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An artery with origin in the radial artery, with distribution to the palmar surface and sides of the thumb, and with anastomoses to the arteries on the dorsum of the thumb.

- Tendon Sheath Anatomy: - A1 pulley: spans the MP joint, approximately 8 mm in width; - note that the FPB inserts just proximal to this pulley and the adductor pollicis inserts distal to the A1 pulley; - oblique pulley: located over the mid aspect of the phalanx, approximately 10 mm in width; - note that the adductor pollicis partially inserts into the oblique pulley; - A2 pulley located at the most distal aspect of the proximal phalanx, and is 9 mm in width; - it may partially span the thumb IP joint; - Zone 1 Flexor Tendon Injuries: - in thumb, zone 1 extends from tip of finger to just distal to IP joint; - contains, oblique and A2 pulleys; - of these, the oblique is more important, but either can be sacrificed if the other remains intact; - most tendon injuries of thumb occur at level of IP crease, which is near point of the FPL insertion; - exposure: - skin laceration needs to be extended both proximally and distally; - flexor tendon sheath is "Z" step cut so that edge of the resected sheath lies about 1 cm beyond excursion of thickened area of sutured tendon; - tendon retrieval: - first, note that FPL tendon lacerations often retract into the thenar area or wrist; - unlike the fingers, the FPL often lacks a vinculum and does not have a lumbrical, and therefore the tendon is free to retract; - when there is tendon retraction, the tendon must be retrieved at the wrist; - second, note that the FPL tendon sheath is narrow in the thenar region, and therefore, passage of the tendon thru the sheath can be frustrating; - it is important to avoid "scuffing" of the tendon edge as it is pulled thru the tunnel; - pass a curved tendon grasper retrograde thru the FPL tendon, and insert a core grasping suture into the free edge of the tendon; - the tendon grasper is then used to pull the suture back thru the tunnel; - delayed reconstruction: FPL Advancement and Pull Thru: - Zone 2 Flexor Tendon Injuries: - over thenar eminence, injuries to FPL tendon are likely to occur in conjunction w/ injuries to thenar muscles & recurrent branch of median nerve; - Tendon Transfers: - the following musculotendinous units have adequate exursion (muscle amplitude), but lack tension strength based on cross sectional area: EPL, EIP, PL; - muscles that replace strength and excursion are the following - FDS to the long and ring fingers, ECU, and ECRL;

- origin: - tuberosity of the scaphoid and the ridge of trapezium; - another slip originates from the transverse carpal ligament; - insertion: lateral surface of the base of the proximal phalanx of thumb; - action: abdcution and medial rotation of the metacarpal of the thumb; - synergists: abductor pollicis longus, EPL;

posterior surface of the base of the proximal phalanx of thumb. internally rotates andabducts the proximal phalanx of thumb on its metacarpal. . . C6. .nerve supply: median nerve. Extensor Pollicis Brevis . it is APB which atrophies.extends proximal phalanx of the thumb.although opposition is result of coordinate function of all long and short muscles that act on the thumb..synergists: APL. . . . T1. . and assists EPL in extending IP joint of the the cases of carpal tunnel syndrome.Discussion: .Discussion: .annular ligament that restrains abductor pollicis longus & EPB over radius is directly over radial tubercle. C8. C7. . APB is most important single muscle that takes part in this complex movement.posterior side at the distal end of the body of both the ulna and radius near their rotates internally and abducts the thumb away from index metacarpal. Extensor Pollicis Longus .Anatomy: .nerve:: PIN branch of deep radial nerve.action: .this area may be involved in DeQuervain's tenosynovitis. and if this atrophy is severe the thumb cannot be pronated. A simplified technique to correct hyperextension deformity of the metacarpophalangeal joint of the thumb. .insertion: . continued action extends and assists abduction of the 1st metacarpal. EPL.origin: .

C8. continued action. Extensor pollicis longus opposition transfer.insertion: posterior surface of the base of the distal phalanx of thumb. .See: Extensor Pollicis Longus Rupture: . . . .FPB is on volar surface of metacarpal and under abductor brevis. . extends proximal phalanx and adducts the 1st metacarpal.Nerve supply: superficial head: Median. .flexes proximal phalanx of the thumb.note: that the "cross over" between the EPL and the ECR tendons can become involved in a cross over syndrome. Effects of extensor pollicis longus transposition and extensor indicis proprius transfer to extensor pollicis longus on thumb mechanics.Origin: .action: extends the distal phalanx of the thumb. .greater multangular bone tuberosity of the trapezium bone deep head.ask pt to place hand flat on table.Exam: . .Anatomy: . it continues along its course to the thumb.trapezoid and capitate bones. .palpate length of tendon.Discussion: .origin: posterior surface of the middle 1/3 of the ulna & interosseous membrane. T1 deep head: Ulnar. . adductor pollicis. . & C8. T1. .. . just distal to the extensor retinaculum.EPL tendon takes 45 deg turn around Lister's tubercle.then after passing over ECRL & ECRB tendons of tunnel I.superficial head: distal border of the flexor retinaculum.nerve: PIN branch of deep radial nerve. & lift only thumb off head of the flexor brevis originates from volar carpla ligament and in the region of the Flexor Carpi Radialis tendon. which defines ulnar border of anatomic snuff box. C7. look for any signs of rupture.other originates from trapezium and from capitate tendon that inserts into radial sesamoid & radial tubercle of proximal phalanx.on ulnar side of Lister's Tubercle contains EPL . Flexor Pollicis Brevis .Tunnel III: . patient will be unable to raise the thumb in line w/ the second metacarpal. and assists in extending the distal phalanx of the thumb.Synergists: FPL. . . C8.w/ rupture. C6. .Insertion: base of the proximal phalanx of the thumb. . continued action flexes first metacarpal and rotates it medially. . .this muscle also attaches to an expansion into the extensor mech. . .Action: .

dorsal sensory branch: .Palmar cutaneous branch of the ulnar nerve. C7. continued action.anatomy and sites of compression in the cubital tunnel: .deep branch. Vol 5. . .Ulnar Nerve in Condylar Fractures: . .terminal branches in the hand: .ulnar nerve passes distally. .Flexor Pollicis Longus .Cubitbal Tunnel Syndrome . .deep motor branch passes adjacent to hook of hamate. . adductor pollicis.C8 and T1 nerve roots give rise to the medial cord which in turn.See: . .insertion: palmer surface of the base of the distal phalanx of the thumb. which and cause contracture of thumb secondary to elbow injuries as accessory head attaches to medial epicondyle of the humeus. . around posterior aspect of medial epicondyle.origin: . .thumb functions most independently (of the digits). . J. . .FPL tendon rests between two sesamoid bones. & deep head of FPB. but in 10 % of population tip of thumb & index finger function simultaneously. . adjacent interosseous membrane and a slip from coronoid process of the ulna or medial epicondyle of humerus. . .Differential Dx: Ulnar Nerve Dysfunction: . which is responsible for trigger thumb mechanism. .The lateral root of the ulnar nerve.Anatomy: .Ulnar Nerve Blocks: . pierces medial intermuscular septum halfway down the arm. C8.FPL Rupture: .synergists: FPB.General Orthopaedics: The Anatomy of the Distal Ulnar Tunnel.See . passes back over medial head of triceps.Anatomy: .just below passes down forearm under FCU . or in lacerations. & then into Guyon's canal. forms the ulnar nerve. . just medial to axillary artery. Engber and JG Gmeiner. WD. T1 > C6.superficial cutaneous branch to ulnar portion of palm & volar surfaces of ulnar 1 1/2 fingers. & enters forearm between two heads of FCU.references: .muscle belly may be involved w/ in isolated anterior interosseous compression syndromes.anterior surface of middle 1/2 of radius. it sends branches to FCU & ulnar half of FDP. annular dorsoulnar aspect of the hand and the ulnar 1 1/2 fingers.FPL may have accessory proximal head.brachial plexus: . . Surg.the nerve emerges from the medial border of the FCU about 5 cm proximal to the pisiform. innervating hypothenar muscles & third & fourth lumbricales. .guyon's canal: . in localized ischemic contracture. . . 1980.The Dorsal Branch of the Ulnar Nerve: An Anatomic Study. Hand. adductor pollicis.action: .Forearm Flexors . & tendon is covered by fibrous canal. all interossei.Pathologic Anomolous Anatomy: .nerve supply: median (AIN branch). Ulnar Nerve . flexes the MP and CMC articulations.Martin Gruber Anastomosis .Thumb Tendon Injuries: .flexes the interphalangeal joint of the thumb.

treatment: . R.w/ severe cases of cubital tunnnel syndrome. FDM.if ulnar nerve is divided below mid-forearm.ganglion (produces motor and sensory deficit) . 1975.Experience with the free vascularized ulnar nerve graft in repair of supraclavicular lesions of the brachial plexus. An additional method for closing the gap in the nerve trunk.synovitis.w/ this lesion. . will not show loss of sensation over dorsoulnar aspect of hand.A Neural Loop of the Deep Motor Branch of the Ulnar Nerve: An Anatomic Study.Epiperineurium-fascial stitches along the stumps of a transected nerve.Trauma to Ulnar Nerve: (see: nerve repair) . clawing of ulnar two fingers does not occur. . .positive Tinel's sign on percussion over ulnar nerve at guyon's canal. p 990.this posture is sometimes called hand of benediction. Primary suture is best.A variation in the path of the deep motor branch of the ulnar nerve at the wrist.Distribution pattern of the deep branch of the ulnar nerve in the hypothenar eminence.clinical findings include positive Froment's test. Aulicino-PL. . MP joints are extended & interphalangeal joints flexed by still-functional extrinsics. . . .paralysis of adductor pollicis produces Froment's sign.if ulnar nerve lesion is above midforearm. wasting of first dorsal interosseous complete claw hand. . . and FCU.thrombosis of ulnar artery or SPA.p 26. & clawing of ring & small fingers. produced by low lesion of median nerve & ulnar nerves. which includes. because extrinsic muscles producing IP joint flexion are also denervated (see high ulnar nerve lesion).Entrapment of Ulnar Nerve at Wrist: .high ulnar nerve lesions . Rogers-MR.clinical findings: .Cubital Tunnel Syndrome: . 4th & 5th fingers are hyperextended at MP joints by long extensors but flexed at interphalangeal joints. there will be decreased two point sensory distribution of ulnar nerve as well as muscle weakness and/or muscle wasting of intrinsic innervated by the ulnar nerve.combined lesions of the median and ulnar nerves: .anomalous muscles. Median Nerve . ulnar nerve symptoms may improve with carpal tunnel surgery alone. . (low ulnar nerve lesions). . . . . palmaris brevis profundus.division of ulnar nerve at wrist results in paralysis of all small muscles of hand except first & second lumbricales & most of thenar muscles. . Bergfield-TG.low ulnar nerve injury . . .frx (frx of 5th CMC or hook of hamate) .diff dx: . .when grasping piece of paper between thumb and index finger. ulnar claw hand is produced. .w/ compression of ulnar & median nerves at wrist. inability to cross index and middle fingers. Lassa and MM Shrewsbury.pts may also develop claw hand . . . . pp 269-271.changes with nerve conduction studies and electromyograms. . FPL fires (IP joint flexion) since adductor does not work.The results of secondary microsurgical repair of ulnar nerve injury. .Repair of median and ulnar nerves. Vol 57-A. J Hand Surg.references: . 1991. . .positive Phalen's test w/ paresthesias in ring & small fingers .anomalous muscle belly at level of the wrist.increase in two point discrimination. 16A. JBJS.

Hand Surg. thumb can be pronated. J. .w/ intact nerve. U. lining up nails at or near 180 deg. .nerve lies superficial to the tendons of the FDP and FPL. it supplies all muscles on front of forearm except FCU & ulnar half of FDP.Anatomical variations of the median nerve in the carpal tunnel. . Surg. . with thenar atrophy & inability to oppose or flex the thumb.ref: Acute compression of the median nerve at the elbow by the lacertus fibrosus. Hand.Exam: . Neurosurgery. and corresponding portion of palm.martin gruber anastomosis .position in the arm: .nerve may be compressed by the fibrous arch of FDS. .Variations of the median nerve in the carpal canal.compression is worsened w/ extension and supination.small hook of bone 5 cm above medial epicondyle. . . . weak flexion & radial deviation of wrist.brachial plexus . .High Median Nerve Lesions .has no branches in arm. Vol 27.median nerve may be displaced medially and compressed by these structures.signs of a median nerve lesion include weak pronation of the forearm. MM al-Qattan and JB Husband.sensory distribution includes thumb. 1997.variations: .crosses brachial artery from lateral to medial in the arm. Bilge et al. ..runs between & deep to FCR & palmaris longus into carpal tunnel. .Anatomy: .Median Nerve Block .pronator teres compression syndrome: . C7.Low Median Nerve Lesions .position in distal forearm and in the carpal tunnel: . .lateral cord: contributes mainly sensory axons from C6 and C7 .references: .is tightened w/ pronation of forearm as bicipital tuberosity of the radius passes posteriorly. J. .FDS tendons lie lateral to the nerve.see: carpal tunnel syndrome and surgical decompression and median nerve injuries at the wrist . 1991.motor branch: . p 787-789. 1990.anterior interosseous branch . .roots: C6. then passes over brachialis. p 101-103. Vol 2.entrapment of median nerve at the elbow and forearm: .lacertus fibrosis: . . thru ligament of Struthers.Median nerve compression by the supracondylar process: A case report.passing superficial to the FDP and beneath FDS. Vol 16. p 44-53. . Lanz. . .medial cord: provides main bulk of motor input through C8 and T1 .references: . .bifid (high division) of median nerve: associated w/ a median artery.this is a site of potential compression. .nerve enters forearm between 2 heads of pronator teres (beneath the superficial-humeral) which is a site of potential compression.present in approximately 1% of individuals of European descent . thumb can't be pronated & nail is < 100 deg.Median Nerve Injuries at the Wrist .Martin Gruber Anastomosis . C8.Entrapment neuropathy of the median nerve at the ligament of Struthers T.cords: .Combined Lesions of the Median and Ulnar Nerves: .may form accessory origin for pronator teres. . . radial 2 1/2 fingers. .Carpal Tunnel Syndrome .median nerve is parallel and anterior to the medial intermuscular septum. .supracondylar process: . .palmar cutaneous branch: . and T1 (? C5) .w/ median nerve palsy.

Radial Artery in Wrist: . the artery divides into princeps pollicis and radialis indicis. the index and middle finger. The muscles of the hand supplied by the median nerve can be remembered using the mnemonic.princeps pollicis artery branches from the radial artery before it is covered by the oblique head of the adductor pollicis muscle.[2] Radial Artery .in the web space. .it passes into palm between oblique & transverse heads of adductor pollicis & then forms deep palmar arch by anastomosing w/ deep branch of ulnar artery. It also supplies the muscles of the thenar eminence by a recurrent thenar branch. Abductor pollicis brevis and Flexor pollicis brevis. Opponens pollicis.radialis indicis: . .radial artery becomes deep palmar as it enters palm between two segments of the first dorsal interosseous muscle. which leaves the nerve proximal to the wrist creases.Radial Artery in the Forearm: .in the mid forearm. the median nerve supplies motor innervation to the 1st and 2nd lumbrical muscles. .here the brachioradialis recieves arterial branches just below elbow.this runs along the radial side of index finger. The median nerve innervates the skin of the palmar side of the thumb. The lateral part of the palm is supplied by the palmar cutaneous branch of the median nerve. It is therefore spared in carpal tunnel syndrome. which provides blood to thumb & thenar side of index finger & gives rise to collat.radial artery terminates in deep palmar arch. This palmar cutaneous branch travels in a separate fascial groove adjacent to the flexor carpi radialis and then superficial to the flexor retinaculum. . . . . . "LOAF" for Lumbricals 1 & 2. half the ring finger. and the nail bed of these fingers. branches. . the radial artery lies beneath the brachioradialis .Hand In the hand.See: Vascular Problems of the Wrist and Hand: . The rest of the intrinsic muscles of the hand are supplied by the ulnar wrist ulnar artery terminates in superficial palmar arch that provides most of the blood supply to the runs along volar aspect of adductor muscle between FPB and tendon of the FPL.

common interosseous artery arises & divides into anterior or volar branch and posterior or dorsal branch.artery divides into an ascending and descending branch along the inferior surface of the FCU. 10-20%.posterior branch runs down forearm on posterior side. .about 1 inch below origin of ulnar artery. .about 1 inch below the antecubital fossa. . . . the condition is asymptomatic in most forearm. .artery runs dorsally and ulnarly. . . . . .because.Radial artery cannulation: influence of catheter size and material on arterial occlusion.alternative is to place a pulse oximeter to the thumb and to compress the radial artery. A prospective study in patients undergoing cardiothoracic surgery. which passes medially beneath the FCU tendon.initial treatment is w/ Fogarty catheter (size 2 Fr).originates between 2-4 cm proximal to the pisiform.Acute exacerbation of carpal tunnel syndrome after radial artery cannulation. and just deep to the FCU.Should an Allen test be performed before radial artery cannulation? Ulnar Artery .radial and ulnar arteries terminate by dividing into superficial and deep branches. compression). . .radial artery is frequently cannulated percutaneously for ABG monitoring and for continuous pressure monitoring. .as it passes down the forearm lying just lateral (deep) to the ulnar nerve.Long-term radial artery cannulation: effects on subsequent vessel function.Wrist hyperextension leads to median nerve conduction block: implications for intra-arterial catheter placement. it divides into two palmar digital branches. . Bedford RF.See: . these patients are at risk for thrombosis of the radial artery. it branches into two volar arteries of thumb. [JC:4sg 51(2):176-8. lying between the medial edges of the FDS and FDP.allen test should be performed in all patients prior to radial artery cannulation. because of collateral circulation from the ulnar artery.Radial artery cannulation.Vascular Problems of the Wrist and Hand: .ascending artery provides vascularization on the ulnar side of the forearm for a length of 9-20 cm and 510 cm wide. . w/ latter being larger. . Anesthesiology.Ulnar Artery in Forearm: .incidence of radial artery thrombosis after cannulation is approx. .at the thumb. . . . the ulnar artery is deeper than radial artery.Aspirin pretreatment prevents post-cannulation radial-artery thrombosis.and 20-gauge catheters. brachial artery divides into radial & ulnar arteries. . Ashford level of MP joint.paired venae comitantes accompany both radial & ulnar passes under the arch of the FDS. > 20% of pts have incomplete palmar arch.if there is an incomplete superficial palmar arch.interosseous branch: .anterior branch runs down forearm in the midline on interosseous membrane.Ulnar Artery in Hand: .. . . but wrist ulnar artery terminates in superficial palmar arch that provides most of the blood supply to the fingers.Radial arterial function following percutaneous cannulation with 18. .references: .Puncture of Artery: . . . .ulnar artery is prime contributor to superficial arch which also receives a branch of superficial branch of the radial artery. . then the pulse ox will not register on the thumb (w/ radial a.dorsal branch of the ulnar artery: . 1979 Aug. . .

.deep arch is a finger's breath superficial.pulsation of the ulnar artery can usually be felt just lateral to the pisiform bone. artery divides into its larger branch which forms most of superficial arch & smaller branch which forms lesser part of deep palmar.just proximal to pisiform bone the ulnar artery gives off volar and dorsal carpal branches which unite w/ volar and dorsal branches of radial artery to form arterial wristlet about carpal bones. . .line drawn across the palm at level of distal border of fully abducted thumb marks the approximate locatation of the superficial arch.superficial arch is much larger & important than the deep arch .immediately distal to this point. . . .

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