The Wrist and Hand Regions

Dr. T Bacoat-Jones

Lutfi, N. M. (n.d.). The Wrist and Hand Regions.

 Objectives
6-14 Axillary, Brachial Plexus, Superficial Features of the Upper Extremities
3, 9, 10 and 13, 14

 State the names, attachments, actions, nerve

supply and blood supply of the muscles of the
shoulder, arm, forearm, and hand.
 Describe the arrangement of the nerves,
arteries and tendons at the wrist.
 Name the boundaries and contents of the
carpal tunnel.
 Objectives
6-14 Axillary, Brachial Plexus, Superficial Features of the Upper Extremities
3, 9, 10 and 13, 14

 Describe the compartments and contents of the

hand.
 Identify the appearance of upper extremity
structures as viewed on radiographs and scans.
 Name the major bursae and the structures
immediately surrounding the bursae
 The Wrist Region
• The wrist (carpal region) is between the forearm and hand.
• Movements of the hand primarily occur at the wrist joint.
• The wrist is formed of two rows of bones (carpal bones):
- Proximal Row (from lateral to medial)
• Scaphoid (the most frequently fractured wrist bone)
• Lunate (the most frequently dislocated wrist bone)
• Triquetrum
• Psiform
- Distal Row (from lateral to medial)
• Trapezium
• Trapezoid
• Capitate
• Hamate
The Wrist Region

• The antebrachial fascia is thickened

posteriorly at the wrist to form a transverse
band known as the Extensor Retinaculum.

• This band retains the extensor tendons in

position, thereby increasing their efficiency.
The Wrist Region

• The deep fascia also thickens anteriorly at the

wrist to form the Flexor Retinaculum.

• The Flexor Retinaculum is a fibrous band that

converts the anterior carpal concavity into a
tunnel: Carpal Tunnel through which the
flexor tendons pass.
6.51 A, B Neurovascular structure in the anterior aspect if the forearm and wrist
The Wrist Region
• The Carpal Tunnel is formed anteriorly by the
flexor retinaculum (from scaphoid to psiform - proximally,
and from the trapezium to hook of the hamate - distally), and
posteriorly by the carpal bones.
• Structures passing through it include:
- Median nerve
- Tendons of the
• FDS
• FDP
• FPL

Dr. Idris Siddiqui

https://www.slideshare.net/idris01/retinacula-of-the-hand
Anatomy of the carpal tunnel p775
 FLEXOR RETINACULUM OF THE WRIST
GUYON’S CANAL: Ulnar a+n
MEDIAN N.
APL FPL
FDP PL FDS
ABDUCTOR
OPPONENS DIGITI MINIMI
POLLICIS
APB
FLEXOR
POLLICIS
PSIFORM
TRAPEZIUM MEDIAL
LATERAL
TRIQUETRUM
SCAPHOID
HAMATE
CAPITATE
RADIAL A.

EPL ECU
EDM
ECRL RIGHT WRIST
ECRB EI Inferior View
ED
 LIGAMENTS OF THE WRIST

ANTERIOR POSTERIOR
MOVEMENTS AT THE WRIST

https://www.crossfit.com/essentials/movement-about-joints-part-3-wrist
 The Wrist: Clinical Considerations

• When a person falls on the outstretched

hand with the forearm pronated, the main
force of the fall is transmitted through the
carpus to the distal ends of the forearm
bones, particularly the radius.

• During such falls, fractures may occur in

the wrist, forearm, or clavicle.
 The Wrist: Clinical Considerations
• Barton’s dislocation/Fracture

An intraarticular
fracture of the distal
radius with
dislocation of the
radiocarpal joint

• A palmar Barton's fracture of the

right wrist, as shown on a 3D-
rendered CT scan
 The Wrist: Clinical Considerations
• Carpal Tunnel Syndrome (CTS): paresthesias,
pain, numbness, and loss or impairment of function
of the hand over the distribution of the median
nerve.
- Usually caused by repetitive motion (repetitive motion
injury), but it may be due to trauma (e.g. fracture of the
lunate), tendonitis, space-occupying lesions (ganglion cysts),
occupational hazards (carpenters, typists, rowers, vibrating
tools…)
 The Wrist: Clinical Considerations
• Carpal Tunnel Syndrome (CTS):

- The signs and symptoms include numbness of the lateral

half of the palmar aspect of the palm, and lateral 3½
fingers, impaired abduction, flexion, opposition of the thumb
and impaired flexion of MPJ 1 and 2.
- Treatment: avoid aggravating activities, rest, splinting,
corticosteroid injections. Surgical decompression is required
in most cases.
Nerve Damage

Published by Homer Small

Synovial Cyst of the wrist p 749
DISTAL RADIO-ULNAR FRACTURES
COLLES FRACTURE
https://myhealth.alberta.ca/Health/aftercareinformation/pages/conditions.aspx?hwid=abq6068
SMITH’S FRACTURE
 RADIOCARPAL
DISLOCATION:

Barton’s Fracture/Dislocation

https://www.medigoo.com/articles/bartons-fracture/
SCAPHOID FRACTURE
 SCAPHOID AND
RADIUS FRACTURES

age@agefotostock.com.
 TQ
Avascular necrosis (AVN) is a
common complication of a
scaphoid fracture. Risk of AVN
depends on the location of the
fracture.

• Fractures in the proximal 1/3

have a high incidence of AVN
(~30%)
• Waist fractures in the middle
1/3 is the most frequent
fracture site and has
moderate risk of AVN.
• Fractures in the distal 1/3 are
rarely complicated by AVN.
The Hand Region

http://www.belgianhandtherapists.be/functional-anatomy-hand
 The Hand Region

• The Hand (manus) forms the distal part of the

upper extremity.
• It contains the metacarpal bones and the
phalanges.
• Because of the importance of manual dexterity
in occupational and recreational activities, a
good understanding of the structure and
function o f the hand is essential.
 The Hand: Surface Anatomy

• Dorsal hand=extensor tendons are visible.

• When a fist is made, the metacarpal phalangeal
and PIP and DIP joints become visible.
• Palmar aspect=has creases:
- 2 transverse
• Proximal
• Distal

- Ulnar longitudinal - hypothenar

- Radial longitudinal - thenar
The Hand: Palmar Aponeurosis
• This is a triangular, well-defined structure that covers
the soft tissues of the palm overlying the flexor
tendons.
• Its proximal end is continuous with the flexor
retinaculum and the palmaris longus muscle tendon.
• Its distal end divides into 4 bands that go the base of
the proximal phalanges of the medial 4 digits.
• The palmar fascia sends radial projections deep into
the structures of the hand dividing it into separate
6.53A, B Palmar fascia and fibrous digital sheaths
6.54A, B Compartments, spaces, and fascia of the palm
 The Hand: Palmar Aponeurosis
• Dupuytren’s Contractures = fibrosis of
the palmar aponeurosis with shortening of
the digital bands, especially those to the 4th
and 5th fingers.
• These fibroses pull the digits in such marked
flexion at the MPJ that they cannot be
straightened.
• Etiology: Unkown, but are associated with
EtOH, epilepsy. They are bilateral in 40% of
cases.
• Treatment: intralesional injections of
corticosteroids, but usually the condition
requires surgical release.
 The Hand:Muscles
• THENAR MUSCLES (Thumb):
- Abductor Pollicis Brevis
- Flexor Pollicis Brevis
- Opponens Pollicis
- Adductor Pollicis
 The Hand: Muscles
• HYPOTHENAR MUSCLES (Little Finger)
- Abductor Digiti Minimi
- Opponens Digiti Minimi
- Flexor Digiti Minimi Brevis

All the muscles of the Hypothenar eminence are supplied

by the ulnar nerve.
 The Hand: Muscles

• THE LUMBRICAL MUSCLES

- Four lumbricals.
- No lumbrical to the thumb.
- No bony origin or insertion.
- They start onto the tendons of the flexor digitorum
profundus, and terminate onto the bases of the proximal
phalanges of the medial 4 digits with the tendons of the
extensor digitorum (extensor expansion), and interossei
muscles.
- They are named from lateral to medial:
• Lumbrical 1 (index)
Median nerve
• Lumbrical 2 (middle) Action: flexion of the
• Lumbrical 3 (ring) MPJ, they wave “Bye-bye”
Ulnar nerve
• Lumbrical 4 (little)
 The Hand: Muscles
Palmar
• THE INTEROSSEOUS MUSCLES
- They attach to the thumb.
- Four dorsal (ABDUCT fingers) Dorsal

• O: by two heads from adjacent metacarpals

• I: side of proximal phalanx
- Three palmar (ADDUCT fingers) to 2, 4, 5
• O: arise by one head from metacarpals 2, 4, 5
• I: bases of proximal phalanges of each
corresponding digit.
Nerve Supply: They are all supplied by the ulnar nerve
Action: PAD/DAB
INTRINSIC MUSCLES OF THE HAND
 OPPONENS
DIGITI
MINIMI

OPPONENS FLEXOR
POLLICIS DIGITI
MINIMI BREVIS

FLEXOR
POLLICIS
BREVIS
ABDUCTOR
LUMBRICALS
DIGITI MINIMI
(4 - MPJ “BYE-BYE”)

ADDUCTOR
POLLICIS

PALMAR DORSAL
INTEROSSEI INTEROSSEI
(3 PAD) to 2, 4, 5 (4 DAB)
LUMBRICAL 2
 The Hand: Nerve Supply
• Median Nerve • Ulnar Nerve
- Abductor pollicis Brevis - Adductor Pollicis
- Part of the Flexor - Part of the Flexor
Pollicis Brevis Pollicis Brevis
- Opponens Pollicis - Abductor Digiti Minimi
– Lumbrical 1 and 2 - Flexor Digiti Minimi
- Lumbricals 3 and 4
- Interossei
 The Hand: Blood Vessels
• The radial and ulnar arteries form or
contribute to the deep and superficial arterial
arches.
• The superficial branch radial a. passes
through the thenar eminence, then it joins
the superficial palmar arch (ulnar artery)
• The deep palmar branch of the ulnar a.
passes through the hypothenar eminence,
then it joins with the radial artery
completing the deep palmar arch.
• The dorsal digital veins and dorsal metacarpal
veins unite to form a dorsal venous arch.
CARPAL
BRANCH RADIAL A.
OF THE
ULNAR A.
 Ulnar artery

Radial artery
Pathology
Fractures of the Hand
BOXER’S FRACTURE
https://img.grepmed.com/uploads/2272/metacarpal-radiology-handxray-clinical-fracture-original.jpeg
FRACTURE OF METACARPAL 5 (BASE)
FRACTURE BASE METACARPAL 5 FRACTURE OF METACARPAL HEADS 3 & 4
FRACTURE OF MET 1
BASE
PIPJ DISLOCATION DIGIT 5
 Mallet or Baseball Finger
Sudden severe tension on a
long extensor tendon may
avulse part of its attachment to
phalanx.
The injury is a result of hyperflexion
of the DIPJ at the extensor digitorum
tendon
Thenar Compartment
Boundaries
Contents:
 Thenar fascia metacarpal bone
 Abductor pollicis brevis mm
 Flexor pollicis brevis mm
 Opponens pollicis mm
 Recurrent or motor branch of the
median nerve
 Tendon of the flexor pollicis
longus,, and radial bursa
Hypothenar Compartment
Boundaries:

Hypothenar fascia, fifth metacarpal bone

Contents:
 Adductor digiti minimi mm
 Flexor digiti minimi brevis mm
 Opponens digiti minimi muscle
 Deep ulnar nerve
Muscles of the
thenar and
hypothenar
eminences.
Central
(intermediate)
Compartment
Boundaries
Components:
Palmer aponeurosis
Fascia contents:
 Ulnar artery
(superficial palmar
artery arch)
 Common palmar digital
branches
 Lumbrical muscles
 Ulnar bursa
surrounding flexor
digitorum tendons
https://www.wikidata.org/wiki/Q25348264
Hypothenar
compartment

Central
compartment

Thenar
compartment
 Adductor-
Interosseous
Compartment
Boundaries –
Adductor-interosseous
fascia, metacarpal bones
II, III, IV
Contents:
 Adductor pollicis mm
 Palmer interosseous
mm
 Dorsal interosseous
mm
 Radial a.
 Deep palmer arch
 Deep ulnar n.
https://www.memorangapp.com/flashcards/43819/Anatomy+of+the+Hand/
Dorsum of Hand
http://www.anatomyqa.com/anatomy/upperlimb/anatomical-snuff-box/
https://web.duke.edu/anatomy/mbs/Lab12_MBS/Lab12.html
 Blood Supply and Drainage
of the Hand
•The superficial palmar
arch is the main continuation of
the ulnar artery.
•It receives a small superficial
branch from the radial
artery and supplies the fingers
with blood via the proper
digital arteries.
•The deep palmar arch is the
main branch of the radial
artery and supplies the deep
hand structures.
•Paired veins accompany
the arterial arches and share
the same names
(i.e. radial and ulnar). The
more
superficial cephalic and basilic
veins drain the dorsal venous
network of the hand.
http://www.davidlnelson.md/articles/anatomy_homepage.htm
Gg76584377 GoGrpah