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HAND IN HAND
A PARTIAL SURVEY OF THE BONES, MUSCLES, NERVES, AND BLOOD VESSELS OF THE FOREARM AND HAND Part I: Bones
A. Radius & Ulna, Distal ends (Calais Germain p. 133) At the distal end of the radius on the lateral side lies a pointed process, the styloid process. There is also a styloid process at the medial side of the head of the ulna. Together, the two styloid processes form a framework that helps the wrist bones, the carpals, in place. B. Carpals, Metacarpals & Phalanges (Martini, figure 7.8, page 191, page Calais-Germain p. 149) Examine a skeletal hand and notice that there are eight wrist bones. The wrist bones are called the carpal bones. Collectively they are called the carpus. Three of these bones articulate with the radius and ulna and are the proximal carpal bones. These are, going lateral to medial, the scaphoid, lunate and triquetral bones. The pisiform bone articulates on the anterior region of the triquetrum. The remaining four carpals rest distal to the proximal carpal bones and articulate with them. These are, going lateral to medial, the trapezium, trapezoid, capitate and hamate. Lets see these in a little more detail. First lets examine the proximal carpal bones. The largest of these bones is the scaphoid, which means trough. The scaphoid articulates with three of the four distal carpal bones, (again going lateral to medial) the trapezium, trapezoid and capitate in its distal region. It articulates with the lateral half of the radius, including the styloid process in its proximal region. The adjacent lunate bone is so called because on of its articular surfaces is shaped like a half moon (lunate means moon). The lunate articulates with the remainder of the distal end of the radius, with the distal radial-ulnar joint as well as with the lateral edge of the ulna. It articulates with two distal carpals, the capitate bone and a small region of the hamate bone. The lunate rests between the scaphoid and the triquetrum and articulates with them as well. The triquetrum refers to the triangular shape of this bone. Its a pretty strange triangle, but a three sided figure nonetheless. The triquetrum articulates with the hamate bone, as well as its lateral neighbor, the lunate bone. Recall that the triquetrum also articulates with a carpal that is positioned anteriorly to the rest. This anterior carpal is the pisiform bone and it can only be seen on the anterior side of the wrist. Sometimes there is a complete fusion between the triquetrum and pisiform, so that they resemble one single bone. This is particularly true on plastic models, but not necessarily on plastic people. The pisiform does not articulate with any other bone and is also the medial most carpal of the wrist. The term pisiform means pea-shape. I can really relate to this bone.

Its nearly time to examine the distal carpals, but we should examine a set of bones that rest distally to them first, the metacarpals. The distal carpals articulate with the metacarpals, which are the bones of the palm. The metacarpals not named, but are merely numbered one through five. One is on the thumb side; five is on the little finger side (see Calais Germain p. 149) . Lets get back to the carpals. If we examine the distal carpals, starting with the lateral side, we find the trapezium. Trapezium means table. The flying trapeze is a flying table. Most of us know the trapeze as a bar. I guess it got more streamlined as acrobats improved. The trapezium articulates at its proximal end with the scaphoid bone, and with metacarpal one at the distal end. Metacarpal #1 is the metacarpal for the thumb (no rhyme intended). The second bone moving medially is the trapezoid, which means table-like. The trapezoid looks very much like the trapezium hence the name. Perhaps they were also running out of names. The trapezoid articulates with metacarpal #2 on the distal end and with the scaphoid at the proximal end. Capitate means little head, and again, like the other little head bones weve seen, it resembles a small cranium. At its distal end, the capitate articulates with third metacarpal; at its proximal end, it articulates with the scaphoid and the lunate. Three final distal carpal is the hamate bone. The term hamate means hook, and there is a very obvious hook on the anterior side of this bone. In fact,

the pisiform and hook of the hamate form two anterior projections which makes it easy to tell if you are looking at the anterior or posterior side of a skeletal hand. The hamate articulates with the last two metacarpals #4 and #5 on the distal end; on the proximal end, the hamate articulates with the triquetrum. To recall these bones in order, several little mnemonic devices have been devised, but my favorite one is this; Silly lovers try positions that they cant handle. For this mnemonic device to make sense, we must break the carpals into proximal and distal groups, and then begin each group on the lateral side working medially. Proximal carpals: Silly = scaphoid, lovers = lunate, try = triquetral, positions = pisiform. Distal carpals: that = trapezium, they = trapezoid, cant = capitate, handle = hamate. Now see if you can name all of the carpals on the skeletal hand. Some of the easiest bones youll learn are the phalanges, the bones of the fingers or digits. They are numbered one through and articulate with the metacarpals of matching numbers. There are three phalanges in each finger, a proximal, middle and distal phalange and two phalanges for the thumb or pollex, a proximal phalange and a distal phalange. As you may have guessed, the proximal phalanges articulate with the metacarpals; the middle and distal phalanges articulate with each other as previously described. (See Calais Germain p. 149).

Part II: Wrist Joint (Calais-Germain p. 152, 155-156)

The carpals are surrounded by a ligament that resembles a broad bracelet. This ligament is called the retinaculum. The retinaculum can be divided into two regions: on the anterior side of this wrist, it is the flexor retinaculum (See CalaisGermain p. 157); on the posterior side it is the extensor retinaculum (See CalaisGermain p. 152). The job of the retinaculum is to hold the tendons firmly in place. One tendon, that of the palmaris longus, is actually superficial to the flexor retinaculum and can be easily seen when the wrist is flexed and the thumb and forefinger are brought together in opposition. We will discuss that tendon with the muscle later in this exercise. The wrist and hands have contain five (count em) five types of joints. First lets examine the joints between the carpals. These joints permit the carpals to slide conservatively over each other. This special joint is called a plane joint. Plane joints can be recognized because their articulating surfaces are essentially flat. More obvious plane joints are located between the vertebrae. The second type of joint is the ellipsoid or condylar joint. The scaphoid, lunate and triquetrum articulate with the radius and ulna to form this joint. Here there is a shallow depression that articulates with a somewhat concave surface. Condyloid joints are also found between the metacarpals and their corresponding the digits. Condyloid joints are similar to ball and socket joints (remember the humerus and glenoid fossa), but condyloid joints only permit for circumduction, flexion and extension, not rotation. The fourth joint type is unique to the hand and is found between the trapezium and the first metacarpal. In this joint both articulating surfaces are saddle-shaped, so the name of the name of this joint is the saddle joint. Again, we find this joint no where else in the body. The final joint is the hinge joint. This joint lies between the proximal and middle phalanges, and the middle and distal phalanges. We visited this joint once before at the elbow. Recall that its job is flexion and extension.

Basic Ligaments of the Hand

Ligaments of the hand are not complicated. If you know the bones, of the hand and forearm, you already know the most of the ligaments. This is because the majority of them are named for the bones they connect. There are two basic rules to follow when learning the names of the ligaments of the hand, or any other appendage. First, ask yourself if the ligament on the palm side or

the back side of the hand. If its on the palm side, we call the ligament palmar. If its on the back side, we call the ligament, dorsal. The second rule is to identify the bones that the ligament connects, and then state the proximal bone first and the distant bone (or bone set) second. For example, a ligament that connects the radius and the carpals is called radial-carpal because the radius is proximal to the carpals. If this ligament is on the back side of the hand it is called the dorsal radial-carpal ligament; If it is on the ventral or palm side, it is called palmar radial-carpal ligament.

Lets begin finding the ligaments by stating with proximal dorsal side . Find the board membranous ligament, resembling membrane, that connects the radius and the ulna. Recall that this is a syndesmosis , or slightly movable joint created by ligaments and free of any synovial membrane. Since it is between bones, it is called interosseous. Since it is in the forearm, we call iot antebrachial. Putting it all together, the ligament is called the antebrachial interosseous membrane. So far so good? Since we are on the dorsal side, every ligament will be prefaced by the tem, dorsal, until we reach the phalanges. Lets just do a list. Find the radius. Now find the ligament that connects it with the carpals. This is the dorsal radial-carpal ligament. This will look like many ligaments. Not to worry. They all share the same name. Now find the ulna and the ligament that connect it with the carpals. This is the dorsal ulnar-carpal ligament. Note the ligaments that connect the carpals to the metacarpals. These are called the dorsal carpal metacarpal ligaments. Now do the same for the palm side, but instead of calling the ligaments, dorsal, we will preface the ligament name with the term, palmar. Now find the following:

1. Palmer radial-carpal ligament 2. Palmer ulnar-carpal ligament 3. Palmar carpal-metacarpal ligament

From here on out, we wont have to worry about designating the ligament dorsal or palmar.
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Ligaments that connect the metacarpals to the proximal phalanges are called the metacarpal phalangeal ligaments. Ligaments that connect the phalanges together are called the interphalangeal ligaments. (remember, inter means between). Its that simple. There are a few ligaments that deviate from my rules. Lets stay to the palm side, and you will find small ligaments that run transversely joining the metacarpalphalangeal ligaments. These are called the deep transverse ligaments. Also note in that in this region, there are narrow plate-like structures that re-enforce the metacarpalphalangeal ligaments. These are the palmar plates. Finally we see short bands on the sides of the metacarpal-phalangeal ligaments. These are the collateral ligaments. If you examine a finger by itself, you will note that it has 2 lateral sides. We use the term collateral to describe these ligaments, because they are paired on either side of the finger. We saw similar ligaments in the elbow joint and will see them again in the knee and foot. The term we use, then is simple, collateral ligaments. Lastly, once again on the palm side, find the two stubby tendons in the region of where radius and ulna meet the carpals. The tendon on the radial side belongs to the muscle, flexor carpi radialis; the tendon on the ulnar side belongs to the muscle, flexor carpi ulnaris. These two tendons frame a short membranous ligament called the flexor retinaculum. The retinacula, in general, are ligaments that hold tendons in place. All the flexor tendons of the wrist are held in place by the flexor retinaculum except of one, the tendon of palmaris longus, which ride on the top the retinaculum and is not seen in our model. The tendons and flexor retinaculum form the carpal tunnel. Ligaments of the flexors for the fingers pass through the carpal tunnel, as well as the median nerve. These structures are absent form this model, but will appear later

Part III: Musculature

A. Muscles that Flex and Extend the Forearm (Martini, figures 11.6-11.7, pages 298-301)

1. Brachialis (Calais Germain p. 138) Model # 8. Anytime you see brach in a term, you know that the term has something to do with the upper arm. The brachialis muscle then, certainly is an arm muscle, having its origin about way down the anterior side of the humerus. The brachialis lies below the biceps brachii. To see it properly, remove the biceps brachii on the model. Its job is to assist the biceps brachii in flexing the elbow. Its point of insertion is the coronoid process of the ulna. Recall that the biceps brachii inserts on the radial tuberosity. The fact that these muscles that flex the arm at the elbow insert on different forearm bones is important. On occasion, the biceps brachii does less work than the brachialis. When you do pull-ups and wrap your hands around the bar so that your fingers are facing you, the biceps brachii is the prime mover or agonist. When you turn your wrists the other way (in pronation), the brachialis is the dominant muscle. Which direction is more difficult? Why? 2. Brachioradialis (Calais Germain p. 138 & 145) Model # 13 Heres a nice little flexor muscle that tells me again where it originates and where it inserts. The brachioradialis originates on the lateral distal edge of the humerus and inserts at the base of the styloid process of the radius. It creates

a long band that goes from the lower arm down to just before the wrist. It can also assist in pronation and, as a result, is particularly pronounced while arm wrestling. The brachioradialis is an easy muscle to find, because it the longest band of muscle that travels from the forearm down to the wrist. Well look at it again when we study the extensor carpi radius longus muscle (#14), which lies next to it. 3. Biceps Brachii (Calais Germain p. 139 & 146) Model # 7 It's time to visit the biceps brachii again, because one of its jobs is to flex the arm at the elbow. Recall that the brachialis is a synergist for this muscle when the arm is flexed at the elbow, but the biceps brachii has another trick up its sleeve. Its a supinator. Supination results when the biceps brachii contracts and the brachialis relaxes. This occurs because the biceps brachii inserts only on the radius; the brachialis, recall, inserts on the ulna. Supination is positioning the hands so the palms are facing up as if youre you were carrying a bowl of soup. The opposite action, pronation results when you dump the soupoin someones head, but I shouldnt get a- head of myself. 4. Triceps brachii (Calais Germain p. 140) Model #s 10, 11, & 12 When I think of the muscles that extend the arm at the elbow, only one

really comes to mind, the triceps brachii. This muscle literally covers the majority of the posterior side of the humerus with its three heads. It inserts into the olecranon process of the ulna, but originates in the infraglenoid tubercle, the posterior-superior region of the diaphysis of the humerus, and the deep head (the hardest one to find) originates under the belly of this muscle about midway down the diaphysis of the humerus. But the triceps brachii as a whole is also easy to find, as long as you know youre looking at the back of the arm. 5. Anconeus (Calais Germain p. 140) Model # 27 The triceps brachii does have a puny little friend that aids in extension. This is the anconeus muscle. The word anconeus has Greek origins, meaning the elbow, or simply, a bend. Its origin is the posterior surface of the lateral epicondyle; its insertion begins at the lateral edge of the olecranon, and moves slightly downward to cover an inch or so of the posterior region of the superior ulna. In other words, it never leaves the lateral side of the arm with this muscle. To say this muscle is short is a bit of an understatement. Still, I always think of the anaconda when I think of the anconeus, and I cant say for sure why. Maybe its because this muscle and the great serpent are exact opposites. The anaconda is long, the anconeus is short; the anaconda wraps around its victims, the anconeus is too short to wrap around much of anything. There may be one similarity between the anconeus and anaconda: pronation. The anconeus plays a minor role in pronation (palms facing down). Coiling of a constrictortype of snake is pronation to its extreme.

The anconeus is not too difficult to find. Just look for the elbow and find a tiny muscle that is associated with it. Anacondas, on the other hand, can be found in the Amazon Jungle. B. Pronators and Supinators: Martini, figures 11.6-11/7, pages 299-301) 6. Pronator teres (Calais Germain p. 145) Model # 16. While the anconeus muscle plays a minor role in pronation, but the pronator teres has the lead. Turning the palms down is what this muscle does best. To accomplish this task, the radius must cross over the ulna, which gives us some idea of where the points of origin and insertion for pronator teres might be. The pronator teres originates on the medial epicondyle of the humerus and inserts on the middle of the lateral side of the radius. While this muscle is deep to the brachioradialis, the bulk of it can be seen superficially. Theres an easy way to find it that will become clearer when the flexor muscles are discussed. But when dealing with superficial flexors, find the palmaris longus first. The palmaris longus is an easy muscle to find, and it is one that it not unfamiliar to us. Working our way from the palmaris longus to the medial side of the arm, the next superficial muscle is a flexor, flexor carpi ulnaris. Working our way medially to the next superficial muscle, we find the pronator teres. Once you find it, it will serve as a good landmark for other muscles. I talk about this later. 7. Pronator quadratus (Calais Germain p. 145) Model # 23.

Youll have to disassemble the model a but to find this muscle. Remove the flexor group in the anterior region, and look for a broad muscle that resembles half a bracelet. This is the pronator quadratus. The name quadratus reveals the fact that this muscle looks something like a rectangle. Once again, the job of the muscle is to pronate, that is pulling the radius over the ulna. The pronator quadratus originates on the anterior distal fourth of the ulna and inserts on the distal anterior distal fourth of the radius. Time to pronounce the pronators done. 8. Supinator (Calais Germain p. 146) In supination, the radius does not cross the ulna anteriorly, but lies on the same plane with it. There are three muscles involved in supination, the biceps brachii, the brachioradialis, and our next guest, the supinator, #28 on your model. There are two layers to this muscle. The superficial layer that originates on the lateral epicondyle of the humerus; the deep layer originates just below the radial notch of the ulna. Both layers insert in the neck region of the radius. Soup anyone? C. Muscles that Flex and Extend the Wrist (Martini, figures 11.8, page 302) 9. Flexor carpi radialis (Calais Germain p. 164) Flexor carpi radius, #17 originates on the medial epicondyle, as all flexor muscles of the wrist do, and inserts on the second metacarpal, passing through s groove in the trapezium on its way. All muscles associated with the radius will be found

thumb-side, a fact that will ease your pain when youre asked to identify them. Furthermore, all flexor muscles lie on the anterior side of the arm, and all extensor muscles lie on the posterior side of the arm. So we expect to find flexor carpi radialis on the anterior side of the arm on the same side as the thumb. See, this isnt so bad! In addition to flexing the wrist, flexor carpi radialis also abducts the wrist. 10. Palmaris longus (Calais Germain p. 164) Palmaris longus is back! I think it is by far the easiest anterior forearm muscle to find, provided its there! A small percentage of people lack palmaris longus which leads us to conclude that the importance of this muscle, other than as a landmark, has been overrated. It originates, again, on the medial epicondyle, but it inserts into the aponeurosis of the palm and the flexor retinaculum (when it comes to its insertion, Palmaris longus makes no bones about it). Recall our little trick from the previous exercise that makes the tendon of this muscle stand out. Note that it is in the central region of the anterior forearm. Its a good landmark yes? The flexor carpi radialis muscle lies laterally to it, and our next muscle lies medially to it. Now its time to visit the ulna again. 11. Flexor carpi ulnaris (Calais Germain p. 165) Like flexor carpi radialis and palmaris longus, flexor carpi ulnaris (#19) flexes the wrist, but it is found on the little finger side, medial to palmaris longus. its origin is once again, the medial epicondyle and its insertion is the

pisiform. This little pea bone uses the hamate and metacarpal five for backup support via ligamentous connection. In addition to flexing the wrist, flexor carpi ulnaris also adducts the wrist. All three flexor muscles in this set are superficial and relatively easy to find. When you combine them with the pronator teres, this little sentence will help you to remember them: Pros Find Paul Fit. Or simply remember P-F-P-F. (Pronator Flexor Palmaris - Flexor). This makes identification of the anterior superficial muscles easy. 12 &13. Extensor carpi radialis longus and brevis (Calais Germain p. 165) Now lets go to the other side of the forearm and examine the extensors. To find the extensors, first relocate the brachioradialis. Medial to the brachioradialis rest two muscles, extensor carpi radialis longus (#14), and extensor carpi radialis brevis (#15 or #15a). Both of these muscles extend and hyperextend the wrist. Again, as their name implies, these muscles rest thumb-side. Both originate from the lateral epicondyle (opposite that of the flexors). Extensor carpi radialis longus inserts on the base of metacarpal #2; brevis inserts on metacarpal #3. Both have tendons that cross under the extensor retinaculum, and both of these muscles help to abduct the wrist, along with their flexor cousin, flexor carpi radialis. And thats the long and short of it. 14. Extensor carpi ulnaris (Calais Germain p. 166) What can I say? This is going to sound repetitive. Extensor carpi ulnaris

(#26) is found on the little finger side. It helps to adduct as well as extend and hyperextend the wrist. Its origin once again, is the lateral epicondyle of the humerus. Its insertion is the base of metacarpal five. Flexors and extensors are easy to learn because everything about them makes sense. Their names tell us where their location, and what they do. They each have common origins, and while their insertions are different, remember that the ulnar side is also the little finger side and that both ulnar muscles will insert on the 5th metacarpal which is associated with the little finger. The radial muscles go to metacarpal II. Palmaris longus goes to the palm. See, its really not that complicated (yet). D. Muscles that Flex and Extend the Fingers (Martini, figures 11.8, page 302) 15. Flexor digitorum profundus (Calais Germain p. 166) Deep in the forearm, lies a large muscle that flexes the fingers. This is flexor digitorum profundus (#21). Youll have to remove the superficial flexor group to see it. The origin of the muscle is the interosseous membrane between the radius and ulna, and the anterior, medial ulna. It spits into four tendons, one for each finger, passing through the carpal tunnel on the way. The carpal tunnel is formed by the flexor retinaculum and a groove produced by the carpal bones that permit the passage of the finger tendons. The median nerve also passes through this tunnel. I will discuss this more when we return to the median nerve later in this exercise. The insertions travel all the way to the distal anterior ends of the phalanges. Its remarkable that this large

muscle is really there for the finger tips. And so it goes. 16. Flexor digitorum superficialis (Calais Germain p. 167) While flexor digitorum profundus is deep, flexor digitorum superficialis is, well, superficialbut not that superficial. The palmaris longus rest upon it, making the flexor digitorum superficialis a deep muscle, depending upon your perspective. No, its not time to go home. To make this simple, look for the muscle tissue that rests directly below palmaris longus. Voila! I give you flexor digitorum superficialis (#20)! As with flexor digitorum profundus, this muscle splits into four tendons, each passing through the carpal tunnel. Now might be good to point out now that there are no muscles in the fingers, only tendons. The digitorum muscle groups really are the muscle of the fingers, even though they are found deep in the forearm. As long as I have you confused, I may as well make the most of the situation. But is it that confusing? Not really, I hope. Lets continue with our muscle. Flexor digitorum superficialis has two heads (two heads are better than one, but tell that to the triceps!) One head has a common origin with flexor digitorum profundus, the interosseus membrane between the radius and ulna and the anterior medial end of the ulna. The other head originates on the anterior surface of the radius in a broad band below the radial tuberosity, ending about half way down the diaphysis of this bone. The insertion points are metacarpals 2 through 5, but here the tendons actually split into Y formations for each finger at the joint between the

proximal and middle phalanges. Recall that profundus goes the extra distance on the fingers, while superficialis says Y bother. 17. Extensor digitorum (Calais Germain p. 167) We do a lot of finger work as humans, and extension and hyperextension of the digits is as useful as flexion. But it only takes one good muscle to straighten the fingers out, so to speak, and thats extensor digitorum (#24). It originates from the lateral epicondyle like all good extensor muscles. It splits into four tendons, which pass through the extensor retinaculum and insert on the digits. These tendons split again at each digit following the edges of the phalanges, and then reunited at the finger tips. A short extension of these tendons also travels beyond the split to give each tendon a pitch-fork appearance (See Calais-Germain, page 167). E. Muscles that Flex and Extend the Thumb (Martini, figures 11.8, page 302) 18. Flexor pollicus Longus (Calais Germain p. 168) Weve ignored the thumb so far for good reason. It has its own muscle group. The thumb is most useful of digits because it permits us to grip things and pick things up (ask any raccoon). Three muscles control thumb action. The first one is flexor pollicus longus (#22), a deep muscle that flexes the thumb. Yes, youre taking the model apart again. Flexor pollicus longus originates on the anterior of the radius and the lateral region of the interosseous membrane. The tendon also passes through the carpal tunnel, and inserts on the thumbs

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distal phalanx. This muscle has a long thin tendon which helps identify it. It also is a muscle used in opposition of the thumb. 19. Abductor pollicus longus (Calais Germain p. 168) Abductor pollicus longus (#29) pulls the thumb away from the hand. It inserts on the posterior surfaces of the radius and ulna and inserts on the lateral base of the first metacarpal. Once again, this is a deep muscle. Its the hitch-hikers muscle. 20. Extensor pollicus longus & brevis (Calais Germain p. 169) The final muscle of the forearm we will examine is extensor pollicus longus and brevis. Like the extensor carpi radialis muscles, this muscle has two parts. Both lie distally to adductor pollicus longus, with the brevis muscle being the most proximal of the two. Both originate on the posterior diaphysis of the ulna and cross the radius to the thumb. Both insert on the thumbs phalanges, the middle phalanx taking the tendon of the brevis muscle and the distal phalanx taking the tendon of the longus muscle. When the thumb is fully extended there is a little depression you can see at the back of the hand between the thumb and forefinger. This is the anatomical snuff box. I wonder what those anatomists were up to? Intrinsic Muscles of the Hand There are several muscles that are located right on the hand, and they are often referred to as the intrinsic muscles of the hand for this reason. While there are twenty kinds of hand intrinsic

muscles, we will limit our study to the obvious ones. These include the abductor pollicis brevis, the flexor pollicis brevis, the adductor pollicis, the dorsal interosseous, and the abductor digiti minimi. 34. Abductor Pollicis Brevis This thumb muscle is to abduct the thumb. Its another hitch hiker muscle. Its origin includes the bones of the scaphoid and trapezium and its insertion is the base of the proximal thumb phalanx. In anatomical position, this muscle follows the lateral contour of the thumb. 36. Flexor Pollicis Brevis Working medially from the lateral-most of the thumb, the Abductor Pollicis Brevis, we find our next muscle, Flexor Pollicis Brevis. This is a meaty little muscle that has its origin in the flexor retinaculum, as well as two of carpal bones, the trapezium and capitate. Its insertion is the proximal phalanx of the thumb. It helps to flex the thumb, hence the name. Aint that great! 35. Adductor Pollicis Keep moving medially on the hand model, and the next muscle youll find once you cross a tendon, is Adductor Pollicis. This is the only adductor muscle of the thumb. Its origin includes all of the carpal and metacarpal bones, and its insertion is the proximal phalanx of the thumb once again. If you splay your thumb and fingers, thats abduction. If you bring them back into position so they touch each other, thats adduction. The thumb is the most versatile appendage we have on the appendicular skeleton, and

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may be surpassed only by the tongue in its ability to perform. This range of motion all adds up to multiple muscles. Lets see some more. 39. Opponens Pollicis A deep muscle that lies between abductor pollicis brevis and flexor pollicis brevis is one that is responsible for opposition, that ability for us to bring our thumb and fingers together, as if you were about to pick something up. This is Opponens Pollicis, a muscle that is as important for our evolutionary history as our forebrain. We are not the only animals with opposable thumbs. Primates and their kin have them, as do raccoons. Still, our ability to make and use tools has no doubt contributed to the success of our species. The origin for this muscle is the trapezium and flexor retinaculum and the insertion is the first metacarpal bone. This muscle effectively uses the saddle joint of the thumb, but before we ride off into the sunset, there are a couple more muscles to consider. 40. Dorsal Interosseous This is the meaty muscle that rests between the thumb and the pointing finger on the dorsal side of the hand. It also marks the spot of an acupuncture

point used to relieve constipation and also to help cure temporary insomnia. If you press this muscle hard, it really hurts, especially if youve avoided the call of the rectal sphincters and put that restroom visit off for a while. By contrast, a gentle massage of the muscle in the evening, combined with closing your eyes and mentally counting to one billion ten, will help you nod off. I never get past seventy thousand; the sun wakes me up. In reality both of these techniques do work. The massage is best done by yourself; the restroom crunch is best done by someone less merciless than you are. No pain, no gain? Oh yes, the origin of this muscle is the metacarpal bones and the insertion is bases of the proximal phalanges, 2-4. 37. Abductor Digiti Minimi I never used to talk about this muscle, and then Austin Powers turned up and now it seems I have no choice. This little guy is a special abductor for the pinkie finger. Its origin is the pisiform bone and its insertion is the proximal phalanx of digit number 5. Needless to say it pulls the little finger away from the other fingers. Without it, the English couldnt hold their teacups just so. There is a reason for everything.

Heres an easy tip for remembering the position of the thenar and hypothenar muscles. First, view the hand as an entity by itself, disregarding anatomical position. In this situation both the thumb and little finger are lateral. Note, then, that The abductors are the most lateral muscles. the flexors are medial to the abductors, and the opponens muscles are deep to the flexors. Isnt that handy?

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Part IV: Nerves (Martini, figures 14.11, page 368)

Here we go beyond the brachial plexus to see what the nerves are up to. Lets have a look. Musculocutaenous nerve # 60 C5,C6,C7 The musculocutaneous nerve innervates the coracobrachialis muscle in the axillary region, and has branches going to the biceps brachii in the upper arm, but the bulk of these fibers travel to the brachialis. The nerve ends in the forearm with its most distal branch called the lateral cutaneous nerve, innervates the skin that region. Damage to the musculocutaenous results in paralyses of the biceps brachii, making flexion the job of the smaller flexor muscles such as the brachioradialis. Numbness of the skin may also occur. This injury is rare, because most of the nerve runs deep. Axillary nerve #61 C5,C6 The axillary nerve leaves us quite early as an upper branch of the radial nerve. It innervates the deltoid muscle and teres minor. Damage to the axillary nerve results in paralysis of the deltoid and teres minor. Abducting the shoulder become difficult, because the entire job is left up to a single muscle. This is a job for Supraspinatus! Try as it might, the supraspinatus is no super hero and the victim is still unable to raise the arm properly. Median nerve # 59 All Roots The median nerve travels down the anterior middle region of the arm, following the brachial artery in the upper arm, but innervating the lions share of the flexor muscles and pronator of the forearm, as well as hand muscles that we will not discuss this course. Damage to the distal median nerve leads to partial paralysis of the thumb, making opposition impossible. Damage in the wrist region is often referred to carpal tunnel syndrome. To understand this syndrome more clearly, let us return to the tendons of the flexor digitorum muscles. Recall that each of the tendons of the flexor digitorum profundus and flexor digitorum superficialis pass through the tunnel created by a depression in the carpal bones and the flexor retinaculum. Each of these tendons is surrounded by a long pad of synovial tissue called a tendinous sheath. Remember the tendinous sheath associated with the tendon of the long head of biceps brachii? Anyway, each tendon rests within the tendinous sheath resembling a hotdog in a bun. When these sheathes become inflamed, they compress the median nerve which in turn lets the victim know that somethings happening. Pins and needles or even burning pain may result which is the median nerves way of saying Im not happy, Holmes. I need my space. As you might guess, cutting an additional longitudinal groove in the floor of the flexor retinaculum relieves the pain, which is a typical surgical procedure--but then its also a setting up the patient for scar tissue. The collagen in scar tissue is much less pliant than the normal ligamentous tissue and may cause even more problems later that are even harder to resolve. The best treatment I have heard of is to first rest the area, and then do deep massage of the forearm and wrist to help break up any extra connective

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tissue (fascia). In my opinion, surgery should be a last resort, and should only be considered an alternative to removing the arm. Radial Nerve: #62; branching into #62a and #65 All Roots The radial nerve is a deep nerve usually running right below the median nerve. In the upper arm it innervates the triceps brachii and a tiny bit of brachialis muscles. It also innervates brachioradialis and the extensors and supinators. Damage here results in permanent flexion of the arm at the elbow and wrist drop. Sometimes this condition can be caused by improper use of crutches, called crutch paralysis. Crutch paralysis results when the radial nerve is damaged near the brachial plexus itself. Placing your weight on crutches in your arm pits can cause this problem. Never, ever do that. Support your weight on the crutchs hand rests next time you need them. Hopefully, that will be never.

The ulnar nerve innervates the elbow joint as well flexor carpi ulnaris, and the medial half of flexor digitorum profundus. It also innervates the ulnar artery and the adductor muscle of the thumb. The ulnar nerve also innervates the fingers along with the median and radial nerves. Damage to the ulnar nerve results in ulnar palsy in which the hand assumes a claw deformity. Because the ulnar nerve travels along the exterior of the bone between the olecranon and medial epicondyle, banging your elbow often results in a weird tingling sensation. Its often called banging the funny bone, although it never makes me laugh. But then, most people appreciate a good joke more than I do.

Summary of Muscular Innervation

1. Median nerve: All flexor mucles of forearm, except flexor carpi ulnaris and the medial portion of flexor digitorum profundus. 2. Ulnar nerve:flexor carpi ulnaris and the medial portion of flexor digitorum profundus. 3. Radial nerve: All extensors.

Ulnar Nerve: # 58 C8, T1

Part V: Blood Vessels

Lets drop in on the blood vessels and see what theyre the distal end is doing. A. Arteries (Martini, figures 22.12, page 584)

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Radial artery, #46 In our last episode, we saw that the radial artery branches from the brachial artery. This artery courses under the brachioradialis muscle, over the supinator and continues to travel distally under the extensor carpi radialis longus and brevis tendons, over the flexor digitorum superficialis muscles and over the styloid process of the radius. It is here that the artery rests most superficially and, as such, it is a typical pulse point. Now we see that it passing under the flexor retinaculum to it fate which will soon be described. Ulnar artery # 58 The ulnar artery also branches from the brachial artery at the same place the radial artery arises, but it travels on the medial side over the surface of flexor digitorum profundus making its way between flexor carpi ulnaris the medial heads of flexor digitorum profundus. It courses under the flexor retinaculum, but is covered by the tendon for flexor carpi ulnaris which is why it is harder to palpate this artery. As to the fate of the radial artery, it happily joins the ulnar artery to form an anastomsis called the superficial palmar arch, #51. A deep arterial arch is also created by the union of the radial and ulnar arteries, but it cannot be seen on our models. It is clearer on the blood vessel plaque. Blood vessels course form each arch to form the digital arteries of the fingers. B. Veins (Martini, figures 22.23, page 597)

Just for grins, lets work our way back to the cephalic and basilica veins from the fingers. As previously explained, most of the veins follow the exact same pattern as the arteries. Digital veins drain blood form the fingers and this blood empties into the venous dorsal and palmar venous networks. You can easily see the dorsal network on the back of your hand. From the venous networks, blood courses either to the radial vein or ulnar vein which follows their corresponding arteries, or to the cephalic or basilic veins. The latter two veins are the superficial veins. Recall that the cephalic and basilic veins join at the elbow to form the median cubital vein. The basilic vein arises from the medial side of the dorsal venous network and travels superficially up the arm, entering a deep stretch on the medial side of the biceps brachii muscle and then coursing up to the axillary vein. By contrast, the cephalic vein also arises from the dorsal venous network and travels on the lateral side and maintains its superficial status throughout its course. I think thats enough about veins. Anymore would be a vane attempt to make this lab longer. Sorry! That pun was ripe for the picking!

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