (see Fig. E1.38). The four branches The sensory portion of the ulnar nerve branches into the
travel deep or dorsal to the superficial palmar arterial arch but at proper digital nerve to the small finger (which becomes the
the distal palm become superficial or palmar to the arteries. As a ulnar digital nerve to the small finger) and the common digital
result of this pattern of innervation the median nerve supplies sen- nerve to the fourth web space (which becomes the radial digi-
sation to the palmar surface of the thumb and index finger, middle tal nerve to the small finger and the ulnar digital nerve to the
finger, and radial half of the ring finger (see Fig. E1.39). The com- ring finger) (Figs. E1.38 and E1.39). The superficial branch also
mon digital nerves also provide branches to supply the lumbrical innervates the palmaris brevis muscle.
muscles to the index and middle finger.
A recommended mnemonic for remembering the median nerve
innervation within the hand is LOAF (lumbricals to the index and
Anomalous Innervation
middle finger, opponens policis, abductor pollicis, and superficial Anatomic variations in communication between the ulnar and
head of the flexor pollicis brevis). In the volar forearm the ulnar nerve median nerves have been described separately by Martin and
innervates the FCU and the FDP to the middle, ring, and small fin- Gruber and have become known as the Martin-Gruber intercon-
gers; the median nerve innervates all the other forearm flexor muscles. nection. In this anomaly, nerve fibers that were destined to be
within the ulnar nerve instead stay within the median nerve
as it is formed by contributions from the lateral and medial
Ulnar Nerve cords. In the forearm these fibers finally join the ulnar nerve
The ulnar nerve is a terminal branch of the medial cord (C8- through an anomalous interconnection between the ulnar
T1) of the brachial plexus, and in the wrist area, it divides into and median nerves. Six variations on this anomaly have been
e20 Anatomy and Examination of the Hand, Wrist, Forearm, and Elbow
described, which are mainly anomalous motor innervation of the superficial palmar arch or as a branch of the princeps pollicis
the thenar, hypothenar, or dorsal interosseous muscles by the artery (to the thumb). The ulnar digital artery to the small finger
proximal portion of the median nerve. This nerve intercon- is usually a branch of the superficial arch.
nection explains why patients with high ulnar nerve lesions The radial artery bifurcates at the level of the wrist to form a
may retain function in areas that are typically innervated by palmar branch, which is usually a minor contributor to the deep
the ulnar nerve. palmar arch, and a dorsal branch that travels deep to the tendons
Another group of anomalies was described originally and in the first compartment, around the thumb metacarpal, pierces
simultaneously by Riche and Cannieu. These Riche-Cannieu the first dorsal interosseous muscle, and enters the palm by pass-
anastomoses occur within the hand between the motor branch ing between the transverse and oblique heads of the AdP muscle.
of the ulnar nerve and the recurrent motor branch of the median There it forms the princeps pollicis artery, which sends digital
nerve. Although these anomalies are rarely of clinical or electro- arteries to the thumb, as well as to the radial digital artery of
physiologic significance, anatomic studies have found intercon- the index finger and the deep palmar arch. The continuation of
nections to be common.12 the radial artery becomes the dominant artery in the deep palmar
arch, joining with a branch from the ulnar artery to provide blood
supply to the interosseous muscles of the hand.
Digital Nerves
The terminal radial and ulnar digital nerves provide sensory func-
tion to the volar aspect of their respective digits, as well as the
EXAMINATION OF THE HAND AND UPPER EXTREMITY
dorsal aspect distal to the DIP joints. They lie just volar to the Where knowledge of anatomy is the science required to evalu-
mid-lateral line of the digit and are always superficial (palmar) to ate a patient with hand pathology, a good examination of the
the artery within the digit (remember: “it always hurts before it hand is definitely an art and requires practice. An examination
bleeds”). The neurovascular bundles travel within a fascial sheath, in the emergency department or office will often focus in on the
which is composed of Grayson ligament on the palmar surface, patient’s symptoms or injuries, but young hand surgeons are
Cleland’s ligament on the dorsal surface, and the Gosset lateral encouraged to practice a full hand examination when appropriate
digital sheet laterally. to get a sense of a “normal exam.” This text will provide some
general principles, specific maneuvers, and clinical pearls, but
more detailed discussions of specific aspects of a hand examina-
Arterial Anatomy tion will be covered in other chapters.
The brachial artery travels through the cubital fossa, anterior to
the brachialis muscle, between the median nerve and the biceps
tendon, and passes under the bicipital aponeurosis. At this point
Patient History
it divides into its two main branches, the ulnar and radial arter- An outline for a patient history can be obtained as summarized in
ies. In the proximal forearm the common interosseous artery Box E1.2. The history will be brief for an acute trauma and may
branches off the ulnar artery and divides into the posterior and be longer for a nontraumatic complaint. When a patient is pre-
anterior interosseous arteries. These arteries pass on either side senting with a complaint of “pain,” ask additional questions to get
of the interosseous membrane between the forearm bones. They the patient to describe the pain more specifically (eg, sharp, burn-
anastomose proximal to the wrist joint. ing, aching, electric shocks). The patient should also be asked to
The arterial anatomy of the hand is one of the areas of great-
est variability. The ulnar artery enters the hand through the
Guyon canal and forms the superficial palmar arterial arch (see
Fig. E1.23). The superficial palmar arch is joined by a smaller BOX E1.2 Taking a History
branch from the radial artery in 80% of individuals (Fig. E1.40).
The ulnar artery also gives off a contribution to the deep palmar GENERAL INFORMATION
arch, which is joined by another terminal branch of the radial Determine the patient’s age, occupation, and important activities
artery in more than 95% of cases. The common digital arteries to and hobbies (eg, playing instruments).
the second, third, and fourth web spaces branch from the super- Determine the dominant hand.
ficial palmar arch. The digital arteries to the radial aspect of the Does the patient have a preexisting condition or injury affecting
index finger and the ulnar aspect of the small finger are variable. hand function?
The radial digital artery to the index finger originates either from Determine significant medical conditions (eg, diabetes mellitus).
Important information to determine in patients sustaining upper
extremity trauma
Radial digital How long ago did the injury occur?
artery to Radial digital Was the injury sustained in a tidy or untidy environment, such as a
index finger artery
farm injury?
Ulnar digital
Was the mechanism of injury sharp or crushing?
artery
What type of treatment did the patient receive?
Common Is the injury work related?
digital artery What is the date of the patient’s last tetanus vaccination?
Superficial
palmar arch Deep palmar Important information to determine in patients with nontraumatic
arch upper extremity problems
Princeps When did the patient’s symptoms (eg, pain, numbness, stiffness)
pollicis artery begin and what activities provoke them?
Have the symptoms been progressive?
Ulnar Are there other areas with similar problems either in the hand or
Radial
artery elsewhere (ie, in a patient with systemic arthritis)?
artery
Are the symptoms nocturnal (eg, night pain or numbness)?
Figure E1.40. The superficial and deep palmar arches and the arterial Any distant history of trauma to the area?
branches to the fingers.
Anatomy and Examination of the Hand, Wrist, Forearm, and Elbow e21
pinpoint the location of any symptoms (eg, pain or paresthesias) when there is decreased active and passive ROM, structural
as much as possible; asking them to point to a location with a abnormalities, ligament tightness, and tendon/muscle/nerve dys-
single finger or move their hand or fingers into the inciting posi- function may be involved. The following maneuvers to evaluate
tion can be helpful to focus the subsequent examination. muscle and tendon function as they relate to joint ROM should
When describing the location of a patient’s symptoms or be noted. The same tests can be used to determine tendon integ-
examination findings, referencing the relationship (eg, proximal rity after acute trauma.
or distal) to identifiable anatomic bony landmarks (eg, PIP joint,
radial styloid, lateral epicondyle) is helpful. Because of the ability Elbow. ROM of the elbow is measured as degrees of flexion or
to pronate and supinate the forearm, the terms medial and lat- extension, where full extension is 0 degrees or neutral. Assess-
eral may cause confusion when describing a location in the hand. ment of the stability of the elbow will be covered in Chapter 36.
Symptoms or findings in the hand should be described as palmar As an important flexor of the elbow and supinator of the fore-
(volar) or dorsal and on the ulnar or radial aspect. arm, the integrity of the biceps tendon can be checked with the
hook test; the patient is asked to maximally flex the elbow, and the
examiner pushes his or her thumb into the tissue of the flexion
Examination of the Extremity crease from the lateral side. The thumb should be able to hook
Before manipulating the patient’s extremity, a visual inspection underneath the tight band of the taut biceps tendon. Lack of a
should evaluate the overall appearance and resting posture of the “hook” indicates likely distal biceps rupture.
arm and hand. The skin should be evaluated for its texture, color,
integrity, and previous scars. Any surface landmarks should be Forearm. Forearm motion is measured as the degrees of pro-
noticed and referenced during the examination (Figs. E1.19C). nation or supination from the neutral position (see Fig. E1.19)
Any areas of swelling, soft tissue compromise, or deformity, as with the elbow flexed to 90 degrees and held against the torso.
with a malaligned fracture or with arthritis, should be identi- It is difficult to differentiate the action of the supinator and the
fied and compared with the opposite side. Manipulation of the
extremity should be tailored to the patient’s injuries or symp-
toms, with the general principle to perform any maneuvers likely
to cause the patient pain.
Vascularity
Skin color, temperature, and turgor of the digits can provide
important information on the vascular status of the extrem-
ity. Cool and pale digits may indicate lack of adequate arte-
rial supply, whereas swollen, purple digits may indicate
venous compromise. Capillary refill of the nail bed, assessed
after releasing manual pressure to this area, provides further
information; refill time of more than 2 seconds is considered A
slow and a sign of poor perfusion. When there is concern for
a vascular injury or after revascularization of the arm, hand,
or digit, more objective measures of arterial flow should be
used. A handheld Doppler ultrasound machine can be used to
assess for arterial perfusion in the pulp of the digits; presence
of an arterial signal indicates adequate perfusion to that finger.
Alternatively a disposable oxygen saturation probe placed on a
finger is a good substitute. Decreased oxygen saturation rela-
tive to an unaffected digit or extremity, or more importantly
lack of an arterial waveform or heart rate reading, indicates
possible arterial compromise.
The Allen test examines the integrity of the palmar arches and
their supply from the radial and ulnar arteries (Fig. E1.41). With
the hand elevated, the patient opens and closes his or her fist sev-
eral times to exsanguinate the blood out of his hand. Both arteries
are occluded with manual pressure over each side of the palmar
wrist. The patient relaxes the hand, which should appear blanched.
The pressure is released from one artery. Brisk return of color to
the fingers and capillary refill should be noted in the fingernails
within 5 to 7 seconds. Lack of rapid capillary refill to all digits after
releasing the pressure from one of the arteries indicates that the B C
patient has a vessel occlusion or an incomplete arch. Figure E1.41. Allen test to evaluate patency of the radial and ulnar
arteries and their communications. (A) With the hand elevated, the
patient opens and closes his fist several times to exsanguinate the
Assessing Range of Motion and Tendon Function blood out of his hand. Both arteries are occluded with manual pres-
Problems with ROM of any joint can be due to pathologies of sure over each side of the palmar wrist. The patient relaxes his hand,
the involved bones, joint surfaces, ligaments, overlying soft tissue which should appear blanched. (B) The pressure is released from the
and skin, or appropriate tendons and muscles and their nerves. radial artery. Failure to achieve rapid capillary refill to all digits indicates
Both active and passive ROM, as well as joint stability, should that the patient has a radial artery occlusion or an incomplete arch. (C)
be assessed. In general, when a joint has full passive ROM but The pressure is released from the ulnar artery. Failure to achieve rapid
decreased active ROM, this indicates a problem limited to the capillary refill to all digits indicates that the patient has an ulnar artery
tendons and muscles or nerves that power the joint. However, occlusion or an incomplete arch.
e22 Anatomy and Examination of the Hand, Wrist, Forearm, and Elbow
biceps in forearm supination, though the supinator may provide will not be using the lateral bands for extension and will have a
the majority of supination strength in full elbow flexion. In con- floppy, easily flexed DIP joint. A patient with central slip injury
trast, the PQ is the main pronator of the forearm with the elbow will need to recruit the intrinsics for PIP extension and will have
fully flexed. Any problems with pronation and supination should tight lateral bands pulling tension down to the terminal tendon.
include an assessment of DRUJ stability and the TFCC. This will result in a taut, extended DIP joint that cannot be pas-
sively moved by the examiner, in addition to a positive Elson test.
Wrist. Wrist motion is measured as the degrees of flexion or ex- Extrinsic Flexor Tendons. Each finger should be examined
tension and radial or ulnar deviation from the neutral wrist posi- separately for function of both the FDP and FDS tendons, although
tion. The ulnar wrist flexors and extensors are capable of ulnar a hypoplastic or absent small finger FDS is a normal variant. Exami-
deviation and the radial tendons the opposite. To test function nation of the FDS is performed with active flexion of the PIP joint
of the ECRB and ECRL, ask the patient to extend and radially for each finger separately while holding the other three fingers in
deviate the wrist with the hand in a fist position (to prevent assis- full extension. Holding the other digits in extension will neutralize
tance in wrist extension by EDC); palpate the taut tendons on the the FDP, which has a common muscle to the digits, isolating the
dorsoradial side of the wrist (see Fig. E1.14). The ECU tendon malfunctioning FDS (Fig. E1.42). Lack of PIP flexion indicates FDS
can similarly be evaluated by asking the patient to extend and injury, though this does not exclude a partial injury to the tendon.
ulnarly deviate the wrist while palpating the taut tendon. Of note, The FDP can be tested by blocking the PIP joint in extension
the ECRB attaches centrally to the base of the third metacarpal. and asking the patient to flex the DIP joint (Fig. E1.43). Lack of
When acting alone, the ECRL produces some radial deviation DIP flexion indicates FDP injury or muscle denervation.
with wrist extension, whereas the ECRB produces only exten- Patients with weakness of active flexion but intact FDP and
sion, which makes it an optimal choice for tendon transfers to FDS tendons on examination should be assessed for stenosing
restore wrist extension. The wrist flexors (FCR and FCU) are flexor tenosynovitis (or trigger finger). The A1 pulley over the
more superficial and can easily be palpated in the distal forearm MCP joint can be palpated at the level of the distal palmar crease.
with wrist flexion and radial or ulnar deviation, respectively. For Pain in this area with a palpable nodule felt with active or passive
the extensors and flexors, when asking a patient to extend or flex finger flexion is indicative of this condition even without active
the wrist in a neutral position, deviation to the ulnar or radial side triggering of the digit.
indicates lack of function in the opposite tendons.
An examination for carpal instability and its effect on ROM
will be presented in Chapters 4 and 5.
In patients who are unconscious or uncooperative or in children elicit pain and palpable crepitus indicative of TM arthritis.
requiring sedation, integrity of the flexor and extensor tendons can The ligaments of the MCP joint should be tested by placing
be evaluated using the tenodesis effect (Fig. E1.44). This is a use- ulnar and radial stress on the proximal phalanx while bracing
ful examination which is due to the normal interplay between the the metacarpal. A lack of an end point to stress or laxity rela-
flexors, extensors, and intrinsic tendons. In the tenodesis effect tive to the contralateral side may indicate an ulnar collateral or
the fingers will extend or flex when the wrist is passively flexed or radial collateral ligament injury. The EPB and APL both con-
extended, respectively. Furthermore, in wrist extension the fingers tribute to abduction of the thumb. Ask the patient to radially
will take on a cascade of a gradual increase in the degree of flexion abduct, “bring the thumb away from the index finger.” Palpate
in the direction of radial to ulnar digits (see Fig. E1.44). Lack of the taut tendons (see Fig. E1.12). Because the EPL extends
tenodesis or lack of a cascade indicates likely tendon injury on the
side of failed motion; for example, lack of extension with wrist flex-
ion indicates extensor tendon injury to that digit.
Intrinsic Muscle Evaluation. The lumbrical muscles are the
key in producing MCP joint flexion and PIP/DIP joint exten-
sion. With chronic lumbrical dysfunction, clawing of the fingers
(as described in the anatomy section above) can occur with hy-
perextension of the MCP joints and flexion of the IP joints. Iso-
lated tightness of a lumbrical (from lengthening of FDP with too
Tight fibers
long of a tendon graft) or retraction of FDP on adjacent finger
(middle, ring, small—causing proximal “pull” on common belly)
can also cause characteristic changes in finger ROM. In this case
flexion of the fingers will cause MCP flexion and a paradoxical
extension of the finger IP joints due to pull of lumbrical on MCP
(flexion) and the lateral bands (PIP and DIP extension). This is
called the lumbrical-plus phenomenon.
Tightness of any of the interosseous muscles and lumbricals Loose fibers
causes poor IP joint flexion with the MCP extended (intrinsic-plus
finger) and should be differentiated from the lumbrical-plus fin-
ger. Intrinsic tightness is confirmed with the Bunnell test. In this
test, PIP joint flexion is passively or actively compared with the
MCP joint held in extension or flexion by the examiner. In a posi-
tive test, flexion of the MCP joints will relax the intrinsic muscle
tension, allowing more flexion of the PIP joint (Fig. E1.45).
A B
Figure E1.44. The tenodesis effect is demonstrated. (A) Flexion of the wrist causes extension of the fingers. (B)
Extension of the wrist causes flexion of the fingers.
e24 Anatomy and Examination of the Hand, Wrist, Forearm, and Elbow
Median Nerve. The palmar surface of the distal pad of the index
FPL finger has exclusive sensory innervation by the median nerve and
is useful to quickly evaluate a proximal median nerve injury. The
thenar eminence should be examined for sensory innervation by
the palmar cutaneous branch. Decreased sensibility in the radial
Figure E1.46. Testing the FPL is performed by blocking the MCP joint digits but not in the thenar eminence indicates median nerve dys-
in extension. function distal to the take-off of the palmar cutaneous branch, as
in compression of the median nerve in carpal tunnel syndrome.
For motor testing of the distal median nerve, the APB muscle is
both the thumb MCP and IP joints, it is very difficult to con- examined by asking the patient to palmarly abduct and extend
firm an EPB laceration. Tenosynovitis involving the APL and the thumb in line with the index finger and resist pressure ap-
EPB tendons within the first dorsal compartment is a common plied by the examiner pushing the thumb away from the index
cause of pain and limited thumb ROM. To test for this, have finger. The examiner can simultaneously feel the APB to see if in
the patient grip their thumb with it flexed into their palm and contracts and observe any signs of atrophy. AIN motor function
then ulnarly deviate their wrist. Significant pain over the radial can quickly be evaluated by asking the patient to flex the thumb
styloid is a positive Finkelstein sign. IP joint against resistance.
The EPL can be evaluated by checking resistance to extension
of the thumb IP joint. However, the EPL is also the only tendon Ulnar Nerve. The ulnar nerve exclusively innervates the digi-
to cause retropulsion of the thumb. To test this, have the patient tal pad of the small finger. Sensibility in the distribution of the
place the hand flat on a table and lift only the thumb off the table dorsal sensory branch can differentiate between a lesion in the
(see Fig. E1.22). The FPL can be tested by having the patient flex nerve proximal or distal to the wrist (normal sensibility distal to
the thumb IP joint against resistance (Fig. E1.46). wrist). To test for ulnar nerve motor function, the examiner can
It is difficult to obtain angular measurements for opposition test the first dorsal interosseous muscle by having the patient
and abduction. Opposition can be evaluated when the thumb is abducted the index finger against resistance. Another test of in-
brought from the position of adduction directly over the third trinsic function is the cross-finger test, in which the patient is
metacarpal; it is measured as the absolute number of centimeters asked to cross the middle finger over the index finger. The AdP
from the flexion crease of the thumb IP joint to the distal palmar can be tested by having the patient pinch a piece of paper be-
crease. Thumb abduction can be measured as the absolute dis- tween the thumb and proximal phalanx of the index finger with
tance from the thumb IP joint flexion crease to the distal palmar both hands. When the AdP is paralyzed or weak, the patient
crease at the base of the small finger. This may be performed will compensate by using the FPL, resulting in more flexion of
either for palmar or radial abduction. the thumb IP joint (Froment paper sign) (Fig. E1.47). Chronic
For additional information regarding the examination of ten- denervation and atrophy of the ulnar-supplied intrinsic muscles
don function and digital ROM, review Video E1-4, “General result in characteristic loss of dorsal soft tissue mass between
Examination of Hand and Wrist Tendon Function.” the metacarpals and the first web space. Testing the strength of
flexion of the distal phalanx during grip can assess ulnar nerve
innervation of the FDP muscle. Weak flexion of the ring and
Neurologic Evaluation small fingers relative to the index and middle fingers indicates a
Examination of the innervation of the hand and wrist includes proximal ulnar nerve lesion.
evaluation of the median, radial, and ulnar nerves’ sensory and
motor functions. Radial Nerve. Sensory function should be tested over the
Absence of sensory function can be assessed by loss of sensi- dorsum of the thumb-index web space because this area is
bility to light touch in a particular nerve distribution. The use of exclusively innervated by the radial nerve. Motor function
more objective tools to measure sensibility includes two-point is evaluated by checking the strength of wrist and digital
discrimination (2PD) and Semmes-Weinstein monofilament extension. Testing the EPL by asking the patient to extend
tests. In general, 2PD ≤ 5 mm and sensibility to the 2.83 mono- the thumb IP joint against resistance is an easy test for distal
filament is normal for the fingertips. In an acute trauma situa- function. Evaluating radial nerve function in finger extension
tion, sensibility at the fingertips should not be assessed solely by requires evaluation of MCP joint extension with the wrist ex-
light touch because patients often can “feel” the proprioceptive tended (to eliminate the tenodesis effect). In addition, the in-
movement of a finger with touch. In these cases, construction of trinsic muscles will produce PIP extension if the MCP joints
a 2PD device with a paper clip provides better evaluation of loss are flexed; this can mislead examiners who do not test for IP
of sensibility. A Semmes-Weinstein monofilament test is more extension with the MCP fully extended.
Anatomy and Examination of the Hand, Wrist, Forearm, and Elbow e25
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Figure E1.47. With a positive Froment paper test the thumb IP joint
hyperflexion compensates for AdP muscle weakness by tightening the
FPL, which can act as a secondary adductor and indicates a low ulnar
nerve palsy. FPL, Flexor pollicis longus.
ACKNOWLEDGMENTS
In writing the third version of this chapter, much of the credit
must go to the authors of the previous version: Shai Luria, MD,
Jay T. Bridgeman, MD, DDS, and Thomas E. Trumble, MD.
The anatomy and examination of the hand have not changed in
the interval and much of their work is included in this version.