Anatomy of the Hand

Abstracted with permission from

Understanding Hand Surgery:

A guide for junior doctors

M Cheema
MBBS, MRCS

S Nadir Ali
MBBS, FRCS (Glasg), FRCSI
&
V Rajaratnam
MBBS(Mal),AM(Mal),MBA(USA),FRCS(Ed)FRCS(Glasg)
FICS(USA),Dip Hand Surgery(Eur)
Co mmon Abbrev iations

2PD Two point discrimination

ADM Abductor digiti minimi
AP * Adductor pollicis
APB * Abductor pollicis brevis
APL * Abductor pollicis longus
ASB * Anatomical snuff box
BR * Brachioradialis
CMCJ * Carpometacarpal joint
CRPS Complex regional pain syndrome (this term is
preferable to RSD, reflex sympathetic dystrophy,
algodystrophy or causalgia etc)
CT * Carpal tunnel
CTD Connective tissue disease
CTS Carpal tunnel syndrome
Digit I Thumb
Digit II Index finger
Digit III Middle / long finger
Digit IV Ring finger
Digit V Little finger
DIPJ * Distal interphalangeal joint
DISI Dorsal intercalated segment instability
DP Distal phalanx
DRL Dorsal radiocarpal ligament
DRUJ * Distal radioulnar joint
ECRB * Extensor carpi radialis brevis
ECRL * Extensor carpi radialis longus
ECU * Extensor carpi ulnaris
ED * Extensor digitorum
EDBM Extensor digitorum brevis manus
EDM * Extensor digiti minimi
EI * Extensor indicis
EPB * Extensor pollicis brevis
EPL * Extensor pollicis longus
FCR * Flexor carpi radialis
FCU * Flexor carpi ulnaris
FDM * Flexor digiti minimi
2 Glossary

FDP * Flexor digitorum profundus

FDS * Flexor digitorum superficialis
FES Functional electrical stimulation
FPB Flexor pollicis brevis
FPL * Flexor pollicis longus
GCT Giant cell tumor
ICSRA Intercompartmental supraretinacular arteries
IF Index finger
IPJ * Interphalangeal joint
JRA Juvenile rheumatoid arthritis
LF Little finger
MCPJ * Metacarpophalangeal joint
MF Middle finger
MP Middle phalanx
MPJ * Metacarpophalangeal joint
NCS Nerve conduction studies
NL Natatory ligament
ODM * Opponens digiti minimi
OP * Opponens pollicis
OT Occupational therapy
PB * Palmaris brevis
PIPJ * Proximal interphalangeal joint
PL * Palmaris longus
PP Proximal phalanx
PQ * Pronator quadratus
PRUJ * Proximal interphalangeal joint
PT * Pronator teres
RA Rheumatoid arthritis
RF Ring finger
RLT Radio-lunato-triquetral (ligament)
RSC Radio-scapho-capitate (ligament)
RSD Reflex sympathetic dystrophy (the term CRPS is
preferable)
RSI Repetitive strain injury
RSL Radio-scapho-lunate (ligament)
SLAC Scapholunate advanced collapse
TAM Total active motion
TFCC Triangular fibrocartilage complex
THC Triquetro-hamato-capitate (ligament)
TLPA Transverse ligament of palmar aponeurosis
Understanding Hand Surgery 3
 * These abbreviations are in accordance with IFFSH
(Inter- national federation of societies for the surgery of hand)
nomencla- ture (2001). All other abbreviations are consistent
with Lister's: The Hand (fourth edition).
Anatomy of H a nd

M. Cheema, V. Rajaratnam

GENERAL FUNCTION OF THE

HAND

The hand extends from the fingertips to the pre & post-central gyri
of the parietal lobe. It is an essential tool to interact with the envi-
ronment. The presence of opposable thumbs has allowed the human
race to build countless tools, from the pre-historic hunter-gatherers
to a teenager ‘texting’ around the clock. It enables skilled workers to
earn a living and is an instrument for written speech as well as non-
verbal communication.

OSTEOLOGY

Carpus

Anatomically the hand consists of 27 bones (8 carpals, 5 Metacarpals

& 14 phalangeal bones). The carpus is an arch spanned by the flexor
retinaculum (volar carpal ligament). The arch consists of 2 rows of
bones whose proximal extent is marked by the proximal volar crease
at the wrist.

Metacarpus (MC)

MCs abut the distal row of the carpus. The MC heads can be seen to
form a graceful curve going down to the 5th MC. It is along this
curve that the deep transverse ligament of palm attaches. The 1st and
last MCs are relatively mobile and are supplied with appropriate
muscles (of thenar & hypothenar eminences) allowing flex-
ion/extension, abduction/adduction and opposition. Especially
invaluable is the saddle shaped 1st CMC joint enabling the thumb to
move freely in all planes. The 2nd - 4th MCP joints lie at the level of
the distal palmar crease.
12 Anatomy of Hand

A4 pulley
A2 pulley

Fig: Dissection of finger showing A2 & A4 pulley

FDP

Fig: A2 & A4 pulleys removed to show FDS decussation (marked in

blue)

PIPJ

Fig: FDS decussatioFnDPwith FDP removed

 Understanding Hand Surgery 13

Phalanges

There are two phalanges for the thumb & three for each of the
fingers.

PIP and MP joints

MCPJ & PIPJ are hinge joints. MCPJ additionally have a rotational
element.

Wrist joint

Wrist joint allows flexion/extension and radial / ulnar deviation. The

long axis of the hand lies in ulnar deviation to the long axis of the
forearm (to compensate for the carrying angle). This allows more
radial deviation than ulnar deviation from a position of supination.
Part of the flexion/extension occurs at the midcarpal joint.

TENDONS

FDS

Its origin sweeps across the proximal forearm; Common flexor

origin + coronoid process of ulna + anterior oblique line of the
radius. At the wrist its tendons appear at either side of palmaris
longus with III and IV tendons lying superficial (to the other two).
Each tendon decussates just distal to the PIPJ to form a tunnel
through which the FDP tendon passes. Insertion is to either side of
the length of the MP. It is a prime flexor of the PIPJ and assists the
lumbricals in flexing the MCPJ as well.

FDP

Originating from the medial side of the olecranon + upper 3/4th of

the ulna. Insert just distal to the DIPJ and is a prime flexor thereof.
It secondarily assists flexion of more proximal joints.
14 Anatomy of Hand
In 2/3rd of cases the ulnar 2 bellies (& associated lumbricals) are
supplied by the ulnar nerve while the rest by anterior interosseous
branch of median nerve. In the other 1/3rd, the innervation is shared
3:1 or 1:3.

5 annular and 3 cruciate pulleys prevent bowstringing of the flexor

tendons in the fingers. They are numbered from proximal to distal. It
is worthwhile to remember that the 'A1' pulley lies at the level of the
MCPJ. Pulleys are numbered A1-A5 and C1-C3, proximal to distal.
Since these pulleys can increase the resistance to tendon movement,
'fibrous flexor sheaths' act as conduits to allow free gliding of the
flexor tendons. Their proximal ends receive slips from the palmar
aponeurosis. When the palmar aponeurosis becomes involved in
Dupuytren's disease, these slips may become palpable & contribute
to the contracture deformity of the digits.

Similar sheaths (synovial flexor sheaths) exist on tendons as they

pass under the carpal tunnel. FDS & FDP tendons possess a com-
mon sheath here, which is deficient radially. These two sets of flexor
sheaths may or may not be continuous for a particular tendon. In the
interval between these sheaths, the lumbricals take their origin from
the FDP tendons.

FPL

FPL is the thumb's equivalent of an FDP tendon. It arises from the

radius distal to the anterior oblique line (up to insertion of PQ). Its
unipennate origin readily differentiates from the tendon of FCR in
distal forearm lacerations (remember, cutaneous branch of the radial
nerve is close too!).

Wrist Flexors

Into the carpometacarpal junction insert the set of most proximal

flexors and extensors, whose long lever arm helps radiocarpal
movement with minimum energy expenditure. They originate from
common flexor and extensor origins respectively.

FCR inserts into the base of the 2nd & 3rd MCs. It is the first tendon
on the ulnar side of the radial pulse.
 Understanding Hand Surgery 15

FCU arises additionally from ulna (with ulnar n. passing between the
two heads & innervating it) to insert into 5th MC base. Pisiform,
which is a sesamoid bone in the tendon of FCU, marks the medial
boundary of Guyon's canal.

ECRL (radial n.) & ECRB (post. i/oss n.) mirror FCR- originating
from the common extensor origin they insert at the base of 2nd & 3rd
MC bases respectively on the dorsum. They lie together in the 2nd
extensor compartment of the wrist (counting from the radial to ulnar
side)

ECU (post. i/oss n.) mirrors FCU- arising from common origin &
s/cut ulnar border, inserts into the base of 5th MC. It passes alone in
the 5th extensor compartment (from the radial side)

Long Extensors

4 tendons of EDC pass through the 4th extensor compartment at the

wrist and end in extensor expansions. Extensor expansion is a
triangular cape draped over the phalanges, whose sides are reinforced
by lumbricals & interossei. While the apex inserts into the base of
DP, slips are inserted into the bases of proximal & middle phalanges.
The latter insertion is also called the ‘central slip’ & if injured can
cause boutonniere’s deformity.

EPL curves around the Lister's tubercle in the 3rd extensor com-
partment (from radial side) to form the radial/dorsal boundary of the
ASB before inserting into the base of DP of the thumb. The other
boundary of ASB is formed by the Abd Poll Long & Ext Poll Br.

Extensor retinaculum / Dorsal carpal ligament

It stretches from radial styloid to pisiform & triquetral. It is not

attached to the ulna.
16 Anatomy of Hand
Flexor retinaculum / Volar carpal ligament

It stretches from the scaphoid & trapezium to the pisiform & hook
of hamate. There is a small partition over the trapezium through
which FCR tendon passes.

NERVES

Median nerve

It is the dominant nerve of the flexor compartment of the forearm

except FCU & ulnar 2 tendons of FDS (and their lumbricals).

Surface Anatomy:
 At elbow - passes through 2 heads of pronator teres
 In forearm - sandwiched between FDS & FDP bellies
 At wrist - Between FCR & Palmaris Longus tendons

Branches:
 Muscular branches to FCR, FDS & 'radial half' of FDP
 Anterior interosseous nerve innervates PQ, FPL and radial half
of FDP.
 Palmar cutaneous branch at wrist, supplying skin of thenar
eminence & radial half of palm.
 Recurrent branch to 3 muscles of thenar eminence (except
Adductor Pollicis supplied by deep branch of ulnar n.). It usually
lies level with the distal border of the outstretched thumb, ap-
proximately an inch distal to the scaphoid tuberosity (Kaplan
line)
 Palmar digital nerves to radial 3½ digits including their nail beds.

Radial nerve

It is the dominant nerve of the extensor compartment of the forearm

and also brachioradialis.
 Understanding Hand Surgery 17
Branches:
 Muscular branches to Anconeus, Brachioradialis & ECRL are
given off in the upper arm.
 Posterior interosseous nerve, supplies ECRB & supinator, before
going into extensor compartment of forearm. In the forearm it
supplies 3 long finger extensors (EDC, EDM & EI), 3 thumb
muscles (Abd. Poll. Long., Ext. Poll. Br., EPL) and ECU.
 Cutaneous branch to radial 3 ½ digits on the dorsum (excluding
the nail beds). It takes origin in the distal forearm under the
brachioradialis at a variable level. Therefore it should be tested
for in lacerations involving radial border of the distal forearm.

Ulnar nerve

It is the dominant nerve of the small muscles of hand including

adductor pollicis, which is the last structure innervated by its deep
branch. If damaged, the patient uses his FPL to compensate for loss
of adduction & gives a positive Froment's sign.

Surface anatomy:
 At elbow - behind the medial epicondyle it passes between the 2
heads of FCU
 In forearm - on undersurface of FCU
 At wrist - medial to ulnar artery (as they both pass into the
Guyon's canal)

Branches:
 Muscular branches to FCU & ulnar half of FDP.
 Dorsal & Palmar cutaneous branches innervate ulnar side of
palm.
 Superficial palmar branch, sensory to ulnar 1½ fingers except the
nail beds.
 Deep palmar branch innervates hypothenar eminence (x3), ulnar
2 lumbricals, all the interossei and Adductor Pollicis.

Digital nerves

They lay anteromedial to the digital arteries. So the vessels remain

patent when an object is grasped.
18 Anatomy of Hand
Brachial plexus

Brachial plexus forms from anterior primary rami of C5 – T1 spinal

cord segments. The roots lay behind the scalenus anterior forming
trunks which appear in the posterior triangle of the neck. Trunks
divide behind the clavicle forming cords in axilla. It is the arrange-
ment of these cords around the 2nd part of axillary artery which gives
them their names (lateral, medial and posterior).

VESSELS

Note that in the forearm, the radial nerve is radial to the radial artery,
while ulnar nerve is ulnar to the ulnar artery.

Radial artery

It lies under cover of brachioradialis. In the middle 1/3rd of forearm

it is medial to the radial nerve and both need to be preserved in
Henry’s (surgical) approach to the radius.

Ulnar artery

It gives off both the anterior & posterior interosseous arteries. The
later is exhausted by the time it reaches the distal 1/3rd of the
extensor compartment. Anterior interosseous supplies the rest of the
extensor aspect and takes part in the anastomoses around the dorsum
of wrist.

Palmar arches

Superficial palmar arch is formed by the superficial palmar branch of

the ulnar artery, completed by the superficial palmar branch of the
radial artery. It gives off 3 palmar digital arteries.

Deep palmar arch is formed at the termination of radial artery,

completed by the terminal part of the ulnar artery. It gives off MC
arteries and makes anastomoses within the dorsum of the hand.
 Understanding Hand Surgery 19
SURFACE ANATOMY OF THE HAND

1. Scaphoid tubercle
2. Palmaris Longus
Hook of hamate 3. Median nerve
4. FCR
Pisiform 1 5. Radial artery
2
FCU
3
5
Ulnar n/vasc.
bundle 4

Fig: Structures on flexor aspect of wrist

1
2 1. Abd Poll Br
3 2. EPL
4 3. Anat Snuff Box
4. Radial styloid
5. Radial artery
5

Fig: Surface anatomy in relation to the anatomical snuff box

20 Anatomy of Hand

1. EDC tendons
2. Head of ulna
2
3. DRUJ
1 3 4. Scaphoid
4

Fig: Surface anatomy of dorsum of hand

FUNCTIONS OF HAND

Chuck / Tripod Grip Open hand / Push

Power grip Handshake

Key pinch Precision pinch

Pulp to pulp pinch

Open grasp

Hook grip
22 Anatomy of Hand

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