ZONES OF HAND

Rose Mary Antony

 Tendons
• White fibrous connective
tissue cords which connect
muscles to bones.
• Tendon continuity is
necessary for transmission of
force from muscle bellies to
hand.
• Disruption of a tendon
causes loss of motion of the
digit, diminished grip or
pinch.
 Tendon injuries
• In order to clarify the results of tendon
repair , it is necessary to define the
different anatomic regions of the tendons
of hand .
 Flexor system
• Muscle bellies originate
from distal humerus and
proximal ulna.
• Musculotendinous
junction is located in the
distal forearm and tendons
pass to the wrist through
the carpal tunnel & into
the hand and digits.
• 2 tendons for each finger and
1 for thumb.
• Flexor digitorum superficialis
divides into 2 tendon slips &
inserts on the middle phalanx
of each digit.
• Flexor digitorum profundus &
flexor pollicis longus tendons
insert on the base of distal
phalanges of fingers & thumb.
FLEXOR ZONE SYSTEM

MODIFIED
VERDAN’S
ZONE
SYSTEM
 Zone 1
• From flexor
superficialis
insertion to the tip
of finger.
• Involves only
flexor digitorum
profundus.
• Skin laceration-
distal to mid finger
crease.
Zone 2

• Bunnell’s no man’s
land - the results
obtained were so
poor that nobody
should attempt to
repair it.
 Zone 2(contd)
• Begins proximal to the
metacarpophalangeal joint
& extends to the
midportion of middle
phalanx.
• 2 flexor tendons enclosed
in the fibrous flexor sheath.
• Corresponds to distal
palmar crease & mid finger
crease.
Zone 3

• From the distal end of

transverse retinacular
ligament to the distal
palmar crease.
• Lumbrical muscle
belly firmly attached to
flexor profundus &
superficialis.
 Zone 4

• Carpal tunnel – distal end

of transverse retinacular
ligament to the proximal
margin.
• Lumbrical muscle belly
thins out & flexor tendons
to the fingers and thumb &
median nerve.
 Zone 5
• From proximal
transverse carpal
ligament at the wrist to
the musculotendinous
junction of the flexor
tendons in the distal
third of forearm.
EXTENSOR SYSTEM

• Injuries to the
extensor tendons
are common
owing to their
relatively exposed
and superficial
location.
Extensor compartments
• 1 - extensor pollicis brevis
and abductor pollicis
longus.
• 2- extensor carpi radialis
longus & brevis.
• 3- extensor pollicis longus.
• 4- 4 tendons of extensor
digitorum + extensor
indicis
• 5- extensor digiti
minimi .
• 6 – extensor carpi
ulnaris.
• The extensor digitorum
tendons are joined by
oblique interconnections –
juncturae tendinum.
• Intrinsic tendons from
lumbricals & interossei join
the extensor mechanism
over the proximal phalanx
& continue distally to the
distal interphalangeal joint.
 DORSAL DIGITAL
EXPANSION

• Extensor mechanism at proximal

interphalangeal joint can be described as
a trifurcation of extensor tendon into the
central slip & 2 lateral slips.
• Central slip attaches to the base of middle
phalanx.
• Lateral bands pass on either side of
proximal interphalangeal joint & get
inserted at the base of distal phalanx.
 EXTENSOR ZONES
VERDAN’S ZONE SYSTEM

• 1- distal interphalangeal
joint
• 2 - middle phalanx
• 3 - proximal
interphalangeal joint
• 4 - proximal phalanx
• 5-metacarpophalangeal
joint
• 6 – metacarpal
• 7 – dorsal retinaculum
• 8 – distal forearm
Zones of thumb

• 1 - interphalangeal joint
• 2 - proximal phalanx
• 3 -metacarpophalangeal
joint
• 4 – metacarpal
• 5 – carpometacarpal joint
or radial styloid
 Resting posture of hand
• When relaxed, the hand
lies in a characteristic
posture with the thumb-
tip held slightly flexed
and fingers held in a
cascade. Any change in
the resting posture can
suggest tendon or even
nerve damage.
 INJURIES
• injury to extensor tendons
• Inability to extend the fingers as in
opening the hand.
• Both flexor tendons of a
finger severed
• Finger lies in an
unnatural position of
hyperextension
compared with uninjured
fingers.
• Passive extension of wrist does not
produce the normal tenodesis flexion of
the fingers.
• If the wrist is flexed , even greater
unopposed extension of the affected finger
is produced.
• When both flexor
tendons are severed,
neither proximal nor
distal interphalangeal
joint can be actively
flexed with the
metacarpophalangeal
joint stabilised.
 •Flexor digitorum profundus

• With proximal
interphalangeal joint
stabilised, active flexion
of distal interphalangeal
joint is not possible.
• Flexor digitorum
superficialis injury
Maintaining the
adjacent fingers in
complete
extension, flexion
of the
interphalangeal
joints is not usually
possible in the
affected finger.
 Thumb
• If flexor pollicis longus
tendon is divided,
flexion at the
interphalangeal joint is
absent when the
metacarpophalangeal
joint is stabilised.
 MEDIAN NERVE INJURY

• Ochsner’s clasping test

patient is asked to clasp
the hands,index finger of
the affected side fails to
flex and remains as a
pointing index.
 ULNAR NERVE INJURY

• Froment’s sign
Patient asked to grip a
sheet of paper between
thumb & index finger
of both hands. Thumb
of the affected side
cannot remain straight
& it flexes.
 RADIAL NERVE INJURY
• Wrist drop
• Patient unable to extend
the wrist if injury
occurs in axilla & radial
groove.
• Finger drop
• Injury to the nerve in
fractures of the
proximal radius.
 Specific extensor tendon
injuries.
MALLET FINGER
• Loss of continuity of the
extensor tendon over distal
interphalangeal joint.
• Person is unable to actively
extend the distal
interphalangeal joint.
 SWAN NECK DEFORMITY

Hyperextension at the
proximal
interphalangeal joints
and flexion at the
distal interphalangeal
joints of the hands
 BOUTONNIERE
DEFORMITY
• Disruption of extensor
tendon at the proximal
interphalangeal joint .
• Loss of extension at
proximal
interphalangeal joint &
compensatory
hyperextension at distal
interphalangeal joint.
THANK YOU